**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents (R) receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice for 1 (R131) of 14 sampled residents. R131 voiced concern with not being able to put on her own compression stockings/TED (thrombo-embolic deterrent) hose, and that she was supposed to be wearing them daily, but that staff were not assisting her. Findings: The facility policy and procedure entitled Care Planning, created on 11/2016, with last revise date of 10/2023, states in part: Policy: . A person-centered care plan will include resident's strengths, needs/problems, personal history, and cultural preferences . Purpose: The care planning process serves as a means to identify the resident's individual needs, goals for care, and provide staff direction on resident's care . Procedure: . 2. Based on the resident's admission assessment, a baseline care plan will be developed withing 48 hours of admission. A. The baseline care plan will provide staff the necessary information to care for the resident including: . ii. admission orders including physician orders . R131 was admitted to the facility on [DATE] with diagnoses that include fracture of Unspecified part of neck of left femur, Unspecified fracture of the lower end of left radius, Fibromyalgia, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Major Depressive Disorder, Pain in left hip, Muscle wasting and atrophy, Muscle weakness generalized, other lack of coordination, Other reduced mobility, Need for assistance with personal care. R131's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/29/24 indicates her cognition is intact with a BIMS (Brief Interview of Mental Status) score of 15 out of 15. Section GG of R131's MDS indicates the following: GG G. Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear - Substantial Maximum Assist. GG H. Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. - Dependent on staff assistance. R131's admission physician orders, dated 10/22/24, include may remove TED hose from non-operative extremity one hour twice daily for hygiene. R131's Baseline Care Plan, created on 10/22/24, states in part: Focus: Impaired functional status related to fall with left hip fracture and left distal radial fracture with need for surgical intervention to both sites, diagnoses of fibromyalgia, insomnia, hyperlipidemia, gastro-esophageal reflux disease, diabetes type 2 with need for insulin, depression with antidepressant use, narcotic use, anticoagulant use, anticonvulsant use . Intervention: Personal Hygiene Assistance Level: Assist of 1, Grooming Assistance Level: Assist of 1, Bathing Assistance Level: Assist of 1, Toileting Assistance Level: Assist of 1 may use bedside commode . (Of note, R131's Baseline Care Plan does not include anything about the need for assistance with lower body dressing or the application of TED hose). R131's Nursing Notes state in part: -Skilled Daily Charting 10/24/24 - Edema: Yes. Wears BLE (Bilateral Lower Extremity) TEDS. -Skilled Daily Charting 10/25/24 - Edema: Yes. Wears BLE TEDS. -Skilled Daily Charting 10/26/24 - Edema: Yes. Wears BLE TEDS. -Skilled Daily Charting 10/27/24 - Edema: Yes. Wears TED stockings. -Skilled Daily Charting 10/28/24 - Edema: Yes. Non-pitting BLE. TEDs on at all times except for skin care. -Skilled Daily Charting 10/29/24 - Edema: Yes. -Skilled Daily Charting 10/31/24 - Edema: No. -Skilled Daily Charting 11/1/24 - Edema: No. -Skilled Daily Charting 11/3/24 - Edema: Yes. +1 to bilateral ankles. -Skilled Daily Charting 11/4/24 - Edema: Yes. Bilateral lower extremities 1+ edema. R131's Treatment Administration Record (TAR) states in part, may remove TED hose from non-operative extremity one hour twice daily for hygiene. Start date: 10/22/24. On 11/4/24 at 9:40 AM, Surveyor interviewed R131 who indicated that she has TED hose and that she is supposed to wear them every day. R131 stated that the staff will assist her with putting them on, but she has to ask them, and sometimes they are too busy to assist her. Surveyor observed that R131's TED hose were not on at this time. (Of note, facility staff were marking removal of TED hose as being completed, twice daily at 6:00 AM and 4:00 PM every day, even when R131 was not wearing her TED hose). On 11/5/24 at 1:29 PM, Surveyor interviewed CNA X (Certified Nursing Assistant). Surveyor asked CNA X how she was made aware of resident care needs. CNA X stated that she uses the [NAME] and care cards, which are located in a binder at the Unit Clerk desk. Surveyor asked CNA X what personal cares she had provided for R131 today. CNA X stated that R131 got herself dressed today and that R131 probably put on her TED hose herself. CNA X said the care cards are updated daily. Surveyor reviewed the care card with CNA X, which did not indicate the need for R131 to have assistance with dressing, or assistance with applying TED hose. On 11/5/24 at 1:40 PM, Surveyor interviewed R131, and observed R131 sitting up in her chair, dressed, with socks and shoes on but not wearing her TED hose. Surveyor asked R131 if she got herself dressed today. R131 replied that staff had assisted her, and this was the first day since she was admitted that they helped her put on her socks and shoes. Surveyor asked R131 if she was able to put on her own TED hose, as staff had suggested. R131 held up her left arm that was in a cast and stated that she is unable to put on TED hose herself with two good hands, let alone one. R131 then pointed to her dresser, where Surveyor observed her TED hose sitting on top of the dresser. On 11/5/24 at 3:41 PM, Surveyor interviewed CNA V. Surveyor asked CNA V how she was made aware of the level of assistance that residents needed. CNA V replied she would look at the care card in the binder at the Unit Clerk desk. Surveyor asked CNA V what help R131 would need from staff. CNA V stated that R131 needs one assist from staff for dressing. Surveyor asked CNA V if R131 required assistance putting on TED hose. CNA V replied she wasn't sure, but that it should say on the care card if she had TED hose. On 11/5/24 at 3:48 PM, Surveyor interviewed LPN S (Licensed Practical Nurse) about R131's care. LPN S stated that R131 wears some kind of compression stocking, but he would have to check the order. LPN S left to check R131's physician orders and returned to say that R131's order stated she is to always wear TED stockings and can remove twice a day for cares. Surveyor asked LPN S who was responsible for assisting residents with putting on and removing their TED hose. LPN S replied the CNAs put them on but ultimately the nurse is responsible for checking to ensure that they are on per physician order. On 11/6/24 at 8:47 AM, Surveyor interviewed CNA Q. Surveyor asked her if R131 wore TED hose. CNA Q replied she did not think R131 wore TED hose, and that when she has assisted R131, she did not put them on or take them off. Surveyor asked CNA Q how a resident's need for TED hose assistance should be conveyed to staff. CNA Q said it would be listed on the CNA care cards, which are updated daily. On 11/6/24, Surveyor interviewed DON B. Surveyor asked DON B (Director of Nursing) how staff are to know what type of care and assistance the residents require. DON B replied that the binder at the Unit Clerk's desk is where they keep that information, and they would also get it in shift-to-shift report. DON B indicated these care cards are updated each night and printed out and put in the binder for the CNAs. DON B stated it was her expectation that staff would refer to the [NAME] and care cards in the white binder to know how to provide the proper cares for the residents. Surveyor asked DON B if aides were trained on how to apply TED hose. DON B stated yes, they were trained on TED hose by their preceptors. Surveyor asked DON B how she monitored staff to ensure that they were implementing the care plan. DON B replied that the aides follow the task list in Point Click Care (PCC). Surveyor asked DON B what kind of staff assistance was required to care for R131. DON B referred to PCC and replied that R131 was an assist of one staff for cares. Surveyor asked DON B if R131's MDS indicated that she was a maximum assist for lower body dressing, would that include help with TED hose. DON B stated she would have to check on that, but she did expect staff to follow the [NAME]. (Of note, R131's [NAME] and CNA care card did not include anything about the need for assistance with lower body dressing or the application of TED hose). Per R131's plan of care the facility had an order for continual wearing of TED hose with removal twice daily for personal hygiene, yet this was not being followed. Facility staff were marking on the TAR the removal of the TED hose, but there was no consistent evidence, per observations and interviews, that the TED hose was even being put on by staff or that they were aware of her need for assistance with TED hose. R131 voiced concerns over not wearing her TED hose and the inability to put them on herself. R131 was not receiving the services dictated in her plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not implement professional standards of practice to prevent pressure injuries (PIs) from developing and/or worsening or to promote healing of PIs for 1 of 4 residents (R19) reviewed for PIs. R19 was admitted with a PI, the facility failed to obtain wound measurements for a 3-week period in June 2024 and 1 missed measurement in October 2024. Evidenced by: The facility policy titled Pressure Injury and Prevention approved on 6/2024 states in part .II. Determining the presence of a PI .E. Throughout stay in facility actions taken to continue ongoing evaluation of skin includes: 1. Weekly total body examination and documentation on the PCC (Point Click Care (electronic health record)) Nurse Advantage Skin Assessment or PCC Skin and Wound App (Application) . R19 was admitted to the facility on [DATE] with diagnoses that include fibromyalgia, generalized anxiety disorder, protein- calorie malnutrition, edema, and reduced mobility. R19's most recent MDS (Minimum Data Set) dated 9/4/24 states that R19 has a BIMS (Brief Interview of Mental Status) of 14 out of 15, indicating that R19 is cognitively intact. The MDS also indicated that R19 is dependent on staff for positioning, toileting, and bathing. Surveyor reviewed weekly wound notes. Surveyor noted that there were no wound measurements completed on 6/12/24, 6/19/24, 6/27/24, and 10/16/24. R19's wound remained stable with the following before and after measurements: 6/5/24: length: 4.16 cm (centimeters), width: 2.63 cm 7/3/24: length: 5.0 cm, width: 2.7cm 10/9/24: length: 4.01 cm, width: 2.76 cm 10/23/24: length: 4.16 cm, width: 2.78 cm On 11/6/24 at 1:02 PM, Surveyor interviewed RCM K (Resident Care Manager), who is also the wound nurse. Surveyor asked RCM K if R19 should have weekly wound measurements completed, RCM K stated yes. Surveyor asked RCM K to review R19's wound documentation from June 12, 19, 27, and October 16. RCM K noted that there were no wound measurements documented on those days, but there was documentation regarding the characteristics of the wound, areas of tunneling, and areas of undermining. Surveyor asked RCM K if there should be a measurement of the length and width of the wound, RCM K stated yes. RCM K stated that the facility uses a camera for wound measurements and if the sticker falls off, the measurement is not captured. RCM K also reported that there is a delay in getting the information from the camera to PCC (Point Click Care), so they may not notice that they camera did not capture the measurement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based interview and record review the facility did not ensure that a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 2 of 4 residents (R11 & R3) reviewed for limited range of motion (ROM) of 14 sampled residents. R3 is not receiving her restorative care per care plan. There are three different splint instructions for R11's splint for staff to follow making it difficult for staff to know which is the correct order. This is evidenced by: The facility policy entitled, Contracture Prevention and Treatment, dated 10/23, states, in part: . POLICY: It is the policy of this Company that each resident will be assessed for potential for developing contractures. Residents at risk will have a care plan for preventative intervention. For residents who do develop contractures due to their diagnosis and general condition, a treatment plan will be followed to minimize the contractures as much as possible. PROCEDURE: . 2. Prevention and/or treatment of contractures will be addressed on the resident care plan . 3. Routine nursing intervention towards prevention of contractures will be an integral part of the basic nursing care for each resident. This includes the following: . C. Range of Motion will be performed during ADL's (activities of daily living) as assigned on the resident care plan. D. Supportive devices such as pillows, foot drop stops, splints, trochanter rolls, and hand rolls shall be used as appropriate . Notice of Resident Rights under Federal Law, states, in part: . Planning and Implementing Care . The right to receive services and/or items included in the plan of care . Respect and Dignity . The right to reside and receive services in the facility with reasonable accommodation of your needs . Example 1 R3 was admitted to the facility on [DATE] and has diagnoses that include Unspecified Dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems), Contracture, Right Knee (shortening of muscles, tendons, skin, or other soft tissues that limits movement in a joint), and Contracture, Left Knee. R3's Annual Minimum Data Set (MDS) Assessment, dated 10/9/24, shows R3 has a Brief Interview of Mental Status (BIMS) score of 8 indicating R3 has moderate cognitive impairment. R3's Care plan, dated 2/22/20, states, in part: . Problem: Restorative Nursing Program: Active Range of Motion. Date Initiated: 2/22/20. Created on: 2/22/20. Goal: R3 will maintain flexion of BLE (bilateral lower extremities). Date Initiated: 2/22/20. Created on: 2/22/20. Revision on: 11/5/24. Target Date: 1/11/25. Interventions/Tasks: -Perform PROM (Passive Range of Motion- the movement of a joint when an outside force, like a therapist or device, moves the body part while the person receiving the exercise is relaxed) to BLE (Bilateral Lower Extremities) 10 repetitions per scheduled time and tolerance using therapy exercises provided . Date Initiated: 2/22/20. Created on: 2/22/20. Revision on: 6/24/20 Position: CNA (certified nursing assistant) . R3's CNA [NAME], dated 11/6/24, states, in part: . Resident Care . -Perform PROM to BLE 10 repetitions per scheduled time and tolerance using therapy exercises provided . CNA's Care Sheet, dated 11/5/24, does not show R3 is to receive PROM to BLEs. R3's CNA Task Charting in PCC (Point Click Care) does not list: Perform PROM to BLE 10 repetitions per scheduled time and tolerance using therapy exercises provided. On 11/5/24, at 2:55PM, Surveyor interviewed OT R (Occupational Therapist/Rehab Director). OT R indicated the facility does not have a restorative program. If a resident coming off therapy requires restorative it would be completed by the CNA's (Certified Nursing Assistants) or the wellness center downstairs. The therapist would make the determination who would do the restorative care. OT R indicated if the restorative care recommended is straight forward like, the walking program or the arm bike, CNAs would complete the restorative care. If the care requires more training the wellness center would be recommended. OT R indicated CNAs would not do any type of range of motion exercises with the residents. On 11/6/24, at 9:33AM, Surveyor interviewed DON B (Director of Nursing) and asked if the facility has a restorative program. DON B indicated no but if a resident is care planned to receive ROM the CNAs would provide it. DON B indicated the facility does offer walk to dine program that the CNAs would complete with residents. Surveyor asked if R3 is receiving PROM as care plan indicates. DON B looked in PCC under tasks and indicated it is not there. DON B checked the CNA [NAME] and PROM instructions for BLE was on the [NAME]. DON B indicated the PROM R3 is to be receiving should be listed under the tasks for CNAs to complete and document completion. Surveyor asked if R3 is receiving PROM and DON B indicated we would not know if it were being completed but if it is not documented can't prove it was completed. Surveyor asked if R3 should be receiving PROM according to care plan and [NAME] and DON B indicated yes. Surveyor asked if staff should be documenting completion of the PROM and DON B indicated yes. On 11/6/24, at 12:57PM, Surveyor interviewed CNA O and asked if R3 receives PROM. CNA O went to computer, looked, and indicated R3 does not receive PROM. Surveyor asked CNA O if a resident were to receive PROM how would staff know and CNA O indicated it would be in PCC for CNAs to see and chart on. CNA O indicated the computer shows R3 does not receive PROM. On 11/6/24, at 1:00PM, Surveyor interviewed CNA P and asked how CNAs would know if a resident were to receive PROM. CNA P indicated by the resident's plan of care in the computer or by actual care plan. Surveyor asked if CNAs perform PROM exercises on a resident would it be charted, and CNA P indicated yes in PCC. On 11/6/24, at 1:13PM, Surveyor interviewed CNA Q and asked how a CNAs would know if a resident was to receive PROM. CNA Q indicated it would come up in Q Shift (every shift) in PCC for CNAs to see and chart completion. Surveyor asked if R3 was to receive PROM and CNA Q looked up in PCC and indicated no. Surveyor asked CNA Q if a resident was to receive PROM do CNAs chart on completion and CNA Q indicated yes under the Q shift tabs and R3 does not have PROM in her tabs. Example 2 R11 was admitted to the facility on [DATE] and has diagnoses that include hemiplegia (a condition that causes partial or complete paralysis or weakness on one side of the body) and Hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), Vascular Dementia (chronic condition that occurs when the brain's blood supply is interrupted, damaging brain tissue and causing a decline in thinking, memory, and behavior), and contracture, left hand. R11's Quarterly MDS Assessment, dated 10/3/24, shows R11 has a BIMS score of 6 indicating R11 has severe cognitive impairment. R11's Care Plan, dated 2/17/20, states, in part: . Problem: Impaired mobility/falls related to: HX (history) s/p (status post) fall with left hip fracture with hemiarthroplasty, hx of ischemic frontal lobe CVA with left sided weakness, worsening Left hand contracture, Hyperlipidemia . Date Initiated: 2/17/20. Created on: 2/17/20. Revision on: 1/10/24 . Interventions: . R11 may wear his resting hand splint to left hand, his wife may apply as desired. Date Initiated: 1/3/24. Created on: 1/3/24.Revision on: 3/25/24 . R11's Care Sheet, dated 11/5/24, states, in part: . Resting hand splint to left hand over night . CNA tasks in PCC for R11 indicates CNAs are to wash and dry left hand thoroughly then apply wrist support every day. On in morning and off at bedtime. On 11/4/24, at 10:31AM, Surveyor observed R11 with left arm/hand splint on but not strapped into place, hanging loosely. On 11/4/24, at 10:31AM, Surveyor interviewed FM W (family member) who indicated CNAs apply the splint to R11's left hand/arm. It does not have to be on 24 hours, but it is usually kept on most of the day, every day and during night. FM W indicated the CNAs do not know how to put the splint on correctly and showed Surveyor it was not strapped on at this time. On 11/5/24, at 2:01PM, Surveyor interviewed CNA X who indicated R11's hand splint to left hand goes on at bedtime and comes off in the morning for cares then a rolled-up wash cloth is placed in left hand. R11's left hand gets washed when splint is removed. On 11/5/24, at 2:25PM, Surveyor interviewed LPN S (Licensed Practical Nurse). LPN S indicated the facility does not have a restorative program, but therapies will give nursing direction for example a resident is to walk so many steps a day. The nursing staff will provide that. LPN S indicated whatever staff is assigned to a resident would be responsible to carry out therapy directions. Surveyor asked LPN S how CNAs would know therapy directions and LPN S indicated it would be on the CNAs care sheet. Surveyor asked when R11 is to wear his arm splint and LPN S indicated R11 should be wearing it now. LPN S then looked at the CNA care sheet and indicated the sheet states the splint is to be on at night and off during the day. Surveyor asked LPN S if we could go make an observation of R11. LPN S and Surveyor noted R11 had the left splint on R11's left hand. LPN S removed the splint and indicated according to the care sheet he is not to have it on. LPN S then looked at R11's care plan and indicated the care plan states R11 may wear splint as desired, and the care sheet states at night. LPN S indicated they should be in sync with each other and are not updated. Surveyor asked how CNAs would know what to follow and LPN S indicated they wouldn't as they should be the same. As Surveyor was talking with LPN S, LPN Y who was sitting at desk next to LPN S indicated looking at R11's CNA tasks in PCC, it states left arm splint is to be on in am and off at bedtime. LPN S indicated now we have three different directions. The directions should be the same on care sheet, care plan and tasks. On 11/5/24, at 2:55PM, Surveyor interviewed OT R and asked when R11 should have his left arm splint on, and OT R indicated the splint is to be on when R11 is up out of bed. If R11 is napping or at night, there is no need to have the splint on. On 11/6/24, at 9:33AM, Surveyor interviewed DON B. Surveyor informed DON B of LPN S and Surveyor's findings regarding conflicting instructions for R11's left arm/hand splint. Surveyor shared there are conflicting orders in the care plan, care sheet and CNA tasks. DON B indicated the instructions should be the same on all three and DON B indicated they are fixing that. Surveyor asked how staff would know which instruction to follow and DON B indicated they would not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure that a resident who requires dialysis receives such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 1 sampled resident (R5) reviewed for dialysis. Facility staff were not fluent in the emergency plan for a resident bleeding from their dialysis fistula site. This is evidenced by: The facility's policy titled Dialysis Services last revised on 8/2013 does not include an emergency plan. According to Clinical Journal of the American Society of Nephrology article titled Diagnosis, Treatment, and Prevention of Hemodialysis Emergencies dated February 2017, .Vascular Access Hemorrhage: Hemorrhage from an AV access is an uncommon but potentially fatal complication if it is not recognized promptly and acted on with an appropriate intervention. Most fatal vascular access hemorrhages occur outside of the dialysis facility, but occasionally, they rupture at the dialysis unit (120). Patients and their families should be educated about the recognition and emergent management of a bleeding AV access . In the event of bleeding from vascular access site, direct continuous pressure with a finger for 15-20 minutes is the most effective method of controlling the bleeding. In the event of rupture of a PSA or aneurysm away from dialysis unit or hospital, direct pressure with a finger at the site of bleeding is the best method of controlling bleeding. Patients should be advised to continue holding direct pressure until emergency medical help arrives and avoid applying a tourniquet, towel, or BP cuff to the extremity . Diagnosis, Treatment, and Prevention of Hemodialysis Emergent .: Clinical Journal of the American Society of Nephrology R5 was admitted to the facility on [DATE] with diagnoses that include displaced comminuted fracture of shaft of right femur, malignant neoplasm of esophagus, wedge compression fracture of fourth lumbar vertebra, and type 2 diabetes mellitus with moderate NPDR (nonproliferative diabetic retinopathy (early stage of diabetic eye disease)). R5's most recent MDS (Minimum Data Set) dated 10/15/24 states that R5 has a BIMS of 12 out of 15, indicating that R5 has moderate cognitive impairment. R5's care plan initiated on 10/8/24 does not include steps for staff to take if R5 is bleeding from his dialysis fistula. R5's CNA (Certified Nursing Assistant) [NAME] does not include steps for staff to take if R5 is bleeding from his dialysis fistula. On 11/5/24 at 2:25 PM, Surveyor interviewed CNA U. Surveyor asked CNA U what steps she would take if she walked in and saw a resident bleeding from their dialysis fistula, CNA U reported that she would go get the nurse. On 11/5/24 at 2:27 PM, Surveyor interviewed CNA V. Surveyor asked CNA V what steps she would take if she walked in and saw a resident bleeding from their dialysis fistula, CNA V reported that is a nurse's area. CNA V also indicated that she would make sure the resident is ok and then step out to let the nurse know. On 11/5/24 at 2:30 PM, Surveyor interviewed CNA T. Surveyor asked CNA T what steps she would take if she walked in and saw a resident bleeding from their dialysis fistula, CNA T stated that she would call the nurse via walkie talkie, make sure the resident is comfortable, and wait for the nurse. Surveyor asked CNA T how staff knows which residents are receiving dialysis, CNA T reported that there is a sheet of paper in the charting room with information on it. Surveyor asked CNA T if she knew what residents are currently on dialysis, CNA T stated no. It is important to note that CNA T was working on R5's hallway. On 11/5/24 at 3:30 PM, Surveyor interviewed LPN S (licensed Practical Nurse). Surveyor asked LPN S what steps he would take if he walked in and found a resident bleeding from their dialysis fistula, LPN S stated that he would apply pressure, notify the MD (Medical Doctor), and obtain further orders. Surveyor asked LPN S what he would expect the CNAs to do in that situation, LPN S stated that they should get one of the nurses ASAP (as soon as possible). On 11/5/24 at 3:38 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what the expectation is for CNAs if they walk into a dialysis resident's room and the resident was bleeding from their fistula, DON B reported that she would expect them to make sure the resident is safe, apply direct pressure, and call the nurse immediately. Surveyor asked DON B if she expects the CNAs to know what residents are on dialysis, DON B reported that the night shift CNAs know who they are so they can get them up and ready in the morning. Surveyor asked DON B if she expects that the CNAs know how to respond to a resident that is bleeding from their dialysis fistula, DON B stated that if it is not something that is taught in their CNA class, she can't expect them to know how to respond. They are told and advised to call the nurse right away because it is a change in condition and that's how they should respond. Surveyor asked DON B if staff is trained upon hire, DON B deferred Surveyor to RN C (Registered Nurse). Surveyor reviewed the staff training checklist that was provided; the checklist does not include education about dialysis safety. On 11/6/24 at 8:46 AM, Surveyor interviewed RN C. Surveyor asked RN C what the expectation is for CNAs that come across a dialysis patient that is bleeding from their fistula, RN C reported that the CNAs should get the nurse right away, and that she is training staff on that now. Surveyor asked RN C if she would expect the CNAs to know which residents are on dialysis, RN C stated yes. Surveyor asked RN C if the CNAs have previously been trained on what to do if a dialysis patient is bleeding out of their fistula, RN C stated no. On 11/6/24 at 10:06, DON B reported to Surveyor that she met with R5 who reported that he doesn't have a fistula, but instead has an Ellipsys device and R5 reported that he doesn't bleed. On 11/6/24 at 1:48 PM, Surveyor interviewed RN Z (dialysis center nurse). Surveyor asked RN Z to explain R5's dialysis access, RN Z stated that he has a fistula in his upper left arm and that it is called an Ellipsys. Surveyor asked RN Z if this is a new type of device, RN Z stated that it is an endo- vascular access, so instead of having a large scar and access, this is a tiny incision where they insert a catheter type of tool. RN Z stated that it is a minimally invasive process. Surveyor asked RN Z if R5 has a decreased risk for bleeding, RN Z stated that they treat it the same as a normal fistula- they hold pressure for 10-15 minutes after dialysis and tell the patient to report any bleeding; there is the same risk as any other access.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not ensure that 4 of 4 sampled residents (R333, R5, R7, and R131) received treatment and care in accordance with professional standards of practice for foot care. The facility failed to ensure daily diabetic foot checks were completed for R333, R5, R7, and R131. As evidenced by: The facility does not have a policy for diabetic foot care. The current standard of practice per the American Diabetes Association copyright 1995-2024, https://diabetes.org, includes, in part: .1. Check your feet daily for sores, cuts, cracks, blisters, or redness . The facility follows PALTmed (Post- Acute and Long- Term Care Medical Association) standard of practice (SOP) dated 8/22/24, .Table 24. Suggested Elements of Comprehensive Monitoring for Patients with Diabetes Who Have Minimal Physical and Cognitive Impairments (emphasis intended) . Foot care: *Daily inspection by patient if able. *Weekly inspection by caregivers * Annual comprehensive foot examination by practitioner (Inspection, evaluation of foot pulses and loss of protective sensation) . Diabetes_Text-August22-2024.pdf It should be noted the SOP is in regard to persons with minimal physical and cognitive status as it relates to allow patient to check feet daily. Example 1 R333 was admitted to the facility on [DATE] with diagnoses including, but not limited to, diabetes mellitus type 2 with neuropathy, fracture of upper and lower end of left fibula, chronic kidney disease stage 3, muscle wasting and atrophy, idiopathic chronic gout, Parkinson's Disease, Dementia. R333's MDS (Minimum Data Set) with a ARD (Assessment Reference Date) of 10/31/24 indicates R333's BIMS (Brief Interview of Mental Status) was an 11 indicating R333 has moderate cognitive impairment. Surveyor reviewed R333's medical record and current physician orders. There is no evidence that CNA's (Certified Nursing Assistants) are checking diabetic residents' feet daily and reporting to the nurse. The facility failed to ensure daily diabetic foot checks were completed for R333. On 11/6/24 at 2:48 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B, does the facility complete daily diabetic foot checks. DON B indicated all CNAs (Certified Nursing Assistants) are instructed to check the feet when they do head to toe check with cares twice daily and to let the nurses know if there are any issues. DON B stated, we do not treat diabetics any differently because all residents get washed up daily. DON B also stated, the nurse does a weekly head to toe and skin assessment on the resident's bath day. DON B stated they don't have a specific diabetic foot check policy and nurses are not doing daily diabetic foot checks. It should be noted due to R333's cognition staff should be assisting R333 with daily foot inspections. Example 4 R131 was admitted to the facility on [DATE] with diagnoses that include fracture of Unspecified part of neck of left femur, Unspecified fracture of the lower end of left radius, Fibromyalgia, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Major Depressive Disorder, Pain in left hip, Muscle wasting and atrophy, Muscle weakness generalized, Other lack of coordination, Other reduced mobility, Need for assistance with personal care. R131 is unable to check her own feet daily due to two recent fractures and impaired mobility. R131 is reliant upon the facility staff to check her feet daily, per standard of practice. Surveyor reviewed R131's medical record and current physician orders. There is no evidence that CNA's (Certified Nursing Assistants) are checking diabetic residents' feet daily and reporting to the nurse. The facility failed to ensure daily diabetic foot checks were completed for R131. On 11/4/24 at 2:10 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if the facility completes daily diabetic foot checks. DON B indicated the CNAs are instructed to do head to toe skin checks on the residents when they do their cares on a daily basis, and to let the nurses know if there are any concerns. DON B stated that the nurse's do a weekly skin assessment on the resident's bath day. DON B indicated that the facility did not have a specific policy regarding diabetic foot checks, as all residents are treated the same. Surveyor asked DON B if the nurses were doing daily diabetic foot checks. DON B replied that they were not. Example 2 R5 was admitted to the facility on [DATE] with diagnoses that include displaced comminuted fracture of shaft of right femur, malignant neoplasm of esophagus, wedge compression fracture of fourth lumbar vertebra, and type 2 diabetes mellitus with moderate NPDR (nonproliferative diabetic retinopathy (early stage of diabetic eye disease)). R5's most recent MDS (Minimum Data Set) dated 10/15/24 states that R5 has a BIMS of 12 out of 15, indicating that R5 has moderate cognitive impairment. R5's CNA (Certified Nursing Assistant) [NAME] states in part .Transfer: 2A SPT (2 Assist Stand Pivot Transfer) to commode or w/c (wheelchair) with FWW (Front wheeled walker) GB (Gait Belt). AMB (Ambulation): 2A Short walk to bathroom with FWW . R5's care plan created on 10/8/24 and updated on 10/15/24 and 10/24/24 states in part .Impaired Functional Status r/t (related to) s/p (status post) fall with comminuted and displaced right intertrochanteric femur fracture with s/p IMN (Intramedullary Nailing (a nail inserted inside if the canal of the bone)) (9/17), dx (diagnosis) of esophageal cancer, constipation, neuropathic pain, hyperphosphatemia, DM2 (diabetes mellitus type 2), NPDR, ESRD (End Stage Renal Disease) with hemodialysis .Interventions: .Dressing Assistance Level: Assist of 1 mod (moderate) to max (maximum) assist, Bathing Assistance Level: Assist of 1 mod assist . Surveyor reviewed R5's nurse's notes, MAR/ TAR (Medication Administration Record/ Treatment Administration Record) and there was no evidence that facility staff were completing daily diabetic foot checks. On 11/6/24 at 1:02 PM, Surveyor interviewed RCM K (Resident Care Manager), who is also the wound nurse. Surveyor asked RCM K if the nurses completed daily diabetic skin checks, RCM K stated that they have weekly skin checks that the nurses complete and that there are certain things that the CNAs do and report back to the nurses. On 11/6/24 at 2:45 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what the Standard of Practice was that they follow for diabetic foot checks, DON B reported that they do not treat diabetic residents any differently than residents without diabetes and that the CNAs are told to report any changes immediately. Surveyor requested a copy of the facility's Diabetic Foot Check Policy, DON B stated that they do not have one. It is important to note that R5 has impaired mobility and impaired vision and should not be expected to complete his own daily diabetic foot checks. Example 3 R7 was admitted to the facility on [DATE] with diagnoses including, but not limited to, diabetes mellitus type 2. R7 was later diagnosed with malignant neoplasm of prostate, secondary malignant neoplasm of bone, dementia with neuropathy, and chronic gout. R7's (Minimum Data Set) with a ARD (Assessment Reference Date) of 7/31/24 indicates R7's BIMS (Brief Interview of Mental Status) was a 0 indicating severe cognitive impairment. R7 cognitive impairment documents: R7 has impaired cognitive function/dementia and impaired though processes r/t dx(s) of dementia and malignant neoplasm of prostate. Goal: R7 will be able to communicate basic needs on a daily basis through the review date. Interventions: .ask yes/no questions in order to determine R7's needs. Re-approach if needed. Identify yourself at each interaction. Face R7 when speaking and make eye contact. Reduce any distractions-turn off TV, radio, close door, etc. Cue reorient and supervise as needed; R7's family member is his APOAHC. Include her in all health care related decisions Surveyor reviewed R7's medical record and current physician orders. There is no evidence that CNA's (Certified Nursing Assistants) are checking diabetic residents' feet daily and reporting to the nurse. The facility failed to ensure daily diabetic foot checks were completed for R7. It should be noted that R7 has Dementia and would not be able to complete his own diabetic foot checks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility did not ensure that each resident receives food and drink that is palatable and at a safe and appetizing temperature. This has the potential to affect the total census of 30 residents. Residents (R) voiced concerns of food not being served at a desirable temperature (R132 and R133). 2 of 2 test trays were observed to not be served at desirable temperatures. Evidenced by: The facility policy titled Food Production and Food Safety: Food Temperatures, dated 2023, includes in part: 1. All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees Fahrenheit. A. Cooking temperatures must be reached and maintained according to regulations, laws and standardized recipes while cooking. B. Hot food items may not fall below 135 degrees Fahrenheit (F) after cooking . 2. All cold food items must be stored at a temperature of 41 degrees F or below. 3. Temperatures should be taken periodically to assure hot foods stay above 135 degrees F and cold foods stay below 41 degrees F during the holding and plating process and until food leaves the service area . 5. Food preparation areas will follow these methods: A. Hold foods at or below 41 degrees F for cold foods and at or above 135 degrees F for hot foods (to keep food out of the temperature danger zone) . Example 1 R132 admitted to the facility on [DATE]. Her MDS (Minimum Data Set) has not been completed by the facility yet. On 11/4/24 at 9:50 AM, Surveyor interviewed R132 who indicated that she usually eats in her room and that her food is never hot. Example 2 R133 admitted to the facility on [DATE]. Her most recent MDS with an ARD (Assessment Reference Date) of 10/25/24 indicates her cognition is intact with a BIMS (Brief Interview of Mental Status) score of 15 out of 15. On 11/4/24 at 10:14 AM, Surveyor interviewed R133 who indicated that she usually eats in her room, that it takes a while for the food to get to her, and that the food is not warm by the time it reaches her. Example 3 On 11/4/24 at 11:01 AM, Surveyor interviewed [NAME] D who stated that she takes the temperature of the food as it comes out of the oven, then it is placed on an electric cart that is plugged in and keeps the food warm. [NAME] D indicated that when the food is ready, the electric cart is taken up to the dining room, where the cook who is serving the food takes the temperatures again before plating the food. On 11/4/24 at 12:48 PM, Surveyor received a test tray after all of the dining room and hall trays had been served. (Of note, the plates for the room trays are set directly onto the tray and are covered by a thin metal cover that has a hole in the top center of it). Surveyor took the temperatures of the food that was served, including salmon, broccoli, mashed potatoes with gravy, cut up melon, milk, and coffee. Surveyor noted that several of the items were not palatable including the broccoli (temperature of 115 degrees F), which also tasted cold, melon (temperature of 52 degrees F), and milk (temperature of 44 degrees F). Example 4 On 11/5/24 at 8:50 AM, Surveyor received a test tray after all of the dining room and hall trays had been served. Surveyor took the temperatures of the food that was served, including scrambled eggs, sausage link, Belgian waffle, cottage cheese, and milk. All of the food items were found to be not palatable including the scrambled eggs (temperature of 124 degrees F), which also tasted cold, sausage link (temperature of 130 degrees F), waffle (temperature of 132 degrees F), cottage cheese (temperature of 49 degrees F). The milk's temperature was 41 degrees F. On 11/6/24 at 9:56 AM, Surveyor interviewed Executive Chef J (EC). Surveyor asked EC J if he would expect the food that is served, even the hall trays or at the end of meal service to be at the desired temperatures. EC J replied yes, that would be his expectation. EC J stated that periodically they get resident concerns about food not being served at the proper temperatures, but nothing recently.

Based on observation and interview, the facility did not distribute and serve food in accordance with professional standards for food service safety. This has the potential to affect all 30 residents. Facility staff were observed touching multiple items in the kitchenette while serving and handling food without changing gloves or performing proper hand hygiene. Multiple cooks and dietary aide were observed dishing up lunch from the steam table with gloves on, stepping away from the steam table, touching other surfaces in the kitchenette, and returning to the steam table for meal plating with the same gloves on. Facility staff were also observed touching common surfaces in the kitchenette, then touching ready to eat foods while wearing the same pair of gloves. Cook E and [NAME] F were observed taking the food temperatures of several food items. [NAME] E and [NAME] F were observed wiping the thermometer probe with an alcohol wipe and inserting it into the next food item without allowing the alcohol to fully air dry, causing a risk of food cross contamination. Evidenced by: Facility policy, entitled Infection Control Policies, Hand Washing, dated 2023, includes in part, Policy: Employees will wash their hands as frequently as needed throughout the day using proper hand washing procedures . Procedure: Hands and exposed portions of arms should be washed immediately before engaging in food preparation . 1. When to wash hands: . F. After handling soiled equipment or utensils. G. During food preparation, as often as necessary, to remove soil or contamination and prevent cross contamination when changing tasks . I. Before donning disposable gloves for working with food and after gloves are removed. J. After engaging in other activities that contaminate the hands (i.e., answering a phone call, using a computer, table, or smartphone, handling trash, etc.) . On 11/4/24 at 11:28 AM, Surveyor observed [NAME] E temping the food in the steam table before serving. [NAME] E was noted to insert the thermometer probe into one food item, wait approximately 2-3 seconds, and then insert the thermometer probe into the next food item without waiting for the alcohol on the thermometer probe to fully dry. On 11/4/24 at 11:36 AM, [NAME] F took over for [NAME] E and began temping the food. Surveyor observed [NAME] F temping the food in the steam table by inserting the thermometer probe into one food item, wait approximately 2-3 seconds, and then insert the thermometer probe into the next food item without waiting for the alcohol on the thermometer probe to fully dry. Surveyor observed [NAME] F placing the bare thermometer probe on the kitchenette counter in between temping of the food without properly sanitizing the thermometer probe. On 11/4/24 at 11:46 AM, [NAME] F donned two pairs of disposable gloves and began meal service. Surveyor noted that the first pair of gloves was torn by the left thumb. Surveyor observed [NAME] F dishing up food from the steam table, stepping away from the steam table and touching drawers, a pen, the refrigerator door, meal cart doors, cupboard doors, and then returning to the steam table and dishing up food without changing gloves or performing hand hygiene. Surveyor also observed [NAME] F touching cookies, bread, and pats of lemon butter with the same pair of gloves. On 11/4/24 at 12:13 PM, Surveyor observed Dietary Aid G (DA) enter the kitchenette, wash hands, and donn a pair of disposable gloves. Surveyor observed DA G touching the silverware, refrigerator door, meal tickets, stepping to the steam table to dish up food, stepping away from the steam table and touching a dinner roll with the same pair of gloves. On 11/4/24 at 12:31 PM, Surveyor observed [NAME] H enter the kitchenette and donn a pair of disposable gloves. Surveyor observed [NAME] H dishing up food at the steam table, stepping away from the steam table, touching the freezer door and scooping ice cream, then touching a cookie and touching bread to make a sandwich while wearing the same pair of gloves. On 11/4/24 at 12:56, Surveyor interviewed [NAME] F, who indicated that all kitchen staff had received education on topics such as sanitation, hand hygiene, and food safety. Surveyor asked [NAME] F if there was a risk for cross contamination if wearing the same gloves to touch food after touching common surfaces. [NAME] F stated yes there would be a risk for cross contamination. Surveyor asked [NAME] F how long he had waited for the alcohol to dry after using it on the thermometer probe. [NAME] F replied he had only let it dry for three seconds before inserting the thermometer probe into the next food item. On 11/5/24 at 8:12 AM, Surveyor observed [NAME] H wearing disposable gloves during meal service. Surveyor observed [NAME] H touching the oven handle, waffle maker, a pen, the sink faucet, the refrigerator door, and then handling cooked waffles and a hardboiled egg with the same pair of gloves. On 11/5/24 at 8:41 AM, Surveyor observed [NAME] I wearing disposable gloves and touching the drawer, refrigerator door, bread for toast, the toast lever, and the toast coming out of the toaster while wearing the same pair of gloves. On 11/5/24 at 9:06 AM, Surveyor interviewed [NAME] H who indicated they had received education at their weekly meetings about hand hygiene and food safety. Surveyor asked [NAME] H when hand hygiene should be performed. [NAME] H stated anytime you switch between activities, you should wash hands or change gloves. Surveyor asked [NAME] H if he had followed that during meal service. [NAME] H replied no, as he was constantly grabbing the cooked waffles off the waffle maker. Surveyor asked how often the common surfaces in the kitchenette were sanitized. [NAME] H stated they are cleaned weekly. Surveyor asked if cross contamination could occur if the kitchen staff were touching common surfaces and then touching food without changing gloves or performing hand hygiene. [NAME] H replied, yes, definitely. On 11/6/24 at 9:56 AM, Surveyor interviewed Executive Chef J (EC). Surveyor asked EC J when he would expect staff to perform hand hygiene or change gloves. EC J indicated that he would expect staff to perform hand hygiene or change gloves during meal service anytime their gloves get contaminated by touching common surfaces and when switching between tasks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that there was a system in place for standard transmission-based precautions to be followed to prevent the spread of infections. This had the potential to affect all 30 residents. The facility failed to do the following: The facility had 14 residents and 9 staff that tested positive for COVID 19. The facility did not complete contact tracing or broad-based testing timely of all residents to identify if others were COVID positive. CNA L (Certified Nursing Assistant) worked for three (3) shifts while experiencing symptoms of cough, body aches, headache, and a sore throat. CNA L did not notify staff of his symptoms until they worsened while he was working at the facility. The facility is not utilizing source control timely on the affected unit. The facility's policy, COVID-19 Testing, Outbreak Situation and Specimen Collection for Licensed Care Areas, reviewed 2/2024, documents in part, as follows: It is the policy of the facility to ensure the safety of its residents and staff in the event of an infectious disease outbreak by complying with any and all directives and other communication from federal, state or local authorities, including but not limited to, the World Health Organization, CDC (Centers for Disease Control) and state and local health officials. Interpreting Results: Positive Tests: Any positive COVID-19 test means the virus was detected and you have an infection. Isolate and take precautions including wearing a high-quality mask to protect others from getting infected. Tell people you had recent contact with that they may have been exposed. Monitor your symptoms. Negative Tests: A negative COVID-19 test means the test did not detect the virus, but this doesn't rule out that you could have an infection. If you have symptoms: You may have COVID-19, but tested before the virus was detectable, or you may have another illness. Maintain precautions and do not report to work while symptomatic. Testing Newly Infected Resident or Employee (Outbreak Situation): A single new case of SARS-CoV-2 infection in any HCP (healthcare provider) or resident should be evaluated to determine if others in the facility could have been exposed. When performing an outbreak response to a known case, facilities should always defer to the recommendations of their local public health authority. A single new case of SARS-CoV-2 infection in any HCP or resident should be evaluated to determine if others in the facility could have been exposed. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g. unit, floor, other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. Staff who do not test positive for COVID-19 but have symptoms should follow facility policies to determine when they can return to work. Residents who have signs or symptoms of COVID must be tested as soon as possible. While test results are pending, residents with signs or symptoms should be placed on transmission based (TBP). Asymptomatic residents with close contact with someone with SARS-CoV-2 infection should have a series of three viral tests. Testing is recommended immediately but not earlier than 24 hours after exposure. If the test is negative, then test at 48 hours after the first test, and again 48 hours after the second negative test. This will typically be daily 1 (exposure day is 0)., then day 3, and day 5. The facility's policy, Infection Prevention and Control Program, last revised 7/2024, documents in part, as follows: Outbreak is the occurrence of more cases of a particular infection than is normally expected . The CDC (Centers of Disease Control), updated March 2024, includes the following guidance: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html states in part; Nursing Homes Assign one or more individuals with training in IPC (Infection Prevention/Control) to provide on-site management of the IPC program. Stay connected with the healthcare-associated infection program in your state health department, as well as your local health department, and their notification requirements. Report SARS-CoV-2 infection data to National Healthcare Safety Network (NHSN) Long-term Care Facility (LTCF) COVID-19 Module. See Centers for Medicare & Medicaid Services (CMS) COVID-19 reporting requirements. Responding to a newly identified SARS-CoV-2-infected HCP (Health Care Provider) or resident. When performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction's public health authority. A single new case of SARS-CoV-2 infection in any HCP or resident should be evaluated to determine if others in the facility could have been exposed. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, respectively. However, source control should be worn by all individuals being tested. In the event of ongoing transmission within a facility that is not controlled with initial interventions, strong consideration should be given to use of Empiric use of Transmission-Based Precautions for residents and work restriction of HCP with higher-risk exposures. In addition, there might be other circumstances for which the jurisdiction's public authority recommends these and additional precautions. If no additional cases are identified during contact tracing or the broad-based testing, no further testing is indicated. Empiric use of Transmission-Based Precautions for residents and work restriction for HCP who met criteria can be discontinued as described in Section 2 and the Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, respectively. If additional cases are identified, strong consideration should be given to shifting to the broad-based approach if not already being performed and implementing quarantine for residents in affected areas of the facility. As part of the broad-based approach, testing should continue on affected unit(s) or facility-wide every 3-7 days until there are no new cases for 14 days. If antigen testing is used, more frequent testing (every 3 days), should be considered. The facility's residents reside on one (1) floor (2nd floor) with the following four (4) halls and corresponding room numbers: East: 239-247 West: 213-223 North: 200-208 South: 224-233 The facility's outbreak affected 14 residents and 9 staff. On 8/19/24 DON B (Director of Nursing) began experiencing symptoms of cough and headache. DON B tested multiple times from 8/19 - 8/21/24. On 8/22/24 DON B tested Covid positive. On 8/19/24 and 8/20/24 RN M (Registered Nurse) completed treatments on all halls. On 8/21/24 RN M started experiencing symptoms of cough, sore throat, and congestion. On 8/22/24 RN M tested Covid positive. Of note after the facility discovered RN M was Covid positive there was no contact tracing or testing of the residents RN M had close contact with. On 8/22/24 CNA N (Certified Nursing Assistant) worked North and South halls. On 8/24/24 CNA N began experiencing symptoms of fever, cough, sore throat, headache, and fatigue. On 8/25/24 CNA N tested Covid positive. R3 (West Hall) began experiencing a cough on 8/23/24 and tested Covid negative. On 8/25/24 R3 tested Covid positive. R3's family member, who resides in Independent Living, was Covid positive and came to visit R3 at the facility. CNA L (Certified Nursing Assistant) worked the following shifts: On 8/21/24 CNA L worked on [NAME] Hall (except rooms [ROOM NUMBERS]). On 8/23/24 CNA L worked North Hall plus room [ROOM NUMBER] on South Hall. On 8/23 CNA L began experiencing symptoms of cough, body aches, headache, sore throat. CNA L worked his shift on 8/23. In addition, CNA L continued to work on 8/24 (below) and 8/26 (below) on the [NAME] Hall before testing Covid positive on 8/26 when his symptoms worsened. CNA L did not report his symptoms to the facility until 8/26, when he tested Covid positive. CNA L worked on 3 of 4 halls on the second floor. (Note, on 8/25 the facility began requiring all staff to wear masks.) On 8/25/24 the facility determined the outbreak began; the facility required all staff to wear masks. The facility did not initiate contact tracing or testing despite determining the facility was in an outbreak. Testing was not determined until 2 days later 8/27/24. On 8/26/24 two (2) other staff tested Covid positive. R15 (South Hall) began experiencing a cough on 8/26/24 and tested Covid positive the same day. On 8/26/24 R334 (South Hall) began experiencing symptoms (not documented) and tested Covid positive the same day. R334 was hospitalized for Covid and later discharged from the facility. On 8/26/24 the facility put admissions on hold, added additional air purifiers to the units, residents encouraged to mask during activities, put group therapy sessions on hold. RN C notified Public Health. On 8/27/24 the facility tested all residents. R2 (South Hall) began experiencing cough and hypoxia on 8/27/24 and tested Covid positive the same day. R2 was hospitalized for Covid and later returned to the facility. R20 (North Hall) began experiencing cough and congestion on 8/27/24 and tested Covid positive the same day. R10 (South) was not experiencing any symptoms. R10 tested Covid positive on 8/27/24. On 8/27/24 R335 (West Hall) began experiencing a cough and tested Covid positive the same day. R335 was receiving hospice care prior to being diagnosed with Covid and passed away a few hours after testing Covid positive. R336 (North) began experiencing a cough on 8/27/24 R336 tested Covid positive on 8/27/24. R7 (South) began experiencing symptoms (not documented) on 8/28/24. R7 tested Covid positive on 8/29/24. R8 (East Hall) was experiencing symptoms of cough on 8/30/24 and tested positive the same day. R11 (West Hall) began experiencing symptoms of fever, cough, and hypoxia on 8/30/24 and tested Covid positive the same day. R14 (West Hall) began experiencing symptoms of cough and body aches and sore throat on 9/2/24 and tested Covid positive the same day. R22 (West Hall) began experiencing symptoms of fatigue on 9/3/24 and tested Covid positive the same day. R13 (West Hall) began experiencing symptoms of loss of appetite on 9/4/24 and tested Covid positive on 9/5/24. RN C (Registered Nurse) completed, Covid outbreak August-September 2024 that documents the following: 8/22/24 two staff members test positive for Covid. 8/25/24 a 3rd staff member tests + for Covid and one resident tests + Masking required now for all staff on 2nd floor. 8/26/24 a 2nd resident tests + for Covid Admissions on hold. More air scrubbers (purifiers) placed on the unit (already had two out). Residents encouraged to mask during activities. Group sessions of therapy on hold. Public Health notified. 8/27/24 R2 with cough, Covid+. R20 (R2's roommate) then tested also + All 2nd floor residents Covid tested. 7 total residents with Covid on the unit. Public Health updated. All therapies now being held on the unit/staying in resident rooms if possible or masking if out of room. All group activities canceled for now. Admissions on hold. Limiting residents coming to dining room-primarily just residents needing assistance or oversight for swallowing come out to dining room. Only one resident at a table. Back dining room blocked off with wall divider and PPE (Personal Protective Equipment) placed for that to be the Covid+ resident dining area due to residents needing assistance with meals. Those residents masking to/from dining area and staff using appropriate PPE in that area. Covid negative residents encouraged to stay in rooms for meals. Encouraged visitors to mask, signs at elevators and on unit. 9/3/24 Three more residents tested positive for Covid over the weekend. Repeat testing done for surveillance of all 2nd floor residents who are not Covid positive. One more resident found to be positive during this testing. Continuing with all precautions listed above. 9/9/24 Back dining room opened back up for residents, (cleaned and disinfected). Covid+ residents to stay isolated in rooms (5 residents still in isolation). One staff member out with Covid, returning Friday 9/13. 9/10/24 Three residents still in Covid isolation, all on west hall. Resuming admissions, on north hall for now. Therapy resume taking residents down to therapy gym (continuing to mask or safely distance from others) 9/15/24 All resident now off Covid isolation. All staff have returned that were out with Covid. 9/16/24 Public Health Department notified by email of Covid + numbers for employees and residents. On 11/05/24 at 3:22 PM and 11/6/24 at 3:40 PM, Surveyor spoke with RN C, the facility's Infection Preventionist. Surveyor asked RN C, what Standard of Practice does the facility use for infection control. RN C stated, CDC (Centers for Disease Control) guidelines and CMS (Centers for Medicare and Medicaid Services). Surveyor asked RN C, how does the facility determine if an infection meets the criteria for the Standard of Practice. RN C stated, for Covid-19 it's based off the CDC, our Medical Director, and Infection Control through a local hospital. Surveyor asked RN C, is the Infection Control program conducted daily. RN C stated, yes. Surveyor asked RN C, when she works. RN C stated, Monday through Friday. Surveyor asked RN C, who monitor infections and potential outbreaks that occur on a weekend. RN C stated, on weekends staff has access to Covid tests, update providers, me, or the supervisor on call. Staff enter the information in progress note, communicate via PCC (Point Click Care), an electronic medical charting, do huddles so staff can identify outbreaks on the weekend and if they need to be monitoring other people for signs/symptoms. Surveyor asked RN C, when a staff member has signs/symptoms of illness how long are they out. RN C stated, the facility follows CDC guidelines. RN C added if there's a Covid-19 outbreak staff are out for at least 7 days. If they test negative that determines if they can return on day 8 otherwise, they are out for 10 days. Surveyor asked RN C, how do you determine if there is an active outbreak. RN C stated when we have 3 cases (residents and staff) together within 72 hours. Surveyor asked RN C, what date did you determine there was an outbreak. RN C stated, 8/25/24 was the third staff within 72 hours. Surveyor asked RN C, how many residents and staff had Covid. RN C stated, 14 residents and 9 staff. Surveyor asked RN C, did Covid positive staff work within 48 hours of symptom onset. RN C stated, yes. RN C reviewed the work assignments for staff that worked within 48 hours of symptom onset (below). RN C stated, on 8/25/24 they had 3 staff and 1 resident that tested Covid positive. Surveyor asked RN C, what did you do. RN C stated, we required all staff to wear a mask, added air purifiers to hallways, held admissions, encouraged all residents to mask, postponed group therapy, and notified Public Health on 8/26/24. Surveyor asked RN C, did the facility complete contact tracing or broad-based testing. RN C stated, on 8/27/24 the facility tested all residents. Surveyor asked RN C, did any residents test positive. RN C stated, yes, on 8/27/24 we ended up with a total of 4 more residents that tested Covid positive for a total of 7 Covid positive residents. Surveyor asked RN C, did you or anybody at the facility complete contact tracing. RN C stated, no. RN C stated, the nurses work at least two (2) wings during their shift. RN C added, contact tracing was hard to determine as nurses are all over. RN C added, she would not be able to contact trace residents over the last 48 hours prior to symptom onset. RN C stated, with future outbreaks the facility will keep residents to their rooms as much as possible if there's a respiratory outbreak or we know others have been exposed, eat in their rooms, wear a mask, distancing, and educate staff. RN C stated, we recently updated our Covid outbreak plan. Surveyor asked RN C, do you know why there was a delay with broad-based testing. RN C stated, no, we've gotten away from the asymptomatic testing. Once there was more affected and 2 halls affected, we decided to test the whole unit. RN C stated, that was part of our updated plan, educate staff and catching things earlier. RN C stated, staff were educated on PPE (Personal Protective Equipment), hand hygiene and masking. Surveyor asked RN C, for documentation of the training. RN C stated, there is no documentation just shift to shift education. RN C stated, the facility completed broad-based testing on 8/27/24 and did another round on 9/3/24. Surveyor asked RN C, who is responsible to do this. RN C stated, we usually discuss it as a team. Surveyor asked RN C, did the facility identify that it should happen sooner. RN C stated, Not in particular. Surveyor asked RN C, should broad-based testing have been completed on day 1, day 3 and day 5. RN C was not aware. Surveyor asked RN C, when CNA L (Certified Nursing Assistant) was working at the facility on 8/23, 8/24 and 8/26 was he experiencing symptoms of cough, body aches, headache, sore throat. RN C stated, yes. RN C added, CNA L started experiencing these symptoms on 8/23/24 and did not notify the facility until his symptoms worsened. Surveyor asked RN C, what would you expect staff to do when experiencing signs/symptoms of illness. RN C stated, staff should test for Covid and mask even if they think it's just allergies. RN C stated, if the Covid test is negative staff should retest two (2) days later or if they develop a fever or symptoms worsen. Surveyor asked RN C, did the facility educate CNA L. RN C stated, DON B (Director of Nursing) followed up with CNA L. Surveyor asked RN C, how soon would you expect CNA L and all staff to notify the facility when they are experiencing signs/symptoms of illness. RN C stated, Right away. Surveyor asked RN C, would you have expected CNA L to notify the facility right away when he started experiencing symptoms. RN C stated, Yes. Surveyor asked RN C, did the facility complete contact tracing for residents. RN C stated, no, we didn't know who comes out to the dining room or where staff worked or where residents are out and about more. RN C stated, the facility identified we need to isolate, test, initiate masking right away if 1 case. If a resident does have symptoms after hours or on a weekend we try to isolate them or mask. Like the first resident she did end up testing positive. Taking precautions such as masking if out and doing that retest. RN C stated, there is no documentation of this. On 11/06/24 at 4:05 PM, Surveyor spoke with DON B (Director of Nursing). DON B stated, the facility just revamped their Covid policy. DON B stated if it's patient #1 (first case) we isolate them. DON B stated, we will report to public health. DON B added, if an employee tests positive we will have all employees mask, isolation resident, day 5 we test, day 7 we test again to be sure. If we have two (2) cases we mask the whole time and the facility locks down essentially, look for trends. DON B added, after 2 cases we will start swabbing everybody (broad-based testing, signs in elevator asking visitors to please be aware of the Covid case/outbreak)-we can't not let them visit, hand hygiene, ask them to mask. We looked at actual assignment to see if anybody is getting isolated. At that point in time, we did not swab everybody we consult with medical director. We started to address that at our daily huddle. We looked at our staffing. With 3rd positive we held off on admissions. A Covid positive resident from IL (Independent Living) was here visiting R3; R3 was our first positive. DON B stated, we got notification the same day the visitor was sent out via 911 later that same day for Covid. Surveyor asked DON B, you were able to determine who gave R3 Covid, but not R3's contacts and did not do this for the other Covid positive residents. DON B stated, Yes. DON B stated, on 8/25/24 we sent Covid tests home with staff and let them know if their test is positive to let us know. DON B stated, At that point in time I would have expected RN C to swab (Covid test) all residents. DON B stated, some staff opted to wear an N95 to not get sick. Surveyor asked DON B, was education provided to CNA L after he worked multiple shifts while symptomatic with Covid. DON B stated, yes, he was written up (verbal) because it was a safety issue. DON B stated, CNA L stated from here on out he understands if he has a sniffle he is testing; DON B added, she was highly upset with him. DON B shared her computerized calendar with Surveyor. On 9/4/24, the date CNA L returned to work, DON B has the following meeting documented. Verbal disciplinary action, next time will be written. Conversation with CNA L advised is NEVER to come to work sick again, explained they why's of issues and then advised it is a safety concern. Advised he will receive a final written warning if this ever occurs again. DON B stated, following this outbreak she has started doing weekly infection control meetings with RN C. DON B added, every Monday she has a one (1) hour meeting with RN C to go through infection control.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all residents were able to formulate an advance directive, specifically related to code status, for 1 of 13 residents (R181) reviewed for code status. R181's most current code status preference form documents I do want CPR . (Cardiopulmonary Resuscitation, Full Code status) and his code status physician order and banner in the Electronic Health Record (EHR) indicate Do Not Resuscitate (DNR); these do not match. This is evidenced by: The Facility's Policy and Procedure titled Cardiopulmonary Resuscitation (CPR) - SNF (Skilled Nursing Facility), approved 1/2021, documents, in part: .Procedure .2. Upon admission to the facility, admission orders will be completed including the patient's wishes as expressed in their Advanced Directives or POLST (Physician Orders for Life Sustaining Treatment) and resuscitation status .4. The resident's Advance Directives and related physician's orders will be reviewed quarterly at the resident's Care Conference or upon significant change in condition. Resident and/or their legal decision-maker shall be asked whether the current orders are consistent with the resident's wishes. If changes or clarifications are requested, the attending physician shall be contacted to update orders to reflect such changes. Any changes shall be clearly documented by completion of a new POLST or Advanced Directive . R181 admitted to the facility on [DATE] and has an activated Power of Attorney for Health Care (POAHC). During the initial screening process of the survey, Surveyor reviewed the paper chart and electronic health record for R181. The [Facility Name] Resident Advance Directive Regarding Cardiopulmonary Resuscitation form in the resident's paper chart notes a typed x slightly outside of the box next to I do want CPR. The form is electronically signed by R181's activated power of attorney FM I (Family Member) on [DATE]. Of note, no time is listed. The form is also signed by a witness and the provider on [DATE] with no times listed. The Physician Orders and the banner in the facility's EHR indicate R181's code status as DNR. On [DATE] at 9:25 AM, Surveyor interviewed RN N (Registered Nurse) and asked where she would you look for a resident's code status. RN N indicated she would look on the face sheet in the EHR, the banner in the EHR or in the chart in the nurse charting room that has the code status form. Surveyor asked RN N where the first place she would look for code status is. RN N indicated the easiest place would be the chart in the charting room because that would have the signed sheet for code status. Surveyor requested RN N to look at R181's code status. RN N opened R181's EHR chart on her computer at her cart and indicated that R181's Advanced directive on his face sheet says DNR, the banner indicates DNR and RN N stated that DNR means do not resuscitate and so that means not to start CPR. On [DATE] at 9:45 AM, Surveyor interviewed RN D and asked where he would look for a resident's code status. RN D indicated, he looks in the computer underneath their banner or on the face sheet in the chart. Surveyor asked where he would look first. RN D indicated, probably the computer but really it depends on where I am in the building; for example, if I'm closer to the chart I would go there, if closer to the computer I would look there. Surveyor reviewed R181's DNR status in the banner of the electronic health record with RN D and asked what he would do if he saw this status. RN D indicated, it says DNR, so I would not start CPR. On [DATE] at 9:32 AM, Surveyor interviewed SDN O (Staff Development Nurse) and asked where she would look for a resident's code status. SDN O indicated, mainly in Electronic Health Record on the banner. Surveyor asked SDN O if this is the first-place staff should look. SDN O indicated it is the easiest because it's right there in the computer, otherwise in the chart on the face sheet. Surveyor asked SDN O who goes through the code status with residents/representatives on admission. SDN O indicated any of the admission nurses. Surveyor asked SDN O if she completes this. SDN O indicated, yes. Surveyor asked SDN O to review the process of code status with new admissions. SDN O indicated, they explain the form and what it means to be a full code versus a DNR. The form is filled out right there and then the form is signed by the provider if they are on site. Otherwise, when the doctor is called with the admission, we get the order with the other orders or other clarifications that are needed. We would write as a phone order or fax to get signature. Surveyor asked SDN O who is responsible for putting the code status in the different places. SDN O indicated when orders are put in the system, it flags into the banner. Whoever is checking off the orders makes sure there is a code status, and the unit clerk scans in all the paperwork. Surveyor asked SDN O who makes sure that the signed CPR/DNR form matches the order in the electronic health record. SDN O indicated, usually the HUC (Health Unit Coordinator) puts in the initial orders and then a nurse checks them off to ensure they are correct. Surveyor clarified with SDN O, the person checking the orders after the HUC should verify the code status form is the same and the orders that were put in the electronic health record. SDN O indicated, right, one nurse checks the orders after the HUC. On [DATE] at 9:40 AM, Surveyor interviewed MI/Coder M (Medical Information/Coder) and asked what the process is for new admissions and orders. MI/Coder indicated, when we get the signed orders from the hospital, basically we enter them in the electronic health record and then we let the nurse managers, or whoever is going to be doing the second look to sign them off, know and they will come and get the chart and get the second look and sign them off. Surveyor asked MI/C if she double checks the code status form that is filled out on admission with the orders, she puts in. MI/Coder M indicated this is done by the nurse. On [DATE] at 10:59 AM, Surveyor interviewed DON B (Director of Nursing) and asked who is responsible for obtaining the code status and having the form signed. DON B indicated when the facility gets the admission, the HUC or a nurse will put in the first orders and then it's double checked by one of the nurse supervisors or myself. The RCM (Resident Care Manager) also helps with check offs. If we notice we don't have orders for a DNR then we reach out to the provider, get the order, and put it in the computer. Surveyor asked DON B who checks the code status from the paper form matches the electronic health record. DON B indicated, either the nursing supervisors or myself, whoever puts them in, then a second person checks them. Surveyor asked DON B, once you have the code status, what is the process for getting the order into the electronic health record. DON B indicated, the nursing supervisors. The HUC is usually the first line person and then it is checked by a RN. Surveyor asked DON B if the HUC is putting in the orders from the hospital. DON B indicated, yes. Surveyor asked DON B if the HUC is checking the signed code form against the order. DON B indicated this would be done by the nurse. Surveyor showed DON B R181's facility code form that has the x marked just outside the box that indicates, I do want CPR, and his banner and physician orders currently in the electronic health record that show DNR. DON B indicated agreement that they did not match. DON B indicated that AA/QA J, (Admissions Assistant/Quality Assurance) in admissions, sent the form to R181's daughter, who is the POA, through the computer so she is the one who marked the form and sent it back. Surveyor asked DON B who would have been responsible for checking the form against the physician orders when it was received back. DON B indicated, the nurse but that she didn't see any initials on the form and usually there would be initials once it is checked by the nurse. DON B continued, when the daughter sent it back it would have gone to AA/QA J, and she would have printed it off. Surveyor asked DON B what AA/QA J should have done with the form when she received it. DON B indicated she should have given it to the HUC since it is an actual order. On [DATE] at 12:59 PM, Surveyor interviewed AA/QA J and asked if she sent the facility Resident Advanced Directive Regarding CPR form to R181's daughter AA/QA J indicated, yes and that an electronic document/signature program was used to send it. Surveyor asked AA/QA J if when the document is sent this way, it makes the document fillable. AA/QA J indicated, yes. Surveyor asked AA/QA J if the document was returned to her. AA/QA J checked the document program and indicated that the form was sent back to her and that she sent it to HUC L (Health Unit Coordinator), the upstairs HUC and that it was forwarded on [DATE] at 2:40 PM. Surveyor asked AA/QA J if she is only responsible for forwarding the document on. AA/QA J indicated, yes. On [DATE] at 1:11 PM, Surveyor interviewed HUC L and asked what she does with the facility labeled Resident Advance Directive Regarding CPR form when it is sent to her filled out. HUC L indicated, she makes sure it is complete, prints them, scans them into the system, and she usually looks to see that there is an order because it's usually already been put in. Surveyor asked HUC L, if she is responsible for making sure the order that is in the electronic health record matches what is on the form. HUC L indicated, yes. Surveyor asked HUC L what she does if it doesn't match. HUC L indicated that she gives it to the nurse manager. Surveyor asked HUC L what she does if the form does match the order in the system. HUC L indicated if it matches it is just scanned into the system. Surveyor asked HUC L if she could recall receiving or what she did with the facility form for R181. HUC L indicated, she could not recall. On [DATE] at 1:19 PM, Surveyor interviewed R181's RCM V and asked if she recalled anyone giving her R181's facility labeled Resident Advance Directive Regarding CPR form and telling her that the code status listed did not match what was in the electronic health record. RCM V indicated her understanding was that they had a state DNR form for R181. On [DATE] at 11:21 AM, Surveyor contacted FM I (Family Member) via telephone and asked if she recalled the facility talking with her about a code status form where it says I do want CPR, I do not want CPR. FM I indicated she did recall this and that do not want CPR should have been marked. On [DATE] at 11:48 AM, MDS Coordinator K (Minimum Data Set) came to the conference room to speak to surveyor. MDS Coordinator K showed surveyor a WI State DNR form that indicates R181's code status as DNR. The form is signed by FM I and includes a date and time by FM I's signature of [DATE] at 11:18 AM. This form is also signed by a provider on [DATE]. Of note, no time is documented by the provider signature. MDS Coordinator K indicated that on [DATE] when R181 was admitted she called FM I and let her know that he was here and confirmed his DNR status. MDS Coordinator K provided a progress note dated and timed [DATE] at 12:49PM that includes, in part, .Did confirm that DNR status was desired. Of note, the facility Advanced Directive Form that has I do want CPR marked is dated [DATE] with no time. The interview with AA/QA J indicated that she forwarded the signed from she received from FM I to the upstairs HUC on [DATE] at 2:40 PM. Surveyor put the facility form which indicated, I do want CPR, and the state DNR form she provided next to each other and asked MDS Coordinator K how the nurses on the floor would know which form to use for code status. MDS Coordinator K indicated she would use what was in the banner in the electronic health record. The facility had an unrecognized discrepancy between R181's code status between the paper forms and the electronic health record.

Based on interview and record review, the facility did not ensure that they had all assessments and behavioral interventions in place for 1 of 5 residents reviewed for unnecessary medications out of a total sample of 16 Residents (R133). R133 does not have resident-centered behaviors for the Certified Nursing Assistants (CNA) staff to monitor. R133 receives antipsychotic medication and does not have an assessment for tardive dyskinesia AIMS (Abnormal Involuntary Movement Scale) or Discus. R133 receives medication for insomnia and does not have a sleep assessment completed. This is evidenced by: The Facilities Policy and Procedure entitled Psychotropic Medication Management dated 10/2023, documents, in part: .To ensure that resident drug regimen is free from unnecessary drugs. An unnecessary drug is any drug when used .without adequate monitoring .A psychotropic drug is any drug that affects the brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: - Anti-psychotic, -Anti-depressant, - Anti-anxiety, and - Hypnotic .1. Indications for Use of Psychopharmacological Medications .k. Set up a monitoring system. 2. Monitoring for Efficacy and Adverse Consequences .f. For Antipsychotics: Abnormal Involuntary Movement Scale (AIMS) form will be completed upon initiation of therapy and every six months thereafter. g. Antipsychotic/Anxiolytics/sedatives/Hypnotics/ Antidepressants and other psychopharmacological drugs: Behavior assessment and monitoring of target behavior and monitoring for side effects will be completed during the duration of therapy .d. New Admissions .2. For residents who do not require a PASARR (Preadmission Screening and Resident Review- is a federal requirement established to identify individuals with mental illness and/or intellectual developmental disability to ensure appropriate placement in the community or a nursing facility) screening and are admitted on an antipsychotic medication, the facility must re-evaluate the use of the antipsychotic medication at the time of admission and/or within 2 weeks of admission (at the time of the initial MDS) (Minimum Data Set- which is a comprehensive assessment of the resident)) and consider whether or not the medication can be reduced or discontinued . [SIC] R133 admitted to the facility 9/18/23 for short term rehabilitation. R133 has the following diagnoses that support the use of the psychotropic medications he is prescribed: bipolar disorder, major depressive disorder, anxiety, and insomnia. R133 receives the following psychotropic medications: buspirone 15 mg (milligrams) BID (twice a day), clonazepam 0.5 mg 2 tabs QHS (every bedtime), desvenlafaxine succinate ER (extended release) 50 mg QD (every day), olanzapine 15 mg QHS, olanzapine 2.5 mg with meals (TID- three time per day), and paroxetine HCL (hydrochloride) ER 15 mg QD. Buspirone is classified as an anti-anxiety medication. Clonazepam is classified as a benzodiazepine medication which is approved to treat anxiety. Desvenlafaxine succinate ER is classified as a SNRI (serotonin and norepinephrine reuptake inhibitor) which is a type of anti-depressant medication. Olanzapine is classified as an anti-psychotic medication. Paroxetine HCL ER is classified as a SSRI (selective serotonin reuptake inhibitor) which is a type of anti-depressant. Example 1 R133's care plan includes the following targeted behaviors to monitor for the medications that he receives: anxiety/nervousness, insomnia/inability to sleep, and restlessness/agitation. R133's CNA (Certified Nursing Assistant) care plan does not list any type of behaviors to monitor for. R133's CNA documentation in the computer under the Task section includes an array of behaviors (i.e., hitting, kicking, biting, etc.) that are not resident specific, therefore, the CNA's do not have an area to document resident specific behaviors. R133 receives anti-psychotic medication, Olanzapine, and has not had an assessment (AIMS or Discus) for tardive dyskinesia. It is important to note this is to be assessed on admission to obtain a baseline and then every six months thereafter. R133 receives medications at bedtime that are not classified as hypnotic medication but are being utilized to treat his insomnia, and he has not had a sleep assessment. It is important to note this too should be assessed on admission to obtain a baseline and then quarterly with MDS. On 10/5/23 at 4:25 PM, Surveyor interviewed CNA E (Certified Nursing Assistant) Surveyor asked CNA E how they know what behaviors to report for R133, CNA E said he doesn't have behaviors, he's been really good so far, no problems. Surveyor asked CNA E how she would know what behaviors to monitor for individual residents, CNA E replied we can tell they're agitated or something. On 10/5/23 at 4:17 PM, Surveyor interviewed LPN F (Licensed Practical Nurse). Surveyor asked LPN F how the CNA's know what behaviors to report to the nurse for R133, LPN F replied he doesn't have any behavior issues, has bipolar, never see behavior issues. Surveyor asked LPN F who completes the tardive dyskinesia assessments for residents on antipsychotic medications, LPN F said nurses do the assessment, everyday each shift charts, it alternates odd and even rooms. Surveyor asked LPN F who completes the sleep assessment or sleep diary for residents receiving medications to induce sleep, LPN F stated the night shift nurse. On 10/5/23 at 4:22 PM, Surveyor interviewed LPN G. Surveyor asked LPN G how the CNA's know what behaviors to report to the nurse for R133, LPN G stated I've not seen any behaviors. Surveyor asked LPN G who completes the tardive dyskinesia assessments for residents on antipsychotic medications, LPN G said the MDS coordinator. Surveyor asked LPN G who completes the sleep assessment or sleep diary for residents receiving medications to induce sleep, LPN G replied staff monitor his sleep at night, will document hours he slept when the EMR (Electronic Medical Record) asks for it. On 10/5/23 at 4:25 PM, Surveyor interviewed LPN H. Surveyor asked LPN H how the CNA's know what behaviors to report to the nurse for R133 or other residents, LPN H explained there's a behavior report, in general if a resident is having behaviors, they would report them to the floor nurse. The CNA's have a spot in their charting where it talks about behaviors, and it would get charted there also. Surveyor asked LPN H who completes the tardive dyskinesia assessments for residents on antipsychotic medications, LPN H said usually the Social Worker does that. Surveyor asked LPN H who completes the sleep assessment or sleep diary for residents receiving medications to induce sleep, LPN H stated the CNA's chart every shift how many hours they slept that shift. Surveyor asked LPN H who is responsible to review the hours/documentation that the CNA's record, LPN H stated we have weekly meetings as part of the behavior meetings, sleeping medications are looked at during that meeting. On 10/5/23 at 4:40 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B how do the CNA's know what behaviors to report to the nurse for R133 or other residents, DON B explained that the CNA's have a task that is assigned for them to do, we do huddles that we just started this week - a group huddle at the beginning of the shift to monitor for behaviors or changes, as well as a communication tab (i.e. UTI (urinary tract infection signs/symptoms)) that the nurses and CNA's are required to read. Surveyor asked DON B should an assessment for tardive dyskinesia be completed for residents that are on antipsychotic medications, DON B said yes, on admission, with change of condition, with a decrease/increase in medication, and with MDS schedule. Surveyor asked DON B should a sleep assessment be done for residents that are receiving sleep inducing medications, DON B replied anyone who has an initial diagnosis of insomnia or medications that state insomnia or if noticing any trends during the night- like they're up during the night to rule out delirium. Surveyor asked DON B if that should be documented somewhere, DON B said under nursing assessments in EMR. Surveyor asked DON B how often the sleep assessment/diary should be done, DON B replied when we have a new admission; I would need to refer to the Policy and Procedure to be sure but initially, then probably 30 days after because after 30 days a resident has become long term, with change of condition, and with change in medication. Surveyor asked DON B to open up R133's record; Surveyor then asked DON B if he has a sleep assessment, DON B stated no he doesn't have one. Surveyor asked DON B if R133 should have an assessment for tardive dyskinesia, DON B stated yes, it should be under the misc. tab in the EMR. Surveyor asked DON B who is responsible for doing the tardive dyskinesia assessment (AIMS or Discus), DON B said their pharmacist, who has been off at a conference. Surveyor asked DON B who is responsible for the tardive dyskinesia assessment to be done in the Pharmacists absence, DON B said we would need to find someone who could. Surveyor asked DON B if R133 should have an assessment for tardive dyskinesia, DON B stated yes. Surveyor asked DON B if R133 should have a sleep assessment, DON B said if he has diagnosis of insomnia or is on a medication for sleep, then yes, he would need one.

Based on observation, interview, and record review, the facility did not ensure that it was free of medication rates of five percent or greater for 2 residents (R3 and R2) of six residents observed during medication pass. The facility had 28 opportunities and 2 medication errors resulting in 7.14% error rate. R3 has Physician Orders to receive Carvedilol with meals for hypertension. Surveyor observed RN C (Registered Nurse) administer R3's Carvedilol before the evening meal. This resulted in a medication timing error. R2 has Physician Orders to receive Artificial Tears Ophthalmic Solution (Artificial Tear Solution) Instill 1 drop into both eyes as needed for dry eyes admin QID prn (4 times per day as needed). Surveyor observed RN D (Registered Nurse) complete his checks during medication pass and voiced he was ready to administer medications. R2's artificial tears were expired. Evidenced by: The facility's policy, Medication and Treatment Administration, revised 1/2020, indicates, in part, the following: It is the policy of the Company that administration standards for the delivery of medications and treatments will be adhered to by all staff responsible for providing these services. Medications and treatments shall be administered as prescribed. The Seven Rights of medication administration shall be observed. i. Right Resident, ii. Right Drug, iii. Right Dose, iv. Right Time, v. Right Route, vi. Right Manufacturer/Pharmacy Recommendations/Right Documentation i.e give with food. vii. Right Documentation Example 1 R3's hospital admission orders, signed 10/3/23, indicate the following: 6.25 mg (milligrams) - Give 1 tablet by mouth with meals for HTN (hypertension). R3's Carvedilol blister pack indicates administer with morning and evening meal On 10/3/23 at 4:08 PM, Surveyor observed RN C (Registered Nurse) administer R3's Carvedilol. Dinner is served on R3's floor between 5:00 - 5:30 PM. The Carvedilol was not administered with a meal and was given approximately 50 minutes - 1 hour 20 mins before R3 would receive dinner. This resulted in a timing error. On 10/3/23 at 4:36 PM, Surveyor reported this medication error to DON B (Director of Nursing). On 10/5/23 at 10:54 AM, Surveyor spoke with DON B (Director of Nursing). DON B stated, after we spoke regarding the medication error on 10/3/23, she checked with R3 to see if he had any chest pain or shortness of breath. DON B stated, R3 stated, no. R3 voiced to DON B that he normally takes his Carvedilol with a meal when at home. DON B stated, dinner isn't served until 5:00-5:30 PM. DON B stated she changed his order to 9:00 AM (breakfast is served around 8:30 AM) and 6:00 PM that way he can take it with food. Surveyor asked DON B, would you expect R3's Carvedilol to be administered with food per the Physician Order and pharmacy recommendation. DON B stated, I would expect it was administered at supper time (clarified with the meal.) DON B stated, RN C told her it was within 1 hour before 1 hour after, however, that's not how the order is written. DON B stated, she checked with the Pharmacist and she said it should be given with food. Example 2 R2 has Physician Orders to receive Artificial Tears Opthalmic Solution (Artificial Tear Solution) Instill 1 drop into both eyes as needed for dry eyes admin QID prn (4 times per day as needed). On 10/4/23 at 8:59 AM, Surveyor observed RN D (Registered Nurse) prepare R2's morning medications and Goodsense Artificial Tears. R2's Goodsense Artificial Tears have an Opened 9/1/23 documented and Expiration 10/1/23 documented. Surveyors observed RN D (Registered Nurse) lock his cart, pick up all medications including the eye drops, and turned to walk towards R2's room. Surveyor asked RN D if he is ready to administer R2's medications. RN D stated, Yes. Surveyor asked RN D, are R2's Goodsense Artificial Tears expired. RN D looked at the eye drops/label stated, Yes. RN D stated he will need to order new eye drops as the facility does not keep them on hand. RN D stated he should not administer expired medications. On 10/5/23 at 10:54 AM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B if she expects staff to follow Physician Orders. DON B stated, yes. Surveyor asked DON B, should staff check medication expiration dates to confirm they are not administering expired medication. DON B stated, yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure residents were being offered nourishing snacks at bedtime daily when there is more than 14 hours between a substantial evening meal and breakfast the following day. This has the potential to affect 31 of 31 residents and 4 of 4 units. R14, R19, R2, R15, and R135 voiced concerns that residents were not consistently being offered a snack at bedtime. There was more than 14 hours between the evening meal and breakfast that facility staff were not offering snacks to all residents. This is evidenced by: The facility policy, entitled Meal Service, dated 8/23, states in part, .Resident (meal) service begins at the following times: breakfast 7:45 AM, dinner 11:45 AM, supper 4:45 (PM) . (It is important to note there is 15 hours between the substantial evening meal and breakfast.) The facility policy, entitled Nourishment/Supplement dated 1/20, states in part, It is the policy of the company that snacks will be offered per resident choice and per their careplan. The type of snack offered will depend on the individual resident's diet and/or texture restrictions and nutritional needs. Resident's may request, and will be provided, a snack at any time unless contraindicated . Purpose: To offer additional food and fluids with between-meal servings. To provide special nourishments to residents with decreased appetite, weight loss or special medical conditions. To offer nutritional snacks at times other than regular mealtimes that accommodate resident choices . Example 1 R14 was admitted to the facility on [DATE], and has diagnoses that include: type 2 diabetes, vitamin D deficiency, and chronic kidney disease. R14's Minimum Data Set (MDS) quarterly assessment, dated 9/1/23, indicates that R14 has a Brief Interview for Mental Status (BIMS) score of 11 indicating that R14's cognition is intact. R14's MDS annual assessment, dated 6/5/23, Section F0400 indicates that it is somewhat important to R14 to have snacks available between meals. On 10/5/23 at 8:25 AM, Surveyor interviewed R14 regarding nourishing snacks offered at bedtime. R14 indicated that she is not offered a snack from facility staff before bedtime. R14 indicated that she would like to be offered snacks at bedtime daily. Example 2 R19 was admitted to the facility on [DATE], and has diagnoses that include: protein-calorie malnutrition, anemia (iron deficiency,) and chronic kidney disease. R19's MDS admission assessment, dated 9/6/23, indicates that R19 has a BIMS score of 13 indicating that R19's cognition is intact. Section F0400 indicates that that it is very important to R19 to have snacks available between meals. On 10/5/23 at 9:13 AM, Surveyor interviewed R19 regarding nourishing snacks offered at bedtime. R19 indicated that she is not offered a snack from facility staff before bedtime. R19 indicated that she does not recall facility staff offering her a snack at bedtime since her admission. R19 indicated that she would like to be offered snacks at bedtime daily. Example 3 R2 was admitted to the facility on [DATE], and has diagnoses that include anemia and chronic kidney disease. R2's MDS quarterly assessment, dated 9/8/23, indicates that R2 has a BIMS score of 14 indicating that R2's cognition is intact. On 10/5/23 at 9:26 AM, Surveyor interviewed R2 regarding nourishing snacks offered at bedtime. R2 indicates that she is offered a snack from facility staff before bedtime twice a week. R2 indicated that she would like to be offered snacks at bedtime daily. Example 4 R15 was admitted to the facility on [DATE] and has diagnoses that include: congestive heart failure, end stage renal disease, celiac disease, anemia, type 2 diabetes, vitamin D deficiency, and chronic kidney disease. R15's MDS admission assessment, dated 8/4/23, indicates that R15 has a BIMS score of 15 indicating that R15's cognition is intact. On 10/5/23 at 9:38 AM, Surveyor interviewed R15 regarding nourishing snacks offered at bedtime. R15 indicated that she was offered a snack once since her admission to the facility. R15 indicated that facility staff never comes around in the evenings and offers snacks to her. R15 indicates that her family is providing her with snacks. Surveyor asked R15 how often she would prefer to be offered a snack at bedtime by facility staff, R15 indicated every day. Example 5 R135 was admitted to the facility on [DATE], and has diagnoses that include: malignant neoplasm (cancer) of prostate, malignant neoplasm of bone, moderate protein-calorie malnutrition, muscle wasting and atrophy (progressive and degeneration or shrinkage of muscles or nerve tissues), anemia, and abnormal weight loss. R135's MDS quarterly assessment, dated 9/21/23, indicates that R135 has a BIMS score of 14 indicating that R135's cognition is intact. Section F0400 indicates that it is somewhat important to R135 to have snacks available between meals. On 10/5/23 at 9:18 AM, Surveyor interviewed R135 regarding nourishing snacks offered at bedtime. Surveyor asked R135 if facility staff is offering him a snack at bedtime. R135 stated, Sometimes. R135 indicated that he asks facility staff for an evening snack when he wants a snack. R135 stated, I like OJ (orange juice) routinely in the evenings. R135 indicated that staff is not offering OJ to him in the evenings/bedtime. R135 indicated that he would like to be offered snacks including his preferred glass of OJ at bedtime daily. On 10/5/23 at 11:10 AM, Surveyor observed facility's kitchenette to be stocked with nourishing snacks including, but not limited to, pudding, applesauce, yogurt, hard boiled eggs, tuna sandwiches, fruit cups, ice cream, sherbert, chex mix, milk, and juices. On 10/5/23 at 2:48 PM, Surveyor interviewed CNA P (Certified Nursing Assistant) regarding nourishing snacks offered at bedtime. CNA P has worked at the facility going on 2 years. CNA P was unable to recall a training process for an evening snack pass offering residents a nourishing snack at bedtime during this time. CNA P indicated that he offers snacks to resident that are not eating well. Surveyor asked CNA P if he is offering snacks to all residents? CNA P stated, Depending on the day, I get so busy, it gets to be hard. We try our best, at the end of the day some things fall short. On 10/5/23 at 1:12 PM, Surveyor interviewed CNA Q regarding nourishing snacks offered at bedtime. Surveyor asked CNA Q what the facility process is for offering snacks at bedtime? CNA Q indicated that snacks are offered to residents that didn't eat well, if a resident requests a snack, or if there is a snack order, the facility will offer resident snacks at the time the order specifies. CNA Q stated, There is no set time that we pass snacks. On 10/5/23 at 1:25 PM, Surveyor interviewed CNA S regarding nourishing snacks offered at bedtime. CNA S has worked at the facility for one and a half weeks. CNA S stated, I haven't had official training for a snack pass. On 10/5/23 at 2:34 PM, Surveyor interviewed CNA E regarding nourishing snacks offered at bedtime. CNA E indicated that he has worked at the facility for two years on the PM shift 2 PM-10 PM. CNA E indicated that if a resident asks for a snack, he provides residents with snack. CNA E stated, I don't offer residents a snack. Surveyor asked CNA E if he has received education or training on a snack pass process at bedtime? CNA E indicated that no training or education was provided. CNA E stated, I have never offered a snack. Surveyor asked CNA E if he offers diabetic resident a snack at bedtime? CNA E stated, We don't. On 10/5/23 at 3:06 PM, Surveyor interviewed LPN T (Licensed Practical Nurse) regarding nourishing snacks offered at bedtime. LPN T stated, I don't think that we have a scheduled snack routine. Surveyor asked LPN T if residents should be going 15 hours without a nourishing snack? LPN T indicated that a nourishing snack with proteins and carbs (carbohydrates) should be provided to diabetic residents to keep sugar levels up and prevent crashes. On 10/5/23 at 3:14 PM, Surveyor interviewed LPN F regarding nourishing snacks offered at bedtime. LPN F indicate that she has worked the PM shift at the facility for 17 years. LPN F indicated that facility staff does not pass snacks after supper. LPN F indicated that there is 15 hours in between supper and breakfast, and residents should be offered snacks at bedtime, especially diabetics. Surveyor asked LPN F why it is important to offer diabetic residents a snack, LPN F stated, Diabetic resident could crash without snack. On 10/5/23 at 3:37 PM, Surveyor interviewed DON B (Director of Nursing) regarding nourishing snacks offered at bedtime. Surveyor asked DON B what the process is for snack pass at the facility? DON B indicated that nursing staff request snacks as needed from the dietary department. The dietary staff stocks the kitchenette with snacks. DON B indicated that there is not designated staff responsible to pass snacks at bedtime. DON B stated, We don't have a lot of people who request snacks or have (eat) snacks. Surveyor asked DON B when PM snack should be passed? DON B indicated when a resident is a brittle diabetic. Surveyor asked DON B if she expects residents to go 15 hours without being offered a snack? DON B stated, If they are not hungry, I don't expect snacks to be offered. On 10/5/23 at 4:04 PM, Surveyor interviewed RD U (Registered Dietician) regarding the facility bedtime snack program. RD U indicated that when there is more than 14 hours in between mealtimes, a snack needs to be offered to residents. RD U indicated that the dietary department stocks the kitchenette with nourishing snacks and provides residents with the Always Available menu upon admission. The facility did not ensure residents were being offered nourishing snacks at bedtime daily when there is more than 14 hours between a substantial evening meal and breakfast the following day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure that pain management was provided consistent with standards of practice for 1 of 3 sampled resident (R1) out of 35. The facility did not thoroughly assess R1's pain according to standards of practice. This is evidenced by: The facility policy entitled, Pain Management, dated 6/21, states, in part: POLICY: To maintain each resident's right to have pain prevented or controlled adequately. PROCEDURE: . 7. Residents will be assessed (through interviews) at least once per shift so pain medications can be administered. 8. Complaints of pain and need for medication will be considered a STAT (immediate) intervention for administration of pain medication. If the resident currently does not have an order for pain medication, the physician will be notified for a medication order. For residents currently receiving pain medication regimen that is noted to be ineffective or have break through, the physician will be notified for further medication orders . R1 was admitted to the facility on [DATE] and has diagnoses that include fracture of unspecified part of neck of left femur, presence of artificial left hip joint, history of falling, and Alzheimer's disease with late onset. R1's Care Plan dated 3/24/23, states, in part: . Problem: Functional Status Interventions: Transfer of Assistance Level: Assist of 1 with standing lift Bed Mobility Assistance Level: Assist of 1 History of Falls . Problem: Services Date Initiated: 3/24/23 . Interventions: Pain Medication, Location of Pain, and Prescence/Characteristics of Pain: (specify) . Important to note: R1 was admitted to facility after having repair of left hip fracture. R1 has nothing in care plan regarding pain and pain interventions. R1's physician orders dated 3/27/23, states, in part: . Pain Monitoring every shift: Rate the pain level between 1-10 with 1 being the least amount of pain and 10 being the highest. Document location of pain Rate the intensity of pain using the following descriptors: A= Aching, B= Burning, C= Cramping, D=Dull, L= Localized, R=m Radiating, S= Sharp/Stabbing, T= Throbbing, O=Other every shift for Pain Non- Pharmacological Interventions Attempted: 0=not applicable, 1= distraction, 2= relaxation, 3= superficial massage, 4= breathing, 5= spiritual practices, 6= environmental modifications, 7= positioning/repositioning . -Acetaminophen Oral Tablet 500 mg (milligrams) (Acetaminophen) Give 2 tablets by mouth three times a day for pain Max daily dose 4000mg from all sources. Order date: 3/24/23 -Oxycodone HCI (hydrochloride) Oral Tablet 5 mg (oxycodone hci) Give o.5 tablet by mouth every 4 hours as needed for pain Order Date: 3/24/23 -Oxycodone HCI (hydrochloride) Oral Tablet 5 mg (oxycodone hci) Give 1 tablet by mouth every 4 hours as needed for pain Order Date: 3/24/23 . R1's March Medication Administration Record (MAR) shows: Acetaminophen Oral Tablet 500 mg (Acetaminophen) Give 2 tablets by mouth three times a day for pain max dose 4000 mg from all sources Start Date: 3/24/23 -3/24/23 shows the 4pm & 8pm doses were administered with no pain ratings or effectiveness noted - 3/25/23 - 3/28/23 shows the 6 am, 4pm & 8pm doses were administered with no pain ratings or effectiveness noted -3/29/23 shows the 6am dose not administered R1 in hospital On 3/24/23: Pain Monitoring every shift: Evening Pain Level- 0 Night Pain Level- 0 On 3/25/23: Pain Monitoring every shift: Day Pain Level- 0 Evening Pain Level- 2 Night Pain Level- 0 On 3/26/23: Pain Monitoring every shift: Day Pain Level- 0 Evening Pain Level- 1 Night Pain Level- 0 On 3/27/23: Pain Monitoring every shift: Day Pain Level- 5 Evening Pain Level- 0 Night Pain Level- 0 On 3/28/23: Pain Monitoring every shift: Day Pain Level- 3 Evening Pain Level- 3 Night Pain Level- 4 On 3/28/23: Pain Monitoring every shift: Day Pain Level- 3 Evening Pain Level- 3 Night Pain Level- 4 On 3/29/23: Pain Monitoring every shift: Day Pain Level- 6 Oxycodone HCI Oral Tablet 5 mg (Oxycodone HCI) Give 0.5 tablet by mouth every four hours as needed for pain Start Date: 3/24/23 . On 3/28/23 MAR shows administration at 4:03 PM for Pain Level- 3 Marked E for effective with no time On 3/28/23 MAR shows administration at 11:38 PM for Pain Level- 4 Marked E for effective with no time On 3/29/23 MAR shows administration at 5:20 AM Pain Level- 4 Marked U for unknown for effectiveness R1's Progress Notes: 3/29/23 at 4:42 AM, it documents: Change of Condition Note CNA (certified nursing assistant) noted, and writer assessed resident's right hip. Noted bruise dark purple in color 9cm (centimeters) x 1cm. Resident with onset of increased pain in right hip with movement. Due to resident's cognitive ability, she is unable to articulate exact location of pain, but gently ROM (Range of Motion) to right leg and resident was moaning with pain. Call placed to resident's APOA (activated power of attorney) at this time to update. Important to note: R1 moaning in pain no administration of pain medication until 5:20 AM. On 3/29/23 at 9:48 AM, it documents: Type: Change of Condition Note. Writer came in to assess pt. (patient) around 6:30 AM this morning and pt. was moaning and groaning throughout the whole interaction. Writer asked pt. where it hurt and pt. would not respond, she mumbled here and there only and was unable to have a conversation w/ (with) writer. Writer noted continued bruising to pt.'s R (right) hip and intact dressing to pt.'s L (Left) hip w/no drainage. CNA (Certified Nursing Assistant) then collected pt.'s vitals and it was noted her O2% (oxygen) was only steady between 89 - 90%, all other VSS (vital signs stable). Writer applied 1.5L (liters) of O2 on pt. and got her saturation up to 92%. Writer then called Clinic at 8:00 AM to report change of condition and got an order to send resident out to ER (emergency room) for an eval. Important to note- R1 was administered pain medication at 5:20AM and now at 6:30AM R1 continues to moan and groan in pain. Nothing is done for R1 at this time for continued pain to include non-pharmacologic interventions such as ice. Physician not updated until 8:00AM. On 3/29/23 at 9:58 AM, it documents: Type: Change in Condition. Writer called clinic at 8:00 AM to report change of condition and got an order to send resident out to ER for an eval. Writer then contacted (nonemergent ambulance service) and they were able to pick resident up around 9:30 AM. POA (power of attorney), updated on all of this. RCM (resident care manager) aware. Important to note: Resident had change in condition at 4:42 AM with increased pain with movement of right leg and purple bruising to right hip. Oxycodone 0.5 mg was administered at 5:20 AM and ineffective. Facility updated a physician at 8:00 AM (three hours and 18 minutes after onset of increased pain). Resident did not get transferred over to hospital until 9:30 AM (an hour and a half after the order was received to send R1 to ER). Nothing is done for R1's pain since administration of the oxycodone at 5:20AM and R1 continues to be in pain. On 3/29/23 at 1:01 PM, it documents: Type: Alert Note. Per ER nurse, resident admitted to the hospital for a broken R hip and bladder infection. Resident to have surgery tomorrow, per nurse. R1's hospital Discharge summary dated [DATE], states, in part: . admit date : [DATE] 10:10AM discharge date : [DATE] Disposition: Back to ALF (assisted living facility) with hospice . Primary Discharge Diagnoses: 1. Fall 2. Right Hip Fx (fracture) 3. Comfort Cares . Per H & P . She presented to the hospital with complaints of unwitnessed fall. Patient has dementia and is not able to provide medical history. POA/daughter is present and able to provide history .it sounds like the patient had an unwitnessed fall around 3 pm afternoon yesterday, was found on the floor of the bathroom around 5:30 PM .ER physician warranted pan-scan for unwitnessed fall . showed right hip fracture . Hospital Course: Fall & Right Hip Fracture Comfort Cares Left hip fracture 3/16/23 and now admitted w/subsequent fall and right hip fx which was surgically repaired 3/30 . Given advanced age and significant co-morbidities, she is at very high risk for complications and prolonged recovery . On 4/6/23, at 4:06 PM, Surveyor interviewed DON B (Director of Nursing) and reviewed progress notes together. Surveyor asked DON B when she would expect a call back from a physician after leaving a message with the triage nurse to update on R1's new onset of increased pain with movement of right leg and purple bruising to right hip area. DON B indicated 30 minutes. DON B indicated the clinic will not let the facility speak directly to the physician; they must update the triage nurse and the triage nurse sends the message to the physician and then the physician gets back to you. Surveyor asked DON B if an onset of increased pain with movement, R1 moaning in pain, and purple bruising to right hip occurring at 4:42 AM, would notifying a physician at 8:00AM be appropriate and DON B indicated no. Surveyor asked DON B after administering a pain medication when a nurse should reassess if pain medication was effective. DON B indicated within 30-60 minutes. What else could you expect a nurse to do if a resident's pain was not controlled after reassessing. DON B indicated the nurse could see what other medications could be administered, non-pharmacological interventions, and call on call physician. R1 had pain post fall and the facility did not attempt other interventions when R1's pain was not well controlled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure 1 resident (R13) of 13 sampled residents were reviewed for self-administration of medications. R13 was observed to have a Ziploc bag with a bottle of Tums tablets on R13's chair next to bed. R13 was observed to have an Albuterol Sulfate HFA Aerosol Solution inhaler and Nicotine inhaler at bedside. This is evidenced by: The facility's policy, Medication- Self Administration, with a revision date of 7/21, states, in part: . Policy: The facility will assure that a resident wishing to self-administer his/her own medications will be evaluated, determined as capable of doing so and have a safe storage area that prevents other residents from gaining access to the medication. Procedure: 1. Once the resident has been evaluated and determined to be capable of safely administering his/her own medications, the physician will be contacted, and a written order of approval will be obtained. 2. A Self-Administration of Medication Assessment will be completed by a licensed nurse. 3. Medications will be stored in a secure and lockable compartment in the resident's room. 4. Resident education will include: No sharing of medications. Not bringing medications into common areas of the facility. Giving discontinued medications to the licensed nurse for proper destruction. Reporting adverse reactions. Taking as directed. Not transferring into different containers. Keeping the facility appraised of changes. A change in condition status will require another Self-Administration of Medication assessment and possibly having to relinquish the medications to be dispensed by the licensed nurse. 5. Ask the resident for a return demonstration of his/her medication routine. 6. Continually evaluate the resident for status change which may indicate an inability to safely manage his/her own medication. Occurrences which may be of concern include Re-ordering medication too often or not often enough. Increased confusion and forgetfulness. Newly prescribed psychotropic medications. Cognitive or medical instability. R13 was admitted to the facility on [DATE] and has a diagnosis that include other intraarticular fracture of lower end of right radius subsequent encounter for closed fracture with routine healing, malignant neoplasm of unspecified part of right bronchus or lung, anemia, chronic obstructive pulmonary disease, essential hypertension, anxiety disorder, vitamin D deficiency, hyperlipidemia, depression, asthma, personal history of nicotine dependence and history of falling. R13's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 5/10/22 indicates R13's cognition is intact with a Brief Interview of Mental Status (BIMS) score of 13 out of 15. R13's Physicians orders, dated 5/3/22, states, in part: . Albuterol Sulfate HFA Aerosol Solutions 108 (90 Base) MCG/ACT 2 puff inhale orally every 4 hours as needed . *R13's Physicians orders, dated 5/5/22, states, in part: . Nicotine Inhaler 10 MG inhale orally as needed for smoking cessation. Will use own supply-RX do not send from Pharmacy. *R13 did not have an order for Tums. Important to note: an order for self-administration was not present on these orders. R13's current Care Plan does not indicate self-administration of any medications. R13's Self-Administration of Medication screen, created on 8/9/22 at 5:58 PM, indicates R13 is safe to self-administer medications. Important to note: Date of Assessment. Surveyor had requested a self-administration assessment for R13 prior. On 8/8/22, around 3:00 PM, Surveyor introduced self to R13. Surveyor asked R13 if R13 had any concerns or questions for Surveyor. R13 voiced concern that someone had taken her inhaler from her bedroom the morning of 8/8/22. R13 thought it was a Registered Nurse that took it but was not sure. R13 stated that they took her inhaler and didn't explain why just that she couldn't have it in her bedroom. R13 stated she had the inhaler in her bedroom and will use it when she needs it. Surveyor asked R13 about the Tums that were on her chair. R13 indicated the Tums on the chair were hers. R13 indicated she has a Nicotine inhaler in her bedroom that she will use, but that it doesn't really do much. R13 showed Surveyor her Nicotine inhaler that was by bedside. On 8/9/22, at 3:23 PM, RN L (Registered Nurse) indicated R13 had wanted to keep the Albuterol Sulfate inhaler in her bedroom, but that it was not currently in her bedroom. Surveyor asked if the Nicotine inhaler is in her bedroom. RN L indicated the Nicotine inhaler is in R13's bedroom. Surveyor asked RN L if RN L could show Surveyor R13's Self-Administration of Medication screen. RN L looked in R13's medical record on the computer and stated, I'm sorry, I don't see it. On 8/9/22, at 3:45 PM, R13 indicated to Surveyor R13 had an Albuterol Sulfate inhaler and Nicotine inhaler at bedside. Surveyor observed bottle of Tums in a Ziplock bag still on chair in bedroom. On 8/11/22, at 9:30 AM, DON B (Director of Nursing) and RN M indicated a Self-Administration of Medication screen should be completed before a resident self-administers medications. RN M indicated R13's screening was completed as soon as the facility learned about the medications being in R13's bedroom. R13's family is very involved and brought in the medications without the facility knowing. RN M indicated the Albuterol Sulfate HFA Aerosol Solution inhaler and Nicotine inhaler now have orders and the screening process was complete. RN M indicated R13 has two Albuterol Sulfate HFA Aerosol Solution inhalers. An RN picked up one of the inhalers on 8/8/22 because the RN thought it was left at bedside. The facility was unaware that R13 has two Albuterol Sulfate HFA Aerosol Solution inhalers. RN M indicated they did not know R13 had Tums in her bedroom, but now that they do, they will work on getting a Physician's order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure that every resident has the right to make choices about aspects of their life in the facility that are significant to them for 2 of 13 residents (R6 and R289) residents reviewed for choices. Resident (R6) requested her bedtime to be around 10:00 PM, staff will place items to get ready for bed after supper. R6 has been told by staff that she needs to go to bed because staff needed to leave work. Resident (R289) requested her bedtime to be around 9:00 PM, R289 reports that staff will get out her evening items to get ready for bed after supper and feels it is a hint to go to bed early. This is evidenced by: The Facility's Policy entitled Notice of Resident Rights Under Federal Law with an unknown last revision date, documents, in part: Self-Determination: 14. You have the right to self-determination, including but not limited to the following rights: a. The right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with your interests, assessments, plan of care and as otherwise set forth here . Example 1: R6 is a long-term resident of the facility. R6 was admitted on [DATE] with a diagnosis history that indicates: Chronic Diastolic (Congestive) Heart Failure, Unspecified Asthma, Chronic Kidney Disease (stage 4), Long Term (Current) use of inhaled steroids, Obstructive Sleep Apnea. R6's admission Minimum Data Set (MDS) assessment on 5/20/22 indicates R6 had a Brief Interview for Mental Status (BIMS) score of 15 indicating her cognition is cognitively intact. Daily Preferences Assessment of bedtime indicates it is very important to choose her own bedtime. R6's care plan states Problem: Impaired Functional Status r/t (related to) s/p (status post) hospital stay for CKD 4 (Chronic Kidney disease), A-fib (Atrial Fibrillation), HFpEF (Heart failure with preserved ejection fraction), hypothyroid, depression . Goal: Will be able to propel w/c (wheel chair) independently . R6 will be able to choose the time that she will get up for the day where to have her meals. Encourage her to be up in her w/c for all meals . Please note: no bedtime routine of time or cares are indicated in the care plan. R6's Resident Preferences Evaluation, effective date of 5/19/22 states, in part: Daily Preferences . 5. How important is it to you to choose your own bedtime? a) Very Important . On 8/8/22 at 2:12 PM, Surveyor interviewed R6. R6 reports They wanted me to get ready for bed after dinner because the staff told me they had to leave by 8:00 PM. Surveyor asked who the staff member was and provided the name to the Surveyor. R6 reported to Surveyor that she did Not want to be rushed, I don't like how that feels, I have a whole page of diagnosis. I have a bad shoulder, a-fib, arthritis, and heart failure and I like to stay up late. On 8/10/22 at 2:45 PM, Surveyor performed follow up interview with R6. R6 reports to Surveyor, the same staff member Makes me go to bed right when she picks up my dinner tray. I do say no and then she just says fine she will help other people and does not come back until she wants to. She tells me I have to go to bed. I have always gone to bed at 10 PM. It makes for a long night. I get itching while I lay there awake, I get bored, and end up awake more when I have to go to bed early like that. On 8/10/22 at 3:40 PM, Surveyor interviewed CNA S (Certified Nursing Assistant). Surveyor asked CNA S what time residents go to bed, she replied Usually we put them down after dinner, we let them sit for 30 minutes if they want to. Surveyor asked CNA S what time does R6 prefer to go to bed at night, she replied around 3:00 PM, even before supper. Surveyor asked CNA S is she would let R6 go to bed for a nap, she replied that R6 won't do it, she wants to be in bed. On 8/11/22 at 2:46 PM, Surveyor interviewed RN R (Registered Nurse). Surveyor asked RN R R6's bedtime routine, she replied R6 likes to get cleaned up, cream on arms and itchy areas, R6 gets her meds around 8:00 PM-9:00 PM, goes to bed about 9:00 PM. Surveyor asked RN R when does CNA S's shift normally end, she replied CNA S shift ends normally around 10:00 PM, sometimes she leaves early about 9:30 PM. Surveyor asked RN R the reasoning for CNA S to leave early, she replied that CNA S may have another job and will put R6 down early, CNA S gets her work done, if she is leaving early, the resident will be in bed. Surveyor asked RN R if R6 ever complained about going to bed early, RN R stated, Not really. On 8/11/22 at 3:15 PM, Surveyor interviewed DON B (Director of Nursing) if there are any bedtime requirements for residents, she replied, no. Surveyor asked DON B if a resident should get to choose what time to go to bed, she replied, yes. Example 2: R289 is a long-term resident of the facility. R289 was admitted on [DATE] with a diagnosis history that indicates: Chronic Obstructive Pulmonary Disease, Asthma, Atrial Fibrillation, Type 2 Diabetes Mellitus. R289's admission MDS assessment on 8/5/22 indicates R289 had a BIMS score of 15 indicating her cognition is cognitively intact. Daily Preferences Assessment of bedtime indicates it is very important to choose her own bedtime. R289's care plan does not provide any preferences of bedtime routine. On 8/11/22 at 2:01 PM, Surveyor interviewed R289. Surveyor asked R289 if there was a certain bedtime, she replied that Right after supper they start bringing in the bedtime stuff like toothbrush, toothpaste, and my gown; it's kind of a hint. I don't usually want to get ready for bed until 9 PM. So, when the bring the stuff in, I take that as a hint. Surveyor asked R289 do staff make you go to bed prior to 9 PM. R289 stated yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility did not provide privacy during personal care and medication pass on 1 of 14 sampled residents (R6) and 1 of 8 supplemental residents (R289). R6 stated during an interview that staff do not put the blinds down when doing cares. R289 stated during an interview that she has to ask staff to close the door or windows, Surveyor observed application of a lidocaine patch with the window blinds open and another staff present without providing privacy. This is evidenced by: Example 1: R6 is a long-term resident of the facility. R6 was admitted on [DATE] with a diagnosis history that indicates: Chronic Diastolic (Congestive) Heart Failure, Unspecified Asthma, Chronic Kidney Disease (stage 4), Long Term (Current) use of inhaled steroids, Obstructive Sleep Apnea. R6's admission Minimum Data Set (MDS) assessment on 5/20/22 indicates R6 had a Brief Interview for Mental Status (BIMS) score of 15 indicating her cognition is cognitively intact. On 8/9/22 at 8:35 AM, Surveyor interviewed R6. Surveyor asked R6 about any concerns with her privacy, she reported Sometimes they do not put down the blinds, I can see the offices next door. On 8/10/22 at 9:55 AM, Surveyor followed up with R6 about privacy during cares last night. R6 reported She didn't put my blinds down or wash my stockings, I had to ask the nurse the close the blinds when she brought me my medicine. Example 2: R289 is a long-term resident of the facility. R289 was admitted on [DATE] with a diagnosis history that indicates: Chronic Obstructive Pulmonary Disease, Asthma, Atrial Fibrillation, Type 2 Diabetes Mellitus. R289's admission MDS assessment on 8/5/22 indicates R289 had a BIMS score of 15 indicating her cognition is cognitively intact. On 8/10/22 at 9:32 AM, Surveyor observed RN H (Registered Nurse) administering a lidocaine patch to R289. RN H walked into the room and asked R289 where she would like her patch applied and R289 lifted the left side of her shirt that is facing the open window with nearby buildings. Surveyor observed another facility staff in the room. RN H did not offer privacy for the windows or if the presence another staff member was permissible. On 8/11/22 at 2:01 PM, Surveyor interviewed R289. Surveyor asked R289 How she felt about her privacy when staff was placing the patch on with the windows open and showing skin, she replied I do have a concern with the blinds open. I have to ask them to close the door before I undress or to do private cares. I don't want to give any freebies. On 8/10/22 at 8:39 AM, Surveyor interviewed LPN F (Licensed Practical Nurse). Surveyor asked LPN F is the window blinds and doors should be closed prior to cares, she replied yes. On 8/10/22 at 10:08 AM, Surveyor interviewed DON B (Director of Nursing), Surveyor asked DON B if staff should close the window blinds and doors prior to cares, she replied yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that the facility is able to provide emergency basic life support immediately when needed, including Cardiopulmonary Resuscitation (CPR), to any resident requiring such care prior to the arrival of emergency medical personnel for 2 of 13 residents (R12 and R286) reviewed for advance directives. R12's Medical Record contained conflicting code status/advanced directives on a signed form, face sheet, and the dashboard. Staff did not follow through on the paperwork needed to change R12's code status to DNR as he wished. Staff reported they would look in different areas of the chart for R12's code status. R286 Medical Record contained conflicting code status/advanced directives on a signed form, face sheet, and the dashboard. R286's printed face sheet in his hard chart indicates he is full code. R286's signed form and dashboard indicate he is DNR. Evidenced by: Facility policy, entitled Advance Directives, reviewed 1/2022, includes, in part: . if a resident has completed an updated advanced directive ., the social services director or designee will document in chart and include a copy of the advanced directive in medical record . The facility will document and communicate the resident's choices to the interdisciplinary team . Example 1 R12 was admitted to the facility on [DATE]. R12's Advanced Directive Form, dated [DATE], signed by RR G (R12's Activated Power of Attorney/Resident Representative), a witness, and a Nurse Practitioner, indicates R12 wishes to be a full code status. R12's MD Progress Note, dated [DATE], include in part: I saw that his code status in point click care was full code and this is the paperwork RR G signed upon admission to the skilled nursing facility upon admission . In the past he has been a DNR (Do Not Resuscitate). I called RR G and discussed. R12 should be a DNR. R12's Physician Orders, includes, [DATE] code status: DNR. On [DATE] at 10:00 AM Surveyor reviewed R12's Electronic Medical Record. R12's Dashboard indicated R12 is a DNR. R12's Face Sheet indicated R12 is a DNR. R12's signed Advanced Directives form indicated R12 was a full code. R12's physician orders indicated R12 is a DNR. On [DATE] at 10:56 AM during an interview, RN I indicated if R12 was found pulseless and nonbreathing he would look at R12's dashboard to verify his code status which is DNR. Surveyor asked RN I about the signed advanced directive form in R12's medical record. RN I indicated R12's dashboard should reflect R12's signed advanced directive sheet. On [DATE] at 11:01 AM LPN J indicated if she found R12 pulseless and nonbreathing she would verify R12's code status by looking at the signed sheet in his chart, indicating R12 is a full code. Surveyor showed LPN J R12's dashboard indicating his code status is DNR. LPN J indicated she would follow the signed advanced directive sheet if saw the discrepancy. On [DATE] at 11:11 AM RN D indicated if she found R12 pulseless and nonbreathing she would look at R12's dashboard to verify his code status with indicates R12 is a DNR. Surveyor and RN D reviewed R12's signed advanced directive sheet together, indicating R12 wishes to be a full code. On [DATE] at 11:20 AM LPN F and RN H indicated if they found R12 pulseless and nonbreathing they would look on the computer at R12's dashboard and if their computer was not open, they would look at the signed advanced directive form. Surveyor, LPN F, and RN H reviewed R12's dashboard and then R12's advanced directive form, noting the discrepancy. LPN F and RN H indicated these documents should reflect each other. LPN F also showed Surveyor R12's Face Sheet that indicated R12 is a DNR. On [DATE] at 11:21 AM ADON E indicated it is her expectation that staff would look in chart first and then look in the resident dashboard when verifying code status. Surveyor and ADON E reviewed R12's medical record, including the Face Sheet, signed advanced directives, and R12's dashboard. ADON E indicated the signed advanced directive is the document that the staff should follow if there is a discrepancy like this. ADON E indicated Surveyor should consult with DON B for sure though. On [DATE] at 12:39 PM RR G indicated she believes R12 would want to be a DNR. RR G indicated the facility has asked her today to sign a document that indicates this. RR G indicated all areas in R12's record should reflect his wishes. On [DATE] at 1:20 PM Surveyor interviewed DON B, DON B indicated staff should look at the residents' dashboard on PCC (electronic health record) to verify code status and they can look in the hard chart too at the advanced directive form. DON B indicated these documents should all reflect the wishes of that resident and each other. DON B and Surveyor reviewed R12's medical record. DON B indicated in December of 2021 R12's Nurse Practitioner asked R12's POA if R12's wished to be a DNR. Surveyor reviewed R286's medical record also, noting on R286's dashboard it indicated he should be a DNR and on his Face Sheet it is noted he should be a Full Code. DON B stated R286 was admitted on [DATE] and was a full code. On [DATE] his wishes changed, and the paperwork was completed, but the Face Sheet was not reprinted in his chart. DON B indicated all documents in R286's chart related to code status should reflect R286's wishes and each other. Example 2 R286 was admitted to the facility on [DATE]. R286's Advanced Directive Form, dated [DATE], signed by R286, a witness, and a Nurse Practitioner, indicates R286 wishes to be DNR. On [DATE] around 10:00 AM Surveyor reviewed R286's hard chart. R286's Face Sheet in hard chart indicates R286 is full code. On [DATE] at 1:20 PM Surveyor interviewed DON B, DON B indicated staff should look at the residents' dashboard on PCC (electronic health record) to verify code status and they can look in the hard chart too at the advanced directive form. DON B indicated these documents should all reflect the wishes of that resident and each other. Surveyor reviewed R286's medical record also, noting on R286's dashboard it indicated he should be a DNR and on his Face Sheet it is noted he should be a Full Code. DON B stated R286 was admitted on [DATE] and was a full code. On [DATE] his wishes changed, and the paperwork was completed, but the Face Sheet was not reprinted in his chart. DON B indicated all documents in R286's chart related to code status should reflect R286's wishes and each other. On [DATE] Surveyor reviewed R286's Face Sheet. The Face Sheet now matched the Advanced Directive Form, Physician order, and dashboard indicating R286 is DNR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 2: R3 is a long-term resident of the facility. R3 was admitted on [DATE] with a diagnosis history that indicates: Parkinson's Disease, Unspecified Dementia without Behavioral Disturbance, Spinal Stenosis, Pain unspecified Joint, Generalized Anxiety Disorder, Generalized Muscle Weakness, History of Falling, Wedge Compression Fracture of First Thoracic Vertebra, Subsequent Encounter for Fracture with Routine Healing. R3's quarterly MDS (Minimum Data Set) assessment on 5/17/22 indicates R3 had a BIMS (Brief Interview for Mental Status) score of 99 indicating severe cognitive impairment. R3's cognitive impairment is rarely or never understood and sometimes understands responding adequately to simple, direct communication only. R3's Functional Assessment: total dependence assistance with two+ persons for physical assist with transfers. R3's moving from seated to standing position assessment was not performed. R3's functional limitation assessment indicates no impairment in the upper extremity and impairment on both sides in the lower extremity. Devices that R3 uses are a wheelchair. Pain assessment for R3 indicates that resident is receiving scheduled pain medication and is not receiving PRN (as needed) pain medication, and unable to answer for a rating of pain level. Fall assessment for R3 indicates no falls since admission. R3's care plan documents the following, in part: Problem: ADL (Activities of Daily Living) Self-care performance deficit r/t (related to) Activity Intolerance, Confusion, Dementia, Limited Mobility. Goal: R3 will maintain current level of function in regards to ADLs and accept staff assistance with all cares. Interventions: . Transfer: R3 uses a broda chair and requires total assist with mobility. She requires 2 assist and a mechanical lift for all transfers . This care plan is initiated on 2/14/20, revision on 3/04/21. Problem: At risk for falls: Confusion, Incontinence, Poor communication/comprehension, Unaware of safety needs, R/T Parkinson's, anxiety and depression. Goal: R3 will have no fall related injuries. Interventions: . Mechanical Lift for transfers . This care plan is initiated on 2/14/20, revision on 8/24/21. Please note, the care plan does not indicate which sling to use, where the sling is located and has not been updated. Problem: Potential risk of impairment to skin integrity R/T incontinence B&B (bowel and bladder), cognition, wounds to hammer toes, hx (history) of pressure and decrease nutritional intake. Goal: Will maintain or develop clean and intact skin by the review date. Interventions: . Use caution during transfers, bed mobility and when propelling in broda chair to prevent striking arms, legs and hands against any sharp or hard surface . This care plan is initiated on 6/8/21. On 5/19/22 at 7:30 AM, Incident Description Note states Resident being transfered via Hoyer lift w/a (with assist) of 2 staff per protocol. Resident slipped from Hoyer sling landing on the floor. 1 staff operating the Hoyer, 1 staff assisting with WC (wheelchair) placement at this time, neither staff were in a position to assist her to the floor. It was witnessed that she did hit her head. Small amount of red drainage noted from the back scalp at this time. Resident alert and assessed with no know injury to rest of her body. VS's (vital signs) and Neuro's initiated. Family, hospice, NP (Nurse Practitioner) and DON (Director of Nursing) notified of the incident. On 5/24/22 at 11:14 AM, Incident Note written by DON B (Director of Nursing) state, in part: Root Cause Summary: Staff walked me through the process. A different sling was used for transfer, as the sling she uses was in the wash. Resident assessed, resident placed back into bed, neuro checks initiated to include VS. All slings have been checked and all slings are in good condition and no need of repair. Hoyer lifts have been checked and are in good condition and no need for repair. For resident using a Hoyer, 2 slings will be available for usage. On 8/11/22 at 2:33 PM, Surveyor interviewed LPN NM K (Licensed Practical Nurse, Nurse Manager). Surveyor observed slings on the floor in LPN NM K's office and asked LPN NM K where the slings were from, she replied they were from R3's room. LPN NM K then held up the white sling the staff used with R3 and demonstrated no physical concerns and that they are different than the others. LPN NM K reported R3 has an extra sling in her closet. Surveyor observed the sling did not have back support material. Surveyor noted another white sling on the floor noting 2 slings. On 8/22/22 at 8:09 AM, Surveyor interviewed DON B. Surveyor asked DON B if staff should have known not to use the sling, she replied, well, no, we have numerous kinds. Surveyor asked DON B if there should have been education on the correct sling, she replied, The staff development nurse initiated education of application of sling and Hoyers in general The facility did not ensure staff were trained on appropriate sling use for R3. R3 fell out of an alternate sling that was used by staff. Based on observation, interview, and record review, the facility did not ensure 2 (R13 and R3) of 13 sampled residents were free from accident hazards and provided supervision and assistive devices to prevent avoidable accidents. R13 had multiple falls after admission. The facility failed to identify and implement interventions to reduce fall risk. R3 was transferred via a Hoyer lift on 5/19/22 with the assist of 2, using a different style Hoyer sling, fell out of the Hoyer lift during a transfer and struck her head. The fall caused 3 abrasions and a hematoma on the back of R3's head and was witnessed by staff of R3 hitting her head. This is evidenced by: The Facility's Policy and Procedure entitled Fall Reduction and Management Program- SNF with a last revised date of 02/21, documents, in part: Policy: It is the policy of the Facility that every effort be made to reduce or minimize serious injury if a fall should happen . Care Planning and Implementation: Based on resident fall evaluation, an individualized care plan with the goal to prevent falls and/or minimize serious injury if fall occurs will be developed, implemented, monitored, and modified as needed. Licensed Nurse and/or Interdisciplinary Team will: 1. Develop an individualized care plan that addresses the risk factors identified, formulate goals that promote resident safety and prevention/reduction of falls and minimize serious injury if fall occurs . 4. Review, evaluate, revise, or modify the care plan on a quarterly basis and as needed . III Ongoing Monitoring . General Staff: . 4. Managers/Supervisors: Manager/Supervisors will be vigilant to potential/actual environmental hazards and will ensure resident environment is free of accident/fall hazards as possible . Example 1 R13 was admitted to the facility on [DATE] and has a diagnoses that include other intraarticular fracture of lower end of right radius subsequent encounter for closed fracture with routine healing, malignant neoplasm of unspecified part of right bronchus or lung, anemia, chronic obstructive pulmonary disease, essential hypertension, anxiety disorder, vitamin D deficiency, hyperlipidemia, depression, asthma, hypertensive urgency, pain in right wrist, muscle wasting and atrophy, other lack of coordination, cognitive communication deficit, dizziness, weakness, unspecified open wound of toe with damage to nail, other reduced mobility, personal history of other mental and behavioral disorders, personal history of nicotine dependence, and history of falling. R13's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 5/10/22 indicates R13's cognition is intact with a Brief Interview of Mental Status (BIMS) score of 13 out of 15. R13's Care Plan noted: Problem: At risk for falls r/t recent fall with fracture. Goal: Will not sustain serious injury through the review date. Interventions: Be sure call light is within reach and encourage to use it for assistance as needed. Created on: 5/3/2022. Encourage to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Created on: 5/3/2022. Ensure that she is wearing appropriate footwear when ambulating or mobilizing in w/c. Created on: 5/3/2022. Staff to provide frequent checks, for safety and needs, encourage her to wait for staff to assist. Created on: 5/16/2022. Transfer Assistance Level: Assist of 1 and walker. Toileting Assistance Level: Assist of 1, encourage her to use the bathroom in frequent intervals while awake and before going to bed. Revision on: 5/11/2022. On communication tool between the Therapy Department and Nursing it states, R13 should be checked on every 30 minutes. It is important to note this is not on R13's Care Plan. It is important to note all of the above interventions were put in place at the time of R13's admission to the facility. There was only one new intervention put in place until R13's fifth fall. R13's falls: On 5/12/22 at 4:30 PM R13 slid off her wheelchair and onto the floor in resident bedroom. Incident Report: R13 stated she was going from her wheelchair to bed with assistance from daughter. R13 felt unsteady so she went to sit back down in w/c but did not make it all the way onto the wheelchair and started to slide off the chair and onto the floor. R13 stated that she did not hit her head or obtain any injuries from the fall. No injuries observed at time of incident. Staff assessed the resident, obtained v/s, and assisted her to bed. VSS, neuro check WNL, denies pain. Other info: Resident was wearing gripper socks. She had returned to facility from outpatient surgery a few hours prior. No interventions discussed in incident report. On 5/13/22 at 3:43 PM R13 fell in bedroom. Incident Report: Team member communicated to writer that patient was sitting on the floor right outside of her doorway. When I approached the patient, she was sitting upright with knees bent. It did not appear that she hit her head or made hard contact with the floor. Resident said she had waited 10 minutes after pressing her call light and slid out of her chair when self-transferring to her wheelchair. Stated that it was hard to do things independently while only having one arm available. Stated that she was in no pain d/t fall. No interventions discussed in incident report. In R13's Progress notes it states frequent checks will be started on R13. On 6/25/22 at 8:00 AM R13 fell in R13's bathroom. Incident Report: Was found lying in the bathroom leaning against the right hand. Stated she was trying to use the toilet, fell and could not get up. Assessed for injuries. Assisted to the toilet and stayed with patient. Other info: Does not understand limitations, self-transfers, does not call for help. No interventions discussed in incident report. On 6/26/22 at 7:45 PM R13 fell in bedroom. Incident Report: Found on the floor sitting next to the bed. No injuries noted. Stated she was transferring from her wheelchair to the bed, lost balance and fell. Vitals obtained, assessed for injuries, assisted to the bed. Other info: Does not utilize call light or call for help, does not understand own limitations. No interventions discussed in incident report. On 7/15/22 at 9:30 PM R13 fell in bedroom. Incident Report: Staff heard the noise from resident room and immediately provided help. When staff entered the resident room and found the resident lying on the floor on her back. Patient is a fall risk patient. She's on 30-minute checks. Between the 30-minute checks, stated attempted to get her own diaper out of the closet without calling for help. She lost her balance kneeled down and fell backward bumping her head on the door. Assessed the resident for pain and any injury. No apparent injuries. ROM WNL. helped resident to get up and walk to bed. Message left for NP (nurse practitioner). Daughter updated on the phone. No injuries observed at time of incident. Other info: Resident transfer and ambulation one assist use walker but resident forgetful. Ambulates herself without assistance. Interventions and root cause analysis was completed for 7/15/22 fall. Risk and Benefit discussed with R13, and NP monitoring BP. Medication change took place at 7/19/22 appointment. On 8/8/22, around 3:00 PM, Surveyor introduced self to R13. Surveyor asked R13 if R13 had any falls while at the facility. R13 indicated that she had multiple falls while at the facility and it was all stupid stuff as to why she had fallen. R13 declined to discuss her recent falls any further. Surveyor observed R13 to be wearing grippy socks and call light was next to her. R13 had a walker and wheelchair in her bedroom. Surveyor observed no other fall interventions in place in R13's bedroom nor any staff completing frequent checks on R13. On 8/9/22, at 2:56 PM, LPN O (Licensed Practical Nurse) indicated when a resident falls an Incident Report should be completed. Surveyor asked what is in place for R13's fall interventions. LPN O indicated R13 is at risk for falls. R13's call light should be within reach; this is a given for all residents at the facility. Staff should encourage R13 to participate in activities, to wear proper footwear, and for staff to check on R13 frequently. Surveyor asked LPN O how often is frequently? LPN stated, a minimum of every two hours. On 8/9/22, at 3:56 PM, Surveyor asked CNA N (Certified Nursing Assistant) what is R13's fall interventions? CNA N indicated R13 likes doing things on her own. Staff provide reminders to use the call light if she needs something. Surveyor asked CNA N if there were any other interventions in place and CNA N stated, not really anything else. On 8/11/22, at 9:30 AM, Surveyor interviewed DON B (Director of Nursing) and RN M (Registered Nurse) indicated R13 is at risk for falls. RN M indicated she had a discussion with R13 on risk and benefits after R13's fall on 7/15/22. (R13's fall on 7/15/22 was R13's fifth fall while at the facility.) RN M indicated after R13's fall on 7/15/22 R13 had stated she had felt dizzy. RN M stated they updated the NP, and they are monitoring R13's blood pressure as this fall seemed to be more medical related. RN M indicated R13's fall interventions include staff try to make her feel like they are here to help, frequent checks, NP monitoring, and R13's family goes outside with her once or twice a day. RN M indicated her family involvement is the best intervention. R13 doesn't really want to do things with us or any activities at the facility.

Based on interview, observation, and record review, the facility did not ensure the accuracy of dispensing and administering of all drugs and biologicals, to meet the needs for 1 of 1 observation of 1 of 8 supplemental residents (R289). RN H (Registered Nurse) was observed dispensing and administering medication without checking medication label against the Electronic Medical Administration Record (EMAR). This is evidenced by: The facility policy titled, Medication and Treatment Administration with a revised date of January 2020, states, in part: It is the policy of the Company that administration standards for the delivery of medications and treatments will be adhered to by all staff responsible for providing these services. Standards: . 8. The medication will be checked three times prior to administration of a drug or treatment: i. Check label when removing drug/treatment from the bin. ii. Check label against MAR (Medication Administration Record) or EMAR before pouring. On 8/10/22 at 9:28 AM, Surveyor observed RN H at the medication cart with 2 stacks of bubble packs. The computer screen was white and was locked that displays the EMAR. Surveyor observed RN H reading the bubble pack, popping out medication into a medication cup, then placing the bubble pack upside down. After several observations, RN H did not compare the medication bubble against the EMAR. After dispensing was completed, Surveyor then followed RN H to R289's room and observed RN H administering the medication from the medication cup and applying a lidocaine patch to R289. On 8/10/22 at 9:36 AM, Surveyor and DON B (Director of Nursing) observed RN H dispensing medication at the medication cart. Surveyor and DON B observed RN H initially not having the EMAR screen on to compare against the bubble pack of medication. Surveyor and DON B went into another room and discussed the observation. DON B stated RN H just had his skills check off with pharmacy. Surveyor asked DON B if the medication should be checked against the EMAR, she replied yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 2: Staff did not follow appropriate infection control practices when performing R17's dressing change. R17 is a long-term resident of the facility. R17 was admitted on [DATE] with a diagnosis history that indicates: Unspecified Dementia with Behavioral Disturbance, Type 2 Diabetes Mellitus, Obesity. R17's quarterly Minimum Data Set (MDS) assessment on 7/17/22 indicates R17 had a Brief Interview of Mental Status (BIMS) score of 6 indicating severely impaired. R17's care plan documents the following, in part: Problem: Alteration in skin integrity r/t (related to) hx (history) of stage 3 pressure injury to coccyx and left buttock and SDTI (suspected deep tissue injury) to her left buttock. Goal: Will continue to have intact skin through next review date. Interventions: Administer treatments as ordered and monitor for effectiveness. Assess/record/monitor wound healing. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. Report improvements and declines to the MD (Medical Doctor) . Follow facility policies/protocols for the prevention/treatment of skin breakdown. Monitor dressing during cares to ensure it is intact and adhering. Report lose dressing to Treatment nurse . On 8/8/22 at 12:05 PM, Surveyor observed RN H (Registered Nurse) change dressing on R17's coccyx. Surveyor asked RN H if he should wash his hands prior to wound care, he replied he grabbed sanitizer prior to entering the room, this was not observed by the Surveyor. Surveyor observed RN H remove dressing from R17's coccyx, pulled off adherent backing of new dressing and apply to R17's coccyx. Surveyor asked RN H if he should have performed hand hygiene from dirty to clean, he replied yes, but you were here so I was just trying to do it for you to see and I had just changed it. Example 3: R6 is a long-term resident of the facility. R6 was admitted on [DATE] with a diagnosis history that indicates: Chronic Diastolic (Congestive) Heart Failure, Unspecified Asthma, Chronic Kidney Disease (stage 4), Long Term (Current) use of inhaled steroids, Obstructive Sleep Apnea. R6's admission MDS assessment on 5/20/22 indicates R6 had a BIMS score of 15 indicating her cognition is cognitively intact. Physician Order start date 6/30/22 states: Use CPAP at HS (hour of sleep) and during naps setting of 14-20cm H20 (water). 02 (oxygen) at 2L (liter) bleed into CPAP when in use, every shift for OSA (obstructive sleep apnea). This physician order is indicated on the TAR (Treatment Administration Record). R6's CNA (Certified Nursing Assistant) [NAME] reviewed by Surveyor, no documentation instructions for CPAP care or cleaning. R6's Care Plan reviewed by Surveyor, no documentation instructions for CPAP care of cleaning. R6's TAR reviewed by Surveyor, no documentation of CPAP care or cleaning is listed to be performed. On 7/3/22, Nursing Note indicated R6's CPAP was cleaned. On 7/18/22, R6 tested positive for COVID. Note: no documentation of CPAP cleaning or care has been performed since 7/3/22. On 8/10/22 at 2:57 PM, Surveyor interviewed RN P (Registered Nurse). Surveyor asked RN P the procedure for monitoring CPAP tubing/cleaning, she replied it is in the MAR (Medication Administration Record), documented in the TAR, and it is done on the resident's shower day. RN P then demonstrated of another resident by showing the Surveyor the TAR documentation of the CPAP cleaning done on the resident's shower day. Surveyor observed the documentation of the other resident has the cleaning initialed by staff designating completion. On 8/11/22 at 3:15 PM Surveyor interviewed DON B. Surveyor asked how she ensures the CPAP cleaning and monitoring is being done, she replied they do random audits and does not exactly have something in place. Based on observation, interview, and record review, the facility did not maintain an infection control program that ensures hand hygiene is performed during wound care per standards of care to help prevent the development and transmission of communicable diseases and infections, and residents are offered hand hygiene prior to meals. This had the potential to affect 3 (R10, R17, and R6) of 13 sampled residents reviewed for infection control. Staff did not complete hand hygiene per standards of practice or ensure barrier between dressings and bedside table. Staff did not follow and provide appropriate infection control standards for the care and cleaning on R6's CPAP (continuous positive airway pressure, a ventilator that assists with breathing) tubing. Staff did not implement a cleaning schedule as evidenced by no documentation in Medical Administration Record (MAR) of care and cleaning being performed. This is Evidenced by: The facility policy, Handwashing/Hand Hygiene, revised 11/2017, states in part, as follows: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Purpose of Hand washing/Hand Hygiene 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. To reduce the risk to the healthcare provider of colonization or infections acquired from a resident. 8. The use of gloves does not replace hand washing/hand hygiene. Procedure: Washing hands with soap and water: a. Wet hands under running water. B. Place an adequate amount of soap into palms of hands. ac. Rub vigorously for 20 seconds . d. Rinse under running water e. Dry hands thoroughly with paper towel. Turn off water with a new paper towel. The Morbidity and Mortality Weekly Report dated 10/25/02 and published by the CDC (Centers for Disease Control and Prevention) entitled, Guideline for Hand Hygiene in Health Care Settings, indicated recommendations to wash hands after removing gloves and to decontaminate hands after contact with body fluids or excretions and when moving from a contaminated body site to a clean body site during patient care. The above information can also be found at: https://www.cdc.gov/handhygiene/providers/index.html with the page last reviewed on January 8, 2021. Facility Policy and Procedure entitled Respiratory Care with an approved date of 02/2021, documents, in part: Policy: Respiratory care services will be provided by the facility or an outside source and available at all times. These will be well organized and directed and appropriately staffed. Procedure: . 4. Respiratory care procedures will be carried out according to proper infection control policies and respiratory equipment will be either disposable or cleaned appropriately to prevent cross-contamination between residents . Manufacturer recommendations, undated, documents, in part: . Cleaning/Care Instructions: Humidifier Chamber: Clean with mild detergent weekly, use distilled water only for humidity. Tubing: Clean with mild detergent weekly. Mask: Wipe cushion with non-alcohol type wipe daily, clean entire mask with mild detergent weekly . Example 1 R10 was admitted to the facility 6/25/21. R10's diagnoses include hemiplegia and hemiparesis following a cerebral infarction (stroke) and pressure injury of sacral region stage 4. On 8/11/22 at 11:25 AM, Surveyor observed RN Q (Registered Nurse) change R10's dressing to her Stage 4 pressure injury to her sacrum. Surveyor observed RN Q did not have supplies set up to complete the dressing change. Surveyor observed RN Q remove R10's dressing. RN Q took 4 gauze pads from an open package in R10's dresser drawer and set the package on top of the dresser. RN Q entered R10's bathroom, turned on the faucet with her left hand, ran the gauze pads under water and added soap to the gauze from the automatic dispenser on the wall. RN Q turned the sink off with her left hand and rubbed the gauze pads together with both of her hands. RN Q then used the same gauze pads to clean around R10's stage 4 pressure injury. RN Q did not clean the dresser or overbed table where she had set supplies and did not set up a barrier. RN Q then removed gloves, used hand sanitizer, and donned clean gloves. RN Q pulled a bottle of Dakins solution from the same dresser drawer and set on top of the dresser. R10 poured Dakins over gauze, inserted the gauze into R10's pressure injury and waited 10 minutes. RN Q opened R10's nightstand, pulled out Phytoplex Z Guard and set in on the overbed table, wrote the date on the new dressing, pulled back R10's blanket, opened brief, opened the top dresser drawer, and pulled out a tweezer, of note this was not cleansed prior to use and used it to remove the gauze soaked in Dakins. RN Q then placed the tweezer on inside of the open dressing wrapper, used a cotton applicator to pack the pressure injury, applied Z Guard paste. applied skin prep to periwound and applied the dressing. Surveyor observed RN Q wash the tweezer with soap and water, dried it with a paper towel, and put it back in the dresser drawer. On 8/11/22 at 11:55 AM, Surveyor spoke with RN Q. Surveyor asked RN Q when washing hands, how should you turn the water off. RN Q stated, with my elbows or a paper towel. Surveyor asked RN Q do you recall how you turn the water off before rubbing the gauze together. RN Q stated, with my hand. RN Q stated, she should have used a paper towel to turn the water off. Surveyor asked RN Q what she used to clean the tweezer. RN Q stated, soap and water - It's my own thing, I think I should clean it because it's dirty. Surveyor asked RN Q, why is it important to clean the surface and set up a barrier before setting up wound care supplies. RN Q stated, we don't want to catch infection and stop any spread of infection. Surveyor asked RN Q if she should disinfect surfaces and use a barrier when setting up wound supplies. RN Q stated she does not do either, however, she should. On 8/11/22 at 2:05 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B, when staff wash hands, how should they turn the sink off. DON B stated, With a paper towel. Surveyor asked DON B if staff touch items in the environment (dresser drawer handles, bottles of product, etc.) what should they do prior to continuing with wound care. DON B stated, they should wash/sanitize their hands before continuing with wound care. Surveyor asked DON B, when using items for wound care, such as tweezers or scissors, what should staff do before and after use. DON B stated, they should be disinfected with alcohol or a disinfectant spray. Surveyor asked DON B, should staff clean the surface and set up a barrier prior to completing wound care. DON B stated, yes. Surveyor shared observations of RN Q during wound care. DON B stated that RN Q should have turned the water off with a paper towel and should have sanitized her hands prior to touching R10's pressure injury. DON B stated, RN Q should sanitize the tweezers before and after use them for R10's treatment. DON B stated, if RN Q is touching items in R10's environment she should sanitize her hands before touching R10's pressure injury. DON B indicated these steps are important to avoid infections.