Every finding on record at Freedom Square Health Care Center

Based on interviews and record review, the facility failed to provide treatment related to respiratory complications to one resident (#2) out of three residents sampled. On 2/10/2026 at 5:55 p.m. Resident #2 began to experience increased mucous production, increased phlegm, and coughing as a result of his illness. On 2/11/2026 at 2:35 a.m. Resident #2 was found to have no pulse and not breathing. Findings Included:An interview was conducted on 2/17/26 at 1:07 p.m. with the Resident Representative (RR) for Resident #2. The RR stated having had several conversations with the facility nursing staff regarding Resident #2's treatment plan after radiation therapy to the esophagus. The RR stated the conversations included the side effects of the radiation therapy which included thick secretion that would need to be coughed up or suctioned to clear the air way. The RR stated the family hired a sitter to be with Resident #2. The RR stated the sitter informed her Resident #2 was throwing up phlegm. The RR stated she requested the sitter to notify the nursing staff at the facility. The RR said on 2/10/26, around 10:48 p.m., the nurse called and informed her the bolus tube feeding could not be administer at 6:00 p.m. or 8:00 p.m. because Resident #2 was coughing and choking. She stated the nurse informed her she had contacted the doctor who ordered intravenous (IV) fluids, chest x-ray, and an x-ray to check for intestinal blockage. She stated The nurse was more concerned about the bolus tube feed than the coughing and choking. The RR stated she reiterated the thick secretions being a side effect of the radiation therapy and asked the nurse if they are able to suction Resident #2. The RR stated the nurse assured her suctioning was available, although Resident #2 had not needed to be suctioned due to Resident #2 being able to clear the secretions. The RR stated the next phone call she received was Staff B, Registered Nurse (RN) informing her Resident #2 had passed away. The RR stated upon arriving to the facility asking Staff B, RN if Resident #2 had been suctioned. Staff B, RN told me that he had not suctioned Resident #2. An interview was conducted on 2/18/26 at 11:06 a.m. with Staff A, Certified Nursing Assistant (CNA). Staff A said she was assigned Resident #2 from 11 p.m. on 2/10/26 to 7 a.m. on 2/11/26. She said when she came in at 11:00 p.m. Resident #2 was acting like himself and around 12:00 a.m. she and Staff B, Registered Nurse (RN) put a brief on him and helped him into bed. Staff A said just before 1:00 a.m. she saw Staff B, RN walking fast down the hall and he asked if I could go watch Resident #2. Staff A said when she got to Resident #2's room he was lying in bed unresponsive. She said the resident was breathing and sounded like something was stuck in his throat. She said the resident then started making a gargling sound in his throat. Staff A said the nurse had left the room and she did not know what to do. Staff A said she never saw Staff B, RN or anyone else try to suction Resident #2 to clear his airway and the oxygen was never applied to the resident. Staff A said when Staff B, RN came back to the room, Staff C, RN; Staff D, CNA; and Staff E, CNA were with him. Staff A said when Staff A came back to the room Resident #2 still had a pulse and was breathing but had a lot of foam coming out of his mouth. Staff A said Resident #2 was a Do Not Resuscitate (DNR) and took his last breath.Review of admission Records showed Resident #2 was admitted on [DATE] with diagnoses including malignant neoplasm of esophagus, gastrostomy status, adult failure to thrive, Alzheimer's disease, and dysphagia.Review of Resident #2's 12/13/25 Minimum Data Set (MDS), Section C, Cognitive Patterns, showed a Brief Interview for Mental Status (BIMS) score of 2, which indicated severely impaired cognition.Review of Resident #2's physician orders showed:-NPO [nothing my mouth] diet. Dated 1/10/26.-Do Not Resuscitate. Dated 1/10/26.Review of Resident #2's progress notes showed:-2/10/26 5:55 p.m.Resident experiencing increased mucus production/phlegm. Resident also has increased coughing. percutaneous endoscopic gastrostomy (PEG) tube feeding held. Called and reported to doctor. Received new orders for an immediate (STAT) chest x-ray 2 view, STAT kidney, ureter, and bladder x-ray, STAT complete blood count and comprehensive metabolic panel, duo-neb inhaler one now and as needed (PRN) every (q) 6hrs, and Tessalon pearls 200 mg q 8hrs as needed for cough via PEG tube.Change in Condition/Situation, Background, Appearance, Review/Recommendation (SBAR) completed.-2/10/26 10:12 p.m.Call placed to on call provider requesting to send resident to hospital at which time on call practitioner stated not to send, but to administer IV fluids and await lab and diagnostics. After speaking with on call, Resident Representative (RR) was made aware of nursing concerns regarding missed bolus feeds and respiratory status, agrees with practitioner on call to stay in facility as opposed to hospitalization and that resident is completing his radiation treatments and would rather him not go out to the hospital, but to be monitored and await result, as increased mucus insertion was a common side effect among radiation treatment. IV fluid orders carried out, resident is stable responsive and alert at time of IV placement. Head of bed elevated call light within reach.- 2/10/26 10:27 p.m.Call placed to on call for primary care provider (PCP) regarding continued concerns about increased mucous, phlegm production, and coughing. Head of bed (HOB) elevated, resident effectively coughing secretions into basin. Per on call, IV fluids normal saline (NS) 0.9% via peripheral intravenous (IV) 100 cubic centimeters(cc)/hour (hr.) x 1 liter (L). Report STAT lab and diagnostics as soon as possible (ASAP) when available. Productive cough noted, self-expectorating secretions into basin. Frequent monitoring by staff. HOB elevated, call light within reach.- 2/10/26 10:37 p.m. Spoke to RR regarding Resident #2's condition, clinical update provided regarding concerns r/t increased mucous and cough. Made aware of new orders for IV and NS. Reported that diagnostics had been completed, awaiting results. Made aware that resident did not tolerate 6:00 p.m. and 10:00 p.m. bolus feeding due to (d/t) severe cough. Continued monitoring, HOB elevated, basin and call light in reach.- 2/11/26 12:09 a.m.Peripheral IV started to right (Rt) hand, tolerated well, patent, good blood return. IV NS 0.9% at 100 cc/hr started. IV site covered with sleeve dressing. HOB elevated. Call light within reach.- 2/11/2026 02:17 2320H IV NS 0.9% started @ 100cc/hr. running well. noted skin tear on his left forearm approx. 4 cleanse with NS and covered with allevyn. 12:50 a.m. [Staff B, RN] saw resident standing on the side of his bed. increasing restlessness. sweating and diaphoretic. Vital signs (VS) blood pressure ( Bp) 156/117, heart rate (HR) 103, temperature (T) low, oxygen (o2) saturation (sat) 45%. Nebulizer breathing treatment (Tx) administered and try to call doctor but unable to contact. 911 activated. Came back to room with oxygen the resident is no longer breathing.-2/11/26 2:35 a.m.1:00 a.m. the resident had no pulse and no breathing. Ambulance arrived. He passed away.An interview was conducted on 2/18/26 at 2:39 p.m. with Staff E, CNA. Staff E said on 2/11/26 she saw Staff B, RN running to get oxygen out of the clean utility room so she went to Resident #2's room. Staff E said the night before she cared for Resident #2 and he did not have any issues. Staff E said when she got to Resident #2's room on 2/11/26 just before 1:00 a.m., he had oxygen tubing but it was not hooked up to oxygen. She said Staff B, RN had the staff help try to sit the resident up and pull him up in bed. Staff E said the resident was very pale, sweating, hot, and had shallow breathing. She said Resident #2 was not coughing. She said Staff B, RN never got oxygen hooked up to the resident even though he was still breathing. Staff E said the staff were like deer in the headlights. An interview was conducted on 2/18/26 at 1:57 p.m. with Staff B, RN. Staff B said he was the assigned nurse for Resident #2 starting at 11:00 p.m. on 2/10/26. He said a little bit before 1:00 a.m. on 2/11/26 Resident #2 was standing by his bed without a brief on and Staff A, CNA helped him get a brief on the resident and get him back in bed. Staff B said after a little bit he went back to the room and Resident #2 had shortness of breath (SOB) so he went and got a nebulizer treatment to administer to the resident. Staff B said he also tried to call the doctor but did not get him. He said he went back to Resident #2's room but did not listen to his lungs because he could hear that he had crackling but the resident was not coughing. Staff B said he checked Resident #2's VS and he had high blood pressure and low oxygen saturation, so he left the room to call 911 and get oxygen. Staff B said he did not call for help from the room, but when he left the room he saw Staff A, CNA and asked her to go watch the resident. He said he was going to get oxygen from the clean utility room and when he came back other staff came with him to the room. He said he did not know what they did then, but he was not able to get oxygen on the resident and Resident #2 took his last breaths. Staff B said he had a nasal cannula but there was no oxygen or suction machine in the resident's room. Staff B said he did not grab the code cart that has oxygen, oxygen masks and suction on it because Resident #2 was a Do Not Resuscitate. An interview was conducted on 2/18/26 at 1:45 p.m. with the Respiratory Therapist (RT). The RT said he had not seen Resident #2 but staff were supposed to call him if something goes wrong with a resident and respiratory therapy might be needed. He said he should be contacted if there are any questions or problems with residents. The RT said if a resident had gurgling sounds or sounded like something was stuck in their throat, you would think the nurse would have suctioned them and placed them on oxygen. The RT said even residents on hospice would be suctioned in that case. As far as giving the resident a nebulizer he said, that is not going to help a whole lot. The RT said that is the type of education he does in the building. He said the nurses were not using their resources.An interview was conducted on 2/17/26 at 3:30 p.m. with the Director of Nursing (DON). The DON said Staff B, RN's timeline of the events did not line up and his note looked like it was documented after the fact in a frantic manor. The DON said she would have expected Staff B, RN to have stayed with the resident and not left the resident with the CNA. She said she did not understand why the nurse did not get the code cart, suction the resident and apply oxygen, which is what the nurse should have done. The DON said if the nurse grabbed the code cart he would have had everything he needed in front of him (i.e. oxygen, oxygen mask, suction, etc.). She said the cart is not only used for codes, it has all the emergency supplies.Review of the facility's Respiratory Protocol, undated showed:When the resident is exhibiting any of the following: rapid breathing, shortness of breath, wheezing, use of accessory muscles, or decreased O2 saturation (under 92% unless previously documented as resident normal).IMMEDIATELY Check airway to make sure nothing is obstructing air flow (clear airway if needed: *Check for any PRN medications to be utilized for relevant symptoms (bronchodilators to be administered through nebulizers or inhalers) and Notify [company name] Respiratory [phone numbers]RESPIRATORY DISTRESS-Check resident airway (clear if needed)-Obtain crash cart -place non-rebreather mask on resident attached to O2 -suction (if needed)-Call Physician-Call 911 if unable to stabilize resident.

Based on observations, interviews, and record review the facility failed to follow the prescribed diet for two (Resident #2 and #6) of three residents sampled. Findings included: Durning an interview on 2/17/26 at 1:07 p.m. Resident #2's resident representative (RR) said on three different occasions when visiting staff were attempting to give Resident #2 fluids or food. RR stated Resident #2 was not to have anything by mouth. A review of Resident #2's medical record revealed an admission date of 12/9/25 and readmission on [DATE] with the following diagnosis to include but not limited to: malignant neoplasm of esophagus; dysphagia; and dementia. A review of Resident #2's Minimum Data Set (MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 2, meaning resident had significant cognitive impairment. A review of Resident #2's physician orders revealed an order dated 12/9/25 for Resident #2 to have nothing by mouth (NPO). Review of the grievance log for December 2025 revealed Resident #2's family had filed grievances on 12/25/25 regarding resident receiving a meal tray. The grievance showed the meal tray was mistakenly given to Resident #2, was not Resident #2's tray as Resident #2 did not receive a tray. Staff were educated. Review of the grievance log for January 2026 revealed Resident #2's family filing a grievance on 1/14/26 regarding Resident #2 receiving a meal tray, again. The grievance showed staff re-educated on verifying meal tray tickets upon delivery of tray to resident. During an interview on 2/17/26 at 3:30 p.m. the Social Service Director (SSD) stated the grievances were filed by Resident #2's family and confirmed Resident #2 had received trays on both occasions. On 2/18/26 at 11:24 a.m. Resident #6 was observed being served the lunch meal in the resident's room. The tray had a small can of ginger ale and the resident's meal. Resident #6 was up and sitting in the wheelchair with the over the bed table. The tray was placed on the over the bed table. Next to the tray were three cans of unopened ginger ale and one open. Staff F, Certified Nursing Assistant (CNA) entered the room and placed a cup of hot chocolate onto Resident 6's tray. Staff F, CNA stated Resident #6 can have what he wants. Staff F, CNA stated he gets enough, when asked about if Resident #6 was on fluid restrictions. A review of Resident #6's medical record revealed an admission date of 12/3/25 with the following diagnosis to include but not limited to: end stage renal disease (ESRD) with dependence on renal dialysis, type 2 diabetes mellitus with diabetic chronic kidney disease, chronic hepatitis, and dementia without behavioral disturbance. A review of Resident #6's MDS dated [DATE] revealed a BIMS of 5, meaning resident had significant cognitive impairment. No behaviors were exhibited in the look back period. Resident #6 was able to complete eating and mobility after being set up with assistance and was on a therapeutic diet. A review of Resident #6's physician orders revealed an order dated 12/3/25 for 1000 milliliter (ml) fluid restriction per 24 hours, Nursing 400 ml (7a-3p - 240 ml, 3p-11p - 100 ml, 11p-7a 60 ml), Dietary 600 ml (120 ml at breakfast, 240 ml at lunch and dinner) related to ESRD, nursing to document amount consumed. A review of Resident #6's medical record did not reveal any notification to the physician or family of Resident #6's noncompliance with fluid restrictions. During an interview on 2/18/26 at 11:47 a.m. Staff G, CNA stated the computer system and tray ticket informs the staff of knowing if a resident is on a specific diet or fluid restrictions and of course, you can always ask the nurse. Staff G, CNA stated being the assigned CNA for Resident #6 and he can have what he likes with his meals just nothing in between. During an interview on 2/18/26 at 2:17 p.m. Staff H, Registered Nurse (RN) stated there would be a physician order for fluid restrictions. If a resident is non-compliant the physician and family would need to be notified. During an interview on 2/18/26 at 3:30 p.m. the Registered Dietitian (RD) stated residents should receive the diets as ordered by the physician. Resident #6 was on dialysis and was on fluid restrictions. The RD stated knowing the resident is non-compliant with fluid intake and has not spoken with dialysis center, the physician nor the family. During an interview on 2/18/26 at 3:18 p.m. the Director of Nursing (DON) stated the expectation is for residents to receive the diets as ordered by the physician and for notification to be made if necessary regarding non-compliance. Review of the facility policy titled Therapeutic and Mechanically-Altered Diets not dated revealed: Policy: It is the policy of the community to provide therapeutic and mechanically altered diets as ordered by the attending physician. Food will be designed in a form to meet individuals' needs and support optimal nutritional status. Procedure: . Tray tickets identify diet orders to ensure the resident receives a diet as order. Response to therapeutic or mechanically-altered diet by the Dietary Manager or Resident Dietitian. When a resident refuses to comply with the therapeutic diet, negative consequences of noncompliance will be explained. If the resident continues to refuse adherence, the Charge Nurse will be notified and the physician will be contacted for possible diet liberalization.

Based on observations and interview, the facility failed to properly wear Personal Protective Equipment (PPE) to mitigate the spread of COVID-19 for three residents (#7, #63, #10) out of 10 residents positive for COVID-19 in the facility during a COVID-19 outbreak. Findings Included: A review of the facility's Special Droplet/Contact Precautions isolation sign revealed the following: Everyone Must: including visitors, doctors and staff Clean hands when entering and leaving room Wear face mask Wear eye protection (face shield or goggles) Gown and glove at door . A review of Resident #63's Physician order, dated 1/28/24, revealed Isolation-Droplet COVID + every shift for isolation for 10 days. A review of Resident #7's Physician order, dated 1/30/24, revealed Special droplet/contact isolation every shift for COVID + 1/29 for 9 days. A review of Resident #10's Physician order, dated 1/30/24, revealed Special droplet/contact isolation every shift for COVID 19 + 1/20 for 9 days, An observation was conducted on 2/6/24 at 9:04 a.m. Staff B, Licensed Practical Nurse (LPN) was observed to don a gown, then a N95 mask over her surgical mask, she secured the top tie to the crown of her head and left the bottom tie hanging by her neck. She donned a face shield and put on gloves, picked up a medicine cup with pills in it and entered Resident #63's room with a Special Droplet/Contact Precautions sign posted on the door. She came out of the room and only had on a surgical mask. An observation was conducted on 2/6/24 at 9:12 a.m. Staff B, LPN was observed to don a gown, then a N95 mask over the same surgical mask, she secured the top tie to the crown of her head and left the bottom tie hanging by her neck. She donned a face shield, put on gloves, picked up a medicine cup from the PPE cart outside of the room and said, I need to give her this one pill, she entered into Resident #63's room again, with the Special Droplet/Contact Precautions sign posted on the door. When she came out of the room she only had on her surgical mask. A medication administration observation was conducted on 2/6/24 at 9:40 a.m. with Staff B, LPN. She was observed to don a gown, then a N95 mask over her surgical mask, she secured the top tie to the crown of her head and left the bottom tie hanging by her neck. She donned a face shield and put on gloves and entered into Resident #7's room with a Special Droplet/Contact Precautions sign posted on the door. During the medication administration Staff B, LPN was observed to pull both, the N95 mask and the surgical mask, down below her lips under the face shield, leaned towards Resident #7, and she spoke to the resident with both masks still below her lips. Staff B, LPN was observed to doff her gloves, gown, face shield, and N95 mask and exited the room with the same surgical mask on. An interview was conducted with Staff B, LPN on 2/6/24 at 10:05 AM she said she was educated not to wear her surgical mask under her N95 and to make sure both straps of the N95 mask were secured around her head. She said wearing the surgical mask under her N95 and not strapping the bottom strap of the N95 mask, It's just what I do. An observation was conducted on 2/6/24 at 9:51 a.m. of Staff C, Certified Nursing Assistant (CNA) coming out of Resident #7's room with a Special Droplet/Contact Precautions sign posted on the door, with her N95 mask and her face shield on. She was then observed to go to Resident #10's room which was observed to have a Special Droplet/Contact Precautions sign posted on the door. She was observed to don a gown, and gloves and entered the room with the same N95 and face shield on. An interview was conducted with the Director of Nursing (DON) on 2/6/24 at 10:25 a.m. she confirmed staff are not supposed to wear a surgical mask under their N95 masks and both straps are supposed to be secured around their head. She said staff should not be pulling their masks down in an isolation room which requires a mask to be worn. She also confirmed face shields and N95 masks are single use and should not be worn room to room. An interview was conducted on 2/8/24 at 9:38 a.m. with Staff D, Infection Preventionist and the DON. They said the facility has been in a COVID-19 outbreak since December 20th, 2023. A review of the facility policy titled Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19, undated, revealed the following: . Remember: PPE must be donned correctly before entering the patient area (e.g. isolation room, unit of cohorting). PPE must remain in place and be worn correctly for the duration of work in potentially contaminated areas. PPE should not be readjusted (e.g. retying gown, adjusting respirator/facemask) during patient care. PPE must be removed slowly and deliberately in a sequence that prevents self-contamination. A step-by-step process should be developed and used during training and patient care. Preferred PPE -Use N95 or Higher Respirator Face shield or goggles N95 or high respirator . One pair of clean, non-sterile gloves Isolation gown Donning (putting on the gear) 4. Put on NIOASH-approved N95 filtering facepiece respirator or higher . Facemask: Mask ties should be secured on crown of head (top tie) and base of neck bottom tie) . Doffing (taking off the gear): 5. Remove face shield or goggles. Carefully remove face shield or goggles by grabbing the strap and pulling upwards and away from head. Do not touch the front of face shield or goggles. 6. Remove and discard respirator (or facemask if used instead of respirator). Do not touch the front of the respirator or facemask.

Based on interviews, observations, and record review the facility did not ensure pressure relieving interventions were ordered and implemented for one resident (#67) out of three sampled residents. Findings included: A review of Resident #67's admission record showed the resident was admitted on [DATE] with diagnoses to include Fournier Gangrene, abscess of the penis, Diabetes Type II, Alzheimer's disease, and peripheral vascular disease. On 2/6/24 at 2:16 p.m. Resident #67 was observed lying on an air flowing parameter mattress, wearing a hospital gown and non-skid socks. A review of the Minimum Data Set (MDS), dated [DATE], showed in Section C: Cognitive Patterns a Brief Interview for Mental Status (BIMS) was not assessed, Short term memory OK revealed a score of 1, Cognitive Skills for Daily Decision Making score of 1 indicating Resident #67 had modified independence. A review of the care plan, dated 12/4/2023, revealed the following: Focus: Resident #67 had actual impairment to skin integrity r/t (related to) diabetic ulcer (wound) to left heel and left medial foot. Goal: Resident #67 will have no worsening skin alteration through review date. Interventions: (dated 12/4/24) to provide treatment per physician order; and follow up interventions; (dated 2/1/24) Resident # 67 to wear [heel protection boot] and to lay on a pressure reduction mattress. A review of Resident #67's Order Summary Report, dated 12/4/23, showed [sic] wound consult and for a pressure redistribution mattress. An order, dated 12/11/23, showed [pressure always relieving boot] on as tolerated every shift. A review of Resident #67's Medication Administration Record (MAR) for January 2024 revealed the use of pressure relieving boots were documented daily while the resident was in the facility. For 2/2/24-2/6/24 there was no documentation indicating pressure relieving boots were worn or refused by Resident #67. A review of Resident #67's wound evaluation and management summary, dated 1/23/24, revealed the following: At the request of Resident #67's doctor, a thorough wound assessment and evaluation was performed. Resident #67's review of systems (ROS) revealed skin support surfaces in use included Group 2 bed mattress (a type of pressure-reducing support surface used to treat or prevent skin tissue breakdown) and pressure relieving boot on the feet. A review of Resident #67's wound evaluation and management summary, dated 2/6/24, revealed Resident #67's review of systems (ROS) showed support surfaces of Group 2 bed mattress and pressure relieving boot. A review of a focused wound exam of the diabetic wound of the left heel, full thickness, dated 1/23/24, showed the wound size 0.3 cm Length (L), 0.5 cm Width (W), 0.1 cm Depth (D) and the wound surface area of 0.15 cm2. A review of a focused wound exam of the diabetic wound of the left heel, full thickness, dated 2/6/24, showed the wound size 0.6 cm Length, 0.4 cm Width, 0.1 cm Depth and the wound surface area of 0.16 cm2. Recommendations included an off-load boot for Resident #67. During an interview on 2/7/24 at 8:20 a.m. Staff E, Licensed Practical Nurse (LPN) said he had just change the dressing on Resident #67's left heel and confirmed the resident was not wearing a heel protection boot. Staff E was unable to locate a heel protection boot in Resident' 67's room and said he would check for orders regarding the heel protector. On 2/7/24 at 11:21 a.m. Resident # 67 was observed lying in bed with a heel protection boot on his left heel and a second boot was on top of the dresser at the foot of the resident's bed. On 2/7/24 at 3:49 p.m. an interview was conducted with Staff G, Licensed Practical Nurse, Unit Manager (LPN, UM). She said orders for a pressure reduction mattress and heel protection boots were ordered today (2/7/24). Staff G said staff is expected to document on Resident #67's Treatment Administration Record (TAR) when heel protection devices and the pressure reduction mattress are in use. A review of the facility policy titled Prevention of Pressure Ulcers, dated May 2018, reviewed and revised October 2019, revealed the following: -Purpose: The purpose of this procedure is to provide information regarding identification of pressure ulcer risk factor and interventions for specific risk factors. -Preparation: Review the resident's care plan to assess any special needs of the resident. - interventions and Preventative Measures, General: For a person in bed determine if the resident needs a special mattress. -Risk Factor-Immobility: When in bed, every attempt should be made to float heels (keep heels off of the bed) by placing a pillow from the knee to ankle or with other devices as recommended by clinical staff or by the physician.

Based on observations, interviews, and record review, the facility failed to honor one resident's (#27) preference to take showers out of four residents sampled for choices Findings included: During an observation on 02/05/2024 at 10:00 a.m., Resident #27 was observed sitting in her wheelchair fully dressed. Resident #27 said she was very frustrated because she had a fall a couple of months of ago that has caused her to have to be put in a Hoyer lift. She stated she has not had a shower since the incident that happened 5 or 6 months ago. During an observation on 02/06/2024 at 12:00 p.m., Resident #27 was observed laying down in bed. Resident #27 restated she had not been able to have a shower since an incident she had 6 months ago. She said she reported her shower concerns to her nurse, certified nursing assistant, and the care plan staff during a care plan meeting. A review of an Admission Record showed Resident #27 was originally admitted on [DATE], readmitted on [DATE] with diagnoses to include local infection of the skin and subcutaneous tissue, unspecified, End Stage, Renal Disease, and Type 2 Diabetes Mellitus with diabetic neuropathy, unspecified, A review of the quarterly Minimum Data Set, dated dated [DATE], showed the resident had a Brief Interview of Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. A review of the Documentation Survey Report, dated from 09/2023 to 02/2024 revealed Resident #27 only received bed baths. On 02/07/2024 at 1:02 PM., an interview was conducted with the Director of Nursing (DON). She said she was not aware Resident #27 was not receiving her showers. She stated her expectation was her staff would follow preferences and the resident's showers days. She stated If a resident was refusing to take showers, then it should be documented and reported to the nurse. She stated a grievance should be filed on the resident's behalf. A review of the facility policy, titled Resident Rights, revised December 2016, showed the following: Policy Statement: Employees shall treat all residents with kindness, respect, and dignity, Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: U. Voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal; V. have the facility respond to his or her grievances.

Based on observations, interviews and record review, the facility failed to ensure one resident (#41) out of thirty-four sampled residents, was provided with ordered psychiatric services; during two of three visits (11/30/2023 and 12/21/2023). Findings included: On 2/5/2024 at 10:03 a.m. Resident #41's room was observed to be on isolation precautions, with signage on the door and Personal Protective Equipment at door side. Resident #41 was overheard calling out multiple times, help, help. Staff responded to the resident and were able to calm the resident. The resident was overheard crying softly at 11:35 a.m. and 2:00 p.m. Staff responded to the room and intervened. On 2/6/2024 at 8:30 a.m. Resident #41 was observed in her room. The resident was overheard crying softly while lying in bed. Staff responded and intervened. This behavior was again overheard at 11:23 a.m. On 2/7/2024 at 7:50 a.m. Resident #41 was observed in her room and lying in bed. She was noted crying softly and calling out help. Staff were observed to respond and intervene. A review of the medical record revealed Resident #41 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the advance directives revealed Resident #41 had a Power of Attorney in place to make her medical and financial decisions. Review of the diagnosis sheet revealed diagnoses to include but not limited to: Dementia, and altered mental status. A review of the Minimum Data Set assessment (Medicare 5 day), dated 1/10/2024, revealed; Cognition: Brief Interview Mental Status score 3 of 15, indicating Resident #41 would not be able to be interviewed related to her care and services. A review of the Physician's order, dated 11/29/2023, revealed psychology services to eval and treat resident for placement in new environment. A review of the Symptom Checklist referral page to psychiatric services, dated 11/30/2023, revealed Resident #41 is to be seen for adjustment to new environment. A review of the Physician's order, dated 12/21/2023, revealed psychology service for sadness. A review of the Symptom Checklist referral page to psychology services, dated 12/21/2023, revealed Resident #41 to be seen for depressive symptoms to include sadness. A review of the nursing progress notes, revealed the following; (a.) 11/30/2023 13:01 Social Service note - Referral sent to [Psychiatric services provider] services. (b.) 12/9/2023 Nursing note - Increased confusion. (c.) 12/9/2023 Nurse narrative change of condition seems different than usual tired, weak confused, drowsy. Send to ER [emergency room ] per MD [Medical Doctor]. (d.) 12/13/2023 Nurse Note 18:50 - Upon admission while attempting to examine skin for any abnormalities or open areas resident refused to let me assess back or buttocks for open areas. Resident smacked my arm x2 and kept screaming, 'no I don't want you to, when attempting to assess back and buttocks, was not able to see if there was any open areas due to this. Reattempted 2 hours later with different CNA [Certified Nursing Assistant], resident apologized upon entering room but when asked if we could look at buttocks, resident answer still no she stated the reason for being , they just did this (most likely referring to hospital skin check). Will attempt later in night. (e.) 12/13/2023 Nurse note 22:20 - Reattempted to assess residents skin on back and buttocks for the third time, resident still refused to let us look at skin. Resident kept shaking head and repeatedly saying NO when attempting. (f.) 12/14/2023 Nurse note 22:23 - Pt is considerably more confused than before she went to the hospital. Frequently calling out, patient is lonely. (g.) 12/15/2023 Nurse Note 09:20 - NP [Nurse Practitioner] and POA [Power of Attorney] notified related to increased confusion. Labs ordered. (h.) 12/21/2023 Social Services - Referral sent to [Psychiatric services provider] Services for sadness. (i.) 12/29/2023 SBAR Change in Condition, MD notified and ok to send to ER. (j.) 1/6/2024 Nurse note - RETURN FROM HOSPITAL. (k.) 1/9/2024 00:00 Encounter note/assessment - Psych note/visit. Assessment completed and notes indicated to follow up within one week or sooner if clinically indicated to evaluate mood and medication efficacy as pt. adjusts to loss of independence. (l.) 1/12/2024 11:15 Social Service note - Referral sent to [Psychiatric services provider] Services. (m.) 2/3/2024 20:44 Nursing Note - Went to retake BS [blood sugar] at 8pm resident refused and was combative, supervisor provided accu check. Resident refused to eat or drink dinner. MD made aware and unsuccessful attempt to call POA. (n.) 2/3/2024 22:01 SBAR - Change of Condition r/t Behavioral symptoms e.g. agitation, psychosis). (o.) 2/4/2024 07:40 Nurse note - Left message with psych to see resident for behaviors. On 2/8/2024 at 9:10 a.m. an interview with the Director Of Nursing (DON) and the Nursing Home Administrator (NHA) was conducted. The DON confirmed Resident #41 had several psychiatric referrals during her admission to include on 11/30/2023, 12/21/2023, and 1/12/2024. The DON explained if the referral is psychology or psychiatry, the timeframes for actual visits are a little different. The DON stated the 11/30/2024 referral was for a psychiatry visit and the visit actually happened on 12/6/2024. The DON stated the visit should have been conducted more timely than seven days. She was not sure as to why it took so long for the visit/assessment to be conducted. The DON verified a nurse progress note, dated 12/21/2023, was a psychiatric (psych) referral related to depressive symptoms of sadness. The DON provided the Symptom Checklist referral sheet, dated 12/21/2023, which was sent to psych. services. The DON could not confirm the referral was acted upon and completed from psych services. The DON stated per the psych services referral, dated 12/21/2023, the visit from psych services should have been conducted and completed prior to Resident #41's hospitalization on [DATE]. The DON and the NHA stated the visit had never been completed by psych services after the 12/21/2023 referral. The DON stated Resident #41 was again referred to psych services on 1/12/2024 with a visit from psych services conducted on 1/16/2024. On 2/8/2024 at 10:05 a.m. a follow up interview with the NHA was conducted. She stated she had reviewed Resident #41's medical record and found a referral for psych services, dated 12/21/2023. She stated the referral was sent to psych services but a visit to Resident #41 never occurred. The NHA stated she called psych services with reference to the referral and asked why this visit did not occur. The NHA stated she was told they received the referral but felt there was not criteria to meet a visit. The NHA stated they did not give her any further information as to why the psych visit was not conducted. She stated psych services did not communicate their decision back to the facility administration. She stated based on review of the medical record and the referral criteria; Resident #41 was presenting with behaviors of sadness, which would benefit from a psych service visit. On 2/8/2024 at 10:40 a.m. an interview with the Social Services Director (SSD) revealed when a resident is admitted , they will do a mini mental health evaluation, as well as look for behaviors and indicators that might require a psychiatric or psychological service visit. She stated once a resident is admitted , the resident is observed and evaluated daily, and if a resident presents with any behaviors that may require a psychiatry or psychological service visit she (social service department), or a unit nurse manager will evaluate the behaviors and then notify the resident's primary physician of the behaviors. She stated the primary physician will then order a referral to psych services, and have them come out for a visit/assessment. The SSD stated after psych services obtains the referral, it will generally take a couple days until the visit. The SSD confirmed she had put in to get an order and referral to Resident #41's primary care physician and psych services on 11/30/2023. She stated the referral and order was placed and sent to psych services, and the visit did not happen until 12/6/2023. The SSD did not know why it took a week to conduct the visit, but agreed a week was not considered a timely visit. The SSD confirmed she had put in to get an order and referral to Resident #41's primary care physician and psych services on 12/21/2023, with relation to increased sadness. She confirmed there had been progress notes, dated 12/13/2023, that identified Resident #41 screaming at and smacking staff, showing behaviors other than sadness. The SSD stated psych services did not come out, nor communicated to them the reason for the missed visit/evaluation. The SSD stated she did not follow up with psych services after the referral was sent to them on 12/21/2023, and she did not follow up with psych services as to why the visit did not occur. A review of the facility policy titled Telephone Orders, revised February 2014, revealed the following: Policy: Verbal telephone orders may be accepted from each resident's attending physician. 1. Verbal telephone orders may only be received by licensed personnel. Orders must be reduced to writing, by the person receiving the order, and recorded in the resident's medical record; 2. The entry must contain the instructions from the physician, date, time, and the signature and title of the person transcribing the information; 3. Telephone orders must be countersigned by the physician during his or her next visit; 4. Unless otherwise prohibited by law, verbal telephone orders for Scheduled II drugs will be permitted in accordance with facility policy. The facility did not have a specific policy and procedure related to obtaining orders and the implementation of timely services for outside facility therapy services.

Based on interviews and record review, the facility failed to accurately document for one resident (#107) on a discharge Minimum Data Set (MDS) out of five residents reviewed for transfer and discharge. Findings included: A review of Resident #107's Admission Record showed Resident #107 was admitted to the facility with diagnoses including pneumonia, low back pain, muscle weakness, and anxiety. A review of Resident #107's Physician order, dated 1/6/24, showed: Ok [okay] to discharge home on 1/6/24 with remaining medications and home health services. A review of a Care Plan Note, dated 10/26/23, showed the following: Focus: Resident #107 wishes to return home with spouse Goal: Discharge goals are to return home when therapy goals are met/medically appropriate for discharge. Interventions: Establish a pre-discharge plan with [Resident #107]/family/caregivers and evaluate progress and revise plan; Make arrangements with required community resources to support independence post discharge home care, PT (physical therapy), OT (occupational therapy), MD (medical doctor), wound nurse; Provide discharge teaching. A review of Resident #107's Transition of Care and Discharge Summary, dated 1/6/24, showed the following: Section A, discharge to Home/ Community, and the reason for discharge, condition improved is selected. Section C, Contacts and Follow-up revealed Home Health Nursing and Therapy services have been arranged for Resident #107. During an interview on 2/8/24 at 10:49 a.m. the Social Services Director (SSD) said on 1/6/24 Resident #107 was discharged from the facility. During an interview on 2/8/24 at 12:17 p.m. the Minimum Data Set Director (MDSD) stated Resident #107 was discharged home. The MDSD reviewed Resident # 107's MDS, Discharge Return Not Anticipated, dated 1/6/24 and stated section A 2105 showed the resident was discharged to a Short-term General Hospital was incorrect. She stated the record would need to be amended. A review of the facility's policy, titled, Certifying Accuracy of Resident Assessment, version 1.1 showed the following: Policy Statement All personnel who complete any portion of the Resident Assessment (MDS) must sign and certify the accuracy of that portion of the assessment. Policy Interpretation and Implementation: Section #2 All personnel who complete any portion of the MDS assessment, tracking form, or correction request form must sign a hard copy of such assessment certifying the accuracy of the portion of the assessment.

Based on record review and interview, the facility failed to ensure prompt efforts were made to resolve grievances filed by the resident or resident representative for four ( Residents #1, #6, #7, #8) of five residents reviewed for resolution of grievances. Findings included: Record review of the facility grievance log for June 12, 2022, revealed Resident #1's representative filed a concern related to care and treatment. The log did not contain a documented resolution or date of notification of a resolution to the representative. On 07/14/2022 at 12:14 p.m., an interview was conducted with the Nursing Home Administrator (NHA). She stated the grievance indicated the representative was unhappy with the staff and incontinent care. The NHA said we had a meeting with the representative on June 13, 2022, we sat with her and went through all of her concerns. She said the representative told her a staff member used [brand name] wipes to clean [Resident #1] while providing incontinent care. The NHA stated the former Risk Manager assessed the resident immediately and educated the staff member related to the use of [brand name] wipes. The NHA said the grievance was not assigned to a specific staff member. The facility was unable to locate education that was provided to staff members on the use of [brand name] wipes. Record review of the facility's monthly grievance log for June 2022, revealed Resident #6 filed a grievance on 6/30/22 related to customer service. A follow up investigation was initiated by the facility on 6/30/22 but there was no documented resolution or date of notification of a resolution to the resident. Record review of the facility's monthly grievance log for May 2022 revealed a representative of Resident #7 filed a grievance related to care on 5/12/22. There was no documentation to review that an investigation was conducted and no resolution date documented on the log. Record review of the facility's monthly grievance log for July 2022 revealed Resident #8 filed a grievance related to care on 7/12/22. There was no documentation to review that an investigation was conducted and no resolution date documented on the log. An interview was conducted with the administrator on July 13, 2022 at 2:25 p.m., who confirmed the grievances listed for Residents #1, #6, #7, and #8 had not been investigated and no resolution was available to review. Review of the undated facility grievance policy revealed that under the paragraph Policy Detail: 4. The outcome of the investigation will be reported to the resident and responsible party within three (3) working days of the resident submitting the written or or verbal grievance. 8. A written grievance shall include a summary statement of the resident's grievance , the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the community as a result of the grievance, and the date the written decision was issued. A follow up interview with the administrator on July 14, 2022 at 10:30 a.m. confirmed the policy was current, in effect, and should have been followed.

Based on interview and medical record review, the facility failed to ensure family notification was provided prior to two invasive procedures performed for one (Resident #1) of nine sampled residents. Findings Included: On 7/12/2022 at 1:25 p.m., a phone interview was conducted with Resident #1's representative as she verbalized concerns about the lack of notification from the facility. She stated, when [Resident #1] was at the facility they removed her [urinary] catheter and her intravenous (IV) line without notifying me. The representative stated, On 05/30/2022, I found [Resident #1's] IV lying on her bedside table. The representative said she asked the Risk Manager about Resident #1's catheter and she told her, She would look into it. I had asked her to call me about the decision. I never received a phone call. The next day I went to the facility, and it was removed. Medical record review of Resident #1's Admission Record revealed the resident was admitted to the facility in May 2022 and resided at the facility for a month. Her primary admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Brief Interview for Mental Status dated 06/23/2022, revealed a score of 6, which indicated severe cognitive impairment. Physician orders dated 05/28/2022 were as follows: please get an order to discontinue Peripheral IV on the left forearm every day for therapy completed on 5/26 due to dehydration for 2 days. Physician orders dated 06/05/2022 [urinary catheter] discontinued (DC' d). On 7/13/2022 at 3:25 p.m., during an interview with the Nursing Home Administrator, she confirmed Resident #1's family should have been notified when the indwelling urinary catheter and the IV was removed. On 07/13/2022 at 4:00 p.m., an interview was conducted with the Unit Manager (UM). She said she was not working when Resident #1 resided at the facility. She confirmed there was no documentation in the resident's medical record that indicated the family was notified of the removal of the indwelling urinary catheter or the intravenous (IV) line. The UM stated, The normal process is staff should contact the family on a change in condition. She confirmed the removal of the urinary catheter and the IV were both considered invasive devices. Review of the facility policy and procedure Change in a Resident Condition or Status revision May 2017. Policy Statement Our facility shall promptly notify the resident, his or Attending Physician, representative (sponsor) of changes in the resident medical/mental condition and /or status. Policy Interpretations and Implementation 2. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff. c. Requires interdisciplinary review and/or revision to the care plan 4. Unless otherwise instructed by the resident, a nurse will notify the residents representative.

Based on observation, interview, and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for one (Resident #5) of one resident with intermittent catheterization orders. Findings Included: On 7/13/2022 at 9:45 a.m., Resident #5 was observed lying in his bed and was receptive to an interview. He appeared comfortable and denied any discomfort. On the right side of the bed a catheter drainage bag was attached. The resident confirmed he had an indwelling urinary catheter and stated, they put it in yesterday. He said he was performing his own straight catheterization at the facility until yesterday. He said yesterday, I tried to straight cath (catheterize) and it started bleeding, so they placed the indwelling catheter. At that time, a voice from a cell phone that was in his lap was heard. The resident smiled and stated, my wife is on the phone. Resident #5's wife stated, [Resident #5] had been having problems performing the straight catheterization since he had been at the facility. It's because of him being in the bed. When he was at home, he never did it in bed. He would always sit in a chair to do it. He needs help, no one helps him. Every time he has a [urinary] catheter, he always gets an infection. The resident was observed as he nodded his head in agreement with his wife. His wife said she visits him almost daily and had frequently informed the staff members that he needed help, but no one cared or helped him. Resident #5 confirmed he was at the facility for short term rehabilitation after he fractured his hip. He was able to use the remote of the bed and raised the head of the bed. He stated I can't even pick up my legs anymore. They're very weak after being in bed so long. Resident #5 denied being able to sit on the edge of the bed without physical assistance to aid in self catheterization. Review of the Admission Record form indicated Resident #5 was admitted to the facility within the past week. The form included the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Brief Interview for Mental Status (BIMS) dated 07/08/2022 revealed a score of 14, which indicated the resident was cognitively intact. A review of hospital Discharge Summary dated 0705/2022, Hospital course revealed, Eventually patient/family agree to skilled nursing facility (SNF) placement. He requires straight catheterization secondary to bladder dysfunction. A review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order did not indicate the resident was to perform self-catheterization. A review of the medication and treatment administration record did not reveal an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the progress notes dated 7/6/2022 at 7:45 p.m. (1945), read as follows - Note Text: this is a nursing admission note for [resident name]: resident has a long history of [CONDITION(S)], congested heart failure (CHF), chronic obstructive pulmonary disease ([CONDITION(S)]), chronic kidney disease stage 4, chronic back and neck pain. Upper extremities are weak and shacking [sic] due to [CONDITION(S)]. Review of the progress note Type Situation-Background-Assessment-Recommendation (SBAR) dated 7/12/2022 at 3:55 a.m., read as follows: Nursing observations, evaluation, and recommendations, are the patient (PT) was attempting to self cath. In order to void. PT was not voiding but did not stop trying. I walked into the room after being called in by the certified nursing assistant (CNA) because [the resident] was having problems with self cath. That is when I saw that PT was bleeding. I cleaned him up and told him to not keep trying. Primary Care Provider Feedback: Primary care Provider responded with the following feedback: A. Recommended to place a [brand name] urinary catheter. Progress note dated 7/12/2022 at 12:04 p.m., orders received to place [brand name] catheter, inserted 16 F [brand name] catheter inflated with approx. 7-9 ml of saline as pt. complained of (c/o) pain when inflating balloon, yellow urine with some sediment noted in drainage bag. Progress note dated 7/12/2022 at 2:39 p.m. (1439) pt. requires assistance with transfers and toileting. Pt self-catheterizes - orders obtained to place indwelling catheter. On 7/13/2022 at 4:50 p.m., during an interview with the Unit Manager, she said she would look into Resident #5's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/14/22 at 10:24 a.m., in an interview with the Director of the Therapy Department, she stated, Resident #5 was independent prior to his hip fracture. The Director reviewed of the Occupational Therapy Evaluation & Plan of Treatment dated on 7/7/2022 and confirmed the resident as in the hospital for a week prior to his admission to the facility. She said the evaluation reason for the current referral had stated, new onset of compromised physical exertion level during activity, decrease in functional mobility, decrease in strength, decrease in coordination, decrease in postural alignment, increased need for assistance from others. Pain limited and painful movement and reduced dynamic balance. The Director confirmed on 7/7/ and on 7/8/2022 the resident had required maximum assistance of two staff members to roll in bed, side to side, and to sit on the edge of the bed. She said he had improved on 7/10/2022 and required the assist of one for bed mobility. She confirmed the resident required assistance of one to sit on the edge of the bed. On 7/14/2022 at 11:45 a.m., a phone interview was conducted with the Advanced Practitioner Registered Nurse (APRN) and he confirmed he knew Resident #5. He denied the resident had any confusion and was alert and oriented. The APRN said he was notified by the facility the resident had blood noted during the straight cath. He said, I had ordered to place an indwelling [brand name] catheter. The blood had indicated trauma which could lead to the urethra swelling and possible closing. That would not be good. The APRN said he was not aware the resident had been performing his own self-straight catheterizations. He was informed the resident's medical record did not contain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The APRN stated, The nurses are not assisting him? The APRN was informed the medical record did not have documentation that indicated the licensed staff assisted the resident. The APRN stated, that is not acceptable. He confirmed his expectation was the licensed staff would perform the straight catheterizations, would monitor, assess, and document accordingly. On 7/14/2022 at 1:07 p.m., Staff E, Licensed Practical Nurse (LPN) confirmed she cared for Resident #5 since his admission. She said she recalled one time he needed assistance to perform the straight cath. She said she helped him because he was shaking so much. She denied the resident had asked for any further assistance after that day. Staff E indicated she was unaware the resident did not have an order to perform self-catheterizations. On 7/14/2022 at 2:00 p.m., during an interview with the Interim Director of Nursing, she explained the new admission process. The nurse would review new resident physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse on the next shift would review the orders. The next day, the orders were reviewed by the Interdisciplinary Team in the morning. She indicated she was unaware the resident did not have orders to self-catheterize. She said she was aware Resident #5 had been ordered indwelling [brand name] catheter related to trauma to the urethra that had resulted in bleeding. She said, The trauma might have been avoided if the straight catheterization was performed by the licensed staff. Intermittent Catheterization: Sterile insertion and removal of a catheter through the urethra every 3-6 hours for bladder drainage may be appropriate for the management of acute or chronic urinary retention. Rationale for Intermittent Catheterization. The rationale for using Intermittent Catheterization: The bladder contracts and the pelvic floor muscles relax and the external urinary sphincter opens to allow voiding and the passage of urine through the urethra. Normally, after the bladder empties, a small amount of urine may remain in the bladder and this is called the post void residual (PVR). If the person cannot urinate or empty the bladder completely, the PVR increases and can contribute to catheter related urinary tract infections (CaUTIs), overflow UI, and permanent damage to the bladder and kidneys. Research has shown that regular bladder emptying reduces intravesical (in the bladder) pressure and improves blood circulation in the bladder wall, making the bladder mucosa more resistant to infectious bacteria. https://www.urotoday.com/urinary-catheters-home/intermittent-catheters/description/definition-intermittent-catheters.html.

Based on observation, interview, and record review, the facility failed to provide admission services for two (Residents #4 and #5) of three residents as evidenced by not providing physician ordered medications. Findings Included: 1. On 7/13/2022 at 9:20 a.m., Resident #4 was observed from the doorway and was receptive to an interview. He said he was admitted last evening, 7/13/22 at 5:00 p.m., and was not happy with the nurse that gave him his medications this morning. He apologized by stating, I don't mean to yell at you, but the hospital told me what the medications were when they gave them. Why is it so different here? They didn't get me my medications until 9:00 p.m. last night. I have pain medications for my back and legs. I know they didn't give me my [MEDICATION(S)]. I need that. Review of the Admission Record form indicated Resident # 4 was admitted to the facility for short term rehabilitation. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of hospital admission physician orders dated 07/11/2022, read to provide [MEDICATION(S)] 40 mg oral tablet 1 tablet by mouth once a day (at bedtime) for [CONDITION(S)] next dose due 7/12 9:00 p.m. (2100), [MEDICATION(S)] 2 g injection every 8 hours through July 24, 2022, [MEDICATION(S)] 500 mg, continue [MEDICATION(S)] 500 mg by mouth (p.o.) twice daily for foot infection through July 24, 2022 next dose 7/12/2022, [MEDICATION(S)] 100 mg capsule continue [MEDICATION(S)] 100 mg p.o twice daily for foot infection through July 24, 2022 next dose 7/12/2022, [MEDICATION(S)] 30 mg 8 to 12 hr oral extended release 1 tablet by mouth every 12 hours next dose 7/12, [MEDICATION(S)] 150 mg oral tablet give 1 tablet by mouth once a day (at bedtime) for depression with difficulty sleeping next dose 7/12/2022, and [MEDICATION(S)] 600 mg oral tablet 1 tablet by mouth twice a day for [CONDITION(S)] next dose 7/12/2022. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Indicating five out of seven physician ordered medications were not administered. Further review of progress notes did not contain documentation of physician notification. 2. On 7/13/2022 at 9:45 a.m., Resident #5 was observed lying in his bed and was receptive to an interview. He appeared comfortable and denied any discomfort when approached. He said he had been at the facility about a week now and it took a while for them to get his [CONDITION(S)] medications right. At that time, a voice from his cell phone was heard. He smiled and stated, my wife is on the phone. Resident #5's wife confirmed the allegation and stated, He told me he wasn't getting all his medications. I talk to him every day. She added if he missed his [CONDITION(S)] medications his tremors increased. At that time, Resident #5 held out his right hand with a slight tremor noted. Review of the Admission Record form indicated Resident #5 was admitted to the facility within the past week. The form contained the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Brief Interview for Mental Status (BIMS) dated 07/08/2022 revealed a score of 14, that indicated the resident was cognitively intact. Review of physician orders and the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] = Other/See nursing notes. Nursing notes read pending. [MEDICATION(S)], tablet 100 mcg give one by mouth in the morning for low [CONDITION(S)] dated 07/07/2022 the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders for [MEDICATION(S)]-[MEDICATION(S)] Tablet 25-100 mg give 1 tablet by mouth five times a day for [CONDITION(S)] start date 07/06/2022 at 10:00 p.m. (2200) the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders for [MEDICATION(S)] Sodium Tablet 70 mg give one tablet by mouth in the morning every Mon. for [CONDITION(S)] dated on 7/11/2022 at 0600 for the first dose to be administered The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] = Other/See nursing notes. Nursing notes reviewed for 07/11/2022 at 6:17 a.m. read can not locate med. On 07/14/2022 at 11:45 a.m., a phone interview was conducted with the Advanced Practice Registered Nurse (APRN) he confirmed he knew Resident #5 and had seen him this morning. He stated I was not notified Resident #5 was not provided his [MEDICATION(S)] on admission. That's not good. He said [CONDITION(S)] medication was very sensitive as the medication left the system quickly. He confirmed if not taken it would increase his tremors. The APRN said he was not notified Resident #5's Rotigontine patch was not administered for five days. The APRN repeated five days and stated, there is no excuse for that. The APRN confirmed it was his expectation that medications that were ordered, were given as prescribed. On 07/13/2022 at 2:10 p.m., an interview was conducted with the Unit Manager. She said, Part of our process with new admissions is transcribing the physician orders. The orders are transcribed and sent to the pharmacy. The medications are then ordered immediately [STAT] and we will receive them within four hours. If the medication is not received, [the nurse] would follow up with the pharmacy. On 07/14/2022 at 3:55 p.m., an interview was conducted with the Interim Director of Nursing she stated, We have a [brand name], medication system, in place where the majority of the medications are available. The nurses need to use the system to see if the admission medications are available, if they are, they need to be administered. Review of the facility policy and procedure revised April 2019 Administering Medications Policy Statement Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 5. Medications administration time are determined by the resident need and benefit, not staff convenience.

Based on interview and record review, the facility failed to follow their investigation procedures for an allegation of neglect related to care and services for one (Resident #1) of three sampled residents reviewed for abuse and neglect. Findings included: A review of the abuse and neglect reporting log revealed an entry dated 06/28/2022 for Resident #1. The resident was discharged from the facility on 06/23/2022. A review of the facility's investigation revealed on 06/28/2022, Resident #1's representative alleged neglect related to bathing, medication administration, and snack availability in the evening. The facility's investigative findings read as follows, The resident's [representative] reported [the resident] preferred a have shower instead of a bed bath, on 06/13/22. Once her concerns were communicated, the facility updated her preferences, and she received a shower per the agreed upon schedule and per her request. The resident's representative also alleged the resident did not receive all of her doses of antibiotic because she was discharged with four doses of her antibiotic that was completed prior to discharge. The facility investigation revealed the [brand name] (automatic medication dispensing system) records found four doses of her antibiotic were received out of the [brand name] dispensing system on sight, prior to the medication being delivered, therefore she did not miss any doses of her antibiotic. Medical record review of Resident #1's Admission Record form revealed she was admitted to the facility in May 2022 and had resided at the facility for a month. Her primary admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Brief Interview for Mental Status dated 06/23/2022, revealed a score of 6 which indicated severely impaired cognition. A review of the physician orders dated 06/07/2022, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of nursing notes on 06/07/2022, showed no documentation related to the omission of the antibiotic. On 07/14/2020 at 1:15 p.m., the Minimum Data Set (MDS) nurse assisted with the Bath Look Back documentation from 05/25/2022 to 06/23/2022. The documentation revealed a bed bath was performed on 06/01/2022, 06/07/2022, 06/09/2022, and on 06/14/2022. Further review revealed one shower was provided on 06/10/2022. The MDS nurse confirmed Resident #1 had a total of four bed baths and one shower in thirty days. On 07/13/2022 at 2:00 p.m., in an interview with the Nursing Home Administrator (NHA), she said on 06/26/2022 she received an e-mail from the Resident #1's [representative]. She said she did not read the e-mail on the day it was received, she read it on 06/28/2022, and did not indicate why there had been a delay in reading the e-mail. The NHA stated, When I read the allegation, I performed the immediate reporting on that day. The NHA stated, The resident's [representative] was concerned [the resident] had not received all of her antibiotics for her urinary tract infection. The NHA said our Director of Nursing (DON) investigated that part of the allegation. The DON told me the resident had taken all of her antibiotics. The NHA went on to say the Risk Manager (RM) had followed up the second concern related to bathing. The RM told me the resident was provided a shower. At that time, the NHA was informed the investigation did not correlate with the medical record. Review of the facility policy and procedure on Abuse Prevention Program dated February 2020. g. Neglect is defined as failure of the facility, its employees or service providers to provide goods and services necessary to avoid physical harm, pain mental anguish, or emotional distress. VI. Internal Investigation of Abuse, Neglect, or Misappropriation Allegations and Response. 1. All incidents will be documented, whether or not abuse occurred, was alleged or suspected. 2. Any incident or allegation involving abuse, neglect, or misappropriation will result in an abuse investigation. 4. Investigation Procedures: the appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident if interview able. Any written statement that has been submitted will be reviewed, along with any pertinent medical records or other documents. Residents to whom the accused had regularly provided care, and employees with whom the accused has regularly worked will be interviewed to determine whether anyone has witnessed any prior abuse, neglect, exploitation, mistreatment or misappropriation of property by the accused individual. 7. Final Abuse Investigation Report. The investigator will report the conclusions of the investigation in writing to the administrator or designee within five working days of the reported incident. The final investigation report shall contain the following: Facts determined during the process of the investigation, review of medical record, and interview of witnesses. Conclusion of the investigation based on known facts. The administrator or designee will review the report. The administrator or designee is then responsible for forwarding a final report of the results of the investigation and of any corrective action taken to the State Department of Health with in five working days of the reported incident. The administrator or designee is also responsible for informing the resident or their representatives of the results of the investigation and of any corrective action taken.

Based on observation, interview, record review, and policy review the facility did not ensure dental services for treatment were provided to one resident (#20) of twenty-five sampled residents. Findings included: Resident #20 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/19/21 at 10:36 a.m. an interview and an observation were conducted with Resident #20. She had eight teeth that needed to be fixed; seven on the right and one on the left. Resident #20 had some missing teeth noted on the right upper side of her mouth. She stated she had never seen a dentist. On 10/20/21 at 3:45 p.m. an interview was conducted with Staff F, Social Services Coordinator. She said that usually the nurse, CNA (certified nursing assistant) or herself is informed of dental issues and she makes a referral unless it's an emergency. Dental services comes once a month. The facility just changed companies. Once a year they do an annual check. There is the standard cleaning and checkups. If they are not on the main list, and if they need service, we make a referral. We switched dental service companies in August (2021). On 10/20/21 at 3:58 p.m. a follow up interview was conducted with Staff F, Social Services Coordinator. Staff F said Resident #20 had a yearly assessment on February 24th (2021). She had a denture follow-up on March 23rd. She had partial dental impressions done on May 21st. She may have a partial. On 10/20/21 at 4:09 p.m. a follow up interview was conducted with Resident #20. She said she needed the hole on the right side of her upper mouth where she was missing some teeth, addressed. On 10/20/21 at 4:17 p.m. an interview was conducted with Staff J, CNA. Staff J said Resident #20 doesn't have dentures. A review of the dental visit made by the dental assistant dated 2/12/21 reflected an upper denture was recommended. A review of the dental visit made by the registered dental hygienist on 2/24/21 revealed Resident #20 had 6 missing maxillary teeth and 2 missing mandibular teeth and that Resident #20 had natural teeth without dentures. A review of the 5/21/21 dental services visit made by the dental assistant indicated Resident #20 was scheduled for impressions but complained of dental pain. Will need X-rays next visit and plan for symptomatic teeth. Review of the 6/24/21 dental services visit made by the dental assistant revealed Resident #20 wants extractions and partials made. Today is our last visit. Will need to seek treatment with a new dentist. Review of notice of termination with dental services provider reflected a termination date of 7/31/21. A review of the contract for the new dental services provider reflected a contract signature date of 5/27/21 by the facility representative. Review of the consent for services, including impressions and dentures, signed by Resident #20 revealed a date of 8/30/21. On 10/21/21 at 10:09 a.m. another interview was conducted with Staff F, Social Services Coordinator. Staff F said they changed companies. The new company just started coming. They had to get all the consents for the residents first. On 10/21/21 at 10:11 a.m. an interview was conducted with the Nursing Home Administrator (NHA). She said she thinks the new company has been coming out. They came out and were getting everybody signed up and ready to go. Resident #20 was signed up in August (2021). On 10/21/21 at 12:19 p.m. a follow up interview was conducted with the NHA. She said Resident #20 told the previous unit manager about her dental concerns and she didn't follow up. That unit manager is no longer here. We dropped the ball. We contacted the dental company already and they will be coming out to see her. Review of the policy, Dental Services, revised December 2016, revealed the following information: Policy Statement Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Policy Interpretation and Implementation 1. Routine and 24-hour emergency dental services are provided to our residents through: a. a contract agreement with a licensed dentist that comes to the facility monthly. 6. Social services representatives will assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the state plan, if eligible.

Based on observations, interviews, and record reviews the facility did not ensure medications were secured for two residents (#47 and #48) out of 29 residents. Findings included: 1. During a facility tour on 10/19/21 at 10:20 a.m., Resident #47 was observed sitting in her wheelchair positioned by her bedside. Resident #47 was noted sleeping and did not respond to the request for interview. An empty medicine cup and a yellow powdered substance were observed spilled on the floor to the left of Resident #47's bed. (Photographic Evidence Obtained) On 10/19/21 at 11:03 a.m., a second observation revealed the yellow powdered substance on the floor. An immediate interview was conducted on 10/19/21 at 11:03 a.m., with Staff B, Registered Nurse (RN). Staff B stated Resident #47 takes her medications crushed. Staff B stated that she had crushed Resident #47's medications and put them in apple sauce that morning. Staff B made the observation of the yellow powdered substance on the floor and said, It looks like medicine to me. It is not from this morning. It maybe 3:00 (p.m.) -11 (p.m.) shift. Staff B stated the only thing she could think of is the yellow powder was crushed baby aspirin which the resident takes. On 10/21/21 at 10:31 a.m., a brown pill was found on the floor inside the doorway of Resident #47's room. (Photographic Evidence Obtained) A review of the Admission Record for Resident #47 revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) dated [DATE] Section C - Cognitive Patterns, showed Resident #47 had a Brief Interview for Mental Status (BIMS) score of 08, indicating moderate cognition impairment. 2. During a tour of Resident #48's room on 10/21/21 at 10:45 a.m., an observation was made of a small, round peach-colored pill on the floor. The pill was underneath a wheelchair positioned in the corner of the room to the left of the bed. (Photographic Evidence Obtained) On 10/21/21 at 11:19 a.m., the Director of Nursing (DON) conducted a tour of the rooms for Residents #47 and #48. The DON saw the pills on the floor and asked Staff C, RN to identify them. Staff C stated the small peach colored pill was [MEDICATION(S)] for Resident #48. The DON stated the brown one was an over the counter (OTC) [MEDICATION(S)]. The DON stated that it is a [MEDICATION(S)] and multiple residents take it as needed. The DON stated the crushed pills in Resident #47's room could not be immediately identified. The DON stated it might be a baby aspirin. Staff C said, She [Resident #47] does not take any yellow pills. The DON said, This is concerning. We will conduct further investigation. A review of the Admission Record for Resident #48 revealed that she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Quarterly MDS dated [DATE] Section C - Cognitive Patterns, showed Resident #48 had a BIMS score of 10, indicating moderate cognition impairment. A review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/21/21 at 1:08 p.m., an interview was conducted with Staff C, RN. Staff C stated that pills should not be found loose on the floor because another resident could take them. Staff C stated the pills could fall maybe when they [nurses] are popping from the blister. Staff C said, Either way they should find the pill that falls and dispose per protocol. Residents should be supervised during med administration. On 10/22/21 11:27 a.m., a follow - up interview was conducted with the DON. The DON said, Pills should not be on floor. The expectation is to supervise resident's during medication administration. Review of a facility policy titled, 5.3 Storage and Expiration of Medications, Biologicals, Syringes and Needles, revised 01/01/13, showed: 3.3 Facility should ensure that all medications and biologicals, including treatment items are securely stored in a locked cabinet / cart or locked medication room that is inaccessible to residents and visitors. A facility policy titled, 6.0 General Dose Preparation and Medication Administration, revision date 01/01/23, showed: 3.9 Facility should not leave medications or chemicals unattended. 5.9 Observe the resident's consumption of the medication(s).

Based on observation, interview and record review, the facility did not ensure behavior and side effect monitoring for [CONDITION(S)] medication was conducted for one resident (#29) of five residents sampled. Findings included: An observation on 10/20/21 at 3:13 p.m. revealed Resident #29 in bed in her night gown and stated she fell from bed the previous night as she attempted to go the restroom herself without waiting for staff to assist her. An additional observation on 10/21/21 at 12:38 p.m. revealed Resident #29 laying down in bed facing the window with the lunch tray untouched. An interview was attempted and Resident #29 did not respond. Review of Resident #29's Admission Record revealed that Resident #29 was readmitted to the facility on [DATE] and with an original admitted [DATE]. Review of a 5-day Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .) Give 2 tablets by mouth at bedtime for depression. The orders did not include behavior and side effect monitoring for the anti- depressant. Review of the October 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A psychological evaluation for Resident #29 dated 09/08/21showed Resident #29 was seen for adjustment disorder with depressed mood, other recurrent depressive disorders. The primary goal of the visit indicated Resident #29 has been sleeping more and is less talkative the last several visits. Review of a psychological note dated 10/04/21 showed Resident #29 was seen for a follow-up and [CONDITION(S)] medication evaluation. Resident #29 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The note revealed a care plan with recommendations to continue [MEDICATION(S)] 15mg at HS (hours of sleep) and to continue to monitor for mood, sedation, medication side effects and behaviors. A psychological progress note dated 10/06/21 identified a goal to continue follow-up on a bi-weekly basis to address treatment goals of reduced depressive and anxious symptoms and improve coping and interpersonal strategies through the use of motivational enhancement and cognitive behavioral therapies. On 10/22/21 at 9:56 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated the expectation is for behavior and side effects monitoring to be completed for anti-depressant and anti-psychotic medications. The DON reviewed Resident #29's MAR for October 2021 and stated it [the monitoring] should have been put in. The DON said, There is no reason why we are not monitoring. The DON further stated they were monitoring before the resident went to the hospital and provided the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON said, When she returned on 08/16/21 orders were not restarted and no one caught it. We will start the orders today. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Monitor side effects to include 0=none, 1=nausea/vomiting, 2=constipation, 3=confusion, 4=anxiety, 5=diarrhea, 6=hypotension, 7=tremors, 10=weight loss /gain, 11=dry mouth, 12=blurred vision and 13=urinary retention. Start date 05/04/21 and D/C (discharge) date 08/12/21. An interview was conducted on 10/22/21 at 11:31a.m. with the facility's pharmacist. The Pharmacist stated she would expect monitoring for a resident taking any anti-depressant. The Pharmacist stated they should be monitoring for set parameters related to dose tolerance and effectiveness. On 10/22/21 at 1:58 p.m., an interview was conducted with Staff A, Licensed Practical Nurse (LPN). Staff A stated they conduct behavior monitoring, side effects monitoring and pain monitoring for all residents taking antipsychotic and antidepressant medications. Staff A stated the monitoring should be in the orders. Staff A said, [Resident #29] is on anti-depressant so we should be monitoring. Review of the facility's policy titled, Behavioral Assessment, Intervention and Monitoring, reviewed and revised in May 2018, Policy Statement #4 showed, The facility will comply with regulatory requirements related to the use of medications to manage behavioral changes. Under the Monitoring section it showed: 1. If the resident is being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. The IDT will monitor progress of individuals with impaired cognition and behavior until stable. New or emergent symptoms will be documented and reported. 3. Interventions will be adjusted based on the impact on behavior and other symptoms, including any adverse consequences related to treatment. 4. The nursing staff and the physician will monitor for side effects and complications related to psychoactive medications, for example, lethargy, abnormal involuntary movements, anorexia, or recurrent falling. 5. (a) The IDT will monitor side effects and complications related psychoactive medications.

Based on interview and record review the facility did not ensure pharmacist recommendations for one resident (#2) of five residents sampled were reviewed and implemented, or if rejected the facility failed to ensure a rationale was provided by the physician, within a timely manner. Findings included: Resident #2's Admission Record revealed an initial admitted [DATE], and an admitted [DATE] with medical diagnoses of chronic [CONDITION(S)], adult failure to thrive, acute respiratory failure, history of falling, and Alzheimer's disease. Resident #2's care plan revealed a focus area, revised on 01/15/21, of [Resident #2] has altered cardiovascular status. Interventions for this focus area included administering medications as ordered by the physician, monitor, document, and report signs/symptoms of anti-arrhythmia complications such as chest pain, vital signs as ordered and notify physician of any abnormal readings. A review of the Consultation Report, recommendation date of 09/01/21, revealed Comment: [Resident #2's] medication administration record (MAR) or prescriber order sheets (POS) includes items that need clarification . Please clarify the following items . 1. New [MEDICATION(S)] order needs a pulse prompt . Response Requested . The document did not have a physician response nor was the document signed or dated by the physician. Resident #2's MAR report for September 2021 revealed, [MEDICATION(S)] Tablet 125 MCG Give 1 tablet by mouth one time a day for heart failure . Start Date 08/31/2021 0900 . D/C (Discontinue) Date 10/15/2021. Further review revealed from 09/01/21 to 09/30/21 no pulse at the time of medication administration was recorded. The Order Summary Report as of 10/22/21 revealed Resident #2 was prescribed one daily [MEDICATION(S)] 125 MCG (microgram) tablet to be provided by mouth for [CONDITION(S)]. This was ordered on 10/18/21. A review of the Consultation Report, recommendation date of 10/08/21, revealed Comment: [Resident #2's] medication administration record (MAR) or prescriber order sheets (POS) includes items that need clarification . Please clarify the following items . 1. New [MEDICATION(S)] order needs a pulse prompt . Response Requested . The document did not have a physician response. The document was had an illegible signature on the Unit Manager line with a date of 10/12/21. Resident #2's MAR report for September 2021 revealed [MEDICATION(S)] Tablet 125 MCG . Start Date 08/31/2021 0900 . D/C (Discontinue) Date 10/15/2021. Resident #2's pulse was recorded at the time of medication administration on 10/14/21 and 10/15/21. Further review revealed [MEDICATION(S)] Tablet 125 MCG . Start Date 10/19/021 0900. No pulse was recorded at the time of medication administration from 10/19/21 to 10/22/21. An interview on 10/22/21 at 9:36 a.m. with the Director of Nursing (DON) revealed recommendations from the pharmacist are reviewed immediately. The requests are either discussed with the doctor over the phone, or they are placed into their files for review once they come to the facility. The DON reviewed Resident #2's online medical record and confirmed a pulse was not recorded at the time of administration for [MEDICATION(S)] until 10/14/21. Resident #2 was sent to the hospital on 10/15/21 (for an unrelated event) and returned on 10/18/21. When a resident goes out to the hospital and returns, the medications and physician orders are reconciled to make ensure the continuality of care. Usually, the follow-up time frame for the recommendations is within 2 weeks. The DON confirmed it is the nursing standard of practice to measure a resident's pulse prior to administrating [MEDICATION(S)]. An interview on 10/22/21 at 9:54 a.m. with Staff A, Licensed Practical Nurse (LPN) revealed that prior to administering medication, a resident's vitals are taken including the pulse. Related to [MEDICATION(S)], Staff A stated currently Resident #2 did not have pulse parameter physician orders for [MEDICATION(S)] administration. Staff A, LPN said, I would withhold it [[MEDICATION(S)]] if her pulse was below 50, or is it 60? Honestly, I would not give it if her pulse was below 50. A follow-up interview on 10/22/21 at 12:58 p.m. with the DON revealed the standard of practice is that [MEDICATION(S)] is not administered if a resident's pulse is less than 60. If the medication is administered with a pulse level less than 60, it can slow the heart further and cause complications. The DON confirmed the lack of pulse monitoring logged at the time of [MEDICATION(S)] medication administration and implementation of the pharmacist recommendation. A policy review of Medication Regimen Review [MRR], effective 12/01/07, revealed . The consultant Pharmacist will conduct MRRs if required under a Pharmacy Consultant Agreement . Facility should independently review each resident's medication regimen directly from the resident's medical chart and with the Interdisciplinary Care Team members, resident or Responsible Party, as needed . Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR and the Director of Nursing to act upon the recommendations contained in the MRR Facility should encourage Physician/Prescriber to either (a) accept and act upon the recommendations contained within the MRR, or (b) reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected . Facility should provide the Medical Director with a copy of the MRRs and should alert the Medical Director where MRRs require follow-up . Facility should maintain copies of MRRs on file in Facility, either as part of the resident's permanent medical record or in a special file, in accordance with Applicable Law.

Based on observation, interview and record review, the facility failed to ensure medications were available and provided for two residents (#11 and #188) of eight residents observed during medication administration. Findings included: 1. A review of the Admission Record for Resident #11 reflected a diagnosis of [CONDITION(S)] ([CONDITION(S)]). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #11's cognition was intact. On 10/22/21 at 9:28 a.m. during the medication administration observation, an interview was conducted with Resident #11. She stated she has not been getting her [MEDICATION(S)] as the facility ran out. Resident #11 said, This happens all the time, and she further said she does not get her [MEDICATION(S)] neither. An interview was conducted at the same time with Staff G, Licensed Practical Nurse (LPN). Staff G said he informed the unit manager, and she thought the [MEDICATION(S)] was on order. A review of the October 2021 physician orders revealed the following: -8/13/21 [MEDICATION(S)] ([MEDICATION(S)]) give 10 milligrams (mg) by mouth one time a day for inflammation, -8/16/21 [MEDICATION(S)] ([MEDICATION(S)]) give 1 tablet by mouth at bedtime for [CONDITION(S)]. A review of the Medication Administration Record (MAR) for October 2021 reflected the following: -[MEDICATION(S)] was signed every day from October 1st to October 22nd, indicating the medication was administered. On October 17th code 5 was documented, and review of the code key showed, Hold,/see nurses notes. On October 20th code 9 was documented, and review of the code key showed, Other/see nurses notes. A review of mediation administration notes for October 2021 revealed there was no note for the 17th or 20th. Further review of the MAR revealed the [MEDICATION(S)] was also documented as administered from October 1st to October 22nd. On 10/22/21 at 10:17 a.m. an interview was conducted with Staff G, LPN. She said she reordered the [MEDICATION(S)] because she did not find it. On 10/22/21 at 10:58 a.m., an interview was conducted with Staff G, LPN. She confirmed she had signed for the [MEDICATION(S)] after reviewing the MAR but had not given it. She said, Oh sorry. I will change it. On 10/22/21 at 11:22 a.m. a telephone interview was conducted with the Consultant Pharmacy Technician. She stated, Fifteen tablets of [MEDICATION(S)] were sent out on 10/15, and thirty tablets of [MEDICATION(S)] on 10/21. It should be there. It was delivered at 6:57 p.m. and signed for by a staff member. Additionally, the technician said fifteen tablets of [MEDICATION(S)] had been sent to the facility on ,d+[DATE]. On 10/22/21 at 11:36 a.m. an observation was conducted with the Unit Manager Staff C, Registered Nurse (RN) of the Emergency Drug Kit (EDK). She pulled up the profile for Resident #11 and it revealed [MEDICATION(S)] and [MEDICATION(S)] were not available. On 10/22/21 at 11:40 a.m. an interview was conducted with the Director of Nursing (DON). She said they can reorder medications on the MAR. On 10/22/21 at 12:31 p.m. in a follow up interview with the DON, she revealed the [MEDICATION(S)] had been delivered to another nursing unit. She confirmed there were eight days the [MEDICATION(S)] was not given but had been signed (documented as administered) on the MAR. A review of the inventory list for the EDK dated 10/22/21 showed both medications were available in the facility. 2. During an interview and observation on 10/19/21 at 1:17 p.m. with Resident #188, she stated nurses were not giving her cream on her legs at night even though she asks every day. The resident's legs were observed purple in color below the knees around the shin area. During a subsequent interview with Resident #188 on 10/21/21 at 9:00 a.m. she stated she still did not get any lotion applied to her legs and would really like it since the doctor ordered it. A Review of the October 2021 physician orders revealed: -[MEDICATION(S)] cream 12% apply to bilateral lower extremity topically at bedtime for rash started 10/7/21. -[MEDICATION(S)] cream 0.1% apply to affected area topically every 12 hours as needed for itching dated 10/7/21. A review of the MDS assessment dated [DATE] revealed a BIMS score of 15, indicating she was cognitively intact. During an observation of the treatment and medication carts with Staff H, LPN on 10/21/21 at 9:57 a.m. she confirmed the prescription ordered [MEDICATION(S)] 12% and [MEDICATION(S)] cream were not in the carts and would need to call the pharmacy to see when they were ordered and received. During a phone interview with the Consultant Pharmacy Technician on 10/21/21 at 10:27 a.m. the pharmacy representative stated the facility ordered the cream, but it was not sent, and confirmed the facility did not receive the [MEDICATION(S)] 12% or [MEDICATION(S)]. A review of the MAR for October 2021 revealed [MEDICATION(S)] 12% was documented as applied to bilateral lower extremities, every night at 9:00 p.m. from 10/7/21 to 10/21/21. In an interview with the wound care Nurse Practitioner on 10/21/21 at 10:40 a.m. she stated the [MEDICATION(S)] 12% was necessary and advised the facility to continue with the cream. The Nurse Practitioner confirmed if it is ordered it should be applied or the physician should be notified. During an interview with the DON on 10/21/21 at 10:46 a.m. she stated any prescription ordered should be ordered and applied according to the physician order. She stated any cream ordered and not applied but checked off as applied would be considered a medication error and she would need to contact the physician, family and speak to the resident. Review of the policy, 5.1 Delivery and Receipt of Routine Deliveries, revised 1/1/13, showed the following: Applicability: The policy 5.1 sets forth procedures relating to the delivery and receipt of routine deliveries. Procedure: 2. Upon delivery by pharmacy, facility nurse or other authorized designee on behalf of facility should: 2.1 Sign the delivery manifest (may be electronic if permitted by applicable law), note the time of arrival, and take responsibility for the receipt, proper storage, and distribution of the delivered medications. Review of the policy, Charting Errors and/or Omissions, revised December 2006, revealed the following: Policy Statement Accurate medical records shall be maintained by this facility. Policy Interpretation and Implementation 2. If it is necessary to change or add information in the resident's medical record, it shall be completed by means of an addendum and signed and dated by the person making such change or addition. Review of the policy, Charting and Documentation, revised July 2017, reflected the following findings: Policy Statement All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation 2. The following information is to be documented in the resident medical record: e. events, incidents., or accidents involving the care plan goals and objectives. 7. Documentation of procedures and treatments will include care-specific details, including: c. the assessment data and/or any unusual findings obtained during the procedure/treatment; f. Notification of family, physician, other staff, if indicated. A review of the policy, Medication and Treatment Orders, revised July 2016, revealed the following: Policy Statement Orders for medications and treatments will be consistent with principles of safe and effective order writing. Policy Interpretation and Implementation 11. Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure refills are readily available.

Based on observation, interview, and record review the facility failed to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: An observation on 10/19/21 at 10:31 a.m. revealed Resident #336 lying under the bed covers. A catheter bag and catheter tubing were observed by the resident's bedside. Red coloring was observed inside of the catheter tubing. The resident was not responsive to an attempted interview. Resident #336's Admission Record revealed an admitted [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #336's [Hospital Name] Discharge Summary report, dated 10/10/21, revealed on page 1 . Patient was stable for discharge however she has some urinary retention. She had 400 cc [cubic centimeters] in her bladder. She has a history of UTIs [urinary tract infections]. A [catheter] was placed Recommend . continuing the [catheter]. Page 9 of the report revealed under discharge instructions to . voiding trials at SNF [skilled nursing facility], continue [catheter]. Resident #336's Medical Certification for Medicaid Long-Term Services and Patient Transfer Form revealed a [catheter] was inserted on 10/9/21 for urinary retention due to an unknown cause. An attempt was made to remove the [catheter] in the hospital; the voiding trial to verify [catheter] removal was not successful. A record review of Resident #336's Order Summary Report on 10/19/21 and 10/20/21 revealed no active orders for [catheter] care and treatments. An observation with Staff D, Certified Nursing Assistant (CNA) on 10/21/21 at 11:13 a.m. confirmed the presence of Resident #336's indwelling catheter. During an interview on 10/21/21 at 11:17 a.m. Staff E, Registered Nurse (RN), who was also acting as a Unit Manager, stated when a resident was admitted with an indwelling catheter, the admitting nurse must enter physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The following day, after a resident is admitted , an interdisciplinary team meeting is held to create a focus care plan for the resident with an indwelling catheter. Staff E, RN reviewed Resident #336's online medical chart and confirmed the lack of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff E, RN said, . this was missed. Staff E, RN stated the purpose of having physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] #336] was also found to have a [CONDITION(S)] [urinary tract infection] and started on [MEDICATION(S)] [antibiotic] today as per primary team . A nursing progress note dated 10/18/21 revealed . order for ABT [antibiotic] for E. Coli in the urine. An interview on 10/21/21 at 11:36 a.m. with the Director of Nursing revealed when a resident is admitted with an indwelling catheter, physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's online medical record confirmed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A policy review of Admission Criteria, revised March 2019, revealed Our facility admits only residents whose medical and nursing care needs can be met . Prior to or at the time of admission, the resident's attending physician provides the facility with information needed for the immediate care of the resident, including orders covering at least . routine care orders to maintain or improve the resident's function until the physician and care planning team can conduct a comprehensive assessment and develop a more detailed interdisciplinary care plan. A policy review of Catheter Care, Urinary, revised September 2014, revealed The purpose of this procedure is to prevent catheter-associated urinary tract infections. Review the resident's care plan to assess for any special needs of the resident . Report other information in accordance with facility policy and professional standards of practice.

Based on observation, interview, and record review the facility failed to ensure the prompt effort to resolve a grievance for one resident (#33) of two residents sampled for missing items. The facility did not ensure a hearing evaluation was completed and followed-up on according to the agreed upon grievance resolution, for Resident #33 related to a missing hearing aid. Findings included: An interview on 10/20/21 at 8:57 a.m. with Resident #33's Power of Attorney (POA) revealed concerns related to missing personal items. The POA stated Resident #33 required hearing aids. Upon admission, Resident #33 had the left hearing aid in, and the right hearing aid was in a bag with extra batteries. The POA gave the bag with the right hearing aid and extra hearing aid batteries to the admitting nurse. Once he reported the missing right hearing aid, the facility stated they would file a grievance and submit a hearing evaluation but there has still not been a resolution to this grievance. As a result, the POA went ahead and ordered another hearing aid for Resident #33. An interview on 10/20/21 at 10:29 a.m. with Resident #33 revealed him to be alert and oriented. Resident #33 stated he has hearing problems and he . cannot really hear in the right ear . because his right hearing aid is missing, so, he is currently only wearing the left one. Resident #33's Admission Record revealed an original admitted [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #33's Medical Certification for Medicaid Long-Term Services and Patient Transfer Form, dated 08/25/21, revealed Resident #33 is hearing impaired and required a surrogate for decision making purposes. Resident #33's Admission Minimum Data Set, dated dated [DATE], revealed Resident #33 has adequate hearing using a hearing aid or other hearing application. A nursing narrative progress note, dated 08/27/21, revealed . Resident [POA] reports not being able to locate resident's hearing aids, which [POA] reports as being in his ears last night, with R [right] hearing aid being removed and placed in the plastic bag with extra batteries, this writer searched room, unable to locate, unable to verify hearing aids existence at this time. Reported to next staff nurse. A record review of the August 2021 Monthly Grievance Log revealed a grievance filed on 8/31/21 for Resident #33 related to missing items. The resolution revealed referred to H [hearing] aide on campus. The date complainant was notified was 09/07/21. A review of Resident #33's Complaint/Grievance Report, dated 8/31/21 revealed Resident #33's POA communicated a verbal concern to the Social Services Coordinator of . lost R [right] hearing aid + [plus] batteries in resident room. Bag is missing. Resident came in with L [left] hearing aid in ear + R [hearing aid] + batteries in a [plastic bag]. The findings of the investigation revealed the hearing aid was not found and actions taken to resolve the grievance were to refer Resident #33 for a hearing evaluation. On 9/10/21 the grievance was signed as being resolved to the complainant's satisfaction. An interview with Staff D, Certified Nursing Assistant (CNA) on 10/21/21 at 9:27 a.m. revealed when a resident is admitted , an admission person completes an inventory log with what personal items the resident was admitted with. All items a resident has must be documented on the form, including how many hearing aids a resident has. So, admitting staff would document if the resident had one or two hearing aids on admission. Staff D, CNA stated Resident #33 has hearing problems and uses a hearing aid. Staff D stated Resident #33's POA assists with putting in the hearing aids in the morning. A record review of Resident #33's Checklist for CNA's to complete for each admission, dated 8/25/21, revealed complete resident belongings sheet . DIRECTIONS: Mark and list items brought for the personal use of the resident/patient. Please bring additional items to the Nurse's Station for proper handling. Under the section assistive devices revealed no information listed related to Resident #33's right or left hearing aid. An interview with the Social Services Coordinator (SSC) on 10/21/21 at 1:01 p.m. revealed the facility process for family/resident concerns is to complete a grievance form for proper concern follow-up. The grievance is assigned to the appropriate department, such as nursing or housekeeping. The grievance follow-up timeframe is usually about three days. A grievance is addressed right away, however; the resolution may take longer depending on the type of grievance, such as missing items. A grievance is considered resolved once it is to the satisfaction of the person who made the grievance. The SSC stated she was familiar with Resident #33's grievance filed on 8/31/21 related to a missing hearing aid. The SSC stated according to Resident #33's grievance, the facility searched for the missing hearing aid but could not locate it. Resident #33 was referred to a hearing clinic and should have been seen on 09/10/21. This evaluation would have been completed in the facility. The SSC reviewed Resident #33's online medical chart but was unable to locate the hearing evaluation. The SSC stated she would review Resident #33's hard medical chart for the hearing evaluation and if unable to find it, she would contact the hearing clinic provider to get the record. The SSC stated Resident #33 was sent to the hospital around 9/10/21 but . regardless of that he should have been seen for a hearing evaluation and the grievance followed-up with. A follow-up interview on 10/21/21 at 2:18 p.m. with the SSC revealed she followed up with the provider who conducts the hearing evaluations. The provider stated he arrived at the building on 9/10/21, however, during that time the facility was having a COVID-19 outbreak and therefore appropriate hearing evaluations could not be done due to the personal protective equipment requirements. So, he did not complete Resident # 33's, or the other resident on schedule that day, hearing evaluation on 9/10/21. The SSC stated the expectation is that someone would have notified her that Resident #33 did not have a hearing evaluation completed on 9/10/21 so another hearing appointment could be set up and the evaluation submitted to the Nursing Home Administrator (NHA) for appropriate grievance resolution. An interview on 10/21/21 at 3:00 p.m. with the NHA revealed herself and the SSC meet weekly to discuss grievances and resolve them as timely as possible. Some grievances may take longer to resolve depending on their nature. The NHA stated she was familiar with Resident #33's grievance related to a missing hearing aid. She was under the impression, that the facility was just waiting for the hearing evaluation to be completed for Resident #33 for the grievance resolution. The NHA confirmed the expectation was that if Resident #33 was not seen for his hearing evaluation appointment on 9/10/21, a follow-up appointment would have been made. A policy review of the Grievance Procedure, not dated, revealed A resident, his/her representative, family member, visitor or advocate may file a verbal or written comment, grievance or complaint concerning resident rights, treatment, abuse, neglect, harassment, medical care, behavior or other residents, theft of property, etc. without fear of treat or reprisal in any manner. Such grievance or complaint may be made anonymously . The Administrator, the Provider's Grievance Official, will review the Grievance/Complaint Form or verbal Grievance/Complaint and will Forward to the respective department for investigation and the initiation of the corrective action, as necessary . Generally, within seven (7) working days, the Grievance Official or designee will contact you and will inform you of the outcome of the Grievance/Complaint . Should you disagree with the findings, recommendations, or actions taken, you may meet with the Administrator or designee or contact one of the Resident Advocacy Organization listed below .

Based on observation, interview and medical record review the facility failed to ensure that their licensed nurses performed comprehensive skin assessments on admission in a timely manner for two (#1 and 6) out of three residents sampled for pressure ulcers as evidenced by omitted admission data collection as standards of practice indicates. And lack of documentation of wound care for Res #1 Findings Included: On 1/18/2020 a phone interview was conducted with Resident #1's family member. He stated, I spoke to the Director of Nursing on 8/20/2020. She said my mother had a small sore on her sacrum. The family member said that the director told him it was a stage 2 or 3. The family member stated, I knew she was downplaying when I spoke with her. It wasn't assessed or treated appropriately. A review of the Nursing Readmission Data Collection assessment dated [DATE], indicated that Resident #1 had been readmitted with an unstageable decubitus ulcer to her sacrum. (Unstageable - Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.) The narrative note on the assessment stated, Resident has a unstageable decubitus ulcer to sacrum area was clean with NS (normal saline) and packed with soaked gauze with dry dressing. No measurements of the wound were found in the Data Collection assessment. A review of the Weekly Wound Data Collection Flow Sheet dated 8/17/2020, revealed the sacrum wound measured as follows, length 5 cm, width 5 cm, depth 3 cm, and undermining of 2.5 cm from 6 to 12 o'clock. The decubitus ulcer was not measured until three days after admission to the facility. Physician orders, dated 8/17/2020, read as follows, Clean sacral area with normal saline (N/S), cover with Allevyn daily ever day shift for wound care. A second physician order [REDACTED]. The Treatment Administration Record (TAR) for Resident #1 was reviewed that included a treatment order with a start date of 8/17/2020. No documentation was in place that indicated wound care had been provided. The second physician's orders [REDACTED]. The TAR indicated that on 8/19/2020, wound care had been provided to Resident #1 sacral area. The TAR also revealed that 8/19/2020 had been the first time since the resident was admitted on [DATE], that care and services had been provided to the sacral area. On 1/8/2021 at approximately 2:45 p.m., the Director of Nursing (DON) was asked about Resident #1 and the facility's process for admission data specific to skin. The DON said that their process was to assess the skin on admission and on the shift that the resident came into the facility. She was asked who was responsible for measuring the wound on admission. She stated, Only the Registered Nurse (RN) or Unit Manager (UM) can measure the wound. She was informed that the Readmission Data Collection assessment had no wound measurements. The DON was asked if she was able to assist in locating documentation. The DON stated, If it's not there then it wasn't done. The DON was also informed that the documentation on the TAR indicated that the first time treatment had been provided to Resident #1's sacral area was five days after she was admitted . The DON said, if it's not documented it's not done. 2. On 1/8/2021 at 2:24 p.m., Resident #6 was observed to be in bed. The head of bed was at approximately 70 degrees. The over bed table was across the bed and the resident was actively watching television. She had bed covers up to her mid torso and appeared comfortable. She was not able to answer simple questions. Medical record review was conducted for Resident #6 that revealed on the Admission Record form she had been readmitted to the facility on [DATE]. The Nursing Readmission Data Collection form dated on 12/21/2020 was reviewed and indicated under section, Skin Conditions pressure ulcer to the left. Description: left inner ankle dressing to area. Further medical review of resident #6 revealed Weekly Wound Data Collection Flow Sheet dated on 12/24/2020, three days after admission, revealed left heel type: Pressure: length 3 cm, width 3.5 cm. depth 0, stage: unstageable. At 3:14 p.m., an interview was conducted with the DON about the admission documentation and omission of measurements related to Resident #6's left heel wound. The DON indicated at that time, only RNs look at the wound. When asked when an assessment was supposed to be completed, the DON stated, The same shift that they come in. The DON went on to say that the Licensed Practical Nurses (LPN) can look at the wound but will only identify that there is a wound. The DON then stated, I am thinking that we are going to have to change our procedure. The DON was asked if any paper forms were used other than the assessment information in the computer. She stated, Only in the computer system, we do not use paper. If you did not find it, it is not there. The facility provided a copy of their policy titled Prevention of Pressure Ulcers/Injuries that was dated on July 2017. Purpose: This purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risks factors and interventions for specific risk factors. Risk Assessment: 1. Assess the resident on admission (within eight hours) for existing pressure ulcer/injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. Pressure Ulcer Staging: Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Stage III - Full thickness skin loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining/tunneling. https://www.hopkinsmedicine.org/gec/series/wound_care.html Wound Assessment Wound assessment includes location, class/stage, size, base tissues, exudates, odor, edge/perimeter, pain and an evaluation for infection. https://www.hopkinsmedicine.org/gec/series/wound_care.html. Wound Documentation Dos & Don'ts: 10 Tips for Success Scope of Practice and Standards of Practice guide nurses 1 and other members of the interprofessional wound care team 2 in caring for patients with wounds. Documentation in the medical record is a key aspect of the standard of practice and serves to record the care delivered to the patient or resident. Your documentation should follow your facility guideline for documentation. Accurate documentation helps to improve patient safety, outcomes, and quality of care. 3,4. Wound Documentation Tip #1: Visual Inspection Do describe what you see: type of wound, location, size, stage or depth, color, tissue type, exudate, [DIAGNOSES REDACTED], condition of peri-wound. https://www.woundsource.com/blog/wound-documentation-dos-don-ts-10-tips-success