Based on observation and staff interview, the facility failed to provide a dignified dining experience for Resident #43. This was a random opportunity for discovery. Resident identifier: #43. Facility Census: 94. Findings included: a) Resident #43 On 02/06/24 at 8:18 AM, an observation was made of Resident #43 being fed. However, Nurse Aide (NA) #59 was standing while assisting the resident with breakfast. On 02/06/24 at 8:25 AM, the Director of Nursing was notified and confirmed the NA should not be standing while feeding the resident.

Based on observation, review of the facility grievance/complaint forms, Resident Council meeting minutes, Resident Council meeting and staff interview, the facility failed to consider resident group views and act upon grievances and recommendations. The facility also failed to provide these groups with responses, action, and rationale taken regarding their concerns pertaining to issues of resident care and life in the facility. This was a random opportunity for discovery. These practices had the potential to affect more than a limited number of residents which reside in the facility. Resident identifier: #16, #44, #66 and #77. Facility Census: 94 Findings included: A review of the Center Operations Policies and Procedures policy title OPS204 with a revision date of 01/08/24 revealed the following: The Policy outline includes but is not limited to; The Administrator will serve as the Grievance Officer who is responsible for overseeing the grievance process, including the Civil Rights grievances/concerns, receiving and tracking grievances through to their conclusions, leading any necessary investigations by the facility, maintaining the confidentiality of all information associated with grievances, the identity of the patient for those grievances submitted anonymously, issuing written grievance decisions to the patient, and or coordinating with state and federal agencies, in consultation with the National Law Department, as necessary in light of specific allegations. The Process outline includes but is not limited to; 1. A description of the procedure for voicing grievances/ concerns will be on each unit in a prominent location and must include: 1.1 The right to file a grievance orally (meaning spoken) or in writing, the right to file grievances anonymously; 1.2 The contact information of the grievance official with whom a grievance can be filed, that is, their name, business address (mailing and email) and business phone number; 1.3 A reasonable expected time frame for completing the review of the grievance; 1.4 The right to obtain a written decision regarding their grievance; and 1.5 The contact information of independent entities with whom grievances may be filed, that is the pertinent Stage agency, Quality Improvement Organization, State Survey Agency, Quality Improvement Organization, State Survey Agency and State Long-Term Ombudsman program or protection and advocacy system. 3. Upon receipt of the grievance/concern, the Grievance/Concern Form will be initiated by the staff member receiving the concern. Patients and/or patient representatives/families may complete the Grievance/Concern Form and submit the completed form to a staff member. 4. Upon receipt of the Grievance/Concern Form, the Administrator or designee will document the grievance/concern on the Grievance Concern Log. 5. When the grievance/concern is logged, the Administrator and appropriate department manager will be notified. 5.1 Immediate action will be taken to prevent further potential violations of any patient right while the alleged violation is being investigated. 6. The department manager will: 6.1 Contact the person filing the grievance to acknowledge receipt; 6.2 Investigate the grievance; 6.3 Take corrective actions, if needed; 6.4 Engage the support of the Ombudsman, if warranted; and 6.5 Notify the person filing the grievance of resolution in a timely manner 7. Written resolution for grievances will be offered per the residents rights 8. Completed Grievance/Concern Forms will be reviewed and retained by the Administrator for a period of no less than three (3) years from the issuance of the grievance decision to assure the patient's interests have been addressed. 10. If the grievance/concern is unable to be resolved satisfactorily, refer the patient/representative to the Market President for assistance. 11. Review grievances/concerns at the Quality Improvement Committee meeting to identify trends. a) Wandering Residents Grievances During a Resident Council Meeting held on 02/06/24 at 2:27 PM, Resident #16, Resident #44, Resident #66 and Resident #77 expressed concerns with wanderers. They stated that they had told all leadership of their concerns verbally but nothing has ever been done. They also stated that they were not told the grievance process other than to report it to someone and they fill out a grievance for them. They stated that no interventions were put in place to prevent wanderers from entering their rooms and messing with or taking their belongings. On 02/06/24 at approximately 3:00 PM a review was completed and three (3) of seven (7) months of Resident Council Meeting Minutes identified the expressed concerns for wanderers made by the residents in the section for Compliments/Ideas/Preferences/Concerns/ Suggestions. - 10/03/23- Administration: Multiple residents upset over wanderers. -11/07/23- Social Services: Concerns about wanderers stealing. -12/05/23- Administration: communication, wanderers. The meetings noted above had been facilitated by the Recreational Director (RD) #27. On 02/06/24 at 3:19 PM during an interview with RD #27 on the grievance process when a verbal grievance was received during the resident council meetings, RD #27 stated that she would write it on a grievance form and give it to the appropriate department manager to resolve. She said she would then follow up to make sure the process was completed and needs were met. When reviewing the grievance log for resident council notes for 10/03/23, 11/07/23 and 12/05/23 with each noted complaints that residents were upset over wanderers RD #27 stated that she did not complete the grievance forms for these concerns. RD #27 stated that it was a building complaint and nothing could be done until the residents that wandered were placed somewhere else. RD #27 acknowledged that she should have completed the grievance process for each noted wanderer concern. b) Grievance responses, action, and rationale taken regarding the residents noted concerns During an interview with RD #27, on 02/06/24 at 3:19 PM, she stated that no one in leadership gave any insight because it came down to a residents rights issue. She further stated that all management including the Administrator and Social Worker talked about this every day that the residents remained in the building because it was an issue every day. She stated the feedback was always the same, the residents rights. She acknowledged that the complaining residents also had rights that were not met. RD #27 acknowledged the grievances were not completed and no responses or action were taken.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and staff interview, the facility failed to maintain privacy and confidentiality of medical records for Resident #43 and #295. These were random opportunities for discovery. Resident Identifiers: #43 and #295. Facility Census: 94. Findings Included: a) Resident #43 On 02/06/24 at 9:03 AM, while observing medication administration, Licensed Practical Nurse (LPN) #31 left the computer screen unattended with Resident #43's information visible. LPN #31 stated, I thought I locked it. On 02/06/24 at 9:30 AM, the Director of Nursing (DON) was notified and confirmed the computer screen should have been locked prior to leaving the area. b) Resident #295 On 02/06/24 at 9:30 PM, a tour of the 100 hall was completed. During the tour, the medication cart was sitting by room [ROOM NUMBER] in which Resident #295 resides. An observation of the computer screen unattended was made with Resident #295's information visible. LPN# 44 was inside of room [ROOM NUMBER] assisting the residents. LPN #44 confirmed the computer screen was visible to anyone walking down the 100 hall. On 02/07/24 at 8:50 AM, the Administrator was notified and confirmed the computer screen should not be visible to anyone walking down the 100 hall. No further information was obtained during the survey process.

. Based on observations, review of the facility grievance/complaint policy, Resident Council meeting and staff interview, the facility failed to make information on how to file a grievance or complaint available to the resident. This was a random opportunity for discovery. This practice had the potential to affect more than a limited number of residents which reside in the facility. Resident identifier: #16, #44, #66 and #77. Facility Census: 94. Findings included: A review of the Center Operations Policies and Procedures policy title OPS204 with a revision date of 01/08/24 revealed the following: The Process outline includes but is not limited to; 1. A description of the procedure for voicing grievances/ concerns will be on each unit in a prominent location and must include: 1.1 The right to file a grievance orally (meaning spoken) or in writing, the right to file grievances anonymously; 1.2 The contact information of the grievance official with whom a grievance can be filed, that is, their name, business address (mailing and email) and business phone number; 1.3 A reasonable expected time frame for completing the review of the grievance; 1.4 The right to obtain a written decision regarding their grievance; and 1.5 The contact information of independent entities with whom grievances may be filed, that is the pertinent Stage agency, Quality Improvement Organization, State Survey Agency, Quality Improvement Organization, State Survey Agency and State Long-Term Ombudsman program or protection and advocacy system. a) Grievance process information not available On 02/06/24 at 2:27 PM during Resident Council, Resident #16, Resident #44, Resident #66 and Resident #77 stated that they did not know the grievance process and that they were never told about a grievance form or how to file a grievance anonymously. On 02/06/24 at 3:19 PM during an interview with the Recreation Director (RD) #27 in regards to the grievance process. RD #27 was not aware of the process for anonymous grievances and/or if someone wanted to complete a grievance form themselves. At this time the RD #27 and surveyor began touring the building and looking for the posting of the description for the procedure of filing a grievance and the grievance forms availability for the residents. RD #27 asked the Administrator (NHA) where the information would be posted and the NHA asked RD #27 what was the process. The RD #27 and NHA then went to the Social Worker's (SW) #34 office and the NHA asked the SW #34 where would the residents get the information and forms. The SW #34 stated that she had the forms and they would have to come to her. When the NHA asked how would it be completed anonymously, the SW stated they could leave it under her door. At 3:31 PM on 02/06/24 the NHA acknowledged that the required process for grievances was not in place. .

. Based on record review and staff interview, the facility failed to notify the State Ombudsman of acute care transfers for Resident #6 and Resident #53. This is true for two (2) of four (4) residents reviewed under the care area of hospitalizations. Resident identifiers: #6 and #53. Facility census: 94. Findings included: a) Resident #6 On 02/07/24 at 11:12 AM, a record review was completed for Resident #6. The review found the resident had been transferred to an acute care facility on 06/12/23 for a temperature and headache and on 10/23/23 for chest pain. Upon completion of the review, the medical records department was asked to provide the confirmation of the State Ombudsman being notified of the transfers to the acute care facility. Medical Records Manager #10 provided the monthly fax receipts for June and October of 2023. However, the review found Resident #6's name was not listed on either monthly fax receipt. On 02/07/24 at 2:00 PM, Medical Records Manager #10 stated, I do not know why these transfers were not included in the monthly faxes. b) Resident #53 On 02/07/23 at 12:10 PM, a record review was completed for Resident #53. The review found the resident had been transferred to an acute care facility on 10/13/23 for abnormal laboratory results. Upon completion of the review, the medical records department was asked to provide the confirmation of the State Ombudsman being notified of the transfer to the acute care facility. Medical Records Manager #10 provided the monthly fax receipts for October of 2023. However, the review found Resident #53's name was not listed on the monthly fax receipt. On 02/07/23 at 2:05 PM, Medical Record Manager #10 stated, I don't know why this transfer was not included in the monthly fax. No further information was obtained during the long term survey process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to notify the resident and/or resident representative regarding the facility bed hold notice of policy and authorization. This is true for three (3) of four (4) residents reviewed under the care area of hospitalizations. Resident Identifiers: #6 , #53 and #10. Facility census: 94. Findings included: a) Resident #6 On 02/07/24 at 11:12 AM, a record review was completed for Resident #6. The review found the resident had been transferred to an acute care facility on 06/12/23 for a temperature and headache and on 10/23/23 for chest pain. Upon completion of the review, the medical records department was asked to provide the signed bed hold notice of policy and authorizations to the acute care facility. Medical Records Manager #10 provided the bed hold policies for both transfers. However, the bed hold policies dated for 06/12/23 and 10/23/23, did not have the signature of the resident or resident representative or date. The Center representative signature and date were blank as well. On 02/07/24 at 2:00 PM, Medical Records Manager #10 stated, I do not know why these were not completed. b) Resident #53 On 02/07/23 at 12:10 PM, a record review was completed for Resident #53. The review found the resident had been transferred to an acute care facility on 10/13/23 for abnormal laboratory results. Upon completion of the review, the medical records department was asked to provide the signed bed hold notice of policy and authorization to the acute care facility. Medical Records Manager #10 provided the bed hold policy for the transfer. However, the bed hold policy dated for 10/13/23 did not have the signature of the resident or resident representative or date. The Center representative signature and date were blank as well. On 02/07/23 at 2:05 PM, Medical Record Manager #10 stated, I don't know why this was not completed. No further information was obtained during the long term survey process. c) Resident #10 A record review, completed on 02/06/24 at 3:13 PM, revealed Resident #10 was transferred to the hospital on [DATE]. There was no evidence in the medical record that a Bed Hold Notice was given to resident/resident's representative. During an interview on 02/06/24 at 3:43 PM, the Director of Nursing (DON) confirmed the facility did not issue a bed hold notice to Resident #10's legal representative. The DON believed the reason for this was resident did not have any remaining Medicaid bed hold days. A review of the facility's Bed Hold Policy Notice was completed on 02/06/24 at 7:53 PM. The following details were outlined in the bed hold notice: -For residents with a Medicaid pay source, there may be instances when a resident leaves the center for temporary hospitalization. -A resident's bed would be held for them while they are in the hospital. -The section indicating the number of hospital bed hold days available to be used in order to guarantee the resident's bed would be held would be completed. -Additionally, the notice stated, If your hospitalization exceeds the number of (bed hold) days indicated, the resident may still return to their previous room, if available, or be readmitted to the first available bed in a semi-private room if you still require the center's services. On 02/06/24 at 10:10 AM, the DON confirmed the facility failed to issue the Bed Hold Notice which would have informed the resident's representative of the resident's right to be readmitted to the first available bed when ready to be released from the hospital. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to coordinate with the appropriate, State-designated authority, to ensure that individuals with a mental disorder, intellectual disability or a related condition receives care and services in the most integrated setting appropriate to their needs by failing to update the Pre-admission Screening and Annual Resident Review (PASARR) for Resident #40 following a diagnosis of Major Depressive Disorder. This is true for one (1) of four (4) residents reviewed for PASARRs during the survey process. Resident Identifier: 40. Facility Census: 94. Findings included: At approximately 3:00 PM on 02/05/24 a record review was conducted for Resident #40. During record review, it was determined that Resident #40 was admitted to the facility on [DATE] with no diagnosis of a Level II mental illness. Resident #40 was diagnosed with Major Depressive Disorder on 01/24/19 and the facility did not update the PASARR for the resident, to reflect that diagnosis. At approximately 9:30 AM on 02/08/24, the Director of Nursing (DON) #56 confirmed there was no updated PASARR for Resident #40 at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to develop and implement a baseline care plan that included the minimum healthcare information necessary to properly care for the immediate needs of residents. This was true for two (2) of 23 residents reviewed during the Long-Term Care Survey Process. Resident identifiers: #196 and #347. Facility census: 94 Findings included: a) Resident #196 A record review, completed on 02/06/24 at 11:00 AM, revealed Resident #196 had been admitted to the facility on [DATE]. The baseline care plan identified Resident #196 was at risk for decreased ability to perform Activities of Daily Living (ADLs) in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting. The following interventions were not complete and failed to indicate the correct level of staff assistance needed: -Provide resident/patient with ______(specify: set-up, supervision, limited, extensive, total) assist of _____(specify #) for bed mobility. -Provide resident/patient with ______ (specify: supervision, limited, extensive, total) assist of ______ (specify #) for transfers using a _____ (specify: walker, roll walker, quad cane, straight cane, pivot transfer, slide board,Total lift etc.). For total lift specify sling type and size___________________. -Provide resident/patient with ______ (specify: set-up, supervision, limited, extensive, total) assist of _____ (specify #) for eating. -Provide resident/patient with _____ (specify: set up, supervision, limited, extensive, total) assist of ______ (specify #) for toileting. -Provide resident/patient with _____ (specify: set-up, supervision, limited, extensive, total) assist of ______ (specify #) for dressing. -Provide resident/patient with ______ (specify: set-up, supervision, limited, extensive, total) assist of _____ (specify #) for personal hygiene (grooming). -Provide resident/patient with _____ (specify: set-up, supervision, limited, extensive, total) assist of _____ (specify #) for bathing. During an interview on 02/06/24 at 11:15 AM, the Director of Nursing (DON) acknowledged the 48 hour baseline care plan did not include the minimum information necessary to properly assist Resident #196 with ADLs. The DON stated it would be addressed immediately. b) Resident #347 On 02/06/24 at 12:40 PM during a medical record review for Resident #347 it is noted that the resident admitted on [DATE]. The physician's orders review identified Buspirone HCL for anxiety and Lovenox for fractures (fx.s). Upon reviewing the baseline care plan for Resident #347 the Buspirone HCL for anxiety and the Lovenox for fx.s was not identified to be part of the baseline care plan. During an interview on 02/06/24 at 12:59 PM, the Director of Nursing (DON) acknowledged that there was not a baseline care plan for the Buspirone HCL for anxiety and the Lovenox for fx.s.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to develop and/or implement a person-centered care plan regarding Post-Traumatic Stress Disorder (PTSD) for Resident #35. This was true for one (1) of one (1) residents reviewed under the care area of mood and behavior. Resident Identifier: #35. Facility Census: 94. Findings Included: a) Resident #35 On 02/05/24 at 11:30 AM, the facility matrix was reviewed. Resident #35 was identified with a diagnosis of PTSD. A record review was completed. A Social Services assessment dated [DATE] identified the resident was a victim of a violent assault. However, the care plan was not developed regarding the diagnosis of PTSD. On 02/07/24 at 10:00 AM, Social Services (SS) #80 was notified regarding the care plan not including the diagnosis of PTSD. On 02/07/24 at 12:00 PM, SS #80 stated, I updated the care plan to include PTSD. No further information was obtained during the survey process.

. Based on record review and staff interview, the facility failed to revise care plans to accurately reflect the conditions of residents. The facility failed to revise a care plan for depression for Resident #15, a COVID diagnosis for Resident #78, and tube feeding for Resident #53. This was true for three (3) of three (3) residents reviewed for care plan revision during the survey. Resident identifiers: #15, #53, #78. Facility census: 94. Findings included: a) Resident #15 At approximately 10:00 AM on 02/06/24, a record review of Resident #15 was conducted. During record review, it was noted that Resident #15 was care planned for a focus of distressed/fluctuating mood symptoms related to: Sadness/depression caused by history of mood disorders, long term care placement. Two interventions for this focus were observed to be Observe for pain and effectiveness of current interventions. Attempt non-pharmacological interventions (initiated on 11/08/21, created on 11/08/21, revised on 11/08/21) and Administer pain medication as ordered and document effectiveness/side effects (initiated on 11/08/21, created on 11/08/21). Both interventions were created by Social Services Director (SSD) #34. At approximately 11:00 AM on 02/07/2024, an interview was conducted with SSD #34 regarding the care plan for Resident #15. SSD #34 indicated that pain was not a factor in Resident #15's depression and that the interventions were entered by mistake and had not been corrected. b) Resident #78 A record review, completed on 02/07/24 at 7:15 PM, revealed Resident #78's care plan indicated, Patient has a actual infection (I) and is at risk for sepsis. COVID-19 Diagnosed Positive 09/05/23. During an interview on 02/08/24 at 8:07 AM, the Director of Nursing (DON) acknowledged the facility had failed to revise resident's care plan and reported that Resident #78 was not still COVID positive. c) Resident #53 On 02/08/24 at 9:00 AM, a record review was completed for Resident #53. The review found the care plan had not been revised to include the resident's dietary status. A physician's order dated 12/28/23 stating, as needed give 237ml (milliliter) per G-tube (gastrostomy tube) if <(less than)50% (percent) of meal is consumed. Osmolite 1.5. (Typed as written.) Another physician's order was found dated 01/22/24 stating, Regular, Liberalized diet, Regular Texture. (Typed as written.) On 02/08/24 at 9:45 AM, the Director of Nursing (DON) was notified and confirmed the care plan should have been revised to include the as needed tube feeding and the type of diet. No further information was obtained during the survey process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, resident interview, and staff interview, the facility failed to provide Activities of Daily Living (ADL) care that is necessary to maintain good oral hygiene care. This was true for one (1) of 23 residents. Resident identifier: #44. Facility Census: 94. Findings included: a) Resident #44 During an interview on 02/05/24 at 1:25 PM Resident #44 stated that she has a hard time with getting her oral care done because she was dependent on the staff and they did not always help her. She was not able to physically get the items she needed to perform oral care but can perform it once they have given her the needed items. During a medical record review, on 02/06/24 at 8:56 PM, of the [NAME] task for Resident #44 Task: Mouth care-cleaning of teeth/dentures/mouth Look Back: 30 (days). This report identified seven (7) days that no oral care was provided by staff and/or self completed by the resident. These dates were marked not applicable. -01/15/24, 01/19/24, 01/20/24, 01/21/24, 01/24/24, 01/29/24, and 02/02/24. During a care plan review on 02/07/24 at 9:35 AM it was identified that the ADL care interventions stated the Resident was an extensive assist for personal hygiene (grooming). On 02/07/24 at 10:05 AM during a review with the Director of Nursing (DON) of the care plan for the resident being an extensive assist for personal hygiene (grooming), the DON stated the task being marked on the [NAME] as not applicable would be for when the resident did not do it. A review of the [NAME] categories was then noted to be resident, staff, resident not available, resident refused and not applicable. The DON acknowledged the resident not completing the task would be if the resident refused and not the not applicable section. The DON stated the not applicable would reflect the task was not completed by the staff member. The DON acknowledged the oral care was not provided on these seven (7) days identified.

. Based on record review and staff interview, the facility failed to follow a physician's order regarding an enteral feeding for Resident #53. This was true for one (1) of one (1) residents reviewed under the care area of tube feeding. Resident identifier: #53. Facility census: 94. Findings included: a) Resident #53 On 02/07/24 at 2:00 PM, a record review was completed for Resident #53. The review found a physician's order dated 12/28/23 stating, as needed give 237ml (milliliter) per G-tube (gastrostomy tube) if <(less than) 50% (percentage) of meal is consumed. Osmolite 1.5. (one point five). (Typed as written.) The resident's weights were reviewed. The resident's weight has remained stable. Upon reviewing the Medication Administration Record for December 2023, the following dates should have had an as needed feeding administered based on the documentation: --12/29/23 lunch (25%) Upon reviewing the Medication Administration Record for January, 2024, the following dates should have had an as needed feeding administered based on the documentation: --01/01/24 breakfast (resident not available) --01/04/24 breakfast (25%) --01/05/24 breakfast (resident not available) --01/05/24 dinner (no documentation) --01/06/24 breakfast (0%) --01/07/24 breakfast (resident not available) --01/10/24 breakfast (25%) --01/11/24 lunch (no documentation) --01/13/24 breakfast (resident not available) --01/14/24 lunch (25%) --01/15/24 lunch (25%) --01/15/24 dinner (no documentation) --01/16/24 lunch (no documentation) --01/16/24 dinner (no documentation) --01/17/24 dinner (no documentation) --01/18/24 lunch (0%) --01/18/24 dinner (25%) --01/19/24 breakfast (no documentation) --01/19/24 lunch (no documentation) --01/19/24 dinner (no documentation) --01/20/24 breakfast (resident not available) --01/22/24 breakfast (resident not available) --01/23/24 breakfast (25%) --01/23/24 dinner (25%) --01/24/24 dinner (no documentation) --01/25/24 breakfast (no documentation) --01/25/24 lunch (no documentation) Upon reviewing the Medication Administration Record for February, 2024, the following dates should have had an as needed feeding administered based on the documentation: --02/01/24 breakfast (0%) --02/02/24 dinner (no documentation) --02/02/24 breakfast (no documentation) --02/02/24 lunch (no documentation) --02/02/24 dinner (no documentation) --02/04/24 breakfast (no documentation) --02/04/24 lunch (no documentation) On 02/08/24 at 11:15 AM, the Director of Nursing (DON) was notified of the tube feedings not being administered per the physician's order. The DON was asked, who charts the meal percentages. The DON responded, the nurse aides. The DON was then asked, how does the nurse know when the resident does not eat 50%? The DON responded, the nurse aides should notify the nurse. The DON was also asked why is the resident not available? The DON stated, the resident was available .the documentation is incorrect. In conclusion, the DON stated, I think there is a problem with the communication .we need to fix this. No further information was obtained during the survey process.

. Based on record review and staff interview, the facility failed to monitor Resident #15 for side effects of psychotherapeutic medications. This was true for one (1) of (1) residents reviewed for monitoring of side effects during the survey process. Resident identifiers: #15. Facility census: 94. Findings included: a) Resident #15 On 02/06/24 at approximately 9:30 AM, a record review was completed for Resident #15. The review found the resident was taking an antidepressant (Sertraline) for depression. The Medication Administration Record (MAR) dated November, 2023 through January 2024 were reviewed and found a physician's order for Sertraline 50mg (milligram) daily for depression dated 09/24/23. The physician's order included a question regarding behavior, Yes or No. However, the physician's order did not include any specific behaviors to monitor. At approximately 12:30 PM on 02/07/24, the Director of Nursing (DON) #56 was notified and confirmed there was no documentation of specific behaviors listed to be monitored.

. Based on observation and staff interview, the facility failed to serve food in a safe and sanitary manner by failing to ensure the food was free of contamination and hazards. This was a random opportunity for discovery. This had the potential to affect more than a limited number of residents. Facility census: 94. a) Test Trays At approximately 11:55 AM on 02/06/24, two (2) test trays containing the facilities lunch menu were delivered by Dietary Manager (DM) #123. The menu for lunch was: Hamburger on roll, lettuce and tomato garnish, grapes, french fries, or cottage cheese fruit platter and a cinnamon muffin. Upon observation of the trays, a pit of a pear was found on the cottage cheese fruit platter. Upon observation of the tray containing the hamburger, a dead insect was found on the lettuce. At approximately 12:08 PM on 02/06/24, DM #123 and the Nursing Home Administrator (NHA) were notified and acknowledged the pear pit as a potential choking hazard and the dead insect on the lettuce.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain a medical record that was complete and accurately documented. The facility failed to obtain a physician signature on a Physician Orders for Scope of Treatment (POST) form for Resident #48 prior to uploading it to the electronic medical record and the facility incorrectly entered a Code Order Status related to the timeframe the Resident #48 desired to have medically assisted nutrition. Additionally, the facility failed to complete a smoking assessment it its entirety for Resident #74. This deficient practice was true for two (2) of 23 resident records reviewed during the annual long-term care survey process. Resident Identifiers: #48 and #74. Facility census: 94. Findings Included: a) Resident #48 During a record review, completed on 02/05/24 at 4:49 PM, the following issues were identified: -The scanned Physician Order for Scope of Treatment (POST) form, signed by resident on 01/15/24, indicated Do Not Resuscitate (DNR), Selective Treatments, and Medically Assisted Nutrition time-limited trial of seven (7) days but no surgically-placed tubes. The scanned POST form was not signed by physician. -There was a Code Status Order which directed, Do Not Resuscitate (DNR), Selective Treatments, and Medically Assisted Nutrition Time-limited trial of 10 days but no surgically-placed tubes. During an interview on 02/06/24 at 2:05 PM, the Director of Nursing (DON) acknowledged the POST form was scanned prior to the physician signing the form and the Code Status order incorrectly listed 10 days, instead of seven (7). b) Resident #74 On 02/05/24 at 4:45 PM, a record review was completed for Resident #74. The review found the resident was a tobacco user. The review, also, found a smoking assessment dated [DATE]. The smoking assessment was incomplete in determining if the resident was an independent smoker. On 02/06/24 at 1:15 PM, the Director of Nursing confirmed the resident was an independent smoker and the smoking assessment was incomplete. No further information was obtained during the survey process.

. Based on observation and staff interview, the facility failed to maintain appropriate infection control standards during medication administration for Resident #15, Resident #47, Resident #43 and Resident #42. These were random opportunities for discovery. Resident Identifiers: #15, #47, #43, and #42. Facility Census: 94. Findings Included: a) Resident #15 On 02/06/24 at 8:22 AM, Licensed Practical Nurse (LPN) #31 was observed during medication administration for Resident #15. During the preparation of the medication the following pill was touched by LPN #31's bare hands: --Zoloft 50mg (milligrams) b) Resident #47 On 02/06/24 at 8:35 AM, LPN #31 was observed during medication administration for Resident #47. During the preparation of the medication the following pills were touched by LPN #31's bare hands: --Ativan 0.5mg --Multivitamin --Zoloft 50mg c) Resident #43 On 02/06/24 at 8:51 AM, LPN #31 was observed during medication administration for Resident #43. During the preparation of the medication the following pill was touched by LPN #31's bare hands: --Lasix 20mg d) Resident #42 On 02/06/24 at 9:05 AM, LPN #31 was observed during medication administration for Resident #42. During the preparation of the medication the following pills were touched by LPN #31's bare hands: --Ferrous Sulfate 324mg --Magnesium Oxide 400mg --Multivitamin --Mucinex 600mg --Allopurinol 100mg --Probiotic one (1) tablet --Lasix 40mg --Potassium Chloride 20meq (milliequivalent) --Lamictal 100mg --Folic Acid 1mg On 02/06/24 at 9:20 AM, LPN #31 was notified and stated, I'm sorry. On 02/06/24 at 9:35 AM, the Director of Nursing (DON) was notified and stated, the pills should not be touched by the nurse's hands. No further information was obtained during the survey process.

. Based on record review and staff interview, the facility failed to offer vaccinations to Resident #4 and #6. This was true for two (2) of five (5) residents reviewed under the care area of immunizations. Resident Identifiers: #4 and #6. Facility Census: 94. Findings Included: a) Resident #4 On 02/07/24 at 1:30 PM, a record review was completed for Resident #4. The review found the pneumococcal vaccine (PCV) 20 was not offered to the resident. On 02/07/24 at 3:00 PM, the Infection Preventionist (IP) # 37 was notified and stated, I made a mistake .I should have offered it to her. b) Resident #6 On 02/07/24 at 2:15 PM, a record review was completed for Resident #6. The review found the PCV 20 vaccine was not offered to the resident. On 02/07/24 at 3:10 PM, the IP #37 was notified and stated, she went out to the hospital .I should've followed up with her son sooner. No further information was obtained during the survey process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and resident and staff interview, the facility failed to include residents/resident representatives to participate in care plan meetings. The facility failed to hold regularly scheduled care plan meetings and to invite residents or their representatives to those meetings. This was true for five (5) of five (5) residents reviewed for care plan meetings. Resident identifiers: #295 #81, #15, #8, #40. Facility census: 94. Findings included: a) Resident #295 At approximately 1:30 PM on 02/05/24, an interview was conducted with Resident #295. During the interview, Resident #295 was asked if the facility held care plan meetings with them or their representatives. Resident #295 stated I'm my own representative and I do not recall ever being a part of these meetings. A record review was conducted for Resident #295 regarding care plan meetings. Record review indicated there were two (2) care plan meetings held regarding Resident #295. These meetings took place on 06/09/21 and 01/12/24. Care plan meetings notes regarding Resident #295 were requested from Social Services Director (SSD) #34 at approximately 3:15 PM on 02/06/24. SSD #34 stated they were unsure if there was any documentation related to the care plan meetings saying, We have been short staffed in this department for close to a year, I'm not sure if there is any documentation for those meetings. At approximately 3:45 PM on 02/06/24, SSD #34 was unable to provide any additional documentation related to care plan meetings for Resident #295. SSD #34 and the Director of Nursing (DON) #56 confirmed the only care plan meetings documented for Resident #295 were on 06/09/21 and 01/12/24 b) Resident #81 At approximately 02:05 PM on 02/05/24, an interview was conducted with Resident #81. During the interview, Resident #81 was asked if they attended care plan meetings. Resident #81 stated I don't even know what that is. I've never been invited to one and I'm not aware that any of my family has either. A record review was conducted regarding care plan meetings for Resident #81. Record review indicates no documentation for care plan meetings was present since the resident was admitted on [DATE]. Care plan meetings notes regarding Resident #81 were requested from SSD #34 at approximately 3:15 PM on 02/06/24. SSD #34 stated they were unsure if there was any documentation related to the care plan meetings saying, We have been short staffed in this department for close to a year, I'm not sure if there is any documentation for those meetings. At approximately 3:45 PM on 02/06/24, SSD #34 was unable to provide any documentation related to Resident #8. SSD #34 and the DON #56 confirmed there was no documentation that a care plan meeting had been held for Resident #81 since they were admitted to the facility on [DATE]. c) Resident #15 At approximately 2:28 PM on 02/05/24, an interview was conducted with Resident #15. During the interview, Resident #15 was asked if the facility held care plan meetings with them or their representatives. Resident #15 stated that they did not know what care plan meetings were. A record review was conducted regarding the care plan meetings for Resident #15. No documentation regarding care plan meetings for Resident #15 were located since admission on [DATE]. Care plan meetings notes regarding Resident #15 were requested from SSD #34 at approximately 3:15 PM on 02/06/24. SSD #34 stated they were unsure if there was any documentation related to the care plan meetings saying, We have been short staffed in this department for close to a year, I'm not sure if there is any documentation for those meetings. At approximately 3:45 PM on 02/06/24, SSD #34 was unable to provide any documentation related to Resident #15. SSD #34 and the DON #56 confirmed there was no documentation present that a care plan meeting had been held for Resident #15 since they were admitted to the facility on [DATE]. d) Resident #8 At approximately 4:42 PM on 02/05/24, an interview was conducted with Resident #8. During the interview, Resident #8 was asked if the facility held care plan meetings with them or their representatives. Resident #8 stated Not that I'm aware of. I've never been a part of anything like that. A record review was conducted regarding the care plan meetings for Resident #8. No documentation regarding care plan meetings for Resident #8 were located since admission on [DATE] Care plan meetings notes regarding Resident #8 were requested from SSD #34 at approximately 3:15 PM on 02/06/24. SSD #34 stated they were unsure if there was any documentation related to the care plan meetings saying, We have been short staffed in this department for close to a year, I'm not sure if there is any documentation for those meetings. At approximately 3:45 PM on 02/06/24, SSD #34 was unable to provide any documentation related to Resident #8. SSD #34 and the DON #56 confirmed there was no documentation that a care plan meeting had been held for Resident #8 since they were admitted to the facility on [DATE]. e) Resident #40 At approximately 3:00 PM on 02/06/24 a record review of care plan meetings regarding Resident #40 was conducted. This review indicated documentation of one (1) care plan meeting taking place since the resident was admitted on [DATE]. The documented meeting took place on 12/06/2023. Care plan meetings notes regarding Resident #40 were requested from SSD #34 at approximately 3:15 PM on 02/06/24. SSD #34 stated that they were unsure if there was any documentation related to the care plan meetings saying, We have been short staffed in this department for close to a year, I'm not sure if there is any documentation for those meetings. At approximately 3:45 PM on 02/06/24, SSD #34 was unable to provide any additional documentation related to care plan meetings for Resident #40. SSD #34 and the DON #56 confirmed the only care plan meetings documented for Resident #40 was on 12/06/23.

Based on observation and staff interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment. A table top in the Transitional Care Unit (TCU) dining area had approximately one third of the laminate covering missing with exposed jagged edges. Resident #43's room floor needed to be cleaned. This was a random opportunity for discovery. This failed practice had the potential to affect a limited number of residents that currently reside in the facility. Resident identifier: #43 Facility Census: 94 Findings included: a) Table top in the TCU dining area; During a tour of the building on 02/06/24 at 08:24 AM a dining table in the TCU dining area was observed to be uncovered. Upon examining the top surface of the table, approximately one third of the table top laminate that covers the inner resin of the table had been torn off. The remaining laminate covering the table top had sharp jagged edges and the inner resin of table was exposed. During an interview with Social Services #80 at 8:19 AM on 02/06/24 and the Director of Nursing (DON) at 8:25 AM on 02/06/24, both acknowledged that the table top was in poor repair and was left uncovered. b) Resident #43 floor During an interview with Resident #43 on 02/08/23 at 12:24 PM, the residents floor near the foot of the bed appeared to have a large black soiled area that was dry in appearance. Resident #43 stated that they have not cleaned under the bed since she had gotten there. The floor area under the roommates bed also appeared dirty with debris and had a lollipop sucker without the wrapper on it that appeared to be stuck to the floor. During an interview with the Nurse Aide (NA) #28 on 02/08/24 at 12:30 PM, she stated that the floor looked pretty dirty under the foot of Resident #43's bed. NA #28 also acknowledged sugar and the unwrapped sucker to be on the floor under the roommates bed. During an interview with the DON on 02/08/24 at 12:35 PM the DON acknowledged the floor was dirty.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure the resident environment remained as free of accident hazards as possible, by failing to keep treatment and medication carts locked when they were out of use and out of sight of nursing staff, and by failing to remove razors with no safety caps from Resident #196's room. This was a random opportunity for discovery. This had the potential to affect more than a limited number of residents. Facility census: 94. Findings included: a) Treatment Cart At approximately 9:43 PM on 02/06/24, an observation found the TCU Treatment Cart having a door open. Upon further inspection, the treatment cart was also unlocked and all doors could be opened. Drawers were full of wound treatment supplies. At approximately 9:45 PM on 02/06/24, an interview was conducted with the Assistant Director of Nursing (ADON) #4. ADON #4 stated I just went down and changed dressings a minute ago and I didn't lock the cart back. b) Resident #196 During an in-room visit on 02/05/24 at 2:45 PM, Surveyor observed two (2) disposable razors with no safety caps on resident's bedside table. Additionally, there were two (2) disposable razors with no safety caps on the shelving unit beside resident's bed. On 02/05/24 at 3:00 PM, the Director of Nursing (DON) acknowledged the uncapped disposable razors as an accident hazard for wandering residents and removed the razors from Resident #196's room. Further record review revealed there were ten (10) wandering residents in the building. Review of the the facility's Needle Handling and Sharps Injury Prevention policy, with a revision date of 04/15/23, directed that safety razors must be placed in sharps disposal container. c) Medication Cart On 02/06/24 at 9:30 PM, a tour of the 100 hall was completed. During the tour, the medication cart was observed sitting by room [ROOM NUMBER] unlocked. Licensed Practical Nurse (LPN)# 44 was inside of room [ROOM NUMBER] assisting the residents. LPN #44 confirmed the medication cart was left unlocked. On 02/07/24 at 8:50 AM, the Administrator was notified and confirmed the medication cart should be locked at all times when left unattended. No further information was obtained during the survey process.

. Based on resident interviews, staff interviews, record review, and resident council, the facility failed to ensure sufficient qualified nursing staff were always available to provide nursing and related services to meet the residents' needs safely and in a manner that promoted resident rights, physical, mental, and psychosocial well-being. Facility census: 94. Findings included: a) Facility Assessment Review of the Facility Assessment, revealed Section A.1. Sufficiency Analysis Summary states, We have daily discussions about unit staffing. Administrator, Scheduler, and Director of Nursing (DON) meet each morning to review current staffing patterns along with any additional needs. If it is determined that there are additional needs due to acuity, additional staff will be added or staffing adjustment will be made. b) Interview with Scheduling and Payroll Manager During an Interview, on 02/07/24 at 9:37 AM, the Scheduling and Payroll Manager stated staffing patterns were determined during the daily discussions held between her, the DON, and the Administrator. She explained it was determined at that time what the staffing needs were and then the Daily Posted Nurse Staffing reflected that decision. When questioned about the Excessively Low Weekend Staffing metric being triggered on the Payroll-Based Journal (PBJ) Staffing Data Report for Fiscal Year Quarter 4 2023 (July 1 - September 30), the Scheduling and Payroll Manager indicated the facility experienced a lot of call-offs in that quarter from all nursing staff members (Registered Nurses, Licensed Practical Nurses, and Nurse Aides.) She went on to say that the PBJ Staffing Data information was entered on a corporate level, and she did not have access to all the details. The Scheduling and Payroll Manager agreed to speak to the corporate person responsible for PBJ results to determine if there was any further information that could be provided. No additional information was given prior to exit. c) Review of Direct Care Hours for Nursing Staff During a review of the facility's Daily Posted Nurse Staffing and the Daily Time Detail Report reflecting clock-in and clock-out punches for all direct nursing care staff, the following discrepancies were identified: -On Sunday, 07/02/23, the Daily Posted Nurse Staff Form listed the total number of staff hours as 327.00. The Daily Time Detail Report, reflecting the actual clock-in and clock-out punches, listed the total number of staff hours as 295.52, reflecting a discrepancy of 31.48 hours not worked as planned. -On Saturday, 08/13/23, the Daily Posted Nurse Staff Form listed the total number of staff hours as 279.50. The Daily Time Detail Report, reflecting the actual clock-in and clock-out punches, listed the total number of staff hours as 247.77, reflecting a discrepancy of 31.73 hours not worked as planned. -On Sunday, 08/20/23, the Daily Posted Nurse Staff Form listed the total number of staff hours as 248.50. The Daily Time Detail Report, reflecting the actual clock-in and clock-out punches, listed the total number of staff hours as 232.97, reflecting a discrepancy of 15.53 hours not worked as planned. -On Sunday, 09/10/23, the Daily Posted Nurse Staff Form listed the total number of staff hours as 281.00. The Daily Time Detail Report reflecting the actual clock-in and clock-out punches listed the total number of staff hours as 238.13, reflecting a discrepancy of 42.87 hours not worked as planned. d) Anonymous Resident Interviews Throughout the Long-Term Care Survey Process there were eight (8) anonymous resident interviews where residents reported issues with staffing: -I have toileting accidents and frequently must wait for over an hour before being changed by staff. I find that very frustrating. -There was someone left in bed all day Saturday and they had dried feces on them (on West). -Sometimes I get my medication at 8 PM, sometimes not until 12 midnight. -Some days are good but other days we only have 1 aide per hall. They have a lot of call offs. -One resident stated the staff needed to use a lift to assist her. She stated she had to wait a long time to go to the bathroom due to needing two (2) staff members to operate the lift. Resident stated, It's a lot of work to get someone up in one of those things. -Sometimes it takes a bit for my call light to be answered. -On evening shift, there are only 2 CNAs for this entire hall (East and West). There was someone left in bed all day Saturday and they had dried feces on them (on West). e) Resident Council During a resident council meeting, held on 02/06/24 at 1:30 PM, three (3) residents stated that staffing was usually bad after 7:00 PM. They reported call lights being answered varied from a five (5) minute wait to one (1) hour. f) Staff Interviews Throughout the Long-Term Care Survey Process there were four (4) anonymous staff interviews where issues with staffing were reported: -One nurse aide mentioned frequently working mandated 16 hours shifts where it took a minimum of four (4) hours to chart. The nurse aide stated she was frequently the only aide assigned to the unit and found it difficult to meet all resident needs during her shift. -Another nurse aide mentioned needing to pull nurse aides off their assigned unit to help with residents who were two (2) people assist and needing to go to other units to assist her peers under the same circumstances. When the nurse aides are pulled from their units to assist residents who were two (2) people assist, the residents on their own unit have longer call-light wait times as a result. -One nurse stated they were Fried from working mandated 16 hours shifts and reported they could not sustain quality resident care at this pace. -Another nurse stated they also were finding it difficult to continue working the mandated 16 hours shifts because of call-offs. g) Hours per Patient Day (HPPD) Report Review of the HPPD report from 01/24/24 - 02/06/24 revealed the following discrepancies between the scheduled hours to work and the actual hours worked: -01/24/24 Scheduled Hours to Work - 383.75 Actual Hours Worked - 289.68 This was a discrepancy of 94.07 hours. 01/25/24 Scheduled Hours to Work - 427.07 Actual Hours Worked - 268.30 This was a discrepancy of 158.77 hours. 01/28/24 Scheduled Hours to Work - 310.00 Actual Hours Worked - 283.15 This was a discrepancy of 26.85 hours. 01/29/24 Scheduled Hours to Work - 381.17 Actual Hours Worked - 306.67 This was a discrepancy of 74.50 hours. 01/30/24 Scheduled Hours to Work - 299.00 Actual Hours Worked - 267.12 This was a discrepancy of 31.88 hours. 02/01/24 Scheduled Hours to Work - 396.42 Actual Hours Worked - 335.48 This was a discrepancy of 60.94 hours. 02/02/24 Scheduled Hours to Work - 322.32 Actual Hours Worked - 280.20 This was a discrepancy of 42.12 hours. 02/03/24 Scheduled Hours to Work - 319.50 Actual Hours Worked - 276.18 This was a discrepancy of 43.32 hours. 02/04/24 Scheduled Hours to Work - 317.13 Actual Hours Worked - 284.13 This was a discrepancy of 33.00 hours.

. Based on record review and staff interview, the facility failed to complete a performance review for three (3) out of three (3) Nurse Aides (NA) reviewed in the sufficient and competent nurse staffing pathway during the Long-Term Care Survey Process. Employee identifiers: NA #5, #29, and #58. Facility census: 94. Findings included: a) Review of Nurse Aide Personnel Files A review of Nurse Aide (NA) employee personnel files was completed on 02/07/24 at 2:30 PM. There was no evidence that NA #5, NA #29, and NA #58 had a yearly performance review on file. The Manager of Scheduling and Payroll reported a change in Administrators in November 2023. She stated, The QAPI (Quality Assurance Performance Improvement) committee identified a need for a PIP (Performance Improvement Plan) and they had me do a complete audit on all personnel files. I identified the absence of annual evaluations, but no action was taken. The decision was eventually made to start with a clean slate in January 2024. I cannot produce annual evaluations for the three (3) Nurse Aides in question. .

. Based on record review and staff interview, the facility failed to keep the daily posted nurse staffing information up-to-date and current. This was true for four (4) out of 12 sampled days during the Long-Term Care Survey Process. Facility census: 94. Findings included: a) Daily Posted Nurse Staffing During a review of the facility's Daily Posted Nurse Staffing and the Daily Time Detail Report reflecting clock-in and clock-out punches for all direct nursing care staff, the following discrepancies were identified: -On Sunday, 07/02/23, the Daily Posted Nurse Staff Form listed a total number of staff hours as 327.00. The Daily Time Detail Report reflecting the actual clock-in and clock-out punches listed a total number of staff hours as 295.52, reflecting a discrepancy of 31.48 hours not worked as planned. -On Saturday, 08/13/23, the Daily Posted Nurse Staff Form listed a total number of staff hours as 279.50. The Daily Time Detail Report reflecting the actual clock-in and clock-out punches listed a total number of staff hours as 247.77, reflecting a discrepancy of 31.73 hours not worked as planned. -On Sunday, 08/20/23, the Daily Posted Nurse Staff Form listed a total number of staff hours as 248.50. The Daily Time Detail Report reflecting the actual clock-in and clock-out punches listed a total number of staff hours as 232.97, reflecting a discrepancy of 15.53 hours not worked as planned. -On Sunday, 09/10/23, the Daily Posted Nurse Staff Form listed a total number of staff hours as 281.00. The Daily Time Detail Report reflecting the actual clock-in and clock-out punches listed a total number of staff hours as 238.13, reflecting a discrepancy of 42.87 hours not worked as planned. During an interview on 02/08/24 at 8:20 AM, the Scheduler acknowledged the discrepancies and stated she usually was the person who revised the Daily Posted Nurse Staffing when there were call-ins but she did not work the weekends. No further information was provided prior to exit.

. Based on observation, record review and staff interview, the facility failed to ensure medications were dated upon opening in accordance with the accepted professional standards of practice. This was a random opportunity for discovery. Resident Identifiers: #9. Facility Census: 94. Findings Included: a) Undated Medications On 02/06/24 at 2:05 PM, a tour of the medication cart on the Transitional Care Unit (TCU) was completed. The tour found the following over-the-counter (OTC) medications and Resident #9's insulin were not dated upon opening: --one (1) bottle of Acetaminophen 325mg (milligrams) --one (1) bottle of Ferrous Sulfate 325mg --one (1) bottle of Magnesium Oxide 400mg --two (2) bottles of Multivitamins --one (1) bottle of Aspirin 81mg --one (1) bottle of Vitamin D 25mcg --one (1) bottle of Vitamin C 500mg --one (1) bottle of Multivitamins with zinc --one (1) bottle of Calcium 500mg --one (1) bottle of Benadryl 25mg --one (1) bottle of Singular 10mg --Resident #9's Lantus insulin On 02/06/24 at 2:08 PM, Registered Nurse (RN) #4 confirmed the medication was not dated upon opening. On 02/06/24 at 2:13 PM, the Director of Nursing (DON) was notified and confirmed the medication should be dated upon opening.

. According to observation, staff interview, resident interview, and policy review, the facility failed to serve food at safe and palatable temperatures by serving cold food at higher temperatures than directed. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents. Facility census: 94. Findings included: a) Food Temperatures At approximately 11:25 AM on 02/05/24, Dietary Manager (DM) #123 was observed taking temperatures of the food prior to service. DM #123 took the temperature of cottage cheese on the serving line, the cottage cheese had a temperature of 42.4 degrees Fahrenheit (F). A policy on food handling was requested. Upon policy review, it was determined that foods that are to be served cold should be served at 41 degrees F or below. DM #123 was made aware and acknowledged the temperature of the cottage cheese was higher than the policy stated. b) Unit tray temperatures At approximately 12:16 PM on 02/06/24, food temperatures were taken by DM #123 on a tray delivered to the floor. The tray contained french fries and sloppy joes, both to be served hot, and applesauce, to be served cold, according to DM #123. The temperature of the sloppy joe was observed to be 132 degrees F while the temperature of the applesauce was observed to be 44.2 degrees F. According to policy review, hot foods should be served at temperatures no lower than 135 degrees F while cold foods should be served at no higher than 41 degrees F. DM #123 acknowledged both foods were outside of the range dictated by the facility's policy.

. Based on observation, record review, and staff interview, the facility failed to maintain safe and working equipment by failing to repair the ice machine in the facility's kitchen. This was a random opportunity for discovery. This had the potential to affect more than a limited number of residents. Facility census: 94. Findings included: At approximately 11:20 AM on 02/05/24, an observation was made of the ice machine during a tour of the kitchen. The ice machine was leaking from underneath, causing puddles to form in the floor of the kitchen. When asked about the leak, Dietary Manager (DM) #123 stated It's been leaking for a while. I put a work order in on TELS (building maintenance program), it just hasn't been fixed yet. At approximately 2:49 PM on 02/05/24, a copy of the work order for the repair of the ice machine was requested from DM #123. DM #123 produced the work order for the ice machine, dated 01/15/24 at 12:47 PM. At approximately 10:59 AM on 02/06/24, an interview was conducted with Senior Maintenance Director (SMD) #130 regarding the ice machine. SMD #130 stated the machine could be fixed and the facility would have to use ice from the other ice machine in the facility until repairs were completed. SMD was asked if they were aware of the work order being put in on 01/15/24 and not being completed, to which they stated This isn't my building, I'm just here to help out, but things happen and things fall through the cracks, unfortunately. At approximately 11:02 AM on 02/06/24, the Nursing Home Administrator (NHA) was notified of, and acknowledged, the ice machine leak and the work order dated for 01/15/24 that had yet to be completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, and staff interview, the facility failed to ensure a resident had reasonable accommodation of needs by failing to ensure the resident had a bed that was long enough for his body length. This was a random opportunity for discovery. Resident Identifier: #88. Facility census: 92. Findings included: a) Resident # 88 During an Observation on 12/19/23 at 8:55 AM, Resident #88 was lying in bed with the head of the bed elevated. His calves were on the foot board and his feet were hanging over the edge of the footboard. During an interview on 12/19/23 at 8:57 AM, Resident #88 stated, I am not comfortable in this bed The surveyor asked the resident if he felt he needed a longer bed and he stated, Well don't you think? A record review on 12/19/23 at 9:15 AM, revealed Resident #88 was admitted on [DATE] with a height of 79 inches (6 feet 7 inches tall.) During an interview, on 12/19/ 23 at 9:20 AM, with Licensed Practical Nurse (LPN) #62 she stated, Yes, he needs a longer bed, he is a tall man. I thought maintenance looked at it, but I guess he didn't. He needs something. During an interview on 12/19/23 at 11:00 AM, the administrator stated, The bed is 7 foot, I will have maintenance take care of it today,

Based on record review and staff interview, the facility failed to report an alleged violation related to abuse, to all the required State authorities. This was a random opportunity for discovery. Resident identifier: #19. Facility census: 92. Findings included: a) Resident #19 Record review of the facility's policy titled, Abuse Prohibition, showed: Physical Abuse Includes hitting, slapping, pinching, kicking, etc., as well as controlling behavior through corporal punishment. A complaint investigation on 12/18/23, discovered a reportable for a Resident-to-Resident altercation with alleged abuse on 11/13/23. The incident included Resident #94 wandering into Resident #19's room, when asked to leave the room Resident #94 punched Resident #19 in the head 4 -5 times. --Section Notes, Nursing Home Administrator (NHA) notified Ombudsman of Resident to Resident with alleged abuse. Resident #19's Minimum Data Set (MDS,) Significant Change Assessment with an Assessment Reference Date (ARD) of 10/19/23 noted the resident had a score of Brief Interview for Mental Status (BIMS) of 15. A BIMS score of 15 indicates that the resident is cognitively intact and has capacity. Subsequent review of facility documentation found this reportable was only reported to the Ombudsman. During an interview, on 12/19/23 at 2:50 PM, the Administrator verified the incident was not reported to Adult Protective services (APS), Office of Health Facility Licensure & Certification (OHFLAC) as required by State law.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide pressure ulcer care in accordance with professional standards of care. This failed practice had the potential to affect two (2) of four (4) residents reviewed for the care area of pressure ulcers. The failure to assess and follow the physician's orders for Resident #87's pressure ulcer caused harm to the resident. The resident developed a pressure ulcer infection, requiring intravenous antibiotics while in the faciity, and also was transferred to the hospital for suspected pressure ulcer infection and deteriorating wound. Resident identifiers: #93, #87. Facility census: 92. Findings included: a) Policy review The facility's policy titled Skin Integrity and Wound Management with effective date 07/01/01 and revision date 02/01/23 gave the following procedures: - Complete comprehensive evaluation of the patient upon admission - Evaluate any reported or suspected skin changes or wounds - Complete wound evaluation weekly b) Resident #93 Review of Resident #93's medical records show the resident was admitted to the facility on [DATE]. The admitting nursing note written on 08/25/23 at 11:00 PM stated the following, The following skin injury/wound(s) were previously identified and were evaluated as follows: Pressure(s): Description: L (left) calf .Resident refused skin check to R (right) leg and back/buttock. Review of the discharge documents from the hospital showed the resident had vascular lesions of the right lower leg and right lower posterior leg and a traumatic lesion of the left lower posterior leg. On 09/11/23 an in-house acquired pressure ulcer of unknown duration to the right gluteus was assessed. The pressure ulcer was reported as unstageable due to eschar. The wound was noted to be 2.9 centimeters (cm) in length and 1.4 cm in width. Depth could not be determined. The wound was noted to have increased drainage with a heavy amount of bloody drainage. The skin surrounding the wound was noted to be red. The resident reported increased pain in the area. Review of the resident's physician's orders showed the following orders were written on 09/12/23: - Cleanse pressure wounds to sacrum and posterior thigh with wound cleanser, pat dry, apply sure prep peri wound, apply alginate to wound bed, cover with optifoam QD (every day) and PRN (as needed) until healed. Review of the resident's Medication Administration Record (MAR) for September 2023 showed this treatment had been signed out by the nurses as performed on 09/17/17 through 09/19/23, and 09/23/23 through 09/27/23. The MAR indicated the resident had refused the treatment on 09/13/23. The MAR was blank for this treatment on 09/20/23 through 09/22/23 and 09/28/23. The order was discontinued on 09/28/23. On 09/26/23, a wound culture was obtained from a wound on the resident's right posterior thigh. The wound grew Klebsiella oxtoca and Citrobacter amalonaticus. Intravenous antibiotics were started. The right gluteus pressure ulcer was reassessed on 09/28/23. The pressure ulcer continued to be unstageable due to slough. The wound was noted to be 2.1 cm in length and 1.6 cm in width. Depth could not be determined. The wound was noted to have a moderate amount of purulent drainage. A right hip pressure ulcer was also assessed on 09/28/23. The pressure ulcer was documented as present on admission. The pressure ulcer was documented as unstageable due to slough. The wound was noted to be 3.0 cm in length and 1.9 cm in width. The depth could not be determined. The wound was noted to have a moderate amount of seropurulent drainage and a moderate odor. A right medial thigh pressure ulcer was also assessed on 09/28/23. The pressure ulcer was documented as present on admission. The pressure ulcer was documented as unstageable due to slough. The wound was noted to be 9.1 cm in length and 8.7 cm in width. The depth could not be determined. The wound was noted to be 10% granulation tissue and 90% slough. The wound was noted to have a moderate amount of seropurulent drainage and a moderate odor. A left gluteal pressure ulcer was also assessed on 09/28/23. The pressure ulcer was documented as present on admission. The pressure ulcer was documented as unstageable due to slough. The wound was noted to be 2.8 cm in length and 2.3 cm in width. The depth could not be determined. The wound was noted to have a moderate amount of seropurulent drainage and a moderate odor. No further pressure ulcer assessments were found in the resident's medical records. Review of Resident #93's physician's orders showed the following pressure ulcer wound care orders were written on 09/28/23: - Santyl external ointment 250 unit/gram (collagenase), apply to posterior thigh, left hip topically every day and night shift for wound care, five total wounds. Review of the resident's MAR for September 2023 showed this treatment had been signed out by the nurses as performed for day shift on 09/30/23. The MAR was blank for this treatment for night shift 09/28/23, for day shift and night shift 09/29/23 and for night shift on 09/30/23. Review of the resident's MAR for October 2023 showed this treatment had been signed out by the nurses as performed for day shift on 10/01/23. The MAR was blank for this treatment for night shift 10/01/23 and for day shift 10/02/23. This order was discontinued on 10/02/23. - Cleanse pressure wound left sacrum with vashe wound cleanser, allow solution to sit on wound for 60 seconds, apply santyl to wound bed, cover with bordered gauze BID (twice a day) and PRN until healed. Review of the resident's MAR for September 2023 showed this treatment had been signed out by the nurses as performed for day shift on 09/30/23. The MAR was blank for this treatment for night shift 09/28/23, for day shift and night shift 09/29/23 and for night shift on 09/30/23. Review of the resident's MAR for October 2023 showed this treatment had been signed out by the nurses as performed for day shift on 10/01/23. The MAR was blank for this treatment for night shift 10/01/23 and for day shift 10/02/23. This order was discontinued on 10/02/23. - Cleanse pressure wound to left hip with vashe wound cleanser, allow solution to sit on wound for 60 seconds, apply santyl to wound bed, cover with bordered gauze BID (twice a day) and PRN until healed. Review of the resident's MAR for September 2023 showed this treatment had been signed out by the nurses as performed for day shift on 09/30/23. The MAR was blank for this treatment for night shift 09/28/23, for day shift and night shift 09/29/23 and for night shift on 09/30/23. Review of the resident's MAR for October 2023 showed this treatment had been signed out by the nurses as performed for day shift on 10/01/23. The MAR was blank for this treatment for night shift 10/01/23 and for day shift 10/02/23. This order was discontinued on 10/02/23. - Cleanse pressure wound to left posterior thigh with vashe wound cleanser, allow solution to sit on wound for 60 seconds, apply santyl to wound bed, cover with bordered gauze BID (twice a day) and PRN until healed. Review of the resident's MAR for September 2023 showed this treatment had been signed out by the nurses as performed for night shift on 09/28/23 and for day shift on 09/30/23. The MAR was blank for this treatment for day shift and night shift 09/29/23 and for night shift on 09/30/23. Review of the resident's MAR for October 2023 showed this treatment had been signed out by the nurses as performed for day shift on 10/01/23. The MAR was blank for this treatment for night shift 10/01/23 and for day shift 10/02/23. This order was discontinued on 10/02/23. - Cleanse pressure wound to right inner groin with vashe wound cleanser, allow solution to sit on wound for 60 seconds, apply santyl to wound bed, cover with bordered gauze BID (twice a day) and PRN until healed. Review of the resident's MAR for September 2023 showed this treatment had been signed out by the nurses as performed for night shift on 09/28/23 and for day shift on 09/30/23. The MAR was blank for this treatment for day shift and night shift 09/29/23 and for night shift on 09/30/23. Review of the resident's MAR for October 2023 showed this treatment had been signed out by the nurses as performed for day shift on 10/01/23. The MAR was blank for this treatment for night shift 10/01/23 and for day shift 10/02/23. This order was discontinued on 10/02/23. - Cleanse pressure wound to right sacrum with vashe wound cleanser, allow solution to sit on wound for 60 seconds, apply santyl to wound bed, cover with bordered gauze BID (twice a day) and PRN until healed. Review of the resident's MAR for September 2023 showed this treatment had been signed out by the nurses as performed for day shift on 09/30/23. The MAR was blank for this treatment for night shift 09/28/23, for day shift and night shift 09/29/23 and for night shift on 09/30/23. Review of the resident's MAR for October 2023 showed this treatment had been signed out by the nurses as performed for day shift on 10/01/23. The MAR was blank for this treatment for night shift 10/01/23 and for day shift 10/02/23. This order was discontinued on 10/02/23. Review of Resident #93's physician's orders showed the following orders written on 10/02/23: - Therahoney External gel (wound dressings), apply to wounds topically two times a day for wound care. Review of the resident's MAR for October 2023 showed this treatment had been signed out by the nurses as performed for day shift and night shift on 10/11/23, night shift on 10/12/23, night shift for 10/16/23, and day shift on 10/16/23 and 10/17/23. The MAR indicated the resident was sleeping for night shift on 10/03/23. The MAR indicated the resident refused the treatment for night shift on 10/04/23, day shift on 10/13/23, and day shift and night shift on 10/14/23. For night shift on 10/02/23, 10/07/23, and 10/09/23, the MAR contained the notation NN, meaning see nurse's note. The nurse's note indicated the treatment had already been performed. The MAR was blank for this treatment for day shift on 10/03/23 and 10/04/23, day shift and night shift on 10/05/23 and 10/06/23, day shift on 10/07/23, day shift and night shift on 10/08/23, day shift on 10/09/23, day shift and night shift on 10/10/23, day shift on 10/12/23, night shift on 10/13/23, day shift on 10/15/23, and night shift on 10/16/23. This order continued until until the resident's discharge on [DATE]. The wounds to be treated were not specified. However, the wound orders also contained instructions to apply therahoney. - Cleanse pressure wound left sacrum with vashe wound cleanser, allow solution to sit on wound for 60 seconds, apply therahoney to wound bed, cover with bordered gauze BID and PRN until healed. Review of the resident's MAR for October 2023 showed this treatment had been signed out by the nurses as performed for night shift on 10/05/23, night shift on 10/08/23, day shift and night shift on 10/09/23, night shift on 10/10/23, day shift and night shift on 10/11/23 and 10/13/23, day shift on 10/14/23, night shift on 10/15/23, and day shift on 10/16/23. The MAR indicated the resident was sleeping for night shift on 10/02/23 and 10/03/23. The MAR indicated the resident refused the treatment on 10/04/23. The MAR was blank for this treatment for day shift 10/03/23 through 10/05/23, day shift and night shift 10/06/23 and 10/07/23, day shift 10/08/23 and 10/10/23, day shift and night shift 10/12/23, night shift 10/14/23, day shift 10/15/23, and night shift on 10/16/23. This order continued until until the resident's discharge on [DATE]. - Cleanse pressure wound left hip with vashe wound cleanser, allow solution to sit on wound for 60 seconds, apply therahoney to wound bed, cover with bordered gauze BID and PRN until healed. Review of the resident's MAR for October 2023 showed this treatment had been signed out by the nurses as performed for night shift on 10/05/23, night shift on 10/08/23, day shift and night shift on 10/09/23, night shift on 10/10/23, day shift and night shift on 10/11/23 and 10/13/23, day shift on 10/14/23, night shift on 10/15/23, and day shift on 10/16/23. The MAR indicated the resident was sleeping for night shift on 10/02/23 and 10/03/23. The MAR indicated the resident refused the treatment on 10/04/23. The MAR was blank for this treatment for day shift 10/03/23 through 10/05/23, day shift and night shift 10/06/23 and 10/07/23, day shift 10/08/23 and 10/10/23, day shift and night shift 10/12/23, night shift 10/14/23, day shift 10/15/23, and night shift on 10/16/23. This order continued until the resident's discharge on [DATE]. - Cleanse pressure wound left posterior thigh with vashe wound cleanser, allow solution to sit on wound for 60 seconds, apply therahoney to wound bed, cover with bordered gauze BID and PRN until healed. Review of the resident's MAR for October 2023 showed this treatment had been signed out by the nurses as performed for night shift on 10/05/23, night shift on 10/08/23, day shift and night shift on 10/09/23, night shift on 10/10/23, day shift and night shift on 10/11/23 and 10/13/23, day shift on 10/14/23, night shift on 10/15/23, and day shift on 10/16/23. The MAR indicated the resident was sleeping for night shift on 10/02/23 and 10/03/23. The MAR indicated the resident refused the treatment on 10/04/23. The MAR was blank for this treatment for day shift 10/03/23 through 10/05/23, day shift and night shift 10/06/23 and 10/07/23, day shift 10/08/23 and 10/10/23, day shift and night shift 10/12/23, night shift 10/14/23, day shift 10/15/23, and night shift on 10/16/23. This order continued until until the resident's discharge on [DATE]. - Cleanse pressure wound to right inner groin with vashe wound cleanser, allow solution to sit on wound for 60 seconds, apply therahoney to wound bed, cover with bordered gauze BID and PRN until healed. Review of the resident's MAR for October 2023 showed this treatment had been signed out by the nurses as performed for night shift on 10/05/23, night shift on 10/08/23, day shift and night shift on 10/09/23, night shift on 10/10/23, day shift and night shift on 10/11/23 and 10/13/23, day shift on 10/14/23, night shift on 10/15/23, and day shift on 10/16/23. The MAR indicated the resident was sleeping for night shift on 10/02/23 and 10/03/23. The MAR indicated the resident refused the treatment on 10/04/23. The MAR was blank for this treatment for day shift 10/03/23 through 10/05/23, day shift and night shift 10/06/23 and 10/07/23, day shift 10/08/23 and 10/10/23, day shift and night shift 10/12/23, night shift 10/14/23, day shift 10/15/23, and night shift on 10/16/23. This order continued until until the resident's discharge on [DATE]. - Cleanse pressure wound to right sacrum with vashe wound cleanser, allow solution to sit on wound for 60 seconds, apply therahoney to wound bed, cover with bordered gauze BID and PRN until healed. Review of the resident's MAR for October 2023 showed this treatment had been signed out by the nurses as performed for night shift on 10/05/23, night shift on 10/08/23, day shift and night shift on 10/09/23, night shift on 10/10/23, day shift and night shift on 10/11/23 and 10/13/23, day shift on 10/14/23, night shift on 10/15/23, and day shift on 10/16/23. The MAR indicated the resident was sleeping for night shift on 10/02/23 and 10/03/23. The MAR indicated the resident refused the treatment on 10/04/23. The MAR was blank for this treatment for day shift 10/03/23 through 10/05/23, day shift and night shift 10/06/23 and 10/07/23, day shift 10/08/23 and 10/10/23, day shift and night shift 10/12/23, night shift 10/14/23, day shift 10/15/23, and night shift on 10/16/23. This order continued until until the resident's discharge on [DATE]. On 10/09/23, the resident was seen in the Infectious Disease Clinic. The physician recommended a surgical referral for possible debridement of the left hip wound. On 10/17/23, the resident was seen in the wound care clinic and sent to the emergency room. The nursing progress note written on 10/17/23 stated, This nurse received a call from [name redacted]Wound Center. The nurse stated that Dr. [name redacted] had sent the resident to [name redacted] ER [emergency room] to be admitted for IV [intravenous] ATB [antibiotics] and severe wounds. Review of the facility's reportables showed on 10/20/23, the facility reported an allegation to the Office of Health Facility Licensure and Certification (OHFLAC), the Regional Ombudsman, and Adult Protective Services (APS) that Resident #93's wound dressing was not changed timely and documentation. The immediate action taken to protect residents was staff suspended pending investigation. The facility requested extensions to complete their investigation. The follow-up report dated November 22, 2023, stated as follows: On October 20, 2023, [name redacted], the daughter of resident [name redacted] reported concerns regarding the care being provided to her mother to the Nursing Home Administrator. The daughter stated that her mothers [sic] wound dressings were not changed timely or done at all. The allegation of neglect was reported to OHFLAC, Regional Ombudsman, and APS. Investigation initiated. Ms. [name redacted] was a short stay resident who was admitted to the [NAME] Center on August 25, 2023. She was alert, oriented and interviewable. Ms. [name redacted] had the ability to make her own medical decisions and express concerns. Ms. [name redacted] had diagnoses of sepsis, acute kidney failure, cellulitis of the limb, and anemia. [Name redacted] required limited assistance with most of her activities of daily living. Previously, Ms. [name redacted] lived at home with her daughter [name redacted] and was able to perform basic ADL's [activities of daily living]. Mrs. [name redacted] was recently receiving home health services from [name redacted]; as well as receiving care at the local wound care center after months of her wounds not healing prior to her admission to [NAME] Center. After a thorough investigation, including staff interviews, schedule review, and evaluating the treatment administration records (TARS) reports, it was determined that Ms. [name redacted] treatments were not completed as prescribed. The investigation concluded a miscommunication between staff nurses and wound care nurse regarding wound dressing responsibility. The wound nurse is no longer employed with Genesis HealthCare. Education was provided to all licensed nursing staff regarding the completion of wound dressing/treatments as prescribed per the medical provider including documentation of completion or refusal of wound dressing/treatments on 10/23/23. The TARS report is being monitored daily by the Director of Nursing to ensure all treatments are completed as prescribed with any corrective action upon discovery. APS interviewed the Nursing Home Administrator and licensed staff regarding neglect, APS notified the Nursing Home Administrator of their response with a report stating Referral not assigned for investigation. The resident was transferred out of center for a wound care appointment and was subsequently transferred to and admitted to the hospital. The resident did not return to the facility. Allegation of neglect was substantiated. During an interview on 12/19/23 at 2:30 PM, the Director of Nursing (DON) there were no assessments of the left calf. The DON also confirmed weekly assessments were not performed of the in-house acquired pressure ulcer to the right gluteus that was first assessed on 09/11/23. The DON also confirmed weekly assessment were not performed of the pressure ulcers first assessed on 09/28/23. The DON also acknowledged the instances when pressure ulcer treatment was not documented as performed on the MAR. c) Resident #87 Review of Resident #87's medical records showed an encounter note written by the nurse practitioner on 12/06/23 that stated, Staff asked me to see resident due to deep tissue injury to bilateral heels .Bilateral heels are mushy with palpation no redness noted .Plan: Deep tissue injury bilateral heels? Apply Skin-Prep and offload heels at night as tolerated. Will monitor and manage as appropriate. Treatment was ordered and provided according to the resident's Treatment Administration Record (TAR). However, no further assessments of the areas could be found. During an interview on 12/18/23 at 2:45 PM, the Director of Nursing (DON) confirmed no further assessment of Resident #87's deep tissue injury was documented. The DON acknowledged the facility's policy stated to assess pressure areas at least weekly.

Based on observation and staff interview, the facility failed to ensure the activity director was certified as an activity professional by a recognized accrediting body. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility census: 92. Findings included: a) During an interview on 12/19/23 at 12:30 PM, with the facilities Activity Director, the surveyor asked her how long she had been certified and how long she had worked at the facility. She stated, I have worked here 7 years and have been an Activity Director for 5 years. I am not certified. I have been through 6 administrators and have told them I need to do this. I have not had the state approved course yet. During an interview, on 12/19/23 at 1:00 PM, with the Administrator she stated, I was not aware that she was not certified, I have only been here a month. I will definitely check into it. A review of the employees hiring records on 12/19/23 at 1:30 PM, revealed the Activity Director was hired at the facility as a Nursing Assistant on 09/16/16 and was hired as the Activity Director on 10/14/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. One (1) of one (1) residents reviewed for non-pressure wounds did not receive wound treatment and care in accordance with professional standards of practice. The facility did not assess or provide treatment to the wounds according to professional standards of care Additionally, the physician-ordered medication parameters were not followed for one (1) of four (4) residents reviewed for medications. Resident identifier: #93. Facility census: 92. Findings included: a1) Resident #93 - non-pressure wounds The facility's policy titled Skin Integrity and Wound Management with effective date 07/01/01 and revision date 02/01/23 gave the following procedures: - Complete comprehensive evaluation of the patient upon admission - Evaluate any reported or suspected skin changes or wounds - Complete wound evaluation weekly Review of Resident #93's medical records show the resident was admitted to the facility on [DATE]. The resident was to complete intravenous antibiotics for right lower extremity necrotic wound. The resident's wound had been diagnosed as squamous cell carcinoma at the hospital, where the wound had been debrided and antibiotics had been started for wound infection. Review of the discharge documents from the hospital documented the resident had vascular lesions of the right lower leg and right lower posterior leg and a traumatic lesion of the left lower posterior leg. The admitting nursing note written on 08/25/23 at 11:00 PM stated the following, Right-Lower extremity has redness. Left-lower extremity has redness .The following skin injury/wound(s) were previously identified and were evaluated as follows: Pressure(s): Description: L (left) calf .Resident refused skin check to R (right) leg and back/buttock. The physician encounter note written on 8/27/2023, no time given, stated, Skin: Debridement of ulcer to right lower extremity. Currently wrapped with bandage in place. Chronic skin issues left lower leg currently wrapped. Review of Resident #93's physician's orders showed the following wound care orders were written on 09/01/23: - For Left Lower Posterior Leg: Cleanse with soap and water. Apply skin prep to peri wound. Apply doubled xeroform to wound bed. Cover with ABD (abdominal) pads. Secure with Kerlix and paper tape, wrapped from ankle to below knee. every evening shift for wound care. Review of the resident's Medication Administration Record (MAR) for September 2023 showed this treatment had been signed out by the nurses as performed on 09/01/23. For 09/03/23, the MAR contained the notation NN, meaning see nurse's note. The nurse's note indicated the treatment had already been performed. The MAR was blank for this treatment on 09/02/23 and 09/04/23. Review of the facility's reportables showed on 10/20/23, the facility reported an allegation to the Office of Health Facility Licensure and Certification (OHFLAC), the Regional Ombudsman, and Adult Protective Services (APS) that Resident #93's wound dressing was not changed timely and documentation. The immediate action taken to protect residents was staff suspended pending investigation. The facility requested extensions to follow-up on new information to complete their investigation. The follow-up report dated November 22, 2023, stated as follows: On October 20, 2023, [name redacted], the daughter of resident [name redacted] reported concerns regarding the care being provided to her mother to the Nursing Home Administrator. The daughter stated that her mothers [sic] wound dressings were not changed timely or done at all. The allegation of neglect was reported to OHFLAC, Regional Ombudsman, and APS. Investigation initiated. Ms. [name redacted] was a short stay resident who was admitted to the [NAME] Center on August 25, 2023. She was alert, oriented and interviewable. Ms. [name redacted] had the ability to make her own medical decisions and express concerns. Ms. [name redacted] had diagnoses of sepsis, acute kidney failure, cellulitis of the limb, and anemia. [Name redacted] required limited assistance with most of her activities of daily living. Previously, Ms. [name redacted] lived at home with her daughter [name redacted] and was able to perform basic ADL's [activities of daily living]. Mrs. [name redacted] was recently receiving home health services from [name redacted]; as well as receiving care at the local wound care center after months of her wounds not healing prior to her admission to [NAME] Center. After a thorough investigation, including staff interviews, schedule review, and evaluating the treatment administration records (TARS) reports, it was determined that Ms. [name redacted] treatments were not completed as prescribed. The investigation concluded a miscommunication between staff nurses and wound care nurse regarding wound dressing responsibility. The wound nurse is no longer employed with Genesis HealthCare. Education was provided to all licensed nursing staff regarding the completion of wound dressing/treatments as prescribed per the medical provider including documentation of completion or refusal of wound dressing/treatments on 10/23/23. The TARS report is being monitored daily by the Director of Nursing to ensure all treatments are completed as prescribed with any corrective action upon discovery. APS interviewed the Nursing Home Administrator and licensed staff regarding neglect, APS notified the Nursing Home Administrator of their response with a report stating Referral not assigned for investigation. The resident was transferred out of center for a wound care appointment and was subsequently transferred to and admitted to the hospital. The resident did not return to the facility. Allegation of neglect was substantiated. During an interview on 12/19/23 at 2:30 PM, the Director of Nursing (DON) confirmed no assessments of wounds present on admission were documented until 09/07/23. The DON confirmed there were no documented attempts to assess the wounds after the resident's initial refusal on admission until the documentation on 09/07/23. The DON confirmed wound care treatment had not been ordered until 09/01/23. The DON also confirmed weekly assessments were not performed of the resident's wounds. The DON also acknowledged the instances when wound care treatment was not documented as performed on the MAR. a2) Resident #93 - medication parameters Review of Resident #93's physician's orders showed an order written on 09/06/23 for metoprolol 12.5 mg twice a day for hypertension. The physician's order included the instructions to hold the medication for systolic blood pressure (the top number) less than 100 or heart rate less than 65. Review of Resident #93's Medication Administration Record (MAR) for September 2023 showed the resident received metoprolol on two (2) occasions when the resident's vital signs indicated the medication should have been held. The dates and times of these occasions were as follows: - On 09/09/23 at 9:00 PM, when the resident's pulse was 62. - On 09/21/23 at 9:00 PM, when the resident's pulse was 61 and the resident's blood pressure was 97/60. Review of Resident #93's Medication Administration Record (MAR) for October 2023 showed the resident received metoprolol on three (3) occasions when the resident's vital signs indicated the medication should have been held. The dates and times of these occasions were as follows: - On 10/10/23 at 9:00 PM, when the resident's pulse was 64. - On 10/12/23 at 9:00 PM, when the resident's pulse was 56. - On 10/16/23 at 9:00 PM, when the resident's pulse was 64 and the resident's blood pressure was 98/65. The resident was discharged from the facility on 10/17/23. During an interview on 12/19/23 at 2:30 PM, the Director of Nursing (DON) acknowledged that Resident #93 received metoprolol at the previously mentioned dates and times despite physician-ordered parameters to hold the medication. No further information was provided through the completion of the survey.

Based on record review and staff interview, the facility failed to provide catheter care in accordance with professional standards of care. This failed practice had the potential to affect two (2) of four (4) residents reviewed for the care area of catheter care. Resident identifiers: #28, #93. Facility census: 92. Findings included: a) Resident #28 Review of Resident #28's medical records revealed the resident had an order for an indwelling urinary catheter due to urinary retention. Review of the resident's Treatment Administration Record (TAR) showed an order written on 10/08/23 to perform indwelling catheter care every day and evening shift. The order was discontinued on 11/17/23. The order to perform indwelling catheter care every day and evening shift was reordered on 12/13/23. There was no evidence the resident had been out of the facility or had the catheter removed from 11/17/23 and 12/13/23. During an interview on 12/18/23 at 3:40 PM, the Director of Nursing (DON) stated an order had been written on 11/17/23 to discontinue Resident #28's indwelling urinary catheter but the resident had refused to have it removed. The DON acknowledged catheter care orders had been discontinued although the resident still had an indwelling urinary catheter. The DON stated she had reentered an order for indwelling catheter care on 12/13/23 when she realized the resident had an indwelling urinary catheter but no orders for catheter care. DON stated an order had been written on 11/17/23 to discontinue the catheter but the resident refused. Catheter care orders were discontinued on 11/17/23 and not reordered until 12/12/23. b) Resident #93 Review of Resident #93's physician's orders showed the resident had an order for an indwelling urinary catheter with orders written on 08/25/23 to perform indwelling urinary catheter care every day and evening shift. Review of the resident's TAR for September 2023 showed the resident's catheter care had not been signed off as performed for evening shift on 09/08/23, for day shift on 09/09/23 through 09/12/23, for day and evening shift on 09/15/23, for evening shift on 09/16/23, for day shift on 09/19/23, for evening shift on 09/20/23, for day shift on 09/21/23 and 09/26/23, and for day and evening shift on 09/29/23. Review of the resident's TAR for October 2023 showed the resident's catheter care had not been signed off as performed for day shift on 10/03/23 and 10/04/23, for day and evening shift on 10/05/23 and 10/06/23, for day shift 10/07/23, 10/08/23, 10/12/23, and 10/15/23. The resident was discharged from the facility on 10/17/23. During an interview, on 12/19/23 at 2:30 PM, the Director of Nursing acknowledged Resident #93's indwelling urinary catheter care was not signed off as performed on the TAR on the above-mentioned dates and times.

. Based on medical record review and staff interview, the facility failed to ensure a complete and accurate medical record pertaining to a Covid-19 diagnosis. This practice affected one (1) of three (3), residents reviewed during a complaint survey. Resident identifier #2. Facility census: #93. Findings included: a) Resident #2 A medical record review on 09/27/23, revealed Resident #2's Covid-19 diagnosis on 08/28/23. Continued review found the facility line listing noted Resident #2's Covid-19 diagnosis on 08/31/23. Resident #2 was put in Isolation precautions on this date. During an interview, on 09/27/22 at 12:30 PM, the Director of Nursing (DON) and Administrator verified the medical diagnosis in Resident #2's medical record was inaccurate. It was confirmed Resident #2 was not diagnosed with Covid -19 until 08/31/23.

Based on review of the medical record, staff interview, and family interview, the facility failed to notify the responsible party of changes in a resident's condition for one (1) of three (3 closed records reviewed. Resident identifier: #99. Facility Census: 95. Findings included: a) Resident #99 A review of Resident #99's care plan revealed a plan initiated on 07/12/22, which indicated this resident was receiving Antiplatelet therapy and Aspirin and was at risk for bleeding. The goal for this care plan stated the resident will not exhibit bleeding by the next review and interventions include observing for bleeding, hematuria, bruising, nose bleeds, gums, and blood in stool. This care plan had been continued each quarter. According to the Nursing Notes dated 05/22/23, a skin check was performed on Resident #99 and there were no skin issues. On 05/26/23, it was identified Resident #99 was up to the wheelchair then transferred to the recliner chair via the Hoyer lift. The dressing to the left arm was saturated with dark brown drainage to the skin tear. The dressing was changed for a second time on this shift. A family interview with Resident #99 's Responsible Party, revealed she came in the facility to visit her mother on 05/26/23, and blood was observed on her sheets, and she had not been made aware of the skin tear her mother received. An interview with Licensed Practical Nurse (LPN) Employee #82, on 08/30/23 at 4:00 PM, revealed she knew this was not reported to the daughter. Employee #82 said she asked the resident if her daughter knew, and she said no but sometimes the staff assume this resident was going to tell her and do not call. There was nothing charted about this incident occurring in the medical record. Review of the medical record for Resident #99 revealed a change in condition form dated 08/07/23 completed by LPN, Employee #82 identifying this nurse went into Resident #99's room to check her blood glucose. Upon entering the room, the nurse noted a dark purple bruise on her inner left eye and underneath Resident #99's left eye. Resident #99 was questioned about her eye and what happened, and the resident said, I don't know. Employee #82 asked her if she bumped her eye or if she sneezed or coughed too hard and the resident stated no. Resident #99 did state the Nursing Assistant notified the nurse of the condition of her eye that morning on dayshift and they did come and look at her eye. (No names specified). This change in condition form verified the responsible family was made aware of this black eye on 08/07/23 at 4:58 PM. During a staff interview with Employee #82, on 08/31/23, at 4:00 PM, it was verified on 08/07/23, the above change in condition form was completed by this LPN, Employee #82. It was identified that the nurse, Employee #55, from the previous shift, failed to record the discoloration of Resident #99 ' s eye in the medical record. According to Employee #82, the Responsible Party was upset because no one notified her of this incident on dayshift when this was identified. .

. Based on interview and record review the facility failed to make prompt efforts to resolve a grievance and to keep the resident notified of progress toward resolution. This is true for One (1) of two (2) residents reviewed during a complaint survey. Resident identifiers: #29. Facility census: 95. Findings included: a) Resident #29 On 08/29/23, at 8:52 AM during an interview Resident #28 stated, he has complained about other residents coming in his room and taking his personal belongings. He stated he had talked to Social Services, but nothing was ever done about the missing items or the intruding residents. On 08/29/23 a review of the facility records regarding missing items and grievances revealed Resident #29 had no concerns or grievances filled out. A continued record review of Resident #29's medical record found a Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/31/23, A review of this MDS found the resident's brief interview for mental status was fifteen (15) the highest score obtainable and indicated Resident #29 was cognitively intact. During an interview with the Social Services Director (SSD) on 08/29/23 at 3:10 PM, she stated, It is what it is. She continued to state, she had been the only SW in the building for months and that she just can't keep up. She stated, Resident #29 complains all the time. She confirmed there were no grievance forms filled out for Resident #29 grievances. On 08/29/23 at 5:11 PM an interview with the Administrator confirmed the missing items and grievances should have been followed up on and replaced. .

. Based on observation, record review, staff interview, the facility failed to ensure staff donned appropriate personal protective equipment (PPE) prior to entering transmission-based precaution (TBP) room. These failed practices had the potential to affect more than a limited number of residents currently residing in the facility. Resident identifiers: #13. Facility census: 95. Findings included: a) Resident #13 An observation on 08/29/23 at 8:22 AM found Maintenance #25 entering Resident #13's room without PPE. The signage on Resident #13's door showed the room was on Contact Plus Airborne Precautions. The TBP sign stated, Perform Hand Hygiene BEFORE and AFTER patient contact, contact with environment & after removal of PPE. Wear an N95 Respirator, Gown, Face Shield and Gloves upon entering this room. Maintenance Director #25 was observed in Resident #13's room without a gown, face shield, or gloves. During an interview on 08/29/23 at 8:30 AM, Maintenance Director #25 stated he did not know Resident #13 was in isolation. He continued to say he did not see the sign on the door. A medical record review for Resident #13 revealed he was on Contact and Airborne Precautions every shift for Isolation due to Covid-19. During an interview on 08/29/23 at 2:01 PM the Administrator verified, Resident #13 was in isolation with, Contact Precautions sign posted on the Residents door. She verified anyone entering should follow the isolation precautions. No further information was provided prior to the end of the survey on 08/29/23 at 6:00 PM. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure a complete and accurate Minimum Data Set (MDS) assessment was completed for one (1) of 20 residents in the long-term care survey sample. Resident identifier: #91. Facility census: 93. Findings included: a) #91 Review of Resident #91's medical records showed the resident had been admitted to the facility on [DATE]. Further review of the medical records showed the resident had been receiving hospice services since admission to the facility. Resident #91's MDS assessment with Assessment Reference Date (ARD) 05/23/22 did not document the resident was receiving hospice services. During an interview on 06/08/22 at 11:37 AM, the Administrator verified Resident #91 was admitted to the facility with hospice services. The Administrator also verified the resident's MDS assessment with ARD 05/23/22 did not document the resident was receiving hospice services. No further information was provided through the completion of the survey. .

. Based on observation, record review and staff interview the facility failed to ensure the care plan was revised and accurate in the Food and Nutrition area for Resident #53. This was true for 1 (one) of 20 (twenty) residents reviewed during the survey process. Resident Identifier #53. Facility Census 93. Findings included: a) Resident #53 On 6/06/22 at 3:01 PM it was observed that Resident #53 has a wander guard on his right ankle for elopement precautions. Record review on 6/07/22 at 9:53 AM shows the following elopement evaluations were found to be completed: 6/5/2022, 1/24/2022, 9/04/2021, 7/06/2021, 3/15/2021. There was change of condition documentation for elopement and elopement attempts or exit seeking on the following dates 9-04-21, 1-24-22, 5-14-22, and 6-05-22. According to his care plan the resident has a history of cutting his wander guard off and is to have plastic silverware and no sharp objects in the room. He has a diagnosis of dementia. There is no active order for plastic silverware. Upon observation of the Residents lunch on 6/07/22 at 12:31 PM he does not have plastic silverware on his tray. This was confirmed on 6-07-22 at 12:32 with Licensed Practical Nurse #25. On 6/08/22 at 11:15 AM during an interview with the Administrator, he provided documentation that the plastic silverware order was discontinued on 5/05/22. The Resident no longer tries to cut his wander guard off. The care plan was not revised and is not accurate. .

. Based on observation and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. The medication cart was left unlocked when unattended. This was a random opportunity for discovery that had the potential to affect a limited number of residents. Facility census: 93. Findings included: a) Medication Administration Facility Task On 06/07/22 at 08:04 AM, Licensed Practical Nurse (LPN) #44 entered Resident #69's room to administer medications. The medication cart was in the doorway of the resident's room, facing the room. LPN #44 did not lock the medication cart when leaving the cart and entering the room. At 8:05 AM, LPN #44 closed the door to the resident's room for privacy to apply a lidocaine patch to the resident's back. The medication cart remained unlocked in the hallway at this time. At 8:06 AM, LPN #44 opened the resident's door and returned to the medication cart. LPN #44 acknowledged the medication cart was unlocked when she was in the resident's room with the door closed. No further information was provided through the completion of the survey. .

. Based on medical record review and staff interview, the facility failed to evaluate residents experiencing impaired nutrition. Two (2) of five (5) residents reviewed for the care area of nutrition were not weighed as ordered by the physician. Resident identifiers: #89 and #68. Facility census: 93. Findings included: a) Resident #89 Review of Resident #89's medical records showed a physician's order written on 04/13/22 for weekly weights. The weights were to be obtained every Wednesday. Prior to the order, the resident had a weight obtained on 04/08/22, and the resident weighed 100.4 pounds. Following the order, the medical records showed the following information for Resident #89's weekly weights on Wednesdays: - 04/13/22: the resident was not weighed - 04/20/22: the resident was not weighed - 04/27/22: the resident was not weighed - 05/04/22: the resident weighed 97.2 pounds - 05/11/22: the resident weighed 102.7 pounds - 05/18/22: the resident was not weighed - 05/25/22: the resident weighed 101.6 pounds The resident was admitted to the hospital 05/30/22-06/04/22. She was not weighed when she returned to the facility. During an interview on 06/07/22 at 12:24 PM, the Director of Nursing confirmed Resident #89 had not been weighed every week as ordered by the physician. No further information was provided through the completion of the survey. b) Resident #68 A medical record review on 06/06/22 for Resident #68, revealed an order for weights to be completed on day shift every Wednesday for four (4) weeks due to weight loss, this order was effective on 05/18/2022. Upon further review, it was discovered no weights had been done on Wednesday, 05/18/22. The weight obtained on Wednesday 05/25/22 for Resident #68 was 87 pounds, this resident was already experiencing impaired nutrition. During an interview with the Director of Nursing (DON) on 06/07/22 at 2:45 PM, verified the weight was not obtained on 05/18/22. She reported the second weight obtained on Wednesday, 06/01/22 for Resident #68 was 88 pounds, which was a slight weight gain. .

. Based on observation, medical record review and staff interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. This was true for two (2) of three (3) residents reviewed in the area of respiratory care during the long term care survey process. Resident identifier: #62 and #86. Facility census: 93 Findings included: a) Resident #62 On 6-06-22 at 12:16 PM observation found Resident #62 had oxygen on via nasal canula. The oxygen tubing was not dated with a change out date. This was confirmed with Registered Nurse (RN) #21. The Policy and Procedure states the oxygen tubing and storage containers for all respiratory supplies are to be changed weekly and dated on the change out date. b) Resident #86 On 06/06/22 at 11:02 AM observation found Resident #86 had oxygen on via nasal canula. The oxygen tubing for the nasal canula was not dated with a change out date. This was confirmed with RN #21 on 06/06/22 at 11:04 AM. The Policy and Procedure states the oxygen tubing and storage containers for all respiratory supplies are to be changed weekly and dated on the change out date. .

. Based on record review and staff interview, the facility failed to ensure performance reviews for Nurse Aides were conducted at least once every 12 months. This was true for one (1) of three (3) Nurse Aides reviewed for the sufficient and competent nurse staffing facility task. This deficient practice had the potential to affect a limited number of residents. Facility census: 93. Findings included: a) Sufficient and competent nurse staffing facility task On 06/07/22 at approximately 2:00 PM, the Administrator was asked for copies of the yearly performance reviews for three (3) Nurse Aides, including Nurse Aide (NA) #24. On 06/07/22 at 4:09 PM, the Administrator stated a yearly performance review had not been conducted for NA #24. No further information was provided through the completion of the survey. .

. Based on record review and staff interview, the facility failed to ensure PRN (as needed) orders for psychotropic medications were limited to 14 days, or that the rationale for extending beyond 14 days was documented along with the duration of the PRN order. This deficient practice had the potential to affect one (1) of one (1) residents reviewed for the care area of fall. Resident identifier: #26. Facility census: 93. Findings included: a) Resident #26 Review of Resident #26's medical records showed an order for written for alprazolam (Xanax) 0.25 mg every night as needed for insomnia. No duration for the order was provided. Additionally, the medical records did not contain a physician's rationale for why the order should be extended beyond 14 days. Review of Resident #26's Medication Administration Record showed the resident last received the PRN alprazolam on 05/28/22. During an interview on 06/07/22 at 2:21 PM, the Director of Nursing (DON) confirmed Resident #26's PRN alprazolam order had been extended for over 14 days without a documented rationale or a duration for the order. No futher information was provided through the completion of the survey. .

. Based on observation and staff interview, it was found that two (2) containers of grape juice stored in the refrigerator had expired. Additional findings included cabinets uses to store pots, pans and baking ware were rusted and could not be sanitized. The wall behind a prep table had peeling yellow paint and rust around the back edge of the table which could not be cleaned and sanitized. These practices had the potential to affect a limited number of residents residing in the facility. Facility census: 106. Findings included: a) Expired juice On 06/06/22 at 11:07 AM an observation with the Dietary Manager (DM) found two (2) containers of grape juice that had expired on 06/04-05/22 in the refrigerator in the kitchen. The DM immediately removed the containers of grape juice and confirmed they were expired. b) Cabinets During this same observation with the DM, two (2) cabinets used to store pots, pans and baking ware were rusted. The DM confirmed the cabinets were rusted and could not be cleaned and sanitized. This contaminated the pots, pans and baking ware. c) Wall During the same observation with the DM, on 06/06/22 ay 11:07 AM, found the wall behind the prep table had bubbling and peeling yellow paint, exposed wood and a rusted latch. The DM stated this had been an opening to serve food but had been closed for some time. The DM confirmed the finding and agreed the wall was in need of repair. .

. Based on medical record review and staff interview the facility failed to have a complete and accurate order regarding an indwelling urinary catheter. This was true for one (1) of three (3) residents reviewed for the care area of catheters. The order for a catheter for Resident #63 did not specify the size of catheter or the balloon inflation. Resident identifier: #63 Facility census: 93. Findings included: a) Resident #63 A medical record review on 06/07/22, revealed Resident #63's catheter order was incomplete. The order did not specify the size of catheter to be used or the amount of cubic centimeters (cc) needed to inflate the balloon. During an interview on 06/07/22 at 4:20 PM with the Director of Nursing (DON), verified the order for Resident #63's catheter was incomplete. .

. b) Invalid Physician's Order for Scope of Treatment (POST) form On 03/02/21 at 9:00 AM, record review revealed a POST form on Resident #34's chart. The bottom of the form indicated it was produced by [NAME] Virginia's Center for End-of-Lafe Care in 2017. In Section D, verbal consent from the (HCS) was accepted on the POST form. The verbal consent was dated 06/01/20 and witnessed by RN #153 and LPN #154. Above the signature line, the following typed guidance is displayed, Signature of Patient/Resident, Parent of Minor, or Guardian/MPOA Representative/Surrogate (Mandatory). Review of instructions on how to complete the POST form from Using the POST Form: Guidance for Healthcare Professionals 2016 Edition outlined: The patient or representative/surrogate and physician/APRN (advanced practice registered nurse) must sign the form in this section. These signatures are mandatory. A form lacking these signatures is NOT valid. On 03/02/21 at 12:03 PM, the Director of Nursing acknowledged there was no written signature of Resident #34's representative and that verbal consent had been accepted. c) Incomplete Physician's Order for Scope of Treatment (POST) form Record review, on 03/02/21 at 8:02 AM, found a [NAME] Virginia Physician Orders for Scope of Treatment (POST) form signed and dated on 10/03/14 was on Resident #8's chart. The POST form directed Resident #8 was a do not resuscitate (DNR). Section B entitled, Medical Interventions, directed that Resident #8 was to have Limited Additional Interventions. It further stated: Use medical treatment, antibiotics, IV Fluids and cardiac monitoring as indicated. Do not use intubation or mechanical ventilation. Transfer to hospital if indicated. Avoid intensive care unit. Section C entitled, Medically Administered Fluids and Nutrition, directed Resident #31 should have IV (intravenous) fluids for a trial period of no longer than _____. The specified time period was left blank and was not completed on the POST form. In 2002, the POST form was incorporated into the [NAME] Virginia Health Care Decisions Act (16-30-25.) POST forms are standardized forms used to reflect orders by a qualified physician for medical treatment of a person in accordance with that person's wishes. The directions for completing the POST form, compiled by the [NAME] Virginia Center for End of Life, require accurately documenting a patient's treatment preferences, which would include accurate documentation of the length of the trial period for IV fluids. On 03/02/21 at 12:05 PM, the Director of Nursing acknowledged the POST form was not completed in its entirety and the form should be updated. Based on observation, record review and staff interview the facility failed to ensure three (3) Residents had completed, accurate and correctly labeled post forms and charts with Residents' code status preferences. The facility failed to accurately complete two (2) post forms for two (2) residents. The facility failed to correctly label one (1) Residents hard copy chart with the correct code status indicator. This was true for three (3) of 29 residents reviewed for advance directives. Resident identifiers: #72, #34 and #8. Facility census: 81. Findings included: a) Resident #72 A record review, on 03/01/21 at 4:03 PM, revealed a post form that stated, Attempt Resuscitation. A physician order that stated, Full Code. Limited interventions. IV fluids x2wks. No feeding tube. An observation, on 03/01/21 at 4:30 PM, revealed Resident's #72's hard copy medical record with an orange round sticker and a Do not Resuscitate (DNR) sticker on the outside of the chart. An interview with Nurse Aid (NA) #111, on 03/02/21 at 12:15 PM, revealed the round stickers on the hard copy charts are code status indicators. The orange is for do not resuscitate (DNR) and the green means full code. An interview with Licensed Practical Nurse (LPN) #138, on 03/02/21 12:20 PM, revealed the orange round sticker on the chart is a guide to the code status preference of the resident. An interview with Administrator, on 03/02/21 at 12:30 PM, confirmed Resident #72's post form stated full code but the hard copy chart was marked with an orange sticker indicator and stated DNR. Administrator confirmed the post form and code status indicator on the hard copy chart did not match. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and staff interview, the facility failed to ensure drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional practices. Medications stored in a medication storage room were expired and refrigerated medications did not have temperature monitoring maintained in 2 of 2 refrigerators observed. One of 3 medication carts inspected did not have medications dated when opened and put in to use. This practice affected more than a limited number of residents. Facility census: 81. Findings included: a. South Medication cart observation On [DATE] at 9:12 AM, an inspection of the South Medication cart revealed a bottle of stock medication, Vitamin C 500 mg open and being used for residents but did not have a date when opened. An interview with LPN #35 at that time, verified all stock medications were to be labeled with the date opened and put into use and the stock med in question did not have a date when opened. b. South Medication Storage room observation An observation with LPN #121, on [DATE] at 09:12 AM, of the South medication storage area revealed a bottle of Biscodyl that was expired 1/21 and a bottle of Multi vitamins once daily expired 2/21. Both medications were available for use. Additionally, the two refrigerators did not have documentation of refrigerator temperature monitoring. On [DATE] at 9:12 AM, observation of the medication refrigerator had a temperature monitoring date of [DATE] for the AM check but no other checks documented. The vaccine refrigerator was only checked once per day. An interview with the Director of Nursing (DON), on [DATE] at 10:20 AM, verified the refrigerators were to be checked twice daily and provided Policy C401 titled Medication and Vaccine Refrigerator /Freezer temperatures for verification. The area under policy notes refrigerators and freezers used to store medications and vaccines will operate under acceptable temperature range and will be checked twice daily. Further interview with the DON on [DATE] at 10:20 AM, verified the facility had not performed refrigerator checks as indicated by policy An inspection of the electronic medication delivery system (Omnicell) on [DATE] at 10:40 AM, RN #51 confirmed the following medications were expired but still in the Omnicell available to be used for residents: 1 Levofloxacin 500 mg/100Ml expired 1/21 1 Dextrose 10% water IV solution expired 2/21 1 Prednisone 5MG tablet expired 1/21 5 Divalproex DR 125 MG capsules expired 1/21 5 Isosorbide 10 MG tablets expired 2/21 5 Donepezil HCL 5 MG tablets expired 2/21 1 vial Vancomycin 1 GM vial expired 1/21 .