**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not provide Notice of Bedhold, Notice of Transfer and did not notify the Ombudsman of residents who transferred from the facility to a hospital for 3 of 3 residents (R) (R1, R3 and R4).Example 1 R1 was admitted to the facility on [DATE] and has an Activated Power of Attorney. On 07/23/25, R1 had a change in condition as a result of a fall resulting in need to be transferred to the hospital for evaluation. A Bedhold, Notice of Transfers was not provided to R1's representative and the facility did not notify the Ombudsman of transfer. On 08/17/25, R1 had a change in condition as a result of a fall resulting in need to be transferred to the hospital for evaluation. A Bedhold, Notice of Transfers was not provided to R1's representative and the facility did not notify the Ombudsman of transfer. Example 2 R3 was admitted to the facility on [DATE] and has a legal guardian. On 08/27/25, R3 had a change in condition and was transferred to the hospital. A Bedhold, Notice of Transfers was not provided to R1's representative and the facility did not notify the Ombudsman of transfer. Example 3 R4 was admitted to the facility on [DATE] with pertinent diagnoses of multiple sclerosis and neurogenic bladder. Record review identified R4 as having intact cognition and was her own decision maker. Record review identified R4 was transferred to the hospital via ambulance on 07/20/25 due to new or worsening urinary incontinence with a suprapubic catheter in place. No bed-hold notice or written transfer notice was documented. No documentation for Ombudsman notification was noted. On 09/03/25 at 1:12 PM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding bed-hold notices, written transfer agreements, and Ombudsmen notifications. NHA A stated that bed-hold notices were given to residents in the facility admission packet and was unaware that a bed-hold must be given with each transfer. NHA A stated that no written notices of transfer were given to residents and was unaware this needed to be done. NHA A stated he was unable to provide documentation that the Ombudsman was notified for the transfer during the months of July and August 2025.

Based on observation, interview and record review, the facility did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 of 3 residents (R) reviewed (R1).-Medication storage room had R1's lorazepam, with an opened date of 12/01/24, stored in unlocked refrigerator.-Medication storage room had 2 open, unlabeled bottles of eye drops in refrigerator.-Medication storage room had 4 opened boxes of expired intermittent catheters.This is evidenced by:Facility policy titled, Storage of Medications, with a revised date of 04/2007, states in part: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use.9. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses's station or other secured location Medications must be stored separately from food and must be labeled accordingly.Facility policy titled, Discarding and Destroying Medications, with a revised date of 04/2007, states in part: All controlled substances shall be retained in a securely locked area with restricted access until authorized individuals destroy them.On 09/02/25 at 10:19 AM, Surveyor observed Certified Medication Aide (CMA) C prepping medications at the med cart in hall 200. Surveyor asked CMA C how resident meds are stored. CMA C showed Surveyor the drawers being organized by resident room number. All medications were labeled and dated. On 09/02/25 at 10:34 AM, Surveyor interviewed Licensed Practical Nurse (LPN) D regarding medication storage. LPN D stated only nurses have access to the medication room and demonstrated entry into locked med storage room. Surveyor asked LPN D where catheters were stored. LPN D began opening cabinet doors in med storage room and pointed to some open boxes. Surveyor observed multiple boxes of various sized intermittent catheters. Surveyor asked LPN D how she knew if catheter was expired. LPN D picked up one of the packaged catheters and looked at the labels and stated she did not know, but that it looked like the one she was holding might be expired. Surveyor asked if any residents were currently using intermittent catheters. LPN D stated not being sure, but did not use any recently.On 09/02/25 at 11:06 AM, Surveyor entered medication room with Director of Nursing (DON) B. Surveyor observed small refrigerator located next to medication dispenser system. A lock was noted on top of refrigerator that was not secured. Surveyor asked DON B to open refrigerator to observe items inside. DON B opened the refrigerator without having to unlock it. Surveyor observed one medication inside. DON B removed the medication. Surveyor observed it to be lorazepam, and it was labeled with R1's information. The bottle was noted as opened on 12/01/24. DON B stated this medication should not be in there as it was expired. Surveyor asked DON B if the refrigerator should be locked. DON B stated that it should be.Surveyor then observed another larger refrigerator in the medication room and observed 2 opened bottles of eye drops inside. One was noted to be latanoprost ophthalmic solution with no label or open date. On the side of the bottle, PM was written. The other bottle was noted to be timolol maleate with no label or open date. On the side of this bottle, AM was written. Surveyor asked DON B what these medications were. DON B stated she did not know, but acknowledged they should be labeled.Surveyor continued to observe the medication room storage cabinets and observed 4 opened boxes of intermittent catheter supplies. The expiration date noted on 3 of the boxes was 05/31/2020. The expiration on one of the boxes was 07/05/2020. Surveyor asked DON B to note the expiration date on the catheter supplies. DON B stated recognition that they were expired and shouldn't be in the cabinet. DON B stated these would be removed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not provide pharmaceutical services that ensure the accurate administering of all drugs and biologicals reviewed for 2 or 4 sampled residents (R), R1 and R2The facility did not ensure that medication orders were transcribed accurately. R1 received wrong dose of medication. The facility did not ensure that medication was given according to physician orders. R2 did not receive medications on 2 occasions in the last 45 days. This is evidenced by:The facility policy, titled Administering Medication by MED-PASS, last revised December 2009 states, 3. Medication must be administered in accordance with the orders, including required time frame. 15. If a drug is withheld, refuse, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug dose.Example 1R1 was admitted to the facility on [DATE], after R1 fell at home and broke R1's hip, requiring surgical repair. R1's diagnoses also included high cholesterol, coronary artery disease, parkinsonism, poor function of the heart, an intracardiac thrombus (clot), and cognitive communication deficit. R1's Minimal Data Set (MDS) Assessment, dated 5/25/25, indicates that R1 is moderately cognitively impaired and dependent for mobility and transfers while she heals from hip surgery. R1 is able to eat and complete oral and personal hygiene with set up assistance. R1's care plan, dated 5/22/2025, states, Administered medications as ordered. Monitor/document for side effects and effectiveness. Surveyor reviewed R1's hospital discharge, dated 5/21/25, which documented R1's provider order for Aspirin (ASA) 81mg twice a day to prevent clotting. Surveyor reviewed R1's electronic Medication Administration Record (eMAR). R1 was admitted on [DATE] in the afternoon, and on 5/22/25, ASA 81mg once a day was transcribed into the eMAR incorrectly. ASA 81mg twice a day was not started until 6/9/25. R1 received the correct ASA dosing on 6/9/25 and 6/10/25. On 6/11/25, R1's order in the eMAR was changed back to the twice a day as originally ordered by R1's provider.On 7/16/25 at 11:22 AM, Surveyor interviewed Registered Nurse (RN) D who reviewed R1's medication orders with Surveyor. RN D stated the discharge orders for ASA for R1 were transcribed wrong by the admitting nurse, and R1 did not get the prescribed amount of medication until 6/9/25. R1 did not receive the correct dosing of ASA for the first few weeks of admission.Example 2R2 was admitted to the facility on [DATE]; diagnoses include paralysis in the right upper limb, nerve pain, osteoarthritis, high blood pressure and high cholesterol. R2 is admitted post stroke for rehabilitation and strengthening. R2's MDS dated [DATE] indicated that R2 is dependent for mobility, transfers and daily activities of living (such as toileting and hygiene). R2 is able feed himself with set up assistance. R2 is moderately impaired cognitively. R2's care plan, updated last 3/12/25, states, Administered medications as ordered. Monitor/document for side effects and effectiveness. Review of R2's medication orders indicates that R2 receives Carbamazepine and Famotidine in the evening (night shift per patient). Review of R2's eMAR shows that R2 did not receive his evening medication on 6/13/25 and 7/11/25. There are no progress notes documenting refusal, the eMAR is blank, the code for refusal is not present and resident was not out of the facility.On 7/16/25 at 11:22 AM, Surveyor interviewed RN D. RN D pulled up R2's eMAR and reviewed it with Surveyor, confirming that medications were not administered to R2 on 6/13/25 and 7/11/25 during PM shift. RN D stated that the working nurse should have documented the reason the medication was not given.On 7/16/25 at 11:25 AM, Surveyor interviewed Assisted Director of Nursing (ADON) C. ADON C stated her expectation is that staff follow orders as written by provider. ADON D stated that ADON D is aware of the event with R1's ASA and is planning to implement a new process. ADON C just started in her role yesterday and is learning and assessing practices. ADON C plans to implement a process in the next week, where a second nurse signs off orders transcribed into the electronic medical record to ensure transcription errors do not occur again. ADON C's expectation is that nurses document the outcome of medication administration.

Based on observation, interview and record review, the facility did not ensure continued monitoring of food's internal temperature. This has the potential to affect all 58 residents (R) in the facility.The facility policy, titled Food Temperatures, states: The temperature of all food items will be taken and properly recorded prior to service of each meal. Under the section labeled Procedures it states: 1. All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees Fahrenheit.On 07/15/25, Surveyor reviewed the facility Resident Council Meeting Minutes from May 13, 2025, which indicated concerns with food coming out late. Surveyor reviewed kitchen food logs, which show food temperatures are taken at the beginning and end of service with no concerns noted.On 07/16/25 at 8:55 AM, Surveyor observed kitchen staff load 1st tray for 300/400 hall into cart. Food service started in the 300 hallway. At 9:27 AM, the cart was pushed to 400 wing and last tray served at 9:32 AM to R7.Surveyor had requested a test tray and checked temperature of over-easy eggs immediately following R7 receiving tray and noted temperature of over-easy eggs was 107.2 degrees Fahrenheit using the facility's thermometer provided by Food Service Director (FSD) F.On 07/16/25 at 9:32 AM, Surveyor interviewed [NAME] E, who indicated R7 prefers eggs cooked over-easy for breakfast (of note, facility eggs are pasteurized). The eggs are placed on tray straight from the grill, so an internal temperature of eggs is not taken and was unaware of temperature of over-easy eggs prior to service to R7. Interview with R7 indicated R7 had no concerns with breakfast and consumed all of the eggs.

Based on record review and staff interview, the facility did not ensure the facility-wide assessment was updated to reflect current resident care needs or the resources needed to support the resident care needs. The facility did not use the facility assessment to inform staffing decisions to ensure there are a sufficient number of staff with the appropriate competencies and skill sets necessary to care for its residents' needs prior to increasing the census. This had the potential to affect all 48 residents residing in the facility. Findings include: The facility assessment must reflect the resident population and the resources needed to care for this population. The facility assessment must be reviewed at least annually and as needed if the facility plans or population would require substantial modifications. Facility assessment, date revised 01/01/25, identified the reason for change to the facility assessment on 01/01/25 was updated ownership. The section of the assessment on resident population identified an average daily census of 37. The census time period was left blank. The section titled Staffing Needs as per Shift identified staffing ratios as follows: Nights: 1 Registered Nurse (RN) to 18 residents, 1 Licensed Practical Nurse (LPN) to 18 residents, 1 Certified Nursing Assistant (CNA) to 18 residents. Days: 1 RN to 18 residents, 1 LPN to 18 residents, 1 CNA to 12 residents, 1 Medication Tech (Med Tech) to 37 residents. Review of facility admissions from 12/19/24 through 01/08/25 identified the facility had 18 new resident admissions in the past 21 days. Review of the daily census for that timeframe identified this increased the facility census from the mid-30s to 48 residents on 01/08/25. The facility assessment was not updated to reflect this rapid increase in resident census and resulting increase in staffing needs required to care for this increased census. On 01/08/25 at 10:10 AM, Surveyor interviewed CNA C about staffing levels to meet resident care needs. CNA C stated since there has been a rapid increase in admissions, the facility administration had not responded to staff requests for increased help to meet resident needs. CNA C stated they typically had 3 CNAs scheduled from 6:00 AM to 6:00 PM and 2 CNAs scheduled from 6:00 PM to 6:00 AM. CNA C stated since the increase in census this resulted in each CNA responsible for the care of 16 to 18 residents on the day shift and over 20 residents on the night shift. CNA C stated this made it very difficult to safely care for resident needs because they often had to pull a CNA from another hall to assist with residents who required a 2-person transfer. This left no one to answer call lights and attend to resident needs on one hall while the CNA was pulled to another hall. CNA C stated often resident scheduled showers were postponed from the evening shift until the next day because it took so long for two CNAs to assist all residents to bed with the increased census, that they could not complete all the scheduled showers. CNA C stated they were aware of staff resigning due to the stress of the increased workload and no response to requests for help from administration. On 01/08/25 at 1:30 PM, Surveyor interviewed RN D about staffing levels to meet resident needs. RN D stated since the rapid increase in admissions, administration had ignored staff requests for help with the increased workload. RN D stated there were usually 2 RNs scheduled for the day shift and those RNs were responsible for all resident medications, treatments, and assessments until the Med Tech arrived at 10:00 AM to take over the medication administration. RN D stated the nurses were also responsible for sometimes as many as three new resident admissions per day. RN D stated if a resident had a fall or other change in condition, it was very difficult to keep up with all other responsibilities due to the increased workload. RN D stated assessments, treatments, and medications were not completed timely due to the increased workload and frequent new admissions. RN D stated they were fearful a resident's change in condition will be missed due to the lack of time to provide quality care and assessments of the residents. RN D stated staff were resigning due to the stress of the increased workload. On 01/08/25 at 2:28 PM, Surveyor interviewed RN E about staffing levels to meet resident needs. RN E stated since the new owners took over there has been a push to increase the resident census and they have been admitting many more residents with increased acuity but have not increased staffing numbers in response to this increase. RN E stated many nurses have stated they do not feel competent to care for some of the higher acuity residents with specialized treatments that they are not familiar with. RN E stated medications, treatments, and assessments are not being completed timely or thoroughly due to the increased workload. RN E stated staff were resigning due to the stress of the increased workload and no response from administration to their requests for increased staffing. On 01/08/25 at 4:30 PM, Surveyor interviewed Nursing Home Administrator (NHA) A about the facility assessment. NHA A stated the facility assessment was just updated on 01/01/25 to reflect the new ownership. Surveyor reviewed the sections of the facility assessment that addressed the average daily census and staffing ratios and asked NHA A if these sections were updated and accurate to reflect the recent rapid increase in census. Surveyor asked why the staffing needs for the residents were not assessed and implemented and in place prior to increasing the census. NHA A stated the average daily census and staff ratios were based on their previous census prior to their recent efforts to increase census. After discussion, NHA A stated these numbers would have to be looked at.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not immediately report to the resident's physician when a resident had difficulty breathing and was transferred via Emergency Medical Services (EMS) to the Emergency Department (ED). This occurred for 1 of 1 resident (R) reviewed, (R21). Findings include: R21 was admitted to the facility on [DATE] with diagnoses including in part, congestive heart failure, atherosclerotic heart disease, essential hypertension, edema, non-ST elevation myocardial infarction, and dilated cardiomyopathy. On 10/01/24 at 6:45 AM, Surveyor noticed R21 not in R21's room. Surveyor interviewed Registered Nurse (RN) F and asked where R21 was as Surveyor did not observe R21 in R21's room. RN F indicated that R21 had been having some shortness of breath and difficulty breathing the last few days and was finally sent out in the middle of the night via EMS. Review of R21's medical record identified the following note: - .On 10/01/24 at 1:39 AM, Resident sent to Hospital ED for difficulty breathing. Hospital returned update with resident being sent out related to myocardial infarction . Surveyor reviewed 24-hour report/change of condition report sheets for 09/19/24 and 09/23/24 and R21 was not listed to follow up with labs or change in condition. Record review identified no other documentation found that facility notified physician of R21's transfer to the ED. On 10/02/24 at 2:34 PM, Surveyor interviewed Nurse Practitioner (NP) H and asked NP H to explain the events that led up to R21's admission to the hospital. NP H indicated that it wasn't until today on 10/02/24 at 8:55 AM that NP H was notified of R21's condition and transfer to the ED which led R21 to be admitted to the hospital. NP H indicated that NP H cannot give Surveyor any more information as NP H is still unclear what transpired with events leading to R21's transfer to the ED. On 10/02/24 at 3:14 PM, Surveyor interviewed Director of Nursing (DON) B and asked if DON B knew why NP H was not notified of R21's disposition of not feeling well and the transfer to the ED. DON B indicated that DON B would look in R21's chart to see if physician or someone was notified. After looking through the Electronic Health Record (EHR) and the call log system that provides physicians' notifications, DON B could not find that NP H was contacted until 10/02/24 at 8:55 AM. DON B indicated there was no notification to any providers of R21's change of condition and transfer to the ED. Surveyor asked DON B what the expectation is for updating the physician of change in condition and notifying the physician of a transfer out. DON B indicated that DON B's expectation would be the standards of practice, which is that the physician is notified within 15-30 minutes of change in condition and for further direction. DON B indicated that the nurse on should have contacted a physician with R21's change in condition and informed nurse was sending R21 to the ED.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not conduct a Preadmission Screening Resident Review (PASRR) Level II screen for R7, who has a serious mental disorder and is taking psychotropic medication to treat symptoms of major mental disorder to ensure he received care and services to meet his needs. The facility practice affected 1 of 3 residents (R7) reviewed. This is evidenced by: According to the State of Wisconsin Department of Health Services (DHS), PASRR is a federal requirement that all applicants to Medicaid-certified nursing facilities be assessed to determine whether they might have an intellectual/developmental disability (ID/DD) and/or mental illness. This is a Level I Screen. The purpose of a Level I Screen is to identify individuals whose total needs require they receive additional services for their ID/DD and/or mental illness. Individuals who test positive at Level I are then evaluated in depth to confirm the determination of an ID/DD and/or mental illness for PASRR purposes. This is a Level II Screen. This assessment produces a set of recommendations for necessary services that are meant to inform the individual's plan of care. Nursing facilities may seek county exemption (DHS form F-20822), for applicants with ID/DD and/or mental illness whose stay in the facility is expected to be recuperative care or short-term. R7 was admitted on [DATE] with diagnoses that include schizoaffective disorder. R7 was prescribed the following psychotropic medications: Haldol, ziprasidone, and sertraline. On 10/26/23, a Level I PASRR screening noted R7 had a major mental disorder and has taken psychotropic medications to treat symptoms or behaviors of a major mental disorder, indicating a Level II PASRR should be completed. On 10/26/23, form F-20822 was completed, indicating R7 had a mental illness, and nursing facility placement was recommended with short term exemption from a Level II screening. The options for short-term exemptions are: -Hospital Discharge Exemption (30 day maximum) -Emergency Placement (7 day maximum) -Respite Care (30 days per year maximum) There was no option for short-term exemption chosen on form F-20822. Per form F-20822, The person may need nursing facility placement beyond the permitted timeframes of the short-term exemptions, Level II screening is required. Surveyor reviewed R7's record and could not locate a Level II PASRR screening. On 10/01/24 at 11:33 AM, Surveyor interviewed Nursing Home Administrator (NHA) A. NHA A confirmed a Level II PASRR was not completed for R7.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure that 1 of 1 resident (R) reviewed for pressure injuries (PI) (R21) received care consistent with professional standards of practice to promote healing of PIs. R21 was at risk for PI development and has existing PIs. The facility failed to apply purple boots for off-loading heels as ordered and did not do thorough admission and weekly PI skin assessments. Findings include: R21 was admitted to the facility on [DATE] with diagnoses including in part, congestive heart failure, atherosclerotic heart disease, diabetes mellitus type 2 with underlying condition with foot ulcer, cellulitis of right and left lower limb, edema, non-ST elevation myocardial infarction, and dilated cardiomyopathy. R21 was admitted with 7 pressure injuries and facility did not identify location, sizes, or stages and is unclear determining the condition of the pressure injuries on admission. R21's Minimum Data Set (MDS) assessment, dated 05/15/24, identified R21 required substantial maximal assistance for bed mobility, taking on and off footwear, rolling left to right, sit to lying, chair to bed, toileting, and for transfers. MDS indicated that R21 was at risk for PIs. Surveyor reviewed R21's activities of daily living care plan initiated on 05/08/24 and revised 05/13/24, in part: -Impaired skin risk is at risk, update the nurse with any signs for skin breakdown. Lotion skin with cares initiated on 05/08/24. -Pressure relief: Roho cushion to wheelchair, purple boots to bilateral feet at all times initiated on 05/24/24 and revised on 07/12/24. -Repositioning: assist of 1-2 as needed, right and left enabler bars initiated on 05/08/24 and revised on 07/12/24. Surveyor reviewed R21's pressure ulcer care plan initiated on 05/08/24 and revised 09/30/24, in part: -Administer treatments as ordered and monitor for effectiveness initiated on 05/30/24. -Followed by wound clinic initiated on 06/27/24. -Purple heel protector boots on at all times initiated on 05/30/24 and revised on 07/09/24. -Resident needs to turn/reposition at least every 2 hours, more often as needed, or requested initiated on 05/30/24 and revised on 06/27/24. Surveyor reviewed physician orders include: .-On 08/12/24, Complete skin only evaluation /assessment weekly every shift every Monday for weekly skin check . Surveyor reviewed Wound Care Clinic notes and nurse progress notes. On 05/08/24, admission skin assessment documented 2 ulcers to left leg dressings dry and intact wound care to follow in am, left heel ulcer dressings dry and intact wound care to follow in am, right foot ulcer dressings dry and intact wound care to follow in am. No PI documentation of measurements or description of condition was noted by the wound clinic to determine the exact location or stages to determine deterioration of each PI. On 05/08/24, a Braden assessment completed. Resident scored 13 at moderate risk for pressure injuries. Wound clinics note stated: in part: On 05/09/24 indicated that R21 had: -posterior right heel wound measures 3.2x2.3x0.4cm. -left posterior heel wound no measurements noted. -Right lateral foot measuring 4x2.3x0cm. Wound clinic ordered: -Nursing staff to change dressing for soilage, saturation or rolling of edges. - Nursing staff to provide continuous pressure relief to heels, coccyx, and other bony prominences. -Avoid pressure to the heel by applying heel suspension boots. Nurse progress note stated: in part: On 05/09/24, indicated R21's right lateral foot, dressings to remain in place, change only of soilage, saturation, or rolling of edges (Hydrofera blue and silicone foam). On 05/16/24, skin assessment completed for PIs that does not include a thorough assessment including documentation of location of PI, PI measurements, or description of condition of PIs noted. Wound clinics note stated, in part: On 05/20/24, wound clinic diagnoses stated, in part: 6. pressure injury of the right foot stage 2. 10. Diabetic ulcer of right heel. Recommendations from wound clinic is as followed: R21 should continue always wearing heel suspension boots when in bed and or chair to prevent further breakdown. Follow up with wound clinic twice weekly. Wound clinics note stated, in part: On 05/30/24, wound clinic recommends: -Nursing staff may change dressings at facility once weekly and visit wound clinic once weekly for evaluation and dressing change. . 5. Apply tubi grip F from base of toes to just below the knees. Continue pressure relief to heels and apply heel suspension boots continuously when patient is in bed. No thorough assessment including documentation of location of PI, PI measurements, or description of condition of PIs noted at this time. Wound clinics note stated, in part: On 06/26/24, No thorough assessment including documentation of location of PI, PI measurements, or description of condition of PIs noted. R21 was hospitalized 07/01-07/03 for surgery of metatarsal 5th toe and antibiotic therapy. Surveyor unable to determine if one of the 7 PIs R21 was admitted with progressed to stage 4 or if R21 was admitted with unstageable PIs that were already stage 3 or 4; that could not be assessed as wound clinic did not number the PIs and specify exact location on the right foot. The facility did not assess or stage PIs from admission to 7/1/24. PI assessment not completed on 07/03/24 when resident was readmitted back to nursing home. Wound clinics note stated, in part: On 07/09/24-Right heel has eschar, contacted nursing at nursing home to reinforce the importance of always keeping purple boots on to offload pressure to the heels. Surveyor unable to determine which PI progressed to eschar or if it had existing eschar, as wound clinic did not number the PIs and specify exact location on the right heel. No thorough PI assessment including documentation of location of PI, PI measurements, or description of condition of PIs was completed by the facility. Wound clinics note stated, in part: On 07/12/24- wound clinic diagnoses R21 with pressure injury to the right heel stage 3. Right lateral heel wound cleansed. Strongly encouraged compliance with heel suspension boots. Surveyor unable to determine which PI progressed to stage 3 or if this is an existing stage 3 PI from admission as wound clinic did not number the PIs and specify exact location on the right foot/heel nor did the facility. Wound clinics note stated, in part: On 07/16/24 Wound clinic ordered: -Posterior right heel wound is friable at one edge, increased drainage. Reinforced need to for purple heel offloading boots at all other times, both in bed and in wheelchair. Wound clinics note stated, in part: On 07/19/24 Posterior right heel measures 1.7x1.5x0.3cm, unattached edges. -Posterior right heel wound is friable at one edge, unchanged drainage. Reinforced need to for purple heel offloading boots at all other times, both in bed and in wheelchair. No thorough PI assessment including documentation of location of PI, PI measurements, or description of condition of PIs noted. Wound clinics note stated, in part: R21 hospitalized 07/24-07/29/24 for SOB acute hypoxia and had wound care during stay. Nurse progress note indicates, R21 admitted back to nursing home on [DATE]. Nurse progress notes indicate PI assessment was not completed until 07/31/24 after resident was re-admitted . Wound clinics note stated, in part: On 08/02/24- Right posterior heel- measures 1.2cmx1.8cmx0.4cm. Wound clinics note stated, in part: On 08/06/24-Right posterior heel- measures 1.5cmx1.8cmx0.4cm. Surveyor unable to determine which PI is being measured as the wound clinic did not number the PIs and specify exact location on the right foot/heel. Skin assessment missed on 08/07/24. Wound clinics note stated, in part: On 08/09/24- Right posterior heel- measures 1cmx1.5cmx0.4cm. Wound clinic notes STRONGLY encouraged compliance with heel suspension boots. She is wearing heel suspension boots but not consistently. Wound clinic ordered: - Follow up on 08/13/24. Wound clinics note stated, in part: On 08/13/24- Right posterior heel- measures 1.5cmx1.7cmx0.6cm. Right lateral foot stage 1 begins no measurements documented. Wound clinic ordered: - Reinforced need to for purple heel offloading boots at all other times unless transferring or walking with PT. Gave post op boot shoes to wear PT as she doesn't have shoes in the facility. -Follow up on 08/16/24. Wound clinics note stated, in part: On 08/16/24-Right posterior heel- measures 1.8cmx1.6cmx0.5cm. Right lateral foot stage 1 measures 0.5cmx0.3cmx0.1cm. No wound clinic follow-up orders. No thorough PI assessment including assessment completed by facility of location of PI, PI measurements, or description of condition of PIs noted. Wound clinics note stated, in part: On 08/23/24- Right posterior heel- measures 1.2cmx1.4cmx1.4cm. Undermining begins at 6 and 7 o clock. (worsens) Right lateral foot stage 1 no measurements documented. Wound clinic ordered: -Follow up on 08/27/24. -Adhered to recommendations of patient wearing heel protectors daily, but staff report resident refuses sometimes. Surveyor unable to determine which PI progressed with undermining, or if this was from an unstageable on admission that had undermining that was not visible at that time as wound clinic did not number the PIs and specify exact location on the right foot/heel. Facility had no PI assessment including documentation of location of PI, PI measurements, or description of condition of PIs noted. Wound clinics note stated, in part: On 08/30/24- Right posterior heel- measures 1.1cmx1.4cmx0.4cm. Right lateral foot stage 1 no measurements documented. Skin assessment missed on 09/02/24 and on 09/06/24 no thorough PI assessment of existing pressure injuries noted. Wound clinics note stated, in part: On 09/17/24- Right posterior heel- measures 0.8cmx0.8cmx0.4cm, with undermining at 12,1,2,3,4,5,6,7 o clock, with depth of 0.3cm. Surveyor unable to determine which PI progressed with undermining as wound clinic did not number the PIs and specify exact location on the right foot/heel. Wound clinic visit missed 09/20/24. Wound clinics note stated, in part: On 09/24/24- Right posterior heel- measures 0.8cmx1cmx0.4cm, with undermining at 1,2,3,4,5,6,7 o clock, with depth of 0.7cm. Surveyor unable to determine which PI progressed with undermining as wound clinic did not number the PIs and specify exact location on the right foot/heel. Observations: On 09/30/24 at 10:25 AM, Surveyor observed R21 sitting in wheelchair with feet sitting on wheelchair pedals watching TV. R21 was not observed to be wearing foot protectors as ordered. Purple boots sitting on chair across the room. On 09/30/24 at 11:35 AM, Surveyor observed R21 sitting in wheelchair with feet sitting on wheelchair pedals watching TV. R21 was not observed to be wearing foot protectors as ordered. Purple boots sitting on chair across the room. On 09/30/24 at 1:40 PM, Surveyor observed R21 sitting in wheelchair with feet sitting on wheelchair pedals watching TV. R21 was not observed to be wearing foot protectors as ordered. Purple boots sitting on chair across the room. On 09/30/24 at 3:22 PM, Surveyor observed R21 sitting in wheelchair with feet sitting on wheelchair pedals. R21 was not observed to be wearing foot protectors as ordered. Purple boots sitting on chair across the room. On 09/30/24 at 4:01 PM, Surveyor observed R21 sitting in wheelchair with feet sitting on wheelchair pedals. R21 was not observed to be wearing foot protectors as ordered. Purple boots sitting on chair across the room. Facility did not apply purple boots on 09/30/24 to offload R21's heels as care planned. Surveyor reviewed treatment documentation that noted R21 only refused twice in the month of September and staff were not documenting consistently that staff applied purple boots. Facility has missing documentation that the treatment to apply purple boots was completed on most days in the month of September. Interviews: On 10/02/24 at 1:35 PM, Surveyor interviewed Director of Nursing (DON) B and asked about comprehensive PI assessments. DON B indicated that comprehensive skin assessments should be completed within 24 hours of admission. The expectation is that assessments be comprehensive and include measurements, description, location, unless the resident has an order not to remove a dressing, as in R21's case. R21 was admitted on [DATE] with an order to remove dressing at follow up wound clinic appointment. Follow up wound clinic appointment was on 05/09/24, when measurements were obtained from wound clinic. Surveyor asked if R21 refuses purple boots for off-loading. DON B indicated R21 does sometimes, but expectation is staff document this and to reapproach R21 as much as possible to apply purple boots. Surveyor asked DON B about September treatment orders and missing documentation of applying purple boots to R21. DON B indicated that staff have not been consistent with applying purple boots to off-load. On 10/02/24 2:01 PM, Surveyor interviewed Certified Nurse Assistant (CNA) G and asked why R21 did not have purple offloading boots on while up in wheelchair from 10:25 AM-4:01 PM on 09/30/24. CNA G indicated that R21 refused to put the purple boots on the morning of 09/30/24. Surveyor asked if CNA G re-offered or tried to encourage R21 to place the purple boots on. CNA G indicated that CNA G did not go back in to offer to apply the purple boots to R21. Surveyor asked if R21 refuses sometimes and if CNA G documented the refusals. CNA G indicated that CNA G did chart at 2:55 PM on 09/30/24 that R21 refused but CNA G indicated that R21 use to refuse a lot before she went into hospital in July but hasn't in a while. On 10/02/24 at 2:15 PM, Surveyor interviewed Registered Nurse (RN) F and asked if R21 refuses R21's purple off loading boots and what is expectation of wearing R21's purple boots. RN F indicated that R21 should always wear the purple boots. RN F indicated that R21 has a history of refusing boots but since had surgery on R21's foot back in July that R21 has been more accepting of staff to place on heels so R21 can get home instead of being in nursing home for so long. On 10/02/24 at 2:25 PM, Surveyor interviewed RN I and asked if pressure injuries could have been avoidable for R21. RN I indicated with all of R21's comorbidities like diabetes mellitus and venous insufficiency, all the PIs are unavoidable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility did not provide the needed services in attempt to maintain R10's mobility. The facility practice has the potential to affect 1 of 3 residents (R), R10, reviewed for limited range of motion and mobility. This is evidenced by: Surveyor requested the facility policy regarding restorative or maintenance programs at the facility. Director of Nursing (DON) B informed surveyor the facility does not have a maintenance or restorative program at the facility and has not for some time due to various reasons. The facility does not have a policy specific to maintenance or restorative programing. Surveyor reviewed R10's most recent Minimum Data Set (MDS) which was a quarterly (MDS) completed on 8/22/24. The MDS notes R10 understands and is understood. R10 does not reject care. R10 has no range of motion impairments and requires supervision with transfers. Ambulation noted as has not been attempted. Surveyor reviewed R10's program that read: Restorative Carryover Recommendations Program Requested: Ambulation Instructions: Walk to and from meals as able in in hallway distance as tolerated with FWW (Front wheeled walker), contact guard with gait belt For the goal of: maintain current level of function (CLOF) and minimize fall risk Dated: 8/01/23 Therapist: PT Surveyor reviewed R10's care plan and noted: Focus: The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) frontotemporal dementia with agitation, COPD (chronic obstructive pulmonary disease), anemia, depression with anxiety, CHF (congestive heart failure), tremors, subarachnoid hemorrhage, seizures and incontinence. Goal: The resident will maintain current level and/or improve based on therapy goal of function through the review date. Revised on: 6/11/24 Target Date: 11/14/24 Intervention: Walking: assist of 1 with walker to and from meals with gait belt and walker, w/c (wheelchair) to follow. Surveyor reviewed R10's [NAME]: (Certified Nursing Assistant) care guide and noted: Mobility: Walking; assist of 1 with walker to and from meals with gait belt and walker. w/c (wheelchair) to follow. On 9/30/24 at 11:32 AM, Surveyor observed staff propel R10 to the dining room in her wheelchair with no offer by staff to ambulate to the dining room. On 9/30/24 at 12:28 PM, Surveyor observed staff take R10 to the dayroom after lunch from the dining room with no offer to ambulate. On 10/01/24 at 6:58 AM, R10 was again taken to the dining room by staff with no offer by staff to ambulate to the dining room. On 10/01/24 at 8:41 AM, R10 was taken from the dining room to the therapy gym where staff placed a gait belt around her waist, assisted her to stand with walker to ambulate. Surveyor reviewed R10's record for evidence R10's maintenance walking program was conducted by staff. No evidence was located in R10's chart. On 10/01/24 at 10:34 AM, Surveyor spoke with Director of Nursing (DON) B requesting evidence of R10's walking program being offered and implemented by staff. DON B provided documentation that showed R10 was not offered her ambulation program from 7/01/24 to present. On 10/01/24 at 9:44 AM, Surveyor spoke with DON B regarding R10's walking program. DON B expressed R10 is being followed in physical therapy with expectation for staff to walk her to and from meals 3 x a day. The program is a maintenance program for R10 to maintain her ambulation status. DON B further expressed she would expect staff to offer R10 her walking program to and from every meal. Surveyor requested R10's Maintenance Program. On 10/01/24 at 1:55 PM, Surveyor spoke with Certified Nursing Assistant (CNA) E regarding R10's ambulation program to and from meals. CNA E indicated she has been on the day shift for the past 5 months and works 2-3 days a week and routinely cares for R10. CNA E further expressed in the morning when R10 first gets up she is a little off balance. CNA E expressed she does her morning care and transfers R10 to her wheelchair and places R10 in the hallway. R10 is taken from the hallway to the dining room. After breakfast R10 often propels herself from the dining room. Before lunch R10 is usually in activities in the dining room and stays there for lunch thus walking is not done. Surveyor asked CNA E if she has spoken with nursing or therapy staff regarding R10's program. CNA E responded she had not talked with anyone about R10's program and the program is important because If you don't use it; you lose it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not ensure a resident with an indwelling catheter was assessed for removal of the catheter as soon as possible for 1 of 1 resident (R) R19, reviewed with indwelling catheters. Findings: The facility policy titled, Indwelling Urinary Catheters, read in part .A resident who enters the facility with an indwelling urinary catheter is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that the catheter was necessary. 1. If the resident has an indwelling urinary catheter, complete the assessment upon admission, quarterly, and with change. 2. Document the reason the catheter is being utilized based on the following: a. Resident has an acute urinary retention or bladder outlet obstruction. 1. Changing indwelling catheters at routine, fixed intervals are not recommended. Rather, it is suggested to change catheters based on clinical indications such as infection, obstruction, or when the closed system is compromised. R19 was admitted to the facility on [DATE]; diagnoses included benign prostatic hyperplasia without lower urinary tract symptoms, urinary tract infection (UTI), and overactive bladder. R19 was admitted with an indwelling catheter. R19's most recent Minimum Data Set (MDS) assessment completed on 08/21/24, confirmed R19 had an indwelling catheter, a urinary toileting program had not been tried, and urinary continence had not been assessed due to R19 having an indwelling catheter. R19's physician orders included an order to: Change catheter every four weeks and as needed for occlusion or malfunction. R19's care plan included: -The resident has a foley catheter: Neurogenic bladder, (of note, documentation does not support this diagnosis). -Change every four weeks and as needed. On 08/12/24, R19 was admitted to the hospital for UTI with sepsis. R19 was re-admitted to the facility on [DATE], with an indwelling catheter and antibiotic treatment. On 10/02/24, Surveyor reviewed R19's history and physical (H&P) completed on 07/26/24, as part of the pre-admission process. Summary of present illness included, in part, His urinary incontinence issues are resolved with the chronic indwelling catheter; they are very pleased with this. R19's plan included chronic indwelling catheter will be changed monthly. On 10/02/24 at 1:35 PM, Surveyor interviewed Director of Nursing (DON) B. DON B indicated the facility's medical director agreed with routinely changing indwelling catheters unless a urologist ordered a specific schedule. This decision does not align with current standards of practice, as routine or fixed changes are not recommended and catheters should be changed based on clinical indications, such as infection, obstruction, or when the system is compromised. DON B agreed routine changing of catheters does not align with the facility policy or the regulatory requirements. DON B stated R19's diagnoses did not meet the criteria for an indwelling catheter. Surveyor requested additional supporting documentation, such as urology visit or orders. The facility did not provide any additional documentation.

Example 2 Surveyor reviewed R25's physician orders which include: .-On 09/29/24 COVID-19 precautions . Surveyor reviewed progress notes: .-On 09/29/24 at 11:37 AM, Resident tested positive today for COVID routine testing. Asymptomatic. MD updated. -On 09/30/24 at 4:42 PM, Covid positive resident remains in isolation and is compliant with same . Observations: On 09/30/24 at 10:50 AM, Surveyor observed R25 have a precaution PPE cart outside room, and no signage on the door. On the PPE cart there was an EBP sign upside down underneath a box of gloves. On 09/30/24 at 10:53 AM, Surveyor interviewed CNA G and asked why R25 was on EBP with PPE cart outside R25's room. CNA G indicated that CNA G did not know and had to go ask RN F. RN F indicated that R25 was on droplet precautions for COVID-19. Surveyor asked RN F about the signage not on the door and an EBP sign lying upside down on PPE cart outside R25's room. RN F indicated that R25 has COVID-19 and there is supposed to be a droplet precaution sign on R25's door, so that everyone knows before entering what PPE to utilize when caring for R25. On 09/30/24 at 10:55 AM, Surveyor observed RN F walk down the hallway and grabbed EBP sign off R25's PPE cart outside the door and continued down the hallway to the nurse's station. On 09/30/24 at 10:56 AM, Surveyor observed RN F apply a droplet precaution sign to R25's door. Surveyor asked RN F when R25 became positive with COVID-19. RN F indicated that R25 tested positive yesterday on 09/29/24. RN F indicated that the day nurse charted on 09/29/24 at 11:38 AM that R25 was positive with COVID-19. Surveyor asked RN F if staff have been going in and out without proper PPE. RN F stated, I will be perfectly honest with you, since there was no sign on the door, I am sure from yesterday 09/29/24 on day shift until just now on 09/30/24 at 10:56 AM, no one has been wearing appropriate PPE to protect themselves from spreading COVID-19. Based on random observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help to prevent the development and transmission of communicable diseases and infections for 2 residents (R) (R17 and R25). Example 1 The facility policy entitled F880 Multidrug-Resistant Organisms (MDRO) and Enhanced Barrier Precautions (EBP) last revised on 3/2024, states under definition of EBP, The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. On 10/01/24 at 7:46 AM, Surveyor observed during med pass with Registered Nurse (RN) J, an Enhanced Barrier Precaution (EBP) sign on R17's room door directing staff to wear Personal Protective Equipment (PPE) of gown and gloves. Surveyor asked RN J reason for EBP signage. RN J stated R17 has an indwelling catheter and Certified Nursing Assistant (CNA) E is changing catheter to a leg bag. Surveyor observed CNA E come out of bathroom to grab additional supplies and noted CNA E was not wearing a protective gown. Surveyor asked RN J if CNA E should be wearing a gown. RN J stated yes confirming EBP signage on door. On 10/01/24 at 7:50 AM, Surveyor interviewed CNA E after coming out of bathroom with R17. CNA E confirmed expectation of need to wear appropriate PPE and stated was just doing task quickly to get R17 to breakfast. On 10/02/24 at 9:40 AM, Surveyor interviewed Director of Nursing (DON) B and notified of observations of CNA E not following EBP. DON B confirmed staff would be expected to follow policies of facility to prevent infections.

Based on observation, interview and record review, the facility did not ensure proper sanitization and food handling practices to prevent the outbreak of foodborne illness for all 28 residents (R). Serving utensil was left in thickener powder. Cooks were observed grabbing ready to eat food with gloved hands, after touching non-sanitized food surfaces, and placing the ready to eat food on plates for residents to eat. Cooks were observed not changing gloves and washing hands after touching non-sanitized food surfaces. Cooks did not perform hand hygiene between glove changes during food service. Cook did not wear hair restraint and/or correctly when entering kitchen, preparing, or serving food. Food (milk) placed in kitchen refrigerator had been opened but was not labeled with an opened date, resulting in the potential for foodborne illnesses to spread. Food items for resident consumption were not labeled with open or discard date. Findings include: Facility policy entitled Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices F812, effective 10/23, states Food Services employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Under section entitled Guidelines states in part: 6. Employees must wash their hands . d. Before coming in contact with any food services. f. After handling soiled equipment or utensils. g. During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. h. After engaging in other activities that contaminate the hands. i. before putting gloves on and after removing gloves. j. Before distributing meals to residents. 10. Food service employees will be trained in the proper use of utensils such as tongs, gloves, deli paper and spatulas as tools to prevent foodborne illness. 11. Gloves are considered single-use items and must be discarded after completing the task for which they are used. The use of disposable gloves does not substitute for proper handwashing. 13. Hair nets and/or chef caps and/or beard restraints must be worn when cooking, preparing, or assembling food to keep hair from contacting exposed food, clean equipment, utensils, and linens. According to the FDA Food Code 2022 documents at 2-402.11 Hair restraints: Effectiveness. (A) Except as provided in (B) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils and linens and unwrapped single service and single use articles. The facility policy entitled Refrigerators and Freezers F812 effective 10/23 states, The facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Under section entitled Guidelines, the policy states in part: 6. All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. 8. The food shall be labeled and clearly marked to indicate the date or day by which the food shall be consumed or discarded. 9. The discard day or date may not exceed the manufacturer's use-by-date or four days, whichever is earliest. The date of opening or preparation counts as day 1. 10. Expiration dates on unopened food will be observed and use by dates indicated once food is opened. 12. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. The facility policy entitled Foods Brought by Family/Visitors F813 states, Staff must be aware of, and approve, food(s) brought to a resident by family/visitors. Under the section Guidelines, the policy states in part: 6. Perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator. Containers will be labeled with the resident's name, the item and the use by date. 7. The food service staff and nursing staff is responsible for discarding perishable foods on or before the use by date. 8. The nursing and/or food service staff must discard any foods prepared for the resident that show obvious signs or potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates). On 09/30/24 at 11:46 PM, Surveyor observed [NAME] C begin tray line after washing hands and putting on gloves, pick up a plate, and using gloved hands, touched serving utensil to dish up food onto plate. [NAME] C then, using contaminated gloved hand, touched green beans to make room for dishing potatoes and proceeded to dish up service line plates. On 09/30/24 at 11:55 AM, Surveyor observed [NAME] C dish up a plate and determined food needed to be placed on a divided plate. Using contaminated gloved hands, [NAME] C picked up divided plate serving utensil and scraped the food into the divided plate. [NAME] C proceeded with gloved hands, picked up corn and potatoes from regular plate and placed onto the divided plate. On 09/30/24 at 11:57 AM, Surveyor observed [NAME] C while waiting to begin room tray service. [NAME] C, with same contaminated gloves, proceeded to touch uniform, opened oven door to remove clean plates for service, retouched uniform, picked up a vegetable spray container and placed back on shelf, turned dial on prep table, touched a clipboard to read notes, and touched a center of a clean plate to check warmth. On 09/30/24 at 12:15 PM, Surveyor observed [NAME] C, without conducting hand hygiene or glove change, proceed to dish resident room trays. On 09/30/24 at 12:16 PM, Surveyor observed [NAME] C wipe gloved hands during room tray plate service on a wet cloth and continued to dish up remaining resident room tray. On 10/01/24 at 7:12 AM, Surveyor observed Registered Nurse (RN) F, walk into kitchen without a hair net two times to get coffee and then chocolate milk. RN F confirmed expectation of facility is to wear a hair net when entering kitchen. On 10/01/24 at 8:05 AM, Surveyor entered kitchen and observed [NAME] D wearing a hair net and beard net that were not fully covering hair down side of face and around neck area, blending pureed food with gloved hands. During process, [NAME] D, with contaminated gloved hands, scooped thickener powder with metal scoop lying inside container and placed in blender, proceeded to place blender container in steam table, moved dirty cutting board to sink area, and proceeded to dish resident meal plates picking up individually cut coffee cake pieces or slices of buttered toast and placing on residents' plates. On 10/01/24 at 8:10 AM, Surveyor observed and interviewed CNA E, who walked into kitchen during tray service without wearing hair net. CNA E stated expectation of facility would be to wear a hair net when entering kitchen. On 10/01/24 at 8:12 AM, Surveyor observed [NAME] D, after conducting hand hygiene and putting on clean gloves, enter storage room and bring out a plastic bagged loaf of bread. With contaminated gloves, [NAME] D took out 2 slices of bread and placed in toaster. [NAME] D proceeded with same contaminated gloves picking up individual coffee cake slices, cracked 2 eggs, wiped gloved hand on a wet cloth, served up more coffee cake, flipped eggs, grabbed vegetable spray for griddle, cracked 2 more eggs which were dripping egg white on gloves, wiped gloved hands on wet cloth, grabbed toast from toaster, removed gloves and without hand hygiene put on clean pair of gloves. [NAME] D flipped eggs and placed on plate, wiped hand with wet cloth and sprayed griddle with vegetable spray. No hand hygiene or glove changes were observed. On 10/01/24 at 12:11 PM, Surveyor observed [NAME] D begin to serve food with contaminated gloves. Surveyor did not observe [NAME] D doff contaminated gloves and perform hand hygiene before serving with contaminated gloves. On 10/02/24 at 8:20 AM, Surveyor observed [NAME] D with same contaminated gloves, begin serving room trays picking up coffee cake or toast. [NAME] D then picked up contaminated blender cup and brought it to 3 compartment sink, removed gloves and without hand hygiene put on a clean pair of gloves. [NAME] D proceeded to open freezer door, walked out with 1 slice of frozen French toast in contaminated gloved hand, opened oven door and placed French toast inside. [NAME] D proceeded to serve breakfast plates and picked up coffee cake or toast with contaminated gloves. [NAME] D opened oven door, and with contaminated gloves, took out warmed French toast, placed on a cutting board holding the French Toast with contaminated gloved hands and with knife cut into small pieces and placed on a resident plate. [NAME] D wiped gloved hands on wet cloth, cracked 4 eggs picking out pieces of broken shell from cracked eggs, removed gloves, and without conducting hand hygiene, put on a new pair of gloves and continued resident meal tray service. On 10/01/24 at 12:31 PM, Surveyor interviewed [NAME] C regarding use of a wet cloth during meal service to wipe off gloves. [NAME] C indicated the wet cloth was from the quaternary sanitation bucket and stated the expectation was to remove gloves and conduct hand hygiene anytime gloves become contaminated. On 10/01/24 at 12:31 PM, Surveyor interviewed [NAME] C regarding observations during meal services on 09/30/24. [NAME] C was unaware of contaminating gloves with examples provided during observation. On 10/01/24 at 12:55 PM, Surveyor interviewed [NAME] D regarding observation during meal service of not wearing beard nets appropriately, touching contaminated items with gloved hands and picking up food, use of sanitization bucket sanitizer cloth to wipe off glove in place of hand hygiene, observations of no hand hygiene prior to and between glove changes. [NAME] D stated that expectation is to remove gloves when contaminated, conduct hand hygiene, and change gloves. [NAME] D stated that the beard nets do not cover full beard. On 10/01/24 at 9:01 AM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding expectation of staff entering kitchen. NHA A stated expectation would be to either wait at kitchen door for assistance from dietary staff or put on a hair net before walking into kitchen. On 09/30/24 at 10:50 AM, Surveyor observed the facility unit refrigerator and freezer which contained the following items: -Black plastic garbage bag with Texas Roadhouse leftovers unlabeled or dated. -Walmart bag with leftover container of raspberries unlabeled or dated. -Domino's pizza box with three slices of left over pizza unlabeled or dated. -Bag with several size containers labeled with a resident name and undated. -Open liter of Diet Mountain Dew unlabeled or dated. -Open jar of Hellman's mayonnaise opened labeled with resident name and undated. -Box of opened mini corn dogs unlabeled or dated. Surveyor observed a sign taped to outside of fridge/freezer, dated 01/15/23, stating, This refrigerator is for resident use only. All items must be labeled with the resident's name and dated. All outdated (3 days) and unlabeled items will be discarded by dietary. Any employee items will be discarded. Employees may keep items in the refrigerator in the employee's breakroom. they must also be labeled and dated. Thank you Dietary Manager. On 09/30/24 at 11:15 AM, Surveyor interviewed RN F regarding responsibility of maintaining nursing unit fridge/freezer. RN F stated any staff who place leftovers into fridge should label and date and believes kitchen staff checks/logs temperature and cleans out item. RN F also stated anyone who goes in fridge should discard things as needed. On 10/01/24 at 11:17 AM, Surveyor interviewed NHA A regarding nursing unit fridge/freezer upon survey entrance on 09/30/24. NHA A stated expectation would be anyone who puts items in the fridge/freezer should label and date and kitchen staff are responsible for routine monitoring and discarding anything undated/past dated. On 10/02/24 at 9:40 AM, Surveyor interviewed Director of Nursing (DON) B regarding observation during kitchen survey. DON B confirmed expectation would be to follow facility policies for infection control.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when an allegation of verbal abuse was not reported immediately but not later than 2 hours after the allegation is made to local law enforcement in accordance with state law through established procedures. The facility practice affected 1 of 1 resident (R) reviewed. (R1). This is evidenced by: Surveyor requested and reviewed the facility policy regarding reporting suspicion of a crime. The policy titled Reporting Abuse Allegations which was dated as last approved on 11/2023 indicated the following: Policy: all suspected violations and all substantiated incidents of abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources and misappropriation will immediately be reported to appropriate state agencies or individuals as may be required by law. Crime is defined by law of the applicable political subdivision where the facility is located. Law enforcement is the full range of potential responders to elder abuse, neglect and exploitation including: police, sheriffs, detectives, public safety officers, corrections personnel, prosecutors . Guidelines: ~Should a suspected violation or a reasonable suspicion or substantiated incident of mistreatment .or abuse. Including suspected crimes .the facility Administrator .will promptly notify the following persons or agencies (verbally and written) of such incident: .Law enforcement officials as appropriate. ~If there is a reasonable suspicion of a crime, exercise caution in handling materials that may be used as evidence or for a criminal investigation. ~Examples of crimes that should be reported include murder, manslaughter, rape, assault and battery, sexual abuse, theft/robbery, drug diversion, identity theft and fraud and forgery additional examples may be available through local of state law enforcement. Work in tandem with local law enforcement in determining what would be reported .Document conversation in facility QAPI of facility assessment .Review such with local law enforcement at least annually. Surveyor reviewed the facility reported incident (FRI) and noted: Date occurred: 1/25/24. Time occurred: 11:00 am Briefly describe the incident (a more detailed summary should be uploaded on the attachments tab): Resident reported that charge nurse was intimidating towards him when he was voicing concerns about the wound treatment being performed. Describe the effect that the incident had on the affected person, the persons reaction to the incident and the reaction of others who witnessed the incident: Resident stated during interview with the administrator that he was scared of nurse during the treatment being provided as he was in a vulnerable state during cares. After immediately reporting the incident to management an investigation was initiated, resident felt instantly better and has since not had any other reaction. Administrator informed resident of staff member suspension immediately and the resident was happy with decision and stated he felt safe. The only witness to the incident was the charge nurse in which the allegation is made against. Explain the steps the entity took upon learning of the incident to protect the affected person and others from further potential misconduct: Administrator immediately initiated investigation and suspended charge nurse in which allegation of emotional abuse was made. Social Worker initiated interviews with other residents and responsible parties and found no other abuse or unsafe environment found. Social Worker and Administrator offering empathetic listening to all residents. Medical Director, ombudsman and physician notified .Head to toe assessment of resident was completed by DON. Administrator initiated in servicing to all staff on abuse prevention policy, protection of residents, resident rights .Resident did not want us to contact law enforcement. Law Enforcement Involvement: Was law enforcement contacted or involved: No. Surveyor reviewed R1's most recent Minimum Data Set (MDS) dated [DATE]. The MDS indicates he understands, is understood and is cognitively intact. On 2/13/24 at 8:49 a.m., an interview was completed with R1 regarding the incident reported above. R1 reported to Surveyor on 1/25/24 at approximately 9:20 a.m., Registered Nurse (RN) C was in his room to complete treatment to his lower extremities. R1 expressed he informed RN C he was not completing the treatment properly per physician orders. R1 reported the more he questioned RN C about the improper treatment the more angered RN C became. R1 reported RN C had both of his knees in R1's bed, was within inches of his face and swore at him and stated, F---in bring out the man in me. Surveyor noted R1's eyes welled with tears as he recollected the incident. R1 further stated he is a tough man, has lived in Milwaukee and has been in fights in the past but this incident scared him and intimidated him as he is now vulnerable and relies on others for his care. R1 explained he took out his cell phone and began recording RN C hoping he would either stop or be recorded on R1's phone. RN C stopped when the recording started. As soon as RN C left R1's room, R1 placed on the call light and a Certified Nursing Assistant responded. R1 asked to speak to administration. The Director of Nursing (DON) B, Nursing Home Administrator (NHA) A and Social Services person came in and immediately began an investigation which included immediate suspension of RN C. RN C never returned to employment. R1 indicated he feels safe and does not have any ill effects from the incident since RN C did not come back to work. R1 expressed he declined informing the police at the time but now believes for the safety of others the police should be informed of the incident. On 2/13/24 at 9:03 a.m., Surveyor spoke with NHA A about the incident and facility investigation. NHA A indicated she, DON B and the Social Worker were called to R1's room. R1 reported feeling scared and intimidated by an interaction with RN C during wound care. R1 had begun recording RN C during the incident due to feeling scared and intimidated. The facility immediately began an investigation and suspended RN C. The facility terminated RN C's employment as there had been a prior incident with RN C with a staff person along with RN C's interaction with R1. RN C had been talked to about his demeanor and approach with his team. RN C has a military background, is straight forward and matter of fact. Surveyor asked NHA A about the failure to report the incident to the police. NHA A indicated the facility did not believe a crime was committed. Surveyor asked NHA A if local law enforcement were involved in the development of the facility policy regarding reporting suspicion of a crime. NHA A indicated she was unsure of police involvement in the policy. On 2/13/24 at 11:09 a.m., NHA A informed Surveyor the police department were here today to discuss involvement in the facility policy for reporting suspicion of a crime. The police officers informed NHA A they had not ever been involved in the past with the development of the policy; specifically, what would constitute a reportable crime as well as calling the on-call officer in the future with any resident abuse concerns. NHA A further expressed there is no evidence of documented conversations with local law enforcement via the QAPI (Quality Assurance Process Improvement) committee.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not thoroughly investigate an allegation of abuse. The facility practice affected 1 of 1 resident reviewed (R1). Findings Include: Surveyor reviewed the facility policies for the abuse prohibition program as follows: Abuse Prevention Program, Training which was dated 9/2023. The policy does not address the facility's investigation process. Abuse Prevention Program which was dated 9/2023. The policy in part reads: Abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment . Comprehensive policies and procedures have been developed to aid the facility administration in preventing abuse, neglect or mistreatment. The abuse prevention program provides policies and procedures that govern at a minimum: timely and thorough investigations of all reports of abuse including reporting of crimes. The current seven components of CMS directed abuse condition of participation are located in separate policies and procedures listed below: .Screening, training, prevention, identification, protection, reporting/response. Abuse Prevention Program, Protection of Residents During Abuse Investigations dated 9/2023. The policy does not address the facility investigation process and thoroughness of the investigation. Surveyor reviewed the facility reported incident (FRI) and found: Date occurred: 1/25/24. Time occurred: 11:00 am Briefly describe the incident (a more detailed summary should be uploaded on the attachments tab): Resident reported that charge nurse was intimidating towards him when he was voicing concerns about the wound treatment being performed. The FRI does not have any further details on what or why R1 felt intimidated by the charge nurse. The FRI did not include a summary or facility findings. Describe the effect that the incident had on the affected person, the persons reaction to the incident and the reaction of others who witnessed the incident: Resident stated during interview with the administrator that he was scared of nurse during the treatment being provided as he was in a vulnerable state during cares. After immediately reporting the incident to management an investigation was initiated, resident felt instantly better and has since not had any other reaction. Administrator informed resident of staff member suspension immediately and the resident was happy with decision and stated he felt safe. The only witness to the incident was the charge nurse in which the allegation is made against. Explain the steps the entity took upon learning of the incident to protect the affected person and others from further potential misconduct: Administrator immediately initiated investigation and suspended charge nurse in which allegation of emotional abuse was made. Social Worker initiated interviews with other residents and responsible parties and found no other abuse or unsafe environment found. Social Worker and Administrator offering empathetic listening to all residents. Medical Director, ombudsman and physician notified .Head to toe assessment of resident was completed by DON. Administrator initiated in servicing to all staff on abuse prevention policy, protection of residents, resident rights .Resident did not want us to contact law enforcement. There is no evidence the facility spoke with other staff to determine if any other concerning incidents involving Registered Nurse (RN) C had been seen or heard and gone unreported. Attachments included a written statement by RN C which described R1 being angered about the treatment RN C was performing. Stating R1 was pounding the bed, gritting his teeth and calling RN C an idiot and stating You are all so stupid .There is no evidence the facility interviewed RN C. Surveyor reviewed R1's most recent Minimum Data Set (MDS) dated [DATE] which indicates he understands, is understood and is cognitively intact. On 2/13/24 at 9:03 a.m., Surveyor spoke with Nursing Home Administrator (NHA) A about the incident and facility investigation. NHA A indicated Director of Nursing (DON) B and the Social Worker were called to R1's room. R1 reported feeling scared and intimidated by an interaction with RN C during wound care. R1 had begun recording RN C during the incident due to feeling scared and intimidated. The facility immediately began an investigation and suspended RN C. The facility spoke with other residents as part of their investigation. The facility provided retraining of staff on the abuse policies but did not interview staff as part of their investigation. The facility terminated RN C's employment as there had been a prior incident with RN C with a staff person. RN C had been talked to about his demeanor and approach with his team. RN C has a military background, is straight forward and matter of fact. The findings or summary of the investigation had not been completed as NHA A was not familiar with Wisconsin's process or form. NHA A expressed NHA A talked with R1 and has raw notes in a notebook about R1 feeling scared and intimidated during his dressing change with RN C and could type something up today if needed. Surveyor informed NHA A recollecting the incident weeks later would not be appropriate and the conversations with R1 about the incident should have been part of the facility investigation. Surveyor inquired about the facility findings or summary of the investigation. NHA A explained RN C's employment was terminated and he did not return to the facility. RN C was terminated due to his approach with R1 and the prior incident with a staff member. The investigation did not include this information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility did not implement procedures for reporting an injury of unknown origin for 1 of 1 resident (R9). R9's record confirmed three separate incidents of an injury of unknown origin not reported to the Nursing Home Administrator or the state Survey Agency (SA). Findings include: Surveyor reviewed the facility titled, Abuse Prevention Program, Training, Prevention of Abuse, and Recognizing Signs and Symptoms of Abuse/Neglect (Identification), revised 08/2022. The policy reads in part . Abuse Prevention Program, Prevention of Abuse: The community staff will not condone any form of resident abuse, neglect, exploitation, or mistreatment and will continually monitor the facility's policies, procedures, training programs, systems, etc., to assist in preventing resident abuse. 10. Provide staff with information on how to report suspected abuse without the fear of reprisal. Recognizing Signs and Symptoms of Abuse/Neglect (Identification): To aid in abuse prevention all personnel are to report any signs of abuse/neglect to their supervisor or to the Director of Nursing Services immediately. 4. Injury of unknown origin is defined as suspicious related to the source of the injury is not observed or the extent or location is unusual or related to the number of injuries either at a single point or over time. 5. The following are some examples of actual abuse/neglect and signs and symptoms of abuse/neglect that should be promptly reported. When in doubt report it. -Welts or bruises -Abrasions or lacerations R9 was admitted to the facility on [DATE]. Diagnoses include Alzheimer's disease and dementia with behavioral disturbance. Minimum Data Set (MDS) assessment dated [DATE] confirmed the following: -is rarely/never understood and rarely/never understands others -Brief Interview for Mental Status score 0/15, with inattentiveness and disorganized thinking, indicating severe cognitive impairment -Wandering behavior -Set up assistance with eating, dependent on staff for personal hygiene and bathing/showering, and substantial assistance from staff with toileting and dressing, supervision and partial assistance from staff with ambulation and transferring -Frequently incontinent of bowel and bladder R9's progress notes indicated the following: -08/28/23, Aides concerned about the bruise on the right side of resident's head. Resident noted with yellowish green faint colored bruise on the right side of her head. It appears to be an old bruise. Informed NP about the area and she observed it with no further action needed at this time. -08/28/23, Skin note: yellowish, greenish light colored bruise to the left side of head -09/01/23, Staff also noticed a red spot on her forehead b/t her eyes. It was not there Thurs. when staff asked her what happened she said she fell. When asked when she fell she said she thought it was last wk. Will cont. to monitor. (Surveyor noted most recent documented fall was 08/10/23) -10/22/23, Bruise found to anterior R hand. Origin unknown R9's record did not indicate any physical behaviors including kicking, pushing, hitting, or grabbing. On 10/25/23 at 3:25 PM, Surveyor interviewed Director of Nursing (DON) B. DON B reviewed R9's injuries documented on 08/28/23, 09/01/23, and 10/22/23. DON B stated she was not made aware of R9's injuries. DON B confirmed facility procedure is as follows; if injury was not witnessed, the resident could not state how the injury occurred, and the injury is suspicious, staff are to report the injury to DON or Nursing Home Administrator (NHA) and an investigation would be initiated. DON B stated staff should have reported R9's injuries to DON or NHA.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not conduct a Preadmission Screening and Resident Review (PASARR) for R5, who has a serious mental disorder to ensure he receives care and services in the most integrated setting appropriate to his needs. The facility practice affected 1 of 2 residents reviewed (R5). R5 was admitted on [DATE] with diagnoses that included Schizoaffective disorder and cognitive and communication deficit. The facility did not complete a Preadmission Screening and Resident Review (PASARR) prior to his admission to ensure he receives care and services in the most integrated setting appropriate to his needs. This is evidenced by: Surveyor reviewed R5's record and noted he was admitted [DATE] with diagnoses that included Schizoaffective disorder and cognitive and communication deficit. Surveyor reviewed R5's record and could not locate a Level 1 Preadmission Screening and Resident Review (PASARR). R5's orders include: 5/18/23 Haloperidol 10 mg at bedtime for schizoaffective disorder 5/18/23 Ziprasidone 60 mg at bedtime for schizoaffective disorder On 10/24/23 at 3:29 PM, Surveyor spoke with Registered Nurse/Care Coordinator (RN) D about R5's PASARR. RN D expressed obtaining PASARR is part of her work responsibilities. RN D expressed this responsibility was part of the social services role in the past and she was not familiar with the process thus R5's level 1 PASARR was not done. RN D further expressed there was some confusion on R5's county of residence. RN D sent the paperwork to the county, it was never received, and she did not follow up with the county.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure care plans were updated for 1 of 12 residents (R22) reviewed. R22's care plan was not updated after two hospitalizations related to gastrointestinal bleed. This is evidenced by: R22 was admitted to the facility on [DATE]. R22's diagnoses include failure to thrive, malnutrition, atrial fibrillation, and weakness. R22's MDS completed on 10/04/23 confirmed R22 scored 15 during BIMS, indicating intact cognition. R22 was admitted to the hospital on [DATE] and 09/25/23 for gastrointestinal (GI) bleed. Surveyor reviewed R22's record which did not include a care plan related to bleeding or GI bleeding. Surveyor reviewed R22's [NAME] and certified nursing assistant (CNA) tasks and noted no care or monitoring related to bleeding or GI bleeding. On 10/24/23 at 3:29 PM, Surveyor interviewed Director of Nursing (DON) B. DON B acknowledged bleeding should have been included in R22's care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 3 R9 was admitted to the facility on [DATE]. Diagnoses include Alzheimer's disease and dementia with behavioral disturbance. Minimum Data Set (MDS) assessment dated [DATE] confirmed R9's Brief for Mental Status (BIMS) score was 0/15, with inattentiveness and disorganized thinking, indicating severe cognitive impairment. R9's care plan includes high risk for falls, with interventions of the following: -anti-rollback to wheelchair, 09/20/23 -if R9 is sleeping outside of her room, assist her to bed, 08/11/23 -call light within reach, 05/25/23 -dycem in wheelchair, 10/16/23 -encourage to rest in recliner, 05/25/23 -fall mat adjacent to bed, 06/27/23 -room door should not be closed when she is in bed, 10/07/23 -Therapy evaluation, 05/25/23 Surveyor reviewed R9's falls investigations and noted the following interventions were not implemented to prevent further falls. -05/25/23, Resident walked into shower room after it was used and before staff locked the door. Staff advised to check door frequently to ensure it's locked when not in use. -06/14/23, Resident was at the nursing station, sat in a swiveling chair on wheels without brakes and slid from the chair to the floor to a sitting position. Activities continues to try and occupy resident with diversional activities. -06/22/23, Resident noted in front of nurses' station on floor. Bed kept in low position. -06/25/23, Resident noted sitting on floor on buttock. Will continue with search for appropriate facility and staff to be vigilant of resident's whereabouts at all times. -06/26/23, Resident discovered in room on floor adjacent to bed sitting position. No new interventions. -07/13/23, Resident tipped forward out of chair catching self with hands to not hit head. No new interventions. On 10/24/23 at 3:29 PM, Surveyor interviewed DON B. DON B stated the interdisciplinary team discusses every fall to ensure a complete investigation and new interventions should be added to the resident's care plan. DON B acknowledged all interventions were not included in R9's care plan. Example 4 R18 was admitted to the facility on [DATE]. Diagnoses include dementia with Lewy bodies and history of urinary tract infections. R18's Minimum Data Set (MDS) assessment, completed on 09/22/23, confirmed R18 scored 3/15 during Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. R18's care plan included at risk for falls, with the following interventions: -Bariatric bed that goes to the floor, 10/16/23 -Bolster mattress, 10/16/23 -Pharmacy to evaluate medications, 07/24/23 -Proper footwear, 08/16/23 -Encourage to use call light, engage brakes on wheelchair, 08/02/23 -Therapy consult, 07/24/23 -Staff educated on equipment and designated area is posted, 09/20/23 Surveyor reviewed R18's falls investigations and noted the following interventions were not implemented to prevent further falls. -08/25/23 Resident face down on the floor next to his bed in his room. Res. legs were tangled up in his sheets & blankets w/his abductor pillow b/t his legs. He was laying on the right side of the bed in reg. clothes. Demonstrated for resident how and when to use call bell and where it's located. This is not an effective intervention as R18 has a BIMS of 3 and would not be able to recall and apply the information as to how to use the call bell. On 10/24/23 at 3:29 PM, Surveyor interviewed DON B. DON B stated the interdisciplinary team discusses every fall to ensure a complete investigation and new interventions should be added to the resident's care plan. DON B acknowledged all interventions were not included in R18's care plan. Based on interview and record review, the facility did not ensure the resident's environment remained as free of accident hazards as possible, and residents received adequate supervision and assistive devices to prevent accidents for 4 of 7 residents (R20, R27, R9, and R18) reviewed. R20 was observed to be maintaining her smoking materials, not using a smoking apron, or being provided supervision with smoking. R20's smoking assessment and care plan identify R20 is at risk for burns and requires supervision with smoking and R20's smoking materials to be secured. R27 was transferred by Certified Nursing Assistant (CNA) E without use of a gait belt. R27's Minimum Data Set (MDS) indicates R27 requires extensive assistance of 2 staff for transfers. Facility standard of practice indicates staff should use a gait belt with transfers. R9's care plan was not updated to include new interventions after multiple falls. R18's care plan was not updated to include new interventions after multiple falls. This is evidenced by: Example 1 Surveyor received and reviewed the policy titled Smoking which is not dated. The policy in part reads: ~Any resident who persists in wishing to smoke .will be reminded smoking can only occur outdoors, in designated areas, in a supervised setting. ~Safe smoking assessments will be performed on residents .equipment and or physical assistance may be recommended/provided if needed. On 10/23/23 at 11:27 AM, Surveyor interviewed R20 regarding her smoking. R20 indicated she maintains her smoking materials in small bag on her person. R20 showed Surveyor the small bag which was at R20's side in her wheelchair. R20 verified cigarettes and lighter were in the bag. R20 further expressed she goes out independently to smoke with no staff supervision to smoking area in front of the building and has since she was admitted . R20 expressed she has some issues with her neck that at times makes her arm and hands numb. On 10/24/23 at 6:59 AM, Surveyor observed R20 exit building in front of the building. R20 went to the smoking area in front of the building and lit a cigarette she removed from a small bag at her side. Surveyor noted no staff present and R20 did not have on a smoking apron. Surveyor reviewed R20's most recent smoking assessment dated [DATE]. The assessment notes R20 utilizes tobacco. The assessment further notes: Poor vision: no Balance problems while sitting or standing: yes total or limited ROM (range of motion) in arms or hands: no Insufficient fine motor skills needed to securely hold cigarette: yes Lethargic/falls asleep easily during tasks or activities: no Burns skin, clothing, furniture or other: yes Drops ashes on self: yes Follows facilities policy on location and time of smoking: yes Concerns: ~Unable to hold a cigarette safely and unable to extinguish a cigarette safely. Surveyor reviewed R20's smoking care plan. The care plan indicates: Focus: Resident has the potential for injury related to smoking. Date Initiated: 08/18/23. Goal: Resident will be complaint with facility smoking policy. Initiated: 08/18/23. Target Date: 12/28/23. Interventions: ~Keep smoking paraphernalia in safe location away from the resident until wants to go out and smoke, to be turned into the nurses. ~Resident to be supervised by assigned staff at all times during smoking activity. Surveyor reviewed R20's care card related to smoking. The card states: Safety: Resident to be supervised by assigned staff at all times during smoking activity. On 10/24/23 at 1:32 PM, Surveyor interviewed Director of Nursing (DON) B about R20's smoking care plan. DON B indicated a care conference was held last week and R20 was provided the facility smoking policy. R20 should not keep her smoking materials on her and should be turning them into the nurse. R20 was sharing her cigarettes and lighter with other residents. DON B further expressed she would expect nurses to be watching as R20 should be supervised with smoking as she is at risk for burns and should be wearing a smoking apron. DON B expressed staff should be following residents' smoking plans of care. DON B further expressed, See her go out on her own all the time and honestly thought she could. DON B indicated she was unaware of R20's most recent smoking assessment and care plan. Example 2 Surveyor received the facility policy titled Safe Lifting and Movement of Residents dated 09/23. The policy in part states: Policy Statement: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Policy Interpretation and Implementation: ~Nursing staff in conjunction with rehabilitation staff, shall assess individual resident needs for transfer assistance on an ongoing basis .Staff will document resident transferring and lifting needs in the care plan. Surveyor reviewed R27's most recent Minimum Data Set (MDS) done on admission and dated 08/31/23. The MDS indicates R27 requires extensive assistance of 2 staff for transfers. Surveyor reviewed R27's care plan and care card. The care plan indicates R27 is at risk for falls but does not indicate R27's transfer status. On 10/24/23 at 9:55 AM, Surveyor observed CNA E approach R27 who was sitting in recliner across from the nurse's station. CNA E reached under R27's arms and assisted her to stand. R27 raised her arms enough for her shirt to raise and expose her breast. CNA E continued to transfer R27 to her wheelchair. No gait belt (transfer belt) was used to transfer R27. Surveyor asked CNA E about the transfer and whether a gait belt is needed. CNA E indicated she does not use a gait belt with R27's transfers as the gait belt does not get tight enough and it slips up. Surveyor asked CNA E what R27's care plan or therapy recommendation is for transferring R27. CNA E responded she did not know and would have to check. Following the observation, Surveyor spoke with DON B regarding the observation. DON B expressed she expects staff to use a gait belt for all resident transfers and would do an immediate teachable moment with CNA regarding the expectation to use a gait belt. Surveyor asked DON B about R27's transfer status. DON B expressed she would need to check and get back to Surveyor. On 10/24/23 at 1:34 PM, DON B informed Surveyor R27 has not been assessed by therapy for transfer status. R27 requires 2 staff with a gait belt to safely transfer. DON B further expressed R27's care plan will be updated to include 2 staff with gait belt for R27's transfers. DON B reiterated it is the facility expectation staff use a gait belt for all transfers to keep residents safe and from falling during transfers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 2 R22 was admitted to the facility on [DATE]. R22's diagnoses include failure to thrive, malnutrition, and weakness. R22 was in transmission-based precautions during the survey related to COVID positive status. R22's admission weight was 162 lbs. R22's care plan includes nutritional problem related to inadequate nutritional intake since admission. Care plan updated by RD C on 10/03/23 to confirm significant weight loss since admission. Care plan revised on 10/20/23. Care plan intervention monitor/record/report signs of malnutrition, significant weight loss 3lbs in one week, >5% in one month, >7.5% in three months, >10% in six months. R22's physician orders include regular diet, nutritional supplement per RD, obtain weekly weight, dated 09/21/23. R22's weights are as follows: 09/23/23: 162 lbs 09/30/23: 151.4 lbs 10/01/23: 151 lbs 10/05/23: 149.2 lbs 10/12/23: 143.6 lbs 10/19/23: Progress note states unable to weigh due to isolation precautions. R22's dietary assessments include the following information: 08/20/23: 162#. Resident reports no changes in weight in past 180 days. 10/03/23: 151#. Weight declined 7.1% in 30 days which is both a significant and unintended weight loss. Recommended high protein diet, high protein snack between meals, increase nutritional supplement from 4oz. to 8 oz., consider appetite stimulant. 10/10/23: Weight has declined further, 149.2#. Recommend juice in between meals to be administered by nursing. 10/20/23: Weight: 143.6#. Weight continues to SIGNIFICANTLY decline. 12.2% unintentional weight loss noted in 30 days. Recommend start fortified foods at meals for added calories. Noted physician declined appetite stimulant at this time. On 10/25/23, Surveyor interviewed DON B. DON B reported she obtained an order to hold weights due to R22's COVID positive status. DON B was not able to provide evidence of this order. Example 3 R131's diagnoses include congestive heart failure and chronic kidney disease. R131 was in transmission-based precautions from 10/10/23-10/13/23 related to COVID positive status. R131 is prescribed a diuretic to reduce fluid volume. R131's assessments indicate edema in his lower extremities. Physician order on 10/11/23, obtain weight for three days, then weekly. R131's care plan, dated 10/14/23 includes nutritional problem related to COVID 19, dehydration, heart failure, chronic kidney disease, anemia, meal intakes <50% average since admission. Interventions include monitor for signs and symptoms of malnutrition, weigh weekly per physician orders. R131's weight on 10/10/23 was 194.6 lbs. On 10/24/23, Surveyor reviewed R131's weights and confirmed there were no further weights documented. R121's progress notes included: -10/11/23, daily weight. Resident is on ISO -10/12/23, daily weight. Resident is on ISO, will be able to obtain 10/13/23. -10/13/23, daily weight. Unable to weigh at this time due to precautions. -10/13/23, transmission-based precautions discontinued. -10/17/23, weekly weight. No weight d/t COVID +. -No further weights in R131's record. On 10/25/23 at 8:04 AM, Surveyor interviewed DON B. DON B reported she obtained an order to hold weights due to R131's COVID positive status. DON B was not able to provide evidence of this order. DON B stated weights for new admissions are important to obtain a baseline weight. Based on observation, record review and interview, the facility did not monitor resident weight status consistent with current standards of practice. The facility practice has the potential to affect an appropriate and prompt response to potential resident weight loss affecting 3 of 3 residents reviewed for weight loss (R81, R131 and R22). R81's weights were not obtained per the facility policy and standards of practice to ensure nutritional parameters were maintained. R81 did not have evidence of snacks being provided. R22 has a diagnosis of malnutrition and was identified by Registered Dietician (RD) C as having significant weight loss and was to be weighed weekly. R22's last weight was obtained on 10/12/23. R131 is a new admission to the facility on [DATE]. R131's last weight was obtained on 10/10/23. This is evidenced by: Surveyor requested and received the facility policy titled Weight Assessment and Intervention dated as effective 10/2023. The policy in part reads: Policy: The Interdisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss .for our residents. Weight Assessment: 1. Each resident is weighed upon admission .and weekly x 4 unless indicated otherwise, monthly thereafter. 2. Weights will be recorded per community protocol. 4. The RD will review the communities weight record of the month to follow individual weight trends . 5. The threshold for significant unplanned and undesired weight loss = (usual weight-actual weight)/(usual weight) x 100: 1 month-5% weight change is significant; greater than 5% is severe, 3 months: -7.5% weight change is significant; greater than 7.5% is severe, 6 months: -10% weight change is significant; greater than 10% is severe. Surveyor reviewed R81's record and noted she was admitted [DATE] with diagnoses that include unspecified severe protein-calorie malnutrition, anemia, other disorder of plasma-protein metabolism, not elsewhere classified, chronic gastric ulcer and diaphoretic hernia. R81's admission MDS dated [DATE] notes she understands, is understood and is cognitively intact. R81 has no mood or behavioral concerns. She has experienced weight loss and is not on a weight loss regimen, weighs 115#. R81's orders include: 09/26/23 regular diet, regular texture, and regular consistency. 10/21/23: Ensure plus bid for weight loss and snacks between meals. 10/23/23: weight times 3 days. 10/26/23 weekly weight every Thursday. R81's weights were noted as follows: 09/26/23 115.3 - R81 was to be weighed daily for 3 days upon admission, and then weekly. 10/23/23: 112.0 This weight is 27 days after admission. 10/24/23: 99.8 10/25/23: 99.2 (15.5 pounds/13.4% loss in less than 1 month). Nutritional assessments: 09/26/23 Category: Malnourished Weight: 115.3 No decrease in intake, weight loss greater than 3 kg (6.6 lbs) Has suffered psychological distress or acute disease in past 3 months, BMI 19 to less than 21 Score: 06=malnourished. Registered Dietician (RD) notes: 10/23/23: Weight has declined to 112#. RD stated to R81 that she has the right to snack on whatever foods that she desires . MVI and Ferrous Sulfate ordered. Prealbumin pending. Will continue to follow. 10/21/23: RD follow up: Weight: 115# (09/26/23). Will request a current weight from nursing, weekly weights recommended. 10/20/23: Recommendations from Dietician. and ordered by [Name], Ensure High Protein drink BID and snacks between meals. Easy to chew diet. Labs -Prealbumin. Get a dental appt scheduled. 10/19/23: Noted PCP did order prealbumin check, to be drawn 10/23/23. Easy to chew diet ordered. High protein R81's Care plan notes: Focus: The resident has nutritional problem or potential nutritional problem r/t significant and unintentional weight loss in 90-180 days, BMI is approaching underweight category, impaired skin, severe protein-calorie malnutrition . Goal: The resident will maintain adequate nutritional status as evidenced weight gain r/t nutrition to reach BMI of 23.0, meal intakes will average 75%, improved nutritional status as evidenced by weight gain r/t nutrition. Surveyor requested R81's snack data since her admission on [DATE]. Surveyor was provided data from 10/01/23 to present. Documentation showed no snacks as follows: 10:00 AM no data on 3/24 days. 2:00 PM: no data on 8/24 days. On 10/25/23 at 8:45 AM, Surveyor spoke with Registered Dietician (RD) C about R81's weight loss. R81's usual body weight was 135 pounds. It is the facility policy to weigh residents the first 3 days after admission and then weekly for 4 weeks. If resident's weight is stable, then monthly weights can be initiated. If not, then weekly weights need to continue. R81's weights were not obtained per the facility policy and standards of practice. The facility has been made aware with several emails sent by the dietary manager about the missed weights. No quality improvement efforts have been started to improve the system of collecting resident weights. It is important the weights be done so weight loss can be responded to promptly. On 10/25/23 at 10:15 AM, Surveyor spoke with Director of Nursing (DON) B about the facility expectation of obtaining resident weights, R81's weight loss and missing snack documentation. DON B explained weights should be done per facility expectation of daily x 3 days post admission and weekly x 4 weeks. This is so baseline weights can be determined. R81 has several health concerns including edema and malnourishment and probably should have been a daily weight with all her health concerns. The facility is aware weights are not being done and residents are not being monitored appropriately. The facility met yesterday to discuss the concern but have not developed a quality improvement plan or put steps into place to fix the system issue. The missing snack documentation indicates a snack was not offered to R81.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure residents received pharmaceutical services (accurate acquiring, dispensing, and administering of all drugs and biologicals) to meet the needs of 2 of 12 residents (R18 and R22). R18 had a physician's order to administer D-Mannose. After R18 ran out of his medication the facility made no effort to obtain a new supply and reported this medication was brought in by family. R22 had a physician's order to administer Lidocaine Viscous Mouth solution. The facility did not receive the medication from the pharmacy and no efforts were made to obtain the medication for five days. This is evidenced by: Example 1 Surveyor reviewed facility policy titled Pharmacy Services, dated 09/2023. The policy reads in part . The facility shall contract with a licensed pharmacist to help obtain and maintain timely and appropriate pharmacy services. This includes .f. Help the facility assure that medications are requested, received, and administered in a timely manner. Surveyor reviewed facility policy titled Medications Brought to the Facility by the Resident/Family, dated 09/2023. The policy reads in part . The facility shall ordinarily not permit residents and families to bring medications into the facility. The facility discourages the use of medication brought in from outside. R18 was admitted to the facility on [DATE]. Diagnoses include dementia with Lewy bodies and history of urinary tract infections. R18's Minimum Data Set (MDS) assessment completed on 09/22/23, confirmed R18 scored 3/15 during Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. R18's physician orders include an order for D-Mannose oral capsule, 4 capsules 3 times per day, for urinary tract infection (UTI) prevention, dated 07/25/23. Surveyor reviewed R18's progress notes, and noted the following: 10/15/23, D-Mannose Medication not available. Family was supposed to bring medication today, then decided against coming Too cold and wet. Will bring another day. 10/16/23, D-Mannose not available, family to bring. 10/17/23, D-Mannose out for an appointment. 10/20/23, R18 was diagnosed with UTI and COVID +. R18's family was updated on R18 having change in mentation, tremors and wandering and guidance from primary care provider (PCP) to send to ER. Family refused R18 to be sent to ER and requested R18 being given D-Mannose. Surveyor was not able to determine if D-Mannose had been received by facility prior to the Survey period, as there was no documentation to indicate if medication was provided by family. Surveyor reviewed R18's medication administration record (MAR) for October and noted the following regarding D-Mannose administration: 10/15/23 8:00 PM, not administered. 10/16/23 8:00 AM and 12:00 PM not administered, 8:00 PM administered dose. 10/17/23 8:00 AM and 12:00 PM not administered, 8:00 PM administered dose. 10/18/23, administered. 10/19/23, administered. 10/20/23, administered. 10/21/23, on order 10/22/23, on order On 10/25/23 at 10:45 AM, Surveyor interviewed Director of Nursing (DON) B. DON B verified R18 did not receive medication as ordered by physician. DON B stated the facility should have ensured R18 received medication as ordered, updated the pharmacy, or updated R18's physician. Example 2 R22 was admitted to the facility on [DATE]. R22's diagnoses include failure to thrive, malnutrition, and weakness. R22's physician orders include regular diet, nutritional supplement per RD, obtain weekly weight, dated 09/21/23. Lidocaine Viscous HCl Mouth/Throat Solution 2 %, give 5 ml by mouth before meals and at bedtime for poor dentition for 14 days, dated 10/19/23. Surveyor reviewed progress notes and noted the following: -10/19/23, reviewed resident and weight loss. MD updated, sent RD recommendation. Declines starting on appetite stimulant at this time. Order to follow up with dentist when off of isolation of covid-appointment was canceled per dental office not wanting to see during isolation, appointment re-scheduled. New order to try nystatin-lidocaine swish and spit compound due to resident poor dentition, to see if resident is not eating due to dentition and no eating. Resident and POA aware of above. Will continue to monitor. -10/20/23, RD C documented weight continues to SIGNIFICANTLY decline. 12.2% unintentional weight loss noted in 30 days. -10/20/23, lidocaine viscous mouth solution, unavailable -10/21/23, lidocaine viscous mouth solution, med not delivered -10/22/23, lidocaine viscous mouth solution, med not available -10/23/23, lidocaine viscous mouth solution, med not available, waiting for pharmacy to deliver, not in e-kit -10/24/23, lidocaine viscous mouth solution, med not available -10/25/23, Spoke with PharMerica about lidocaine/nystatin solution, that still has not showed up to facility. -10/25/23, received medication at 2:15 PM. 10/25/23 at 12:54 PM, Surveyor interviewed DON B. DON B reported she was unsure why R22's medication was not delivered by pharmacy. DON B stated if a resident's medication is not available the expectation is the nurse will call the pharmacy to update or order the medication. DON B reported nursing staff completed an in-service on 10/12/23, providing education on pharmacy and medications, and documentation should not indicate 'medication unavailable,' as the nurse is expected to call the pharmacy and enter a progress note.

Based on record review and staff interview, the facility did not ensure a Registered Nurse (RN) worked at the facility for at least eight consecutive hours a day, seven days a week, on 3 of 5 days reviewed on Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year (FY) Quarter 3 2023 (April 1-June 30, 2023). This has the potential to affect all residents in the facility. The facility did not have a RN working in the facility for at least eight consecutive hours on 04/25/23 (Tuesday), 05/13/23 (Saturday), and 05/14/23 (Sunday). This is evidenced by: The Code of Federal Regulation (CFR) 483.35 (b) states, in part: . except when waived, the facility must use the services of a registered nurse for at least 8 hours a day; 7 days a week. On 10/23/23, Surveyor at entrance requested from Nursing Home Administrator (NHA) A the staff postings, the daily staff assignments, and the nursing schedules for April 1 through June 30, 2023. On 10/25/23, Surveyor interviewed NHA A about the PBJ Staffing Report regarding the no RN working at least eight consecutive hours a day, 7 days a week. NHA A stated NHA A was collecting the employee clocked hours for the dates in question. NHA A stated the facility errored in reporting all the hours. NHA A stated the agency staff hours were undoubtedly not reported. NHA stated that the facility has an RN on every day. On 10/26/23, facility provided documentation for RN hour verification. Surveyor reviewed documentation. RN hours for 05/28/23 and 06/03/23 were verified. Surveyor was unable to verify RN hours for 04/25/23, 05/13/23, and 05/14/23.

Based on interview and record review, the facility did not ensure that the mandatory staffing data that had been submitted from 04/01/23-06/30/23 was complete, accurate, and auditable. This has the ability to affect all 30 residents in the facility. The submitted data from 01/01/22-03/31/23 was not complete, accurate, or auditable. This is evidenced by: The Payroll Based Journal (PBJ) Staffing Data Reports that were generated quarterly document that the facility triggered No RN Hours for the dates of 04/25 (TU); 05/13 (SA); 05/14 (SU); 05/28 (SU) 06/03 (SA) Failed to have Licensed Nursing Coverage 24 Hours/Day for the dates of 04/01 (SA); 04/02 (SU); 04/03 (MO); 04/04 (TU); 04/06 (TH); 04/07 (FR); 04/08 (SA); 04/09 (SU); 04/10 (MO); 04/11 (TU); 04/12 (WE); 04/14 (FR); 04/15 (SA); 04/16 (SU); 04/17 (MO); 04/18 (TU); 04/20 (TH); 04/21 (FR); 04/22 (SA); 04/23 (SU); 04/24 (MO); 04/25 (TU); 04/26 (WE); 04/28 (FR); 04/29 (SA); 04/30 (SU); 05/01 (MO); 05/04 (TH); 05/05 (FR); 05/08 (MO); 05/09 (TU); 05/13 (SA); 05/14 (SU); 05/17 (WE); 05/18 (TH); 05/19 (FR); 05/23 (TU); 05/27 (SA); 05/28 (SU); 05/31 (WE); 06/01 (TH); 06/03 (SA); 06/04 (SU); 06/08 (TH); 06/09 (FR); 06/10 (SA); 06/11 (SU); 06/13 (TU); 06/14 (WE); 06/16 (FR); 06/17 (SA); 06/18 (SU); 06/19 (MO); 06/22 (TH); 06/23 (FR); 06/24 (SA); 06/25 (SU); 06/26 (MO); 06/30 (Fr). On 10/25/23 at 11:30 a.m., Surveyor interviewed NHA A about the PBJ Staffing Report. NHA A stated NHA A was collecting the employee clocked hours for the dates in question. NHA A stated the facility errored in reporting all the hours. NHA A stated the agency staff hours were undoubtedly not reported, so the information in the report was inaccurate. On 10/25/23, Surveyor did not receive any documentation from the facility by the end of the survey to audit the information submitted for the PBJ staffing report in comparison to the employee clocked hours. On 10/26/23, NHA A provided documentation for RN hours and licensed nursing coverage 24 hours per day. Surveyor reviewed staffing documentation and verified RN hours for 05/28/23 and 06/03/23. Surveyor was unable to verify RN hours for 04/25/23, 05/13/23 and 05/14/23. Surveyor reviewed licensed nursing coverage hours and facility had coverage 24 hours per day. PBJ Staffing Report had inaccurate data entry and missing data.

Based on interview and record review, the facility did not identify issues to which quality assessment and assurance activities are necessary or develop and implement appropriate plans of action to correct identified quality deficiencies. This has the potential to affect all 30 residents. The facility does not have a QAPI system in place and has failed to identify key areas of deficient practice and implement action plans to correct these deficient practices or identify areas needing improvement to develop, implement, monitor, and evaluate action plans to achieve specific goals to improve quality of care. This is evidenced by the following: The policy titled Quality Assurance & Performance Improvement (QAPI,) was reviewed. The policy stated, in part, .QAPI Mission The facility will maintain an ongoing, facility wide QAPI Plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems .The administrator is responsible for assuring that this facility's QAPI Program complies with federal, state and local regulatory agency requirements . The facility QAPI Plan, dated January 1, 2023, states in part: .The goals of the QAPI Committee include: 1. To monitor and evaluate the appropriateness and quality of care provided within the framework of the QAPI Plan, including the development of up to three overall QAPI projects annually; 2. To oversee the facility systems and processes related to improving quality of care and services; 3. TO promote consistent facility systems and processes and appropriate practices in resident care; 4. To help identify negative outcomes relative to resident care and resolve them appropriately; 5. To help departments, consultants and ancillary services implement plans to correct identified issues in quality of care; 6. To coordinate the development, implementation, monitoring, and evaluation of action plans to achieve specified quality goals; 7. To help departments, consultants and ancillary services establish effective accountability for care and quality, and; 8. To coordinate and facilitate communication regarding the delivery of quality resident care within and among debarments and services, and between facility staff, residents, and family members . On 10/25/23, Surveyor reviewed the facility QAPI binder. In June of 2023 there was a sign in sheet for the June 2023 QAPI meeting with minutes indicating discussion of survey results, plan of correction (POC) for survey deficiencies was the PIP (performance improvement plan). September 2023 QAPI meeting had sign in sheet and audits/education conducted for the deficiencies identified in the June survey. The QAPI binder did not indicate evaluation of audits or education for effectiveness in the correction of past survey deficiencies. There was no evidence of the facility tracking data to identify current deficient practice concerns or putting interventions in place to improve quality of care for the residents. On 10/25/23 at 11:35 a.m., Surveyor interviewed Nursing Home Administrator (NHA) A regarding the QAPI process and if the facility was aware of the following areas identified during current recertification survey: falls, weight monitoring, pharmacy service, and smoking. NHA A stated the facility had started to address smoking but the residents who smoked are no longer at the facility and the issue was dropped. The current smoking issue identified regarding a resident smoking independently who should be supervised was not known before the current survey as the facility did not follow through with the previously identified smoking safety concerns. NHA A stated the other issues were not known prior to the survey, as the facility was not tracking to identify concerns. NHA A stated the facility currently does not have a QAPI system in place. NHA A stated the facility has undergone so many changes in leadership with Administrators and Director of Nursing positions as well as many other facility staff. NHA A stated there has not been consistency to have a QAPI system in place. The facility does not have a QAPI system in place and has failed to identify key areas of deficient practice and implement action plans to correct these deficient practices.

Based on interview and record review, the facility did not provide dementia management and abuse prevention training to all staff. This deficient practice had the potential to affect all 30 residents (R) residing in the facility. The facility did not implement and maintain a dementia training program for all staff, as determined by the facility assessment. Findings include: Surveyor reviewed the facility's Abuse Prevention Program, Training, revised 08/2022. This program reads, in part . Mandated staff training/orientation programs will be provided that include abuse prevention of all types, identification of abuse, recognizing signs and symptoms, reporting of abuse, and understanding behavioral symptoms that may lead to an increase in abuse. 1. At least, upon hire and annually each community employee will complete abuse in-service education. 4. Topics should include: d. Dementia management and understanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond. j. Conflict resolution and anger management skills, including .resident to resident conflicts. 5. Document such training per community protocol. 6. Staff education may change as the community changes. Utilize the Facility Assessment to identify changes in required training. Surveyor reviewed the Facility Assessment, revised 05/05/23, confirming the facility population included residents with dementia. The Facility Assessment indicated staff training and education in dementia management. Surveyor conducted interviews of staff and asked the following question, Has the facility provided you training in dementia management and abuse prevention? On 10/25/23 at 2:07 PM, Certified Nursing Assistant (CNA) F reported she has worked at the facility for three years. CNA F stated she may have received training, way back when, it is not an annual thing. On 10/25/23 at 2:13 PM, Licensed Practical Nurse (LPN) H reported she has worked at the facility since October 26, 2023. LPN H stated she received training through the agency she is employed with but had not received training through the facility. On 10/25/23 at 2:16 PM, Certified Medication Technician (CMT) G reported she has worked at the facility for a couple of years. CMT G stated the facility has not provided in-services or education on dementia care. CMT G reported the facility does not have an orientation process for new employees. On 10/25/23 at 3:03 PM, Surveyor requested staff training related to dementia management and abuse prevention. Director of Nursing (DON) B reported she was not able to provide evidence of training offered to staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure 2 of 3 residents (R2 and R6) or their representatives, were given the opportunity to participate in care plan conferences in which decisions regarding the residents' care are made. 1. R2's most recent care planning conference (CPC) was documented as being held 2/20/23; however, family was not notified of the meeting. 2. R6's most recent CPC was documented as being on 12/28/22. Interview with R6's Guardian indicated the last session was held in the Fall of 2022. This is evidenced by: The facility policy titled Resident/Family Participation- Assessment/Care Plans last dated May 2022 states in part, Each resident and his/her family members are encouraged to participate in the development of the resident's comprehensive assessment and person-centered care plan . The resident and/or his/her representative, are invited to attend and participate in the resident's assessment and care planning conference. Notice shall be made by mail, electronic mail and/or telephone in a language that he or she can understand . The Social Services Director/Designee . is responsible for contacting the family and for maintaining records of such notices . On 6/13/23 at 8:15 AM, Surveyor interviewed RN G (Registered Nurse and Social Services Designee) regarding the process of care conferences. RN G stated she has been acting as social services designee since April 2023, with the termination of the previous social services individual. RN G stated the previous person was terminated because the facility learned that care conferences were not being conducted. RN G stated the procedure is that when a resident is admitted , within 48 - 72 hours, a care conference is conducted. Also, the conferences should be held quarterly to coincide with the MDS (Minimum Data Set) assessments and annually, as well as if there is a significant change in the resident and again one week prior to discharge of the resident to ensure outside resources are in place for the resident to discharge home. RN G stated that she is working to catch up on those not completed from the previous staff person but . I know we haven't gotten to all of them yet . On 6/13/23 at 12:38 PM, Surveyor interviewed RN D (Registered Nurse and MDSA Coordinator) regarding care plan conferences and the facility procedure. RN D stated that she was on maternity leave and returned in November and noticed . a mess with care plan sessions . She stated that care conferences should be conducted to correlate with the date of the MDS and noted many were not completed. She assisted the facility with catching up on those that were late. Then, around January/February 2023, a new social worker took over and she wasn't holding care conferences. RN D stated this individual was terminated because she wasn't holding the care conferences. In April, RN D stated RN G took over as social services designee and is making attempts to get caught up on care conferences to coordinate with the MDS assessments. RN D stated the procedure is that she schedules the care conferences and also coordinates the initial sessions, to be done within 48 - 72 hours of admission, and all discharge sessions. RN D further stated the correct procedure is to notify the resident and representatives of the meeting date and time. Family is notified if the resident is their own decision-maker. Example 1 R2 was hospitalized from home from 1/27/23 - 2/16/23. She was admitted to the facility on [DATE] with extensive medical diagnoses, including but not limited to wedge compression fracture of lumbar vertebra, interstitial pulmonary disease, chronic obstructive pulmonary disease, emphysema, chronic respiratory failure with hypoxia, congestive heart failure, essential hypertension, atherosclerosis of native arteries of extremities with intermittent claudication, hydronephrosis with ureteropelvic junction obstruction, reflux uropathy and urinary retention. The most recent MDSA (Minimum Data Set Assessment) was dated 2/23/23, which was an admission assessment. In reviewing the medical record of R2, Surveyor noted the following documentation: 2/20/2023 08:29 Social Services Late Entry: Note Text: IDT (Interdisciplinary Team) met with resident for care conference 48/72 hour meeting. Code status reviewed, meds reviewed, discharge discussed. Note: This late entry was documented on 2/27/2023 at 8:30 AM. There were no other indications of a conference being held, what was discussed and who attended. The individual who documented this entry is no longer employed by the facility to interview. Example 2: R6 has medical diagnoses that include, but are not limited to, diabetes mellitus, type II, bipolar disorder, peripheral vascular disease, major depressive disorder, anxiety disorder, atherosclerotic heart disease of native coronary artery, chronic pain, dysphagia,and cognitive communication deficit. R6 has an extensive history of falls. She has severely impaired daily decision-making abilities and is under Guardianship. On 6/13/23 at 4:50 PM, Surveyor interviewed R6's Guardian (Guardian F) related to general care, notification received by the facility and the completion of care conferences. Guardian F stated the last care conference conducted with her for R6 was last Fall. Prior to that time, Guardian F stated the conferences were held on a regular basis. Guardian F stated that she visits with R6 every 2-3 weeks and if she has any concerns, she addresses it with those visits, but was concerned as there were no care conferences held in quite a while. Surveyor then reviewed R6's medical record and noted Minimum Data Set Assessments were completed as follows: - 11/22/22 (Quarterly) - 2/21/23 (Annual) - 5/23/23 (Quarterly) Care Conference meetings were documented as being held on 12/28/22. There were no corresponding care conferences held for February 2023, or May 2023.

Based on interviews and record reviews, the facility did not ensure the legal representative of 1 of 4 residents reviewed (R3), were notified of a resident's change in condition. R3 had a significant change in condition resulting in the transport to the emergency room (ER) where he subsequently passed away. The POA/Spouse (Power of Attorney) was not notified of this change in condition by the facility, instead, was made aware by the ER physician. This is evidenced by: The facility policy and procedure for Change in a Resident's Condition states, The facility staff shall promptly notify the resident, his or her Attending Physician, and resident representative of changes in the resident's medical/mental condition and/or status . The policy goes on to state notification by the Nurse Supervisor/Charge Nurse is to make these notifications in the following circumstances (not all-inclusive): - An accident involving the resident which results in injury and has the potential for requiring physician intervention; - A significant change in the resident's physical, mental, or psychosocial status, including a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications; -A need to transfer the resident to a hospital/treatment center R3 had medical diagnoses that included, but were not limited to Parkinson's Disease, diabetes mellitus-type 2 with neuropathy, hypertensive heart disease with heart failure, congestive heart failure, chronic respiratory failure with hypoxia, vascular dementia, paroxysmal atrial fibrillation, coarctation of the aorta, long-term use of anticoagulants and cognitive communication deficit. According to the most recent Minimum Data Set Assessment which was an annual assessment, dated 3/28/23, R3 required limited assistance of one staff to meet his most basic daily needs of bed mobility, transfers, dressing, bathing, and personal hygiene. He required extensive assistance of one staff for toileting. He was scored 15/15 on the basic interview of mental status, indicating that he was fully cognizant. In reviewing the medical record of R3, Surveyor noted that R3's spouse was activated Power of Attorney when two physicians deemed R3 incapacitated on 8/7/19. Further review of R3's medical record indicated that on 5/20/23 nursing documented a late entry for 5/19/23 at 1945. The documentation indicated that R3 was noted in the nursing station lethargic and confused. At 6:15 PM, R3 began to slide from the wheelchair, but did not fall, as staff intervened and assisted R3 to bed, when he began to vomit. His blood pressure was recorded as being elevated (173/107) and pulse was 83. The oxygen tank attached to R3 was noted to be empty and refilled. Oxygen was then administered at 4 liters per minute and reading was 91% on the 4 liters of oxygen. The documentation also indicated that R3's blood sugar was 200 (high). A Nitroglycerin tablet was administered and R3's blood pressure came down to 158/95. R3 complained of a major headache and continued to vomit. The on-call physician was called and ordered to send R3 to the ER. The documentation in the record indicated that R3's POA (POA C) was telephoned on multiple occasions to notify of the event, but no contact was made as the POA's telephone line was busy. The documentation went on to state that the ER was notified that contact with the POA had to be made and the ER stated they would conduct the notification. Surveyor telephoned POA C initially on 6/12/23 at 10:30 AM. POA C stated that she did not receive a call from the facility indicating that R3 had fallen, but rather, was called by the ER physician and informed that R3 was being evaluated. POA C stated that she only wanted to know what transpired resulting in R3 being sent to the ER to be evaluated. She was concerned that R3 had a fall as the ER physician indicated a brain hemorrhage too large to have resulted from a Cerebrovascular Accident and was suspicious that a fall had occurred. POA C also stated that she had called the facility Nursing Home Administrator (NHA A) and the Director of Nursing (DON B) multiple times and left voice mail messages for a return call with further information on R3's ER event, and to date, has not received a return call. Surveyor then had the facility obtain the ER Summary. The document indicated R3 suffered from an intracranial bleed and passed away on 5/20/23. There was no indication that a fall transpired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and record reviews, the facility did not ensure 1 of 3 residents reviewed for falls (R1), received treatment and care in accordance with professional standards of practice in relation to post-fall assessments. The facility did not continually monitor R1's vitals after a fall with unknown head injury. The facility did not follow physician orders to schedule R2 for an appointment with urology following recent placement of a Foley catheter when in hospital. This is evidenced by: According to National Institute of Health and Care Excellence (NICE) 2013, Falls: assessment and prevention of falls in older people a Post-fall assessment includes nursing to perform a physical assessment of the resident at the time of the fall, including vital signs (which may include orthostatic blood pressure readings) and an evaluation of head, neck, spine and/or extremity injuries. Also, the assessment should include a monitoring of vital signs and should be repeated minimally every hour for four hours then reviewed. The NICE also states that Neurological observations, Glasgow Coma Scale (GCS) and changes in level of consciousness, headache or vomiting should be assessed where a head injury is sustained as a result of the fall, or if the fall was unobserved and it is not known if the head was hit. These assessments should be completed initially and every 15 minutes for the first hour then every 30 minutes until GCS is within normal limits, then continue hourly for the next four hours, then every two hours for the next 24 hours. Example 1 R1 has medical diagnoses which include, but are not limited to toxic nephropathy, muscle weakness, anxiety disorder, depression, chronic kidney disease, and essential hypertension. In reviewing the Minimum Data Set Assessments completed for R1, the latest being an annual assessment dated [DATE], the following was noted: - Hearing, vision, and speech were normal - R1 was scored 15/15 for Basic Interview of Mental Status (BIMS) - R1 was independent with bed mobility. This assessment also indicated that R1 transfers and ambulates with one staff assist occurring 1-2 times during the assessment period, has limited assistance of one staff for dressing and extensive assistance of one staff for toileting and personal hygiene. R1 was coded as having no limitations in range of motion. - R1 was noted to be continent of bladder function and incontinent of bowels. - R1 had no prior history of falls. On 6/12/23 at 8:40 AM, Surveyor interviewed R1. R1 stated that he fell during a dream and rolled out of bed. He also stated that he did not know if he hit his head or not, but that . the next thing I knew, I woke up on the floor on my stomach . R1 stated that he was assessed by a nurse at the time, but that no other assessments were completed. R1 was able to state the standard of practice for vital signs as once every 15 minutes for the first hour, then every 30 minutes for the next hour, every hour for the next four hours and finally every four hours for the next 24 hours. R1 stated that did not occur. He stated he only had one set of vital signs taken and the next set was taken the following morning around 8:00 AM. He stated that he was told that sets of vital signs were recorded in his record, but that they actually were not completed, I only had someone assess me twice after the fall and that was initially after the fall and then the next morning. Surveyor then reviewed R1's medical record and noted no additional vital signs located in R1's record following the fall. The only set of vital signs recorded were dated 5/4/23 at 9:00 AM. The fall occurred 5/6/23 at or around 11:30 PM, in which R1 was discovered lying on his stomach on the floor beside his bed. There were no recorded vital signs or a neurological assessment immediately following the fall. The last recorded set of vital signs in R1's record was dated 5/4/23, two days prior to the fall. There are none recorded after this date. Surveyor then reviewed the Interdisciplinary Team Progress Notes and noted no vital signs or neurological assessments documented. The Surveyor then reviewed the fall risk assessment completed 5/7/23 at 2:56 AM and no vital signs or neurological assessment were documented on this assessment. An interview was conducted with DON B (Director of Nursing) on 6/13/23 at 7:28 AM in which DON B stated the expectation of any fall is for the resident to have a neurological and vital sign assessment for 72 hours. Surveyor asked DON B to locate assessments that were completed following R1's fall. At 7:35 AM, DON B approached Surveyor and stated he was only able to find the Risk Management documentation indicating the fall occurred. There was no set of vital signs or a neurological assessment included in this documentation. Example 2 R2 was hospitalized from home from 1/27/23 - 2/16/23. She was admitted to the facility late afternoon of 2/16/23. Medical Diagnoses for R2 were extensive and included wedge compression fracture of lumbar vertebra, interstitial pulmonary disease, chronic obstructive pulmonary disease, emphysema, chronic respiratory failure with hypoxia, congestive heart failure, essential hypertension, atherosclerosis of native arteries of extremities with intermittent claudication, hydronephrosis with ureteropelvic junction obstruction, reflux uropathy and urinary retention. A review of the hospital Discharge summary dated [DATE] revealed no orders to see urology for a indwelling Foley catheter change. It does state, . would benefit from urology follow-up outpatient for voiding trials . Under Follow-Up Issues to Address, it states, Urology follow-up for voiding trial as the patient has chronic Foley for significant urinary retention and hydronephrosis resulting from urinary retention which has improved with Foley catheter . The document goes on to indicate the Foley was placed on 2/9/23 and that R2 will need a urology follow-up. The nurse practitioner saw R2 on 2/23/23 and noted in her documentation that a follow-up CT (Computerized Tomography) scan was to be done and ordered this scan to be completed. This scan was completed 3/6/23. The Nurse Practitioner (NP) also ordered a follow-up Urology appointment. In the NP's documentation under Urinary Retention it stated, . has a chronic indwelling Foley catheter which was placed while hospitalized . Follow-up was ordered with Urology. However, there is no appointment made at the time of our visit. I have placed additional orders for the facility to schedule this follow-up, and asked the director of nursing to be sure this appointment is made . There was no evidence uncovered to indicate this appointment was made or attended by R2.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not evaluate and document 1 of 2 residents' (R4) pressure injuries on a weekly basis. R4 has bilateral (both) hip pressure injuries that were present on his admission. The facility did not assess and document R4's pressure injuries with each dressing change or at least weekly. Evaluation of pressure injury location, measurements, staging and wound description were not noted on a weekly basis. This is evidenced by: Surveyor reviewed R4's record and noted R4 was admitted [DATE] with diagnoses that includes multiple pressure ulcers to his back and thigh/hips. Surveyor reviewed R4's most recent quarterly Minimum Data Set (MDS) dated [DATE]. The quarterly MDS notes R4 has three stage 2 pressure injuries. Surveyor reviewed R4's Skin Evaluations from 9/15/22 to present. The following was noted: 9/21/22 Skin Evaluation indicates resident has current skin issues. There is no location of pressure injuries No staging or measurements of pressure injuries No wound bed description or wound exudate information No peri wound condition noted No dressing saturation information No comment on wound odor, tunneling, undermining or tissue condition The only noted documentation states: Skin note: see wound clinic notes 9/28/22 Skin Evaluation indicates resident has current skin issues again no information is documented related to pressure injury location, staging, measurements, wound bed description, wound exudate information, no peri wound condition noted, no dressing saturation information, no comment on wound odor, tunneling, undermining or tissue condition noted. The only information noted states: see wound clinic notes. Surveyor reviewed wound clinic notes. Surveyor noted visits on 10/03/22, 9/29/22 and 9/21/22 since 9/15/22. The wound clinic notes show resident history, wound treatment completed at appointment and recommendations and treatment orders. The clinic notes do not include documentation showing monitoring of pressure injury by staging, measurements, wound bed description, wound exudate, peri wound condition dressing saturation, wound odor, tunneling, undermining or tissue condition noted. Surveyor requested and reviewed the facility policy titled Pressure Injury/Skin Breakdown-Clinical Guidelines dated effective 06/2022. The policy in part states: Assessment and Recognition: The Nursing Staff will complete a evaluation of skin weekly. Treatment/Management: Based on the results of the evaluations staff will implement interventions . On 10/05/22 ay 2:10 PM, Surveyor met with Nursing Home Administrator (NHA) A, who was working as floor nurse, to discuss R4's pressure injury evaluations and documentation. NHA A indicated the facility was under the impression the wound clinic was completing wound evaluations and documenting wounds weekly when resident was in clinic for appointment. NHA A expressed R4's pressure injuries are improving. The facility did not evaluate pressure injuries by staging, measurements or wound descriptions. NHA A further indicated she can see now the weekly evaluations were not done. Surveyor asked NHA A about the facility policy indicating facility nursing staff would evaluate pressure injuries weekly. NHA A responded she was not aware facility policy directed nursing staff at the facility to evaluate the wounds weekly and she thought wound clinic was doing so.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility did not ensure 3 of 5 residents reviewed for unnecessary medications (R5, R12 and R21) had appropriate behaviors and monitoring of these behaviors to justify the use of psychotropic medications. - R5 uses an antipsychotic and an antidepressant medication and has had no Gradual Dose Reduction (GDR) with the antipsychotic medication since August of 2021. Behavior monitoring and staff interviews indicate R5 does not have behaviors to justify an antipsychotic use. - R12 receives an antidepressant and an antianxiety medication. There have been no GDRs attempted or adjustments made for the antianxiety medication since 8/13/21. Observations were made during the survey period (10/3/22 - 10/5/22) in which R12 displayed no behaviors of anxiety. Staff interviews also indicate that R12 has no behaviors to justify the use of these psychotropic medications. - R21 receives antipsychotics, antidepressants and antianxiety medication for her behaviors. She has behaviors of sporadic yelling out; however, she is unaware that she does this and it is infrequent. Staff interviews and observations made throughout the survey period (10/3/22 - 10/5/22) indicate no behaviors that place herself or others at risk for harm. R21's antianxiety and antidepressants have not undergone a GDR or adjustment since their initiation back in December of 2020. On 3/21/22, she was placed on the antipsychotic and this was increased on 5/12/22. This is evidenced by: On 10/4/22 at 1:27 PM, an interview was conducted with NHA A (Nursing Home Administrator). NHA A stated , . we have not had behavioral meetings among the Interdisciplinary Team. I do plan to initiate these to discuss resident behaviors, interventions and medications. There just has been so many other things to fix, but now that we have consultants coming in to help, I will be able to make that a priority . Example 1: R5 has medical diagnoses that include but are not limited to Encephalopathy, Cerebral Ischemia, Frontotemporal Neurocognitive Disorder, Anoxic Brain Damage and Mixed Anxiety and Depressed Mood. Surveyor reviewed Minimum Data Set Assessments to determine behavioral needs. The following assessments were reviewed and their findings: Quarterly 10/13/21 - R5 was coded on her Brief Interview of Mental Status (BIMS) as 8/15, indicating moderate to severe cognitive loss. - PHQ-9 (Patient Health Questionnaire) score was 3/27 The PHQ-9 is a questionnaire that objectifies the degree of depression severity an individual has. A PHQ-9 score total of 0-4 points equals normal or minimal depression. Scoring between 5-9 points indicates mild depression, 10-14 points indicates moderate depression, 15-19 points indicates moderately severe depression, and 20 or more points indicates severe depression. - Behaviors- none - R5 was receiving an antipsychotic, antidepressant and an antianxiety medication during this assessment. Quarterly 1/9/22 - R5 was coded on her Brief Interview of Mental Status (BIMS) as 6/15, indicating severe cognitive loss. - PHQ-9 (Patient Health Questionnaire) score was 8/27 - Behaviors- none - R5 was receiving an antipsychotic and an antidepressant medication during this assessment. Annual 4/11/22 - R5 was coded on her Brief Interview of Mental Status (BIMS) as 3/15, indicating severe cognitive loss. - PHQ-9 (Patient Health Questionnaire) score was 0/27, indicating no depressive symptoms - Behaviors- none - R5 was receiving an antipsychotic and an antidepressant medication during this assessment. Quarterly 7/12/22 - R5 was coded on her Brief Interview of Mental Status (BIMS) as 3/15, indicating severe cognitive loss. - PHQ-9 (Patient Health Questionnaire) score was 0/27, indicating no depressive symptoms - Behaviors- none - R5 was receiving an antipsychotic and an antidepressant medication during this assessment. R5 receives the following medications of concern: - Antipsychotic: Quetiapine Fumarate 8/3/21 was 25MG BID. On 9/29/22, the physician decreased the dosage to 25 mg in the evening for mood and give 12.5 mg by mouth in the morning for mood. - Antidepressant: Zoloft Tablet (Sertraline HCl), 100 mg by mouth in the morning for behaviors (1/28/22) Note that this was an increase in dosage. The order prior to this was 75 MG once daily. Surveyor reviewed R5's care plans in relation to behaviors and depression and noted the facility identified depression with symptoms of crying. There was a care plan for psychotropic medication usage related to frontal lobe dementia with agitation. Nonpharmocological approaches to assist R5 to meet her needs included one-to-one with staff, offer food and/or fluids, assist R5 up into the wheelchair and provide music. There were no care plan problems indicating R5 displays behaviors that may be detrimental to her or others. Surveyor then reviewed R5's Behavior monitoring for the past four months and noted the following: June: - data not consistently completed on all three shifts - 50 of 90 shifts were left blank with no data entered. Of the 40 remaining, resident was documented as having no behaviors. July: 93 shifts - data not consistently completed on all three shifts - 50 of 93 shifts were left blank with no data entered. Of the 43 remaining, resident was documented as having no behaviors. August: 93 shifts - data not consistently completed on all three shifts - Repetitive movements entered 15 shifts; 8/12 night shift recorded repetitive movements at 2331 and no behaviors at 0107. 8/27 was entered twice on nights at 2315 and again at 0004. - no data entered for 21 shifts September; 90 shifts plus an additional 7 night shifts were documented - data not consistently completed on all three shifts - Not Applicable was documented 6 times - no behaviors 67 shifts - no data entered 8 shifts - repetitive movements 10 times - Rejection of care x1 - wandering x2 Without adequate monitoring, the nurse and practitioners are unable to make a critical analysis of behaviors, if medications are benefiting an individual or if the medication use should be tapered off. Surveyor made observations of R5 throughout the survey period (10/3/22 - 10/5/22) and noted no behaviors at all from R5 that indicated a need for an antipsychotic medication. On 10/05/22 at 9:34 AM, Surveyor interviewed CNA E (Certified Nursing Assistant) regarding R5 and her behaviors. CNA E stated that R5, Really doesn't have any behaviors, just fidgeting in her chair. Doesn't hit out or yell or kick or anything like that. Pretty quiet, actually. Speech is really soft and sometimes you have to listen carefully to what she wants, but no behaviors. On 10/05/22 at 9:56 AM, Surveyor interviewed SS D (Social Services) regarding R5 and her behaviors. SS D stated that R5 .does not have any real behaviors, does have crying episodes but no behaviors that would create a potential of harm to herself or others . Example 2 R12 has medical diagnoses that include, but are not limited to Bipolar Disorder, Major Depressive Disorder, Anxiety Disorder, Chronic Pain and Vascular Dementia. R12 takes psychotropic medications for her depression and bipolar disease. Surveyor reviewed Minimum Data Set Assessments to determine behavioral tendencies and needs. The following assessments were reviewed and their findings: Quarterly 8/31/21: - Brief Interview of Mental Status (BIMS)- 5/15, indicating severe cognitive loss - Behaviors- none - PHQ-9 (Patient Health Questionnaire) score was 5/27 The PHQ-9 is a questionnaire that objectifies the degree of depression severity an individual has. A PHQ-9 score total of 0-4 points equals normal or minimal depression. Scoring between 5-9 points indicates mild depression, 10-14 points indicates moderate depression, 15-19 points indicates moderately severe depression, and 20 or more points indicates severe depression. Medications: Antianxiety and Antidepressant medications were received during this assessment. Quarterly 11/24/21: - Brief Interview of Mental Status (BIMS)- 8/15, indicating moderate to severe cognitive loss - Behaviors- none - PHQ-9 (Patient Health Questionnaire) score was 10/27 - Medications: Antianxiety and Antidepressant medications were received during this assessment. Annual dated 2/23/22: - Brief Interview of Mental Status (BIMS)- 7/15, indicating moderate to severe cognitive loss - Behaviors- none - PHQ-9 (Patient Health Questionnaire) score was 4/27 - Medications: Antianxiety medications were received during this assessment. Quarterly dated 5/26/22: - Brief Interview of Mental Status (BIMS)- 7/15, indicating moderate to severe cognitive loss - Behaviors- none - PHQ-9 (Patient Health Questionnaire) score was 6/27 - Medications: Antidepressant and Antianxiety medications were received during this assessment. Quarterly dated 8/26/22: - Brief Interview of Mental Status (BIMS)- 7/15, indicating moderate to severe cognitive loss - Behaviors- none - PHQ-9 (Patient Health Questionnaire) score was 4/27 - Medications: Antidepressant and Antianxiety medications were received during this assessment. Surveyor reviewed the comprehensive care plan for R12 and noted the facility identified R12 as displaying symptoms of anxiety and depression with symptoms of withdrawal. Staff interventions include to redirect R12, provide activity and encourage to express her feelings. Included in R12's medication regimen are the following: Buspirone, an antianxiety medication. On 8/13/21, a Gradual Dose Reduction (GDR) was completed on this medication from 15 Milligrams (MG) Three times daily to 10 MG in the morning and 15 MG twice daily. There have been no further attempts for a reduction. Sertraline, an antidepressant medication. R12 was receiving 100 MG every morning and 50MG every evening. This order was dated 11/25/20. There was no GDR of this medication. Behavior Monitoring was then reviewed for the past four months and the following was identified: June: 90 shifts - 40 of 90 shifts documented R12 as having no behaviors - the other 50 shifts were left blank July: 93 shifts - 55 of the 93 shifts documented R12 as having no behaviors - the other 38 shifts were left blank August: 93 shifts - 71 of the 93 shifts documented R12 as having no behaviors - 1 shift documented R12 as wandering - 1 shift documented not applicable - the other 20 were left blank September: 90 shifts - 75 of the 90 shifts documented R12 as having no behaviors - 5 shifts documented not applicable - 1 shift documented wandering - the remaining 9 shifts were left blank On 10/4/22 at 1:52 PM, Surveyor interviewed CNA E (Certified Nursing Assistant). CNA E is a primary caregiver of R12 and knows her well. CNA E stated R12, Really doesn't have any behaviors, just self-transfers, no kicking, hitting, pinching, biting, screaming. It's just transferring herself. She is quick and if we don't catch her, will transfer herself, but isn't supposed to. CNA E was asked if R12 displays any symptoms of depression, especially since grandson passed away. CNA E stated, No, sometimes she will say that she sees him in the building, but no crying or tearfulness, no withdraw. Has always liked being on her own. At 1:56 PM, Surveyor interviewed CNA F, another primary caregiver to R12. CNA F stated, R12 has, No behaviors that I am aware of, quiet, self-transfers. No hitting, screaming, yelling or anything that would be considered harmful to herself or others. I haven't noticed any crying or tearfulness, even after her grandson passed away. She talks about him but doesn't cry or anything when she does. On 10/05/22 at 9:56 AM, Surveyor approached SS D (Social Services) regarding behaviors displayed by R12. SS-D stated, She is targeted for wandering but it really isn't wandering, no exit-seeking, doesn't impede on others or enter rooms and rummage. She has a friend here (R6) and she will go into his room and visit with him. No crying or tearfulness. Does have a diagnosis of depression and nursing is monitoring her for that . I do know the last behavior for her was documented on 6/23/22. Surveyor then requested any Gradual Dose Reductions or physician justification for not reducing that had been completed in the past year. At 3:26 PM, SS D approached Surveyor and stated, I went through her records. She hasn't had a change in her medications for a very long time. Example 3 R21 has medical diagnoses that include but are not limited to Unspecified Dementia without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety and Major Depressive Disorder. R21 receives antipsychotic, antidepressant, antianxiety and opioid medications as part of her medication regimen. Surveyor then reviewed Minimum Data Set Assessments completed by the facility for R21. The following were reviewed: Quarterly 9/8/21: - Brief Interview of Mental Status (BIMS)- 11/15 indicating minor cognitive decline - Behaviors- none - PHQ-9 (Patient Health Questionnaire) score was 2/27 The PHQ-9 is a questionnaire that objectifies the degree of depression severity an individual has. A PHQ-9 score total of 0-4 points equals normal or minimal depression. Scoring between 5-9 points indicates mild depression, 10-14 points indicates moderate depression, 15-19 points indicates moderately severe depression, and 20 or more points indicates severe depression. Medications: Antianxiety, Antidepressant and Hypnotic medications were received during this assessment. Quarterly 12/8/21: - Brief Interview of Mental Status (BIMS)- 8/15 indicating moderately severe cognitive decline - Behaviors- none - PHQ-9 (Patient Health Questionnaire) score was 0 Medications: Antianxiety and Antidepressant medications were received during this assessment. Annual 3/9/22 - Brief Interview of Mental Status (BIMS)- 11/15 - Behaviors- verbal behaviors that were not directed towards others, did not place at risk for illness or injury, did not interfere with activities or social interactions, did not place others at significant risk for injury or intrude on others privacy or activity and did not disrupt care or living arrangement. This occurred 1-3 days during the assessment period of 7 days - PHQ-9 (Patient Health Questionnaire) score was 4/27 Medications: Antianxiety and Antidepressant medications were received during this assessment. Quarterly 6/9/22 - Brief Interview of Mental Status (BIMS)- 4/15 indicating severe cognitive loss - Behaviors- other behavioral symptoms not directed at others 1-3 days during the assessment period of 7 days - PHQ-9 (Patient Health Questionnaire) score was 0/27 Medications: Antianxiety, Antipsychotic, Antidepressant and Opioid medications medications were received during this assessment. Quarterly 9/9/22: - Brief Interview of Mental Status (BIMS)- no BIM Score, facility identified both a short-term and long-term memory problem with severely impaired daily decision-making skills. - Behaviors- other behavioral symptoms not directed at others 4-6 days during the assessment period of 7 days and Wandering 1-3 days during the 7 day period - PHQ-9 (Patient Health Questionnaire) score was 0 Medications: Antianxiety, Antipsychotic, Antidepressant and Opioid medications medications were received during this assessment The Care Plan identified a potential for impaired psycho-social well being and behaviors related to anxiety. Her targeted behaviors on the care plan were repetitive questioning or concerns. Interventions included to offer support, redirect, use a calm approach, return to her room, TV, snacks, 1:1 visits, allow R21 to call son and calm reassurance. The facility also identified a problem of R21 yelling or calling out and targeted this behavior. Current medications on R21's schedule include: Antipsychotic Seroquel initiated 3/21/22 for dementia related behaviors. Dosage at that time was 12.5 Milligrams (MG) twice daily. On 5/12/22, the medication was increased to 25 MG once daily. Antianxiety Lorazepam Tablet 1 MG, Give 1 mg by mouth at bedtime related to Anxiety Disorder. This was initiated 12/1/2020 and has had no reduction attempts made. Note resident was receiving this medication prior to this start date, but was hospitalized on [DATE]. Upon discharge, hospital kept resident on this medication with no changes made. Antidepressant Escitalopram Oxalate Tablet, Give 20 mg by mouth in the morning related to Major Depressive Disorder. This was initiated 12/13/2020 and no attempts at reduction have been made. Note resident was receiving this medication prior to this start date, but was hospitalized on [DATE]. Upon discharge, hospital kept resident on this medication with no changes made Surveyor then reviewed the Behavior Monitoring completed by the facility for the past four months and noted the following: - June: 90 shifts - not consistently documented on all three shifts. - Yelling/Screaming documented four times - No behaviors 25 times - The remaining 61 shifts were left blank July: 93 shifts - Grabbing, yelling/screaming, and wandering 2 shifts - yelling/screaming 8 times - No behaviors documented 39 shifts - The remaining 44 shifts were left blank August 93 shifts - Rejection of care on 1 shift - yelling/screaming on 27 shifts - no behaviors were documented 50 shifts - There were 18 shifts left blank September: 90 shifts Behaviors appear to have dramatically increased from the previous three months: - yelling/screaming 49 shifts - abusive language and wandering x3 - no behaviors documented 38 shifts - 8 shifts were left blank On 10/05/22 at 12:39 PM, Surveyor interviewed CNA E related to R21's behaviors. CNA E is one of R21's primary caregivers and knows her well. CNA E stated R21's behaviors are sporadic throughout the day, yelling or screaming. If you go in there and ask her what is wrong, she has no idea she was doing it. She'll say, I don't need anything, I wasn't yelling. Does not generally occur with cares. No grabbing or hitting, no kicking or spitting CNA E stated that R21's yelling and screaming really doesn't place herself or others at risk for harm, does not impede on others, but . just every once in a while will scream or yell out for no apparent reason. Not consistent, just sporadic. Doesn't even know she is doing it. At 3:26 PM, Surveyor interviewed SS D regarding R21's behaviors. A discussion ensued regarding the inaccurate documentation by staff and the need for accuracy as critical analysis are made based on much of the documentation and monitoring. SS D stated understanding, then further stated, The increases in her behaviors could indicate a built up tolerance for the medications and maybe another medication should be tried, or maybe an increase should be done. I understand, her medications may need adjusting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure a medication administration error rate of less than 5%. During the Medication Administration Task, Surveyor identified two errors from 26 opportunities, yielding a medication error rate of 7.69%. This is evidenced by: On 10/4/22, Surveyor observed Registered Nurse (RN) C administer medications. The following errors were noted: 1. RN C administered 8 units of Insulin Aspart to R11 at 7:30 AM. R11 received her morning meal at 8:10 AM, consisting of scrambled eggs, one slice toast, 4 ounces of cranberry juice and hot tea. R11 began to eat her meal at 8:13 AM. This was 43 minutes after she was administered a short-acting insulin. At 8:13 AM, Surveyor interviewed R11. R11 stated that the insulin is typically given when the nurse can give it, not normally given right when I eat. There is always a time span of about 1/2 hour or so. It hasn't really affected me, that I know of. Drugs. com states the following in relation to Insulin Aspart: . Insulin Aspart is a fast-acting insulin that starts to work about 15 minutes after injection . After using Novolog (Aspart), you should eat a meal within 5 to 10 minutes . 2. Also on 10/4/22, RN C administered oral medications to R3 at 8:56 AM. In addition to the oral medications, RN C also indicated that R3 needed a nebulizer treatment. RN C entered R3's room and auscultated his lungs. She then stepped out into the hall to retrieve medications. RN C returned to R3's room with a 0.4 ML (Milliliter) single-use plastic tube of Lubricating eye drops. She began to open the medication holding tank of R3's nebulizer machine, opened the tube of Lubricating drops, and was about to squeeze the eye drops into the nebulizer medication holding tank, when Surveyor stopped her and informed her the medication was not an inhalant, but in fact an eye drop. RN C then stopped and stated, Oh my goodness, I have the wrong tube, then went back to the medication cart in the hall to retrieve a tube of Albuterol inhalant. On 10/4/22 at 4:36 PM, Surveyor interviewed RN C regarding her knowledge of the above error practices. RN C stated that all short-acting insulin should be given 10 - 15 minutes within a meal. I normally tell the CNAs (Certified Nursing Assistants) to take the resident to the dining room when I give it so that they will eat right away. [NAME] eats in her room. I did not do that and should have. She should have eaten her breakfast within 10 minutes of me giving her the insulin. When asked about the dangers of some eye drops being swallowed or inhaled, RN C had no knowledge of this risk. Although the Lubricant eye drops did not contain Tetrahydrozoline, a toxic ingredient for inhaling or swallowing that is a main ingredient in many over the counter eye drops, she had no way of knowing this at the time of the medication error that was stopped by Surveyor. RN C stated, Yeah, I probably would have noticed that before I squeezed the eye drops into the nebulizer. The plastic vials are very different. Surveyor then pointed out that during the observation, RN C was actually about to squeeze the eye drops into the nebulizer when she was stopped. RN C stated, Yeah, I guess I didn't catch it, but I would have dumped it out and cleaned out the machine.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 4: R4 was admitted [DATE] with diagnosis including major depressive disorder. R4's Minimum Data Set (MDS) most recent quarterly dated 7/14/22 notes R4 takes: ~Antipsychotic, Antianxiety, Antidepressant and Opioid. R4's physician orders include: 4/12/22 Quetiapine (Antipsychotic) 50 mg bid (twice a day) for depression 4/07/22 Duloxetine (Antidepressant) 60 mg in am for depression 9/17/22 Buspirone (Antianxiety) 10 mg bid for anxiety 6/20/22: Hydrocodone/Acetaminophen (Opioid) 5-325 Q (every) 12 hours prn(as needed), not to exceed BID Surveyor requested pharmacy reviews conducted since R4's admission on [DATE]. Facility provided consulting pharmacy review dated 9/13/22. NHA indicated she was not aware of any other pharmacy reviews conducted since R4's admission. NHA could not locate any evidence in R4's record showing his medications were reviewed. Pharmacist recommendation dated 9/13/22 notes: please evaluate the current dose and consider a dose reduction. CMS guidelines indicate that 2 GDR (Gradual dose reductions) attempts must be made in 2 separate quarters in the first year, than annually thereafter. If no GDR is attempted a risk vs benefit statement for continued therapy is required. Recommendation: Trial dose reduction of one medication to ensure GDR success. The pharmacy recommendation is dated as faxed to the MD 10/04/22, after Surveyor requested R4's pharmacy review of medications. Based on observation, interview and record review, the facility did not ensure the medication regimen for 4 of 5 residents (R) reviewed (R12, R5, R21, R4) for unnecessary medications, was completed at least monthly by a licensed pharmacist and was maintained in the resident's medical records. Note: The pharmacist must review each resident's medication regimen at least once a month in order to identify irregularities and to identify clinically significant risks and/or actual or potential adverse consequences which may result from, or be associated with medications each resident receives. This is evidenced by: On 10/4/22 at 1:27 PM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding the completion of Pharmacy Medication Reviews for residents. NHA A returned to the facility 6/16/22 and is acting in the capacity of both NHA and partial Director of Nursing (DON). NHA A stated, Quite honestly, I don't know if they have been getting completed. I will look, but I can say that we have not had behavioral meetings among the Interdisciplinary Team. I do plan to initiate these to discuss resident behaviors, interventions and medications. There just has been so many other things to fix, but now that we have consultants coming in to help, I will be able to make that a priority. I will search for any we may have, but I don't think there are any. When asked what the process normally would be, NHA stated, Any recommendations made would be reviewed by DON or myself and the physician would be given a form of the recommendation to sign. The physician would note if they want any changes as a result of the recommendation. At 3:36 PM, NHA A approached Surveyor and indicated that she was still unable to locate any pharmacy medication regimen reviews but that she had a phone call out to PharMerica, the facility's current pharmacy. On 10/05/22 at 9:06 AM, NHA A approached Surveyor and stated, I do have some reports that the pharmacy sent me that require physician notification. They are not all residents, but do have some. I sent out notices to the doctors regarding the recommendations last night. I have them on my desk and will get them to you, but they require follow up. Note: There were 6 pharmacy recommendations to the physicians, some of which were dated by the pharmacist in July, that had not yet been submitted to the residents' physicians. A phone call was attempted to the current Pharmacy Consultant, Pharmacist G on 10/5/22 at 12:43 PM. However, as of this writing (10/6/22 10:33 AM) a return phone call has not yet been received by Surveyor. Example 1: R12 has medical diagnoses that include, but are not limited to Type II Diabetes Mellitus with Peripheral Angiopathy, Bipolar Disorder, Major Depressive Disorder, Anxiety Disorder, Atherosclerotic Heart Disease of Native Coronary Artery, Hyperlipidemia, Chronic Pain, Essential Hypertension, Peripheral Vascular Disease, Gastro-Esophageal Reflux Disease, Vascular Dementia and History of falling. R12 takes psychotropic medications for her depression and bipolar disease. In reviewing R12's Medical Record for Pharmacy Medication Regimen Reviews from January 2022 to present day, Surveyor noted the following: - January 2022 - June 2022, no pharmacy reviews were located. - On 7/22/22, the Pharmacist requested a Gradual Dose Reduction (GDR) of Buspirone, an antianxiety medication, as R12 was receiving this medication since 8/13/21. The Pharmacist request to the physician was to decrease the evening dose or complete a risk vs benefit statement. This recommendation was first submitted to the physician on 10/4/22, after Surveyor began to question whether the pharmacy reviews were completed. - There was no Pharmacist review for August 2022. - On 9/13/22, the Pharmacist made a recommendation for a GDR in Sertraline, an antidepressant. The pharmacist requested a GDR or a risk vs benefit statement if the physician wished to continue the current therapy. This recommendation was first submitted to the physician on 10/4/22. On 10/05/22 9:56 AM, Surveyor interviewed Social Services (SS) D regarding her knowledge of Pharmacy Regimen Reviews conducted for R12 related specifically to the psychotropic medications. SS D stated that R12 was targeted for wandering behaviors, but really has no wandering or exit-seeking. She stated she would look to see if pharmacy has reviewed R12's medication regimen. At 3:26 PM, SS D approached Surveyor and stated, I went through her (R12) records and she hasn't had a change in her medications for a very long time. I am unable to find where any reviews were completed prior to July 2022. Example 2: R5 has medical diagnoses that include but are not limited to Encephalopathy, Cerebral Ischemia, Congestive Heart Failure, Frontotemporal Neurocognitive Disorder, Anoxic Brain Damage, Chronic Obstructive Pulmonary Disease, Anemia and Mixed Anxiety and Depressed Mood. R5 receives antipsychotic and antidepressant medications as part of her medication regimen. In reviewing R12's Medical Record for Pharmacy Medication Regimen Reviews from January 2022 to present day, Surveyor noted the following: - There were no Pharmacy reviews located from January 2022 - June 2022. - July 22, 2022 the Pharmacist reviewed R5's record and requested an AIMS (Abnormal Involuntary Movement Scale). Note: An AIMS test is one of the most widely used questionnaires for dyskinesias. Dyskinesias are uncontrollable, involuntary movements that can include twitches, jerks, twisting or writhing movements. Dyskinesia can affect various parts of the body such as the arms, legs and torso, and are most commonly caused by medications, such as long term use of levodopa in Parkinson's disease and use of antipsychotic medications. - A review was completed for August 2022. - On 9/13/22, Pharmacist G made a recommendation for a Gradual Dose Reduction (GDR) for the antidepressant as R5's depression scores were 0, indicating no signs or symptoms of depression. This recommendation was first submitted to R5's physician on 10/4/22 after Surveyor had asked questions about the pharmacy reviews. On 10/05/22 at 9:56 AM, Surveyor interviewed SS D regarding R5 and her behaviors. SS D stated that R5 .does not have any real behaviors, does have crying episodes but no behaviors that would create a potential of harm to herself or others. She just had a GDR of her Seroquel (antipsychotic). Example 3: R21 has medical diagnoses that include but are not limited to Dementia, Peripheral Vascular Disease, Major Depressive Disorder, Gastro-Esophageal Reflux Disease, Hyponatremia, Hypo-osmolality, Syndrome of Inappropriate Secretion of Antidiuretic Hormone and Cardiac Murmur. R21 receives antipsychotic, antidepressant, antianxiety and opioid medications as part of her medication regimen. In reviewing R21's Medical Record for Pharmacy Medication Regimen Reviews from January 2022 to present day, Surveyor noted the following: - January 2022 - May 2022 no pharmacy reviews were located - On 6/14/22 a review was completed but was first submitted to R21's Physician on 9/11/22. - On 7/22/22 a review was completed but was first submitted to R21's Physician on 9/11/22. - On 9/13/22 a review was completed in which Pharmacist G made a recommendation to complete Gradual Dose Reductions (GDR) of the antianxiety and antidepressant medications or complete a risk versus benefit to justify continued use of these medications. This was first submitted to R21's physician on 10/4/22. On 10/05/22 at 9:56 AM, Surveyor interviewed SS D regarding R21 and her behaviors and whether any Pharmacy Medication Regimen Reviews were completed prior to June 2022. SS D stated R21 does have sporadic yelling/screaming out but that these do not create a risk for harm to herself or other residents. She stated she would see if she could locate pharmacy reviews for R21. At 3:26 PM, SS D approached Surveyor and stated, I am unable to locate further information on any GDRs or new pharmacy reviews that you don't have.