Based on observation, record review, and interview, the facility failed to ensure that before a resident was allowed to self-administer updraft treatments, the Interdisciplinary Team (IDT) conducted an assessment to determine if this practice was safe, obtain a physician order for self-administration, and develop a care plan to address educating the resident on self-administration, to prevent potential errors in administration for 1 (Resident #64) sampled resident. The findings are: Review of a quarterly Minimum Data Set with an Assessment Reference Date of 05/01/2024 revealed Resident #64 scored 00 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status. Review of Resident #64's Care Plan did not reference the resident self-administrating medication. On 05/07/2024 at 8:01 AM, Resident #64's was observed lying in bed. A nebulizer treatment was running with the mask not secured to the resident's face, and no nurse present in the room. The surveyor went to the hallway and asked Registered Nurse (RN) #1 to come to Resident #64's bedside. Upon entry to Resident #64's room and seeing the nebulizer, she stated, I didn't put that on [Resident #64], but it's not good. When asked, Do you know how long Resident #64 has had the nebulizer running with the face mask off? She stated, No, it must've been this morning's dose, they increased it, but I'd say it's been since [6:00 AM] in the morning or so. I'd have to look at the documentation. When asked, Does Resident #64 have a self-administration order? She stated, No, [the resident] does not, [he/she] has to be watched. On 05/07/2027 at 8:06 AM, the Surveyor interviewed the Director of Nursing (DON) and asked, Can you tell me what you observe? He stated, Resident #64 with [his/her] nebulizer mask not on [Resident #64's] face, it's hanging off. When asked, Do you know how long Resident #64 has had the nebulizer running with the mask off? He stated, No. When asked, Does Resident #64 have a self-administration order? He stated, No. When asked, Should the resident be left unattended to self-administer medications?, he stated, No. On 05/07/2027 at 8:08 AM, the Surveyor interviewed the Assistant Director of Nursing (ADON) and asked, Can you tell me what you observe? She stated, Resident #64's been left with nebulizer on face, and I don't know how long it's been unattended. When asked, Does resident #64 have a self-administration order?, she stated, I don't think so. When asked, Should the resident be left unattended to self-administer medications?, she stated, No. The facility provided a policy titled, Self-Administration of Medications with a revision date of December 2016 that documented, Policy Statement: Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. 2. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, including (but not limited to) the resident's: a. Ability to read and understand medication labels; b. Comprehension of the purpose and proper dosage and administration time for his or her medications; c. Ability to remove medications from a container and to ingest and swallow (or otherwise administer) the medication; and d. Ability to recognize risks and major adverse consequences of his or her medications. 3. If the team determine that a resident cannot safely self-administer medications, the nursing staff will administer the resident's medications . The facility provided a policy titled, Administering Medications with a revision date of April 2019 that documented, Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation .27. Residents may self-administer their own medications only if the Attending Physician, in conjunction with their Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a Minimum Data Set (MDS) was accurately coded to indicate the presence of a Percutaneous Endoscopic Gastrostomy (PEG) tube for 1 (Resident #57) out of 1 sampled resident. The findings are: 1. Review of an Order Summary revealed Resident #57 had diagnoses of gastrostomy status and dysphagia following cerebral infraction. 2. Review of a quarterly MDS with an Assessment Reference Date of 04/24/2024 revealed Resident #57 scored a 5 (0-7 indicates severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). Section K indicated, Feeding Tube (e.g., nasogastric, or abdominal PEG) .No had been on 04/24/2024 at 5:58 AM. 3. On 05/08/2024 at 11:25 AM, the Surveyor interviewed the MDS Coordinator, and asked them to check section K in the most recent MDS, dated [DATE], and identify if Resident #57 was coded for a PEG tube. The MDS Coordinator stated, Resident #57 has a peg tube, and it's marked no. Should have been marked yes. The MDS Coordinator said it was important to have an accurate MDS to provide the correct plan of care. Review of the facility policy Certifying Accuracy of the Resident Assessment revealed, All personnel who completes any portion of the Resident Assessment (MDS) must sign and certify the accuracy of that portion of the assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the comprehensive care plan was individualized to addressed appropriate care and services for use of oxygen for 01 (Resident #54) of 01 sampled residents. The findings are: Review of a Face Sheet revealed Resident #54 was admitted to the facility on [DATE] with a diagnosis of dyspnea. Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/15/2024 reveled a score of 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). On 05/05/2024 at 10:50 AM, the Surveyor observed a lab technician currently in Resident #54's room conducting a chest x-ray. On 05/05/24 at 11:07 AM, the Surveyor interviewed Resident #54 and asked, Do you know why you just had a chest x-ray? Resident #54 stated, They did the x-ray because I can't breathe. Resident #54 is observed to be receiving 2.5-3.0 liters of oxygen via nasal cannula. On 05/07/24 at 01:36 PM, the Surveyor observed Resident #54 on 2 liters of oxygen via nasal cannula. Review of Physician Orders revealed an order dated 05/05/2024, .Oxygen as needed for Shortness of Breath 2 liters/min per nasal cannula (As needed) PRN . Review of a Care plan for Resident #54 which was revised on 05/06/2024 did not reveal an indication the resident was receiving oxygen. On 05/07/2024 at 10:32 AM, the Surveyor interviewed the Minimum Data Set (MDS) Coordinator and asked, Should Resident #54's care plan document oxygen use? She stated, Yes. When asked, Why should it document oxygen use?, she stated, So it is accurate, is placed on the care plan, and staff know [the resident] uses oxygen. On 05/07/2024 at 03:05 PM, the Surveyor interviewed the Director of Nursing (DON) and asked, Should Resident #54's care plan document oxygen use? He stated, Yes. When asked, Why should it document oxygen use?, he stated, That way all the staff know. Review of a facility policy titled, Care Planning- Interdisciplinary Team, revision date of September 2013, revealed, Policy Statement: Our facility's Care Planning/ Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident.

Based on observation, record review, and interview, the facility failed to ensure residents' fingernails were kept clean for 01 (Residents #08) of 01 sample mix residents; that residents were showered on scheduled shower days for 01 (Resident #81) of 01 sample mix resident; and that male residents were shaved to promote good personal hygiene for 02 (Resident R #81, #08) of 02 sample mix resident. The findings are: 1. Review of a Care Plan for Resident #81 dated 12/28/2023 revealed, .The resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) dementia, debility, weakness, UTI (urinary tract infection) . Personal Hygiene/ Oral Care: The resident is able to: set up assist .Bathing/ Showering: The resident is able to: set-up assist . a. Review of a Facility In-service dated 01/29/2024 revealed, Medicare residents' showers MUST be done on their scheduled day. If a Medicare resident refuses, notify your nurse as you would with the LTC (Lont Term Care) resident. If a Medicare resident is in with therapy, work around therapy's schedule. Any issues or questions, come see me . b. Review of Resident #81's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/01/2024 revealed, .GG0130. Self-Care . E. Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower. Supervision or touching assistance . I. Personal hygiene: The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face, and hands (excludes baths, showers, and oral hygiene). Supervision or touching assistance . c. Review of document titled ADL Bathing Task revealed that for 30 days, 04/09/2024 through 05/02/2024, Resident #81 received a shower/bath on 04/09/2024; 04/16/2024; 04/25/2024; and 05/02/2024 with a documented refusal on 04/23/2024. Resident #82 did not receive a shower on schedule days 04/11/2024; 04/13/2024; 04/18/2024; 04/20/2024; 04/27/2024; 04/30/2024; 05/04/2024. As of the time of receipt of this document, 10:07 AM, Resident #81 was not yet bathed today, 05/07/2024. d. On 05/05/2024 at 10:50 AM, the Surveyor observed Resident #81 lying in bed. The resident appeared unshaven. e. On 05/06/2024 at 08:44 AM, the Surveyor observed Resident #81 sitting up on side of bed. The resident appeared unshaved. f. On 05/06/2024 at 08:56 AM, the Surveyor interviewed Resident #81 and asked, Do you prefer to be unshaven with hair on your face? The resident stated, I would like the hair off of my face. g. On 05/07/2024 at 10:04 AM, the Surveyor interviewed Registered Nurse (RN) #01 at Resident #81's bedside and asked, Does Resident #81 appear well groomed? She stated, No. When asked, Does Resident #81 appear to need to be shaved? She stated, Yes. When asked, Can you tell me why Resident #81 should be clean shaved? She stated, Preferences and good grooming. When asked, When was the residents last bath/ shower? She stated, Last bath was on [05/02/2024]. When asked, Should the resident be shaved on shower days and as needed? She stated, Yes. h. On 05/08/2024 at 09:25 AM, the Surveyor interviewed the Director of Nursing (DON) and asked, Should the Resident #81 be bathed/ showered on the scheduled shower day? He stated, Yes, all residents be showered on their scheduled day. When asked, How often should Resident #81 be shaved? He stated, On shower days and as needed. 2. Review of the Order Summary indicated that Resident #8 had diagnoses of cerebral infarction and hemiplegia on left non dominant side. a. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/05/2024 indicated that Resident #8 scored a 14 (13-15 indicates cognitively intact) on the Brief Interview Mental Status (BIMS). b. Review of the Care Plan for Resident #8 revealed, Focus: the resident has an ADL self-care deficit, Goal: the resident will improve current level of function in ADLs through the review date, Interventions: Bathing/Showering: extensive assist X1, resident prefers shower. c. On 05/05/24 at 12:30 PM Surveyor observed that Resident #8's fingernails were an inch past the nail bed. The surveyor observed the nails were jagged, yellowing, and had a brown substance underneath them. The surveyor also observed that Resident #8 had not been shaved. Resident #8 stated they wanted their nails cleaned and trimmed and had asked staff for something to clean them with. Resident #8 then stated I would like to be shaved as well. d. On 05/06/2024 at 9:00 AM, the surveyor observed that Resident #8 had not been shaved or had nail care performed. e. On 05/07/2024 at 1:48 PM, the surveyor asked Certified Nursing Assistant (CNA) #4 to described Resident #8's nails. CNA #4 stated they are dirty and long. Surveyor asked if they needed to be trimmed and when should the task be done. CNA #4 said confirmed they did, and it should be done every time they get a shower. The surveyor asked what could happen with the resident having long nails. CNA #4 said could cause infection. The surveyor asked CNA #4 to look at Resident #8's face. CNA #4 said the Resident needs shaved. The surveyor asked what could be the issue for a Resident to not have their face shaved regularly. CNA #4 said dignity. f. On 05/07/2024 at 1:51 PM, the surveyor asked Licensed Practical Nurse (LPN) #1 to described Resident #8's nails. LPN #1 said they are long and need trimmed. The surveyor asked what could happen with the resident having long nails. LPN #1 said scratches. The surveyor asked for LPN #1 to look at Resident #8's face. LPN#1 said that they need shaved. g. A review of the facility policy Activities of Daily Living (ADLs), Supporting states Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, record review, interviews, and facility policy review, the facility failed to provide a meaningful program of activities for twelve residents reviewed for activities. Specifically, the facility failed to ensure the activity program was designed to meet the individual activity needs, interests, and abilities for Residents who reside on the secure unit, and the facility failed to ensure that activities were provided on the weekend for all 97 residents in the facility. The findings are: On 05/05/2024 at 11:20 AM, the surveyor identified that there were no activities being provided on the secure unit. A jigsaw puzzle was observed on the table. No residents were observed to attempt the puzzle. On 05/06/2024 at 2:30 PM, during the resident council meeting 6 members of the council reported that no activities are being held on the weekends. They reported that occasionally a CNA (Certified Nursing Assistant) will put-in a movie or games will be left in the dining room, but no structured activities are held. On 05/07/2024 at 2:07 PM, the surveyor observed no activities taking place on the secure unit. On 05/08/2024 at 11:00 AM, the Activity Director (AD) was asked to address the provision of activities on the secure unit. The AD described how the Unit Coordinator is typically responsible, however she is not working this week and it is virtually impossible to do both. The AD reported that in March of this year the previous AD and her assistant both quit on the same day. The AD reports that the Administrator is aware of the situation however there is nothing in place right now, but they are attempting to hire someone. When asked about weekend activities the AD described how she frequently comes in on Saturday to play bingo but that isn't something she can do all the time. When asked if anyone from the nursing staff was assigned to assist with activities on the weekend AD replied, Not at this time. On 05/08/2024 at 11:00 AM, the surveyor observed no activities being provided on the secure unit. CNA #4 was asked if an activity had been completed this morning. CNA #4 reported that the activity director came and turned on some gospel music. CNA #4 was asked how often someone from the activity department comes to the secure unit to complete an activity. CNA #4 reported, Usually never. CNA #4 continued to describe how the Unit Coordinator tries to have activities when working, however she is on vacation. CNA #4 reported no activities are usually held on the weekend. Review of a Policy titled, Preparation for Activities indicated the Activity Director/Coordinator is responsible for the scheduling of activity functions and programs, and that activity programs are coordinated with Nursing, Therapy, Dietary and Housekeeping Services, as well as any special services such as dialysis and outside appointment by individuals.

Based on observation, interview, and record review, the facility failed to ensure that smokeless tobacco was kept at the nurses station to prevent accidents for 2 (Resident #45 and Resident #67) out of 2 sampled residents and failed to ensure that a fall mat was well maintained for 1 (Resident #20) of 1 sampled residents. The findings are: 1. A review of the annual Minimum Data Set (MDS) with an Assessment reference Date (ARD) of 04/17/2024 revealed Resident #45 scored a 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). a. A review of the Care Plan for Resident #45 revealed, Focus: The Resident uses smokeless tobacco, Goal: The Resident will not use smokeless tobacco without supervision through the review date, Interventions: Instruct the resident about the facility policy on smoking: locations, times, safety concerns. b. On 05/05/2024 at 11:40 AM, the surveyor observed Resident #45 sitting up in recliner, on the bedside table over Resident #45's lap sat two plastic containers of wintergreen snuff. One of the plastic containers was missing a lid, with smokeless tobacco lining the inside of the container. The surveyor observed a brown liquid dripping down Resident #45's chin, a lump is observed on the right side bottom lip area. c. On 05/06/2024 at 9:30 AM, the surveyor observed that the smokeless tobacco is still sitting on the bedside table. The surveyor observed brown stains in the floor next to the bedside table. d. On 05/07/2024 at 8:45 AM, Certified Nursing Assistant (CNA) #1 said that they did not know if Resident #45 could have tobacco, and it had always there as long as they worked in the facility. The surveyor asked what could happen with the smokeless tobacco on the bedside table. CNA #1 stated that another resident could get into it. e. On 05/07/2024 at 8:50 AM, Licensed Practical Nurse (LPN) #1 stated that the smokeless tobacco has always been on [Resident #45's] table for the four years they had worked there. The surveyor asked what could happen with the smokeless tobacco on the bedside table. LPN #1 stated the resident could choke on it. f. A review of the Smoking Safety Screen and Care plan revealed that 1. Notes on Safety from IDTC (i.e. resources required to support resident, other resident safety, potential injury, capabilities): Resident is able to use smokeless tobacco under supervision of staff. Smokeless tobacco is stored in nurse's station. 2. Review of an admission Record revealed Resident #67 had diagnoses of urine retention and nicotine dependence. a. Review of a Care Plan initiated 01/23/2023 revealed, Resident will not use smokeless tobacco without supervision throughout review date . b. On 05/05/2024 at 11:00 AM, the surveyor observed Resident #67 sitting up at bedside with chewing tobacco in their mouth and dribbling from their mouth. A package of chewing tobacco was observed in the resident's left front shirt pocket, another on the bedside table, and multiple packs of chewing tobacco noted in drawer at bedside. c. On 05/06/2024 at 9:00 AM, the surveyor observed Resident #67 lying in bed with a package of chewing tobacco in front pocket. d. On 05/07/2024 at 8:10 AM, the surveyor observed Resident # 67 sitting up in bed with chewing tobacco dribbling from mouth and a package of chewing tobacco in their front shirt pocket. e. On 05/07/2024 at 8:30 AM, Registered Nurse (RN) #1 verified Resident #67 had smokeless tobacco in their mouth and in their pocket. RN #1 said that the family brings in chewing tobacco and that staff will take it to the nurse's station and store it. f. A facility policy provided by the Administrator in the Survey Readiness Book titled Smoking Policy-Residents with revision date of December 2007 stated .15. Smoking articles for residents without independent smoking privileges: Residents without independent smoking privileges may not have or keep any types of smoking articles, including cigarettes, tobacco, etc . Anyone who provides smoking supervision to residents shall be advised of any restrictions/concerns and the plan of care related to smoking. 3. Review of the Care Plan for Resident #20 dated 12/20/2023 revealed, .The resident is at risk for falls r/t (related to) impaired mobility, severely impaired cognition, ALZ (Alzheimer's)/dementia, incontinence, behaviors, AEB (as evidenced by) fall risk score, h/o (history of) falls, uses w/c (wheelchair) for mobility & lift for transfers. 2-1-21 unwitnessed fall; 6/7/22 Resident had unwitnessed fall with no injury; 8/25/23- unwitnessed fall with no injury Date Initiated: 12/20/2023 .fall mat at bedside . a. Review of the quarterly MDS with an ARD of 03/13/2024 revealed Resident #20 scored 03 (indicates severely impaired) on the Staff Assessment for Mental Status (SAMS). b. On 05/05/2024 at 10:34 AM, the surveyor observed Resident #20 lying in bed. A fall mat on the floor by the bed had a tear near the center, and a piece of the fall mat is missing from the side. c. On 05/06/2024 at 2:36 PM, the surveyor observed the fall mat by the bed of Resident #20 to have a tear near the center and a piece of the fall mat missing from the side. d. On 05/06/2024 at 2:37 PM, the surveyor interviewed Certified Nurse Aide (CNA) #5 at Resident #20's bedside and asked, Should the residents fall mat be torn and have a piece missing from the side? She stated, No, ma'am it shouldn't. When asked, Why should the fall mat be in proper working condition without tears and pieces missing from the side? She stated, Because it'll get where us or the resident can get caught on it and fall. e. On 05/06/2024 at 02:28 PM, the surveyor interviewed the Director of Nursing at Resident #20's bedside and asked, Should the residents fall mat be torn and have a piece missing from the side? He stated, No, ma'am it needs to not have any missing pieces or tears in case they fall that way it protects them from any injuries. f. The facility policy titled, Hazardous Areas, Devices and Equipment with a revision date of 2017 included, Policy Statement: All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. Policy Interpretation and Implementation 1. As part of the facility's overall safety and accident prevention program, hazardous areas and objects in the resident environment will be identified and addressed by the Safety Committee .Identification of Hazards: 1. A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include but are not limited to .Devices and equipment that are improperly used or poorly maintained .Assessment and Analysis of Hazards: 1. Assessment and analysis of hazardous areas and equipment will include resident-specific information including identification of vulnerable residents. 2. Any element of the resident environment that has the potential to cause injury and that is accessible to a vulnerable resident is considered hazardous .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to (1) ensure that residents receiving inhaled corticosteroids (an anti-inflammatory medication) were instructed to rinse their mouths to prevent irritation and infection for 1 (Resident #67) sampled resident, (2) ensure residents receive medications as ordered for 2 (Residents #57 and #79) sampled residents, (3) ensure that wound care was performed in a manner to prevent contamination and infection for 1 (Resident #19) sampled resident, and (4) ensure that residents were monitored and treated for urinary tract infections for 1 (Resident #22) sampled resident. The findings are: 1. Review of an admission Record revealed Resident #67 was re-admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease and chronic respiratory failure. a. Review of a 5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/10/2024 revealed Resident #67 scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). b. Review of a Physician's Order dated 08/28/2023 revealed, .[named brand] Inhalation Aerosol Powder Breath Activated 100-25 mcg/ACT (microgram/activation) (Fluticasone Furoate-Vilanterol) 1 puff inhale orally one time a day related to chronic obstructive pulmonary disease with (acute) exacerbation. Rinse/ spit after administration. a. On 05/07/2024 at 08:14 AM, during observation of medication administration for the 100 Hall with Registered Nurse (RN) #01, RN #1 did not have Resident #67 rinse mouth after receiving corticosteroid medication via inhaler, instead giving Resident #67 additional medications and had the resident swallow pills with water. b. On 05/07/2024 at 08:26 AM, the surveyor interviewed RN #01 and asked, Should Resident #67 have rinsed and spit after the use of the inhaler? She stated, Yes, I forgot. When asked, Why should Resident #67 rinse and spit after inhaler use? She stated, Because of the risk of thrush. c. Review of Manufacturer Guidelines for [named brand] (fluticasone furoate 100 mcg and vilanterol 25 mg inhalation power) that were received on 05/08/2024 at 11:49 AM revealed, .[named brand] can cause serious side effects, including: fungal infection in your mouth or throat (thrush). Rinse your mouth with water without swallowing after using [named brand] to help reduce your change of getting thrust . 2. Review of Physician's Orders for Resident #79 revealed diagnoses of osteoarthritis, dementia, and blepharitis (inflammation of the eyelids). a. Review of a quarterly MDS with an ARD of 05/01/2024 revealed that Resident #79 scored 0 (0-7 indicates severe cognitive impairment) on the BIMS. b. Review of Physician's Orders revealed an order dated 03/15/2024 that specified, .Hydrocodone-Acetaminophen Tablet 5-325 mg (milligram) Give 1 tablet by mouth two time a day related to Primary Osteoarthritis, Left Shoulder Hold Date from 05/06/2024 1237 to 05/07/2024 0800 .Order dated 04/27/2024 Lorazepam Oral Tablet 0.5 mg (Lorazepam) Give 0.5 mg by mouth two times a day related to Dementia Hold Date from 05/06/2024 1239 to 05/07/2024 0800 . [named brand] Ophthalmic Solution Instill 2 drops in both eyes four times a day for dry eyes . c. On 05/07/2024 at 08:31 AM, during observation of medication administration for the 100 Hall with RN #01, Resident #79 did not receive Hydrocodone-Acetaminophen and Lorazepam. Resident #79 was given one drop per eye of the ordered eye drops. d. Review of Resident #79's Medication Administration Record (MAR) revealed the resident did not receive Hydrocodone-Acetaminophen Tablet 5-325 mg or Lorazepam Oral Tablet 0.5 mg (Lorazepam). e. On 05/07/2024 at 10:04 AM, the surveyor interviewed RN #01 and asked, If a medication is on hold, but to be administered at 08:00 AM today, 05/07/2024 should the resident have receive it? She stated, Yes, it should be given. When asked, Why should it be given? She stated, Because it's following the order. When asked, If eye drops are not ordered at 0800 should they be administered? She stated, No. When asked, If the physician order documents two drops per eye should two drops be instilled? She stated, Yes. When asked, Why? She stated, So they are getting the required amount. 3. On 05/07/2024 at 09:16 AM, during observation of medication administration for 400 Hall with Licensed Practical Nurse (LPN) #01, Resident #57 did not receive Guaifenesin oral tablet that was ordered to be administered at 08:00 AM via Percutaneous Endoscopic Gastrostomy (PEG) (a tube is passed into the stomach through the abdominal wall to provide nutrition or medication) Purple colored syringe with no written date on the outside of the bag but had a stamped expiration date of 02/05/2024 was used to verify placement with ten milliliters (mL) of air. Sixty mL of water flush, medication mixed with water, 60 mL of flush followed after medication through tube. LPN #01 placed syringe tube back inside syringe without cleaning the syringe before putting it back in the storage bag and hung it back on the intravenous (IV) pole. a. On 05/07/2024 at 10:10 AM, the surveyor interviewed LPN #01 and asked, Should the PEG tube syringe have been cleaned and dried prior to you putting the plunger in the syringe and placing both in the storage bag? He stated, Probably. When asked, What is the date on the bag the PEG tube syringe is stored in? He stated, 02/05/2024 is the expiration date. When asked, How often should the syringe be changed? He stated, Supposed to be changed every night. a. On 05/08/2024 at 09:25 AM, the Surveyor interviewed the Director of Nursing (DON) and asked, If a resident has a physician order for Refresh Tears Ophthalmic Solution instill 02 drops in both eyes and is ordered for 0600; 1200; 1600; and 2000 be administered at 08:31 AM? He stated, No. When asked, Why should the eye drops not have been administered at that time? He stated, It wasn't the scheduled time. When asked, Where would the nurse sign off at that time? He stated, There is not a place. When asked, If the orders stated two drops per eye how many drops should be instilled in the residents eyes? He stated, Two. When asked, Why should two drops be instilled in the residents eyes? He stated, That's what the order says to do. When asked, If a resident uses a [named brand] inhaler should the nurse have the rinse their mouth after and administration and spit out the water? He stated, Yes. When asked, Why should they resident rinse and spit? He stated, To get the nasty taste out. When asked, How often should PEG tube syringed be changed? He stated, Every twenty four (24) hours. When asked, Why should they be changed every 24 hours? He stated, To prevent bacteria and stuff from harboring in the syringe. When asked, Should the PEG tube syringe be cleaned and dried after medication administration before replacing the syringe plunger back in the tube and placed both back in the storage bag? He stated, Yes. When asked, Why should it be cleaned and dried prior to putting the tube in the syringe and placing it back in the storage bag? He stated, That way it is clean and ready for the next scheduled use of it. b. Review of a 'Med Pass Observation Report' for RN #01 dated 04/12/2024 that revealed, .Observation: Ophthalmic administered properly (i.e. 3-5 minutes between drops): met . Inhalers properly administered (i.e. 1 min between puffs); mouthpiece cleaned . Medication administered per manufacturers specifications . Calculated Error Rate: Total # of errors: 0 x 100/ Total # of Doses Given: 3= 0% c. Review of a 'Med Pass Observation Report' for LPN #02 with no date revealed, .Observation: Medication via feeding tube properly administered (i.e. flushed with water before & after med) . Calculated Error Rate is not filled in. d. Review of a Policy titled, Enteral Tube Feeding via Syringe (Bolus) with a revision date of November 2018 that documented, General Guidelines 1. Use aseptic technique when preparing or administrating enteral feedings. 4. Review of Medical Diagnoses revealed Resident #19 had diagnoses of multiple sclerosis and pressure ulcer of sacral region, stage 4 (indicates full-thickness skin loss extends through the fascia with considerable tissue loss). a. Review of a quarterly MDS with an ARD of 03/11/24 revealed Resident #19 scored 15 (13-15 indicates intact cognition) on the BIMS. b. On 05/06/2024 at 10:09 AM, Licensed Practical Nurse [LPN] #2 was observed performing wound care. With assistance from another staff, the resident was rolled to right side and resident's brief was opened. Solid waste 2 inches by 4 inches was observed between resident's buttocks and soiled the bottom edge of bandage covering the wound. No barrier was placed under the soiled brief nor was incontinent care performed before performing wound care. c. On 05/06/2024 at 10:20 AM, when LPN #2 was finishing wound care, the edge of an abdominal pad was 1/4 inch away from the solid waste and secured with tape. A scant amount of solid waste was observed on the tapes edge closest to the solid waste. d. Review of the Physician's Order dated 04/25/2024 indicated, Cleanse stage 4 pressure ulcer to sacrum with wound cleanser, pat dry with gauze, moisten [named gauze and antimicrobial solution], pack into wound loosely, cover with abdominal pad, secure with paper tape daily and as needed. e. On 05/06/2024 at 10:30 AM, the surveyor asked LPN #2, Is there anything you would have done differently? LPN #2 said I would have gone ahead and let the aides [CNAs - Certified Nursing Assistants] clean and change Resident #19's incontinent brief before I did treatment. I didn't want to change the brief because I haven't done that for a long time and could only remember, clean front to back, but that is about it honestly. The surveyor asked what could be a negative outcome of leaving solid waste in brief while performing treatment. LPN #2 said, The potential for cross contamination. 5. Review of the Order Summary indicated that Resident #22 had diagnoses of Alzheimer's disease and urinary tract infection. a. Review of the Order Summary indicated that Resident #22 had a telephone order for UA (urinary analysis) w/reflex to Culture (STAT (immediately) Eligible) on 04/26/2024. b. Review of the Lab Results that was received on 04/26/2024 and reviewed on 04/30/2024 indicated that Resident #22 had brown, cloudy urine that contained excess bacteria and mucus. c. Review of the MAR for May indicated that Resident #22 received Ceftriaxone Sodium Solution Reconstituted 1 GM Use 1 gram intravenously one time only for UTI for 1 Day was administered on 05/01/24 at 2:40 PM. (This medication is an antibiotic.) d. Review of the Care plan for Resident #22 specified, Focus: resident has an ADL (activities of daily living) self-care deficit, Goal: the resident will improve current level of function in ADLs through the review date, Interventions: Personal Hygiene: the resident requires 1 assist by 1 staff with personal hygiene, Toileting: the resident requires extensive assist of 2 staff for toileting. e. Review of the Quarterly Minimum Data Set (MDS with an Assessment Reference Date of 03/29/24 indicated that Resident #22 received a score of 0 (severe cognitive impairment) on the BIMS. Section H indicated that Resident #22 is always incontinent of bowel and bladder. f. On 05/07/2024 at 8:45 AM, the surveyor asked CNA #1 if Resident #22 is exhibiting symptoms of a urinary tract infection (UTI). CNA #1 responded, I first reported it two weeks ago, when giving a shower the resident had a puddle of pee in the floor. It was bloody, brown in color and the odor was fishy. The surveyor asked if they had any symptoms more recent than two weeks ago. CNA #1 said, Yes, we have reported it to the nurse. The surveyor asked what could happen to the resident with continued symptoms. CNA #1 said, Well she can go septic. g. On 05/07/2024 at 8:50 AM, the surveyor asked Licensed Practical Nurse (LPN) #1 to look at Resident #22's UA (Urinalysis) lab results. LPN #1 read off the results and stated that the resident received a one-time Rocephin shot. The surveyor asked if Resident #22 had any orders or reported symptoms since then. LPN #1 said, No. The Surveyor asked what could happen if resident does have continued symptoms. LPN #1 said the resident could go septic, and that they should have followed up on Resident #22. h. On 05/07/2024 at 9:20 AM, the surveyor asked the Director of Nursing (DON) the protocol for lab work. DON stated, We use [named laboratory], the results are reviewed by the APN (advanced practice nurse) who reviews and adjust orders as needed. i. On 05/07/2024 at 10:48 AM, the surveyor asked the APN, What is the protocol for ordering a resident a Rocephin injection for a UTI. The APN stated, Monitor the site they give it in When asked, Is the residents urine retested to verify the injection was effective. The APN stated, No, we do not retest urine. j. On 05/07/2024 at 1:30 PM, the surveyor asked CNA #2 if they had reported symptoms of a continued UTI for Resident #22. CNA #2 stated that they overheard a CNA report it to LPN #1 on Sunday when surveyors entered the building around lunch. k. On 05/07/2024 at 1:53 PM, CNA #2 approached the surveyor stating that CNA #3 wanted to have a phone interview. The surveyor went into the shower room on 100 Hall with CNA #2 who called CNA #3. The surveyor asked when CNA #3 last worked. CNA #3 stated, I work Thursday, Friday, Saturday, and Sunday. The surveyor asked what happened with Resident #22. CNA #3 stated that about two weeks ago she reported that Resident #22 was still bleeding to LPN #1, who told them that the UA had not been reported. CNA #3 continued stating they reported the symptoms again and was told the resident was on an antibiotic a few days later. CNA #3 stated they reported the same symptoms again last weekend, and that LPN #1 made the CNA feel brushed off about it. After the phone interview CNA #2 said that the last time they had Resident #22 in the shower, they had urine in the floor. The surveyor asked CNA #2 to describe what the urine looked like. CNA #2 said the urine was blood tinged, with a foul odor, and it had lumps that looked like clots. CNA #2 stated they only wanted what was best for Resident #22. l. Review of Progress Notes, revealed an entry dated 05/07/2024 at 2:54 PM and authored that LPN #4 that documented, CNA at 1430 (2:30 PM) reported resident has blood in urine in AM shower, was with CNA when they changed .brief at 1430 scant amount of blood noted in brief, no foul odor noted, u/a with c/s performed resident tolerated well. Another progress note indicated, : IN/OUT catheter performed using sterile technique. Urine noted to be blood tinged. No foul odor noted. UA obtained and sent to WRMC. Resident tolerated procedure well. Signed by the ADON (Assistant Director of Nursing) on 05/07/2024 at 1:30 PM. Another progress note indicated, Received preliminary result from u/a, contacted DON and APRN (advanced practice registered nurse) and received orders from APRN to start [cranberry] tabs 2 tabs TID (three times a day) x 2 days until culture grows out on specimen. signed by LPN #4 on 05/07/2024 at 2:54 PM. Another progress note states Ertapenem Sodium Solution Reconstituted 1 GM Inject 1 gram intramuscularly every 24 hours for infection for 10 Days signed by LPN #3 on 05/08/2024 at 11:39 AM. m. Review of the Order Summary indicated new orders for Resident #22 on 05/07/2024 that indicated Cath UA with c/s r/t blood in urine and Azo Tabs Oral Tablet (Phenazopyridine HCl) Give 2 tablet by mouth three times a day related to UTI. An order on 05/08/24 states Ertapenem Sodium Solution Reconstituted 1 GM Inject 1 gram intramuscularly every 24 hours for infection for 10 Days.

Based on observation, record review, and interview, the facility failed to ensure all pharmaceuticals were available for, and provided to, residents during medication administration for 2 (Residents #79 and #57) sampled residents. The finding are: 1. Review of Physician Orders for Resident #79 revealed an order dated 03/15/2024 that indicated, .Hydrocodone-Acetaminophen Tablet 5-325 mg (milligram) Give 1 tablet by mouth two time a day related to Primary Osteoarthritis, Left Shoulder Hold Date from 05/06/2024 1237 to 05/07/2024 at 8:00 AM Another order dated 04/27/2024 indicated, Lorazepam Oral Tablet 0.5 mg (Lorazepam) Give 0.5 mg by mouth two times a day related to Dementia Hold Date from 05/06/2024 at 12:39 PM to 05/07/2024 at 8:00 AM . a. On 05/07/2024 at 08:31 AM, during observation of medication administration for the 100 Hall with Registered Nurse (RN) #01, Resident #79 did not receive Hydrocodone- Acetaminophen and Lorazepam. b. On 05/07/2024 at 09:47 AM, the Surveyor interviewed RN #01 and asked, Should Resident #79 have received Hydrocodone-Acetaminophen and Lorazepam during the 08:00 AM medication pass? She stated, No, it's been on hold. c. On 05/07/2024 at 6:44 PM, a review of Resident #79's Medication Administration Record (MAR) revealed the resident did not receive Hydrocodone-Acetaminophen Tablet 5-325 mg or Lorazepam Oral Tablet 0.5 mg (Lorazepam). 2. Review of Physician Orders for Resident #57 revealed an order dated 01/08/2024 that indicated, .Guaifenesin Oral Tablet 400 (Guaifenesin) Give 400 mg (milligram) via PEG (percutaneous endoscopic gastrostomy) tube two times a day for cough . New order placed at 10:40 AM, after medication pass, documented, Guaifenesin ER Tablet Extended Release 12 Hour 600 mg Give 1 tablet by mouth every 12 hours as needed for cough/ congestion . a. On 05/07/2024 at 09:16 AM, during observation of medication administration for 400 Hall with Licensed Practical Nurse (LPN) #01, Resident #57 did not receive Guaifenesin oral tablet. b. On 05/07/2024 at 09:16 AM, LPN #02 stated, We only have the 600 mg Mucinex, but the APRN is here today, so I'll get her to change it. c. Review of a Progress Note dated 05/07/2024 at 09:49 AM revealed, Guaifenesin oral tablet 400 mg .Give mg via PEG-Tube two times a day for cough order to be clarified. d. Review of Physician Orders for Resident #57 revealed an order dated 05/07/2024 at 10:40 AM that specified, guaifenesin oral tablet 400 mg (Guaifenesin) Give mg via PEG-Tube two times a day for cough discontinue. e. Resident #57's MAR was reviewed on 05/07/2024 at 5:54 PM and indicated the resident did not receive the first ordered dose of Guaifenesin Oral Tablet 400 mg on 05/07/2024. f. On 05/08/2024 at 09:25 AM, the surveyor interviewed the Director of Nursing (DON) and asked, If a resident has a medication placed on hold until 05/07/2024 at 08:00 AM should it be administered on 05/07/2024 at 08:00 AM? He stated, Yes. When asked, Why should it be administered at that time? He stated, Because that is what the order says. When asked, If a resident has a physician order for Mucinex 400 mg due at 08:00 AM, should the facility have Mucinex 400 mg to administer? He stated, Yes. When asked, Should the LPN go to the Advanced Practice Registered Nurse (APRN) after the medication was due and not found to have the correct dosage and have the APRN change the order? He stated, No, that should not happen. g. Review of a Policy titled Administering Medications with a revision date on 2019 that indicated, Policy Statement: Medications are administered in a safe and timely manner, and as prescribed .Medications are administered in accordance with prescriber orders, including any required time frames .

Based on observation, interview, and record review, the facility failed to ensure physician orders were followed to maintain a medication rate of less than 5% to prevent complications for 02 (Resident # 79, #57) of 03 residents observed during medication pass resulting in medication errors. Six errors were identified in 27 opportunities resulting in a medication error rate of 22.22%. The findings are: 1. Review of a Physician's Order for Resident #67 dated 08/28/2023 revealed, .[named brand] Inhalation Aerosol Powder Breath Activated 100-25 mcg/ACT (microgram/activation) (Fluticasone Furoate-Vilanterol) 1 puff inhale orally one time a day related to chronic obstructive pulmonary disease with (acute) exacerbation. Rinse/ spit after administration. (This is a combination medication for the treatment of chronic obstructive pulmonary disease and asthma. It contains fluticasone furoate, an inhaled corticosteroid.) a. On 05/07/2024 at 08:14 AM, during observation of medication administration for the 100 Hall with Registered Nurse (RN) #01, RN #01 did not have Resident #67 rinse their mouth after receiving this medication via inhaler, instead giving Resident #67 additional medications and had them swallow pills with water. b. On 05/07/2024 at 08:26 AM, the Surveyor interviewed RN #01 and asked, Should Resident #67 have rinsed and spit after the use of the inhaler? She stated, Yes, I forgot. When asked, Why should Resident #67 rinse and spit after inhaler use? She stated, Because of the risk of thrush. (Thrush is a fungal (yeast) infection that can grow in your mouth, throat, and other parts of your body.) 2. Review of a Physician's Order for Resident #79 dated 03/15/2024 documented, .Hydrocodone-Acetaminophen Tablet 5-325 mg (milligram) Give 1 tablet by mouth two time a day related to Primary Osteoarthritis, Left Shoulder Hold Date from 05/06/2024 at 12:37 PM to 05/07/2024 at 8:00 AM .Order dated 04/27/2024 Lorazepam Oral Tablet 0.5 mg (Lorazepam) Give 0.5 mg by mouth two times a day related to Dementia Hold Date from 05/06/2024 1239 to 05/07/2024 0800 . Refresh Tears Ophthalmic Solution . Instill 2 drops in both eyes four times a day for dry eyes . a. On 05/07/2024 at 08:31 AM, during observation of medication administration for the 100 Hall with Registered Nurse (RN) #01, Resident #79 did not receive Hydrocodone-Acetaminophen, and Lorazepam. Resident #79 was given one (01) drop per eye of the physician order eye drops. b. Review of Resident #79's Medication Administration Record (MAR) revealed the resident did not receive Hydrocodone-Acetaminophen Tablet 5-325 mg or Lorazepam Oral Tablet 0.5 mg (Lorazepam). The MAR also documented Refresh Tears Ophthalmic Solution .Instill 2 drops in both eyes four times a day for dry eyes administration times: 0600; 1200; 1600; 2000. c. On 05/07/2024 at 10:04 AM, the Surveyor interviewed RN #01 and asked, If a medication is on hold, but to be administered at 08:00 AM today, 05/07/2024, should the resident have receive it? She stated, Yes, it should be given. When asked, Why should it be given? She stated, Because it's following the order. When asked, If eye drops are not ordered at 0800 should they be administered? She stated, No. When asked, If the physician order documents 02 drops per eye should 02 drops be instilled? She stated, Yes. When asked, Why? She stated, So they are getting the required amount. 3. Review of a Physician's Order for Resident #57 dated 01/08/2024 revealed, .Guaifenesin Oral Tablet 400 .Give 400 mg via PEG (percutaneous endoscopic gastrostomy) tube two times a day for cough .New order placed at 10:40 AM, after medication pass, documented, Guaifenesin ER Tablet Extended Release 12 Hour 600 mg Give 1 tablet by mouth every 12 hours as needed for cough/ congestion .Change feeding tube syringe every 24hours . a. On 05/07/2024 at 09:16 AM, during observation of medication administration for 400 Hall with Licensed Practical Nurse (LPN) #01, Resident #57 did not receive Guaifenesin oral tablet that was ordered to be administered at 8:00 AM through PEG tube. Purple colored syringe with no written date on the outside of the bag but had a stamped expiration date of 02/05/2024 was used to verify placement with ten milliliters (mL) of air. Sixty mL of water flush, medication mixed with water, 60 mL of flush followed after medication through tube. LPN #01 placed syringe tube back inside syringe, and without cleaning the syringe placed it back in the storage bag and hung it back on the intravenous (IV) pole. b. On 05/07/2024 at 10:10 AM, the surveyor interviewed LPN #01 and asked, What is the date on the bag the PEG tube syringe is stored in? He stated, 02/05/2024 is the expiration date. When asked, How often should the syringe be changed? He stated, Supposed to be changed every night. c. On 05/07/2024 at 10:31 AM, LPN #01 came to the conference room and stated to the surveyor, The APN (Advanced Practice Nurse) said to discontinue the 400 mg and do Mucinex 600 mg. When asked, Should the order have been clarified prior to the end of the medication pass? He stated, I guess so, probably. d. On 05/08/2024 at 09:25 AM, the surveyor interviewed the Director of Nursing (DON) and asked, If a resident has a medication placed on hold until 05/07/2024 at 08:00 AM should it be administered on 05/07/2024 at 08:00 AM? He stated, Yes. When asked, Why should it be administered at that time? He stated, Because that's what the order says. When asked, If a resident has a physician order for [named brand] Ophthalmic Solution instill 02 drops in both eyes and is ordered for 0600; 1200; 1600; and 2000 be administered at 08:31 AM? He stated, No. When asked, Why should the eye drops not have been administered at that time? He stated, It wasn't the scheduled time. When asked, Where would the nurse sign off at that time? He stated, There is not a place. When asked, If the orders stated two drops per eye how many drops should be instilled in the residents eyes? He stated, Two. When asked, Why should two drops be instilled in the residents eyes? He stated, That's what the order says to do. When asked, If a resident uses an inhaler should the nurse have the rinse their mouth after administration and spit out the water? He stated, Yes. When asked, Why should they resident rinse and spit? He stated, To get the nasty taste out. When asked, If a resident has an order for Mucinex 400 mg due at 08:00 AM should the facility have the Mucinex 400 mg to administer to the resident? He stated, Yes. When asked, Why should the facility ensure it had the Mucinex 400 mg dosage? He stated, Because its ordered for the resident. When asked, Should the LPN ask the APRN to change the order to match the Mucinex 600 mg that the facility has in stock? He stated, No, that shouldn't happen. When asked, How often should PEG tube syringed be changed? He stated, Every twenty four (24) hours. When asked, Why should they be changed every 24 hours? He stated, To prevent bacteria and stuff from harboring in the syringe. When asked, Should the PEG tube syringe be cleaned and dried after medication administration before replacing the syringe plunger back in the tube and placed both back in the storage bag? He stated, Yes. When asked, Why should it be cleaned and dried prior to putting the tube in the syringe and placing it back in the storage bag? He stated, That way it is clean and ready for the next scheduled use of it. e. Review of Manufacturer Guidelines for [named brand] (fluticasone furoate 100 mcg and vilanterol 25 mg inhalation power) on 05/08/2024 at 11:49 AM that documented, .[named brand] can cause serious side effects, including: fungal infection in your mouth or throat (thrush). Rinse your mouth with water without swallowing after using [named brand] to help reduce your change of getting thrush . 4. The facility provided a policy titled, Administering Medications with a revision date of April 2019 that included, Policy Statement: Medications are administered in a safe and timely manner, and as prescribed . 3. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions . Medications are administered in accordance with prescriber orders, including any required time frame . 6. Medication errors are documented, reported, and reviewed by the QAPI (Quality Assurance and Performance Improvement) committee to inform process changes and or the need for additional staff training. 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) . 21. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. 22. The individual administering the medication initials the residents MAR on the appropriate line after giving each medication and before administering the next. 23. As required or indicted for a medication, the individual administering the medication records in the resident's medical record: a. The date and time the medication was administered . 25. Staff follows established infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable . 5. The facility provided a policy titled, Adverse Consequences and Medication Error with a revision date of February 2023 that documented, .Medication Errors 1. A medication error is defined as the preparation or administration of drugs or biologicals which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. 2. Examples of medications error include: a. Omission- a drug is ordered but not administered .Wrong time; and/ or h. Failure to follow manufacturer's instructions and/ or accepted professional stands (e.g., failure to shake medication that is labeled shake well; crushing a medication on the do not crush list without an order.

Based on observation, record review, and interview, the facility failed to ensure that resident had incontinent care performed before wound treatment care to prevent potential cross contamination of infection for 1 (Resident #19) sampled resident, to ensure a Percutaneous Endoscopic Gastrostomy (PEG) tube syringe was properly changed or cleaned after use for 1 (Resident #57) sampled resident, and to ensure a catheter bag was properly maintained for 1 (Resident #67) sampled resident. 1. Review of Medical Diagnoses revealed Resident #19 had diagnoses of multiple sclerosis and pressure ulcer of sacral region, stage 4. a. A quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 03/11/24 documented the resident scored 15 (13-15 indicates intact cognition) on a Brief Interview for Mental Status [BIMS]. b. On 05/05/2024 at 10:00 AM, Resident #19 said, I am worried about my pressure ulcer [PU]. I got my PU at another facility, and I had to get part of my sacrum removed. I am supposed to get a wound vac [Vacuum Assisted Closure of Wound - negative pressure wound therapy that helps wounds heal more quickly] but I currently have an infection and am worried about it healing. c. On 05/06/2024 at 10:09 AM, wound treatment for Resident #19 was observed. Licensed Practical Nurse [LPN] #2 was observed donning a gown and gloves required for Enhanced Barrier Precautions [EBP] before performing wound care. With staff assistance, resident was rolled to right side and resident's brief was opened. Solid waste measuring 2 inches by 4 inches was observed between the resident's buttocks and soiled the bottom edge of the bandage covering the wound. LPN #2 removed the soiled bandage and packing from wound, discarded in biohazard bag along with gloves. Performed hand hygiene with Alcohol Based Hand Rub [ABHR] then donned new gloves. d. On 05/06/2024 at 10:15 AM, LPN #2 cleansed inner to outer circumference around wound with moistened 4 inch x 4 inch gauze. With each swiping motion, a scant amount of solid waste was observed on the gauze as it was being placed in biohazard bag. e. On 05/06/2024 at 10:20 AM, LPN #2 packed 1 foot of saturated gauze in the base of wound with sterile cotton tipped applicator, then covered with an abdominal pad. The edge of the abdominal pad was 1/4 inch away from the solid waste and secured with tape. A scant amount of solid waste was observed on the tapes edge closest to the bm. f. A review of a Physician Order dated 04/18/2024: Wound Vac, Stage 4 Pressure Ulcer to Sacrum to be changed every Tuesday and Saturday in facility and on Thurs [Thursday] in clinic and as needed. Cleanse wound with Dial soap and water, Pat dry with gauze, use skin prep pad to peri wound, then use clear drape to peri wound to create a window pane around the wound. Cut black foam to fit wound bed. Do not allow black foam to touch intact skin, bridge away from bony areas, cover with the drape and confirm seal. Every day shift every Tue, Thurs, Sat AND as needed. g. A review of the Physician's order [PO] dated 4/25/24: Cleanse stage 4 pressure ulcer to sacrum with wound cleanser, pat dry with gauze, moisten [named brand of gauze], pack into wound loosely, cover with abdominal pad, secure with paper tape daily and as needed, until resident returns to wound clinic, every day shift and as needed. h. On 05/06/2024 at 10:30 AM, the surveyor asked LPN #2 if there was anything they would have done differently. LPN #2 said I would have went ahead and let the aides [CNAs -Certified Nursing Assistants] clean and change the resident's incontinent brief before I did treatment. I didn't want to change the brief because I haven't done that for a long time and could only remember, clean front to back, but that is about it honestly. The surveyor asked what could be a negative outcome of leaving solid waste in a resident's brief while performing treatment? LPN #2 said there was a potential for cross contamination. i. A facility policy provided on 05/07/2024 at 01:30 PM by the Nurse Consultant titled Wound Care did not address performing wound treatment before performing incontinent care. 2. Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/24/2024 indicated Resident #57 scored a 5 (0-7 indicates severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). A. A review of the Order Summary indicated Resident #57 had medical diagnoses of gastrostomy status and dysphagia following cerebral infraction. B. A review of the Order Summary revealed Resident #57 had an order that indicated Change feeding tube syringe every 24 hours. C. On 05/05/2024 at 12:15 PM, the surveyor observed a feeding tube syringe in a clear plastic bag hanging from an IV (intravenous) pole, water was collected in the bottom of the plastic. The surveyor observed a printed date that read, 02/05/24. D. On 05/06/2024 at 8:30 AM, the Surveyor observed that the feeding tube syringe had not been changed. E. On 05/07/2024 at 9:16 AM, during observation of medication administration for 400 Hall with Licensed Practical Nurse (LPN) #01, Resident #57 had a purple-colored syringe with no written date on the outside of the bag but with a stamped expiration date of 02/05/2024. LPN #1 used the syringe to verify placement of the resident's PEG tube with ten milliliters (mL) of air. Sixty mL of water flush, medication mixed with water, 60 mL of flush followed after medication through tube. LPN #01 placed syringe tube back inside the syringe but did not clean the syringe prior to putting it back in the storage bag and hung it back on the IV pole. F. On 05/07/2024 at 10:10 AM, the surveyor interviewed LPN #01 and asked, Should the PEG tube syringe have been cleaned and dried prior to you putting the plunger in the syringe and placing both in the storage bag? He stated, Probably. When asked, What is the date on the bag the PEG tube syringe is stored in? He stated, 02/05/2024 is the expiration date. When asked, How often should the syringe be changed? He stated, Supposed to be changed every night. G. On 05/08/2024 at 09:25 AM, the Surveyor interviewed the Director of Nursing (DON) and asked, How often should PEG tube syringed be changed? He stated, Every twenty four (24) hours. When asked, Why should they be changed every 24 hours? He stated, To prevent bacteria and stuff from harboring in the syringe. When asked, Should the PEG tube syringe be cleaned and dried after medication administration before replacing the syringe plunger back in the tube and placed both back in the storage bag? He stated, Yes. When asked, Why should it be cleaned and dried prior to putting the tube in the syringe and placing it back in the storage bag? He stated, That way it is clean and ready for the next scheduled use of it. H. The Facility provided a policy title, Enteral Tube Feeding via Syringe (Bolus) with a revision date of November 2018 that documented, General Guidelines 1. Use aseptic technique when preparing or administrating enteral feedings. 3. Review of an admission Record revealed Resident #67 had a diagnosis of retention of urine. a. On 05/05/2024 at 11:00 AM, Resident # 67 was observed in bed with catheter bag uncovered and in the floor underneath the bed with an ant crawling on it. b. On 5/05/2024 at 11:00 AM, Resident # 67's nebulizer mask was observed lying on the nightstand uncovered, not in a bag. The bag laying on Resident # 67's nightstand was dated 4/27. c. On 05/07/2024 at 8:30 AM, Resident # 67's nebulizer mask in the drawer of his night stand and the nebulizer mask was not in a bag. d. On 5/07/24 at 8:30 AM, RN #1 stated that Resident #67's Foley catheter should have been in a privacy bag hanging from the bedside and not in the floor. e. On 05/07/24 at 8:30 AM RN #1 stated that Resident #67's nebulizer bag should have been stored in a plastic bag and not laying on the bedside night stand or in the drawer. Review of an Infection Control Policy indicated that 4. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities. Review of a Foley Catheter insertion, Male resident with a revision date of October 2010 documented: Steps in procedure 25. Attach catheter to drainage tubing. Tape catheter to top of thigh or lower abdomen. Secure drainage tubing to bottom bed sheet with clip from drainage bag.

Based on observation, interview, and record review, the facility failed to ensure that residents receive a diet that meets their nutritional needs, is visually pleasing, prepared in a manner to maintain nutritional content and taste to encourage consumption and maintenance of good nutrition and hydration status. The findings are: 1. Resident #25 had a diagnosis of unspecified dementia. a. Review of the Minimum Date Set (MDS) with an Assessment Reference Date (ARD) of 02/28/2024 revealed Resident #25 received a score of 14 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status. Resident #25 required set up only for eating as they were capable of eating independently. a. On 05/05/2024 at 12:33 PM, Resident # 25 is observed with their lunch meal. The resident took a fork and inserted it multiple times into a large square of meatloaf. The resident is heard to say that the meatloaf looks like something that has been pulled from the toilet. The resident is observed to take a bit of the meatloaf and immediately lay the fork down on the plate. Resident #25 described the meatloaf as having no taste. b. On 05/05/2024 at 12:50 PM, a test tray was requested from the dietary department. Dietary Aide (DA) #1 reported they had run out of scalloped potatoes and meatloaf. DA #1 was asked how many residents didn't receive the meatloaf and scalloped potatoes. DA #1 relayed her belief that there were 2 or 3 residents who were given the substitute which was a beef patty and mashed potatoes. DA #1 was asked to retrieve the Dietary Manager (DM) who was outside. Upon entry, the DM was asked how many residents did not receive the meatloaf and scalloped potatoes. The DM reported everyone received the menu items. The DA provided a test tray consisting of a beef patty with tomato sauce, Brussels sprouts, and mashed potatoes. Upon initial entry into the kitchen the Brussels sprouts were observed on top of the range in large pots of water being cooked for lunch. The DM accompanied this surveyor to the conference room. This surveyor sampled a Brussels sprout. The texture of the Brussels sprout suggested it was overcooked, and it was void of any seasoning with a bitter flavor. A second surveyor agreed the vegetable was overcooked and tasted as if no seasoning of any kind had been added. The DM stated, Well, it's warm. The mashed potatoes were also bland and void of seasoning. The DM described the potatoes as needing more salt. c. On 05/06/2024 at 2:30 PM, a resident council meeting was held with 6 residents who unanimously agreed that the food in the facility was not good. The food was described as poorly cooked and lacking seasoning. Resident #28 described an incident in which he/she returned breakfast because it was inedible. Resident #28 described receiving a fried egg that was cooked hard, which was not his/her preference and toast that was burned on one side. Resident #27 described asking if he/she could have another tray. When the second plate arrived, it contained a second hard fried egg and burned toast. The resident reports that he/she was told by the staff, just don't turn it over. Resident #401 concurred with Resident #28, confirming the poor breakfast meal. d. On 05/07/2024 at 8:04 AM, three trays, 2 pureed and 1 regular, were observed sitting in the kitchen window waiting to be delivered. DA #1 was asked to obtain a thermometer so that the temperature of the pureed food could be measured. DA obtained a thermometer and cleaned the end with an alcohol pad. The thermometer was submerged into the pureed bread. When digital numbers stabilized the reading was 127 degrees Fahrenheit. The thermometer was removed, cleaned with an alcohol pad, and placed into what was identified as scrambled eggs. The eggs registered at 125.2 degrees Fahrenheit. At this time the Dietary Manager returned from the hall and began placing covers on top of the unserved trays. e. On 05/07/2024 at 8:10 AM, a test tray was requested and was brought to the conference room. The Dietary Manager was asked to identify the type of egg product that was used. The Dietary Manager described a liquid product that is packaged in a carton. The serving of eggs on the plate was observed to have a perfectly smooth surface on top, unlike scrambled eggs. Two surveyors, the Dietary Consultant, and the Nursing Consultant each took a sample of the egg product. The eggs were congealed into a solid mass that could be cut with a spoon. The eggs were void of any seasoning. f. On 05/08/2024 at 9:02 AM Review of the facility grievance records reveal Resident #55 filed a grievance on 03/18/2024 concerning the menus, food temperatures, and cooking procedures. During a follow-up on 04/02/2024 Resident #55 expressed that the food had been fine lately, however on 05/05/2024 at 10:20 AM the resident continued to verbalize dissatisfaction with the food. g. On 05/08/2024 at 10:00 AM, the DM was asked if she tasted the food served in the kitchen and the reply was yes. The DM was asked if the kitchen seasons the food prior to serving. The DM discussed that she is continually reminding the cooks that the recipe can be added too, but they can't delete ingredients, that she tells the cooks to season as if they were at home. The DM was asked how long Brussels sprouts should be cooked prior to serving. The DM described the presence of a new cook in the kitchen. The DM reports coming in on Sunday and seeing the Brussels sprouts being cooked on top of the stove, ready to serve at 10:20 AM. When asked when preparation of the vegetable should have taken place the DM verbalized that the cooking shouldn't have started until 10:30 AM. She continued that normally they would have been cooked in the oven. 2. A review of the Quarterly Minimum Data Set with an Assessment Reference Date (ARD) of 04/10/2024 indicated Resident #21 scored a 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). a. On 05/05/2024 at 12:15 PM, Resident #21 stated that Food here is not even fit to feed to the dogs. b. On 05/06/2024 at 1:38 PM, Resident #21 pulled a 1/2 a baked potato out of the refrigerator and stated, This is what I was served one day, only 1/2 a baked potato not a full one. The surveyor observed that the skin was wrinkled, the potato itself was dark brown with white throughout with a small portion missing. Resident #21 then stated, You can see where I tried to eat it but its inedible, this is what we are served for meals the food is disgusting here. Resident #21 reported they had not lost weight because of the snacks kept in their room.

Based on observation and interview the facility failed to ensure food was used prior to the use by date. The findings are: On 05/05/2024 at 10:30 AM, the following items were observed in what is referred to as the cook's refrigerator, all of which had a use by date of or before 05/04/2024: 1. 1/4 steam table pan of sliced ham 2. 1/4 steam table pan of macaroni and tomatoes. 3. 1/2 gallon container 1/2 full of stewed tomatoes. 4. 1/4 steam table pan of mechanical soft ham. 5. 1/4 quarter steam table pan of mechanical soft meatballs. 6. A plastic container of pizza sauce, 1/3 full. Also located in the cook's refrigerator was a plastic bag containing 4 hard-boiled eggs with a use by date of 04/28/2024 and a plastic 1 pound bag of sliced turkey with no use by date. On 05/05/2024 at 10:40 AM, a plastic container 1/2 full of chopped tomatoes was located in the walk in refrigerator. The tomatoes had a use by date of 05/04/2024. On 05/05/2024 at 10:47 AM, a 1 pound bag of spaghetti was observed on a shelf in the dry storage area. The bag was not sealed, leaving the food item exposed to air and contamination. On 05/05/2024 at 11:00 AM, a clear plastic container was observed on the bottom shelf of the work table. Inside the container were 14 individually bagged sugar cookies that had no date. On 05/08/2024 at 10:00 AM, the Dietary Manager (DM) said leftovers are utilized by the facility for no longer than two days. Review of a Policy titled Food Receiving and Storage revealed, all foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by

Based on observation, and interview, the facility failed to ensure a comprehensive, person-centered care plan was developed to address the necessary care and monitoring related to the administration of antidepressants and psychotropic medications to enable staff to determine the effectiveness of the medication and promptly identify any potential adverse effects for 1 (Resident #89) of 18 (Residents #2, #11, #22, #24, #29, #32, #39, #42, #53, #66, #69, #71, #75, #80, #81, #82, #86 and #89) sampled residents who had Physician Orders for an antidepressant and 3 (Residents #75, #82 and #89) sampled residents who had Physician Orders for an antipsychotic. The findings are: Resident #89 had diagnoses of Alzheimer's Disease with Late Onset, Unspecified, Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/22/23 documented the resident scored 5 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and received an antipsychotic medication and an antidepressant medication 4 of the 7 day look back period. a. The Physician Orders dated 02/22/23 documented, .Escitalopram Oxalate Oral Tablet 10 MG [milligram] (Escitalopram Oxalate) Give 1 tablet by mouth one time a day related to Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety . Risperidone Oral Tablet 0.25 MG (Risperidone) Give 0.25 mg by mouth two times a day related to Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety . b. The Care Plan with an initiated date of 02/22/22 did not address the use of antidepressant and/or antipsychotic medications. c. On 04/06/23 at 10:14 AM, the Surveyor asked the Administrator who was responsible for writing Care Plans. She directed this Surveyor to Registered Nurse (RN) #1 and stated, He is responsible for our long-term care, Care Plans. d. On 04/06/23 at 10:16 AM, the Surveyor asked RN #1 if the use of antidepressant and antipsychotic medications should be included on the plan of care. RN #1 stated, Yes. The Surveyor asked RN #1 to review Resident #89's Care Plan to determine if the use of antidepressant and antipsychotic medications were listed. After reviewing the plan of care RN#1 stated, No, it's not there. e. The facility policy titled, Goals and Objectives, Care Plans, provided by the Administrator on 04/06/23 at 11:51 AM documented, Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence . 4. Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved .

Based on observation, and interview, the facility failed to ensure expired medications and medical supplies were removed and placed into an area for destruction to prevent potential administration to residents. The failed practice had the potential to affect all 91 residents who resided in the facility and received medication and or medical supplies from 2 of 2 medication rooms and 1 medication cart according to a list provided by the Administrator on 04/03/23 at 3:07 p.m. The findings are: 1. On 04/06/23 at 9:45 a.m., the following items were in the Medication Supply Room: a. 2 - Incentive Spirometer with an expiration date of 1/28/2021. b. 1 - Urinary Catheter Kit dated 1/28/23. c. 1 - Hypodermoclysis Prep Kit with an expiration date of 9/25/22. d. 1 - Intravenous Start Kit with an expiration date of 1/13/23. e. 2 - Statlocks with expiration dates of 12/28/2021 and 5/28/2022. f. 1 - medium (red top) vial with an expiration date of 1/17/2022. 2. On 04/06/23 at 9:50 a.m., the following items were in the 200 Hall Medication Room: a. 1 - 8oz bottle of hand sanitizer with an expiration date of 7/22. b. 3 - Angio catheters with expiration dates of 6/2016, 12/31/2020 and 1/28/2022. c. 4 - red top tubes with expiration dates of 6/17/2021 and 7/10/2021. d. 1 - Pink top tube with an expiration date of 9/10/2021. e. 1 - Grey told tube with an expiration date of 6/30/2020. f. 1 - Sani cloth with an expiration date of 7/2020. g. 1 - Sterile single use needle with an expiration date of 11/2022. 3. On 04/06/23 at 10:00 a.m., the 300 Hall Medication Cart, contained the following expired medication: a. 1 container of hemorrhoid ointment with an expiration date of 1/2023. 4.The facility policy titled, Storage of Medications, provided by the Administrator on 04/06/23 at 11:51 a.m. documented, .Policy Interpretation and Implementation . 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be destroyed .

Based on observation, and interview, the facility failed to ensure dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect all 91 residents who received meals from the kitchen (Total Census: 91) as documented on the Midnight Census report provided by the Administrator on 04/03/23 at 3:07 PM. The findings are: 1. On 04/04/23 at 9:38 AM, Dietary Employee (DE) #1 opened the refrigerator door and removed pitchers of orange juice and tea and a bottle of cranberry juice and placed them on the counter. Without washing her hands, she picked up glasses by the rims and placed them on the counter. She then poured the beverages into the glasses to be served to the residents with their lunch meal. The Surveyor asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, Washed my hands. 2. On 04/04/23 at 9:42 AM, DE #1 opened the refrigerator door and removed a half gallon of milk and placed it on the counter. At 9:45 AM, she washed her hands, pulled tissue papers from the dispenser, and turned off the faucet. She used the same tissue to dry her hands, contaminating her hands. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents who received a pureed diet. She picked up the bowls with her fingers touching the interior surfaces of the bowls and put them up. 3. On 04/04/23 at 10:11 AM, DE #2 removed a ziplock bag of cheese slices from the refrigerator and placed it on the counter. She picked up a bag of bread from the counter and untied the bag. Without washing her hands, she removed slices of bread from the bag and placed them on a plate. She removed slices of cheese from the bag and placed them on the slices of bread and topped them with slices of bread. She then put cheese sandwiches in individual bags and placed them on a shelf in the refrigerator to be served to the residents who asked for a cheese sandwich with their lunch meal. 4. On 04/04/23 at 10:41 AM, DE #1 turned on the faucet and washed her hands. She turned off the faucet with tissue paper, contaminating the tissues. She then, used the same tissue to dry her hands, contaminating her hands. She picked up plates, with her fingers inside of the plates, and placed them on the plate warmer. 5. On 04/04/23 at 11:00 AM, DE #2 opened the refrigerator door and removed a pitcher of apple juice and placed it on the counter. Without washing her hands, she picked up a glass by the rim and placed it on the counter. She poured apple juice into the glass and placed the glass on the cold side of the steam table to be served to the resident with their lunch meal. The Surveyor asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, Washed my hands. 6. The facility policy titled, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, provided by the Dietary Supervisor on 04/04/23 at 12:11 PM documented, .6. Employees must wash their hands: .h. After engaging in other activities that contaminates the hands .

Based on observation, record review and interview, the facility failed to ensure privacy was provided during the provision of perineal hygiene care to prevent potential exposure of the resident's body to visitors or other residents for 1 (Resident #49) of 33 (Residents #49, #58, #21, #57, #26, #15, #18, #3, #69, #63, #40, #67, #8, #1, #45, #2, #24, #59, #11, #27, #17, #75, #327, #6, #51, #38, #71, #54, #61, #65, #22, #46 and #20) sampled residents who required assistance with bathing. This failed practice had the potential to affect all 77 residents who required assistance with bathing, according to list provided by the Director of Nursing (DON) on 2/09/22. The findings are: Resident #49 had diagnoses of Dementia, Impaired Mobility, and Inability to Communicate Needs. The Quarterly Minimum Data Set with an Assessment Reference Date of 11/23/21 documented the resident was severely impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status, required extensive physical assistance of two-plus persons for toilet use, and was always incontinent of bowel and bladder. a. The Care Plan with a revision date of 11/23/21 documented, .The resident has bladder incontinence r/t [related to] Confusion, Dementia, Impaired Mobility, Inability to communicate needs, Loss of peritoneal tone . Clean peri-area with each incontinence episode . b. On 02/07/22 at 8:48 AM, Resident #49 was lying in bed. The window blinds beside her bed were open, leaving the window that overlooked the front driveway exposed. Certified Nursing Assistant (CNA) #1 and CNA #2 performed perineal (peri) care. They removed Resident #49's incontinent brief, cleaned Resident #49's perineal area with wet wipes and applied a new brief. Both CNAs then washed their hands and exited the room. CNA #1 was asked, How should you have provided privacy while you were providing peri care? She stated, I should have closed the curtain. I am sorry. The resident's spouse, who was standing in the room, stated, .I am glad you said something about that. c. On 2/8/22 at 9:50 AM, the Director of Nursing (DON) was asked, When do you expect your staff to provide privacy when performing peri care on a resident? She stated, Any time they are doing peri care. She was informed of the blinds on the window by Residents #49's bed not being closed during peri care. She stated, People driving by could have seen in . d. The facility policy titled, Perineal Care, provided by the DON on 02/10/22 at 8:31 AM, documented, .The purposes of this procedure are to provide cleanliness and comfort to the resident to prevent infections and skin irritation and to observe the resident's skin condition . The policy did not address providing privacy.

Based on observation, interview and record review, the facility failed to ensure staff routinely changed the linens on a resident's bed to maintain a comfortable and homelike environment for 2 (Residents #67 and #75) of 46 (Residents #67, #75, #58, #21, #57, #26, #15, #18, #3, #69, #63, #40, #77, #41, #1, #45, #2, #24, #59, #49, #11, #27, #17, #76, #127, #6, #51, #38, #71, #54, #61, #55, #22, #46, #20, #327, #43, #12, #9, #25, #44, #8, #78, #47, #377 and #65) sampled residents were dependent on staff to change their bed linens. The findings are: 1. Resident #75 had diagnoses of Dementia, Kidney Failure, and Type II Diabetes. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/13/22 documented the resident scored 15 (13-15 13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), required limited assistance of two-plus persons with personal hygiene, required one-person physical assistance with bathing, and was always continent of bowel and bladder. a. The Care Plan with a revision date of 10/27/21 documented, .The resident has an ADL [activities of daily living] self-care performance deficit . history of falls, Gait balance problems . The resident has MIXED bladder incontinence r/t [related to] requiring toileting transfer assist . Clean peri-area with each incontinence episode . b. On 2/6/22 at 12:47 PM, Resident #75 stated, We don't get a bath as often as we should, and we don't get our sheets changed once a week. c. On 2/6/22 at 2:13 PM, Resident #75 stated her sheets were not being changed and that she scratches at night due to having bugs in her bed. d. On 2/6/22 at 2:29 PM, the Director of Nursing (DON) accompanied the surveyor to Resident #75's room because the resident stated she thought she had bugs in her bed. The DON inspected the resident's bed, and there were brown specks scattered on the linens, but no bugs were identified. e. On 02/08/22 at 1:48 PM, Certified Nursing Assistant (CNA) #1 was asked, How often are the residents' linens changed? She stated, Every other day or if soiled; we change them when they get their bath. 2. Resident #67 had diagnoses of Type 2 Diabetes, Urinary Incontinence and Altered Mental Status. The Quarterly MDS with an ARD of 1/13/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS and was independent with setup for personal hygiene and bathing. a. The Care Plan with a revision date of 11/25/21 documented, .The resident has an ADL [activities of daily living] self-care performance deficit r/t unsteady gait .falls .has limited physical mobility . b. On 2/6/22 at 12:48 PM, Resident #67 stated she was admitted in late November (2021) and her sheets were not changed until she was moved to the COVID Unit in late January (2022). 3. On 02/08/22 at 1:52 PM, CNA #5 was asked, How often are the residents' sheets changed? She stated, They are changed when they get their showers. She was asked, What if the resident refuses their shower or does not get their shower? She stated, If they don't get their shower, then if they ask us or if we see it's dirty, we will change them. She was asked, Are you aware of [Resident #75] or [Resident #67] not getting their bed linens changed for over a week at a time? She stated, I don't work this hall a lot . I'm just helping out . 4. The facility policy titled, Bed, Making an Occupied, provided by the DON on 02/10/22 at 8:31 AM documented, .The purpose of this is to provide the resident with a clean and comfortable environment and to prevent skin irritation and breakdown . The policy did not address how frequently the bed should be made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #18 had diagnoses of Alzheimer's Disease, Vascular Dementia without Behavioral Disturbance, Generalized Anxiety Disorder and Obsessive Compulsive Disorder. The Quarterly Minimum Data Set with an Assessment Reference Date of 12/15/2021 documented the resident was severely impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS), required extensive physical assistance of one person with personal hygiene and physical help of one person in part of the bathing activity, and was frequently incontinent of bowel and bladder. a. The Care Plan with a revision date of 09/09/21 documented, .The resident has an ADL self-care performance deficit . PERSONAL HYGIENE: The resident requires limited assistance) by 1 staff with personal hygiene and oral care. The Care Plan did not address the resident's needs for assistance with bathing or incontinence. b. The Bathing Task Logs for December 2021, January 2022 and February 2022, provided by the DON on 02/07/22 at 1:00 PM, documented ADL - T, TH, SAT Evening & PRN. The logs documented the resident received 8 baths in December, 7 baths in January, and 2 baths so far in February as follows: December 2021: 12/4/21 (Saturday), 12/9/21 (Thursday), 12/11/21 (Saturday), 12/18/21 (Saturday), 12/20/21 (Monday), 12/21/21 (Tuesday), 12/25/21 (Saturday), 12/30/21 (Thursday). January 2022: 1/1/22(Saturday), 1/4/22(Tuesday), 1/8/22 (Saturday), 1/20/22(Thursday), 1/22/22 (Saturday), 1/27/22(Thursday), 1/29/22 (Saturday). Resident #18 refused bathing on 01/13/22 (Thursday) and 01/25/22 (Tuesday) and Not Applicable was documented on 01/18/22 (Tuesday). c. On 02/06/22 at 12:07 PM, during the noon meal, Resident #18 was in the dining room and had chin hair approximately ¼ inch long. d. On 02/07/22 at 9:53 AM, Resident #18 was on the 300 Hall walking in the hallway. She had chin hair approximately ¼ inch long. e. On 02/08/22 at 8:30 AM, Resident #18 was ambulating around the dining area of the Memory Care Unit and was wearing the same clothes she had on 02/07/22 and continued to have chin hair approximately ¼ inch long. f. On 02/08/22 at 8:33 AM, CNA # 4 was asked what is involved with grooming on shower day. CNA # 4 stated, Their bed linens are changed, they get a shampoo, and the CNAs trim their nails and curl their hair on shower days. g. On 02/08/22 at 9:05 AM, CNA # 3 was asked if it was acceptable for the resident to be in the same clothes for two days and have chin hair. CNA #3 stated, No, but she also has multiple outfits that look the same. h. On 02/08/22 at 9:17 AM, the DON accompanied the surveyor to the Dining/Commons area of the Memory Care Unit to see Resident #18 and was asked, Is it acceptable to have on the same clothes for two or three days in a row? The DON stated, No, shower days are scheduled three times a week and should include a change of clothing, nail care, facial hair removal and trimming by CNAs as long as they are not diabetic. It should include a shampoo. i. On 02/08/22 at 8:33 AM, the surveyor asked CNA #4 what the shower schedule was for the resident. CNA #4 stated, We usually have a schedule in the computer; She gets an evening shower, I think Tuesday, Thursday, Saturday. 5. The Grievance Logs for November 2021 to February 8, 2022, documented seven concerns regarding showers and/or clothes not being changed. 6. On 02/09/22 at 8:30 AM, CNA #4 was asked, How often are the residents supposed to get their shower? She stated, Three times a week. She was asked, To your knowledge, does [Resident #75] or [Resident #67] receive three baths a week? She stated, I don't normally work this hall. She was asked, Where is it documented if a resident refuses their bath? She stated, In the [software]; every shift, we get a list of residents that we are supposed to give a bath. They are supposed to get a bath every other day. She was asked, Are there times that the bath gets skipped? She stated, Sometimes, and if they refuse [their bath], we document it in the [software] . 7. On 02/09/22 at 8:22 AM, CNA #2 was asked, How often are the residents supposed to receive their baths? She stated, Two to three days a week . we document it in the [software]. It will have a list of the residents that are scheduled for a bath. If they refuse, we document it in the [software] . 8. The facility policy titled, Shower/Tub Bath, provided by the DON on 02/09/22 at 12:42 PM documented, . The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin.Reporting 1. Notify the supervisor if the resident refuses the shower/tub bath . 9. The facility policy titled, Care of Fingernails/Toenails, provided by the DON on 02/09/22 at 12:42 PM documented, . The purposes of this procedure are to clean the nail bed, to nails trimmed, and to prevent infections . General Guidelines 1. Nail care includes daily cleaning and regular trimming . Based on observation, interview and record review, the facility failed to ensure fingernails regularly trimmed and cleaned to promote good personal hygiene and grooming for 1 (Residents #8) of 46 (Residents #8, #58, #21, #57, #26, #15, #18, #3, #69, #63, #40, #77, #41, #1, #45, #2, #24, #59, #49, #11, #27, #17, #76, #127, #6, #51, #38, #71, #54, #61, #55, #22, #46, #20, #327, #43, #12, #9, #25, #44, #78, #47, #377, #67, #75 and #65) sampled residents who were dependent for nail care; failed to ensure facial hair was removed for 1 (Resident #18) of 13 (Residents #18, #15, #3, #77, #59, #11, #51, #71, #55, #12, #9, #78, and #377) sampled residents who required assistance for shaving; failed to ensure baths or showers were regularly provided for 4 (Residents #8, #18, #67, and #75) and resident's clothing was changed daily for 2 (Residents #8 and #18) to maintain good hygiene of 33 (Residents #49, #58, #21, #57, #26, #15, #18, #3, #69, #63, #40, #67, #8, #1, #45, #2, #24, #59, #11, #27, #17, #75, #327, #6, #51, #38, #71, #54, #61, #65, #22, #46 and #20) sampled residents who required assistance with bathing. These failed practices had the potential to affect all 77 residents who required assistance with nail care, 76 residents who required assistance with showers/bathing, and 40 residents who required assistance with facial hair, according to list provided by the Director of Nursing (DON) on 02/09/2022. The findings are: 1. Resident #8 had diagnoses of Dementia without Behavioral Disturbance, Unsteadiness on Feet, Other Abnormalities of Gait and Mobility and Chronic Congestive Heart Failure. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/22/2022 documented the resident scored 3 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS), required limited physical assistance of 1 person for personal hygiene and physical help of one person in part of the bathing activity, and was frequently incontinent of bladder. a. The Care Plan with a revision date of 11/25/21 documented .The resident has an ADL [activities of daily living] self-care performance deficit . BATHING/SHOWERING: The resident requires physical assist by 1 staff with showering on shower DAYS and as necessary. Provide sponge bath when a full bath or shower cannot be tolerated. PERSONAL HYGIENE: The resident requires limited assistance by 1 staff with personal hygiene and oral care . The resident has potential for impairment to skin integrity . trim/file nails PRN [as needed] . b. The Bathing Task Log provided by the DON on 02/07/22 at 1:00 PM documented, ADL - TU [Tuesday], Th [Thursday], SAT [Saturday] Day & [and] PRN [as needed]. The log documented Resident #8 received a shower on the following days: December 2021: 12/1/21 (Wednesday), 12/7/21 (Tuesday), 12/9/21 (Thursday), 12/14/21 (Tuesday), 12/21/21 (Tuesday) and 12/23/21 (Thursday). Resident Refused was documented on 12/18/21 (Saturday); Not Applicable was documented on 12/2/21 (Thursday). Resident #8 received 7 bed baths/showers during the month of December 2021. January 2022: 1/3/22 (Monday), 1/4/22 (Tuesday), 1/6/22 (Thursday), 1/11/22 (Tuesday), 1/13/22 (Thursday), 1/15/22 (Saturday), 1/18/22 (Tuesday), 1/20/22 (Thursday), 1/25/22 (Tuesday) and 1/27/22 (Thursday). Resident Refused was documented on 1/22/22 (Saturday) and 1/29/22 (Saturday). Resident #8 received 10 showers during the month of January 2022. c. On 02/06/22 at 12:07 PM, during the noon meal, Resident #8 was feeding herself with her hands. Her hair was oily, and her fingernails were long, jagged, and extended approximately 1/4 to 1/2 inch beyond the fingertips. d. On 02/07/22 at 10:06 AM, Resident #8 was in the dining area looking at a magazine. She had on the same shirt she was wearing on Thursday 02/06/22. Her hair was greasy, and her fingernails were long, jagged, and extended approximately 1/4 to 1/2 inch beyond the fingertips, with dirt underneath them. The fingernails on her right hand were partially covered with red nail polish. e. On 02/08/22 at 8:27 AM, Resident #8 was seated at a table in the dining area of the Memory Care Unit eating breakfast. The resident had the same shirt she had on Thursday 02/06/22 and Friday 02/07/22. Her hair was greasy, and her fingernails remained long and jagged, with residual nail polish on the right hand. f. On 02/08/22 at 8:33 AM, Certified Nursing Assistant (CNA) #4 was asked what the shower schedule was for Resident #8. CNA #4 stated, We usually have a schedule in the computer. She gets a shower Tuesday, Thursday, Saturday. g. On 02/08/22 at 8:53 AM, CNA #3 was asked if Resident #8's hair looked dirty. CNA #3 stated, Yes, and she gets a shower today. CNA #3 was asked if Resident #8's nails looked cared for. CNA #3 stated, They look okay; she likes them not too short. CNA #3 was asked if it was acceptable for residents to be in the same clothes for three days. CNA #3 stated, No, they are supposed to be changed daily. h. On 02/08/22 at 9:17 AM, the DON accompanied the surveyor to the Dining/Commons area on the locked unit (300 hall) to see Resident #8. The DON was asked, Is her hair clean? The DON stated, No, looks oily. The DON looked at the resident's nails and stated, If they were mine, I would trim them a little. They are long. The DON was asked, Is it acceptable to have on the same clothes for two or three days in a row? The DON stated, No, shower days are scheduled three times a week and should include a change of clothing, nail care with trimming by the CNAs as long as they are not diabetic. It should include a shampoo. 2. Resident #75 had diagnoses of Dementia, Kidney Failure, and Type II Diabetes. The Quarterly MDS with an ARD of 1/13/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS, required limited assistance of two plus persons with personal hygiene and one person physical help in part of the bathing activity, and was always continent of urine. a. The Care Plan with a revision date of 10/27/21 documented, .The resident has an ADL self-care performance deficit . BATHING/SHOWERING: Avoid scrubbing & [and] pat dry sensitive skin.The resident has mixed bladder incontinence r/t [related to] requiring toileting transfer assist . b. The Bathing Task Logs for December 2021 and January 2022, provided by the DON on 02/08/22 at 10:27 AM, documented ADL - TU, Th, SAT & PRN [as needed]. The log documented Resident #75 received a shower on the following days: December 2021: 12/2/21 (Thursday), 12/07/21 (Tuesday), 12/16/21 (Thursday), 12/21/21 (Tuesday) and 12/28/21 (Tuesday). Resident #75 received 5 showers during the month of December 2021. January 2022: 01/04/22 (Tuesday), 01/06/22 (Thursday), 01/11/22 (Tuesday), 01/13/22 (Thursday), 01/15/22 (Saturday), 01/18/22 (Tuesday), 01/20/22 (Thursday), 01/25/22 (Tuesday), 01/27/22 (Thursday), 01/29/22 (Saturday). Resident #75 received 10 showers during the month of January 2022. c. On 2/6/22 at 2:05 PM, Resident #75 stated, We don't get a bath as often as we should, and we don't get our sheets changed once a week. d. On 02/08/22 at 8:48 AM, Resident #75 was asked, How often do you prefer to get your bath? She stated, Every other day. She was asked, When was the last time you received your bath? She stated, Saturday [2/5/22]. e. On 02/10/22 at 7:54 AM, the DON was shown the bathing logs for December 2021 and January 2022 and was asked, Is it an acceptable practice for [Resident #75] not to receive a bath as she was scheduled? The DON stated, No that is not acceptable. 3. Resident #67 had diagnoses of Type 2 Diabetes, Urinary Incontinence, Urinary Tract Infection and Altered Mental Status. The Quarterly MDS with an ARD of 01/13/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS and was independent with setup for personal hygiene and bathing. a. The Care Plan with a revision date of 11/25/21 documented, .The resident has an ADL self-care performance deficit r/t unsteady gait . BATHING/SHOWERING: Avoid scrubbing & pat dry sensitive skin . b. The Grievance Log dated November 2021 through 2/8/22 documented a concern dated 11/30/21 that the resident had not had a bath since she was admitted on [DATE]. c. The Bathing Task Logs for December 2021 and January 2022 provided by the DON on 02/08/22 at 10:27 AM documented ADL - TU, TH, SAT & PRN. Resident #67 received a shower / bed bath on the following days: December 1 through December 31, 2021: 12/7/21 (Tuesday), 12/16/21 (Thursday), 12/21/21 (Tuesday) and 12/28/21 (Tuesday). Resident #67 received 4 showers for the month of December 2021. January 1 through January 31, 2022: 01/01/22 (Saturday), 01/04/22 (Tuesday), 01/06/22 (Thursday), 01/11/22 (Tuesday), 01/18/22 (Tuesday), 01/20/22 (Thursday) and 01/27/22 (Thursday). Resident Refused was documented on 01/25/22 (Tuesday), Not Applicable was documented on 01/13/22 (Thursday), 01/15/22 (Saturday) and 01/29/22 (Saturday). Resident #67 received 7 showers / bed baths for the month of January 2022. d. On 02/06/22 at 2:05 PM, Resident #67 stated she was not getting her baths regularly. e. On 02/08/22 at 8:48 AM, Resident #67 was asked, How often do you prefer to get your bath? She stated, Two times a week. She was asked, When was the last time you received your bath? She stated, It was Saturday [02/05/22]. f. On 02/10/22 at 7:54 AM, the DON was shown the bathing logs for December 2021 and January 2022. She was asked, Is it an acceptable practice for [Resident #67] not to receive a bath as she was scheduled? The DON stated, No that is not acceptable.

Based on observation, record review and interviews, the facility failed to ensure foot care was regularly provided and toenails were clean, trimmed, and free of jagged edges to prevent potential complications for 1 (Resident #20) of 46 (Residents #20, #58, #21, #57, #26, #15, #18, #3, #69, #63, #40, #77, #41, #1, #45, #2, #24, #59, #49, #11, #27, #17, #76, #127, #6, #51, #38, #71, #54, #61, #55, #22, #46, #327, #43, #12, #9, #25, #44, #8, #78, #47, #377, #67, #75 and #65) sampled residents who were dependent on staff for nail care. This failed practice had the potential to affect all 77 residents who were dependent or required assistance with nail care, according to a list provided by the Director of Nursing (DON) on 02/09/2022. The findings are: Resident #20 had diagnoses of Other Nail Disorders, Morbid Obesity and Dementia. The Quarterly Minimum Data Set with an Assessment Reference Date of 12/17/21 documented the resident scored 5 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status, required extensive two-plus person assistance with personal hygiene and was totally dependent on one-person physical assistance for bathing. a. The Care Plan with a revision date of 12/16/21 documented, The resident has an ADL [Activities of Daily Living] self-care performance deficit .BATHING/SHOWERING: .Check nail length and trim and clean on bath day and as necessary . Report to nurse if resident refuses to bathe . exhibits behavioral indicators . refusing care: bathing . resistive to care: personal hygiene / bathing . often refuses personal hygiene . The Care Plan did not address refusal of podiatry services. b. On 02/06/22 at 12:42 AM, Resident #20's toenails on both feet extended 1/4 inch beyond the tips of the toes and had jagged edges. Resident #20 was asked, Has anyone offered to clip your toenails? She stated, No. c. On 02/07/22 at 9:54 AM, Resident #20 was lying in bed; her toenails remained as previously described. d. On 02/08/22 10:07 AM, the DON accompanied the surveyor to Resident #20's room. Resident #20 was lying in bed; her toenails on both feet remained and previously described. The DON was asked, Who is responsible for cutting her nails? She stated, .she is a diabetic, so the Podiatrist does her toenails. She has been refusing to let him cut them. He is coming next week. She was asked to ask the resident if she would allow the Podiatrist to cut her nails. The DON asked the resident if the podiatrist could cut her toenails next week and she stated, Yes. e. On 02/08/22 at 12:53 PM, the DON stated, .She is not diabetic. I added her nail care to the Nurses MAR [Medication Administration Record]. It should have been done on her shower days. f. A facility policy titled, Care of Fingernails/Toenails, provided by the DON on 02/09/22 at 12:42 PM documented, The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections.1. Nail care includes daily cleaning and regular trimming.4. Trimmed and smooth nails prevent the resident form accidentally scratching and injuring his or her skin .

Based on observation, record review and interview, the facility failed to ensure laboratory (lab) services were provided as ordered by the physician in order to provide the physician with necessary information to guide treatment decisions for 1 (Resident #54) of 1 sampled resident who had physician orders for monitoring of Dilantin levels. This failed practice had the potential to affect 2 residents who required monitoring of Dilantin levels, according to a list provided by the Director of Nursing (DON) on 02/10/2022. The findings are: Resident #54 had diagnoses of Seizures and Cognitive Communication Deficit following a Cerebral Infarction. The Quarterly Minimum Data Set with an Assessment Reference Date of 12/13/2021 documented the resident scored 3 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status. a. A Laboratory Report dated 3/12/21 documented the resident's Dilantin level was less than 3.0. The reference range (therapeutic range) was documented as 10.0 to 20.0. b. A Laboratory Report dated 3/21/21 documented the resident's Dilantin level was 4.1. c. A Physician Order dated 3/24/21 documented, Phenytoin [Dilantin] Suspension 125 MG/5ML [milligrams per milliliter] Give 4 ml via PEG [Percutaneous Endoscopic Gastrostomy] Tube three times a day related to Epilepsy . This was documented as a current order on the Order Summary Report dated 2/9/22. d. A Physician Order dated 4/27/21 documented, .Dilantin Level Every 3 Months in March, June, Sept [September] & [and] Dec [December] R/T [related to] Seizures . Start Date 6/21/2021 . This was documented as a current order on the Order Summary Report dated 2/9/22. e. A Laboratory Report dated 6/22/21 documented the resident's Dilantin level was 4.6. As of 2/8/22, this was the most recent Dilantin level available for review. f. The Care Plan with a revision date of 12/13/21 documented, .The resident has a Epilepsy/seizure disorder .Give seizure medication .Monitor /document side effects and effectiveness .Monitor Dilantin level as ordered and report results to MD [Medical Doctor] . g. On 02/08/22 at 9:58 AM, Licensed Practical Nurse (LPN) #2 administered Phenytoin (Dilantin) 4ml to the resident via PEG tube. LPN #2 was asked when the resident had her last seizure and what her current Dilantin level was. She stated she was not sure but that she would provide the information. h. On 02/09/22 at 9:05 AM, the DON was asked if 06/22/21 was the last Dilantin level drawn before yesterday. She stated, Yes. She was asked, Isn't the Dilantin level supposed to be drawn every three months, so September and December were omitted also? She stated, Yes. The DON was asked for the Dilantin level that was drawn yesterday (Tuesday 02/08/22). She stated, It was therapeutic. The surveyor asked to see the lab report. The report documented the Dilantin level on 02/08/22 was, < [less than] 3.00 flag L [low] Reference 10.0-20.0 [Normal Range] . The DON was asked, Is less than 3 therapeutic? She stated, We have talked to the Nurse Practitioner, and they are okay with that because she has not had any seizures . She was asked, Who is responsible for ensuring that ordered lab work is drawn and monitored? She stated, [LPN #1] does our lab audits but she is being pulled to the floor at nights . i. The facility policy titled, Lab and Diagnostic Test Results - Clinical Protocol, provided by the DON on 02/10/22 at 8:31 AM documented, .1. The physician will identify, and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. 2. The staff will process test requisitions and arrange for tests .