**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice for 1 or 16 residents (R9) reviewed for change of condition.R9 went to the hospital for evaluation following a fall from bed. R9 sustained fractures (fx) of left clavicle (collar bone) and left ribs 3-6 and nursing assessments were not performed on return to the facility.Evidenced by:The facility's Fall Prevention and Management policy, dated 2/28/25, states, in part: .Definitions Fall: The Centers for Medicare and Medicaid Services (CMS) defines a fall as an unintentional change in position that results in someone landing on the ground or a lower surface. Procedure .6. Responding to a fall .l. Follow up assessments of the resident will be completed no less than the next 3 consecutive shifts. m. All assessments will be documented in the E.H.R. (electronic health record) with vital sign collection.R9 admitted to the facility on [DATE] and has diagnoses that include, in part: Multiple Sclerosis (a disease that causes breakdown of the protective covering of nerves, which can cause weakness and lack of coordination); dementia (decline in mental ability severe enough to interfere with daily life); muscle weakness; cognitive communication deficit (difficulty in communication caused by cognitive process rather than speech or language issues).R9's Minimum Data Set (MDS), dated [DATE], indicate a Brief Interview of Mental Status (BIMS) score of 4, indicating moderate cognitive impairment.R9's Progress Notes state, in part:*11/29/24 11:46 AM Writer was called to assess the resident at approximately 9:46 AM d/t (due to) a fall out of bed.*11/29/24 1:51 PM .A CT (Computed Tomography Scan / CAT scan; a medical imaging procedure that uses Xray and computer technology to create detailed, cross-sectional images of the body) of the head and cervical spine were completed that showed a left clavicle fracture. Xray showed left sided rib fx of 3, 4, 5, 6.*11/29/25 5:38 PM Resident returned to facility around 5:00 PM. Assisted into bed. Sling in place. Resident is to wear sling for comfort and immobilization. Biggest risk is for pneumonia as R9 has 3 broken ribs. Monitor for SOB (shortness of breath) and s/s (signs and symptoms) of pneumonia.*11/30/24 4:01 PM Resident lying in supine position in bed when TL (Team Lead) went into check on her. Resident had left arm in sling. When asked if she was in pain, resident responded yes PRN (as needed) Morphine given at 3:15 PM for comfort. Curing the time writer was in room, encouraged resident to deep breath. Continue to monitor for comfort and continue to reposition resident.R9's Neurological Assessment sheet with start date of 11/29/24 indicates that neurological checks were completed on 11/29/24 at 9:40 AM, 9:55 AM, 10:10 AM, and 10:25 AM. The following dates/times are listed with no assessment documented: 11/29/24 10:55 AM, 11/29/24 11:25 AM, 11/29/24 12:25 PM, 11/29/24 1:25 PM, 11/29/24, 5:25 PM, 11/29/24 9:25 PM, 11/30/24 1:25 AM, 11/30/25 5:25 AM, 11/30/24 9:25 AMR9's Physician's Order Sheet, dated 11/29/24, no time indicated, states D/C (discontinue) neuro checks due to CT scan completed.R9's Emergency Department/Urgent Care Documentation dated 11/29/24, states, in part: .Patient Instructions Patient has a fractured clavicle. Sling is given for this. She also has 3 broken ribs. Biggest risk is pneumonia. Incentive spirometry is recommended. Watch for signs of pneumonia such as cough and fever.On 8/6/25 at 10:15 AM, Surveyor interviewed RN/UM F and asked about nursing assessments following R9's return from hospital evaluation with noted fractures. RN/UM F stated that neurological assessments were discontinued per physician orders, but pain and respiratory assessments should have been completed at least once per shift following resident's return to facility. Surveyor asked if those assessments were completed. RN/UM F stated no, there were no assessments documented until 4:01 PM the following day.On 8/6/25 at 4:02 PM, Surveyor interviewed DON B and asked about assessments for R9 following her hospital evaluation with noted fractures. DON B indicated assessments were not completed and should have been done once per shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that a resident maintains acceptable parameters of nutritional status and is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet for 1 of 16 residents (R2) reviewed for nutrition.R2 was not weighed weekly for four weeks from time of admission and did not have a reweight when there was a loss of 9.8 pounds one month after admission. A nutritional supplement was ordered for R2 and was not routinely documented.As evidenced by: The facility's Nutritional Assessment and Care Planning policy, dated 3/20/23, states, in part: Realizing the importance of good nutrition in promoting optimal health and to identify problems which impact nutritional status, facility conducts nutritional assessment of all residents within 5 to 14 days of admission and at least quarterly or more often as needed and develops an individualized plan of care for each resident. Procedure . Weight .a. Weight is to be measured within 24 hours of admission, weekly while on Medicare or for at least one month and until weights are stable for other admissions, or more frequently as determined to be necessary.b. If weight varies by more than 4# (pounds) from previous weight, a reweight must be obtained within 48 hours. c. Amount of weight loss or gain is noted and whether it is planned or not, along with an evaluation of the source of the weight change (diuresis, poor appetite, fluid overload, etc.) .5. Need for, appropriateness, acceptance, and tolerance of therapeutic and mechanically altered diets, with referral to other disciplines as necessary. Use of nutritional supplements and appropriateness of them. A therapeutic diet is defined as a diet ordered to manage problematic health conditions and refers to alteration in nutritional content of foods (including the provision of nutritional supplement during meals which alter the nutritional content of the diet). R2 admitted to the facility on [DATE] and has diagnoses including: dementia with mood disturbance (a decline in mental ability severe enough to interfere with daily life ); breakdown of internal fixation device of bone in right lower leg (a mechanical failure or malfunction of the hardware used to stabilize a bone fracture); depression; anxiety disorder; Type 2 Diabetes Mellitus (a condition where the body either doesn't produce enough insulin or cannot properly use the insulin it produces, leading to elevated blood sugar levels); Crohn's disease of both small and large intestine (a chronic inflammatory bowel disease that can lead to diarrhea, abdominal pain, weight loss, and fatigue).R2's MDS (Minimum Data Set) dated 7/22/25, indicates a BIMS (Brief Interview of Mental Status) score of 6, indicating severe cognitive impairment.R2's Physician Orders include: *Ensure or supplement of choice at breakfast and at supper. start date 7/17/25 end date 8/6/25*Ensure or supplement of choice at lunch.start date 7/18/25 end date 8/6/25*Give Glucerna at meals: document under intake supplement (lunch) start date 7/31/25 end date 8/6/25*Give Glucerna if eats less than 50% of meal: document under intake supplement (breakfast and supper) start date 6/17/25 end date 7/31/25R2's Progress Notes include:*4/22/25 Nutrition admission Assessment.Wt. (weight) 4/14/25 207.2# .Appetite: resident with regular diet and tolerating meals with fair to good intake (51-100%) at most meals x 10 since admit, poor intake (1-50%) x 6.Assessment: Resident at moderate nutrition risk due to age, diagnosis, past medical history, regular diet and fair to good intake at most meals. Will monitor intake and appetite, progress, labs, weight and follow up with recommendation as needed.*7/17/25 Nutrition Assessment.Wt: 7/13/25 190.3#, 6/15/25 192.8#, 5/18/25 197.4#, 4/14/25 207.2# .Assessment: Resident at moderate to high nutrition risk due to age, diagnoses, past medical history, Regular diet with varied intake at most meals, breakfast seems to be the best at 76-100%. Current weight loss of 16.9# since admit. Will send a referral to nursing to offer Ensure with lunch and supper.*7/18/25 Nutrition Follow up: New order for Ensure or nutrition supplement of choice with meals TID (three times a day) due to weight loss. Will continue to monitor weight.R2's Vitals report indicates the following weights:*4/14/25 207.2 lbs (pounds)*5/18/25 197.4 lbs*6/1/25 193.4 lbs*6/8/25 193.4 lbs*6/15/25 192.8 lbs*6/29/25 193.6 lbs*7/6/25 192.8 lbs*7/13/25 190.3 lbs*7/20/25 190.6 lbs*8/1/25 187.4 lbsImportant to note: there is no documentation of a reweight following the 5/18/25 weight. R2's Vitals report indicates the following documentation for Supplements:*5/1/25 12:26 PM Supplements 240 ml Amount 76-100%*7/1/25 9:49 PM Supplements Amount 76-100%*7/6/25 12:08 PM Supplements Amount 26-50%*8/5/25 12:58 PM Supplements Not Taken: Refused*8/6/25 8:38 AM Supplements Not Taken: RefusedImportant to note that supplement was ordered for three times daily (scheduled) from 7/18/25 through 8/6/25 for a total of 57 times. In that time frame supplements were documented as offered on two occasions. R2's Vitals report indicates that meal intakes were documented as 1-25% or less, as follows:Breakfast:4/27/25,5/15/25,6/6/25, 6/7/25, 6/8/25, 6/21/25,7/9/25, 7/17/25 (8 instances)Lunch: 4/18/25, 4/21/25, 4/26/25, 5/2/25, 5/4/25, 5/7/25, 5/10/25, 5/14/25, 5/15/25, 5/16/25, 5/17/25, 5/23/25, 5/25/25, 5/26/25, 5/30/25, 6/2/25, 6/7/25, 6/8/25 6/9/25, 6/17/25, 6/19/25, 6/22/25, 6/23/25, 6/25/25, 6/26/25, 6/29/25, 7/2/25, 7/22/25, 7/23/25, 7/27/25, 8/1/25, 8/4/25 (32 instances)Dinner: 4/14/25, 4/19/25, 4/20/25, 4/21/25, 4/24/25, 5/6/25, 5/8/25, 5/20/25, 5/21/25, 5/27/25, 5/29/25, 6/1/25, 6/2/25, 6/21/25, 6/26/25, 6/30/25, 7/1/25, 7/15/25, 7/26/25, 8/2/25 (20 0ccurrences)Important to note: a supplement was documented as offered for just one of the 60 instances of meal intake of 1-25% or less.On 8/4/25 at 2:53 PM, Surveyor interviewed R2 during initial screening. R2 indicated thinking that R2 had lost weight. R2 stated that a friend had come to visit and made a comment about the weight R2 had lost.On 8/5/25 at 2:46 PM, Surveyor interviewed CNA L (Certified Nursing Assistant) who indicated that nutritional supplements and intakes are documented in the computer. CNA L stated that weights are done monthly unless told by the nurse otherwise. CNA L indicated that if a weight is off by 5-10 pounds a reweight will be done.On 8/6/25 at 8:12 AM, Surveyor interviewed CNA E who stated that nutritional supplements are written on the care plan and the meal ticket and that anyone who doesn't eat at least 50% of their meal is offered an Ensure. CNA E indicated that supplements and intakes are documented with a percentage consumed or that the supplement was refused. If refused, the nurse is also updated.On 8/6/25 at 9:35 AM, Surveyor interviewed RN/UM F (Registered Nurse/Unit Manager) who indicated that residents are weighed weekly for 4 weeks from time of admission, then if stable, changed to monthly. RN/UM F stated that a reweight is done if the weight is off; 5 or 10 pounds, dependent on the situation. Surveyor asked if R2 had been weighed weekly at admission. RN/UM F stated no, unless it was on paper. Surveyor asked if a reweight had been done following the 5/18/25 weight which indicated a 9.8# loss. RN/UM F stated, no, it is not charted in the computer. RN/UM F stated that R2 had just moved from another unit the week prior and the RN/UM G may have additional information. Surveyor asked about documentation of nutritional supplements. RN/UM F stated that the documentation is not always completed; everyone knows that they need to document on the supplement/intakes for all three meals.On 8/6/25 at 10:47 AM, Surveyor interviewed RN/UM G who indicated that weekly weights are expected for the first four weeks. RN/UM G stated that most residents on RN/UM G's unit remain at least weekly weights. Surveyor asked RN/UM G about weekly weights from time of admission for R2. RN/UM G provided no further documentation and stated that the weights should have been completed. RN/UM G stated that a weight change of 4# would trigger a reweight and stated that no reweight was found for R2 following the 5/18/25 weight loss. Surveyor asked about documentation of nutritional supplements. RN/UM G stated that the supplements are documented in the computer by the CNAs.On 8/6/25 at 1:25 PM, Surveyor interviewed RD D (Registered Dietician) who stated that weight changes are discussed with a 5% change in 30 days and a 10% change at 180 days, or when concerns are verbalized. RD D indicated that dietary should have had a referral for R2 in May with the loss of 9.8 pounds; R2 didn't quite trigger for significant weight loss. On 8/6/25 at 3:38 PM, Surveyor interviewed DON B (Director of Nursing) who indicated that residents are to be weighed at least weekly times four from time of admission, then weight frequency is determined per resident. DON B indicated that a reweight is done if weight is off by 5 or more pounds. DON B reviewed weight documentation for R2. DON B indicated that the weekly weights should have been done and a reweight was indicated following the 5/28/25 weights. DON B reviewed supplement documentation and how most instances of mealtime supplements were not documented in the computer. DON B indicated that supplements are to be administered as ordered and documented in computer for each occurrence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not immediately notify and consult with a resident's physician when there was a significant change in condition. This occurred for 1 of 17 residents (R46) reviewed for change in condition. R46 had a change in condition on 5/5, 5/26, and 6/10/24 that was not reported to R46's provider timely. This is evidenced by: The facility policy, entitled Physician Notification/Change in Condition dated 1/22/2024, states, in part: Policy: .A change in condition is when there is: .2. A significant change in the resident's physical, mental or psychological status (that is a deterioration in health, mental or psychological status in either life-threatening conditions or clinical complications. 3. A need to alter treatment significantly (that is. a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment.Please refer to the attached physician notification parameters tool for more information about falls and other conditions requiring physician notification. Alteration in mental status: Immediate notification-sudden change in mental status: lethargy, loss of consciousness, syncope, vertigo. According to the American Medical Directors Association Acute Change of Condition in Long-Term Care Setting standard of practice. A facility should notify the physician for bleeding the next office day when the bleeding is controlled with no further episodes .Alteration in mental status: sudden notify immediately. R46 was admitted to the facility on [DATE], and has diagnoses that include Non-ST elevation myocardial infarction (a type of heart attack), unspecified diastolic heart failure (heart condition which reduces the amount of blood [NAME] out to the body), venous insufficiency (a condition which decreases the leg veins ability to send blood back to the heart), chronic atrial fibrillation (an irregular and often rapid heart rhythm), and personal history of renal calculi (kidney stones / hard deposits of minerals and salts inside the kidneys). R46's Quarterly Minimum Data Set (MDS) assessment dated [DATE] shows R46 has a Brief Interview of Mental Status (BIMS) score of 6, indicating severe cognitive impairment. R46's progress notes include: 5/5/24 4:57AM- Writer called to room as resident was noted to have frank blood in his pull-up (incontinent brief). Upon further assessment, resident noted to have hematuria (blood in urine) with small amount of blood from penis. No open areas noted. Resident has had this before. Denies any pain/discomfort. Resident is afebrile. Will continue to monitor. No documentation indicating R46's provider was updated. 5/26/2024 4:36 PM- Writer called to resident's room. Resident was sitting on the toilet and CNA was attempting to arouse resident, which was difficult. Vitals were taken at this time and WNL (within normal limits). Staff then transferred resident into bed via golvo lift (mechanical transfer device). RN notified about event and came to unit No documentation indicating R46's provider was updated. 5/26/24 4:51PM- called to unit for resident's unresponsive episode. Resident is seen lying in bed, alert. He does not recall passing out. Resident most likely with vasovagal response (a sudden drop-in heart rate and blood pressure leading to fainting) as he is alert at time of assessment. Pulse is 40, not unusual for this resident .updated provided to dtr (daughter) via phone call. No documentation indicating R46's provider was updated. 6/10/24 9:48PM- writer summoned to resident's bathroom by staff who report bright red blood in resident's urine during his shower. Writer observed and confirmed bright red blood present. Resident denies any s/sx's (signs / symptoms) consistent with UTI (urinary tract infection). Resident is afebrile (free of fever). RN notified. No documentation indicating R46's provider was updated. On 6/13/23 at 9:54 AM, Surveyor interviewed RN E (Registered Nurse). Surveyor asked if a resident is experiencing hematuria (blood in urine) what would be the next steps. RN E stated it would depend on the resident's diagnosis and medications. If there is a large amount of blood or pain or if the bleeding is new the physician should be notified right away or within 24 hours. Surveyor asked if a resident is sitting on the toilet and becomes difficult to arouse, what would be the next steps. RN E stated, call the nurse, sternal rub, if arouses assist to bed or chair, if new condition update physician right away. On 6/13/24 at 10:20 AM, Surveyor interviewed RN H. Surveyor asked if a resident is experiencing hematuria what would be the next steps. RN H stated ensure it is urinary related, not an open area or other symptom, check diagnoses, if new issue update physician. Surveyor asked what is the timing of that update to the physician. RN H stated fairly quickly, if all else is stable (no other signs and symptoms) within 2 hours. Surveyor asked if a resident is difficult to arouse what are the next steps. RN H stated check vital signs, check that all else is normal, check to see if this is something that occurs for this resident, ensure safety, ensure that the resident comes around. If new for the resident, update the physician right away and ask about any additional orders. Surveyor read progress note from 5/25/24 and asked if physician should have been notified. RN H stated this is not a resident that she knows has had incidents in the past and if this is not normal for him the physician should have been notified. He does get diuretics (water pills) twice daily, there are things that we could do right away. RN H stated that she would like to review the resident's chart. At 10:43AM, RN H stated after looking at the chart, I would've updated the physician right away when it happened. He was changed to palliative care on 5/6/24, but there are notes about hematuria, low pulse, poor intake, doc (Physician) should have been updated at that time. There was a progressive change, and he may have needed a change in his orders at that time. On 6/13/24 at 2:40 PM, Surveyor interviewed RN I. Surveyor asked if a resident is experiencing hematuria what are the next steps. RN I stated it depends if it is chronic or acute, if new will contact physician. If chronic, then no need to call unless there is a large amount of blood. Surveyor asked is hematuria a concern for R46. RN I stated I don't recall. If it is new for him there should be a call to the doctor. Surveyor asked if a resident is difficult to arouse what are the next steps. RN I stated it depends on the situation, but an assessment should be done. Surveyor asked if a resident has a vaso-vagal incident should the physician be notified. RN I stated it depends; I wouldn't leave my shift knowing something was off with him. Surveyor asked when the physician might need to be updated in relation to a pulse. RN I stated immediate notification per the facility parameters. On 6/13/24 at 3:15 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked if a resident is having hematuria would you expect staff to notify the physician. DON B stated yes, especially if it is something new. Surveyor asked if a resident is difficult to arouse and staff assess a resident with a vaso-vagal incident would staff be expected to update the physician. DON B stated if it is new, yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure prompt resolution of all grievances for 2 of 14 residents (R47 and R32) reviewed for grievances out of a total sample of 17 residents. R47 voiced a grievance/concern to staff and did not receive any follow up on her voiced grievance/concern. R32 voiced a grievance/concern to staff and did not receive any feedback or a resolution to her concern/grievance. Evidenced by: Facility policy, entitled Grievance Policy and Procedure, effective date of 12/11/23, includes, in part: . staff are to ensure the prompt resolution of all grievances regarding the resident's rights. Any person is able to freely voice having a concern or problem with any matter concerning their rights including those with respect to care and treatment . the behavior of staff and other residents, and other concerns regarding their long-term care facility stay. (Facility Name) promotes an environment with the objective that all residents feel comfortable . The party shall provide verbal or in written statement describing his or her grievance/concern to the household Social Services staff, Registered Nurse, or any other staff member with whom he/she feels comfortable . Any household staff member made aware of a grievance/concern will notify the Director of Social Services/Grievance Officer . An investigation will be conducted concerning the grievance and its cause. Within 5 business days, if possible, a resolution to the grievance shall be determined following a review of the investigation results. The party who filed the grievance will then receive a summary of the grievance, findings, conclusion, and any action taken. If the party is still not satisfied with the disposition of the grievance, the party may bring the grievance to the attention of the Administrator and Administrative Team . Example 1 R47 admitted to the facility on [DATE]. Her most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 3/14/24 indicates R47 is cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 out of 15. On 6/11/24 at 10:59 AM R47 voiced a concern related to the quality of food being served in the facility. R47 indicated she told LPN D (Licensed Practical Nursing) about her concern and she saved some meat to show management. R47 indicated the facility did not follow up with her concern. R47 indicated she feels like it is no use bringing concerns forward if there will not be any follow up. On 6/11/24 at 4:06 PM during an interview LPN D (Licensed Practicing Nurse) indicated R47 reported to her a concern regarding the chicken in her pot pie on 6/1/24. LPN D indicated she did not fill out a grievance, did not start an investigation, and did not meet with R47 related to a resolution to her grievance. LPN D indicated she was not sure if this happened once or if R47 had concerns related to the quality of other foods. LPN D indicated any concern related to residents' stay or care is considered a grievance and she should have followed the facility grievance process. On 6/13/24 at 10:55 AM during an interview SW C (Social Worker) indicated residents can voice concerns to any staff member or can fill out a grievance form. SW C indicated when staff receive concerns, they are to fill out a grievance form and then the Grievance Official will oversee the grievance process and alert all who need to be involved in an investigation. SW C indicated there was not a grievance form with this concern on it and if there was an investigation it would have been completed and a resolution would have been discussed with R47. SW C indicated the facility can't track and trend if grievances are not recorded using the grievance process. On 6/13/24 at 11:17 AM DON B (Director of Nursing) indicated staff need to fill out grievance forms for all resident concerns so the facility can investigate, track, trend, and work out a resolution to the residents' concerns. DON B indicated there are only 3 grievances recorded since January 2024. Example 2 R32 admitted to the facility on [DATE]. Her most recent MDS with ARD of 3/21/24 indicated R32 is cognitively intact with a BIMS score of 15 out of 15. On 6/11/24 at 10:26 AM R32 voiced a concern about CNA F (Certified Nursing Assistant)being grumpy, unfriendly, rough, disrespectful, nasty and was taking it out on R32. R32 indicated CNA F would not assist her with rearranging things in her room because she did not have time. R32 indicated she verbally reported this grievance to RN E (Registered Nurse) and has not heard anything back about the follow up from her concern. R32 indicated this interaction was not nice and made R32 feel like a bother. R32 indicated she relies on staff to meet her daily needs and stated, I'm in a wheelchair so I can't bend over and do some things. On 6/12/24 at 10:44 AM RN E indicated R32 voiced a concern to her regarding CNA F dressing inappropriately and being in her room complaining about being the only staff on the unit, complaining about being underpaid, and complaining about being overworked. RN E indicated CNA F should not be talking like this in a resident room as it can cause a resident to have mental anguish. RN E indicated she was unsure if other residents had concerns related to CNA F. RN E indicated she did not follow the facility's grievance process/policy or the facility's abuse process/policy. RN E indicated she did not think this was an allegation of abuse and should have filled out a grievance form so the facility management team could have investigated this further. Surveyor reviewed CNA F's personnel file and had no concerns with education or with disciplinary actions. On 6/13/24 at 11:17 AM DON B indicated staff need to fill out grievance forms for all resident concerns so the facility can investigate, track, trend, and work out a resolution to the residents' concerns. DON B indicated there are only 3 grievances recorded since January 2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that lab values were monitored according to professional standards of practice for one resident (R8) out of 17 reviewed for professional standards of care. Specifically, the facility failed to properly identify and notify staff of one resident's lab value that differs from the accepted therapeutic range, which has the potential to cause R8 to experience adverse effects from not properly holding or administering the medication. R8 was recommended an INR (international normalized ratio, assesses how fast blood clots) therapeutic range from 1.5 to 2, which was not made readily available to nursing staff to review prior to holding or administering medication. Findings include: The National Library of Medicine's article titled International Normalized Ratio (INR) (2023), indicates: For normal patients who are not on anticoagulation (blood thinning medication), the INR is usually 1.0 regardless of the ISI (international sensitivity index) or the particular performing laboratory. For patients who are on anticoagulant therapy, the therapeutic INR ranges between 2.0 to 3.0. INR levels above 4.9 are considered critical values and increase the risk of bleeding . Complications: INR level below the target range is associated with increased risk of thrombosis (blood clot). Research showed that more than three-fold risk of recurrent venous thromboembolism (blood clot in veins) is associated with the subtherapeutic INR level. On the other hand, INR above the therapeutic range is associated with increased risk of bleeding among which the most concerning condition is an intracranial hemorrhage (brain bleed). Patients can also present with gastrointestinal bleeding (stomach or intestinal bleeding), hematuria (blood in urine) or bleeding from any other site. Review of the facility policy titled Warfarin (Coumadin)(anticoagulant) Therapy last reviewed on 11/23/23 states in part, Policy: All residents receiving Warfarin therapy will receive monitoring per resident observation and INR lab draws as ordered by the physician. Additionally, the policy states, Procedure: 5. Upon received of the results, the nurse will notify the physician/medical provider of INR results less than 2.0 or greater than 3.0 (unless other guidelines have been established by the physician/medical provider) .7. The nurse will notify the physician/medical provider of symptoms of active bleeding. Review of the facility policy titled Physician Orders, Obtaining and Processing last reviewed on 3/18/2024 states in part, Care Plan: 3. Use care to add information/medications/interventions to care plan in appropriate area/problem. Review of the facility policy titled Diagnostic Services last reviewed on 1/20/2023 states in part, Guideline: AMDA- Acute Change of Condition in[sic] the Long-Term Care Setting Clinical Practice Guideline. The policy also states, Procedure: 3. Lab results in the extreme low (XL), panic high (PH) range, or that are positive (See Appendix A-attached) will be reported to the physician promptly, on the same day they are drawn/results obtained. Other results to be reported promptly are . INR/PT (prothrombin time, assesses how fast blood clots) 3 IUs (international units, unit of measurement for INR test) or above (get order to hold warfarin) . 4. INR/PT INR below 3 IUs . Of note: Appendix A lists INR critical high above 6 and no critical low is listed. R8 was admitted to the facility on [DATE] with diagnosis that include in part . Hemiplegia (one-sided paralysis or weakness) and hemiparesis (one-sided muscle weakness) following cerebral infarction (stroke) affecting left non-dominant side, unspecified fracture of T9-T10 (fracture of vertebra in the spine), paroxysmal atrial fibrillation (uncontrolled irregular heart rhythm), hypertension (high blood pressure), and long-term use of anticoagulants. Review of R8's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/14/2024 indicates R8 has a Brief Interview for Mental Status (BIMS) score of 15 of 15, which indicates R8 is cognitively intact. Primary medical condition is listed as stroke with additional diagnosis of hypertension. The High-Risk Drug Classes indicates R8 is receiving an anticoagulant. R8's care plan states, in part, Problem: Alteration in Cardio-respiratory Perfusion/Neurological Status r/t Disease Process- A-fib (atrial fibrillation), HTN (hypertension), Hx (history) of CVA (cerebrovascular accident-stroke) with L (left) hemiparesis/plegia AEB: SOB (shortness of breath) with exertion, edema (swelling), hx long term use anticoagulant . Approach: Monitor for any s/s (signs/symptoms) of active bleeding (blood in stools, epistaxis (bloody nose), bruising). Of note: There is no indication on the care plan specifying R8's INR range. Physician's order dated 3/11/2021, states in part, May HOLD any meds if condition warrants. Physician order dated 3/28/2024, states in part, LABS: INR weekly . warfarin tablet; 1 mg (milligram); amt: 1 tab; oral Special Instructions: give 1 tab PO (by mouth) daily at 1900 (7:00 PM) for anticoagulant. Of note: Physician orders do not indicate R8's INR range. In review of R8's EMAR (electronic medication administration record), the facility administered warfarin as ordered from 5/12/2024 through 6/9/2024. The medication was held (not administered) on 6/10/2024 and 6/11/2024 for an INR of 2.6. In review of R8's progress note dated 6/6/24 at 9:25 AM, [Physician] reviewed INR again from yesterday as [APNP] did review yesterday, with INR being 2.6, no hematuria noted at this time, with no new orders to be given. Progress note dated 6/8/24 at 9:29 PM states, Hematuria noted in urine this evening. Resident offers no c/o (complaint). RN updated, will continue to monitor. Progress notes dated 6/9/24 at 6:33 AM and 10:11 PM state, Moderate hematuria, no c/o pain or discomfort and Resident continues w/ frank blood (bright red blood) in urine. No c/o offered. Progress note dated 6/10/24 at 9:10AM states, MD SEE: [Physician] saw resident for routine see, reviewed physician orders, VS (vital signs), weights, and overall status, note to be dictated when she returns to her office. [Physician] updated on hematuria over the weekend, noting last INR was 2.6, with new order to hold coumadin tonight on 6/10 and to recheck INR on Wednesday. Physician progress note dated 6/10/2024 states R8 has an INR goal between 1.5 and 2. Of note: This note is the only indication, in the paper or electronic record, of R8's recommended INR range. Progress note dated 6/11/24 at 12:45 PM states, [APNP] in house and updated that hematuria continues w/ resident, noting that coumadin (warfarin) was held last night per [Physician] order. New order given today to hold coumadin tonight and wait for INR tomorrow. In review of the R8's paper chart on 6/12/2024 at 2:22 PM, Surveyor located a page titled Temporary Changes/New Problems Log, this sheet was blank upon review. A Physician Order Sheet includes the following orders: 6/10/24-hold coumadin x1 tonight, 6/11/24-hold warfarin today, 6/12/24-hold warfarin tonight 6/12/24, coagulation tomorrow 6/13/24. A sheet titled Anticoagulant/INR Tracking Form was also located with R8's name at the top and three entries, the last being on 8/9/2023. This sheet also contains a note stating, per [Physician]- no spreadsheet needed for INR. Of note: Nothing in the R8's paper chart indicated the resident's INR range. On 6/12/24 at 3:53 PM, Surveyor interviewed RN I (Registered Nurse). Surveyor asked RN I what the process is for notifying a physician after receiving lab results. RN I stated that if the lab value is outside parameters, they scan the results and email them to the nurse practitioner and physician. If RN I doesn't hear anything back within an hour, RN I will call the on-call physician. Surveyor asked RN I what the normal INR range is according to standards of practice. RN I was unsure but reported that R8 is supposed to be on the lower end of the therapeutic range. Surveyor asked RN I where the prescribed therapeutic range for R8 was located. RN I stated that it should be listed in the chart, and that residents will be at different therapeutic ranges depending on why they are taking warfarin. RN I stated that R8 is on brittle warfarin because when she has an INR of two, R8 starts having blood in her urine. Surveyor asked RN I to show them where the ordered therapeutic range can be found in the chart. RN I was unable to locate this information. On 6/12/24 at 3:58 PM, Surveyor interviewed RN J. Surveyor asked RN J what her expectation would be for receiving a lab result outside of expected parameters. RN J states that it depends on the patient. Surveyor asked RN J specifically regarding R8's lab parameters. RN J states that she does better on a low INR and that the physician is aware. RN J also states that R8 is better off when she is below 2 because she ends up with hematuria (blood in urine). RN J also reported that staff have held warfarin for several days due to an INR result of 2.6 and 2.3. Surveyor asked RN J at what level hematuria is likely to occur for R8. RN J states that R8 usually has hematuria with an INR over 2. Surveyor asked RN J how staff track R8's INR range. RN J states that staff keep an INR tracking sheet in the paper chart, but that they are not using that sheet per physician order because the resident doesn't need to be in the normal therapeutic range to avoid hematuria. On 6/12/24 at 4:33 PM, Surveyor interviewed RN I. Surveyor asked RN I if she would expect R8's therapeutic INR range to be recorded in the chart. RN I said yes. Surveyor asked RN I what the process is for holding medications. RN I said this isn't commonly done on their shift, however when the staff RN receives the lab result, if it is out of range, the nurse holds the medication on the EMAR (electronic medication administration record) and notifies the physician. Surveyor asked RN I how they know what to report to the physician if no INR range can be found in R8's chart. RN I reported that they report every INR result or look at the last result to compare. On 6/13/24 at 10:07 AM, Surveyor interviewed RN K. Surveyor asked RN K to show Surveyor where the ordered therapeutic INR range could be found for R8. RN K was unable to locate this information in the paper chart. RN K then looked through the electronic medical record. The only indication of an ordered therapeutic INR range for R8 was located in a physician progress note from 6/10/24, after Surveyors were already in the building and questioning R8's INR range. Previous physician progress note also read from April of 2024 and it did not indicate a therapeutic INR range for R8. RN K stated that there is a policy with a lot of different lab values that specifies when to update the physician. Surveyor referenced this policy previously, and only indicates reporting around the normal INR therapeutic range. On 6/13/24 at 10:55 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B where she would expect to find a resident's ordered INR reference range. DON B states that she would expect to find this information in the physician's orders. Surveyor asked DON B if physician recommendations are considered orders at this facility. DON B indicates that physician recommendations are considered orders. Surveyor asked DON B where she would expect to find a therapeutic INR value if she was unfamiliar with R8 or any other resident. DON B indicated that she would expect to find it on the Anticoagulant/INR Tracking Form and in the care plan. The facility did not ensure that physician's orders for R8's therapeutic lab values were easily accessible and documented for all staff to review as needed in accordance with professional standards of practice.

Based on interview and record review, the facility has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect all 52 residents. The staff line lists contain signs/symptoms (s/sx) such as something I ate, sick, ill, cold sx. They are not specific. The staff line lists were missing some Date last Symptom occurred dates. The facility's COVID summary not complete or accurate. This is evidenced by: The facility policy entitled Nursing Services/Infection Control: Infections: Reporting, Interventions, and Surveillance, dated 2/10/24, states, in part: . Policy: An infection control report will be initiated for any resident with symptoms of an infection, in order to provide a systemic approach for monitoring, controlling the spread of and reducing infections. An infection may be identified by observation of clinical signs/symptoms, physician's diagnosis, and diagnostic tests . Staff calling in ill with infectious signs/symptoms will be given guidelines of when they can safely return to work. Staff may be encouraged to consult with their own physician prior to returning to work. Staff line lists will be maintained by the ADON (Assistant Director of Nursing) . Procedure: For Staff . 2. Staff calling in with gastrointestinal signs/symptoms (vomiting, diarrhea-may also have headache, fever/chills, and abdominal cramps) are required to stay home until they are symptom free for at least 48 hours. Symptomatic staff with Influenza like illness signs/symptoms (fever, chills, cough, sore throat, runny nose) are required to stay home at least 24 hours after they no longer have a fever (without fever reducing medicines) . 3. Staff should review all signs and symptoms with infection preventionist to determine return to work date . 5. The Infection Control Nurse/ADON will maintain staff line lists which include staff names, household/department, dates when calling in, signs/symptoms if determined to be infectious, dates signs/symptoms ended, and date staff returned to work. The facility policy entitled Gastroenteritis-Like Illness, dated 2/21/24, states, in part: . All facility staff should be monitoring for and reporting gastrointestinal illness among residents and staff year-round . Employees will report symptoms of gastrointestinal-like illness when calling in or when on duty so as to limit the spread . D. Management of Ill Staff . 5. A log should be maintained to record ill staff symptoms, date when they became ill, date they became well, and when they returned to work by the Infection Control Nurse or designee . Example 1 The May 2024 staff line list contains 9 call ins. 3 of 9 staff did not have specific symptoms on the line lists. Symptoms include: something I ate and sick. These symptoms are not specific to allow the infection preventionist or designee to track, trend, and surveil for illnesses and outbreaks. The Date of Last Symptom dates were left blank on the staff line list for 1 resident in May. Note: Without date of last symptom the return-to-work dates cannot be determined. The March 2024 staff line list contains 16 staff call ins. 7 of the 16 staff did not have specific symptoms on the line lists. Symptoms include: ill, sick, cold s/sx, GI (gastrointestinal,) and possible allergic reaction. These are not specific symptoms. The Date of Last Symptom dates were left blank on the staff line list for 1 resident in March. Note: Without date of last symptom the return-to-work dates cannot be determined. The February 2024 staff line list contains 27 staff call ins. 9 of 27 staff did not have specific symptoms on the line lists. Symptoms include: sick, not feeling well, upper respiratory, and ill. These are not specific symptoms. The Date of Last Symptom dates were left blank on the staff line list for 2 residents in February. Note: Without date of last symptom the return-to-work dates cannot be determined. The January 2024 staff line list contains 35 staff call ins. 6 of 35 staff did not have specific symptoms on the line lists. Symptoms include: upper respiratory s/sx, GI, In ER (emergency room) all night-no specific, other, doesn't feel well, and sick. These are not specific symptoms. The Date of Last Symptom dates were left blank on the staff line list for 1 resident in January. Note: Without date of last symptom the return-to-work dates cannot be determined. Example 2 The facility COVID Outbreak Summary for December does not provide accurate information. The COVID end date is inaccurate. Facility identified outbreak being over 12/30/24 with isolation ending. A resident tested positive 12/19/24 and then a staff tested positive 13 days later. Staff continued to test positive from January through April with last staff testing positive on 4/26/24. May 10th would have ended outbreak with no positive tests from 4/26/24 until 5/10/24. Outbreak summary did not include what interventions went into place and when medical director was notified. The outbreak summary did not include when and how residents, staff, and families were notified of outbreak. On 6/13/24 at 9:03AM, Surveyor interviewed DON B (Director of Nursing) and IP G (Infection Preventionist.) Surveyor asked IP G if something I ate, ill, not feeling good, or cold sx are specific sx. IP G indicated no; they could be more specific. Surveyor asked if specific symptoms should be on the staff line lists and IP G indicated yes. Surveyor asked IP G if Date of last symptom dates should be on the line lists and IP G indicated yes, they should be on there to determine the return-to-work dates. Surveyor asked IP G looking at COVID line list and Outbreak Summary if the end date or isolation end date is accurate and IP G confirmed that the outbreak continued into April with last staff testing positive on 4/26/24 and outbreak would have ended May 10th. Surveyor mentioned to IP G Outbreak Summary should include details such as when medical director was notified, interventions put into place and when, and if public health was notified and when.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, and record review, the facility did not ensure 2 Residents (R)(R209 and R30) of 2 residents reviewed for respiratory care received care consistent with professional standards of practice. R209 and R30's respiratory care equipment was not sanitized and stored in a manner to maintain infection control standards. Findings include: The facility's Oxygen Administration policy, dated 4/19/16, contained the following information: Replace oxygen cannula or mask, humidifier bottle if used, and tubing every 7 days. Obtain a physician's order prescribing a 7 day change, document in the resident's MAR (Medication Administration Record)/TAR (Treatment Administration Record) and date the supplies when changed. Supplies should be changed also when visibly soiled, or when known contamination occurs. The facility's Nursing Services: Nebulizer Care procedure, dated 4/19/16, states supplies should be changed also when known contamination occurs. The procedure instructs staff to clean the mask with soap and warm water for approximately 1 minute or until clean, shake out the mask completely, set the mask on a paper towel to air dry and keep the device in a clean area. 1. On 3/20/23, Surveyor reviewed R209's medical record. R209 was admitted to the facility on [DATE] with diagnoses including acute respiratory disease, viral pneumonia, acute on chronic respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions) and chronic obstructive pulmonary disease (COPD). R209 had no cognitive impairment, but required staff assistance for activities of daily living (ADLs). R209's medical record contained a physician order, dated 3/14/23, for Ipratropium-albuterol 0.5 mg (milligrams)-3 mg per nebulizer 4 times daily. On 3/20/23 at 10:38 AM, Surveyor interviewed R209. Surveyor noted a nebulizer (respiratory treatment) device and a mask (placed on the face for the respiratory treatment) on R209's bedside table. The mask was intact (not taken apart) and laying directly on the surface of the table. Surveyor noted a film on the inside of the mask and particles throughout the mask. Surveyor asked R209 if the mask was cleaned after treatments. R209 stated staff turned the machine off and set the mask on the table, but did not observe staff clean the mask. R209's soiled mask was observed numerous times on R209's bedside table in direct contact with the table surface on 3/20/23 and 3/21/23. On 3/21/23 at 11:11 AM, Surveyor interviewed Unit Manager (UM)-C who stated masks should be cleaned when soiled and changed out weekly. UM-C also stated masks should be rinsed after treatments and placed on the resident's vanity to dry. UM-C stated if a resident coughed in a mask, the mask should be cleaned as well. On 3/21/23 at 11:13 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-D who stated masks are rinsed with soap and water after use and placed on a paper towel to dry. LPN-D verified R209 had a nebulizer treatment that morning. LPN-D stated R209 was busy with therapy and LPN-D did not get to wash R209's mask; however, LPN-D would clean the mask before leaving. LPN-D stated R209 would receive another nebulizer treatment at 1:00 PM. On 3/21/23 at 11:16 AM, Surveyor interviewed UM-E who stated nebulizer masks are taken apart for cleaning, rinsed with water after use, and set on a barrier to dry. UM-E stated each resident should have an order to exchange/clean the mask. On 3/21/23 at 11:19 AM, Surveyor and UM-E entered R209's room. UM-E verified R209's mask was soiled and did not look like it was cleaned. LPN-D replaced R209's mask with a clean mask. On 3/21/23 at 12:51 PM, Surveyor interviewed UM-F who stated R209 did not have a previous order for cleaning/exchanging nebulizer equipment; however, an order was now entered. 2. On 3/20/23, Surveyor reviewed R30's medical record. R30 was last admitted to the facility on [DATE] with diagnoses of acute and chronic respiratory failure, COPD and pneumonia. R30 had moderate cognitive impairment and required staff assistance for ADLs. On 3/20/23 at 11:20 AM, Surveyor interviewed R30. Surveyor noted a nebulizer machine and mask on R30's bedside table. R30's mask was in direct contact with the surface of the table. R30 stated R30 had a respiratory treatment earlier that day and used the nebulizer machine and mask on the bedside table. Surveyor noted the mask had a film with particles throughout the inside part of the mask that was connected to the nebulizer machine via tubing. Surveyor asked R30 if the mask was cleaned after treatments. R30 stated R30 thought staff probably cleaned the mask. R30's soiled mask was observed numerous times on R30's bedside table in direct contact with the table surface on 3/20/23 and 3/21/23. On 3/21/23 at 11:11 AM, Surveyor interviewed UM-C who stated masks should be cleaned when soiled and changed out weekly. UM-C also stated masks should be rinsed after treatments and placed on the resident's vanity to dry. UM-C stated if a resident coughed in a mask, the mask should be cleaned as well. On 3/21/23 at 11:13 AM, Surveyor interviewed LPN-D who stated masks are rinsed with soap and water after use and placed on a paper towel to dry. On 3/21/23 at 11:16 AM, Surveyor interviewed UM-E who stated nebulizer masks are taken apart for cleaning, rinsed with water after use, and set on a barrier to dry. UM-E stated each resident should have an order to exchange/clean the mask. On 3/21/23 at 11:19 AM, Surveyor and UM-E entered R30's room. UM-E verified R30's mask was soiled and did not look like it was cleaned. LPN-D replaced R30's mask with a clean mask. On 3/21/23 at 12:51 PM, Surveyor interviewed UM-F who stated R30 did not have a previous order for cleaning/exchanging nebulizer equipment; however, an order was now entered.