Based on observation, record review and staff and resident interview, the facility failed to ensure a resident with limited Range of Motion (ROM) was able to reach the call light to call for assistance. This was a random opportunity for discovery and had the potential to affect a limited number of residents. Resident Identifier: #38. Facility Census: 65 Findings included: a) Resident #38 During the initial interview process, Resident #38 was observed sitting upright in bed and leaning toward the left. The resident attempted to position himself, but was unable. The patient attempted to use the call light, but was unable to reach it. The patient has a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. The state surveyor pushed the call light for the resident at the resident's request. Nurse Aide (NA) #36 answered the call light promptly and asked the Director of Nursing (DON) for assistance with repositioning the resident. b) NA #36 reported the patient will use his call light and stated, When he has it, he usually does. The DON reported the resident used to have a pancake call light. The DON instructed NA #36 to place the resident's call light on the right side of the bed in reach for the resident.

Based on observation and record review, the facility failed to provide a home-like environment during the dining experience. This failed practice had the potential to affect more than a limited number of residents. FACILITY:FACILITY. Facility Census: 65. Findings included: a)The facility's policy and procedure stated, All items are removed from trays and are appropriately placed in front of the resident, packages are opened, and lids are removed. b) On 03/31/25 at 12:55 PM during the facility's dining observation, the staff left a resident's food on their tray when during the lunch meal. An additional resident's tray was left on the table beside the resident's meal while they ate lunch.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure documentation that the appropriate information was communicated to the receiving health care institution or provider upon resident transfer. This deficient practice had the potential to affect one (1) of two (2) residents reviewed for the care area of hospitalization. Resident identifier: #66. Facility census: 65. Findings included: a) Resident #66 Review of the facility's policy titled, Discharge and Transfer, with effective date 06/01/96 and revision date 03/24/25, showed for hospital transfers, the following would be sent to the hospital with the resident: - eInteract Nursing Home to Hospital Transfer From (in states where no state specific form is required) - medication list - Advance Directives - Physician's Orders for Scope of Treatment (POST) form or equivalent The policy and procedure also stated a copy of the eInteract form would be placed in the resident's medical record. Review of Resident #66's progress notes stated the resident was transferred to the hospital on [DATE] due to increased confusion, lethargy, abnormal vital signs, and increased respirations. The resident's electronic health record contained no eInteract transfer form. The progress notes contained no documentation regarding information or documents sent to the receiving hospital with the resident. On 04/04/25 at 4:36 PM, the Director of Nursing (DON) confirmed an eInteract transfer form had not been completed when Resident #66 was transferred to the hospital. She stated the following documents are sent to the hospital with residents upon transfer: face sheet, medication administration record, advance directives or POST form, and physician's determination of capacity. She confirmed there was no documentation of what documents were sent to the receiving hospital with Resident #66 on 02/12/25. No further information was provided through the completion of the survey process.

Based on record review and staff interview, the facility failed to ensure an accurate Minimum Data Set (MDS) regarding weight loss. This was true for one (1) of two (2) residents reviewed under the care area of tube feeding. Resident Identifier: #61. Facility Census: 65. Findings Include: a) Resident #61 On 03/31/25 at 4:51 PM, a record review identified the resident was noted with significant weight loss. The resident's weight on 02/05/25 was 176.8 pounds. The resident's weight on 03/07/25 was 167.2 pounds. This is a significant weight loss of -5.43% in 30 days. A review of the MDS significant change dated 03/10/25 section K regarding weight loss was reviewed on 03/31/25 at 7:00 PM. The MDS stated no or unknown for the question K0300 for loss of 5% or more in the last month or loss of 10% or more in 6 months. On 04/02/25 at 3:40 PM, the Director of Nursing (DON) confirmed the MDS was incorrect regarding significant weight loss.

Based on record review and staff interview, the facility failed to prevent the development of an avoidable pressure ulcer to the right heel for Resident #22. This was true for one (1) of three (3) records reviewed under the care area of pressure ulcers. Resident Identifier: #22. Facility Census: 65. Findings include: a) Resident #22 On 04/01/25 at 11:30 AM, a record review was completed for Resident #22. A progress note dated 03/31/25 at 1:41 PM stated, Note: Resident has a blister to her right heel. NP (Nurse Practitioner) in facility this morning and visited resident. New order for Sure Prep to right heel BID (twice daily). POA (Power of Attorney) notified and in agreement with order. On 04/01/25 at 12:19 PM, the Director of Nursing confirmed the resident had developed a pressure ulcer on her right heel.

Based on observation, record review, and staff interview, the facility failed to transfer oxygen tanks in a safe manner. This was a random opportunity for discovery. Facility Census: 65. Findings Include: a) Oxygen tanks On 04/03/25 at 12:32 PM, an observation of the Maintenance Director carrying four (4) oxygen tanks, with no carrier used. The Maintanence Director had two (2) oxygen tanks in each hand, as he walked around the building the tanks were clanking together. On 04/03/25 at 12:34 PM, an interview was held with the Maintanence Director. the Maintanence Director stated, I know I'm not supposed to carry them this way .I'm trying to help her (referring to the oxygen delivery person) and she is tired. On 04/03/25 at 12:48 PM, the Corporate RN was notified. The Corporate RN shook her head in agreement and confirmed the oxygen tanks should not be transported without a carrier.

Based on record review and staff interview, the facility failed to provide pneumococcal immunizations according to standards of practice. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of immunizations. Resident identifier: #59. Facility census: 65. Findings included: a) Resident #59 Review of the facility's policy titled, Pneumococcal Vaccination, with effective date 05/04/15 and revision date 09/13/24, gave the following instructions: - Obtain patient/representative consent for pneumococcal vaccination - Administer the vaccine Review of Resident #59's electronic health records showed the resident's Medical Power of Attorney (MPOA) consented on 10/28/24 for the resident to receive the pneumococcal vaccination. Resident #59's Medication Administration Records (MARs) for October and November 2024 contained no documentation the resident received pneumococcal vaccination. On 04/02/25 at 1:55 PM, the Director of Nursing (DON) confirmed the facility had no documentation Resident #59 had received pneumococcal vaccination after her MPOA consented for the vaccination.

b) Resident #22 On 03/31/25 at 12:38 PM, the lunch trays arrived at the dining room on A hall. Resident #22 was sitting with another resident. Nurse Aide (NA) #66 sat Resident #22's food in front of her. The resident was sitting in a geri-chair with a clothing protector on, which was covering up her hands. The resident was tearful throughout the entire experience. On 03/31/25 at 12:49 PM, Licensed Practical Nurse (LPN) # 78 began feeding the Resident #22. The resident waited 11 minutes before a staff member started assisting the resident with lunch. LPN #78 was standing while assisting Resident #22. On 03/31/25 at approximately 1:05 PM, LPN #78 was interviewed regarding standing while feeding the resident and the resident's wait time for meal assistance. LPN #78 stated, I didn't know. On 04/01/25 at 9:05 AM, the Director of Nursing (DON) was notified of the issue regarding the dignity of the resident during meal time. The DON stated, I will give the nurse education. c) Resident #57 On 03/31/25 at 12:38 PM, the lunch trays arrived at the dining room on A hall. Resident #57 was seated with two (2) other residents at the table. The resident did not receive his food until 12:43 PM, which was five (5) minutes, while the other residents were eating their meals. On 04/01/25 at 9:05 AM, the DON was notified. The DON stated, We are working on meals .Dietary does not put the trays in the cart by rooms. They are loading them on the cart randomly. Based on observation, record review and staff interview, the facility failed to provide care in a manner and environment that promoted a dignified dining experience for the residents. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #61, #50, #22, #57, #1, #2, #29. Facility Census: 65. Findings included: a) On 03/31/25 at 12:55 PM, during the dining observation, resident's were not seated at the same time at tables, the lunch meal did not arrive at the same time for resident's at the same table, six (6) residents were left seated in the center of the dining room while the other resident's were at their tables and served beverages and lunch meals and clothing protectors were placed on residents without asking their preference. At 1:05 PM, Resident #61 tried multiple times to feed Resident #50 from their tray. The state surveyor intervened for staff to re-direct the resident. Resident #50 received the lunch tray at 1:13 PM. Resident #1 was fed at 01:32 PM after the tablemate's lunch had been fed beginning at 1:12 PM. Staff began feeding Resident #2 at 1:16 PM at the same table as Resident #29. Resident #29 was continuously reaching for her tray on table which was moved out of reach by staff. Resident #29 was fed her lunch tray in the dining room after 1:45 PM. Resident's #29's food was on the table the whole time. The facility's policy and procedure stated, Meals are served table by table.

Based on record review and staff interview, the facility failed to complete a change in condition (CIC) for Resident #22's development of a pressure ulcer on the right heel. This was a random opportunity for discovery. Resident Identifier: #22. Facility Census: 65. Findings Include: a) Resident #22 On 03/31/25 at 2:30 PM, a progress note was reviewed. The progress note dated 03/31/25 at 1:16 PM stated, Resident has a blister to her right heel. NP (Nurse Practitioner) in facility this morning and visited resident. New order for Sure Prep to right heel BID (twice daily). POA (Power of Attorney) notified and in agreement with order. (Typed as written.) Upon further review, no change in condition was found for Resident #22. On 04/01/25 at 2:00 PM, an interview was held with the Director of Nursing (DON). The DON confirmed the resident did have a blister to the right heel and no change in condition had been completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to implement or develop comprehensive, person-centered care plans for four (4) of 22 residents. Resident #22's care plan was not implemented regarding a dietary restriction, documenting meal intakes, and for the risk of limited engagement. Resident #31's care plan was not implemented for monitoring of medication side effects and behaviors, pain assessments,and anticoagulation monitoring. The facility failed to develop a care plan for Resident #57 and #59 to include all diagnoses. Resident Identifiers: #22, #31, #57, #59, #25. and #51. Facility Census: 65. Findings included: a) Resident #22 On 03/31/25 at 12:38 PM, the lunch trays arrived at the dining room on A hall. Resident #22 was sitting with another resident. Nurse Aide (NA) #66 sat Resident #22's food in front of her. The resident was sitting in a geri-chair with a clothing protector on, which was covering up her hands. The resident was tearful throughout the entire dining experience. On 03/31/25 at 12:49 PM, Licensed Practical Nurse (LPN) # 78 began feeding the Resident #22. The resident waited 11 minutes before a staff member started assisting her with lunch. LPN #78 was standing while assisting Resident #22 and feed the resident pork, which was listed as a dietary restriction. On 03/31/25 at approximately 1:05 PM, LPN #78 was interviewed regarding the dietary restriction. LPN #78 stated, I didn't know. NA #66 stated, I think its a religious thing NA #66 then stated, I served her the food .I didn't realize it was pork .I laid the lunch ticket over here (on counter behind the resident) . After reviewing the lunch ticket, No Pork is typed on the lunch ticket twice. On 04/01/25 at 9:05 AM, the Director of Nursing (DON) was notified of the issue regarding the dietary restriction for the resident. The DON stated, it is not a religious restriction .I think she just didn't eat pork .I agree the care plan under the focus area of nutritional risk was not implemented due to the intervention listed no pork diet as ordered. On 04/01/25 at 11:10 AM, a telephone interview was held with the Medical Power of Attorney (MPOA). The MPOA was asked, is the dietary restriction for pork due to a religious reason? The MPOA stated, no .she was raised to not eat pork .my grandmother never ate pork On 04/01/25 at 11:30 AM, the care plan intervention under the focus area of nutrition risk was not implemented regarding monitor intake at all meals, offer alternate choices if needed, alert dietician and physician to any decline in intake. On 04/02/25 at 11:00 AM, a further review of the meal intake for the last 30 days from 03/04/25 through 04/01/25 was completed. The review found missing documentation for meal intake for the follwing days: --03/09/25 missing documentation for one (1) meal --03/14/25 missing documentation for one (1) meal --03/19/25 missing documentation for one (1) meal --03/23/25 missing documentation for one (1) meal --03/30/25 missing documentation for one (1) meal On 04/02/25 at 12:19 PM, the DON confirmed the meal intakes were not documented; and, the care plan was not implemented. On 03/31/25 at 12:38 PM, the resident was observed in the dining room. The resident was sitting in a geri-chair with a clothes protector on, covering her hands. The resident was tearful throughout the entire dining experience. On 03/31/25 at 3:15 PM, the resident was observed sitting in a geri-chair. The resident was sitting in a corner, tearful for approximately 20 minutes before a staff member approached her. A review of the care plan on 04/01/25 at 11:30 AM, under the focus area of risk for limited engagement found two (2) interventions in regards to the resident being tearful. The first intervention states, observe for signs and symptoms for tearfulness .offer her Hug'able doll to her and if necessary gently guide her to a calm private location. The second intervention listed is as follows: (Resident name) enjoys watching the (name of program) channel in her room. If you notice signs of tearfulness, .offer to put on the (name of program) channel for her. Quiet time in her room while watching her favorite channel helps to calm her down and comfort her. On 04/02/25 at 12:30 PM, the Director of the Memory Unit (DOMU), confirmed the care plan interventions were not implemented. The DOMU then stated, Sometimes other residents don't want the channel changed .I agree there was no huggable doll around and she could be taken to her room to turn on (name of program). On 04/02/25 at 12:49 PM, the DON confirmed the care plan had not been implemented when the resident became tearful. b) Resident #31 On 04/01/25 at 9:14 PM, a record review for unnecessary medications was completed for Resident #31. The review found the care plan interventions were not being implemented regarding the monitoring of medication side effects and behaviors, pain assessments, and anticoagulation monitoring for 01/2025 and 02/2025. The care plan intervention under the focus area of exhibits or has the potential for .behaviors is monitor medications especially new/changed/discontinued, for side effects and resident's/patient's response to contributing to verbal behaviors. The following dates on the Medication Administration Record (MAR) with no documentation are as follows: --01/09/25 day shift --01/13/25 day shift --01/14/25 day shift --01/15/25 day shift --01/16/25 day shift --01/17/25 night shift --01/28/25 day shift --02/11/25 day shift --02/12/25 day shift The care plan intervention under the focus area of resistive to care is observe for pain. Atttempt non-pharmacologic interventions to alleviate pain. The following dates on the MAR with no documentation are as follows: --01/09/25 day shift --01/13/25 day shift --01/14/25 day shift --01/15/25 day shift --01/16/25 day shift --01/17/25 night shift --01/28/25 day shift --02/11/25 day shift --02/12/25 day shift The care plan intervention under the focus area of risk for injury or complications related to the use of antiplatelet and anticoagulant therapy, observe for active bleeding, (i.e. hematuria, bruising, guaiac + stool, nose bleeds, bleeding gums, etc. The following dates on the MAR with no documentation are as follows: --01/09/25 day shift --01/13/25 day shift --01/14/25 day shift --01/15/25 day shift --01/16/25 day shift --01/17/25 night shift --01/28/25 day shift --02/11/25 day shift --02/12/25 day shift On 04/02/25 at 11:15 AM, the DON confirmed the care plan had not been implemented in these care areas. c) Resident #57 On 04/01/25 at 10:31 AM, a record review was completed for Resident #57. The review found the care plan had not been developed to include all diagnoses. The following diagnoses were not included: --unspecified protein-calorie malnutrition --dysphagia, unspecifed On 04/02/25 at 11:15 AM, the DON confirmed the diagnoses were not developed in the care plan. d) Resident #59 On 04/01/25 at 3:00 PM, a record review was completed for Resident #59. The review found the care plan had not been developed to include all diagnoses. The following diagnoses were not included: --hypertension --hyperlipidemia --osteoporosis --anemia --muscle weakness --muscle spasms On 04/02/25 at 11:15 AM, the DON confirmed the diagnoses were not developed in the care plan. e) Resident # 25 On 04/03/25 at 9:52 AM a review of the medical record for Resident #25 who was admitted on [DATE] with diagnoses of schizoaffective disorder, depressive type, anxiety disorder, major depressive disorder, vascular dementia with agitation, psychotic disorder, seizures and mood disturbance. A review of the care plan found the following: Focus is at risk for complications related to the use of antipsychotic, and antidepessant medications dated created 08/17/23 with revision on 11/23/24. Goal will have the smallest most effective dose without side effects through to next review. Date initiated 08//28/23 and revision date of 04/02/25. Interventions administer medications as ordered, be alert for side effects of antidepressants including: sedation, dry mouth . Initiated 08/14/24 revised on 08/15/24. -Be alert for side effects of antipsychotic medication including: blurred vision, sedation, dry mouth . Initiated 08/14/24 revised 08/15/24. A review of the Medication Administration Record (MAR) found a physicians order on 01/13/25 to Monitor for behaviors: 1. pacing, 2. emotional outbursts. 3. verbal agression every day and night shift. Document number (#) of behaviors if none then 0. A review of the Medication Administration Record (MAR) found a physicians order on 01/13/25 to Monitor for behaviors: 1. refusal of care, 2. physical agression toward staff. 3. delusions every day and night shift. Document number (#) of behaviors if none then 0. The January 2025 MAR had no evidence of monitoring behaviors on the following shifts: 01/14-16/25 day shift and night shift. 01/17/25 for night shift 01/28/28 for nght shift The February 2025 MAR had no evidence of monitoring behaviors on day shift on 02/11-12/25/21/25. The March 2025 MAR found no evidence of behavior monitoring on the following: 03/08/25 for night shift 03/12/25 for day shift 03/15/25 for night shift 03/17/25 for day shift In an interview on 04/03/25 at 8:40 AM with the Administrator, he concurred there were issues with documentation and care plans. f) Resident #51 On 04/03/25 at 9:52 AM a review of the medical record for Resident #51 who was admitted on [DATE] with diagnoses of depression, Alzheimer's, dementia with behavioral disorder and wandering. f) Resident #51 On 04/03/25 at 9:52 AM a review of the medical record for Resident #51 who was admitted on [DATE] with diagnoses of depression, Alzheimer's, dementia with behavioral disorder and wandering. A review of the care plan found the following: Focus is at risk for complications related to the use of antipsychotic, and antidepessant medications dated created 08/17/23 with revision on 11/23/24. Goal will have the smallest most effective dose without side effects through to next review. Date initiated 08//28/23 and revision date of 04/02/25. Interventions administer medications as ordered, be alert for side effects of antidepressants including: sedation, dry mouth . Initiated 08/14/24 revised on 08/15/24. -Be alert for side effects of antipsychotic medication including: blurred vision, sedation, dry mouth . Initiated 08/14/24 revised 08/15/24. A review of the Medication Administration Record (MAR) found a physicians order on 01/13/25 to Monitor for behaviors: 1. pacing, 2. emotional outbursts. 3. verbal agression every day and night shift. Document number (#) of behaviors if none then 0. A review of the Medication Administration Record (MAR) found a physicians order on 01/13/25 to Monitor for behaviors: 1. refusal of care, 2. physical agression toward staff. 3. delusions every day and night shift. Document number (#) of behaviors if none then 0. The January 2025 MAR had no evidence of monitoring behaviors on the following shifts: 01/14-16/25 day shift and night shift. 01/17/25 for night shift 01/28/28 for nght shift The February 2025 MAR had no evidence of monitoring behaviors on day shift on 02/11-12/25. The March 2025 MAR found no evidence of behavior monitoring on the following: 03/09/25 for night shift 03/12/25 for day shift 03/15/25 for night shift 03/17/25 for day shift In an interview on 04/03/25 at 8:40 AM with the Administrator, he concurred there were issues with documentation and care plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure care plans were revised for Residents #42 fall, #22 dependent for meals, #57 independent for mobility, #4 full code, #23 give fluids when NPO, and #28 hospice when not ordered. These failed practices affected more than a limited number of residents. Resident identifiers: #42, #22, #57, #4, #23, and #28. Facility census: 65. Findings included: a) Resident #42 On [DATE] at approximately 11:00 AM, a record review was completed for Resident #42. The review found the resident had a fall on [DATE]. An x-ray was completed with no abnormalities found. However, the resident continued to complain with pain upon movement. A computed tomography scan (CT ) was ordered by the facility physician on [DATE]. The CT results were received on [DATE], with the following finding:There are fractures of the left superior and inferior rami, there is also a fracture through the left side of the sacrum. The care plan was reviewed on [DATE] at 11:15 AM. The care plan had not been revised indicating the resident had a fall with injury. The care plan focus area states, Resident is at risk for falls . On [DATE] at 12:19 PM, the Director of Nursing (DON) confirmed the care plan had not revised to indicate the resident had an actual fall with major injury. b) Resident #22 On [DATE] at 11:30 AM, a record review was completed for Resident #22. The care plan under the focus area of Resident requires assistance with activities of daily living (ADL) states the resident is set up assist with eating. However, on [DATE] at 12:38 PM, an observation of the resident being feed per staff was made. On [DATE] at 12:19 PM, the DON confirmed the care plan had not been revised to indicate the resident is dependent at times for meals. c) Resident #57 On [DATE] at 10:31 AM, a record review was completed for Resident #57. The care plan was reviewed and found an intervention of provide resident/patient with supervision ambulating using a walker. However, throughout the survey, from [DATE] through [DATE], no observations of the resident using a walker were made. The resident does walk with a bended at waist gait. This type of gait is due to the resident's diagnosis of Parkinson's disease. On [DATE] at 1:11 PM, the DON was interviewed regarding Resident #57's ability to ambulate. The DON stated, when he first came here he used a walker, but now with the dementia he doesn't know what to do with a walker. The DON confirmed the resident ambulated independently and the care plan had not been revised. d) Resident #4 The facility failed to revise Resident #4's care plan for a change in Code status. On [DATE] at 8:52 AM, the resident's order stated, No CPR- Do not attempt Resuscitation. Comfort focused treatment. Maximize comfort through symptom management, allowing natural death. Use oxygen suction and manual treatment of airway obstruction as needed for comfort. Avoid treatments listed in full or selective treatment unless consistent with comfort goals. Transfer to hospital only if comfort cannot be achieved in the current setting. No artificial means of nutrition. No directions specified for order. The Resident #4's care plan stated, the resident has an established advanced directive of FULL CODE Full Code- Attempt to sustain life by all medically effective means. Provide appropriate medical and surgical treatment as indicated to attempt to prolong life, including intensive care. On [DATE] at 04:12 PM, the resident's updated POST form, dated and signed [DATE], was obtained. The POST form was marked, No CPR: Do Not Attempt Resuscitation and Comfort -focused Treatments. The DON confirmed the resident's care plan stated the resident's advanced directive was for a full code. e) Resident #23 The facility failed to revise Resident #23's care plan to reflect a change in advance directives for an alternate means of nutrition and encourage fluids with meals for an NPO (nothing by mouth) resident. On [DATE] at 2:22 PM, the resident's physician order stated, Full Code- Attempt to sustain life by all medically effective means. Provide appropriate medical and surgical treatment as indicated to attempt to prolong life including intensive care. No artificial means of nutrition desired. No directions specified for order. The resident's current care plan stated, Resident #23 has a HCS and Full Code- Attempt to sustain life by all medically effective means. Provide appropriate medical and surgical treatment as indicated to attempt to prolong life including intensive care. No artificial means of nutrition desired. The resident's orders stated NPO with Enternal Feed. On [DATE] at 04:10 PM, the Director of Nursing confirmed the resident's care plan stated, No artificial means of nutrition desired. On [DATE] at 8:45 AM, the DON confirmed, Resident #23's care plan stated Encourage resident to consume all fluids of choice during meals. Resident's current diet order stated, NPO (nothing by mouth) diet. f) Resident #38 The facility failed to revise Resident #38's care plan who is not receiving hospice services. No order was found on the resident's medical chart for hospice services. The resident's care plan stated, Notify Hospice of yet another fall with minor injury to gain (name of hospice) input for plan of care (POC) intervention., (Name of hospice) to provide resident with a wheelchair with cushion to help enhance independence. and Resident will achieve acceptable level of pain control, as defined by the patient through his hospice care. On [DATE] at 10:15 AM, the DON confirmed, the resident's care plan stated the resident was receiving Hospice Services. No resident in the facility was receiving hospice services at this time per report.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure physician orders were followed. medications were administered timely, behaviors, and pain were monitored. This had the potential to affect more than a limited number of residents. Resident identifiers: #31, #22, #59, #57, #25, #51 and facility late mdications, #28, #49, #37, #23, #36, #8, #7, $41, #50, #9, #41, #50, #20, #63, #42, #58, #61, #23, #10, #15, #17, #267, and #268. Facility census: 65. Findings included: a) Resident #31 On 04/01/25 at 9:30 AM, a record review was completed for Resident #31. The review found the physician's orders were not being followed on the 01/2025 and 02/2025 medication administration records (MARs). The following physician's orders and dates are as follows: --Anticoagulant Medication Monitoring: --01/09/25 day shift --01/13/25 day shift --01/14/25 day shift --01/15/24 day shift --01/16/25 day shift --01/17/25 night shift --01/28/25 day shift --02/11/25 day shift --02/12/25 day shift --Monitor for Behaviors: --01/09/25 day shift --01/13/25 day shift --01/14/25 day shift --01/15/24 day shift --01/16/25 day shift --01/17/25 night shift --01/28/25 day shift --02/11/25 day shift --02/12/25 day shift --Ask resident if they are having pain: --01/09/25 day shift --01/13/25 day shift --01/14/25 day shift --01/15/24 day shift --01/16/25 day shift --01/17/25 night shift --01/28/25 day shift --02/11/25 day shift --02/12/25 day shift --Monitor swallowing during med pass: --01/09/25 day shift --01/13/25 day shift --01/14/25 day shift --01/15/24 day shift --01/16/25 day shift --01/17/25 night shift --01/28/25 day shift --02/11/25 day shift --02/12/25 day shift --Antiembolism monitoring: --02/11/25 --02/12/25 On 04/01/25 at 12:19 PM, the Director of Nursing (DON) confirmed the physician's orders were not followed. b) Resident #22 On 03/31/25 at 12:38 PM, an observation was made of the resident being fed pork at lunch time. On 03/31/25 at 2:00 PM, the physician's orders were reviewed for Resident #22. The review found a physician's order for regular, dysphagia advanced texture, standard thin liquids consistency, no pork or pork products. Send finger foods when possible. On 04/01/25 at 11:30 AM, the DON confirmed the physician's order was not followed regarding the dietary restriction of no pork. c) Resident #59 On 04/01/25 at 10:00 AM, a record review was completed for Resident #59. The review found the physician's orders were not being followed on the MARs for 01/2025, 02/2025 and 03/2025. The following physician's orders and dates are as follows: --Ask resident if they are having pain: --01/09/25 day shift --01/13/25 day shift --01/14/25 day shift --01/15/24 day shift --01/16/25 day shift --01/17/25 night shift --01/28/25 day shift --02/11/25 day shift --02/12/25 day shift --03/08/25 night shift --03/12/25 day shift --03/15/25 night shift --03/17/25 day shift --Is resident free from adverse/side effects of antidepressant medication: --01/09/25 day shift --01/13/25 day shift --01/14/25 day shift --01/15/24 day shift --01/16/25 day shift --01/17/25 night shift --01/28/25 day shift --02/11/25 day shift --02/12/25 day shift --03/08/25 night shift --03/12/25 day shift --03/15/25 night shift --03/17/25 day shift --Is resident free from adverse/side effects of antipsychotic: --01/09/25 day shift --01/13/25 day shift --01/14/25 day shift --01/15/24 day shift --01/16/25 day shift --01/17/25 night shift --01/28/25 day shift --02/11/25 day shift --02/12/25 day shift --03/08/25 night shift --03/12/25 day shift --03/15/25 night shift --03/17/25 day shift --Monitor for behaviors: --01/09/25 day shift --01/13/25 day shift --01/14/25 day shift --01/15/24 day shift --01/16/25 day shift --01/17/25 night shift --01/28/25 day shift --02/11/25 day shift --02/12/25 day shift --03/08/25 night shift --03/12/25 day shift --03/15/25 night shift --03/17/25 day shift --Monitor swallowing during med pass: --01/09/25 day shift --01/13/25 day shift --01/14/25 day shift --01/15/24 day shift --01/16/25 day shift --01/17/25 night shift --01/28/25 day shift --02/11/25 day shift --02/12/25 day shift --03/08/25 night shift --03/12/25 day shift --03/15/25 night shift --03/17/25 day shift --Is resident free from adverse/side effects of antimanic/antiseizure medication: --01/09/25 day shift --01/13/25 day shift --01/14/25 day shift --01/15/24 day shift --01/16/25 day shift --01/17/25 night shift --01/28/25 day shift --02/11/25 day shift --02/12/25 day shift --03/08/25 night shift --03/12/25 day shift --03/15/25 night shift --03/17/25 day shift On 04/01/25 at 12:19 PM, the Director of Nursing (DON) confirmed the physician's orders were not followed. d) Resident #57 On 04/01/25 at 10:00 AM, a record review was completed for Resident #57. The review found the physician's orders were not being followed on the MARs for 01/2025, 02/2025 and 03/2025. The following physician's orders and dates are as follows: --Ask resident if they are having pain: --01/09/25 day shift --01/13/25 day shift --01/14/25 day shift --01/15/24 day shift --01/16/25 day shift --01/17/25 night shift --01/28/25 day shift --02/11/25 day shift --02/12/25 day shift --03/08/25 night shift --03/12/25 day shift --03/15/25 night shift --03/17/25 day shift --Monitor for behaviors: --01/09/25 day shift --01/13/25 day shift --01/14/25 day shift --01/15/24 day shift --01/16/25 day shift --01/17/25 night shift --01/28/25 day shift --02/11/25 day shift --02/12/25 day shift --03/08/25 night shift --03/12/25 day shift --03/15/25 night shift --03/17/25 day shift --Monitor swallowing during med pass: --01/09/25 day shift --01/13/25 day shift --01/14/25 day shift --01/15/24 day shift --01/16/25 day shift --01/17/25 night shift --01/28/25 day shift --02/11/25 day shift --02/12/25 day shift --03/08/25 night shift --03/12/25 day shift --03/15/25 night shift --03/17/25 day shift --Ketoconazole Shampoo 2% apply to scalp topically every day shift Monday, Wednesday, Saturday for tinea versicolor --01/23/25 --03/12/25 On 04/01/25 at 12:19 PM, the Director of Nursing (DON) confirmed the physician's orders were not followed. e) Resident # 25 On 04/03/25 at 9:52 AM a review of the medical record for Resident #25 who was admitted on [DATE] with diagnoses of schizoaffective disorder, depressive type, anxiety disorder, major depressive disorder, vascular dementia with agitation, psychotic disorder, seizures and mood disturbance. A review of the care plan found the following: Focus is at risk for complications related to the use of antipsychotic, and antidepessant medications dated created 08/17/23 with revision on 11/23/24. Goal will have the smallest most effective dose without side effects through to next review. Date initiated 08//28/23 and revision date of 04/02/25. Interventions administer medications as ordered, be alert for side effects of antidepressants including: sedation, dry mouth . Initiated 08/14/24 revised on 08/15/24. -Be alert for side effects of antipsychotic medication including: blurred vision, sedation, dry mouth . Initiated 08/14/24 revised 08/15/24. A review of the Medication Administration Record (MAR) found a physicians order on 01/13/25 to Monitor for behaviors: 1. pacing, 2. emotional outbursts. 3. verbal agression every day and night shift. Document number (#) of behaviors if none then 0. A review of the Medication Administration Record (MAR) found a physicians order on 01/13/25 to Monitor for behaviors: 1. refusal of care, 2. physical agression toward staff. 3. delusions every day and night shift. Document number (#) of behaviors if none then 0. The January 2025 MAR had no evidence of monitoring behaviors on the following shifts: 01/14-16/25 day shift and night shift. 01/17/25 for night shift 01/28/28 for nght shift The February 2025 MAR had no evidence of monitoring behaviors on day shift on 02/11-12/25/21/25. The March 2025 MAR found no evidence of behavior monitoring on the following: 03/08/25 for night shift 03/12/25 for day shift 03/15/25 for night shift 03/17/25 for day shift f) Resident #51 On 04/03/25 at 9:58 AM a review of the medical record for Resident #51 who was admitted on [DATE] with diagnoses of depression, Alzheimer's, dementia with behavioral disorder and wandering. A review of the care plan found the following: Focus is at risk for complications related to the use of antipsychotic, and antidepessant medications dated created 08/17/23 with revision on 11/23/24. Goal will have the smallest most effective dose without side effects through to next review. Date initiated 08//28/23 and revision date of 04/02/25. Interventions administer medications as ordered, be alert for side effects of antidepressants including: sedation, dry mouth . Initiated 08/14/24 revised on 08/15/24. -Be alert for side effects of antipsychotic medication including: blurred vision, sedation, dry mouth . Initiated 08/14/24 revised 08/15/24. A review of the Medication Administration Record (MAR) found a physicians order on 01/13/25 to Monitor for behaviors: 1. pacing, 2. emotional outbursts. 3. verbal agression every day and night shift. Document number (#) of behaviors if none then 0. A review of the Medication Administration Record (MAR) found a physicians order on 01/13/25 to Monitor for behaviors: 1. refusal of care, 2. physical agression toward staff. 3. delusions every day and night shift. Document number (#) of behaviors if none then 0. The January 2025 MAR had no evidence of monitoring behaviors on the following shifts: 01/14-16/25 day shift and night shift. 01/17/25 for night shift 01/28/28 for nght shift The February 2025 MAR had no evidence of monitoring behaviors on day shift on 02/11-12/25. The March 2025 MAR found no evidence of behavior monitoring on the following: 03/09/25 for night shift 03/12/25 for day shift 03/15/25 for night shift 03/17/25 for day shift g) Facility On 04/03/25 at 11:30 AM, the daily staff postings were reviewed for 03/29/25 and 03/30/25. The review found only two (2) nurses scheduled for both dates; one (1) on the red hall and one (1) on the blue hall. The red hall has 26 beds and the blue hall had a census of 42 residents who reside on the blue hall. No other nurse was scheduled on the blue hall during day shift. The nurse schedule provided had noted a need for day shift on 03/29/25 and 03/30/25. The daily nursing hours per patient day was above the minimum; but, multiple medications were late and multiple treatment orders were incomplete. The acuity of the residents was higher on these day with only one (1) nurse on the blue hall. The following list of late medications for each resident is as follows: Resident #28 -03/29/25 Neurontin 300mg (milligram) by mouth three times daily--ordered for 2:00 PM; given at 3:42 PM. This was one hour and 42 minutes late. -03/29/25 Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/3ml (milliters) inhale orally three times daily--ordered for 2:00 PM; given at 3:42 PM. This was one hour and 42 minutes late. Resident #62 -03/30/25 Midodrine 10mg by mouth three times daily--ordered for 9:00 AM; given at 11:32 AM. This is two hours and 32 minutes late. -03/30/25 Zinc 50mg by mouth daily--ordered for 9:00 AM; given at 11:32 AM. This is two hours and 32 minutes late. -03/30/25 Glimepiride 1mg by mouth daily--ordered for 9:00 AM; given at 11:32 AM. This is two hours and 32 minutes late. -03/30/25 Diltiazem 90mg give 2 capsules by mouth daily--ordered for 9:00 AM; given at 11:32 AM. This is two hours and 32 minutes late. Resident #49 -03/30/25 Losartan Potassium 100mg by mouth daily--ordered for 10:00 AM; given at 11:40 AM. This is one hour and 40 minutes late. -03/30/25 Metoprolol Succinate 100mg by mouth daily--ordered for 10:00 AM; given at 11:40 AM. This is one hour and 40 minutes late. l --03/30/25 Farxiga 10mg by mouth daily--ordered for 10:00 AM; given at 11:39 AM. This is one hour and 39 minutes late. -03/30/25 Spironolactone 25mg by mouth daily--ordered for 10:00 AM; given at 11:39 AM. This is one hour and 39 minutes late. -03/30/25 Apixaban 5mg by mouth two times daily--ordered for 10:00 AM; given at 11:39 AM. This is one hour and 39 minutes late. -03/30/25 Divalproex 500mg by mouth two times daily--ordered for 10:00 AM; given at 11:39 AM. This is one hour and 39 minutes late. Resident #37 -03/30/25 Duloxetine 20mg by mouth daily--ordered for 8:00 AM; given at 9:54 AM. This is one hour and 54 minutes late. --03/30/25 Farxiga 10mg by mouth daily--ordered for 8:00 AM; given at 9:54 AM. This is one hour and 54 minutes late. -03/30/25 Amlodipine Besylate 10mg by mouth daily--ordered for 8:00 AM; given at 9:54 AM. This is one hour and 54 minutes late. -03/30/25 Folic Acid 1mg by mouth daily--ordered for 8:00 AM; given at 9:54 AM. This is one hour and 54 minutes late. -03/30/25 Quetiapine Furmarate 25mg 1/2 tablet by mouth daily--ordered for 8:00 AM; given at 9:55 AM. This is one hour and 55 minutes late. -03/30/25 Magnesium Oxide 400mg by mouth daily--ordered for 8:00 AM; given at 9:54 AM. This is one hour and 54 minutes late. -03/30/25 Potassium Chloride 10meq (milliequivilant) by mouth daily--ordered for 8:00 AM; given at 9:55 AM. This is one hour and 55 minutes late. -03/30/25 Lisinopril 10mg by mouth daily--ordered for 8:00 AM; given at 9:54 AM. This is one hour and 54 minutes late. -03/30/25 Senna 8.6mg by mouth twice daily--ordered for 8:00 AM; given at 9:55 AM. This is one hour and 55 minutes late. -03/30/25 Thiamine 100mg by mouth daily--ordered for 8:00 AM; given at 9:55 AM. This is one hour and 55 minutes late. -03/30/25 Metoprolol Tartrate 50mg by mouth twice daily--ordered for 8:00 AM; given at 9:55 AM. This is one hour and 55 minutes late. -03/30/25 Basaglar 75 units subcutaneous daily--ordered for 8:00 AM; given at 9:56 AM. This is one hour and 56 minutes late. Resident #23 -03/29/25 Enteral feed Jevity 1.5 calories 474 ml three times daily--ordered for 5:00 PM; given at 7:10 PM. This is 2 hours and 10 minutes late. Resident #36 -Tylenol Extra Strength 500mg give 2 tablets by mouth twice daily--ordered for 10:00 AM; given at 11:47 AM. This is one hour and 47 minutes late. -Glycolax Powder give 17 grams by mouth daily--ordered for 10:00 AM; given at 11:47 AM. This is one hour and 47 minutes late. Resident #8 -Protonix 40mg by mouth twice daily--ordered for 9:00 AM; given at 10:52 AM. This is one hour and 52 minutes late. -Escitalopram 5mg by mouth daily--ordered for 9:00 AM; given at 10:52 AM. This is one hour and 52 minutes late. -Tylenol Extra Strength 500mg by mouth three times a day--ordered for 9:00 AM; given at 10:52 AM. This is one hour and 52 minutes late. Resident #7 -03/29/25 Sertraline 25mg by mouth daily--ordered for 9:00 AM; given at 10:57 AM. This is one hour and 57 minutes late. Resident #41 -03/30/25 Cymbalta 20mg by mouth daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. -03/30/25 Zinc 220mg by mouth daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. -03/30/25 Colace 100mg by mouth twice daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. -03/30/25 Metformin 1000mg by mouth twice daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. -03/30/25 Protonix 40mg by mouth twice daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. -03/30/25 Synthroid 100mcg (microgram) by mouth daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. -03/30/25 Farxiga 10mg by mouth daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. -03/30/25 Eliquis 5mg by mouth twice daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. -03/30/25 Sitagliptin 25mg by mouth daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. -03/30/25 Furosemide 40mg by mouth daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. -03/30/25 Digoxin 125mcg by mouth daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. Resident #50 -03/29/25 Tylenol Extra Strength 500mg give 2 tablets twice daily--ordered for 9:00 AM; given at 11:09 AM. This is two hours and 9 minutes late. -03/29/25 Protonix 40mg daily--ordered for 9:00 AM; given at 11:09 AM. This is two hours and 9 minutes late. -03/29/25 Aspirin 81mg daily--ordered for 9:00 AM; given at 11:09 AM. This is two hours and 9 minutes late. -03/29/25 Omeprazole 20mg twice daily--ordered for 9:00 AM; given at 11:09 AM. This is two hours and 9 minutes late. -03/29/25 Buspar 10mg daily--ordered for 9:00 AM; given at 11:09 AM. This is two hours and 9 minutes late. The following physician's orders for resident treatments were not followed: Resident #9 -03/29/25 apply antifungal to bilateral groin areas twice daily--no documentation for day shift -03/30/25 apply antifungal to bilateral groin areas twice daily--no documentation for day shift --03/29/25 cleanse MASD to left buttock with no-rinse foaming wash and pat dry. Apply calazime cream to open areas only. Apply hydroguard to surrounding skin every day and night shift --no documentation for day shift --03/30/25 cleanse MASD to left buttock with no-rinse foaming wash and pat dry. Apply calazime cream to open areas only. Apply hydroguard to surrounding skin every day and night shift --no documentation for day shift Resident #41 -03/29/25 Eye scrubs: mix baby shampoo with warm water, gently wipe each eye separately, rinse with warm water and pat dry, using clean technique every day and night shift--no documentation for day shift. -03/30/25 Eye scrubs: mix baby shampoo with warm water, gently wipe each eye separately, rinse with warm water and pat dry, using clean technique every day and night shift--no documentation for day shift. -03/29/25 Cleanse ulcer to right lower extremity with normal saline, pat dry, apply collagen particles, cover with hydrogel impregnated gauze, wrap with kerlix, and secure with ace wrap every Tuesday, Thursday and Saturday--no documentation for day shift. Resident #50 -03/29/25 Cleanse bilateral buttocks and scrotum with warm water and mild soap, rinse and dry completely. Apply barrier cream after episodes of incontinence--no documentation for day shift. -03/30/25 Cleanse bilateral buttocks and scrotum with warm water and mild soap, rinse and dry completely. Apply barrier cream after episodes of incontinence--no documentation for day shift. -03/29/25 Hydrocortisone External Cream 2.5% Apply to face, back and thighs every day and night shift--no documentation for day shift. -03/30/25 Hydrocortisone External Cream 2.5% Apply to face, back and thighs every day and night shift--no documentation for day shift. Resident #20 -03/29/25 Apply Ammonium Lactate External cream to bilateral lower legs every day and night shift--no documentation for day shift. -03/30/25 Apply Ammonium Lactate External cream to bilateral lower legs every day and night shift--no documentation for day shift. -03/29/25 Silver Sulfadiazine cream 1% apply to bilateral groin and buttocks every day and night shift--no documentation for day shift. -03/30/25 Silver Sulfadiazine cream 1% apply to bilateral groin and buttocks every day and night shift--no documentation for day shift. Resident #63 -03/29/25 Apply barrier cream to MASD to sacrum every day and night shift--no documentation for day shift. -03/30/25 Apply barrier cream to MASD to sacrum every day and night shift--no documentation for day shift. -03/29/25 Cleanse surgical incision to right shoulder with wound cleanser, pat dry, cover with dry dressing every day and night shift--no documentation for day shift. -03/30/25 Cleanse surgical incision to right shoulder with wound cleanser, pat dry, cover with dry dressing every day and night shift--no documentation for day shift. Resident #42 -03/29/25 Cleanse right heel DTI with normal saline, pat dry, apply betadine to area and cover with foam dressing. Secure with kerlix and tape every Tuesday, Thursday and Saturday--no documentation for day shift. Resident #58 -03/29/25 Apply kerlix and coban starting behind the toes up to below the knee on bilateral lower extremities every 3 days per Vascular Surgery--no documentation for day shift. Resident #61 -03/29/25 Enteral Feed: Cleanse site daily with soap and water every day shift--no documentation for day shift. -03/30/25 Enteral Feed: Cleanse site daily with soap and water every day shift--no documentation for day shift. -03/29/25 Monitor surgical incision to right rear head for possible signs/symptoms of infection every day and night shift-no documentation for day shift. -03/30/25 Monitor surgical incision to right rear head for possible signs/symptoms of infection every day and night shift-no documentation for day shift. Resident #23 -03/29/25 Cleanse PEG site with normal saline moistened gauze and pat dry, apply bacitracin and a split gauze and secure with tape every day shift--no documentation for day shift. -03/30/25 Cleanse PEG site with normal saline moistened gauze and pat dry, apply bacitracin and a split gauze and secure with tape every day shift--no documentation for day shift. Resident #10 -03/29/25 Acetic Acid Irrigation Solution 0.25% use 30 cc (cubic centimeters) via irrigation every day and night shift for occlusion--no documentation for day shift. -03/30/25 Acetic Acid Irrigation Solution 0.25% use 30 cc (cubic centimeters) via irrigation every day and night shift for occlusion--no documentation for day shift. -03/29/25 Apply z-guard to buttocks every day and night shift for MASD--no documentation for day shift. -03/30/25 Apply z-guard to buttocks every day and night shift for MASD--no documentation for day shift. Resident #15 -03/29/25 Apply skin prep daily to arterial ulcers to 1st, 2nd and 3rd digits. Notify provider if any signs/symptoms of infection every day shift--no documentation for day shift. -03/30/25 Apply skin prep daily to arterial ulcers to 1st, 2nd and 3rd digits. Notify provider if any signs/symptoms of infection every day shift--no documentation for day shift. Resident #17 -03/29/25 Monitor left foot for any skin changes related to incident where foot was ran over with a wheel chair x one week. Notify physician if any changes occur every day shift--no documentation for day shift. -03/30/25 Monitor left foot for any skin changes related to incident where foot was ran over with a wheel chair x one week. Notify physician if any changes occur every day shift--no documentation for day shift. --Resident #267 -03/29/25 Apply skin prep outer great left toe every day shift DTI--no documentation for day shift. -03/30/25 Apply skin prep outer great left toe every day shift DTI--no documentation for day shift. Resident #268 -03/29/25 Monitor surgical incision to left hip, Report any signs/symptoms of infection to provider. Cleanse area with wound cleanser, Pat dry. May leave open to air if no drainage every day and night shift--no documentation for day shift. -03/30/25 Monitor surgical incision to left hip, Report any signs/symptoms of infection to provider. Cleanse area with wound cleanser, Pat dry. May leave open to air if no drainage every day and night shift--no documentation for day shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to have sufficient staffing for the B hall on 03/29/25 and 03/30/25. This failure has the potential to affect more than a limited number of residents. Facility Census: 65. Findings Include: a) B hall residents On 04/03/25 at 11:30 AM, the daily staff postings were reviewed for 03/29/25 and 03/30/25. The review found only two (2) nurses scheduled for both dates; one (1) on the red hall and one (1) on the blue hall. The red hall has 26 beds and the blue hall had a census of 42 residents. No other nurse was scheduled on the blue hall during day shift. The nurse schedule provided had noted a need for day shift on 03/29/25 and 03/30/25. The daily nursing hours per patient day were above the minimum; but, multiple medications were late and multiple treatment orders were incomplete. The acuity of the residents was higher on these days with only one (1) nurse on the blue hall. The following list of late medications for each resident is as follows: --Resident #28 -03/29/25 Neurontin 300mg (milligram) by mouth three times daily--ordered for 2:00 PM; given at 3:42 PM. This was one hour and 42 minutes late. -03/29/25 Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/3ml (milliters) inhale orally three times daily--ordered for 2:00 PM; given at 3:42 PM. This was one hour and 42 minutes late. --Resident #62 -03/30/25 Midodrine 10mg by mouth three times daily--ordered for 9:00 AM; given at 11:32 AM. This is two hours and 32 minutes late. -03/30/25 Zinc 50mg by mouth daily--ordered for 9:00 AM; given at 11:32 AM. This is two hours and 32 minutes late. -03/30/25 Glimepiride 1mg by mouth daily--ordered for 9:00 AM; given at 11:32 AM. This is two hours and 32 minutes late. -03/30/25 Diltiazem 90mg give 2 capsules by mouth daily--ordered for 9:00 AM; given at 11:32 AM. This is two hours and 32 minutes late. --Resident #49 -03/30/25 Losartan Potassium 100mg by mouth daily--ordered for 10:00 AM; given at 11:40 AM. This is one hour and 40 minutes late. -03/30/25 Metoprolol Succinate 100mg by mouth daily--ordered for 10:00 AM; given at 11:40 AM. This is one hour and 40 minutes late. l --03/30/25 Farxiga 10mg by mouth daily--ordered for 10:00 AM; given at 11:39 AM. This is one hour and 39 minutes late. -03/30/25 Spironolactone 25mg by mouth daily--ordered for 10:00 AM; given at 11:39 AM. This is one hour and 39 minutes late. -03/30/25 Apixaban 5mg by mouth two times daily--ordered for 10:00 AM; given at 11:39 AM. This is one hour and 39 minutes late. -03/30/25 Divalproex 500mg by mouth two times daily--ordered for 10:00 AM; given at 11:39 AM. This is one hour and 39 minutes late. --Resident #37 -03/30/25 Duloxetine 20mg by mouth daily--ordered for 8:00 AM; given at 9:54 AM. This is one hour and 54 minutes late. --03/30/25 Farxiga 10mg by mouth daily--ordered for 8:00 AM; given at 9:54 AM. This is one hour and 54 minutes late. -03/30/25 Amlodipine Besylate 10mg by mouth daily--ordered for 8:00 AM; given at 9:54 AM. This is one hour and 54 minutes late. -03/30/25 Folic Acid 1mg by mouth daily--ordered for 8:00 AM; given at 9:54 AM. This is one hour and 54 minutes late. -03/30/25 Quetiapine Furmarate 25mg 1/2 tablet by mouth daily--ordered for 8:00 AM; given at 9:55 AM. This is one hour and 55 minutes late. -03/30/25 Magnesium Oxide 400mg by mouth daily--ordered for 8:00 AM; given at 9:54 AM. This is one hour and 54 minutes late. -03/30/25 Potassium Chloride 10meq (milliequivilant) by mouth daily--ordered for 8:00 AM; given at 9:55 AM. This is one hour and 55 minutes late. -03/30/25 Lisinopril 10mg by mouth daily--ordered for 8:00 AM; given at 9:54 AM. This is one hour and 54 minutes late. -03/30/25 Senna 8.6mg by mouth twice daily--ordered for 8:00 AM; given at 9:55 AM. This is one hour and 55 minutes late. -03/30/25 Thiamine 100mg by mouth daily--ordered for 8:00 AM; given at 9:55 AM. This is one hour and 55 minutes late. -03/30/25 Metoprolol Tartrate 50mg by mouth twice daily--ordered for 8:00 AM; given at 9:55 AM. This is one hour and 55 minutes late. -03/30/25 Basaglar 75 units subcutaneous daily--ordered for 8:00 AM; given at 9:56 AM. This is one hour and 56 minutes late. --Resident #23 -03/29/25 Enteral feed Jevity 1.5 calories 474 ml three times daily--ordered for 5:00 PM; given at 7:10 PM. This is 2 hours and 10 minutes late. --Resident #36 -Tylenol Extra Strength 500mg give 2 tablets by mouth twice daily--ordered for 10:00 AM; given at 11:47 AM. This is one hour and 47 minutes late. -Glycolax Powder give 17 grams by mouth daily--ordered for 10:00 AM; given at 11:47 AM. This is one hour and 47 minutes late. --Resident #8 -Protonix 40mg by mouth twice daily--ordered for 9:00 AM; given at 10:52 AM. This is one hour and 52 minutes late. -Escitalopram 5mg by mouth daily--ordered for 9:00 AM; given at 10:52 AM. This is one hour and 52 minutes late. -Tylenol Extra Strength 500mg by mouth three times a day--ordered for 9:00 AM; given at 10:52 AM. This is one hour and 52 minutes late. --Resident #7 -03/29/25 Sertraline 25mg by mouth daily--ordered for 9:00 AM; given at 10:57 AM. This is one hour and 57 minutes late. --Resident #41 -03/30/25 Cymbalta 20mg by mouth daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. -03/30/25 Zinc 220mg by mouth daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. -03/30/25 Colace 100mg by mouth twice daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. -03/30/25 Metformin 1000mg by mouth twice daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. -03/30/25 Protonix 40mg by mouth twice daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. -03/30/25 Synthroid 100mcg (microgram) by mouth daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. -03/30/25 Farxiga 10mg by mouth daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. -03/30/25 Eliquis 5mg by mouth twice daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. -03/30/25 Sitagliptin 25mg by mouth daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. -03/30/25 Furosemide 40mg by mouth daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. -03/30/25 Digoxin 125mcg by mouth daily--ordered for 8:00 AM; given at 9:58 AM. This is one hour and 58 minutes late. --Resident #50 -03/29/25 Tylenol Extra Strength 500mg give 2 tablets twice daily--ordered for 9:00 AM; given at 11:09 AM. This is two hours and 9 minutes late. -03/29/25 Protonix 40mg daily--ordered for 9:00 AM; given at 11:09 AM. This is two hours and 9 minutes late. -03/29/25 Aspirin 81mg daily--ordered for 9:00 AM; given at 11:09 AM. This is two hours and 9 minutes late. -03/29/25 Omeprazole 20mg twice daily--ordered for 9:00 AM; given at 11:09 AM. This is two hours and 9 minutes late. -03/29/25 Buspar 10mg daily--ordered for 9:00 AM; given at 11:09 AM. This is two hours and 9 minutes late. The following physician's orders for resident treatments were not followed: --Resident #9 -03/29/25 apply antifungal to bilateral groin areas twice daily--no documentation for day shift -03/30/25 apply antifungal to bilateral groin areas twice daily--no documentation for day shift --03/29/25 cleanse MASD to left buttock with no-rinse foaming wash and pat dry. Apply calazime cream to open areas only. Apply hydroguard to surrounding skin every day and night shift --no documentation for day shift --03/30/25 cleanse MASD to left buttock with no-rinse foaming wash and pat dry. Apply calazime cream to open areas only. Apply hydroguard to surrounding skin every day and night shift --no documentation for day shift --Resident #41 -03/29/25 Eye scrubs: mix baby shampoo with warm water, gently wipe each eye separately, rinse with warm water and pat dry, using clean technique every day and night shift--no documentation for day shift. -03/30/25 Eye scrubs: mix baby shampoo with warm water, gently wipe each eye separately, rinse with warm water and pat dry, using clean technique every day and night shift--no documentation for day shift. -03/29/25 Cleanse ulcer to right lower extremity with normal saline, pat dry, apply collagen particles, cover with hydrogel impregnated gauze, wrap with kerlix, and secure with ace wrap every Tuesday, Thursday and Saturday--no documentation for day shift. --Resident #50 -03/29/25 Cleanse bilateral buttocks and scrotum with warm water and mild soap, rinse and dry completely. Apply barrier cream after episodes of incontinence--no documentation for day shift. -03/30/25 Cleanse bilateral buttocks and scrotum with warm water and mild soap, rinse and dry completely. Apply barrier cream after episodes of incontinence--no documentation for day shift. -03/29/25 Hydrocortisone External Cream 2.5% Apply to face, back and thighs every day and night shift--no documentation for day shift. -03/30/25 Hydrocortisone External Cream 2.5% Apply to face, back and thighs every day and night shift--no documentation for day shift. --Resident #20 -03/29/25 Apply Ammonium Lactate External cream to bilateral lower legs every day and night shift--no documentation for day shift. -03/30/25 Apply Ammonium Lactate External cream to bilateral lower legs every day and night shift--no documentation for day shift. -03/29/25 Silver Sulfadiazine cream 1% apply to bilateral groin and buttocks every day and night shift--no documentation for day shift. -03/30/25 Silver Sulfadiazine cream 1% apply to bilateral groin and buttocks every day and night shift--no documentation for day shift. --Resident #63 -03/29/25 Apply barrier cream to MASD to sacrum every day and night shift--no documentation for day shift. -03/30/25 Apply barrier cream to MASD to sacrum every day and night shift--no documentation for day shift. -03/29/25 Cleanse surgical incision to right shoulder with wound cleanser, pat dry, cover with dry dressing every day and night shift--no documentation for day shift. -03/30/25 Cleanse surgical incision to right shoulder with wound cleanser, pat dry, cover with dry dressing every day and night shift--no documentation for day shift. --Resident #42 -03/29/25 Cleanse right heel DTI with normal saline, pat dry, apply betadine to area and cover with foam dressing. Secure with kerlix and tape every Tuesday, Thursday and Saturday--no documentation for day shift. --Resident #58 -03/29/25 Apply kerlix and coban starting behind the toes up to below the knee on bilateral lower extremities every 3 days per Vascular Surgery--no documentation for day shift. --Resident #61 -03/29/25 Enteral Feed: Cleanse site daily with soap and water every day shift--no documentation for day shift. -03/30/25 Enteral Feed: Cleanse site daily with soap and water every day shift--no documentation for day shift. -03/29/25 Monitor surgical incision to right rear head for possible signs/symptoms of infection every day and night shift-no documentation for day shift. -03/30/25 Monitor surgical incision to right rear head for possible signs/symptoms of infection every day and night shift-no documentation for day shift. --Resident #23 -03/29/25 Cleanse PEG site with normal saline moistened gauze and pat dry, apply bacitracin and a split gauze and secure with tape every day shift--no documentation for day shift. -03/30/25 Cleanse PEG site with normal saline moistened gauze and pat dry, apply bacitracin and a split gauze and secure with tape every day shift--no documentation for day shift. --Resident #10 -03/29/25 Acetic Acid Irrigation Solution 0.25% use 30 cc (cubic centimeters) via irrigation every day and night shift for occlusion--no documentation for day shift. -03/30/25 Acetic Acid Irrigation Solution 0.25% use 30 cc (cubic centimeters) via irrigation every day and night shift for occlusion--no documentation for day shift. -03/29/25 Apply z-guard to buttocks every day and night shift for MASD--no documentation for day shift. -03/30/25 Apply z-guard to buttocks every day and night shift for MASD--no documentation for day shift. --Resident #15 -03/29/25 Apply skin prep daily to arterial ulcers to 1st, 2nd and 3rd digits. Notify provider if any signs/symptoms of infection every day shift--no documentation for day shift. -03/30/25 Apply skin prep daily to arterial ulcers to 1st, 2nd and 3rd digits. Notify provider if any signs/symptoms of infection every day shift--no documentation for day shift. --Resident #17 -03/29/25 Monitor left foot for any skin changes related to incident where foot was ran over with a wheel chair x one week. Notify physician if any changes occur every day shift--no documentation for day shift. -03/30/25 Monitor left foot for any skin changes related to incident where foot was ran over with a wheel chair x one week. Notify physician if any changes occur every day shift--no documentation for day shift. --Resident #267 -03/29/25 Apply skin prep outer great left toe every day shift DTI--no documentation for day shift. -03/30/25 Apply skin prep outer great left toe every day shift DTI--no documentation for day shift. --Resident #268 -03/29/25 Monitor surgical incision to left hip, Report any signs/symptoms of infection to provider. Cleanse area with wound cleanser, Pat dry. May leave open to air if no drainage every day and night shift--no documentation for day shift. -03/30/25 Monitor surgical incision to left hip, Report any signs/symptoms of infection to provider. Cleanse area with wound cleanser, Pat dry. May leave open to air if no drainage every day and night shift--no documentation for day shift. On 04/03/25 at 3:30 PM, the DON confirmed the physician's orders were not followed for medication administration or treatments were completed. The DON stated, I don't know what happened those days .I was out-of-town. failed to provide sufficient staffing for the B hall. ASC PS & all findings FACILITY Sufficient and Competent Nurse Staffing 04/03/25 09:18 AM The daily staff posting is hanging at the nurses station. Review of NHPPD 05/27/24 2.89 07/06/24 2.71 08/19/24 2.80 09/03/24 3.31 11/01/24 2.84 11/29/24 2.91 12/26/24 2.65 RN punches 12/14/24 [NAME] Young 12.78 06/09/24 [NAME] 12.35 06/09/24 [NAME] 12.28 07/06/24 [NAME] Young 13.30 08/18/24 [NAME] Young 13.12 09/02/24 [NAME] 12.00 10/31/24 [NAME] 8.00 11/29/24 [NAME] 13.00 Annual evaluation/Staff Education & Competencies Brooke [NAME] 12/14/24---04/24/24 [NAME] 07/28/24---04/24/24 Reydhen Maylig 12/14/24---04/24/24 [NAME] 01/11/25---04/22/24 [NAME] 09/05/24---04/22/24 Interviews with staff 04/03/25 9:50 AM RN #26 we are mandated if needed---I haven't been mandated for a couple of months .no I don't feel like I have enough time .I do my treatments and charting in the evening (12 hour shifts). I'm supposed to get a new nurse who will take another med cart .she starts next week yes we have agency. Last weekend we didn't get coverage for a call in .I had 42 residents. 04/03/25 10:05 AM NA #41 we have mandation days .we take turns too .in the last month I've gotten mandated 2 times .no I feel I have to rush with care so the little things have to wait like straightening up their rooms and nail care .I work 12 hour shifts 3xs a week. Interview with DON 04/03/25 10: for staffing if there are shifts that need covered we use team reach (mass texting system) then we use mandation--per union rules it starts with the people with less seniority then they go to the bottom of the list and we just go down the list. If we still can't get it covered then we have on-call unit managers and ADONs who can cover .we all walk the halls to answer call lights. CNA ratio is 1:10 residents. Daily staffing postings were reviewed for 03/29/25 and 03/20/25. There were two (2) nurses scheduled; one on the red hall and one on the blue hall. The red hall has 26 beds and the blue hall has 42 residents who reside on the blue hall. One nurse had 42 residents. No other nurse was scheduled on the blue hall during day shift. Both of the days, 03/29/25 and 03/30/25, had multiple late medications administered. The treatments were reviewed for both days and

Based on observation, staff interview and record review, the facility failed to ensure daily menus were followed. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. FACILITY:FACILITY. Facility Census: 65. Findings included: a) The facility's menu for 03/31/25 was BBQ Pork on Roll, Gelatin Cubes with Whipped Topping and Potato Chips. The BBQ was served on white sandwich bread in the Dining Room and on the hallways per states surveyors' observations. Resident #10, #56 and #26 were on regular diets and all three residents received light bread in place of a roll. Resident #26 demonstrated difficulty picking up and eating the BBQ on light bread. On 04/01/25 at 12:00 PM, the Corporate Dietary Manager #83 confirmed there were no buns/rolls served for the BBQ yesterday. The Corporate Dietary Manager #83 stated, No, we did not. and that the bread truck ran this date. b) The facility's menu for 04/01/25 was Breaded Fish Filet on Roll, Tartar Sauce, Lettuce and Tomato Garnish, Sliced Peaches and Seasoned Potato Wedges. Lettuce and tomato garnish was not served due to serving temperatures.

Based on record review, staff interview, resident interview and observation, the facility failed to prepare and serve food at a safe and appetizing temperature. This failed practice had the potential to affect more than a limited number of residents. FACILITY:FACILITY. Facility Census: 65. Findings included: a) The facility's policy and procedure stated, All foods will be held at appropriate temperatures, greater than 135 (degrees) F (or as state regulation requires) for hot holding, and less than 41(degrees) F for cold food holding. b) On 04/01/25 at 12:00 PM, the food holding temperature were taken by the Corporate Dietary Manager #83. The following temperatures were obtained: -Holding Temperatures for lunch meal: Lettuce 51.8 - put in freezer Shredded Lettuce 50 - put in freezer Fish - 164.2 Potato Wedges - 183.7 Ground Fish - 181.5 Advanced Mechanical Soft potato wedges - 191.1 (skin off) Meatballs - 195.2 Pureed peaches - 40.3 Rice - 184.2 Pureed rice - 182.1 Pureed fish - 194.7 Peaches - 40.9 Cottage cheese - 39.4 Pureed rice - 172.4 Pureed bread - 170 Fortified pudding - 39.4 The regular leaf lettuce, shredded lettuce and tomatoes were placed in the refrigerator to cool. Final temperatures at 12:16 PM were: Lettuce - 49.4 Shredded lettuce - 45.2 Tomatoes - 52.9 The Corporate Dietary Manager #83 asked the state surveyor, Do you want us to serve? referring to the lettuce and tomato. The state surveyor responded by saying they couldn't tell him to serve or not to serve. Lettuce and tomatoes were not served. No substitution was given for vegetable. c) On 04/01/25 at 12:55 PM, a temperature test tray was taken to B/Blue Wing to check the temperature. Temperatures were taken and confirmed by Corporate Dietary Manager #83. Temperatures were as follows: Fish sandwich - 127.7 Potato wedges - 113.1 Peaches - 96.6

Based on observation, staff interview and record review, the facility failed to ensure food was stored properly and food preparation equipment was clean. This failed practice had the potential to affect more than a limited number of residents. FACILITY:FACILITY. Facility Census: 65. Findings included: a) The facility's policy and procedure stated, All foods are labeled and dated with the name of the product and the date received and use by date once opened. Manufacturer use by dates are used unit opened. Prepared foods are labeled and dated with the name of product, date opened, and use by date. b) On 03/31/25 at 11:25 PM, the Kitchen Investigation was initiated with the Corporate Dietary Manager #83. The following items were observed and confirmed: Frozen chicken breast in an opened ziploc with no dates on the package. Imperial Beef Base was opened and not dated. Celery and Lettuce were opened, uncovered in a box and not dated. Sandwich bread was opened and not dated. The Corporate Dietary Manager #83 asked, Do we need a use by date? c) On 04/01/25 at 10:40 AM, the pantry on the Memory Unit contained an opened can of Dr. Pepper with tape over opening. An open date only was written on the can and no use by date. The finding was confirmed by Memory Support Director #52. She stated, I will get rid of that ASAP. d) On 04/01/25 at 04/01/25 11:55 AM, the pantry on C hall contained a resident's sherbet opened and not dated, Hormel Thick and Easy - Honey Thick water opened with no date range/use by date, and resident's snacks (fortified pudding and applesauce) with no date range/use by date. These findings were confirmed by Licensed Practical Nurse(LPN) #11. e) The sink behind the dining room serving center for handwashing had a brown substance in the sink bowl and no trash can to dispose of paper towels/garbage. The Corporate Dietary Manager #83 stated, We don't serve here. Dried food on the outside of the refrigerator in the kitchen was confirmed by the manager.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain complete, accurate, and timely medical records. This deficient practice had the potential to affect five (5) of 22 residents reviewed in the long-term care survey sample. Resident Identifiers: #5, #58, #25, #51, and #3. Facility census: 65. Findings included: a) Resident #5 On 04/01/25 at 8:48 AM, Licensed Practical Nurse (LPN) #11 was observed administering morning medications to Resident #5. One of the medications administered to the resident was Zyrtec (cetirizine hydrochloride) 10 mg. Review of Resident #11's physicians' orders showed on 03/29/25 the resident was ordered Zyrtec allergy oral tablet (Cetirizine HCl [hydrochloride], give 1 tablet by mouth one time a day for sinusitis. The order did not specify the dosage for the medication. On 04/01/25 at 9:50 AM, the Director of Nursing confirmed Resident #5's Zyrtec didn't have a dosage ordered. She stated the pharmacy only supplies one dosage of Zyrtec to the facility. She stated she would have the order revised to include the dosage. According to the Zyrtec (Cetirizine hydrochloride) packaging insert available on-line on the Food and Drug Administration Website, the medication comes in 10 milligrams (mg) and 5 mg tablets, as well as syrup. No further information was provided through the completion of the survey process. b) Resident #58 On 03/31/25 at 4:00 PM, the Physician Orders for Scope of Treatment (POST) form for Resident #58 was reviewed. The review found the resident's signature was not dated when completed. On 04/01/25 at 9:30 AM, the Director of Nursing (DON) confirmed the resident's signature was not dated. The DON stated, I saw that. c) Resident # 25 On 04/03/25 at 9:52 AM a review of the medical record for Resident #25 who was admitted on [DATE] with diagnoses of schizoaffective disorder, depressive type, anxiety disorder, major depressive disorder, vascular dementia with agitation, psychotic disorder, seizures and mood disturbance. A review of the care plan found the following: Focus is at risk for complications related to the use of antipsychotic, and antidepessant medications dated created 08/17/23 with revision on 11/23/24. Goal will have the smallest most effective dose without side effects through to next review. Date initiated 08//28/23 and revision date of 04/02/25. Interventions administer medications as ordered, be alert for side effects of antidepressants including: sedation, dry mouth . Initiated 08/14/24 revised on 08/15/24. -Be alert for side effects of antipsychotic medication including: blurred vision, sedation, dry mouth . Initiated 08/14/24 revised 08/15/24. A review of the Medication Administration Record (MAR) found a physicians order on 01/13/25 to Monitor for behaviors: 1. pacing, 2. emotional outbursts. 3. verbal agression every day and night shift. Document number (#) of behaviors if none then 0. A review of the Medication Administration Record (MAR) found a physicians order on 01/13/25 to Monitor for behaviors: 1. refusal of care, 2. physical agression toward staff. 3. delusions every day and night shift. Document number (#) of behaviors if none then 0. The January 2025 MAR had no evidence of monitoring behaviors on the following shifts: 01/14-16/25 day shift and night shift. 01/17/25 for night shift 01/28/28 for nght shift The February 2025 MAR had no evidence of monitoring behaviors on day shift on 02/11-12/25/21/25. The March 2025 MAR found no evidence of behavior monitoring on the following: 03/08/25 for night shift 03/12/25 for day shift 03/15/25 for night shift 03/17/25 for day shift In an interview on 04/03/25 at 8:40 AM with the Administrator, he concurred there were issues with documentation and care plans. d) Resident #51 On 04/03/25 at 9:58 AM a review of the medical record for Resident #51 who was admitted on [DATE] with diagnoses of depression, Alzheimer's, dementia with behavioral disorder and wandering. A review of the care plan found the following: Focus is at risk for complications related to the use of antipsychotic, and antidepessant medications dated created 08/17/23 with revision on 11/23/24. Goal will have the smallest most effective dose without side effects through to next review. Date initiated 08//28/23 and revision date of 04/02/25. Interventions administer medications as ordered, be alert for side effects of antidepressants including: sedation, dry mouth . Initiated 08/14/24 revised on 08/15/24. -Be alert for side effects of antipsychotic medication including: blurred vision, sedation, dry mouth . Initiated 08/14/24 revised 08/15/24. A review of the Medication Administration Record (MAR) found a physicians order on 01/13/25 to Monitor for behaviors: 1. pacing, 2. emotional outbursts. 3. verbal agression every day and night shift. Document number (#) of behaviors if none then 0. A review of the Medication Administration Record (MAR) found a physicians order on 01/13/25 to Monitor for behaviors: 1. refusal of care, 2. physical agression toward staff. 3. delusions every day and night shift. Document number (#) of behaviors if none then 0. The January 2025 MAR had no evidence of monitoring behaviors on the following shifts: 01/14-16/25 day shift and night shift. 01/17/25 for night shift 01/28/28 for nght shift The February 2025 MAR had no evidence of monitoring behaviors on day shift on 02/11-12/25. The March 2025 MAR found no evidence of behavior monitoring on the following: 03/09/25 for night shift 03/12/25 for day shift 03/15/25 for night shift 03/17/25 for day shift In an interview on 04/03/25 at 8:40 AM with the Administrator, he concurred there were issues with documentation and care plans. e) Resident #3 The facility failed to ensure therapy documentation was completed timely for Resident #3. The facility's policy and procedure for Charting was reviewed. The policy stated, 4. Standardly, documentation is completed on the day of service, preferably at the time of service. 4.1 For extenuating circumstances, clinical documentation is completed and included in the medical record no later than seven days after service, and/or consistent with site of service policy, as per the most restrictive timeframe. Resident #3's speech therapy documentation was reviewed. Documentation reviewed included: Speech Therapy Evaluation completed on 2/21/25 - signed 2/25/25. Speech Therapy Progress Report due 3/7/25 - signed 3/11/25. Speech Therapy Recertification due 3/23/35 - signed 3/26/25. Speech Therapy Daily Notes: Date of Service: 3/27/25 Completion Date: 3/31/25 Date of Service: 3/26/25 Completion Date: 3/31/25 Date of Service: 3/25/25 Completion Date: 4/1/25 Date of Service: 3/24/25 Completion Date: 4/1/25 Date of Service: 3/21/25 Completion Date: 3/25/25 Date of Service: 3/20/25 Completion Date: 3/24/25 Date of Service: 3/19/25 Completion Date: 3/24/25 Date of Service: 3/16/25 Completion Date: 3/19/25 Date of Service: 3/14/25 Completion Date: 3/16/25 Date of Service: 3/13/25 Completion Date: 3/16/25 Date of Service: 3/12/25 Completion Date: 3/16/25 Date of Service: 3/11/25 Completion Date: 3/16/25 Date of Service: 3/10/25 Completion Date: 3/16/25 Date of Service: 3/7/25 Completion Date: 3/11/25 Date of Service: 3/6/25 Completion Date: 3/10/25 Date of Service: 3/5/25 Completion Date: 3/10/25 Date of Service: 3/4/25 Completion Date: 3/4/25 Date of Service: 3/3/25 Completion Date: 3/7/25 Date of Service: 2/27/25 Completion Date: 3/3/25 Date of Service: 2/26/25 Completion Date: 3/2/25 Date of Service: 2/25/25 Completion Date: 3/2/25 Date of Service: 2/24/25 Completion Date: 2/27/25 Date of Service: 2/21/25 Completion Date: 2/24/25 On 04/02/24 at 04:40 PM, the Speech Therapist confirmed her documentation is sometimes late. The Speech Therapist reported, she reviews her notes she has written during the therapy session with the resident to complete her documentation electronically at a later time/date. The Speech Therapist reported Net Health goes down frequently and there are parts of the building where internet connection unavailable at times. The Speech Therapist stated, The timeliness is on me.

Based on observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. These were random opportunities for discovery that had the potential to affect more than a limited number of residents. The facility failed to ensure Enhanced Barrier Precautions (EBP) signage was appropriately placed outside Resident #3's room. The facility failed to follow EBP for Resident #7. The facility also failed to provide resident hand hygiene in the dining room. Resident Identifiers: #3 and #7. Facility census: 65. Findings included: a) Resident #3 The facility's policy titled Enhanced Barrier Precautions, with effective date 01/06/20 and revision date 12/16/24, stated Enhanced Barrier Precautions (EBP) would be implemented for residents with wounds or indwelling medical devices. On 04/01/25 at 8:43 AM, Licensed Practical Nurse (LPN #11) stated where the EBP signage is placed outside the residents' room notifies staff which resident in that room required EBP. A sign above the resident name plates indicates the resident in Bed A required EBP. A sign below the resident name plates indicates the resident in bed B require EBP. A sign beside the name plates indicates both residents in the room require EBP. Review of Resident #3's physician's orders showed the resident had an order written on 03/27/25 for Infection precautions - enhanced barrier. The resident had an indwelling urinary catheter and a pressure ulcer dressing. During an observation on 04/01/25 at 12:55 PM, Resident #3 was noted to be in bed B. The EBP outside her door was above the name plates, indicating her roommate, Resident #268, required EBP. On 04/01/25 at 2:36 PM, the Director of Nursing stated both Resident #3 and Resident #268 required EBP. She confirmed the sign should have been beside the name plates to indicate both residents required b) Hand hygiene The facility failed to provide a safe and sanitary dining environment by not providing resident hand hygiene before meals. The facility's policy and procedure for Patient Hand Hygiene stated, Educate the patient and their representative on performing hand hygiene after toileting and before meals. On 03/31/25 at 12:55 PM during the dining room observation, no hand hygiene was observed being performed for any residents eating in the facility's main dining room. Resident #13 began eating his lunch which included a sandwich. The state surveyor intervened and asked the Recreation Director if the residents usually have hand hygiene completed prior to meals. The Recreation Director stated, We should be doing that. The Social Services Director went out of the dining room to go get hand sanitizer packets. c) Resident #7 On 04/02/25 at 3:31 PM an observation of a decubitus dressing change on Resident #7 with Registered Nurse (RN) #69 found RN #69 did not wear Personal Protection Equipment (PPE- gown) during the dressing change and then during incontinence brief change. RN #69 doubled checked the Enhanced Barrier Precautions (EBP) sign outside the door and stated that both residents are on EBP and she should have worn a gown and not just gloves.

Based on staff interview and observation, the facility to ensure garbage was disposed of properly. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 65. Findings included: a) Dumpsters On 04/01/25 at 9:55 AM, two dumpsters located behind a wooden fence were observed by a state surveyor. Gloves and food as well as cup lids, straws, plastic forks, and boxes laying around both dumpsters. were found. On garbage dumpster #1 both lids were open with lids laid back. Garbage dumpster #2 was open with the lid broken off. On 04/01/25 at 10:00 AM, the Administrator was notified and the state of the dumpsters were confirmed. The Facility Administrator stated, I see what you are saying. Usually the dumpsters are replaced yearly. We will have to call the company and get a new dumpster. Let me call (Name of the Director of Nursing) and let her know. She is my go to person.

Based on record review and staff interview, the facility failed to ensure required members of the Quality Assurance and Performance Improvement (QAPI) team were present to hold the required quarterly meeting. Facility Census: 65. a) QAPI members On 04/03/25 at 1:10 PM, a review of the sign in sheets for QAPI was completed. The review found the Director of Nursing (DON) position was empty during the dates of 02/19/24 through 04/08/24. There was no one filling in the DON position. Therefore, for the dates of 02/19/24 through 04/08/24, the required members did not attend. On 04/03/25 at 2:30 PM, this time frame was confirmed by the Administrator and the current DON. b) QAPI meetings On 04/03/25 at 2:40 PM, a review of the sign in sheets for QAPI was completed. The review found there were no meetings held in the months of 01/2025, 02/2025 or 03/2025. On 04/03/25 at 3:00 PM, the Administrator confirmed there were no meetings held in 01/2025, 02/2025 or 03/2025.

Based on record review and staff interview, the facility failed to ensure two (2) allegations of resident-to-resident sexual abuse were reported in a timely fashion and/or to the appropriate state agencies. Resident identifiers: #27 and #23. Facility census: 55. The Office of Health Facility Licensure and Certification (OHFLAC) Long-Term Care Reporting Requirements guidance, dated December 4, 2019, instructs that OHFLAC and Adult Protective Services (APS) should receive an immediate fax report of allegations within two (2) hours. Findings included: a) Resident #27 and Resident #23 Alleged Victims of Resident-to-Resident Sexual Abuse. A review of facility reportables revealed a facility reportable, dated 03/11/24 that revealed Resident #27 had been an alleged victim of sexual abuse by Resident #24, noting Resident #27 was walking past Resident #24 in the hallway and he grabbed her buttocks. The incident in question was reported to the Office of Health Facility Licensure and Certification (OHFLAC)and the long-term care Ombudsman. Adult Protective Services (APS) did NOT receive a faxed report. Additionally a facility reportable, dated 03/21/24, revealed Resident #23 had been an alleged victim of sexual abuse by Resident #24, noting that Resident #23 was standing at the nurses station when Resident #24 patted her on the buttocks. The incident in question was reported to OHFLAC and the long-term care Ombudsman. Adult Protective Services (APS) did NOT receive a faxed report. The Administrator, during an interview on 10/08/24/21 at approximately 10:10 AM, acknowledged the former interim Administrator at the time had mistakenly followed old guidance as to who should receive the reportable and confirmed that APS had not been notified as required.

Based on record review and staff interview, the facility failed to develop and implement a comprehensive person -centered care plan for one (1) of three (3) residents reviewed in the complaint survey process. The facility failed to address Resident #24's inappropriate sexual behaviors towards residents. Facility identifier: #24. Facility census: 55. Findings included: a.) Resident #24 A review of the comprehensive person -centered care plan for Resident #24 showed a focused area of Resident #24 having a history of exhibiting sexually inappropriate behavior toward staff. Review of the following facility reportables noted inappropriate sexual behaviors toward other residents on the following dates: -03/11/24 -03/21/24 -06/24/24 -08/07/24 During an interview on 10/07/24 at 2:40 PM, the Social Worker confirmed had been exhibiting sexually inappropriate behaviors towards residents and that his care plan should have been updated.

Based on medical record review and staff interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. This deficient practice was true for one (1) out of three (3) residents reviewed during a complaint survey process. Resident identifier: #3. Facility census: 55. Findings included: a) 04/15/24 Monthly Medication Regimen Review On 10/08/24 at 9:00 AM, an electronic medical review was completed on Resident #3. When reviewing the pharmacist's monthly medication review it was noted that on 04/15/24 the pharmacist noted Resident #3 receives Divalproex Sodium Dr. The current diagnosis is dementia with behaviors. The recommendation went on to request, Please monitor valproic acid trough concentration on the next convenient lab day, one (1) week after any dosage change, and annually thereafter to rule out toxicity. The electronic medical record revealed that the Nurse Practitioner (NP) had seen the monthly medication regimen review and had agreed to the recommendation on 05/02/24 noting I accept the recommendation(s) above. Please implement as written. There was no evidence that the resident's attending physician had reviewed the written pharmacist recommendation. It was noted on the paper recommendation that the former Director of Nursing (DON) wrote that Resident #3 was scheduled to have lab work done on Tuesday, 05/07/24. However, there was no evidence in the medical record of the results of the scheduled lab work. During an interview on 10/08/24 at approximately 11:15 AM, the current DON reported the the facility protocol was for the attending physician to review any monthly pharmacist recommendations and then to follow the attending physician orders. The DON stated since the attending physician had not reviewed the 04/15/24 monthly medication review recommendation and the lab work had not been obtained. She stated the nursing staff had failed to followed up with the NP's directive/order to obtain the lab work by bringing the recommendation to the attending physician's attention as well.

Based on medical record review and staff interview, the facility failed to ensure the attending physician documented in the resident's medical record that an identified irregularity had been reviewed and what, if any, action was to be taken to address it. This deficient practice was true for one (1) out of three (3) residents reviewed during a complaint survey process. Resident identifier: #3. Facility census: 55. Findings included: a) 04/15/24 Monthly Medication Regimen Review On 10/08/24 at 9:00 AM, an electronic medical review was completed on Resident #3. When reviewing the pharmacist's monthly medication review it was noted that on 04/15/24 the pharmacist noted Resident #3 receives Divalproex Sodium Dr. The current diagnosis is dementia with behaviors. The recommendation went on to request, Please monitor valproic acid trough concentration on the next convenient lab day, one (1) week after any dosage change, and annually thereafter to rule out toxicity. The electronic medical record revealed that the Nurse Practitioner had seen the monthly medication regimen review and had agreed to the recommendation on 05/02/24 noting I accept the recommendation(s) above. Please implement as written. There was no evidence that the resident's attending physician had reviewed the written pharmacist recommendation. It was noted on the paper recommendation that the former Director of Nursing (DON) wrote that Resident #3 was scheduled to have lab work done on Tuesday, 05/07/24. However, there was no evidence in the medical record of the results of the scheduled lab work. During an interview on 10/08/24 at approximately 11:15 AM, the current DON reported the facility protocol was for the attending physician to review any monthly pharmacist recommendations and then to follow the attending physician orders. The DON stated the attending physician had not reviewed the 04/15/24 monthly medication review recommendation and the lab work had not been obtained. She stated that moving forward a copy of any monthly medication review that the Nurse Practitioner signed off on would be given directly to the attending physician for his review.

. Based on observation and staff interview the facility failed to ensure the resident environment was clean and sanitary. The dementia care unit dining area was unclean, a vitals machine had a brown splattered substance on the bottom, and there was a smeared brown substance on a hand sanitizer dispenser . This failed practice has the potential to effect all residents currently residing in the dementia care unit. Facility Census: 65 Findings Include: a) A tour of the dementia care unit on 04/01/24 beginning at 12:30 PM found the floor in the dining room to be littered with food debris the walls in the dining room had what appeared to be food splatters on several spots on the walls throughout the dining room. By the sink there was food splatters on the wall and several gnats were noted to be positioned on the wall around the food splatters. An additional tour of the dining room on 04/01/24 at 1:58 PM with the Market President found the dining room had been freshly mopped however there was spread red jello on the floor and food particles were still noted on the floor throughout the dining room. The walls still had food splatters on them. Also there was a smeared brown substance on the hand sanitizer dispenser and on the vital machine there was a brown substance covering the base of the machine. The Market President was also showed these two (2) items.

. Based on observations, record review, resident interviews and staff interviews, the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and support the physical, mental and psychosocial well-being of each resident. This was a random opportunity for discovery. This failed practice had the potential to affect more than a limited number of residents residing in the facility. Resident identifiers: Resident #26, Resident #15, and Resident #32. Facility Census: 65. Findings Include: a) Observations: During several observations throughout the complaint revisit survey on 04/01/24 to 04/02/24, several group activities were not being conducted as scheduled. The monthly activity calendar for the Blue Hall scheduled events were as follows: -04/01/24 2:00 PM Getting to Know me (3) three residents were in attendance 4:00 PM Meaningful Moments was not conducted -04/02/24 9:30 AM Sensory Group was not conducted 10:30 AM Move and Grove was not conducted 2:00 PM PB&J Day (Peanut Butter and Jelly) The monthly activity calendar for the Red Hall (Memory Unit) was dated for the month of February. During several observations of the Memory Unit, no activities were being conducted. A few residents were in the TV lounge and several strolling and/or pacing throughout the unit. During an observation on 04/02/24 at 2:00 PM the PB and J day was not being conducted in the main dining room (MDR) as a group activity. The RD was making the pb and j sandwich and placing them baggies to serve to the residents in the units. During an observation on 04/02/24 at 2:07 PM the memory unit was receiving a snack. During an immediate interview Nurse Aide (NA) #29 stated I am passing the residents snacks. The PB&J sandwiches were left over from last night, so I just served them. The PB & J were dated 03/31/24 use by 04/05/24. During a MDR observation on 04/02/24 at 2:25 PM the PBJ group activities were not being conducted. The RD stated I am getting the cart ready to take to the floor to serve the residents. I didn't do it as a group activity. b) Staff Interviews During a interview on 04/01/24 at 1:42 PM Recreation Aide #7 stated I worked today from 10:30 AM to 4:30 PM. I am part time. The Director is off today. I recently got trained for the Memory Unit. I just deliver the mail and go over to talk to them, I can't get them to color with me. The (recreational director name) can get them to color. There is no activity director over on the unit. There is no structured activity on the unit, they do the best they can over there. During an interview on 04/02/24 at 10:43 PM the Recreation Director (RD) stated I did not have a sensory group this morning, I was busy and had no help. I have another assistant but she has not shown up for work in three (3) months. The Move and Groove activity at 10:30 AM, I just put on some music and let them do their thing. During the observation two (2) residents were in the Main Dining Room coloring and one resident just strolling through. Further interview with the RD stated The memory unit does not have a daily calendar, The old Director told me not to do anything on the memory unit, they would take care of it. We go over daily, that is where my office is. Like today is PB and J day so the residents on the memory unit will participate in that activity and last week we made Easter eggs and they got to color them. The nurses and CNA's are supposed to do activities daily and record their participation. During an interview on 04/02/24 at 12:00 PM the Interim Administrator was informed of the lack of activities being conducted on the Red and Blue Units. During an interview on 04/02/24 at 3:35 PM the RD acknowledged the activity programming needed to improve on the Blue hall and on the memory unit. Resident #26 During a interview on 04/02/24 at 11:12 Am Resident #26 stated what activities I have never been to any activities since I have been here. What kind of activities do they have here? During a record review on 04/02/24 Resident #26's recreation participation record was void any activities participation on the following days in March 2024: -02, 03, 04, 05, 09, 11, 12, 13, 15, 16, 17, 20, 21, 24, 25, 27, 29 and 30. During an interview on 04/02/24 at 3:12 PM the Interim Administrator acknowledged the participation records were void of the participation in any group and/or individual activities for Resident #26. Resident #15 During an interview on 04/02/24 at 1:33 PM Resident #15 stated, I don't participate in activities that interest me. No, I don't have any suggestions. During a record review on 04/02/24 Resident #15's recreation participation record was void any activities participation on the following days in March 2024: -02, 03, 04, 06, 08, 09, 11, 13, 14, 16, 18, 20, 21, 24, 25, 26, 27, 29 and 30. During an interview on 04/02/24 at 3:12 PM the Interim Administrator acknowledged the participation records were was void of the participation in any group and/or individual activities for Resident #15. Resident #32 During an interview on 04/02/24 at 1:35 PM Resident #32 stated the only thing the activity people do is take our menu orders for lunch and dinner. During a record review on 04/02/24 Resident #32's recreation participation record was void any activities participation on the following days in March 2024: -02, 03, 04, 12, 24, 25, 28, 29 and 30. During an interview on 04/02/24 at 3:12 PM the Interim Administrator acknowledged the participation records were void of the participation in any group and/or individual activities for Resident #32. A review of a facility policy titled Therapeutic Program with a revision date of 05/01/22 read as follows: POLICY: Memory Support Programs will have a structured, daily, therapeutic program that is developed and implemented to meet the Memory Support Program Philosophy and Standards of Care, and recognize patient/resident specific strengths, preferences and goals. Memory Care During several observations in the Memory Unit (red Hall) throughout the complaint revisit survey on 04/01/24 to 04/02/24, no group or individual activities were being conducted. A few residents were in the TV lounge and several strolling and/or pacing throughout the unit. The monthly activity calendar for the Red Hall (Memory Unit) was dated for the month of February. During several observations of the Memory Unit, no activities were being conducted. During an observation on 04/02/24 at 2:00 PM the PB and J day activity was not being conducted in the Main Dining Room (MDR) as a group activity. The RD was making the pb and j sandwich and placing them baggies to serve to the residents in the units. During an observation on 04/02/24 at 2:07 PM the memory unit was receiving a snack. During an immediate interview Nurse Aide (NA) #29 stated I am passing the residents snacks. The PB&J sandwiches were left over from last night, so I just served them. The PB & J were dated 03/31/24 use by 04/05/24. Staff Interviews During an interview on 04/01/24 at 1:42 PM Recreation Aide #7 stated I worked today from 10:30 AM to 4:30 PM. I am part time. The Director is off today. I recently got trained for the Memory Unit. I just deliver the mail and go over to talk to them, I can't get them to color with me. The (recreational director name) can get them to color. There is no activity director over on the unit. There is no structured activity on the unit, they do the best they can over there. During an interview on 04/01/24 at 3:30 PM Licensed Practical Nurse (LPN) #4 stated we do not have activities on this unit, the LPN and NA (Nurse Aide) do not have time to conduct the activities. If we had activities we would have less behaviors. All we get done is give medication, break up fights and redirect the residents from the doors or other resident's rooms. During a interview on 04/01/24 at 3:32 PM NA #6 stated the Activity staff never come over unless it is to get something. We are unable to provide them with that kind of time needed to dedicate to activities. During an interview on 04/02/24 at 10:43 PM the Recreation Director (RD) stated The memory unit does not have a daily calendar, The old Director told me not to do anything on the memory unit, they would take care of it. We go over daily, that is where my office is. Like today is PB and J day so the residents on the memory unit will participate in that activity and last week we made Easter eggs and they got to color them. The nurses and CNA's are supposed to do activities daily and record their participation. During an interview on 04/02/24 at 12:00 PM the Interim Administrator was informed of the lack of activities being conducted on the Red Unit. During an interview on 04/02/24 at 3:35 PM the RD acknowledged the activity programming needed to improve on the Red hall. Red Hall Resident Participation Records During a record review on 04/02/24 all residents recreation participation records for the Red hall were reviewed for the month of March 2024 and April 2024. The following days were coded for participation in an activity: -03/18/24 -03/20/24 -03/21/24 -03/30/24 During an interview on 04/02/24 at 3:35 PM The RD acknowledged the lack of group and/or individual activities provided in the Memory Unit.

Based on observations and staff interviews the facility failed to ensure the activities program is directed by a qualified professional. This had a potential to affect all residents residing in the facility. Facility Census: 65 Findings Include: a) Activity Professional During several observations throughout the complaint revisit survey on 04/01/24 to 04/02/24, several group activities were not being conducted as scheduled. The monthly activity calendar for the Blue Hall scheduled events were as follows: -04/01/24 2:00 PM Getting to Know me (3) three residents were in attendance 4:00 PM Meaningful Moments was not conducted -04/02/24 9:30 AM Sensory Group was not conducted 10:30 AM Move and Grove was not conducted The monthly activity calendar for the Red Hall (Memory Unit) was dated for the month of February. During several observations of the Memory Unit, no activities were being conducted. During an interview on 04/02/24 at 10:43 PM the Recreation Director (RD) stated I am not certified, I started this position in January and I have one week of classes. The RD stated I complete the MDS, Care plans and assessment and complete the monthly calendars. The RD from Salem comes one time a month if I need her. During an interview on 04/02/24 at 12:00 PM the Interim Administrator acknowledged the facility did not have a certified activity professional full time.

. Based on observations, water temperature measurement 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 water temperature was found to be 119 degrees and the medication and treatment cart were discovered unlocked and unattended on the night of 04/01/24. This failed practice had the potential to affect more than an isolated number of residents. Facility Census: 65. Findings Include: a) Water Temperature An observation on 04/01/24 at 4:00 PM found the hot water in the restroom in the front lobby of the building was too warm to the touch. At 4:45 PM on 04/01/24 a visiting Maintenance Director came to the restroom and obtained the temperature. He stated, This will be in Celsius we will convert it Fahrenheit. The temperature obtained was 48.7 degrees Celsius. This converts to 119.7 degrees Fahrenheit. The state operations manual (SOM) page 340 contained the following in regards to water temperatures: Water Temperature Time Required for a 3rd Degree Burn to Occur 155°F 68°C 1 sec 148°F 64°C 2 sec 140°F 60°C 5 sec 133°F 56°C 15 sec 127°F 52°C 1 min 124°F 51°C 3 min 120°F 48°C 5 min 100°F 37°C Safe Temperatures for Bathing (see Note) NOTE: Burns can occur even at water temperatures below those identified in the table, depending on an individual's condition and the length of exposure. The visiting maintenance director indicated the water needed to be adjusted and it was too warm. b) Night Shift Observations on 04/01/24 On 04/01/24 at 9:30 PM the facility was entered by state surveyors. Immediate observations upon entering the facility found the medication cart and treatment cart were both unlocked and unattended. The nurse was observed in a resident room at the time of the observations. Licensed Practical Nurse (LPN) #17 stated, I am sorry I was running back and forth wrapping someone's leg and did not lock the carts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to develop and implement a baseline care plan within 48 hours of admission for resident #41 that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. This was true for one (1) of three (3) residents reviewed during a complaint survey. Resident identifier: #41. Facility Census 64. a) Resident #41 During a medical record review on 02/14/24 at 10:28 AM, Resident #41 was identified to have a BIMS of 10 and lacked capacity. The baseline care plan, dated 02/02/24, reviewed for Resident #41 identified only one (1) focus that was incomplete, one (1) incomplete goal, and outlined only two (2) interventions for the incomplete focus. - FOCUS: Resident/Patient requires assistance/is dependent for mobility related to: _____. - GOAL: Resident will utilize_____bed rail(s) _____ (indicate one: independently; with assistance) for _____ (indicate: turning and repositioning while in bed; transferring to/from bed). - INTERVENTIONS: 1) Head of bed elevated as a mobility enabler, 2) PT/OT screen. Additional record review revealed the following diagnoses and physician orders: Diagnoses included but was not limited to: -Type 2 diabetes mellitus without complications; -Alzheimer's disease; -Major depressive disorder; -Dementia. Physicians orders included but was not limited to: -Metformin HCl Tablet 500 mg, give 1 tablet by mouth two times a day for diabetes; -Abilify Oral Tablet 5 MG, Give 1 tablet by mouth one time a day for Dementia with Behaviors; -Glucagon Emergency Kit 1 MG (Glucagon (rDNA)), Inject 1 mg intramuscularly as needed for BG (blood glucose) less than 70, Not arousable conscious or able to swallow Hold all diabetic meds until provider authorizes resumption, remain with pt. (patient) and keep in bed/chair for safety. Repeat blood glucose in 15 min AND Inject 1 mg intramuscularly as needed for BG less than 70, Not arousable conscious or able to swallow If repeat blood glucose is below 70mg/dl and pt is NOT arousable, conscious or able to swallow. Continue to hold all diabetic medications until provider authorizes resumption. Remain with pt. Keep pt. in bed/chair for safety. Dose check cannot be performed. The unit of measure selected does not match the medispan recommended unit of measure for this medication; -Insta-Glucose Gel 77.4 % (Glucose), Give 1 dose by mouth as needed for BG less than 70, Pt arousable conscious and able to swallow Hold all diabetic medications until provider authorizes resumption. Remain with pt. Keep pt.in bed/chair for safety. Repeat blood glucose in 15 min. AND Give 1 dose by mouth as needed for BG less than 70, Pt arousable conscious and able to swallow If repeat blood glucose is below 70mg/dl and pt is arousable, conscious and able to swallow. Continue to hold all diabetic medications until the provider authorizes resumption. Remain with pt. Keep pt.in bed/chair for safety; -Sertraline HCl Tablet 50 MG, Give 1 tablet by mouth one time a day for Depression; -Namenda Tablet 10 MG (Memantine HCl), Give 1 tablet by mouth two times a day for dementia; -Aricept Tablet 10 MG (Donepezil HCl), Give 1 tablet by mouth at bedtime for dementia; There was no mention of Resident #41 ' s Type 2 diabetes mellitus without complications, Alzheimer's disease, Major depressive disorder, or Dementia in resident ' s baseline care plan. During an interview with the Assistant Director of Nursing (ADON) Staff #23 on 02/14/24 at 11:35 AM, the ADON confirmed Resident #41 had been admitted to the facility on [DATE] and the baseline care plan had not yet been completed in its entirety for resident #41.

Based on record review and staff interview, the facility failed to ensure two (2) residents received treatment and care in accordance with professional standards of practice. The facility failed to ensure neurological checks were completed for Resident #66 and Resident #67. This failed practice was true for two (2) of three (3) residents reviewed in the complaint care survey process. Resident identifier: #66, #67. Facility Census: 64. Findings included: a) Resident #66 During a record review, on 02/13/24 at 11:07 AM, an unwitnessed fall was identified for Resident #66 on 09/13/23. The unwitnessed fall required neurological checks to be completed. During a review of the 09/13/23 initiated neurological checks form Neurological Evaluation Flow Sheet, under the section to be completed After First 8 Hours Completed Above, Evaluate Every 8 Hours for At Least 64 Additional Hours the following two (2) neurological checks were not completed per the dates and times documented on the form; * 09/14/23 at 1800 * 09/15/23 at 0200 During an interview on 02/13/24 at 3:47 with the DON, the DON acknowledged that the neurological checks had not been completed as evident by the incomplete Neurological Evaluation Flow Sheet form dated 09/13/23 for Resident #66's unwitnessed fall. b) Resident #67 During a record review on 02/12/24 at 02:20 PM a witness fall was identified for Resident #67. Resident #67 did hit her head on 08/02/23. This fall was noted to require neurological checks to be completed. During a review of the 08/02/23 initiated neurological checks form Neurological Evaluation Flow Sheet, under the section to be completed After First 8 Hours Completed Above, Evaluate Every 8 Hours for At Least 64 Additional Hours the following four (4) neurological checks were not completed per the dates and times documented on the form; * 08/04/23 at 20:15 * 08/05/23 at 04:15 * 08/05/23 at 12:15 * 08/05/23 at 20:15 During an interview, on 02/13/24 at 3:49, with the DON, the DON admitted that the neurological checks had not been completed as evident by the incomplete Neurological Evaluation Flow Sheet form dated 08/02/23 for Resident #67's witnessed fall with resident hitting her head.

Based on observation, record review, and staff interviews the facility failed to ensure they maintained medical records that were complete, accurately documented, readily accessible and systematically organized in the resident's medical record. This was true for one (1) of three (3) residents reviewed for falls during the complaint survey. Resident identifier: #50. Facility Census: 64. a) Resident #50 During a medical record review for Resident #50 on 02/13/24 at 9:56 AM a fall was identified to have happened on 09/02/23 and documented as incident #737 on the fall list that was provided by the facility. During the review of the resident's medical record for 09/02/23 there was no changes in condition documented in her chart, there were no nurses' notes, no care plan updates, or any other pertinent documentation correlated to the documented fall that was referenced as incident #737 for Resident #50 on 09/02/23. On 02/14/24 at 11:37 AM during an interview with the Assistant Director of Nursing (ADON) #23, the ADON acknowledged that Resident #50 was documented to have fallen on 09/02/23 identified as incident #737 on the facility fall list. She further stated that she was unable to provide any medical records or documentation that correlated to the documented fall referenced as incident #737 for Resident #50 on 09/02/23.

Based on medical record review and staff interview the facility failed to maintain the resident's highest practicable level of physical, mental, and psychosocial well-being and the ability to prevent or minimize adverse consequences related to medication therapy to the extent possible. The facility failed to act upon the pharmacist medication regimen review reports for comments and recommendations identified for three (3) of three (3) residents reviewed during the complaint survey. Resident identifiers: Resident #50, Resident #66, and Resident #67. Census: 64. Findings included: a) Resident #50 On 02/13/23 at approximately 4:55 PM during a medical record review of Resident #50's medication regimen reviews, a progress note report was ran to identify any DRR (drug regimen review) reports received from 08/01/23 to 02/13/24. Two (2) drug regimen reports dated 09/25/23 and 10/20/23 were identified with Note: A medication regimen review was performed- see report for comments/ recommendation(s) noted. No reports were provided for 09/25/23 or 10/20/23. During an interview with Director of Nursing (DON) on 02/13/23 at 4:56 PM. The DON admitted that the drug regimen reviews reports could not be found and the drug regimen review reports were not completed for 09/25/23 and 10/20/23. b) Resident #66 On 02/13/23 at approximately 4:55 PM during a medical record review of Resident #66's medication regimen reviews, a progress note report was ran to identify any DRR (drug regimen review) reports received from 08/01/23 through 02/13/24. Three (3) drug regimen reports dated 08/25/23, 09/25/23 and 12/22/23 were identified with Note: A medication regimen review was performed- see report for comments/ recommendation(s) noted. No reports were provided for 08/25/23, 09/25/23 and 12/22/23. During an interview with Director of Nursing (DON) on 02/13/23 at 4:56 PM. The DON admitted that the drug regimen reviews reports could not be found and the drug regimen review reports were not completed for 08/25/23, 09/25/23 and 12/22/23. c) Resident #67 On 02/13/23 at approximately 4:55 PM during a medical record review of Resident #67's medication regimen reviews, a progress note report was ran to identify any DRR (drug regimen review) reports received from 08/01/23 through 2/13/24. One (1) drug regimen report dated 08/28/23 was identified with Note: A medication regimen review was performed- see report for comments/ recommendation(s) noted. No report was provided for 08/28/23. During an interview with Director of Nursing (DON) on 02/13/23 at 4:56 PM. The DON admitted that the drug regimen reviews reports could not be found and the drug regimen review report was not completed for 08/28/23.

. Based on observation and staff interview, the facility failed to provide care to residents in a manner that promoted the right to a dignified existence and failed to protect a residents privacy during care. These were random opportunities for discovery. Resident identifier: #43 and #23. Facility census: 60. Findings included: a) Resident #43 On 04/03/23 at 11:50 AM, Resident #43 was observed asleep in the television room/day room of the memory care unit. Readily visible was an uncovered urinary catheter leg bag hanging below Resident's left pants leg. The urinary catheter bag had no covering, and it was instantly noticeable the bag was approximately 1/3 full of urine. On 04/03/23 at 12:00 PM, Resident #43 was escorted into the dining room by staff for the lunch time meal. Resident #43 was seated in the dining room with approximately 15 other residents. During an interview on 04/03/23 at 12:24 PM, Licensed Practical Nurse (LPN) #78 agreed the noticeably visible urinary catheter bag should have been identified as a dignity issue and addressed prior to them being escorted into the dining room. b) Resident (R) #23 An observation of wound care on 04/04/23 at 3:35 PM, found Registered Nurse (RN)#76 and RN #80 failed to close the door and pull the curtains while changing the dressing on R#23's coccyx. The above findings were reviewed with RN #80 immediately after this observation. She reported she was unaware that the curtains should have been pulled around the bed and the door closed to maintain R#23's privacy during care. .

. Based on record review and staff interview, the facility failed to report incidents resulting in serious bodily injury in a timely manner to the appropriate state agencies. This was true for one (1) of three (3) residents reviewed for falls and one (1) of six (6) residents reviewed for accidents during the Long-Term Care Survey Process. Resident identifiers: #51 and #11. Facility census: 60. Findings included: a) Resident #51 A record review, completed on 04/05/23 at 9:30 AM, revealed the following details: -Resident #51 experienced a fall on 01/16/23 and was sent to the hospital. -A General nursing note, on 01/17/23 at 8:20 AM, noted Patient returned from hospital with 12 sutures to wound to scalp. -The facility's reportables log did not reflect the incident had been reported to the appropriate state agencies. During an interview on 04/05/23 at 10:38 AM, Social Worker #44 stated the fall resulting in 12 sutures to Resident #51's scalp had not been reported as a fall with serious bodily injury. Social Worker #44 explained the facility had been using different guidelines at that time which had not identified the need to receive sutures as a serious bodily injury. b) Resident (R) #11 Review of the medical record on 04/04/23, revealed R#11 developed second degree burns on her abdomen and thighs after spilling a cup of hot coffee. The facility's reportables log lacked any information the incident was reported to the appropriate state agencies as required. During an interview on 04/04/23 at 3:21 PM, Social Worker (SW) #44 stated How would I report it? The issue was the coffee was too hot and staff were educated on the concern. After further discussion SW #44 agreed it was a serious injury which should have been reported within two (2) hours after the incident occurred. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to complete an accurate comprehensive assessment for one (1) of two (2) residents reviewed for pressure ulcers. The comprehensive assessment does not identify Resident #23's pressure ulcer. This is true for one (1) of two (2) residents reviewed for pressure ulcers. Resident identifier: #23. Facility census: 60. Findings include: a) Resident (R) #23 Review of the medical record on 04/03/23, revealed R#23 developed an in house acquired pressure ulcer on his coccyx on 02/15/22. The skin and wound evaluation forms dated 11/11/22 states there is a Stage 2 pressure ulcer with partial thickness skin loss, exposed dermis, and 80% epithelial tissue in the wound on the sacrum. The medical record lacks weekly wound assessments until surveyor intervention on 04/03/23. A wound assessment dated [DATE] notes the Stage 2 pressure ulcer on the sacrum remains. The comprehensive minimum data set (MDS) assessment with an assessment reference date (ARD) of 02/27/23 was completed for a significant change in Resident #23's condition. Section M0210 is coded incorrectly, failing to identify R #23's pressure ulcer. During an interview on 04/04/23 at 2:30 PM, the Director of Nursing (DON) acknowledged R#23's pressure ulcer remains. The DON agreed the comprehensive MDS assessment with an ARD of 02/27/23, was coded incorrectly and fails to identify the Stage 2 pressure ulcer. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility staff failed to accurately complete the significant change comprehensive assessment for a resident with a pressure ulcer. This is true for one (1) of two (2) reviewed for pressure ulcers. Resident identifiers: 23. Facility census: 60. Findings include: a) Review of the medical record on 04/03/23, revealed R#23 developed an in house acquired pressure ulcer on his coccyx on 02/15/22. The skin and wound evaluation forms dated 11/11/22 states there is a Stage 2 pressure ulcer with partial thickness skin loss, exposed dermis, and 80% epithelial tissue in the wound on the sacrum. The medical record lacks weekly wound assessments until surveyor intervention on 04/03/23. A wound assessment dated [DATE] notes the Stage 2 pressure ulcer on the sacrum remains. The quarterly minimum data set assessments (MDS) with assessment reference dates (ARD) of 09/13/22 and 12/08/22 are coded incorrectly under section M0210 and fail to identify R#23's pressure ulcer. The comprehensive MDS assessment with an ARD of 02/27/23 was completed for a significant change in Resident #23's condition. Section M0210 is coded incorrectly, failing to identify R #23's pressure ulcer. During an interview on 04/04/23 at 2:30 PM, the Director of Nursing (DON) acknowledged R#23's quarterly and comprehensive MDS assessments listed above were coded incorrectly and fail to identify the Stage 2 pressure ulcer, present since 02/15/22. .

. Based on medical record review and staff interview, the facility failed to update Resident #55's care plan to reflect a change in nutritional status. This is true for one (1) of six (6) residents reviewed for the care area of nutrition. Resident identifier: #55. Facility census: 60. Findings included: a) Resident (R) #55 A review of the medical record on 04/11/23 revealed an active diagnosis of Adult Failure to Thrive (AFTT) on R#55's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 02/10/23. R#55's last weight was 134.5 pounds. The care plan identifies the diagnosis of AFTT, but was not updated to reflect this change. The nutritional Focus states Resident has low risk for decline in nutritional status with weight loss. The goals include meal consumption of greater than 75% of three (3) meals a day and maintain a weight of 150 to 160 pounds. **The care plan lacks measurable goals and intervention for R#55's AFTT diagnosis. On 04/11/23 at 9:25 AM, R#55's record was reviewed with Registered Nurse Consultant #83 and the Senior Nursing Home Administrator #77. Both staff acknowledged R#55's current diagnosis of AFTT and agreed the nutritional care plan was not updated to address this change. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, and staff interview the facility failed to assess pressure ulcers weekly to promote the healing of pressure areas. This was true for two (2) of two (2) residents reviewed for pressure areas. Resident identifiers #46 and #23. Facility census 60. Findings Included: a) Resident #46 A medical record review for Resident #46 revealed the following physician orders: -- Apply HYDRA Guard two times a day and as needed to sacrum to maintain skin integrity every day and night shift for to maintain skin integrity. -- Wash coccyx/buttocks with wound wash, pat dry. Apply foam dressing. Change every other day and as needed as soiled every night shift every two 2 day(s) for wound healing. -- Apply skin prep to bilateral heels and ensure that heels are offloaded. Monitor skin for any changes to skin integrity. Continued review of Resident #46's medical record found the following Care plan: Focus: Resident #46 is at risk for skin breakdown related to impaired cognition, impaired mobility, incontinence, poor safety awareness. Has Stage II to coccyx. Goal: Stage II to coccyx will show improvement by next review. Decrease in area affected, no signs or symptoms of worsening or infection. Intervention: Weekly wound assessment to include measurements and description of wound status. A medical record review for Resident #46 revealed the last Pressure Ulcer wound evaluation was completed 11/10/22. During an interview on 04/04/23 at 12:23 PM the Director of Nursing stated No Wound Assessments have been completed since November 2022 since the Wound Care Nurse left. b) Resident (R) #23 Review of the medical record on 04/03/23, revealed R#23 developed an in house pressure ulcer on his coccyx on 02/15/22. The skin and wound evaluation forms dated 11/11/22 states there is a Stage 2 pressure ulcer with partial thickness skin loss, exposed dermis, and 80% epithelial tissue in the wound on the sacrum. The wound area measures 22.6 centimeters (cm) with a length of 4.4 cm and a width of 6.8 cm. The progress of the wound is noted to be stalled. The medical record lacks any weekly wound assessments until surveyor intervention on 04/03/23. A wound assessment dated [DATE] notes a Stage 2 pressure ulcer on the sacrum measuring 3.49 cm long by 7.5 cm wide by 0.1 cm deep. The wound bed is 10% epithelial with light sanguineous /bloody discharge and dark reddish brown excoriated surrounding tissue. During an interview on 04/04/23 at 12:28 PM the Director of Nursing (DON) acknowledged R#23 had an in house acquired pressure ulcer in February 2022 and wound assessments were not being conducted weekly since the facility lost their wound nurse in November 2022. .

. Based on observation, record review, and staff interview, the facility failed to ensure each resident was afforded the amount of supervision required to prevent accidents during the lunch time hour. This was true for one (1) of three (3) residents reviewed for falls in the Long-Term Care Survey process. Resident identifier: #42. Facility census: 60. a) Resident #42 Review of the facility matrix, on 04/03/23 at 10:43 AM, revealed Resident #43 had a history of falls with injury. Review of the physician orders, on 04/03/23 at 10:44 AM, found the following order, Nonskid footwear for resident safety as resident allows which was given on 04/19/21. Review of Resident #42's care plan, on 04/03/23 at 10:45 AM, found the following focus area: [Resident's First Name] is at risk for falls: cognitive loss, lack of safety awareness, hx [history] of falls with injury. An intervention associated with the focus area was listed as: Encourage nonskid shoes when out of bed. A dining room observation, on 04/03/23 at 12:12 PM, revealed: -11 residents were in the dining room eating. -CNA #34 was the only staff in the dining room and was feeding another resident at a table as well as encouraging a third resident, at the same table as the CNA, to eat by providing verbal cues. -Resident #42 was finished eating and removed her slippers placing them on the edge of the dining room table. -Resident #42 then removed the nonskid sock from her left foot, wrapped her fork up in her nonskid sock, and placed it inside one of her slippers. -Resident #42 then removed the other nonskid sock from her right foot and placed it on the table. At 12:20 PM, Resident #42 stood up and walked barefoot over to the sink area to grab a paper towel then walked out of dining room barefoot. As Resident #42 was walking out of the dining room barefoot, she had to pass CNA #34 who was sitting at a table close to the door feeding another resident. CNA #34 did not identify Resident #42 was barefoot. At 12:27 PM, Resident #42 was observed walking up and down the hallway past LPN #78 who was feeding a male resident his lunch. LPN #37 did not identify that Resident #42 was barefoot. At 12:29 PM, Speech Therapist #33 walked past Resident #42 in the hallway and did not notice she was barefoot. At 12:33 PM, Recreational Assistant #41 entered the memory care unit, saw Resident #42 walking up the hallway, and identified resident was walking barefoot. Recreational Assistant #41 acknowledged the resident was supposed to have nonskid footwear on due to her history of falls resulting in injury. .

. Based on record review and staff interview, the facility failed to maintain a complete and accurate medical record for one (1) of 24 sampled residents during the Long-Term Care Survey Process. Specifically, the facility failed to accurately accept verbal consent on a Physician Orders for Scope of Treatment (POST) form by using only one (1) witness to the consent. Resident identifiers: #43. Facility census: 60. Findings Included: a) Resident #43 A medical record review, completed on 04/03/23 at 1:52 PM, revealed the following details: -There was a Physician Orders for Scope of Treatment (POST) form on file for Resident #43. - Liscensed Practical Nurse (LPN) #46 had accepted verbal consent from Resident #43's Health Care Surrogate (HCS). The verbal consent was accepted on 11/22/22. LPN #46 was the only witness to the verbal consent. Review of instructions on how to complete the POST form from Using the POST Form: Guidance for Healthcare Professionals 2021 Edition, page 20, outlined: If the incapacitated patient's MPOA [Medical Power of Attorney] representative or Health Care Surrogate [HCS] is unavailable at the time of form completion, this section can be signed by two witnesses for verbal confirmation of agreement from the patient's MPOA representative or Health Care Surrogate [HCS]. The form should be signed at the earliest available opportunity. During an interview on 04/04/23 at 9:45 AM, Corporate Administrator #77 provided evidence the Social Worker had followed-up with the HCS and was already in the process of obtaining an original signature. Corporate Administrator #77 also acknowledged there was only one (1) witness to the verbal consent on the POST which was dated 11/22/22 and agreed it did not meet the POST form guidance which outlined the form being signed by two (2) witnesses for verbal confirmation of agreement from the resident's HCS. .

. Based on staff interview, resident council meeting, and record review the facility failed to provide residents a confidential way to file a grievance. This failed practice has the potential to affect more than an isolated number of residents currently residing in the facility. Facility census: 60. Findings Included: a) Grievances On 04/05/23 at 10:23 AM, during a Resident Council meeting it was revealed there was no confidential way for the residents and/or family members to file a grievance without involving a staff member. On 04/05/23 at 1:45 PM, an observation throughout the facility found no grievance forms available throughout the facility. During an interview on 04/11/23 at 8:56 AM, with the Social Work Director #44 stated the Residents must come to a staff member to file the grievance on the computer. She stated that there are no grievance forms available for residents to file a grievance anonymously. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview the facility failed to provide Notice of Discharge to the Office of the State Long Term Care (LTC) Ombudsman during a discharge / transfer or the Resident Representative. This was true for three (3) of three (3) Hospitalizations reviewed. Resident Identifier #60, #51 and # 45. Facility Census 60. Findings Included: a) Resident #60 A medical record review on 09/13/22 at 1:27 PM, revealed resident #60 was discharged to the hospital on [DATE]. Subsequent review of Resident #60's medical record showed it did not contain documentation the Notice of Transfer or Discharge was provided to the Resident Representative, or the Ombudsman of the discharges on 03/31/23. During an interview 04/04/23 at 2:30 PM the Social Service Director stated she does not send out discharge and transfer notices to the ombudsman or send a bed hold notice if they are not above 90 % capacity. On 04/04/23 at 2:48 PM Corporate Business Development #79 verified, the ombudsman should have been notified and a bed hold should have been sent to the resident/resident representative with all hospital transfers and discharges. b) Resident #51 An electronic medical record review completed on 04/04/23 at 1:21 PM, found Resident #51 was discharged to the hospital on [DATE]. There was no evidence a copy of the written Notice of Transfer/Discharge was provided to the long-term care Ombudsman. During an interview on 04/04/23 at 3:00 PM, Social Worker #44 stated the facility was unable to produce evidence a copy of the Notice of Transfer/Discharge was given to the long-term care Ombudsman. Social Worker #44 reported she never sends a copy of the notice to the ombudsman for any resident which is hospitalized . c) Resident (R) #45 Review of the medical record on 04/10/23 revealed Resident #45 was urgently discharged to the hospital on [DATE]. The record lacks evidence a written Notice of Transfer/Discharge was provided to the long-term care Ombudsman. During an interview on 04/04/23 at 3:00 PM, Social Worker #44 reported she never sends a copy of the notice to the ombudsman for any resident whichA is hospitalized . .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to provide evidence the resident and/or the resident's representative was provided a written Bed Hold Notice for a hospital transfer. This was true for three (3) of three (3) residents reviewed for hospitalizations during the Long-Term Care Survey Process. Resident identifiers: #51, #45, and #60. Facility census: 60. Findings included: a) #60 A medical record review on 09/13/22 at 1:27 PM revealed resident #60 was discharged to the hospital on [DATE]. Subsequent review of resident #60's medical record showed it did not contain documentation that the resident / resident's representative was provided a written Bed Hold Notice for a hospital transfer of the discharges on 03/31/23. During an interview 04/04/23 at 2:30 PM the Social Service Director, stated she does not send a bed hold notice if they are not above 90 % capacity. On 04/04/23 at 2:48 PM Corporate Business Development #79 verified both a bed hold policy should have been sent with all hospital transfers and discharges. b) Resident #51 An electronic medical record review was completed on 04/04/23 at 1:21 PM, found Resident #51 was discharged to the hospital on [DATE]. There was no evidence the resident / resident's representative was provided a written Bed Hold Notice for a hospital transfer. During an interview on 04/04/23 at 3:02 PM, Social Worker #44 stated the facility did not provide a written Bed Hold Notice because the facility was not charging for a bed hold because their census was not high enough. c) Resident #45 Review of the medical record on 04/10/23 revealed, Resident #45 was urgently discharged to the hospital on [DATE]. The record lacks evidence the resident / resident's representative was provided a written Bed Hold Notice for a hospital transfer. During an interview on 04/04/23 at 2:30 PM, Social Worker #44 stated the facility did not provide a written Bed Hold Notice because the facility was not charging for a bed hold because their census was not high enough. On 04/04/23 at 2:46 PM Corporate Registered Nurse #82 acknowledged Resident #45 should have received a copy of the bed hold policy. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, medical record review and staff interview, the facility failed to implement comprehensive person-centered care plans for residents with wounds. In addition, the facility failed to include in the care plan the side effects of psychotropic medications which staff should watch for. This was found for one (1) of five (5) residents reviewed for unnecessary medications, one (1) of two (2) reviewed for pressure ulcers and one (1) of one (1) reviewed for wounds. Resident identifiers: #23, #17 and #43. Facility census: 60. Findings include: a) Resident (R) #23 Review of the medical record on 04/03/23, revealed R#23 developed an in house pressure ulcer on his coccyx on 02/15/22. The skin and wound evaluation forms dated 11/11/22 states there is a Stage 2 pressure ulcer with partial thickness skin loss, exposed dermis, and 80% epithelial tissue in the wound on the sacrum. The medical record lacks any weekly wound assessments until surveyor intervention on 04/03/23. A wound assessment dated [DATE] notes a Stage 2 pressure ulcer on the sacrum measuring 3.49 cm long by 7.5 cm wide by 0.1 cm deep. The wound bed is 10% epithelial with light sanguineous/bloody discharge and dark reddish brown excoriated surrounding tissue. The care plan updated 04/04/23, identifies the Stage 2 pressure ulcer on the sacrum. Interventions include weekly assessments by a licensed nurse. During an interview on 04/04/23 at 12:28 PM the Director of Nursing (DON) acknowledged R#23 developed an in house pressure ulcer on 02/15/22. The DON reported wound assessments were not conducted weekly since the facility lost their wound nurse in November of 2022. b) Resident (R) #17 A random observation on 04/03/23 at 2:52 PM, found the following on the bottom of R#17's left foot: --a black fluid filled blister on the great toe -- a black necrotic area on the distal 2nd toe --a black and scabby area on the posterior middle section of the 3rd toe. Review of the medical record on 04/04/23, found an acute care note dated 03/02/22 stating R#17's diagnoses include recurrent deep vein thrombosis (DVT) and peripheral artery insufficiency. The left toes were noted to have a bluish discoloration and cool to touch. The resident declined further evaluation or treatment and was readmitted to the facility. A change in condition form on 01/13/23 identified the second and third toes on the left foot to be dark purple. The physician note dated 01/28/23 identifies R#17's history of chronic emboli and DVT, and notes some discoloration of the second, third and forth toes associated with some dark spots and minimal drainage. His assessment included cellulitis and gangrene. Nursing documentation includes the following related to R#17's blackened toes: --01/14/23 nurses note identifies discoloration in toes, 2nd and 3rd purple in color. --01/14/23 eMAR note states monitor left leg for any adverse changes, report to doctor any adverse changes. --01/22/23 skin check identifies necrotic toes - no additional information provided --02/02/23 skin check identifies necrotic toes - no additional information provided --03/27/23 skin check states no skin injury or wounds --03/31/23 eMAR note states visual inspection only, open and discolored areas on the bottom of the toes. --03/31/23 nurse's progress note .completed a visual inspection and noted open and discolored areas on the bottom of toes .refused hands on evaluation . --04/01/23 eMAR note states visual inspection, resident refuses hands on evaluation. Discoloration of toes. --04/02/23 eMAR note states nurse was only allowed to complete a visual inspection Noting redness and swelling with discoloration of toes. --04/04/23 skin check states no skin injury or wounds The current care plan identifies the discoloration of the left lower toes and states to monitor and report any adverse changes. On 04/04/23 at 11:28 AM, the DON acknowledged the black areas on the bottom of R#17's left toes. She agreed the record lacks visual observations which could assist with determining a change in R#17's left toes. She agreed the care plan states weekly skin assessment by a licensed nurse and these are not being done. c) Resident (R) #43 Review of the medical record on 04/11/23, revealed R#43's diagnoses include Alzheimer's disease, Dementia with agitation, anxiety, depression, and wandering. Her psychotropic medications include: --Clonazepam (benzodiazipine used to treat panic disorders) 0.5 milligrams (mg) twice a day for restlessness, agitation, repetitive chatter and cursing --Risperidone (atypical antipsychotic) 1 mg twice a day for dementia with behavioral disturbance, pacing, aggression. agitation, and repetitive behavior --Trazodone hydrochloride (antidepressant) 75 mg at bed time for depression The care plan identifies the use of psychotropic medications and includes an intervention for staff to monitor for adverse effects, but does not identify the medication side effects. On 04/11/23 at 9:45 AM, the dementia unit manager Licensed Practical Nurse (LPN) #48, stated the nurses know what side effects to look for because a list comes with the medication when it is delivered. No list was provided to the survey team. On 04/11/23 at 10:00 AM, corporate resource nurse Registered Nurse (RN) #83 confirmed the care plan lacks any information related to the side effects of R#43's psychotropic medications. In addition, there is no nursing documentation indicating staff is monitoring the resident daily for medication side effects. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice. Resident #38's antibiotics were not given as ordered, Resident #17's wound changes were not documented, Vancomycin trough levels were not drawn correctly causing a resident to miss his antibiotic and a resident was allowed to self administer a medication without a physician's order. These findings are true for one (1) of one (1) residents reviewed for wounds and one (1) of two (2) residents reviewed for infections. The remainder were random opportunities for discovery. Resident identifiers: #38, #63, #17 and #45. Facility census: 60. Findings include: a) Resident (R) #38 On 04/04/23 at 3:39 PM, a medical record review displayed the following physician order with a start date of 02/10/23, Cefdinir Capsule 300 MG Give 1 capsule by mouth two times a day for right pleural effusion for 7 Days. The Medication Administration Record (MAR), on 02/11/23 at 8:00 PM, noted the medication was not administered due to resident refusing. It is important to note that Resident #38 has been determined to be severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of three (3). There was no indication in the electronic medical record that the physician had been notified for further directives. As a result, Resident #38 only received 13 of the 14 ordered doses of the antibiotic. During an interview on 04/05/23 at 11:30 AM, the Director of Nursing reported if a patient missed a dose of an antibiotic, the standard of professional practice would be to notify the doctor and ask if he would like to continue the medication until all ordered doses were received. She then stated she would double check to determine if that had been done by the nurse on duty. On 04/05/23 at 12:10 PM, Regional Resource Nurse #81 reported there was no evidence Resident #38's physician was contacted for further directive. As a result, Resident #38 only received 13 of the 14 ordered doses of the antibiotic. b) Resident (R) #63 Review of the medical record on 04/10/23, revealed a nursing note dated 02/13/23 stating Resident self administered 30 MCG (micrograms) Avonex injection to left thigh according to directions. Resident's family brought medication from home. Per (name) DON (Director of Nursing) resident is able to administer injection for MS (Multiple Sclerosis) to herself. The physician admission orders dated 02/01/23 states the resident may not administer own medications. The medical record was reviewed with Corporate Registered Nurse (RN) #82 on 04/10/23 at 3:00 PM. RN #82 confirmed the physician order states R#63 may not administer her own medications and acknowledged the progress note states the DON gave permission for R#63 to give herself the injection. c) Resident (R) #17 A random observation on 04/03/23 at 2:52 PM, found the following on the bottom of R#17's left foot: --a black fluid filled blister on the great toe --a black necrotic area on the distal 2nd toe --a black and scabby area on the posterior middle section of the 3rd toe. Review of the medical record on 04/04/23, found an acute care note dated 03/02/22 stating R#17's diagnoses include recurrent deep vein thrombosis (DVT) and peripheral artery insufficiency. The left toes were noted to have a bluish discoloration and cool to touch. The resident declined further evaluation or treatment and was readmitted to the facility. A change in condition form on 01/13/23 identified the second and third toes on the left foot to be dark purple. The physician note dated 01/28/23 identifies R#17's history of chronic emboli and DVT, and notes some discoloration of the second, third and forth toes associated with some dark spots and minimal drainage. His assessment included cellulitis and gangrene. Nursing documentation includes the following related to R#17's blackened toes: --01/14/23 nurses note identifies discoloration in toes, 2nd and 3rd purple in color. --01/14/23 eMAR (electronic medication administration record) note states monitor left leg for any adverse changes, report to doctor any adverse changes. --01/22/23 skin check identifies necrotic toes - no additional information provided --02/02/23 skin check identifies necrotic toes - no additional information provided --03/27/23 skin check states no skin injury or wounds --03/31/23 eMAR note states visual inspection only, open and discolored areas on the bottom of the toes. --03/31/23 nurse's progress note .completed a visual inspection and noted open and discolored areas on the bottom of toes .refused hands on evaluation . --04/01/23 eMar note states visual inspection, resident refuses hands on evaluation. Discoloration of toes. --04/02/23 eMAR note states nurse was only allowed to complete a visual inspection Noting redness and swelling with discoloration of toes. --04/04/23 skin check states no skin injury or wounds On 04/04/23 at 11:28 AM, the DON acknowledged the black areas on the bottom of R#17's left toes. She agreed the record lacks visual observations that could assist with determining a change in R#17's left toes. She agreed staff should be assessing these areas daily and documenting the visual inspection since the resident refuses for staff to touch his foot. d) Resident (R) #45 Review of the medical record on 04/10/23, revealed R #45 returned to the facility on [DATE] after emergency surgery for a ruptured appendix and sepsis. Acute care discharge instructions included Vancomycin (antibiotic) 1500 milligrams (mg) intravenously every 12 hours for 21 days. Vancomycin trough (drawn one (1) hour before the next dose) levels are to be drawn weekly and sent to the infectious disease physician at the acute care center. Review of the Medication Administration Record (MAR) for April 2023 note the Vancomycin is scheduled to be given at 9:00 AM and 9:00 PM daily. According to the MAR, the Vancomycin trough levels are scheduled to be drawn on Mondays at 9:00 AM and 9:00 PM. The facility lab results note the following: --04/03/23 10:30 AM - Vancomycin trough level was drawn. Level was 17.7 (normal range is 10.0-20.0) **1.5 hours after scheduled dose --04/04/23 4:27 AM - Vancomycin trough level was drawn. The record notes the time of the last dose was 10:00 PM. The level was high at 26.5 **6.5 hours after last dose --04/06/23 1:35 PM - Vancomycin trough level was 12.7 ** 13.5 hours after last dose The MAR dated April 2023 notes R#45's did not receive his prescribed Vancomycin on 04/04/23 at 9:00 PM, 04/05/23 at 9:00 AM, or on 04/06/23 at 9:00 AM. An interview with Corporate RN #82 on 04/10/23 at 12:00 PM, confirmed Vancomycin trough levels should be drawn one (1) hour before the next dose. RN#82 agreed R#45's levels were not drawn at the correct time causing the resident to miss multiple doses of Vancomycin. .

. Based on record review and staff interview the facility failed to ensure Nurse Aides (NA) were able to demonstrate competencies on an annual basis. This was true for four (4) of five (5) nurse aides reviewed for staffing during the Long-Term Survey Process (LTCSP). Staff Identifiers: Nurse Aide (NA) #50,#35, #42, and #52. Facility census: 60. Findings included: a) Staff Competencies A facility records review revealed NA #50, NA #35, NA #42, and NA #52 did not receive their 12-month Competency review. During an interview on 04/06/23 at 2:51 PM the Corporate Administrator confirmed there were no annual competency / skills check completed for NA #50, NA #35, NA #42, and NA #52. He stated the NA evaluations were something the facility was working on getting completed. .

. Based on record review and staff interview the facility failed to complete yearly performance evaluation for all Nurse Aides (NA). This was true for five (5) of five (5) nurse aides reviewed for staffing during the Long-Term Survey Process (LTCSP). Employee Identifiers: Nurse Aide (NA) #50, #35, #42, #2, amd NA #52. Facility census: 60. Findings included: a) Facility NA's Annual Evaluations A facility records review revealed NA #50, NA #35, NA #42, NA #2, and NA #52 did not receive their 12-month evaluation. During an interview on 04/06/23 at 2:51 PM the Corporate Administrator confirmed there were no annual evaluations completed for NA #50, NA #35, NA #42, NA #2, and NA #52. He stated NA evaluations were something the facility was working on getting completed. .

. The facility failed to ensure the daily nurse staff posting was completed accurately for three (3) days throughout the long-term care survey process. This was a random opportunity for discovery and has the potential to affect all residents currently residing in the facility. Facility census: #60. Findings included: a) Nurse Staff Posting An observation on 04/03/23, 04/04/23, and 04/05/23 of the facility posted staffing data, found the required Resident census was not documented. During an interview on 04/06/23 at 10:08 AM the Administrator verified the census was not documented. She stated she would add the census now. .

. Based on observation, record review and staff interview, the facility failed to ensure prescribed medications were available to be administered as ordered and staff failed to document the administration of controlled substances in the narcotic drug count book at the time of disposition. This is true for one (1) of five (5) residents and one (1) of two (2) nurses observed during medication administration. Resident identifiers: #15, #18, and #37. Facility census: 60. Findings include: a) Resident (R) #15 A medication administration observation was conducted with Registered Nurse (RN) #76 on 04/04/23 at 9:10 AM. RN #76 reported, R#15's Dorzolamide HCL eye drops (for glaucoma) were not available for administration. A medical record review on 04/05/23 confirmed R#15 missed one of two daily prescribed doses of Dorzolamide HCL eye drops. The nurse documented the medication was not available. b) Narcotic Administration Medication observations with RN #76 on 04/04/23, revealed the following: --At 8:44 AM RN #76 administered Gabapentin 400 milligrams (mg) (a Schedule V controlled substance) to R#18 without documenting in the controlled substance usage log. --At 9:15 AM RN #76 administered Morphine Sulfate (a Schedule II narcotic) 15 mg to R#37 without documenting in the controlled substance usage log. The above findings were reviewed with RN #76 on 04/04/23 at 9:25 AM. RN #76 acknowledged not signing out the controlled medication at the time of dispensing. The Senior Nursing Home Administrator #77, agreed RN #76 should sign out the controlled medications at the time she administers them. .

. Based on record review, and staff interview, the facility failed to ensure the physician responded to monthly drug regimen reviews. This was true for four (4) of five (5) reviewed for unnecessary medications. Resident identifier #1, #51, #43 and #36. Facility census: 60. Findings included: a) Resident #1 A medical record review for Resident #1 revealed the following monthly drug regimen reviews unsigned or responded to by the physician. --09/28/22 Recommendation to initate Senna 8.2 MG two tablets once daily at bed time due to opioid analgesic use. --09/28/22 Recommendation to reevaluate the three or more Central Nervous System (CNS) depressants. --03/13/23 Recommendation clarify the as needed analgesic order to include Pain, Site, and sequence. -03/13/23 Recommendation potential drug -drug interaction -03/28/23 Recommendation to initate Senna 8.2 MG. During an interview on 04/11/23 at 11:02 AM Corporate Administrator #77 verified the physician or the DON did not sign all recommendations or follow up timely. b) Resident #51 A medical record review for Resident #51 revealed the following monthly drug regimen reviews unsigned or responded to by the physician. --04/19/22 Recommendation decrease Risperidone due to falls. --2/21/23 Recommendation attempt a gradual dose reduction of Risperidone. --3/23/23 Recommendation decrease Risperidone due to falls. During an interview on 04/11/23 at 12:37 PM the Resource Nurse #83 verified the physician or the DON did not sign all recommendations or follow up timely. c) Resident (R) #43 The facility policy titled Timeliness of Medication Regimen Review (MRR) Reports states the physician is expected to review the irregularity, document a response and sign the MRR within 30 days. If the physician does not respond within 35 days the Director of Nursing (DON) is to contact him. The DON is to contact the Medical Director and/or the Administrator if the physician fails to respond in 40 days. Review of the medical record on 04/11/23 identified the following MRR concerns: --04/19/22 the MRR request was for the physician to add an appropriate indication for the administration of the atypical antipsychotic Risperdal. The MRR form was not signed by the physician or DON. Further record review noted the Risperdal order was corrected on 06/05/22 (55 days after the recommendation). --05/03/22 the MRR recommended a decrease in Dicyclomine (antispasmodic with strong sedating properties) because of the risk of falls. The medication administration record identifies the drug was decreased ten (10) days after the recommendation was made. However, the MRR consultant report is not signed by the physician or the DON and the medical record lacks a physician response to this recommendation. --07/20/22 the MRR noted there were no annual or biannual scheduled labs on the chart for review. The form lacks physician response and signatures from the physician and DON. --12/18/22 the MRR recommended a gradual dose reduction (GDR) for Clonazepam (benzodiazepine used for panic disorders). The physician decline this recommendation on 03/16/23 (almost 3 months late). The DON signed the form on 03/16/23. --01/23/23 the MRR noted the resident receives Risperidone (atypical antipsychotic) which may cause involuntary movements including tardive dyskinesia. The pharmacist requested the facility monitor for involuntary movements now and at least every six (6) months. The last Abnormal Involuntary Movement Scale (AIMS) assessment in the chart is dated 06/21/22. The form lacks a response or signature from the physician or the DON. During an interview on 04/11/23 at 11:03 AM, the Senior Nursing Home Administrator #77, confirmed the above findings and missing records for R#43's MRR. d) Resident (R) #36 Review of the medical record on 04/11/23 identified the following MRR concerns: --04/19/22 the MRR notes R#36 receives Risperidone (atypical antipsychotic) which may cause involuntary movements including tardive dyskinesia. The pharmacist requested the facility monitor for involuntary movements now and at least every six (6) months. The AIMS assessment was completed on 09/28/22, five (5) months after the recommendation. The MRR is not signed by the physician or the DON. --05/03/22 the MRR note R#36 is due for a GDR of her Risperdal 0.5 milligrams (mg) at bedtime (antipsychotic). The physician and the DON failed to sign or respond to this recommendation. --08/24/22 the MRR recommends the physician discontinue Meloxicam (a NSAID) and initiate acetaminophen because NSAID use is associated with gastric bleeding. The pharmacist requested Omeprazole 20 mg be started daily for stomach protection if the Meloxicam cannot be discontinued. The physician accepted the recommendation and ordered Omeprazole on 10/24/22 (two (2) months later). The DON signed the form 10/24/22. --11/15/22 the pharmacist made the same recommendation as she did on the MRR dated 08/24/22. The physician accepted and signed the recommendation on 02/28/23 (105 days after the recommendation) and wrote Prilosec 20 mg daily (a medication he ordered 10/24/22). The DON signed the form on 02/28/23. --10/23/22 the MRR again recommends a GDR for the Risperdal 0.5 mg at bed time. The physician and the DON failed to sign or respond to this recommendation. During an interview on 04/11/23 at 11:03 AM, the Senior Nursing Home Administrator #77, confirmed the above findings related to R#36's MRR. .

. Based on medical record review and staff interview, the facility failed to monitor residents for side effects of psychotropic medications. This is true for three (3) of five (5) residents reviewed for unnecessary medications. Resident identifiers: #43, #36, #51. Facility census: 60. Findings include: a) Resident (R) #43 Review of the medical record on 04/11/23, revealed R#43's diagnoses included Alzheimer's disease, dementia with agitation, anxiety and wandering. Her current medications include: --Clonazepam (benzodiazepine used for panic disorders and mania) 0.5 milligrams (mg) twice a day for restlessness, agitation, repetitive chatter and cursing --Risperidone (atypical antipsychotic) 1 mg twice a day for dementia with behavioral disturbance pacing, aggression, agitation, and repetitive chatter --Trazodone hydrochloride (antidepressant) 75 mg at bedtime for depression The pharmacist's monthly medication regimen review (MMR) dated 01/23/23, notes R#43 receives Risperdal which may cause involuntary movements including tardive dyskinesia. An Abnormal Involuntary Movement Scale (AIMS) assessment is not documented in the previous six (6) months. Please monitor for involuntary movements now and at least every six months per facility policy. The medical record notes the last AIMS test was completed on 06/21/22. **An AIMS assessment was not completed per the pharmacist's recommendation. The medical record is silent for information indicating staff is monitoring the resident daily for side effects of the psychotropic medications. On 04/11/23 at 9:20 AM, the Senior Nursing Home Administrator #77, confirmed the last AIMS assessment was completed on 06/21/22. On 04/11/23 at 9:45 AM, the dementia unit manager Licensed Practical Nurse (LPN) #48, stated the nurses know what side effects to look for because a list comes with the medication when it is delivered. No list was provided to the survey team. On 04/11/23 at 10:00 AM, corporate resource nurse Registered Nurse (RN) #83 confirmed there is no nursing documentation indicating staff is monitoring the resident daily for medication side effects. b) Resident (R) #36 Review of the medical record on 04/11/23 revealed R#36's diagnoses include non-Alzheimer's dementia, alcohol induced persistent dementia, alcohol induced psychotic disorder with delusions, restlessness and agitation, wandering and anxiety. Her current medications included the following psychotropic meds: --Depakote (treats manic depression disorders) 250 milligrams (mg) three (3) times a day for alcohol induced dementia as evidenced by verbal and physical aggression --Duloxetine hydrochloride (antidepressant) 30 mg once a day for depression --Mirtazapine (antidepressant) 7.5 mg at bed time for appetite stimulation --Risperdal (atypical antipsychotic) 0.5 mg at bed time for impulsive, combative, pacing and restless behaviors --Trazodone hydrochloride (antidepressant) 25 mg at bedtime for depression The pharmacist's monthly medication regimen review (MMR) dated 04/19/22, notes R#36 receives Risperdal which may cause involuntary movements including tardive dyskinesia. An Abnormal Involuntary Movement Scale (AIMS) assessment is not documented in the previous six (6) months. Please monitor for involuntary movements now and at least every six months per facility policy. The medical record notes and AIMS assessment was completed on 09/28/22, five months after being requested. The previous evaluation was 08/10/21. **AIMS assessments are not being completed every six months. In addition, the records lack any information indicating staff are monitoring the resident daily for side effects of the psychotropic medications. On 04/11/23 at 9:45 AM, the dementia unit manager Licensed Practical Nurse (LPN) #48, stated the nurses know what side effects to look for because a list comes with the medication when it is delivered. No list was provided to the survey team. On 04/11/23 at 10:00 AM, corporate resource nurse Registered Nurse (RN) #83 confirmed there is no nursing documentation indicating staff is monitoring the resident daily for medication side effects. c) Resident #51 A medical record review for Resident #51 revealed monthly drug regimen reviews unsigned or responded to by the physician. --04/19/22 Recommendation decrease Risperidone due to falls. --2/21/23 Recommendation attempt a gradual dose reduction of Risperidone. --3/23/23 Recommendation decrease Risperidone due to falls. During an interview on 04/11/23 at 12:37 PM the Resource Nurse #83 confirmand the Drug Regimen Review recommendation for a gradual dose reduction was not responded to or not followed for a psychotropic medication. .

. Based on observation and staff interview, the facility failed to provide food services in accordance with professional standards. The facility failed to ensure food was labeled and dated, domed lids were visibly stained / whitened with what the Food Service Director identified as lime / calcium buildup, a ceiling vent was covered in dust, and various repairs were needed. This practice had the potential to affect more than a limited number of residents. Facility census: 60. Findings included: a) Tour of the Kitchen and the Nourishment Room on the Blue Hall. During an initial tour of the kitchen on 04/03/23 at 10:10 AM with the Food Service Director, the following issues were identified: -There were two (2) two-pound clear bags of what was identified as [NAME] Crispy cereal that was unlabeled. There was also a third bag of what was identified as [NAME] Crispy cereal that was unlabeled and with approximately 1/4 of the bag remaining. The Food Service Director acknowledged the dietary staff failed to follow protocol when they did not label the food. -One (1) of four (4) ceiling vents was covered in dust. The dust extended around the vent / fan and was visible upon entrance to the kitchen. The Food Service Director stated he has put an order in for the maintenance staff to clean the vents and that his staff are prohibited from doing so themselves. -The domed lids were visibly stained / whitened with what the Food Service Director identified as lime / calcium buildup. The Food Service Director stated the facility has hard water and has been unsuccessful with its attempts to resolve the issue using Lime-A-Way. Observation on 04/03/23 at 10:35 PM, found one (1) undated quart container of Nectar Thick liquid in the Blue Hall fridge close to the nurses station. The Food Service Director discarded the container stating he had no way of determining when it was opened and if it was still good. The Food Service Director confirmed the expectation would be that all items would be labeled and dated per facility protocol. During a second tour of the kitchen on 04/04/23 at 2:10 PM, with the Food Service Director #21, the following issues were identified: -There was a section of the wall under the table located by the handwashing sink where approximately a 4' section of the base trim was detached from the wall. -There was an approximate 7 x 11 section of the wall under the dish machine missing plaster by the pipes. -There was one (1) broken / damaged tile in front of the stove. The Food Service Director #21 confirmed all the above-mentioned issues needed to be addressed. .

. Based on record review and staff interview, the facility failed to ensure the Medical Director attended quarterly Quality Assurance and Performance Improvement Committee Meetings (QAPI). This has the potential to affect more than a limited number of residents currently residing in the facility. Facility census: 60. Findings included: a) QAPI meetings A facility record review on 04/05/23 at 10:21 AM of QAPI committee meeting sign-in sheet revealed the Medical Director did not attend any meetings from 06/2022 until 03/28/23. During an Interview on 04/05/23 at 10:41 AM the Administrator verified the Medical Director did not attend quarterly QAPI meetings as required. .

. Based on observation, staff interview and policy review, the facility failed to establish and maintain an effective infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections. Staff failed to perform adequate hand hygiene and used their thumb nail to open pill blisters during medication pass. Gloves were not changed timely during wound care. Bed pans were not covered and labeled. A food cart was in disrepair and a resident consumed the remainder of another resident's lunch. This is true for one (1) of two (2) nurses observed during medication administration, one (1) of one (1) observed for wound care and one (1) of three (3) food carts. The remainder were random opportunities for discovery. Resident identifier: #18, #15, #35, #23, and #11. Facility census: 60. Findings include: a) Resident #35 On 04/03/23 at 12:04 PM, Resident #35 finished eating his meal and stood up in the dining room. He walked over to the sink and washed his hands. When finished, he sat back down at a different table. He sat in Resident #114's empty seat where approximately 25% of the meal was remaining. At 12:12 PM, 11 residents were in the dining room eating. Nursing Assistant (NA) #34 was the only staff in the dining room and was feeding one resident at a table while encouraging a third resident, at the same table to eat by providing verbal cues. NA #34 did not notice when Resident #35 began eating from the other resident's plate at a different table. At 12: 20 PM, NA #34 identified Resident #35 sitting at a different table and eating from Resident #114's plate. NA #34 redirected Resident #35 and assisted him back to his table. At 12:25 PM, NA #34 stated, Now I can't confirm how much she [Resident #114] ate because he [Resident #35] pretty much cleaned her plate. NA #34 acknowledged that even though both residents were on a regular diet and Resident #35 did not have any allergies, it was not desirable to have Resident #35 eat from someone else's plate using the other resident's utensils. b) Medication administration 1. Hand Hygiene Policy The facility hand hygiene policy with a revision date of 11/15/22, states staff should apply soap and rub hands vigorously for 20 seconds when washing hands. 2. Observations During observations of medication administration on 04/04/23, Registered Nurse (RN) #76 utilized her thumb nail to pop open pill blisters on medication cards for resident's #18 and #15, before dropping the pills into the medication cup and administering them to the residents. In addition, she washed her hands for ten seconds, based on the wall clock in R#15's room. On 04/04/23 at 9:25 AM, RN #76 reported the hand washing policy was to wash your hands for 30 seconds. She acknowledged she did not know she only washed her hands for ten seconds. On 04/04/23 at 9:35 AM, the Senior Nursing Home Administrator (SNHA) #77, presented the facility hand washing policy and agreed staff are to wash their hands for a minimum of 20 seconds. The Director of Nursing (DON) reported opening pill blisters with a thumb nail is a contamination risk, during an interview on 04/05/23 at 9:00 AM. c) Resident (R) #23's wound care An observation of wound care was completed on 04/04/23 at 3:35 PM with RN #76 and RN #80. RN #76 removed the soiled dressing from R#23's coccyx and cleaned the area with wound cleaner and four by four gauze. Without changing gloves she applied calcium alginate to the wound bed. RN #76 removed her soiled gloves, sanitized her hands, applied clean gloves, and applied the outer mepiplex dressing to R#23's coccyx. During an interview immediately after this observation, RN#76 acknowledged she forgot to change her gloves after removing the soiled dressing. d) Bed pan storage On 04/03/23 at 1:53 PM, an uncovered and unlabeled bed pan was found hanging in the pipe frame in the shared bathroom of R#11. The facility administrator agreed the bed pan should be covered and labeled, for safe sanitary storage. e) B hall Food cart handles During an observation of the noon meal on 04/03/23, the handles on the food cart on B hall were found in disrepair. The rubber covering on both handles was cracked and missing in sections. The cart was dirty and crusty around the handles. The New Administrator #63 confirmed these findings during an interview 04/04/23 at 7:45 AM and acknowledged the handles needed replaced and the cart cleaned. .

. a) Resident #19 On 03/23/22 at 10:20 AM, observation revealed the resident lying on the bed mattress without any sheets. Resident #19 stated, they came in about 45 minutes ago and ripped the sheets off and left, they didn't even want to leave me a blanket. On 03/23/22 at 10:25 AM, nurse aide #24 said there are no clean fitted sheets in laundry to make up the bed. On 3/23/22 at 10:35 AM, the Assistant Director of Nursing (ADON) observed Resident #19 in bed with no sheets on the bed. The ADON stated, she will try and find at least a flat sheet to put on the bed. ADON #24 said, the laundry department is ordering more sheets for the facility due to being short. Based on observation and staff interview, the facility failed to provide clean bed linens in good condition. There were no clean bed linens available for Resident #19's bed. Resident identifier: #19. Facility census: 61. Findings included: .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services to promote healing of a pressure ulcer. Pressure ulcer assessments were not documented and treatments were not completed as ordered. This is true for one (1) of one (1) resident reviewed for pressure ulcers. Resident identifier: #17. Facility census: 61. Findings included: a) Resident (R) #17 Review of the medical record found, R #17 returned from the acute care center on 03/09/22. The nursing progress note dated 03/09/22 states R #17 has a stage 3 pressure ulcer to her sacrum, a stage 2 pressure ulcer to both buttocks, and an unstageable pressure ulcer on the right heel. The wound tracking note provided by facility staff is dated 03/09/22 and identifies one (1) pressure ulcer on R #17's sacrum measuring 2.5 centimeters (cm) long, 3.25 cm wide, 1.25 cm deep. The wound was noted to have a light serous drainage with macerated edges. **The medical record and wound tracking record lack any other measurements or assessments of R #17's pressure ulcers. The current physician orders include treatments for an unstageable pressure ulcer to the sacrum, a Stage 2 pressure ulcer to the left buttocks, and a closed unstageable pressure ulcer to the right heel. Review of the Treatment Assessment Record (TAR) for March 2022 found the following: --An unstageable pressure ulcer to the sacrum to be cleaned and treated every day shift on Monday, Wednesday and Friday. The treatment was not signed off on Friday 3/18/22 and Monday 3/21/22. --Treatment for a stage 2 pressure ulcer to the left buttocks to be completed daily. Treatments were not completed on 03/17/22, 03/18/22, and 03/21/22. --An unstageable pressure ulcer to the right heel to be cleaned and treated every day shift on Monday, Wednesday and Friday. Treatments were not completed on 03/21/22. During an interview on 03/22/22 at 2:30 PM, Licensed Practical Nurse (LPN) #7 reviewed the computerized record and confirmed the medical record states R #17 returned to the facility on [DATE] with a Stage 3 pressure ulcer on her sacrum, Stage 2 pressure ulcers on both buttocks and an unstageable pressure ulcer on the right heel. LPN #7 reviewed the wound tracking program and confirmed there is only one assessment for R #17's unstageable sacral pressure ulcer dated 03/09/22 and no assessments for the other pressure ulcers noted in the admission note. In addition, LPN #7 acknowledged R #17 wounds are not always treated on day shift as ordered. .

. Based on observation, record review, and staff interview, the facility failed to ensure the facility was free from accident hazards. A harmful cleaning product was found unattended in the shower room and a treatment cart on the B-Hall was unlocked. This was a random opportunity for discovery. Facility census: 61. Findings included: a) Observation of shower room On 3/21/22 at 12:50 PM, observation of the shower room found a large plastic canister half full of a liquid product with an attached spray hose. The liquid in the canister was identified as, Triad II Disinfectant Cleaner. On 3/21/22 at 12:55 PM, nurse aide (NA) #15 confirmed the canister should not be in the shower room unattended, and there is no lock on the shower room door. On 3/21/22 at 1 PM, the Administrator observed the shower room and stated, the cleaner should not be in the shower room it should be locked up with housekeeping since it is a disinfectant cleaner. The Administrator also stated it is housekeeping's responsibility to store any cleaning products after use. Cleaning products should never be left unattended. On 3/21/22 at 2 PM, the Administrator provided a copy of Material Safety Data Sheet for Triad II Disinfectant Cleaner. Emergency Overview from Material Safety Data Sheet states, Danger, Corrosive, Causes Skin and Eye Burns. Harmful or Fatal if Swallowed. b) Treatment Cart An observation, on 03/21/22 at 12:40 PM, found the facility's treatment cart unlocked and unattended on the B-Hall. No nursing staff were in sight. During an interview on 03/21/22 at 12:48 PM, the Administrator remarked that the treatment cart should always be locked when unattended. The Administrator then requested another staff member find LPN # 7 and request she come to lock the cart. .

. c) Resident #1 On 03/22/22 at 10:00 AM, an electronic medical record review was completed. A monthly medication review was completed by the consulting pharmacist on 12/24/21. The pharmacist's report revealed Resident #1 had recently experienced a fall, on 12/11/22, while attempting to toilet self in the middle of the night. The consulting pharmacist completed a comprehensive review of the medical record and identified the following medications which may contribute to falls: -Depakote 250 mg at 09:00 AM. -Risperidone 0.25 mg BID. -Citalopram 10 mg daily. The consulting pharmacist made the following recommendation: Please evaluate these medications as possibly causing or contributing to this fall and review the Depakote/Risperdal for effectiveness and discontinue one of the orders, maximizing the other. Additionally, the consulting pharmacist documented, If this therapy is to continue, it is recommended that a) the prescriber document an assessment of risk versus benefit, indicating that the medication is not believed to be contributing to falls in this individual; and b) the facility interdisciplinary team ensures ongoing monitoring for effectiveness and potential adverse consequences. During an interview on 03/22/22 at 3:31 PM, the Assistant Director of Nursing (ADON) stated the facility could not produce any evidence the physician had reviewed and what, if any, action had been taken to address it. If the attending physician desired no change in the medication, the physician did not document a rationale in the resident's medical record. Based on policy review, record review, and staff interview, the facility failed to ensure monthly pharmacy medication recommendations were reviewed by the physician and acted upon timely. This is true for two (2) of five (5) residents reviewed for unnecessary medications. Resident identifiers: R#58 and #1. Facility census: 61. Findings included: a) Policy The facility policy titled, 9.1 Medication Regimen Review, dated 11/28/16, states the pharmacy must review the medical record at least once a month. Facility staff should ensure copies of the medication regimen review (MMR) are given to the physician, medical director, and Director of Nursing (DON) and the Physician/Prescriber and the DON act upon the recommendations in a timely manner. b) Resident (R) # 58 Review of the electronic medical record on 03/22/22, found progress notes stating the pharmacist made recommendations for the physician during the monthly drug regimen review (DRR) on 03/17/22 and 02/13/22. The medical record does not identify what the recommendations are or a response from the physician or DON. During an interview on 03/22/22 at 11:30 AM, the Assistant Director of Nursing reported she could not find the DRR's dated 03/17/22 and 02/13/22 for R #58. At 1:40 PM, an unsigned copy of the DRR for 02/13/22 was presented to the survey team. The DRR is not signed by the physician and lacks any information indicating the physician reviewed and accepted or declined the recommendation. .

. Based on record review and staff interview, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs. This was true for one (1) of five (5) residents reviewed for unnecessary drugs during the long-term care survey process. Resident identifier: #1. Facility census: 61. Findings included: a) Resident #1 On 03/22/22 at 10:00 AM, an electronic medical record review was completed. A monthly medication review was completed by the consulting pharmacist on 12/24/21. The pharmacist's report revealed Resident #1 had recently experienced a fall, on 12/11/22, while attempting to toilet self in the middle of the night. The consulting pharmacist completed a comprehensive review of the medical record and identified the following medications which may contribute to falls: -Depakote 250 mg at 09:00 AM. -Risperidone 0.25 mg BID. -Citalopram 10 mg daily. The consulting pharmacist made the following request: Please evaluate these medications as possibly causing or contributing to this fall and review the Depakote/Risperdal for effectiveness and discontinue one of the orders, maximizing the other. Additionally, the consulting pharmacist recommended the physician consider: -Depakote increased to 250 mg AM and 500 mg HS or changing to Keppra 500 BID if he has convulsions while reducing the Risperdal to 0.25 mg HS x 2 weeks - - OR - - -Risperidone to 0.5 mg HS and reviewing the Depakote for discontinuation - - OR - - -Changing the Risperidone to quetiapine 50 mg BID and discontinuing Depakote -Would adding buspirone 10 mg BID for anxiety and/or acetaminophen 650 mg BID for arthritis help? The consulting pharmacist also added, If this therapy is to continue, it is recommended that a) the prescriber document an assessment of risk versus benefit, indicating that the medication is not believed to be contributing to falls in this individual; and b) the facility interdisciplinary team ensures ongoing monitoring for effectiveness and potential adverse consequences. During an interview on 03/22/22 at 3:31 PM, the Assistant Director of Nursing (ADON) stated the facility could not produce any evidence the physician had reviewed and what, if any, action had been taken to address it. If the attending physician desired no change in the medication, the physician did not document a rationale in the resident's medical record. .

. Based on facility documentation, policy review and staff interview, the facility failed to provide documentation that testing was completed and the results of each staff test for one (1) of eight (8) staff members reviewed for compliance with staff COVID -19 testing. Facility Census: 61. Findings Included: a) Staff Covid-19 testing and surveillance Record review of the facility's policy titled, COVID-19, Review date 11/15/21, showed: --Patients, facility staff, and visitors will be tested according to CMS and State Department of Health requirements and Genesis guidance. --COVID-19 testing results will be documented. Facility documentation review of the facility's infection control practices found the facility was unable to provide the required staff COVID-19 documentation for testing for Licensed Practical Nurse (LPN) # 88. Continued review of facility documentation found, LPN #88's first shift worked at the facility was 02/14/22. Subsequent review revealed, there has been confirmed COVID-19 cases over the last four (4) weeks in the facility. On 03/23/22 at 10:45 AM during an Interview the Administrator stated there is no documentation or evidence for COVID-19 testing in the facility system for LPN #88. The Administrator verified they should have the documentation of Covid -19 testing and results for LPN #88. No other information was provided prior to the end of survey on 03/23/22 at 5:15 PM. .

. Based on facility documentation, policy review and staff interview, the facility failed to maintain documentation related to current staff COVID-19 vaccination for one (1) of eight (8) staff members reviewed for compliance with Covid -19 vaccinations. Facility Census: 61. Findings included: a) Staff COVID-19 Vaccination Record review of the facility's policy titled, COVID-19 Vaccination, dated 08/02/21, showed: --The first dose of the vaccine must be obtained by August 23, 2021 or upon hire, or per state or local guidelines. In a two-dose series, the second dose must be obtained within 30 days of the first dose. --All personnel will be fully vaccinated against COVID-19 and obtain any necessary booster immunizations when, and if, the boosters are required and/or are necessary. --Proof of COVID-19 vaccinations will be maintained in the employee's confidential medical file. Facility documentation review of the facility's Infection control practices found the facility was unable to provide the required staff Covid-19 documentation for completed vaccination in a two-dose series for Recreation Aide #62 and Nurse Aide #46. Continued review of facility documentation found, Recreation Aide #62's first of Moderna was administered 01/19/22, No second dose was administered. Nurse Aide #46's first dose of Moderna was administered 12/10/21 with no second dose documented. During an interview on 03/23/22 at 12:06 PM the Corporate Representative #71 stated that Recreation Aide #62's and Nurse Aide #46 were only partial vaccinated, and they missed their second dose of the two-dose series. Corporate Representative #71 verified; they should have had their second vaccine within 30 days after their first dose. During an interview on 03/23/22 at 2:10 PM the Assistant Director of Nursing (ADON) stated that Nurse Aide #46 did receive her second dose of Moderna, but it was not documented. No other information was provided prior to the end of survey on 03/23/22 at 5:15 PM. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure three (3) of 18 residents reviewed during the long-term care survey process had advance directives completed as recognized by State Law. Residents #261 and #262 had incomplete Physician Orders for Scope of Treatment (POST) forms. Additionally, the facility failed to update Resident #25's POST form to reflect a different code status. Resident identifiers: #261, #262, and #25. Facility Census: 61. Findings included: a) Resident #261 A medical record review, completed on [DATE] at 2:27 PM, found the following: - Court Appointed Guardianship paperwork indicating Resident #261's family member was her legal decision-maker. - POST form, dated [DATE], 2021 edition. Section E of the POST form indicated that verbal consent was accepted by Resident #261's legal guardian but was witnessed by only one (1) staff member. The directions for completed the POST form indicate if the legal representative is unavailable at the time of form completion, this section can be signed by two (2) witnesses for verbal confirmation of agreement from the patient's representative. Section F of the POST form was signed by the Physician. However, the physician's printed name, phone number, and license number sections were not completed. The Using the POST Form Guidance for Healthcare Professionals, 2021 Edition directs the health care provider completing this form (MD, DO, APRN, or PA) must print their name, sign, and date this section for the form to be legally valid. Failure to print their name or provide a license number may result in the WV e-Directive Registry being unable to verify the provider's information, thus preventing the form from being available through the Registry. Failure to provide a contact number may result in the inability to contact the provider regarding any errors in the form completion that need to be addressed. During an interview on [DATE] at 8:46 AM, the Administrator acknowledged the standard for any verbal consent was for two (2) witnesses. The Administrator also acknowledged Section F was not completed as per professional standards. b) Resident #262 A medical record review, completed on [DATE] at 2:41 PM, found the following: - POST form, 2021 edition. The POST form indicated that Resident #262 did not desire CPR (cardiopulmonary resuscitation) and wanted no artificial means of nutrition. The POST form was signed by the physician but lacked a signature from Resident #262 / or their legal representative. The directions for completing the POST form state the signature section provides a declaration on behalf of the patient (or incapacitated patient's Medical Power of Attorney (MPOA) representative or health care surrogate) related to their voluntary participation in the completion of the POST form and agreement with the orders on the form. The patient (or incapacitated patient's MPOA representative or health care surrogate) must sign and date this section for the form to be legally valid. During an interview on [DATE] at 8:45 AM, the Administrator reported it was her belief the staff should have documented verbal consent with two (2) witnesses until Resident #262's legal representative could sign the POST form. c) Resident #25 A review of Resident #25's medical record showed a Physician Order for Scope of Treatment (POST) form dated [DATE] that stated, Yes CPR: Attempt Resuscitation, including mechanical ventilation, defibrillation and cardioversion. The care plan stated, CPR, full treatment. A physician order dated [DATE] stated, Do not Resuscitate (DNR). During an interview on [DATE] at 2:45 PM, Registered Nurse (RN) #1 stated that Resident # 25 was confirmed to be a DNR and the POST form was being updated now. .

. c) Resident #29 On 03/22/22 at 12:28 PM, a medical record review and review of the facility's reportables were reviewed. Resident #29 experienced a fall on 03/09/22 after being noncompliant with the use of a wheeled walker. The fall was reported to appropriate state agencies and the five (5) day follow up report noted the hospital could not conclusively determine if Resident #29 had facial fractures. Resident #29 experienced a fall on 03/14/22 from the wheelchair to the floor. The fall was reported to appropriate state agencies and the five (5) day follow up report noted Resident #29 had been transported to the hospital where they could not confirm if resident had facial fractures. The five (5) day follow up was faxed to appropriate state agencies on 03/18/22. On 03/14/22 at 6:14 PM, LPN #35 documented Resident #29 returned from the emergency room and had been diagnosed with a nasal fracture (from previous fall). The hospital discharge report included the findings of a CT (computer tomography) Scan of Facial bones. A CT scan combines a series of X-ray images taken from different angles around the body and uses computer processing to create cross-sectional images of the bones, blood vessels and soft tissues inside the body. CT scan images provide more-detailed information than plain X-rays do. The findings of Resident #29's CT scan included, There is again demonstrated a nasal fracture of questionable chronicity, unchanged however from 03/09/22. During an interview on 03/22/22 at 1:29 PM, Social Worker #34 was questioned as to why the identified nasal fracture was not identified as a major injury and reported within two (2) hours of the facility having knowledge of the fracture nor was it mentioned in the five (5) day follow-up of the original report. Social Worker #34 reported she was filling in for the Administrator when the reports were made, and she had not known it should have been reported as a major injury. Social Worker #34 did not recall a nasal fracture being confirmed by the emergency room and said that it must have been an oversight. Based on facility documentation, record review, and staff interview the facility failed to report an allegation of abuse. The facility failed to report a serious bodily injury to the proper State authorities. In addition, the facility failed to report a second serious bodily injury to the appropriate agencies in a timely manner. The failed practice was true for three (3) of five (5) residents reviewed for falls. Resident identifiers: #46, #161, and #46. Facility census: 61. Findings included: a) Resident #46 During a confidential interview a Resident stated that a Nurse Aide (NA) was heard yelling at Resident #46 during a night over the weekend and slammed Resident #46's door. The Resident would not disclose the name of the NA and stated it was not in Confidential Resident's best interest to disclose NA name for fear of retaliation. During a second confidential interview a Resident stated that a Nurse Aide (NA) had yelled in the middle of the night at Resident #46. The Confidential Resident stated the yelling and door slam noises woke this Resident. The confidential Resident would not disclose the name of the NA and stated would not disclose the name due to the fear of repercussion. During an interview on 03/22/22 at 1:45 PM, Resident #46 was interviewed by two (2) members of the survey team about the concerns and accusations of verbal abuse as disclosed by other concerned residents in the facility. Resident #46 stated, Yes, night time NA had yelled at him. Resident #46 stated that he was talking loudly to roommate who was halfway falling out of bed because roommate was hard of hearing and cannot hear Resident #46 unless he talks really loud. Resident #46 stated that next thing that occurred was the nighttime NA came into room and yelled at Resident #46 stating, be quiet, quit deviling your roommate. Resident #46 stated that anytime something happens with roommate or roommate began to yell the NA would always yell at Resident #46 as it was always his fault. Resident #46 stated that he got yelled at a lot so he has kind of gotten use to it now so he did not think about reporting it to anyone that night. Resident #46 stated that a lot of the times staff will just pull the call light out the wall so he cannot call for help if needed. Resident #46 stated that if staff do not pull the call light out of the wall, then they throw the call light on the floor out if his reach. Resident #46 stated for example he had not been feeling well and a little weak today so he used the call light and asked for assistance to the bathroom. Resident #46 stated the nurse screamed at him and said, No I am not helping you. Resident #46 stated that the Nurse told him there was nothing wrong with him so get up and walk. During an interview on 03/22/22 at 2:04 PM, the Administrator was notified of an abuse allegation related to Resident #46. The Administrator was informed of the allegation details that a NA yelled at Resident #46 all the time and how Resident #46 had been told problems were always his fault. The Administrator was informed Resident #46 had asked for help to go to the bathroom today and the Resident disclosed the Nurse scolded him and said, There is nothing wrong you, get up and walk. Informed Administrator that Resident #46 stated he had the ability to go to the bathroom most days independently, but was not feeling well today. The Administrator stated that Resident #46 had a lot of behaviors and when he gets a new roommate he tends to act out. The Administrator continued to be informed that Resident #46 stated that he only talks loud to roommate because roommate was hard of hearing. Resident #46 stated the roommate cannot hear when Resident #46 talks to roommate unless he talks loudly. Resident #46 did confirm a NA yelled at him one night for taking loudly to his roommate. The Administrator was also informed Resident #46 disclosed staff had been known to take Resident #46's call bell and unplugged it or even throw it on the floor or out of reach of Resident #46. The Administrator stated that she personally had answered Resident #46's call bell several times today. The Administrator stated an interview will be conducted with Resident #46 and staff interviews will be completed. A review of the facility's documentation on 03/23/22 at 10:00 AM, showed a Grievance/Concern form was completed on 03/22/22 for the allegation of abuse for Resident #46. The Grievance/Concern form dated 03/22/22 also had a resolved date of 03/22/22. A corresponding written statement by administrator showed a face to face interview with Resident #46 and the Administrator occurred on 03/22/22. The written statement read Resident #46 was understanding that staff are trying to keep him at a level of independence. The record showed Resident #46 again stated the need of assistance with getting up out of bed to get to the restroom. The record showed Licensed Practical Nurse (LPN) #7 was informed Resident #46 needed assistance with getting up out of bed to go to the restroom only. LPN #7 was asked to pass the information that Resident #46 needed assistance with getting up from bed to the walker to other staff. The Grievance/Concern form was marked the concern was not a civil rights issue, the concern of abuse was not confirmed, and the concern was resolved based on a face to face interview with Resident #46 and Administrator. During a confidential interview a Resident identified the NA who yelled at Resident #46 as NA #17. The confidential Resident stated that NA #17 was loud and had also yelled at this resident in the past. During an additional confidential interview a Resident stated that NA #17 can be mean and was the NA who yelled at Resident #46 over the weekend. This confidential Resident stated to please not identify this Resident's identity for fear of being kicked out of the facility and the fear of being in trouble with NA #17, especially if NA #17 found out the confidential Resident told. During an interview on 03/23/22 at 1:10 PM, with the Administrator and Corporate Representative (CR) #2 was notified of the abuse allegation related to Resident #46. The Administrator was notified of the allegation of abuse originally on 03/22/22 at 2:04 PM with no reportable completed. Administrator and CR #2 was informed of the identity of the alleged perpetrator NA #17 and the alleged abuse information identified in the confidential interviews. CR #2 stated that a reportable will be completed and the abuse allegation will be acted upon immediately. Administrator stated NA #17 will be suspended upon investigation. b) Resident #161 A review of Resident #161's medical record showed a change of condition dated 01/31/22 that stated Resident #161 had a fall. A transform form dated 01/31/22 showed Resident #46 was transferred to the hospital. A progress note dated 02/01/22 stated,Called (name of hospital) for update. Nurse stated Resident #161 is in observation unit awaiting Ortho for consult for surgery due to right hip fracture. A review of facility documentation showed a reportable to Adult Protective Services (APS) dated 02/01/22. The fax result confirmation page to the Office of Health Facility Licensure and Certification (OHFLAC), Ombudsman and APS showed an ok confirmation date of 02/03/22. During an interview on 03/23/22 at 4:45 PM, Administrator stated that two (2) days after a fall with major injury (FMI) was too late to report to appropriate state agencies. .

. c) Resident #261 Observation, on 03/21/22 at 11:45 AM, found Resident #261 was wearing oxygen. There was no date on the oxygen tubing and the oxygen humidifier bottle was dated 03/13/22. A record review, completed on 03/21/22 at 3:15 PM, revealed an order for oxygen tubing to be changed on every Sunday and the directive to label each component with date and initials. During an interview on 03/22/22 at 9:15 AM, RN #1 verified the oxygen humidifier was dated 03/13/22, the sterile storage bag attached to the oxygen concentrator was also dated 03/13/22, and that the oxygen tubing did not have any date or initials. RN #1 confirmed the physician order was not followed and that all components should reflect a date of 03/20/22. Based on observation, record review and staff interview, the facility failed to label, date, and store oxygen tubing in accordance to professional standards for the care for oxygen administration. These were random opportunities for discovery. Resident identifiers: #25, #29 and #261. Facility census: 61. Findings included: Record review of the facility's policy titled Oxygen: Nasal Cannula, revised on 06/01/21, showed replace disposable set-up every seven days. Date and store in treatment bag when not in use. a) Resident #25 An observation on 03/21/22 at 1:25 PM, showed Resident #25's oxygen nasal cannula and tubing laying on the floor beside bed. During an interview on 03/21/22 at 1:25 PM, Registered Nurse (RN) #5 stated that the tubing and nasal cannula would be changed and should not be stored on the floor. RN #5 stated the facility ran out of the clear storage plastic bags to store oxygen supplies but the facility was supposed to be ordering some. b) Resident #59 An observation on 03/21/22 at 11:15 AM, showed Resident #59's oxygen tubing was not labeled or dated. A review of Resident #59's medical record showed a physician order dated 03/01/22 stated, Oxygen tubing change weekly. Label each component with date and initials. An observation on 03/22/22 at 3:30 PM, showed Resident #39's oxygen tubing was not labeled or dated. During an interview on 03/22/22 at 3:35 PM, the Assistant Director of Nursing (ADON) confirmed there was no label or date on the oxygen tubing and there should have been. .

. e) 1:12 Ratio on Nights for Nurse Aides The facility assessment, dated 02/16/22, stated that based on the facility resident population and their needs for care and support, the facility would utilize the following staffing plan for direct care Nurse Aides (NAs) to ensure they had sufficient staff to meet the needs of residents at any given time: 7:00 AM - 3:00 PM - 1:7.5 Ratio on Days 3:00 PM - 11:00 PM - 1:7.5 Ratio on Evenings 11:00 PM - 7:00 AM - 1:12 Ratio on Nights A review of the Daily Time Detail Report for ten random days was completed on 03/22/22 at 2:40 PM. The Nurse Aide ratio of 1:12 on nights was not met on the following four (4) dates: -01/01/22 The facility census on 01/01/22 was 55 residents. On the 11:00 PM - 7:00 AM shift the facility had three (3) NAs working. This was a 1:18 ratio. -01/02/22 The facility census on 01/02/22 was 55 residents. On the 11:00 PM - 7:00 AM shift the facility had three (3) NAs working. This was a 1:18 ratio. -02/12/22 The facility census on 02/12/22 was 58 residents. On the 11:00 PM - 7:00 AM shift the facility had two (2) NAs working. This was a 1:29 ratio. -02/13/22 The facility census on 02/13/22 was 57 residents. On the 11:00 - PM - 7:00 AM shift the facility had four (4) NAs working. This was a 1:14.25 ratio. Based on observations, staff interviews, and record review, the facility failed to provide sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. This practice has the potential to affect more than a limited number of residents. Facility census: 61. Findings included: a) Observation of Staffing Observations of staffing on 03/21/22 and 03/22/22 identified one (1) Licensed Practical Nurse (LPN) and two (2) nursing assistants (NA) covering the blue hall with 33 residents. Lunch observations on 03/21/22 found LPN #7 in the dining room with four (4) of the 33 residents and the two (2) nursing assistants on the Blue Hall to pass trays, answer call lights and feed four (4) residents (R #13, R #33, R #17 and R #35). Residents #35 and #17's food trays were on the meal cart for greater than 30 minutes and had to be remade before staff could feed the residents. b) The facility assignment sheets dated 03/21/22 and 03/22/22 6:00 AM-6:00 PM verifies the Blue Hall was staffed with one (1) LPN and 2 (two) NAs. c) Review of the medical records on 03/23/22 found 24 of the 30 residents residing on the Blue Hall required total to extensive assist with activities of daily living (ADL) and four (4) of the 30 require full assistance with eating. --R #20 assistance of 1 (one) - 2 (two) staff with ADLs and eats independently --R #15 extensive assistance of 2 (two) staff and supervision with meals --R #12 extensive assistance of 2 (two) staff with most ADLs and supervision with meals --R #13 total to extensive assist of 2 (two) staff with ADLs, and full assistance with meals --R #2 extensive assistance of 2 (two) staff and supervision with meals --R #19 extensive assist with ADLs and eats independently --R #34 total to extensive assist of two (2) staff with ADLs and eats independently --R #30 extensive assist of two (2) with ADLS and supervision with meals --R #55 extensive assist of two (2) with ADLs and supervision with meals --R #43 limited to extensive assist of one (1) with most ADLs and supervision with meals --R #5 extensive assist of two (2) for all ADLS eats independently --R #45 extensive assist of two (2) with ADLs and supervision with meals --R #14 extensive assistance of two (2) with ADLs and supervision with meals --R #11 extensive assistance of two (2) with ADLs and supervision with meals --R #33 extensive assistance of two (2) with ADLs and full assistance with meals --R #51 extensive assistance of one (1) to two (2) staff with ADLs and assistance with meals --R #17 extensive assistance with all ADLs and full assistance with meals --R #58 extensive assistance of two (2) with ADLs and eats independently --R #35 extensive to total assistance with all ADLs and full assistance with meals --R #53 extensive assistance of two (2) with ADLs, eats independently --R #112 extensive to total assistance with all ADLs and eats independently --R #32 extensive assistance with all ADLs and eats independently --R #52 extensive assistance with all ADLs including meals --R #39 extensive to limited assistance of two (2) with ADLs and independent with eating d) Staff interviews During a confidential interview, NA #A reported there should be four (4) aides on the blue hall for the shift and there were only two (2). NA #2 acknowledged they can not complete the resident care with only two (2) NAs on the shift. During an interview on 03/22/22 at 8:30 AM, LPN #7 stated with only one nurse on the unit and no wound nurse, treatments are not completed as ordered on day shift. NA #12 confirmed Residents #13, #33, #17 and #35 require full assistance with meals during an interview on 03/23/22 at 11:00 AM. .

. Based on record review and staff interview, the facility failed to ensure that nurse aides had demonstrated competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. This was true for one (1) of three (3) nurse aides reviewed. The facility was unable to produce evidence Nurse Aide (NA) #75 had demonstrated competency in skills and techniques necessary to care for residents' needs prior to allowing NA #75 to provide direct care to residents. Staff identifier: NA #75. Facility census: 61. Findings included: a) NA #75 A review of NA #75's training's were reviewed on 03/23/22 at 12:30 PM. There was no record of the facility had completed a Competency/Skills performance checklist for NA #75. A Competency/Skills performance checklist would have included a record of when NA #75 performed the duties and skills typically performed by a NA and the determination of satisfactory or unsatisfactory performance by an instructor or designated facility representative supervising the performance. On 03/23/22 at 2:30 PM, the Administrator explained that NA #75 was what the facility referred to as a POD Worker. A POD worker was described as an employee who was shared between multiple agency owned nursing home facilities within the area. NA #75 was not specifically hired by this facility. Therefore, the facility did not have NA #75's Competency/Skills performance checklist on file in their records. .

. Based on observation and staff interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards. Staff did not consistently obtain the temperature of resident's personal in-room refrigerators. Resident's food items were not at acceptable temperatures during the time of service. These were random opportunities for discovery. Rooms # A2, B2, B4, B5, B7, B12. Facility Census 61. Findings included; a) Temperature logs On 3/21/22 at 11:45 AM, during the initial tour, observation found personal resident refrigerators in their rooms did not have completed temperature logs. Room A2 and B4 missing dates on temperature logs: March 5, 2022; March 6, 2022; March 7, 2022; March 13, 2022; March 14, 2022; March 15, 2022; and March 16, 2022. Room B2 missing dates on temperature logs: March 6, 2022; March 7, 2022; March 8, 2022; March 9, 2022; March 13, 2022; March 15, 2022; and March 16, 2022. Room B5 missing dates on temperature logs: March 6, 2022; March 7, 2022; March 8, 2022; March 9, 2022; March 13, 2022; March 14, 2022; March 15, 2022; March 16, 2022; March 18, 2022; and March 20, 2022. Room B7 missing dates on temperature logs: March 2, 2022; March 3, 2022; March 4, 2022; March 6, 2022; March 10, 2022; March 11, 2022; March 13, 2022; March 15, 2022; and March 16 2022. Room B12 missing dates on temperature logs: March 4, 2022; March 6, 2022; March 10, 2022; March 11, 2022; March 13, 2022; March 15, 2022; March 16, 2022; and March 19, 2022. On 3/21/22 at 3:45, the Administrator stated that housekeeping and maintenance is in charge of checking the refrigerators and completing the temperature logs daily. The Administrator did observe the missing dates on the personal refrigerators temperature logs in residents rooms who have refrigerators and agreed the temperature logs were incomplete. b) Food temperature Observation of lunch service on 03/21/22, found an unheated food cart sitting in the hall for more than 30 minutes. At 12:40 PM, Nurse Aide (NA) #21 removed one (1) of the two (2) remaining trays in the cart. NA #21 immediately carried the tray to the kitchen for a temperature check per surveyor request. Dietary employee #26 noted the following food temperatures for Resident (R) #35's pureed food: meat and gravy - 96.8° Fahrenheit (F), mashed potatoes 100.7° F, and vegetables 76 ° F. The Dietary Manager #39 reported hot foods should be greater than 165° F and acknowledged these food temperatures were unsafe. Kitchen staff were directed to make new trays for R #35 and R #17. .

. Based on observation and staff interview, the facility failed to maintain the freezer in a safe and operational way. This had the potential to affect more than a limited number of residents. Facility Census 61. Findings included; a) Freezer On 03/21/22 at 11:04 AM, during the initial tour in the kitchen with the Dietary Manager (DM) #39 observation of the freezer found an excessive ice build up in the back of freezer and a pipe in the back of the freezer was disconnected. DM #39 stated, the freezer has been down for two (2) months. The water came down in back of the freezer and froze the rubber mat to the freezer floor, and busted the pipe in the back of the freezer. Observation with DM #39, found hunks of ice hanging down in the back of the freezer. On 03/22/22 at 3:00 PM, an interview with Maintenance Director #32 confirmed the freezer has not worked properly for a few months. MD #32 said a company is coming in to fix the freezer on 03/24/22. .

. Based on facility documentation and staff interview, the facility failed to have a certified Infection Preventionist. This failed practice had the potential to affect all residents residing at the facility. Facility Census: 61. Findings included: a) Infection Preventionist Record review of the facility's documentation of Infection control practices found the facility was unable to provide the required Infection Control Preventionist Certification or documentation. During an interview on 03/22/22 at 3:31 PM the Administrator stated they did not have the Infection Control preventionist Certificate on file. She stated that they would provide the certificate the next day 03/23/22. On 03/23/22 at 11:20 AM the Administrator stated that no staff at the facility have completed the specialized training in infection prevention and control at this time. No other information was provided prior to the end of survey on 03/23/22 at 5:15 PM. .