Based on observations, interview, and record review, the facility failed to ensure handrolls were applied to 1 (Resident #8) of 2 sampled residents who had an order for hand rolls. The findings are: 1. Resident #8 had a diagnosis of Primary generalized (osteo)arthritis. A significant Change Minimum Data Set (MDS) with Assessment Reference Date of 1/26/24 documented functional limitations to upper and lower extremities. A Staff Interview for Mental Status (SAMS) documented the resident was moderately cognitively impaired. A Care Plan with review date of 2/5/24 documented, .Bilateral Hand Rolls at all times as resident will Tolerate/Allow with the Exception of During Bathing Times . On 02/29/24 at 10:58 AM, Resident #8 was in the sitting room with no hand rolls in the resident's hands. On 2/29/24 at 11:00 AM, the Surveyor asked Registered Nurse (RN) #1 if Resident #8 was supposed to have hand rolls in place. RN #1 stated, Sometimes [the resident] will allow them and sometimes [the resident] will refuse. Also, [the resident] will open his/her hands up and let them fall out. The Surveyor asked, Did [Resident #8] refuse them today? RN #1 stated, I don't know. On 2/29/24 at 11:06 AM, the Surveyor asked Certified Nursing Assistant (CNA) #1 if Resident #8 was supposed to have hand rolls in place. CAN #1 stated, I don't know for sure. The Surveyor asked, Did you assist him up today? CNA #1 stated, No, I helped transfer [the resident] from [the] chair into the other chair so that [the resident] could go to his/her appointment. The Surveyor asked, Do you know if [the resident] refused them today? CNA #1 stated, I'm not sure. On 3/1/24 at 8:00 AM, a policy received from the Director of Nurses (DON) titled, Positioning, Splints, Pressure Relieving devices and Body Alignment, documented, 4.2. Have proper equipment to relieve pressure and maintain body alignment (for example, blue boots, pillows, handroll, etc.) .

Based on observation, interview, and record review, the facility failed to ensure privacy was maintained for 1 (Resident #11) of 7 sampled residents who resided on Pine [NAME] and utilized the bathroom on their hallway; a lunch tray or substitute was served sequentially for 1 (Resident #128) of 17 sampled residents who received a meal tray on the Cedar Unit and failed to ensure Certified Nursing Assistants (CNA) were seated when providing assistance with eating for 5 (Residents #67, #150, #128, #61, and #52) of 10 sampled residents who resided on the Cedar Unit. The findings are: 1. Resident #11 had diagnoses of Epilepsy and Epileptic Syndromes with Complex Partial Seizures, Major Depressive Disorder, Anxiety Disorder, Altered Mental Status, unspecified, and Constipation. The resident received a score of 10 (8-12 indicates moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). a. On 02/26/24 at 12:40 PM, Resident #11 was observed sitting on the toilet when CNA #9 went in to assist Resident #11 with pulling up the resident's pants and putting on a new brief. The automatic door remained open, allowing the resident to be seen from the hallway. The stall door was opened, and CNA #9 was assisting Resident #11 just outside the stall. There was no privacy curtain between the open stall and the hallway. The automatic door closure holds the door open for 24 seconds before closing, which allows anyone in the hallway to see directly into the stall. Another resident pushed the automatic door open, exposing Resident #11 a second time to the Surveyor who was standing in the hallway, just outside the bathroom. b. On 02/27/24 at 12:00 PM, the automatic door was observed opening and staying open for 24 seconds as a resident entered. The bathroom with the automatic door closure did not have a privacy curtain, leaving residents exposed to anyone standing or passing in the hallway. c. On 02/29/24 at 10:04 AM, the Surveyor tested the time the door remained open. Once the button was pushed and the door started opening, giving a clear view to the stall, it took 24 seconds to close. d. On 02/29/24 at 10:07 AM, CNA #8 was asked if there was a problem with the way the door closes. CNA #8 stated, It leaves the person exposed. It should be closed so they are covered. I should push the wheelchair away and shut the door. The other bathroom has a privacy curtain, but this one does not, I don't know why. The Surveyor asked, would it be better to have a privacy curtain. CNA #8 nodded yes and said probably. The Surveyor asked what is the issue with this door remaining open. CNA #8 stated It is a privacy issue. e. On 5/11/2022, Resident #11 ' s Care Plan identifies problems with communication and memory; Resident #11 exhibits Cognitive Impairments as evidence by poor decision-making skills and difficulty understanding others at times; it identifies a goal on 05/22/2024 of Resident #11 to have positive experiences in daily; have a routine without overly demanding tasks and without becoming overly stressed; the care plan identifies Resident #11 to have Activity of Daily Living (ADL) self-care deficit, requiring assistance from staff to complete ADL tasks, due to cognitive and communication deficits, and physical limitations complicated by psychotic disorder. Resident #11 is identified to be a 1 person stand-pivot assist with gait belt for all transfers, as Resident will allow. Resident #11 had a bowel and bladder management program due to the resident being incontinent of both bowel and bladder due to Other psychotic disorder not due to a substance or known physiological condition, decreased physical mobility and cognitive decline; Resident #11 has complications related to incontinence this quarter; and Resident #11 may use adult incontinent briefs, which will be checked and change as frequently as needed to prevent any skin related problems. f. The facility policy, Activities of Daily Living (ADL), provided by the Director of Nursing (DON) on 2/29/24 at 2:52 PM documented, .(d) (1). Privacy is provided to each resident . g. The facility policy, Resident/Elder Rights, provided by the DON on 3/1/24 at 8:00 AM documented, .Privacy .Your privacy will include: personal care . 2. Resident #128 had diagnoses of Schizophrenia and Diabetes Mellitus. On the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/29/23 the resident received a score of 14 (13-15 indicates cognitively intact) on a BIMS and was dependent on staff for assistance for eating. a. On 2/26/24 at 11:45 AM, Resident #128 was observed sitting at the dining table awaiting his lunch tray. At 11:53 AM, the other residents at the assist table where Resident #128 was seated had received their lunch trays. Multiple staff members were overheard by this Surveyor to say that they are having problems locating a tray on the cart for this resident. Resident #128 was observed to wave his/her arms and in a frustrated tone express the belief that there was a tray which has been previously unnoticed by the staff remaining on the cart. b. On 2/26/24 at 12:07 PM, Resident #128 was told that their tray was mistakenly given to someone else and that another tray would be provided. Resident #128 was not offered fluids or alternatives. c. On 2/26/24 at 12:24 PM, Resident #128 received a tray, 31 minutes after the rest of the residents at the table were served. 3. On 02/26/24 at 11:54 AM, CNA #2 moved between two residents sitting at the assist table. CNA #2 was standing while feeding the residents. At 11:58 AM, CNA #2 moved to a third resident at the table and continued to stand while assisting the resident with lunch. a. On 02/26/24 at 12:05 PM, CNA #4 moved between two residents, standing while assisting them with their noon meal. b. On 02/28/24 at 12:34 PM, Licensed Practical Nurse (LPN) #1 was asked where a CNA should position themselves when providing meal assistance. LPN #1 stated, They should sit down beside or across from the resident. c. On 2/28/24 at 12:45 PM, CNA #6 was asked where a CNA should position themselves while assisting a resident with meals. CNA #6 stated, You should sit down beside them. You should make conversation, tell them what they are about to receive. d. On 3/1/24 at 8:00 AM, the Director of Nursing (DON) provided a policy titled, Meal Service. It documented, Purpose: The purpose of this policy is to ensure adequate nutrition for the residents within long term care guidelines . All possible efforts will be made to make mealtimes pleasant. e. A policy titled, Resident/Elder Rights documented, .The residents/elders of [Facility] have the right to a dignified existence . [Facility] will protect and promote the rights of their residents . Dignity - [Facility] will treat you with dignity and respect in full recognition of your individuality .

Based on observation, interview, and record review the facility failed to ensure resident clothing was clean and maintained in a respectable manner to promote dignity and self-confidence for 1 (Resident #87) sampled resident who were dependent on staff for care, and failed to ensure residents fingernails were trimmed and cleaned to promote good hygiene for 1 (Resident #93) sampled resident who were dependent on staff for nail care. This had the potential to affect 33 residents who were dependent on staff for care The findings are: 1. Resident #87 had a diagnosis of Hemiplegia, unspecified affecting right dominant side. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9-19-2023 documented a Brief Interview Mental Status (BIMS) score of 10 (8-12 indicates moderate cognitive impairment). a. On 2/26/24 at 7:26 PM, Resident #87 was wearing a t-shirt that had spots of spilled food that were white and dry. b. On 2/27/24 at 11:33 AM, Resident #87 was wearing a lightweight jacket that had spilled food on the front of it, dried on, white in color. c. On 2/28/24 at 9:44 AM, Resident #87 was wearing a lightweight jacket that had spilled food on the front of it, dried on, white in color. d. The Care Plan with a review date of 1/4/22 for Resident #87 documented a self-care deficit: the Resident required limited assistance from staff to complete ADL (Activities of Daily Living) tasks, d/t (due to) cognitive and communication deficits, and physical limitations complicated by Dementia in other diseases classified elsewhere with behavioral disturbance Note: Major Neurocognitive d/t TBI (Traumatic Brain Injury). e. On 02/28/24 at 2:24 PM, the Surveyor asked Registered Nurse (RN) #2, when are resident clothes changed. RN #2 said after they eat, if needed. When they get up in the morning, after they receive their shower. f. On 02/28/24 at 02:28 PM, the Director of Nursing (DON) provided a policy titled Activities of Daily Living (ADL) that documented, 4. PROCEDURE. A. Hygiene. 1. Resident self image is maintained . 6. Frequent showers or baths are scheduled and assistance provided when required . 2. Resident #93 had diagnoses of Schizoaffective Disorder, Bipolar Type and Type 2 Diabetes without complications. A Quarterly MDS with an ARD of 12/12/2023 documented a BIMS of 10. a. On 02/26/24 at 08:33 PM, Resident #93's fingernails were dirty, 1/4 inch long, with a dark substance under the nails. b. On 02/28/24 at 11:02 AM, Resident #93's fingernails were 1/4 inch long, with a dark substance under the nails. c. On 02/28/24 at 11:06 AM, Resident #93 was asked if staff cut and clean their fingernails when they shower. Resident #93 stated, No, they do not have time. The Surveyor asked if the resident refused to let the CNA in the shower perform nail care. Resident #93 stated, No. The Resident confirmed they were diabetic. d. On 02/28/24 at 12:20 PM, the Surveyor asked RN #2 when residents had their fingernails trimmed. RN #2 stated, Weekly. The Surveyor asked for documentation of when residents fingernails were last cut. RN #2 stated, I do not have paperwork showing that the residents nails were cut. I have asked [Resident #93] if I can cut them today, resident has agreed. e. On 02/28/24 at 01:15 PM, the Administrator provided a policy titled, Nail Care that documented, .4. Procedure .e. Clip resident's nails without injuring the surrounding skin .

Based on observation, interview, and record review, the facility failed to ensure smoking assessment interventions were followed for 1 (Resident #149) sampled resident. The findings are: Resident #149 had a diagnosis of Chronic obstructive pulmonary disease, unspecified. A Significant Change Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 1-9-2024 documented a Brief Interview for Mental Status (BIMS) score of 11 (8-12 indicates moderate cognitive impairment). On 02/28/24 at 09:48 AM, Resident #149 was observed outside smoking and was not wearing a smoking apron. The Care Plan with a review dated of 2/6/2024 documented Resident is at risk for injury to self and others related to smoking-must wear smoking apron and be directly supervised at ALL times . Resident must wear smoking apron and be directly supervised at ALL times . Enforce smoking restrictions. On 02/28/24 at 09:56 AM, the Surveyor asked Certified Nursing Assistant (CNA) #7, does the resident (Resident #149) require a smoking apron. CNA #7 stated, I do not know, I will have to check . On 02/28/24 at 01:33 PM, the Director of Nursing (DON) provided a policy titled, Resident Smoking that documented, .Documentation from the assessment will be included in the initial and quarterly Care Plan specifying Supervised or Unsupervised Smoker, or requires smoking apron or other adaptive or enabling device . Protective equipment will be made available for the individuals requiring this type of equipment .

Based on observation, interview, and record review, the facility failed to ensure and maintain their Schedule II-V medications in a permanently affixed compartment. The findings are: 1. On 2/29/2024 at 9:30 AM, on the Aspen East/West Halls the Surveyor observed the narcotic box, locked in the refrigerator, behind the locked medication room door. The narcotic box was locked, but not permanently affixed to the refrigerator that it was stored in. 2. On 2/29/24 at 2:03 PM, on the Elm Unit, Licensed Practical Nurse (LPN) #3 unlocked the refrigerator in the medication storage room and put the narcotic box on the counter. There were 7 vials of Ativan (a controlled substance) in the medication lock box. The narcotic box was not permanently affixed to the refrigerator. a. On 2/29/24 at 2:18 PM, on the [NAME] Unit, LPN #4 unlocked the refrigerator and walked out of the medication storage room with the box. LPN #4 stated, The nurse is on break, and I got to go find the key. The narcotic box was not permanently affixed to the refrigerator. b. On 2/29/24 at 2:49 PM, Registered Nurse (RN) #1 opened the narcotic box on the [NAME] Unit. There were 11 vials of Ativan and 1 bottle of Ativan in the narcotic box. The narcotic box was not permanently affixed to the refrigerator.

8. On 02/26/24 at 11:54 AM, Certified Nursing Assistant (CNA) #2 was observed moving between two residents (Residents #61, and #67) who required assistance with dining. CNA #2 rearranged their chairs, moving them into place for ease in feeding. Without sanitizing hands, CNA #2 peeled and handed a banana to a resident, then turned to another resident to complete the process of thickening his drink. Hands were not sanitized between residents. CNA #2 continued to set up the resident's tray, offering food items and fluids. CNA #2 turned back toward the resident on the right, picked up their spoon and provided a bite of vegetable and then banana. At 11:58 AM, CNA #2 walked around the resident on her right and proceeded to assist a third resident at the table. During the entirety of the meal CNA #2 did not sanitize hands. 9. On 2/26/24 at 11:59 PM, CNA #3 provided assistance with tray set up and feeding for two residents (Residents #95, and #150). CNA #3 moved between residents, bringing bites of food to their mouth. CNA #3 did not sanitize hands between assisting residents. 10. On 2/26/24 at 12:05 PM, CNA #4 provided assistance to 2 residents during the noon meal. CNA #4 brings the spoon to the mouth of the resident on the right then returns the spoon to the plate. CNA #4 then turns to the resident on their left, picks up the spoon and brings the bite of food to the resident's mouth and then returns the spoon to the plate. CNA #4 was observed to not sanitize hands between residents. At 12:15 PM, CNA #4 holds the hand of the resident on to the right. CNA #4 returned to the resident on the left without sanitizing hands. 11. On 02/28/24 at 12:08 PM, CNA #5 used a bare hand to hold the edge of a slice to bread to spread butter. CNA #5 then picked up the slice of bread with a bare hand and moved the bread from one plate to the next. 12. On 02/28/24 at 12:10 PM, CNA #6 placed a slice of bread on the bare palm of their hand to spread butter. Upon completion CNA #6 used both bare, unsanitized hands to fold the bread in half and give it to a resident. 13. On 02/28/24 at 12:34 PM, Licensed Practical Nurse (LPN) #1 was asked when a CNA should sanitize their hands during the feeding process. LPN #1 stated, They need to sanitize between residents, when changing tasks, when they encounter something soiled. LPN #1 was asked about holding a food item in bare hands. LPN #1 stated, I would think they need to have on gloves. 14. On 2/28/24 at 12:45 PM, CNA #6 was asked when hands should be washed or sanitized when providing resident assistance during meals. CNA #6 stated, You are supposed to sanitize hands between residents. When asked about the appropriateness of holding a food item in a bare hand the CNA stated, Yeah, you aren't supposed to do that. Based observation, interview, and record review, the facility failed to ensure foods stored in the freezer, refrigerator and dry storage area were covered, sealed, and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; expired food items were promptly removed/discarded on or before the expiration or use by date to prevent the growth of bacteria; ensure cold dairy products were maintained at 41 degrees Fahrenheit or below to prevent the growth of bacteria; dietary staff washed their hands before handling clean equipment or food items to prevent the potential for cross contamination for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 155 residents who received meals from 1 of 1 kitchen (Total Census:157). The findings are: 1. On 02/28/24 at 09:25 AM, two opened boxes of cobbler dough sheets were on a shelf in the walk-in refrigerator. Neither box was covered or sealed. 2. On 02/28/24 at 09:29 AM, an opened gallon of soy sauce was on a shelf in the kitchen. The manufacturer specification on the gallon documented, Refrigerate after opening for quality. 3. On 02/28/24 at 11:01 AM, a carton of orange juice in a cabinet on [NAME] Court had an expiration date of 02/27/24. 4. On 02/28/24 at 11:18 AM, a packet of ginger soy chicken mix in the cabinet on Cedar Court had an expiration date of 05/21/21. 5. On 02/28/24 at 11:51 AM, the temperature of the dairy products taken out of the food cart on Pine Court to serve to the residents for the lunch meal were checked and read by the Registered Dietitian with the following results: a. Nutritional shake - 60 degrees Fahrenheit. The manufacturer specification on the box documented thaw and keep refrigerated. b. Milk - 49 degrees Fahrenheit. 6. On 02/28/24 at 11:54 AM, Dietary Employee (DE) #1 was wearing gloves when he/she plugged the toaster cord into the outlet, contaminating the gloves. Without washing hands, DE #1 placed slices of bread in the toaster, then removed the slices of bread from the toaster and placed them on the plate. DE #1 then used the same contaminated gloved hand to pick up a slice of bread and used it to top a turkey sandwich. At 12:04 PM the surveyor asked DE #1, what should you have done after touching dirty objects and before handling food items. DE #1 stated, I should have changed gloves and washed my hand. 7. A facility policy titled, Employee Cleanliness documented, .Hands should be washed according to proper procedures. a. Beginning shift. b. After breaks. c. After disposing of trash or food. d. Before putting on gloves. e. Any other time deemed necessary .

Based on record review and interview, the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) within 14 days of determining a decline in Activities of Daily Living (ADLs) for 1 (Resident #180) of 8 (R #10, R #17, R #20, R #46, R #54, R #123, R #152, and R #180) sampled residents. This failed practice had the potential to affect all 65 residents that reside on [named] Unit as documented on the [named] Unit Resident Census which was provided by Licensed Practical Nurse (LPN) #2 on 11/14/22 at 10:05 AM. The findings are: Resident #180 had a diagnosis of Bipolar and Vascular Dementia. The Quarterly MDS with an Assessment Reference Date (ARD) of 10/19/22 documented Resident #180 scored a 6 on a Brief Interview for Mental Status (BIMS) (0-6 Indicates Severely Cognitively Impaired) and required total dependence with toileting and eating and extensive assistance with transfers and bed mobility. 1. Chart review on 11/16/22, showed the most current Significant Change in Status MDS was dated 11/16/22. 2. On 11/16/22 review of the October 2019 Resident Assessment Instrument (RAI), Page 47 showed, . An SCSA (Significant Change in Status Assessment) is appropriate if there are . two or more areas of decline or two or more areas of improvement . 3. On 11/16/22 at 01:34 PM, The Surveyor asked the MDS Coordinator, What is a Significant Change in Status MDS? She answered, When 2 or more care levels are identified as a decline or improvement in 2 or more areas then the Interdisciplinary team met and decide if a significant change needs to be done. The Surveyor asked her to review Resident #180's previous MDSs for a Significant Change MDS. She did then and responded, Then once it's been identified then I have 14 days to open it up then 14 days to complete it so I'm only 1 day behind. a. The RAI Manual page 2-7 which was provided by the MDS Coordinator documented, . Guidelines for Determining Significant Change in Resident Status . Decline in two or more of the following Overall deterioration of resident's condition; resident receives more support (e.g., in ADLs .) .

Based on observation, interview and record review the facility failed to ensure resident's fingernails were cleaned and trimmed to promote good personal hygiene and grooming for 1 resident (R #3) of 6 (R #3, R #16, R #20, R #48, R #104, and R #158) sampled residents on the unit who were dependent for nail care. The findings are: 1.Resident #3 had diagnoses of Cerebral Palsy, Non-Alzheimer's Dementia and Parkinson's Disease. An Annual MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 09/08/2022 documented a BIMS (Brief Interview for Mental Status) of 10 (8-12 indicates moderately impaired), total assistance of two people required for bathing and extensive assistance of one person required for personal hygiene. a. On 11/14/22 at 10:28 AM, Resident #3 was sitting up in a wheelchair in the day room. She had her hands hanging down on both sides of the chair. The fingernails on each hand were greater than ¼ inch past her fingertips. The nails on her 3rd [third] and 4th [fourth] finger of her right hand and the thumb and 3rd finger of her left hand were jagged and rough. b. On 11/15/22 at 9:10 AM, Resident #3 was lying in bed, her fingernails remained long and jagged. c. The Care Plan with a revision date of 12/22/21 documented, Resident is extensive to total assistance from one or more staff with all ADL (Activities of Daily Living) care due to Cognitive and Physical deficits related to Multiple Mental and Medical Diagnoses including Cerebral Palsy and Dementia. Check toenails and fingernails according to schedule or as needed and provide appropriate care . d. On 11/16/22 at 8:36 AM, The surveyor asked Registered Nurse (RN)#1, Who is responsible for nail care? RN #1 stated, This is my second day here; I haven't done any here. But normally, the nurses do the diabetics, and the assistants can do everyone else. The Surveyor then asked, What can happen if nails are left long and jagged? She stated, They could scratch themselves which could cause an infection. RN #1 stated, I'll notify the RN Supervisor (RN #2) and get that taken care of today. e. On 11/16/22 at 8:43 AM, The RN Supervisor (RN #2) was in the day room. The surveyor asked RN #2, When is nail care provided? She replied, We check them during care and provide it as needed. R #3 was in the day room and the surveyor asked her to describe R #3's nails, she looked at her hands and stated Oh, they do need trimming, I'll get that taken care of. f. On 11/17/22 at 11:30 AM, The (Named) Unit Master Bath Schedule was provided by the Administrator which documented R #3 received a bath on Wednesday and Friday.

Based on Observation, Interview and Record review the facility failed to ensure that 1 resident (Resident #17) was repositioned, range of motion preformed, and incontinent care provided while up in wheelchair. This failed practice had the potential to affect 4 (R #17, R #25, R #26, and R #36) residents that resided on the (named East and West) Units who were totally dependent on staff for ADL's (Activities of Daily Living) as indicated on a list provided by the Director of Nursing (DON) on 11/17/22 at 8:58 AM. The findings are: 1. Resident # 17 had diagnoses of Profound intellectual Disabilities, generalized Idiopathic Epilepsy and Epileptic Syndromes, not Intractable, without status Epilepticus, Unspecified mental disorder due to known physiological condition. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/12/22 showed the resident scored a 00 (00 indicated a severe cognitive deficit) on the Brief Interview of Mental Status (BIMS), the resident was totally dependent for toileting and eating and required extensive assistance for transfers and bed mobility. 2. Review of Physicians orders on 11/16/22 at 09:30 AM, showed, Physician Orders (no date), May be up in Wheelchair with Dycem under and on top of Raised Foam Cushion, Padded Lap Tray with Velcro Strap, and Foot Box when out of bed. Padding on wheelchair to prevent skin injury. Every Shift Enablers & and Other Device. 3. Review of the Care Plan on 11/16/22 at 09:35 AM, with a start date of 4/20/22 and last reviewed/revised on 10/28/22 showed, Category skin PROBLEM: At risk for alterations in skin integrity r/t poor safety awareness, fragile skin and incontinence of bowel and bladder. Target Date: 01/18/2023 (Short Term Goal) GOAL: Resident's skin will remain intact through the review date. Start Date: 09/27/2022 APPROACH: May be up in Wheelchair with Dycem under and on top of Raised Foam Cushion, Padded Lap Tray with Velcro Strap, and Foot Box when out of bed. Padding on wheelchair to prevent skin injury. Start Date: 06/07/2022 APPROACH: Provide incontinence care for bowel and bladder every 2 hours and as needed Start Date:06/07/2022 APPROACH: Use pressure relieving measures with repositioning every 2 hours and as needed to maintain comfort and functional alignment. 4. The following observations were made of Resident #17: a.On 11/14/22 at 10:05 AM, R #17 was in Day Room with a lap top tray attached to the wheelchair. The Resident was unable to undo the tray. b. On 11/14/22 at 01:05 PM, R #17 remained in the dining room with the tray attached. c. On 11/15/22 at 07:57 AM, R #17 was in day room in chair with tray attached to w/c [wheelchair]. d. On 11/15/22 at 09:00 AM, Resident #17 was going to get her hair cut in her w/c then back to dining/day room. e. On 11/15/22 at 01:25 PM, R #17 was put to bed on her left side. f. On 11/16/22 at 08:06 AM, R #17 was in the dining room in her w/c with the tray attached. g. On 11/16/22 at 08:09 AM, R #17 was assisted to her room and a call light was placed within her reach. 5. The following interviews were conducted regarding Resident #17: a. On 11/15/22 at 01:30 PM, the Surveyor asked Certified Nursing Assistant (CNA) #2, Have you changed or repositioned Resident #17 any time today before she was laid down at 1:25 PM? CNA #2 stated, No. b. On 11/15/22 at 1:33 PM, the Surveyor asked CNA #5, have you changed or repositioned Resident #17 any time today before she was laid down at 1:25 PM? CNA#5 stated, No. The Surveyor asked Surveyor asked CNA #5, Why is the tray being used for Resident #17? She stated, to keep her in her chair; she leans forward and its dangerous. The Surveyor asked CNA #5, Has Administration tried anything prior to using the tray? She stated, I don't know. c. On 11/15/22 at 1:35 PM, The Surveyor asked CNA #4, Have you changed or repositioned Resident #17 any time today before she was laid down at 1:25PM? The CNA stated, No. d. On 11/15/22 at 1:36 PM, The surveyor asked the Restorative Nursing Assistant (CNA #6), Have you changed or repositioned Resident #17 any time today before she was laid down at 1:25 PM? CNA #6 stated, no. e. On 11/15/22 at 1:47 PM, the Surveyor asked CNA #3, Have you changed or repositioned Resident #17 any time today before she was laid down at 1:25 PM? CNA #3 stated, No. f. On 11/17/22 at 08:40 AM, the Surveyor asked the DON, How often do you expect your staff to check for residents who are incontinent or need to be repositioned? She stated, Every 2 hours. Surveyor asked DON, Is it ever ok for a totally dependent resident to sit and not be checked on for longer than 2 hours? She stated, no. g. On 11/17/22 at 10:00 AM, The Surveyor asked Registered Nurse (RN #3), How do you monitor the staff to ensure the residents are being repositioned or given peri care? She responded, Making rounds, opening doors, and checking behind doors. The Surveyor asked RN #3, How often should a resident be checked on for incontinent care or repositioning? She stated, Every (q) 2 hours. The Surveyor asked, Is it ok for a totally dependent resident to sit and not be checked for longer than 2 hours? She stated, no. The surveyor asked RN #3 What could potentially occur from prolonged sitting? She stated, Develop a pressure sore. 6. On 11/17/22 at 08:58 AM, a form provided by the DON titled, POSITIONIG IN CHAIR POLICY B .Resident remains in a sitting position no longer than two hours at a time before repositioning, unless otherwise ordered .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure indwelling catheter drainage bags were kept below the level of the bladder to prevent potential infection risk and secured to prevent pulling and potential for meatal injury for one resident (Resident #61) of three sample residents (Resident #51, #61, #71) reviewed. This failed practice had the potential to affect three residents who had catheters according to a list provided by the Director of Nursing (DON) on 11/17/22 at 8:10 AM. The findings are: 1. Resident #61 was admitted to the facility on [DATE] with Diagnoses of Urinary Retention, Schizoaffective Disorder Bipolar Type, and Personal History of Urinary Tract Infections. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/03/22 documented the resident was moderately impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS). a. On 11/14/22 at 10:37 AM, Resident #61 was lying in bed with eyes closed, the foley catheter drainage bag tubing was coming from the left leg of his pants at the left ankle and was stretched tight across the mattress over to the wheelchair sitting adjacent to the bed and secured on the armrest of the wheelchair with a hook. The drainage bag was slightly above the level of the bladder. b. On 11/16/22 at 8:02 AM, Resident #61 was lying in bed on his right side. The foley catheter drainage bag tubing was coming out of the left pant leg at the ankle. The tubing was stretched tight across the bed to the arm rest of the wheelchair sitting adjacent to the bed. The catheter tubing had a white and pink colored substance in the tubing. Certified Nursing Assistant (CNA) #1 emptied the catheter drainage bag. The catheter leg band was loose and just above left knee, the catheter ran out of an incontinent brief on left side thigh area. The Surveyor asked CNA #1 if it was acceptable for the catheter tubing to be pulled tight and hanging from armrest of the wheelchair with the leg band loose, above the knee and not preventing the catheter from pulling on urinary meatus. CNA #1 stated. No, it isn't and removed the foley drainage bag from the armrest of wheelchair and secured it underneath the wheelchair. CNA #1 stated, This is how it is supposed to be secured, below the bladder. The Surveyor asked, If the facility usually used incontinent briefs for residents who had indwelling catheters? CNA #1 stated, No, but resident # 61 is incontinent of bowel. c. On 11/16/22 at 1:00 PM, review of Resident #61's current Physician Orders documented, .Foley Catheter and Drainage Bag Change Q [every] 3 weeks on 7A-7P Diagnoses Urinary tract infection, site not specified start date 11/10/22 . d. On 11/16/22 at 1:10 PM, review of progress notes dated 07/05/2022 at 09:28 documented, .New orders: per [Dr] . resident to be transported to (Named) emergency room (ER) due to continued bacterial growth in urine after being treated with Gentamicin and Daptomycin as well as previous oral antibiotics . e. On 11/16/22 at 2:30 PM, review of Resident #61's Care Plan with a start date of 1/18/21 documented, . Approach: Use a catheter strap. Assure enough slack is left in the catheter between the meatus and strap. Approach: Position bag below level of bladder. Approach: Avoid obstructions in the drainage. Start Date 1/18/2021 f. On 11/17/22 at 9:38 AM, The Surveyor interviewed the DON and asked, If it was facility practice to use incontinent briefs for residents with indwelling catheters with bowel incontinence? She stated, Yes, we do use incontinent briefs on bowel incontinent residents with catheters. The Surveyor asked, If it is acceptable for catheter drainage bags to be secured at or above level of the bladder and pulled tight without being secured to prevent pulling on urinary meatus? The DON stated, No it is not. I need to see if the resident transfers himself. g. On 11/17/22 at 9:00 AM, the facility policy Urinary Catheter Insertion and Removal NS 701 was reviewed and documented .o. secure catheter to inner thigh of resident with a leg strap to prevent movement and urethral, as resident will allow .p.3. Collection bags are always kept below the level of the bladder .

Based on observation, record review and interview, the facility failed to ensure foods stored in a dry storage area was covered to minimize the potential for cross contamination for residents who received meals from 1 of 1 kitchen; expired snacks were promptly removed/ discarded on or before the expiration or use by date to prevent the growth of bacteria; dietary staff washed their hands between dirty and clean tasks and before handling clean equipment or food items to prevent potential for cross contamination. These failed practices had the potential to affect 174 residents who received meals from the kitchen (total census: 184) as documented on a list provided by the Registered Dietitian. The findings are: 1.The following items were observed uncovered or expired: a. On 11/14/22 at 10:08 AM, An opened box was on a cart in the kitchen. The box was not covered. b. On 11/15/22 at 10:12 AM, A box that contained 15 bags of assorted chips in a cabinet on [named unit] had an expiration date of 9/2022. 2. The following observations were made in the kitchen: a. On 11/14/22 at 10:19 AM, Dietary Employee #1 was wearing gloves on her hands. She picked a log of ham and placed it on the cutting board on the counter. She used a knife to open the wrap that covered the ham, contaminating the meat. She did not change her gloves or wash her hands. She used the contaminated knife to slice the meat. She placed slices of ham in a grinder and ground the ham to be served to the residents. At 9:06 AM, The Surveyor asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. b. On 11/15/22 at 7:01 AM, Dietary Employee #2 pushed a cart that contained boxes of beef base into the refrigerator. She did not wash her hands, she picked up a pan with her thumb inside the pan and placed it on the counter. She scooped macaroni and cheese into the pan to be served to the residents for lunch. c. On 11/15/22 at 7:07 AM, Dietary Employee #2 turned on the food preparation sink faucet and obtained water. She turned off the sink with her bare hand. She did not wash her hands, she picked up a spoon by the tip that goes into the food and used it to transfer mixed vegetables from the kettle into a pan to be pureed and served to the residents on pureed diets. d. On 11/15/22 at 10:00 AM, Dietary Employee #3 turned on the food preparation sink, rinsed the tomatoes, then she turned off the faucet., she picked up gloves and placed them on her hands which contaminated the gloves. She used her contaminated hand to pick up the tomatoes, sliced them, and placed them in a bowl to be served to the residents. The Surveyor asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. 3. The facility policy on hand washing provided by the Registered Dietitian on 11/15/2022 at 3:07 PM documented, 'Before putting on gloves and between glove change. Any other time deemed necessary.