Based on observations, interviews, and record review, the facility failed to provide foods preferable to a resident to meet their abilities to feed them self for 1 (Resident #83) of 1 resident reviewed for meal preferences and activities of daily living (ADL). Findings include: A review of Resident Rights, dated 07/16, 09/16, indicated, .You have the right to receive service with reasonable accommodation of your individual needs and preferences . A review of the Activities of Daily Living (ADLs), Supporting policy, revised March 2018, indicated, Policy Statement Residents will (sic) provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs) . 6. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences . A review of a facility in-service titled, In-Service dated 07/01/2024, included review of the facility policy titled, Assisting the Impaired Resident with In-Room Meals revised September 2013, indicated, .Preparation .Review the resident's care plan and provide for any special needs of the resident .3. Check the tray before serving it to the resident to be sure that it is the correct diet ordered and that the consistency is appropriate . A review of the admission Record indicated the facility admitted Resident #83 with diagnoses that included affective mood disorder, constipation, and depression. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/08/2024, revealed Resident #83 had a Staff Assessment of Mental Status (SAMS) score of 3 which indicated the resident had severe cognitive impairment. Resident #83 required set up and clean up assistance with meals, partial to moderate assistance with dressing, substantial to maximal assistance with personal hygiene and toileting. Resident #83 had active diagnoses of anxiety disorder, depression and psychotic disorder A review of Resident #83's Care Plan, revised 09/15/2023, revealed the resident required secured/special care neighborhood related to dementia diagnosis, had an activities of daily living (ADL) self-care deficit related to dementia diagnosis, and had a potential for nutritional problem related to dementia. Interventions included providing assistance setting up the meal and providing finger foods when having difficulty using utensils, Resident #83 frequently used hands to eat, initiated on 02/23/2023, and provide and serve diet as ordered, revised on 07/04/2024. A review of the Order Summary revealed Resident #83 had a regular diet, finger food texture, regular consistency. A review of the Meal Tray Card, revealed Resident #83 had standing orders for almond milk, assorted fruit juices, one each bacon, cold cereal, a hard-boiled egg, sausage patty, water, and one slice white toast. During an observation on 07/15/2024 at 7:54 AM, a red colored beverage in a non-spill cup was on the table in front of the resident. Resident #83 was served a meal tray by Certified Nursing Assistant (CNA) #2, containing 1 slice white toast, scrambled eggs, 1 slice bacon, and 1 sausage link. Resident #83 pushed the utensils away and began using hands to eat. During an interview on 07/15/2024 at 8:20 AM, CNA #3 stated the standing orders listed on resident's meal tray card are items residents should receive each meal and Resident # 83 should have received cold cereal (name brand), a hard-boiled egg, and a sausage patty. CNA #3 stated Resident #83 did not receive those food choices because the kitchen did not send them. CNA #3 stated they usually will call the kitchen and get items that are not sent but did not on this occasion. During an interview on 07/15/2024 at 8:22 AM, CNA #2 stated Resident #83 is ordered finger food and was unsure why the resident would receive cereal. CNA #2 stated Resident #83 did not receive the hard-boiled egg or the sausage patty, and that the food items should have been provided. During an interview on 07/17/2024 at 3:55 PM, the Director of Nursing (DON) stated the aides should be looking at preferences when preparing the tray and if they do not receive the items should go and collect it from the kitchen. We do ongoing training on this. The kitchen is the first line of defense and serving staff is the second line of defense to ensure residents receive the items. We do not have a policy on this.

Based on record review and interview, the facility failed to ensure the resident's responsible part/legal representative was notified when a resident refused treatment to provide the necessary information to guide treatment and decrease the potential for related complications for 1 (Resident #110) of 1 sample mix residents. The findings are: Review of a facility policy titled, Change in a Resident's Condition or Status, dated February 2021, indicated our facility promptly notifies the resident, his or her primary care provider, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The nurse will notify the resident's primary care provider or physician on call when there has been a (an): significant change in the resident's physical/emotional/mental condition; need to alter the resident's medical treatment significantly; refusal of treatment or medications two (2) or more consecutive times. A significant change of condition is a major decline or improvement in the resident's status that impacts more than one area of the resident's health status. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. A review of an admission Record indicated the facility admitted Resident #110 with diagnoses that included fracture of left femur, dysphagia, difficulty in walking, hemiplegia and hemiparesis. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/29/2024 revealed Resident #110 had a Brief Interview for Mental Status (BIMS) of 8, which indicated the resident had moderate cognitive impairment. The resident required set up/clean up help for eating, supervision for toileting, and was occasionally incontinent of bowel and bladder; and had no pressure ulcers upon admission. A review of Resident #110's Physician Orders, for the month of April 2024, revealed an order, dated 04/24/2024, for physical therapy, 5-7 times per week for 8 weeks for left hip fracture, to address and improve functional mobility; an order dated 04/24/2024, for occupational therapy, 5-7 times a week for 8 weeks for therapeutic exercises and self-care training; an order dated 04/24/2024, for speech therapy, 5-7 times per week for 6 weeks for cognitive communication, and dysphagia; and an order, dated 04/24/2024, triad to bilateral buttocks and intergluteal cleft every shift for skin integrity. Review of Resident #110's Care Plan, revised on 05/10/2024, revealed the resident had the potential for pressure ulcer development related to impaired mobility. Interventions included, follow facility policies/protocols for the prevention/treatment of skin breakdown; inform the resident/family/caregivers of any new area of skin breakdown (initiated 05/08/2024.) A review of Resident #110's, Progress Notes New, dated 01/01/2024 - 07/16/2024, revealed no family notification for, triad to bilateral buttocks and intergluteal cleft every shift for skin integrity. There was no family notification for Review of Resident #110's Nursing Admit/Readmit Assessment and Care Plan, dated 04/23/2024, revealed Resident #110 admitted with red blanchable area to bilateral buttocks .redness noted to intergluteal cleft with no open area noted. A telephone interview with Resident #110 responsible party on 07/15/2024 at 9:43 a.m. revealed Resident #110 admitted to the facility for therapy after surgery, should have been walking, but the facility did not Tell me he wasn't doing physical therapy, but they did call on the second week. Review of Resident #110's Occupational Therapy Treatment Encounter Note(s), dated 04/24/2024 through 05/06/2024, revealed Resident #110 refused occupational therapy on 05/02/2024. There was no family notification of Resident #110's refusal of therapy documented. Review of Resident #110's Physical Therapy Treatment Encounter Note(s), dated 04/24/2024 through 05/06/2024, revealed Resident #110 refused physical therapy on 05/01/2024 and again on 05/02/2024. There was no family notification of Resident #110's refusal of therapy documented. Review of Resident #110's Speech Therapy Treatment Encounter Note(s), dated 04/24/2024 through 05/06/2024, revealed Resident #110 refused speech therapy on 04/30/2024, 05/02/2024, 05/03/2024, and again on 05/06/2024. There was no family notification of Resident #110's refusal of speech therapy. On 07/18/2024 at 9:19 AM, Certified Occupational Therapy Aid (COTA), revealed during an interview that Resident #110 was taking physical, speech, and occupational therapy, due to a decline in (activities of daily living) ADLs ambulation, and weakness. The COTA revealed if a resident refuses therapy, they encourage the resident, as they can't make the resident do therapy, and we educate them. The COTA revealed that therapy does not notify the responsible party or Power of Attorney on a daily basis regarding refusals, they notify the nurse/APN/social worker, and the family is usually notified during the care plan meeting. The COTA revealed they did not call and notify the families and there was no documentation for Resident #110 therapy refusals. On 07/18/2024 at 9:40 AM, Licensed Practical Nurse (LPN) # 5 revealed during an interview that she had not been notified of the resident's refusal of meals, therapy, or showers, and that family/responsible party should be notified of any change in condition, new orders, refusing care or refusing ADL's and the nurse caring for the resident should document the notification. On 07/18/2024 at 9:55 AM, Social Services (SS) revealed during an interview that she had not been notified of Resident #110 refusals for showers, meals, and therapy, and she had not notified the family related to therapy, meals, or shower refusals. On 07/18/2024 at 10:06 AM, LPN # 8 revealed during an interview she was aware of resident's refusals, and that the family, DON, Advanced Practical Nurse (APN), and the physician should be notified of all changes in condition. LPN #8 was asked if she notified the power of attorney (POA) / family of the new order for triad dated 4/24/2024, in which LPN #8 replied, If it's not documented, then it wasn't done, so no. On 07/18/2024 at 10:35 AM, during interview the Director of Nursing (DON) revealed the doctor, APN, and family should be notified of any changes of condition as soon as they are happening and that it was the floor nurse's responsibility.

Based on observation, interview, and record review, the facility failed to ensure proper nail care was provided to a resident who was dependent on nail care for one (Resident #27) resident and the facility failed to ensure a resident who required assistance with personal hygiene was regularly offered hair care to maintain good grooming and hygiene for one (Resident #96) of two sampled (Resident #27 and #96) residents reviewed for activities of daily living (ADLs). Findings include: A review of a facility policy titled, Activities of Daily Living (ADLs), Supporting, revised March 2018, indicated, Policy Statement . Residents who are unable to carry out ADLs independently will receive the services necessary to maintain .grooming and personal and oral hygiene .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently .in accordance with the care plan .support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care) .A resident's ability to perform ADLs will be measured using clinical tools .will be evaluated in reference to the ARD . MDS definitions: .Limited Assistance .Extensive Assistance .Total Dependence - Full staff performance of an activity with no participation by resident for any aspect of the ADL activity. Resident is unwilling or unable to perform any part of the activity . A review of a facility In-Service, dated 05/16/2024, indicated, Ensure nail care is completed every shower day! Nail care can also be completed PRN if nails become broken or took (sic) long before next nail care time! They should be trimmed and filed to residents liking . A review of a facility In-Service, dated 05/28/2024, indicated, Resident's must obtain two showers (sic) weekly . If a resident wants a shower and it is not their shower day the resident can be showered . A review of a facility In-Service, dated 07/01/2024, indicated a review of the Activities of Daily Living (ADLs), Supporting policy revised March 2018, which included, Policy Statement .Residents who are unable to carry out ADLs independently will receive the services necessary to maintain .grooming and personal and oral hygiene .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently .in accordance with the care plan . support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care) .A resident's ability to perform ADLs will be measured using clinical tools .will be evaluated in reference to the ARD . MDS definitions: . Limited Assistance . Extensive Assistance .Total Dependence - Full staff performance of an activity with no participation by resident for any aspect of the ADL activity. Resident is unwilling or unable to perform any part of the activity . A review of a facility In-Service, dated 07/01/2024, indicated a review of the Brushing and Combing Hair procedure, revised February 2018, The purpose of this procedure is to provide hair and scalp care . General Guidelines 1. The resident's hair should be brushed and combed every morning before breakfast and whenever necessary throughout the day . A review of the admission Record, indicated the facility admitted Resident #27 with diagnoses that included dementia, depression, trigeminal neuralgia, and hearing loss. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/20/2024 revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated the resident had severe cognitive impairment. Resident #27 required substantial/maximal assistance with personal hygiene, had diagnosis of dementia. A review of Resident #27's Care Plan, initiated 10/20/2023, revealed the resident lacked the capacity to understand and make decisions regarding healthcare due to the diagnosis of dementia. The resident had an ADL self-care performance deficit related to weakness, initiated 04/06/2023. Interventions included checking nail length, to trim, and clean on bath day and as necessary. To report any changes to the nurse and required extensive assistance of one (1) staff member. A review of Resident #27's Order Summary revealed Resident # 27 was to receive palliative care/comfort care. A review of a podiatry document, dated 05/29/2024, revealed Resident #27 received treatment that included debridement of two nails. A review of a document titled Follow Up Question Report, revealed Resident #27 received a shower on 07/11/2024. Review of the Grievance Tracking Log, dated 04/18/2024, revealed Resident # 27's daughter requested finger and toenails be cut. During an observation on 07/15/2024 at 7:00 AM Resident #27 was sitting up in bed, hair was greasy and uncombed. During a concurrent interview and observation on 07/15/2024 at 12:55 PM, Resident #27's Responsible Party stated staff was asked to do finger and toenails and they have not done that. Responsible Party described resident's great toes as thick and yellow, the second toe on the left foot as purple in color, and nail on right second toe was curling around end of the toe. During a concurrent observation and interview on 07/16/2024 at 3:16 PM, Certified Nursing Assistant (CNA) #6 stated Resident #27 received a shower today and we don't do nail care that is up to the doctor. CNA #6 did not know the reason nail care was not done for resident by staff. CNA #6 was asked to describe resident's toenails and stated the right second toenail is growing over around it. CNA #6 stated she did not know if a resident's toenail should be so long it wrapped over the resident's toe. During a concurrent observation and interview on 07/16/2024 at 03:22 PM, Licensed Practical Nurse (LPN) #7 stated Resident #27 received a shower earlier today and full nail care was provided if needed. Checking fingernails on both hands, LPN #7 stated it looks like this was missed. Checking toenails, LPN #7 stated they were unsure if the CNAs would feel the right second toe could be clipped because it looks like it wraps around the toe. The CNA should have notified the nurse if they were not comfortable clipping or filing a resident's nails. During an interview on 07/17/2024 at +3:55 PM, the Director of Nursing (DON) stated residents should receive a shower twice a week minimum on scheduled days and as needed. Some residents may request more showers. If a resident is visibly soiled, they should be offered a shower. Residents receive nail care on shower days twice a week and PRN if they are long and if they do not need to be cut, they would need to be filed. If a family requests nail care to be carried out and a resident refused, the family would be notified. The nurse should have been notified of Resident #27's toenails. A review of the admission Record, indicated the facility admitted Resident #96 with diagnoses that included cognitive communication deficit, dementia without behavioral disturbance, major depressive disorder, anxiety disorder and altered mental status. The admission MDS, with an ARD of 03/31/2024, revealed Resident #96 had a BIMS score of 1 which indicated the resident had severe cognitive impairment. Section F0400, Interview for daily preferences, C. indicated it was very important to choose the type of bathing. Resident required partial/moderate assistance with bathing and personal hygiene. A review of Resident #96's Care Plan, dated 04/04/2024, revealed the resident lacked the capacity to understand and make decisions due to dementia; has an ADL deficit related to dementia; no discharge anticipated. Interventions included honor the resident's customary routine for bathing and allow healthcare agent to review the resident current status and make healthcare decisions at least quarterly and more often as needed. A review of Order Summary, revealed Resident #96 had an order to admit to the Secured Neighborhood. A review of Individual Support Plan (ISP) for Secure Neighborhood/Alzheimer's Unit - V 1, dated 04/02/2024, revealed Resident #96 had a bathing preference of showers to be done in the morning. Resident specific interventions for bathing included, Resident is self-conscious about body odor and requests showers and clean clothes, and requires minimal assistance with bathing, During an observation on 07/15/2024 at 8:08 AM, CNA #2 brought Resident #96 to the dining room, hair disheveled, un-brushed, matted to sides of head, fuzzy, and bunched at the crown. During an interview on 07/15/2024 at 12:14 PM, Resident #96's Power of Attorney stated resident needed showers and the resident's hair was greasy. During a concurrent observation and interview on 07/17/2024 at 12:36 PM, CNA #3 stated Resident #96 received a shower on 07/17/2024, prefers showers on Tuesdays and Thursdays and if resident requests extra showers, is soiled, drops food on clothing additional shower would be provided. CNA #3 could not state why resident did not receive a shower on Monday when hair was greasy. Resident #96's hair was fuzzy, bunched at crown. CNA was asked to describe resident's hair. CNA #3 stated that resident did their own hair and CNA did not assist. During an interview on 07/17/2024 at 03:55 PM, the Director of Nursing (DON) stated residents should receive a shower twice a week minimum on scheduled days and as needed. Some residents may request more showers. If a resident is visibly soiled, they should be offered a shower. If a resident refuses a shower, they are offered a PRN shower/bath on different day, notes are made in the chart, and notification of the physician and family are done.

Based on document review and interview, the facility failed to ensure a Registered Nurse (RN) worked at least 8 consecutive hours a day. The deficient practice had the potential to affect all residents. Findings include: A review of the Punch Date and Time, for 01/20/2024 revealed the RN punched in at 12:00 AM, out at 03:15 AM, total hours 3.25, punched in at 03:45 AM, out at 7:36 AM, total hours 3.85, punches totaling 7.10 hours. A second RN punched in at 11:34 AM, out at 5:27 PM, total hours 5.88 hours, punched in 5:57 PM, out at 7:57 PM total hours 2.00, punches totaling 7.88 hours. The RN punch in / punch out hours did not overlap. On 02/04/2024, an RN punched in for 7.63 total hours. On 02/11/2024, the RN punched in at 12:00 AM, punched out at 12:58 AM, total hours 0.97, punched in at 1:28 AM and out at 7:17 AM, total hours 5.82, punches totaling 6.79 hours. A second RN punched in at 10:03 AM, punched out at 12:44 PM, total hours 2.68, punched in 1:17 PM, punched out at 6:30 PM, total hours 5.22, total time punched 7.90 hours. The RN punch in /punch out hours did not overlap. On 2/17/2024, the RN punched in at 9:00 AM, out at 12:25 PM, total hours 3.42, punched in 12:57 PM, punched out 5:26 PM, total hours 4.48, punches totaling 7.90 hours. During an interview on 07/18/2024 at 8:31 AM, the Administrator stated that on 01/20/2024 the RN hours were reported as 7.88, on 01/27/2024 as 7.97 hours, on 02/04/2024 as 7.63 hours, 02/11/2024 as 7.9 hours, and on 02/17/2024 as 7.9 hours. The RN did not stay the full 8 hours those days, They clocked out a little early. During an interview on 07/18/2024 at 10:19 AM, the Administrator stated the facility has an RN every day, Pretty consistently and we just missed those and usually the RN would notify someone if not able to complete the shift. During an interview on 07/18/2024 at 10:04 AM, the Director of Nursing (DON) stated an RN is always on site and on 01/20/2024, 01/27/2024, 02/04/2024, 02/11/2024, and 02/17/2024 there was not an RN, and the DON was not notified. Floor staff would continue resident care as they are trained per their job title if an RN is not available to work. The DON stated notification should be made when there is no coverage. RNs are made aware of the 8-hour requirement when hired into the RN coverage pool and during orientation.

Based on observations, document review, and interviews, the facility failed to post the nurse staffing information on a daily basis, to include the facility name, the current date, the number and actual hours worked by staff, and the resident census. The deficient practice had the potential to affect all residents. Findings include: A review on 07/15/2024 at 6:05 AM of the Direct Care Daily Staffing posted next to the time clock in the front lobby, indicated a date of 07/12/2024, listed staffing numbers and total scheduled hours for Registered Nurse (RN), Licensed Practical Nurse (LPN), Certified Nursing Assistant (CNA). The Direct Care Staffing document did not indicate the facility name, current census, or actual hours worked. There was no posting for 07/13/2024 or 07/14/2024. On 07/18/2024 at 10:45 AM, an observation of the posted Direct Care Daily Staffing documents dated 07/16/2024 and 07/17/2024 contained no facility name, actual hours worked or census. During a concurrent interview and observation with the Director of Nursing (DON) on 07/18/2024 at 1:13 PM, the posted documents did not contain the facility name, census, actual hours worked, or current daily staffing. The dates listed on the Direct Care Daily Staffing postings were 07/16/2024 and 07/17/2024. The DON stated the staffing and assignment sheets are posted daily by the on-call nurse. The weekend on-call would post staffing and assignment sheets from Friday to Monday. Licensed Practical Nurse (LPN) # 4 should have posted staffing and assignments for today and should contain the name of the facility, date, census, and staffing numbers. During an interview on 07/18/2024 at 1:17 PM, LPN # 4 stated sheets were posted last night, and number of staff and hours are filled in and the DON fills in the facility name and census. LPN # 4 did not do weekend staff posting.

Based on observation, record review, and interview, the facility failed to ensure the narcotic medication for Resident # 87 was recorded correctly. This failed practice had the potential to affect 1 (Resident #87) sampled resident who had a physician order for anti-convulsant medication. The findings are: 1. Review of an admission Record indicated Resident #87 had a diagnosis of polyneuropathy (nerve damage). 2. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/30/2024 documented the resident scored a 12 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS). 3. The Physicians Order reads, Pregabalin Oral Capsule 75 MG (Pregabalin) *Controlled Drug* Give 1 tablet by mouth two times a day for (nerve damage). 4. On 07/17/2024 at 11:13 AM, the Surveyor was checking the medication cart on Hall 500. When checking the narcotics there was a discrepancy on Pregabalin 75 mg. The narcotic book showed #34 capsules and the medication card showed #33 capsules. 5. On 07/18/2024 at 12:10 PM, Licensed Practical Nurse (LPN) #4 was asked, What is the process of administering narcotics to a resident? LPN #4 said, We pull the resident up on the Electronic Medical Record (EMR), check their residents 5 medication rights, open the narcotic box with a key, find the correct medication, check for the correct count, pop the pill in a cup, give the medication to the resident, after they take the medicine, we record it in the narcotic book, and verify time given. 6. On 07/18/2024 at 12:23 PM, LPN #5 was asked, What is the process of administering narcotics to a resident? LPN #5 said, Look at the Medication Administration Record (MAR), check the resident to see what is due, unlock the narcotic box with key, find the card with the residents name and medication, check the patients 5 medication rights, pop the pill in a cup, sign out medication in the narcotic book, put the medication back into the narcotic box, give the medication to the resident, and click yes, on the computer. LPN #5 was asked what you do to assure no medication error. LPN #5 said At the beginning of each shift the outgoing nurse and incoming nurse does a count and makes sure the count is correct. 7. On 07/18/2024 at 12: 43 PM, the Director of Nursing (DON) was asked if when nurses are hired, they receive any training on narcotic medication administration and when. The DON stated, Yes, they receive training from the manager and nurse trainer, but [DON] will train them on this, in the future. 7. On 07/18/2024 at 12:50 PM, the Director of Nursing (DON) provided, Medication Labeling and Storage policy. Policy heading . The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys . 7. Controlled substances (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976) and other drugs subject to abuse are separately locked into permanently affixed compartments, except when using single unit package drug distribution systems in which quantity stored is minimal and a missing dose can be readily detected .

Based on observations, interviews and policy review, the facility failed to serve meals in accordance with professional standards for food service safety. Specifically, the facility failed to ensure staff performed hand hygiene after touching clothing and face before serving a meal tray to a resident. This failed practice had the potential to affect 11 residents residing on the secure unit. Findings include: A review of a facility policy titled, Employee Cleanliness and Hand Washing Technique, revised March 2005, indicated, Dietary Employees will .practice good hygiene . are required to wash their hands on the occasions listed below: e. after blowing nose or touching face or hair .any other time deemed necessary . A review of a facility policy titled, Handwashing/Hand Hygiene, revised August 2015, indicated, This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to .residents . Use an alcohol-based hand rub .Before and after assisting a resident with meals . A review of a facility in-service titled, In-Service dated 07/01/2024, included review of the facility policy titled, Assisting the Impaired Resident with In-Room Meals revised September 2013, indicated, . Preparation 11. Employees must perform hand hygiene before serving food to residents . if there is contact with . clothing . the employee must perform hand hygiene before serving food . During an observation on 07/15/2024 at 8:11 AM, Certified Nursing Assistant (CNA) #2 used both hands and adjusted scrub jacket and wiped mouth and right cheek/face with right hand, picked up a plate, used it to cover another plate containing food, placed it on a meal tray and delivered it to a resident room. Upon entering the resident room, the meal tray was placed on a table, the cover plate, lids on beverages and a bowl were removed and the meal was served to the resident. During an interview on 07/15/2024 at 8:39 AM, CNA # 2 stated they should have washed their hands after straightening their jacket and touching their face to prevent transmission of communicable disease. During an interview PM 07/17/2024 at 3:55 PM, the Director of Nursing (DON) stated hand hygiene should be done before serving a meal tray and if someone touches their clothing or face, they should perform hand hygiene again because anything is transmissible and we need to protect our elderly population.

Based on observations, interviews and record review, the facility failed to ensure a resident's food was not touched by another resident, prior to consumption for 1 (Resident #83) of 1 resident reviewed for infection control practices during dining observation. This failed practice had the potential to affect 11 residents residing on the secure unit. Findings include: The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/08/2024 revealed Resident #83 had a Staff Assessment of Mental Status (SAMS) score of 3 which indicated the resident had severe cognitive impairment. Resident #83 required set up and clean up assistance with meals, partial to moderate assistance with dressing, substantial to maximal assistance with personal hygiene and toileting. Resident #83 had active diagnoses of anxiety disorder, depression and psychotic disorder. A review of Resident #83's Care Plan revealed the resident required secured/special care neighborhood related to dementia diagnosis, had an activities of daily living (ADL) self-care deficit related to dementia diagnosis. Interventions included providing assistance setting up the meal and providing finger foods when having difficulty using utensils, and Resident #83 frequently used hands to eat, initiated on 02/23/2023. A review of the Order Summary, revealed Resident #83 had a regular diet, finger food texture, regular consistency. During an observation on 07/15/2024 at 7:54 AM, Resident #83 was served a meal tray by Certified Nursing Assistant (CNA) #2, containing 1 slice white toast, scrambled eggs, 1 slice bacon, and 1 sausage link. Resident #83 began using hands to eat the scrambled eggs. On 07/15/2024 at 7:55 AM, a resident seated across the table from Resident #83, placed hand on Resident #83's plate, pulling the toast and removing it from the plate. The resident then placed the palm of their right hand on the plate, placing fingers in the scrambled eggs, removed hand, placed in their mouth, removing eggs from their fingers. The resident then placed fingers on plate and attempted to pull plate away from Resident #83 and removed the sausage link from Resident #83's plate, touching the top rim of the plate. CNA #2 relocated the resident to another table. Resident #83 continued to eat eggs off the plate, using their fingers. CNA #2 did not remove or provide another plate to Resident #83. During an interview on 07/15/2024 at 8:22 AM, CNA #2 stated the plate should have been removed from Resident #83 when the other resident removed the food and provided a new meal due to contamination of the food by another resident. During an interview on 07/17/2024 at 3:55 PM, the Director of Nursing (DON) stated if a resident takes food from another resident's plate, the plate should be removed immediately and another plate should be provided. The resident should not continue to eat food, from a plate, that was touched by someone else because anything is transmissible and we need to protect our elderly population.

Deficiency Text Not Available

Based on observation, interview, and record review, the facility failed to ensure staff followed physician's orders for prescribed oxygen flow rates for 1 (Resident #105) and failed to ensure a physician order was obtained to administer oxygen for 1 (Resident #83) of 2 sampled residents. The findings are: 1. Review of physician order with a start date of 6/11/2023 for Resident #105 noted oxygen at 3-6 liters per minute per nasal canula for shortness of breath as needed. a. Review of a care plan for oxygen therapy with an initiated date of 6/12/2023, noted Resident #105 has oxygen at 3-6 liters per minute for shortness of breath. b. On 07/17/23 at 12:32 PM observed Resident #105 in bed with oxygen on and running at 1.5 liters per minute via nasal cannula. c. On 07/18/23 at 9:15 AM observed Resident #105 in bed with oxygen on and running at 1.5 liters per minute via nasal cannula. d. On 07/18/23 3:48 PM observed Resident #105 in bed with oxygen on and running at 1.5 liters per minute via nasal cannula. e. On 07/18/23 at 4:05 PM an interview with Licensed Practical Nurse (LPN) #2 who stated Resident #105 is on oxygen for shortness of breath. LPN #2 confirmed the oxygen was running at 1.5 liters per minute and confirmed it should be 3-6 liters per minute. LPN #2 stated the nurses are responsible for ensuring the residents oxygen is on at the ordered rate. f. On 07/20/23 at 12:05 PM the Director of Nursing (DON) confirmed the nurses are responsible for ensuring residents receive oxygen at the prescribed rate and confirmed oxygen use requires a physician's order. 2. On 07/17/2023 at 1:14 PM observed Resident #83 in bed. Oxygen was administered at 2 liters per minute via nasal cannula. a. On 07/18/2023 at 10:24 AM observed Resident #83 in bed. Oxygen was administered at 2 liters per minute by nasal canula. b. On 07/19/2023 at 8:38 AM observed Resident #83 in bed watching TV. Oxygen was administered at 2 liters per minute by nasal canula. c. A review of the physician's order failed to reveal an order for oxygen therapy. d. On 07/19/2023 at 8:51 AM an interview with LPN #1 revealed Resident #83 needed oxygen the week prior, and stated she got an order for oxygen from the nurse practitioner. LPN #1 accompanied the surveyor to Resident #83 room and confirmed the oxygen was flowing at 2 liters per minute. LPN #1 confirmed there should be an order for the oxygen, and confirmed the nurses on the floor are responsible for ensuring there is an order. 3. On 07/20/2023 at 12:04 PM an interview with the DON who stated oxygen is considered a medication and requires an order and confirmed the nursing staff on the floor are responsible for ensuring orders are followed. The DON stated, If a patient has oxygen ordered, and the oxygen saturations show it is required, the concentrator should be set up with a mask or cannula and the rate set up within range reflected in the order. If adjustment is needed outside of the order range, they need to do a callback to the physician to adjust the order. 4. A policy provided by the DON documented .Oxygen Administration .the purpose of this procedure is to provide guidelines for safe oxygen administration .verify that there is a physician's order for this procedure .review the physician orders .review the resident's care plan to assess for any special needs of the resident .unless otherwise ordered, start at the rate of 2 to 3 liters per minute .adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered .

Based on observation, record review and interview, the facility failed to ensure facial was removed to promote good hygiene and dignity for 1 (#3) of 4 (#1, #2, #3, #4) sampled residents that were dependent or needed assistance for Activity of Daily Living (ADL) care. The findings are: 1.Resident #3 had diagnoses of Dementia, Cataracts, and Muscle Wasting and Atrophy. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/16/22 documented the resident scored 5 (0-7 severe impairment) on the Brief Interview for Mental Status (BIMS), required extensive assist of two staff for bed mobility, transfer, toilet use, and personal care; and limited assist of one staff for dressing; was frequently incontinent of bowel and bladder; had no behaviors and did not reject care. a. The Care Plan with a Revision Date of 04/20/22 documented, .resident has an ADL self-care performance deficit r/t [related to] limited mobility .resident requires physical help in part of bathing activity by one staff member twice a week and PRN [as needed] .personal hygiene .resident requires limited assist by one staff with personal hygiene and oral care . b. On 03/31/23 at 8:21 a.m., Resident #3 was sitting in a wheelchair in her room. She had facial hair at approximately 1 inch length above her top lip and covering her chin area. The Surveyor asked, Do you like the hair on your chin and above your lip? Resident #3 rubbed her chin with her hand and replied, No, I used to shave it off, but I can't see to do it now. The Surveyor asked, Does it bother you to have hair on your chin and above your lip? Resident #3 replied, Yes. c. On 04/05/23 at 9:45 a.m., the Director of Nursing (DON) provided a copy of the bathing documentation. Resident #3 received a shower on 03/31/23 at 12:25 p.m. There was no documentation that she refused to be shaved. d. On 04/05/23 at 9:48 a.m., the Surveyor asked Certified Nursing Assistant (CNA) #1, Who is responsible for shaving the female residents? CNA #1 replied, the CNA. The Surveyor asked, Why should female residents not have facial hair? CNA #1 replied, Dignity. e. On 04/05/23 at 9:49 a.m., the Surveyor asked CNA #2, Who is responsible for shaving the female residents? CNA #2 replied, The CNAs, same as nail care. The Surveyor asked, Why should female residents not have facial hair? CNA #2 replied, Dignity. f. On 04/05/23 at 9:50 a.m., the Surveyor asked CNA #3, Who is responsible for shaving the female residents? CNA #3 replied, The CNAs, it should be offered every shower day. The Surveyor asked, Why should female residents not have facial hair? CNA #3 replied, Dignity. g. On 04/05/23 at 9:52 a.m., the Surveyor asked Licensed Practical Nurse (LPN) #1, Who is responsible for shaving the female residents? LPN #1 replied, The CNAs and nurses. The Surveyor asked, Why should female residents not have facial hair? LPN #1 replied, Dignity. h. On 04/05/23 at 2:43 p.m., the Surveyor asked the DON, Who is responsible for shaving the female residents? The DON replied, The CNAs. The Surveyor asked, Why should female residents not have facial hair? The DON replied, It's a dignity issue. 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? The DON replied, That they are abiding by the policy and procedure set in place for grooming and ADL care. i. On 04/05/23 at 3:14 p.m., the Surveyor asked the Administrator, What are your expectations from your staff regarding following the facilities policy and procedures and the CMS guidelines? The Administrator replied, That they follow them. j. The facility policy titled, Activities of Daily Living (ADLs), Supporting, provided by the DON on 04/05/23 at 10:01 a.m. documented, .residents will provided with care, treatment and services as appropriate to maintain or improve their ability to carry out Activities of Daily Living .residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .

Based on record review, and interview, the facility failed to ensure written notification of transfers was provided to the Ombudsman, and the resident, when resident was discharged from the facility for 1 (Resident (R) #86) of 1 sampled resident who was transferred to the hospital in the past 3 months. The findings are: 1. The Facility Initiated Transfer dated 3/28/2022 documented the resident was discharged from the facility to other (home, assisted living .) 2. On 3/29/22 at 1:14 pm, the Social Service Director was asked about the resident. She stated the Ombudsman, and the resident were notified when non coverage was reported to the facility, 2/17/2022. Attempts were made for alternate placement, R refused all homeless shelters in the vicinity, assisted living facilities denied having placement availability, R denied having any family he could live with, 2 adult children that he was unable to contact, 2 cousins-one he was unable to contact and the other he didn't want to contact. R stated his parents and brother were still alive, but he couldn't contact them, reason unknown and not provided. R had a 60-day letter of approval from the [State designated Professional Associates]. She stated she attempted to contact the Adult Protective Services and left a message on 3/28 and 3/29/22 but there has been no return phone call. She stated that resident had made numerous phone calls from the facility to the cousin and other family members, who she didn't know. The admission information in the resident's record had documentation that he was homeless prior to hospitalization. 3. On 3/29/22 at 1:20 PM, the Business Office Manager was asked about the resident. She stated she assisted the resident with applying for Social Security disability, it was mailed by her the end of December 2021or first of January 2022. She denied assisting the resident in any other aspect of his discharge. 4. On 03/29/22 at 01:24 PM, the Regional Ombudsman stated the facility did contact her regarding resident's denial of Medicaid. She stated she did tell the facility that discharging to a motel wasn't considered by the ombudsman's office to be a safe discharge. She stated she gave the facility several options within the community. She tried emergency housing, and nothing was available. After talking with the resident, he refused to go to a homeless shelter, which she stated was also considered a non-safe discharge but was a consideration. Resident refused to go to his cousins. Resident had options that he refused to pursue, he had capacity with a cognitive level score of 15. She stated, .I contacted the State Ombudsman who reported, that the state office didn't receive the 30-day notice of discharge as of this date 3/29/2022. 5. On 03/29/22 at 03:17 PM, The BOM was asked, Did you send a copy of the 30-day letter of discharge to the Ombudsman? She stated, .No, I didn't know I was supposed to send them one . Did the Ombudsman receive a copy, either the regional or the state? She stated, No ma'am, I don't believe so. Did the resident receive a copy of the 30-day letter of discharge? She stated, .Yes, I believe he did . Did the resident sign that he received a copy? She stated, No he didn't. How do you document that the resident received a copy, since you already informed me that the Ombudsman didn't receive a copy? She stated, I can't prove he received a copy.

Based on record review and interview, the facility failed to ensure a comprehensive care plan was developed to address the necessary monitoring and precautions related to resident having nothing by mouth (NPO), to meet the needs of the resident and minimize the potential for complication for 1 (Resident #8) of 2 (Residents #8 and #69) sampled residents who had a physician order for Percutaneous Endoscopic Gastrostomy [peg tube]. This failed practice had the potential to affect 2 residents with PEG tubes as documented on a list provided by Director of Nursing (DON) on 3/30/22. The findings are: Resident #8 had diagnoses of Aphasia, Altered Mental Status, and Dementia. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/31/21 documented resident scored 9 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status, required supervision with set up help only for eating. a. The Physician order dated 03/18/22 documented, NPO [nothing by mouth] b. The Plan of Care dated 03/21/22 documented, .resident requires tube feeding via PEG [Percutaneous Endoscopic Gastrostomy] tube r/t [related too] swallowing problem. The Plan of Care does not reflect the resident's NPO status or any monitoring. c. On 03/28/22 at 02:58 p.m., a 32-ounce water glass was at the resident's bedside. Licensed Practical Nurse (LPN) #1 was asked, Should resident have a water cup at the bedside if she is NPO? She stated, No. She was asked, What could happen if she was to drink it? She stated, Possible aspiration. I will remove it. d. On 03/29/22 at 02:38 p.m., the resident was in her room at a personal refrigerator. The resident had a half empty gallon jug of sweet tea, in the refrigerator. When resident was asked if she drinks it, she just smiled. e. On 03/29/22 at 2:48 p.m., the Director of Nursing was asked, If a resident is NPO, should they have a water glass at the bedside? She stated, No She was asked, Should the resident have tea in their refrigerator? She stated, No, I will have to educate the son. f. On 03/30/22 at 08:40 a.m., the closet care plan did not document the resident's tube feeding or NPO status.

Based on record review and interview, the facility failed to ensure mail was delivered to the residents on Saturdays to promote resident rights and prevent potential delays in receipt of mail for 5 (Residents (R) #31, 34, 41, 49 and 20) of 48 (Residents #2, R8, R10, R16, R18, R20, R23, R25, R28, R30, R31, R32, R33, R34, R35, R40, R41, R43, R44, R45, R49, R53, R54, R55, R58, R62, R64,R65, R67, R73, R81, R83, R85, R86, R87, R96, R907, R98, R99, R100, R148, R149, R248, R249, R250, R298, and R348) sampled residents who received mail. The failed practice had the potential to affect 101 facility residents who may receive mail on Saturdays. The findings are: 1. On 03/29/22 at 10:30 AM, Resident Council President (R#20) and four regular resident council attendees (R#31, R#34, R#41, and R#49) were asked if they received mail on Saturdays. All five resident council members stated they only received mail Monday through Friday. Members were asked if they would like to receive mail on Saturdays. R#20 stated, That would be very nice. Resident #34 and R#49 stated they don't receive much mail, but it would be nice to get it when it was delivered. R#31 stated, Yes, I would like for it to be delivered each day it came. R#41 stated, Yes. 2. On 03/29/22 at 2:50 PM, the Administrator, Social Worker #1, and Social Worker #2 were asked who was responsible for resident mail. Social Worker #1 and Social Worker #2 stated they were. Social Worker #1 and Social Worker #2 were asked if mail was delivered to the residents on Saturdays. The Administrator stated mail was not. Social Worker #2 stated mail from Saturday was left in mailbox and delivered on Mondays. Social Worker #1 and Social Worker #2 were asked if they felt mail should be delivered on Saturdays and both stated Yes. 3. The Mail policy, received from the Administrator on 03/29/22 at 3:16 PM, documented, . 4. Mail and packages will be delivered to the resident as soon as possible (including Saturday deliveries). 4. On 03/30/22 at 3:00 PM, Social Worker #1 was asked if any residents received mail at other addresses than the facility. Social Worker #1 stated she was not aware of any residents having PO [post office] Boxes.

Based on observation, record review and interview the facility failed to ensure an order from the physician for nothing by mouth was followed to prevent potential aspiration complication for 1 (Resident #8) of 2 (Residents #8 and #69) sampled residents who had order to have nothing by mouth. This failed practice had potential to affect 3 residents who had nothing by mouth orders. The findings are: Resident #8 had diagnoses of Aphasia, Altered Mental Status, and Dementia. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/31/21 documented resident scored 9 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status, required supervision with set up help only for eating. a. The Physician order dated 03/18/22 documented, NPO [nothing by mouth] . Enteral feeding every 6 hours . b. The Plan of Care dated 03/21/22 documented, .resident requires tube feeding via PEG [Percutaneous Endoscopic Gastrostomy] tube r/t [related too] swallowing problem. c. On 03/28/22 at 02:58 p.m., a 32-ounce water glass was at the resident's bedside. Licensed Practical Nurse (LPN) #1 was asked, Should resident have a water cup at the bedside if she is NPO? She stated, No. She was asked, What could happen if she was to drink it? She stated, Possible aspiration. I will remove it. d. On 03/29/22 at 02:38 p.m., the resident was in her room at a personal refrigerator. The resident had a half empty gallon jug of sweet tea, in the refrigerator. When resident was asked if she drinks it, she just smiled. e. On 03/29/22 at 2:48 p.m., the Director of Nursing was asked, If a resident is NPO, should they have a water glass at the bedside? She stated, No She was asked, Should the resident have tea in their refrigerator? She stated, No, I will have to educate the son.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #73 had diagnoses of COPD and Acute Myocardial Infarction. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/06/2022 documented the resident scored 6 (0-7 indicates severely impaired) on a Brief Interview for Mental Status and used oxygen while a resident. a. A Physician's order dated 03/10/22 documented, Ensure CPAP mask is on correctly at bedtime . with 2 LPM O2 at HS [at bedtime]. Oxygen as needed for shortness of breath 2 l/m [liters a minute] per nasal cannula prn [as needed]. b. The Plan of Care revised on 1/3/22 documented, The resident has altered respiratory status related difficulty breathing r/t [related to] COPD . Monitor for s/s of respiratory distress and report to MD [Medical Doctor] prn . c. On 03/27/22 at 03:00 p.m., the resident was lying in bed. The C-pap machine was on the bedside table with tubing and mask lying in a chair with wet a pillowcase lying on top of the tubing. d. On 03/28/22 at 08:02 a.m., the resident was lying in the bed with O2 at 3 l/m via n/c. The C-pap tubing and mask were lying on the bedside table, open to air. e. On 03/29/22 at 08:30 a.m., the resident was lying in the bed with O2 at 3.5 l/m via n/c. The C-pap tubing and mask were lying on the bedside table, not covered. 5. Resident #348 had diagnosis of Chronic Diastolic Heart Failure, and Paroxysmal Atrial Fibrillation. The resident was admitted to the facility on [DATE] and no Minimum Data Set (MDS) was complete. a. The March 2022 Medication Administration Record (MAR) documented, Oxygen every shift for shortness of breath 4 LPM to keep sats [oxygen saturation] above 90% . b. On 03/27/22 at 03:25 PM, the resident was lying in bed, receiving O2 via n/c at 3.5 l/m from concentrator sitting at the bedside. LPN #4 was present in the room also. The Nebulizer machine was sitting on the bedside table located on the left side of the bed with the mask lying on top of the machine open to air. c. On 03/27/22 at 04:18 PM, the resident was lying in bed and the O2 saturation rate was 81%. He was receiving O2 at 3.5 l/m via the nebulizer mask. Based on observation, record review, and interview, the facility failed to ensure oxygen was consistently administered at the flow rate ordered by the physician, to minimize the potential for other respiratory complications for 2 (Residents #23 and #348) of 6 (Residents #23, #35, #65, #67, #73, and #348) sampled residents who had physician's orders for oxygen therapy. Failed to ensure C-PAP (Continuous Positive Airway Pressure) mask and tubing were stored in a bag or other closed container when not in use to prevent potential contamination for 1 (Resident #73) of 1 resident who had orders for C-PAP therapy. Failed to ensure up-draft masks were stored in a bag or closed container when not in use to prevent potential contamination for 2 (Residents #44 and #348) of 5 (Residents: 44, 348, 96, 83 and 67) sampled residents who had orders for updrafts. These failed practices had the potential to affect 20 residents who had orders for oxygen, 2 residents who had C-PAP orders and 10 residents who used updrafts according to lists provided by the Director of Nursing (DON). The findings are: 1. Resident #23 had diagnoses of Atrial Fibrillation, Acute on Chronic Diastolic (Congestive) Heart Failure, and Acute Respiratory Distress. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/3/22 documented the resident scored 5 (0-7 indicates severely impaired) on a Brief Interview for Mental Status (BIMS) and received oxygen while a resident. a. On 03/27/22 at 04:24 pm, a Trilogy Bi-pap mask was lying on the bedside table, not stored in any type of bag. b. On 03/30/22 at 1:20 pm, Certified Nursing Assistant (CNA) # 2 was asked how oxygen tubing and masks should be cared for when not in use? CNA #2 stated, They should be put in a bag that is dated. c. On 03/30/22 at 1:30 pm, Licensed Practical Nurse (LPN) #2 was asked how oxygen tubing and masks should be cared for when not in use? LPN #2 stated, They should be in a dated bag. d. On 03/30/22 at 1:35 pm, the DON was asked how oxygen tubing and masks should be stored when not in use? The DON stated, In bags that are changed out weekly on Sundays just like the oxygen tubing and humidity bottles. The DON was asked if it is acceptable for updraft or trilogy masks to be lying out on bedside table and not in a bag. The DON stated, No. 2. Resident #44 had diagnoses of Atherosclerotic Heart Disease of Native Coronary Artery, Paroxysmal Atrial Fibrillation, Chronic Obstructive Pulmonary Disease, Dependence on Renal Dialysis, and Acute and Chronic Acute Respiratory Failure with Hypoxia. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/9/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and had no documented oxygen use. a. On 03/27/22 at 11:30 am, the updraft mask was lying on the resident's bedside table. It was not stored in a bag and was not dated. b. On 03/30/22 at 1:20 pm, CNA #2 was asked how oxygen tubing and masks should be cared for when not in use? CNA #2 stated, They should be put in a bag that is dated. c. On 03/30/22 at 1:25 pm, CNA #3 was asked how oxygen tubing and masks should be cared for when not in use? CNA #3 stated, They should be placed in a bag. d. On 03/30/22 at 1:35 pm, the DON was asked how oxygen tubing and masks should be stored when not in use? The DON stated, In bags that are changed out weekly on Sundays just like the oxygen tubing and humidity bottles. She was asked if it is acceptable for updraft or trilogy masks to be lying out on the bedside table and not in a bag. The DON stated, No.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Ativan dosage was reduced or discontinued, in the absence of a physician's documented evaluation of the potential risks versus benefits of continuing a prn (as needed) medication in order to determine the lowest effective dose and reduce the potential for adverse reactions to the medication effects for 1 (Resident #73) of 9 (Residents #2, #10, #54, #73, #81, #83, #85, #87 and #248) sampled residents who had a physician's order for Ativan. This failed practice had the potential to affect 18 residents who had physician's orders for Ativan according to a list provided by the Director of Nursing (DON) on 03/30/2022. The findings are: Resident #73 was admitted on [DATE] had diagnoses of Dementia with Lewy Bodies, Major Depressive Disorder and Anxiety Disorder. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/06/2022 documented the resident scored 6 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and had no documented behavior in the past 14 days. a. The Plan of Care dated 12/08/21 documented, Review medications and record possible causes of cognitive deficit: new medications or dosage increases; anticholinergics, opioids, benzodiazepines . b. A Physician's Order dated 02/10/22 documented, .Lorazepam tablet 0.5MG [milligrams] .give 0.5 mg by mouth as needed for anxiety related to anxiety disorder . c. A Pharmacist MRR-Antipsychotic (Medication Record Review) Report dated 3/14/22 had no documentation related to PRN [as needed] Lorazepam. d. On 03/29/22 at 01:44 PM, the DON was asked, why Resident #73 had not had any clinical documentation from the physician on the residents PRN Ativan (Lorazepam). She stated, I am not sure. She was asked, Is there any documentation in the chart every 14 days for the use of Ativan? She stated, No. e. As of 3/29/22, the March 2022 Medication Administration Records documented Resident #73 had received Ativan 0.5mg on the 5th and the 8th with no documentation indicating the resident exhibited any behaviors or indicators of anxiety. f. The facility policy Tapering Medications and Gradual Drug Dose Reduction received from the DON on 03/29/22 at 03:30 p.m., documented, After medications are ordered for a resident, the staff and practitioner shall seek an appropriate dose and duration for each medication that also minimizes the risk of adverse consequences .

Based on observation, record review and interview, the facility failed to ensure food items stored in the kitchen, the walk-in refrigerator, the walk-in freezer, and storeroom had a receive date or an expiration date, opened food items had an open date or use by date, and expired food items were promptly discarded to prevent the potential of food borne illness in 1 of 1 kitchen. This failed practice had the potential to affect 99 residents (total census: 101) who received meals from the kitchen according to a list provided by Dietary Employee #3 on 3/31/22. The findings are: 1. On 03/27/22 at 11:25 AM the following observations were made: a. On a shelf in a 2-door stainless steel refrigerator across from the stove, there was an opened bottle of Carmel Syrup with no receive date or expiration date. b. On the shelf above a worktable located near the stove, there was jar of chicken base with no receive date or expiration date. 2. On 3/27/22 at 11:37 AM, in the walk-in refrigerator, there was an open bag of chili pods, a opened jar of Cream of Coconut, and a 32-ounce carton of orange juice with no dates. In the same refrigerator there was a box containing 95 single serving packets of tartar sauce with an expiration date of 1/27/22. 3. On 3/27/22 at 11:41 AM, in the walk-in freezer there was a 5-pound bag of breaded chicken patties with no dates. 4. On 3/27/22 at 11:50 AM, in the dry storage room there was a box of pancake mix dated 1/23 and no year documented. The production date on the box of pancake mix was 2/20/20. There were single serving packets of ranch salad dressing, and tartar sauce which had been removed from their original packaging with no dates, or expiration dates. On the can rack there was a can of grape jelly with no date.

Based on observation, record review and interview, the facility failed to ensure all staff and visitors were fully screened, upon entrance, and contact and droplet precautions were followed by staff entering isolation resident room, to prevent the spread of COVID-19 and other communicable diseases in 1 of 1 facility. These failed practices had the potential to affect all 101 residents who resided in the facility per the Resident Census and Condition of Resident form dated, 3/27/22. The findings are: 1. On 03/27/22 at 10:55 AM, (Sunday) the surveyors entered the facility, and the weekend Registered Nurse (RN) Supervisor informed the surveyors the temperature machine for screening was not working and she could not find covers for the thermometer. She told surveyors to put 98.6 (for the temperature) in the computer to complete the entry. The RN was asked how long it had not been working and she stated, All morning. She was asked if the staff were screened-in for the day shift. She stated, No, to be honest. 2. The COVID Policy and Procedure received from the Administrator on 03/27/22 at 5:30 PM, documented, .3. b. Anyone arriving at the facility (including staff) is screened for fever and symptoms of COVID-19 before entering .11. a. For a resident on Contact Precautions: staff don gloves and isolation gown before contact with the resident and/or his/her environment; b. For a resident on Droplet Precautions: staff don a facemask within six feet of resident .17. Signage on the use of specific PPE [personal protective equipment] (for staff) is posted in appropriate locations in the facility . 3. The policy on Isolation-Categories of Transmission Based Precautions received from the Administrator on 03/27/22 at 5:30 PM documented, .2. Transmission based precautions are additional measures that protect staff, visitors, and other residents from becoming infected .5. Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed . 4. On 03/28/22 at 08:32 AM, the Administrator was asked what the procedure was for new admissions and residents who returned from the hospital. The Administrator stated, They are rapid tested and if test positive the residents go outside to enter the 400 hall COVID unit and if negative and unvaccinated the resident is on isolation for 5 days until tested again. 5. On 03/28/22 at 8:59 AM, the Maintenance Assistant entered a room on the 500-hall. Resident #18 was on contact and droplet precautions. The signage posted on the wall next to the door stated, Contact and Droplet Precautions. There was a plastic container with 3 drawers full of PPE (shoe covers, gown, and goggles,) and a box of gloves on the handrail at the door's entrance. Upon exiting the room, the Maintenance Assistant was asked if he was aware that the resident was on precautions. He stated, I did not know until now. I thought that was all done with. He was asked if he noticed the signage and the plastic cabinet and pointed to them and he said, I do now. He was asked what the procedure was to enter a room with the precaution signs and cabinet of PPE, and he stated he was to wear everything in that thing, pointing to the cabinet of PPE. The Maintenance assistant was then asked what else needed to be done once he exited any resident's room that he had touched things in, and he stated he did not know. He was asked if he followed hand washing policy and he stated he did not help resident but does Wash his hands or use hand sanitizer throughout the day. 6. On 03/28/22 at 10:32 AM, the Administrator was asked when paper screenings were received. The Administrator stated he had them do them for all the employees sometime in the afternoon yesterday. The Administrator was asked, Was that once surveyors were here and he stated, Yes, that was done in the afternoon. The Administrator was asked if there was a way to get a printout of all that entered and not screening by temperature. The Administrator stated he could call and ask visitors and staff if they were screened. Surveyor reminded Administrator what Weekend RN Supervisor stated to surveyors upon entry. He stated, They have access to debit cards to go to Walmart and most of the CNAs have thermometers. He stated there was an entrance in the back with a screening temperature reader that was functioning and both nurses' stations have ways to check temperatures. The Administrator was asked if there was a way to determine who entered through the front door and who entered through the back door, and he stated he only receives emails each time a person screens in. The Administrator stated IT [information technology] said there was not a way to print a list. 7. On 03/30/22 at 10:14 AM, the Infection Control Prevention (ICP) was asked What precautions were put into place for unvaccinated staff? The ICP stated, We try to have them not take care of unvaccinated residents .We switch them out with other residents' staff .there is a list of unvaccinated residents back behind the computer at each desk and . I prefer them to wear N95 all the time. The ICP was asked How do you ensure visitors know precautions to take? The ICP stated the front desk receptionist monitors visitors and vendor book and checks COVID cards.