Based on observation, interview, record review and facility policy review, the facility failed to ensure medications were administered without errors resulting in an error rate of more than 5% for 2 (Resident #126 and Resident #227) of 7 residents who were observed during the 8:00 AM medication administration. The findings are: 1. An undated Administering Medications policy was reviewed and read in part, Medications are administered as prescribed and are administered according to prescriber orders. 2. A Medication Crushing Guidelines policy dated 2001, was reviewed and read in part Medications that should not be Crushed or Chewed B. Enteric coated medications are designed to pass through the stomach without breaking down until they reach the intestinal tract. This route may be chosen due to changes made when in contact with stomach acid, to prevent the irritation of the stomach lining and to prolong the action of the medication. Timed release tablets are designed to release their medication over a period, usually 8-24 hours. The tablets should not be crushed. 3. The Long-Term Care Survey Process was reviewed and indicated the Medication Administration error rate was 5.56%. There were 36 opportunities and 2 errors. 4. An admission Record was reviewed and read in part, Resident #126 was admitted with diagnoses that included Vitamin B 12 deficiency. a. An Order Summary Report with an active and start date of 5/14/2025, was reviewed and read in part that Resident #126 had a Physician's Order for [Vitamin B supplement] oral tablet 500 mcg [microgram] give 2 tablets by mouth one time a day. b. A Medication Administration Record was reviewed and read in part [Vitamin B supplement] Oral Tablet 500 mcg (micrograms). Give 2 tablets by mouth one time a day, order date 5/13/2025. c. On 05/14/25 at 8:14 AM during the observation of the 8:00 AM medication administration, Licensed Practical Nurse (LPN)#4 was observed administering [Vitamin B12 supplement] 1 tablet to Resident # 126. The Physician's Order dated 05/13/2025, was for 2 tablets. At the conclusion of the observation, LPN #4 confirmed that all the medications had been administered that were due for the 8:00 AM medication pass. d. On 5/14/2025 at 10:58 AM, LPN #4 was asked to review the Physician's Order for Resident # 126 dated 5/13/2025, for [Vitamin B 12 supplement] 500 mcg. LPN #4 confirmed that the order was written to give 2 tablets. LPN #4 confirmed only 1 tablet was administered on the 5/14/2025 8:00 AM medication administration, stating that's on me. e. On 05/14/25 at 11:59 AM, the Advance Practice Registered Nurse (APRN) did not recall the order for Resident #126, but stated Vitamin B12 was usually given for anemia, and should be administered as ordered. 5. An admission Record was reviewed and read in part that Resident #227 had diagnoses that included cerebrovascular disease (group of conditions that affect blood flow to the brain), hemiplegia/hemiparesis (a condition that causes muscle weakness or paralysis to one side of the body) and thrombophilia (a condition that causes the blood to be more likely to clot). a. An Order Summary Report with an active as date of 5/14/2025, was reviewed for Resident #227 and it read in part Resident #227 had a Physician's Order for [non-steroidal anti-inflammatory drug] oral tablet delayed release 81 mg [milligram] give 1 tablet by mouth. b. On 05/14/25 at 8:08 AM, during the observation of the 8:00 AM medication administration, LPN #4 was observed administering medications to Resident #227, LPN #4 punched out Resident #227's medications including the delayed release medication into a plastic cup then poured into an envelope. LPN #4 then crushed the medications. The crushed medications were poured into a cup with applesauce and administered to Resident #227. c. On 05/14/25 at 10:58 AM, LPN #4 confirmed that the enteric coated medication had been crushed, and that the medication should not have been crushed. d. On 05/14/25 at 11:59 AM, the Advance Practice Registered Nurse (APRN) confirmed that enteric coated and delayed release were basically the same acting medication. Their purpose was to pass through the stomach without dissolving before passing into the intestinal tract. 6. On 05/15/25 at 9:23 AM, the Director of Nursing (DON) confirmed her expectation of the nursing staff was to administer medications correctly, according to the Physician's Orders, and to follow the facilities policies. 7. On 05/15/25 at 9:41 AM, the Administrator confirmed her expectation of the nursing staff was to administer medications according to the Physician's Orders and to follow facility policies.

Based on observation, interview, and facility policy review, it was determined that the facility failed to prepare and serve food in a safe and sanitary manner as evidenced by staff eating in the kitchen's preparation area and not performing hand hygiene after touching personal items and before serving residents. The failed practice had the potential of affecting 71 of 73 residents. On 5/12/2025 at 5:52 PM, upon entrance to the facility's kitchen, [NAME] #1 was observed eating food out of a small dish while standing on the serving line. [NAME] #1 picked up a cellphone from the top shelf of the steam table that was playing music, turned the music off, and sat the phone back down. [NAME] #1 then picked up a spoon handle and stirred the food on the steam table. On 5/13/2025 at 8:20 AM, during an interview with the Dietary Manager (DM), who had been with facility for 5 years, the DM confirmed that staff had been in-serviced on safe food handling and handwashing and hand hygiene. The DM confirmed that it was not appropriate to eat while standing at the serving line. The DM also confirmed that staff should wash their hands after touching a personal item such as a cellphone. On 5/13/2025 at 8:29 AM, [NAME] #2 confirmed that it was not appropriate to eat while serving food and hand hygiene should be done anytime you touch something dirty, before touching something clean. [NAME] #2 also confirmed they had signed in-services on hand hygiene and safe food handling. On 5/13/2025 at 8:33 AM, [NAME] #3 confirmed they had signed in-services and read policies on handwashing and safe food handling. [NAME] #3 confirmed that food should not be eaten while serving food. On 5/14/25 at 8:49 AM, [NAME] #1 confirmed eating a dessert while standing at the serving line in the kitchen and touching the cellphone. [NAME] #1 also acknowledged that it was against the facility's kitchen policy. [NAME] #1 confirmed being trained and educated on safe food handling and hand hygiene. On 05/14/25 at 4:06 PM, the Administrator stated they were responsible for the facility's kitchen operations. The Administrator stated that all kitchen staff were in-serviced and educated on handwashing and safe food handling policies. The Administrator confirmed that it was against facility policy to eat on the serving line. The DM provided a Cleanliness and Handwashing policy that indicated no staff will eat in the preparation area of the kitchen. The DM provided an in-service which indicated that hands must be washed after handling a cellphone because cellphones are considered dirty.

Based on observation, record revie, and interview, the facility failed to ensure that before a resident was allowed to self-administer Bronchodilator medication via nebulizer, the Interdisciplinary Team [IDT] conducted an assessment to determine if this practice was safe, to ensure a physician order [PO] was obtained and a care plan was developed to address self-administration of medication via nebulizer, to prevent potential errors in administration for 1 Resident #2 sampled residents. who had PO for Bronchodilator nebulizer treatments [tx]. The findings are: 1. Resident #2 had diagnosis [dx] of Acute Respiratory Failure with Hypoxia and Shortness of Breath [SOB]. A Significant Change Minimum Data Set [MDS] with an Assessment Reference Date [ARD] dated 01/30/24 documented . Section C - Cognitive Patterns .C0500. [Brief Interview for Mental Status [BIMS] Summary Score: 10 . a. On 02/20/24 at 11:59 AM, Resident #2 was seated in a wheelchair [w/c] in her room, holding a nebulizer tubing with smoke coming from it. There was not a nurse in the room with resident. b. A Physician's Order dated 02/22/24, documented Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML milligram/milliliter (Ipratropium-Albuterol) 3 ml inhale orally four times a day related to SHORTNESS OF BREATH, RINSE/SPIT AFTER ADMINISTRATION. c. A care plan saved to the survey folder documented [resident's name] has a Respiratory Infection Acute Respiratory Infection & Pneumonia .Bronchodilators via [by] nebulizer as ordered by the physician. Monitor/document side effects and effectiveness. Record BP [blood pressure], pulse and respiration rate . d. On 02/20/24 at 12:00 PM, Licensed Practical Nurse [LPN] #1 was asked if resident could administer an updraft treatment [tx] by themselves. LPN #1 stated, Yes, I think so but let me check. e. On 02/22/24 at 02:18 PM, LPN #2 was asked, to your knowledge are there any residents in the facility that can self-administer medications? LPN #2 stated, Not to my knowledge. The surveyor asked, if there are, where would that documentation be? LPN #2 stated, There would be a waiver in electronic record and have a physician's order for them. The surveyor asked to your knowledge, are there any residents that can have an updraft treatment by themselves? LPN #2 No, they shouldn't do that. f. On 02/22/24 at 02:44 PM, the surveyor asks if there was a self-administration assessment for Resident #2. The Nurse Consultant stated, There isn't a self-administration assessment on resident. What was resident doing, an updraft? I told them under no circumstances do they leave a resident by themselves while doing an updraft treatment.f. On 02/22/24 at 02:44 pm the surveyor asks if there was a self administration assessment for Resident #2. The Nurse Consultant stated, There isn't a self administration assessment on resident. What was resident doing, an updraft? I told them under no circumstances do they leave a resident by themselves while doing an updraft treatment. g. A policy provided by the Nurse Consultant on 02/22/24 at 03:30 pm titled Self-Administration of Medications 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 .

Based on observation, interview, and record review the facility failed to ensure staff covered the catheter bag with the privacy shield for 1(Resident #13) of 5 (Residents #13, #40, #66, #68, and #273) privacy shield was not pulled down over the catheter bag, assuring residents privacy. This lack of privacy care had the potential to affect the resident's dignity. The findings are: On 2/21/2024 at 9:23 AM, Resident #13 privacy bag is raised up on catheter bag and can be seen facing the entrance of the door. On 2/22/2024 at 9:46 AM, Resident #13 catheter bag is hanging from the right side of the bed. The privacy bag is still raised up on the catheter, urine can be seen from Resident's door upon entrance. On 2/23/2024 at 9:21 AM, Resident #13 catheter is hanging from the right side of bed. The privacy bag shield is still raised, and urine can be seen. On 2/23/2024 at 9:25 AM, the Surveyor asked Licensed Clinical Nurse (LPN)#1 if she saw an issue with Resident's catheter. LPN#1 said, are you talking about the privacy part? The Surveyor responded, yes, it has been this way for the last 3 days. The Surveyor asked why privacy shields are provided on the catheter bag. The LPN#1 said, it is a dignity issue. On 2/23/2024 at 10:15 AM, the Surveyor asked the Director of Nursing (DON) what staff are trained for catheter care. The DON stated, The nurses and nurse aides. The Surveyor asked who empties the catheter bags and how often? The DON said, The Certified Nursing Assistants (CNA) and they empty them once a shift or as needed. The Surveyor asked the DON, why should the privacy shield be pulled all the way down. The DON said, It's a dignity issue.

Based on interview and record review, the facility failed to ensure an Advance Beneficiary Notice [ABN] was provided to inform the residents and/or their responsible parties of financial liability for continued care and services after their Medicare coverage was discontinued for 5 Residents (#6, #19, #32, #42, and #276) sampled residents who were discharged from Medicare Skilled services in the last 6 months and remained in the facility and/or discharged home. This failed practice had the potential to affect 41 residents who received a Beneficiary Notice and were discharged or remained in the facility the last 6 months after they were released from Medicare Services. The findings are: 1. Resident #6 was provided with a Notice of Medicare Provider Non-Coverage. The last covered date of Part A Service was 8-11-23. Resident signed, but no date provided. 2. Resident #19 was provided with a Notice of Medicare Provider Non-Coverage. The last covered date of Part A Service was 11-8-23. Resident signed on 11-7-23. 3. Resident #32 was provided with a Notice of Medicare Provider Non- Coverage. The last covered date of Part A Service was 10-6-23. Resident signed on 10-4-23. 4. Resident #42 was provided with a Notice of Medicare Provider Non-Coverage. The last covered date of Part A Service was 7-26-23. Resident signed on 7-21-23. 5. Resident #276 was provided with a Notice of Medicare Provider Non-Coverage. The last covered date of Part A Service is 11-6-23. Resident signed on 11-3-23. 4. On 2-22-2024 at 1:30 PM, the Nurse Consultant stated, There are 5 residents that had no Advance Beneficiary Notice. Out of the 8 picked, 5 did not have an Advance Beneficiary Notice. They provided a Performance Improvement Project.

Based on record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement program [QAPI] Committee developed and implemented appropriate plans of action to prevent repeated deficiencies for F554, which referenced Self Administer of Medications. These failed practices had the potential to affect 75 residents The findings are: A Recertification survey was conducted on 02/20/24 at the facility. During this survey, F554, Self-Administer of Medications, was cited for the facility failed to ensure that before a resident was allowed to self-administer a bronchodilator medication (a type of medication that make breathing easier) via nebulizer, the Interdisciplinary Team [IDT] conducted an assessment to determine if this practice was safe, to ensure a Physician's Order [PO] was obtained and a care plan [CP] was developed to address self-administration of medication via nebulizer, to prevent potential errors in administration for 1 (Resident #2) sampled residents who had PO for bronchodilator nebulizer treatments. This failed practice had the potential to affect 6 sampled residents who had PO for medications given via nebulizer. A review of the facility's Plan of Correction, with a correction date of 12/29/22, indicated: A. Based on observation, record review, and interview, the facility failed to ensure that before a resident was allowed to self-administer medications, the IDT conducted an assessment to determine if this practice was safe, to prevent potential complications for 1 (Resident #5) of 1 sampled resident who had a Topical Analgesic at the bedside and for 1 (Resident #18) of 1 sampled resident who had an Albuterol Inhaler at the bedside. The findings are: 1. Resident #5 had a diagnosis of Rheumatoid Arthritis. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/24/22 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and was able to make themself understood, and ability to understand others; had adequate vision with corrective lenses and had no functional limitation in range of motion to the upper extremities and received scheduled pain medication. a. The Care Plan documented, .The resident has acute pain . Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment . Date Initiated: 06/21/2022 . The resident has capacity to understand and make decisions regarding healthcare . Arrange for care plan conference with healthcare providers and resident to review the resident's current status and to make healthcare decisions at least quarterly and more often as needed . Follow up with physician for any needed orders related to resident care decisions .Date Initiated: 06/28/2022 . b. The November 2022 Physician Orders documented, .Tylenol 8 Hour Arthritis Pain Tablet Extended Release 650 MG [Milligram] Give 1 tablet by mouth every 6 hours as needed for pain related to RHEUMATOID ARTHRITIS . Order Date 10/16/2022 . Lidocaine Patch 5 % Apply to affected area topically one time a day for pain . Order Date 10/06/2022 . Voltaren Gel 1 % . Apply to Shoulders topically every 8 hours as needed for pain . Order Date 10/02/2022 . Norco Tablet 7.5-325 MG [Milligram] . Give 2 tablet by mouth every 8 hours as needed for pain . Order Date 06/21/2022 . On 11/28/22 at 9:02 AM and at 12:04 PM, Resident #5 was sitting in her wheelchair in her room. There were three bottles of Absorbine Plus on her bedside table. The bottle documented, .Extra Strength Formula . Pain Relieving Liquid . Fast Absorbing for RAPID RELIEF Relieves: Sore Muscles, Arthritis Pain . Menthol 40% . Topical Analgesic . Keep out of reach of children . On 11/29/22 at 11:10 AM, Licensed Practical Nurse (LPN) #1 accompanied the Surveyor to Resident #5's room. The Surveyor asked, What are those three bottles on [Resident #5's] bedside table? LPN #1 stated, It's Absorbine Plus. Resident #5 stated, I apply it myself when my muscles around my neck get sore. It's an over-the-counter medication. I've been using it for years. The Surveyor asked LPN #1, Does the resident have an order for that medication? LPN #1 stated, No. The Surveyor asked, Has [Resident #5] been assessed to self-administer the Absorbine Plus? LPN #1 stated, No. 2. Resident #18 had a diagnosis of Chronic Obstructive Pulmonary Disease [COPD]. The admission MDS with an ARD of 10/23/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS and was able to make self-understood, and ability to understand others; had adequate vision with corrective lenses and had no functional limitation in range of motion to the upper extremities; had no shortness of breath with exertion, sitting at rest or when lying flat. On 11/28/22 at 9:56 AM, Resident #18 was sitting in her wheelchair in her room. An Albuterol inhaler was laying in front of her on her bedside table. Resident #18 stated she administers it herself. On 11/28/22 at 11:23 AM, Resident #18 was sitting in her wheelchair in her room, The Albuterol inhaler was in front of her on her laying on bedside table. The Physician Order dated 11/17/2022 documented, .Albuterol Sulfate HFA [Hydrofluoroalkane] Aerosol Solution 108 (90 Base) MCG/ACT [Micrograms/Airway Clearance Therapy] 2 puff inhale orally every 4 hours as needed for SOB (Shortness of Breath)/WHEEZING ***wait 1 minute between puffs*** . The Care Plan documented, .[Resident's Name] has nutritional problem or potential nutritional problem r/t [related to] COPD . Administer medications as ordered. Monitor/Document for side effects and effectiveness . Date Initiated: 10/26/2022 . The resident has capacity to understand and make decisions regarding healthcare . Follow up with physician for any needed orders related to resident care decisions . Date initiated 11/01/2022 . On 11/29/22 at 11:07 AM, LPN #1 accompanied the surveyor to Resident #18's room. The Surveyor asked, What is that on her bedside table? LPN #1 stated, That is her emergency Albuterol inhaler. Resident #18 stated, I administer it four times a day and as needed. The Surveyor asked LPN #1, Was the resident assessed to self-administer her inhaler? LPN #1 stated, I do not know. The Surveyor asked LPN #1, Does [Resident #18] have an order to self-administer medication? LPN #1 stated, According to the resident's EHR [Electronic Health Record] she has not been assessed or have an order to self-administer her inhaler. On 11/29/22 at 11:22 AM, the Surveyor asked the Director of Nursing (DON), Are residents allowed to self-administer medication? The DON stated, Yes, with proper documentation. An assessment has to be completed and a physician order needs to be obtained. The Surveyor asked, [Resident #18], does she have a physician's order to self-administer her Albuterol Inhaler? The DON stated, No, she does not. The Surveyor asked, [Resident #5] does she have a physician's order for Absorbine Plus? The DON stated, No, she does not. The Surveyor asked, Has [Resident #5] been assessed to self-administer the Absorbine Plus? The DON stated, No. The facility policy titled, Self-Administration of Medications, received from the Nurse Consultant on 11/30/22 at 1:45 PM documented, .Residents have the right to self-administer medications if the interdisciplinary team had determined that is clinically appropriate and safe for the resident to do so . 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 are clinically appropriate for the resident . For self-administering residents, the nursing staff will determine who will be responsible (the resident or the nursing staff) for documenting that medication were taken . Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents . Staff shall identify and give to the Charge Nurse any medications found at the bedside that are not authorized for self-administration, for return to the family or responsible party . Nursing staff will review the self-administered medication record on each nursing shift, and they will transfer pertinent information to the Medication Administration Record (MAR) kept at the nursing station, appropriately noting that the doses were self-administered . 3. A policy titled, Quality Assurance and Performance Improvement (QAPI) Plan, provided by the Administrator on 02/20/24 at 11:00 AM, documented, .2. Reinforce and build upon effective systems and processes related to the delivery of quality care and services; 3. Provide structure and processes to correct identified quality and/or safety deficiencies 4. Establish and implement plans to correct deficiencies and to monitor the effects of these action plans on resident outcome . 4. On 02/23/24 at 11:58 AM, the Surveyor asked how the QAA Committee knows when an issue arises in any department. The Administrator said, we do QAA meetings and look over all the different topics to see what they need to address. The Surveyor asked how the QAA Committee knows when a deviation from performance or a negative trend is occurring. The Administrator said, a grievance process, quality measures, monitoring the issues. The Surveyor asked how the QAA Committee decides which issues to work on. The Administrator said, by the importance of the issue. The Surveyor asked how long the QAA Committee will monitor an issue that has been corrected. The Administrator said, from one QAA to the next to ensure there are no issues. The Surveyor asked, is the QAA Committee aware of repeated survey deficiencies. The Administrator said, no.

Based on observation, interview, and record review, the facility failed to ensure staff followed proper infection prevention and control practices to prevent the development and transmission of infections and or other communicable diseases for 1 (Resident #2) of 3 (#1, #2, #3) sampled residents, as evidenced by failure to change gloves between dirty to clean tasks during incontinent care; and failure to perform hand hygiene/and or change gloves after handling contaminated surfaces; and failure to ensure equipment was sanitized and clean of contamination prior to residents use. The findings are: 1. Resident #2 had diagnoses of Dementia, Urinary Tract Infections, and Anxiety. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/17/23 documented the resident scored 8 (8-12 moderately impaired) on the Brief Interview for Mental Status (BIMS), required extensive assist of two staff for transfer, toilet use, and personal hygiene; and was always incontinent of bowel and bladder. 2. The Care Plan with a revision date of 04/17/23 documented, .has bladder incontinence .r/t [related to] .confusion, dementia, history of UTI [Urinary Tract Infection] .brief use .check/change every two hours and prn [as needed] .clean peri-area with each incontinence episode . 3. On 05/10/23 at 12:46 p.m., Resident #2 was sitting in a wheelchair in her room with a call light in her hand. The call light had been activated. The Surveyor asked, Have you been waiting long? Resident #2 replied, Over twenty minutes and I've pooped all over myself and my [family member] is going to be here. The Surveyor asked, How many staff does it take to assist you? Resident #2 replied, It takes two people, my wheelchair won't fit in the bathroom, and that's what I've been doing, pooping on myself because no one will come help me. 4. On 05/10/23 at 12:53 p.m., Certified Nursing Assistants (CNAs) #1 and #2 raised Resident #2 up out of the wheelchair using an electric [named] lift. As she was lifted from the wheelchair, loose feces were observed running out of her pants around the waistband onto the floor and into the wheelchair. a. Observed CNA #1 walk through the feces on the floor of Resident #2's room. She threw a dry bath towel on the floor, and with her right foot, wiped the feces from the floor, leaving feces on the floor. She placed another dry bath towel in Resident #2's wheelchair and wiped the feces from the chair, leaving feces in the chair/cushion. She picked up the dirty towels that contained feces, wadded them up, then placed them into a clear trash liner. She opened Resident # 2's door with the contaminated gloves on and exited her room. CNA #1 did not change the contaminated gloves or perform hand hygiene prior to opening the door or exiting the room. b. On 05/10/23 at 12:57 p.m., CNA #2 began to perform incontinent care on Resident #2. c. On 05/10/23 at 1:04 p.m., CNA #2 picked up a clean brief, a pair of pajama pants, and a blanket from R#2 bed using the same contaminated gloves that were used to perform incontinent care and placed them on the contaminated wheelchair cushion. He removed Resident #2's contaminated sheets from under her and placed them in a clear trash liner. He did not change gloves and did not perform hand hygiene. d. On 05/10/23 at 1:05 p.m., CNA #2 placed a clean brief under Resident #2 with contaminated gloves on. He rolled her onto her back and continued to perform incontinent care on her. e. On 05/10/23 at 1:07 p.m., CNA #2 wiped Resident #2's right inner thigh in an upward motion, using an adult wet wipe, then he discarded it. He wiped Resident #2's left inner thigh in an upward motion using an adult wet wipe then discarded it. He then secured Resident #2's brief. CNA #2 did not change his gloves and did not perform hand hygiene between dirty to clean tasks. 5. On 05/10/23 at 1:24 p.m., CNA #2 and CNA #3 transferred Resident #2 from the bed to the wheelchair that was contaminated with feces. She was then assisted to the Dining Room. 6. On 05/10/23 at 1:30 p.m., CNA #2 put the blanket that was on the contaminated wheelchair on Resident #2's bed. 7. On 05/10/23 at 2:35 p.m., the Surveyor asked CNA #1, When is hand hygiene performed? CNA #1 replied, At the beginning, the end, and in between, as needed. The Surveyor asked, When are you supposed to change your gloves? CNA #1 replied, I change them all the time, if I get something on them, I change them. The Surveyor asked, How/which way do you wipe when performing peri/incontinent care on a female? CNA #1 replied, Front to back. The Surveyor asked, What is the cleaning protocol when there is feces on a resident's wheelchair cushion? CNA #1 replied, Get it all off then sanitize really well. The Surveyor asked, Why should the contaminated wheelchair cushion be sanitized before putting the resident in the wheelchair? CNA #1 replied, Don't want to spread bacteria. The Surveyor asked, What about placing residents' blankets on the contaminated wheelchair cushion, then placing it on the resident's bed? CNA #1 replied, Don't want to do that either. 8. On 05/10/23 at 2:48 p.m., the Surveyor asked CNA #2, When is hand hygiene performed? CNA #2 replied, Before and after you leave the resident's room. The Surveyor asked, When are you supposed to change your gloves? CNA #2 replied, After changing resident briefs, sheets. I don't like touching anything clean with dirty gloves. The Surveyor asked, How/which way do you wipe when performing peri/incontinent care on a female? CNA #2 replied, Down, front to back. The Surveyor asked, Why should peri-care on female residents be performed front to back? CNA #2 replied, It could be feces that can cause bacteria and UTI and infection. The Surveyor asked, What is the cleaning protocol when there is feces on a resident's wheelchair cushion? CNA #2 replied, Supposed to take cushions off and get new ones. The Surveyor asked, Why should the contaminated wheelchair cushion be sanitized before putting the resident in the wheelchair? CNA #2 replied, That way there's no bacteria. 9. On 05/11/23 at 1:25 p.m., the Surveyor asked the Infection Control Prevention (ICP) Nurse, When is hand hygiene performed? The ICP replied, Before, during, and after care, after touching anything. The Surveyor asked, When are you supposed to change your gloves? The ICP replied, Anytime they are soiled. The Surveyor asked, How/which way do you wipe when performing peri/incontinent care on a female? The ICP replied, From front to back. The Surveyor asked, Why should peri-care on female residents be performed front to back? The ICP replied, Because we don't want to transmit any bacteria to the vaginal area and urethra to cause an UTI. The Surveyor asked, Why should dirty gloves be changed before performing clean tasks? The ICP replied, It could transmit bacteria to a clean site. The Surveyor asked, What is the cleaning protocol when there is feces on a resident's wheelchair cushion? The ICP replied, Because there still maybe bacteria in there. The Surveyor asked, Can CNA's use disinfectant? The ICP replied, yes. 10. On 05/11/23 at 3:08 p.m., the Surveyor asked the Director of Nursing (DON), When is hand hygiene performed? The DON replied, Before and after personal care. The Surveyor asked, When are you supposed to change your gloves? The DON replied, Anytime they are visibly soiled, from dirty to clean. The Surveyor asked, How/which way do you wipe when performing peri/incontinent care on a female? The DON replied, Front to back. The Surveyor asked, Why should peri-care on female residents be performed front to back? The DON replied, Risk of UTI, clean to dirty. The Surveyor asked, What is the cleaning protocol when there is feces on a resident's wheelchair cushion? The DON replied, Clean and disinfect. The Surveyor asked, What are your expectations from your staff regarding following the facilities policy and procedures and the Centers for Medicare and Medicaid Services (CMS) guidelines related to the concerns found during the survey? The DON replied, My expectations are to follow policy and procedure. 11. On 05/11/23 at 3:09 p.m., the Surveyor asked the Administrator, When is hand hygiene performed? The Administrator replied, Before and after providing personal care, in between residents, and room to room. The Surveyor asked, When are you supposed to change your gloves? The Administrator replied, Anytime they are visibly soiled, from dirty to clean. The Surveyor asked, How/which way do you wipe when performing peri/incontinent care on a female? The Administrator replied, Front to back. The Surveyor asked, Why should peri-care on female residents be performed front to back? The Administrator replied, So we don't transfer bacteria and feces to the urethra. The Surveyor asked What are your expectations from your staff regarding following the facilities policy and procedures and the CMS guidelines related to the concerns found during the survey? The Administrator replied, I expect them to follow policy and procedures. 12. The facility policy titled, Perineal Care provided by the Administrator on 05/10/23 at 3:43 p.m. documented, .the purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the resident's skin condition .wash perineal area, wiping from front to back .rinse perineum thoroughly in same direction . 13. The facility policy titled, Handwashing/Hand Hygiene, policy provided by the Administrator on 05/10/23 at 3:43 p.m. documented, .this facility considers hand hygiene the primary means to prevent the spread of infection .all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .wash hands with soap .and water .when hands are visibly soiled .and .after contact with a resident with infectious diarrhea .including but not limited to infections caused by norovirus, salmonella, shigella, and C-Diff [Clostridium Difficile] .use an alcohol-based hand rub .before and after direct contact with residents .before moving from a contaminated body site to a clean body site during resident care .after contact with a resident's intact skin .after contact with blood or bodily fluids .after handling contaminated equipment .after contact with objects in the immediate vicinity of the resident .after removing gloves .the use of gloves does not replace hand washing/hand hygiene . 14. The facility policy titled, Cleaning Spills or Splashes of Blood or Body Fluids, provided by the Administrator on 05/10/23 at 3:43 p.m. documented, .the purpose of this procedure is to minimize the danger of environmental contamination and the possible spread .to employees and residents while cleaning up spills of blood or body fluid splashes .as all residents' blood and body fluids are considered potentially infectious .wipe up the spill or splash with a cloth or paper towels .discard the saturated cloth or paper towels into the plastic biohazard bag .disinfect the area by swabbing with a cloth or paper towel which has been moderately saturated with a 1:100 bleach solution .allow to air dry .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to offer an invitation to participate in care plan meetings for 1 (Resident #122) of 2 residents reviewed for care plan meetings. This had the potential to affect the newly admitted resident's participation in the care meetings. Findings included: A review of a facility document titled, Arkansas Patient Rights, dated 09/2017, indicated the resident has The right to be adequately informed of his or her medical condition and proposed treatment unless the Patient is determined to unable to provide informed consent under Arkansas law, the right to be fully informed in advance of any nonemergency changes in care of treatment that may affect the Patient's well-being, and expect with respect to a Patient adjudged incompetent the right to participate in the planning of all medical treatment. A review of facility's undated policy titled, Care Planning- Interdisciplinary Team, indicated The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and the revisions to the resident's care plan. A review of an admission Record indicated the facility admitted Resident #122 on 11/11/2022 with diagnoses that included hemiplegia and hemiparesis affecting left, non-dominant side, hypertensive urgency, major depressive disorder, and congenital renal artery stenosis. Review of the admission Minimum Data Set (MDS), dated [DATE], revealed Resident #122 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Additionally, the MDS indicated the resident needed extensive assistance with bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, and personal hygiene. A review of Resident #122's care plan, initiated 11/22/2022, revealed Resident #122 had the capacity to understand and make decisions regarding healthcare. An interview with Resident #122 on 11/30/2022 at 8:40 AM in their room revealed the resident had not been told about a care plan conference. A review of Resident #122's medical record revealed a care pan conference had not occurred with the resident or their family since admission to the facility. An interview with the Social Services Director (SSD) on 12/01/2022 at 9:05 AM revealed there had been no care plan conference held for Resident #122 and their family. The facility tried to get them done within 10 to 14 days of admission. An interview with the Director of Nursing (DON) on 12/01/2022 at 1:13 PM revealed the care plan meeting with the resident and family should take place within a week of admission. An interview with the Administrator on 12/01/2022 at 2:52 PM revealed the care plan meeting with the resident and family should be set up within 14 days of admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to ensure a significant change in status Minimum Data Set (MDS) was completed upon discharge from hospice services for 1 (Resident #59) of 2 residents reviewed for resident assessments. Findings included: A review of a facility policy titled, Change of a Resident's Condition or Status, revised February 2021, indicated, A 'significant change' of condition is a major decline or improvement in the resident's status that: impacts more than one is of the resident's health status; requires interdisciplinary review and/or revision to the care plan. A review of an admission Record indicated the facility admitted Resident #59 with diagnoses that included unsteadiness on feet, other lack of coordination, muscle weakness, and muscle wasting and atrophy. A review of the admission Minimum Data Set (MDS), dated [DATE], revealed Resident #59 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident had severe cognitive impairment. Further review of the MDS revealed Resident #59 was receiving hospice services. A review of Progress Notes, dated 10/10/2022, indicated Resident #59's family no longer wanted Resident #59 to receive hospice services. A review of a level of care (LOC) application, dated 10/13/2022, indicated Resident #59 was discharged from hospice services on 10/10/2022. A review of the five-day MDS, dated [DATE], revealed Resident #59 was not receiving hospice services. An interview with Licensed Practical Nurse (LPN) #1, the MDS Coordinator, on 12/01/2022 at 9:30 AM revealed a significant change in status MDS should be completed when anything changed outside of the resident's baseline. LPN #1 stated a significant change in status MDS should be completed when a resident was admitted to or discharged from hospice. According to LPN #1, a significant change in status MDS should have been completed for Resident #59 when the resident was discharged from hospice services. An interview with the Director of Nursing (DON) on 12/01/2022 at 1:13 PM revealed a significant change in status MDS should be completed when there was a significant change in the resident activities of daily living (ADL). The DON confirmed a significant change in status MDS should be completed when a resident discharged from hospice. An interview with the Administrator on 12/01/2022 at 2:52 PM revealed a significant change in status MDS should be completed anytime there was a significant change in the resident's ADLs. The Administrator stated the facility should have completed a significant change in status MDS for Resident #59 within 14 days of discharge from hospice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurate and complete to facilitate the ability to plan and provide necessary care and services for 1 (Resident #23) of 19 (Residents #5, #10, #19, #20, #21, #23, #26, #31, #32, #34, #38, #41, #51, #54, #59, #68, #122, #172, and #221) sampled residents whose MDS was reviewed. This failed practice had the potential to affect all 65 residents who resided in the facility as documented on the Resident Census and Conditions of Resident provided by the Administrator on 11/28/22. The findings are: Resident #23 had diagnoses of Shortness of Breath and Heart Failure. The admission MDS with an Assessment Reference Date (ARD) of 10/24/22 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and did not receive oxygen therapy while a resident. a. The Physician Order dated 10/17/22 documented, .OXYGEN 3L/NC [liters per nasal cannula] CONTINUOUSLY every shift for Shortness of Breath . b. The MDS dated [DATE] under Section O Special Treatments, Procedures, and Programs documented, .Respiratory Treatments Oxygen therapy . While NOT a Resident - was marked with an 'X' and While a Resident . was not marked . c. The October 2022 Medication Administration Record (MAR) documented, .OXYGEN 3L/NC CONTINUOUSLY every shift for Shortness of Breath - Order Date: 10/17/2022 . The order was initialed by staff, three times a day from 10/17/22 to 10/31/22. d. On 11/30/22 at 11:43 AM, the Surveyor asked the MDS Coordinator, Who is responsible for completing Section O? She replied, Me. The Surveyor asked, How long has the resident been on oxygen therapy? She replied, Since admission, The Surveyor asked, Is Section O0100 C coded correctly? She replied, No, it is not, I will correct that.

Based on observation, record review, and interview, the facility failed to ensure oxygen was administered as ordered by the physician for 1 (Resident #23) of 11 (Residents #5, #10, #18, #19, #23, #26, #32, #38, #41, #59 and #122 I put in ascending order) sampled residents who had physician orders for oxygen. The findings are: Resident #23 had diagnoses of Shortness of Breath and Heart Failure. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/24/22 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and did not receive oxygen therapy while a resident. a. The Physician Order dated 10/17/22 documented, .OXYGEN 3L/NC [liters per nasal cannula] CONTINUOUSLY every shift for Shortness of Breath . b. The Care Plan with an initiated date of 11/18/22 documented, .The resident has altered cardiovascular status r/t [related to] CHF [Congestive Heart Failure] . OXYGEN SETTINGS: O2 [Oxygen] via nasal cannula @ [at] 3L [Liters] continuously . c. On 11/28/22 at 9:48 AM and at 11:33 AM, Resident #23 was sitting her wheelchair in her room with oxygen in place at 2 liters per nasal cannula. d. On 11/29/22 at 11:08 AM, Licensed Practical Nurse (LPN) #1 accompanied the Surveyor to Resident #23's room. Resident #23 was lying in bed with oxygen in place via nasal cannula at 2 liters. The Surveyor asked LPN #1, How many liters of oxygen is ordered for the resident? LPN #1 stated, 3 liters. The Surveyor asked, How many liters is Resident #23 receiving according to the flow meter? LPN #1 stated, 2 liters, I will adjust it to 3 liters. e. The facility policy titled, Oxygen Administration, provided by the Nurse Consultant on 11/30/22 at 1:45 PM documented, .The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to obtain informed consent and properly assess the use of side rails for 1 (Resident #41) of 1 resident reviewed for the use of side rails. Findings included: Review of a facility policy titled, Proper Use of Side Rails, dated 12/2016, specified, An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's a. Bed mobility; b. Ability to change positions, transfer to and from bed or chair and to stand and toilet; c. Risk of entrapment from the use of side rails; and d. That the bed's dimensions are appropriate for the resident's size and weight. The use of side rails as an assistive device will be addressed in the resident's care plan. Further review of the policy revealed, Documentation will indicate if less restrictive approaches are not successful prior to considering the use of side rails. The risks and benefits of side rails will be considered for each resident. Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks. A review of an admission Record indicated the facility admitted Resident #41 with diagnoses that included hemiplegia (weakness to one side of the body) following cerebral infarction (stroke) and morbid obesity. The quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #41 had a Brief Interview for Mental Status (BIMS, a structured evaluation for cognition) score of 13, which indicated the resident was cognitively intact. The resident required extensive assistance to total assistance with all activities of daily living (ADLs), including bed mobility. The use of bed/side rails was not indicated on the MDS. A review of Resident #41's care plan, revised 07/12/2021, revealed interventions related to the resident's ADL self-care performance deficit directed staff to assist the resident with two staff members to turn and reposition in bed. Further review of the care plan revealed no care plan or interventions for the use of side rails for positioning or bed mobility. Observations on 11/28/2022 at 2:43 PM revealed Resident #41's bed had a half side rail in the up position on the resident's left side of the bed. The resident was not present. Observations on 11/29/2022 at 3:32 PM revealed Resident #41 lying flat in the bariatric bed with a half side rail in the up position on the resident's left side. Observations on 11/30/2022 at 1:10 PM revealed Resident #41 lying in bed with a half side rail in the up position on the resident's left side. A review of Resident #41's medical record revealed there was no consent with discussion of the risks and benefits for the use of the half side rail. Further review of Resident #41's medical record revealed no assessment had been completed for the use of the half side rail. Consent for the side rail was obtained and an assessment was completed for the use of the side rail during the survey, on 11/30/2022. During an interview on 12/01/2022 at 12:06 PM, Certified Nurse Aide (CNA) #4 stated the only resident in the facility that had side rails was Resident #41, and the resident used them to hold themself over. She stated she did not have any part of doing an assessment for the use of side rails. During an interview on 12/01/2022 at 12:15 PM, CNA #5 stated the nurse took care of any assessments for the use of side rails. CNA #5 stated Resident #41 used the side rail to position themself. During an interview on 12/01/2022 at 12:23 PM, Licensed Practical Nurse (LPN) #6 stated she was unsure what type of assessment was done for residents to use side rails but thought they needed a consent and order for the use of a side rail. LPN #6 stated the facility considered side rails restraints, but they were also used to assist with repositioning. LPN #6 stated Resident #41 used their side rail for rolling over and holding themself over on their side. She stated the resident also used it to know where the edge of the bed was for security. She stated the use of side rails should be care planned. During an interview on 12/01/2022 at 12:39 PM, LPN #7 stated Resident #41 was the only resident with a side rail in the facility. She stated the use of side rails was assessed, but she was unsure of the process. She stated the resident should have an order and a consent for the use of a side rail and it should be care planned. During an interview on 12/01/2022 at 12:49 PM, the Assistant Director of Nursing (ADON) stated she had started at the facility the first of October 2022. She stated side rails were assessed quarterly, and they must have a consent and order for the use of side rails. She stated the use of side rails should be care planned. During an interview on 12/01/2022 at 1:37 PM, the Director of Nursing (DON) stated the resident was assessed for side rail use on admission, usually within the first 24 to 48 hours after admission, if the resident requested them or would benefit from them. She stated then they should be reassessed quarterly. The DON stated they should obtain a consent and physician order for the side rails, and the use of side rails should be care planned. She stated Resident #41 used the side rails for repositioning and bed mobility. During an interview on 12/01/2022 at 3:13 PM, the Administrator stated side rails should be assessed upon placement and quarterly. She stated the resident should have a consent and a physician's order, and the use of side rails should be care planned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, it was determined that the facility failed to ensure adequate medication monitoring for 1 (Resident #10) of 5 residents reviewed for unnecessary medications. Specifically, the facility failed to obtain lab tests (to measure blood clotting times) as ordered for Resident #10 who was receiving anticoagulation medication. Findings included: Review of a facility policy titled, Anticoagulation-Clinical Protocol, dated 11/2018, specified, The physician should adjust the anticoagulant dose or stop, taper, or change medications that interact with the anticoagulant, and/or monitor the PT/INR [Prothrombin Time/international normalized ratio; tests to measure how quickly blood clots used in determining dosage changes for Coumadin] very closely while the individual is receiving warfarin, to ensure that the PT/INR stabilizes within a therapeutic range. A review of an admission Record indicated the facility admitted Resident #10 with a diagnosis that included chronic atrial fibrillation with long term use of anticoagulants (blood thinner) with the presence of a cardiac pacemaker. The annual Minimum Data Set (MDS), dated [DATE], revealed Resident #10 had a Brief Interview for Mental Status (BIMS, a structured evaluation for cognition) score of 10, which indicated the resident had moderate cognitive impairment. The resident required limited assistance with all activities of daily living (ADLs). The MDS indicated the resident received an anticoagulant medication daily. A review of Resident #10's care plan, revised 04/12/2021, revealed interventions related to the resident's anticoagulant therapy directed staff to monitor for warning and side effects of medications, administer anticoagulant medication as ordered by the physician and monitor for effectiveness every shift, do daily skin inspections and report abnormalities to the nurse, and obtain labs as ordered and report abnormal lab results to the physician. A review of the Order Summary Report for active orders as of 12/01/2022 indicated Resident #10's orders included: - PT/INR weekly on Wednesday related to the long-term use of anticoagulant medications and the presence of a cardiac pacemaker, ordered 09/22/2022. - Coumadin (an anticoagulant) 2 milligrams (mg), one tablet by mouth one time a day every Tuesday, Thursday, Saturday for blood clot prevention, ordered 08/25/2022. - Coumadin 3 mg, one tablet by mouth one time a day every Monday, Wednesday, Friday, and Sunday for blood clot prevention, ordered 11/17/2022. A review of Resident #10's medical record revealed no PT/INR test results for Wednesday 11/02/2022 or Wednesday 11/23/2022. The test results were requested from the facility on 11/30/2022 and were not provided by the end of the survey. During an interview on 12/01/2022 at 12:23 PM, Licensed Practical Nurse (LPN) #6 stated the physician and nurse practitioner (NP) monitored residents on Coumadin by monitoring labs. LPN #6 stated LPN #3 was responsible for putting lab orders into the laboratory computer system. She stated once the lab results were received, the nurse working the medication cart should send the results to the physician to get new orders. She stated she was unsure why Resident #10's labs were not done. During an interview on 12/01/2022 at 12:39 PM, LPN #7 stated the floor nurse monitored residents on Coumadin by drawing labs. She stated when she got an order for a lab, the ADON would put the order into the lab's computer system, so they knew what labs to draw and when they were due to be drawn. She stated the lab results were followed up by the floor nurse, who would notify the physician to review. During an interview on 12/01/2022 at 12:49 PM, the Assistant Director of Nursing (ADON) stated she had been working at the facility since the first of October 2022. She stated residents on Coumadin were monitored by the physician through labs. She stated she had just been made responsible for the labs a few weeks earlier, and she was still trying to figure out how to make it flow better. The ADON stated she was not aware Resident #10 was not getting their PT/INR's drawn as ordered. During an interview on 12/01/2022 at 1:37 PM, the Director of Nursing (DON) stated residents on Coumadin were monitored by the physician through labs, and the labs were being monitored by the ADON and the DON. The DON stated there had been confusion and a mix up with the scheduling of Resident #10's lab orders, and on the days the lab results were missing, the order for the labs did not get entered into the lab's computer system. She stated the ADON was now printing a report daily to see what labs were due the next day and was to ensure the orders were put into the lab's computer system. She stated the hope was to get all residents off Coumadin and on a less risky anticoagulant that did not require frequent lab draws. During an interview on 12/01/2022 at 3:13 PM, the Administrator stated residents on Coumadin were to be monitored by the nurse managers, and the ADON was responsible for ordering the labs. She stated she expected the facility to implement a Coumadin flow sheet with daily monitoring, to make sure the physician was notified, follow up if medication changes were made, and order labs if needed.

Based on observation, record review, and interview, the facility failed to ensure before a resident was allowed to self-administer medications, the interdisciplinary team (IDT) conducted an assessment to determine if this practice was safe, to prevent potential complications for 1 (Resident #5) of 1 sampled resident who had a Topical Analgesic at the bedside and for 1 (Resident #18) of 1 sampled resident who had an Albuterol Inhaler at the bedside. The findings are: 1. Resident #5 had a diagnosis of Rheumatoid Arthritis. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/24/22 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and was able to make self-understood, and ability to understand others; had adequate vision with corrective lenses and had no functional limitation in range of motion to the upper extremities and received scheduled pain medication. a. The Care Plan documented, .The resident has acute pain . Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment . Date Initiated: 06/21/2022 . The resident has capacity to understand and make decisions regarding healthcare . Arrange for care plan conference with healthcare providers and resident to review the resident's current status and to make healthcare decisions at least quarterly and more often as needed . Follow up with physician for any needed orders related to resident care decisions .Date Initiated: 06/28/2022 . b. The November 2022 Physician Orders documented, .Tylenol 8 Hour Arthritis Pain Tablet Extended Release 650 MG [Milligram] Give 1 tablet by mouth every 6 hours as needed for pain related to RHEUMATOID ARTHRITIS . Order Date 10/16/2022 . Lidocaine Patch 5 % Apply to affected area topically one time a day for pain . Order Date 10/06/2022 . Voltaren Gel 1 % . Apply to Shoulders topically every 8 hours as needed for Pain . Order Date 10/02/2022 . Norco Tablet 7.5-325 MG [Milligram] . Give 2 tablet by mouth every 8 hours as needed for pain . Order Date 06/21/2022 . c. On 11/28/22 at 9:02 AM and at 12:04 PM, Resident #5 was sitting in her wheelchair in her room. There were three bottles of Absorbine Plus on her bedside table. The bottle documented, .Extra Strength Formula . Pain Relieving Liquid . Fast Absorbing for RAPID RELIEF Relieves: Sore Muscles, Arthritis Pain . Menthol 40% . Topical Analgesic . Keep out of reach of children . d. On 11/29/22 at 11:10 AM, Licensed Practical Nurse (LPN) #1 accompanied the Surveyor to Resident #5's room. The Surveyor asked, What are those three bottles on [Resident #5's] bedside table? LPN #1 stated, It's Absorbine Plus. Resident #5 stated, I apply it myself when my muscles around my neck get sore. It's an over-the-counter medication. I've been using it for years. The Surveyor asked LPN #1, Does the resident have an order for that medication? LPN #1 stated, No. The Surveyor asked, Has [Resident #5] been assessed to self-administer the Absorbine Plus? LPN #1 stated, No. 2. Resident #18 had a diagnosis of Chronic Obstructive Disease [COPD]. The admission MDS with an ARD of 10/23/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS and was able to make self-understood, and ability to understand others; had adequate vision with corrective lenses and had no functional limitation in range of motion to the upper extremities; had no shortness of breath with exertion, sitting at rest or when lying flat. a. On 11/28/22 at 9:56 AM, Resident #18 was sitting in her wheelchair in her room. An Albuterol inhaler was laying in front of her on her bedside table. Resident #18 stated she administers her inhaler four times a day and as needed. b. On 11/28/22 at 11:23 AM, Resident #18 was sitting in her wheelchair in her room, The Albuterol inhaler was in front of her on her laying on bedside table. c. The Physician Order dated 11/17/2022 documented, .Albuterol Sulfate HFA [Hydrofluoroalkane] Aerosol Solution 108 (90 Base) MCG/ACT [Micrograms/Airway Clearance Therapy] 2 puff inhale orally every 4 hours as needed for SOB/WHEEZING ***wait 1 minute between puffs*** . d. The Care Plan documented, .[Resident's Name] has nutritional problem or potential nutritional problem r/t [related to] COPD . Administer medications as ordered. Monitor/Document for side effects and effectiveness . Date Initiated: 10/26/2022 . The resident has capacity to understand and make decisions regarding healthcare . Follow up with physician for any needed orders related to resident care decisions . Date initiated 11/01/2022 . e. On 11/29/22 at 11:07 AM, LPN #1 accompanied the surveyor to Resident #18's room. The Surveyor asked, What is that on her bedside table? LPN #1 stated, That is her emergency Albuterol inhaler. Resident #18 stated, I administer it four times a day and as needed. The Surveyor asked LPN #1, Was the resident assessed to self-administer her inhaler? LPN #1 stated, I do not know. The Surveyor asked LPN #1, Does [Resident #18] have an order to self-administer medication? LPN #1 stated, According the resident's EHR [Electronic Health Record] she has not been assessed or have an order to self-administer her inhaler. 3. On 11/29/22 at 11:22 AM, the Surveyor asked the DON, Are residents allowed to self-administer medication? The DON stated, Yes, with proper documentation. An assessment has to be completed and a physician order needs to be obtained. The Surveyor asked, [Resident #18], does she have a physician's order to self-administer her Albuterol Inhaler? The DON stated, No, she does not. The Surveyor asked, [Resident #5] does she have a physician's order for Absorbine Plus? The DON stated, No, she does not. The Surveyor asked, Has [Resident #5] been assessed to self-administer the Absorbine Plus? The DON stated, No. 4. The facility policy titled, Self-Administration of Medications, received from the Nurse Consultant on 11/30/22 at 1:45 PM documented, .Residents have the right to self-administer medications if the interdisciplinary team had determined that is clinically appropriate and safe for the resident to do so . 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 . For self-administering residents, the nursing staff will determine who will be responsible (the resident or the nursing staff) for documenting that medication were taken . Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents . Staff shall identify and give to the Charge Nurse any medications found at the bedside that are not authorized for self-administration, for return to the family or responsible party . Nursing staff will review the self-administered medication record on each nursing shift, and they will transfer pertinent information to the medication administration record (MAR) kept at the nursing station, appropriately noting that the doses were self-administered .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. A review of an admission Record indicated the facility admitted Resident #122 on 11/11/2022 with diagnoses that included hemiplegia and hemiparesis affecting left, non-dominant side, hypertensive urgency, major depressive disorder, and congenital renal artery stenosis. The admission Minimum Data Set (MDS), dated [DATE], revealed Resident #122 had a Brief Interview for Mental Status (BIMS, a structured evaluation for cognition) score of 15, which indicated the resident was cognitively intact. Additionally, the MDS indicated the resident needed extensive assistance with bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, and personal hygiene. Resident #122 required total dependence for bathing. The MDS also indicated it was very important to Resident #122 to choose between a tub bath, shower, bed bath, or sponge bath. A review of Resident #122's care plan, initiated 11/22/2022, revealed Resident #122 had the capacity to understand and make decisions regarding healthcare. An interview with Resident #122 on 11/28/2022 at 1:01 PM in their room revealed the resident had only received two baths since their admission. A review of The Intervention/Task Schedule Report, dated 11/30/2022 through 12/06/2022, revealed Resident #122 received a bath daily and/or pro re nata (PRN; as needed) A review of the point of care (POC), dated 11/01/2022 through 11/30/2022, revealed Resident #122 was scheduled to receive a bath on Tuesdays, Fridays, and PRN. The resident received a bath on 11/15/2022, 11/23/2022, and 11/29/2022. The POC also indicated Resident #122 refused a bath on 11/17/2022. An interview with Certified Nurse Aide (CNA) #8 on 12/01/2022 at 11:10 AM revealed residents got one shower a week. She also indicated she had given Resident #122 their showers. An interview with the Director of Nursing (DON) on 12/01/2022 at 1:13 PM revealed residents should get one shower a week. The schedule was done per their preferences and room number. An interview with the Administrator on 12/01/2022 at 2:52 PM revealed residents should be getting a shower twice a week or PRN. There were residents that had set schedules or they went by room number. Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to provide assistance with activities of daily living (ADLs) for 6 (Resident #172, Resident #26, Resident #19, Resident #21, Resident #34, and Resident #122) of 6 dependent residents reviewed for ADLs. Specifically, the facility failed to: - Provide showers for Resident #26, Resident #19, Resident #21, Resident #34, and Resident #122. - Shave Resident #21 when needed. - Transfer Resident #172 out of bed. Findings included: Review of a facility policy titled, Activities of Daily Living (ADLs), Supporting, dated 03/2018, specified, 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. The policy also indicated, Appropriate care and services will be provide for resident's who are unable to carryout ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); b. Mobility (transfer and ambulation, including walking); c. Elimination (toileting); d. Dining (meals and snacks); and e. Communication (speech, language, and any functional communication systems). 1. A review of an admission Record indicated the facility admitted Resident #19 with a diagnosis that included hemiplegia (one-sided weakness) following a cerebral infarction (stroke) affecting the left non-dominant side. The quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #19 had a Brief Interview for Mental Status (BIMS, a structured evaluation for cognition) score of 13, which indicated the resident was cognitively intact. The resident required extensive assistance with all activities of daily living (ADLs) and was totally dependent on staff for bathing. A review of Resident #19's care plan, initiated 04/18/2022, indicated the resident required the assistance of one staff for showering, and the resident was to receive showers on Mondays, Wednesdays, and Fridays by female care givers only. The care plan revealed interventions that directed staff to provide a sponge bath when a full bath or shower could not be tolerated (initiated 05/03/2021), avoid scrubbing and pat sensitive areas dry (initiated 05/03/2021), and check the resident's nail length and trim and clean them on bath days and as necessary (initiated 05/03/2021). Observations on 11/28/2022 at 1:21 PM, revealed Resident #19's hair was oily. During an interview at this time, Resident #19 stated they were not getting showered like they were supposed to. A review of Resident #19's bathing report for 11/01/2022 through 11/30/2022 indicated the resident was to receive showers on Monday, Wednesday, Friday, and as needed. The report revealed the resident received eight out of 13 bathing opportunities. The resident did not receive their scheduled shower on 11/04/2022, 11/18/2022, 11/23/2022, 11/25/2022, or 11/30/2022. A review of Resident #19's medical record revealed no documentation of the resident refusing care, including showers. During an interview on 12/01/2022 at 12:06 PM, Certified Nurse Aide (CNA) #4 stated showers were given two to three times a week, depending on the preference. She stated the schedule was done by the Director of Nursing (DON). CNA #4 stated if a resident refused their shower, she would reapproach them a second and third time if necessary, and if they continued to refuse, she would report it to the charge nurse and document it. She stated Resident #19 was a total assist with showers and did not refuse care. During an interview on 12/01/2022 at 12:15 PM, CNA #5 stated residents were given showers twice a week by the shower aide. She stated she was not sure if the resident's shower schedule was based on their preference or by their room number. She stated if the resident refused their shower, the CNA should talk to the nurse, and if the resident had not been bathed in a week, then the DON would talk to the resident. CNA #5 stated Resident #19 was a total assist of two for transfers, and the resident did not refuse care. During an interview on 12/01/2022 at 12:23 PM, Licensed Practical Nurse (LPN) #6 stated showers were scheduled to be given every other day and were scheduled based on the residents' room number. She stated if a resident refused their shower, the CNA should tell the nurse, with the reason why, and the nurse should write a progress note. LPN #6 stated Resident #19 was an extensive assist for their ADLs and would only refuse if they did not feel well. During an interview on 12/01/2022 at 12:39 PM, LPN #7 stated showers were scheduled twice a week by room number, and then it was changed for those with specific preferences. She stated if the resident refused, the CNA should tell the nurse and the nurse would talk to the resident, re-try about three times, and document if they continued to refuse. During an interview on 12/01/2022 at 12:49 PM, the Assistant Director of Nursing (ADON) stated showers were provided twice a week, but some refused and only wanted a shower once a week. The ADON stated the schedule was done by room number but changed per the resident's preference. She stated if the resident refused their shower, the CNA was supposed to notify the charge nurse so they could talk to the resident and encourage them, but if they still refused, then the nurse would make a progress note. She stated they should try multiple times and offer again the next day. The ADON stated if a shower was missed or refused, the staff should ask again on another shift or the next day. During an interview on 12/01/2022 at 1:37 PM, the DON stated showers were provided at least once a week, scheduled by both by room number and by preference. She stated if the resident refused their shower, the CNA was supposed to attempt three times, and if they continued to get refusals, they should tell the nurse. The nurse should find out why the resident was refusing, and if they could not get the resident to agree, then they should put in a progress note, notify the family to get them involved, and continue to try to get them to take a shower. During an interview on 12/01/2022 at 3:13 PM, the Administrator stated showers were given twice a week and as needed and were scheduled both by room number and by resident preference. She stated if the resident was refusing their shower, the CNA should reattempt and notify the nurse so she could try as well. 2. A review of an admission Record indicated the facility admitted Resident #26 with diagnoses that included osteoarthritis, spinal stenosis (a condition where the spinal column narrows and compresses the spinal cord), and low back pain. The annual Minimum Data Set (MDS), dated [DATE], revealed Resident #26 had a Brief Interview for Mental Status (BIMS, a structured evaluation for cognition) score of 13, which indicated the resident was cognitively intact. The resident required extensive assistance with all activities of daily living (ADLs), including bathing. A review of Resident #26's care plan, initiated 05/13/2022, indicated the resident was totally dependent on two staff to provide the resident's bath/shower, and the care plan revealed interventions that directed staff to provide a sponge bath when a full bath or shower could not be tolerated (initiated 05/13/2022), and check the resident's nail length and trim and clean them on bath days and as necessary (initiated 05/13/2022). During an interview on 11/28/2022 at 12:59 PM, Resident #26 stated they were not getting their showers as scheduled. A review of the Intervention/Task Schedule Report revealed Resident #26 was scheduled for baths on Mondays and Thursdays. A review of Resident #26's bathing report for 11/01/2022 through 11/30/2022 revealed the resident received four showers on 11/08/2022, 11/15/2022, 11/17/2022, and 11/29/2022, and one bed bath on 11/24/2022, out of eight bathing opportunities. The resident did not receive three of their scheduled baths in November 2022. A review of Resident #26's medical record revealed no documentation of the resident refusing care, including showers. During an interview on 11/29/2022 at 12:20 PM, Resident #26 stated they got a shower that morning and it felt so good. The resident stated they deserved to have good showers just like everyone else. During an interview on 12/01/2022 at 12:06 PM, Certified Nurse Aide (CNA) #4 stated showers were given two to three times a week, depending on the preference. She stated the schedule was done by the Director of Nursing (DON). CNA #4 stated if a resident refused their shower, she would reapproach them a second and third time if necessary, and if they continued to refuse, she would report it to the charge nurse and document it. She stated it depended on the day as to what type of assistance Resident #26 required. She stated sometimes the resident was able to wash their face and other times they were a total assist with showers, but the resident would also refuse at times. She stated the resident had refused their shower that morning. During an interview on 12/01/2022 at 12:15 PM, CNA #5 stated residents were given showers twice a week by the shower aide. She stated she was not sure if the resident's shower schedule was based on their preference or by their room number. She stated if the resident refused their shower, the CNA should talk to the nurse, and if the resident had not been bathed in a week, then the DON would talk to the resident. CNA #5 stated the level of assistance Resident #26 required depended on how they were feeling, and the resident would refuse their showers. During an interview on 12/01/2022 at 12:23 PM, Licensed Practical Nurse (LPN) #6 stated showers were scheduled to be given every other day and were scheduled based on the residents' room number. She stated if a resident refused their shower, the CNA should tell the nurse, with the reason why, and the nurse should write a progress note. LPN #6 stated Resident #26 required extensive assistance with their showers and would sometimes refuse due to not feeling well. During an interview on 12/01/2022 at 12:39 PM, LPN #7 stated showers were scheduled twice a week by room number and then it was changed for those with specific preferences. She stated if the resident refused, the CNA should tell the nurse and the nurse would talk to the resident, re-try about three times, and document if the resident continued to refuse. During an interview on 12/01/2022 at 12:49 PM, the Assistant Director of Nursing (ADON) stated showers were provided twice a week, but some refused and only wanted a shower once a week. The ADON stated the schedule was done by room number but changed per the resident's preference. She stated if the resident refused their shower, the CNA was supposed to notify the charge nurse so they could talk to the resident and encourage them, but if they still refused, then the nurse would make a progress note. She stated they should try multiple times and offer again the next day. The ADON stated if a shower was missed or refused, the staff should ask again on another shift or the next day. During an interview on 12/01/2022 at 1:37 PM, the DON stated showers were provided at least once a week, scheduled both by room number and by preference. She stated if the resident refused their shower, the CNA was supposed to attempt three times, and if they continued to get refusals, they should tell the nurse. The nurse should find out why the resident was refusing and if they could not get the resident to agree, then they should put in a progress note, notify the family to get them involved, and continue to try to get them to take a shower. During an interview on 12/01/2022 at 3:13 PM, the Administrator stated showers were given twice a week and as needed and were scheduled both by room number and by resident preference. She stated if the resident was refusing their shower, the CNA should reattempt and notify the nurse so she could try as well. 3. A review of an admission Record indicated the facility admitted Resident #34 with a diagnosis that included profound intellectual disabilities. The quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #34 had a Brief Interview for Mental Status (BIMS, a structured evaluation for cognition) score of 7, which indicated the resident had severe cognitive impairment. The resident required limited assistance with all activities of daily living (ADLs), except the resident required extensive assistance with bathing. A review of Resident #34's care plan, revised 03/17/2020, indicated the resident required the assistance of one staff for showering. The care plan revealed interventions that directed staff to provide a sponge bath when a full bath or shower could not be tolerated, avoid scrubbing and pat sensitive areas dry, use short, simple instructions such as hold the washcloth, put soap on the washcloth, and wash your face; to promote independence; and check the resident's nail length and trim and clean them on bath days and as necessary. Observations on 11/28/2022 at 9:09 AM revealed Resident #34's hair looked oily and was not combed. Observations on 11/30/2022 at 8:36 AM revealed Resident #34's hair was very messy and ratted on the top of their head, and the resident had a body odor. Observations on 12/01/2022 at 9:44 AM revealed Resident #34's hair was uncombed and sticking up. A review of Resident #34's bathing report from 11/01/2022 through 11/30/2022 indicated the resident was to receive showers on Tuesdays, Fridays, and as needed, and the nurse was to be notified of refusals. According to the report, Resident #21 received four showers out of nine bathing opportunities, on 11/01/2022, 11/08/2022, 11/15/2022, and 11/25/2022. A review of Resident #34's medical record revealed no documentation of the resident refusing care, including showers. During an interview on 12/01/2022 at 12:06 PM, Certified Nurse Aide (CNA) #4 stated showers were given two to three times a week, depending on the preference. She stated the schedule was done by the Director of Nursing (DON). CNA #4 stated if a resident refused their shower, she would reapproach them a second and third time if necessary, and if they continued to refuse, she would report it to the charge nurse and document it. She stated residents should be shaved every time a shower was given. She stated Resident #34 was a total assist with showers but would refuse at times. During an interview on 12/01/2022 at 12:15 PM, CNA #5 stated residents were given showers twice a week by the shower aide. She stated she was not sure if the resident's shower schedule was based on their preference or by their room number. She stated if the resident refused their shower, the CNA should talk to the nurse, and if the resident had not been bathed in a week, then the DON would talk to the resident. CNA #5 stated Resident #34 was an assist of one for their showers. During an interview on 12/01/2022 at 12:23 PM, Licensed Practical Nurse (LPN) #6 stated showers were scheduled to be given every other day and were scheduled based on the residents' room number. She stated if a resident refused their shower, the CNA should tell the nurse, with the reason why, and the nurse should write a progress note. LPN #6 stated Resident #34 could do a lot for themself, but they had a lot of psych issues and would refuse their showers at times and would give no reason as to why. During an interview on 12/01/2022 at 12:39 PM, LPN #7 stated showers were scheduled twice a week by room number, and then it was changed for those with specific preferences. She stated if the resident refused, the CNA should tell the nurse and the nurse would talk to the resident, re-try about three times, and document if they continued to refuse. During an interview on 12/01/2022 at 12:49 PM, the Assistant Director of Nursing (ADON) stated showers were provided twice a week, but some refused and only wanted a shower once a week. The ADON stated the schedule was done by room number but changed per the resident's preference. She stated if the resident refused their shower, the CNA was supposed to notify the charge nurse so they could talk to the resident and encourage them, but if they still refused, then the nurse would make a progress note. She stated they should try multiple times and offer again the next day. The ADON stated if a shower was missed or refused, the staff should ask again on another shift or the next day. During an interview on 12/01/2022 at 1:37 PM, the DON stated showers were provided at least once a week, scheduled both by room number and by preference. She stated if the resident refused their shower, the CNA was supposed to attempt three times, and if they continued to get refusals, they should tell the nurse. The nurse should find out why the resident was refusing, and if they could not get the resident to agree, then they should put in a progress note, notify the family to get them involved, and continue to try to get them to take a shower. During an interview on 12/01/2022 at 3:13 PM, the Administrator stated showers were given twice a week and as needed and were scheduled both by room number and by resident preference. She stated if the resident was refusing their shower, the CNA should reattempt and notify the nurse so she could try as well. 4. A review of a admission Record indicated the facility admitted Resident #21 with diagnoses that included rheumatoid arthritis, spinal stenosis (a condition where the spinal column narrows and compresses the spinal cord), and osteoporosis. The quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #21 had a Brief Interview for Mental Status (BIMS, a structured evaluation for cognition) score of 3, which indicated the resident had severe cognitive impairment. The resident required limited assistance with all activities of daily living (ADLs), including personal hygiene, and the resident was totally dependent on one person for bathing. A review of Resident #21's care plan, revised 07/31/2022, indicated the resident required the assistance of one staff for showering. The care plan revealed interventions that directed staff to provide a sponge bath when a full bath or shower could not be tolerated, avoid scrubbing and pat sensitive areas dry, and use short, simple instructions such as hold the washcloth, put soap on the washcloth, and wash your face; to promote independence; and check the resident's nail length and trim and clean them on bath days and as necessary. The care plan indicated the resident would refuse at times, and the staff were to encourage compliance, honor the resident wishes, and notify the nurse if the resident refused showers/bathing. A review of Resident #21's bathing report from 11/01/2022 through 11/30/2022 indicated the resident was to receive showers on Tuesdays, Fridays, and as needed, and the nurse was to be notified of refusals. According to the report, Resident #21 received four showers out of nine bathing opportunities, on 11/01/2022, 11/08/2022, 11/15/2022, and 11/25/2022. A review of Resident #19's medical record revealed no documentation of the resident refusing care, including showers. Observations on 11/28/2022 at 9:05 AM revealed Resident #21 was in their room, sitting in a chair next to the bed. The resident's hair was uncombed, and they had facial hair on their chin approximately two millimeters (mm) long. Observations on 11/29/2022 at 12:09 PM revealed Resident #21 continued to have long hair on their chin and their hair was slightly oily. Observations on 11/30/2022 at 8:34 AM revealed Resident #21 continued to have long hair on their chin and their hair was oily. During an interview at this time, the resident stated they wished the staff would help them remove the facial hair. Resident #21 stated they had not had a shower either and would really like one. During an interview on 12/01/2022 at 12:06 PM, Certified Nurse Aide (CNA) #4 stated showers were given two to three times a week, depending on the preference. She stated the schedule was done by the Director of Nursing (DON). CNA #4 stated if a resident refused their shower, she would reapproach them a second and third time if necessary, and if they continued to refuse, she would report it to the charge nurse and document it. She stated residents should be shaved every time a shower was given. She stated Resident #21 was a total assist with showers twice a week and did not refuse care. During an interview on 12/01/2022 at 12:15 PM, CNA #5 stated residents were given showers twice a week by the shower aide. She stated she was not sure if the resident's shower schedule was based on their preference or by their room number. She stated if the resident refused their shower, the CNA should talk to the nurse, and if the resident had not been bathed in a week, then the DON would talk to the resident. CNA #5 stated Resident #21 was an assist of one for their showers. During an interview on 12/01/2022 at 12:23 PM, Licensed Practical Nurse (LPN) #6 stated showers were scheduled to be given every other day and were scheduled based on the residents' room number. She stated if a resident refused their shower, the CNA should tell the nurse, with the reason why, and the nurse should write a progress note. LPN #6 stated Resident #21 was a limited assist with their showers and would refuse at times due to pain or not feeling well. During an interview on 12/01/2022 at 12:39 PM, LPN #7 stated showers were scheduled twice a week by room number, and then it was changed for those with specific preferences. She stated if the resident refused, the CNA should tell the nurse and the nurse would talk to the resident, re-try about three times, and document if they continued to refuse. LPN #7 stated the residents should be shaved every shower day, including women. During an interview on 12/01/2022 at 12:49 PM, the Assistant Director of Nursing stated showers were provided twice a week, but some refused and only wanted a shower once a week. The ADON stated the schedule was done by room number but changed per the resident's preference. She stated if the resident refused their shower, the CNA was supposed to notify the charge nurse so they could talk to the resident and encourage them, but if they still refused, then the nurse would make a progress note. She stated they should try multiple times and offer again the next day. The ADON stated if a shower was missed or refused, the staff should ask again on another shift or the next day. The ADON stated residents should be shaved at least weekly, including women. During an interview on 12/01/2022 at 1:37 PM, the DON stated showers were provided at least once a week, scheduled by both by room number and by preference. She stated if the resident refused their shower, the CNA was supposed to attempt three times, and if they continued to get refusals, they should tell the nurse. The nurse should find out why the resident was refusing, and if they could not get the resident to agree, then they should put in a progress note, notify the family to get them involved, and continue to try to get them to take a shower. The DON stated residents should be shaved with each shower, and women should be shaved with every shower and more often if needed. During an interview on 12/01/2022 at 3:13 PM, the Administrator stated showers were given twice a week and as needed and were scheduled both by room number and by resident preference. She stated if the resident was refusing their shower, the CNA should reattempt and notify the nurse so she could try as well. She stated residents should be shaved with each shower. 5. A review of an admission Record indicated the facility admitted Resident #172 on 11/10/2022 with diagnoses that included myocardial infarction (heart attack), low back pain, and weakness. The annual Minimum Data Set (MDS), dated [DATE], revealed Resident #172 had a Brief Interview for Mental Status (BIMS, a structured evaluation for cognition) score of 15, which indicated the resident was cognitively intact. The resident required extensive assistance with all activities of daily living (ADLs), including transfers. A review of Resident #172's care plan, initiated 11/21/2022, revealed the resident did not have a care plan for their ADL status with interventions directing the staff on the type of assistance the resident required. A review of Resident #172's medical record revealed no other documentation of the resident refusing care, including transfers. Observations on 11/28/2022 at 9:03 AM revealed Resident #172 lying in bed on their back with no shirt on and just a sheet covering them. Observations on 11/29/2022 at 11:54 AM revealed Resident #172 lying in bed with no shirt on and just a sheet covering them. Observations on 11/30/2022 at 8:53 AM revealed Resident #172 lying in bed with no shirt on and just a sheet covering them. During an interview at this time, Resident #172 stated they wanted to get up. The resident stated they had only been up a couple of times since they had been admitted approximately three weeks ago. Observations on 12/01/2022 at 9:33 AM revealed Resident #172 lying in bed with no shirt on and just a sheet covering them. During an interview at this time, Resident #172 stated the staff did not get them out of bed the previous day. The resident stated the staff were supposed to give the resident a shower that day (12/01/2022), so maybe they would be able to stay up then. During an interview on 12/01/2022 at 12:06 PM, Certified Nurse Aide (CNA) #4 stated Resident #172 was a total assist with their ADLs, and the resident should be getting up for lunch. She stated she did not know of the resident refusing care. During an interview on 12/01/2022 at 12:15 PM, CNA #5 stated Resident #172 was a two-person assist and the resident stated they could do more than they actually could. She stated Resident #172 would tell the staff the resident did not want to get out of bed. During an interview on 12/01/2022 at 12:23 PM, Licensed Practical Nurse (LPN) #6 stated Resident #172 required extensive assistance with their ADLs. She stated this was the first week she had been taking care of the resident but stated the resident should be getting out of bed at least daily even though they were a total mechanical lift. She stated all they could do was encourage the resident to get out of bed. During an interview on 12/01/2022 at 12:39 PM, LPN #7 stated residents should be encouraged to be out of bed at least daily and preferably every meal. During an interview on 12/01/2022 at 1:37 PM, the Director of Nursing (DON) stated residents should generally be gotten out of bed at least daily, but it was the residents' preference. During an interview on 12/01/2022 at 3:13 PM, the Administrator stated residents should get out of bed at least daily, depending on their plan of care.

Based on observation, record review, and interview, the facility failed to ensure a medication (heparin flush and a normal saline flush) were not left at the bedside to prevent a potential accident/hazard for 1 (Resident #221) of 1 sampled resident who received Intravenous (IV) therapy in the last 30 days. The findings are: 1. Resident #221 had diagnoses of Dementia and Urinary Tract Infections (UTI). The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/13/22 documented the resident scored 6 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and was occasionally incontinent of bowel and bladder, received an antibiotic 2 days of the 7 day lookback period and received IV medications while not a resident and while a resident. f. The Care Plan with an initiated date of 11/13/22 documented, .The resident is on antibiotic therapy Vancomycin r/t [related to] infection UTI . Administer ANTIBIOTIC medications as ordered by physician . If IV is infiltrated: stop infusion and thoroughly examine the site . c. The November 2022 Medication Administration Record (MAR) documented, .Vancomycin HCl [Hydrochloride] Solution 2000 MG/400ML [Milligram/Milliliter] Use 2000 mg [milligram] intravenously one time a day related to URINARY TRACT INFECTION . D/C [Discontinued] Date 11/16/22 . Vancomycin HCl Solution 2000 MG/400ML Use 2000 mg intravenously one time a day related to URINARY TRACT INFECTION . D/C Date 11/21/22 . PICC [Peripherally Inserted Central Catheter] (LEFT ARM): FLUSH Q [every] SHIFT WITH HEPARIN (IF CLAMPED) OR NORMAL SALINE (IF NOT CLAMPED) every shift . D/C Date 11/27/2022 . a. On 11/28/22 at 9:43 AM, Resident #221 was out of his room. There was a syringe of Heparin Flush 5ml and a syringe of Normal Saline 10cc (cubic centimeter) were on his end table. b. On 11/28/22 at 11:43 AM, Resident #221 was resting in bed. The Surveyor asked if he was receiving an antibiotic. He stated, Yes, I had an IV, they took the IV out on Friday. The Heparin and Normal Saline flushes were still lying on the end table. g. On 11/29/22 at 11:09 AM, Licensed Practical Nurse (LPN) #1 accompanied the Surveyor to Resident #221's room. Resident #221 was lying in bed. The Surveyor asked LPN #1, What is on [Resident #221's] end table? LPN #1 stated, Two unopened flushes. The Surveyor asked, What kind of flushes? LPN 1# stated, One is normal saline, and the other is a heparin flush. The Surveyor asked, What are the flushes for? LPN #1 stated, For his IV he had, that was discontinued last week. The Surveyor asked, Should the flushes/medication be left on his end table. LPN #1 stated, No. h. On 11/29/22 at 11:22 AM, the Surveyor asked the Director of Nursing (DON), Should a normal saline and a heparin flush be left in a resident's room on his end table? The DON stated, No. i. The facility policy titled, Storage of Medications, provided by the Nurse Consultant on 12/01/22 at 3:08 PM documented, .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a pneumococcal vaccine was administered after consent was obtained to minimize the potential for contracting pneumonia for 4 (Residents #11, #20, #39 and #61) of 5 (Residents #1, #11, #20, #39 and #61) sampled residents whose immunization records were reviewed. This failed practice had the potential to affect 39 residents who had not received a pneumococcal vaccine as determined by the total census of 65, minus the 26 residents who had received a pneumococcal vaccine, according to the Resident Census and Conditions of Residents form dated 11/28/22. The findings are: 1. Resident #61 was admitted to the facility on [DATE] and had diagnoses of Diabetes Mellitus, Fractured Left Humerus, History of a Transient Ischemic Attack and Cerebral Infarction. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/27/22 documented the resident scored 11 (8 - 12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS) and the resident's Pneumococcal vaccination was not up to date and was not offered. a. The Immunization Record in the Electronic Health Record (EHR) contained no documentation of a pneumococcal vaccination or the consent status. b. The PARTICIPATION IN IMMUNIZATION PROGRAMS form in the EHR documented, .I [Resident's Name] a resident of [Facility Name] agree to participate in the immunization programs established by this facility and by state law . I authorize the facility to administer a one-time pneumococcal vaccine to me . and was E-Signed on 10/23/22. 2. Resident #39 was admitted to the facility on [DATE] and had diagnoses of Chronic Obstructive Pulmonary Disease, Adult Failure to Thrive, Severe Protein-Calorie Malnutrition and Tobacco Use. The Quarterly MDS with an ARD of 11/06/22 documented the resident scored 13 (13-15 indicates cognitively intact) on a BIMS and the resident's Pneumococcal vaccination was not up to date and was offered and declined. a. The Immunization Record in the EHR contained no documentation of the pneumococcal vaccination or the consent status. b. The PARTICIPATION IN IMMUNIZATION PROGRAMS form in the EHR documented, .I [Resident's Name] a resident of [Facility Name] agree to participate in the immunization programs established by this facility and by state law . I authorize the facility to administer a one-time pneumococcal vaccine to me . and was E-Signed on 3/15/22. 3. Resident #11 was admitted to the facility on [DATE] and had diagnoses of Dementia, Anxiety, and a Left Femur Fracture. The Quarterly MDS with an ARD of 11/08/22 documented the resident scored 4 (0 - 7 indicates severely cognitively impaired) on a BIMS and the Pneumococcal vaccination was not up to date, was offered and was declined. a. The Immunization Record in the EHR contained no documentation of the pneumococcal vaccination or the consent status. b. The PARTICIPATION IN IMMUNIZATION PROGRAMS form in the EHR documented, .I [Resident's Name] a resident of [Facility Name] agree to participate in the immunization programs established by this facility and by state law . I authorize the facility to administer a one-time pneumococcal vaccine to me . and was E- Signed on 8/5/22. 4. Resident #20 was admitted to the facility on [DATE] and had diagnoses of Heart Failure, Chronic Kidney Disease, Chronic Atrial Fibrillation, Supraventricular Tachycardia and COVID-19. The Quarterly MDS with an ARD of 10/07/22 documented the resident scored 13 (13 - 15 indicates cognitively intact) on a BIMS and the Pneumococcal vaccination was not up to date and was not offered. a. The Immunization Record in the EHR contained no documentation of the pneumococcal vaccination or the consent status. b. The PARTICIPATION IN IMMUNIZATION PROGRAMS form in the EHR documented, .I [Resident's Name] a resident of [Facility Name] agree to participate in the immunization programs established by this facility and by state law . I authorize the facility to administer a one-time pneumococcal vaccine to me . and was E- Signed on 8/1/22. 5. On 12/01/22 at 8:39 AM, the Surveyor asked the Infection Preventionist (IP), Was the pneumonia vaccination administered to [Resident #61] , [Resident #39], [Resident #11] and [Resident #20]? The IP stated, No. The Surveyor asked, Why? The IP stated, I haven't gotten to the pneumonia vaccinations, yet. I've only been doing infection control for a couple of months. 6. On 12/01/22 at 11:38 AM, the Surveyor asked the Director of Nursing (DON), When are the residents offered the pneumonia vaccination? The DON stated, Upon admission. The Surveyor asked, Who is responsible to ensure the residents are offered and administered their pneumonia vaccination? The DON stated, Social and IP is responsible for administering. 7. On 12/01/22 at 11:44 AM, the Surveyor asked the Social Service Director (SSD), When are the residents offered vaccinations? The SSD stated, During admission the consents are electronically signed and uploaded in their EHR. I assume the IP checks the electronic record and administers the vaccinations if the resident/family consent. 8. On 12/01/22 at 12:01 PM, the Surveyor asked the IP, When are the residents offered vaccinations? The IP stated, Influenza in the fall, COVID-19 on admission. I know now, Pneumonia is offered on admission. When the residents were admitted and signed the consent to receive the Pneumonia, I was not informed. The Surveyor asked, Who is responsible to ensure the residents are offered and administered vaccinations? The IP stated, Social Director and me. 9. The facility policy titled, Pneumococcal Vaccine, provided by the Administrator on 10/28/22 at 10:30 AM documented, .All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections . Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated . Assessments of pneumococcal vaccination status will be conducted within (5) working days of the resident's admission if not conducted prior to admission . Resident's/representatives have the right to refuse vaccination. If refused, appropriate entries will be documented in each resident's medical record indicating the date of the refusal of the pneumococcal vaccination . For residents who receive the vaccines, the date of vaccination, lot number, expiration date, person administering, and the vaccination will be documented in the resident's medical record .

Based on record review and interview, the facility failed to ensure the Residents, Resident Representatives and Families were notified by 5:00 PM the next calendar day following the occurrence of a confirmed positive COVID-19 of 2 (Residents #22 and #51) of 3 (Residents #22, #51 and #225) sampled residents who had a confirmed COVID-19 positive case in the last 4 weeks. This failed practice had the potential to affect 64 residents according to the Census Report provided by the Administrator on 11/28/22. The findings are: 1. The Staff and Resident COVID-19 Positive Log provided by the Administrator on 11/28/22 at 10:30 AM documented one staff member tested positive for COVID-19 on 11/9/22, Resident #225 tested positive on 11/13/22, two staff members tested positive on 11/14/22, Resident #51 tested positive on 11/15/22 and Resident #22 tested positive for on 11/20/22. 2. Resident #51's Covid Antigen Test received from the Infection Preventionist (IP) on 12/01/22 at 12:45 PM documented the resident tested positive on 11/15/22. 3. Resident #22's Covid Antigen Test received from the IP on 12/01/22 at 12:45 PM documented the resident tested positive on 11/20/22. 4. Resident #51's and Resident #22's [Communication Software] messages completed on 11/30/22, contained no messages sent out of a confirmed occurrence of COVID-19 from 11/15/22 to 11/21/22. 5. On 12/01/22 at 12:13 PM, the Surveyor asked the Administrator, Who receives the COVID-19 results? The Administrator stated, The Infection Preventionist performs the rapid test on the residents and staff, and she informs me of the results. The Surveyor asked, What is the facility's mechanism that is used to inform the residents, their representative, and families of confirmed or suspected COVID 19? The Administrator stated, [Communication Software]. The Surveyor asked, Who is responsible for informing the residents, resident representatives, and family of a confirmed COVID positive? The Administrator stated, Me, the nurses notify the COVID positive resident's family or representative. The Surveyor asked, Who notifies the resident, resident representatives, and families if you are not here? The Administrator stated, If needed the Business Office Manager but I can do the [Communication Software] from home. The Surveyor asked, When do you notify the residents, resident representatives, and families, of a confirmed or suspected COVID-19? The Administrator stated, Immediately, if possible, if not within 24 hours. The Surveyor asked the Administrator to review her [Communication Software] call log for the month of November and asked, When were the residents, resident representatives and families notified of a confirmed COVID-19? The Administrator stated, On 11/9/22 and 11/14/22. The Surveyor asked, On 11/15/22 and on 11/20/22 a resident tested positive for COVID-19. Were the residents, resident representative and families notified according to your [Communication Software] message log? The Administrator stated, No, I missed those. 6. The Centers for Medicare and Medicaid Service Memorandum Ref: QSO-20-29-NH provided by the Administrator on 12/01/22 at 11:15 AM documented, .COVID-19 Reporting. The facility must . Inform residents, their representatives, and families of those residing in facilities by 5p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19 .