Based on observation and staff interview, the facility failed to ensure they honored the residents right to receive meal trays in a dignified manner. This was a random opportunity for discovery during the Long-Term Care Survey process. Facility Census:113. Resident identifier: #71. Findings include: a) Resident #71 01/22/25 03:06 PM Resident #71's roommate was served approximately six (6) minutes before Resident #71 was served. During an interview, on 01/22/25 at 3:10 pm with the Administrator, she confirmed Resident #71 should have been served and assisted with eating after the roommates' tray was delivered.

Based on record review and staff interview, the facility failed to thoroughly investigate an allegation of abuse of Resident #319. This was true for one (1) of nine (9) residents reviewed for abuse during the survey process. Resident identifiers: #319, #320, #46, #50, #54, #40, and #8. Facility census: 120. Findings include: a) Resident #319 At approximately 1:00 PM on 01/28/25, a review was conducted of a facility reported incident involving Resident #319. This incident alleged Resident #319 was the victim of abuse/neglect at the facility. The residents interviewed by the facility were described as like residents meaning they were in similar condition to Resident #319. In reviewing the statements, the facility interviewed Residents #320, #46, #50, #54, #40, and #8. All of the statements taken from the residents, except the one from Resident #46 were not dated and did not state who the employee was taking the statements. One statement, had the name of Resident #46 at the top of the form, as the person giving the statement, however, it was signed by Resident #8. In the initial report, dated 09/24/2024 at 12:45 PM, Social Worker (SW) #62 documented Resident interviewed and investigation began. However, no statement from Resident #319 was found. At approximately 2:30 PM on 01/28/2025, an interview was conducted with SW #62, with the Administrator in attendance, regarding the incomplete statements from the various residents and the missing statement from Resident #319. SW #62 and the administrator acknowledged the statements not being dated, and the statement identifying Resident #46 as the resident giving the statement but being signed by Resident #8. When SW #62 was asked where the statement from Resident #319 was, that was mentioned in the initial report, he stated, I briefly spoke with him, I remember I asked him if he was ok, and he nodded. I wouldn't ' t have taken a statement at that time because I hadn't started the investigation yet. However, upon further review, it was determined Resident #319 was not in the facility at the time SW #62 stated he interviewed the resident, as he was sent out to the hospital a day prior, on 09/28/2024. SW #62 stated the initial report should have stated he spoke with the resident's representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure Resident #108's Discharge Minimum Data set was coded to accurately reflect the location where the resident was discharged to. This was true for one (1) of 36 sampled residents reviewed during the long-term care survey process. Resident Identifier: #108. Facility Census: 113. Findings include: a) Resident #108 A review of Resident #108's medical record at 10:52 am on 01/27/25 found a Discharge summary dated [DATE] which indicated the resident was transferred to another long-term care facility. A review of the discharge Minimum data set (MDS) with an assessment reference date of 01/08/25 found section A2105 was coded with the number 04 which indicated the resident was discharged to Short Term General Hospital. However, this section should have been coded 02 Nursing home. An interview with the Nursing Home Administrator (NHA) at 2:05 PM on 01/27/25 confirmed this MDS was inaccurate.

Based upon record review and staff interviews, the facility failed to refer one (1) of eight (8) residents who had a newly evident serious mental health disorder diagnsis for a level II review. This was true for one (1) of eight (8) records reviewed. Resident identifier: #85. Facility census: 120. Findings included: a) Resident #85 Major depressive order was added as a diagnosis in the electronic medical record on 11/04/24, for resident #85. The last PASARR was completed on 06/03/24. During an interview with the Director of Nursing (DON) on 01/23/25 at 12:32 PM the PASARR was reviewed PASARR with her and she acknowledged the error.

b) Resident #99 A record review on 01/27/05 at 10:30 AM, revealed a care plan for Resident #99 initiated on 04/24/24, revised on 10/24/24 read as follows: Focus: At risk for impaired psychosocial well-being related to history of physical trauma related to falls resulting in major injury and will refuse Vital Signs, refused shower, become verbally and physically aggressive at times. Goal: The resident will verbalize a maintained/improved psychosocial wellbeing as evidenced by the elimination and/or mitigation of triggers that may cause re-traumatization through next review date. Interventions: Consideration should be given to methods of assistance given to resident such as: Same sex care giver, removal of clothing slowly, remove from areas where Further record review of the Nursing Assistant (NA) assignment sheets from 01/13/25 to present revealed that Resident #99 was assigned a female caregiver every day, every shift. During an interview on 01/27/25 at 10:45 AM, The Director of Nursing (DON), stated, We do not have male caregivers right now. We have not had one for a while. I do not know why that is in the care plan. I will get it fixed. Based on observation, record review and staff interview, the facility failed to implement Resident #47's care plan regarding accident hazards in his room and failed to implement Resident #99's care plan in regard to same sex caregivers. This was true for two (2) of 36 resident care plans reviewed during the survey process. Resident identifiers: #47, #99. Facility census: 120. Findings include: a) Resident #47 At approximately 1:18 PM on 01/20/2025, 2:00 PM on 01/21/2025, and 3:30 PM on 01/22/2025, Resident #47's over the bed table was observed sitting on the fall mat to the left side of his bed. The over- the- bed table was placed diagonally, from the top of the fall mat, in a way that exposed the metal bottom, and wheels, of the table, leaving the resident open to landing on them if he were to fall out of bed. Licensed Practical Nurse (LPN) #97 acknowledged the table on the fall mat at approximately 3:35 PM on 01/22/25 and stated the table was usually always on the mat because the resident reaches over and gets his water off of the table. At approximately 4:00 PM on 01/22/25, an interview was conducted with the Director of Nursing (DON) and Administrator. During the interview, it was determined the facility had not tried any alternative fall interventions for the resident to make the water more accessible without placing the table on the fall mat. Upon review Resident #47's care plan, it was determined the resident had a focus for falls. One intervention under the fall focus reads Ensure resident's room is free of potential visible hazards. The DON acknowledged at 3:35 PM on 01/28/25 the care plan had not been implemented due to the over the bed table sitting on the resident's fall mat.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to revise care plan after placing resident on a Q one (1) hour checks for three (days). This was a random opportunity for discovery during the Long-Term Care survey process. Facility identifier: #96. Facility Census: 113. Findings include: a) Resident #96 Record review on 01/23/25 at 11:09 AM of Resident #96 care plan, which stated the following Focus -Resident is an elopement risk related to dementia and wandering behaviors. Resident has exit seeking behaviors. Resident has had an elopement. Goal -Resident [NAME] not exit property if unsafe to navigate community. Interventions -Apply secure device. Check placement every shift. check function and door transmitter daily. Document in the order the expiration date of the secured devices. -Assess for hunger, thirst, ambulation/re-admission, quarterly, and PRN(as needed) -Educate resident/resident representative of the need for secure unit/device to maintain resident safety -Evaluate need of secured unit, notify medical provider as needed. -Notify medical provider, resident representative of behavior changes. -Notify staff of elopement risk. -Obtain a current photograph and list of identifiable characteristics, and place in the elopement risk identification book. -Provide diversionary activities as needed. Redirect when appropriate. -Provide structured activities as times of increased elopement risk, diversional tasks, redirection of ambulation pattern, and utilization of safe wandering areas. -Q one-hour checks to be completed x 3-day duration. Further record review found the intervention for Q one (1) hour checks to be completed X(times) three (3) day duration was initiated on 07/09/24. The MAR(medication administration record) for that time frame was documented to having checks every hour for three (3) days. An interview with the Director of Nursing (DON) was completed on 01/23/25 at approximately 1:00 PM. When asked if Q one-hour checks should completed for a 3 day duration still be listed in the current care plan the DON stated, it should not. The DON Confirmed after three (3) days the care plan was not revised/updated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to ensure they provided an ongoing program of activities of support the needs of each resident. One resident (1) did not have an Activity Preference Assessment (ADA) within in seven (7) Days of Admission. This was a random opportunity for discovery during the long-term care survey process. Resident identifier: #368. Facility census: 113. Findings include: a) Resident #368 On 01/27/25 at 01:07 PM during record review it was revealed that Resident #368 was admitted on [DATE]. The activity preference interview was not completed till 11/11/24 On 01/27/25 at approximately 1:30 PM the Director of Nursing (DON) provided a paper stating, When UDA should be completed/How UDA will trigger. On the list it revealed the Activity preference interview triggers to be completed by day seven (7) after admission/re-admission then annually. On 01/27/25 at 2:05 PM the Activity Director (AD) acknowledged the assessment should have been done by day seven (7).

Based on observation, record review, and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. A medication dosage was not specified in a physician's order for Resident #42. A physician's order for no straws was not followed for Resident #88. This deficient practice had the potential to affect two (2) of 36 residents reviewed in the long-term care survey sample. Resident identifiers: #42 and #36. Facility census: 120. Findings included: a) Resident #42 On 01/22/25 at 9:31 AM, Licensed Practical Nurse (LPN) #21 was observed administering medications to Resident #42. One of the medications given to Resident #42 was Vitamin D3 1000 international units (IU) or 25 micrograms (mcg). The Vitamin D3 tablet was dispensed from a floor stock bottle of Vitamin D3 located in the medication cart. Review of Resident #42's physician's orders showed an order written on 01/11/25 for Vitamin D3 oral tablet (cholecalciferol) Give 1 tablet by mouth one time a day for vitamins. The dosage of the medication to be given was not specified. On 01/22/25, the Director of Nursing confirmed the physician's order for Resident #42's Vitamin D3 did not specify the dosage to be given. No further information was provided through the completion of the survey. b) Resident #88 Review of Resident #88's physician's orders showed an order written on 11/29/24 for Regular diet, dysphagia advanced texture, thin liquids consistency, double entree portions, no straws. On 01/27/25 at 1:05 PM, Resident #88 was observed sitting in a wheelchair in the lounge with his lunch tray on an overbed table. The lunch tray ticket stated, No straws. There were no straws on his lunch tray. However, a large Styrofoam cup with a straw was also on the overbed table. This was a Styrofoam cup the facility used to give fluids to residents. Medical Records Worker #25 was the closest staff member and was alerted by the surveyor that Resident #88 had a straw in his beverage cup despite a physician's order not to have one. Medical Records Worker #25 confirmed Resident #88's tray ticket stated the resident was not to have a straw. She removed the straw from the resident's cup with his permission. On 01/27/25, Resident #88's diet order was changed and the instruction no straws was removed from the order. On 01/28/25 at 1:52 PM, Speech Therapist #109 was interviewed. She stated Resident #88 was safe to have straws. No further information was provided through the completion of the survey process.

Based on record review and staff interview the facility failed to provide necessary behavioral health care and services to attain or maintain the highest practicable physical, mental and psychocial well-being. This failed practice was found true for (1) one of (2) two residents reviewed for mood/behavior during the Long-Term Care Survey Process. Resident identifier: #99. Facility census: 120. Findings Include: a) Resident #99 A record review on 01/21/25 at 10:00 AM, revealed that Resident #99 had diagnoses that included the following: Dementia with mood disturbance Dementia with anxiety Generalized anxiety disorder Major Depressive disorder, Recurrent severe with psychotic features Further record review of Resident #99's, Behavior Monitoring and Interventions report, revealed that from 10/01/24 to present Resident 99 had 15 days that he was marked for behaviors. Further record review of Resident #99's Behavior notes from nursing reveal an additional 13 behavior notes since 10/01/24. A record review on 01/27/24 at 10:00 PM, revealed a Care plan for Resident #99 that reads as follows: Focus: At risk for impaired psychosocial wellbeing related to history of physical trauma related to falls resulting in major injury and will refuse Vital Signs, refused shower, become verbally and physically aggressive at times. Goal: The resident will verbalize a maintained/improved psychosocial wellbeing as evidenced by the elimination and/or mitigation of triggers that may cause re-traumatization through next review date. Interventions: Approach the provision of care and services for those residents with history of trauma with dignity and respect. Consideration should be given to methods of assistance given to resident such as: Same sex care giver Removal of clothing slowly Remove from areas. Further record review of the medcial record for Resident #99 revealed no Psychiatric Consultations in the medcial record. During an interview on 01/27/25 10:11 AM Interview with DON stated, (Facility Psych Services named) has not seen him. I will see about getting him an appointment. A record review on 01/27/24 at 10:45 AM, revealed that Resident #99 had no social service notes, other than care plan notes. None of the care plan notes addressed how they are helping Resident #99 with his behaviors and psychiatric issues. During an interview on 01/27/25 at 11:40 AM, The Licensed Social Worker (LSW) #62 stated, He likes to get up and walk around the nurses station. He does get physically aggressive. Everyday he is verbally aggressive. The State Agency (SA) asked, What interventions are we doing to help with his aggressive behavior? LSW #62 replied, My office is right beside the nurses station. I usually go out and redirect him to sit down. The LSW confirmed that Resident #99 had no personal interventions and that he had not had a Psych appointment since admission.

Based on record review and staff interview the facility failed to provide medically related social services necessary to attain or maintain the highest practicable physical, mental and psychocial well-being. This failed practice was found true for (1) one of (2) two residents reviewed for mood/behavior during the Long-Term Care Survey Process. Resident identifier: #99. Facility Census: 120. Findings Include: a) Resident #99 A record review on 01/21/25 at 10:00 AM, revealed that Resident #99 had diagnoses that include the following: Dementia with mood disturbance Dementia with anxiety Generalized anxiety disorder Major Depressive disorder, Recurrent severe with psychotic features Further record review of Resident #99's, Behavior Monitoring and Interventions report, revealed that from 10/01/24 to present Resident #99 had 15 days marked for behaviors. Further record review of Resident #99's Behavior notes from nursing revealed an additional 13 behavior notes since 10/01/24. A record review on 01/27/24 at 10:00 PM, revealed a Care plan for Resident #99 that read as follows: Focus: At risk for impaired psychosocial wellbeing related to history of physical trauma related to falls resulting in major injury and will refuse Vital Signs, refused shower, become verbally and physically aggressive at times. Goal: The resident will verbalize a maintained/improved psychosocial wellbeing as evidenced by the elimination and/or mitigation of triggers that may cause re-traumatization through next review date. Interventions: Approach the provision of care and services for those residents with history of trauma with dignity and respect. Consideration should be given to methods of assistance given to resident such as: Same sex care giver Removal of clothing slowly Remove from areas. Further record review of the medcial record for Resident #99 revealed no Psychiatric Consultations in the medcial record. During an interview on 01/27/25 10:11 AM Interview with DON stated, (Facility Psych Services named) hah not seen him. I will see about getting him an appointment. A record review on 01/27/24 at 10:45 AM, revealed that Resident #99 had no social service notes, other than care plan notes. None of the care plan notes addressed how they are helping Resident #99 with his behaviors and psychiatric issues. During an interview on 01/27/25 at 11:40 AM, The Licensed Social Worker (LSW) #62 stated, He likes to get up and walk around the nurses station. He does get physically aggressive. Everyday he is verbally aggressive. The State Agency (SA) asked, What interventions are we doing to help with his aggressive behavior? LSW #62 replied, My office is right beside the nurses station. I usually go out and redirect him to sit down. The LSW confirmed that Resident #99 had no personal interventions and that he had not had a Psych appointment since admission.

Based on observation, record review and staff interview, the facility failed to ensure residents were free from significant medication errors. This deficient practice had the potential to affect (1) of four (4) residents reviewed during the medication administration facility task. Resident identifier: #73. Facility census: 120. Findings included: a) Policy Review The facility's policy titled Medication Administration with approval effective date 12/02/24 gave the following procedure: - Read medication label three (3) times before administering medication - First, when pulling the medication from the drawer - Second, when comparing label to MAR [Medication Administration Record] - Third, when preparing to administer the medication b) Resident #73 On 01/22/25 at 8:48 AM, observation was made of Licensed Practical Nurse (LPN) #20 administering medications to Resident #73. Resident #73's medications were dispensed by pharmacy in three (3) plastic packets. One plastic packet was labeled to contain the following medications: - Aripiprazole, 5 milligrams (mg) - Citalopram Hydrobromide, 10 mg - Divalproex Sodium, 500 mg Another plastic packet was labeled to contain the following medications: - Furosemide, 40 mg - Lisinopril, 2.5 mg - Metoprolol Succinate, 25 mg - Pantoprazole Sodium, 40 mg The third plastic packet was labeled to contain the following medications: - Risperidone, 1 mg - Metformin HCl, 1000 mg LPN #20 reviewed Resident #73's Medication Administration Record (MAR) on the medication cart computer and made sure each medication to be administered was in one of the plastic packets from pharmacy. She then administered all the medications contained in the three (3) packets to Resident #73. Review of Resident #73's physician's orders showed no current orders for Aripiprazole (Abilify). Further review of the resident's physician's orders showed the resident had previously been prescribed Aripiprazole, an antipsychotic medication, for schizoaffective disorder. The resident was prescribed Aripiprazole 5 mg daily on 10/12/24. An order had written on 11/26/24 to decrease Aripiprazole to 2.5 mg every day for seven (7) days and then discontinue the medication. The resident's MAR did not contain an order for Aripiprazole. Further review of Resident #73's medical records showed a psychotropic medication evaluation was held by the Pharmacy and Therapeutics Committee on 11/26/24. During this meeting, the decision was made to perform a Gradual Dose Reduction (GDR) of Resident #73's Aripiprazole. On 01/22/25 at 10:25 AM, the packets for Resident #73's medications to be administered on the morning of 01/23/25 were reviewed. One of the packets was labeled to contain Aripiprazole 5 mg. The pill was described on the packet as a blue, rectangular pill. A blue, rectangular pill was contained in the packet. On 01/22/25 at 11:47 AM, the Director of Nursing (DON) confirmed Resident #73 physician's orders did not contain a current order for Aripiprazole. She stated she would call the pharmacy to determine why the medication was dispensed. On 01/22/25 at 3:26 PM, the DON stated she had spoken to the pharmacy. The pharmacy had stated they had made an error when they received the order on 11/26/25 to reduce and then discontinue the medication and had not carried out the order. However, the DON acknowledged LPN #20 should have checked each medication in the packets with the MAR and not administered the Aripiprazole because there was no current order for it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record reviews and staff interview's the facility failed to ensure residents were provided with needed dental services. This failed practice was found true for one (1) of four (4) residents reviewed for dental services during the Long-Term Care Survey process. Resident identifier: #55. Facility census: 120. Findings include: a) Resident #55 During an interview with Resident #55 on 01/21/25 at 09:38 AM the resident stated, Don't have upper dentures because it is too expensive for dentures and to have any teeth pulled. Resident #55 went on to state, I am having some pain with my bottom teeth, sometimes it's hard to chew. Record review on 01/22/25, at 2:13 PM, showed the admission [NAME] Data Set (MDS) on 09/19/24 had yes marked for question F} mouth facial pain, or difficulty chewing. On 11/22/24 the administrator was present with the surveyor when Resident #55 stated she had teeth pain and she had not been talked to about coverage for residents in the nursing home. She also said no one had talked to her about dentures. The Administrator informed Resident #55 they could take care of whatever issues she had and get her into a dentist and possibly get dentures.

Based on observation, staff interview and resident interview the facility failed to serve food at palatable temperatures. This was a random opportunity for discovery during the Long-Term Care Survey Process. Resident identifier #29. Facility census: 120. Findings include: a) Resident #29 During an observation on 01/22/25 at 12:55 PM, Resident #29 was served a lunch tray. The light was turned on in his room. The tray was set on his bedside table and the lid was taken off. Resident was asleep. Constant observation from 12:55 PM to 1:50 PM showed that no staff members entered Resident #29's room and that Resident #29 continued to be asleep. At 2:10 PM a Nursing assistant (NA) entered Resident #99's room. During an interview on 01/22/25 at 1:50 PM, NA #49 stated, We usually leave them in there for about an hour if they don't eat. I was getting ready to take his. At this time Resident #29 woke up and said I am hungry. He grabbed the butter knife out of his bag and stuck it in his dessert. With the SA in the room NA #49 gave him a spoon. An observation on 01/22/25 at 2:30 PM, revealed that Resident #29 had eaten most of his food. During an interview on 01/22/25 at 2:30 PM, Resident #29 stated, I ate the shit, It was cold. During an interview on 01/22/25 at 2:33 PM, NA #49 stated, No, I did not heat up his tray before he ate it.

Based on observation, resident interview, record review, and staff interview, the facility failed to provide ordered assistive eating devices. This was a random opportunity for discovery. Resident identifier: #51. Facility census: 120. Findings included: a) Resident #51 Resident #51 was observed in his bed on 01/20/25 at 1:33 PM and was noted to have food on his clothing. His lunch tray was on the bedside table in front of him. There was also food on the bedside table. His plate did not have a plate guard. Review of Resident #51's physician's orders showed an order written on 01/06/25 for regular diet, dysphagia advanced texture, thin liquids consistency, regular utensils and plate guard. The resident had a diagnosis of contracture to his right hand, which was his dominant hand. On 01/22/25 at 12:50 PM, Resident #51 was observed eating in his bed from the tray on his bedside table. His meal ticket stated he was to have ground roast turkey, poultry gravy, cornbread dressing, honey roasted carrots, buttered dinner roll/bread, margarine, brown sugar glazed angel food cake, and a plate guard. He did not have a plate guard. When questioned, Resident #51 stated he was sometimes given a plate guard, and it helps him feed himself a little bit. Therapist #114 confirmed Resident #51 did not have a plate guard as ordered. She stated she would get one for him. No further information was provided through the completion of the survey process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interviews, the facility failed to accurately record the DNR status of Resident #32, in the electronic medical record. This was a random opportunity for discovery. Resident identifier: #32. Facility census: 120. Findings include: a) Resident #32 Resident #32's POST form signed and dated on [DATE] was for Do Not Resuscitate (DNR) with Selective Treatments. The physician orders and dashboard in the electronic health care record and document CPR. During a staff interview with LPN #21, she was asked where she would look to find the resident's lifesaving preferences. She stated either the POST form or the dashboard in the medical record. Record review revealed the dashboard, and the POST form do not match. On [DATE] at 10:56 AM, an interview with Unit Charge LPN #21 was held. The LPN was asked the question, If residents were to be found not breathing, how would you know what care to provide, i.e. CPR or DNR? LPN #21 stated since she does some of the admissions, she knew which one most of the residents have selected. LPN #21 said if she was logged into the computer system, she would either go to the miscellaneous tab to see the POST form, or she would look at the dashboard.

Based on observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure Enhanced Barrier Precautions (EBP) were appropriately initiated. This was a random opportunity for discovery. The facility also failed to ensure appropriate hand hygiene was performed during pressure ulcer dressing changes for one (1) of one (1) residents observed for pressure ulcer dressing changes. Resident identifiers: #51 and #31. Facility census: 120. Findings included: a) Policy Review - Enhanced Barrier Precautions The facility's policy and standard procedure titled Enhanced Barrier Precautions with approval effective date 04/01/24 stated Enhanced Barrier Precautions (EBP) are indicated for residents with indwelling medical devices, including urinary catheter. A sign was to be posted on the resident door to indicate EBP was required. b) Resident #51 On 01/20/25, Resident #51 was noted to have an indwelling urinary catheter. He did not have a sign on his door to indicate Enhanced Barrier Precautions (EBP) were required. No personal protective equipment (PPE) was available at his doorway, but PPE was available elsewhere in the hallway. A review of the resident's physician's orders did not reveal an order for EBP. On 01/20/25 at 2:06 PM, Licensed Practical Nurse (LPN) #82 confirmed Resident #51 should have EBP due to his indwelling urinary catheter. She stated she would get signage and PPE for the resident's door. No further information was provided through the completion of the survey process. c) Resident #31 On 01/28/25 at 9:20 AM, Resident #31's pressure ulcer dressing changes were observed as performed by Registered Nurse (RN) #75. RN #75 started by performing hand hygiene and donning gloves. She removed the dressing from Resident #31's upper back pressure ulcer. She cleaned the wound with wound cleanser. The wound was bleeding. RN #75 changed gloves but did not perform hand hygiene. She applied medical-grade honey and dressing to the resident's upper back pressure ulcer. RN #75 proceeded to the resident's posterior thigh, sacrum, and left buttocks wound. She did not change gloves or perform hand hygiene before removing the dressing and cleaning the area. She then changed gloves but did not perform hand hygiene. She applied Dakin's solution and gauze to the posterior thigh and sacral area of the wound. She applied medical-grade honey to the left buttock area of the wound. RN #57 proceeded to the resident's left lower extremity. She changed gloves but did not perform hand hygiene. She removed the dressing to the resident's left foot. She cleansed the left outer ankle with wound cleanser and applied betadine. She changed gloves and cleansed the left lateral lower leg with wound cleanser. She changed gloves and applied medical-grade honey and a dressing. RN #57 proceeded to the resident's right foot. She changed gloves but did not perform hand hygiene. She cleansed the resident's right foot pressure ulcers with wound cleanser. She changed gloves but did not perform hand hygiene. She applied Dakin's solution and wrapped the area in Kerlix. At no time during the dressing changes did RN #57 perform hand hygiene, although she did apply clean gloves several times as stated above. On 01/28/25 at 10:02 AM, the Director of Nursing (DON) acknowledged hand hygiene was indicated during pressure ulcer dressing changes, particularly when moving between different pressure ulcer sites. No further information was provided through the completion of the survey process.

b) Resident #56 An observation on 01/22/25 at 11:00 PM, revealed a bottle of Povidone Iodine Prep Solution setting on the dresser in Resident #56's room. During an interview on 01/22/25 at 11:00 PM, Resident #56 stated, They leave all kinds of stuff in here. An observation on 01/22/25 at 11:10 PM, with the Director of Nursing (DON) revealed that Resident #56's room door was shut. The state agency (SA) knocked on the door. A Nursing Assistant (NA) came to the door and stated, We are doing wound care. Give us just a few minutes. During an observation, and interview on 01/22/25 at 11:25 PM, the DON in Resident #56's room showed that the Povidone Iodine Prep Solution was no longer on the dresser. The DON opened the dresser drawers and found the solution in the drawer with 6 bottles of skin prep solution and several unwrapped gauze pads. The DON confirmed that the items should not be in Resident #56's room. c) Material Safety Data Sheet (MSDS) A review of the MSDS for the Povidone Iodine Prep Solution on 01/22/25 at 12:10 PM, under Section 2 {Hazards Identification} reads as follows: Causes eye irritation. May be harmful if swallowed. May be harmful if contact with skin. Call a posion control center/doctor if you feel unwell. Based on observation, record review and staff interview, the facility failed to ensure the resident environment was as free of accident hazards as possible for Residents #47, #56, and #71. These were random opportunities for discovery. Resident identifiers: #47, #56, and #71. Facility census: 120. Findings include: a) Resident #47 Observations made At approximately 1:18 PM on 01/20/25, 2:00 PM on 01/21/2025, and 3:30 PM on 01/22/2025, Resident #47's over the bed table was observed sitting on the fall mat to the left side of his bed. The over the bed table was placed diagonally, from the top of the fall mat, in a way that exposed the metal bottom, and wheels, of the table, leaving the resident open to landing on them if he were to fall out of bed. Licensed Practical Nurse (LPN) #97 acknowledged the table on the fall mat at approximately 3:35 PM on 01/22/2025 and stated the table is usually always on the mat because the resident reaches over and gets his water off of the table. At approximately 4:00 PM, on 01/22/2025, an interview was conducted with the Director of Nursing (DON) and Administrator. During the interview, it was determined the facility had not tried any alternative fall interventions for the resident to make the water more accessible without placing the table on the fall mat. d) Resident #71 Record review on 11/22/25 review of Resident #71's care plan revealed the following Focus ~Gerald has experienced an actual fall in facility, risk for falls related to weakness, cognition, medications and incontinence, previous falls. Goal Resident will not sustain major injury related to falls through review date. Interventions -apply abdominal binder as needed to prevent resident from pulling on tube. -FALL RISK : Defined perimeter mattress to bed to help patient identify edges of bed. -FALL RISK: Fall mats to (both sides) of bed while in bed to help prevent injury. -FALL RISK: Keep bed in lowest position except when providing care. - Gerichair -Hipsters to be worn at all times -Hourly checks while in bed -Physician to review for unusual behavior. -Q1h(Every Hour) incontinence checks. -Weighted blanket while in bed to provide comfort. Observations On 11/21/24 at 1:20 PM surveyor observed Resident #71 in bed with the bed in lowest position, no weighted blanket was on Resident #71 and there was no fall mat on the Left side of the bed ( The fall mat was slid between the wall and closet). Further observations on 11/22/24 at approximately 2:00 PM resident #71 remained in bed this time legs were off the right side of the bed and the fall mat was not in the left side of the bed, the weighted blanket was not on Resident #71, and no hipsters were on Resident #71. During an interview with the Director of Nursing (DON) on 11/22/24 at approximately 3:00 PM in the room with Resident #71, the DON confirmed the left side floor mat was not beside the bed, the resident did not have hipsters on, however at this time DON confirmed the weighted blanket was on the resident. The surveyor also noted the weighted blanket was on Resident #71 that previously was not on him. Which showed staff came into room and did not place the fall mat back to the left side of the resident's bed and did not ensure the hipsters was on Resident #71. Resident #71, was care planted to have these items in place as fall interventions to prevent injury incase of a fall.

Based on record review, resident interview and staff interview the facility failed to monitor the effectiveness of pain medications in accordance with professional standards of practice. This failed practice was found true for (1) one of (7) seven residents reviewed for pain during the Long-Term Care Survey Process. Resident identifier: #31. Facility census: 120. Findings Include: a) Resident #31 During an interview on 01/28/24 at 9:15 AM, Resident #31 stated, I hurt all the time. They are waiting on something from the pharmacy. A record review on 01/28/24 of Resident #31's current orders revealed an order for Oxycodone-Acetaminophen oral tablet 5-325 to give (1) one tablet by mouth every (8) eight hours as needed for pain. The order had a start date of 11/04/24. Further record review of Resident #31's Medication Administration Reports (MAR's) for the months of 11/2024, 12/2024, and 01/2025 revealed that Resident #31 was given the Oxycodone-Acetaminophen (5) five times without checking the effectiveness of the medication. During an interview on 01/28/24 at 2:00 PM the DON confirmed that the effectiveness of the pain medicine was not monitored according to the MAR.

Based on observation, record review, and staff interview, the facility failed to store and label medications in accordance with professional standards of care. Multiuse vials of insulin had not been dated when opened. Additionally, multiuse vials of insulin had not been discarded 28 days after opening. These were random opportunities for discovery. Resident identifiers: #83, #85, #80, #62, #51, #61, and #57. Facility census: 120. Findings included: a) Policy review The facility's policy titled Vials and Ampules of Injectable Medications stated as follows: Expiration Dates: Unopened vials expire on the manufacturer's expiration date. When a vial is opened, the nurse records the opened date on the vial. Since opening a vial triggers a shortened expiration date that is unique for that vial, the nurse may record the expiration date on the vial. Triggered expiration dates may be found on the manufacture's [sic] package insert, on the package, or on a reference chart by pharmacy, or by contacting the pharmacist. b) A2 Hallway Cart On 01/22/25 at 9:10 AM, inspection of the A2 hallway medication cart was made with Licensed Practical Nurse (LPN) #20 in attendance. In the cart was a multi-use vial of aspart insulin for Resident #83. The vial had not been dated when first accessed. The vial was delivered by the pharmacy on 01/20/25. LPN #20 confirmed the vial had not been dated when opened. Review of Resident #83's physician's orders showed the resident was still receiving this medication. Also in the cart was a multi-use vial of Lantus insulin for Resident #61. The vial had a handwritten opening date of 11/21/24 and a handwritten expiration date of 12/22/24. This was confirmed by LPN #20. No packaging insert was in the insulin box. The Lantus insulin package insert available on the Food and Drug Administration (FDA) Website stated multi-use vials can be used for 28 days after opening. Review of Resident #61's physician's orders showed the resident was still receiving this medication. Also in the cart was a multi-use vial of Novolog insulin for Resident #61. The vial had a handwritten opening date of 11/24/24 and a handwritten expiration date of 12/[illegible]/24. This was confirmed by LPN #20. No packaging insert was in the insulin box. The Novolog insulin package insert available on the Food and Drug Administration (FDA) Website stated multi-use vials of Novolog may be kept for up to 28 days after use. Review of Resident #61's physician's orders showed the resident was still receiving this medication. Also in the cart was a multi-use vial of Novolog insulin for Resident #51. The vial had a handwritten opening date of 12/14/24 and a handwritten expiration date of 01/13/25. This was confirmed by LPN #20. No packaging insert was in the insulin box. Review of Resident #51's physician's orders showed the resident was still receiving this medication. Also in the cart was a multi-use vial of Novolog insulin for Resident #57. The vial had a handwritten opening date of 12/16/24 and a handwritten expiration date of 01/13/25. This was confirmed by LPN #20. No packaging insert was in the insulin box. Review of Resident #57's physician's orders showed the resident was still receiving this medication. c) B1 Hallway Cart On 01/22/25 at 9:10 AM, inspection of the B1 hallway medication cart was made with Licensed Practical Nurse (LPN) #21 in attendance. In the cart was a multi-use vial of aspart insulin for Resident #85. The vial had not been dated when first accessed. The vial was delivered by the pharmacy on 12/30/24. LPN #21 confirmed the vial had not been dated when opened. Review of Resident #85's physician's orders showed the resident was still receiving this medication. Also in the cart was a multi-use vial of Lantus insulin for Resident #85. The vial had a handwritten opening date of 12/19/24 and a handwritten expiration date of 01/18/25. This was confirmed by LPN #21. No packaging insert was in the insulin box. The Lantus insulin package insert available on the Food and Drug Administration (FDA) Website stated multi-use vials of Lantus can be used for 28 days after opening. Review of Resident #85's physician's orders showed the resident was still receiving this medication. Also in the cart was a multi-use vial of Lantus insulin for Resident #62. The vial had a handwritten opening date of 12/05/24 and a handwritten expiration date of 01/04/25. This was confirmed by LPN #21. No packaging insert was in the insulin box. Review of Resident #62's physician's orders showed the resident was still receiving this medication. Also in the cart was a multi-use vial of Lantus insulin for Resident #80. The vial had a handwritten opening date of 11/24/24 and a handwritten expiration date of 12/24/24. This was confirmed by LPN #21. No packaging insert was in the insulin box. Review of Resident #80's physician's orders showed the resident was still receiving this medication. No further information was provided through the completion of the survey process.

Based on observation and record review the facility failed to ensure food is prepared in a form designed to meet the individual needs of each resident. This was a random opportunity for discovery and has the potential to affect more than a limited number of residents. Resident identifiers: #37, #47, #76, #51, #29, #79, #98, and #88. Facility Census: 113. Findings Include: a) On 01/27/25 at 12:37 PM during the noontime meal service it was noted the facility was serving kielbasa sausage. At 12:37 PM on 01/27/25 Employee #162 the district food manager (DFM) was overheard asking [NAME] #146 if she had ground kielbasa. She replied, no. She indicated she thought the kielbasa meet the requirement for the mechanical and advanced diets. Employee #162 advised [NAME] #146 that it needed to be ground. By this point in service the entire A unit of the facility had been served. Employee #162 DFM then indicated to the Dietary Manager (DM) they had run out of ground kielbasa. It was at this time [NAME] #146 was asked by the surveyor if she had ran out of ground kielbasa or had not prepared any. She stated, I did not prepare any. I did not know it needed to ground. A review of the Consistency Census Report provided by the DM found the following residents on A unit should have been served ground kielbasa, Resident #47, #76, #51, #29, #79, #98, #88, and #113. A review of the Kielbasa recipe provided by the facility and used by the facility to prepare the food found the following, .1. For Ground: Measure the desired # (number) of servings into food processor. Grind to appropriate consistency. If needed add gravy or broth to moisten the meat. An interview with the Nursing Home Administrator (NHA) at approximately 1:15 PM on 01/27/25 she confirmed there was a mix up in the kitchen. She stated, I thought we caught them all and replaced them before they reached the residents. When advised that only A unit tray which was replaced while the surveyor was conducting her observation was Resident #47. She stated, I checked on them. The only two who I am not sure of was (First name of Resident #98) and (First Name of Resident #76). Nurse Aide (NA) #19 was then asked by the NHA in the presence of the surveyor what king of meat Resident #76 had on his tray. NA #19 stated the meat was big pieces. She stated we have taken it to the kitchen like that before and they told us it was okay as long as it had gravy on it. b) Resident #37 An observation on 01/20/25 at 1:15 PM revealed that Resident #37 was served a pork chop in its whole form. Further Observation of Resident # 37 eating her lunch meal, showed that she had a right-hand contracture, and she was struggling to eat her pork chop in its whole form. A record review on 01/20/25 at 1:45 PM, of Resident #37's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/02/24, Section S, question S3100A revealed that Resident #37 had a right-hand contracture. Section S, question S3200A indicates that Resident #37's dominant side is the right side. An observation on 01/20/25 at 2:00 PM revealed that Resident #37 did not eat her meat. During an interview on 01/20/25 at 2:00 PM, the State Agency (SA) asked Resident # 37, How come you did not eat your meat. Resident #37 was Aphasic and pointed toward her meat and made a cutting motion and shook her head no. An observation on 01/22/25at 1:10 PM, of Resident #37 eating her lunch, revealed that she was served a turkey slice in its whole form. Further observation showed that Resident #37 did not eat her turkey. During an interview ON 01/22/25 AT 2:00 PM, the administrator confirmed that Resident #37 had a right-hand contracture and could use help cutting up her meat.

Based on observation and staff interview, the facility failed to ensure the ice machines in the A and B hall pantries were clean and sanitary. In addition, the microwave in the B-hall nutrition pantry was rusted. This failed practice had the potential effect more than an isolated number of residents. Facility Census: 120. Findings Include: a) A and B hall pantries During an observation of the A hall pantry at 11:10 am on 01/20/25, found the ice machine was not clean. The grate were the cups or containers would sit was covered in white scaly substance. The certified dietary manager (CDM) removed the grate and under the grate there was an accumulation of water and a brown slimy like substance. The CDM agreed the ice machine needed to be cleaned. During an observation of the B hall pantry at 11:15 am on 01/20/25, found the ice machine was not clean. The grate where the cups or containers would sit to be filled with ice was covered in a white scaly substance. The CDM removed the grate and under the grate there was an accumulation of water and a brown slimy like substance. The CDM agreed the ice machine needed to be cleaned. Also, in the B hall pantry there was a microwave which was rusting. The CDM agreed the microwave needed replacement.

Based on record review and staff interview, the facility failed to make good faith attempts to correct quality deficiencies related to complete and thorough investigations, despite being cited multiple times in the past and identifying issues related to the investigations. This has the potential to affect more than a limited number of residents. Facility census: 120. Findings include: a) Current survey At approximately 1:00 PM on 01/28/2025, a review was conducted of a facility reported incident involving Resident #319. This incident alleged Resident #319 was the victim of abuse/neglect at the facility. The residents interviewed by the facility were described as like residents meaning they were in similar condition to Resident #319. In reviewing the statements, the facility interviewed Residents #320, #46, #50, #54, #40, and #8. All the statements taken from the residents, except the one from Resident #46 were not dated and did not state who the employee was that took the statements. One statement, had the name of Resident #46 at the top of the form, as the person giving the statement, however, it was signed by Resident #8. In the initial report, dated 09/24/2024 at 12:45 PM, Social Worker (SW) #62 documented Resident interviewed and investigation began. However, no statement from Resident #319 was found. At approximately 2:30 PM on 01/28/2025, an interview was conducted with SW #62, with the Administrator in attendance, regarding the incomplete statements from the various residents and the missing statement from Resident #319. SW #62 and the administrator acknowledged the statements not being dated, and the statement identifying Resident #46 as the resident giving the statement but being signed by Resident #8. When SW #62 was asked where the statement from Resident #319 was, that was mentioned in the initial report, he stated I briefly spoke with him, I remember I asked him if he was ok, and he nodded. I wouldn't have taken a statement at that time because I hadn't started the investigation yet. However, upon further review, it was determined Resident #319 was not in the facility at the time SW #62 stated he interviewed the resident, as he was sent out to the hospital a day prior, on 09/28/24. SW #62 stated the initial report should have stated he spoke with the resident's representative. b) Past surveys Upon review of deficiencies from past surveys, dating back to the facility's prior annual survey on 08/22/23, it was determined the facility had been surveyed four (4) times prior to this survey. Of those four (4) times, the facility was cited for failing to thoroughly investigate allegations three (3) times. The dates the facility was cited for failing to complete thorough investigations are: -08/22/2023 -01/31/2024 -05/07/2024 c) Administrator Interview At approximately 3:00 PM on 01/28/2025, an interview was conducted with the Administrator regarding the facility's Quality Assurance and Performance Improvement (QAPI) process. During the interview, the Administrator stated the facility was aware of issues with investigations being completed thoroughly. The Administrator stated she realized she needed to be more involved in investigations taking place in the facility due to issues being identified. However, the same issues remained during the current survey.

Based on staff interview and record review the facility failed to ensure two (2) of five 5 residents resident received treatment as ordered by their physician. The facility failed to follow physician's orders for wound treatments for Resident #54 and #66. Resident identifiers: #54 and #66. Facility Census: 104. Findings included: a) Resident #66 On 06/11/2024 at approximately 11:00 AM during a medical record review for Resident #66, it was identified with reviewing the Treatment Administration Record (TAR) that the physician's orders were not followed daily for the following days and treatments. 05/15/25 - Wound care: cleanse left posterior thigh with wound cleanser; dry, apply calcium alginate and foam dressing daily and as needed daily on day shift for wound healing (written as ordered). Order not completed. 05/07/24- Oxygen at two (2) via nasal cannula (NC) every shift (written as ordered). The night shift order was not completed. 05/07/24- Sacral Ulcer Stage IV apply silver alginate in wound covered by sacral foam dressing each shift. every day and night shift for sacral ulcer Stage IV (written as ordered). Day shift order was not completed. On 06/11/2024 at 11:33 PM during an interview with the Director of Nursing (DON) she stated that she had reviewed the treatments, and she agreed the treatments had not been completed. She further stated that she was unable to identify why the treatments were not completed. b) Resident #54 On 06/11/24 at 3:00 PM, a record review was completed for Resident #54. The review found the treatment orders on the June 2024 treatment administration record (TAR) had no documentation for the following: --06/02/24 Cleanse pressure to right buttocks with Dakins solution 0.125% and dry. Apply Dakins moistened gauze and adaptic to wound bed and cover with ABD (abdominal) pad and foam dressing daily and as needed --06/02/24 Cleanse pressure to sacrum with Dakins solution 0.125% and dry. Apply Dakins moistened gauze to wound bed and cover with ABD pad and foam dressing daily and as needed --06/02/24 Triamcinolone Acetonide External Cream 1% Apply to BLE (bilateral lower extremities) and right hip topically every night shift for rash --06/02/24 Wound care: Cleanse pressure to left buttocks with Dakins solution 0.125% and dry. Apply Dakins moistened gauze to wound bed and cover with ABD pad and foam dressing daily and as needed --06/02/24 Wound care: Cleanse Vascular wounds to left lower extremity with soap and water, pat dry, apply Triamcinolone cream and Xerofoam, wrap with kerlix daily. --06/02/24 Wound care: Cleanse Vascular wounds to right lower extremity and right hip with soap and water, pat dry, apply Triamcinolone cream and Xerofoam, wrap with kerlix daily. On 06/12/24 at 4:00 PM, the Director of Nursing (DON) was notified of the blank spaces on the June 2024 TAR. The DON confirmed there was no documentation found for the 06/02/24 date. The DON stated, they didn't document it.

c) Resident #37 During a tour of the building on 06/10/24 at 06:08 PM in Room #B3, Resident #37 was noted to have a breakfast meal tray sitting on the side of her sink. The tray appeared to have been eaten from with remnants of food remaining. On 06/10/24 at approximately 6:10 PM, during an interview with the Assistant Director of Nursing (ADON) #81, she stated Resident #37 was known to be a slow eater but there was no reason why the used tray should still be in her room at this time. The ADON acknowledged the infection control concern with leaving the residents breakfast tray accessible. Based on observation, record review and staff interview, the facility failed to maintain appropriate infection control standards for foley catheter care storage and/or disposal of a bed pan and timely removal of a meal tray. These were random opportunities for discovery. Resident identifier: #8, #37. Room identifier: #A19. Facility Census: 104. Findings included: a) Resident #8 On 06/11/24 at 10:30 AM, foley catheter care was observed which was performed by Nurse Aide (NA) #32. While performing the care, NA #32 placed soiled linen directly on the floor. Upon completion of the foley catheter care, NA #32 was emptying the urinary drainage bag. NA #32 did not place a barrier between the graduated cylinder and the floor. When NA #32 had completed emptying the urinary drainage bag, a wet substance was observed on the floor. NA #32 was asked, what is the wet substance on the floor? NA #32 stated, it's urine .I should have put something on the floor. On 06/11/24 at 10:48 AM, the Director of Nursing (DON) was notified of the infection control breaches regarding the lack of using barriers for the soiled linen and the emptying of the graduated cylinder. b) Room A19 On 06/10/24 at 6:21 PM, an observation of a bariatric bed pan leaning on top of the bathroom trash can was made. The bariatric bed pan was not labeled or stored in an appropriate manner. On 06/10/24 at approximately 6:23 PM, Licensed Practical Nurse (LPN) #112 was asked, do you know whose bed pan this is? LPN #112 stated, I don't know let me get an aide. On 06/10/24 at 6:27 PM, NA #34 entered the residents' room. NA #34 was asked, do you know whose bed pan this is? NA #34 stated, I just started my shift .I'm not sure who the bed pan belongs to .but I will get rid of it. On 06/11/24 at 11:33 AM, the DON was notified of the bariatric bed pan leaning on top of the bathroom trash can. The DON acknowledged the bed pan should be labeled and stored correctly.

Based on observation and staff interviews, the facility failed to provide reasonable accommodation in regards to a call light being out of reach. This was a random opportunity for discovery. Resident Identifiers: #1 and #65. Facility Census: 107 Findings included: a) Resident # 1 An observation and interview on 05/07/24 at 9:58 AM, with Resident #1 found the resident lying in her bed without a call light in sight. Upon being asked about her pain level, and how she would notify staff if she needed assistance, the Resident stated that she would use her call light, but couldn't locate it. The call light was observed on the floor near her bed. On 05/07/24 at 10:05 AM, Nurse Aide (NA) #80 confirmed that call light was on the floor, and not within the residents reach. b) Resident #65 An observation on 05/07/24 at 10:13 AM found Resident #65 laying in her bed with no call light in sight. The call light was observed on the floor near the bed's wheels. On 05/07/24 at 10:21 AM, Registered Nurse (RN) #65, confirmed that the call light was on the floor, and not within reach. RN # 65 stated that residents should always have their call system in reach. RN # 65 placed the call light in reach at this time and stated that she usually schedules call light checks when she dispenses medications. On 05/07/24 at 02:35 PM, the findings were discussed with the Administrator.

Based on record review and resident and staff interview, the facility failed to ensure allegations of neglect were thoroughly investigated by concluding personal care was provided to a resident in a timely manner, but failing to establish how long the resident waited to receive care. This was true for one (1) of three (3) residents reviewed for allegations of neglect during the survey process. Resident identifier: 57. Facility census: 107. Findings include: A) Record Review During the survey process, a record review was conducted of a facility reported incident involving Resident #57 on 01/21/24. The statement provided to Social Services Designee (SSD) #104 by Resident #57 was My CNA wouldn't get me up because I was wet, I was getting chaffed. They kept saying they would or would give me an excuse like they were out of rags. The employee assigned to provide care for Resident #57 was Nurse Aide (NA) #40. NA #40 provided a statement to the Nursing Staff Scheduler regarding the incident. The statement provided was, CNA stated there was no rags and had to wait on laundry to bring them out. Once she got rags, they got Resident #57 up at 9 AM. Resident #57 had a BM and CNA told resident that she's gonna put her feet up because her feet was swollen and CNA was going to get some rags and clean her up and get her out of bed. Resident was cleaned and up by 9 AM. A statement provided to the NSS by NA #29 regarding the incident was, ME and the CNA got resident up at 9 AM. CNA told resident let me go get some rags, there is none of the cart. CNA told resident that her feet was swollen to see if she would like to stay in bed. Resident said no and CNAs got her up at 9 AM. The five (5) day follow up the facility submitted stated the complaint of neglect was unsubstantiated due to personal care being provided in a timely manner. However, there was no mention in the investigation of what time Resident #57 initially requested to be assisted out of bed, only that there were no clean rags available to clean the resident with, causing the resident to have to wait until laundry delivered clean rags before being able to be assisted out of bed. The facility also did staff education on providing care in a timely manner as a result of the investigation. B) Resident interview At approximately 11:35 AM on 05/07/24, an interview was conducted with Resident #57 regarding the facility reported incident on 01/21/24. Resident #57 stated I wanted to get up a little after seven that morning, but they told me there were no clean rags to clean me up with, and that I would have to wait until laundry finished and brought some clean ones out before they could get me up. They finally got me up around 9 that morning Resident #57 stated she had soiled her brief before she requested to be helped out of bed that morning. C) Staff interview At approximately 12:50 PM on 05/07/24, an interview was conducted with SSD #103 and SSD #104 regarding the allegation of neglect. SSD #104 was asked if Resident #57 was asked what time she requested to be gotten out of bed that morning, to which they replied If I would have asked the resident that, it would be in the statement. SSD #104 acknowledged there was no mention of what time Resident #57 initially requested to be assisted out of bed that morning. SSD #104 was informed Resident #57 told this surveyor she initially requested to be assisted out of bed a little after 7 that morning, they replied If that's what she said then that's probably what happened, she is usually pretty with it. SSD #103 then stated Resident #57 is blind so she wouldn't know what time it was when she requested to get up. It may have felt like she waited from seven until nine, but she would not have any way to know that. When asked about educating the facility staff on providing care in a timely manner after the allegation was found to be unsubstantiated, SSD #103 stated If it makes the resident feel better, we will do education. At approximately 01:10 PM an interview was conducted with Housekeeper #60 regarding clean washcloths. Housekeeper #60 stated I get here at 7 AM. There is no one here from 11 PM to 7 AM so there are times that I will come in and there will be no clean washcloths and I will have to wash them. It usually takes about 45 minutes to wash them, and depending on how many loads you have to make out of what piled up from night shift to day shift, it could take longer. It takes anywhere from 30 minutes to an hour for them to dry, and then I have to fold them and deliver them to the floor. So, it can take anywhere from an hour and a half to two hours to get them washed, dried, and on the floor. At approximately 01:35 PM on 05/07/24, and interview was conducted with the Administrator regarding the allegation of abuse. The administrator stated I haven't heard anything about linens not being available when asked about the availability of washcloths that morning. The administrator acknowledged there was no timeline established as to when Resident #57 requested to be assisted out of bed, and when they were assisted out of bed at 09:00 AM that morning. When asked how it could be determined that care was provided in a timely manner without knowing how long Resident #57 had to wait that morning, the Administrator stated Somehow during the investigation, SSD #104 had to determine care was provided in a timely manner. The administrator then retrieved task sheets from that morning to see if Resident #57 had been provided care before 09:00 AM, but stated There is nothing helpful in the task sheets. At approximately 01:47 PM on 05/07/24, an interview was conducted with NA #40. NA #40 stated Normally when we come in the mornings we try to stock our linen carts but we didn't have any clean washcloths in clean linen at the time.We had about 10 or 11 washcloths on the cart at the time. Resident #57 requested to get up between 07:30 AM and 08:00 AM that morning. We had residents that wanted up earlier than that, so at that time, the 10 or 11 clean washcloths that were on the cart had already been used. I started looking for a towel or anything I could use to clean Resident #57 up with, but I couldn't find anything so I had to wait on laundry to bring them out. At this point, they had some in the dryer and had to fold them when they got done. They got them out on the floor to us at around 09:00 AM, and I immediately went and got Resident #57 cleaned up and out of bed.

Based on record review and resident and staff interview, the facility failed to ensure personal care was provided to a resident in a timely manner, by making a resident wait to be cleaned and assisted out of bed because there were no clean linens. This was true for one (1) of one (1) residents reviewed for ADL care during the survey process. Resident identifier: 57. Facility census: 107. Findings include: A) Record Review During the survey process, a record review was conducted of a facility reported incident involving Resident #57 on 01/21/24. The statement provided to Social Services Designee (SSD) #104 by Resident #57 was My CNA wouldn't get me up because I was wet, I was getting chaffed. They kept saying they would or would give me an excuse like they were out of rags. The employee assigned to provide care for Resident #57 was Nurse Aide (NA) #40. NA #40 provided a statement to the Nursing Staff Scheduler regarding the incident. The statement provided was, CNA stated there was no rags and had to wait on laundry to bring them out. Once she got rags, they got Resident #57 up at 9 AM. Resident #57 had a BM and CNA told resident that she's gonna put her feet up because her feet was swollen and CNA was going to get some rags and clean her up and get her out of bed. Resident was cleaned and up by 9 AM. A statement provided to the NSS by NA #29 regarding the incident was, ME and the CNA got resident up at 9 AM. CNA told resident let me go get some rags, there is none of the cart. CNA told resident that her feet was swollen to see if she would like to stay in bed. Resident said no and CNAs got her up at 9 AM. The five (5) day follow up the facility submitted stated the complaint of neglect was unsubstantiated due to personal care being provided in a timely manner. However, there was no mention in the investigation of what time Resident #57 initially requested to be assisted out of bed, only that there were no clean rags available to clean the resident with, causing the resident to have to wait until laundry delivered clean rags before being able to be assisted out of bed. The facility also did staff education on providing care in a timely manner as a result of the investigation. B) Resident interview At approximately 11:35 AM on 05/07/24, an interview was conducted with Resident #57 regarding the facility reported incident on 01/21/24. Resident #57 stated I wanted to get up a little after seven that morning, but they told me there were no clean rags to clean me up with, and that I would have to wait until laundry finished and brought some clean ones out before they could get me up. They finally got me up around 9 that morning Resident #57 stated she had soiled her brief before she requested to be helped out of bed that morning. C) Staff interview At approximately 12:50 PM on 05/07/24, an interview was conducted with SSD #103 and SSD #104 regarding the allegation of neglect. SSD #104 was asked if Resident #57 was asked what time she requested to be gotten out of bed that morning, to which they replied If I would have asked the resident that, it would be in the statement. SSD #104 acknowledged there was no mention of what time Resident #57 initially requested to be assisted out of bed that morning. SSD #104 was informed Resident #57 told this surveyor she initially requested to be assisted out of bed a little after 7 that morning, they replied If that's what she said then that's probably what happened, she is usually pretty with it. SSD #103 then stated Resident #57 is blind so she wouldn't know what time it was when she requested to get up. It may have felt like she waited from seven until nine, but she would not have any way to know that. When asked about educating the facility staff on providing care in a timely manner after the allegation was found to be unsubstantiated, SSD #103 stated If it makes the resident feel better, we will do education. At approximately 01:10 PM an interview was conducted with Housekeeper #60 regarding clean washcloths. Housekeeper #60 stated I get here at 7 AM. There is no one here from 11 PM to 7 AM so there are times that I will come in and there will be no clean washcloths and I will have to wash them. It usually takes about 45 minutes to wash them, and depending on how many loads you have to make out of what piled up from night shift to day shift, it could take longer. It takes anywhere from 30 minutes to an hour for them to dry, and then I have to fold them and deliver them to the floor. So, it can take anywhere from an hour and a half to two hours to get them washed, dried, and on the floor. At approximately 01:35 PM on 05/07/24, and interview was conducted with the Administrator regarding the allegation of abuse. The administrator stated I haven't heard anything about linens not being available when asked about the availability of washcloths that morning. The administrator acknowledged there was no timeline established as to when Resident #57 requested to be assisted out of bed, and when they were assisted out of bed at 09:00 AM that morning. When asked how it could be determined that care was provided in a timely manner without knowing how long Resident #57 had to wait that morning, the Administrator stated Somehow during the investigation, SSD #104 had to determine care was provided in a timely manner. The administrator then retrieved task sheets from that morning to see if Resident #57 had been provided care before 09:00 AM, but stated There is nothing helpful in the task sheets. At approximately 01:47 PM on 05/07/24, an interview was conducted with NA #40. NA #40 stated Normally when we come in of the mornings we try to stock our linen carts but we didn't have any clean washcloths in clean linen at the time.We had about 10 or 11 washcloths on the cart at the time. Resident #57 requested to get up between 07:30 AM and 08:00 AM that morning. We had residents that wanted up earlier than that, so at that time, the 10 or 11 clean washcloths that were on the cart had already been used. I started looking for a towel or anything I could use to clean Resident #57 up with, but I couldn't find anything so I had to wait on laundry to bring them out. At this point, they had some in the dryer and had to fold them when they got done. They got them out on the floor to us at around 09:00 AM, and I immediately went and got Resident #57 cleaned up and out of bed.

Based on record review and resident and staff interview, the facility failed to provide a safe, comfortable, and homelike environment by failing to ensure the availability of clean washcloths. This has the potential to affect more than a limited number of residents. Resident identifier: 57. Facility census: 107. Findings include: a) Record Review During the survey process, a record review was conducted of a facility reported incident involving Resident #57 on 01/21/24. The statement provided to Social Services Designee (SSD) #104 by Resident #57 was My CNA wouldn't get me up because I was wet, I was getting chaffed. They kept saying they would or would give me an excuse like they were out of rags. The employee assigned to provide care for Resident #57 was Nurse Aide (NA) #40. NA #40 provided a statement to the Nursing Staff Scheduler regarding the incident. The statement provided was, CNA stated there was no rags and had to wait on laundry to bring them out. Once she got rags, they got Resident #57 up at 9 AM. Resident #57 had a BM and CNA told resident that she's gonna put her feet up because her feet was swollen and CNA was going to get some rags and clean her up and get her out of bed. Resident was cleaned and up by 9 AM. A statement provided to the NSS by NA #29 regarding the incident was, ME and the CNA got resident up at 9 AM. CNA told resident let me go get some rags, there is none of the cart. CNA told resident that her feet was swollen to see if she would like to stay in bed. Resident said no and CNAs got her up at 9 AM. b) Resident #57 At approximately 11:35 AM on 05/07/24, an interview was conducted with Resident #57 regarding the facility reported incident on 01/21/24. Resident #57 stated I wanted to get up a little after seven that morning, but they told me there were no clean rags to clean me up with, and that I would have to wait until laundry finished and brought some clean ones out before they could get me up. They finally got me up around 9 that morning Resident #57 stated she had soiled her brief before she requested to be helped out of bed that morning. c) Staff interview At approximately 01:10 PM an interview was conducted with Housekeeper #60 regarding clean washcloths. Housekeeper #60 stated I get here at 7 AM. There is no one here from 11 PM to 7 AM so there are times that I will come in and there will be no clean washcloths and I will have to wash them. It usually takes about 45 minutes to wash them, and depending on how many loads you have to make out of what piled up from night shift to day shift, it could take longer. It takes anywhere from 30 minutes to an hour for them to dry, and then I have to fold them and deliver them to the floor. So, it can take anywhere from an hour and a half to two hours to get them washed, dried, and on the floor. At approximately 01:47 PM on 05/07/24, an interview was conducted with NA #40. NA #40 stated, Normally when we come in of the mornings we try to stock our linen carts but we didn't have any clean washcloths in clean linen at the time. We had about 10 or 11 washcloths on the cart at the time. Resident #57 requested to get up between 07:30 AM and 08:00 AM that morning. We had residents that wanted up earlier than that, so at that time, the 10 or 11 clean washcloths that were on the cart had already been used. I started looking for a towel or anything I could use to clean Resident #57 up with, but I couldn't find anything so I had to wait on laundry to bring them out. At this point, they had some in the dryer and had to fold them when they got done. They got them out on the floor to us at around 09:00 AM, and I immediately went and got Resident #57 cleaned up and out of bed.

e) Resident #57 During the survey process, a record review was conducted of a facility reported incident involving Resident #57 on 01/21/24. It was noted the facility reported the incident to the State Agency (SA), Nurse Aide Registry (NAR), the Ombudsman, and Adult Protective Services (APS) on 01/22/24. The five day follow up to the incident, however, was not sent to APS. The five day follow up was sent to the SA, NAR, and Ombudsman on 01/23/24. f) Resident #112 During the survey process, a record review was conducted of a facility reported incident involving Resident #112 on 04/17/24. It was noted the facility reported the incident to the State Agency (SA), Nurse Aide Registry (NAR), the Ombudsman, and Adult Protective Services (APS) on 04/17/24. The five day follow up to the incident, however, was not sent to APS. The five day follow up was sent to the SA, NAR, and Ombudsman on 04/23/24. Based on record review and staff interview, the facility failed to ensure that all alleged violations involving abuse and neglect were reported, to the appropriate state agencies as required. This was a random opportunity for discovery and a deficient practice identified during complaint investigation. The deficient practice was true for five (5) out of five (5) resident records sampled under the abuse/neglect category. Resident identifiers: #73, #77, #10, #57, and #112. Facility census: 107. Findings included: a) Resident #73 Record review, completed on 05/07/24 at 8:00 AM, revealed a facility reportable dated 01/19/24 describing an alleged incident of facility neglect. The facility had erroneously served Resident #73 pureed Shrimp and Sausage Jambalaya for dinner despite the fact she had a known shrimp allergy. There was no evidence the facility had shared the five (5) day follow-up investigative details with Adult Protective Services (APS). b) Resident #77 Record review, completed on 05/07/24 at 8:10 AM, revealed a facility reportable dated 01/31/24 describing an alleged incident of facility abuse. Resident #77 alleged that two (2) nurse aides had hurt her ankle when they took her to the shower. There was no evidence the facility had shared the five (5) day follow-up investigative details with APS. c) Resident #10 Record review, completed on 05/07/24 at 8:21 AM, revealed a facility reportable dated 03/11/24 describing an alleged incident of facility abuse. Resident #10 alleged a nurse aide grabbed her left arm and hurt her. There was no evidence the facility had shared the five (5) day follow-up investigative details with APS. d) Social Services Interview During an interview on 05/07/24 at 1:50 PM, Social Worker #103 acknowledged the facility had failed to share the five (5) day follow-up investigative details with APS and stated she did not realize it was necessary to do so.

Based on record review and staff interview the facility failed to provide notice for resident room changes, including the reason for the change, before the resident's room or roommate in the facility is changed. This is true for four (4) of five (5) residents reviewed for room changes during a complaint survey. Resident Identifiers: #29, #10, #84 and #101. Resident Census: 97. Findings included: a) Resident Room Changes On 01/30/24 a review of resident room changes revealed: 1. Room changes were completed for Resident #29 on 01/15/24 and 01/08/24 with no room move assessments completed. 2. A room change completed for Resident #10 on 01/25/24 with no room move assessment completed. 3. A room change was completed for Resident #84 on 01/18/24 with no room move assessment completed. 4. A room change was completed for Resident #101 on 01/07/24 with no room move assessment completed. During an interview on 1/30/24 at 1:20 PM the Director of Nursing (DON) stated that she was unable to locate documentation for Residents #29, #84, #10, and #101's room changes.

Based on observation and staff interview the facility failed maintain the residents right to personal privacy and confidentiality of their personal and medical records. This was a random opportunity of discovery. Resident Identifiers: #69 and #95. Facility Census: 97 Findings Included: a) Resident #69 On 01/29/24 at 08:09 PM it was observed that Licensed Practical Nurse (LPN) #122 had left the computer screen opened on the medication cart. The LPN was in a residents' room and the medication cart and computer screen were left unattended. The personal and medical records for Resident #69 were exposed and available to anyone walking past the medication cart. This was confirmed with LPN #122 on 01/29/24 at 8:13 PM and the Administrator at 8:28 PM. b) Resident #95 On 01/29/24 at 08:20 PM it was observed that Licensed Practical Nurse (LPN) #71 had left the computer screen opened on the medication cart. The LPN was in a resident's room and the medication cart and computer screen were left unattended. The personal and medical records for Resident #95 were exposed and available to anyone walking past the medication cart. This was confirmed with LPN #71 on 01/29/24 at 08:21 PM and the Administrator at 08:28 PM.

Based on record review and staff interview, the facility failed to complete a thorough investigation of a verbal abuse allegation and report the results to the appropriate State Agencies within a five (5) day follow up of the incident in accordance with State law. Resident identifier: Resident #67. Facility Census: 97. Findings Include: a) Resident #67 A review of the facility reportable log on 01/29/24 at 2:25 PM, revealed the following verbal abuse allegation: The alleged victim (Resident #67's name) Alleged Perpetrator name: Housekeeper #12 name Date of incident: 10/16/23 Brief description of the incident: Resident reported that when she ask for a roll of toilet paper (Housekeeper #12 name) replied hell, I gave you two (2) rolls yesterday. The reporting forms were void of any documentation that a thorough investigation of the verbal abuse allegation had occurred. The forms were also void of any documentation of a five (5) day follow up report completed and sent to the appropriate state agencies in accordance with the State Law. During an interview, on 01/29/24 4:00 PM, the Administrator stated, I am sure we completed the investigation and the five day follow up of the verbal abuse allegation that occurred on 10/16/23 with (Resident #67's name). Let me look into this and I will get back to you. During an interview, on 01/30/24 at 9:15 AM, the Administrator stated they were unable to find the investigation and/or the five day follow up of the incident. I have contacted the (area Ombudsman Name) to see what she received concerning this incident. During an interview, on 01/30/24 at 1:27 PM, the Administrator acknowledged the allegation of verbal abuse involving Resident #67's with no investigation and/or no evidence to produce that a five day follow up was sent to the required State agencies.

Based on record review and staff interview, the facility failed to implement a comprehensive person-centered care plan for wound care treatments. This was found for one (1) of three (3) respidents reviewed for pressure ulcers. Resident Identifiers: #11 and #63. Facility Census: 97 Findings Included: a) Resident #11 On 1/30/24 at 11:35 AM record review of Resident #11s' comprehensive personal-centered care plan: Focus: .has impaired skin integrity related to limited physical mobility, incontinence, morbid obesity, has pressure ulcers to left posterior thigh X 3 areas, sacrum and right buttock. Intervention/tasks: Administer treatments as ordered by medical provider. Apply barrier creams post incontinent episodes. Complete skin at risk assessment upon admission, quarterly, and as needed, complete weekly skin checks, Resident #11 had Physician orders for multiple pressure ulcer wound care. There is a care plan for the wound care, however, the facility failed to implement the care plan as written. Review of the Treatment Administration Report for Resident #11 for the last three (3) months shows the following treatments were not completed: 11/04/23 - cleanse pressure area to left buttock with wound cleaner, dry, supply collagen and foam dressing daily and prn (as needed) every day shift - cleanse pressure area to left buttock with wound cleaner, dry, supply collagen and foam dressing daily and prn every day shift, left buttock #2 -cleanse pressure to left posterior thigh with wound cleanser, dry, supply calcium alginate and foam dressing daily and prn every day shift for Stage III -cleanse pressure to left posterior thigh with wound cleanser, dry, supply calcium alginate and foam dressing daily and prn every day shift for Unstageable #1 I-cleanse pressure to left posterior thigh with wound cleanser, dry, supply calcium alginate and foam dressing daily and prn every day shift for Unstageable #2 - cleanse pressure area to right buttock with wound cleaner, dry, supply collagen and foam dressing daily and prn every day shift - cleanse pressure area to sacrum with wound cleaner, dry, supply calcium alginate and foam dressing daily and prn every day shift -new order cleanse right skin tear to stump with wound cleanser, pat dry, apply calcium alginate and foam dressing every day shift for wound healing 11/06/23 - cleanse pressure area to left buttock with wound cleaner, dry, supply collagen and foam dressing daily and prn every day shift - cleanse pressure area to left buttock with wound cleaner, dry, supply collagen and foam dressing daily and prn every day shift, left buttock #2 -cleanse pressure to left posterior thigh with wound cleanser, dry, supply calcium alginate and foam dressing daily and prn every day shift - cleanse pressure area to right buttock with wound cleaner, dry, supply collagen and foam dressing daily and prn every day shift - cleanse pressure area to sacrum with wound cleaner, dry, supply calcium alginate and foam dressing daily and prn every day shift -cleanse skin tear to RBK amputation site with wound cleanser, pat dry, apply calcium alginate and foam dressing every day shift -monitor care: monitor dressing to left posterior thigh every shift -monitor care: monitor dressing to pressure area to the left buttock #1 every shift -monitor care: monitor dressing to pressure area left buttock #2 every shift -monitor care: monitor dressing to pressure area on sacrum every shift -monitor care: monitor dressing to pressure area to right buttock every shift 11/16/23 -Wound care: cleanse left inner thigh with wound cleanser, dry, apply foam dressing daily and PRN every day shift for shearing -Wound care: cleanse left posterior thigh (#1) with wound cleanser, dry, apply collagen and foam dressing daily and PRN every day shift for Stage II -Wound care: cleanse left posterior thigh (#2) with wound cleanser, dry, apply collagen and foam dressing daily and PRN every day shift for Stage II -Wound care: cleanse left posterior thigh with wound cleanser, dry, apply foam dressing daily and PRN every day shift for shearing -Wound care: cleanse left posterior thigh with wound cleanser, dry, apply calcium alginate and foam dressing daily and PRN every day shift -Wound care: cleanse right buttock with wound cleanser, dry, apply collagen and foam dressing daily and PRN every day shift -Wound care: cleanse sacrum with wound cleanser, dry, apply calcium alginate and foam dressing daily and PRN every day shift for Stage III -Wound care: cleanse skin tear to right stump with wound cleanser, dry, apply calcium alginate and foam dressing daily and PRN every day shift -Wound care: Monitor dressing to left inner thigh Q (every) shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to left posterior thigh #1 Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to left inner thigh #2 Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to left posterior thigh #1 Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to left posterior thigh #2 Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to right buttock Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to right stump Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to sacrum Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) 12/11/23 -Wound care: Cleanse left inner thigh with wound cleanser, dry, apply foam dressing daily and PRN for shearing -Wound care: Cleanse left posterior thigh (#1) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II -Wound care: Cleanse left posterior thigh (#2) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II -Wound care: Cleanse left posterior thigh with wound cleanser, dry, apply foam dressing daily and PRN for shearing -Wound care: Cleanse left poster thigh with wound cleanser, dry, applycalcium alginate and foam dressing daily and PRN for Unstageable -Wound care; Cleanse right buttock with wound cleanser, dry, apply collagen and foam dressing daily and PRN -Wound care; Cleanse sacrum with wound cleanser, dry, calcium alginate and foam dressing daily and PRN for Stage III -Wound care; Cleanse skin tear to right stump with wound cleanser, dry, apply calcium alginate and foam dressing daily and PRN -Wound care: Monitor dressing to left posterior thigh #1 Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to left posterior thigh #2 Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to left posterior thigh Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) 12/23/23 -Wound care: Cleanse left inner thigh with wound cleanser, dry, apply foam dressing daily and PRN for shearing -Wound care: Cleanse left posterior thigh (#!) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II -Wound care: Cleanse left posterior thigh (#2) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II -Wound care: Cleanse left posterior thigh with wound cleanser, dry, apply foam dressing daily and PRN for shearing -Wound care: Cleanse left poster thigh with wound cleanser, dry, applycalcium alginate and foam dressing daily and PRN for Unstageable -Wound care; Cleanse right buttock with wound cleanser, dry, apply collagen and foam dressing daily and PRN -Wound care; Cleanse sacrum with wound cleanser, dry, calcium alginate and foam dressing daily and PRN for Stage III -Wound care; Cleanse skin tear to right stump with wound cleanser, dry, apply calcium alginate and foam dressing daily and PRN -Wound care: Monitor dressing to left posterior thigh #1 Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to left posterior thigh #2 Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to left posterior thigh Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to left posterior thigh Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to right buttock Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) 12/28/23 -Wound care: Cleanse left inner thigh with wound cleanser, dry, apply foam dressing daily and PRN for shearing -Wound care: Cleanse left posterior thigh (#1) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II -Wound care: Cleanse left posterior thigh (#2) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II -Wound care: Cleanse left posterior thigh with wound cleanser, dry, apply foam dressing daily and PRN for shearing -Wound care: Cleanse left poster thigh with wound cleanser, dry, apply calcium alginate and foam dressing daily and PRN for Unstageable -Wound care; Cleanse right buttock with wound cleanser, dry, apply collagen and foam dressing daily and PRN -Wound care; Cleanse sacrum with wound cleanser, dry, calcium alginate and foam dressing daily and PRN for Stage III -Wound care; Cleanse skin tear to right stump with wound cleanser, dry, apply calcium alginate and foam dressing daily and PRN -Wound care: Cleanse left posterior thigh (#1) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II 01/06/24 -Wound care: Cleanse left inner thigh with wound cleanser, dry, apply foam dressing daily and PRN for shearing -Wound care: Cleanse left posterior thigh (#1) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II -Wound care: Cleanse left posterior thigh (#2) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II -Wound care: Cleanse left posterior thigh (#2) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II -Wound care: Cleanse left posterior thigh with wound cleanser, dry, apply foam dressing daily and PRN for shearing -Wound care: Cleanse left poster thigh with wound cleanser, dry, apply calcium alginate and foam dressing daily and PRN for Unstageable -Wound care; Cleanse right buttock with wound cleanser, dry, apply collagen and foam dressing daily and PRN -Wound care; Cleanse sacrum with wound cleanser, dry, calcium alginate and foam dressing daily and PRN for Stage III -Wound care; Cleanse skin tear to right stump with wound cleanser, dry, apply calcium alginate and foam dressing daily and PRN -Wound care: Monitor dressing to left posterior thigh #1 Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to left posterior thigh #2 Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to left posterior thigh Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to right buttock Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to right stump Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to sacrum Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Devise: Resident is on a pressure reducing/relieving mattress for pressure reducing/relieving every shift 01/07/24 -Wound care: Cleanse left posterior thigh (#1) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II -Wound care: Cleanse left posterior thigh (#2) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II -Wound care: Cleanse left inner thigh with wound cleanser, dry, apply foam dressing daily and PRN for shearing -Wound care: Cleanse left posterior thigh (#2) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II -Wound care: Cleanse left posterior thigh with wound cleanser, dry, apply foam dressing daily and PRN for shearing -Wound care: Cleanse left poster thigh with wound cleanser, dry, apply calcium alginate and foam dressing daily and PRN for Unstageable -Wound care; Cleanse right buttock with wound cleanser, dry, apply collagen and foam dressing daily and PRN -Wound care; Cleanse sacrum with wound cleanser, dry, calcium alginate and foam dressing daily and PRN for Stage III -Wound care; Cleanse skin tear to right stump with wound cleanser, dry, apply calcium alginate and foam dressing daily and PRN -Wound care: Monitor dressing to left posterior thigh #1 Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to left posterior thigh #2 Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to left posterior thigh Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to right buttock Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to right stump Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to sacrum Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Devise: Resident is on a pressure reducing/relieving mattress for pressure reducing/relieving every shift 01/11/24 -Wound care: Cleanse left posterior thigh (#1) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II -Wound care: Cleanse left posterior thigh (#2) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II -Wound care; Cleanse sacrum with wound cleanser, dry, calcium alginate and foam dressing daily and PRN for Stage III -Wound care; Cleanse skin tear to right stump with wound cleanser, dry, apply calcium alginate and foam dressing daily and PRN -Wound care: Monitor dressing to left posterior thigh #1 Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to left posterior thigh #2 Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to right stump Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to sacrum Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Devise: Resident is on a pressure reducing/relieving mattress for pressure reducing/relieving every shift 01/15/24 -Wound care: Cleanse left posterior thigh (#1) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II -Wound care: Cleanse left posterior thigh (#2) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II -Wound care; Cleanse sacrum with wound cleanser, dry, calcium alginate and foam dressing daily and PRN for Stage III -Wound care; Cleanse skin tear to right stump with wound cleanser, dry, apply calcium alginate and foam dressing daily and PRN -Wound care: Monitor dressing to left posterior thigh #1 Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to left posterior thigh #2 Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to right stump Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to sacrum Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Devise: Resident is on a pressure reducing/relieving mattress for pressure reducing/relieving every shift 01/19/24 -Wound care: Cleanse left posterior thigh (#1) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II -Wound care: Cleanse left posterior thigh (#2) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II -Wound care; Cleanse sacrum with wound cleanser, dry, calcium alginate and foam dressing daily and PRN for Stage III -Wound care; Cleanse skin tear to right stump with wound cleanser, dry, apply calcium alginate and foam dressing daily and PRN -Wound care: Monitor dressing to left posterior thigh #1 Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to left posterior thigh #2 Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to right stump Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to sacrum Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Devise: Resident is on a pressure reducing/relieving mattress for pressure reducing/relieving every shift 01/21/24 -Wound care: Cleanse left posterior thigh (#1) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II -Wound care: Cleanse left posterior thigh (#2) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II -Wound care; Cleanse sacrum with wound cleanser, dry, calcium alginate and foam dressing daily and PRN for Stage III -Wound care; Cleanse skin tear to right stump with wound cleanser, dry, apply calcium alginate and foam dressing daily and PRN -Wound care: Monitor dressing to left posterior thigh #1 Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to left posterior thigh #2 Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to right stump Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to sacrum Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Devise: Resident is on a pressure reducing/relieving mattress for pressure reducing/relieving every shift 01/25/24 -Wound care: Cleanse left posterior thigh (#1) with wound cleanser, dry, apply calcium alginate and foam dressing daily and PRN for Stage II -Wound care: Cleanse left posterior thigh (#2) with wound cleanser, dry, apply calcium alginate and foam dressing daily and PRN for Stage II b) Resident #63 On 1/30/24 at 02:35 PM record review of Resident #63s' comprehensive personal-centered care plan: Focus: .has impaired skin integrity related to limited physical mobility, Multiple sclerosis, morbid obesity, contractures, has pressure ulcers to right medial heel, sacrum and left lateral ankle. Intervention/tasks: Administer treatments as ordered by medical provider. Apply barrier creams post incontinent episodes. Complete skin at risk assessment upon admission, quarterly, and as needed, complete weekly skin checks, Resident #63 had Physician orders for multiple pressure ulcer wound care. There is a care plan for the wound care, however, the facility failed to implement the care plan as written. Review of the Treatment Administration Report for Resident #63 for the last three (3) months shows the following treatments were not completed: 11/07/23 -Cleanse left buttock with IHWC (in house wound cleanser), pat dry, apply collagen and foam dressing daily 11/08/23 -Cleanse left buttock with IHWC (in house wound cleanser), pat dry, apply collagen and foam dressing daily 11/16/23 -Wound Care: Cleanse left buttock with wound cleanser, dry, apply collagen and foam dressing daily and PRN -Wound Care: Monitor dressing to left buttock Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) 12/02/23 -Santyl External ointment 250 units/GM. Apply to left outer ankle topically every 3 days for wound care 12/23/23 -Wound Care: Cleanse left ankle with in house wound cleanser, pat dry, apply Santyl to wound bed and cover with dry dressing every shift -Wound Care: Cleanse wound to sacrum with in house wound cleanser, pat dry, apply Santyl and cover with dry dressing every shift -Devise: Resident is on a pressure reducing/relieving mattress for pressure reducing/relieving every shift -Dolphin mattress every shift for pressure ulcer -Wound Care: Monitor dressing to left ankle Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound Care: Monitor dressing to sacrum Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) 12/28/23 -Wound Care: Cleanse wound to sacrum with in house wound cleanser, pat dry, apply Santyl and cover with dry dressing every shift 01/06/24 -Wound Care; Monitor dressing to left ankle Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound Care; Monitor wound/wound vac to sacrum Q shift. Ensure that wound vac is intact. Notify provider if any increased redness, swelling or signs or symptoms of infection present. 01/07/24 -Zinc Oxide external paste apply to perineal area topically every shift for moisture dermatitis -Devise: Resident is on a pressure reducing/relieving mattress every shift -Wound Care; Monitor dressing to left ankle Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound Care; Monitor wound/wound vac to sacrum Q shift. Ensure that wound vac is intact. Notify provider if any increased redness, swelling or signs or symptoms of infection present. 01/11/24 -Zinc Oxide external paste apply to perineal area topically every shift for moisture dermatitis -Left lateral ankle wound care: clean with IHWC, pat dry, apply hydrofera blue to wound bed and bordered gauze Q 3 days and PRN for wound healing -Wound Care; Monitor dressing to left ankle Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound Care; Monitor wound/wound vac to sacrum Q shift. Ensure that wound vac is intact. Notify provider if any increased redness, swelling or signs or symptoms of infection present. 01/15/24 -Zinc Oxide external pa

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d) Observation of A 2's unit On 1/29/24 at 12:26 PM the following hazards were identified during a tour of A2's residential rooms that are currently being used for storage rooms: * room [ROOM NUMBER] entry door was not equipped with a lock to prevent entry. The through wall heating unit was on at the time of the tour. The outer covering of the heating unit was not on this unit and the operable electrical parts of the unit were exposed. The room was not maintained to be free of accident hazards. * room [ROOM NUMBER] entry door was not equipped with a lock to prevent entry. The stored items included but were not limited to trash cans still in boxes, a push dolly cart, a large lift, 3 (three) beds and several mattresses, The egress of the room was not maintained to be free of accident hazards. * room [ROOM NUMBER] entry door was not equipped with a lock to prevent entry. The stored items included but were not limited to boxes of PPE containers still in shipping boxes, dressers with missing drawers, a storage cart, and beds. The egress of the room was not maintained to be free of accident hazards. * room [ROOM NUMBER] entry door was not equipped with a lock to prevent entry. The stored items included but was not limited to wheelchairs, several beds, and a medication cart. The egress of the room was not maintained to be free of accident hazards. *room [ROOM NUMBER] entry door was not equipped with a lock to prevent entry. The stored items included but were not limited to several beds that were marked broken. The egress of the room was not maintained to be free of accident hazards. On 1/29/24 at 1:15 PM during an interview with the administrator, the administrator stated these storage rooms are not currently in use and the goal was to do the repairs needed to the beds and then reopen the rooms. The administrator stated she had no true concerns with wanderers being in this area as they are redirected. The administrator did acknowledge the rooms with the egresses that were not maintained to be free from hazard would not be safe for the residents if they were to wander into the rooms. The Administrator asked the Director of Plant Maintenance (DOPM) #31 to go and obtain and install locks for the storage rooms' entry doors. During an interview with the Director of Plant Maintenance Staff #31 at 1:35 PM on 1/29/24, he acknowledged that the through the wall heating unit without the outer covering exposing the operable electrical parts in room [ROOM NUMBER] was not safe for the residents if they were to wander into the room. DOPM #31 unplugged the unit. Resident #13 was noted to be wondering in the A2 unit hallway area without supervision on 01/29/24 at 3:53 PM. On 01/30/24 at 1:30 PM a review was completed of the resident response analyzer report that was provided by the facility upon the entry of survey. This assessment report identifies a total of 16 residents identified as being wanderers. e) Treatment cart At approximately 1:43 PM on 01/29/24, the A2 treatment cart was observed with a door open. Upon approaching the cart, it was left unlocked, and all doors were able to be opened. The treatment nurse was in a room providing care, with the treatment cart out of sight. The open and unlocked cart was witnessed by Director of Plant Maintenance (DPM) #31 and Licensed Practical Nurse (LPN) #9. At approximately 3:00 PM on 01/29/24, a record review of a list of wandering residents, provided by the Director of Nursing (DON) #63. This list indicated 16 wandering residents in the facility that could have potentially had access to the unlocked treatment cart. Based on observation and staff interview the facility failed to ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. This was a random opportunity for discovery. Facility census: #97 Findings Included: a) B1 Hall medication cart On 01/29/24 at 08:09 PM observation of the medication cart on B1 hall was unlocked and left unattended by Licensed Practical Nurse (LPN) #122. There were six (6) residents sitting near the medication cart. According to a Resident Response Analyzer report of wandering residents provided by the Director of Nursing on 01/29/24, there were sixteen (16) residents that wandered throughout the facility. The LPN was away from the medication cart for four (4) minutes. According to the facility Policy # NS-1197-02 Nursing mediation Safety Precautions: c. Lock medication cart when not in the immediate vicinity of the cart . which she failed to do. This was confirmed with the LPN on 01/29/24 at 08:13 PM and the administrator on 01/29/24 at 08:23 PM. b) B2 Hall medication cart On 01/29/24 at 8:20 PM observation of the medication cart on B2 hall revealed the cart was unlocked and left unattended by Licensed Practical Nurse (LPN) #71. There was one (1) resident sitting in front of the medication cart. According to a Resident Response Analyzer report of wandering residents provided by the Director of Nursing on 01/29/24, there were sixteen (16) residents that wandered throughout the facility. According to the facility Policy # NS-1197-02 Nursing mediation Safety Precautions: c. Lock medication cart when not in the immediate vicinity of the cart . which she failed to do. This was confirmed with the LPN on 01/29/24 at 08:21 PM and the Administrator on 01/29/24 at 08:23 PM. c) Resident #12 Review of Resident #12's physician's orders showed the following order originally written on 09/22/22 and renewed on 5/22/2023, Plastic ware only. No silverware. The resident was observed on 01/30/24 at 8:15 AM. He was eating breakfast sitting on a couch in the hallway, with the breakfast tray on a bedside table in front of him. He was using silverware. There were no staff members present in the hallway. The resident moved to a different couch at 8:20 AM, leaving the tray and silverware on the bedside table. There were still no staff members in the hallway until Mobile dietary manager #221 entered the hallway at 8:22 AM to deliver food to another resident. Mobile dietary manager #221 confirmed that Resident #12's tray ticket said, Plastic ware (no silverware) but the resident had silverware instead of plastic ware. He stated he did not know why the resident had that order. He removed the resident's silverware and stated he would bring plastic ware in case the resident wanted to eat some more of his breakfast. During an interview, on 01/30/24 at 8:50 AM, the Director of Nursing stated Resident #12 had an order for plastic ware because he had attempted to cut off his Secure Care alarm in the past. A Secure Care alarm is a device worn on the ankle which prevented elopement by alarming when the resident attempted to leave the facility. No further information was provided through the completion of the complaint investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to offer sufficient fluid intake to maintain proper hydration and health. This failed practice was found true for (1) one of (3) three residents reviewed for hydration. Resident identifier: #91. Facility census: 97. Findings include: a) Resident #91 During an observation on 01/29/24 at 11:00 AM and 2:00 PM, Resident #91's pink water pitcher at her bedside was found to be empty. A record review on 01/29/24 at 2:00 PM of Resident #91's hospitalizations revealed that Resident #91 had been hospitalized on [DATE]. One of her admitting diagnoses was dehydration. Resident #91's last Dietary Nutritional assessment dated [DATE] shows that her estimated fluid needs are 1200-1400 milliliters (ml) per day. She is also to use a (2) two handled cup for fluid consumption. A record review on 01/29/24 at 2:30 PM of Resident #91''s fluid intake for the month of 01/2024 after she returned from the hospital, reveals the following daily total fluid intakes: 01/23/24- 1540 ml 01/24/24-840 ml 01/25/24-960 ml 01/26/24-1460 ml 01/27/24-240 ml 01/28/24-360 ml An observation on 01/29/24 at 3:15 PM found Resident #91's pink water pitcher to be empty. During an interview, on 01/29/24 at 3:15 PM, with (NA) Nursing Assistant #114 she said the facility did hydration pass at 6:00 AM, 2:00 PM, and 6:00 PM. An observation on 01/30/24 at 8:15 AM of Resident # 91's breakfast tray revealed that her meal ticket called for a 2 Handled Cup with a Lid. Resident #91's fluids were not served in a 2 handled cup. On 01/30/24 at 8:15 AM, nurse aide (NA) #76, observed the resident did not have a 2 handled cup. NA #76 stated, She is getting better at drinking out of a straw. During an interview, on 01/30/24 at 9:00 AM, with Dietary Manager (DM) he stated, We had the cups onto their tray before we put them on the meal cart, I must have missed hers. During an interview, on 01/30/24 at 1:35 PM, with the Director of Nursing (DON) she said the resident's family had been offered Hospice and a Feeding Tube and the family had declined. Record review on 01/30/24 at 2:00 PM, found there are no notes in Resident #91's chart to show that Hospice services or a Feeding Tube was offered.

Based on record review and staff interview, the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice and the comprehensive person-centered care plan. The facility failed to follow the physician's order and the comprehensive care plan intervention to document the post-dialysis weight provided by the dialysis center weekly. This deficient practice had the potential to affect one (1) of three (3) residents reviewed for receiving dialysis treatments. Resident identifier: #4. Facility census: 97. Findings included: a) Resident #4 Review of Resident #4's physician's orders showed the following order written on 09/28/23, Document dry weight (post-dialysis weight) provided by dialysis center weekly, every day shift, every Thursday. Resident #4's comprehensive care plan had the following intervention implemented on 07/03/23 and revised on 01/18/24, Obtain weight as ordered. Report abnormal fluctuations to medical provider, nephrologist/ dialysis center, resident, resident representative. Document dry weight (post dialysis) provided by dialysis center weekly. Review of Resident #4's Treatment Administration Record (TAR) showed blanks where the weight should have been documented on 01/04/24, 01/11/24, 01/18/24, and 01/25/24. Review of Resident #4's weights documented in his electronic health records (EHR) showed the most recent weight was documented on 01/06/24. During an interview on 01/30/24 at 8:55 AM, the Director of Nursing (DON) stated the weights had been documented by the dialysis center on the dialysis communication sheets. The DON provided the communication sheets and confirmed the sheets had not been scanned into the medical record. The post-dialysis weight for 01/04/24 had been entered into the dialysis assessment in the electronic health record. The post-dialysis weights for 01/11/24, 01/18/24, and 01/25/24 had not been entered into the dialysis assessments in the electronic health record. The DON confirmed Resident #4's weight had not been documented in the medical record as ordered by the physician and as specified in the comprehensive care plan.

Based on resident interviews, observation and staff interview the facility failed to provide the appropriate nutritive content as prescribed for a renal diet. This was a random opportunity for discovery. Facility Census: 97. Findings included: a) Resident #50 During an observation, on 01/29/24 at 12:37 PM, of Resident #50's tray, the diet ticket on the tray had Parsley pork chops, Herb Noodles, Capri Vegetable Blend, Dinner Roll, and Carrot cake. The Parsley Pork Chop was marked through, and tenders were written on the ticket. Resident #50 said she did not order any chicken tenders. She added that a staff member took her order this morning and she was told Kielbasa was the meat for the meal and this was what she ordered. Resident #50 stated, the lunch is crap, this is hard. The Resident demonstrated by tapping the chicken tender on her plate. A clicking noise could be heard when the resident tapped the chicken on the plate. The Resident stated she never ordered chicken tenders because they were always hard. The administrator entered the room during the interview. The resident showed the administrator how hard her chicken tender was by tapping it on the side of her plate. The administrator agreed the chicken tenders were overcooked and charred on the edges. On 12/29/24 at 2:02 PM, the Regional Dietary Manager (RDM) Staff # 220 confirmed Resident #50 should have had the pork chops and said the kitchen staff did not cook any pork chops. RDM #220 added staff should be following the production sheets and cooking the right food items. He stated Resident #50 had a renal diet and would not get Kielbasa, but she should have been given the pork chops. He stated at least 4 to 5 residents received renal diets and they should have been served pork chops as well.

Based on medical record review, policy review, resident interview and staff interview, the facility failed to ensure three (3) of three (3) residents and/or residents representatives reviewed were afforded the right to participate in the care planning process. Resident identifiers: #6, #12 and #69. Facility Census: 97. Findings included: A review of the facility policy titled Plan of Care Overview with no effective date is read as follows. 1. General Care Planning (PoC) Goals and Guidelines. .c. Resident/representative will have the right to participate in the development and implementation of his/her own PoC including but not limited to : .vi. Right to be informed, in advanced, of changes to the PoC d. The facility will: .iii. Review care plans quarterly and/or with significant changes in care. .v. support the residents rights to participate in treatment and care planning During an interview, on 01/31/24 at 9:05 AM, Regional Registered Nurse (RRR) (RN) #224 stated the facility policy titled Plan of Care Overview had no effective date or revision date. a) Resident #6 During an interview, on 01/29/24 at 12:47 PM, Social Services #47 and Social Services #55 stated, We have a care plan meeting every three months for every resident. We send care plan meeting letters to the representatives and invite the residents when they have capacity. Sometimes they attend in person or by phone. Sometimes the resident attends. The disciplines that usually attend the meeting are Activities, Dietary, Nursing, and us. We go over the care plan and answer any questions they may have. We also go over the POST form. During an interview, on 01/30/24 at 9:13 AM, Resident #6 stated, care plan meeting I don't think I have been to a care plan meeting in a while. No I have not had one, well. During a record review, on 01/30/24 at 10:13 AM, Resident #6's medical record revealed a Minimum Data Set (MDS) with a Assessment Reference Date (ARD) of 12/12/23 and MDS with ARD 11/16/23 were completed. Further review of the medical record was void of any documentation of a care plan meeting being held for the MDS with ARD of 12/12/23 and/or MDS with ARD of 11/16/23. Further review of the medical record revealed Resident #6's physician determination of capacity form dated 08/11/23 was coded as having capacity to make decisions. During an interview, on 01/30/24 at 1:04 PM, Social Services #47 acknowledged there was no care meeting held for Resident #6. Then stated, I will assure you an audit will be conducted. During an interview on 01/30/24 at 2:39 PM, Social Services #55 acknowledged there was no care meeting held for Resident #6. b) Resident #12 During an interview, on 01/29/24 at 12:47 PM, Social Services #47 and Social Services #55 stated, We have a care plan meeting every three months for every resident. We send care plan meeting letters to the representatives and invite the residents when they have capacity. Sometimes they attend in person or by phone. Sometimes the Resident attends. The disciplines that usually attend the meeting are Activities, Dietary, Nursing, and us. We go over the care plan and answer any questions they may have. We also go over the POST form. During a record review on 01/30/24 at 10:27 AM, Resident #12's medical record revealed a MDS with an ARD of 11/03/23 and MDS with ARD 08/08/23 were completed. Further review of the medical record was void of any documentation of a care plan meeting being held for the MDS with ARD of 11/03/23 and/or MDS with ARD of 08/08/23. Further review of the medical record revealed a Resident #12's physician determination of capacity form dated 12/06/22 was coded as incapacitated to make medical decisions. During an interview on 01/30/24 at 1:04 PM, Social Services #47 acknowledged there was no care meeting held for #12. Then stated, I will assure you an audit will be conducted. During an interview on 01/30/24 at 2:39 PM, Social Services #55 acknowledged there was no care plan meeting held for #12. At the close of the survey, no further evidence was provided indicating the Resident or the Responsible Party participated in his care planning process. c) Resident #69 During an interview on 01/29/24 at 12:47 PM, Social Services #47 and Social Services #55 stated we have a care plan meeting every three months for every resident. We send care plan meeting letters to the representatives and invite the residents when they have capacity. Sometimes they attend in person or by phone. Sometimes the Resident attends. The disciplines that usually attend the meeting are Activities, Dietary, Nursing, and us. We go over the care plan and answer any questions they may have. We also go over the POST form. During a record review on 01/30/24 at 11:37 AM, Resident #69's medical record revealed a MDS with ARD of 01/19/24 and MDS with ARD of 10/25/23 were completed. Further review of the medical record was void of any documentation of a care plan meeting being held for the MDS with ARD of 01/19/24 and/or MDS with ARD of 10/25/23 . Further review of the medical record revealed Resident #69's physician determination of capacity form dated 02/17/22 was coded as demonstrating incapacity to make medical decisions. During an interview on 01/30/24 at 1:04 PM, Social Services #47 acknowledged there was no care meeting held for #69. Then stated, I will assure you an audit will be conducted. During an interview on 01/30/24 at 2:39 PM, Social Services #55 acknowledged there was no care meeting held for R #69. At the close of the survey, no further evidence was provided indicating the resident or the responsible party participated in his care planning process.

Findings Included: c) Resident #11 On 1/30/24 at 11:35 AM record review of Resident #11s' wound care orders and review of the Treatment Administration Report (TAR) for Resident #11 for the last three (3) months shows the following treatments orders were not completed: 11/04/23 - cleanse pressure area to left buttock with wound cleaner, dry, supply collagen and foam dressing daily and prn every day shift - cleanse pressure area to left buttock with wound cleaner, dry, supply collagen and foam dressing daily and prn every day shift, left buttock #2 -cleanse pressure to left posterior thigh with wound cleanser, dry, supply calcium alginate and foam dressing daily and prn every day shift for Stage III -cleanse pressure to left posterior thigh with wound cleanser, dry, supply calcium alginate and foam dressing daily and prn every day shift for Unstageable #1 I-cleanse pressure to left posterior thigh with wound cleanser, dry, supply calcium alginate and foam dressing daily and prn every day shift for Unstageable #2 - cleanse pressure area to right buttock with wound cleaner, dry, supply collagen and foam dressing daily and prn every day shift - cleanse pressure area to sacrum with wound cleaner, dry, supply calcium alginate and foam dressing daily and prn every day shift -new order cleanse right skin tear to stump with wound cleanser, pat dry, apply calcium alginate and foam dressing every day shift for wound healing 11/06/23 - cleanse pressure area to left buttock with wound cleaner, dry, supply collagen and foam dressing daily and prn every day shift - cleanse pressure area to left buttock with wound cleaner, dry, supply collagen and foam dressing daily and prn every day shift, left buttock #2 -cleanse pressure to left posterior thigh with wound cleanser, dry, supply calcium alginate and foam dressing daily and prn every day shift - cleanse pressure area to right buttock with wound cleaner, dry, supply collagen and foam dressing daily and prn every day shift - cleanse pressure area to sacrum with wound cleaner, dry, supply calcium alginate and foam dressing daily and prn every day shift -cleanse skin tear to RBK amputation site with wound cleanser, pat dry, apply calcium alginate and foam dressing every day shift -monitor care: monitor dressing to left posterior thigh every shift -monitor care: monitor dressing to pressure area to the left buttock #1 every shift -monitor care: monitor dressing to pressure area left buttock #2 every shift -monitor care: monitor dressing to pressure area on sacrum every shift -monitor care: monitor dressing to pressure area to right buttock every shift 11/16/23 -Wound care: cleanse left inner thigh with wound cleanser, dry, apply foam dressing daily and PRN every day shift for shearing -Wound care: cleanse left posterior thigh (#1) with wound cleanser, dry, apply collagen and foam dressing daily and PRN every day shift for Stage II -Wound care: cleanse left posterior thigh (#2) with wound cleanser, dry, apply collagen and foam dressing daily and PRN every day shift for Stage II -Wound care: cleanse left posterior thigh with wound cleanser, dry, apply foam dressing daily and PRN every day shift for shearing -Wound care: cleanse left posterior thigh with wound cleanser, dry, apply calcium alginate and foam dressing daily and PRN every day shift -Wound care: cleanse right buttock with wound cleanser, dry, apply collagen and foam dressing daily and PRN every day shift -Wound care: cleanse sacrum with wound cleanser, dry, apply calcium alginate and foam dressing daily and PRN every day shift for Stage III -Wound care: cleanse skin tear to right stump with wound cleanser, dry, apply calcium alginate and foam dressing daily and PRN every day shift -Wound care: Monitor dressing to left inner thigh Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to left posterior thigh #1 Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to left inner thigh #2 Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to left posterior thigh #1 Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to left posterior thigh #2 Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to right buttock Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to right stump Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to sacrum Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) 12/11/23 -Wound care: Cleanse left inner thigh with wound cleanser, dry, apply foam dressing daily and PRN for shearing -Wound care: Cleanse left posterior thigh (#!) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II -Wound care: Cleanse left posterior thigh (#2) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II -Wound care: Cleanse left posterior thigh with wound cleanser, dry, apply foam dressing daily and PRN for shearing -Wound care: Cleanse left poster thigh with wound cleanser, dry, applycalcium alginate and foam dressing daily and PRN for Unstageable -Wound care; Cleanse right buttock with wound cleanser, dry, apply collagen and foam dressing daily and PRN -Wound care; Cleanse sacrum with wound cleanser, dry, calcium alginate and foam dressing daily and PRN for Stage III -Wound care; Cleanse skin tear to right stump with wound cleanser, dry, apply calcium alginate and foam dressing daily and PRN -Wound care: Monitor dressing to left posterior thigh #1 Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to left posterior thigh #2 Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to left posterior thigh Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) 12/23/23 -Wound care: Cleanse left inner thigh with wound cleanser, dry, apply foam dressing daily and PRN for shearing -Wound care: Cleanse left posterior thigh (#!) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II -Wound care: Cleanse left posterior thigh (#2) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II -Wound care: Cleanse left posterior thigh with wound cleanser, dry, apply foam dressing daily and PRN for shearing -Wound care: Cleanse left poster thigh with wound cleanser, dry, applycalcium alginate and foam dressing daily and PRN for Unstageable -Wound care; Cleanse right buttock with wound cleanser, dry, apply collagen and foam dressing daily and PRN -Wound care; Cleanse sacrum with wound cleanser, dry, calcium alginate and foam dressing daily and PRN for Stage III -Wound care; Cleanse skin tear to right stump with wound cleanser, dry, apply calcium alginate and foam dressing daily and PRN -Wound care: Monitor dressing to left posterior thigh #1 Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to left posterior thigh #2 Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to left posterior thigh Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to left posterior thigh Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to right buttock Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) 12/28/23 -Wound care: Cleanse left inner thigh with wound cleanser, dry, apply foam dressing daily and PRN for shearing -Wound care: Cleanse left posterior thigh (#1) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II -Wound care: Cleanse left posterior thigh (#2) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II -Wound care: Cleanse left posterior thigh with wound cleanser, dry, apply foam dressing daily and PRN for shearing -Wound care: Cleanse left poster thigh with wound cleanser, dry, apply calcium alginate and foam dressing daily and PRN for Unstageable -Wound care; Cleanse right buttock with wound cleanser, dry, apply collagen and foam dressing daily and PRN -Wound care; Cleanse sacrum with wound cleanser, dry, calcium alginate and foam dressing daily and PRN for Stage III -Wound care; Cleanse skin tear to right stump with wound cleanser, dry, apply calcium alginate and foam dressing daily and PRN -Wound care: Cleanse left posterior thigh (#1) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II 01/06/24 -Wound care: Cleanse left inner thigh with wound cleanser, dry, apply foam dressing daily and PRN for shearing -Wound care: Cleanse left posterior thigh (#1) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II -Wound care: Cleanse left posterior thigh (#2) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II -Wound care: Cleanse left posterior thigh (#2) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II -Wound care: Cleanse left posterior thigh with wound cleanser, dry, apply foam dressing daily and PRN for shearing -Wound care: Cleanse left poster thigh with wound cleanser, dry, apply calcium alginate and foam dressing daily and PRN for Unstageable -Wound care; Cleanse right buttock with wound cleanser, dry, apply collagen and foam dressing daily and PRN -Wound care; Cleanse sacrum with wound cleanser, dry, calcium alginate and foam dressing daily and PRN for Stage III -Wound care; Cleanse skin tear to right stump with wound cleanser, dry, apply calcium alginate and foam dressing daily and PRN -Wound care: Monitor dressing to left posterior thigh #1 Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to left posterior thigh #2 Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to left posterior thigh Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to right buttock Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to right stump Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to sacrum Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Devise: Resident is on a pressure reducing/relieving mattress for pressure reducing/relieving every shift 01/07/24 -Wound care: Cleanse left posterior thigh (#1) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II -Wound care: Cleanse left posterior thigh (#2) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II -Wound care: Cleanse left inner thigh with wound cleanser, dry, apply foam dressing daily and PRN for shearing -Wound care: Cleanse left posterior thigh (#2) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II -Wound care: Cleanse left posterior thigh with wound cleanser, dry, apply foam dressing daily and PRN for shearing -Wound care: Cleanse left poster thigh with wound cleanser, dry, apply calcium alginate and foam dressing daily and PRN for Unstageable -Wound care; Cleanse right buttock with wound cleanser, dry, apply collagen and foam dressing daily and PRN -Wound care; Cleanse sacrum with wound cleanser, dry, calcium alginate and foam dressing daily and PRN for Stage III -Wound care; Cleanse skin tear to right stump with wound cleanser, dry, apply calcium alginate and foam dressing daily and PRN -Wound care: Monitor dressing to left posterior thigh #1 Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to left posterior thigh #2 Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to left posterior thigh Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to right buttock Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to right stump Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to sacrum Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Devise: Resident is on a pressure reducing/relieving mattress for pressure reducing/relieving every shift 01/11/24 -Wound care: Cleanse left posterior thigh (#1) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II -Wound care: Cleanse left posterior thigh (#2) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II -Wound care; Cleanse sacrum with wound cleanser, dry, calcium alginate and foam dressing daily and PRN for Stage III -Wound care; Cleanse skin tear to right stump with wound cleanser, dry, apply calcium alginate and foam dressing daily and PRN -Wound care: Monitor dressing to left posterior thigh #1 Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to left posterior thigh #2 Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to right stump Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to sacrum Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Devise: Resident is on a pressure reducing/relieving mattress for pressure reducing/relieving every shift 01/15/24 -Wound care: Cleanse left posterior thigh (#1) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II -Wound care: Cleanse left posterior thigh (#2) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II -Wound care; Cleanse sacrum with wound cleanser, dry, calcium alginate and foam dressing daily and PRN for Stage III -Wound care; Cleanse skin tear to right stump with wound cleanser, dry, apply calcium alginate and foam dressing daily and PRN -Wound care: Monitor dressing to left posterior thigh #1 Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to left posterior thigh #2 Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to right stump Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to sacrum Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Devise: Resident is on a pressure reducing/relieving mattress for pressure reducing/relieving every shift 01/19/24 -Wound care: Cleanse left posterior thigh (#1) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II -Wound care: Cleanse left posterior thigh (#2) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II -Wound care; Cleanse sacrum with wound cleanser, dry, calcium alginate and foam dressing daily and PRN for Stage III -Wound care; Cleanse skin tear to right stump with wound cleanser, dry, apply calcium alginate and foam dressing daily and PRN -Wound care: Monitor dressing to left posterior thigh #1 Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to left posterior thigh #2 Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to right stump Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to sacrum Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Devise: Resident is on a pressure reducing/relieving mattress for pressure reducing/relieving every shift 01/21/24 -Wound care: Cleanse left posterior thigh (#1) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II -Wound care: Cleanse left posterior thigh (#2) with wound cleanser, dry, apply collagen and foam dressing daily and PRN for Stage II -Wound care; Cleanse sacrum with wound cleanser, dry, calcium alginate and foam dressing daily and PRN for Stage III -Wound care; Cleanse skin tear to right stump with wound cleanser, dry, apply calcium alginate and foam dressing daily and PRN -Wound care: Monitor dressing to left posterior thigh #1 Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to left posterior thigh #2 Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to right stump Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound care: Monitor dressing to sacrum Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Devise: Resident is on a pressure reducing/relieving mattress for pressure reducing/relieving every shift 01/25/24 -Wound care: Cleanse left posterior thigh (#1) with wound cleanser, dry, apply calcium alginate and foam dressing daily and PRN for Stage II -Wound care: Cleanse left posterior thigh (#2) with wound cleanser, dry, apply calcium alginate and foam dressing daily and PRN for Stage II d) Resident #63 On 1/30/24 at 02:35 PM record review of Resident #63s' wound care orders and review of the Treatment Administration Report (TAR) for Resident #63 for the last three (3) months shows the following treatments orders were not completed: 11/07/23 -Cleanse left buttock with IHWC (in house wound cleanser), pat dry, apply collagen and foam dressing daily 11/08/23 -Cleanse left buttock with IHWC (in house wound cleanser), pat dry, apply collagen and foam dressing daily 11/16/23 -Wound Care: Cleanse left buttock with wound cleanser, dry, apply collagen and foam dressing daily and PRN -Wound Care: Monitor dressing to left buttock Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) 12/02/23 -Santyl External ointment 250 units/GM. Apply to left outer ankle topically every 3 days for wound care 12/23/23 -Wound Care: Cleanse left ankle with in house wound cleanser, pat dry, apply Santyl to wound bed and cover with dry dressing every shift -Wound Care: Cleanse wound to sacrum with in house wound cleanser, pat dry, apply Santyl and cover with dry dressing every shift -Devise: Resident is on a pressure reducing/relieving mattress for pressure reducing/relieving every shift -Dolphin mattress every shift for pressure ulcer -Wound Care: Monitor dressing to left ankle Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound Care: Monitor dressing to sacrum Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) 12/28/23 -Wound Care: Cleanse wound to sacrum with in house wound cleanser, pat dry, apply Santyl and cover with dry dressing every shift 01/06/24 -Wound Care; Monitor dressing to left ankle Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound Care; Monitor wound/wound vac to sacrum Q shift. Ensure that wound vac is intact. Notify provider if any increased redness, swelling or signs or symptoms of infection present. 01/07/24 -Zinc Oxide external paste apply to perineal area topically every shift for moisture dermatitis -Devise: Resident is on a pressure reducing/relieving mattress every shift -Wound Care; Monitor dressing to left ankle Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound Care; Monitor wound/wound vac to sacrum Q shift. Ensure that wound vac is intact. Notify provider if any increased redness, swelling or signs or symptoms of infection present. 01/11/24 -Zinc Oxide external paste apply to perineal area topically every shift for moisture dermatitis -Left lateral ankle wound care: clean with IHWC, pat dry, apply hydrofera blue to wound bed and bordered gauze Q 3 days and PRN for wound healing -Wound Care; Monitor dressing to left ankle Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound Care; Monitor wound/wound vac to sacrum Q shift. Ensure that wound vac is intact. Notify provider if any increased redness, swelling or signs or symptoms of infection present. 01/15/24 -Zinc Oxide external paste apply to perineal area topically every shift for moisture dermatitis -Devise: Resident is on a pressure reducing. relieving mattress every shift -Wound Care; Monitor dressing to left ankle Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) -Wound Care; Monitor wound/wound vac to sacrum Q shift. Ensure that wound vac is intact. Notify provider if any increased redness, swelling or signs or symptoms of infection present. 01/19/24 -Zinc Oxide external paste apply to perineal area topically every shift for moisture dermatitis -Weekly skin assessment to be completed. Documentation to be completed on weekly skin assessment -Devise: Resident is on a pressure reducing. relieving mattress every shift -Wound Care; Monitor dressing to left ankle Q shift to ensure the condition of the dressing is intact and drainage is contained. Monitor area surrounding wound. Notify medical provider if presence of complications (e.g. increased redness, swelling or drainage, abnormal odor, or new of worsening pain/discomfort.) 01/21/24 -Zinc Oxide external paste apply to perineal area topically every shift for moisture dermatitis [TRUNCATED]

Based on record review and staff interview the facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and determined drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled. This was a random opportunity for discovery and had the potential to affect a limited number of residents who currently reside at the facility. Resident identifier: #100. Facility census 97. Findings included: a) Gabapentin A review of the medical records for Resident #100, found they were ordered to receive Gabapentin (used for relieving pain for certain conditions in the nervous system) 900 milligrams (mg) to be administered three (3) times a day. The order date was 07/12/23. On 01/29/24 at 2:40 PM the Director of Nursing (DON) was asked why did the Controlled Substance Record (CSR) had two (2) separate pages with the same medication and same dose. DON verified both pages were the same as follows: (named Resident #100) Gabapentin tab 600 mg Give 1 and ½ tabs by mouth three times daily. The number of tablets delivered on 07/14/23 was 30 on each page. On 01/29/24 at 3:10 PM DON was asked if the nurse giving the medication would have removed two (2) tablets and wasted ½ of one? The DON said the medication came already broken in half by the pharmacy. The DON went on to say she would have to contact the pharmacy to find out more information. A review of the facility Controlled Medications book was reviewed and found a dose of the Gabapentin was missed on 07/20/23, the second dose due at 2:00pm. However, it was not clear if the missed dose was a whole 600 mg tablet or a half of the tablet of 300 mg. On 01/30/24 at 8:12 AM Director of Nursing (DON) reviewed the CSR logbook as well and agreed there was no way to know which dose was missed, because it did not state which punch card containing the medication was a whole tablet versus the half tablet. The DON stated there was a missing dose. The DON agreed there was not any nursing note to explain why the full ordered dose was not given. On 01/31/24 at 12:00 PM, the DON said she has tried to contact the pharmacy to get information about the punch cards being labeled the same and has not received any answer.

Based on record review and staff interview the facility failed to ensure the dietary staff had the appropriate competencies and skills sets to carry out the functions of the food and nutrition services. This was a random opportunity for discovery. Facility Census: #97 Findings include: a) On 01/29/24 at 10:58 AM the Dietary Director was unable to provide the required state food handlers cards for eight (8) of the fourteen (14) staff members in the kitchen area. This was confirmed with the Administrator on 01/29/24 at 1:30 PM at which time she stated she would see if there were any that were missing in the Human Resource file. However, on 01/31/24 at 11:10 AM, she was only able to provide an additional two (2) food handler cards. Therefore, six (6) of the fourteen (14) staff kitchen staff's food handler cards were not available.

Based on observation and staff interviews the facility failed to ensure menus were followed and residents received the correct serving of food items. This has the potential to affect all residents who receive nutrition from the kitchen. Facility census: 97 Findings included: a) On 1/29/24 at 12:06 PM, kitchen line staff were observed plating resident trays for the noon meal. The meal consisted of kielbasa, capri vegetable blend, and baked beans. Staff were using a scoop #12 which held 2.66 ounces to serve the kielbasa for the pure and ground diets. According to the Diet Guide Sheet, the #10 scoop should have been used. The #10 scoop held 3.25 ounces. Residents received a pureed and ground diet received .59 ounces less than the required serving size. Further observation on 01/29/24 at 12:10 PM, found the ground and pureed capri vegetable blend was also being served with scoop #12 which held 2.66 ounces when the Diet Guide Sheet showed the pureed and ground capri vegetable blend should have been served with #10 (3.25) ounce scoop. Residents receiving a pureed and ground diet received .59 ounces less than the required serving size. On 01/29/24 at 12:10 PM, the Regional Dietary Manager (RDM) #220 confirmed the wrong Disher/Scoops were being used to serve the kielbasa and capri vegetable blend.

e) Resident #40. An observation of the noon time meal on 01/29/24 of Resident #40's lunch tray showed that the resident was served a tray that consisted of Kielbasa, pork and beans, and Capri blend vegetables. The pork and beans and the Capri blend vegetable juice was running all over the plate and covered the bottom of the kielbasa. The roll was placed on top of the pork and beans and had absorbed all the juices. During an interview with Resident #40, at 12:15 PM on 01/29/24, she stated , They serve it like this all the time. It's disgusting. An interview, on 01/29/24 at 12:20 PM, with the administrator confirmed the meal was not attractive. She asked the resident if she wanted something else, the resident requested a hotdog. The Administrator took the tray back to the kitchen to get her something else to eat. Based on observation, staff interview and resident interview, the facility failed to serve and prepare food in a palatable, attractive, and appetizing manner. This had the potential to affect more than a minimal number of residents at the facility. Resident identifiers: #50 and #68. Facility Census: 97. Findings included: a) Resident #50 On 01/24/24 at 12:40 PM, observation found the resident in her room with her lunch meal tray. The resident was not eating the meal. When asked how her meal was, the resident stated, this food is crap, this is hard. The resident picked up a chicken tender and tapped it on her plate to demonstrate how hard the chicken tender was. The chicken tender did make a noise when tapped on the plate. The resident also said the chicken tenders were burnt on the edges. Observations found the chicken tenders were dry and crusty with dark brown discoloration around the edges. The resident added she didn't even order the chicken tenders because the menu said the meat was kielbasa. She said, I never order the chicken tenders because they are always hard and dried out. On 01/29/24 at 12:43 PM, the Administrator observed the meal with the resident and confirmed the chicken tenders were overcooked. b) Resident #68 During observation of the noon meal in the dining room on B- hallway on 01/30/24 at 12:44 PM, Resident #68 called the surveyor over to show that the tater tots were hard and over cooked. The resident demonstrated by throwing a tater tot onto the table. The tater tot bounced across the table. Registered Dietary Manager (RDM) # 220 confirmed the tater tot was hard and over cooked, he stated that he was working with the staff to start batch cooking in the deep fryer. The Administrator also came by the resident's table and confirmed the observation by stating, that's a hard tot. The administrator offered to get the resident another food item but the resident declined c) Breakfast Observation Observation of the kitchen serving area at approximately 7:15 AM on 01/30/24, with the Regional Dietary Manager (RDM) #221 found the scrambled eggs being served for breakfast had streaks of a brown discoloration and the bottom of the serving pan for the eggs on the steam table had a charred matter in the center of the pan . RDM #221 confirmed the scrambled eggs were overcooked and discolored with flakes of burnt eggs. Several plates containing the eggs had already left the kitchen for service to the residents. Staff in the kitchen continued to plate the scrambled eggs from the steam table for service to the residents. In addition, the Culinary Manager (CM) #98 was scrambling eggs in a skillet on the stove. The CM was using liquid egg whites from a carton. When asked if the scrambled eggs should be made with egg whites only, he stated this is all I have. The order did not come in. d) Food Temperatures On 01/30/24 at 8:10 AM, the temperature of the breakfast meal was obtained for the last tray served at the facility with Regional Dietary Manager (RDM) #221. The temperatures were as follows: Oatmeal, 94.1 degrees Fahrenheit (F) Pureed Ham, 120.4 degrees Fahrenheit (F) Scrambled eggs, 116 degrees Fahrenheit (F) RDM #221 said he would have expected the temperatures to be at 120 degrees (F) or higher. Then he added he was not sure about the temperatures in this state. At 9:26 AM on 1/30/24, the above observations were discussed with the administrator. Review of the grievance concern logs completed on 12/07/23, 11/07/23 and 11/29/23 found residents complained of cold food. The facility resolved the grievances by speaking with dietary to ensure food would be served at the proper temperatures.

Based on observation, record review, and staff interview, the facility failed to procure, store, prepare, and serve food in a sanitary manner, by failing to store food containers in a sanitary manner, and by failing to record refrigerator temperatures. This was a random opportunity for discovery. This had the potential to affect more than a limited number of residents. Facility Census: 97. a) Kitchen observation At approximately 1:07 PM on 01/29/24, a plastic food container was removed from the dishwasher and placed on the drying rack in the dish room. The container was sealed with the lid, with water inside, failing to allow it to properly air dry. Culinary Director (CD) #98 and Regional Dietary Manager (RDM) #220 witnessed the container on the drying rack, sealed with water inside, unable to properly air dry. b) On 01/29/24 at 08:25 PM, observation of the refrigerator in the warming kitchen off the dining room on the B hall temperature log posted on the refrigerator shows the last refrigerator temperature was checked on 08/16/23 morning shift According to the facility Policy for # HCSG Policy 019, Food Storage: Cold Foods Revision date 02/2023 an accurate thermometer will be kept in each refrigerator and freezer. A written record of daily temperatures will be recorded. This was confirmed with the Administrator on 01/29/24 at 8:28 PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility Census: 97. Findings included: a) Isolation Caddie At approximately 11:36 AM on 01/29/24, an observation was made of an isolation caddie on the door of room A14. The top right pocket contained candy, empty candy wrappers, and used medical gloves. Nursing Staff Scheduler (NSS) #24 witnessed the condition of the isolation caddie on the door of room A14. b) Clean linen cart At approximately 8:09 PM on 01/29/24, an observation was made of a clean linen cart on the A Hall of the facility, between rooms A5 and A7. This linen cart was uncovered, with the linens exposed, a jacket sitting on top of the cart, an open bottle of body wash and open bottle of lotion sitting on the clean linens on the top shelf. An open [NAME] Butter and an open bottle of soda was on the second shelf. At approximately 8:11 PM on 01/29/24, Executive Director (ED) #100 witnessed the clean lined cart open, with linens exposed, jacket on top of the cart, and open items on the cart.

Based on observation and staff interview, the facility failed to ensure the Daily Staffing Posting information was accurate and the facility failed to maintain the Daily Staffing Posting data for a minimum of 18 months. This was a random opportunity for discovery and had the potential to affect all residents. Facility Census: 97. Findings included: a) Accurate and Current Data On 1/31/24 at 8:00 AM the 1/06/24, 1/07/24, 1/27/23 and 1/28/24 Staffing Posting Forms were reviewed and the total number of Direct Care staff for each Direct Care department per shifts was not identified. On 1/31/24 at 8:10 AM the Administrator acknowledged that the Staffing Posting Forms reflect FTE's (full time equivalent's) and not the actual total number of Direct Care staff for each Direct Care department per shift as required. b) Maintain the daily Staffing Posting Form a minimum of 18 months On 1/29/24 at 3:06 PM a review of the Staffing Posting Form and the Punch Detail Report was completed for 1/06/24, 1/07/24, 1/27/23 and 1/28/24. The Staffing Posting Forms for 1/06/24 and 1/07/24 had handwritten corrections marked for the census line only. The Staffing Posting Form did not identify the callouts and illnesses that were indicated on the Punch Detail Reports for the nurse aides (NA's) sick call-out on 1/06/24, the NA sick call-out on 1/07/24, the NA sick-call out on 1/27/23, and the NA and Licensed Practical Nurse (LPN) sick call-outs on 1/28/24. On 1/29/24 at 3:15 PM, during an interview with the Administrator the Staffing Posting Forms were reviewed and the Administrator stated it looked like someone had printed this form from the computer and she would get with the Director of Nursing to find the originals. On 1/29/24 at 3:19 PM, the Administrator stated the original Staffing Posting Form is used to enter any necessary changes that may be written on the form into the data system and the original form is not kept. She further stated that the Staffing Posting Form provided for 1/06/24, 1/07/24, 1/27/23 and 1/28/24 were the electronically updated data. On 1/31/24 at 8:10 AM, the facility data retention requirements were reviewed with the Administrator. The Administrator acknowledged that the facility Staffing Posting Forms does not reflect the NA sick call-out on 1/06/24, the NA sick call-out on 1/07/24, the NA sick-call out on 1/27/23, and the NA and LPN sick call-outs on 1/28/24. She further acknowledged that the original Staffing Posting Forms for 1/06/24, 1/07/24, 1/27/23 and 1/28/24 are not available as they do not maintain the original Staffing Posting Form for the minimum of 18 months.

Based on observation and staff interview, the facility failed to ensure each resident received privacy during care. This was based on a random opportunity for discovery and was true for Resident #37, who was not provided privacy during an injection. Resident Identifier: Resident #37. Census: 71. Findings included: a) Resident #37 An observation, on 08/15/23 at 08:22 AM, revealed Licensed Practical Nurse (LPN) #22 administered two (2) injections to Resident #37, at a site located on the resident's abdomen. Prior to administering the injections, LPN #22 did not provide privacy for Resident #37, who was seated in a chair at the foot of the bed. LPN #22 lifted the resident's gown to chest level exposing the resident's undergarments and abdomen. The resident's roommate was in bed at this time, eating the breakfast meal. Resident #37's roommate had a direct view of the procedure being conducted. An interview, with LPN #22, on 08/15/23 at 08:24 AM, confirmed privacy had not been provided to the resident receiving the injections and should have been. An interview with the Administrator, on 08/22/23 at 8:05 AM, revealed it was a dignity issue and the resident was to have privacy. At this time, the Administrator provided a policy: Resident's Rights, NS-1021-00-VA, dated 08/11/17, which showed under Procedures, section d., residents were to have their privacy respected when treatment, medication, or care was being administered including, closing the door or privacy curtain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, observation, staff interview the facility failed to Promptly resolve a grievance concerning a non-working television (TV.) This was a random opportunity for discovery. Resident identifier: #229. Facility census: 71. Findings included: a) Resident #229 While observing a dressing change on 08/16/23 at 3:20 PM, Resident # 229 stated in the presents of RN #18 and RN#19 that her TV had not worked since she has been here. Resident #229 was admitted on [DATE]. RN #19 picked up the TV remote and turned the TV on. A blue screen came on saying no channels were available. Resident #229 said that was all it did and that she had asked for someone to fix it several times and was told they would let someone know; however, no one ever came to her room to look at the TV. Resident #229 was in a room alone due to being placed in Transmission Based Precautions (TBP). On 08/21/23 at 12:12 PM, a follow-up visit with Resident #229 found the TV was fixed the following day the resident spoke to this surveyor. During a meeting with the administrator on 08/21/23 at 12:37 PM, she was asked about how long the TV in Resident #229's room had not been working. She stated, I believe her TV was only down for two (2) days. The administrator had previously said in an interview that the TV repair service was in the facility last week due to the cable not working.

Based on resident interview, facility documents review, and staff interviews, the facility failed to implement written policies and procedures for reporting an allegation of abuse in a timely manner. This was true of one (2) out of three (3) residents reviewed in the care area of abuse and misappropriation of property. Resident Identifiers: Resident #229, #10. Facility census 71. Findings included: a) Policy The facility policy titled, [NAME] Virginia Abuse, Neglect, and Misappropriation. The accurate and timely identification of any event which would place our residents at risk is a primary concern of the facility. In the event an allegation is made, the facility will take measures to protect residents from harm during an investigation. Accurate and timely reporting of incident. Immediate reporting: not later than two (2) hours after the allegation is made if the events involve abuse or result in serious bodily injury. The resident's condition will be stabilized by nursing, if appropriate. 1. A physical examination (head-to-toe) will be performed by Director of Nursing or nurse designee and document in the resident's medical record. In the event the alleged perpetrator is a staff member that staff member will be removed from the areas of the resident living and interviewed by nursing on duty and asked to put their statement in w 1. The staff member will be escorted off the premises by another staff member. 2. The accused staff member will be suspended, by the Executive Director or designee, pending the outcome of the investigation of the incident. b) Resident #229 While observing a dressing change on 08/16/23 at 2:10 PM, Resident #229 reported to this surveyor and Registered Nurse (RN) #18 that Nurse Aide (NA)#47 hurt her and made her PICC-line bleed. Resident #229 said NA #47 was pulling her up in the bed by her left arm and it felt like it pulled the PICC-line out. Resident #229 went on to say when she told NA #47, she hurt her, NA#47 said, La-Di-Dah, prove it. This statement was witnessed by RN #18. Resident #229 said this incident occurred on Sunday evening 08/13/23. The dressing to the PICC-line had a large amount of dried blood inside of the dressing around the insertion site. RN #18 struggled to remove all the dried blood. The above information was reported to the Administrator by the surveyor on 08/16/23 at 3:37 PM, immediately after leaving the room of Resident #229. On 08/16/23 at 4:19 PM, Administrator and Social Services (SS) #93 came in the room with all the surveyors present to provide additional information about this allegation. SS #93 said, on Monday 08/14/23 someone poked their head in his door while he was busy getting ready for the stand-up meeting and told him he needed to go talk to (called Resident # 229 by last name). SS #93 said he did not know who told him, because he was busy, and they were behind him. SS #93 went on to say after the stand-up meeting as he was going to see Resident # 229 he ran into the son of Resident # 229 and asked him if his mother had said anything to him about someone hurting her. SS #93 was then asked how he knew he needed to talk to her about an alleged abuse before he talked to the resident. SS #93 pointed at the Administrator and said she told me that she (the Resident) said someone hurt her. The administrator shook her head to indicate no and said, I did not. SS #93 stated that the son went in the room with him and asked his mother, Who hurt you, Mom? Where are you hurt? Resident # 229 told the son she hurt me when she pulled me up and made me bleed. SS #93 said the son began pulling her top down and saying, Where, where, I don't see blood! SS #93 said he did not see any blood either. SS #93 demonstrated with his hands saying, Resident # 229 put both hands in the air and was waving them saying never mind, never mind it did not happen then just stop, to the son. SS#93 went on to say, So (called Resident # 229 by her last name) said it did not happen. SS #93 was asked if he had asked Resident # 229 if she wanted to talk to him after her son's visit, and why did he talk to her son before he talked to the resident SS #93 did not answer. Then the SS #93 raised his voice and put his open hands towards this surveyor and said very loudly, I have five (5) days to handle the reportable this and this is just Wednesday. SS #93 was asked if he had written a note or anything about his conversation with Resident #229 on 08/14/23. SS#93 replied he was busy but if he did it would be in the chart. A review of the chart did not find a notes made by SS #93. On 08/21/23 at 8:34 AM the following social service note dated 8/17/23 was discovered in the electronic chart: Type: Social Services Note SS was informed that resident had said she was hurt when being moved in bed last night. (Called resident's son by first name) was coming in and SS went with him to discuss with resident. (Called resident's son by first name) asked her where she was hurt, and she indicated her left shoulder. (Stated resident's sons first name) pulled her gown back and said to his mom there is no blood. Resident said Well it must be the other shoulder. The son looked there and once again said to his mom there is no blood. Resident said oh well I guess it didn't happen. Resident looked at SS and ask do you see any blood? SS replied no mama I do not see anything, and she once again said oh well it didn't happen. (Name of son) said that at times his mother's stories are inconsistent. As on 08/21/23 at 8:00 AM, there was no determination of capacity or incapacity for Resident #229 in the medical record. At 1:48 PM on 08/21/23, the Administrator was asked what the facility did after receiving the information regarding Resident # 229 on 08/16/23. The Administrator said she started the investigation after the surveyors left the building on or about 5 PM on 08/16/23. The administrator said she interviewed Resident # 229 herself and in her opinion, she was an inconsistent reporter and could not be relied on for information. The administrator insisted this surveyor review the typed pages of the interviews she did on 08/16/23 and 08/17/23 before she would provide the reportable information. A review of the reportable allegations found SS #93 did report to the nurse aide registry at the Office of Health Facility Licensure and Certification (OHFLAC) on 08/16/23. The report stated: Resident said when being moved up in bed she told (named NA #47 by name) that she hurt her. She said she told NA #47; NA #47 said La Di Da and walked * Summary of Statement: This nurse was in the room on 08/15/23 talking with the resident. Residents bed was raised in air and this nurse asked resident if I could put her bed down and she stated yes. Resident stated she wasn't feeling well but could not state specific details. Resident then asked about therapy services. Resident then went on to say they hurt her while pulling her up in bed. I asked her who and when and when and she could not tell me when. NA was in the room doing hand hygiene and when she stepped out the resident stated it was her but did not know the NA name or when. No specific pain or complaint of pain. This nurse notified SS#93 to follow up with the resident. This report also had a witness statement from RDCO #158 dated 08/15/23. Resident stated a girl pulled her up in the bed, hurt her arm and that's where the blood came from around her PICC-line. Resident described the girl as being thin with short black hair. Also stated it was night shift, then stated well she works during the day and night. Resident then stated it was (called NA#47 by first name). The surveyor asked if anyone else was helping NA#47. Resident stated I can't remember who it was. Resident stated when she told the girl it hurt when pulling her up the girl said La da di da. Resident then stated no one has brushed her teeth or hair since she's been here. Resident stated, I'm not trying to be a tattle tale. Signed by: RN #18 Dated: 08/16/23 Fax confirmation had the date and time the allegation mentioned above was reported on 08/16/23 at 5:17 PM. Agencies notified were: Adult Protection Services, Nurse Aide Registry - Office of Health Facilities Licensure and certification (nurse aide registry,) local policy department, local health department, and the Ombudsman. riting, signed and dated. c) Resident #10 A record review showed a progress note, dated 04/18/23 at 18:37 hours, that noted Resident #10's left middle finger was swollen due to a broken wrist and showed the resident had two (2) rings on the swollen middle finger. Orders were obtained by the physician to send the resident out to have the rings cut off. There was no evidence of the whereabouts of the rings when the resident returned to the facility. Further review of the progress notes, showed a note entered on 08/04/23, where the resident's daughter complained about the rings missing and wanted the issue looked into. There was no evidence the daughter's complaint was reported to the agencies in accordance with State law and there was no evidence a five (5) day follow-up of any investigation reported to the same agencies. An interview, with Social Services Designee #93, on 08/15/23 at 4:21 PM, revealed he was not aware of any missing items. SS #93, stated further, the allegation should have been reported and it had not been. An interview, with the Administrator, on 08/16/23 at 04:55 PM, revealed no jewelry had been found and the two (2) missing rings should have been reported to the appropriate agencies. At the time of exit, on 08/22/23, there was no further information provided, by the facility, regarding Resident #10's missing rings. .

b) Resident #229 While observing a dressing change on 08/16/23 at 2:10 PM, Resident #229 reported to this surveyor and Registered Nurse (RN) #18 that Nurse Aide (NA)#47 hurt her and made her PICC-line bleed. Resident #229 said NA #47 was pulling her up in the bed by her left arm and it felt like it pulled the PICC-line out. Resident #229 went on to say when she told NA #47, she hurt her, NA#47 said, La-Di-Dah, prove it. This statement was witnessed by RN #18. Resident #229 said this incident occurred on Sunday evening 08/13/23. The dressing to the PICC-line had a large amount of dried blood inside of the dressing around the insertion site. RN #18 struggled to remove all the dried blood. The above information was reported to the Administrator by the surveyor on 08/16/23 at 3:37 PM, immediately after leaving the room of Resident #229. On 08/16/23 at 4:19 PM, Administrator and Social Services (SS) #93 came in the room with all the surveyors present to provide additional information about this allegation. SS #93 said, on Monday 08/14/23 someone poked their head in his door while he was busy getting ready for the stand-up meeting and told him he needed to go talk to (called Resident # 229 by last name). SS #93 said he did not know who told him, because he was busy, and they were behind him. SS #93 went on to say after the stand-up meeting as he was going to see Resident # 229 he ran into the son of Resident # 229 and asked him if his mother had said anything to him about someone hurting her. SS #93 was then asked how he knew he needed to talk to her about an alleged abuse before he talked to the resident. SS #93 pointed at the Administrator and said she told me that she (the Resident) said someone hurt her. The administrator shook her head to indicate no and said, I did not. SS #93 stated that the son went in the room with him and asked his mother, Who hurt you, Mom? Where are you hurt? Resident # 229 told the son she hurt me when she pulled me up and made me bleed. SS #93 said the son began pulling her top down and saying, Where, where, I don't see blood! SS #93 said he did not see any blood either. SS #93 demonstrated with his hands saying, Resident # 229 put both hands in the air and was waving them saying never mind, never mind it did not happen then just stop, to the son. SS#93 went on to say, So (called Resident # 229 by her last name) said it did not happen. SS #93 was asked if he had asked Resident # 229 if she wanted to talk to him after her son's visit, and why did he talk to her son before he talked to the resident SS #93 did not answer. Then the SS #93 raised his voice and put his open hands towards this surveyor and said very loudly, I have five (5) days to handle the reportable this and this is just Wednesday. SS #93 was asked if he had written a note or anything about his conversation with Resident #229 on 08/14/23. SS#93 replied he was busy but if he did it would be in the chart. A review of the chart did not find a notes made by SS #93. On 08/21/23 at 8:34 AM the following social service note dated 8/17/23 was discovered in the electronic chart: Type: Social Services Note SS was informed that resident had said she was hurt when being moved in bed last night. (Called resident's son by first name) was coming in and SS went with him to discuss with resident. (Called resident's son by first name) asked her where she was hurt, and she indicated her left shoulder. (Stated resident's sons first name) pulled her gown back and said to his mom there is no blood. Resident said Well it must be the other shoulder. The son looked there and once again said to his mom there is no blood. Resident said oh well I guess it didn't happen. Resident looked at SS and ask do you see any blood? SS replied no mama I do not see anything, and she once again said oh well it didn't happen. (Name of son) said that at times his mother's stories are inconsistent. As on 08/21/23 at 8:00 AM, there was no determination of capacity or incapacity for Resident #229 in the medical record. At 1:48 PM on 08/21/23, the Administrator was asked what the facility did after receiving the information regarding Resident # 229 on 08/16/23. The Administrator said she started the investigation after the surveyors left the building on or about 5 PM on 08/16/23. The administrator said she interviewed Resident # 229 herself and in her opinion, she was an inconsistent reporter and could not be relied on for information. The administrator insisted this surveyor review the typed pages of the interviews she did on 08/16/23 and 08/17/23 before she would provide the reportable information. A review of the reportable allegations found SS #93 did report to the nurse aide registry at the Office of Health Facility Licensure and Certification (OHFLAC) on 08/16/23. The report stated: Resident said when being moved up in bed she told (named NA #47 by name) that she hurt her. She said she told NA #47; NA #47 said La Di Da and walked * Summary of Statement: This nurse was in the room on 08/15/23 talking with the resident. Residents bed was raised in air and this nurse asked resident if I could put her bed down and she stated yes. Resident stated she wasn't feeling well but could not state specific details. Resident then asked about therapy services. Resident then went on to say they hurt her while pulling her up in bed. I asked her who and when and when and she could not tell me when. NA was in the room doing hand hygiene and when she stepped out the resident stated it was her but did not know the NA name or when. No specific pain or complaint of pain. This nurse notified SS#93 to follow up with the resident. This report also had a witness statement from RDCO #158 dated 08/15/23. Resident stated a girl pulled her up in the bed, hurt her arm and that's where the blood came from around her PICC-line. Resident described the girl as being thin with short black hair. Also stated it was night shift, then stated well she works during the day and night. Resident then stated it was (called NA#47 by first name). The surveyor asked if anyone else was helping NA#47. Resident stated I can't remember who it was. Resident stated when she told the girl it hurt when pulling her up the girl said La da di da. Resident then stated no one has brushed her teeth or hair since she's been here. Resident stated, I'm not trying to be a tattle tale. Signed by: RN #18 Dated: 08/16/23 Fax confirmation had the date and time the allegation mentioned above was reported on 08/16/23 at 5:17 PM. Agencies notified were: Adult Protection Services, Nurse Aide Registry - Office of Health Facilities Licensure and certification (nurse aide registry,) local policy department, local health department, and the Ombudsman. riting, signed and dated. Based on record review, facility documentation of reportable occurrences review, resident and staff interview, the facility failed to ensure that all alleged violations of abuse, were reported immediately, and failed to ensure the results of an investigation was reported within five (5) working days of the occurrence, to all officials (including to the State Survey Agency and Adult Protective Services (APS), where state law provides for jurisdiction in long-term care facilities) in accordance with State law, through established procedures. This deficient practice was found true for two (2) of three (3) residents reviewed. An allegation of abuse, the staff had knowledge of, was not reported, in a timely manner, involving Resident #229. An allegation of misappropriation of personal items, the facility had knowledge of, was not reported in a timely manner, for Resident #10. There was no evidence the results, of a five (5) day investigation, were reported in a timely manner involving Resident #10 and #229. Resident identifiers: Resident #10 and Resident #229. Census: 71. Findings included: a) Resident #10 A record review showed a progress note, dated 04/18/23 at 18:37 hours, that noted Resident #10's left middle finger was swollen due to a broken wrist and showed the resident had two (2) rings on the swollen middle finger. Orders were obtained by the physician to send the resident out to have the rings cut off. There was no evidence of the whereabouts of the rings when the resident returned to the facility. Further review of the progress notes, showed a note entered on 08/04/23, where the resident's daughter complained about the rings missing and wanted the issue looked into. There was no evidence the daughter's complaint was reported to the agencies in accordance with State law and there was no evidence a five (5) day follow-up of any investigation reported to the same agencies. An interview, with Social Services Designee #93, on 08/15/23 at 04:21 PM, revealed he was not aware of any missing items. SS #93, stated further, the allegation should have been reported and it had not been. An interview, with the Administrator, on 08/16/23 at 04:55 PM, revealed no jewelry had been found and the two (2) missing rings should have been reported to the appropriate agencies. At the time of exit, on 08/22/23, there was no further information provided, by the facility, regarding Resident #10's missing rings. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide an accurate and complete Minimum Data Set (MDS) assessment for Resident #31. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident Identifier: #31. Facility Census: 71. Findings Included: a) Resident #31 On 08/15/23 at 12:53 PM, the MDS modification of admission MDS dated [DATE] was reviewed. Under section I Active diagnoses, two (2) diagnoses were not indicated under the psychiatric/mood disorder section. The two (2) diagnoses that were not listed were anxiety disorder and depression. On 08/15/23 at 1:18 PM, MDS Registered Nurse (RN) #86 confirmed the diagnoses of anxiety disorder and depression were not included on the MDS. No further information was obtained during the long-term survey process. .

. Based on observation, record review, and staff interview, the facility failed to develop and/or implement the care plan with fall and pressure ulcer precautions for Resident #50 and dialysis instructions for dialysis for Resident #11. This was true for two (2) of 24 residents reviewed during the long-term survey. Resident Identifiers: #50 and #11. Facility Census: 71. Findings Included: a) Resident #50 On 08/14/23 at 3:07 PM, a record review was completed for Resident #50. A physician's order dated 05/13/23 stated, heel protectors when up every shift and a physician's order dated 08/13/23 also stated, resident to have elastic tubular stockings to BLE (bilateral lower extremities) as tolerated every shift. The care plan pressure ulcer precautions were reviewed and did list the intervention of tubular stockings to BLE as tolerated. However, the care plan did not list heel protectors when up every shift. On 08/14/23 at 1:15 PM, the resident was observed sitting in a scoot chair with no stockings to the bilateral lower extremities. The resident was observed with bare feet. This observation was confirmed by Nurse Aide (NA) #36. On 08/15/23 at 9:41 AM, the resident was observed again sitting in a scoot chair without wearing his stockings to the bilateral lower extremities or heel protectors in place. This observation was confirmed by Licensed Practical Nurse (LPN) #39. On 08/21/23 at 11:20 AM, a fall precaution intervention of bed will be placed by wall to better facilitate a home like environment for resident was found. On 08/21/23 at 11:22 AM, NA #36 confirmed the bed was not placed against the wall as the care plan stated. On 08/15/23 at 9:48 AM, the Administrator confirmed the pressure ulcer interventions were not being implemented. The Administrator stated, I'll get this taken care of right away. On 08/21/23 at 11:45 AM, Corporate Nurse #158 confirmed the care plan was not implemented regarding the fall precaution intervention. No further information was obtained during the long-term survey process. b) Resident #11 During an interview on 08/14/23 at 1:52 PM, Resident #11 stated she has dialysis three days a week with a pick up time of 11:40 AM. She states she does not get lunch prior to leaving. Breakfast is served at approximately 7:00 AM and therefore she does not eat again until dinner which is approximately 5:00 PM. Resident #11 states she was getting a sandwich but has not received anything for lunch for the last month. She would like lunch prior to leaving the facility for dialysis because she is a diabetic and gets hungry. Review of documented weight does not reflect a weight loss. Record review shows the order to read Dialysis: (name of center) . Dialysis days are Tuesday, Thursday, Saturday at 12:10 PM. Transportation provided by STAT ambulance services with pick up time at 11:40 AM. According to the Minimum Data Set (MDS) Section C dated 08/04/23, Resident #11 has a Brief Interview for Mental Status (BIMS) of fifteen (15). According to Physicians Determination of Capacity form dated 07/12/23 Resident #11 demonstrates capacity to make decisions. The facility Hemodialysis Care and Monitoring Policy and Procedure Section VIII Pre-Dialysis: . c. states: Provide meal or snack prior to leaving the facility for dialysis unless otherwise ordered. Review of the care plan for Resident #11 shows: Focus for potential for altered nutrition status/nutrition related problems due to Dialysis. She has a therapeutic diet order: Renal diet, regular texture, regular consistency. Goal reads: Resident will maintain adequate nutritional status through review date. Interventions/Tasks are: Communicate with dialysis center. Notify medical provider and resident representative of unplanned weight changes. Observe for s/sx of aspiration/dysphagia i.e. choking, coughing, pocketing food, loss of liquids/solids from mouth when eating/drinking, difficulty/pain when swallowing. Obtain labs per medical providers order. There is no care plan focus, goal or intervention for the facility to provide the resident with a lunch or snack prior to leaving for dialysis. This order was found to be discontinued on 06/28/23 and never restored: Bagged snack to be sent with resident to dialysis on Tu-Th-Sa No directions specified for order. Other Discontinued 06/28/2023 Revision Date 06/15/2023 During an interview on 08/15/23 at 10:52 AM with the Regional Director of Clinical Operations (RDCO) #159, she states there should be an order and a care plan for lunch to be provided prior to dialysis. She stated the Dietary Manager was out on this date. The RDCO went to the kitchen and returned to state there should have been a bag lunch sent to the refrigerator on the floor on dialysis days but she has no documentation of their procedure nor that they have been sending the lunch. She will implement an order, a procedure and make sure Resident #11 is provided lunch prior to dialysis.

Based on medical record review and staff interview the facility failed to have a complete discharge plan / recapitulation of stay. This is true for 1 of 3 Residents reviewed for discharge. Resident identifier #76. Facility census 71. Findings Included: a) Resident #76 Medical record review of Resident #76's discharge from the facility on 06/09/23 Revealed a Discharge summary / Recapitulation of stay completed 06/09/23 at 9:12 AM. Continued review found section D. Activities Director was incomplete. Section C. Dietary Services final summary was completed and signed by the Culinary Director 07/05/23. No Resident or Representative Signature in section E. Subsequent review of Resident #76's medical record showed no further information on the discharge / discharge planning. During an interview with the Director of Nursing on 08/15/23 at 1:48 PM, she stated that she would provide a copy of the summary with the Resident Signature. On 08/15/23 at 2:23 PM a second copy of the Discharge Summary / Recapitulation of stay completed 06/09/23 was provided. Section C Dietary Services final summary and section D. Activities Director was incomplete. Section E Signatures was signed by the Resident on 06/09/23. On 08/16/23 at 8:52 AM during an interview the DON verified the Discharge Summary / Recapitulation of stay was not completed to provide necessary information to continuing care providers pertaining to the course of treatment while the resident was in the facility and the resident's plans for care after discharge. She also confirmed there was no other documentation regarding Resident #76's discharge.

Based on resident interview, staff interview and record review the facility failed to provide a service for daily oral care for a dependent resident. This failed practice was true for One (1) out of one (1) reviewed for ADL care. Resident identifier: # 229. Facility census 71. Findings included: a) Resident #229 During an observation of a dressing change on 08/16/23 at 3:20 PM, Resident # 229 stated in the presents of Registered Nurse (RN) #18 and RN#19 that she has not had any oral care since she has been there. During a follow-up visit with Resident #229 on 08/21/23 at 11:52 AM, revealed Resident #229 stated she still had not received any oral care. She was asked if she had a toothbrush. Resident # 229 responded with; they have never given me one. During an interview, on 08/21/23 at 12:16 PM, Nurse Aide (NA) #11, was asked if she provided oral care for Resident #229 today. She replied yes, I did. NA #11 was asked if she could show the surveyor where the oral care supplies were kept in the room. NA #11 went in Resident #229's room and began looking in the drawer of the nightstand and in the wardrobe. NA #11 was unable to find any oral care products in the room of Resident #229. NA #11 was asked what kind of oral care did she provided. NA #11 explained that Resident #229 only has dentures, so she just put a fizzy tablet in the cup with the dentures. NA #11 was asked if a resident had natural teeth what would she do. NA #11 said, Of course I would make sure they had a toothbrush, toothpaste, and mouth wash. NA #11 was informed Resident #229 had natural teeth on the bottom and dentures only on the top. NA #11 stated she did have the supplies for natural teeth and denture care earlier but threw them away because she did not want someone to pick them up off of the floor and use them. On 08/21/23 at 1:10 PM, Director of Nursing was informed of the above conversation with NA #11.

Based on resident interview, staff interview and record review the facility failed to recognize, evaluate, and address the needs of a resident to ensure the resident was provided a bag lunch prior to going to dialysis three (3) days a week. This was true for two (2) of two (2) residents reviewed for dialysis services. Resident Identifier: #11 Facility Census: 71 Findings included: a) Resident #11 During an interview, on 08/14/23 at 1:52 PM, Resident #11 stated she has dialysis three days a week with a pickup time of 11:40 AM. She stated she did not get lunch prior to leaving. Breakfast was served at approximately 7:00 AM and therefore she did not eat again until dinner which was approximately 5:00 PM. Resident #11 stated she was getting a sandwich but had not received anything for lunch for the last month. She said she would like lunch prior to leaving the facility for dialysis because she was a diabetic and gets hungry. Review of documented weight does not reflect a weight loss. Record review shows the order to read Dialysis: (name of center) . Dialysis days are Tuesday, Thursday, Saturday at 12:10 PM. Transportation provided by (Name) of ambulance services with pick up time at 11:40 AM. According to the Minimum Data Set (MDS) Section C dated 08/04/23, Resident #11 has a Brief Interview for Mental Status (BIMS) of fifteen (15). According to Physicians Determination of Capacity form dated 07/12/23 Resident #11 demonstrated capacity to make decisions. The facility Hemodialysis Care and Monitoring Policy and Procedure Section VIII Pre-Dialysis: . c. states: Provide meal or snack prior to leaving the facility for dialysis unless otherwise ordered. Review of the care plan for Resident #11 shows: Focus for potential for altered nutrition status/nutrition related problems due to Dialysis. She has a therapeutic diet order: Renal diet, regular texture, regular consistency. Goal reads: Resident will maintain adequate nutritional status through review date. Interventions/Tasks are: Communicate with dialysis center. Notify medical provider and resident representative of unplanned weight changes. Observe for s/sx (signs and symptons) of aspiration/dysphagia i.e. choking, coughing, pocketing food, loss of liquids/solids from mouth when eating/drinking, difficulty/pain when swallowing. Obtain labs per medical providers order. There was no care plan focus, goal, or intervention for the facility to provide the resident with a lunch or snack prior to leaving for dialysis. This order was found to be discontinued on 06/28/23 and never restored. The order that started on 06/15/23 stated that a bagged snack was to be sent with the resident to dialysis Tuesday, Thursday, and Saturday. During an interview, on 08/15/23 at 10:52 AM, with Regional Director of Clinical Operations (RDCO) #159, she states there should be an order and a care plan for lunch to be provided prior to dialysis. She stated the Dietary Manager was out on this date. The RDCO went to the kitchen and returned to state there should have been a bag lunch sent to the refrigerator on the floor on dialysis days, but she has no documentation of their procedure nor that they have been sending the lunch. She will implement an order, a procedure and make sure Resident #11 is provided lunch prior to dialysis

Based on observation, Centers for Disease Control and Prevention (CDC) website review, and staff interview the facility failed to provide dressing changes that meet the professional standards of care. This was true for one (1) out of one (1) resident observed for peripherally inserted central catheter (PICC). Resident identifier: #229. Facility census 71. Findings included: a) Resident #229 During an observation of a PICC dressing change on 16/23 at 2:10 PM, for Resident # 229 with Registered Nurse (RN) #18 and RN#19 the following was observed: RN #18 removed the transparent dressing covering, donned sterile gloves, and tried to use a Chlorhexidine sponge (this type of sponge is on the end of a plastic handle filled with the Chlorhexidine and to be activated you have to squeeze the two (2) smaller tabs on the sides. Squeeze the tabs together and hold the sponge down to fill with the Chlorhexidine. RN #18 failed to hold the sponge pointing downward to fill with the cleanser. There was a large amount dried blood on and around the insertion site. RN #18 tried to take the catheter out of the securlock (a device used to prevent the catheter from being inadvertently removing the catheter.) RN #18 tried to remove for seven (7) minutes before giving up. RN#18 attempted to clean the blood down the catheter with the sponge, but the sponge was too large to fit between the catheter and the skin. RN #18 attempted this again with a second sponge. To prevent RN #18 from dislodging the catheter it was suggested she clean the dried blood by using the Chlorhexidine on the cotton swaps because those could easily fit between the catheter and the skin. It was suggested not to clean with the swab in a movement towards the insertion site but instead in a movement away from the insertion site. When RN #18 put the transparent dressing cover over the catheter there was still particles of dried blood on the catheter and around the site. The time of completing the dressing change was 3:35 PM. A surgical mask is required to be worn during a sterile dressing change. It is recommended that the nurse and the patient wear a mask. This was not done. According to the Centers for Disease Control and Prevention (CDC) PICC lines should be changed at least once per week. If the dressing becomes loose, wet, or dirty, the dressing must be changed more often to prevent infection. PICC line dressings must be inspected daily. Moist dressings are breeding grounds for infections. On 08/16/23 at 3:37 PM, the observation mentioned above was reported to the Administrator and Director of Nursing. On 08/21/23 at 12:10 PM, a follow-up visits to Resident #229 found the same dressing was still in place and still had the dried blood underneath the dressing. This was verified by the Assistant Director of Nursing at 12:16 PM on 08/21/23.

Based on record review, policy review and staff interview the facility failed to provide ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. This was true for one (1) of two (2) residents reviewed for dialysis services. Resident identifier: #11 Facility Census: 71 Findings Included: a) Resident #11 On 08/16/23 at 11:55 AM record review found several Pre and Post Dialysis Evaluations were missing. This was confirmed with the Regional Director of Clinical Operations (RDCO) #159 at this time. According to the facility Hemodialysis Care and Monitoring Policy and Procedure the facility will provide a method for on-going communications and collaboration for the development and implementation of the dialysis care plan. VIII Pre Dialysis a. Evaluation will be completed within four (4) hours of transportation to dialysis to include but not limited to: i. Accurate weight. ii Blood pressure, pulse, respirations and temperature. b. Medications administered or medication(s) withheld prior to dialysis. c. Provide meal or snack prior to leaving facility for dialysis unless otherwise ordered. d. Send copy of nursing evaluation with resident to dialysis center. i. Include MAR ii Emergency contact and facility contact information XI Post Dialysis a. Nurse to review notes from dialysis center. i Review resident tolerance to treatment. ii Review medications that may have been given during dialysis. iii Review if blood transfusion was given. 1. Check labs for hemoglobin/hematocrit values. iv Post dialysis notes will be unloaded into EHR or placed on hard medical record. b. Nurse to complete the post-dialysis evaluation upon return from dialysis center to include not not limited to: i Thrill absence or presence. ii Bruit absence or presence. iii Pulse in access limb - record number of beats per minute and character of pulse. iv Blood pressure, pulse, respirations, and temperature upon return to facility. v Visual inspection of site for bleeding, swelling, or other abnormalities. vi Any abnormal or unusual occurrence resident reports while at dialysis center. c. Allow resident time to rest. d. Provide meal or snack unless otherwise indicated. Record review of the Pre and Post dialysis evaluations on 08/16/23 at 2:10 PM found the following: The resident was out of the facility from June 28 through July 10, 2023. Her first dialysis treatment since returning was on 07/13/23. There have been fifteen (15) opportunities for Pre and Post evaluations since 07/14/23. Six (6) Pre dialysis evaluations are not completed and five (5) Post dialysis evaluations are not completed. 07/18/23 Pre and Post dialysis evaluations are not completed 07/20/23 Pre and Post dialysis evaluations are not completed 07/22/23 Pre and Post dialysis evaluations are not completed 07/27/23 Pre dialysis evaluation is not completed 08/01/23 Pre and Post dialysis evaluations are not completed 08/10/23 Pre and Post dialysis evaluations are not completed The above information was confirmed with the RDCO on 08/16/23 at 2:10 PM.

Based on record review and staff interview, the facility failed to complete the monthly medication reviews for Resident #51. This was true for one (1) of five (5) residents reviewed under the care area of unnecessary medications. Resident #51. Facility Census: 71. Findings Included: a) Resident #51 On 08/16/23 at 10:30 AM, a review of the monthly medication reviews from the pharmacy was completed. The review found a monthly review dated 05/07/23 recommending a gradual dose reduction (GDR) for Melatonin 3mg (milligrams) at HS (hours of sleep) was not completed or signed by the physician. On 08/16/23 at 12:10 PM, the Director of Nursing (DON) stated, May's was not done .I'm not sure why. No further information was obtained during the long-term survey process.

. Based on observation, record review, facility documentation review and staff interview, the facility failed to ensure the facility provided medications with an error rate of five (5) percent or less. This was found true for one (1) of four (4) residents observed during the medication administration task of the Long Term- Care Survey Process (LTCSP). The facility medication error rate was 7.69. Resident identifier: Resident #48. Census: 71 Findings included: a) Resident #48 An observation, of the medication pass for Resident #48, on 08/15/23 at 08:39 AM , showed a physician's order on the medication administration record, for Nasacort 1 spray in each nostril to be administered at 09:00 AM. Licensed Practical Nurse (LPN) # 39, stated at this time, the Nasocort was not in the medication cart. LPN #39, went on to prepare the oral medications for the resident. LPN #39 was observed to crush Keppra 750 mg. When questioned, LPN #39 stated if the medication was to be crushed there would be an order not to crush. The surveyor requested to see a Do Not Crush list , however, LPN #39 could not produce a list and indicated she did not know where to find one, while looking on the cart. A record review, showed a physician's order that read May crush meds or open capsules as needed unless on Do Not Crush list. May mix with food or fluids. Further interview with LPN #39, on 08/15/23 at 08:51 AM, revealed Resident #48 would not have the Nasocort until the evening hours and would not receive the nasal spray during the 9 AM medication pass, in accordance with the physician's orders noted in the electronic medical record During an interview with the Administrator on 08/15/23 at 10:12 AM , a 'Do Not Crush List was requested. The facility provided a do not crush list which contained the medication, Keppra 750 mg, as a medication that was not to be crushed and stated the staff had been in-serviced on it . During an interview with Registered Nurse (RN) #159, on 08/15/23 at 04:00 PM, information was provided that was obtained from the pharmacist titled LIST, dated February 2023-Resource #390224, which noted Keppra 750 mg was a medication on the Do Not Crush list. A record review noted Resident # 48 missed the dose of Nasocort Nasal spray on 08/15/23, with the medication not administered until the following day during the 9:00 AM medication pass. This was confirmed by interview on 08/16/23 at 04:15 PM with RN #158.

Based on record review and staff interview the facility must obtain laboratory services to meet the needs of the residents. The facility was responsible for the quality and timeliness of the laboratory services. This was true for one (1) of seven (7) residents reviewed for laboratory services during the Long-Term Care Survey Process. Resident identifier: #32 Facility census: 71. Findings included: a) Resident #32 A review of the medical record on 08/16/23, revealed Resident #32 had an order on 05/24/23 for a urinalysis with culture and sensitivity. The urine was collected on 05/24/23 and results of the culture and sensitivity were ready on or before 05/28/23. The facility made no effort to contact the laboratory services to obtain the results. The results were received by the facility on 06/01/23, and the nursing staff did not review the laboratory results for the urine culture until 06/05/23. The results indicated an abnormal acinetobacter baumannii. The delay in reviewing the laboratory results, also delayed the treatment of the urinary tract infection for Resident #32. An order was received on 06/05/23 to start Ertapenem one (1) gram intramuscularly (IM) daily for seven (7) days. In an interview with the Director of Nursing, (DON) on 08/16/23 at 10:00 AM, verified the results were not reviewed timely and this caused a delay in the order of the antibiotic needed to treat the urinary tract infection for Resident #32. Based on record review and staff interview the facility must obtain laboratory services to meet the needs of the residents. The facility was responsible for the quality and timeliness of the laboratory services. This was true for one (1) of seven (7) residents reviewed for laboratory services during the Long-Term Care Survey Process. Resident identifier: #32 Facility census: 71. Findings included: a) Resident #32 A review of the medical record on 08/16/23, revealed Resident #32 had an order on 05/24/23 for a urinalysis with culture and sensitivity. The urine was collected on 05/24/23 and results of the culture and sensitivity were ready on or before 05/28/23. The facility made no effort to contact the laboratory services to obtain the results. The results were received by the facility on 06/01/23, and the nursing staff did not review the laboratory results for the urine culture until 06/05/23. The results indicated an abnormal acinetobacter baumannii. The delay in reviewing the laboratory results, also delayed the treatment of the urinary tract infection for Resident #32. An order was received on 06/05/23 to start Ertapenem one (1) gram intramuscularly (IM) daily for seven (7) days. An interview with the Director of Nursing, (DON) on 08/16/23 at 10:00 AM, verified the results were not reviewed timely and this caused a delay in the order of the antibiotic needed to treat the urinary tract infection for Resident #32.

Based on record review and staff interview the facility failed to ensure the physician was promptly notified of laboratory results that fell outside of clincial reference ranges. This resulted in a delay of treatment for a resident who had a urinary tract infection. This was true for one (1) of seven (7) residents reviewed for laboratory services during the Long-Term Care Survey Process. Resident identifier: #32 Facility census: 71. Findings included: a) Resident #32 A review of the medical record on 08/16/23, revealed Resident #32 had an order on 05/24/23 for a urinalysis with culture and sensitivity. The urine was collected on 05/24/23 and results of the culture and sensitivity were ready on or before 05/28/23. The facility made no effort to contact the laboratory services to obtain the results. The results were received by the facility on 06/01/23, and the nursing staff did not review the laboratory results for the urine culture until 06/05/23. The results indicated an abnormal acinetobacter baumannii. The delay in reviewing the laboratory results, also delayed the treatment of the urinary tract infection for Resident #32. An order was received on 06/05/23 to start Ertapenem one (1) gram intramuscularly (IM) daily for seven (7) days. In an interview with the Director of Nursing, (DON) on 08/16/23 at 10:00 AM, verified the results were not reviewed timely and this caused a delay in the order of the antibiotic needed to treat the urinary tract infection for Resident #32. Findings included: a) Resident #32 A review of the medical record on 08/16/23, revealed Resident #32 had an order on 05/24/23 for a urinalysis with culture and sensitivity. The urine was collected on 05/24/23 and results of the culture and sensitivity were ready on or before 05/28/23. The facility made no effort to contact the laboratory services to obtain the results. The results were received by the facility on 06/01/23, and the nursing staff did not review the laboratory results for the urine culture until 06/05/23. The results indicated an abnormal acinetobacter baumannii. The delay in reviewing the laboratory results, also delayed the treatment of the urinary tract infection for Resident #32. An order was received on 06/05/23 to start Ertapenem one (1) gram intramuscularly (IM) daily for seven (7) days. An interview with the Director of Nursing, (DON) on 08/16/23 at 10:00 AM, verified the results were not reviewed timely and this caused a delay in the order of the antibiotic needed to treat the urinary tract infection for Resident #32.

Based on medical record review and staff interviews the facility failed to ensure documentation was accurate and correct. This was true for one (1) out of two (2) reviewed for dialysis. Resident identifier: #229, Facility census 71. Findings included: a) Resident #229 weights While reviewing the medical records for Resident #229 for the care area of dialysis it found in the weight file it was documented Resident #229 weighted 182.2 pounds on 08/05/23 and on 08/12/23 Resident #229 weighted 79.2 pounds. After a review of the dialysis communication sheet, it was found the 79.2 was supposed to be kilograms not pounds. The above information was shown to the Director of Nursing (DON). The DON agreed the weight was entered wrong on 08/15/23 02:54 PM. The DON agreed this was an inaccurate medical record. b) Resident #229 Chest x-ray A review of the Treatment Administration Record (TAR) found that Resident had an order to have a two (2) view chest x-ray every shift until 08/14/23. May DC (discontinue) order once obtained. Start date 08/11/23. On 08/11/23 from 7a to 7p shift Licensed Practical Nurse (LPN) #27 documented as completed. On 08/12/23 LPN #26 also documented it as done. On 08/14/23 Registered Nurse (RN) #94 documented on the 7A to 7P shift as completed. LPN #41 also documented the chest x-ray was completed on the 7P to 7A shift. Record review revealed the Chest x- was completed on 08/14/23 at 4:11 PM. On, 08/15/23 at 4:22 PM, Director of Nursing said she did not know why the nursing staff put check marks instead of a code to see a nursing note. Also, no nursing notes were provided for the above dates by the close of this survey.

. Based on observation, record review, resident interview and staff interview, the facility failed to thoroughly investigate allegations of abuse and/or neglect for four (4) of four (4) residents reviewed for the care area of abuse. Resident #51's elopement, Resident #3's wound care not being provided, missing rings for Resident #10 and allegations of verbal and physical abuse by a nursing assistant (NA) during repositioning of Resident #229 were not thoroughly investigated. Resident identifiers: #51, #3, #10 and #229. Facility Census: 71. Findings Included: a) Resident #51 On 08/21/23 at 3:00 PM, the facility reportable log was reviewed. Resident #51 was listed as an elopement from the facility on 07/28/23. The immediate reporting of allegations stated, SW (Social Worker) and DON (Director of Nursing) alerted to resident elopement by staff on the floor. Staff searched rooms and door/outside areas for resident. A staff leaving the facility saw her and stayed with her alerting DON that she was with the resident at the bottom of the hill. Staff member stayed with (Name of Resident) until the DON, SW, and UCN (unit charge nurse) arrived shortly after. The immediate action was listed as Elopement procedure started. (Typed as written.) However, upon reviewing the five (5) day investigation follow-up, SW #92 decided the allegation was unsubstantiated because the staff on the unit was busy with other residents. Also, SW #92 stated, the resident was at the bottom of the hill from the facility when the staff leaving work found her, but it wasn't substantiated because the staff was busy with other residents and didn't hear the door alarm. SW #92 stated, it did happen but it wasn't on purpose .they were busy. In conclusion on 08/21/23 at 3:30 PM, SW #92 did acknowledge the elopement did take place and stated, we will get this corrected right away. b) Resident #3 On 08/21/23 at 3:45 PM, the facility reportable log was reviewed. Resident #3 was listed as wound care not provided on 06/28/23. The immediate reporting of the allegation stated, Resident was due to have a dressing change daily starting yesterday on 06/28 after an ingrown toenail was removed His dressing was not changed per schedule. The immediate action stated, dressing changed, conference held with MPOA (Medical Power of Attorney), disciplinary action and inservice/education. Audit and investigation began. (Typed as written.) However, upon reviewing the five (5) day investigation follow-up, SW #92 decided the allegation was unsubstantiated because the staff states it was an unintentional med error. Upon reviewing the written statement from Registered Nurse (RN) #96 which stated I unintentionally looked over a wound care order to soak residents right great toe with Epsom salt and to apply band aid w/ (with) TAO (triple antibiotic ointment). (Typed as written.) The corrective action by the facility states, Family conference held, Unit charge nurse received disciplinary action, audit of wound care to be completed Dressing changed immediately, DON to supervise his dressing changes to ensure compliance. Education and in-services completed. (Typed as written.) On 08/21/23 at 4:00 PM, SW #92 stated, this incident did happen .however, it was an unintentional medication error . It was not substantiated because it wasn't intentional. In conclusion, SW #92 did acknowledge the wound care was not completed as ordered and the allegation was substantiated. No further information was obtained during the long-term survey process. c) Resident #229 While observing a dressing change on 08/16/23 at 2:10 PM, Resident #229 reported to this surveyor and Registered Nurse (RN) #18 that Nurse Aide (NA)#47 hurt her and made her PICC-line bleed. Resident #229 said NA #47 was pulling her up in the bed by her left arm and it felt like it pulled the PICC-line out. Resident #229 went on to say when she told NA #47, she hurt her, NA#47 said, La-Di-Dah, prove it. This statement was witnessed by RN #18. Resident #229 said this incident occurred on Sunday evening 08/13/23. The dressing to the PICC-line had a large amount of dried blood inside of the dressing around the insertion site. RN #18 struggled to remove all the dried blood. The above information was reported to the Administrator by the surveyor on 08/16/23 at 3:37 PM, immediately after leaving the room of Resident #229. On 08/16/23 at 4:19 PM, Administrator and Social Services (SS) #93 came in the room with all the surveyors present to provide additional information about this allegation. SS #93 said, on Monday 08/14/23 someone poked their head in his door while he was busy getting ready for the stand-up meeting and told him he needed to go talk to (called Resident # 229 by last name). SS #93 said he did not know who told him, because he was busy, and they were behind him. SS #93 went on to say after the stand-up meeting as he was going to see Resident # 229 he ran into the son of Resident # 229 and asked him if his mother had said anything to him about someone hurting her. SS #93 was then asked how he knew he needed to talk to her about an alleged abuse before he talked to the resident. SS #93 pointed at the Administrator and said she told me that she (the Resident) said someone hurt her. The administrator shook her head to indicate no and said, I did not. SS #93 stated that the son went in the room with him and asked his mother, Who hurt you, Mom? Where are you hurt? Resident # 229 told the son she hurt me when she pulled me up and made me bleed. SS #93 said the son began pulling her top down and saying, Where, where, I don't see blood! SS #93 said he did not see any blood either. SS #93 demonstrated with his hands saying, Resident # 229 put both hands in the air and was waving them saying never mind, never mind it did not happen then just stop, to the son. SS#93 went on to say, So (called Resident # 229 by her last name) said it did not happen. SS #93 was asked if he had asked Resident # 229 if she wanted to talk to him after her son's visit, and why did he talk to her son before he talked to the resident SS #93 did not answer. Then the SS #93 raised his voice and put his open hands towards this surveyor and said very loudly, I have five (5) days to handle the reportable this and this is just Wednesday. SS #93 was asked if he had written a note or anything about his conversation with Resident #229 on 08/14/23. SS#93 replied he was busy but if he did it would be in the chart. A review of the chart did not find a notes made by SS #93. On 08/21/23 at 8:34 AM the following social service note dated 8/17/23 was discovered in the electronic chart: Type: Social Services Note SS was informed that resident had said she was hurt when being moved in bed last night. (Called resident's son by first name) was coming in and SS went with him to discuss with resident. (Called resident's son by first name) asked her where she was hurt, and she indicated her left shoulder. (Stated resident's sons first name) pulled her gown back and said to his mom there is no blood. Resident said Well it must be the other shoulder. The son looked there and once again said to his mom there is no blood. Resident said oh well I guess it didn't happen. Resident looked at SS and ask do you see any blood? SS replied no mama I do not see anything, and she once again said oh well it didn't happen. (Name of son) said that at times his mother's stories are inconsistent. As on 08/21/23 at 8:00 AM, there was no determination of capacity or incapacity for Resident #229 in the medical record. At 1:48 PM on 08/21/23, the Administrator was asked what the facility did after receiving the information regarding Resident # 229 on 08/16/23. The Administrator said she started the investigation after the surveyors left the building on or about 5 PM on 08/16/23. The administrator said she interviewed Resident # 229 herself and in her opinion, she was an inconsistent reporter and could not be relied on for information. The administrator insisted this surveyor review the typed pages of the interviews she did on 08/16/23 and 08/17/23 before she would provide the reportable information. A review of the reportable allegations found SS #93 did report to the nurse aide registry at the Office of Health Facility Licensure and Certification (OHFLAC) on 08/16/23. The report stated: Resident said when being moved up in bed she told (named NA #47 by name) that she hurt her. She said she told NA #47; NA #47 said La Di Da and walked * Summary of Statement: This nurse was in the room on 08/15/23 talking with the resident. Residents bed was raised in air and this nurse asked resident if I could put her bed down and she stated yes. Resident stated she wasn't feeling well but could not state specific details. Resident then asked about therapy services. Resident then went on to say they hurt her while pulling her up in bed. I asked her who and when and when and she could not tell me when. NA was in the room doing hand hygiene and when she stepped out the resident stated it was her but did not know the NA name or when. No specific pain or complaint of pain. This nurse notified SS#93 to follow up with the resident. This report also had a witness statement from RDCO #158 dated 08/15/23. Resident stated a girl pulled her up in the bed, hurt her arm and that's where the blood came from around her PICC-line. Resident described the girl as being thin with short black hair. Also stated it was night shift, then stated well she works during the day and night. Resident then stated it was (called NA#47 by first name). The surveyor asked if anyone else was helping NA#47. Resident stated I can't remember who it was. Resident stated when she told the girl it hurt when pulling her up the girl said La da di da. Resident then stated no one has brushed her teeth or hair since she's been here. Resident stated, I'm not trying to be a tattle tale. Signed by: RN #18 Dated: 08/16/23 Fax confirmation had the date and time the allegation mentioned above was reported on 08/16/23 at 5:17 PM. Agencies notified were: Adult Protection Services, Nurse Aide Registry - Office of Health Facilities Licensure and certification (nurse aide registry,) local policy department, local health department, and the Ombudsman. riting, signed and dated. d) Resident #10 Record review revealed a progress note, dated 04/18/23 at 6:37 PM hours, that noted Resident #10's left middle finger was swollen due to a broken wrist and the resident had two (2) rings on the swollen middle finger. Orders were obtained by the physician to send the resident out to have the rings cut off. There was no evidence of the whereabouts of the rings when the resident returned to the facility. Further review of the progress notes showed a note entered on 08/04/23, where the resident's daughter complained about the rings missing and wanted the issue looked into. There was no evidence the daughter's complaint was investigated by the facility. An interview, with Social Services Designee #93, on 08/15/23 at 04:21 PM, revealed he was not aware of any missing items. SS #93, stated further, the allegation should have been investigated but was not. An interview, with the Administrator, on 08/16/23 at 04:55 PM, revealed no jewelry had been found and the allegation of two (2) missing rings should have been investigated. At the time of exit, there was no further information, regarding an investigation provided, regarding the missing rings. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise a care plan for Resident #51's actual elopement, discontinuation of fall precautions for Resident #50, current diagnoses for Resident #31, discontinuation of a urinary catheter for Resident #329 and an accrual of actual falls for Resident #278. This was true for five (5) of 24 residents reviewed during the long-term survey. Resident Identifiers: #51, #50, #31, #329 and #278. Facility Census: 71. a) Resident #51 On 08/21/23 at 9:00 AM, the care plan was reviewed for Resident #51. The resident was noted with an actual elopement on 07/28/23. However, the care plan listed risk for elopement on the care plan. The care plan had not been revised to reflect an actual elopement had taken place. On 08/21/23 at 11:45 AM, Corporate Nurse #158 confirmed the care plan had not been revised to reflect the actual elopement which occurred on 07/28/23. b) Resident #50 On 08/21/23 at 9:30 AM, the care plan was reviewed for Resident #50. A progress note dated 08/15/23 at 12:17 PM, states, New order to DC (discontinue) position change alarm to bed and chair. Resident removes alarm and throws and pulls cords out. The fall interventions of position change alarms to bed and chair had not been removed from the care plan. On 08/21/23 at 11:45 AM, Corporate Nurse #158 confirmed the discontinued fall precautions had not been removed from the care plan. c) Resident #31 On 08/15/23 at 11:00 AM, the care plan was reviewed for Resident #31. The care plan did not list two (2) of the resident's current diagnoses. The diagnoses were anxiety disorder and depression. On 08/15/23 at 1:18 PM, Registered Nurse (RN) #86 confirmed the diagnoses were not listed on the care plan. d) Resident #329 During the initial interview phase of the Long-Term Care Survey Process on 08/14/23 at 3:31 PM, it was observed that Resident #329 did not have a urinary catheter. This was confirmed with Licensed Practical Nurse #23 on 08/14/23 at 3:34 PM. Record review on 08/15/23 at 10:40 AM found the urinary catheter was discontinued on 08/10/23 at 4:41 PM. However, the care plan was not revised to reflect that the urinary catheter was discontinued. This was confirmed on 08/15/23 at 11:10 AM with the Director of Nursing. e) Resident #278 Resident # 278 was admitted on [DATE] and has had 12 falls, was sent out to the a local hospital on [DATE] and re-admitted on [DATE]. Dates of falls: 08/24/22 at 8:24 AM 08/24/22 at 9:39 AM 08/25/22 at 11:13 AM 08/27/22 at 10:03 AM 08/28/22 at 12:41 AM 08/31/22 at 4:11 PM 09/04/22 at 11:05 AM 09/06/22 at 5:30 AM 09/06/22 at 4:15 PM 09/07/22 at 7:45 AM 09/13/22 at 6:45 AM 10/01/22 at 3:00 AM The Care Plan did not reflect any of the actual falls. The care plan stated as a Focus Resident #278 is at risk for falls related to (nothing was written). During an interview on 08/15/23 at 1:23 PM, with Minimum Data Set (MDS) Nurse #86, she confirmed the care plan was not updated to reflect actual falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** g) Resident #50 On 08/15/23 at 3:07 PM, a record review was completed for Resident #50. The review found two (2) physician's orders regarding pressure ulcer precautions. The first physician's order was heel protectors when up every shift dated 05/13/23 and resident to have elastic tubular stockings to BLE (bilateral lower extremities) as tolerated every shift dated 08/13/23. On 08/14/23 at 1:15 PM, the resident was observed sitting up in a scoot chair with no elastic tubular stocking or heel protectors to the bilateral lower extremities. The resident was noted with bare feet. On 08/14/23 at 1:20 PM, Nurse Aide (NA) #36 confirmed the resident was not wearing the elastic tubular stocking or the heel protectors were in place. On 08/15/23 at 9:41 AM, the resident was observed sitting up in the scoot chair with no elastic tubular stockings or heel protectors to the bilateral lower extremities. On 08/15/23 at 9:42 AM, Licensed Practical Nurse (LPN) #39 confirmed the resident did not have the stockings or heel protectors in place. On 08/15/23 at 9:48 AM, the Administrator was notified the physician's orders for pressure ulcer precautions were not in place. The Administrator stated, I'll get this taken care of right away. h) Resident #51 Record review of the facility's undated policy titled, Neurological Checks (Neuro Checks), showed: Frequency of Neuro-Checks o Every 15 minutes times four (4). o Every 60 minutes times four (4). o Every 4 hours times four (4). o Daily times four (4) days. A record review revealed Resident #51's had an unwitnessed fall on 05/05/23 at 7:30 PM, Neuro Checks were started. Continued review for Resident #51's Neurological Evaluation from the fall on 05/05/23 found they were not completed as ordered. The fourth daily neuro check was not documented. During an interview on 08/22/23 at 9:30 AM the Director of Nursing acknowledged that Neurological Checks should have been completed per policy for resident #51's unwitnessed fall on 05/05/23. Based on record review, policy review and staff interview the facility failed to follow physicians orders. This was true in the care areas of late medication administration, missed medications, following orders for fall precautions, rechecking blood glucose level, performing neurological checks and reviewing laboratory results. Resident Identifiers: #20, #32, #38, #50, #51, #229, #278, #329. Facility Census: 71 Findings Included: a) Resident #38 1. Missed order to recheck blood glucose On 05/12/23 at 12:00 noon, the blood glucose level read HI on the glucometer. Indicating the blood glucose was over 500. According to the progress note on 05/12/23 at 13:48 PM, the provider was notified with a new order to administer 16 units of Novolog and recheck in 1 hour. The Novolog was administered as ordered, however there was no recheck on the blood glucose in one hour. This was confirmed with the Director of Nursing on 08/16/23 at 11:10 AM. No further documentation was provided. 2. Late administered medications Scheduled for 06/21/23 at 10:00 AM Administered on 06/21/23 at 11:43 AM (43 minutes late) Docusate Sodium Tablet 100 mg two times a day Lisinopril 10 mg one time a day Clonidine HCL tablet 0.2 mg two times a day Terazosin HCL Capsule 2 mg one time a day Ferrous Sulfate 325 mg one time a day MagOx 400 mg one time a day Lasix 20 mg two times a day Multi-Vitamin one tablet one time a day Potassium Tablet 20 meq one time a day Lexapro Tablet 10 mg one time a day Depakote Sprinkles Capsule DR 125 mg two times a day Miralax Powder 17 grams mixed in 4-8 ounces of beverage one time a day Vitamin D tablet 50 mcg one time a day Lantus Solution 100 units/ml insulin 10 units SQ one time a day Scheduled for 06/29/23 at 12:00 noon Administered on 06/29/23 at 01:22 PM (22 minutes late) Novolog solution 100 units/ml per sliding scale (4 units for a blood glucose of 249) Scheduled for 07/28/23 at 10:00 AM Administered on 07/28/23 at 01:51 PM ( 2 hours and 51 minutes late) Lexapro 10 mg tablet one time a day Clonidine HCL 0.1 mg tablet two times a day Depakote Sprinkles Capsule DR 250 mg two times a day Potassium 20 meq tablet one time a day Multi-Vitamin one tablet one time a day Lasix 20 mg two times a day Terazosin HCL Capsule 2 mg one time a day Ferrous Sulfate 325 mg one time a day MagOx 400 mg one time a day Lisinopril 10 mg one time a day Docusate Sodium Tablet 100 mg two times a day Miralax Powder 17 grams mixed in 4-8 ounces of beverage one time a day Vitamin D tablet 50 mcg one time a day Lantus Solution 100 units/ml insulin 10 units SQ one time a day Scheduled for 07/28/23 at 12:00 noon Administered on 07/28/23 at 01:56 PM (56 minutes late) Novolog solution 100 units/ml per sliding scale (8 units for a Blood glucose of 306) Scheduled for 08/01/23 at 6:00 AM Administered on 08/01/23 at 7:31 AM (31 minutes late) Seroquel 75 mg tablet three times a day Protonix DR 40 mg one time a day Tylenol 325 mg give 650 mg three times a day Ativan 0.5 mg tablet three times a day Scheduled for 08/16/23 at 10:00 AM Administered on 08/16/23 at 11:32 AM (32 minutes late) Lantus Solution 100 units/ml inject 10 units SQ one time a day Ducusate Sodium Tablet 100 mg two times a day According to the facility Medication Administration Policy Section B. Administration 11.) Medications are administered within sixty (60 minutes of scheduled time, except before, with or after meal orders, which are administered based on meal times. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility. Missed medications: Scheduled for 06/04/23 at 6:59 AM Administered MISSED Novolog solution 100 units/ml per sliding scale Blood glucose not obtained, no Novolog administered. Scheduled for 06/05/23 at 6:59 AM Administered MISSED Novolog solution 100 units/ml per sliding scale Blood glucose not obtained, no Novolog administered. Scheduled for 06/27/23 at 6:59 AM Administered MISSED Novolog solution 100 units/ml per sliding scale Blood glucose not obtained, no Novolog administered. 3. Missed blood glucose checks On 08/15/23 record review shows the following blood glucose checks were not completed. The resident has a history of diabetes with his blood glucose levels floating above 500. The following was confirmed with the Director of Nursing on 08/16/23 at 11:10 AM. 06/04/23 at 6:59 AM 06/05/23 at 6:59 AM 06/27/23 at 6:59 AM b) Resident #329 1. Missed medication On 08/07/23 at 9:00 PM Resident #329 was to received a dose of Cefdinir Oral Capsule 300 mg 1 capsule via PEG-tube two times a day for diverticulitis until 08/12/23 at 11:59 PM (for 10 doses total). This was her first dose and it was not administered. According to Nursing progress note dated 08/08/23 at 2:03 AM, the medication was not given due to Awaiting arrival from pharmacy. On 08/0823 she received the 9:00 AM dose, now her first dose. She received two doses on the following dates: 08/08/23, 08/09/23, 08/10/23, 08/11/23 and one dose on 08/12/23. Therefore she only received nine (9) of the ten (10) doses ordered. This missed medication error was confirmed with the Director of Nursing on 08/16/23 at 11:15 AM. 2. Late mediation administration Scheduled on 08/17/23 at 10:00 AM Administered on 08/17/23 at 11:46 AM (46 minutes late) Enteral Feed Order two times a day for Tube flush. Flush tube with at least 30 ml of water before and after each med pass and feeding. Scheduled on 08/07/23 at 6:00 AM Administered on 08/07.23 at 10:18 AM (3 hours and 18 minutes late) Enteral Feed Order three times a day Bolus Glucerna 1.5 240 milliliters (ml) three times a day Novolog injection solution 100 units/ml insulin per sliding scale (6 units for a blood glucose of 280) Scheduled on 08/18/23 at 04:00 AM Administered on 08/18/23 at 06:43 AM (1 hour and 43 minutes late. Enteral Feed order every 4 hours for Enteral tube flush. Flush Enteral tube with 200 ml of water Scheduled on 08/16/23 at 05:00 PM Administered on 08/16/23 at 07:22 PM (1 hour and 22 minutes late) Enteral Feed Order after meal bolus Glucerna 1.5 240 ml three times a day Novolog injection solution 100 units/ml per sliding scale (6 units for a blood glucose of 222) Scheduled on 08/17/23 at 8:00 AM Administered on 08/17/23 at 11:46 AM (2 hours and 46 minutes late) Enteral Feed order every 4 hours for Enteral tube flush. Flush Enteral tube with 200 ml of water Scheduled on 08/17/23 at 9:00 AM Administered on 08/17/23 at 11:46 AM (1 hour and 46 minutes late) Enteral Feed Order three times a day Bolus Glucerna 1.5 240 milliliters (ml) three times a day Macrobid oral capsule 100 mg via G tube two times a day for UTI Aspirin 81 mg tablet via G tube one time a day Furosemide Oral tablet 40 mg via G tube one time a day Losartan potassium tablet via G tube one time a day Metoprolol Tartrate 25 mg via G tube two times a day Glipizide 100 mg Tablet via G tube two times a day According to the facility Medication Administration Policy Section B. Administration 11.) Medications are administered within sixty (60 minutes of scheduled time, except before, with or after meal orders, which are administered based on meal times. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility. c) Resident #20 On 08/16/23 at 9:00 AM record review shows the following medications to be administered late according to the policy. Scheduled for 06/21/23 at 10:00 AM Administered on 06/21/23 at 11:58 AM (58 minutes late) Depakote Tablet Delayed Release give 1000 mg (milligrams) two (2) times a day Ascorbic Acid Tablet 500 mg give 1 tablet two times a day Lexapro Oral Tablet 10 mg one time a day Potassium Chloride ER Tablet 20 MEQ (milliequivalents-equilevant) one time a day AZO Cranberry Tablet 250-30 mg 1 Tablet two times a day Furosemide Tablet 40 mg two times a day Myrbetriq Tablet ET 50 mg one time a day Metoprolol Tartrate Tablet 50 mg two times a day Methenamine Hippurate tablet 1 Gram (GM) two times a day for UTI D-Mannose Powder give 500 mg two times a day Protonix Tablet DR 40 mg one time a day Eliquis Tablet 5 mg two times a day Refresh Tears Solution install 1 drop in both eyes one time a day UTI Stat liquid give 30 milliliter (ml) by mouth one time a day Scheduled for 06/21/23 at 10:00 PM Administered on 06/21/23 at 3:03 AM (4 hours and 3 minutes late) Cimetidine Tablet 400 mg Give 400 mg at bedtime Eliquis 5 mg two times a day for history of pulmonary embolism D-Mannose Powder give 500 mg two times a day Methenamine Hippurate tablet 1 Gram (GM) two times a day for UTI Metoprolol Tartrate Tablet 50 mg two times a day Furosemide Tablet 40 mg two times a day Flomax Capsule 0.4 mg at bedtime Depakote Tablet Delayed Release give 1000 mg (milligrams) two (2) times a day Sucralfate Tablet 1 GM one tablet before meals and at bedtime Seroquel Tablet 25 mg at bedtime Scheduled for 07/19/23 at 9:00 AM Administered on 07/19/23 at 10:30 AM (30 minutes late) Macrobid Oral Capsule 100 mg two times a day for UTI Scheduled for 07/28/23 at 10:00 AM Administered 07/28/23 at 1:58 PM (2 hours and 58 minutes late) Escitalopram Oxalate Tablet 15 mg one time a day AZO Cranberry Tablet 250-30 mg 1 Tablet two times a day Potassium Chloride ER Tablet 20 MEQ (milliequilevant) one time a day Depakote Tablet Delayed Release give 1000 mg (milligrams) two (2) times a day Ascorbic Acid Tablet 500 mg give 1 tablet two times a day Myrbetriq Tablet ET 50 mg one time a day Metoprolol Tartrate Tablet 50 mg two times a day Furosemide Tablet 40 mg two times a day Methenamine Hippurate tablet 1 Gram (GM) Refresh Tears Solution install 1 drop in both eyes one time a day UTI Stat liquid give 30 milliliter (ml) by mouth one time a day D-Mannose Powder give 500 mg two times a day Protonix Tablet DR 40 mg one time a day Eliquis Tablet 5 mg two times a day Sucralfate Tablet 1 GM one tablet before meals and at bedtime Scheduled for 08/01/23 at 06:00 AM Administered 08/01/23 at 7:34 AM (34 minutes late) Calcium Vitamin D table 1 tablet three times a day Scheduled for 08/09/23 at 06:59 AM Administered 08/09/23 at 10:46 AM (2 hours and 47 minutes late) Sucralfate Tablet 1 GM one tablet before meals and at bedtime Record review show the following medications were not administered in accordance to the above policy. Scheduled for 06/04/23 at 06:59 AM Administered MISSED Sucralfate Tablet 1 GM before meals and at bedtime Scheduled for 06/05/23 at 06:59 AM Administered MISSED Sucralfate Tablet 1 GM before meals and at bedtime Scheduled for 06/17/23 at 06:59 AM Administered MISSED Sucralfate Tablet 1 GM before meals and at bedtime Scheduled for 06/27/23 at 06:59 AM Administered MISSED Sucralfate Tablet 1 GM before meals and at bedtime The above late and missed medication findings were confirmed on 08/16/23 at 12:15 PM with the Director of Nursing. According to the facility Medication Administration Policy Section B. Administration 11.) Medications are administered within sixty (60 minutes of scheduled time, except before, with or after meal orders, which are administered based on meal times. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility. d) Resident #32 A review of the medical record on 08/16/23, revealed Resident #32 had an order on 05/24/23 for a urinalysis with culture and sensitivity. The urine was collected on 05/24/23 and results of the culture and sensitivity were ready on or before 05/28/23. The facility made no effort to contact the laboratory services to obtain the results. The results were received by the facility on 06/01/23, and the nursing staff did not review the laboratory results for the urine culture until 06/05/23. The results indicated an abnormal acinetobacter baumannii. The delay in reviewing the laboratory results, also delayed the treatment of the urinary tract infection for Resident #32. An order was received on 06/05/23 to start Ertapenem one (1) gram intramuscularly (IM) daily for seven (7) days. In an interview with the Director of Nursing, (DON) on 08/16/23 at 10:00 AM, verified the results were not reviewed timely and the delay in obtaining the order of the antibiotic needed to treat the urinary tract infection for Resident #32. e) Resident #229 A review of the medical records for Resident #229 discovered she was admitted on [DATE] to this facility. Resident #229 had an order to receive Midodrine HCL (this medication is used treat low blood pressure) oral tablet 5 mg three times a day with meals. A caution is with this medication stating it should be given three (3) to four (4) hours before bedtime or lying down (lying on your back could cause serve hypertension). Also, a warning not to double the dose and give at four-hour (4) intervals. Information obtained from Mayoclinic.org. A review of the facility form, Medication Admin Audit Report revealed the following medication were dispensed more than an hour late for Resident #229: A review of the Medication Administration Record (MAR) found Resident #229 missed five (5) doses due to being unavailable on 08/06/23 at 9 AM, 1 PM, and 6 PM, on 08/07/23 at 9 AM, 1 PM. In addition, the 6 PM dose was given on 08/08/23 at 12:23 AM, this was administered by Licensed Practical Nurse (LPN)#39. On 08/14/23 Registered Nurse (RN) #94 gave the 9 AM dose at 12:21 PM and documented she gave the 1 PM dose also at 12:23 PM on the same day. The Director of Nursing was shown the above findings on 08/22/23 at 8:25 AM. At the conclusion of this survey no additional information was given. f) Resident #278 A review of the medical record for Resident # 278 revealed, Resident #278 was admitted on [DATE] and had 12 falls. He was sent out to a local hospital on [DATE] and re-admitted on [DATE]. Dates of falls that did not have complete and/or failed to initiate neurological checks (a tool used to examine to determine if the nervous system is intact). *08/24/22 at 8:24 am not done *08/24/22 at 9:39 am not completed *08/25/22 at 11:13 am not completed *08/27/22 at 10:03 am not completed *08/28/22 at 12:41 pm not completed *09/06/22 at 5:30 am fall again on 09/06/22 4:15 PM did not start neuros over On 08/22/23 at 9:30 AM, the above situation was discussed with the Director of Nursing (DON.) No other information was provided.

Based on observations, Resident interviews, staff interviews, and record reviews the facility failed to ensure all staff had appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. These findings were true for one (1) out of one (1) in the care area of parenteral care, one (1) out of two (2) in the care area of dialysis, one (1) out of one (1) reviewed for Activities of daily Living (ADL), three (3) out of three (3) reviewed for abuse, five (5) out of five (5) reviewed for arbitration agreements, one (1) of one (1) reviewed for laboratory services, drug regimen reviews, medication error rate greater than five (5) percent, Quality Assurance and Assessment (QAA) meetings, Quality of care areas included: incomplete neurological assessments, late medication administration, not administering antibiotic and treatment timely and missed medications, and infection control. These practices have the potential to affect all residents at the facility. Facility census: 71. Findings included: a) Parenteral care 1. Resident #229 During an observation of a PICC dressing change on 16/23 at 2:10 PM, for Resident # 229 with Registered Nurse (RN) #18 and RN#19 the following was observed: RN #18 removed the transparent dressing covering, donned sterile gloves and tried to use a Chlorhexidine sponge (this type of sponge is on the end of a plastic handle filled with the Chlorhexidine and to be activated you have to squeeze the two (2) smaller tabs on the sides. Squeeze the tabs together and hold the sponge down to fill with the Chlorhexidine.) RN #18 failed to hold the sponge pointing downward to fill with the cleanser. There was a large amount dried blood on and around the insertion site. RN #18 tried to take the catheter out of the securlock (a device used to prevent the catheter from being inadvertently removing the catheter.) RN #18 tried to remove for seven (7) minutes before giving up. RN#18 attempted to clean the blood down the catheter with the sponge, but the sponge was too large to fit between the catheter and the skin. RN #18 attempted this again with a second sponge. To prevent RN #18 from dislodging the catheter it was suggested she clean the dried blood by using the Chlorhexidine on the cotton swaps because those could easily fit between the catheter and the skin. It was suggested not to clean with the swab in a movement towards the insertion site but instead in a movement away from the insertion site. When RN #18 put the transparent dressing cover over the catheter there was still particles of dried blood on the catheter and around the site. The time of completing the dressing change was 3:35 PM. A surgical mask is required to be worn during a sterile dressing change. It is recommended that the nurse and the patient wear a mask. This was not done. PICC lines should be changed at least once per week. If the dressing becomes loose, wet, or dirty, the dressing must be changed more often to prevent infection. PICC line dressings must be inspected on a daily basis. Moist dressings are breeding grounds for infections. The above was referenced by: https://www.cdc.gov. On 08/16/23 at 3:37 PM, the observation mentioned above was reported to the Administrator and Director of Nursing. On 08/21/23 at 12:10 PM, a follow-up visits to Resident #229 found the same dressing was still in place and still had the dried blood underneath the dressing. This was verified by the Assistant Director of Nursing at 12:16 PM on 08/21/23. b) Activities of daily living Resident #229 During an observation of a dressing change on 08/16/23 at 3:20 PM, Resident # 229 stated in the presents of Registered Nurse (RN) #18 and RN#19 that she has not had any oral care since she has been there. During a follow-up visit with Resident #229 on 08/21/23 at 11:52 AM, revealed Resident #229 stated she has still not received any oral care. She was asked if she had a toothbrush. Resident # 229 responded with; they have never given me one. During an interview on 08/21/23 at 12:16 PM Nurse Aide (NA) #11, she was asked if she provided oral care for Resident #229 today. She replied yes, I did. NA #11 was asked if she could show me where the oral care supplies are kept in the room of Resident #229. NA #11 went in Resident #229's room and began looking in the drawer of the nightstand and in the wardrobe. NA #11 was unable to find any oral care products in the room of Resident #229. NA #11 was asked what kind of oral care did she provide? NA #11 explained that Resident #229 only has dentures, so she just put a fizzy tablet in the cup with the dentures. NA #11 was asked if a resident had nature teeth what would she do? NA #11 said of course I would make sure they had a toothbrush, toothpaste, and mouth wash. NA #11 was informed Resident #229 had nature teeth on the bottom and dentures only on the top. That is when NA #11 stated she did have the supplies for denture and oral care earlier but threw them away because she did not want someone to pick them up off of the floor and use them. On 08/21/23 at 1:10 PM, Director of Nursing was informed of the above conversation with NA #11. c) Dialysis care Resident #11 On 08/16/23 at 11:55 AM record review found several Pre and Post Dialysis Evaluations were missing. This was confirmed with the Regional Director of Clinical Operations (RDCO) #159 at this time. According to the facility Hemodialysis Care and Monitoring Policy and Procedure the facility will provide a method for on-going communications and collaboration for the development and implementation of the dialysis care plan. VIII Pre Dialysis a. Evaluation will be completed within four (4) hours of transportation to dialysis to include but not limited to: i. Accurate weight. ii Blood pressure, pulse, respirations and temperature. b. Medications administered or medication(s) withheld prior to dialysis. c. Provide meal or snack prior to leaving facility for dialysis unless otherwise ordered. d. Send copy of nursing evaluation with resident to dialysis center. i. Include MAR ii Emergency contact and facility contact information XI Post Dialysis a. Nurse to review notes from dialysis center. i Review resident tolerance to treatment. ii Review medications that may have been given during dialysis. iii Review if blood transfusion was given. 1. Check labs for hemoglobin/hematocrit values. iv Post dialysis notes will be unloaded into EHR or placed on hard medical record. b. Nurse to complete the post-dialysis evaluation upon return from dialysis center to include not not limited to: i Thrill absence or presence. ii Bruit absence or presence. iii Pulse in access limb - record number of beats per minute and character of pulse. iv Blood pressure, pulse, respirations, and temperature upon return to facility. v Visual inspection of site for bleeding, swelling, or other abnormalities. vi Any abnormal or unusual occurrence resident reports while at dialysis center. c. Allow resident time to rest. d. Provide meal or snack unless otherwise indicated. Record review of the Pre and Post dialysis evaluations on 08/16/23 at 2:10 PM found the following: The resident was out of the facility from June 28 through July 10, 2023. Her first dialysis treatment since returning was on 07/13/23. There have been fifteen (15) opportunities for Pre and Post evaluations since 07/14/23. Six (6) Pre dialysis evaluations are not completed and five (5) Post dialysis evaluations are not completed. 07/18/23 Pre and Post dialysis evaluations are not completed 07/20/23 Pre and Post dialysis evaluations are not completed 07/22/23 Pre and Post dialysis evaluations are not completed 07/27/23 Pre dialysis evaluation is not completed 08/01/23 Pre and Post dialysis evaluations are not completed 08/10/23 Pre and Post dialysis evaluations are not completed The above information was confirmed with the RDCO on 08/16/23 at 2:10 PM. d) Investigating abuse/ neglect / misappropriation of resident personal property 1) Resident #51 On 08/21/23 at 3:00 PM, the facility reportable log was reviewed. Resident #51 was listed as an elopement from the facility on 07/28/23. The immediate reporting of allegations stated, SW (Social Worker) and DON (Director of Nursing) alerted to resident elopement by staff on the floor. Staff searched rooms and door/outside areas for resident. A staff leaving the facility saw her and stayed with her alerting DON that she was with the resident at the bottom of the hill. Staff member stayed with (Name of Resident) until the DON, SW, and UCN (unit charge nurse) arrived shortly after. The immediate action was listed as Elopement procedure started. (Typed as written.) However, upon reviewing the five (5) day investigation follow-up, SW #92 decided the allegation was unsubstantiated because the staff on the unit was busy with other residents. Also, SW #92 stated, the resident was at the bottom of the hill from the facility when the staff leaving work found her, but it wasn't substantiated because the staff was busy with other residents and didn't hear the door alarm. SW #92 stated, it did happen but it wasn't on purpose .they were busy. In conclusion on 08/21/23 at 3:30 PM, SW #92 did acknowledge the elopement did take place and stated, we will get this corrected right away. 2) Resident #3 On 08/21/23 at 3:45 PM, the facility reportable log was reviewed. Resident #3 was listed as wound care not provided on 06/28/23. The immediate reporting of the allegation stated, Resident was due to have a dressing change daily starting yesterday on 06/28 after an ingrown toenail was removed His dressing was not changed per schedule. The immediate action stated, dressing changed, conference held with MPOA (Medical Power of Attorney), disciplinary action and inservice/education. Audit and investigation began. (Typed as written.) However, upon reviewing the five (5) day investigation follow-up, SW #92 decided the allegation was unsubstantiated because the staff states it was an unintentional med error. Upon reviewing the written statement from Registered Nurse (RN) #96 which states, I unintentionally looked over a wound care order to soak residents right great toe with epsome salt and to apply bandaid w/ (with) TAO (triple antibiotic ointment). (Typed as written.) The corrective action by the facility states, Family conference held, Unit charge nurse received disiplanary action, audit of wound care to be completed Dressing changed immediately, DON to supervise his dressing changes to ensure compliance. Education and inservices completed. (Typed as written.) On 08/21/23 at 4:00 PM, SW #92 stated, this incident did happen .however, it was an unintentional medication error . It was not substantiated because it wasn't intentional. In conclusion, SW #92 did acknowledge the wound care was not completed as ordered and the allegation was substantiated. No further information was obtained during the long-term survey process. 3) Resident #229 While observing a dressing change on 08/16/23 at 2:10 PM, Resident # 229 reported to this surveyor and Registered Nurse (RN) #18 that Nurse Aide (NA)#47 hurt her and made her PICC-line bleed. Resident #229 said NA #47 was pulling her up in the bed by her left arm and it felt like it pulled the PICC-line out. Resident #229 went on to say when she told NA #47, she hurt her, NA#47 said, La-Di-Dah, prove it. This statement was witnessed by RN #18. Resident #229 said this incident occurred on Sunday evening - 08/13/23. The dressing to the PICC-line had a large amount of dried blood inside of the dressing around the insertion site. RN #18 struggled to remove all of the dried blood. The above information was reported to the Administrator by the surveyor on 08/16/23 at 3:37 PM, immediately after leaving the room of Resident #229. On 08/16/23 at 4:19 PM, Administrator and Social Services (SS) #93 came in the room with all of the surveyors present to provide additional information about this allegation. SS #93 said, on Monday 08/14/23 someone poked their head in his door while he was busy getting ready for the stand-up meeting and told him he needed to go talk to (called Resident # 229 by last name). SS #93 said he did not know who told him, because he was busy, and they were behind him. SS #93 went on to say after the stand-up meeting as he was going to see Resident # 229. Then he ran into the son of Resident # 229 and asked him if his mother had said anything to him about someone hurting her? SS #93 was then asked how did he know he needed to talk to her about an alleged abuse before he talked to the resident? SS #93 pointed at the Administrator and said she told me that she (the Resident) said someone hurt her. The administrator shook her head to indicate no and said, I did not. SS #93 stated that the son went in the room with him and asked his mother, Who hurt you, Mom? Where are you hurt? Resident # 229 told the son she hurt me when she pulled me up and made me bleed. SS #93 said the son began pulling her top down and saying, Where, where, I don't see blood! SS #93 said he did not see any blood either. SS #93 demonstrated with his hands saying, Resident # 229 put both hands in the air and was waving them saying never mind, never mind it did not happen then just stop, to the son. SS#93 went on to say, So (called Resident # 229 by her last name) said it did not happen. SS #93 was asked if he had asked Resident # 229 if she wanted to talk to him after her son's visit, and also why did he talk to her son before he talked to the resident? SS #93 did not answer. Then the SS #93 raised his voice and put his open hands towards this surveyor and said very loudly, I have five (5) days to handle the reportable this and this is just Wednesday. SS #93 was asked if he had written a note or anything about his conversation with Resident #229 on 08/14/23? SS#93 replied he was busy but if he did it would be in the chart. A review of the chart did not find a note made by SS#93. On 08/21/23 at 8:34 AM the following note was discovered in the electronic chart: Type: Social Services Note Focus: Effective Date: 8/15/2023 08:28:00 Department: Social Services Position: Social Services Designee Created By: SS #93 Created Date: 8/17/2023 09:13:18 Note Text: SS was informed that resident had said she was hurt when being moved in bed last night. (Called resident's son by first name) was coming in and SS went with him to discuss with resident. (Called resident's son by first name) asked her where she was hurt, and she indicated her left shoulder. (Stated resident's sons first name) pulled her gown back and said to his mom there is no blood. Resident said Well it must be the other shoulder. The son looked there and once again said to his mom there is no blood. Resident said oh well I guess it didn't happen. Resident looked at SS and ask do you see any blood? SS replied no mama I do not see anything, and she once again said oh well it didn't happen. (Name of son) said that at times his mother's stories are inconsistent. As on 08/21/23 at 8:00 AM, there was no determination of capacity or incapacity for Resident #229 in the medical record. At 1:48 PM on 08/21/23, the Administrator was asked what the facility did after receiving the information regarding Resident # 229 on 08/16/23 ? The Administrator said she started the investigation after the surveyors left the building on or about 5 PM on 08/16/23. The administrator said she viewed Resident # 229 herself and in her opinion, she is an inconsistent reporter and cannot be relied on for information. The administrator insisted that this surveyor review the typed pages of her interviews she did on 08/16/23 and 08/17/23 before she would provide the reportable information. A review of the reportable found the following: Facility form titled: Nurse Aide Registry Immediate fax report of Allegation This form is to be completed in its entirety to report allegations of abuse, neglect or misappropriation of resident property by a nursing assistant. *Dated 08/14/23 (noting the date the resident reported the incident) *Is this report being submitted within 24 hours of the incident? NO * If no please explain: This was blank *Named of alleged perpetrator: NA #47 * Title NA * Allegation: Resident said when being moved up in bed she told (named NA #47 by name) that she hurt her. She said she told NA #47; NA #47 said La Di Da and walked away. *Name of victim: (named Resident #229) *Reported to APS: yes *APS report obtained: No *Name of complainant: (named Resident #229) *Signature and title of person completing form: (signed by SS #93) *Date: 08/16/23 - this was the date the incident was reported, 2 days after the facility received notification of the allegation. A facility form titled: Witness Statement *Name/Title of witness: (named Regional Director of Clinical Operation) RDCO #158 *Name/Title of person taking statement: (named Regional Director of Clinical Operation) RDCO #158 *Date of occurrence: 08/15/23 * Summary of Statement: This nurse was in the room on 08/15/23 talking with the resident. Residents bed was raised in air and this nurse asked resident if I could put her bed down and she stated yes. Resident stated she wasn't feeling well but could not state specific details. Resident then asked about therapy services. Resident then went on to say they hurt her while pulling her up in bed. I asked her who and when and when and she could not tell me when. NA was in the room doing hand hygiene and when she stepped out the resident stated it was her but did not know the NA name or when. No specific pain or complaint of pain. This nurse notified SS#93 to follow up with the resident. Signed by RDCO #158 Dated: 08/15/23 Facility form titled: Witness Statement *Name/Title: (named RN #18) *Name/title of person taking statement: (Named Director of Nursing (DON) #15 Summary statement: Resident stated a girl pulled her up in the bed, hurt her arm and that's where the blood came from around her PICC-line. Resident described the girl as being thin with short black hair. Also stated it was night shift, then stated well she works during the day and night. Resident then stated it was (called NA#47 by first name). The surveyor asked if anyone else was helping NA#47. Resident stated I can't remember who it was. Resident stated when she told the girl it hurt when pulling her up the girl said La da di da. Resident then stated no one has brushed her teeth or hair since she's been here. Resident stated, I'm not trying to be a tattle tale. Signed by: RN #18 Dated: 08/16/23 Fax confirmation had the date and time the allegation mentioned above was reported on 08/16/23 at 5:17 PM. Agencies notified were: Adult Protection Services, Nurse Aide Registry - Office of Health Facilities Licensure and certification (nurse aide registry,) local policy department, local health department, and the Ombudsman. 4) Resident #10 A record review showed a progress note, dated 04/18/23 at 18:37 hours, that noted Resident #10's left middle finger was swollen due to a broken wrist and showed the resident had two (2) rings on the swollen middle finger. Orders were obtained by the physician to send the resident out to have the rings cut off. There was no evidence of the whereabouts of the rings when the resident returned to the facility. Further review of the progress notes, showed a note entered on 08/04/23, where the resident's daughter complained about the rings missing and wanted the issue looked into. There was no evidence the daughter's complaint was investigated by the facility. An interview, with Social Services Designee #93, on 08/15/23 at 04:21 PM, revealed he was not aware of any missing items. SS #93, stated further, the allegation should have been investigated but was not. An interview, with the Administrator, on 08/16/23 at 04:55 PM, revealed no jewelry had been found and the allegation of two (2) missing rings should have been investigated At the time of exit, there was no further information, regarding an investigation provided, regarding the missing rings. e) Drug regimen reviews Resident #51 On 08/16/23 at 10:30 AM, a review of the monthly medication reviews from the pharmacy was completed. The review found a monthly review dated 05/07/23 recommending a gradual dose reduction (GDR) for Melatonin 3mg (milligrams) at HS (hours of sleep) was not completed or signed by the physician. On 08/16/23 at 12:10 PM, the Director of Nursing (DON) stated, May's was not done .I'm not sure why. No further information was obtained during the long-term survey process. f) Medication administration 1. Resident #48 An observation, of the medication pass for Resident #48, on 08/15/23 at 08:39 AM , showed a physician's order on the medication administration record, for Nasacort 1 spray in each nostril to be administered at 09:00 AM. Licensed Practical Nurse (LPN) # 39, stated at this time, the Nasocort was not in the medication cart. LPN #39, went on to prepare the oral medications for the resident. LPN #39 was observed to crush Keppra 750 mg. When questioned, LPN #39 stated if the medication was to be crushed there would be an order not to crush. The surveyor requested to see a Do Not Crush list , however, LPN #39 could not produce a list and indicated she did not know where to find one, while looking on the cart. A record review, showed a physician's order that read May crush meds or open capsules as needed unless on Do Not Crush list. May mix with food or fluids. Further interview with LPN #39, on 08/15/23 at 08:51 AM, revealed Resident #48 would not have the Nasocort until the evening hours and would not receive the nasal spray during the 9 AM medication pass, in accordance with the physician's orders noted in the electronic medical record During an interview with the Administrator on 08/15/23 at 10:12 AM , a 'Do Not Crush List was requested. The facility provided a do not crush list which contained the medication, Keppra 750 mg, as a medication that was not to be crushed and stated the staff had been in-serviced on it . During an interview with Registered Nurse (RN) #159, on 08/15/23 at 04:00 PM, information was provided that was obtained from the pharmacist titled LIST, dated February 2023-Resource #390224, which noted Keppra 750 mg was a medication on the Do Not Crush list. A record review noted Resident # 48 missed the dose of Nasocort Nasal spray on 08/15/23, with the medication not administered until the following day during the 9:00 AM medication pass. This was confirmed by interview on 08/16/23 at 04:15 PM with RN #158. g) Laboratory Services 1) Resident #32 A review of the medical record on 08/16/23, revealed Resident #32 had an order on 05/24/23 for a urinalysis with culture and sensitivity. The urine was collected on 05/24/23 and results of the culture and sensitivity were ready on or before 05/28/23. The facility made no effort to contact the laboratory services to obtain the results. The results were received by the facility on 06/01/23, and the nursing staff did not review the laboratory results for the urine culture until 06/05/23. The results indicated an abnormal acinetobacter baumannii. The delay in reviewing the laboratory results, also delayed the treatment of the urinary tract infection for Resident #32. An order was received on 06/05/23 to start Ertapenem one (1) gram intramuscularly (IM) daily for seven (7) days. An interview with the Director of Nursing, (DON) on 08/16/23 at 10:00 AM, verified the results were not reviewed timely and this caused a delay in the order of the antibiotic needed to treat the urinary tract infection for Resident #32. h) Arbitration Agreements A review of the facility Arbitration Agreement found: Right to Resend- -The Resident or his or her representative has the right to resend this Arbitration Agreement within thirty days after signing it. Arbitrator Appointment and Neutrality- -Under the Arbitration Agreement, disputes or claims arising between the parties will be resolved through binding arbitration and shall be conducted by one or more neutral arbitrators. If the parties are unable to agree on the appointment of a single arbitrator, each party shall appoint one arbitrator and the third arbitrator shall be appointed by the other two arbitrators. During an interview on 08/16/23 at 11:05 AM with Social Services Designees (SSD) #92 and #93, SSD #92 explained to this surveyor that she informs Residents or his or her representative they have 60 days to resend the Arbitration Agreement and that that the arbitrators are only chosen by the court system. SSD #92 was asked if there was documentation with this information. SSD #92 stated that this is how she has always explained it. An interview with the Director of Nursing on 08/16/23 at 12:01 PM, she verified that SSD #92 was explaining the Arbitration Agreement inaccurately. I) Quality of Care 1) Resident #38 1. Missed order to recheck blood glucose On 05/12/23 at 12:00 noon, the blood glucose level read HI on the glucometer. Indicating the blood glucose was over 500. According to the progress note on 05/12/23 at 13:48 PM, the provider was notified with a new order to administer 16 units of Novolog and recheck in 1 hour. The Novolog was administered as ordered, however there was no recheck on the blood glucose in one hour. This was confirmed with the Director of Nursing on 08/16/23 at 11:10 AM. No further documentation was provided. 2. Late administered medications Scheduled for 06/21/23 at 10:00 AM Administered on 06/21/23 at 11:43 AM (43 minutes late) Docusate Sodium Tablet 100 mg two times a day Lisinopril 10 mg one time a day Clonidine HCL tablet 0.2 mg two times a day Terazosin HCL Capsule 2 mg one time a day Ferrous Sulfate 325 mg one time a day MagOx 400 mg one time a day Lasix 20 mg two times a day Multi-Vitamin one tablet one time a day Potassium Tablet 20 meq one time a day Lexapro Tablet 10 mg one time a day Depakote Sprinkles Capsule DR 125 mg two times a day Miralax Powder 17 grams mixed in 4-8 ounces of beverage one time a day Vitamin D tablet 50 mcg one time a day Lantus Solution 100 units/ml insulin 10 units SQ one time a day Scheduled for 06/29/23 at 12:00 noon Administered on 06/29/23 at 01:22 PM (22 minutes late) Novolog solution 100 units/ml per sliding scale (4 units for a blood glucose of 249) Scheduled for 07/28/23 at 10:00 AM Administered on 07/28/23 at 01:51 PM ( 2 hours and 51 minutes late) Lexapro 10 mg tablet one time a day Clonidine HCL 0.1 mg tablet two times a day Depakote Sprinkles Capsule DR 250 mg two times a day Potassium 20 meq tablet one time a day Multi-Vitamin one tablet one time a day Lasix 20 mg two times a day Terazosin HCL Capsule 2 mg one time a day Ferrous Sulfate 325 mg one time a day MagOx 400 mg one time a day Lisinopril 10 mg one time a day Docusate Sodium Tablet 100 mg two times a day Miralax Powder 17 grams mixed in 4-8 ounces of beverage one time a day Vitamin D tablet 50 mcg one time a day Lantus Solution 100 units/ml insulin 10 units SQ one time a day Scheduled for 07/28/23 at 12:00 noon Administered on 07/28/23 at 01:56 PM (56 minutes late) Novolog solution 100 units/ml per sliding scale (8 units for a Blood glucose of 306) Scheduled for 08/01/23 at 6:00 AM Administered on 08/01/23 at 7:31 AM (31 minutes late) Seroquel 75 mg tablet three times a day Protonix DR 40 mg one time a day Tylenol 325 mg give 650 mg three times a day Ativan 0.5 mg tablet three times a day Scheduled for 08/16/23 at 10:00 AM Administered on 08/16/23 at 11:32 AM (32 minutes late) Lantus Solution 100 units/ml inject 10 units SQ one time a day Ducusate Sodium Tablet 100 mg two times a day According to the facility Medication Administration Policy Section B. Administration 11.) Medications are administered within sixty (60 minutes of scheduled time, except before, with or after meal orders, which are administered based on meal times. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility. Missed medications: Scheduled for 06/04/23 at 6:59 AM Administered MISSED Novolog solution 100 units/ml per sliding scale Blood glucose not obtained, no Novolog administered. Scheduled for 06/05/23 at 6:59 AM Administered MISSED Novolog solution 100 units/ml per sliding scale Blood glucose not obtained, no Novolog administered. Scheduled for 06/27/23 at 6:59 AM Administered MISSED Novolog solution 100 units/ml per sliding scale Blood glucose not obtained, no Novolog administered. 3. Missed blood glucose checks On 08/15/23 record review shows the following blood glucose checks were not completed. The resident has a history of diabetes with his blood glucose levels floating above 500. The following was confirmed with the Director of Nursing on 08/16/23 at 11:10 AM. 06/04/23 at 6:59 AM 06/05/23 at 6:59 AM 06/27/23 at 6:59 AM 2) Resident #329 1. Missed medication On 08/07/23 at 9:00 PM Resident #329 was to received a dose of Cefdinir Oral Capsule 300 mg 1 capsule via PEG-tube two times a day for diverticulitis until 08/12/23 at 11:59 PM (for 10 doses total). This was her first dose and it was not administered. According to Nursing progress note dated 08/08/23 at 2:03 AM, the medication was not given due to Awaiting arrival from pharmacy. On 08/0823 she received the 9:00 AM dose, now her first dose. She received two doses on the following dates: 08/08/23, 08/09/23, 08/10/23, 08/11/23 and one dose on 08/12/23. Therefore she only received nine (9) of the ten (10) doses ordered. This missed medication error was confirmed with the Director of Nursing on 08/16/23 at 11:15 AM. 2. Late mediation administration Scheduled on 08/17/23 at 10:00 AM Administered on 08/17/23 at 11:46 AM (46 minutes late) Enteral Feed Order [TRUNCATED]

Based on observation and staff interview, the facility failed to maintain the kitchen in a safe and sanitary manner in accordance with professional standards of practice. During the kitchen tour it was discovered the walk-in cooler had debris on the floor. The threshold seal was missing to the walk-in cooler and the serving lids for the steam table were stored on a dirty shelf, and the ice machine was not draining properly. This had the potential to affect all residents receiving nutrition from the kitchen. Facility census: 71. Findings included: a) Kitchen tour During the kitchen tour on 08/14/23 at 11:50 AM, it was discovered the floor to the walk-in cooler was dirty and needed to be cleaned and the threshold rubber sealing was missing to the walk-in cooler. The serving lids for the pans on the steam table were stored rim down on a dusty shelf and the ice machine drain lines were in direct contact with the floor drain, with no stop gap to prevent back flow. In an interview with the acting Dietary Manager (DM), on 08/14/23 at 12:01 PM, the DM verified the walk-in cooler needed to be cleaned, the rubber strip to the entrance to the walk-in cooler needed to be repaired. DM also verified the steam table lids were stored on a dusty shelf and the ice machine was not draining properly.

Based on staff interview and facility documentation the facility failed to explain the arbitration agreement to residents or their representatives to understand the terms of the agreement. This has the potential to affect all residents residing in the facility. Facility census: 71. Findings included: a) Binding Arbitration Agreement A review of the facility Arbitration Agreement found: Right to Resend- -The Resident or his or her representative has the right to resend this Arbitration Agreement within thirty days after signing it. Arbitrator Appointment and Neutrality- -Under the Arbitration Agreement, disputes or claims arising between the parties will be resolved through binding arbitration and shall be conducted by one or more neutral arbitrators. If the parties are unable to agree on the appointment of a single arbitrator, each party shall appoint one arbitrator and the third arbitrator shall be appointed by the other two arbitrators. During an interview on 08/16/23 at 11:05 AM with Social Services Designees (SSD) #92 and #93, SSD #92 explained to this surveyor that she informs Residents or his or her representative they have 60 days to resend the Arbitration Agreement and that that the arbitrators are only chosen by the court system. SSD #92 was asked if there was documentation with this information. SSD #92 stated that this is how she has always explained it. An interview with the Director of Nursing on 08/16/23 at 12:01 PM, she verified that SSD #92 was explaining the Arbitration Agreement inaccurately.

Based on observations and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed with to maintain a separation between the clean and soiled area of the laundry room to prevent contamination of airflow. This practice had the potential to affect more than an isolated number of residents. Facility census: 71. Findings included: a) Laundry Room During tour of the laundry area on 08/15/23 at 3:12 PM an observation found the door between clean and dirty laundry area open. This exposed clean clothes and linens being folded to soiled clothing and linens being sorted and washed. A continued observation revealed the door to outside from the dirty laundry opened. During an interview, on 08/15/23 at 3:20 PM, the laundry supervisor verified the doors were open. He verified the doors should not be propped open. He stated they were all the time telling laundry aides to keep the doors closed.

Based on facility documentation and staff interview the facility failed to have the minimum quarterly Quality Assessment and Assurance (QAA) meetings to identify and correct Quality deficiencies. This had the potential to affect more than an isolated number of residents that reside at the facility. Facility census: 71. a) QAA meetings Record review of the facility's undated policy titled, Quality Assurance performance Improvement (QAPI),showed the facility will have a QAPI meeting every month. On 08/22/23 at 9:45 AM a review of QAPI plan, policy and meeting sign in sheets revealed no documentation for QAA / QAPI meetings were available from 02/28/23 through 07/11/23. On 08/22/23 at 9:51 AM the Administrator stated that they don't have documentation of a QAA / QAPI meeting from 2/28/23 until 07/11/23.

. Based on observation, confidential resident interviews, medical record reviews and staff interviews, the facility failed to ensure residents substitutes of similar nutritive value when the residents did not choose to eat the food that was initially served. This was true for two (2) of six (6) residents reviewed for substitutes and had the potential to affect a limited number of residents. Resident identifiers: Confidential resident interviews. Facility census: 76. Findings included: a) Confidential Resident Interviews Two (2) confidential resident interviews were conducted with residents who requested they remain nameless. Both residents complained there was not enough food being served. They both stated the only substitute they had was cottage cheese and fruit. One of the residents explained that the Resident Council voted each month on the substitute. Both confirmed that sometimes the facility did not have either the cottage cheese or the fruit. One of the residents stated that with the other company (company who previously owned the facility) they had at least three (3) options if they did not like the main menu and now they have nothing. One resident presented a paper which they explained every resident gets every morning which had the Lunch and Dinner menus for that day. On 06/14/23 lunch consisted of Hawaiian Baked Ham, buttered green beans, baked sweet potatoes, dinner roll and fresh fruit. The dinner menu was crispy breaded chicken, seasoned spinach, cornbread and cookies. Always Available for Lunch or Dinner Cottage Cheese/Fruit. In addition there was a statement that read Substitutions May Be Made Based on Physician's Order. When both residents were asked what the statement about substitutions meant, both residents denied any knowledge of the meaning of the substitution statement. Both stated they used to have salads, hamburgers and fries and other items to choose from as substitutes. They both said, now we have nothing. An interview, with the Dietary Manager (DM) on 06/14/23 at 9:20 AM, revealed that due to dietary budget changes, the only option for a substitute was cottage cheese and fruit. The DM provided a copy of the menu for this day which showed Salisbury Steak, Capri Vegetable Blend and Parmesan noodles as a substitute for the lunch meal. Again the DM said that due to the dietary budget changes those items were not available. DM said the only alternative was cottage cheese and fruit. The DM also stated that even though the menu showed breakfast meat for each breakfast meal. The DM said the facility could only provide breakfast meat three (3) days per week. When the DM was asked about the menu that was given to the residents each day she stated that the Activity Director (AD) produced and distributed those to the residents. An interview with the Administrator, Corporate Nurse and Director of Nursing (DON), on 06/15/23 at 9:30 AM, found that although no one verified the current substitute did not meet the regulation, the substitutes had been changed and a variety of options were now available to the residents. These included cottage cheese with fruit, cheeseburger with menu sides, hot dog with menu sides, pinto beans/cornbread, chicken tenders with menu sides and a Chef Salad.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure two (2) of four (4) residents discharged from Medicare services, received a notice of Medicare non- coverage prior to the discharge. Resident identifiers: #25 and #387. Facility census: 85. Findings included: a) Resident #25 Record review found the resident began receiving Medicare skilled services on 04/01/22, when readmitted to the facility after a hospital stay. On 12/08/21 the physician determined the resident had capacity to make medical decisions. According to the form entitled Beneficiary Notice, provided by the facility during the survey, the resident's discharge date from Medicare services was 06/01/22. The resident remained at the facility with skilled days remaining after termination of skilled care services. On 06/28/22 at 2:15 PM, the administrator confirmed she was unable to find evidence the Centers for Medicare Services (CMS) forms 10055 and 10123 were provided to the resident notifying the resident skilled services were ending. b) Resident #387 Record review found the resident was admitted to the facility on [DATE]. The resident was receiving skilled services and the payer source was Medicare. On 03/18/22, the resident was discharged to home. On 06/29/22 at 8:27 AM, the Certified Occupational Therapy Assistant (COTA) #101 said the Resident had met her goals in therapy and was being discharged from Medicare services. This was a facility initiated discharge from skilled services. On 06/29/22 at 8:30 AM, the administrator said she was unable to find evidence the resident received the notice of Medicare Non-coverage. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to timely submit a correct discharge tracking Minimum Data Sets (MDS) for Resident # 86 and Resident #85 The MDS was inaccurate in the area of discharge status. This was true for two (2) of three (3) closed records reviewed during the Long Term Care Survey Process. Resident identifiers: #86 and #85. Facility census: 85 Findings included: a) Resident #86 A medical record review for Resident #86 revealed a discharge MDS had been coded as a acute care hospital discharge for Resident # 86, who was discharged to community on 05/05/22. During an interview with the Director of Nursing on 06/29/22 at 8:10 AM, she verified the discharge MDS tracking completed for Resident #86 was inaccurate in the area of discharge status. She verified the resident was discharge to the community (home) not to a acute care facility. b) Resident #85 A medical record review for Resident #85 revealed a discharge MDS had been coded as another nursing home or swing bed for Resident # 85 who was discharged to acute hospital on [DATE]. During an interview with the DON 06/29/22 at 9:03 AM, she verified the discharge MDS tracking completed when Resident #85 was inaccurate in the area of discharge status. She verified the resident was discharge to the acute hospital not to another nursing home or swing bed. .

. Based on record review and staff interview, the facility failed to ensure a complete and accurate Minimum Data Set (MDS) assessment for one (1) of 18 residents reviewed in the long-term care survey sample. Resident identifier: #32. Facility census: 85. Findings included: a) Resident #32 Review of Resident #32's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 06/20/22 showed a physician-prescribed weight loss had occurred. Further review of Resident #32's medical records showed the resident had experienced weight-loss. However, no physician-prescribed weight loss was documented in the records. During an interview on 06/28/22 at 10:55 AM, the Dietary Services Supervisor confirmed Resident #32's MDS with ARD 06/20/22 was incorrect and the resident's weight loss was not prescribed by the physician. No further information was provided through the completion of the survey process. .

. Based on observation, record review, staff interview and resident interview, the facility failed to ensure respiratory care was provided according to professional standards of practice. These were random opportunities for discovery. Resident Identifiers: #16 and #27. Facility Census: 85. Findings Included: a) Resident #16 On 06/27/22 at 11:33 AM, the oxygen tubing and nasal cannula were observed laying in the floor. On 06/27/22 at 11:35 AM, Licensed Practical Nurse (LPN) #72 verified the oxygen tubing and nasal cannula were laying in the floor. LPN #72 stated, I will get some new tubing right now. On 06/27/22 at 11:45 AM, the Administrator was notified. No further information was obtained during the survey process. b) Resident #27 During an interview with Resident #27 on 06/27/22 at 2:45 PM, reported her bilevel positive airway pressure (BiPAP) mask was not being cleaned. A medical record review on 06/28/22 revealed an order for the BiPAP to be cleaned daily with a start date of 06/07/22. In an interview on 06/28/22 at 3:30 PM with the Director of Nursing (DON), reported night shift was to do the cleaning of the BiPAP mask before being applied at night. The DON was unable to verify with any documentation that the task was being completed daily. .

. Based on medical record review and staff interview, the facility's consultant pharmacist failed to recognize and report irregularities to the attending physician. This was true for one (1) of five (5) residents reviewed for unnecessary medications. Resident #79. Facility census: 85. Findings include: a) Resident #79 Review of Resident 79's medical records revealed a physician's order dated 05/03/22 for: Metoprolol 25 milligrams (mg) two times daily for treatment of hypertension. Hold if heart rate (HR) is 60 beats per minute (bpm) and notify the physician. Review of Resident #79's Medication Administration Record (MAR) for May and June 2022 found from 05/03/22 through 06/28/22 no HR was recorded prior to the administration of Metoprolol as directed by the physician's orders. Consultant Pharmacist had completed a Medication Regimen Review (MRR) for Resident #79, on 05/19/22 and 06/22/22 and failed to recognize the Metoprolol was being administered without obtaining a HR as directed by the physician ordered parameters. On 06/29/22 at 10:12 AM, the Director of Nursing (DON) confirmed Resident #79's HR had not been obtained as directed by the physician ordered parameters. The Nursing Home Administrator (NHA) was present during the interview. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure complete and accurate Physician's Order for Scope of Treatment (POST) forms. This deficient practice had the potential to affect five (5) of eighteen residents reviewed in the long-term care sample. Resident identifiers: #13, #19, #35, #70 and #61. Facility census: 85. Findings included: a) Resident #13 Review of Resident #13's medical records showed a Physician's Order for Scope of Treatment (POST) form to indicate end-of-life wishes. A verbal consent for the POST form had been obtained from the resident's Power of Attorney (POA) on [DATE]. During an interview on [DATE], Social Worker #84 confirmed the POST form should have been signed by the POA during visitation or she should have mailed the form for his signature. No further information was provided through the completion of the survey. b) Resident #19 Review of Resident #19's medical records showed a Physician's Order for Scope of Treatment (POST) form to indicate end-of-life wishes. A verbal consent for the POST form had been obtained from the resident's Medical Power of Attorney (MPOA) on [DATE]. During an interview on [DATE] at 1:58 PM, the Medical Power of Attorney stated she visited the resident approximately every two (2) weeks. During an interview on [DATE], Social Worker #84 confirmed the POST form should have been signed by the MPOA. No further information was provided through the completion of the survey. c) Resident #35 Record review found the resident's responsible party had completed the post form via telephone with two witnesses on [DATE]. The POST form directed no Cardiopulmonary resuscitation (CPR), comfort measures with no decision made concerning medically assisted nutrition. The guidance for Health Care Professionals for Using the POST Form 2021 edition specifies: .The signature section provides a declaration on behalf of the patient (or incapacitated patient ' s Medical Power of Attorney (MPOA) representative or health care surrogate) related to their voluntary participation in the completion of the POST form and agreement with the orders on the form. The patient (or incapacitated patient ' s MPOA representative or health care surrogate) must sign and date this section for the form to be legally valid. If the incapacitated patient ' s MPOA representative or health care surrogate is unavailable at the time of form completion, this section can be signed by two witnesses for verbal confirmation of agreement from the patient ' s MPOA representative or health care surrogate. The form should be signed at the earliest available opportunity . On [DATE] at 8:19 AM, the Social Service Supervisor #86 stated, she has called the Resident's brother and he is coming in to sign the form, he lives locally. On [DATE] at 4:08 PM, the administrator confirmed she had no further information to provide. d) Resident #70 A medical record review on [DATE] revealed the POST signed by Resident #70 was not dated and the Primary Care Provider's name and telephone number had not completed. An interview with the Licensed Social Worker (LSW) on [DATE] at 8:56 AM, verified Resident #70 did not date her signature and the Primary Care Providers name and telephone number was not completed. e) Resident #61 A medical record review on [DATE] 08:14 AM revealed Resident #61 POST form dated [DATE] was completed by responsible party via telephone with two witness. During an interview on [DATE] at 9:01 AM Social Service Supervisor #86 stated we could have mailed it to the POA for the signature. .

. d) Resident #59 On 06/28/22 at 2:00 PM, a record review found a physician's order dated 06/23/22 for a fasting blood sugar (FS BS) twice daily and notify provider if the blood sugar is less than (<) 60 or greater than (>) than 350. The review found the blood sugar results were outside the perimeter four (4) times during the month of June, 2022. The physician was not notified three (3) out of the four (4) times. The three (3) blood sugar results outside the perimeter are as follows: --06/14/22 at 5:00 PM the result was 378 --06/18/22 at 5:00 PM the result was 358 --06/21/22 at 5:00 PM the result was 385 On 06/28/22 at 3:50 PM, the Director of Nursing (DON) confirmed there were no progress notes indicating the physician was contacted regarding the blood sugar results being outside the perimeter. No further information was obtained during the survey process. Based on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. For Resident #19, the weekly fingerstick blood glucose was not recorded. For Residents #59 and #35, professional standards for insulin therapy were not followed. For Resident #79, physician-ordered medication parameters were not followed. This deficient practice had the potential to affect four (4) of five (5) residents reviewed for unnecessary medications. Resident identifiers: #19, #59, #35, #79. Facility census: 85. Findings included: a) Resident #19 Review of Resident #19's medical records showed an order written on 06/20/22 for a fingerstick blood glucose to be obtained every Wednesday. The order was to begin on 06/22/22. Review of Resident #19's Treatment Administration Record (TAR) showed a check mark indicating the fingerstick blood glucose had been performed on 06/22/22 at 5:00 PM. However, the result of the fingerstick blood glucose had not been recorded on the TAR. The fingerstick blood glucose result was not recorded elsewhere in the resident's medical record. During an interview on 06/28/22 at 8:33 AM, the Director of Nursing confirmed Resident #19's fingerstick blood glucose result was not recorded in the medical records on 06/22/22. No further information was provided through the completion of the survey. b) Resident #35 Review of the physician's orders found an order for: NovoLOG Solution 100 UNIT/ML (Insulin Aspart),Inject as per sliding scale: if 0 - 59 = 0 Units Initiate standing order for hypoglycemia; 60 - 150 = 0 Units; 151 - 200 = 2 Units; 201 - 250 = 4 Units; 251 - 300 = 6 Units; 301 - 350 = 8 Units; 351 - 400 = 10 Units; 401 - 999 = 0 Units Notify Physician, subcutaneously four times a day related to Diabetes Mellitus due to underlying condition with Hyperglycemia. Notify physician if BG (blood glucose) <60 and >400 -Start Date: 04/02/22. On 06/27/22 at 4:27 PM, the Director of Nursing (DON) reviewed the June 2022 Medication Administration Record (MAR) and confirmed the following: On 06/01/22 the Resident blood glucose (BG) reading was 482. There was no evidence in the medical record the physician was contacted. On 06/02/22 the Resident's BG 503 at 5:00 PM. A progress note dated 06/02/22 at 5:58 PM: (Name of physician) contacted, awaiting orders. Will continue to monitor. There was no evidence the physician returned the telephone call and was aware of the BG reading. On 06/17/22, the Resident's BG was 464 at 12:00, and 478 at 5:00 PM. There was no evidence the physician was contacted. On 06/23/22, the resident's BG was 460 at 12:00 noon. A nursing note dated 12/23/22 at 12:57 PM noted, Not administered due to sliding scale. Again there was no evidence the physician was contacted. At the close of the survey no further information was provided. c) Resident #79 Review of Resident 79's medical records revealed a physician's order dated 05/03/22 for: Metoprolol 25 milligrams (mg) two times daily for treatment of hypertension. Hold if heart rate (HR) is 60 beats per minute (bpm) and notify the physician. Review of Resident #79's Medication Administration Record (MAR) for May and June 2022 found from 05/03/22 through 06/28/22 no HR was recorded prior to the administration of Metoprolol as directed by the physician's orders. Consultant Pharmacist had completed a Medication Regimen Review (MRR) for Resident #79 on 05/19/22 and 06/22/22 and failed to recognize the Metoprolol was being administered without obtaining a HR as directed by the physician ordered parameters. On 06/29/22 at 10:12 am the Director of Nursing (DON) confirmed Resident #79's HR had not been obtained as directed by the physician ordered parameters. The Nursing Home Administrator (NHA) was informed of these findings. .

. Based on observation and staff interview the facility failed to maintain the kitchen in a safe and sanitary manner in accordance with professional standards for food service safety. During the kitchen tour it was discovered the baking pans were stored on a dirty shelf and frozen beef patties were not dated after opening. This had the potential to affect a limited number of residents receiving nourishment from the kitchen. Facility census: 85 Findings included: a) Kitchen tour During the kitchen tour on 06/27/22 at 11:35 AM, it was discovered baking sheet pans and muffin tins were stored on a shelf with a crusty grease buildup. Also beef patties were found in the walk-in freezer not dated after opening. An interview with the Dietary Manager on 06/27/22 at 11:38 AM, verified the shelf needed to be cleaned and the beef patties were not dated after opening. .