Based on observation, and interview, the facility failed to ensure accommodation of needs were met by not ensuring the call light was within reach for one (Resident #23) of one resident The findings are: Resident #23 had a diagnosis of vascular dementia as listed on the Medical Diagnosis sheet. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/18/2023 revealed the resident received a score of three on a Staff Assessment for Mental Status (SAMS), indicating Resident #23 was moderately cognitively impaired. a. On 07/15/2024 at 3:10 PM, Resident #23 was observed to be lying in bed. The call light was observed to be at the very top of the bed behind the curtain and out of reach of the resident. Registered Nurse (RN) #2 entered the room. The surveyor asked where the resident's call light should be located. RN #2 stated it should be next to the resident's hand so it would be within the resident's reach. b. On 07/16/2024 at 9:39 AM, Resident #23 was in bed. The call light was noted to be lying on the other bed and well out of reach of Resident #23. Certified Nursing Assistant (CNA) #3 was asked to step into the room. The surveyor asked CNA #3 if the call light was within reach of Resident #23. She said it was not but that it should be. CNA #3 placed the call light on Resident#23's bed next to the resident's hand. c. On 07/17/2024 at 11:48 AM, the Administrator was asked if the facility had a policy and procedure for call lights. He said there was not one.

Based on observation, interviews, and record review, the facility failed to ensure interventions were implemented to promote safety while smoking for one (Resident #78) of one sampled resident. Findings include: 1. Review of the Diagnosis Report revealed Resident #78 had diagnosis of chronic obstructive pulmonary disease (COPD) and major depressive disorder. 2. Review of the 5 day Minimum Data Sheet (MDS) with an Assessment Reference Date (ARD) of 03/22/2024 noted Resident #78 scored 15 on a Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. 3. Review of the Smoking Assessment dated 07/10/2024 indicated Resident #78 was safe to smoke without supervision but does require smoke apron. 4. Review of Resident #78's Care Plan initiated 07/09/2024 stated, .The resident can smoke UNSUPERVISED.The resident requires a smoking apron while smoking .The resident's smoking supplies are stored in the med [medication] room. NO LONGER SAFE TO KEEP CIGARETTES WITH [resident] . 4. On 07/15/2024 at 2:56 PM, Resident #78 was observed in the smoking room, unsupervised, with no smoking apron on. 5. On 07/16/2024 at 10:16 AM, the surveyor observed Resident #78 in the smoking room smoking a cigarette with no supervision and no smoking apron. Resident #78 had cigarettes and lighter in their possession 6. On 07/17/2024 at 9:36 AM, Certified Nursing Assistant (CNA) #1 was asked where Resident #78's smoking paraphernalia was kept. CNA #1 stated that the resident was allowed to keep her cigarettes and lighter in her room, in the drawer. CNA #1 was asked if Resident #78 required a smoking apron while smoking and she stated that Resident #78 did require a smoking apron but that she doesn't always use it. 7. On 07/17/2024 at 9:47 AM, Registered Nurse (RN) #2 was asked if Resident #78 required a smoking apron and if she was allowed to keep smoking paraphernalia in her room. RN #2 stated it would be care planned and a smoking assessment would determine. 8. On 07/17/2024 at 10:00 AM, the Director of Nursing (DON) was interviewed about Resident #78's care plan and smoking assessment. The DON was asked if Resident #78 should be using a smoking apron according to his/her care plan, and the DON stated Resident #78 should be using an apron and that the resident's cigarettes and lighter should not be kept in the resident's room according to the smoking assessment dated 07/2024. 9. A review of the facility policy titled, Policy and Procedure - Smoking, indicated, .8. Upon a Resident's admission to the facility, designated Facility Employees will conduct an assessment to establish guidelines for each Resident who wishes to smoke. Any restrictions will be noted in the Resident's record. A resident's smoking procedures will be addressed in the Resident's care plan. Residents will be assessed for keeping any smoking paraphernalia in their possession or locked up by nursing staff.

Based on observation, record review, interview and facility policy review, it was determined the facility failed to ensure staff performed hand hygiene before applying and taking off gloves, before, during and after perineal care for 1 (Resident #63) sampled resident observed during incontinent care. Additionally, the facility failed to ensure dirty wipes were not placed on clean wipes to prevent cross contamination during incontinent care for Resident #63. The findings are: On 07/15/2024 at 1:14 PM, Certified Nursing Assistant (CNA) #4 and CNA #5 were observed assisting Resident #63 from a wheelchair with a lift into the resident's bed. After getting the resident into bed, the CNAs proceeded to perform incontinent care on Resident #63 without performing hand hygiene before putting on gloves. The CNAs rolled Resident #63 onto the resident's left side, then CNA #4 performed incontinent care on the resident by handing a soiled perineal wipe across the resident to CNA #5 to dispose of in a trash bag placed on the resident's nightstand. CNA #5 put the soiled wipe in the trash bag, handed the trash bag to CNA #4, then without changing gloves, put her right hand on the resident's back to prevent the resident from falling. CNA #4 took the trash bag and laid it on resident's bed. CNA #4 picked up a stack of clean wipes in her left hand, then proceeded to perform incontinent care on the resident with her right hand. CNA #4 would take a soiled wipe in her right hand, place it on top of the clean wipes in her left hand, and fold it over before disposing of it in the trash bag. CNA #4 did not perform hand hygiene between putting on and taking off her gloves. On 07/15/2024 at 1:37 PM, CNA #4 was asked would you have done anything different during incontinent care? She said no. The surveyor asked should you put dirty wipes on top of clean wipes to fold them after using them? CNA #4 said no, that's cross contamination. The surveyor asked should hand hygiene be performed before and between glove change. CNA #4 said yes. On 07/15/2024 at 1:45 PM, CNA #5 was asked if they should have done anything different during incontinent care. She said no. The surveyor asked if the resident should be touched with dirty gloves after disposal of dirty wipes in the trash bag on the nightstand. She said no. The surveyor asked if hand hygiene should be performed before and between glove changes. CNA # 5 said yes. On 07/18/2024 at 8:10 AM, the Infection Control (IC) Nurse said for infection control to be maintained during incontinent care, we have to be sure to wipe properly, front to back, wear gloves and wash hands when going from dirty to clean, before putting on gloves and after care is finished. The surveyor asked if a CNA should touch a soiled wipe then return to hold the resident without changing gloves or washing their hands. The IC said that is probably not the best practice. I need to ensure education is provided. On 07/18/2024 at 8:14 AM, the Director of Nursing (DON) said to maintain infection control during incontinent care, wiping front to back, changing gloves before and after perineal care, having disposal bag within reach, right beside me. The surveyor asked if a CNA should touch a soiled wipe then return to hold the resident without changing gloves or washing hands. The DON said, No because that is contamination. On 07/18/2024 at 9:00 AM, the DON said there was not a hand hygiene policy. A policy and procedure found in the Infection Control Book provided by the Infection Preventionist documented, Policy: To provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections .(f) The hand hygiene procedures to be followed by staff involved in direct resident contract . A copy of the new employee orientation with competency checkoff documented, .Hand Washing .Hands should always be washed before and after contact with each resident. Hands should be washed even when gloves have been used .

Based on observation, record review and interview the facility failed to ensure that food was labelled correctly, and hand hygiene was performed in the kitchen to prevent cross contamination. The findings are: On 07/15/2024 at 10:45 AM, during an observation of the walk-in refrigerator, the surveyor noted two cardboard boxes containing a full sheet of strawberry shortcake to be used for lunch the following day, neither were labeled with a date. The Dietary Manager confirmed the findings. On 07/15/2024 at 10:47 AM, the surveyor observed 5 full bags of lettuce, and 1/4 of a bag of lettuce with no date, the lettuce in the open bag was turning brown with liquid at the bottom. The Dietary Manager confirmed the findings and stated that they were throwing away the open bag as it looked old. On 07/15/2024 at 10:48 AM, the surveyor observed a full container of cream cheese not sealed on the top left shelf of the refrigerator, with a received date of 06/26/2024. The Dietary Manager confirmed that it was not sealed. On 07/15/2024 at 10:52 AM, during observation in the dry storage area was a 1/4 full bag of fettucine pasta that was not sealed. The Dietary Manager confirmed the findings. On 07/15/2024 at 10:53 AM, during observation in the dry storage area was a bin of eight 1.5 pound full bags of white pepper gravy with no received date on the bin or individual bags. The Dietary Manager confirmed the findings. On 07/15/2024 at 10:54 AM, during observation in the dry storage area was a bin of ten, 13 ounce full bags of brown gravy with no received date on the bin or individual bags. The Dietary Manager confirmed the findings. On 07/15/2024 at 10:55 AM, during observation in the dry storage area was a bin of six 1.4 pound full bags of chicken gravy with no received date on the bin or individual bags. The Dietary Manager confirmed the findings. On 07/15/2024 at 10:56 AM, during observation in the dry storage area on the lowest shelf were two boxes of croissants with no received date, The Dietary Manager confirmed the findings and said there were approximately 25 croissants. On 07/15/2024 at 10:58 AM, during observation in the walk-in freezer, an opened bag of French fries was not sealed properly. The Dietary Manager confirmed the findings and stated that the French fries had ice crystals on them. On 07/15/2024 at 11:05 AM, on a prep table, the lower shelf contained a 42 ounce container of quick oats that was opened and not dated. The Dietary Manager confirmed the findings. On 07/16/2024 at 10:51 AM, the surveyor observed the Dietary Aide adding 12 beef fritters to the fryer basket with gloved hands. After putting the basket in the fryer, the Dietary Aide then removed her gloves. She then put on new gloves to clean the prep table and put away the frozen beef fritters with no hand hygiene in between. On 07/16/2024 at 11:39 AM, the Dietary Manager put on gloves to redo the pureed potato salad, as the previous batch was contaminated. She checked the consistency against her gloved hand to ensure it was pudding consistency. The Dietary Manager took off the glove and put on another glove with no hand hygiene. She cleaned up the work area and took the temperature of the pureed potato salad before performing hand hygiene. On 07/17/2024 at 3:30 PM, during an interview the Dietary Manager said hand hygiene should be performed in between tasks, changing gloves, or anytime your hands become contaminated. She then stated it is to prevent cross contamination in the kitchen. On 07/18/2024 at 8:35 AM, during an interview the Dietary Aide said you should perform hand hygiene before you start anything and when you change gloves, to prevent cross contamination. On 07/18/2024 at 9:02 AM, the surveyor asked the Administrator for hand hygiene and food storage polices for the kitchen. The Administrator said they do not have those policies, they are following Medicaid/Medicare guidelines.

3. Resident #41 had diagnoses of COPD and Unspecified, Dysphagia, Oropharyngeal Phase. a. A Physicians Order dated 04/12/23 documented, Continuous Positive Airway Pressure . every night shift for sleep apnea on at bedtime off in am . b. The Care Plan with an initiated date and revision date of 03/17/23 did not address COPD, respiratory therapy, or CPAP therapy. c. On 06/05/23 at 1:07 PM, Resident #41 was not in his room. A CPAP mask was lying on the bedside table, not in a storage bag. d. On 06/06/23 at 9:26 AM, Resident #41 was not in his room. A CPAP mask was lying on the bedside table, not in a storage bag. e. On 06/06/23 at 1:41 PM, Resident #41 was in his room resting with his eyes closed. The Surveyor asked Resident #41 who was responsible for caring for his CPAP, and if he had a bag to store the mask in to protect it from germs. Resident #41 said, No, I take care of it myself. In the mornings, I take it off and sit it to the side. I will use a bag for my CPAP if they give one to me. f. On 06/08/23 at 10:59 AM, the Surveyor pointed out the CPAP mask lying on a magazine on Resident #41's bedside table to LPN #1 and asked who was responsible for Resident #41's CPAP machine equipment and what the procedure was for storing the CPAP mask. LPN #1 said, The nurses, or treatment nurses are responsible. The Surveyor asked LPN #1 the possible outcome of not having respiratory therapy on Resident #41's Care Plan and the CPAP mask not being stored in a ziplock bag. LPN #1 said, Not getting equipment cleansed properly, dirt, infection, and probably the reason the storage bag for his mask was overlooked. 4. On 06/09/23 at 9:00, the Administrator said, We do not have a CPAP or oxygen policy. Based on observations, record review, and interview, the facility failed to ensure oxygen tubing was properly stored in a plastic bag or container when not in use to prevent potential cross contamination for 1 (Resident #20) of 3 (Residents #19, #20, and #67) sampled residents who had a Physician Orders for Oxygen (O2) and failed to ensure Continuous Positive Airway Pressure (CPAP)/Bilevel Positive Airway Pressure (BiPAP) mask were stored in a plastic bag or container when not in use to prevent cross contamination for 2 (Residents # 15 and #41) of 3 (Residents #14, #20 and #41) sampled residents who had Physician Orders for CPAP/BiPAP therapy as documented on lists provided by the Administrator on 06/09/23 at 9:00 AM. The findings are: 1. Resident #15 had diagnosis of Chronic Obstructive Pulmonary Disease (COPD), Unspecified and Acute Respiratory Failure with Hypoxia. a. A Physicians Order with a start date of 11/17/22 documented, BI-PAP with basic settings turn on, attach O2 and place on resident, document use/refusals . b. A Physicians Order with a start date of 03/06/23 documented, O2 @ [at] 4L [liters] per NC [nasal cannula] PRN [as needed] . c. A Care Plan with a revision date of 05/03/23 documented, .Requires PRN use of oxygen therapy r/t [related to] CHF [Congested Heart Failure], COPD. ****Has BIPAP to be used at HS [hour of sleep]-Frequently refuses to wear . Assess concentrator every shift and prn to ensure proper maintenance. Example: sufficient amt [amount] of water in bottle, tubing clean, tubing in storage bag on concentrator when not in use, accurate dates on bottle, tubing, mask . d. On 06/05/23 at 3:08 PM, Resident #15 was lying in bed with O2 at 4 liters per minute (LPM) via nasal cannula (NC). A Continuous Positive Airway Pressure (CPAP) mask was sitting on a cabinet beside the bed not in a plastic bag or container e. On 06/06/23 at 1:52 PM, Resident #15 was not in her room. A CPAP mask was lying on a cabinet beside the bed, not in a plastic bag or container. f. On 06/08/23 at 10:32 PM, Resident #15 was not in her room. A CPAP mask was lying on a cabinet beside the bed, not in a plastic bag or container. g. On 06/08/23 at 10:43 AM, the Surveyor showed Certified Nursing Assistant (CNA) #3, the CPAP mask lying on the cabinet beside the bed, and asked, Should the mask be stored the way it is now? CNA #3 said, No, it should be in a plastic bag and kept sterilized. The Surveyor asked what could happen if the mask is not kept in the plastic bag when not in use. CNA #3 said, It could cause an upper respiratory infection and distress. h. On 06/08/23 at 10: 57 AM, the Surveyor asked the Director of Nursing (DON) how a CPAP mask should be stored when it is not being used. The DON said, In a plastic ziplock bag. The Surveyor asked why you put the mask in a plastic bag. The DON said, To keep it clean and protect it. The Surveyor asked if the mask is not kept clean, what could happen. The DON said, It could become contaminated. 2. Resident #20 had diagnoses of COPD and Obstructed Sleep Apnea. a. A Physicians Order with a start date of 01/25/22 documented, O2 at 2 LPM [liters per minute] prn SOB [Shortness of Breath]/respiratory distress . b. A Care Plan with a start date of 05/23/23 documented, .has oxygen therapy/CPAP prn r/t COPD, Asthma, Sleep Apnea . Assess concentrator every shift and prn to ensure proper maintenance. Example: sufficient amt [amount] of water in bottle, tubing clean, tubing in storage bag on concentrator when not in use, accurate dates on bottle, tubing, mask . c. On 06/05/23 at 12:55 PM, Resident #20 was sitting up in bed. The Oxygen (O2) concentrator was on 2 liters the nasal cannula (NC) was on the floor. d. On 06/06/23 at 1:40 PM, Resident #20 was lying in bed. The O2 concentrator was running on 2 liters the NC was on the floor. e. On 06/08/23 at 10:19 AM, the Surveyor asked CNA #2 where a resident's NC should be stored when not in use. CNA #2 said, They're put in a plastic ziplock bag. The Surveyor asked why the NC was put in a plastic bag. CNA #2 said, For infection control. The Surveyor asked what could happen if the NC is left out of the bag when the resident is not wearing it. CNA #2 said, It could be contaminated with germs and dirt. f. On 06/08/23 at 10:22 AM, the Surveyor asked Licensed practical Nurse (LPN) #1 how NC was stored when a resident isn't wearing it. LPN #1 said, It should be in a plastic bag, dated, and folded up. The Surveyor asked why should the NC be put in a plastic bag. LPN #1 said, It is for infection control.

Based on observation, record review, and interview, the facility failed to ensure staff sat with the residents and did not stand over them while assisting them with eating to promote dignity for 1 (Residents #29) of 9 (Residents #294, #44, #74, #29, #87, #49, #90, #25 and #48 sampled residents who required assistance with eating. The findings are: 1. Resident #29 had diagnoses of Alzheimer's and Cerebrovascular Accident (CVA). The Annual Minimum Data Set with an Assessment Reference Date of 1/27/22 documented the resident was severely impaired in cognitive skills for daily decision making per the Staff Assessment for Mental Status, required extensive assistance with one-person assist with eating. a. The Physician Order dated 11/25/20 documented, NAS [No Added Salt] diet, pureed texture, Regular consistency . b. The revised Care Plan dated 1/31/22 documented, [Resident #29] has an ADL [Activity of Daily Living] self-care performance deficit r/t [related to] CVA, severely impaired mobility and cognition. EATING: [Resident #29] requires assist per staff with meals to ensure adequate intake . c. On 4/11/22 at 12:41 PM, Certified Nursing Assistant (CNA) #1 was assisting Resident #29 with her lunch meal in the resident's room. CNA #1 was standing beside the resident's bed assisting/feeding the resident and continued to stand over the resident throughout the entire meal. The CNA was asked, Should you stand over a resident while feeding them? She replied, I think it's okay. The CNA was asked, Were you trained to sit next to the resident when feeding them? She replied, Yes, when we are assisting the residents in the dining room. d. On 4/14/22 at 9:12 AM, Nurse Manager #1 was asked, When staff are assisting residents with their meal, in their room, should the staff member stand over them while feeding them? She replied, No, it's a dignity issue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure their abuse prohibition policies and procedures included the process for investigating injuries of unknown origin and reporting to the Office of Long-Term Care (OLTC) for 1 of 1 (Resident #90) sampled resident who had an injury of unknown origin. The findings are: Resident #90, with an admission date of 12/23/21, had diagnoses of Displaced Mid-Cervical Fracture Left Femur, Alzheimer's Disease, Acute Pain, and Heart Failure. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/16/22 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS), was totally dependent on two plus persons for transfers, required extensive assistance of two persons for bed mobility, dressing, eating, toileting, and personal hygiene. a. Physical Therapy Treatment Encounter Note dated for 12/21/21 from the facility the resident lives in documented, .He [resident] has difficulty advancing his left LE (lower extremity) . b. A Health Status Note dated 12/31/2021 written by a Licensed Practice Nurse (LPN) #2 documented, Restorative aid reported to this nurse that resident is stiff and not wanting to bend/slide out of high back w/c [wheelchair] with complaints of pain. Restorative aid and therapist assisted in pulling resident up in w/c and per therapist, resident placed in Geri-chair with staff assist x [times] 2 with use of mechanical lift until further evaluated. This nurse asked resident while in Geri-chair of pain or discomfort anywhere and resident stated, 'No, I am not in any pain anywhere.' while shaking head. Will continue with plan of care. c. A Transfer to Hospital Summary Note dated 1/2/2022 at 09:14 a.m., written by LPN #3 documented, .Received return call from [facility physician] with order to send to ER [emergency room] for eval [evaluation] and treatment if indicated . d. Hospital Discharge summary dated for 1/2/22 documented .He was admitted with a left-sided femoral neck fracture. This [injury] may well of happened several days before admission . e. A second Health Status Note dated 1/2/2022 at 16:27 by LPN #4 documented, .Received call from resident's daughter who states: 'The doctor just came back with x-ray results and his left hip is broken. They are going to take him off his blood thinners and get ortho involved to see what can be done.' This nurse voiced understanding. Notified Administrator of situation, due to this being a fracture of unknown origin as resident has had no incidents/falls since admission. Administrator states, Since this is not any kind of suspected abuse we have until the next day to report it and we will handle it in the morning. Will await further information on resident from family/hospital. f. On 04/12/22 at 02:19 PM, the Administrator was asked for Incident and Accident (I & A) report and/or reportable for the resident. At 02:40 PM, the Administrator stated there was no I & A or reportable because the injury did not occur at this facility, and the family reports the resident had fallen several times at the previous facility where the resident lived. The Administrator provided a printed copy of page one of the hospital Discharge summary dated [DATE]. The Administrator stated, This documents that the fracture happened several days before. The Administrator also provided a copy of the physical therapy notes dated 12/21/21 and stated, This is the therapy notes from the other facility where the therapist said the resident was having difficulty moving his left leg. g. The Policy and Procedure on the Preventions of Resident Abuse, Neglect, Exploitation and Misappropriation of Resident's Property provided by the Administrator on 04/13/22 at 08:03 AM, documented, . all reported allegations will be reported by the Administrator, Administrator's designee, and/or DON to the OLTC per reporting regulations. Corrective actions will take place depending upon the outcome of the investigation . h. On 04/13/22 at 11:42 AM, the Administrator was asked if the facility had a policy specific for investigation and reporting injuries from an unknown injury. The Administrator stated, Is this about the fractured hip? The surveyor stated, Yes. The Administrator stated, It wasn't an unknown origin. We know he had falls. I have statements from the family, or it's documented that the family stated the resident had fallen at the other facility. I did call the Administrator this morning and asked for documentation but was told her company won't release information. I don't think I have a specific policy, but I will look. i. On 04/13/22 at 03:42 PM, the Administrator was asked if the facility had policies and procedures specifically related to investigating and reporting injuries of an unknown origin and he stated, No ma'am I did not. We follow state and federal guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure an injury of unknow origin was immediately reported to the Office of Long Term Care (OLTC) and other agencies in accordance with state law to ensure a thorough investigation was completed and appropriate protective measures were initiated for 1 (Resident #90) of 26 (Residents #2, 3, 6, 9, 10, 15, 23, 28, 29, 33, 34, 35, 37, 44, 46, 55, 58, 59, 72, 74, 75, 77, 81, 84, 90, and 294) sampled residents who were severely cognitively impaired. This failed practice had the potential to affect 48 residents who were cognitively impaired according to a list provided by the Administrator on 4/14/2022. The findings are: Resident #90 had diagnoses of Displaced Mid-Cervical Fracture Left Femur, Alzheimer's Disease, Acute Pain, and Heart Failure. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/16/22 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS), was totally dependent on two plus persons for transfers, required extensive assistance of two persons for bed mobility, dressing, eating, toileting, and personal hygiene. 1. A Health Status Note dated 12/31/2021 written by a Licensed Practice Nurse (LPN) #2 documented, Restorative aid reported to this nurse that resident is stiff and not wanting to bend/ sliding out of high back w/c [wheelchair] with complaints of pain. Restorative aid and therapist assisted in pulling resident up in w/c and per therapist, resident placed in Geri-chair with staff assist x [times] 2 with use of mechanical lift until further evaluated. This nurse asked resident while in Geri-chair of pain or discomfort anywhere and resident stated, 'No, I am not in any pain anywhere.' while shaking head. Will continue with plan of care. a. Physical Therapy Treatment Encounter Note dated for 12/21/21 documented .He [resident] has difficulty advancing his left LE (lower extremity) . b. A Transfer to Hospital Summary Note dated 1/2/2022 at 09:14, written by LPN #3 documented, .Received return call from [facility physician] with order to send to ER [emergency room] for eval [evaluation] and treatment if indicated . c. Hospital Discharge summary dated for 1/2/22 documented .This [injury] may well of happened several days before admission . 2. A second Health Status Note dated 1/2/2022 at 16:27 by LPN #4 documented, .Received call from resident's daughter who states: The doctor just came back with x-ray results and his left hip is broken. They are going to take him off his blood thinners and get ortho involved to see what can be done. This nurse voiced understanding. Notified Administrator of situation, due to this being a fracture of unknown origin as resident has had no incidents/falls since admission. Administrator states, Since this is not any kind of suspected abuse we have until the next day to report it and we will handle it in the morning. Will await further information on resident from family/hospital. 3. On 04/12/22 at 02:19 PM, the Administrator was asked for Incident and Accident (I & A) report and/or reportable for the resident. At 02:40 PM, the Administrator stated there was no I & A or reportable because the injury did not occur at this facility, and the family reports the resident had fallen several times at the previous facility where the resident lived. The Administrator provided a printed copy of page one of the hospital Discharge summary dated [DATE]. The Administrator stated, This documents that the fracture happened several days before. The Administrator also provided a copy of the physical therapy notes dated 12/21/21 and stated, This is the therapy notes from the other facility where the therapist said the resident was having difficulty moving his left leg. 4. The Policy and Procedure on the Preventions of Resident Abuse, Neglect, Exploitation and Misappropriation of Resident's Property provided by the Administrator on 04/13/22 at 08:03 AM, documented, . all reported allegations will be reported by the Administrator, Administrator's designee, and/or DON to the OLTC per reporting regulations. Corrective actions will take place depending upon the outcome of the investigation . 5. On 04/13/22 at 11:42 AM, the Administrator was asked if the facility had a policy specific for investigation and reporting injuries from an unknown injury. The Administrator stated, Is this about the fractured hip? The surveyor stated, Yes. The Administrator stated, It wasn't an unknown origin. We know he had falls. I have statements from the family, or it's documented that the family stated the resident had fallen at the other facility. I did call the Administrator this morning and asked for documentation but was told her company won't release information. I don't think I have a specific policy, but I will look. 6. On 4/13/22 at 11:17 AM, the surveyor notified the Administrator that the state office had been consulted, and it was suggested that the Administrator start an investigation concerning the fractured hip for Resident #90. 7. On 04/13/22 at 03:42 PM, the Administrator was asked if the facility had policies and procedures specifically related to investigating and reporting injuries of an unknown origin and he stated, No ma'am I did not. We follow state and federal guidelines.

Based on observation, record review, and interview, the facility failed to ensure all soiled areas were cleansed of urine; staff wiped from the front to back during incontinent care to promote good hygiene and prevent potential infection for 1 (Resident #84) of 19 (Residents #294, #44, #28, #9, #29, #87, #27, #84, #68, #62, #40, #49, #48, #24, #90, #77, #89, #7, and #23) sample residents who were dependent on staff for incontinent care. The findings are: 1. Resident #84 had diagnoses of Dementia and Urinary Tract Infection (UTI). The admission Minimum Data Set with an Assessment Reference Date of 3/21/22 documented the resident scored 5 (0-7 indicates severe cognitive impairment) on the Brief Interview for Mental Status and required extensive assistance with two-plus people for toilet use and was always incontinent of bowel and bladder. a. The Initial Care Plan dated 3/14/22 documented, The resident is receiving antibiotic therapy. UTI . Practice good infection control standards/measures while providing care . The resident has an ADL [Activities of Daily Living] self-care performance deficit . incontinent of bowel and bladder. Extensive assist x [times] 2 with incontinent care episodes . b. The Physician Order dated 3/14/22 documented, AZO Cranberry Tablet 250-30 MG (Cranberry-Vitamin C-Probiotic) Give 1 tablet by mouth one time a day for UTI PROPHYLAXIS . Discontinued 4/12/22 . c. On 4/11/22 at 12:59 PM, Certified Nursing Assistant (CNA) #1 and CNA #2 provided incontinent care to the resident. CNA #2 tucked the wet brief between the resident's legs. The resident was rolled on her right side. CNA #2 wiped the left buttock, then wiped the rectal area from back to front times one wipe. She then rolled up the wet brief towards the resident's buttocks and tugged twice to remove the brief from under the resident . d. On 4/11/22 at 1:14 PM, CNA #2 was asked, When performing peri-care, which way should you wipe when cleansing the perineal area? She replied, Front to back. She was asked, Which way did you wipe when cleansing the resident's rectal area? The CNA replied, Back to front. She was asked, When performing peri-care on the buttocks should you have cleansed her right buttock? She replied, Yes. The CNA was asked, When removing a brief from under the resident, should you pull on the brief to remove it? She replied, No. e. On 4/14/22 at 9:12 AM, Nurse Manager #1 was asked, When providing peri-care, should the CNA wipe back to front? She stated, No, front to back. She was asked, Why? She stated, There's a risk for an UTI. She was asked, When providing peri-care should the CNA's cleanse the buttocks of urine? She replied, Yes, it could cause skin breakdown, if not cleansed of urine. She was asked, Should the CNA pull on the brief to remove it from under the resident? She replied, No, it could cause shearing.

Based on observation, record review and interview, the facility failed to ensure a positioning device was utilized to decrease the potential for further decline in range of motion for 1 (Resident #74) of 7 (Residents #25, #40, #90, #74, #44, #48 and #9) sampled resident who had hand contractures. The findings are: Resident #74 had diagnoses of Dementia and Cerebral Infarction. The Quarterly Minimum Data Set with an Assessment Reference Date of 3/9/22 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status, was totally dependent on the assistance of two plus people for transferring, required extensive assistance with two plus people for bed mobility, dressing, toilet use, personal hygiene, and required extensive assistance of one person with eating, had functional limitation in range of motion to the upper extremity on both sides. a. The revised Care Plan dated 3/14/22 documented, [Resident #74] has an ADL [Activities of Daily Living] self-care performance deficit . CONTRACTURES: [Resident #74] has contractures of the RIGHT FOOT & [and] LEFT HAND. Provide skin care Q [Every] SHIFT to keep clean and prevent skin breakdown. b. On 4/11/22 at 1:55 PM and on 4/12/22 at 9:04 AM, resident was lying in a low bed. The left hand was contracted in a fist position, with no device in place. c. On 4/12/22 at 9:32 AM, Licensed Practical Nurse (LPN) #1 was asked, What is your policy or procedure to prevent resident's contractures from worsening? She replied, We use carrots for their hands. The LPN accompanied the surveyor to the Resident's room, and was asked, Is the resident able to open his left hand? The LPN replied, No. The resident's left hand was in a tight fist, the LPN was able to open hand approximately an inch, no pressure areas or odor noted to palm. The LPN was asked, Does the resident have a device or need a device placed in his hand to prevent a pressure area or further contracture? She replied, Yes, I think we tried to keep one in his hand before, I will get a carrot for his hand. d. On 4/14/22 at 9:12 AM, Nurse Manager #1 was asked, What is your policy or procedure to prevent resident's contractures from worsening? She replied, We place devices, in their hands, like carrots or even a washcloth.

Based on record review and interview, the facility failed to ensure an antianxiety dose reduction was attempted, in the absence of a physician's documented evaluation of the potential risks versus benefits of continuing the medication and any contraindications for attempting a dose reduction, in order to determine the lowest effective dose and reduce the potential for adverse medication effects for 1 (Resident #74) of 1 sampled residents who had a physician's order for Clonazepam. The findings are: Resident #74 had diagnoses of Dementia and Anxiety. The Quarterly Minimum Data Set with an Assessment Reference Date of 3/9/22 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status and received an antianxiety medication 7 out of the last 7 days. a. A Physician's Order dated 10/26/20 documented, . Clonazepam Tablet Disintegrating 0.5 MG [Milligram] Give 1 tablet by mouth two times a day for Anxiety . b. The revised Care Plan dated 3/14/22 contained no documentation related to the administration of antianxiety medication or monitoring for adverse effects or complications related to the use of the antianxiety medications. c. A Pharmacist Consultation Report dated April 2021 documented, CMS REQUIRES Residents have two failed gradual dose reductions of anti-anxiety drugs within the first year . unless clinically contraindicated; CLONAZEPAM 0.5MG TWO TIMES A DAY FOR ANXIETY SINCE 10/26/20 . May we implement the following order? CONSIDER REDUCTION OF CLONAZEPAM 0.5 MG AM DOSE TO 1/2 TABLET . The Physician disagreed with the recommendation, with a clinical justification statement on 5/14/21. There was no documentation found that a second dose reduction was implemented or completed by the Pharmacist for the continued use and or reduction of the medication. d. On 4/13/22 at 3:42 PM, Nurse Manager #1 was asked, When a resident is prescribed an antianxiety medication, how many dose reduction are required in the first year? She replied, Twice the first year, then once yearly. She was asked, Were two gradual dose reductions attempted for the resident's Clonazepam since 10/26/20? She stated, No, just the one on 5/14/21, I talked to the Pharmacist, and he cannot find any documentation of a second reduction attempted or recommended. She was asked, Who is responsible to ensure dose reductions are completed as required? She replied, The Pharmacist. e. The Policy and Procedure on Pharmacy Services (Medication Regimen Review and Unnecessary Drugs) provided by Nurse Manager #1 on 4/14/22 documented, . To ensure a monthly review of each resident's medical record by a pharmacy. The Primary care physician will be notified, of any negative findings per the monthly pharmacy consultant report, for his/her consideration and review. The Physician will then then address in writing if there is to be any changes or his/her rational for no change .The pharmacist will report any irregularities to the attending physician . Any irregularities will be addressed in a timely manner. Irregularities include, but are not limited to: Any unnecessary drug, when an excessive dose, duration, without adequate monitoring or indication for its use in the presence of adverse consequences which indicate the dose should be reduced or discontinued. Psychotropic Drugs: Any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include: . Anti-anxiety . Residents who use psychotic drugs will receive gradual dose reductions and non-pharmacological interventions, unless clinically contraindicated, in order to discontinue these drugs.

2. Resident (R) #9 had diagnoses of Congestive Heart Failure and Chronic Obstructive Pulmonary Disease. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 4/4/22 documented the resident was severely impaired in cognitive skills per a Staff Assessment for Mental Status (SAMS) and received oxygen while a resident a.The Physician order dated 1/19/21 documented, .Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) [milligram/milliliter] 0.083(%) [percent] 1 vial inhale orally every 4 hours as needed for Wheezing/SOB [shortness of breath]; CHANGE O2 [oxygen] tubing and humidifier every Sunday and Wednesday 10/6 shift every night shift related to Chronic Obstructive Pulmonary Disease . b. The Plan of Care revised on 4/5/22 documented, .Administer [Resident #9] medications as ordered. Document any side effects noted and the effectiveness of medication as needed. Give medications as ordered by physician. Monitor/document side effects and effectiveness; O2 as ordered via nasal cannula. Check for proper placement. Change out tubing/equipment twice weekly if used routinely as needed if used PRN [as needed] or rarely . c. On 04/11/22 at 01:02 PM, Resident #9 was in her room. Oxygen was in use at 2 liters via nasal canula. The Nebulizer machine, tubing and mask were lying on the heating and cooling unit, not dated or in a bag. d. On 04/11/22 at 01:17 PM, Certified Nursing Assistant (CNA) #3 was asked, Should a nebulizer be in a bag and dated? She stated, Yes. She was asked, Can you look at the residents and tell me what you see, please? She stated, Her nebulizer machine is on her heat and air unit and should be in a bag and dated. She was asked, What can happen if you don't keep a nebulizer and the tubing clean? She stated, They can get an upper respiratory infection. Based on observation, record review, and interview, the facility failed to ensure oxygen supplies were stored and labeled properly, updraft mask/mouthpiece was dated, labeled, or stored in a bag or other closed container when not in use to prevent potential contamination for 2 (Residents #68, and #9) of 6 (Residents #90, #294, #68, #23, #62 and #9) sampled residents who had a physician's order for updrafts and oxygen therapy. The findings are: 1. Resident #68 had diagnoses of Asthma, Chronic Obstructive Pulmonary Disease (COPD) and History of Pneumonia due to Coronavirus Disease. The admission Minimum Data Set with an Assessment Reference Date of 3/4/22 documented the resident scored 11 (8-12 indicated moderately impaired) on a Brief Interview for Mental Status, had shortness of breath or trouble breathing with exertion and received oxygen therapy while a resident. a. The Physicians Order dated 3/1/22 documented, . Change tubing and humidifier every Sunday and Wednesday 10/6 [10:00 p.m. - 6:00 a.m.] shift every night shift for OXYGEN USE . Albuterol Sulfate Nebulization Solution 0.63 MG/3ML [Milligram/Milliliter] 3 ml inhale orally via nebulizer every 4 hours as needed for SOB [Shortness of Breath]/Wheezing . b. The revised Care Plan documented, The resident has ASTHMA/COPD . The resident will be free of s/sx [signs/symptoms] of respiratory infections through review date . Give aerosol or bronchodilators as ordered. Monitor/document any side effects and effectiveness. c. The April 2022 Medication Administration Record (MAR) documented, Albuterol Sulfate Nebulization Solution 0.63 MG/3ML [Milligram/Milliliter] 3 ml inhale orally via nebulizer every 4 hours as needed for SOB [Shortness of Breath] / Wheezing . and was initialed as being administered on 4/5/22 at 5:43 PM. d. On 4/12/22 at 9:27 AM, Licensed Practical Nurse (LPN) #1 was asked, What is your policy for changing out/storing oxygen/updraft supplies? She replied, They are changed twice a week, the 10-6 shift does that, plus they date all the oxygen supplies. The LPN accompanied the surveyor to the resident's room, the updraft machine and mouthpiece was lying on the shelve, the storage bag was under the machine. The LPN was asked, Is that the proper way to store an updraft mouthpiece when it's not in use? She replied, No. The LPN was asked, What date was the updraft mouthpiece and storage bag last changed out? She replied, I do not know, they are not dated. e. On 4/14/22 at 9:12 AM, Nurse Manager #1 was asked, What is your policy for changing out/storing oxygen/updraft supplies? She replied, It is changed out on Wednesday and Sunday night, should be stored in a plastic bag when not in use, and supplies should be dated.

Based on observation and interview, the facility failed to ensure 1 of 2 ice machines were maintained in clean and sanitary condition; the fan guard on the walk-in refrigerator was cleaned. Dietary Staff washed their hands between dirty and clean tasks and before handling clean equipment or food items; food items stored in the freezer, dry storage areas were sealed or covered, and hot food was maintained at or above 135 degrees Fahrenheit (F) on the steam table to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The findings are: 1. On 04/11/22 at 12:55 PM, the following observations were made: a. There was a 12-pound tub of potato salad not sealed closed in the short 3-door refrigerator in front of the serving line. b. The walk-in refrigerator's fan guard was covered with thick, blackish debris. Dietary Employee #1 was asked to describe what she saw, and she stated, It's a brownish fussy buildup of dust. c. On a shelf on the right in the walk-in refrigerator there were eleven 5-pound bags of shredded lettuce with no receive date. The lettuce in six of the bags was brownish, slimy, and watery. The lettuce in the other five bags were brownish and mushy. Dietary Employee #1 was asked to describe the lettuce and she said it's brown and bad. d. Inside of the walk-in freezer there was a box containing 20 biscuits not sealed after opening. When Dietary Employee #1 was asked how food should be stored, she stated, It should be closed up where it won't be exposed to air. e. The water/ice dispenser outside of the dining room was checked for cleanliness. When dietary employee #1 wiped the ice dispenser chute with a white napkin there was a sticky brownish substance on the napkin. Dietary Employee #1 was asked to describe what she saw, and she stated, It's the color of tea. I don't know what it is. Housekeeping cleans this one. 2. On 4/13/22 at 9:01 AM, the interior surfaces of the ice machine in the kitchen had black and gray residue on it. Dietary Employee #1 was asked to wipe the Black/gray residue on the interior surfaces. She did so, and the black/gray substance easily transferred to the white napkin. Dietary Employee #1 stated, It had black /gray dirt. She was asked, Who used the ice from the ice machine and how often do you clean the ice machine. She stated, We use it to chill foods, and we clean it once or twice a week. Sometimes we give it to the residents when they ask for it. On 4/14/22 at 6:42 AM Dietary Employee #2 was asked, who uses the ice from the ice machine in the kitchen? She stated, Sometimes we give it to the residents when they ask for it. 3. On 4/13/22 at 9:11 AM, the stove had an accumulation of grease carbon build up. 4. On 4/13/22 at 9:14 AM, Dietary Employee #2 used a dish towel to wipe off the food cart. Dietary Employee #2 did not wash her hands after wiping off the food cart. She used her contaminated hands to pick up clean dishes from the clean area of the dish washing machine and stacked them with her fingers touching the interior surface of the dishes. On 4/14/22 at 6:42 AM Dietary Employee #2 was asked, What should you have done after touching dirty objects and before handling clean equipment or food items? She stated, Washed my hands. 5. On 4/13/22 at 9:24 AM, an open of box of iodized salt was on a rack above the food preparation counter. 6. On 4/13/22 at 9:30 AM, the following observations were made in the walk-in freezer: a. An open box of biscuit stored on a shelf in the freezer was not covered or sealed. b. An open box of sausage stored on a shelf in the freezer was not covered or sealed. 7. An open box of egg rolls stored on a shelf in the freezer was not covered or sealed. 8. On 4/13/2022 at 11:13 AM, Dietary Employee #3 checked the temperature of the hot food items that had been placed on the serving line on the steam table in the kitchen in preparation for the lunch meal service. The temperature of the beef patties was 112 degrees Fahrenheit. The above food item was not reheated before being served to the residents. 9. On 4/13/22 at 11:43 AM, Dietary Employee #4 was on the tray line assisting with the meal service. He picked up trays cards and condiments and placed them on the meal trays, contaminating his hand. Without washing his hands, he picked up plates and placed them on the trays with his fingers inside the plates. 10. On 4/13/22 at 3:40 PM, Dietary Employee #6 removed a carton of nectar thickened apple juice from the refrigerator and placed it on the counter. Without washing her hands, she picked up glasses by the rims and poured thickened apple juice to be served to the residents who received thickened liquids for the supper meal. At 4:30 PM Dietary Employee #6 was asked, What should you have done after touching dirty objects and before handling clean equipment or food items? She stated, I should have washed my hands. 11. On 4/13/22 at 4:05 PM, Dietary Employee #5 pulled her blouse up. Without washing her hands, she picked up a clean blade with her bare hand and attached it to the base of the blender to be used in pureeing food items to be served to the residents on pureed diets for the supper meal. At 4:32 PM, the Dietary Employee #3 was asked, What should you have done after touching dirty objects and before handling clean equipment or food items? She stated, I should have washed my hands.