**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the care plan reflected the individual care needs for one of six sampled residents (Resident 1). * The facility failed to provide adequate monitoring when Resident 1 was continually wandering around the facility to prevent elopement and/or accidents. In addition, the facility failed to develop a person-centered care plan to address Resident 1's high risk for elopement and fall. This failure resulted to Resident 1 being unsupervised and had a fall with injury in the patio.Findings: Review of the facility's P&P titled Fall Management System revised 4/2025 showed it is the policy of this facility to provide an environment that remains as free of accident hazards as possible. It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. Review of the facility's P&P titled Comprehensive Resident Centered Care Plan revised 1/2021 showed the IDT shall develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights, that include measurable objectives and timeframes to meet a resident/'s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Closed medical record review for Resident 1 was initiated on 9/24/25. Resident 1 was admitted to the facility on [DATE], and was discharged on 9/7/25. Review of Resident 1's Elopement/Wandering Evaluation dated 8/19/25, showed the resident was high risk for elopement wandering. Resident 1 had a predisposing disease of dementia (brain disorders that cause a progressive decline in cognitive abilities). The section for History of elopement in the last six months showed a yes response to the following questions:- does resident makes statements about a desire to leave the facility, etc.;- does the wandering place the resident at risk of getting to a potentially dangerous place (stairs, outside the facility); and- does the wandering significantly intrude on the privacy or activities of others. Review of Resident 1's Fall Risk Evaluation dated 8/19/25, showed the resident was categorized as high risk for falls. Review of Resident 1's Care Plan Report showed a care plan problem was initiated on 8/19/25, to address the following:- at risk for repeat falls, the interventions included to provide redirection and cuing when the resident wheels self around;- potential for injury related to exit seeking behavior and risk for elopement, the interventions included to monitor the resident's whereabout; and- elopement risk/wanderer related to impaired safety awareness and exit seeking behavior. However, the elopement care plan showed the goals and interventions were developed only on 8/28/25, when Resident 1 had a fall in the patio. Review of Resident 1's MDS assessment dated [DATE], showed the following:- section C for Cognitive Patterns showed Resident 1 had a BIMS score of 5 (severe cognitive impairment); and- section GG for Functional Abilities showed Resident 1 had no impairment on upper and lower extremity and uses wheelchair for mobility device. Review of Resident 1's Progress Notes dated 8/28/25, showed at 1450 hours, a resident was heard yelling nurse. The nurse was notified of someone was screaming help at the patio outside of the resident's room. The note further showed Resident 1 was noted lying on his left side with a cut in the forehead and multiple cuts and scrapes on the arms and legs. Review of Resident 1's SBAR Summary for Providers dated 8/28/25, showed the resident had a fall and the physician had ordered for the resident to be transferred to the acute care hospital. Review of Resident 1's IDT dated 8/29/25, showed Resident 1 had a fall on 8/28/25. The note showed prior to the incident, the resident had been wheeling self independently with constant supervision by nursing staff. The resident was last seen by the CNA and LVN by the nurse's station at around1440 hours. The note further showed the resident continued to wheel self and constant redirection had been offered to the resident, but had not been easily redirected. On 9/25/25 at 1315 hours, an interview and concurrent medical review was conducted with RN 2. RN 2 stated Resident 1 was a wanderer. Resident 1 would wheel himself everywhere inside the facility and sometimes from room to room. When asked for how long Resident 1 was in the patio, RN 2 was not able to determine. RN 2 acknowledged the resident's whereabouts were not monitored. On 9/25/25 at 1430 hours, an interview and concurrent medical review was conducted with the ADON/IP. The ADON/IP stated the resident would wheel self constantly and goes from room to room. The facility staff would always redirect Resident 1 and the resident would stop but would then continue to wheel himself aimlessly. When asked where did the CNA last saw Resident 1, the ADON/IP was unable to provide the information. The ADON/IP verified Resident 1 was alone and unsupervised in the patio when the fall incident happened. On 9/25/25 at 1615 hours, the Administrator and DON was made aware and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 84) observed during medication pass observation. * Resident 84 was assessed not for safe self-administration of the medications when Resident 84 was observed with a Cepacol Extra-Strength Sore Throat Benzocaine 15 mg/menthol 2.6 mg lozenges (lozenges containing medication to relieve sore throat and pain) at the resident's bedside. In addition, the facility failed to ensure a care plan was developed to address the self-administration of the medications for Resident 84. These failures had the potential for Resident 84 to self-administer the medications inaccurately and negatively affect Resident 84's well-being. Findings: Review of the facility's P&P titled Self-Administration of Medications by Residents (undated) showed the following:- Each resident who desires to self-administer medication is permitted to do so if the facility's interdisciplinary team (IDT) has determined that the practice would be safe for the resident and other residents of the facility.- It is the responsibility of the IDT to determine if it is safe for the resident to self-administer drugs before the resident may exercise that right. The IDT must determine whether the resident or the nursing staff will be responsible for storage and documentation of the administration of the medications, as well as the location where the medications will be administered. These determinations should appear on the resident's comprehensive plan of care- All nurses and aides are required to report to the charge nurse on duty any medications found at the beside not authorized for bedside storage and to give unauthorized medications to the charge nurse for return to the family or responsible party. On 7/24/25 at 0827 hours, an observation and concurrent interview was conducted with Resident 84. A plastic bag with medication was observed in the side of the duffle bag on Resident 84's bed. Resident 84 stated the medication was her cough drops she took with her to the dialysis center because her throat gets dry. Medical record review for Resident 84 was initiated on 7/24/25. Resident 84 was admitted to the facility on [DATE]. Review of Resident 84's H&P examination dated 11/18/24, showed Resident 84 had the capacity to understand and make decisions. Review of Resident 84's medical record failed to show an assessment was conducted by the IDT of Resident 84's ability to self-administer medications. Review of Resident 84's Order Summary Report dated 7/23/25, failed to show for a physician's order for the Cepacol Extra-Strength Sore Throat Benzocaine 15 mg/menthol 2.6 mg; and to allow Resident 84 to self-administer the medication. Review of Resident 84's Care Plan Report (undated) failed to show a care plan problem was developed to address Resident 84's self-administration of the Cepacol Extra-Strength Sore Throat Benzocaine 15 mg/menthol 2.6 mg medication. On 7/24/25 at 0827 hours, an observation and concurrent interview for Resident 84 was conducted with LVN 7. LVN 7 verified Resident 84 had a package of Cepacol Extra-Strength Sore Throat Benzocaine 15 mg/Menthol 2.6 mg in the duffle bag on her bed. LVN 7 verified Resident 84 would need to have an assessment, physician's order, and care plan to keep the medication at bedside. LVN 7 also verified there was no assessment, physician's order, or care plan for the self-administration of the medications, therefore Resident 84 should not have had the medication at the bedside.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure three of five final sampled residents (Residents 7, 71, and 109) reviewed for unnecessary medications were free from the unnecessary psychotropic medications. * The facility failed to ensure Resident 109's physician's order and informed consent for the use of the quetiapine (antipsychotic medication) and risperidone (antipsychotic medication) medications included the diagnoses and the specific behavior manifestation; and the psychoactive medication evaluation and care plan were initiated for the use of the quetiapine and risperidone medication. In addition, the facility failed to ensure the physician's order for the use of the PRN alprazolam medication (antianxiety) had a stop date. * The facility failed to ensure Resident 71's orthostatic blood pressure was accurately monitored as ordered by the physician for the use of the quetiapine medication. In addition, the facility failed to accurately monitor Resident 71's behavior and implement the non-pharmacological interventions for Resident 71's use of the quetiapine medication. * The facility failed to ensure Resident 7 was not prescribed with two antidepressant medications for the same behavior manifestation. These failures had the potential for the residents to have adverse effects from the psychotropic medications and prescriber to have incorrect data when adjusting the dosage of the psychotropic medications.Findings: Review of the facility's P&P titled Psychotropic Medications revised 2/2024 showed based on a comprehensive assessment, the facility will ensure that: - Residents who use psychotropic drugs receive gradual dose reductions (GDR), and behavioral interventions, unless contraindicated, in an effort to discontinue these drugs; - PRN orders for psychotropic drugs are limited to 14 days. Except for PRN orders for anti-psychotic medications, if the attending physician or prescribing practitioner believes that it is appropriate or the PRN psychotropic medication order to be extended beyond 14 days, he or she should document their rationale in the resident’s medical record and indicate the duration for the PRN (as needed) order. Further review of the facility’s P&P showed on admission, the admitting nurses will review the transfer orders for any psychotropic medicators. The licensed nurse shall review the classification of the drug, the appropriateness of the diagnosis, its indication, monitors behavior, and related adverse side effects prior to verification of admission orders with the Attending Physician. The medical record must show documentation of the diagnosed condition for which a psychotropic medication is prescribed. Upon change of condition or initiation of a new order for psychoactive medications, the facility will obtain consent prior to the initiation of the new medication. New physician’s orders for the psychotropic medications will be communicated to the Social Services department for review with the IDT and appropriate care planning will be done to ensure updated information in the resident’s psychosocial care plan. 1. Medical record review for Resident 109 was initiated on 7/22/25. Resident 109 was admitted to the facility on [DATE], with diagnoses of anxiety disorder and vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, and mood disturbance. Review of Resident 109’s H&P examination dated 7/17/25, showed Resident 109 could make his needs known but could not make medical decisions. Review of Resident 109’s Order Summary Report for July 2025 showed a physician’s order dated 7/17/25, for the following: - to administer quetiapine (antipsychotic medication) 25 mg one tablet daily for hallucinations. - for the use of the quetiapine medication, to monitor Resident 109 for the episodes of psychotic behavior as evidenced by hallucinations, every shift, and - to administer risperidone (antipsychotic medication) 1 mg one tablet every 12 hours for hallucinations. a. Review of Resident 109’s Informed Consent for quetiapine medication dated 7/17/25, showed a consent was obtained for the use of quetiapine 25 mg every day at noon. The facility documented “manifested by hallucinations” for the reason for treatment. Review of Resident 109’s Informed Consent for risperidone medication dated 7/17/25, showed a consent was obtained for the use risperidone 1 mg two times a day. The facility documented “manifested by hallucinations” for the reason for treatment. Further review of Resident 109’s order summary report and informed consents failed to show the diagnosis for the quetiapine and risperidone medications. b. Review of Resident 109’s medical record failed to show a psychoactive medication evaluation was conducted for Resident 109’s use of the quetiapine and risperidone psychotropic medications. Review of Resident 109’s plan of care failed to show a care plan problem was developed to address Resident 109’s hallucinations or the use of the quetiapine and risperidone psychotropic medications. Review of Resident 109’s MAR for July 2025 showed Resident 109 was administered the antipsychotic medications on the following date and times: - quetiapine medication 25 mg daily on 7/17 to 7/22/25 at 1200 hours, - risperidone medication 1 mg every 12 hours on 7/17/25 at 2100 hours, 7/18 to 7/22/25 at 0900 and 2100 hours, and 7/23/25 at 0900 hours. Further review of the MAR for July 2025 showed Resident 109 was monitored for the episodes of psychotic behaviors as evidenced by hallucinations for the use of the quetiapine medication on 7/17/25, during the PM and NOC shift, and from 7/18 to 7/22/25, during the day, PM, and NOC shifts. However, the MAR failed to show the specific type of hallucination Resident 109 was monitored for. On 7/24/25 at 1356 hours, an interview and concurrent medical record review for Resident 109 was conducted with the DON. The DON stated the informed consent for the use of the psychotropic medications should include the ordered psychotropic medication, the dose, frequency, diagnosis, and manifested behaviors. The DON stated the informed consent was obtained by the physician and the licensed nurse was responsible for verifying the informed consent was obtained prior to the administration of the psychotropic medication. The DON stated the licensed nurse was responsible for ensuring the information on the informed consent was accurate, and if it was not, the licensed nurse should clarify the information with the physician. The DON stated the psychoactive medication evaluation was initiated upon the resident’s admission to the facility and when a psychotropic medication was prescribed to the resident. The DON verified the psychoactive medication evaluation was not conducted for Resident 109’s use of the quetiapine and risperidone medication. Additionally, the DON stated there was no care plan initiated for Resident 109’s use of the antipsychotic medications or for the symptoms of hallucinations. When asked about Resident 109’s symptoms of hallucinations, the DON stated the behavior was not specific and did not indicate if Resident 109 was having auditory or visual hallucinations. On 7/24/25 at 1536 hours, follow-up interview and concurrent medical record review for Resident 109 was conducted with the DON. The DON stated the licensed nurse who entered the physician’s orders was expected to ensure there was a proper diagnosis for the medication prescribed. The DON stated if the diagnosis was not documented, the licensed nurse should contact the physician and clarify the order. The DON stated the licensed nurse should have clarified the diagnosis and the manifesting behaviors to ensure Resident 109 was properly monitored for the use of the antipsychotic medication. c. Review of Resident 109’s Order Summary Report showed a physician’s order dated 7/15/25, to administer alprazolam (antianxiety medication) 0.25 mg one tablet by mouth every 24 hours as needed for anxiety manifested by verbalization of feeling anxious. However, the physician’s order for PRN alprazolam failed to include a stop date. Review of Resident 109’s MAR for July 2025 showed Resident 109 was administered the alprazolam 0.25 mg medication on 7/23/25 at 0515 hours. On 7/24/25 at 1356 hours, an interview and concurrent medical record review for Resident 109 was conducted with the DON. The DON stated the licensed nurses were responsible for ensuring the physician’s orders for the PRN psychotropic medications had a stop date. The DON further stated if the PRN psychotropic medication order did not have a stop date, the licensed nurses were expected to contact the physician to clarify the order. The DON reviewed Resident 109’s medical record and verified the above findings. 2. Medical record review for Resident 71 was initiated on 7/22/25. Resident 71 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 71’s H&P examination dated 4/2/25, showed Resident 71 had a fluctuating capacity to understand and make decisions. a. Review of Resident 71’s Order Summary Report dated 7/2025, showed a physician’s order dated 4/1/25, to obtain Resident 71’s orthostatic BP (blood pressure) in the lying position every seven days, and to wait 15 minutes prior to position changes; and obtain Resident 71’s orthostatic BP in the sitting position every seven days, and to wait 15 minutes prior to position changes. Review of Resident 71’s MAR for June 2025 showed the following: - dated 6/13/25, the BP readings were documented as 119/61 mmHg for both the lying and sitting position, and - dated 6/20/25, the BP readings were documented as 134/76 mmHg for both the lying and sitting position. On 7/28/25 at 1425 hours, an interview and concurrent medical record review for Resident 71 was conducted with LVN 2. LVN 2 stated Resident 71 was monitored for orthostatic hypotension weekly, by obtaining Resident 71’s BP readings in the lying and sitting positions. LVN 2 reviewed Resident 71’s medical record and verified the above findings. LVN 2 stated the BP readings should not be the same. On 7/29/25 at 1100 hours, an interview was conducted with the DON. The DON stated the residents on the psychotropic medications were monitored every shift for side effects related to the use of the psychotropic medication, such as headache, dizziness and orthostatic hypotension. The DON stated the licensed nurse was expected to compare the BP readings and determine if there was a drastic drop in the BP. The DON stated the BP readings should not be the same for the different positions. b. Review of Resident 71’s Order Summary Report for July 2025 showed the following physician’s orders: - dated 4/1/25, for the use of the quetiapine antipsychotic mediation, to monitor Resident 71 for episodes of schizoaffective disorder behavior as evidenced by angry outburst for no apparent reason and provide the nonpharmacological interventions and document the interventions as follows: 0-back rub, 1-redirection, 2-speak to/approach in a calm manner, 3- reposition, 4- offer snacks/fluid/milk, 5- assess for pain, 6- provide a quiet environment, 7- encourage to express feelings, 8- take to activities, 9- provide reassurance, every shift, and - dated 7/1/25, to administer quetiapine 100 mg one tablet by mouth two times a day for schizoaffective disorder manifested by angry outbursts for no apparent reason. Review of Resident 71’s plan of care showed a care plan problem dated 4/3/25, addressing Resident 71’s use of the antipsychotic medication related to the diagnosis of schizophrenia manifested by angry outbursts. The interventions included to document the episodes of Resident 71’s behavior, and to document the nonpharmacological interventions: back rub, speak to/approach in a calm manner, reposition, offer snacks/fluids, assess for pain, provide a quiet environment. Review of Resident 71’s MAR for June and July 2025 showed the number of episodes Resident 71 had for schizoaffective disorder behavior as evidence by angry outburst for no apparent reason on the following dates and shifts: - dated 6/1/25, during the NOC shift, two episodes; - dated 6/2/25, during the dayshift, two episodes, and during the PM shift, one episode; - dated 6/4/25, during the NOC shift, one episode; - dated 6/12/25, during the NOC shift, one episode; and - dated 7/4/25, during the NOC shift, one episode. Further review of the MAR for June and July 2025 showed the licensed nurses documented the behaviors were observed on the above dates and shifts, however, the licensed nurses documented “NA” for the nonpharmacological interventions implemented related to the use of the quetiapine medication. Additionally, on the days the licensed nurses documented “0” behaviors were observed during the shift, the licensed nurses were documenting the nonpharmacological interventions implemented for the behavior. For example: - dated 6/1/25, for the day shift, showed the licensed nurse documented Resident 71 was provided with 1-redirection, 2-spoke to/approached in a calm manner, and 3- repositioning; however, the licensed nurse documented “0” behavior during the shift. - dated 6/9/25, for the NOC shift, showed the licensed nurse documented Resident 71 was provided with 2-spoke to/approached in a calm manner, 3- repositioning, and 6- provided a quiet environment; however, the licensed nurse documented “0” behavior during the shift. - dated 7/10/25, for the PM shift, showed the licensed nurse documented Resident 71 was provided with 3- repositioning, 6- provided a quiet environment, and 9- provided reassurance; however, the licensed nurse documented “0” behavior during the shift. - dated 7/11/25, for the PM shift, showed the licensed nurse documented Resident 71 was provided with 1-redirection, 2-spoke to/approached in a calm manner, and 3- repositioning; however, the licensed nurse documented “0” behavior during the shift. On 7/24/25 at 1622 hours, an interview and concurrent record review for Resident 71 was conducted with LVN 6. LVN 6 stated the licensed nurses were responsible for monitoring Resident 71 for the episodes of angry outbursts and documenting the observed behaviors every shift. LVN 6 stated if the behavior was observed, the licensed nurse should implement the nonpharmacological interventions and document in the MAR. LVN 6 further stated, if the licensed nurse documented the implementation of the nonpharmacological interventions for the behavior, then there should have been a documentation of the behavior observation during that shift. LVN 6 verified on 7/10 and 7/11/25 during the PM shift, she had documented she provided the nonpharmacological interventions to Resident 71; however, under the monitoring of Resident 71’s behavior, LVN 6 had documented “0. LVN 6 verified the finding and stated her documentation of Resident 71’s behavior was inaccurate. On 7/28/25 at 1425 hours, an interview and concurrent medical record review for Resident 71 was conducted with LVN 2. LVN 2 reviewed Resident 71’s MAR for June 2025 and verified the above findings and stated the monitoring of behavior and documentation of the nonpharmacological intervention was inaccurate. LVN 2 stated if a behavior was observed, the nonpharmacological interventions should not be documented as “NA.” On 7/29/25 at 1100 hours, an interview was conducted with the DON. The DON stated for the licensed nurse shall review the classification of the drug, appropriateness of the diagnosis, its indication, behavior monitors and related adverse side effects prior to verification of admission orders with the Attending Physician. Upon the initial comprehensive assessment, the SSD designee shall review new admissions for any psychiatric, mood or behavior disorders, mental and psychosocial difficulties, and/or physician's orders for psychotropic medications. The facility's Interdisciplinary Team (IDT) will review to ensure: the psychotropic medication was prescribed to treat a specific diagnosed condition, as documented in the clinical record; not in excessive dosage; behavior is not related to delirium or other reversible conditions; and monitoring for adverse consequences and effectiveness of medications are in place. Medical record review for Resident 7 was initiated on 7/22/25. Resident 7 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 7’s H&P examination dated 5/10/25, showed Resident 7 had capacity to understand and make decisions. Review of Resident 7's Order Summary Report dated 7/24/25, showed a physician's order dated 5/8/25, for Remeron oral tablet (an antidepressant medication) 7.5 mg give one tablet by mouth once a day for depression manifested by episodes of verbalization of sadness and bupropion hydrochloride extended-release oral tablet (an antidepressant medication) 150 mg give one tablet by mouth once a day for depression manifested by verbalization of feeling sad. On 7/24/25 at 1530 hours, an interview and concurrent medical record review for Resident 7 was conducted with LVN 4. LVN 4 verified and acknowledged the Remeron and bupropion medications had the same indication for the antidepressant use and behavior manifestation of verbalization of sadness. LVN 4 further stated the licensed nurse should have clarified with the physician. On 7/24/25 at 1600 hours, an interview and concurrent medical record review for Resident 7 was conducted with LVN 5. LVN 5 acknowledged the monitoring of the same behavior for Remeron and bupropion medications would make it challenging to determine the effectiveness of the medications. LVN further stated the staff should have clarified the medication orders with the physician. On 7/24/25 at 1620 hours, an interview and concurrent medical record review for Resident 7 was conducted with the DON. The DON stated the licensed nurse had clarified with the physician that the medication for Remeron should have been indicated for poor oral intake.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure two of four sampled residents (Residents 10 and 71) reviewed for PASRR were accurately screened. * The facility failed to ensure Level II PASRR screenings were completed following a positive Level I PASRR screening. This failure posed the risk for Residents 10 and 71 being not properly screened, and the risk of not receiving adequate level of services, comprehensive assessment, and intervention. Findings: According to https://www.dhcs.ca.gov/services/MH/Pages/PASRR_faq_level2.aspx: - PASRR consists of a Level 1 Screening, a Level 2 Evaluation (if needed), and a Determination. If the Level 1 Screening is positive, a PASRR Level 2 Evaluation will be performed. A Level 2 Evaluation is a person-centered evaluation that is completed for anyone identified by the Level 1 Screening as having, or suspected of having, a PASRR condition, i.e., serious mental illness (SMI), intellectual disability (ID), developmental disability (DD), or related condition (RC). The Level 2 Evaluation helps determine the most appropriate placement of an individual, considering the least restrictive setting, and whether specialized services are needed. - The Level 2 Evaluation has three main goals: o Confirm whether the individual has an SMI or ID/DD or RC; o Assess the individual’s need for Medicaid certified nursing facility (NF) services; and o Assess whether the individual requires specialized services. According to the DHCS, federal law requires all individuals seeking admission to a Medicaid Certified Nursing Facility (NF) to receive a Level 1 Screening. The Level 1 Screening identifies if an individual has a suspected Mental Illness (MI) or an Intellectual/Developmental Disability or Related condition (ID/DD/RC). If MI is suspected, then a Level II Mental Health Evaluation may be conducted to determine if the individual can benefit from specialized mental health services. This process is known as the Preadmission Screening and Resident Review (PASRR). Review of the facility’s P&P titled PASRR revised 7/2022 showed the following: - It is the policy of this facility to ensure that each resident is properly screened using the PASRR specified by the State. Upon admission of a resident to the facility, the Admissions or Licensed Nursing personnel will complete the Level 1 PASRR. - A PASRR shall be completed on every resident upon admission. - After admission, IDT members will review the assessment for accuracy and the need for PASRR Level II referral. Based upon the assessment, the facility will ensure the proper referral to the appropriate state agencies for the provision of specialized services to residents with Intellectual Disability/Related Condition or Serious Mental Illness. 1. Medical record review for Resident 10 was initiated on 7/28/25. Resident 10 was readmitted to the facility on [DATE]. Review of Resident 10’s PASRR Level 1 Screening Results dated 11/21/24, showed a SMI Level II Mental Health Evaluation was required and an ID/DD/RC Level II Mental Health Evaluation was not required. Further review of Resident 10’s medical record failed to show documented evidence of a follow-up call or inquiry being sent to DHCS, or the submission of a new Level I PASRR screening. On 7/28/25 at 1352 hours, an interview and concurrent medical record review for Resident 10 was conducted with the MDS Assistant. The MDS Assistant verified Resident 10’s Level I PASRR screening was completed; however, RN 1 was unable to locate documentation of a follow-up attempted by the facility to address the need for Level II Mental Health Evaluation, or the submission of a new Level I PASRR screening for Resident 10. 2. Medical record review for Resident 71 was initiated on 7/22/25. Resident 71 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 71’s H&P examination dated 4/2/25, showed Resident 71 had fluctuating capacity to understand and make decisions. Review of Resident 71’s PASRR Level I Screening dated 4/7/25, showed Resident 71 had a positive Level I Screening for serious mental illness. Review of Resident 71’s Notice of PASRR Level I Screening Results dated 4/7/25, showed a serious mental illness Level II Mental Health Evaluation was required. Further review of Resident 71’s medical record failed to show a new Level I Screening was submitted. On 7/23/25 at 1503 hours, an interview and concurrent medical record review for Resident 71 was conducted with the MDS Nurse. The MDS Nurse stated when the Level I Screening was positive, a Level II Evaluation would be needed, and a follow-up would be required. The MDS Nurse stated the State agency usually contacted the facility to follow-up on the Level II Evaluation within a few days of the positive Level I Screening. The MDS Nurse stated if the facility had not heard from the State agency in 72 hours, the facility would follow-up with DHCS. The MDS Nurse reviewed Resident 71’s medical record and verified the above findings. The MDS Nurse stated if the State agency was unable to contact the facility to conduct the Level II Evaluation, the facility should complete another Level I PASRR Screening to ensure another Level II Evaluation would be done. On 7/23/25 at 1601 hours, a follow-up interview was conducted with the MDS Nurse. The MDS Nurse stated a PASRR Level I Screening was not completed and should have been completed for Resident 71 after the facility had received the notification from DHCS. On 7/29/25 at 1122 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to develop a plan of care to reflect the individual care needs for two of 19 final sampled residents (Residents 1 and 24). * The facility failed to develop a care plan to address Resident 1's refusal of the COVID-19 vaccine. * The facility failed to develop a care plan to address Resident 24's noncompliance with the continuous use of oxygen via nasal cannula as ordered by the physician. These failures posed the risk of the residents not receiving the appropriate treatment and services.Findings: Review of the facility’s P&P titled Care Plan and Care Plan Update revised 2/2022 showed it is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical mental and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care. The Procedures section showed the care plan will be initiated based on identified problem and medical change of condition. 1. Medical record review for Resident 1 was initiated on 7/22/25. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1’s H&P examination dated 5/1/25, showed Resident 1 had the capacity to understand and make decisions. Review of Resident 1’s immunization report dated 2/1/24 through 7/31/25, showed Resident 1 had refused to receive the COVID-19 vaccination. Review of Resident 1’s medical record failed to show a care plan problem was initiated to address the resident’s refusal to receive the COVID 19 vaccination. On 7/25/25 at 1438 hours, an interview was conducted with the IP. The IP stated when a resident refused a vaccination, the IP would initiate a care plan for those who refused. On 7/29/25 at 1531 hours, an interview and concurrent medical record review for Resident 1 was conducted with RN 1. RN 1 stated if a resident refused a vaccination, there should be a care plan initiated. RN 1 reviewed Resident 1’s plan of care and verified there was no care plan initiated for the refusal of COVID-19. On 7/29/25 at 1608 hours, the Administrator, DON, and Clinical Resource were informed and acknowledged the findings. 2. Medical record review for Resident 24 was initiated on 7/22/25. Resident 24 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 24’s H&P examination dated 7/8/25, showed the resident had the capacity to understand and make decisions. Review of Resident 24’s Order Summary Report dated 7/24/25, showed a physician’s order dated 7/14/25, for continuous oxygen at 2 LPM via nasal cannula/mask to keep oxygen saturation above 90% every shift related to COPD. Further review of Resident 24’s medical record failed to show documented evidence of the care plan for the resident's noncompliance with the continuous use of oxygen via nasal cannula. On 7/24/25 at 0756 hours, an observation and concurrent interview was conducted with Resident 24. Resident 24 was observed without oxygen via nasal cannula. Resident 24’s nasal cannula was observed inside a plastic set up bag. The oxygen was on 2 LPM and the nasal cannula was connected to the oxygen concentrator. Resident 24 stated a staff was with him when he removed his nasal cannula. On 7/24/25 at 1031 hours, an observation and concurrent interview for Resident 24 was conducted with CNA 4. CNA 4 stated Resident 24 sometimes removed his oxygen, and the resident put it back on. CNA 4 stated he asked Resident 24 to put back the oxygen if he saw him without the oxygen. CNA 4 stated he saw Resident 24 removed his oxygen a few times, however, he could not recall when he last saw Resident 24 without the oxygen. On 7/24/25 at 1131 hours, an interview and concurrent medical record review for Resident 24 was conducted with LVN 4. LVN 4 verified there was no care plan for Resident 24’s noncompliance with the continuous use of oxygen via nasal cannula. LVN 4 stated the licensed nurse should have started a care plan for the Resident 24’s noncompliance with the continuous use of the oxygen via nasal cannula. LVN 4 further stated he saw Resident 24 removed the nasal cannula before and he asked the resident to put it back. LVN 4 stated Resident 24 was able to put back his nasal cannula. LVN 4 stated he did not remember the date when Resident 24 removed his nasal cannula. On 7/25/25 at 1357 hours, an interview and concurrent medical record review for Resident 24 was conducted with the DON. The DON acknowledged the above findings. The DON stated the licensed nurse who observed Resident 24 being non-compliant should have addressed in the care plan about the resident’s noncompliance with the continuous use of the oxygen via nasal cannula.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and facility P&P review, the facility failed to properly conduct a post fall monitoring and communication for one of three residents (Resident 84) reviewed for accidents. * Resident 84's fall was not communicated to the dialysis center for continued monitoring. * Resident 84's post-fall neurological checks were not completed accurately and for the full 72 hours. These failures put the resident at risk for increased injury as well as a potential delay in the identification and provision of necessary interventions if the resident had any change in condition.Findings: Medical record review for Resident 84 was initiated on 7/22/25. Resident 84 was admitted to the facility on [DATE]. Review of Resident 84's Incident Note dated 6/19/25 at 0800 hours, showed the resident had a fall which resulted in a bump to the back of her head, and neurological checks were initiated. a. Review of Resident 84's Order Summary Report showed a physician's order dated 5/21/25, for dialysis appointments every Tuesday, Thursday, and Saturday at 0900 hours. Review of Resident 84's Nursing Facility Pre-Dialysis Assessment sheets dated 6/19/25, showed the form was to be completed and sent with the resident to the dialysis treatment. However, the form failed to show Resident 84 had a fall, for the dialysis center to be aware and could monitor the resident for any potential fall-related injuries while at the dialysis appointment. Review of Resident 84's Nursing Note dated 6/19/25 at 1532 hours, showed the resident left for her dialysis appointment at 0830 hours, and had returned to the facility at 1300 hours. Review of Resident 84's Progress Notes *NEW* failed to show if the facility had communicated the resident's fall to the dialysis center. Review of Resident 84's Transfer Out note dated 6/19/25 at 2018 hours, showed the resident was transferred to the acute care hospital. Review of Resident 84's Nurses Note dated 6/20/24 at 0345 hours, showed the resident returned to the facility with a diagnosis of a thoracic vertebrae fracture and a TLSO in place. On 7/24/25 at 0840 hours, an interview and concurrent medical record review was conducted with the DON. The DON reviewed Resident 84's medical records and verified the resident record failed to show the resident's fall was communicated to the dialysis center, so the dialysis center could continue to monitor the resident for any fall-related injuries, as well as to use caution with the resident. b. Review of Resident 84's 72 Hours Neuro-Checklist initiated on 6/19/25 at 0800 hours, showed the following neurological checks were to be completed as scheduled:- every 30 minutes for two checks, written for 0830 and 0900 hours, then- every hour for three checks, written for 1200, 1500, and 1800 hours, then- every two hours for two checks, written for 2000, 2200 and 0000 hours, then - every four hours for four checks, written for 6/20/25 at 0400, 0800, 1200, and 1600 hours, then- every six hours for six checks, written for 2200 hours, on 6/21/25 at 0400, 1000, 1600, 2200 hours, and the last one on 6/22/25 at 0400 hours. The log showed Resident 84's neurological checks were not completed for the following date and times: - dated 6/19/25 at 0900 and 1200 hours, due to the resident being out of the facility for dialysis.- dated 6/19/25 at 2000, 2200, and 2400 hours, due to the resident being in the acute care hospital. Further review of 84's 72 Hours Neuro-Checklist showed the log's time schedule did not go up to the full 72 hours and was not scheduled accurately. Review of Resident 84's Nursing Note dated 6/19/25 at 1532 hours, showed the resident had left for the dialysis appointment at 0830 hours, and returned to the facility at 1300 hours. On 7/24/25 at 0840 hours, an interview and concurrent medical record review was conducted with the DON. The DON reviewed Resident 84's medical record and verified the post-fall neurological checks were not completed per the facility's protocol when the resident returned from the dialysis center at 1300 hours. In addition, the DON verified the neurological checks were not conducted for the full 72 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 19 final sampled residents (Residents 24 and 95) were provided with the appropriate respiratory care when: * The facility failed to ensure Resident 24 received continuous oxygen at 2 LPM via nasal cannula as ordered by the physician. * The facility failed to change the oxygen tubing, nebulizer, and mask for Resident 95 per facility's protocols. These failures had the potential to negatively impact the residents' medical conditions.Findings: 1. Review of the facility's P&P titled Oxygen Administration reviewed 2/2023 showed it is the policy of this facility that oxygen therapy is administered by licensed nurse as ordered by the physician or as a nursing measure and an emergency measure until the order can be obtained. The purpose of the oxygen therapy is to provide sufficient oxygen to the blood stream and tissues. Medical record review for Resident 24 was initiated on 7/22/25. Resident 24 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 24’s H&P examination dated 7/8/25, showed the resident had the capacity to understand and make decisions. Review of Resident 24’s Order Summary Report dated 7/24/25, showed a physician’s order dated 7/14/25, for continuous oxygen at 2 LPM via nasal cannula/mask to keep the oxygen saturation above 90% every shift related to COPD. On 7/24/25 at 0756 hours, an observation and concurrent interview was conducted with Resident 24. Resident 24 was observed without oxygen via nasal cannula. Resident 24’s nasal cannula was observed inside a set up bag. The oxygen was on 2 LPM and the nasal cannula was connected to the oxygen concentrator. Resident 24 stated a staff was with him when he removed his nasal cannula. On 7/24/25 at 0801 hours, an observation and concurrent interview for Resident 24 was conducted with LVN 4. LVN 4 verified Resident 24 was not receiving oxygen via nasal cannula. LVN 4 acknowledged the nasal cannula was inside the set-up bag and Resident 24 would not be able to reach the nasal cannula. LVN 4 administered the oxygen at 2 LPM via nasal cannula to Resident 24. On 7/24/25 at 0808 hours, an observation of Resident 24 and concurrent interview was conducted with Resident 24 and LVN 4. Resident 24 stated he took out his oxygen at 0630 hours and a staff was with him. Resident 24 denied SOB. LVN 4 checked Resident 24's oxygen saturation level and the oxygen saturation result was 75%. LVN 4 stated he would be calling his supervisor and Resident 24’s physician. On 7/24/25 at 0817 hours, LVN 4 was observed applying a non-rebreather mask at 15 LPM to Resident 24. On 7/24/25 at 0820 hours, RN 1 was observed auscultating Resident 24’s chest and checking the oxygen saturation level. RN 1 stated Resident 24’s oxygen saturation was 99% while receiving oxygen via non-rebreather mask. On 7/24/25 at 1031 hours, an observation and concurrent interview for Resident 24 was conducted with CNA 4. CNA 4 stated he was not sure if Resident 24 had an oxygen when he saw Resident 24 this morning. CNA 4 stated Resident 24 sometimes removed his oxygen and the resident put it back on. CNA 4 stated he asked Resident 24 to put back the oxygen if he saw him without oxygen. On 7/24/25 at 1131 hours, an interview was conducted with LVN 4. LVN 4 stated he saw Resident 24 at 0710 hours and did not notice if the resident had an oxygen via nasal cannula or not. LVN 4 stated Resident 24 was sent to the acute care hospital via 911 because the resident’s oxygen saturation level could not keep up to 90% even with the breathing treatment and receiving oxygen via nasal cannula. On 7/24/25 at 1142 hours, an interview was conducted with RN 1. RN 1 stated Resident 24 was transferred to the acute care hospital via 911 at 1104 hours. RN 1 stated Resident 24 remained alert and responsive. RN 1 stated Resident 24 was on oxygen at 10 LPM via nonrebreather mask and the oxygen saturation was 98%. RN 1 stated Resident 24’s oxygen saturation at around 0930 hours was at 84% and the resident was on 5 LPM of oxygen. RN 1 further stated the staff were not able to stabilize Resident 24’s oxygen saturation and informed the resident they would not be able keep him in the facility because of the desaturation. RN 1 stated Resident 24 initially refused but eventually agreed to be transferred to the acute care hospital. RN 1 stated Resident 24’s physician ordered the transfer and she called 911 at 1040 hours. On 7/24/25 at 1659 hours, a telephone interview was conducted with CNA 5. CNA 5 stated Resident 24 removed his nasal cannula and asked him to put the nasal cannula in the set-up bag before he changed the resident’s diaper at around 0630 hours. CNA 5 stated he responded to a bed alarm in another room after he finished changing Resident 24’s diaper. CNA 5 stated he told Resident 24 before he left the room to press the call light button so the charge nurse could put back the resident’s nasal cannula. CNA 5 stated he forgot to tell another CNA or a licensed nurse about the nasal cannula because he answered a bed alarm in the other room. On 7/25/25 at 1350 hours, an interview was conducted with the DON. The DON acknowledged the above findings. The DON stated the CNA should have told someone or other staff about Resident 24’s nasal cannula being kept in the set-up bag. The DON stated Resident 24 was alert and would be able to make needs known by using the call light. 2. Review of the Facility’s P&P titled Disposition of Respiratory Equipment Disposables dated 8/2019 showed supplies will be clearly dated when initially set up or changed weekly. Medical record review of Resident 95 was initiated on 7/22/25. Resident 95 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 95's Order Summary Report dated 7/28/25, showed a physician's order dated 4/29/25, to administer Ipratropium-Albuterol (medication to relieve difficulty breathing) Inhalation Solution 0.5-2.5 (3) mg/3 ml (Ipratropium-Albuterol), one vial to be inhaled orally every four hours as needed for shortness of breath/wheezing. On 07/22/25 at 0750 hours, Resident 95 was observed to have breathing treatment equipment at the resident's bedside table, including the oxygen tubing, mask, and nebulizer, bagged and dated 4/20/25. On 7/22/25 at 0830 hours, an observation and concurrent interview for Resident 95 was conducted with LVN 1. Resident 95 was observed having breathing treatment equipment at the resident's bedside table, including the oxygen tubing, mask, and nebulizer, bagged and dated 4/20/25. LVN 1 stated they should have changed it weekly, and Resident 95 had an active physician's order for breathing treatment nebulizer as needed. LVN 1 verified the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being for two of two final sampled residents (Residents 50 and 95) reviewed for pain management. * The facility failed to ensure the nonpharmacological interventions, and its effectiveness were consistently documented prior to the administration of the acetaminophen (pain medication) for Resident 50. In addition, the facility failed to document the complete pain assessment as per the care plan for Resident 50. * The facility failed to document the complete pain assessment, as per the care plan for Resident 95. These failures have the potential to put Residents 50 and 95 at risk for the resident's pain being improperly managed.Findings: Review of the facility’s P&P titled Recognition and Management of Pain revised 7/2017 showed it is the policy of the facility to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident’s goals and preferences. The Care Plan will include preventive or care interventions (pharmacological and nonpharmacological) for any resident admitted with pain. The Interdisciplinary Care Plan will reflect the location and type of pain, pharmacological and no-pharmacological interventions, with evaluation and revision as indicated. 1. Medical record review for Resident 50 was initiated on 7/22/25. Resident 50 was admitted to the facility on [DATE]. Review of Resident 50’s H&P examination dated 4/11/25, showed Resident 50 had the capacity to understand and make decisions. Review of Resident 50’s Order Summary Report dated 7/24/25, showed the following physician’s orders: - dated 4/10/25, to implement the nonpharmacological interventions for pain as needed. To document 1-repositining, 2-dim light/quiet environment, 3-relaxation, 4- distraction, 5-music, 6-massage. - dated 5/29/25, to administer acetaminophen 500 mg, two tablets by mouth every six hours as needed (PRN) for pain management. Review of Resident 50’s plan of care showed a care plan problem dated 4/10/25, addressing Resident 50’s acute/chronic pain. The interventions included administering the analgesia medication as per the physician's orders, to monitor/document the probable cause of each pain episode, and to monitor/record the pain characteristics: quality (e.g. sharp, burning), severity (1 to 10 scale), anatomical location, onset, duration (e.g. continuous, intermittent), aggravating factors, relieving factors. Review of Resident 50’s MAR for 7/2025 showed Resident 50 was administered the acetaminophen 500 mg two tablets by mouth every six hours as needed for pain management on the following dates: - on 7/2/25 at 2057 hours, for a pain level of 3 (on a 0 to 10 pain scale, 0 = no pain and 10 = worst pain). - on 7/4/25 at 0209 and 2126 hours, 7/18/25 at 0124 hours, 7/20/25 at 0241 hours, 7/21/25 at 0326 hours, 7/22/25 at 1912 hours, and 7/23/25 at 0300 hours, for a pain level of 3. - on 7/6/25 at 0306 hours, 7/14/25 at 1550 hours, 7/18/25 at 2134 hours, and 7/20/25 at at 1846 hours, for a pain level of 4. - on 7/23/25 at 1550 hours, for a pain level of 5. Further review of Resident 50’s MAR for 7/2025 showed the documentation of the nonpharmacological pain interventions implemented and its effectiveness for the ordered PRN medication on the following dates and times: - on 7/4/25 at 0140 hours, - on 7/6/25 at 0230 hours, and - on 7/20/25 at 0210 hours. Review of Resident 50’s Progress Notes for 7/2025 failed to show the documentation of the nonpharmacological pain interventions attempted and its effectiveness prior to the administration of the pain medication for the above dates, when the acetaminophen pain medication was administered. Additionally, further review of the Progress Notes failed to show the documentation of the pain assessment conducted for Resident 50’s pain (including the pain location, quality, characteristics, and alleviating/aggravating factors) prior to the administration of the acetaminophen pain medication for the above dates. On 7/28/25 at 1343 hours, an interview and concurrent medical record review for Resident 50 was conducted with LVN 2. LVN 2 stated when the residents complained of pain, the licensed nurse assessed the resident’s pain to determine the pain scale, location, characteristics, and the alleviating/aggravating factors and would document the pain assessment in the progress notes. LVN 2 stated the nonpharmacological pain interventions would be implemented and its effectiveness would be documented in the MAR. LVN 2 stated if the nonpharmacological interventions implemented were ineffective, then the ordered pain medication would be administered. LVN 2 stated Resident 50 usually complained of pain in her back or legs and had the acetaminophen medication for pain. LVN 2 reviewed Resident 50’s medical record and verified the above findings. On 7/29/25 at 1100 hours, an interview was conducted with the DON. The DON stated when the resident reported pain, the licensed nurse was expected to assess the resident’s pain: pain scale, location, and characteristics, and should implement the nonpharmacological pain interventions. The DON stated the licensed nurses were expected to document the pain assessment whenever the resident reported pain, and the nonpharmacological interventions would be implemented and its effectiveness or ineffective would be documented. The DON stated if the nonpharmacological interventions implemented were ineffective, then the PRN pain medication would be administered as per the physician’s order. On 7/29/25 at 1122 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 2. Medical record review of Resident 95 was initiated on 7/22/25. Resident 95 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 95’s Order Summary Report dated 7/28/25, showed a physician order dated 5/29/25, for hydrocodone-acetaminophen (pain medication) oral tablet 5-325 mg. The order was to give one tablet by mouth every six hours as needed for moderate ( pain level of 4 - 6, on the pain scale of 0 to 10 with 0 = no pain and 10 = worst pain) to severe pain (pain level of 7 to 10). Review of Resident 95’s care plan dated 4/29/25, addressed the acute/chronic pain related to chronic physical disability and disease process. The interventions included monitoring and recording the pain characteristics: quality (e.g., sharp, burning), severity (using the pain scale of 1 to 10), anatomical location, onset, duration (e.g., continuous, intermittent), aggravating factors, and relieving factors. Review of Resident 95’s MAR for July 2025 showed the following: - dated 7/5/25, the pain level was 7. However, there was no documentation of the location and pain characteristics. - dated 7/8 and 7/22/25, the pain level was 6, with generalized body pain. However, there was no documentation of the pain characteristics. - dated 7/14/25, the pain level was 5, with generalized body pain. However, there was no documentation of the pain characteristics. - dated 7/21/25, the pain level was 7, with generalized body pain. However, there was no documentation of the pain characteristics. - dated 7/23 and 7/24/25, the pain level was 8, with generalized body pain. However, there was no documentation of the pain characteristics. - dated 7/25/25, the pain level was 4. However, there was no documentation of the location and pain characteristics. On 7/29/25 at 1030 hours, an interview and concurrent medical record review for Resident 95 was conducted with RN 1. RN 1 stated before the licensed nurse administered a pain medication, they should have assessed the pain location and characteristics, including onset, quality, etc., and documented the findings in the e-MAR progress notes. RN 1 verified the findings. On 7/29/25 at 1130 hours, the DON was informed of the above findings. The DON stated the licensed nurse should have documented the pain location and characteristic when they administered the pain medication. The DON verified the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the competency of two licensed nurses (LVNs 7 and 8) and the DSD interviewed regarding the facility's glucometer operation and protocols. * LVNs 7 and 8, and the DSD were not aware of how long the glucose control solutions used to do Quality Control checks for the glucometers are good for from the date they were opened. In addition, LVNs 7 and 8, and the DSD were not able to verbally state the facility's protocol on when to conduct the quality control checks and the process to conduct quality control checks for the glucometer. These failures had the potential of not providing care to the residents in a safe and competent manner. Findings: Review of the facility's P&P titled Performance Evaluations revised 7/2010 showed it is the policy of the company that employees are to be given regular performance evaluations. The Supervisor/Department Head will evaluate the employee's performance using the applicable performance evaluation form. Review of the glucometer manufacturer's manual titled Assure Platinum Blood Glucose Monitoring System User Instruction Manual (undated) showed under When to Perform a Control Solution Test:- Before testing with the Assure Platinum System glucometer for the first time- When you open a new bottle of test strips- Whenever you suspect the meter or test strips may not be functioning properly- If test results appear to be abnormally high or low or are not consistent with clinical symptoms- Use the control solution within 90 days (3 months) of first opening On 7/24/25 at 1425 hours, an inspection of Medication Cart 1, a concurrent interview, and facility document review was conducted with LVN 7. LVN 7 stated the glucometer, test strips, and supplies had been replaced on her cart the day before. The Quality control (QC) test results were not available in the glucometer history and were not documented on the facility document titled Quality Control Record dated July 2025. When asked LVN 7 was unable to verbalize the facility protocol of when it was appropriate to conduct a QC test, the process for completing the Quality Control Record, or the life of test streps and control solutions once opened. LVN 7 stated she was unaware of the protocol and needs an in-service on glucometer protocols. On 7/29/25 at 1019 hours, an interview and concurrent facility staff in-service training record review for LVNs 7 and 8 was conducted with the DSD. The DSD provided documentation of LVNs 7 and 8 receiving an in-service on 6/7/24, titled Quality Control Assure Blood Glucose Machine. The course content was listed as testing blood glucose for high/low solutions for proper calibration for accuracy. Additionally, LVNs 7 and 8 were tested for skills competency on blood glucose testing on 11/14/24. The competency form showed LVN 7 and LVN 8 passed the competency. When the DSD was asked if the staff were instructed during the training about the life of the test strips and the control solutions once opened for Quality Control checks on the glucometer, the DSD stated the test strips were good for 30 days the the staff were supposed to look at the expiration date. On 7/29/25 at 1054 hours, an interview was conducted with LVN 8. When asked about the facility's process regarding Quality Control checks for the glucometer, LVN stated the facility conducted Quality Control checks when they get new glucometer machine; however, he was not sure about the Quality Control checks with the new testing strips. LVN 8 stated the new testing strips needed to be logged in the book, and a new page for the Quality Control checks needed to be started for a new glucometer machine. LVN also stated the testing strips were good for 30 days after opening. LVN 8 also stated the control solution once opened was good for 30 days. Further review of the in-service training records showed on 7/24/25, an additional in-service titled Quality Control Blood Glucose Machine was conducted by the facility. The in-service was presented by the DSD with LVNs 7 and 8 in attendance. However, when the staff were interviewed regarding the facility's process for Quality Control checks for glucometer, the DSD, and LVNs 7 and 8 were unable to accurately verbalize facility protocol on when to conduct a Quality Control check, the process for completing the Quality Control Record, or the life of test strips and control solutions once opened. On 7/29/25 at 1248 hours, an interview was conducted with the DON. The DON acknowledged and verified the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the medication was administered as ordered by the physician for one of two residents (Resident 84) investigated for dialysis. * The facility failed to administer Resident 84's furosemide (a diuretic medication) as per the physician's order. This failure had the potential for the resident to have an adverse outcomes related to the diuretic not being administered as ordered. Findings: Medical record review for Resident 84 was initiated on 7/22/25. Resident 84 was admitted to the facility on [DATE]. Review of Resident 84's Order Summary Report showed the following physician's order:- dated 5/21/25, for the resident's dialysis appointments every Tuesday, Thursday, and Saturday at 0900 hours,- dated 11/6/24, to hold all the blood pressure medications prior to dialysis on Tuesdays, Thursdays, and Saturdays, and - dated 11/14/25, for furosemide 40 mg by mouth daily for edema (swelling). Review of Resident 84's MAR for July 2025 showed a documentation of 2 (hold/see nurses note) on Resident 84's furosemide on 7/10 and 7/22/25 at 0900 hours. Review of Resident 84's eMAR-Medication Administration Notes showed the following:- dated 7/10/25 at 0947 hours, the furosemide was held due to all the blood pressure medications were to be held on dialysis days, and- dated 7/22/25 at 1012 hours, the furosemide was held due to dialysis. On 7/24/25 at 0840 hours, an interview and concurrent record review was conducted with the DON. The DON reviewed Resident 84's medical record and verified the furosemide was held on 7/11 and 7/22/25. The DON stated the resident's furosemide medication was not indicated for the blood pressure as per the physician's order, the furosemide medication should have been administered to the resident on those days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the pharmacist consultant performed a monthly MRR (Medication Regimen Review) to identify potential irregularities for two of five sampled residents (Residents 4 and 7) reviewed for unnecessary medications. * The facility failed to ensure Resident 4 had a monthly MRR completed by the pharmacist consultant for May 2025. * The facility failed to ensure Resident 7's MRR for June and July 2025 conducted by the pharmacist consultant addressed the use of two antidepressant medications (mirtazapine and bupropion) for the same manifested behavior of verbalization of sadness. These failures put the residents at risk for adverse outcomes related to the medications the residents were receiving. Findings: Review of the facility’s P&P titled Medication (Drug) Regiment Review (MRR) reviewed January 2022 showed the pharmacist will review each resident's medication regimen at least once a month to identify irregularities and to identify clinically significant risks and/or adverse consequences resulting from or associated with medications 1. Medical record review for Resident 4 was initiated on 7/22/25. Resident 4 was admitted to the facility on [DATE]. Review of the facility’s MRR binder failed to show the pharmacist consultant conducted a MRR for Resident 4 for May 2025. Review of the May 2025’s MRR Current Resident Listing showed a list of the residents’ medication regimens reviewed by the pharmacist consultant. Resident 4’s name was not included on the list. On 07/25/25 at 1033 hours, an interview and concurrent medical record review for Resident 4 was conducted with the DON. The DON stated the pharmacist consultant should do a MRR on all the residents at the facility every month. The DON verified Resident 4 was admitted at the facility for the entire month of May 2025 and should have had a MRR conducted by the pharmacist consultant. The DON also reviewed May 2025's MRR and verified Resident 4 was not listed as having been reviewed by the pharmacist consultant. 2. Medical record review for Resident 7 was initiated on 7/22/25. Resident 7 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 7's Order Summary Report dated 7/24/25, showed a physician's order dated 5/8/25, for Remeron oral tablet 7.5 mg (mirtazapine), to be given one tablet by mouth once a day for depression manifested by episodes of verbalization of sadness. In addition, Resident 7 had a physician's order written on the same date for bupropion hydrochloride extended release (XL) oral tablet Extended Release 24 Hour 150 mg (bupropion HCl), to be given one tablet by mouth once a day for depression manifested by verbalization of feeling sad. On 7/24/25 at 1620 hours, an interview and concurrent medical record review for Resident 7 was conducted with the DON. The DON was asked if the pharmacist consultant conducted a MRR to address the resident's use of two antidepressant medications for the same behavior manifested by feeling sad. The DON verified a MRR was conducted by the pharmacist consultant for June and July 2025; however, the facility was not able to provide documentation the pharmacist addressed the use of two antidepressants (mirtazapine and bupropion) as ordered by the physician, for the same behavior manifestations of verbalization of feeling sad. Furthermore, the DON verified there was no pharmacy recommendations received from the MRR conducted by the pharmacist consultant for June and July 2025 for Resident 7. The DON verified the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 7.14%. One of the two licensed nurses (LVN 7) observed during the medication administration was found to have made errors. * LVN 7 failed to ensure the sevelamer medication (phosphate binder) was administered to Resident 84 on time and with a meal as per the physician's orders. LVN 7 failed to ensure the furosemide medication (diuretic) was administered to Resident 84 as ordered. These failures created the risk for the resident to have potential side effects or complications related to the medications.Findings: Review of the facility's P&P titled Administration of Medications (undated) showed the following:- Medication shall be administered as prescribed by the resident's physician, nurse practitioner, or physician's assistant.- Medications must be administered in accordance with the written orders of the attending physician.- Unless otherwise specified by the resident's attending physician, routine medications will be administered per the facility time ranges. On 7/24/25 at 0827 hours, a medication administration observation for Resident 84 was conducted with LVN 7. LVN 7 prepared and administered Resident 84's medications which included the following:- sevelamer (phosphate binder) 800 mg two tablets- vitamin D (supplement) 25 mcg one tablet- docusate sodium (stool softener) 250 mg one tablet- lidocaine patch (topical pain relief) 4% one patch to left shoulder- Rena Vite (supplement) one tablet- Letrozole (antiestrogen) 2.5 mg one tablet- Miralax (laxative) 17 gm- allopurinol (reduces uric acid) 100 mg one tablet- fish oil (supplement) 500 mg two tablets LVN 7 administered the sevelamer tablets to Resident 84 at 0842 hours. LVN 7 stated Resident 84 ate breakfast in her room between 0730 and 0800 hours. Medical record review for Resident 84 was initiated on 7/22/25. Resident 84 was admitted to the facility on [DATE]. Review of Resident 84's Order Summary Report dated 7/23/25, showed the following physician's orders:- dated 11/14/24, for furosemide oral tablet 40 mg one tablet by mouth one time a day for edema- dated 1/24/25, for sevelamer HCl oral tablet 800 mg two tablets by mouth with meals for phosphate binder. LVN 7 was not observed preparing the furosemide oral tablet 40 mg medication during the medication pass observation, and the sevelamer was administered at 0842 hours, without meals. On 7/24/25 at 1342 hours, an interview and concurrent medical record review for Resident 84 was conducted with LVN 7. LVN 7 reviewed Resident 84's active medication orders. LVN 7 verified she did not administer the sevelamer medication to Resident 84 on time and with her meals. Additionally, LVN 7 verified she did not administer the furosemide 40 mg tablet medication. LVN 7 stated she held Resident 84's furosemide 40 mg because she knew it could lower the blood pressure before the dialysis and should have clarified with the physician because the indication for the furosemide was for edema, and not hypertension. On 7/29/25 at 1200 hours, an interview and concurrent medical record review for Resident 84 was conducted with the DON. The DON reviewed Resident 84's active medication orders. The DON verified the sevelamer should have been given according to the physician's orders and the furosemide should not have been held because the indication was for edema.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage, labeling, and disposal of medications. * The facility failed to ensure the expired medications were removed from the Medication Room. In addition, the facility failed to ensure medications used for different routes were not stored together in one container, and the medications were labeled. * The facility failed to ensure the expired medications were removed from Medication Carts B and C. * The facility failed to ensure the supplies were labeled for Medication Cart C. * The facility failed to ensure the three sachets of Calazinc body shield (skin protectant) were not kept at Resident 24's bedside. These failures posed the potential risk for the residents to receive the expired medications and treatments, and for the unauthorized access to unsecured supplies.Findings: Review of the facility's P&P titled Medication Storage in the Facility (undated) showed medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or designated administrative personnel. Further review of the P&P showed outdated, contaminated, or deteriorated medications and those in containers that are disposed of according to procedures for medication destruction, and reordered from the pharmacy, if a current order exits. Medication storage conditions are monitored on a monthly basis and corrective action taken if problems are identified. 1. On 7/23/25 at 0951 hours, an inspection of the Medication Room and concurrent interview was conducted with RN 1. During the inspection of the Medication Room, the following was identified: - Four boxes of acetaminophen (medication to relieve pain and reduce fever) suppositories containing 12 rectal suppositories in each box, with expiration date of 7/2024.- Six culture swabs with expiration date of 6/27/25.- Inside the medication refrigerator, a medication bin contained two of the brimonidine (eye drop medications to treat glaucoma and ocular hypertension) 0.2% medication, dorzolamide (eye drop medications to treat elevated intraocular pressure in individuals with open-angle glaucoma or ocular hypertension) HCL (hydrochloride) 2%, two of the timolol maleate (eye drop medications to lower the pressure in the eye by reducing the build up of fluid) 0.25% medications. The identified eye drops were stored in the same bin with the insulin glargine (a long acting insulin medication injected to individuals diagnosed with type 1 and 2 diabetes, and Retacrit (medication injected to individuals to treat anemia).- Two boxes of Trulicity (an injectable medication to treat type 2 diabetes). One box contained four single dose pens with no label; one box with no discard/expiration date. RN 1 acknowledged and verified all of the above findings. 2. On 7/24/25 at 1423 hours, an inspection of Medication Cart B and concurrent interview was conducted with RN 1 and the IP. During the inspection of Medication Cart B, the following was identified: - Tegaderm (transparent adhesive film dressing used for wound care or to protect medical device sites) film with an expiration date of 3/26/25.- A box containing 23 surgical masks with an expiration date of 1/14/25.- 16 medical face masks ear-loop with eye shield with an expiration date of 5/31/24. RN 1 and the IP acknowledged and verified all of the above findings. 3. On 7/24/25 at 1429 hours, an inspection of Medication Cart C and concurrent interview was conducted with LVN 2. During the inspection of Medication Cart C, the following was identified: - Two boxes of Molnlycke Mefix self-adhesive fabric. One box with full roll of tape, and the other box with the roll almost finished had expiration date of 1/28/25.- 74 pieces of the Telfa (type of non-adherent wound dressing) adhesive dressings with an expiration date of 1/2025.- 100 ml bottle of normal saline. The cap showed date opened 7/24/25, with no documentation of the time the bottle was opened. LVN 2 stated the bottle was good for 24 hours after it was opened and she opened the bottle at approximately 0900 hours. LVN 2 acknowledged and verified all of the findings. 4. Review of the facility's P&P titled Medication Access and Storage revised 2/2019 under the Procedure section showed only licensed nurses, the consultant pharmacist and those lawfully authorized to administer medications ( e.g., medication aides) are allowed access to medications. Medication rooms, medication and treatment carts, and medication supplies are locked or attended by persons with authorized access. On 7/22/25 at 1013 hours, during the initial tour of the facility, Resident 24 was observed lying in bed with eyes closed. Three sachets of Calazinc body shield was observed on top of Resident 24’s bedside cabinet. Medical record review for Resident 24 was initiated on 7/22/25. Resident 24 was admitted to the facility on [DATE], and readmitted on [DATE] . Review of Resident 24’s H&P examination dated 7/8/25, showed the resident had the capacity to understand and make decisions. Review of Resident 24’s Order Summary Report dated 7/24/25, showed the following physician’s order: - dated 7/8/25, for the right posterior thigh MASD: cleanse with normal saline, pat dry, apply Calazinc, and cover with dry dressing daily for 21 days then re-evaluate; and - dated 7/8/25, for the coccyx area Stage 2 pressure injury: cleanse with normal saline, pat dry, apply Calazinc, and cover with dry dressing daily until further order. On 7/22/25 at 1103 hours, an observation and concurrent interview was conducted with Resident 24. Resident 24 was asked about the three sachets of the Calazinc body shield cream on top of his bedside cabinet. Resident 24 stated the staff applied the Calazinc body shield cream between his legs. On 7/22/25 at 1108 hours, an observation and concurrent interview for Resident 24 was conducted with CNA 4. CNA 4 verified there were three sachets of Calazinc body shield cream on top of Resident 24's bedside cabinet. CNA 4 stated the Calazinc body shield cream should have been in the treatment cart. On 7/24/25 at 1047 hours, an interview and concurrent medical record review for Resident 24 was conducted with LVN 6. LVN 6 acknowledged the findings. LVN 6 stated the treatment nurse or the charge nurse applied the Calazinc body shield cream to Resident 24 as ordered by the physician. LVN stated Resident 24’s Calazinc body shield cream should not be on the bedside and should be in the treatment cart. On 7/25/25 at 1410 hours, an interview was conducted with the DON. The DON acknowledged the above findings. The DON stated the licensed nurse should have kept Resident 24’s Calazinc body shield cream in the treatment cart.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen when: * The facility failed to ensure the kitchen staff were wearing hair restraints and clothing that covers body hair. * The facility failed to ensure the pitchers and pitcher covers were properly air dried. * The facility failed to ensure one of the multiple pitchers was clean and free of particle. * The facility failed to ensure the sanitary condition of the kitchen hood over the stove was maintained. These failures had the potential to cause foodborne illnesses in a highly susceptible residents population of 88 facility residents who consumed food prepared in the kitchen.Findings: Review of the facility's document titled Diet Type Report dated 7/22/25, showed 88 of 90 residents in the facility received food prepared in the kitchen. 1. According to the USDA Food Code 2022, Section 2-402.11 Effectiveness, (A) Except as provided in (B) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. Review of the facility's P&P titled Dress Code dated 2023 under the Proper Dress section, showed the following:- Hat for hair, if hair is short,- Hair net for hair if hair is long, and- Beards and mustache (any facial hair) must wear beard restraint. a. On 7/22/25 at 0802 hours, an observation of Dishwasher 1 and concurrent interview was conducted with the Kitchen Manager. Dishwasher 1 was observed walking in the kitchen towards the dishwashing area without a hair cover. The Kitchen Manager verified Dishwasher 1 had no hair restraint. The Kitchen Manager stated Dishwasher 1 shaved his head. The Kitchen Manager acknowledged Dishwasher 1's hair grew back and had very short hair. On 7/22/25 at 0805 hours, an observation and concurrent interview was conducted with the CDM (Certified Dietary Manager) inside the kitchen. The CDM acknowledged the above findings. In addition, the CDM was observed with beard but not wearing a beard restraint. The CDM verified he was not wearing beard restraint and stated he needed to shave. b. On 7/23/25 at 1015 hours, an observation of the pureed biscuit food preparation by [NAME] 1 and concurrent interview was conducted with the CDM. [NAME] 1 had black hairy forearms which were uncovered during the puree food preparation. The CDM was asked about the facility process regarding body hair like hairy arms. The CDM stated he would check the facility's P&P. On 7/24/25 at 0953 hours, a follow-up interview was conducted with the CDM. The CDM verified and stated the facility's policy showed to wear hat or hair net, face covering for beard and mustache, and clothing to cover the body hair. 2. According to the USDA Food Code 2022, Section 4-901.11, Equipment and Utensils, Air-Drying Required, showed items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items prevents them from drying and may allow an environment where microorganism can begin to grow. Review of the facility's P&P titled Dishwashing dated 2023 under the Procedure section, showed the dishes are to be air dried in racks before stacking and storing. On 7/22/25 at 0813 hours, during the initial tour of the kitchen, multiple white pitchers were observed stacked with blue covers on a tray without drying mesh. In addition, the white pitchers and blue covers of the pitcher were wet. The CDM was made aware and verified the findings. 3. According to the USDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Review of the facility's P&P titled Sanitation dated 2023 under the Procedure section, showed all the utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. On 7/22/25 at 0813 hours, during the initial tour of the kitchen, one of the multiple white pitchers had an orange particle inside. The CDM verified the findings and put away the dirty pitcher on a cart with the dishes to be cleaned. 4. According to the USDA Food Code 2022 Section 4-204.11 Ventilation Hood Systems, Drip Prevention. Exhaust ventilation hood systems in food preparation and warewashing areas including components such as hoods, fans, guards, and ducting shall be designed to prevent grease or condensation from draining or dripping onto food, equipment, utensils, linens, and single-service, and single-use articles. Review of the facility's P&P titled Hoods, Filters, and Vents dated 2023 showed the hoods must be cleaned every two weeks and must be free of dust and grease. On 7/22/25 at 0818 hours, during the kitchen tour, a concurrent observation and interview was conducted with the CDM. The kitchen hood on top of the stove had brownish black substance. The CDM verified the findings and stated the kitchen hood needed to be cleaned. On 7/29/25 at 0919 hours, the Administrator, DON, and CDM were informed and acknowledged the above findings.

Based on observation, interview, and facility document review, the facility failed to ensure one glucometer (Glucometer A) from one of two medications carts (Medication A) inspected with the glucometers, was maintained in safe operating condition. This failure had the potential for residents requiring glucose checks to have inaccurate readings. Findings: Review of the glucometer manufacturer's manual titled Assure Platinum Blood Glucose Monitoring System User Instruction Manual under When to Perform a Control Solution Test showed:- Before testing with the Assure Platinum System glucometer for the first time- When you open a new bottle of test strips- Whenever you suspect the meter or test strips may not be functioning properly- If test results appear to be abnormally high or low or are not consistent with clinical symptoms- Use the control solution within 90 days (3 months) of first opening On 7/24/25 at 1425 hours, an inspection of Medication Cart A and concurrent interview and review of the form titled Quality Control Record Assure Platinum Blood Glucose Monitoring System was conducted with LVN 7 and the IP. One Quality Control Record showed Assure Platinum Meter Serial # 1040-4437483 for Unit 2 dated 7/2025. The last entry on the form for the Quality Control showed 7/2024. On the bottom of the page, below the entry on 7/2024, was a handwritten note showing SEE NEW PAGE NEW GLUCOMETER. Another Quality Control Record showed Assure Platinum Meter Serial # 1040-4437484 for Unit 2 dated 7/2025. The first entry on the left-hand column of the form was dated 7/25/25. No other information was documented on the form to show quality control check was conducted for the new glucometer. The IP stated the glucometer, test strips, and solution were replaced last night on all carts as a plan of correction for the concerns identified regarding Quality Control checks for the glucometer. When asked for the facility's process prior to using a new glucometer, the IP stated a Quality Control check was done when there was a new glucometer to be used. The IP also stated the night shift licensed nurse was informed to conduct a Quality Control check tonight. When asked if blood sugar checks were done today, the IP stated yes, and verified the facility used the new glucometer without performing Quality Control check prior to using the new glucometer. In addition, the Quality Control Record showed from 7/1 to 7/21/25, for the Normal Control solution, the record showed an expiration of 5/2027; however, the expiration on the solution was 2/5/27. For the High Control solution, the record showed an expiration date of 2/6/27; however, the expiration date on the solution was 2/6/27. LVN 7 verified the findings and stated she was not aware of the facility's protocols for the glucometer check. LVN 7 also stated she agreed a Quality Control check should be done when new strips were opened or for new glucometers.

Based on interview, facility document review, and facility P&P review, the facility failed to establish and maintain an infection control program designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections. * The facility failed to ensure the monthly infection surveillance documents were summarized and analyzed accurately reflect the total number of CAI (Community-Acquired Infection) in the facility for April and May 2025. * The facility failed to develop a water management program which included the process to identify, test, and prevent Legionella (a bacteria which can cause a serious type of lung infection) and other opportunistic waterborne pathogens. In addition, the failure to accurately analyze the data from the infection surveillance log for the months of April and May 2025 resulted in incorrect information for the facility's mapping and infection control minutes regarding the CAI in the facility. These failures had the potential for increased risk of infections and compromising the residents' medical conditions. Findings: 1. Review of the facility's P&P titled Infection Prevention and Control Plan (undated) showed the objective of this requirement is for the facility to develop a comprehensive Infection Control Policy that establishes a facility-wide system for the prevention, identification, investigation and control of infections of residents, staff and visitors that is based upon facility assessment, best practices and regulatory compliance for the goal of quality systems for care. A collaborative effort between the facility leadership, employees, resident/resident representative, facility staff, Medical Director, and pharmacist is essential for success of the infection Prevention and Control Program. It is the policy that this facility's Infection Prevention and Control Program is based upon information from the Facility Assessment and follows national standards and guidelines to prevent, recognize and control the onset and spread of infection whenever possible. The Infection Prevention and Control Program includes a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to regulatory requirements and following accepted national standards. Further review of the facility's P&P showed the elements of the infection prevention and control plan include written standards, policies, and procedures for the Infection Prevention and Control program which include (among others listed) surveillance: a system of surveillance designed to identify possible communicable diseases or infection before they can spread to other persons in the facility. Review of the facility's form titled Prevention and Control Surveillance Log for 4/2025 showed a total of 31 CAI and 10 HAI ( Healthcare-Associated infection). However, when the total number of infections were counted from the log, the total number of CAI in the surveillance log was 32. Review of the facility's form titled Prevention and Control Surveillance Log for 5/2025 showed a total of 20 CAI and 12 HAI. However, when the total number of infections were counted from the log, the total number of CAI in the surveillance log was 21. Review of the facility's Infection Prevention and Control Meeting Minutes dated 5/27/25, for April 2025 showed the facility had a report for April 2025 with 31 CAI. Review of the facility's Infection Prevention and Control Meeting Minutes dated 6/26/25, for May 2025 showed the facility had a report for May 2025 with 20 CAI. Review of the facility's Infection Prevention Mapping for May 2025 showed a total of 20 CAI in the facility. On 7/25/25 at 1438 hours, an interview and concurrent facility's document review was conducted with the IP. The IP stated her responsibilities included the Antibiotic Stewardship in coordination with the Infection Control Program in the facility which addressed if the antibiotic prescribed to the residents were appropriate for what were being treated, dosage, and the drug of choice for infection. When asked how she monitored the facility's Infection Control Program, the IP stated she conducted rounds daily for all shifts, provided inservices, addressed issues identified, and followed up with the staff if they were able to understand the inservices provided. The IP also stated she asked the staff questions. When asked about the purpose of the Infection Surveillance, the IP stated it was used to track and trend the infections in the facility. The IP reviewed the total number of CAI documented on the surveillance log for 4/2025 and verified there was a total of 32 CAI and not 31 as documented on the log. The IP also reviewed the total number of CAI documented on the surveillance log for 5/2025 and verified there was a total of 21 CAI and not 20 as documented on the log. The IP also verified the information presented in the Infection Prevention and Control Meeting held on 5/27 and 6/26/25, were incorrect for the total number of CAI. The IP also verified the facility's Infection Prevention Mapping for May 2025 showed incorrect total of the CAI in the facility. 2. According to AFL 18-39 dated 9/17/18, Health Care Facility Requirements include for:Hospitals, CAHs, and SNFs must have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. These facilities must have water management plans and documentation that, at a minimum, ensure each facility:Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system;Develops and implements a water management program that considers the ASHRAE industry standards and the CDC toolkit;Specifies testing protocols and acceptable ranges for control measures and documents the results of testing and corrective actions when control limits are not maintained; andMaintains compliance with other applicable federal, state, and local requirements On 7/28/25 at 1057 hours, an interview and concurrent Legionella Water Management Program review was conducted with the Maintenance Director. The Maintenance Director stated the facility did not conduct Legionella testing because there was no sitting water. The Maintenance Director stated in the event of a Legionella outbreak, the water in the facility will be tested and would ask for help from the health department for guidance. The Maintenance Director was not able to provide a written plan to address the testing protocols and acceptable ranges for control measures, and corrective actions when control limits were not maintained. The facility's Legionella Water Management Program did not show the acceptable water temperature ranges to ensure control limits were maintained. On 7/29/25 at 1232 hours, an interview and concurrent Legionella Water Management Program review was conducted with the Administrator. The Administrator stated it was important to have a sanitary water supply since the Legionella can spread and have a potential concern for an outbreak. When asked for the facility's testing protocols for Legionella if there was a suspected outbreak, the Administrator stated the facility would notify the Department of Health and stop supplying water to the residents and the facility would test the water. When asked for the facility's protocols for testing, the Administrator was not able to provide. On 7/29/25 at 1238 hours, an interview was conducted with the IP. When asked for the facility's process regarding water management and potential Legionella in the facility, the IP stated the facility would report it to Public Health first to get guidance on what to do. When asked how the facility would test for Legionella in the facility, the IP stated there was a PCR testing kit for Legionnaire and would reach out to the Public Health for guidance on which company to ask to conduct testing. On 7/29/25 at 1436 hours, a concurrent interview was conducted with the DON, IP, and Clinical Resource. When asked regarding the facility's process or protocols in the event of suspected Legionella case in the facility, the DON stated the facility will reach out to the Public Health for guidance. The DON stated the facility will make sure it was safe for the staff and residents, and if the facility had to get certain tests done, the facility will reach out to the testing company who could provide the test. The DON verified there was no written plan to address the testing protocols for Legionnaires and was not aware because the facility did not have Legionnaire cases. On 7/29/25 at 1608 hours, an interview was conducted with the Administrator, DON, and Clinical Resource who acknowledged and verified the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were coordinated to meet the resident's needs when discharged from the facility for one of two sampled residents (Resident 1). This failure resulted in Resident 1 not having appropriate care at home, which had the potential to negatively affect Resident 1's health. Findings: Review of the facility's P&P titled Criteria for Transfer and Discharge revised 2/2023 showed upon a resident's discharge the facility must provide information to the receiving provider, which must include a minimum of the following: contact information of the practitioner responsible for the care of the resident, resident representative information including contact information, advance directive information, all special instructions or precautions for ongoing care as appropriate, comprehensive care plan goals, and all other necessary information, including a copy of the resident's discharge summary, and any other documentation, as applicable, to ensure a safe and effective transition of care. Review of the facility's P&P titled Job Description Social Service Manager dated 11/2021 showed the Social Service Manager's responsibilities include: to participate in discharge planning, refer the resident/families to appropriate social services agencies when the facility does not provide the services or needs of the resident, provide information to resident/families as to Medicare/Medicaid, and other financial assistance programs available to the resident, and provide direct assistance and support to residents/families with the process of application, submission, and coordination with the relevant programs and their offices. Closed medical record review for Resident 1 was initiated on 9/18/24. Resident 1 was admitted to the facility on [DATE], and discharged to home on 9/5/24. Resident 1 was dependent on staff to complete her ADL cares. Review of Resident 1's H&P examination dated 9/1/24, showed Resident 1 had lower extremity paralysis related to breast cancer with spinal metastasis. Review of Resident 1's MDS assessment dated [DATE], showed Resident 1 had a BIMS Score of 15 and had no cognitive impairment. Review of Resident 1's social services Care Plan for discharged initiated on 3/4/24, showed the facility should arrange Resident 1's community resources to support independence with post discharge home care. The facility needed to provide Resident 1 or her family member with the contact numbers for all community referrals. Resident 1 needed written instructions and visual aids, as required, to ensure care continuity post discharge. Review of Resident 1's recapitulated Order Summary Report for September 2024 showed a physician's order dated 9/4/24, to discharge Resident 1 to home with palliative care per the family's request. The order also showed for the DME to be delivered at home. Review of Resident 1's Social Services Progress Notes for March to September 2024 showed the following progress notes: - On 9/4/24, Resident 1 was seen by the physician on 9/1/24, and expressed her desire to go home. The physician discussed and agreed with Resident 1's discharge plan. Resident 1 wished to be discharged home with palliative care. Resident 1 signed the consents and her DME was coordinated for home. The note showed Resident 1 was to be discharged by 9/5/24 at noon. - On 9/10/24, the SSD called the outside services to follow up on a referral for Resident 1's home services. The SSD was unable to get in contact with the outside service's case manager and left a voice message. Further review of the social services progress notes failed to show documentation Resident 1's palliative care was coordinated and confirmed to provide the services at the resident's home. There was no contact information for Resident 1's palliative care agency. Review of Resident 1's Discharge Summary and Post-Discharge Plan of Care (instructions provided to Resident 1 upon discharge) dated 9/5/24, showed Resident 1 was discharged home on 9/5/24, with palliative care. Resident 1 was non-ambulatory and required extensive assistance with ADL cares. Resident 1 had MASD in her sacral to medial buttocks, an unstageable wound on her left lateral heel, and generalized body itchiness. The Discharge Summary and Post-Discharge Plan of Care showed Resident 1 needed an ongoing skin treatment. Additionally, Resident 1 had an indwelling urinary catheter and was provided supplies for home. The Discharge Summary and Post-Discharge Plan of Care showed Resident 1 was discharged with palliative care; however, the instructions failed to show documentation of the palliative care agency's contact person, phone number, and address. Under the section for medical equipment/devices ordered, the Discharge Summary and Post-Discharge Plan of Care indicated no medical equipment/devices were ordered for Resident 1. On 9/18/24 at 1139 hours, an interview was conducted with Resident 1. Resident 1 stated she was discharged home from the facility on 9/5/24, per her request. Resident 1 stated she informed the facility about two weeks prior to 9/5/24, that she wanted to be discharged with palliative care services. When asked what services she needed for home, Resident 1 stated she needed a caregiver at least twice daily because she was immobile, and her husband was unable to fully support her care due to his disabilities. Prior to discharge, Resident 1 stated the SSD informed her that the palliative care agency was confirmed for care at home; however, Resident 1 stated no one came in to provide care or supplies when she arrived home. Resident 1 stated she had to call and set up home care services herself after she was discharged from the facility. On 9/18/24 at 1427 hours, an interview and concurrent closed clinical record review was conducted with the SSD. The following was discussed: - When asked about the process for discharge, she stated once the physician cleared a resident for discharge, the social services department set up the home service agency, such as palliative care, as ordered prior to discharge. The contact information for the home service agency was provided to a resident in their discharge information packet. When asked how the palliative care agency knew what a resident's discharge needs were, the SSD stated the palliative care agency was responsible for assessing a resident and ordering any medical services and DME prior to discharge. When asked how the home service agencies were provided the report on a resident's care, the SSD stated the palliative care agency received the report and obtained records from the facility about the resident prior to discharge. - When asked about Resident 1, she stated she oversaw Resident 1's discharge. Resident 1 informed her that she wanted to go home with palliative care. When asked how Resident 1's palliative care was coordinated, the SSD stated Resident 1 found the palliative care agency and set up the services herself. When asked if she provided Resident 1 with information on other home service agency options, such as home health or hospice, the SSD stated no because Resident 1 was adamant about receiving palliative care; Resident 1 informed her that she already did her own research. When asked if she had documentation regarding her conversation with Resident 1, the SSD stated no. The SSD stated she assisted Resident 1 to log on to a portal to sign up for palliative care. When asked if she received a case number or confirmation notification to show Resident 1's palliative care services were confirmed for home, the SSD stated no. When asked if the palliative care agency coordinated with the facility and obtained report on Resident 1's discharge needs, the SSD reviewed Resident 1's medical record and stated she did not have documented evidence the palliative care agency contacted the facility to coordinate care. The SSD stated she did not recall if she called Resident 1's palliative care agency to coordinate care or confirm coordination was completed. She did not have the contact information for Resident 1's chosen palliative care agency. On 9/23/24 at 1325 hours, an interview was conducted with the ADON/IP. The ADON/IP stated she assisted the floor nurses as needed with discharge. When asked about the discharge process, the ADON/IP stated the physician initiated discharge and placed an order for home services or DME as needed. Upon receipt of an order, the nursing coordinated with the SSD to ensure discharge resources were provided to a resident. The ADON/IP stated the SSD was responsible for ensuring home services and DME were confirmed prior to discharge. If a resident was ordered palliative care, the SSD should have coordinated for palliative care to meet with nursing and receive clinical report. On 9/23/24 at 1517 hours, an interview was conducted with the Administrator and DON. When asked who was responsible for coordinating the resident discharges, the Administrator stated the SSD oversaw the resident discharges. The Administrator and DON were informed of the above findings. The Administrator stated they spoke to Resident 1 about her discharge multiple times, and she insisted she wanted to go home with palliative care. On 9/23/24 at 1527 hours, the Administrator called the SSD to ask about Resident 1's discharge. The SSD stated Resident 1 found the palliative care company herself; however, upon review of their documentation, the Administrator acknowledged there was no documented evidence of their conversations with Resident 1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to obtain the informed consent for the use of psychotropic medication (medications affecting brain activity) for one of five final sampled residents (Resident 37) reviewed for unnecessary medications. * The facility failed to ensure an informed consent was obtained when alprazolam (antianxiety medication) was prescribed for an extended period for Resident 37. This failure posed the risk for Resident 37 and her responsible party to not be informed of the potential risks and benefits of the alprazolam medication. Findings: According to AFL 24-7 titled Assembly [NAME] (AB) 48 - Nursing Facility Resident Informed Consent Protection Act of 2023 dated 2/28/24, with an effective date of 1/1/24, the facilities must obtain a resident's written informed consent for treatment using psychotherapeutic drugs. Medical record review for Resident 37 was initiated on 7/29/24. Resident 37 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 37's Progress Notes - H&P Note dated 5/6/24, showed Resident 37 did not have the capacity to understand and make decisions. Review of Resident 37's Order Summary Report dated 7/31/24, showed a physician's order dated 7/22/24, to administer alprazolam 0.5 mg every six hours as needed for anxiety manifested by restlessness for 30 days. Further review of Resident 37's medical record did not show an informed consent for the use of alprazolam medication. On 7/31/24 at 1305 hours, an interview and concurrent medical record review for Resident 37 was conducted with RN 2. When asked about the informed consent for the use of the alprazolam medications, RN 2 reviewed Resident 37's medical record and was unable to find documentation the informed consent was obtained from Resident 37's responsible party for the use of the alprazolam medication. On 8/1/24 at 1009 hours, an interview and concurrent medical record review for Resident 37 was conducted with the DON. The DON was informed and verified the findings. The DON stated when a resident had a physician's order for a psychotropic medication, the physician should educate the resident or their responsible party regarding the medication's purpose, risks, and side effects. The resident or responsible party would sign the informed consent form which was a paper document to show they agreed and understood the treatment plan for the use of the psychotropic medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Medical record review for Resident 54 was initiated on [DATE]. Resident 54 was admitted to the facility on [DATE]. Review of Resident 54's H&P examination dated [DATE], showed Resident 54 had the capacity to understand and make decisions. Review of Resident 54's POLST dated [DATE], showed Resident 54 wanted CPR and full treatment to be done if the resident was found without a pulse and/or breathing. The section for Artificially Administered Nutrition showed no artificial means of nutrition, including feeding tubes was selected. Further review of the POLST showed Resident 54 had no advanced directive. Review of Resident 54's Advance Health Care Directive dated [DATE], under Part 2: Instructions for Health Care showed choice to prolong life was selected. Review of Resident 54's Social Services Assessment/Evaluation - V1 dated [DATE], showed Resident 54 had no advance directive. Review of Resident 54's MDS dated [DATE], Section S showed Resident 54 had no advance directive. Review of Resident 54's H&P examination dated [DATE], showed Resident 54 was not able to make all his needs known and could not make his own decisions. Review of Resident 54's Order Summary Report dated [DATE], showed a physician's order dated [DATE], for Resident 54's code status, full treatment with no artificial means of nutrition including feeding tubes. On [DATE] at 0835 hours, an interview was conducted with the Social Services Assistant and Social Services Resource Personnel. The Social Services Assistant verified the above findings. The Social Services Assistant verified Resident 54's code status did not match his Advance Directive wishes. On [DATE] at 1000 hours, an interview was conducted with the Social Services Resource Personnel. The Social Services Resource Personnel stated she spoke with Resident 54's family member to clarify the resident's advance directive. The Social Services Resource Personnel stated Resident 54's family member stated she wished to prolong life and to initiate feedings. On [DATE] at 1334 hours, an interview and concurrent medical record review for Resident 54 was conduced with the DON. The DON stated Resident 54's advance directive did not match his POLST. The DON was informed and acknowledged the above findings. Based on interview, medical record review, and facility P&P review, the facility failed to provide and document in the medical record the information regarding their rights to formulate the advance directives and to ensure the POLST was accurate for three of 20 final sampled residents (Residents 2, 54, and 74). * Resident 2's POLST showed DNR status; however, the resident's medical record showed full code status. * Resident 74's responsible party had not been provided the information regarding their rights to formulate the advance directive. * Resident 54's POLST and code status did not match the resident's advance directive. These failures had the potential for the residents' decisions regarding their healthcare and treatment options not being honored. Findings: Review of the facility's P&P titled Advance Directives and Associated Documentation revised 12/2023 showed it is the policy of the facility to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, to formulate an advance directive. Prior to, upon, or immediately after admission, a facility staff member shall provide the resident/family or responsible agent written information, in a manner easily understood by the resident or resident representative, regarding the right to formulate an advance directive. Document in the resident health record that, at the time of admission, the resident representative has been provided with written information regarding advance directives. Advance care planning will occur periodically to review the advance directive and/or preferences regarding treatment options with the resident or their representative to ensure they are still the wishes of the resident. Such reviews will be made during the assessment process and recorded in the medical record. 1. Medical record review for Resident 2 was initiated on [DATE]. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's H&P examination dated [DATE], showed Resident 2 did not have the capacity to understand and make decisions. Review of Resident 2's POLST dated [DATE], showed Resident 2's code status was DNR. Review of Resident 2's Order Summary Report dated active as of [DATE], showed a physician's order dated [DATE], for code status: DNR, comfort focused treatment, long term artificial nutrition including feeding tubes. Review of Resident 2's Social Services Assessment/Evaluation dated [DATE], showed full code status. On [DATE] at 0935 hours, an interview and concurrent medical record review was conducted with the SSA. The SSA stated the social services department was in charge of making sure the residents' POLSTs were accurate and reflect the current wishes of the residents or their representatives. The SSA stated the POLST in the residents' physical charts should reflect the current wishes of the residents or their representatives. The SSA verified Resident 2's POLST showed DNR; however, the social services assessment showed full code status. 2. Medical record review for Resident 74 was initiated on [DATE]. Resident 74 was admitted to the facility on [DATE]. Review of Resident 74's H&P examination dated [DATE], showed Resident 74 did not have the capacity to understand and make decisions. Review of Resident 74's POLST dated [DATE], showed Resident 74 did not have an advance directive. Review of Resident 74's Social Services Assessment/Evaluation dated [DATE], showed Resident 74 did not have an advance directive. Further review of Resident 74's medical record failed to show evidence Resident 74's representative was informed of their right to formulate an advance directive. On [DATE] at 0818 hours, an interview and concurrent medical record review was conducted with the SSA. The SSA verified Resident 74's representative was not informed of their right to formulate an advance directive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 20 final sampled residents (Resident 2) was free from the physical restraints. * The facility failed to obtain the informed consent and the restraint assessment was conducted prior to applying a compression glove (helps provide support, relief and recovery from sore muscles andpainful joint stiffness in the wrists, palms, and fingers. It also helps to push the excess fluid out of the hand) on Resident 2's right hand. This failure posed the risk of compromising the resident's independence and psychosocial well-being. Findings: Review of the facility's P&P titled Restraint, Physical revised 2/2023 showed physical restraints for behavior control shall only be used with a written order designed to lead to a less restrictive way of managing, and ultimately elimination of, the behavior for which the restraint is applied. If it is determined that a resident requires the use of a restraint, a thorough assessment will be performed by the licensed nurse and documented in the resident's clinical record. Any resident using a physical restraint must have a documentation in the clinical chart that identifies the risks/benefits of the restraint. On 7/29/24 at 0815, 1230, 1415, and 1442 hours, Resident 2 was observed lying in bed with a compression glove on his right hand, with the right thumb fully covered with the glove and the rest of the fingers were exposed. Medical record review for Resident 2 was initiated on 7/29/24. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's H&P examination dated 7/24/23, showed Resident 2 did not have the capacity to understand and make decisions. Review of Resident 2's Order Summary Report showed a physician's order dated 7/29/24, for the resident will tolerate wearing glove to right hand for 1-2 hours in moments when feeling uncomfortable or when increase thumb sucking occurs in order to decrease thumb sucking behaviors and decrease risk for skin breakdown assessing skin prior to and post compression glove application to ensure skin integrity. Review of Resident 2's medical record failed to show documentation an informed consent was obtained prior to applying the compression glove on the right hand. Review of Resident 2's medical record failed to show documentation a restraint assessment was conducted prior to applying the compression glove on the right hand. On 7/29/24 at 1415 hours, an observation and concurrent interview with LVN 1 was conducted. LVN 1 verified Resident 2 should only be wearing the compression glove for one to two hours. LVN 1 stated she did not apply the compression glove for Resident 2 and she did not consider it as a restraint. On 7/29/24 at 1442 hours, an observation and concurrent interview with the OT was conducted. The OT verified Resident 2 should only be wearing the compression glove on the right hand for one to two hours. The OT stated she did not apply the compression glove for Resident 2. The OT stated the rehabilitation department was in charge of applying and removing the compression glove. The OT verified the compression glove was used to control Resident 2's thumb-sucking behaviors. The OT stated she did not consider the compression glove as a restraint.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to report the allegation of sexual abuse between two nonsampled residents (Residents 19 and 21) to the CDPH L&C and LTC Ombudsman Programs as per the facility's P&P. This failure had the potential for the residents to be vulnerable for further abuse. Findings: Review of the facility's P&P titled Abuse: Prevention of and Prohibition Against dated 10/2022 showed if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the Administrator and to other officials according to state law. The Administrator or the individual making the allegation immediately reports his or her suspicion to the appropriate State or Federal agencies in the applicable timeframes. On 7/31/24 at 0901 hours, the CDPH, L&C Program received the OSLTCO S223 form dated 7/31/24, regarding Resident 19's family member complaint about Resident 21 exposed himself and did a sexual act in the bathroom. Resident 19's family member reported the sexual abuse incident to the facility's staff. a. Medical record review for Resident 19 was initiated on 7/31/24. Resident 19 was admitted to the facility on [DATE]. Review of Resident 19's H&P examination dated 3/1/24, showed Resident 19 was oriented to self. b. Medical record review for Resident 21 was initiated on 7/31/24. Resident 21 was admitted to the facility on [DATE]. Review of Resident 21's H&P examination dated 4/5/24, showed Resident 21 was alert. On 7/31/24 at 1048 hours, and interview was conducted with Family Member 1. Family Member 1 stated Resident 19 informed him about the inappropriate sexual behavior of Resident 21. Family Member 1 stated he reported to the charge nurse on Sunday 7/28/24, who was taking care of Resident 19. Family Member 1 further stated on Monday morning, 7/29/24, he informed the PT who worked with Resident 19 about the inappropriate sexual behavior of Resident 21. On 7/31/24 at 1306 hours, an interview for Residents 19 and 21 was conducted with CNA 5. CNA 5 stated Resident 19 was alert and understand what he was asked, not confused, and not speaking English language. CNA 5 stated Resident 21 was alert but with confusion and speak Spanish language only. On 7/31/24 at 1356 hours, an interview was conducted with the PTA. The PTA stated he spoke to Resident 19's family member on Monday and was informed about the inappropriate sexual behavior on one of the residents. The PTA stated and acknowledged he forgot to report right away about the allegation of sexual abuse. The PTA stated he reported the incident of allegation of abuse the following morning to the Administrator. On 7/31/24 at 1623 hours, an interview was conducted with the Administrator. The Administrator verified he was the abuse coordinator of the facility. The Administrator was asked when he became aware about the incident of allegation of sexual abuse. The Administrator stated he was made aware by the Ombudsman and the DON about the allegation of sexual abuse on 7/30/24 at 1509 hours. The Administrator acknowledged the allegation of sexual abuse report was late. On 8/1/24 at 0957 hours, a telephone interview was conducted with LVN 8. LVN 8 stated she was made aware by Resident 19's family member about the resident incident of other resident inappropriate sexual behavior. LVN 8 stated she reported the allegation of sexual abuse to her supervisor. On 8/1/24 at 1023 hours, a telephone interview was conducted with LVN 9. LVN 9 stated she was made aware about the resident incident by the family member. LVN 9 stated she reported to the DON on that Sunday afternoon about the information the resident family member provided to her and stated she spoke to the DON via telephone. LVN 9 stated she put the information in the communication for other nurses to monitor the resident and as well as the alleged resident. On 8/1/24 at 1047 hours, an interview was conducted with the DON. The DON acknowledged she received a report from the licensed nurse, but the information was very vague and not clear on what was going on and not a concern to investigate. The DON was informed of the above findings and verified the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plan was implemented to reflect the individual care needs for one of 20 final sampled residents (Resident 54). * The facility failed to ensure Resident 54's left ½ (half) side rail was elevated as an enabler as per the care plan. This failure had the potential for Resident 54 to not be provided with appropriate, consistent, and individualized care. Findings: Review of the facility's P&P titled Comprehensive Resident Centered Care Plan revised 1/2021 showed the IDT shall develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. Medical record review for Resident 54 was initiated on 7/29/24. Resident 54 was admitted to the facility on [DATE], with a diagnosis of hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting the left non- dominant side. Review of Resident 54's quarterly MDS dated [DATE], showed Resident 54's BIMS score was 12, moderately impaired cognition. The MDS showed Resident 54 had an impairment on one side for both upper and lower extremities functional limitation. The MDS also showed Resident 54 required substantial to maximal assistance where the helper would do more than half the effort for rolling from left to right in bed. Review of Resident 54's Order Summary Report dated 7/31/24, showed a physician's order dated 5/16/24, to apply the left ½ side rail for bed mobility. Review of Resident 54's plan of care showed a care plan problem initiated on 6/4/24, addressing Resident 54's use of the left ½ side rail as an enabler. On 7/31/24 at 0813 hours, Resident 54 was observed lying in bed with the right ½ side rail elevated instead of the left side rail. On 7/31/24 at 0817 hours, an interview as conducted with CNA 11. CNA 11 stated Resident 54 was unable to lift his left shoulder and required assistance with repositioning. Concurrent observation of Resident 54 was conducted with CNA 11. CNA 11 verified Resident 54's right 1/2 side rail was elevated. CNA 11 stated Resident 54 used his right arm to grab the right side rail during care and for repositioning, to pull himself up in bed. On 7/31/24 at 1316 hours, an interview was conducted with LVN 7. LVN 7 stated Resident 54 had hemiplegia and weakness affecting his left side for both upper and lower extremities. LVN 7 stated Resident 54 used the left side rail during care and was unable to grab the right side rail with his left hand during care, due to his left-sided weakness. An observation and concurrent record review for Resident 54 was conducted with LVN 7. LVN 7 verified Resident 54 had a physician order for the left ½ side rail and verified Resident 54's right ½ side rail was elevated, with no side rails on the left side. On 8/1/24 at 1410 hours, the Administrator and DON were informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to provide the services to attain or maintain the highest practicable well-being for one of five sampled residents (Resident 69) reviewed for unnecessary medications. * Resident 69 was administered midodrine (antihypotensive medication used to treat low blood pressure) medication when Resident 69's systolic blood pressure was above the parameter prescribed by the physician. This failure had the potential to negatively affect Resident 69's health condition and well-being. Findings: Medical record review for Resident 69 was initiated on 7/29/24. Resident 69 was admitted to the facility on [DATE]. Review of Resident 69's Order Summary Report showed a physician's order dated 4/26/24, to administer midodrine 2.5 mg one tablet by mouth every eight hours for hypotension; and to hold if systolic blood pressure more than 120 mmHg. Review of Resident 69's MAR for July 2024 showed Resident 69 was administered the midodrine medication when the resident's systolic blood pressure was above 120 mmHg as follows: - On 7/2/24 at 2200 hours, a blood pressure of 128/70 mmHg; - On 7/3/24 at 2200 hours, a blood pressure of 121/70 mmHg; - On 7/4/24 at 2200 hours, a blood pressure of 122/70 mmHg; - On 7/9/24 at 2200 hours, a blood pressure of 122/66 mmHg; - On 7/12/24 at 2200 hours, a blood pressure of 132/70 mmHg; - On 7/13/24 at 2200 hours, a blood pressure of 134/60 mmHg; - On 7/15/24 at 2200 hours, a blood pressure of 126/84 mmHg; - On 7/20/24 at 2200 hours, a blood pressure of 132/68 mmHg; - On 7/21/24 at 2200 hours, a blood pressure of 122/70 mmHg; and - On 7/30/24 at 0600 hours, a blood pressure of 132/74 mmHg. On 7/31/24 at 1334 hours, an interview and concurrent medical record review for Resident 9 was conducted with RN 2. RN 2 stated when a checkmark was indicated on the MAR, it meant the medication was administered by the nurses. RN 2 verified the midodrine medication was administered to Resident 69 when the resident's systolic blood pressure was above the parameter prescribed by the physician. On 8/1/24 at 1015 hours, an interview and concurrent medical record review for Resident 69 was conducted with the DON. The DON was informed and verified the above findings. The DON stated the nurses should have held the midodrine medication when Resident 69's systolic blood pressure was above 120 mmHg.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of one final sampled resident (Resident 28) and two nonsampled residents (Residents 21 and 47) reviewed for Wander Guard use were remained free from the accident hazards. * The facility failed to monitor the Wander Guard for functionality for Residents 21, 28, and 47. This failure had the potential to place the residents at risk for serious injuries and posed the risk for not having accurate information documented to prevent further accidents and or injuries to the residents. Findings: Review of the facility's P&P titled Wander System Monitoring Program dated 1/2023 showed the residents identified to be at risk for wandering will be evaluated for a wander-monitoring device. Each monitoring device will be tested for placement and function per manufacturers recommendation. According to the Wander Guard Universal Tester Operating Instructions (undated), to test the bracelets daily as detailed in the instructions. Failure to test daily could result in injury to or death to a person. 1. Medical record review for Resident 28 was initiated on 7/31/24. Resident 28 was admitted to the facility on [DATE]. Review of Resident 28's Elopement/Wandering Evaluation dated 7/11/24, showed Resident 28 was evaluated as a high risk of elopement. Review of Resident 28's plan of care addressing the risk for injury related for elopement dated 7/13/24, showed the interventions included for the Wander Guard as ordered and to monitor for the placement and functionality. On 7/31/24 at 0827 hours, an interview for Resident 28 was conducted with CNA 6. CNA 6 stated Resident 28 had an episode of getting out in the back door and a staff saw him right away and redirected. CNA 6 stated Resident 28 had a wander guard on his right ankle. CNA 6 verified there was no attempt reported for Resident 28 getting out of the facility unassisted. 2. Medical record review for Resident 21 was initiated on 7/31/24. Resident 21 was admitted to the facility on [DATE]. Review of Resident 21's Order Summary Report dated 8/1/24, showed a physician's order dated 3/5/23, to monitor the placement and functionality of wander guard every shift, (+) if the device in place and functioning correctly, and (-) if not working and replaced. Review of Resident 21's MAR for the month of July 2024 showed the initials of the licensed staff monitoring the placement and functioning of the wander guard. However, there were no information for (+) or (-) documented on the MAR as per the physician's order. On 8/1/24 at 0824 hours, an observation and concurrent interview was conducted with Resident 21. Resident 21 was observed in the wheelchair and able to propel himself in the hallway. When asked if he had any device on him, Resident 21 was able to show the Wander Guard on hid right ankle. 3. On 7/29/24 at 1119 hours, Resident 47 was sitting in his wheelchair and observed wih a wander guard device on his right forearm. Medical record review for Resident 47 was initiated on 7/29/24. Resident 47 was admitted to the facility on [DATE]. Review of Resident 47's Order Summary Report dated 8/1/24, showed a physician's order dated 7/18/23, to apply the Wander Guard to the resident's right wrist for safety and to alert the staff if the resident tries to get out of the facility unassisted. However, further review of the Order Summary report failed to show a physician's order to monitor the placement and functionality of the Wander Guard. Review of Resident 47's Elopement/Wandering Evaluation dated 5/30/24, showed Resident 47 was a high risk for elopement. On 8/1/24 at 0842 hours, an interview and concurrent medical record review for Residents 21, 28, and 47 was conducted with LVN 7. LVN 7 verified Residents 21, 28, and 47 had a Wander Guard placed due to an attempt going out of the facility unassisted. LVN 7 verified the monitoring of the Wander Guard for Residents 21, 28, and 47 were documented in the MAR. LVN 7 was asked on how the functioning of the Wander Guard was monitored, LVN 7 was not sure and asked the other staff. LVN 7 was able to show the Wander Guard tester device to check the functionality of the wander guard. LVN 7 stated the Maintenance Supervisor was checking the Wander Guard once a week. LVN 7 stated and acknowledged the monitoring of the functionality of the Wander Guard was not done. LVN 7 verified of the above findings. On 8/1/24 at 0848 hours, an interview and concurrent facility document review for Residents 21, 28, and 47 was conducted with Maintenance Supervisor. The Maintenance Supervisor stated he was responsible for checking the Wander Guard function on the exit doors of the facility and was able to show the log of checking the functioning of the Wander Guard done weekly. The Maintenance Supervisor was asked if he was responsible for checking the functionality of the Wander Guard on the residents, the Maintenance Supervisor stated no and stated the licensed nurses should check everyday. The Maintenance Supervisor stated the licensed staff should have the Wander Guard Tester device for checking the functioning of the the Wander Guard and should be available in the medication cart or nurses station for the licensed nurse use. On 8/1/24 at 1338 hours, an interview and concurrent medical record review for Residents 21, 28, and 47 was conducted with the DON. The DON was informed and verified the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services to maintain the IV access for one of one final sampled resident reviewed for IV care (Resident 79). * The facility failed to ensure the initial PICC line external catheter measurement was documented in the medical record and failed to confirm baseline measurements of the PICC line external catheter and arm circumference measurements prior to administration of IV antibiotics. These failures had the potential to delay the identification of catheter related complications for this resident. Findings: On 7/29/24 at 0951 hours, Resident 79 was observed in bed with a PICC line to the right upper arm with a two-port external catheter. A transparent dressing dated 7/24/24, was observed on the PICC line site. When asked about the PICC line, Resident 79 stated the PICC line was inserted at the acute care hospital. Medical record review for Resident 79 was initiated on 7/29/24. Resident 79 was admitted to the facility on [DATE]. Review of the LN- Initial admission Record dated 7/2/24, showed Resident 79 had a right upper extremity PICC line with two lumens. Review of the admission Note dated 7/2/24, showed Resident 79 was noted with a two-lumen PICC line on the right upper arm. The right upper arm circumference was documented as 26 cm and external length was 1 cm. Review of Resident 79's IV MAR for July 2024 showed Resident 79 was administered daptomycin (antibiotic) 500 mg intravenously one time daily for MRSA Bacteremia from 7/3/24 to 7/30/31, at 0900 hours. Further review of the IV MAR showed Resident 79's PICC line arm circumference and external length were measured weekly with dressing changes on 7/3, 7/10, 7/17, and 7/24/24. The IV MAR showed Resident 79's arm circumference was 26 cm and the external length of the PICC was 32 cm. Review of Resident 79's medical record failed to show documented evidence of Resident 79's baseline arm circumference and external length measurements of the PICC line from the acute care hospital and failed to show the nurse had confirmed the baseline measurements of Resident 79's arm circumference and the PICC line external length measurement prior to use of the PICC line. On 7/31/24 at 1116 hours, an interview and concurrent medical record review for Resident 79 was conducted with RN 2. RN 2 stated for the residents admitted to the facility with a PICC line, the RN was responsible for measuring the external length of the PICC from the insertion site to the tip of the lumen and documenting the number of lumens, the resident's arm circumference, and the external length measurements. RN 2 stated the RN would also compare the measurements with the reports from the acute care hospital. RN 2 was asked what the nurse should do if the hospital records did not show the resident's PICC line measurements. RN 2 stated the nurse would call the acute care hospital to verify the resident's baseline external length and arm circumference prior to using the PICC line due to the potential for PICC line dislodgement during the transfer from the acute care hospital to the facility. RN 2 stated once the nurse called the acute care hospital to confirm the measurements, the nurse would document the measurements in the resident's medical record and request for the acute care hospital to send the documents. Concurrent medical record review for Resident 79 was conducted with RN 2. RN 2 verified the above findings. On 8/1/24 at 1334 hours, an interview was conducted with the DON. The DON stated for the residents admitted with a PICC line, she expected staff to measure the arm circumference and the external length of the PICC line catheter and compare with the resident's baseline measurement from the acute care hospital records. The DON further stated if the measurements were not indicated on the acute care hospital records, she expected the nurse to inform the physician and to call the acute care hospital to confirm and document in the resident's medical records. On 8/1/24 at 1410 hours, the DON and Administrator were informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 7/29/24 at 0951 hours, Resident 50 was observed lying in bed awake, confused, and verbally nonresponsive. Resident 50's nebulizer mask was observed on top of the nebulizer machine (an electrically powered machine that turns liquid medication into a mist so that it can be breathed directly into the lungs through a face mask), not stored in a bag and the nebulizer tubing was not dated. The ADON/IP verified Resident 50's nebulizer mask was not stored in a bag when not in use and the nebulizer tubing was not dated. Medical record review for Resident 50 was initiated on 7/31/24. Resident 50 was admitted to the facility on [DATE]. Review of Resident 50's Order Summary Report showed a physician's order dated 2/10/24, for Ipratropium-Albuterol (bronchodilator) Solution 0.5-2.5 (3) mg/3 ml 3 ml inhale orally every four hours as needed for SOB or wheezing via nebulizer. On 7/30/24 at 1125 hours, an interview was conducted with LVN 4. LVN 4 stated the nebulizer mask, tubing, and plastic bag should be changed and dated weekly and as needed. LVN 4 also stated the nebulizer mask and tubing should be stored in a plastic bag when not in use. On 8/1/24 at 1428 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. 4. Review of the facility's P&P titled Oxygen Administration (mask, cannula, catheter, use of humidifier) dated 12/2023 showed the following: - turn the unit (oxygen) on the desired flow rate and assess equipment for proper functioning; - oxygen tubing is to be replaced every seven days. Medical record review for Resident 687 was conducted on 7/31/24. Resident 687 was admitted to the facility on [DATE]. Review of Resident 687's Order Summary Report showed an order dated 7/25/24, for continuous oxygen at two liters per minute via nasal cannula to keep oxygen saturation level above 90% every shift. On 07/29/24 at 0853 hours, an observation was conducted of Resident 687's room. Resident 687 was sitting in bed receiving oxygen via nasal cannula at three liters per minute. The oxygen tubing was not labeled nor dated. The nebulizer machine was placed on the bedside dresser. The nebulizer tubing was hanging inside a plastic bag and was not dated or labeled. On 07/29/24 at 0919 hours, an observation and concurrent interview was conducted with the ADON/IP. The ADON/IP verified Resident 687 was receiving oxygen at three liters per minute . The ADON/IP further verified the oxygen tubing and nebulizer tubing were not labeled. Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the safe respiratory care for three of three final sampled residents (Resident 8, 50, and 61) and one nonsampled resident (Resident 687) reviewed for respiratory care. * The facility failed to ensure Resident 8's CPAP machine was cleaned as per the manufacturer's user cleaning guidelines. * The facility failed to ensure Resident 61's oxygen tubing was not touching the floor. * The facility failed to ensure Resident 50's nebulizer tubing was dated and mask was stored in a bag when not in use. * The facility failed to ensure Resident 687 was administered the oxygen as ordered by the physician. Additionally, the facility failed to ensure the nebulizer tubing and oxygen tubing were changed and labeled as per the facility's P&P. These failures had the potential to adversely affect the health, well-being, and posed the risk for equipment contamination and respiratory complications. Findings: 1. Review of the facility's P&P titled Care of BiPAP (Bilevel Positive Airway Pressure) and CPAP dated 2/2022 showed specific cleaning instruction guidelines are obtained from the manufacturer of the CPAP device. The components of the machine such as the masks, nasal pillows, tubing and headgear should be cleaned with a mild detergent daily and allow to airdry. Tubing is to be changed once a month or as needed. On 7/30/24 at 1127 hours, an interview was conducted with Resident 8. Resident 8 was in bed and Resident 8's bedside table was noted to have a CPAP (ResMed AirSence 10) machine which was turned off with the tubing and the mask on the clear plastic bag. Resident 8 was asked if he was using the CPAP machine regularly, Resident 8 stated yes. Resident 8 was asked if the staff regularly cleaned his CPAP machine and tubing. Resident 8 stated the facility staff cleaned the CPAP machine once a week, the mask and tubing every after use. Resident 8 stated he did not know when the last time the CPAP mask, tubing, and strap were last changed. Review of the ResMed AirSence 10 (CPAP machine) user guide (undated) showed under the caring for the device section to regularly clean the tubing assembly, water tub, and mask to prevent the growth of the germs that can adversely affect the health. Medical record review for Resident 8 was initiated on 7/30/24. Resident 8 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 8 was cognitively intact. Section O showed Resident 8 was coded for the use of oxygen and non-invasive machine. Review of Resident 8's Order Summary Report dated 7/30/24, showed a physician's order dated 12/6/23, for the following care of the CPAP machine: - to wash CPAP humidified container with hot water and soap, leave open to air dry every day shift; and - to wipe down CPAP mask visible residue with wet washcloth and leave to air dry. On 7/30/24 at 1133 hours, an interview for Resident 8 was conducted with CNA 6. CNA 6 stated the treatment nurses were responsible for cleaning the CPAP mask, and had seen the licensed nurses cleaning the machine. CNA 6 verified Resident 8's use of the CPAP every night. On 7/30/24 at 1144 hours, an interview for Resident 8 was conducted with LVN 3. LVN 3 was the treatment nurse and stated she was responsible for cleaning Resident 8's CPAP machine daily. LVN 3 stated she did not know on how often the CPAP machine was cleaned. On 7/31/24 at 0913 hours, an interview and concurrent medical record review for Resident 8 was conducted with the DON. The DON was asked for the copy of the CPAP machine user guide/manual. The DON verified there was no copy of the CPAP machine manual. The DON verified and acknowledged the facility did not follow the care and maintenance of the CPAP machine per the manufacturers user guide. The DON stated the cleaning and maintenance of the CPAP machine should have been followed to prevent respiratory complication and functioning of the machine. 2. On 7/29/24 at 1003 hours, and 7/31/24 at 0905 hours, Resident 61 was observed wearing a nasal cannula attached to an oxygen machine with a setting of four liters per minute. The nasal cannula oxygen tubing was observed on the floor. An observation and concurrent interview with LVN 7 in Resident 61's room was conducted. LVN 7 verified the oxygen tubing was on the floor. LVN 7 stated the oxygen tubing should have been placed on a clear plastic bag to reduce the risk of infection. Medical record review for Resident 61 was initiated on 7/31/24. Resident 61 was admitted to the facility on [DATE]. Review of Resident 61's Order Summary dated 7/31/24, showed a physician's order dated 7/1/24, to administer oxygen via nasal cannula at 2 liters/min continuously to keep the resident's oxygen saturation level above 90%. On 8/1/24 at 1335 hours, an interview was conducted with the DON. The DON was informed and verified the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to provide the adequate and appropriate pain management for one of five final sampled residents (Resident 69) reviewed for unnecessary medication use. * The facility failed to ensure the pain medication was administered as per the physicians' orders for Resident 69. This failure had the potential for Resident 69 to not receive effective treatment for pain. Findings: Medical record review for Resident 69 was initiated on 7/29/24. Resident 69 was admitted to the facility on [DATE]. Review of Resident 69's Order Summary Report showed the following physician's orders: - dated 3/4/24, to administer acetaminophen (over the counter pain medication) 325 mg two tablets by mouth every four hours as needed for general discomfort for pain levels of 1-3 (on a 0-10 pain scale with 0 = no pain and 10= worst pain); - dated 4/9/24, to administer Norco (hydrocodone-acetaminophen, a narcotic analgesic medication) 5-325 mg one tablet by mouth every four hours as needed for moderate pain for pain levels of 4-6; and - dated 4/9/24, to administer hydrocodone-acetaminophen (same as Norco) 10-325 mg one tablet by mouth every four hours as needed for severe pain for pain levels of 7-10. Review of Resident 69's MAR for July 2024 showed Resident 69 was administered the Norco 5-325 mg medication on the following dates and times when the resident's pain level was not within the levels of 4-6 for Norco 5-325 mg as ordered: - On 7/1/24 at 0550 hours, Resident 69 was documented with a pain level of 7. - On 7/5/24 at 0420 hours, Resident 69 was documented with a pain level of 7. - On 7/9/24 at 0445 hours, Resident 69 was documented with a pain level of 7. - On 7/12/24 at 2305 hours, Resident 69 was documented with a pain level of 7. - On 7/15/24 at 2400 hours, Resident 69 was documented with a pain level of 7. - On 7/19/24 at 0510 and 2350 hours, Resident 69 was documented with a pain level of 7. - On 7/21/24 at 0420 hours, Resident 69 was documented with a pain level of 7. - On 7/22/24 at 0550 hours, Resident 69 was documented with a pain level of 7. - On 7/26/24 at 0630 hours, Resident 69 was documented with a pain level of 7. - On 7/27/24 at 0600 hours, Resident 69 was documented with a pain level of 7. - On 7/28/24 at 0430 hours, Resident 69 was documented with a pain level of 7. - On 7/29/24 at 0420 hours, Resident 69 was documented with a pain level of 7. On 7/31/24 at 1334 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 was informed and verified the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 7/29/24 at 0951 hours, Resident 50 was observed lying in bed awake with bilateral half side rails elevated. Resident 50 was confused and nonverbal. Medical record review for Resident 50 was initiated on 7/31/24. Resident 50 was admitted to the facility on [DATE]. Review of Resident 50's H&P examination dated 2/16/24, showed Resident 50 had a history of CVA or stroke and cognitive communicative deficit. Review of Resident 50's Order Summary Report showed a physician's order dated 5/24/24, for bilateral half side rails for positioning and ease in mobility as an enabler. On 7/30/24 at 1047 hours, an interview was conducted with CNA 7. CNA 7 stated she provided total assistance with Resident 50's dressing, repositioning, and personal hygiene. CNA 7 also stated Resident 50 could move his arms up; however, Resident 50 could not grab the side rails to help turn or reposition. On 7/30/24 at 1125 hours, an observation and concurrent interview was conducted with LVN 4. LVN 4 verified Resident 50's bilateral half side rails were elevated. On 7/31/24 at 1402 hours, an interview conducted with LVN 6. LVN 6 stated that Resident 50 was nonverbal and dependent on the staff for ADL care. LVN 6 also stated Resident 50 could not grab the side rails during repositioning. Record review of Resident 50's MDS dated [DATE], under the section GG for mobility, showed Resident 50 was dependent for upper dressing, roll to the left and right, and sitting to lying. On 8/1/24 at 1428 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of nine final sampled residents reviewed for side rail use (Residents 50 and 54) remained free from the accident hazards associated with the use of elevated side rails. * The facility failed to obtain a physician's order and informed consent and failed to conduct a side rail evaluation prior to the use of the right half side rail for Resident 54. * The facility failed to ensure the proper assessment for Resident 50 prior to the use of the side rails. These failures have the potential to put Residents 50 and 54 at risk for serious injuries. Findings: The FDA issued a Safety Alert entitled Entrapment Hazards with Hospital Bed Side Rails. Residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, acute urinary retention, etc., that may cause them to move about the bed or try to exit from the bed. Entrapment may occur when a resident is caught between the mattress and bed rail or in the bed rail itself. Inappropriate positioning or other care related activities could contribute to the risk of entrapment. Review of the facility's P&P titled Bed Rails revised 12/2023 showed it is the policy of the facility to attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails. After the facility has attempted alternatives to bed rails and determined that these alternatives failed to meet the resident's assessed needs, the facility's IDT will assess the resident for risks of entrapment. The risk and benefits regarding the use of bed rails will be considered for each resident. If the use of bed rails is recommended by the IDT, the facility must obtain informed consent from the resident, or if applicable the resident representative for the use of bed rails prior to installation or use. The facility will check the resident bed and if used, bed rails regularly to verify they are still installed correctly, and connections are secure as rails may shift or loosen over time. The facility will update the resident care plan as needed related to the identified and/or ongoing need or resident choice for the use of bed rails. 1. On 7/31/24 at 0813 hours, Resident 54 was observed in bed with the right half side rail elevated. Medical record review for Resident 54 was initiated on 7/29/24. Resident 54 was admitted to the facility on [DATE], with a diagnosis of hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting the left non-dominant side. Review of Resident 54's MDS dated [DATE], showed Resident 54's had moderately impaired cognition and one-sided impairment for both upper and lower extremity functional limitation. The MDS also showed Resident 54 required substantial to maximal assistance, where the helper would do more than half the effort, for rolling from left to right in bed. Review of Resident 54's Order Summary Report dated 7/31/24, showed a physician's order dated 5/16/24, to apply the left half side rail for bed mobility. Review of Resident 54's Plan of Care showed a care plan problem initiated on 6/4/24, addressing Resident 54's use of the left half side rail as an enabler. Review of Resident 54's medical record showed an informed consent was obtained on 6/4/24, for the use of the left half side rail for bed mobility. Review of Resident 54's Bed Rail Safety Evaluation dated 5/16/24, under the equipment factors, showed the resident used the left half side rail for bed mobility. Review of Resident 54's LN-Restraint/Enabling Device/Safety Device Evaluation dated 5/16/24, showed the device recommended was the left half side rail for bed mobility. Further review of Resident 54's medical record failed to show the following: - a physician's order for the use of the right half side rail, - an informed consent for the use of the right half side rail, - a bed rail safety evaluation for the right half side rail prior to use, and - a care plan problem addressing the use of the right half side rail. On 7/31/24 at 1316 hours, an interview was conducted with LVN 7. LVN 7 stated Resident 54 had hemiplegia affecting his left side with left sided weakness to his upper and lower extremities. LVN 7 stated Resident 54 used the left side rail because he was unable to grab the right side rail with his left hand during care, due to his left sided weakness. An observation and concurrent record review for Resident 54 was conducted with LVN 7. LVN 7 verified Resident 54 had a physician order for the left half side rail and LVN 7 verified Resident 54's right half side rail was elevated, with no side rail observed on the left side of the bed. On 7/31/24 at 1340 hours, an interview and concurrent record review for Resident 54 was conducted with the DOR. The DOR stated the physical therapy was responsible for screening the residents for bed mobility when conducting the bed side rail evaluations. The Director of Rehab stated for the residents with left sided weakness and required assistance with positioning in bed, to pull himself up, the side rail should be on the right side, on the non-affected side. Concurrent record review of Resident 54's Bed Rail Safety Evaluation dated 5/16/24, was conducted with the Director of Rehab. The Director of Rehab verified the evaluation was for the left half side rail. On 8/1/24 at 1334 hours, an interview was conducted with the DON. The DON was asked about the facility's policy for the use of the side rails. The DON stated after a physician's order was obtained, the facility's IDT would conduct a bed side rail assessment and obtain an informed consent; the maintenance would perform an entrapment assessment; and a care plan would be initiated. The DON stated if a resident was able to move on one side of the body, the IDT would determine which side of the bed for the side rail to be placed. Concurrent record review for Resident 54 was conducted with the DON. The DON verified the above findings. The DON stated the side rail should be placed to match the physician's order. On 8/1/24 at 1410 hours, the Administrator and DON were informed and acknowledged the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's P&P titled Psychotropic Drug Use dated 8/2017, showed the Licensed Nurses shall review the classification of the drug, the appropriateness of the diagnosis, its indication/behavior monitors and related adverse effects prior to verification of admission orders with the Attending Physician. Medical record review for Resident 14 was initiated on 7/30/2024. Resident 14 was admitted to the facility on [DATE], with diagnosis of anxiety, bipolar disorder and schizophrenia. Review of Resident 14's Order Summary Report dated 7/30/24, showed the following orders dated: - 2/20/24, quetiapine rumarate (antipsychotic) 25 mg one tablet by mouth at bedtime manifested by auditory hallucination as evidence by hearing voices not present related to other schizophrenia - 5/10/22, clonazepam (antianxiety) 1 mg one tablet by mouth every 12 hours for anxiety disorder manifested by verbalization of feeling anxious Review of Resident 14's comprehensive plan of care initiated on 4/1/24, showed a care plan problem initiated for schizophrenia m/b hallucinations. The interventions included to administer medications as ordered and monitor for side effects and effectiveness. However, the care plan failed to include intervention to monitor Resident 14 for signs of orthostatic hypotension related to the use of psychotropic medications. Review of Resident 14's MAR dated 7/1-/31/24, failed to show documentation Resident 14 was monitored for signs of orthostatic hypotension. On 8/1/2024 at 1530 hours, an interview and concurrent medical record review for Resident 14 was conducted with the DON. The DON verified the findings and stated the blood pressure should be checked for the residents who were receiving the psychotropic medications to monitor for orthostatic hypotension. Based on interview and medical record review, the facility failed to ensure two of five final sampled residents (Residents 14 and 37) reviewed for unnecessary medications were free from the unnecessary psychotropic medications. * The facility failed to ensure the physician's documentation of the rationale for extending the use of alprazolam (antianxiety medication) beyond the 14-day duration for Resident 37. * The facility failed to monitor Resident 14 for signs of orthostatic hypotension for the use of antipsychotic medication. These failures had the potential to place Residents 14 and 37 at risk for receiving unnecessary medication and increased risk of serious adverse reactions from the medications. Findings: 1. Review of the FDA black box warning for alprazolam showed the continued use of benzodiazepines, including Xanax (brand name for alprazolam), may lead to clinically significant physical dependence. The risks of dependence and withdrawal increase with longer treatment duration and higher daily dose. Medical record review for Resident 37 was initiated on 7/29/24. Resident 37 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 37's Progress Notes - H&P Note dated 5/6/24, showed Resident 37 did not have the capacity to understand and make decisions. Review of Resident 37's MAR for July 2024 showed the following: -A physician's order dated 6/14/24, to administer alprazolam 0.5 mg one tablet every six hours as needed for anxiety for 21 days. This order was discontinued on 7/5/24. Resident 37 was administered six doses of alprazolam medication from 7/1 to 7/4/24; - A physician's order dated 7/5/24, to administer alprazolam 0.5 mg one tablet every six hours as needed for anxiety for 14 days. This order was discontinued on 7/19/24. Resident 37 was administered 21 doses of alprazolam medication from 7/5 to 7/18/24; and - A physician's order dated 7/22/24, to administer alprazolam 0.5 mg every six hours as needed for anxiety manifested by restlessness for 30 days. Resident 37 was administered 14 doses of alprazolam medication from 7/22 to 7/31/24. Further review of Resident 37's medical records failed to show documented evidence of physician's rationale for extending the use of alprazolam medication beyond the fourteen-day period. On 7/31/24 at 1305 hours, an interview and concurrent medical record review for Resident 37 was conducted with RN 2. When asked about the physician's orders for the alprazolam medications, RN 2 reviewed Resident 37's medical record and was unable to find documentation of the physician's rationale for extending the use of alprazolam medication beyond the fourteen-day period. On 8/1/24 at 1009 hours, an interview and concurrent medical record review for Resident 37 was conducted with the DON. The DON was informed and verified the findings. Cross reference to F552.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. On [DATE] at 0847 hours, an observation of Resident 35's room was conducted. A bottle of Frankincense and Myrrh Foot Pain Relief Rubbing Oil (used for temporary relief from burning, shooting, pricking, tingling, stabbing pain and numbness of the feet) and Longevity Essential Oil Deep Penetrating Joint and Pain Relief Antibacterial Antiviral Formula (used for pain and joint relief) were observed on Resident 35's bedside dresser. Resident 35 stated the CNA applied the Frankincense and Myrrh Foot Pain Relief Rubbing Oil on her legs and the Longevity Essential Oil Deep Penetrating Joint and Pain Relief Antibacterial Antiviral Formula was used for her neuropathy (weakness, numbness, and pain from nerve damage). Medical record review for Resident 35 was initiated on [DATE]. Resident 35 was readmitted to the facility on [DATE]. Review of Resident 35's MDS dated [DATE] showed Resident 35's BIMS score of 15 (cognitive intact). Further review of Resident 35's medical record failed to show a physician's order for the Frankincense and Myrrh Foot Pain Relief Rubbing Oil and Longevity Essential Oil Deep Penetrating Joint and Pain Relief Antibacterial Antiviral Formula and a care plan problem addressing the use of the above medications. On [DATE] at 0919 hours, an observation and interview was conducted with the ADON/IP. The ADON/IP verified the above finding. The ADON/IP stated Resident 35 was not supposed to have the above medications at bedside. Resident 35 agreed to have the medication bottles removed and the ADON/IP stated she would have the physician called if the medications were needed. 6. On [DATE] at 0906 hours, an observation of Resident 66's room was conducted. A box of Arthro-7 (supplement used to treat joint pain) was observed on Resident 66's bedside dresser. Medical record review for Resident 66 was initiated on [DATE]. Resident 66 was admitted to the facility on [DATE]. Review of Resident 66's MDS dated [DATE], showed Resident 66 had moderate cognitive impairment. On [DATE] at 0908 hours, an observation and interview was conducted with LVN 1. LVN 1 verified the above finding and stated Resident 66 was not supposed have the medication at bedside. LVN 1 stated the resident's family brought him stuff and she did not see the medication before. LVN 1 was asked who supposed to be checking the resident's bedside and LVN 1 stated she checked the residents' bedside during her shift but did not check Resident 66's bedside yet. On [DATE] at 1030 hours, an interview was conducted with Resident 66. Resident 66 stated his family brought the box of Arthro-7 for him but had not take the medication. On [DATE] at 1420 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the proper storage and disposal of medications for one of one medication storage room, three of four medication carts inspected for medication storage and labeling. In addition, the facility failed to ensure the medications were not stored at the bedside for one of 20 final sampled residents (Resident 35) and one nonsampled resident (Resident 66). * The facility failed to ensure the oral medications were stored separate from externally used medications in the medication room. * The facility failed to ensure the medications in the bubble packs (type of pre-formed, plastic packaging that seal individual tablets until they are taken) were secured, sealed and free from tears or damage for two nonsampled residents (Residents 1 and 88). * The facility failed to ensure Medication Cart C was not left unlocked and unattended. * The facility failed to ensure the medication for one discharge nonsampled resident (Resident 83) and expired medication for one nonsampled resident (Resident 56) were removed from the medication cart. * The facility failed to ensure an unopened insulin vial for one nonsampled resident (Resident 22) was stored in the medication refrigerator. * The facility failed to ensure Residents 35 and 66's medications were not kept at the bedside. These failures had the potential to negatively impact the residents' well being. Findings: Review of the facility's P&P titled Medication Storage in the Facility (undated) showed the following: - The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications; - Only licensed nurses, the consultant pharmacist, and those lawfully authorized to administer medications are allowed access to medications; - Medication rooms, medication carts, and medication supplies are locked or attended by persons with authorized access; - Orally administered medications are kept separate from externally used medications, such as suppositories, liquids, and lotions; - Eye medications are kept separate from ear medications; - Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label; - Refrigerated medications are kept in closed and labeled containers, with internal and external medications separated; and - Outdated, contaminated or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy, if a current order exists. 1. On [DATE] at 0926 hours, an inspection of the facility's Medication Room and concurrent interview was conducted with RN 1. a. The following was observed inside the medication cabinet: - Three boxes of Glutose (oral glucose gel, used to treat low blood sugar levels was stored with Tylenol (over the counter medication used to relieve pain and reduce fever) suppositories and Prep-H (medication used to relieve internal swelling caused by hemorrhoids) suppositories; - A box of Salonpas lidocaine cream (medication used to provide pain relief) was stored with the ear wax removal drops, Refresh PM (medication use to relieve dry eyes) eye drops, and boxes of sodium chloride hypertonicity ophthalmic ointment (medication used to draw water out of a swollen cornea); - A box of oral Cepacol (lozenges used to temporarily relieve pain from minor mouth problems) and three bottles of Robitussin DM (medication used to temporarily relieve cough) was stored with three bottles of saline nasal spray. b. The following was observed inside Medication Refrigerator B: - One Humalog (fast-acting insulin used to control high blood sugar) pen and three Basaglar (long-acting insulin used to control high blood sugar) were observed inside the freezer area; - One bottle of oral lorazepam liquid (antianxiety medication) was stored with Rhopressa 0.02% ophthalmic solution (medication used to reduce high eye pressure in glaucoma or ocular hypertension), Lantus (long-acting insulin used to control high blood sugar) pen, Humalog pen, Novolog (rapid-acting insulin used to control high blood sugar) and Humulin (short-acting insulin used to control high blood sugar) pens. RN 1 verified the above findings. 2. On [DATE] at 1059 hours, an inspection of Medication Cart B and concurrent interview was conducted with LVN 1. The following was observed: a. A bubble pack containing tamsulosin (medication used to treat symptoms of enlarged prostate gland) for Resident 83 was observed inside the cart. Closed medical record review for Resident 83 was initiated on [DATE]. Resident 83 was admitted to the facility on [DATE]. Review of Resident 83's Order Summary Report showed a physician's order dated [DATE], for the resident may leave against medical advice. b. A bubble pack of entecavir (antiviral medication used to treat Hepatitis B) Resident 1 was observed with a tear on one of the individual bubbles where an entecavir medication was individually stored. c. A bubble pack of gabapentin (medication used to treat partial seizures and nerve pain) for Resident 88 was observed with a tear on two of the individual bubbles where gabapentin medications were individually stored, and a tape was used to secure the bubble pack. LVN 1 verified the above findings. 3. On [DATE] at 1132 hours, Medication Cart C parked in the hallway was observed unlocked and unattended. The visitors and unlicensed staff were observed passing by. The Clinical Resource verified the above findings. On [DATE] at 1142 hours, an interview was conducted with LVN 3. LVN 3 stated she was assigned to Medication Cart C. LVN 3 stated she went to the resident's room and did not close or push the lock button all the way in to lock the medication cart. 4. [DATE] at 1452 hours, an inspection of Medication Cart A and concurrent interview was conducted with RN 2. The following was observed: a. An unopened vial of Novolog for Resident 22 was observed inside the medication cart, not refrigerated. b. A vial of Humulin for Resident 56 was observed with an opened date of [DATE], and expiration date of [DATE]. RN 2 verified the above findings.

Based on interview, facility document review, and facility P&P review, the facility failed to ensure the education was provided to the staff and family/visitor on safe food handling of outside food as per the facility's P&P. This failure had the potential to cause foodborne illnesses to the medically vulnerable resident population who consumed food brought from outside sources. Findings: Review of CMS S&C-09-39 dated 5/29/09, showed the residents have the right to choose to accept food from visitors, family, friends, or other guests according to their rights to make choices. The CMS guideline further shows the facility has the responsibility under the food safety regulation to help the visitors to understand safe food handling practices such as not holding or transporting foods containing perishable ingredients at temperatures above 41 degrees Fahrenheit. Review of the facility's P&P titled Food Brought by Family and Visitor revised 7/21/21, showed the resident and or resident representative will be informed of the policy and provided safe food handling guidance in the form of verbal and writing. This guidance will be documented and retained by nursing or in the medical record as a progress note and/or care plan. Review of the facility's document titled Bringing in Food for a Resident dated 2023 failed to show instructions for safe food handling of food brought into the facility. On 8/1/24 at 1257 hours, an interview was conducted with the CDM. The CDM stated when visitors wanted to bring in food from outside, he was involved in speaking with them to ensure the therapeutic diets and textures were met. The CDM stated he did not discuss about the hand hygiene and prevention of the cross contamination with the visitors. When asked about the education provided to the staff regarding safe food handling to ensure the staff were able to provide appropriate education to the residents and visitors, the CDM stated that was the DSD's responsibility. On 8/1/24 at 1311 hours, an interview was conducted with the DSD. The DSD provided the facility document titled Bringing in Food for a Resident and stated he reviewed the contents of the document when conducting in-services to the staff regarding safe food handling. The DSD further stated the document was reviewed with the residents and families when the visitors wanted to bring in food from outside. The DSD was asked to show if the document addressed safe food handling. The DSD reviewed the document and stated the document did not discuss the safe food handling for preparing, cooling, and storage of food, or how to prevent cross contamination. On 8/1/24 1334 hours, an interview and concurrent review of the facility's P&P titled Food Brought by Family and Visitor and the facility document titled Bringing in Food for a Resident was conducted with the DON. The DON verified the facility documents did not provide education about the safe food handling. On 8/1/24 at 1405 hours, the Administrator and CDM were informed and acknowledged the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident 50 was initiated on 7/30/24. Resident 50 was admitted to the facility on [DATE]. Review of Resident 50's Order Summary Report showed a physician's order dated 6/6/24, for PRAFO application to the resident's RLE daily five times/week for up to four hours as tolerated; and to monitor skin integrity every shift every Monday, Tuesday, Wednesday, Thursday, and Friday. On 7/31/24 at 0853 hours, an interview was conducted with the RNA. The RNA stated Resident 50 had an order for PRAFO application on the right lower leg for four hours a day as tolerated by the resident and applied it between 0930 to 1030 hours. The RNA also stated she would check the resident for any signs of pain, redness on his skin prior to applying the PRAFO and document on the RNA sheet. On 7/31/24 at 0957 hours, Resident 50 was observed lying in bed asleep with no signs of pain or discomfort. The right lower extremity PRAFO was observed present. Resident 50 was confused and nonverbal. On 7/31/24 at 1415 hours, review of a copy of Resident 50's RNA sheet for PRAFO showed missing docuementation from 7/24 to 7/26/24. On 7/31/24 at 1426 hours, a concurrent interview and document review was conducted with LVN 2. LVN 2 verified Resident 50's RNA sheet showed missing documentation for dates 7/24 to 7/26/24. LVN 2 stated she would report to the RN supervisor for any missing documentation. On 8/1/24 at 1428 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical records for four of 20 final sampled residents (Residents 14, 17, 20, and 50) were accurate and complete. * The facility failed to ensure Resident 50's RNA documentation was complete. * The facility failed to ensure Resident 17's Smoking Evaluation was accurately completed. * The facility failed to ensure Resident 50's RNA documentation was complete. * The facility failed to ensure Resident's TARs regarding the indwelling urinary catheter securement and monitoring Resident 14's edema were completed. * The facility failed to ensure Resident 14's medical record did not contain another resident's health information. These failures had the potential for the residents' care needs not being met as their medical information were inaccurate. Findings: Review of the facility's P&P titled Charting and Documentation undated showed the purpose is to provide the following: 1. A complete account of the resident's care, treatment, response to the care, signs symptoms, etc., as well as the progress of the resident's care. 2. Guidance to the physician in prescribing appropriate medications and treatments. 3. The facility, as well as other interested parties, with a tool for measuring the quality of care provided to the resident. 4. Nursing service personnel with a record of the physical and mental status of the resident. 5. Assistant in the development of a Plan of Care for each resident. 1. Medical record review for Resident 17 was initiated on 7/29/24. Resident 17 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 17's H&P examination dated 12/2/23, showed Resident 17 had the capacity to understand and make decisions. Review of Resident 17's MDS dated [DATE], showed Resident 17 had no impairments in her functional limitation in range of motion for her upper extremity (shoulder, elbow, wrist, and hand). Review of Resident 17's Plan of Care showed a care plan problem dated 4/7/23, addressing Resident 17's potential for injury related to smoking and continuous use of cigarettes. The interventions showed to complete the smoking assessment, observe Resident 17 smoking in designated areas, and report noncompliance or unsafe smoking habits to the MD and responsible party. The care plan interventions further showed Resident 17 preferred to smoke unsupervised and had stated she was able to hold cigarettes and put it out safely in the smoking receptacle. Review of Resident 17's quarterly LN-Smoking Evaluation dated 5/22/24, showed Resident 17 smoked five times a day, did not have any dexterity problems, and was able to light her own cigarette. Under the Safety section, the evaluation showed Resident 17 was not able to safely light, hold, or dispose of safety materials, and did not need adaptive clothing, device, or assistance. On 7/30/24 at 0730 hours, a smoking observation was conducted of Resident 17. Resident 17 was observed on a wheelchair and wheeling herself through the facility's side door. Resident 17 was observed smoking and holding her cigarette with no observed limitations in her upper extremities. On 7/30/24 at 1433 hours, an interview as conducted with CNA 10. CNA 10 stated Resident 17 smoked four to five times a day and did not wear an apron when smoking. CNA 10 stated Resident 17 was able to feed herself with minimal set-up assistance required and hold her own cigarettes and light her cigarettes safely. On 7/31/24 at 1420 hours, an interview was conducted with the Activities Director. The Activities Director stated he was familiar with Resident 17 and had accompanied her to smoke on multiple occasions. The Activities Director stated Resident 17 did not have any impairment or weakness in her hands and upper extremities and that Resident 17 was able to light and hold her own cigarettes and deposit her smoking materials appropriately and safely. On 8/1/24 at 1334 hours, an interview was conducted with the DON. The DON stated Resident 17 was able to self-ambulate in her wheelchair, open facility doors, and feed herself. The DON stated she had observed Resident 17 smoking and stated Resident 17 did not have any upper extremity impairments. Concurrent record review for Resident 17 was conducted with the DON. The DON verified the above findings. The DON stated the smoking evaluation for Resident 17 was conducted inaccurately. When asked, the DON stated she expected the assessments and documentation to be accurate to reflect the resident's current condition. On 8/1/24 at 1410 hours, the DON and Administrator were informed and acknowledged the above findings. 3. Medical record review for Resident 14 was initiated on 7/30/24. Resident 14 was admitted to the facility on [DATE]. Review of Resident 14's quarterly MDS dated [DATE], showed Resident 14 had a BIMS score of 15 which meant the resident was cognitively intact. Review of Resident 14's Order Summary Report for July 2024 showed a physician's order dated 5/9/22, to secure the Foley catheter with catheter strap or patch to thigh every shift. Further review of the Order Summary Report showed the physician's orders dated 6/20/22, to monitor the left and right lower extremities edema every shift. a. Review of Resident 14's TAR for July 2024 showed the entry to secure the Foley catheter; however, there were no nurses' initials on the following dates: - Wednesday, 7/3/24 - Wednesday, 7/10/24 - Sunday, 7/14/24 - Monday, 7/15/24 - Tuesday, 7/16/24 - Friday, 7/19/24 - Monday, 7/22/24 - Wednesday 7/24/24 b. Further review of Resident 14's TAR for July 2024, showed the entries for monitoring the left lower extremity and right lower extremity edema monitoring every shift; however, there were no nurses' initials on the following dates: - Wednesday, 7/3/24 - Wednesday, 7/10/24 - Sunday, 7/14/24 - Monday, 7/15/24 - Tuesday, 7/16/24 - Friday, 7/19/24 - Monday, 7/22/24 - Wednesday 7/24/24 On 7/31/24 at 1010 hours, a concurrent interview and medial record review with the DSD was conducted. The DSD verified the above findings regarding missing nurses' initials. On 8/1/24 at 1530 hours, an interview with the Administrator and DON was conducted. The Administrator and DON verified the above findings. 4. Medical record review for Resident 14 was initiated on 7/29/24. Resident 14 was admitted to the facility on [DATE]. Further review of Resident 14's medical record showed an Integrative Psychology Progress Note dated 11/4/22, for Resident 20 was in Resident 14's medical record. On 8/1/24 at 0954 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to offer and provide the education for influenza and pneumococcal immunizations for two of five final sampled residents (Residents 20 and 35) reviewed for immunizations. * The facility failed to obtain the consent and provide education on the influenza vaccine to Residents 20 and 35. * The facility failed to ensure Resident 35's Immunization Record was accurate for receiving the pneumococcal vaccine. These failures had the potential for the residents to be uninformed of the risks and benefits of receiving the influenza vaccine and potentially affect care provided. Findings: Review of the facility's P&P titled Infection Prevention- Immunizations, Influenza and Pneumococcal (Resident), undated, showed it is the policy of this facility to ensure that before entering the influenza and or pneumococcal immunization, each resident's legal representative receives education regarding the benefits and potential side effects of the immunization. Prior to vaccination, the resident and/ or resident representative will be provided information and education regarding the benefits and potential side effects of the influenza and/or pneumococcal immunization (Influenza and Pneumonia vaccine information sheet) 1. Medical record review for Resident 20 was initiated on 7/31/24. Resident 20 was admitted to the facility on [DATE]. Review of Resident 20's Immunization Record dated 10/26/23, showed the resident received the influenza vaccine. There was no documented evidence in Resident 20's medical record a consent for vaccination was signed by the resident or their representative. 2. Medical record review for Resident 35 was initiated on 7/31/24. Resident 35 was admitted to the facility on [DATE]. Review of Resident 35's Immunization Record dated 10/26/23, showed the resident received the influenza vaccine. There was no documented evidence the consent for vaccination was signed by the resident or their representative. Additionally, Resident 35's pneumoccal vaccine consent form did not show the resident had previously received the pneumococcal vaccine. On 8/1/24 at 0922 hours, an interview was conducted with the ADON/IP. The ADON/IP verified th above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurate and complete for six of nine sampled residents (Residents 14, 20, 37, 50, 54, and 69) reviewed for side rails use. * The facility failed to ensure Residents 14, 20, 37, 50, and 69's entrapment assessments were accurate. * The facility failed to ensure Resident 14's bed entrapment assessment was complete. * The facility failed to ensure Resident 54's bed entrapment assessment was completed for the right half side rail prior to use. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. The seven areas in the bed system where there is a potential for entrapment are: - Zone 1: within the rail; - Zone 2: under the rail, between the rail supports or next to a single rail support; - Zone 3: between the rail and the mattress; - Zone 4: under the rail, at the ends of the rail; - Zone 5: between split bed rails; - Zone 6: between the end of the rail and the side edge of the head or foot board; and - Zone 7: between the head or foot board and the mattress end. Review of the facility's P&P titled Proper Use of Bed Rails revised 12/2023 showed the following: - Entrapment is an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail; - Bed rails are adjustable metal or rigid plastic bars that are attached to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eight lengths. Also, some bed rails are not designed as part of the bed by the manufacturer and may be installed on or used along the side of a bed. Examples of bed rails include, but are not limited to side rails, bed side rails, grab bars and assist bars; - Assessment should assess resident's risk of entrapment between mattress and bed rail or in the bed rail itself; and - The facility will assure the correct installation and maintenance of bed rails, prior to use. This includes: (a) checking with the manufacturer(s) to make sure the bed rails, mattress, and bed frame are compatible. Rails should be selected and placed to discourage climbing over rails, (b) ensuring that the bed's dimensions are appropriate for the resident by confirming that the bed rails are appropriate for the size and weight of the resident using the bed, ensuring that the bed's dimensions are appropriate for the resident by, installing bed rails using the manufacturer's instructions and specifications to ensure a proper fit, inspecting and regularly checking the mattress and bed rails for areas of possible entrapment, and ensuring the bed frame, bed rail and mattress do not leave a gap wide enough to entrap a resident's head or body, regardless of mattress width, length, and/or depth, (c) observing ongoing precautions such as following manufacturer's equipment alerts and recalls and increasing resident supervision, especially with the use of air-filled mattresses or therapeutic air-filled beds that may present a different entrapment risk than rail entrapment, (d) conducting routine preventative maintenance of beds and bed rails to ensure they meet current safety standards and are not in need of repair. During a concurrent observation, medical record review, and facility document review for Residents 20, 37, and 50 showed the residents' bed entrapment assessments were not accurate for Zone 5. For example: 1. On 7/29/24 at 0845 hours, during the initial tour of the facility, Resident 37 was observed lying in bed with the bilateral half padded side rails elevated. Resident 37 was confused and mumbled words; unable to verify the use of the side rails. Medical record review for Resident 37 was initiated on 7/29/24. Resident 37 was admitted to the facility on [DATE]. Review of Resident 37's H&P examination dated 5/6/24, showed Resident 37 did not have the capacity to make her own medical decisions. Review of Resident 37's Order Summary Report showed a physician's order dated 5/22/24, for bilateral half padded side rails to aid with bed mobility and minimize risk of injury in the event of seizure activity. Review of Resident 37's Bed Rail 7 Zones Entrapment assessment dated [DATE], showed, Pass was circled for Zones 1 through 7. On 7/30/24 at 1033 hours, an observation and concurrent interview was conducted with the ADON/IP Nurse. The ADON/IP Nurse verified Resident 37's bilateral side rails were elevated. On 8/1/24 at 1030 hours, a concurrent interview and document review was conducted with the Maintenance Supervisor. The Maintenance Supervisor verified he documented the entrapment assessment on Resident 37's Bed Rail 7 Zones Entrapment Assessment. When asked about the assessments of the entrapment, the Maintenance Supervisor verified the bed entrapment assessments for Zones 5 was inaccurate. The Maintenance Supervisor stated he should have marked not applicable, N/A, for Zone 5. The Maintenance Supervisor verified the above findings. On 8/1/24 at 1428 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. 2. On 7/29/24 at 0951 hours, Resident 50 was observed lying in bed awake with bilateral half side rails elevated. Resident 50 was confused and nonverbal; unable to verify the use of the side rails. Medical record review for Resident 50 was initiated on 7/31/24. Resident 50 was admitted to the facility on [DATE]. Review of Resident 50's H&P examination dated 2/16/24, showed Resident 50 had history of CVA or stroke and cognitive communicative deficit. Review of Resident 50's Order Summary Report showed a physician's order dated 5/24/24, for bilateral half side rails for positioning and ease in mobility as an enabler. Review of Resident 50's Bed Rail 7 Zones Entrapment assessment dated [DATE], showed, Pass was circled for Zones 1 through 7. On 7/30/24 at 1125 hours, an observation and concurrent interview was conducted with LVN 4. LVN 4 verified Resident 50's bilateral half side rails were elevated. On 8/1/24 at 1030 hours, a concurrent interview and document review was conducted with the Maintenance Supervisor. The Maintenance Supervisor verified he documented the entrapment assessment on Resident 50's Bed Rail 7 Zones Entrapment Assessment. When asked about the assessments of the entrapment, the Maintenance Supervisor verified the bed entrapment assessments for Zones 5 was inaccurate. The Maintenance Supervisor stated he should have marked N/A for Zone 5. On 8/1/24 at 1428 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. 3. On 7/29/24 at 1045 hours, Resident 20's bed was observed with half padded bilateral upper side rails. Medical record review for Resident 20 was initiated on 7/29/24. Resident 20 was admitted to the facility on [DATE]. Review of Resident 20's Order Summary Report showed a physician's order dated 6/4/24, for padded bilateral half side rail up when in bed to minimize risk for injury in the event of seizure activity with verified informed consent obtained by the MD from the resident/responsible party. On 7/30/24 at 1200 hours, an interview was conducted with Resident 20. Resident 20 stated she used the side rails when she moved around in bed. When asked if the side rails helped, Resident 20 stated the side rails helped her a lot in changing positions. On 7/31/24 at 0916 hours, a follow-up observation was conducted in Resident 20's room. Resident 20's bed was observed with wooden headboard, padded bilateral half upper side rails, and a waffle mattress. On 8/1/24 at 0958 hours, an observation and concurrent interview was conducted with the DOR. The DOR verified Resident 20 had bilateral half side rails. When asked about the purpose of the resident's side rail use, the DOR stated he was somewhat familiar of Resident 20 and the purpose of the side rail use was for bed mobility. Review of Resident 20's Bed Rail 7 Zones Entrapment assessment dated [DATE], showed all the zones passed the assessment. However, Resident 20 had no lower side rails and Zone 5 indicated passed. Review of Resident 20's Plan of Care showed a care plan problem initiated on 4/4/23, to address Resident 20's use of side rail as an enabler. The interventions/tasks included to assess the gaps between the mattress, bed fame or side rail; and the use of side rail will be reevaluated quarterly and/or as needed. On 8/01/24 at 1032 hours, an interview was conducted with the Maintenance Director. The Maintenance Director stated he checked off Zone 5 because there was no problem. The Maintenance Director was asked why Zone 5 was assessed, the Maintenance Director did not give a response. When asked if he should have documented N/A in Zone 5, the Maintenance Director stated could be. On 8/01/24 at 1420 hours, an interview was conducted with the DON and Administrator. The DON and Administrator were informed and acknowledged the above findings. 6. On 7/31/24 at 0813 hours, Resident 54 was observed in bed with the right half side rail elevated. Medical record review for Resident 54 was initiated on 7/29/24. Resident 54 was admitted to the facility on [DATE], with a diagnosis of hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage affecting the left non- dominant side. Review of Resident 54's MDS dated [DATE], showed Resident 54's had moderately impaired cognition and had one-sided impairment for both upper and lower extremity functional limitation. The MDS also showed Resident 54 required substantial to maximal assistance, where the helper would do more than half the effort, for rolling from left to right in bed. Review of Resident 54's Order Summary Report dated 7/31/24, showed a physician's order dated 5/16/24, to apply the left half side rail for bed mobility. Review of Resident 54's Bed Rail 7 Zones Entrapment assessment dated [DATE], showed an entrapment assessment was conducted by the Maintenance Supervisor for the left half side rail. The assessment showed Zones 1, 2, 3, 4, 5, 6, 7, and 8 were marked as passed. Further review of Resident 54's medical record failed to show the following: - a physician's order for the use of the right half side rail, - a informed consent for the use of the right half side rail, - a bed rail safety evaluation, and - a bed rail entrapment assessment prior to the use of the right half side rail. On 7/31/24 at 1316 hours, an interview and concurrent observation was conducted with LVN 7. LVN 7 stated Resident 54 had left-sided weakness and used the left side rail to grab during care and repositioning. LVN 7 verified Resident 54's right half side rail was elevated and verified there were no side rails on the left side of the bed . On 8/1/24 at 1030 hours, an interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor stated he was responsible for the side rail entrapment assessments. The Maintenance Supervisor stated the nurse would provide him with the authorization form for the resident, which would indicate the specific rail and side. Concurrent review of Resident 54's Bed Rail 7 Zones Entrapment assessment dated [DATE], was conducted with the Maintenance Supervisor. The Maintenance Supervisor verified he conducted the assessment for the left half side rail. The Maintenance Supervisor also verified Zone 5 was marked as pass. The Maintenance Supervisor acknowledged Zone 5 did not need to be measured and should be marked as not applicable. On 8/1/24 at 1334 hours, an interview was conducted with the DON. The DON was asked about the facility's policy for the use of side rails. The DON stated after a physician's order was obtained, the facility's IDT would conduct a bed side rail assessment and obtain an informed consent; the maintenance would perform an entrapment assessment; and a care plan would be initiated. The DON stated if a resident was able to move on one side of the body, the IDT would determine which side of the the side rail would be placed. Concurrent record review for Resident 54 was conducted with the DON. The DON verified the above findings. The DON stated the side rails should be placed to match the physician's order. On 8/1/24 at 1410 hours, the Administrator and DON were informed and acknowledged the findings. 4. On 8/1/24 at 0931 hours, Resident 14 was observed lying in bed with the bilateral upper half side rails elevated. Medical record review for Resident 14 was initiated on 7/29/24. Resident 14 was admitted to the facility on [DATE]. Review of Resident 14's Order Summary Report showed a physician's order for bilateral half side rails for positioning and ease in mobility as an enabler. Review of Resident 14's Bed Rail 7 Zones Entrapment assessment dated [DATE], showed, Pass for Zone 5. Review of Resident 14's Bed Rail 7 Zones Entrapment assessment dated [DATE], showed the following sections were blank: - Zone 1 to 7 - Type of Mattress - Mattress Condition - Length and Width of Mattress On 8/1/24 at 1029 hours, an interview and concurrent medical record review was conducted with the Maintenance Supervisor. The Maintenance Supervisor verified the above findings. The Maintenance Supervisor acknowledged Zone 5 should have been marked as N/A since Resident 14 is only using the bilateral upper side rails. 5. On 8/1/24 at 1027 hours, Resident 69 was observed lying in bed with the bilateral upper half side rails elevated. Medical record review for Resident 69 was initiated on 7/29/24. Resident 69 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 69's Order Summary Report showed a physician's order for bilateral half side rails up in bed to aid in bed mobility. Review of Resident 69's Bed Rail 7 Zones Entrapment assessment dated [DATE], showed, Pass for Zone 5. On 8/1/24 at 1029 hours, an interview and concurrent medical record review was conducted with the Maintenance Supervisor. The Maintenance Supervisor verified the above findings. The Maintenance Director acknowledged that Zone 5 should have been marked as N/A since Resident 69 was only using the bilateral upper side rails.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen when: * The facility failed to ensure the kitchen utensils and equipment were clean and stored in sanitary conditions. * The facility failed to ensure the kitchen utensils were in good condition. * The facility failed to ensure the personnel entering the kitchen donned hair covering in the kitchen. * The facility failed to ensure the proper labeling and dating of the foods in the kitchen was utilized once the food item was opened. * The facility failed to ensure the fan unit inside the walk-in refrigerator was clean and free of buildup. These failures had the potential to cause foodborne illnesses in a highly susceptible resident population of 88 facility residents who consumed food prepared in the kitchen. Findings: Review of the facility document titled Diet Type Report dated 7/29/24, showed 88 of 92 residents in the facility received food prepared in the kitchen. 1. According to the USDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the USDA Food Code 2022, 4-602.13, Non- Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. Review of the facility's P&P titled Sanitation dated 2023 showed all utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. On 7/29/24 at 0800 hours, during an initial tour of the kitchen, the following was observed: - a metal spoon with brown colored stain on both sides, - a metal lemon squeezer with dried black food particles, - multiple clean kitchen utensils stored on top of a dirty baking sheet pan. The sheet pan was observed with dried food particles, multiple dried brown dust particles, and two brownish colored screws. - the drawer holding the baking sheet pan, that contained clean cooking utensils was observed with an orange-brown discoloration on the inner bottom wall of the drawer. A white towel was used to wipe the drawer wall and the towel was observed with a brownish color stain. The CDM verified the above findings. 2. Review of the facility's P&P titled Sanitation dated 2023 showed all utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. Plastic ware, china, and glassware that becomes unsightly, unsanitary, or hazardous because of chips, cracks, or loss of glaze shall be discarded. Review of the facility's P&P titled Can Opener and Base dated 2023 showed proper sanitation and maintenance of the can opener and base is important to sanitary food preparation. Metal shavings and shredding can result from a dull cutting blade or worn-out cogwheel. The can opener must be thoroughly cleaned each work shift and when necessary, more frequently. To replace the blade on the can opener, as needed. a. On 7/29/24 at 0800 hours, during the initial tour of the kitchen, a frayed plastic spatula was observed. The CDM verified the finding. b. On 7/30/24 at 1415 hours, during a follow-up visit in the kitchen, an observation was conducted of the stationary table can opener. The can opener was observed with chipped stainless-steel coating, exposing the blade. The CDM verified the finding. 3. According to the USDA Food Code 2022, Section 2-402.11 Hair Restraints, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. Review of the facility's P&P titled Dress Code dated 2023, under the section Proper Dress showed hat for hair, if hair is short; hair net for hair if hair is long. On 7/30/24 at 1120 hours, an observation and concurrent interview was conducted with the Maintenance Assistant. The Maintenance Assistant was observed in the kitchen passing the marked red line without a hair net. The Maintenance Supervisor verified the findings . When asked the Maintenance Assistant stated he should wear a hair net when entering the kitchen. On 8/1/24 at 1257 hours, an interview was conducted with the CDM. The CDM stated he expected individuals who entered the kitchen to stay behind the red line. If they needed to pass the red line, the individual should wear a hair net and a beard mask. 4. Review of the facility's P&P titled Labeling and Dating of Foods dated 2023 showed all food items in the storeroom, refrigerator, and freezer need to be labeled and dated based on established procedures for either food safety or product rotation. The individual opening or preparing a food shall be responsible for date marking at the time of processing and/or storage. On 7/29/24 at 0800 hours, during the initial tour of the kitchen, the following was observed to be unlabeled with an open date or use-by date: - an opened bag of hamburger buns and - two opened bags of hot dog buns. The CDM verified the above findings. The CDM stated he did not know when the bags were opened, the items should have had an opened date when first opened. 5. According to the USDA Food Code 2022, 4-602.13, Non- Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. Review of the facility's P&P titled Sanitation dated 2023 showed all equipment shall be maintained as necessary and kept in working order. On 7/29/24 at 0800 hours, during the initial tour of the kitchen, the fan unit inside the walk-in refrigerator was observed with grey colored fuzz. A white towel was used to wipe the substance and the grey fuzzy substance was observed on the towel. The CDM verified this finding. On 8/1/24 at 1405 hours, the Administrator and CDM were informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of infections were implemented as evidenced by: * The facility failed to implement their infection control surveillance program for August 2023 through June 2024. The facility conducted surveillance of resident infections based on whether the residents were prescribed antimicrobials. Residents who were not prescribed antimicrobials were not included in the facility's infection control surveillance program. * The facility failed to accurately track and monitor for the infections for April and May 2024. * The facility failed to ensure the staff performed hand hygiene before and after meal tray distribution. * The facility failed to ensure the infection control practices were implemented in the facility's laundry room. These failures posed the risk for not identifying infections and controlling the transmission of communicable disease to other residents throughout the facility. Findings: Review of the facility's P&P titled Infection Prevention - Surveillance of Infections and Reporting, (undated), showed the facility to maintain an ongoing system of surveillance designed to identify possible communicable diseases or infections to ensure that measures are taken to prevent any potential outbreak. The IP/Designee will review the log during the morning routine to ensure all potential/ actual infections/ outbreaks are being identified. 1.a. Review of the facility's monthly Prevention and Control Surveillance Log from August 2023 to June 2024 showed the following surveillance data: - August 2023, total of 26 cases including 20 CAI and 6 HAI - September 2023, total of 21 cases including 15 CAI and 6 HAI - October 2023, total of 26 cases including 19 CAI and 7 HAI - November 2023, total of 23 cases including 18 CAI and 5 HAI - December 2023, total of 24 cases including 17 CAI and 7 HAI - January 2024, total of 26 cases including 20 CAI 20 and 6 HAI - February 2024, total of 30 cases including 22 CAI and 8 HAI - March 2024, total of 26 cases including 19 CAI and 7 HAI - April 2024, total of 33 cases including 25 CAI and 8 HAI - May 2024, total of 30 cases including 27 CAI and 3 HAI - June 2024, total of 28 cases including 21 CAI and 7 HAI Review of the facility's monthly Prevention and Control Surveillance log from August 2023 through June 2024 showed documentation of the residents having an HAI or CAI and prescribed with antimicrobial medications. Further review of the facility's monthly Prevention and Control Surveillance Log from August 2023 through June 2024 showed the facility failed to conduct surveillance for all resident infections, specific to the residents who had signs and symptoms of infection, met the McGeer's criteria (method used to retrospectively counting true infection), and were not prescribed antimicrobial medications. On 7/31/24 at 1300 hours, an interview was conducted with the ADON/IP. When asked if she included the residents with signs and symptoms of infection, met the McGeer's criteria, and were not prescribed antimicrobial medications on the monthly Prevention and Control Surveillance Log, the ADON/IP stated she did not. The ADON/IP stated the facility monitored the residents who met the McGeer's criteria but were not prescribed antimicrobial medications on the COC log. On 8/1/24 at 1102 hours, a follow-up interview and concurrent facility document review was conducted with the ADON/IP. The ADON/IP verified the monthly Prevention and Control Surveillance Log from August 2023 through June 2024 did not include the residents with symptoms of infection who met the McGeer's criteria but were not prescribed with antimicrobial medications. b. Review of the facility's monthly Prevention and Control Surveillance Log for April 2024 showed the following: - an onset date of 4/17/24, for Resident 29's amoxicillin (antibiotic) 875-125 mg one tablet by mouth every 12 hours for 14 days, the log did not show whether the resident had CAI, HAI or did not meet the McGeer's criteria. Review of the facility's monthly Prevention and Control Surveillance Log for May 2024 showed the following: - an onset date of 5/13/24, for Resident 537's doxycycline (antibiotic) 100 mg one tablet by mouth two times a day for 10 days, the log did not show whether the resident had CAI, HAI, or did not meet the McGeer's criteria. - an onset date of 5/4/24, for Resident 26's cefdinir (antibiotic) 300 mg one capsule by mouth two times a day for seven days, the log did not show whether the resident had CAI, HAI or did not meet the McGeer's criteria. - a total number of residents who did not meet the McGeer's criteria was two. Review of Resident 537's Surveillance Data Collection Form dated 5/14/14, showed the resident's doxycycline did not meet the McGeer's criteria. On 7/31/24 at 1300 hours, an interview and concurrent facility document review was conducted with the ADON/IP. The ADON/IP verified the above findings and stated the surveillance log for April and May 2024 had missing entries for the section to indicate CAI, HAI, or did not meet the McGeer's criteria. The ADON/IP stated the log for May 2024 was inaccurate because the total number of residents who did not meet the McGeer's criteria should have been three. 2.a. Review of the facility's P&P titled Hand Hygiene dated 10/2022 showed all personnel shall follow the handwashing/hand hygiene procedure to help prevent the spread of infections to other personnel, residents, and or visitors. Under the Procedure section, it showed to use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non- antimicrobial) and water for the following situations: - after contact with objects in the immediate vicinity of the resident; - after removing gloves; - before and after eating or handling food; and - before and after assisting a resident with meals. On 7/29/24 at 1226 hours, a dining observation was conducted. CNA 2 was observed delivering a meal tray inside room [ROOM NUMBER]. CNA 2 then proceeded to remove the plate and cup covers. CNA 2 was then observed bringing the plate cover back to the meal cart and removing Resident 47's meal tray from the meal cart. CNA 2 then placed the meal tray on top of Resident 47's bedside table and donned gloves. CNA 2 was observed moving the resident's wheelchair and placing bib around the resident's neck. With her gloves hands, CNA 2 removed the plastic covers from Resident 47's drinks. CNA 2 then removed her gloves and left the room. CNA 2 proceeded to get another meal tray from the cart and brought it to Resident 61's room without perform hand hygiene. On 7/29/24 at 1233 hours, an interview was conducted with CNA 2. CNA 2 verified she donned gloves to move Resident 47's wheelchair and bedside table. CNA 2 verified she did not perform hand hygiene after removing her gloves, leaving the resident's room and before serving Resident 61's meal tray. CNA 2 was asked about the facility's protocol when delivering and serving multiple resident trays and after removing gloves. CNA 2 stated she should have used hand sanitizer after removing her gloves and before serving another resident's meal tray. b. On 7/29/24 at 1249 hours, a dining observation was conducted. CNA 3 was observed delivering a meal tray to Resident 43, proceeded to remove the plate cover and opened the milk carton then left the room. CNA 3 was then observed removing Resident 689's meal tray from the cart, delivering it to the resident, and removing the plate cover without performing hand hygiene. CNA 3 then left Resident 689's room and delivered Resident 688's meal tray to his room and removed the plate cover without performing hand hygiene. On 7/29/24 at 1254 hours, an interview was conducted with CNA 3. CNA 3 verified the above findings and stated she was supposed to perform hand hygiene with each time she delivered a meal tray to a different resident. 3. Review of the facility's P&P titled Laundry dated January 2024 showed it is the policy of the facility that careful precautionary procedures must be followed by laundry personnel to prevent spread of infectious diseases to other staff members, residents, and visitors. On 7/29/24 at 1412 hours, an inspection of the laundry area and concurrent interview with CNA 1 and Laundry 1 was conducted. The pen holder with multiple writing materials, water bottle, and personal cell phone were observed on the laundry folding table. CNA 1 and Laundry 1 verified the findings and CNA 1 stated the water bottle and cell phone belong to her. Laundry 1 stated the laundry folding table was a clean area and should not have other things on the table. On 8/1/24 at 1420 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their antibiotic stewardship program when the facility failed to conduct an assessment for the McGeer's criteria to determine the true infection. This failure had the potential for inaccurately identifying for true infections and potentially inhibited the residents' physicians from discontinuing the unnecessary antimicrobials. Findings: Review of the facility's P&P titled Antibiotic Stewardship, undated, showed it is the policy of the facility to implement an Antibiotic Stewardship Program (ASP) that is incorporated in the overall Infection Prevention and Control Program which will promote appropriate use of antibiotic while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotic use. This policy has the potential to limit antibiotic resistance in the post-acute setting, while improving treatment efficacy and resident safety, and reducing treatment - related costs. The Core Elements of stewardship are the same for both acute care setting and nursing homes, as outlined by CDC (Center for Disease Control); however, facilities may have a difference in the implementation of these elements: leadership, accountability, drug expertise, action to implement recommended policies or practices, tracking measures, reporting data, education for clinicians, nursing staff, residents, and families about antibiotic resistance and opportunities for improvement. 1.a. Review of the facility's infection control binder showed Surveillance Data Collection Form being used to assess for McGeer's criteria to determine the true infection. Review of the facility's monthly Prevention and Control Surveillance Logs from August 2023 through June 2024 showed the following surveillance data. - August 2023, 26 infected residents with antibiotics - September 2023, 21 infected residents with antibiotics - October 2023, 26 infected residents with antibiotics - November 2023, 23 infected residents with antibiotics - December 2023, 24 infected residents with antibiotics - January 2024, 26 infected residents with antibiotics - February 2024, 30 infected residents with antibiotics - March 2024, 26 infected residents with antibiotics - April 2024, 33 infected residents with antibiotics - May 2024, 30 infected residents with antibiotics - June 2024, 28 infected residents with antibiotics However, the facility failed to show documentation the McGeer's/Surveillance Data Collection form was completed to assess for the true infection for the residents who were admitted from the acute care hospital with antibiotics: On 7/31/24 at 1300 hours, an interview and concurrent facility document review was conducted with the ADON/IP. The ADON/IP verified the above findings. The ADON/IP stated she did not complete the Surveillance Data Collection Form for the residents who were admitted from the acute care hospital with antibiotics. The ADON/IP stated she was trained to only complete the Surveillance Data Collection Form for the residents who were prescribed antibiotics at the facility. b. Medical record review for Resident 29 was initiated on 7/31/24. Resident 29 was admitted to the facility on [DATE]. Review of Resident 29's Surveillance Data Collection Form dated 5/15/24, showed Resident 29 met the McGeer's criteria and was prescribed Augmentin (antibiotic) 875-125 mg by mouth every 12 hours. However, the bottom portion of the form did not show if the infection was HAI, CAI, or did not meet the criteria. c. Medical record review for Resident 75 was initiated on 7/31/24. Resident 75 was admitted to the facility on [DATE], and readmitted [DATE]. Review of Resident 75's Surveillance Data Collection Form dated 6/3/24, showed Resident 75 was prescribed Levaquin (antibiotic) 500 mg by mouth daily for seven days and did not meet the McGeer's criteria. The Additional Notes section showed, Patient's clinical indication does not meet McGeer's criteria. Resident's ATB (antibiotic) started from the ER. Renal calculi. However, there was no documented evidence to show the facility had notified the physician that Resident 75's antibiotic did not meet the McGeer's criteria. d. Medical record review for Resident 537 was initiated on 7/31/24. Resident 537 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 537's Surveillance Data Collection Form dated 5/13/24, showed Resident 537 was prescribed doxycycline (antibiotic) 100 mg two times a day for seven days and Augmentin 875-125 mg two times a day for seven days and did not meet the McGeer's criteria. However, the bottom portion of the form did not show if the infection was HAI, CAI or did not meet the criteria; and the Additional Notes section showed, Recurrent infection. In addition, there was no documented evidence to show the physician was notified that Resident 537's antibiotic medications did not meet the McGeer's criteria. e. Medical record review for Resident 538 was initiated on 7/31/24. Resident 538 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the facility's monthly Prevention and Control Surveillance Log for April 2024 showed Resident 538 was prescribed mupirocin (antibiotic) external ointment 2 % for right foot wound dehiscence on 3/15/24. However, there was no documented evidence the Surveillance Data Collection Form was completed. On 7/31/24 at 1300 hours, an interview and concurrent facility document review was conducted with the ADON/IP. The ADON/IP verified the above findings. The ADON/IP stated the whole Surveillance Data Collection Form should be completed. The ADON/IP stated the licensed nurses initiated the McGeer's criteria tool/Surveillance Data Collection Form and she completed the bottom portion of the form to show if the infection was HAI, CAI, or did not meet the criteria. The ADON/IP stated she documented on the bottom portion of the Surveillance Data Collection Form if the prescribed antibiotic met the McGeer's criteria or not; and if it did not meet the criteria, she then would discuss it with the physician if the antibiotic should be continued or not. The ADON/IP also stated she would document the physician's decision on the bottom portion of the form. On 8/1/24 at 1420 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to arrange for the transportation to and from ophthalmology appointments for one of two sampled residents (Resident 1). This posed the risk of the resident not receiving the necessary vision related care and treatment. Findings: On 1/30/24 at 0922 hours, a telephone interview was conducted with Family Member 1. Family Member 1 stated Resident 1 missed her ophthalmology appointments in December 2023 and January 2024 because the facility did not arrange for the transportation. Family Member 1 stated the ophthalmology appointments were crucial as Resident 1 had diabetes and glaucoma and needed to have her eyes examined and eye pressure checked. Medical record review for Resident 1 was initiated on 1/30/24. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's History and Physical Note dated 8/11/23, showed Resident 1's diagnoses included diabetes and glaucoma. Review of Resident 1's Physician Order dated 6/15/23, showed Resident 1 had a follow-up ophthalmology appointment on 12/15/23 at 1010 hours. Review of Resident 1's Progress Notes dated 12/15/23 at 1449 hours, showed the transportation company could not take Resident 1 to her scheduled ophthalmology appointment as it was in a different county and the appointment had to be rescheduled. Review of Resident 1's Physician Order dated 12/18/23, showed Resident 1's rescheduled ophthalmology appointment was on 1/19/24 at 1030 hours. Review of Resident 1's Progress Notes dated 12/15/23 to 1/18/24, did not show the arranged transportation for Resident 1's ophthalmology appointment scheduled on 1/19/24 at 1030 hours. Review of Resident 1's Progress Notes dated 1/19/24 at 1037 hours, showed the transportation company could not take Resident 1 to her scheduled ophthalmology appointment on 1/19/24 at 1030 hours, as there was no availability. On 1/30/24 at 1142 hours, an interview and concurrent medical record review was conducted with the Director of Social Services. The Director of Social Services verified the above findings. The Director of Social Services verified the attempts or issues related to transportation arrangement must be documented. The Director of Social Services verified there was no documented evidence the transportation was arranged for Resident 1's ophthalmology appointment on 1/19/24, and the family was not notified about the lack of transportation until after the resident's appointment had passed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to develop a plan of care to reflect the individual care needs for one of three sampled residents (Resident 2). * Resident 2's care plan for hearing had an incorrect intervention. This failure had the potential risk of not providing the appropriate and individualized care for Resident 2. Findings: Review of the facility's P&P titled Care Plan and Care Plan Update revised 2/2022 showed the facility will assure the completion of the resident assessment process enabling the development of an individualized comprehensive care plan for the resident. Medical record review for Resident 2 was initiated on 9/20/23. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's History and Physical examination dated 5/5/23, showed Resident 2 had blindness and hearing loss. Review of Resident 2's MDS dated [DATE], showed Resident 2 had severely impaired vision and minimal difficultly for hearing. Review of Resident 2's plan of care dated 8/28/23, showed the facility developed a care plan problem addressing a risk for communication problem related to hearing deficits. The care plan interventions for Resident 2 included to communicate by lip reading, writing, using gestures, and sign language. On 9/21/23 at 1235 hours, an interview was conducted with Resident 2. When asked about the extent of her visual impairment, Resident 2 stated she only could see a white screen in front of her. Resident 2 stated she was unable to see shadows, people, or objects. On 9/20/23 at 1607 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above findings. The DON stated the care plans were to be individualized and tailored to every resident. The DON also stated the care plan intervention for Resident 2 was incorrect because Resident 2 was blind and would not be able to communicate with lip reading writing, using gestures, or sign language. The DON further stated it should be removed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to provide the necessary care and services to ensure one of three sampled residents (Resident 1) maintained his highest practicable physical well-being. * The facility failed to administer acetaminophen (a fever and pain reducing medication) as prescribed by the physician for Resident 1. This failure had the potential to negatively impact Resident 1's well-being. Findings: Medical record review for Resident 1 was initiated on 9/20/23. Resident 1 was admitted to the facility on [DATE], and readmitted [DATE]. Review of Resident 1's History and Physical examination dated 7/25/23, showed Resident 1 was recently hospitalized for sepsis (a condition where the body is responding to an infection). Review of Resident 1's Order Summary Report dated 6/29/23 through 7/26/23, showed the following orders: - dated 7/6/23, to administer acetaminophen 325 mg two tablets by mouth every six hours as needed for the body temperatures > 99.9 degrees F. - dated 7/18/23, to administer acetaminophen 325 mg two tablets by GTevery six hours as needed for the body temperatures > 99.9 degrees F. Review of Resident 1's Vitals Documentation for temperatures showed the following: - On 7/9/23 at 0915 hours, the temperature = 102.2 F - On 7/11/23 at 1054 hours, the temperature = 102.4 F Review of Resident 1's MAR for July 2023 showed to monitor the vital signs and record any Covid signs and symptoms. The following temperatures were recorded: - on 7/9/23, the temperature = 102.2 F - on 7/10/23, the temperature = 102.2 F - on 7/11/23, the temperature = 102.4 F - on 7/12/23, the temperature = 102.4 F Further review of Resident 1's MAR for July 2023 showed Resident 1 did not receive acetaminophen 325 mg two tablets on 7/9, 7/10, and 7/12/23,for the temperatures > 99.9 F as ordered. On 9/20/23 at 1607 hours, an interview and concurrent medical record review was conducted with the DON. The DON reviewed Resident 1's MAR and verified the above findings. The DON reviewed the Nurse's Progress Notes for 7/9, 7/10 and 7/12/23,and stated there was no documentation showing the medication order and interventions were carried out regarding Resident 1's elevated temperatures. The DON further stated the staff should have administered the ordered acetaminophen and provided the cooling measures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and interview, the facility failed to ensure resident care was provided in a manner to promote dignity and respect for one of 18 final sampled residents (Resident 82) and one nonsampled resident (Resident 71). * The facility failed to ensure the staff sat next to Residents 71 and 82 while assisting them to eat. This had the potential to negatively impact the residents' feelings of self-worth and well-being. Findings: 1. On 7/20/23 at 0805 and 0809 hours, Resident 71 was observed being assisted to eat by CNA 5. CNA 5 was observed standing over Resident 71 who was seated in a wheelchair. On 7/20/23 at 1016 hours, an interview was conducted with CNA 5. CNA 5 acknowledged she was standing over Resident 71 when assisting the resident with eating. CNA 5 stated she was standing over Resident 71 so she could focus on what the resident was eating. When asked about the facility's policy for assisting the residents with meals, CNA 5 stated she did not know she had to sit down while assisting the residents with eating. Medical record review for Resident 71 was initiated on 7/18/23. Resident 71 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 71 required extensive assistance from one person for eating. 2. On 7/20/23 at 0811 hours, Resident 82 was observed being assisted to eat by CNA 6. CNA 6 was observed standing over Resident 6 who was seated in bed. On 7/20/23 at 0821 hours, an interview was conducted with CNA 6. CNA 6 acknowledged she was standing over Resident 82 when assisting the resident with eating. When asked about the facility's policy for assisting residents with meals, CNA 6 did not answer. Medical record review for Resident 82 was initiated on 7/18/23. Resident 82 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 82 required limited assistance from one person for eating. On 7/21/23 at 0844 hours, an interview was conducted with the DSD. When asked about the facility's policy for assisting the residents with meals, the DSD stated the staff should be seated beside the resident or at the resident's eye level when assisting the residents to eat to promote the resident's dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide one nonsampled resident (Resident 28) trust fund statements quarterly. This failure had the potential for loss and misuse of Resident 28's personal funds. Findings: Review of the facility's P&P titled Resident Trust Fund revised 3/1/23, showed the facility will send out the Resident Trust Fund statement to the resident or the resident's legal representative within 30 days from the end of the quarter. The facility Executive Director will be responsible to ensure quarterly statements are submitted in a timely manner and in accordance with the State or Federal regulations. On 7/18/23 at 0857 hours, a telephone interview was conducted with the Ombudsman. The Ombudsman stated Resident 28 had concerns about not receiving her quarterly statements for her funds at the facility. On 7/21/23 at 1154 hours, a follow-up telephone interview was conducted with the Ombudsman. The Ombudsman stated the BOM was aware of Resident 28's concern regarding not receiving her quarterly trust fund statement from the facility for over a year. The Ombudsman stated when she followed up with the BOM about Resident 28's concern, the BOM stated she provided a copy to Resident 28; however, the Ombudsman stated the BOM did not have documentation to show a copy of the statement was provided to Resident 28. Medical record review for Resident 28 was initiated on 7/18/23. Resident 28 was admitted to the facility on [DATE]. Review of Resident 28's H&P examination dated 10/31/22, showed Resident 28 had the capacity to understand and make decisions. Review of Resident 28's Trust Statement for June 2023 showed the amount of money debited and credited from Resident 28's money with a closing balance. On 7/20/23 at 1510 hours, an interview and concurrent facility document review was conducted with the BOM. The BOM verified Resident 28 had a trust fund (funds that belong to the resident, such as social security checks, pension checks or personal funds) handled by the facility. The BOM stated she was responsible for providing Resident 28's quarterly statements for her trust fund. The BOM stated Resident 28's last quarterly trust fund statement was for June 2023. The BOM stated she personally handed the copies of the statements to Resident 28 and kept an electronic copy in the facility's records. The BOM stated she also sent a copy of Resident 28's quarterly statements to Resident 28's responsible party through the mail. However, the BOM verified there was no documented evidence the resident or responsible party received the June 2023 quarterly statement. On 7/20/23 at 1523 hours, an observation and concurrent interview was conducted with the BOM. The BOM was observed handing a copy of the June 2023 quarterly statement to Resident 28. The BOM was observed inspecting Resident 28's belongings; however, the BOM was unable to find previous copies of the trust fund statements in Resident 28's belongings. On 7/20/23 at 1524 hours, an interview was conducted with Resident 28. Resident 28 stated she did not remember receiving her June 2023 quarterly trust fund statement from the BOM. Resident 28 stated she had not received any statements from the facility or the BOM in years. On 7/20/23 at 1624 hours, an interview was conducted with the DON. The DON was informed of the above findings. The DON stated the trust fund statements should be provided to the residents or their responsible party quarterly by the BOM. On 7/21/23 at 1324 hours, a telephone interview was conducted with Family Member 1. Family Member 1 stated she had not received any copy of Resident 28's trust fund statements, including the quarterly statement for June 2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Medical record review for Resident 18 was initiated on 7/18/21. Resident 18 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the MDS dated [DATE], showed Resident 18 was cognitively intact. Review of Resident 18's Physician Orders for Life-Sustaining Treatment (POLST), undated, showed Resident 18 had no advance directive. The POLST did not show the advance directive information was offered and discussed with Resident 18. Further review of Resident 18's medical record did not show the information was provided to Resident 18 for the formulation of the advance directive. On 7/19/23 at 1149 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 reviewed the medical record and verified the above findings. RN 1 stated the Advance Directive Acknowledgment form should be completed and placed in the resident's medical record. On 7/19/23 at 1511 hours, an interview and concurrent medical record review was conducted with SSD. The SSD verified the above findings. The SSD stated the nursing staff were responsible in completing and placing the completed Advance Directive Acknowledgement form in the resident's medical record. The SSD stated she only followed up with the residents who marked on the advance directive acknowledgment form for the need of additional information regarding the formulation of an advance directive. 3. The facility's P&P titled Advance Directives and Associated Documentation revised on 1/2022 showed the facility is to obtain copy of the advance Directive and conservatorship/guardianship documents and place in the resident health record. Medical record review for Residents 7 and 38 was initiated on 7/18/23. - On 7/18/23 at 1114 hours, review of Resident 7's advance directive was conducted. The form titled Advance Directive Acknowledgement form did not show if the resident had or had not executed an advance irective. - On 7/18/23 at 1240 hours, review of Resident 38's medical record was conducted. There was no Advance Directive Acknowledgement form found in Resident 38's medical records. On 7/18/23 at 1436 hours, a concurrent interview and medical record review was conducted with RN 5. RN 5 verified Resident 7's Advance Directive Acknowledgement form did not show if Resident 7 had or had not executed an advance directive. Furthermore, RN 5 verified Resident 38 did not have an advance directive in the resident's medical record. On 7/19/23 at 1053 hours, a concurrent interview and record review was conducted with the SSD. The SSD stated the Advance Directive Acknowledgement forms were completed by the nursing staff. The SSD verified Resident 7's Advance Directive Acknowledgement form was incomplete and Resident 38 did not have an Advance Directive Acknowledgement form in the medical record. Based on interview, medical record review, and facility P&P review, the facility failed to provide the information on how to formulate an advanced directive and maintain a copy of the resident's advance directives in the medical record for four of 18 final sampled residents (Residents 4, 16, 18, and 38) and one nonsampled resident (Resident 7). These failures have the potential for the residents' decision regarding their healthcare and treatment options not being honored. Findings: Review of the facility's P&P titled Advance Directives and Associated Documentation revised January 2022 showed prior to, upon, or immediately after admission, a facility staff member shall: - Provide the resident/family or responsible agent written information regarding the right to accept or refuse medical treatment and the right to formulate Advance Directives - Document in the resident health record that, at the time of admission, the resident/family has been provided with written information regarding advance directives - Inquire whether he/she has completed an Advance Directive. Obtain a copy of the Advance Directive and conservatorship/guardianship documents and place in the resident health record. Once the advance directive or information regarding resident preferences regarding treatment options is received by the facility, it will be confirmed in the resident medical record and communicated to members of the care plan team. 1. Medical record review for Resident 4 was initiated on 7/18/23. Resident 4 was readmitted to the facility on [DATE]. Review of Resident 4's MDS dated [DATE], showed a BIMS score of 12 which indicated Resident 4 had moderate impaired cognition. Also, under the advance directive section showed there was no advanced directive. Review of Resident 4's POLST (undated) showed the section regarding advance directive was left blank. Review of Resident 4's Advance Directive Acknowledgement form dated 10/20/21, showed Resident 4 had executed an advance directive. Review of Resident 4's California General Durable Power of Attorney showed it was signed and dated on 4/14/21. However, the medical record did not include Resident 4's advance directive. On 7/19/23 at 0910 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 was informed and verified the above finding. RN 1 stated if a resident had an advance directive, the licensed nurse would request for a copy of the advance directive and placed the copy in the resident's chart. RN 1 further stated for any other follow up regarding the advance directives, it would be referred to the social services department. On 7/19/23 at 0954 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD was informed and verified the above finding. The SSD stated she had a copy of Resident 4's advance directive. The SSD pulled out a copy of Resident 4's advance directive from a binder in her office. The SSD acknowledged the copy should be in Resident 4's medical record. 2. Medical record review for Resident 16 was initiated on 7/19/23. Resident 16 was readmitted to the facility on [DATE].d Review of Resident 16's MDS dated [DATE], showed Resident 16's BIMS score was 14 which indicated Resident 16 was cognitively intact. Also, under Section S9040H, was coded as 3 or No Advanced Directive. Review of Resident 16's POLST (undated), showed Section D regarding advance directive was unmarked. Review of Resident 16's Advanced Directive Acknowledgement form dated 5/9/22, showed no documented evidence if Resident 16 had an advance directive or not or provided information if literature regarding advance directive was provided. Review of Resident 16's IDT- Care Plan Review dated 3/27/23 and 6/22/23, did not show documented information of an advance directive information offered to Resident 16. Further review of Resident 16's nurses progress notes and social services progress notes did not show documented evidence of an advance directive information offered to Resident 16. On 7/19/23 at 0817 hours, an interview was conducted with Resident 16. Resident 16 stated she could not remember if information regarding the advance directive was offered to her because she was out of it when she was initially admitted . On 7/19/23 at 0910 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified the above findings. RN 1 stated upon the resident's admission, the resident or resident's representative would be asked regarding information with advance directive and to complete the Advance Directive Acknowledgement form. RN 1 further stated if the resident or resident's representative wanted more information regarding the advance directive, they will be referred to the social services department. On 7/19/23 at 0924 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD verified the above findings. The SSD stated if the Advanced Directive Acknowledgement form was not completed, she did not get a copy. The SSD further stated she provided Resident 16 information regarding the advance directives. However, the SSD was not able to provide documented evidence she provided Resident 16 information regarding formulation of an advance directive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Closed medical record review for Resident 85 was initiated on 7/20/23. Resident 85 was admitted on [DATE] and discharged on 5/18/23. Review of Resident 85's Orders Summary Report from 5/2/23 to 5/18/23, showed a physician's order dated 5/15/23, to discharge home with a home health RN. Review of Resident 85's Discharge Note dated of 5/18/23, showed Resident 85 discharged to home. Review of Resident 85's Discharge MDS by MDS Nurse 1 dated 5/18/23, showed the discharge status was coded as 03, meaning discharge to an acute care hospital. On 7/20/23 at 1302 hours, an interview with MDS Nurse 1 and the MDS Resource was conducted in the MDS office. MDS Nurse 1 was informed and verified the above finding. MDS Nurse 1 stated the discharge status should have been coded as 01, meaning discharged to the community. The MDS Resource stated she was also responsible for verifying the accuracy of the documentation in the MDS before signing the document. Based on interview and medical record review, the facility failed to ensure the MDSs for two of 18 final sampled residents (Residents 4 and 16) and one nonsampled resident (Resident 85) were accurate. This posed the risk of the residents not receiving an individualized plan of care based on the residents' specific needs. Findings: 1. Medical record review for Resident 16 was initiated on 7/19/23. Resident 16 was readmitted to the facility on [DATE]. Review of Resident 16's MAR for the months of June and July 2023 showed Resident 16 was administered quetiapine (a medication use to treat symptoms of schizophrenia or bipolar disorder) 25 mg one-half tablet daily at bedtime for other schizophrenia manifested by auditory hallucinations as evidence by hearing voices not present. Review of Resident 16's MDS dated [DATE], showed the following: - Resident 16's BIMS score was 14 which indicated Resident 16 was cognitively intact. - The anticoagulant section showed Resident 16 was administered an anticoagulant for seven days. However, review of Resident 16's Order Summary Report for June and July 2023 failed to show documented evidence the physician had ordered an anticoagulant medication. - The section if a gradual dose reduction (GDR) had been attempted showed there was no GDR attempted. However, review of Resident 16's Psychiatric Evaluation Note dated 6/7/23, showed a note for GDR for Seroquel (brand name of quetiapine) 12.5 mg was contraindicated for Resident 16. - The section if the resident had an Advance Directive showed Resident 16 did not have an advance directive. However, Review of Resident 16's POLST (undated) showed section D was unmarked. Also, review of Resident 16's Advance Directive Acknowledgement form dated 5/9/22, did not indicate if Resident 16 had an advance directive or not. On 7/19/23 at 0959 hours, an interview and concurrent medical record review was conducted with MDS Nurse 1. MDS Nurse 1 stated she miscoded the anticoagulant in Section N. The anticoagulant section should be coded as 0. MDS Nurse 1 stated the GDR section in Section N should had been coded with a date when the psychiatrist noted Resident 16's GDR for Seroquel was contraindicated. MDS Nurse 1 further stated she coded Section S for the advance directive as no advance directive if there were no copies of residents' advance directives in the residents' medical record. On 7/19/23 at 1022 hours, a telephone interview was conducted with the MDS Resource. The MDS Resource was informed and acknowledged the above findings. The MDS Resource stated if Resident 16's POLST was unmarked in section D and the Advanced Acknowledgement form was incomplete, then Section S for advance directive should be marked as not completed. 2. Medical record review for Resident 4 was initiated on 7/19/23. Resident 4 was readmitted to the facility on [DATE]. Review of Resident 4's MDS dated [DATE], showed Resident 4's BIMS score was 12 which indicated Resident 4 had moderate impaired cognition. In addition, the section for advance directive showed Resident 4 did not have an advance directive. Review of Resident 4's POLST (undated) showed the section for advance directive was left blank. Review of Resident 4's Advance Directive Acknowledgement form dated 10/20/21, showed Resident 16 had executed an advance directive. Further medical record review for Resident 4 showed a copy of Resident 4's advance directive was in the SSD's personal binder in her office. On 7/19/23 at 0959 hours, an interview and concurrent medical record review was conducted with MDS Nurse 1. MDS Nurse 1 further stated she coded Section S for the advance directive as no advance directive because there was no advance directive in the resident's medical record. On 7/19/23 at 1022 hours, a telephone interview was conducted with the MDS Resource. The MDS Resource was informed and acknowledged the above findings. The MDS Resource stated if Resident 4's POLST was unmarked in section D, the Advanced Acknowledgement form indicated Resident 4 had executed an advance directive, and had a copy of the advance directive then, Section S for advance directive should be coded advance directive available and reviewed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plans of care to reflect the individual care needs for two of 18 final sampled residents (Residents 15 and 42). These failures had the potential risk of not providing appropriate, consistent, and individualized care to these residents. Findings: Review of the facility's P&P titled Care Plan and care plan update revised February 2022 showed each resident receives quality of care and services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The facility's P&P also showed individualized comprehensive person-centered care plan includes all problems, goals, and interventions will be documented. 1. On 7/18/23 at 0955 hours, and 7/20/23 at 1558 hours, an observation and concurrent interview was conducted with Resident 15. Resident 15 was observed in bed and stated she always stayed in bed. When Resident 15 was asked if she attended any activities, she stated she did not get up and stayed in bed all day. Medical record review for Resident 15 was initiated on 7/20/23. Resident 15 was admitted to the facility on [DATE]. Review of Resident 15's MDS dated [DATE], showed Resident 15 had moderate cognitive impairment and required extensive assistance of one staff for bed mobility. On 7/20/23 at 0923 hours, an interview for Resident 15 was conducted with CNA 1. CNA 1 stated Resident 15 refused to get up in a wheelchair and if Resident 15 was up in a wheelchair, Resident 15 wanted to get back to bed. CNA 1 stated the staff offered Resident 15 to be up in wheelchair but refused. On 7/20/23 at 1441 hours, an interview for Resident 15 was conducted with RNA 1. RNA 1 stated a therapeutic exercise was provided to Resident 15. RNA 1 stated Resident 15 was not seen up in wheelchair due to the resident refused to be up. RNA 1 stated Resident 15 was offered and explained to be up and out of bed but refused. RNA 1 stated they reported to the nurses when Resident 15 refused care. On 7/20/23 at 1449 hours, an interview and concurrent medical record review for Resident 15 was conducted with RN 3. RN 3 stated Resident 15 always stayed in bed and refused to be up in wheelchair. RN 3 stated the DON and IDT were informed about Resident 15's refusal of care, and a plan of care had been developed. When asked, RN 3 was unable to find a plan of care and verified there was no plan of care developed for Resident 15's refusal to get out of bed. 2. Medical record review for Resident 42 was initiated on 7/18/23. Resident 42 was admitted to the facility on [DATE]. Review of the Order Summary Report dated 7/20/23, showed a physician's order dated 7/18/23, to administer levofloxacin (antibiotic medication) 500 mg one tablet by mouth at bedtime for UTI until 7/21/23. Review of Resident 42's plan of care failed to show documented evidence a care plan problem was developed to address Resident 42's use of antibiotic medication to treat UTI. On 7/20/23 at 1457 hours, an interview and concurrent medical record review for Resident 42 was conducted with RN 3. RN 3 verified Resident 42 was on antibiotic medication for UTI. RN 3 was asked if a care plan problem was developed for the use of antibiotic medication for Resident 15. RN 3 reviewed the medical record and was unable to find a care plan problem addressing the use of antibiotic medication for Resident 42. On 7/21/23 at 1507 hours, an interview was conducted with the DON. The DON was informed and verified the above findings. The DON stated there should have been a care plan problem formulated for every problem of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the facility's P&P titled Physician Orders revised November 2019 showed physician's orders shall be obtained prior to the initiation of any medication or treatment. Medical record review for Resident 12 was initiated on 7/18/23. Resident 12 was admitted to the facility on [DATE]. Review of Resident 12's MDS dated [DATE], showed Resident 12 was cognitively intact. On 7/19/23 at 0823 hours, a medication administration observation for Resident 12 was conducted with LVN 1. LVN 1 administered the following medications to Resident 12: -one tablet of aspirin (antiplatelet medicatiion) enteric coated 81 mg -one capsule of duloxetine HCL DR (antidepressant and nerve pain medication) 60 mg -one tablet of Xifaxan (antibiotic used to prevent reoccurrence of liver problems) 550 mg. -one scoop of polyethylene glycol powder (used to treat occasional constipation) 17 g -two patches of lidocaine (pain reliever) 5% to the left and right knees. Review of Resident 12's Order Summary Report dated 7/19/23, showed a physician's order dated 6/30/23, for Zyrtec (antihistamine used to treat allergy symptoms such as hives and itching) allergy oral tablet 10 mg one tablet by mouth in the morning for chronic allergy. However, the above medication was not administered to Resident 12 during the medication administration. On 7/19/23 at 1003 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 stated she administered Zyrtec (generic name was cetirizine) to Resident 12 after the medication administration observation because she could not find the medication. When asked about the Zyrtec supply, LVN 1 showed the bottle of loratadine 10 mg. LVN 1 verified she administered the medication from the loratadine bottle. However, LVN 1 stated Zyrtec was not the same as loratadine, after she verified it with the electronic MAR and the internet. LVN 1 verified Resident 12 did not have a physician's order for loratadine. LVN 1 stated she should have not administered the loratadine medication to Resident 12. Further review of Resident 12's medical record failed to show a physician's order to administer loratadine 10 mg to Resident 12. On 7/19/23 at 1005 hours, an interview was conducted with Resident 12. Resident 12 verified she received two additional tablets from LVN 1, after she received her morning medications from LVN 1. On 7/20/23 at 1350 hours, an interview was conducted with the DON. The DON was informed and verified the above findings. The DON stated the licensed nurses should check the medications with the electronic MAR prior to administering the medications. Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services to ensure two of 18 final sampled residents (Residents 33 and 82) and one nonsampled resident (Resident 12) attained and maintained their highest practicable well-being. * The facility failed to consult the physician when Resident 33 was administered the following medications at the same time: midodrine (antihypotensive or medication used to treat low blood pressure) medication and metoprolol (antihypertensive or medication used to treat high blood pressure), diltiazem (antihypertensive) and isosorbide dinitrate (used to prevent chest pain and lowers blood pressure). In addition, the parameters for midodrine, metoprolol, and diltiazem were not followed when administering these medications. These failures had the potential for Resident 33 to not receive necessary therapeutic effect of the medications and to experience adverse effects. * The facility failed to coordinate the care of Resident 82 with the contracted hospice. There was no physician's order to indicate the frequency of licensed staff and CHHA (certified home health aide) visits. The hospice binder for Resident 82 had a POC (plan of care) summary for another resident, the scheduled visitation calendar was blank, the hospice agency forms such as the Emergency Plan, Oxygen Safety Assessment, Agreement, and Education Form, Safety Guidelines, and Family Guide for Death at Home were blank, and the certification and plan of care were not in the hospice binder or Resident 82's medical records. These failures had the potential for Resident 82 to not receive the appropriate care and treatment. * The facility failed to ensure Resident 12 was administered Zyrtec (antihistamine to treat symptoms of seasonal allergies) as per the physician's order. Findings: 1. Medical record review for Resident 33 was initiated on 7/18/23. Resident 33 was readmitted to the facility on [DATE]. Review of Resident 33's Order Summary Report showed physician's order dated 6/21/23, to administer the following medications: - diltiazem ER (extended release) 180 mg by mouth daily for hypertension. Hold for SBP less than 110 mmHg (millimeter(s) of mercury) - metoprolol 25 mg two times a day for hypertension. Hold for SBP less than 110 mmHg or heart rate less than 60 beats per minute - isosorbide dinitrate ER 30 mg by mouth daily for hypertension - midodrine 5 mg one tablet by mouth two times a day for hypotension. Hold for SBP more than 120 mmHg. Review of Resident 33's MAR for July 2023 showed the following: - Resident 33 was administered with isosorbide dinitrate medication on 7/1, 7/2, 7/3, 7/5, 7/7, 7/9, 7/10, 7/12, 7/14, 7/16, 7/17, and 7/19/23 at 0900 hours. - Resident 33 was administered with diltiazem medication on 7/2, 7/3, 7/7, 7/10, 7/12, 7/14, 7/16, 7/17, and 7/19/23 at 0900 hours. In addition, Resident 33 was administered diltiazem medication on 7/12/23 at 0900 hours, even when the blood pressure was 107/78 mmHg. - Resident 33 was administered with metoprolol medication on 7/2, 7/3, 7/7, 7/9, 7/10, 7/14, 7/16, 7/17, 7/18, and 7/19/23 at 0900 hours, and on 7/1, 7/2, 7/4, 7/5, 7/7, 7/8, 7/9, 7/10, 7/12, 7/13, 7/14, 7/15, 7/16, 7/18, and 7/19/23 at 1700 hours. In addition, Resident 33 was administered metoprolol medication on 7/9/23 at 0900 hours, when the blood pressure was 108/62 mmHg. -Resident 33 was administered with midodrine medication on 7/1, 7/3, 7/5, 7/9, 7/13, 7/14, 7/15, 7/16, and 7/18/23 at 0900 hours, and on 7/1, 7/2, 7/3, 7/4, 7/5, 7/6, 7/7, 7/8, 7/11, 7/16, and 7/17/23 at 1700 hours. In addition, Resident 33 was administered midodrine medication on 7/3, 7/14, 7/16/23 at 0900 hours when the blood pressure was more than 120 mmHg. On 7/20/23 at 1502 hours, an interview and concurrent medical record review for Resident 33 was conducted with the DON. The DON was informed and verified the above findings. The DON stated the antihypertensive and antihypotensive medications were prescribed in the hospital and continued in the facility. The DON also verified these medications were administered beyond the parameters as per the physician's order. The DON stated they would have to clarify the administration of these medications with the physician. 2. Review of the facility's P&P titled End of Life Care - Hospice revised date 1/2017 showed hospice services will be offered as appropriate and as ordered by the physician. These services will be integrated into the overall individualized, interdisciplinary care plan. Hospice services will be in partnership with the facility and a contract hospice agreement will be in place between the facility and hospice servicing company. Review of the Hospice Services Agreement between the facility and Hospice Provider A signed 7/7/23, showed the following: - In the admission process, the agency responsibility showed if the provider is a facility, then copies of the initial assessment will be part of the client record and any and all components of the agency chart is available upon request to the facility; - In the assessment of the resident, the agency responsibility showed a complete physical assessment will be competed by an RN employee of the hospice. The initial assessment will include evaluation of the support services available to the resident, and their coping ability, and determine ongoing evaluations what the family and the resident needs are; - In coordinating, supervising, and evaluating the care and services provided, the agency responsibility showed all hospice services will be coordinated and supervised by the hospice agency, specifically the RN case manager, including placement of residents, and provision of ancillary services; and - In the development, review, and revision and review of the plan of care, the agency responsibility showed the care plan will be developed once the initial visit has been made and in collaboration with all the members of the IDG (interdisciplinary group), including but not limited to the provider of services. The provider responsibility showed both the plan of care and the nursing care plan developed by the agency will be part of the resident's record in the facility. Medical record review for Resident 82 was initiated on 7/18/23. Resident 82 was admitted to the facility on [DATE]. Review of Resident 82's Order Summary Report showed a physician's order dated 7/11/23, to admit Resident 82 for hospice services provided by Hospice Provider A. There was no physician's order to show the frequency of the licensed staff and CHHA visits. a. Review of Resident 82's medical record failed to show the current hospice written certification form, and updated hospice plan of care while Resident 82 was receiving hospice services. b. Upon inspection of the hospice binder for Resident 82, the following was observed: -A POC (plan of care) Summary for another resident was observed inside the hospice binder for Resident 82; -The Monthly Projected Hospice Visit Schedule was left blank; -The hospice agency forms such as Emergency Plan, Oxygen Safety Assessment, Agreement, and Education Form, Safety Guidelines, and Family Guide for Death at Home were blank; and -The documentation in the Sign-In Sheet, and Communicate Note were not legible. On 7/20/23 at 0846 hours, an interview and concurrent medical record review for Resident 82 was conducted with RN 2. RN 2 verified the above findings. RN 2 verified the hospice written certification form and updated hospice plan of care for Resident 82 were not in Resident 82's medical record. When asked about the frequency of the hospice staff visit, RN 2 verified there was no physician's order to show the hospice staff visit frequency, and RN 2 was observed looking into the POC Summary located in Resident 82's hospice binder. RN 2 was informed the POC Summary she was looking at, was not for Resident 82 but for another resident. When asked who the facility's hospice coordinator was, RN 2 stated it was the DON. On 7/20/23 at 0919 hours, an interview and concurrent medical record review for Resident 82 was conducted with the SSD. The SSD stated she was the facility's hospice coordinator but was only assigned this role a week ago. When asked if she checked the forms from Hospice Provider A, the SSD stated she did not check the forms nor the hospice binder for Resident 82. The SSD verified the hospice written certification form and updated hospice plan of care for Resident 82 were not in Resident 82's medical record. The SSD also verified the hospice agency forms were blank and the POC Summary inside the Resident 82's hospice binder was for another resident. On 7/20/23 at 0932 hours, an interview and concurrent medical record review for Resident 82 was conducted with the DON. The DON verified the above findings. The DON verified the hospice written certification form and updated hospice plan of care for Resident 82 were not in Resident 82's medical record. When asked about the frequency of the hospice staff visit, the DON verified there was no physician's order to show the hospice staff visit frequency, and the DON was observed looking into the POC Summary located in Resident 82' hospice binder. The DON was informed the POC Summary she was looking at was not for Resident 82 but for another resident. During this time, a medical record staff gave copies of hospice written certification form, current treatment/ medication/ DME (durable medical equipment) list, and a plan of care dated 7/19/23, from Hospice Provider A. On 7/20/23 at 0946 hours, an interview and concurrent medical record review for Resident 82 was conducted with the Medical Records Director. The Medical Records Director verified the above findings. The Medical Records Director they checked Resident 82's hospice binder and it was blank, so the facility requested the forms from Hospice Provider A.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the intravenous accesses for one of 18 sampled residents (Resident 336). The facility failed to ensure the PICC line external catheter and arm circumference measurements were performed and documented in the medical record for Residents 336. This failure had the potential to delay identification of catheter related complications for the resident. Findings: Review of the facility's P&P titled Care of Peripheral Inserted Central Lines (PICC) - dressing change and site care, undated, showed the dressing were routinely changed every seven days or when the dressing becomes loose, wet or soiled. The documentation in the medical records includes the appearance of the insertion site. Medical record review for Resident 336 was initiated on 7/20/23. Resident 336 was admitted to the facility on [DATE]. Review of Resident 336's IV Administration Record for July 2023 showed the resident had a PICC line catheter. However, the medical record failed to show the length of the external catheter and arm circumference above the insertion site were obtained upon admission. On 7/19/23 at 0908 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified Residents 336's medical record did not show the PICC line external catheter and arm measurements. RN 1 stated the PICC external catheter line and resident's arm circumference measurements had to be done upon admission and with every dressing change to ensure the intravenous access line not getting dislodged. On 7/20/23 at 0903 hours, an interview was conducted with the DON. The DON stated all residents with PICC and midline catheters had to have measurements of the arm circumference and external catheter length.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care for one of 18 final sampled residents (Resident 336). * The facility failed to ensure Resident 336's nasal cannula (flexible tube to deliver oxygen into the nose) tubing was dated as per the facility's P&P. In addition, a CNA was observed turning on and off the concentrator machine. These failures posed the risk for the resident's oxygen equipment to become contaminated which had the potential to negatively affect the residents' medical conditions. Findings: Review of the facility's P&P titled Oxygen, Use of, revised October 2021 showed oxygen nasal cannula tubing and humidifiers will be changed every seven days with identifiable date. Review of the facility's P&P titled Oxygen Administration revised July 2017 showed the oxygen therapy is administer by licensed nurses as ordered by the physician. On 7/17/23 at 1037 hours, 7/19/23 at 1347 hours, and 7/20/23 at 1349 hours, Resident 336 was observed receiving oxygen through nasal cannula at 2 liters per minute. The nasal cannula was unlabeled and undated. Medical record review for Resident 336 was initiated on 7/20/23. Resident 336 was admitted to the facility on [DATE]. Review of Resident 336's Order Summary Report dated 7/19/23, showed a physician's order dated 7/12/23, to administer oxygen at 2 liters per minute through a nasal cannula as needed for low oxygen saturation levels less than 90 %. On 7/20/23 at 1349 hours, a concurrent observation and interview was conducted with CNA 2. CNA 2 was observed in Resident 336's room preparing to change the oxygen tubing and humidifier water bottle. CNA 2 verified Resident 336's nasal cannula was unlabeled and undated. CNA 2 stated she changed the oxygen tubing and humidifier bottle every Sunday and as needed. CNA 2 was asked on how she changed the oxygen tubing and humidifier bottle on the concentrator machine. CNA 2 stated she turned off the concentrator machine, change the tubing and humidifier bottle, and turned back on the concentrator machine. On 7/20/23 at 1307 hours, an interview and concurrent medical record review for Resident 336 was conducted with RN 3. RN 3 verified Resident 336's use of oxygen therapy. RN 3 stated the oxygen tubing was changed once a week and as needed. RN 3 stated all the humidifier bottle and tubing should have been labeled. RN 3 was informed of the findings of Resident 336's nasal cannula undated and unlabeled. RN 3 stated the nasal cannula might have been changed and forgot to label it. On 7/21/23 at 1010 hours, an interview and concurrent medical record review for Resident 336 was conducted with the DSD. The DSD stated the licensed nurses would operate the oxygen machine. The DSD verified the team leader for the CNAs was given the position to change the oxygen tubing and humidifier bottle of the concentrator machine every Sunday. The DSD stated training was provided including the checking the function of the tubing and the machine. On 7/21/23 at 1354 hours, an interview was conducted with the DON. The DON stated the licensed nurses was responsible to administer oxygen therapy to the residents as per the physician's order. The DON was informed of the above findings. The DON stated she expected the CNA staff to change the tubing only and not to turn on and off the concentrator machine. The DON stated the licensed nurse were responsible for turning on and off the contractor machine.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident 4 was initiated on 7/18/23. Resident 4 was readmitted to the facility on [DATE], with End Stage Renal Disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life) required hemodialysis (a process of purifying the blood of a person whose kidneys are not working normally). Review of Resident 4's H&P examination dated 9/13/22, showed Resident 4 had the capacity to understand and make decisions. Review of Resident 4's Order Summary Report for June and July 2023 showed a physician's order dated 4/27/23, for fluid restriction of 1000 ml/24 hours as follows: * Nursing to provide 520 ml of fluid: - 80 ml for the 11-7 shift - 240 ml for the 7-3 shift - 200 ml for the 3-11 shift * Dietary to provide 480 ml of fluid: - 236 ml at breakfast - 122 ml at lunch - 122 ml at dinner Review of Resident 4's Fluid Intake Task for July 2023, showed the CNAs documented daily total fluid intake for Resident 4 with ranges from 390- 900 ml, which exceeded the prescribed dietary fluid intake of 480 ml of fluid. For example: - On 7/6/23, Resident 4 had a total of 650 fluid intake. - On 7/823, Resident 4 had a total of 710 ml fluid intake. - On 7/9/23, Resident 4 had a total of 590 ml fluid intake. - On 7/10/23, Resident 4 had a total of 890 ml fluid intake. - On 7/11/23, Resident 4 had a total of 880 ml fluid intake. - On 7/12/23, Resident 4 had a total of 680 ml fluid intake. - On 7/14/23, Resident 4 had a total of 710 ml fluid intake. Review of Resident 4's MAR for June and July 2023, showed licensed nurses documented daily fluid intake for Resident 4 on 7-3 shift with the ranges of 240-598 ml and on 3-11 shift with the ranges of 200-598 ml, which exceeded the prescribed nursing fluid intake of 520 ml. For example: - On 7/6/23, Resident 4 had a total of 598 ml fluid intake for 7-3 shift and 200 ml fluid intake for 3-11 shift; - On 7/823, Resident 4 had a total of 598 ml fluid intake for 7-3 shift and 200 ml fluid intake for 3-11 shift; - On 7/9/23, Resident 4 had a total of 598 ml fluid intake for 7-3 shift and 598 ml fluid intake for 3-11 shift; - On 7/10/23, Resident 4 had a total of 598 ml fluid intake for 7-3 shift and 200 ml fluid intake for 3-11 shift; - On 7/11/23, Resident 4 had a total of 598 ml fluid intake for 7-3 shift and 200 ml fluid intake for 3-11 shift; - On 7/12/23, Resident 4 had a total of 598 ml fluid intake for 7-3 shift and 200 ml fluid intake for 3-11 shift; and - On 7/14/23, Resident 4 had a total of 598 ml fluid intake for 7-3 shift and 355 ml fluid intake for 3-11 shift. On 7/20/23 at 1344 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated theresident's fluid restriction was pre-calculated and not totalled daily. The DON verified the daily total from the licensed nurses and CNAs documentation did not match the physician's fluid restriction order of 1000 ml/24 hours. The DON acknowledged the above findings. On 7/20/23 at 1345 hours, an interview and concurrent medical record review was conducted with the DSD. The DSD verified and acknowledged the above findings. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure dialysis care was provided for two of 18 final sampled residents (Residents 4 and 33). * The facility failed to implement and monitor the fluid intake for Resident 33 as per the physician's order. There were two physician's orders for fluid restrictions for Resident 33 with different fluid breakdowns for nursing and dietary. There was no documentation by the nursing staff for the actual fluid intake by Resident 33, and the CNA's documentation of the resident's fluid intake showed the resident took more than the prescribed fluid intake. * The facility failed to ensure the physician's order for 1000 ml fluid restriction (a diet which limits the amount of daily fluid consumption) was followed and carried out accordingly for Resident 4. These failures had the potential for Residents 4 and 33 not being provided with the appropriate care and treatment, and the possibility of medical complications related to the dialysis access site. Findings: 1. Review of the facility's P&P titled Dialysis (Renal), Pre and Post Care reviewed date 5/2021 showed to assess or evaluate the resident's condition and monitor for complications before and after dialysis treatments. Under the Pre-dialysis Care section, showed to conduct a pre-dialysis evaluation and document in the facility/dialysis center nursing communication record. Under the Post-dialysis Care section, showed upon return to the facility, conduct a post-dialysis evaluation/ assessment including but not limited to the evaluation of the dialysis access site and dressing and vital signs, and to review any pertinent information from the dialysis nurse, in the facility/ dialysis center nursing communication record. Medical record review for Resident 33 was initiated on 7/18/23. Resident 33 was readmitted to the facility on [DATE], with a diagnosis of end stage renal disease (kidneys no longer function) requiring hemodialysis treatment. Review of Resident 33's Order Summary Report showed the following physician's orders dated: - 6/21/23, for dialysis every Tuesday, Thursday, and Saturday; - 6/21/23, for dialysis type: hemodialysis AV fistula (arteriovenous fistula is a surgically created connection of an artery to a vein), and location: right upper arm; - 6/21/23, to monitor dialysis access site for signs and symptoms of infection, swelling, bleeding every shift for the right upper arm AV fistula - 6/21/23, to monitor for bruit (he sound of blood flowing through a narrowed portion of an artery)/thrill (a vibration felt upon palpation of a blood vessel) every shift for right upper arm AV fistula; -6/27/23, for 1200 ml fluid restriction daily, fluid breakdown on days-nursing (0700-1500 hours shift) 240 ml, and dietary-breakfast 240 ml; PM-nursing (1500-2300 hours shift) 240 ml, and dietary-lunch 120 ml; and NOC-nursing (2300-0700 hours shift) 120 ml, and dietary-dinner 240 ml. The order showed 600 ml/ day for nursing, and 600 ml/ day for dietary; and -7/2/23, for fluid restriction: 1200 ml/day: nursing 480 ml/day (0700-1500 hours shift: 300 ml, 1500-2300 hours shift:120 ml; 2300-0700 hours shift: 60 ml), and dietary 720 ml/day (eight ounce with each meal). a. Review of Resident 33's Nursing Facility Pre-Dialysis Assessment and Nursing Facility Post-Dialysis Assessment forms showed inconsistency of documentation regarding the resident's dialysis access. For example: - On 6/22, 6/27, 7/1, 7/4, 7/6, 7/8, and 7/15/23, the licensed staff documented the right upper arm AV shunt (arteriovenous shunt is a U-shaped plastic tube inserted between an artery and a vein) as Resident 33's dialysis access type on the pre and post-dialysis assessments. - On 7/11/23, the licensed staff documented the right upper arm AV fistula on the pre-dialysis assessment and right upper arm AV shunt on the post-dialysis assessment. - On 7/13/23, the licensed staff documented the right upper arm AV shunt on the pre-dialysis assessment and right upper arm AV fistula on the post-dialysis assessment. - On 7/18/23, the licensed staff documented the right upper arm AV shunt on the pre-dialysis assessment, and then only documented right upper arm on the post-dialysis assessment. b. Review of Resident 33's Medication Administration Record for July 2023, showed the two physician's orders for fluid restrictions were marked as checked on 7/1 to 7/19/23, but did not show the actual fluid intake by Resident 33. c. Review of the CNA documentation of Resident 33's fluid intake showed Resident 33 exceeded the prescribed dietary fluid intake. For example: - On 7/7/23, Resident 33 had a total of 800 ml fluid intake; - On 7/9/23, Resident 33 had a total of 810 ml fluid intake; - On 7/10/23, Resident 33 had a total of 860 ml fluid intake; - On 7/11/23, Resident 33 had a total of 800 ml fluid intake; - On 7/12/23, Resident 33 had a total of 870 ml fluid intake; - On 7/13/23, Resident 33 had a total of 1040 ml fluid intake; - On 7/15/23, Resident 33 had a total of 810 ml fluid intake; - On 7/16/23, Resident 33 had a total of 780 ml fluid intake; - On 7/17/23, Resident 33 had a total of 910 ml fluid intake; and - On 7/18/23, Resident 33 had a total of 1020 ml fluid intake. On 7/20/23 at 1450 hours, an interview was conducted with CNA 5. When asked if Resident 33 was on fluid restriction, CNA 5 answered yes, and stated if Resident 33 drank more than the fluid restriction, then she would ask the charge nurse to check the resident. When asked what Resident 33's fluid restriction was, CNA 5 stated about 360 ml for breakfast and 240 ml for lunch. CNA 5 stated the kitchen provided the beverages on the tray, and Resident 33 usually drank whatever served on her meal tray. CNA 5 stated she documented these fluid intake amounts in Resident 33's electronic health record. On 7/20/23 at 1502 hours, an interview and concurrent medical record for Resident 3 was conducted with the DON. The DON verified the above findings. The DON verified Resident 33 had an AV fistula on the right upper arm. The DON verified the licensed nurses documented two different access types on the pre and post-dialysis assessment forms. The DON stated the nurses were supposed to assess the fistula site for bruit and thrill before and after dialysis and document the correct access type in the assessment form. When asked about Resident 33's fluid restriction, the DON verified there were two physician's orders for fluid restriction. The DON stated the physician's order for fluid restriction dated 7/2/23, was supposed to clarify the physician's order for fluid restriction dated 6/27/23. The DON verified there was no documentation from the nurses for how much fluid Resident 33 took during their shift. The DON also verified Resident 33 consumed more than the prescribed fluid intake as shown in Resident 33's dietary fluid intake recorded by the CNAs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 18 final sampled residents (Resident 51) remained free from accident hazard due to the use of side rails. * The facility failed to ensure the assessments for the risk for entrapment were completed for Resident 51 prior to the use of bilateral half side rails. In addition, the facility failed to obtain informed consent for the use of the side rails. This failure had the potential to put the resident at risk for entrapment and serious injury. Findings: Review of the facility's P&P titled Bed Rails revised January 2022 showed after the facility has attempted alternatives to bed rails and determined that these alternatives failed to meet the resident's assessed needs, the facility's IDT will assess the resident for risks of entrapment and possible benefits of using bed rails. It the use of bed rails is recommended by the IDT, the facility must obtain informed consent from the resident, or if applicable, the resident representative for the use of bed rails prior to installation. On 7/18/23 at 0959 hours, 7/19/23 at 1155 hours, and 7/20/23 at 0759 hours, Resident 51 was observed lying in bed with bilateral half side rails elevated. Medical record review for Resident 51 was initiated on 7/18/23. Resident 51 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 51's H&P examination dated 2/10/23, showed Resident 51 did not have the capacity to understand and make decisions. Review of Resident 51's Order Summary Report for July 2023 showed a physician's order dated 2/7/23, may use half side rails for positioning and ease in mobility as an enabler. Review of Resident 51's MDS dated [DATE], showed Resident 51 required extensive assistance from one staff for bed mobility. Review of Resident 51's plan of care showed a care plan problem addressing the use of half side rails as an enabler. The interventions included to re-evaluate the use of side rails quarterly and as needed. Further review of Resident 51's medical record failed to show documented evidence Resident 51 was assessed for the risk of entrapment and an informed consent was obtained for the use of bilateral side rails as per the facility's P&P. On 7/19/23 at 1156 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified there was no assessment on the risk of entrapment, and Resident 51 did not have an informed consent for the use of the side rails in Resident 51's medical record. On 7/19/23 at 1234 hours, an interview and concurrent medical record review was conducted with MDS Nurse 1. The MDS Nurse 1 verified there was no assessment on the risk of entrapment for the use of side rails for Resident 51. On 7/20/23 at 1350 hours, an interview was conducted with the DON. The DON was informed and verified the above findings. The DON stated a safety assessment should be completed before the use of side rails, then the MDS will re-evaluate and complete the assessment quarterly, annually, and as needed. The DON stated an informed consent should be obtained before the use of the side rails. Cross reference to F909, example #9.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure the accurate administration and storage as evidenced by: * The facility failed to ensure the electronic MAR for Resident 636 was not signed prior to the medication administration. * The facility's medication error rate was 3.45%. One of two licensed nurses (LVN 1) who were observed during the medication administration was found to have an error. LVN 1 failed to administer one of Resident 12's medications. * The narcotic medication was not properly stored. These failures had the potential to negatively impact the residents' health outcomes. Findings: 1. On 7/19/23 at 0902 hours, a medication administration observation for Resident 636 was conducted with RN 4. RN 4 prepared and signed the electronic MAR before giving the following medications to Resident 636: - one tablet of aspirin (antiplatelet medication) enteric coated 81 mg - one drop of brimonidine tartate (eye drop used to lower pressure inside the eye) 0.15% to both eyes - one drop of timolol maleate (eye drop used to treat high pressure inside the eye) 0.5% to the left eye - one tablet of benazepril HCL (used to lower blood pressure) 40 mg - one tablet of hydrochlorothiazide (used to reduce the amount of water in the body) 25 mg - 55 units of Lantus Solostar (used to lower blood sugar level) - two tablets of vitamin b-12 (supplement) 500 mcg - one tablet of lovastatin (used to treat high cholesterol) 40 mg - one table of ferrous sulfate (supplement) 325 mg. On 7/19/23 at 0943 hours, an observation and concurrent interview was conducted with RN 4. RN 4 verified he signed for the above medications on the electronic MAR before administering them to Resident 636. RN 4 stated he was supposed to administer the medications first, then sign the electronic MAR. 2. On 7/19/23 at 0823 hours, a medication administration observation for Resident 12 was conducted with LVN 1. LVN 1 administered the following medications to Resident 12: -one tablet of aspirin (antiplatelet medication) enteric coated 81 mg -one capsule of duloxetine HCL DR (antidepressant and nerve pain medication) 60 mg -one tablet of Xifaxan (antibiotic used to prevent reoccurrence of liver problems) 550 mg -one scoop of polyethylene glycol powder (used to treat occasional constipation) 17 g -two patches of lidocaine (pain reliever) 5% to the left and right knees Review of Resident 12's Order Summary Report dated 7/19/23, showed a physician's order dated 6/30/23, for Zyrtec (antihistamine used to treat allergy symptoms such as hives and itching) allergy oral tablet 10 mg one tablet by mouth in the morning for chronic allergy. However, the above medication was not administered to Resident 12 during the medication administration. On 7/19/23 at 1003 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 stated she administered Zyrtec to Resident 12 after the medication administration observation. When asked why she administered the Zyrtec after the observation, LVN 1 stated she could not find the Zyrtec supply in the medication cart. On 7/20/23 at 1350 hours, an interview was conducted with the DON. The DON was informed and verified the above findings. The DON stated the licensed nurses should sign the electronic MAR after administering medications to each resident. The DON stated the licensed nurses should notify the physician when the medication was not available and obtain a physician's order for an available alternative medication. 3. Review of the facility's P&P titled Policy and Procedures for Med Pass Controlled Medication Storage (undated) showed medications listed in Schedules II, III, IV, and V (including refrigerated items) are stored under double lock in a locked cabinet or safe designated for that purpose, separate from all other medications. According to the United States Drug Enforcement Administration (DEA), morphine is categorized as a Schedule II narcotic. The DEA labels Scheduled II drugs as having a high potential for abuse and considered dangerous. On 7/20/23 at 0937 hours, an inspection of IV Cart 1 and concurrent interview was conducted with RN 2. One bottle of liquid morphine sulfate (narcotic pain medication) was observed in the second drawer of IV Cart 1. RN 2 acknowledged the morphine sulfate was for a resident who was scheduled for discharge that day and was not properly stored. RN 2 stated narcotic (substance used to treat moderate to severe pain) medications should be stored in a double locked medication cart. RN 2 verified IV Cart 1 did not have a double lock. On 7/21/23 at 1354 hours, an interview with LVN 2 was conducted. LVN 2 stated the narcotics were stored in the double locked medication carts. LVN 2 verified narcotics could not be stored in IV Cart 1 because IV Cart 1 was not double locked.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility document review, the facility failed to ensure the Pharmacy Consultant's recommendations were acted upon for one of 18 final sampled residents (Resident 33). * The Pharmacy Consultant recommended to verify the diagnosis and behavior for the prescribed risperidone (antipsychotic) medication for Resident 33 was not acted upon. This failure had the potential to put Resident 33 at risk for adverse consequences related to the medication. Findings: Medical record review for Resident 33 was initiated on 7/18/23. Resident 33 was initially admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 33's Order Listing Report showed the following physician's orders dated: - On 5/17/23, to administer risperidone 1 mg every 12 hours for unspecified psychosis manifested by mood swings -On 6/21/23, to administer risperidone 1 mg every 12 hours for schizoaffective disorder manifested by mood swings Review of the Consultant Pharmacist's Medication Regimen Review for Resident 33 dated 5/2/23, showed to verify the diagnosis and behavior for the prescribed risperidone medication for Resident 33. Under the Follow-through column, a handwritten note showed, in H&P per MD. On 7/20/23 at 1502 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above findings. When the DON was asked how the facility informed the prescribing physician about the pharmacy consultant's recommendations, the DON stated they called the prescribing physician to inform of the pharmacy consultant's recommendation. When asked about the pharmacy consultation's recommendation to verify the diagnosis and behavior for the prescribed risperidone medication for Resident 33, the DON reviewed Resident 33's H&P examination and stated the diagnosis was there, but the H&P examination did not mention about the mood swings. The DON could not locate any documentation to show the nurses had verified the behavior manifestation for the risperidone with the attending physician. When asked how soon the facility should follow-up on the pharmacy consultant's recommendations, the DON stated as soon as they received the consultation reports, but they have 30 days to follow-up. The DON verified the pharmacy consultant's recommendation to verify the diagnosis and behavior for the prescribed risperidone medication for Resident 33 was not acted upon. Cross-reference to F758, example #3.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure three of 18 final sampled residents (Residents 16, 33, and 43) was free from unnecessary psychotropic medications. * The facility failed to ensure Resident 16's episodes of behaviors for the use of quetiapine (a medication use to treat symptoms of schizophrenia or bipolar disorder (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) and clonazepam (antianxiety medication) were summarized and made available to the prescriber on a monthly basis to serve as reference for gradual dose reduction. * The facility failed to ensure Resident 43's episodes of behaviors for the use of Cymbalta (medication to treat depression and anxiety), mirtazapine (antidepression medication), and temazepam (medication to treat sleeping problems) were summarized and made available to the prescriber on a monthly basis to serve as reference for gradual dose reduction. * The facility failed to monitor the specific behavior manifestation for Resident 33's use of risperidone. In addition, Resident 33's medical record failed to show monthly psychotropic summaries related to the use of risperidone were completed for March and April 2023. These failures have the potential of not providing the correct data to the prescriber in order to adjust the dose of the psychotropic medications for the residents. Findings: Review of the facility's P&P titled Psychotherapeutic Drug Use- CA revised February 2023 showed a monthly psychotropic summary sheet will be completed to document the behavior manifestations/behavior data will be completed to be use as a guide for potential gradual dose reduction. 1. Medical record review for Resident 16 was initiated on 7/19/23. Resident 16 was readmitted to the facility on [DATE]. Review of Resident 16's Order Summary for June and July 2023 showed the following: -a physician's order dated 4/19/23, to administer quetiapine fumarate 25 mg one-half tablet by mouth at bedtime manifested by auditory hallucinations as evidenced by hearing voices not present related to other schizophrenia. - a physician's order revised 4/19/23, to monitor episodes of psychotic behavior manifested by auditory hallucinations as evidenced by hearing voices not present every shift. - a physician's order dated 5/10/22, to administer clonazepam tablet 1 mg by mouth every 12 hours manifested by verbalization of feeling anxious related to anxiety disorder. - a physician's order dated 5/10/22, to monitor and record number of anxiety behavior manifested by verbalization of feeling anxious every shift. Review of Resident 16's MAR for June and July 2023 showed Resident 16 received quetiapine 25 mg one-half tablet daily at bedtime and clonazepam 1 mg every 12 hours. Review of Resident 16's Psychotropic Summary Sheet for quetiapine and clonazepam failed to show the total number of episodes of behavior and summarized for January, February, and March 2023. On 7/20/23 at 1404 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN verified the above findings. LVN 3 stated she started completing the Psychotropic Summary Sheet forms in April 2023 and was not sure who completed the form before. LVN 3 further stated the data from the residents' Psychotropic Summary Sheet were used in the psychotropic meeting for the psychiatrist to review and to determine if the dosage of the medication should be adjusted. On 7/20/23 at 1446 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified and acknowledged the above findings. The DON stated the RN who used to complete the Psychotropic Summary Sheet had resigned. The DON further stated after the RN resigned, the Psychotropic Summary Sheet was not completed and that was the reason why there were no summary in the Psychotropic Summary Sheet forJanuary, February, and March 2023. 2. Medical record review for Resident 43 was initiated on 7/19/23. Resident 43 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 43's Order Summary for the months of June and July 2023 showed the following: - a physician's order dated 6/24/22, to administer mirtazapine tablet 15 mg by mouth at bedtime manifested by poor oral intake related to major depressive disorder. -a physician's order dated 3/23/22, to monitor and record episodes of depression manifested by poor appetite every meal as evidenced by oral intake less than 50% with meals. - a physician's order revised 4/4/23, to administer Cymbalta capsule delayed release 30 mg by mouth one time a day for pain management. - a physician's order dated 3/23/22, to monitor and record number of depression behavior manifested by verbalization of feeling sad every shift. - a physician's order dated 3/23/33, to administer temazepam capsule 15 mg by mouth at bedtime manifested by inability to sleep related to insomnia. - a physician's order dated 3/23/22, to monitor inability to sleep and record number of hours of sleep every evening and night shift. Review of Resident 43's MAR for June and July 2023, showed Resident 43 received mirtazapine 15 mg daily at bedtime, Cymbalta 30 mg daily, and temazepam 15 mg daily at bedtime. Review of Resident 43's Psychotropic Summary Sheet for medications mirtazapine, Cymbalta, and temazepam failed to show the total number of episodes of behavior and summarized for January, February, and March 2023. On 7/20/23 at 1404 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN verified the above findings. LVN 3 stated she started completing the Psychotropic Summary Sheet forms in April 2023 and was not sure who completed the form before. LVN 3 further stated data from the residents' Psychotropic Summary Sheet were used in the psychotropic meeting for the psychiatrist to review to determine if the dosage of the medication should be adjusted. On 7/20/23 at 1446 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified and acknowledged the above findings. The DON stated the RN who used to complete the Psychotropic Summary Sheet had resigned. The DON further stated after the RN resigned, the Psychotropic Summary Sheet was not completed and that was the reason why there were no summary in the Psychotropic Summary Sheet for January, February, and March 2023. 2. Review of the facility's P&P titled Psychotherapeutic Drug Use - CA revised 2/2023 showed the following: - The licensed nurses shall review the classification of the drug, the appropriateness of the diagnosis, its indication/ behavior monitors and related adverse side effects prior to verification of admission orders with the attending physician; and - A monthly psychotropic summary sheet will be completed to document the behavior manifestations/ behavior data will be completed to be use as a guide for potential gradual dose reduction. Medical record review for Resident 33 was initiated on 7/18/23. Resident 33 was initially admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 33's Order Summary Report dated 3/17/22, showed the following physician's order dated 6/21/23: -To administer risperidone 1 mg two times a day for schizoaffective disorder manifested by mood swings -To monitor episodes of psychotic behavior as evidenced by mood swings every shift, related to the use of risperidone. Review of Resident 33's MAR for July 2023 showed Resident 33 was administered risperidone 1 mg on 7/1 to 7/19/23 at 0900 and 1700 hours. a. Further review of the medical record failed to show documentation of the specific behavior manifestation or failed to specify a behavior considered for mood swing to justify Resident 33's use of risperidone. b. Review of Resident 33's Order Listing Report showed the following previous physician's orders for Resident 33 related to the use of risperidone on: - 3/27/23, to administer risperidone 1 mg at bedtime for unspecified psychosis manifested by mood swings; - 4/12/23, to administer risperidone 1 mg at every 12 hours for unspecified psychosis manifested by mood swings; and - 5/17/23, to administer risperidone 1 mg at bedtime for unspecified psychosis manifested by mood swings Review of the Psychotropic Summary Sheet showed the monthly psychotropic summary related to the use of risperidone was completed for March and April 2023. On 7/20/23 at 0955 hours, an interview was conducted with RN 4. When asked about Resident 33's mood swings, RN 4 stated Resident 33 was monitored for mood changes. When asked to elaborate, RN 4 answered Resident 33 did not have any mood swings or behaviors during his shift. On 7/20/23 at 1007 hours, an interview was conducted with CNA 5. When asked about Resident 33's mood swings, CNA 5 stated sometimes Resident 33 was agitated. On 7/20/23 at 1502 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above findings. The DON was asked how the staff monitored Resident 33's mood swings for the use of risperidone, the DON stated when monitoring for mood swings, the staff monitored for the general manifestations such as when Resident 33 got angry, depressed, or anxious. The DON acknowledged the behavior monitoring should be for a specific behavior. The DON also verified Resident 33's Psychotropic Summary Sheet for risperidone was only completed in May and June 2023. The DON stated the RN who was supposed to complete the monthly behavior summary sheets had resigned and another nurse only started completing it in May 2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to ensure the staff implemented the proper disposal and storage of medications in a safe manner as evidenced by: * The facility failed to ensure the discontinued medications were properly disposed. * The facility failed to ensure the oral and suppository medications were properly stored in the medication cart. * The facility failed to ensure the medication carts were properly locked and secured. Medication Cart 2 was left unlocked and unattended. This had the potential for unauthorized persons to have access to the medications inside the medication cart. These failures had the potential for the drug diversion and to result in an unsafe handling and storage of the residents' medications. Findings: 1. On 7/19/23 at 1207 hours, an observation and concurrent interview was conducted with RN 1 in Medication room [ROOM NUMBER]. One of three waste disposal bins with a blue top was noted with whole pills not fully dissolved. RN 1 acknowledged the waste disposal bin had medications not fully dissolved. On 7/20/23 at 0833 hours, an observation and concurrent interview was conducted with the DON in Medication room [ROOM NUMBER]. The DON verified three unidentified whole medication tablets found in one of three waste disposal bins were not fully dissolved. The DON acknowledged the medications in the waste disposal bin were to be fully diluted to ensure the whole pills were not reused or taken. The DON added more water into the waste disposal bin and stated she would provide an in-service to the nurses. On 7/21/23 at 0914 hours, an interview was conducted RN 2. RN 2 measured the opening of the waste disposal bin at 19 cm by 19 cm and verified not all medication tablets have been dissolved. 2. Review of the facility's P&P titled Policy and Procedures for Med Pass Medication Storage in the Facility - Storage of Medications (undated) showed the orally administered medications are kept separated from the externally used medications, such as suppositories, liquids, and lotions. On 7/20/23 at 1414 hours, an observation and concurrent interview was conducted with RN 3. RN 3 verified one bottle of suppository acetaminophen (pain medication) 650 mg and one bottle of suppository bisacodyl (stool softener) 10 mg were found next to multiple bottles of oral medications in the Medication Cart 1 including one bottle of fish oil (supplement), one box of Salonpas patch (pain medication), one bottle of Tums (antacid), and one bottle of calcium citrate (supplement). RN 3 acknowledged suppositories and oral medications were to be stored separately to prevent cross contamination since oral medications and suppository medications were administered through different routes. RN 3 stated the suppository medications were placed with the oral medications due to an overflow of the medications in the medication cart. 3. On 7/21/23 at 1145 hours, Medication Cart 2 parked in the hallway was observed to be unlocked and unattended. There were two residents noted to be seated in their wheelchairs near the medication cart and facility staff were observed passing by. On 7/21/23 at 1146 hours, when asked who was in charged of Medication Cart 2, LVN 2 was observed walking towards the medication cart. LVN 2 verified he left Medication Cart 2 unlocked and unattended. LVN 2 stated he went to the resident's room because the bed alarm went off and forgot to lock the medication cart.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menu for the pureed garlic bread sticks was followed when the wrong scoop size was used to serve the pureed bread for the residents on pureed diet. This failure had the potential for the residents to not receive adequate nutrition and appropriate servings to meet their individual needs. Findings: Review of the facility's P&P titled Menu Planning dated 2023 showed the menus are planned to meet the nutritional needs of the residents in accordance with the established national guidelines, physician's orders, and, to the extent medically possible, in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council and National Academy of Sciences. Review of the facility's document titled List of Puree Patients on 7/19/23, showed there were nine residents on pureed diet. Review of the facility's menu spreadsheet Cycle 2 2023 for Week 4 dated 7/19/23, for noon meal showed to serve lasagna, California blend vegetable, garlic bread stick, marbled sour cream pound cake with whole milk and water. The menu spreadsheet also showed to serve pureed garlic bread for pureed diets. Review of the facility's recipe for Garlic Bread Stick undated showed for pureed diet, to use the #12 scoop (1/3 cup). On 7/19/23 at 1200 hours, during the trayline observation, the [NAME] was noted to be using #16 scoop (1/4 cup) to serve pureed bread instead of #12 scoop as per the facility's recipe for pureed bread. On 7/19/23 at 1223 hours, an observation, interview, and concurrent traycart inspection was conducted with the Certified Dietary Manager. A traycart was seen near the kitchen door and the Certified Dietary Manager stated the trays in the cart were ready to be delivered to the residents. The Certified Dietary Manager was asked to show the items to be served for the residents on pureed diets. The Certified Dietary Manager showed a tray for Resident 52. The meal ticket for Resident 52 showed the resident was on pureed diet, and the tray showed Resident 52 was served with the pureed bread. When asked about the scoop used for the pureed bread, the Certified Dietary Manager verified the serving scoop size used during the plating was not what was shown on the recipe for the pureed bread. The Certified Dietary Manager acknowledged the [NAME] should have used #12 scoop instead of #16 scoop to serve the pureed bread.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food preferences were followed for one of 18 final sampled residents (Resident 4) and one nonsampled resident (Resident 12) as evidenced by: * Resident 4 disliked broccoli and cauliflower but was served with California vegetable blend with broccoli and cauliflower. * Resident 12 liked a double portion of salad and fruit but was only served a single serving of salad and fruit. These failures had the potential to negatively impact the residents' well-being. Findings: Review of the facility's P&P titled Food Preferences dated 2023 showed the resident's food preferences will be adhered within reason. Substitutes for all foods disliked will be given from the appropriate food group. Review of the facility's menu spreadsheet Cycle 2 2023 for Week 4 dated 7/19/23, for the noon meal showed to serve lasagna, California blend vegetable, garlic bread stick, marbled sour cream pound cake with whole milk, and water. In addition, pureed garlic bread will be served for the residents on pureed diets. On 7/19/23 at 1223 hours, a trayline observation, interview, and concurrent traycart inspection was conducted with the Certified Dietary Manager. A traycart was seen near the kitchen door and the Certified Dietary Manager stated the trays in the cart were ready to be delivered to the residents. Upon inspection of the traycart, the following was observed: - Resident 4's lunch tray contained lasagna, California vegetable blend with cauliflower and broccoli, garlic bread stick, and yellow cake. Resident 4's tray card showed Resident 4 disliked broccoli and cauliflower; - Resident 12's lunch tray contained lasagna, California vegetable blend, garlic bread stick, a bowl of side salad, and a bowl of fresh fruit. Resident 12's tray card showed, double protein, double salads and fruits. The Certified Dietary Manager verified the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to implement the infection control practices designed to provide a safe and sanitary environment; and prevent the transmission of diseases and infections to all residents. * The facility failed to ensure the infection control practices were implemented in the facility's laundry room. * The facility failed to ensure RN 4 provided the sanitary condition during the medication administration. * The facility failed to ensure RN 3 performed hand hygiene during the medication administration. * The facility failed to ensure CNAs 4 and 5 performed hand hygiene when passing the lunch trays and assisting in between the residents. These failures posed the risk for transmission of disease-causing microorganisms. Findings: 1. Review of the facility's P&P titled Laundry Personnel revised 2/2023 showed no personal belongings would be kept in the laundry area. The facility had a designated employee cabinet. Review of the facility's P&P titled Dryer, Lint Trap Cleaning revised 1/2020 showed laundry employee should control accumulations of flammable and combustible waste materials and residue so that they would not contribute to a fire emergency. The Laundry procedures would include a lint trap log record. The laundry employee would record the cleaning and lint trap removal at least every two hours while the dryer is in use. The Maintenance Director should review with each laundry staff upon orientation those parts of the fire prevention plan which include routine cleaning of the dryer and removal of the lint trap. Review of the facility's Daily Cleaning Dry Filters Log failed to show documentation of the staff's initials for 7/20/23. On 7/20/23 at 1004 hours, an inspection of the laundry area and concurrent interview with Housekeeping 1, 2 and the Maintenance Director was conducted. The following was observed: - A pile of lint was discovered in Dryer Machine One's lint trap while it was being used. Housekeeping 1 verified the findings and stated the lint trap of Dryer Machine One was last cleaned at approximately 0830 hours. - A clear bag under the laundry folding table and a water bottle and cellphone by the window near the laundry folding table area were observed. Housekeeping 2 verified the findings and claimed the clear bag, water bottle and cellphone were Housekeeping 2's personal belongings. Housekeeping 2 stated personal belongings should be kept in the employee lockers. The Maintenance Director stated the dryer machines' lint traps should be cleaned every two hours to ensure there were no lint present and documented in the Daily Cleaning Dry Filters Log. The Maintenance Director additionally confirmed personal belongings were not allowed in the laundry room and should be kept in the employee lockers. 2. On 7/19/23 at 0902 hours, a medication administration observation for Resident 636 was conducted with RN 4. RN 4 prepared a total of seven tablets to be administered orally, two medications for eye drop instillation and one subcutaneous (the innermost layer of the skin) injection. RN 4 was observed placing the prepared medications on top of Resident 636's bedside table, next to Resident 636's urine filled urinal. On 07/19/23 at 0949 hours, an interview was conducted with RN 4. RN 4 verified he placed Resident 636's medications next to the resident's urine filled urinal on the bedside table. 3. During the medication administration observation on 7/19/23 at 0836 hours, RN 3 was observed administering the oral medications and eye drop medications without performing hand hygiene between the medication routes. On 7/19/23 at 0852 hours, an interview was conducted with RN 3. RN 3 acknowledged he did not perform hand hygiene between the medication administration of oral medication and eye drop medication. RN 3 stated he was supposed to perform hand hygiene between administering different medication routes. RN 3 stated the importance of hand hygiene between medication routes was to prevent cross-contamination and further infection for the resident. 4. Review of the facility's P&P titled Hand Hygiene revised 10/2022 showed all personnel shall follow the handwashing/ handhygiene procedure to help prevent the spread of infections to other personnel, residents, and visitors. Hand hygiene is a general term that applies to hand washing, antiseptic hand wash, and alcohol-based hand rub. Under the Procedure section, showed to use an alcohol-based hand rub containing at least 62% alcohol, or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: - Before and after direct contact with residents; - After contact with objects in the immediate vicinity of the resident; and - Before and after assisting a resident with meals. a. During the dining observation on 7/18/23 at 1244 hours, CNA 5 was observed with several cloth protectors (garment worn hanging from the neck on the chest to protect clothing from accidentally spilled food) and went to Room E. CNA 5 was observed placing the cloth protector over Resident 50. Without performing hand hygiene, CNA 5 then placed a cloth protector over Resident 58. On 7/18/23 at 1311 hours, an interview was conducted with CNA 5. CNA 5 verified the above findings. CNA 5 acknowledged she did not perform hand hygiene when she placed the clothing protectors in between the residents. b. During the dining observation on 7/18/23 at 1301 hours, CNA 4 was observed assisting Resident 2 to eat. Then without performing hand hygiene, CNA 4 was observed assisting Resident 41 with the lunch tray. On 7/18/23 at 1315 hours, an interview was conducted with CNA 4. CNA 4 verified the above findings. CNA 4 acknowledged he did not perform hand hygiene when he was assisting in between the residents with their lunch trays. On 7/21/23 at 0931 hours, an interview was conducted with the IP. When asked about performing hand hygiene during passing of the meal trays and assisting resident with meal trays, the IP stated the staff should perform hand hygiene in between residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 11. On 7/18/23 at 0842 hours, Resident 13 was observed in his bed with bilateral upper side rails raised. Medical record review of Resident 13 was initiated on 7/20/23. Resident 13 was initially admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 13's Order Summary Report as of 7/19/23 showed a physician's order dated 12/22/22, to provide bilateral half side rails for bed mobility and positioning. 12. On 7/18/23 at 0842 hours, Resident 1 was observed in bed with bilateral upper side rails padded and raised. Medical record review of Resident 1 was initiated on 7/21/23. Resident 1 was initially admitted on [DATE], and readmitted on [DATE]. Review of Resident 1's Order Summary Report as of 7/19/23 showed a physician's order dated 7/26/22, to provide bilateral half padded side rails to minimize injury from physical restlessness in bed. On 07/20/23 at 1035 hours, an interview with RN 4 was conducted. RN 4 stated Resident 13 used the upper bilateral side rails as an enabler. RN 4 stated he was unsure if Resident 1 had the bilateral upper side rails for safety precaution. Review of Residents 1 and 13's Bed System Measurement Device Test Results Worksheet dated 7/17/23, showed Resident 1 and 13's bed assessment passed. However, there was no documented evidence bed entrapment assessments were completed. On 7/19/23 at 1502 hours, an interview with the Maintenance Director was conducted in the activity room. The Maintenance Director verified there were no entrapment assessments completed for Residents 1 and 13's bilateral upper side rails. 9. On 7/18/23 at 0959 hours, 7/19/23 at 1155 hours, and 7/20/23 at 0759 hours, Resident 51 was observed lying in bed with bilateral half side rails elevated. Medical record review for Resident 51 was initiated on 7/18/23. Resident 51 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 51's H&P examination dated 2/10/23, showed Resident 51 did not have the capacity to understand and make decisions. Review of Resident 51's Order Summary Report for the month of July 2023 showed a physician's order dated 2/7/23, may use half bed side rails for positioning and ease in mobility as an enabler. Review of Resident 51's MDS dated [DATE], showed Resident 51 required extensive assistance from one staff for bed mobility. On 7/19/23 at 1156 hours, an interview was conducted with RN 1. RN 1 stated Resident 51 used the bilateral bed side rails as an enabler for bed mobility. On 7/20/23 at 0803 hours, an interview was conducted with CNA 8. CNA 8 stated Resident 51 used the bilateral bed side rails to prevent him from falling. On 7/20/23 at 7/20/23 at 1054 hours, an interview was conducted with RN 3. RN 3 stated Resident 51 used the bilateral bed side rails as an enabler. RN 3 stated Resident 51 was able to hold onto the side rail with his left hand only during turning and repositioning. 10. On 7/18/23 at 0838 hours, and 7/19/23 at 1103 hours, Resident 59 was observed lying in bed with bilateral half side rails elevated. Medical record review for Resident 59 was initiated on 7/18/23. Resident 59 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 59's H&P examination dated 1/25/23, showed Resident 59 had the capacity to understand and make decisions. Review of Resident 59's Order Summary Report for the month of July 2023 showed a physician's order dated 8/3/22, to provide an adjustable bed with bilateral half side rail up for bed mobility and positioning. Review of Resident 59's MDS dated [DATE], showed Resident 59 required extensive assistance from one staff for bed mobility. On 7/19/23 at 1103 hours, an interview was conducted with Resident 59. Resident 59 stated she used the bilateral side rails to help her turn and reposition in bed. Review of the facility's document titled Bed System Measurement Device Test Results Worksheet dated 7/17/23, for Residents 51 and 59, showed Zones 1 to 4 for the upper side rails were marked off as P. However, Zones 6 and 7 were left blank. On 7/19/23 at 1500, an interview and concurrent facility document review was conducted with the Maintenance Director. The Maintenance Director stated P meant pass under the zone boxes in the Bed System Measurement Device Test Results Worksheet. The Maintenance Director stated the nurse would inform him if a resident's bed needed side rails. The Maintenance Director stated he would install the side rails; however, he did not document the measurements or complete an entrapment assessment. 5. On 7/18/23 at 0840 hours and 1355 hours, Resident 77 was observed in bed with bilateral half side rails elevated. Review of Resident 77's recapitulated physician orders showed a physician's order dated 6/13/23, may use half siderails for positioning and ease in mobility as an enabler. Review of Resident 77's LN -Restraint/Enabling Device/Safety Device Evaluation - V2 dated 6/13/23, showed the identified medical condition requiring the enabling device, interventions implemented prior to using the device, benefits and risk of the device. However, further review of Resident 77's medical record failed to show documented evidence an entrapment assessment related to the use of the side rails was completed. 6. On 7/18/23 at 0906 hours and 1500 hours, Resident 62 was observed in bed with bilateral half side rails elevated. Review of Resident 62's recapitulated physician orders showed a physician's order dated 10/12/22, to provide an adjustable bed with bilateral half siderail up for bed mobility and positioning. Review of Resident 62's also had an assessment titled LN -Restraint/Enabling Device/Safety Device Evaluation - V2 dated 4/21/23, showed the identified medical condition requiring the enabling device, interventions implemented prior to using the device, benefits and risk of the device. However, further review of Resident 62's medical record failed to show documented evidence an entrapment assessment related to the use of the side rails was completed. 7. On 7/18/23 at 0917 hours and 1000 hours, Resident 7 was observed in bed with padded bilateral half side rails elevated. Review of Resident 7's recapitulated physician orders showed a physician's order dated 11/14/22, to provide padded bilateral half rails to minimize injury from involuntary movement/seizure . Review of Resident 7's LN -Restraint/Enabling Device/Safety Device Evaluation - V2 dated 5/8/23, showed the identified medical condition requiring the enabling device, interventions implemented prior to using the device, benefits and risk of the device. However, further review of Resident 7's medical record failed to show documented evidence an entrapment assessment related to the use of the side rails was completed. 8. On 7/18/23 at 0928 hours and 1210 hours, Resident 38 was observed up in wheelchair. Resident 38's bed with bilateral half side rails elevated. Review of Resident 38's recapitulated physician orders showed a physician's order dated 1/16/23, to provide an adjustable bed with bilateral half siderail up for bed mobility. Review of Resident 38's LN -Restraint/Enabling Device/Safety Device Evaluation - V2 dated 7/7/23, showed the identified medical condition requiring the enabling device, interventions implemented prior to using the device, benefits and risk of the device. However, further review of Resident 38's medical record failed to show documented evidence an entrapment assessment related to the use of the side rails was completed. On 7/19/23 at 1420 hours, an interview with the Maintenance Director was conducted. The Maintenance Director stated bed entrapment are checked every six months and provided current entrapment assessments for Residents 7, 38, 62, and 77. The Maintenance Director showed the zones on the entrapment assessments; however, the entrapment assessments did not have specific measurements of the gap between the side rails and bed. On 7/19/23 1504 hours, an interview with CNA 7 was conducted. CNA 7 confirmed Residents 77 and 38 had side rails. CNA 7 stated the residents use the side rails to hold onto during repositioning. On 7/19/23 at 1517 hours, an interview with CNA 9 was conducted. CNA 9 confirmed Residents 7 and 62 always had side rails. Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurate, complete; and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of bed side rails for all 80 residents with side rails. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. The seven areas in the bed system where there is a potential for entrapment are: - Zone 1: within the rail; - Zone 2: under the rail, between the rail supports or next to a single rail support; - Zone 3: between the rail and the mattress; - Zone 4: under the rail, at the ends of the rail; - Zone 5: between split bed rails; - Zone 6: between the end of the rail and the side edge of the head or foot board; and - Zone 7: between the head or foot board and the mattress end. Review of the facility's P&P titled Bed Safety Inspection Clinical Guidance revised February 2022 showed to adopt the FDA approved measurement and guidance for the Seven Zones of Bed Entrapment. A concurrent observation, medical record review, and facility document review for Residents 1, 4, 7, 13, 15, 16, 23, 33, 38, 43, 49, 51, 59, 62, 77, 82, and 336 showed the residents' bed entrapment assessments were not accurate or the bed inspection gap measurements were recorded from bed to side rails. For example: 1. On 6/18/23 at 0822 hours and 6/19/23 at 0754 hours, Resident 4 was observed in bed with bilateral half side rails elevated. Medical record review for Resident 4 was initiated on 7/18/23. Resident 4 was readmitted to the facility on [DATE]. Review of Resident 4's H&P examination dated 9/13/22, showed Resident 4 had the capacity to understand and make decisions. Resident 4 had a history of seizures (sudden disruption of the brain's normal electrical activity accompanied by altered consciousness and/or other neurological and behavioral manifestations). Review of Resident 4's Order Summary Report for the months of June and July 2023 showed a physician's order dated 10/20/21, to provide an adjustable bed with half side rails up for bed mobility and positioning and padded side rails on bed secondary to seizure prophylaxis. On 7/18/23 at 0822 hours, an interview was conducted with Resident 4. Resident 4 stated she did not know why she had the bilateral half side rail. On 7/19/23 at 0834 hours, an observation and concurrent interview was conducted with CNA 3. CNA 3 verified Resident 4's bilateral half side rails were up. CNA 3 stated Resident 4 used the bilateral bed side rails to protect her from falling. On 7/19/23 at 1614 hours, an interview was conducted with LVN 4. LVN 4 stated she was not sure why Resident 4's had bilateral bed half side rails and why the side rails were padded. LVN 4 stated Resident 4 did not have any episodes of seizures. 2. On 6/18/23 at 0830 hours and 6/19/23 at 0817 hours. Resident 16 was observed in bed with bilateral half side rails elevated. Medical record review for Resident 16 was initiated on 7/19/23. Resident 16 was readmitted to the facility on [DATE]. Review of Resident 16's MDS dated [DATE], showed Resident 16's BIMS score was 14 which indicated Resident 16 was cognitively intact. Review of Resident 16's Order Summary Report for June and July 2023 showed a physician's order dated 5/9/22, to provide an adjustable bed with bilateral half side rail up for bed mobility and positioning. On 7/19/23 at 0817 hours, an interview was conducted with Resident 16. Resident 16 stated she used the bilateral half side rails to help her move from side to side due to her bilateral legs being weak. On 7/19/23 at 0842 hours, an interview was conducted with CNA 3. CNA 3 stated Resident 16 used the side rails to help her feel secure when turning from side to side in the bed. On 7/19/23 at 1607 hours, an observation and concurrent interview was conducted with LVN 4. LVN 4 stated Resident 16 used her bed side rails for safety. 3. On 6/18/23 at 0840 hours, Resident 23 was observed in bed with bilateral half side rails elevated. Medical record review for Resident 23 was initiated on 7/19/23. Resident 23 was readmitted to the facility on [DATE]. Review of Resident 23's MDS dated [DATE], showed Resident 23 had severely impaired cognition. Review of Resident 23's Order Summary Report for the months of June and July 2023 showed a physician's order dated 6/12/23, may use half bed side rails for positioning and ease in mobility as an enabler. On 7/9/23 at 0850 hours, an interview was conducted with CNA 3. CNA 3 stated Resident 23 used the bilateral bed side rails for fall safety. On 7/19/23 at 1626 hours, an observation and concurrent interview was conducted with LVN 4. LVN 4 verified Resident 23 had bilateral half side rails up in bed. LVN 4 stated Resident 23 used the bilateral half side rails in bed for safety reasons. 4. On 6/18/23 at 0930 hours and 6/19/23 at 0856 hours, Resident 43 was observed in bed with bilateral bed half padded side rails elevated. Medical record review for Resident 43 was initiated on 7/19/23. Resident 43 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 43's MDS dated [DATE], showed Resident 43 had severely impaired cognition. Review of Resident 43's Order Summary Report for the months of June and July 2023 showed a physician's order dated 3/23/22, to provide an adjustable bed with bilateral half side rail up for bed mobility and positioning. On 7/19/23 at 1047 hours, an observation and concurrent interview was conducted with LVN 2. LVN 2 verified Resident 43 had bilateral half bed side rails up. LVN 2 stated Resident 43 used the bed side rails for fall prevention. On 7/19/23 at 1226 hours, an interview was conducted with the Maintenance Director. The Maintenance Director stated only two beds in the facility did not have side rails. The Maintenance Director stated they had a new measuring tool for the bed entrapment that the facility started in the last two or three weeks ago. The Maintenance Director illustrated how he would inspect the bed side rails for entrapment by placing the cylinder measuring tool on the side of the bed facing down, arm in a certain position, and openings in between the rails and the side of the bed. The Maintenance Director further stated the cylinder measuring tool should not go through any of the gaps to make sure there was no risk of entrapment for the residents. On 7/19/23 at 1414 hours, a follow-up interview and concurrent facility document review was conducted with the Maintenance Director. The Maintenance Director provided his bed inspection and entrapment log binder. The Maintenance Director stated there were no measurements documented in the Bed System Measurement Device Test Result Worksheet forms because all the beds and side rails were standard and had the same measurements. The Maintenance Director described the different zones in the document and stated the measurements should be less than four and ¾ inches on all the zones. The Maintenance Director verified Resident 43's Bed System Measurement Device Test Result Worksheet form was missing from his log binder for 7/17/23. The Maintenance Director stated he left the form in his office. However, after the Maintenance Director looked for the form in his office and the DON's office, he was unable to locate the form. On 7/19/23 at 1451 hours, the Maintenance Staff provided Resident 43's Bed System Measurement Device Test Result Worksheet dated 7/17/23. Review of Resident 43's Bed System Measurement Device Test Result Worksheet showed an F in Zone 4. On 7/19/23 at 1500, another follow-up interview and concurrent facility document review was conducted with the Maintenance Director. The Maintenance Director stated P meant pass and F meant fail under the zone boxes in the Bed System Measurement Device Test Result Worksheet form. The Maintenance Director was shown Resident 43's form had a F in zone 4, and he stated he made a mistake when he was filling out the form. When asked to provide the previous entrapment assessment for the residents with side rails, the Maintenance Director stated he did not have any of the forms. The Maintenance Director further stated the nurses would tell him if a resident's bed required side rails and he will just install the side rails; however, he would not measure nor completed an entrapment assessment. 13. Medical record review for Resident 336 was initiated on 7/20/23. Resident 336 was admitted to the facility on [DATE]. On 7/18/23 at 1036 hours, Resident 336 was observed in bed with upper side rails up on both sides of the bed. Review of the Order Summary report as of 7/19/23, showed a physician's order dated 7/12/23, to use half side rails for positioning and ease in mobility as an enabler. Review of the Restraint/Enabling Device/Safety Device Evaluation dated 7/12/23, showed Resident 336 assessment for the use of the side rails as an enabler in bed. However, there was no documented evidence the entrapment assessment was completed for the use of side rails. On 7/19/23 at 1028 hours, an interview was conducted for Resident 336 with CNA 7. CNA 7 stated Resident 336 needed total assistance repositioning in bed. CNA 7 stated Resident 336 was able to grab and hold the side rails during care. CNA 7 stated Resident 336 was unable to reposition herself in bed. On 7/19/23 at 1415 hours, an interview and concurrent facility record review for Resident 336 was conducted with the Maintenance Director. The Maintenance Director was able to show the facility's maintenance log for the beds. The Maintenance Director was able to show the most current entrapment assessment. When asked for the measurement on each bed gap between the mattress and the side rails, the Maintenance Director was able to show the zones but there was no specific measurement taken from the bed. 14. Medical record review for Resident 15 was initiated on 7/20/23. Resident 15 was admitted to the facility on [DATE]. On 7/18/23 at 0950 hours and on 7/19/23 at 0942 hours, an observation and concurrent interview was conducted with Resident 15. Resident 15 was observed in bed with upper side rails elevated and on LAL (Low Air loss) mattress. Resident 15 stated she was able to turn and reposition herself in bed. Review of the Order Summary Report as of 7/20/23, showed a physician's order dated 3/5/23, for Resident 15 to provide LAL mattress. On 7/19/23 at 1226 hours, an interview and concurrent facility record review for Resident 15 was conducted with the Maintenance Director. The Maintenance Director stated there was a measuring tool used on checking the entrapment of the side rails and the mattress. The Maintenance Director stated the facility was utilizing the same bed mattresses and were able to measure and assess for entrapment except for the residents using LAL mattress. The Maintenance Director acknowledged and verified there was no entrapment assessment for Resident 15. 15. On 7/18/23 at 0912 and 1232 hours, 7/19/23 at 0904 and 0921 hours, and 7/20/23 at 0806 hours, Resident 82 was observed in bed with bilateral side rails elevated. Medical record review for Resident 82 was initiated on 7/18/23. Resident 82 was admitted to the facility on [DATE]. Review of Resident 82's MDS dated [DATE], showed Resident 82 had severe cognitive impairment and required extensive assistance of one staff for bed mobility. Review of Resident 82's Order Summary Report showed a physician's order dated 6/16/23, for bilateral half side rails as enabler for bed mobility. Review of Resident 82's LN-Restraint/ Enabling Device/ Safety Device Evaluations - V 2 dated 6/16/23, showed the side rails enabled the resident to maintain proper body positioning/ alignment and bed mobility. However, the evaluation did not include an entrapment assessment. Further review of Resident 82's medical record failed to show documented evidence an entrapment assessment related to the use of the side rails was completed . 16. On 7/18/23 at 0858 hours, 7/19/23 at 0916 hours, and 7/20/23 at 0808 hours, Resident 49 was observed in bed with bilateral side rails elevated. Resident 49 stated she sometimes used the side rails and wanted to have bed side rails. Medical record review for Resident 49 was initiated on 7/18/23. Resident 49 was admitted to the facility on [DATE]. Review of Resident 49's MDS dated [DATE], showed Resident 49 had moderate cognitive impairment and required extensive assistance of two staff for bed mobility. Review of Resident 49's Order Summary Report showed a physician's order dated 9/9/21, for an adjustable bed with bilateral half side rails up for bed mobility and positioning. Review of Resident 49's LN-Restraint/ Enabling Device/ Safety Device Evaluations - V 2 dated 6/16/23, showed the side rails potentially protected resident from injury, enabled resident to maintain proper body positioning/alignment and bed mobility, and potentially prevented resident from rolling out of bed. However, the evaluation did not include an entrapment assessment. Further review of Resident 49's medical record failed to show documented evidence an entrapment assessment related to the use of the side rails was completed. 17. On 7/18/23 at 1530 hours, 7/18/23 at 0917 hours, and 7/20/23 at 0932hours, Resident 33 was observed asleep in bed with bilateral side rails elevated. Medical record review for Resident 33 was initiated on 7/18/23. Resident 33 was readmitted to the facility on [DATE]. Review of Resident 33's MDS dated [DATE], showed Resident 49 had moderate cognitive impairment and required extensive assistance of two staff for bed mobility. Review of Resident 33's Order Summary Report showed a physician's order dated 6/21/23, for bilateral half side rails for positioning and ease in mobility as an enabler. Review of Resident 33's LN-Restraint/ Enabling Device/ Safety Device Evaluations - V 2 dated 6/16/23, showed the side rails enabled resident to maintain proper body positioning/ alignment and bed mobility, and increased sense of safety/ security per resident request. However, the evaluation did not include an entrapment assessment. Further review of Resident 33's medical record failed to show documented evidence an entrapment assessment related to the use of the side rails was completed. On 7/19/23 at 1443 hours, an interview and concurrent facility document review was conducted with the Maintenance Director. The Maintenance Director verified the above findings. When asked about the bed inspection process, the Maintenance Director stated he checked the beds monthly and as needed. The Maintenance Director stated he checked the functionality of the bed, the remote control, bed brakes, the foot board, the headboard, the wirings, and the different zones of possible entrapment, to which he showed a documentation. The Maintenance Director stated he used a triangular cylinder shape measuring device which showed measurement of four and ¾ inches on the side of the circumference and made sure the measuring device did not go through the gaps in between the bed and the side rails. When asked if he inspected the bed when there was a change of bed or mattress such as a low air loss mattress, the Maintenance Director stated he did the measurements but did not document. Review of the facility's document titled Bed System Measurement Device Test Results Worksheets dated 7/17/23, for Residents 33, 49, and 82, showed Zones 1 to 4 for the upper side rails were marked as P or pass; however, Zones 6 and 7 were not checked. The Maintenance Director verified the above findings. The Maintenance Director stated he did not document the measurements for Zones 1 to 4, because they used the same standard bedframe and standard mattress. The Maintenance Director stated he did not check the gaps between the end of the rail and the side edge of the head or foot board (Zone 6) and between the head or foot board and the mattress end (Zone 7) because the bed was fixed, and the facility used the same standard bedframe and standard mattress. The Maintenance Director verified there were no entrapment assessment for Residents 33, 49, and 82 related to the use of side rails. Review of the facility's document titled Bed/ Mattress/ Side Rail Maintenance Log showed the following: - The measurement of a standard bed frame size was 80 inches, the standard mattress length was 80 inches, the width was 34.5 inches, and the height/ thickness was six inches. - The different type/size of siderails and the different zones, the measurements for Zones 1 to 4, Zone 5 was marked N/A, and Zones 6 and 7 were blank. - Under the section Monthly Maintenance Checks, Rooms A, B, C, and D were documented as meet or m in January, April, July; while the remainder of the rooms were documented as meet or m in April, May, June. - In addition, the log showed Rooms F and G were documented as big boy in April. The Maintenance Director verified the above findings. The Maintenance Director stated he documented meet or m when the bed met the measurements required for each zone of possible areas of entrapment. The Maintenance Director stated he inspected the beds monthly, and it was his mistake when he documented Rooms A, B, C, and D were inspected on January, April, and July. When asked about Rooms F and G documented as big boy in April, the Maintenance Director stated these were the bariatric beds (a specialized bed made specifically to accommodate larger and heavier patients). The Maintenance Director verified he used the same log using the sizes of a standard bedframe, length, width and height for a bariatric bed. On 7/19/23 at 1600 hours, a follow-up interview was conducted with the Maintenance Director. The Maintenance Director stated he should have documented the correct measurements of the bariatric bed, the bed frame size should be 82 inches, the bariatric mattress length should be 82 inches, the width should be 42 inches, and height/thickness was six inches. On 7/21/23 at 1321 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above findings. When asked about the side rails, the DON stated there should be a physician's order, a consent, a care plan and an assessment in order for a resident to have side rails. When asked about the assessment, the DON stated the assessment included informed consent, the alternative or non-restrictive approach prior to using the side rails, and the reason why the resident used or needed the side rails. When asked about the entrapment assessment, the DON stated the side rails assessment done by the nursing did not include the entrapment assessment; however, the Maintenance Director was responsible in installing the side rails and doing the entrapment assessment.

Based on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the proper labeling and dating of the foods in the kitchen was utilized once the food item was opened. * The facility failed to ensure the ice machine's ice maker was free from black residue. * The facility failed to ensure the quaternary sanitizing strips to measure the concentration of ammonium compound the sanitizing solution for the manual ware washing and sanitization buckets were not expired. * The facility failed to ensure the kitchen equipment was clean. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared from the kitchen. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility on 7/18/23, showed 78 of 82 residents in the facility received food prepared in the kitchen. 1. Review of the facility's P&P titled Storage of Food and Supplies dated 2023 showed the Food should be arranged in food groups to facilitate storing, locating, and taking inventories. Labels should be visible and the arrangement should permit rotation of supplies so that oldest items will be used first. All food will be dated - month, day, year. No food will be kept longer than the expiration date on the product. Dry food items which have been opened will be tightly closed, labeled and dated; and bread will be delivered frequently and used in the order that it is delivered to assure freshness. Bread products not used within five days can be frozen. Some breads do last five to seven days. a. On 7/18/23 at 0747 hours, during the initial tour of the kitchen, two bags containing white bread and a bag containing English muffins were observed opened with no opened date and no use-by date. The Certified Dietary Manager verified the findings and stated the food items should have been properly labeled and dated with the opened and use-by date. b. On 7/18/23 at 0748 hours, an observation of the walk-in refrigerator in the kitchen was conducted with the Certified Dietary Manager and the following was identified: - A container of tuna salad was noted to be opened with a use-by date of 7/15/23; - A container of cheese was opened with a delivery date of 4/14/23, but no opened and use-by dates; and - Containers of margarine and mayonnaise were noted to be opened with no opened and use-by dates. The Certified Dietary Manager verified the above findings. 2. Review of the facility's P&P titled Ice Storage Compartment and Ice Machines revised 2/2023 showed it is the policy of this facility to assure resident safety in the use of the ice machines. The following procedures should be followed to reduce the likelihood of contamination of ice chest (ice storage compartment) and ice machines: ice storage compartment (monthly cleaning and sanitizing); and ice machine (semi-annual, twice per year, and sanitizing procedures). Review of the facility's document titled Service Visit Record for Ice Machine Cleaning dated 7/18/23, showed the ice machine was visually inspected and has completed the three-month service which included inside cleaning and sanitizing filter. On 7/19/23 at 1126 hours, an ice machine inspection and concurrent interview and facility document review was conducted with the Maintenance Supervisor. A blackish substance was observed on the ice catch basin and steel panel inside the ice machine. The Maintenance Supervisor stated the blackish substance on the inside of the ice machine could not be removed, as he just deep cleaned the ice machine yesterday 7/18/23; and the Maintenance Supervisor showed the ice machine cleaning log. The ice catch basin and steel panel was wiped with a white paper towel, and a black residue was observed on the paper towel. The Maintenance Supervisor verified the above finding. 3. According to the USDA Food Code 2022, 4-301.12, Manual Ware Washing, the three- compartment requirement allows for the proper execution of the three-step manual ware washing procedure. If properly used, the three compartments reduce the chances of contaminating the sanitizing water and therefore diluting the strength and efficacy of the chemical sanitizer that may be used. Alternative manual ware washing equipment, allowed under certain circumstances and conditions, must provide for accomplishment of the same three steps: application of cleaners and the removal of soil, removal of any abrasive and removal or dilution of cleaning chemicals, and sanitization. Review of the manufacturer's Safety Information on the pH Test Papers (undated) showed the pH test papers are marked with an expiration date and will perform as designed until that date as long as stored in a dry area and protected from sunlight. Review of the facility's document titled 2-Compartment Sink Log showed the chemical sanitization was checked from May to July 2023. Review of the facility's document titled Red Bucket Sanitation Log showed the quaternary sanitizer solution was checked from May to July 2023. a. On 7/21/23 at 1040 hours, an observation and concurrent interview was conducted with the Dietary Aide. When asked about the manual washing, the Dietary Aide stated he used the dishwasher and also did manual dishwashing. When asked to check the sanitizer solution, the Dietary Aide was observed checking the concentration of the sanitizer using a piece of quaternary sanitizer strip. The Dietary Aide stated he had been using the quaternary sanitizer strip from the container since May 2023. The quaternary sanitizer strip container had an expiration date of 5/15/23. The Dietary Aide verified the quaternary sanitizer strip was expired. b. On 7/21/23 at 1100 hours, an observation and concurrent interview was conducted with the Cook. When asked about the quaternary sanitizer bucket (red sanitizing bucket), the [NAME] stated he used the quaternary sanitizer solution using the same quaternary sanitizer strip used by the Dietary Aide. The [NAME] verified the quartenary test strip had expired. The Certified Dietary Manager verified the above findings. When asked for another quaternary sanitizer strip, the Certified Dietary Manager stated he would have to order a new one. 4. According to the USDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the USDA Food Code 2017, 4-602.13, Non- Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. a. On 7/21/23 at 1101 hours, an observation and concurrent interview was conducted with the Cook. When asked about the microwave in the kitchen, the [NAME] stated the microwave was used to warm up the resident's food. The [NAME] stated he cleaned the microwave every after trayline service. However, the microwave was noted with food debris. The [NAME] and Certified Dietary Manager verified the finding. b. On 7/21/23 at 1102 hours, an observation and concurrent interview was conducted with the Certified Dietary Manager. A meat slicer was noted wrapped with a plastic cover. When asked about the meat slicer, the Certified Dietary Manager stated they used the meat slicer. The Certified Dietary Manager was asked to remove the plastic cover, and the meat slicer was observed to have food debris near the blade. The Certified Dietary Manager was observed taking the meat slicer apart and cleaning the meat slicer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility document review, the facility failed to provide the necessary care and services to ensure one of three sampled residents (Resident 1) was free from accident hazards. * Resident 1 was admitted to the facility on [DATE], after an ORIF left proximal humerus surgery on 4/27/23. Resident 1 had an order for NWB (non-weight bearing) on the left upper extremity and to wear the left arm sling at all times. Resident 1 had episodes of removing the left arm sling. However, there was no documented evidence the use of left arm sling was monitored from 5/9-5/21/23. There was no documented evidence of the physician notification regarding Resident 1's noncompliance with the use of arm sling. Resident 1 had an unwitnessed fall from the bed on 5/11/23. Family Member 1 stated the follow-up x-ray on 5/19/23, showed the re-fracture of the left shoulder and the resident required to have another surgery. This failure created the risk for poor health outcomes to Resident 1. Findings: Review of the facility's P&P titled Fall Management Systems (undated) showed the facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible. Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision, assistive devices and functional programs as appropriate to prevent accidents. Residents with a Fall Risk Evaluation that are considered high risk will have an individualized care plan developed that includes measurable objectives and timeframes. The care plan interventions will be developed to prevent falls and will consider the particular elements of the assessment that put the resident at risk. 1. On 7/6/23 at 1355 hours, a telephone interview was conducted with Family Member 1 to inquire about a complaint filed in July 2023. Resident 1 had the left shoulder surgery from a fall which occurred at home. Family Member 1 stated Resident 1 was admitted to the facility for rehabilitation and was able to walk with assistance. Family member 1 stated usually, one family member stayed with Resident 1 from 1000 to 1800 or 1900 hours. Family Member 1 stated Resident 1 had fell out of bed when a family member left the faciity on 5/11/23, and the family member was told Resident 1 was okay. On 5/19/23, Resident 1 went to acute care hospital for an x-ray and had a follow up post-surgery appointment. Family Member 1 was shown Resident 1's x-ray result with the left shoulder re-fracture from the fall and was informed Resident 1 would need another surgery. Resident 1 was prepared for the left shoulder surgery on 5/25/23; however, his heart rhythm was began having atrial fibrillation, and he had difficulty breathing. Resident 1 was sent to the acute care hospital emergency department and passed away a few days later. Closed medical record review for Resident 1 was initiated on 7/6/23. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's History and Physical Examination dated 4/26/23, showed Resident 1 sustained a fall with the left proximal humerus (upper arm long bone) fracture and had an ORIF left proximal humerus surgery on 4/27/23. Review of Resident 1's plan of care showed a care plan problem dated 5/9/23, to address Resident 1's high risk for falls related to confusion, deconditioning, gait/balance problem, poor communication/comprehension, unawareness of safety needs, hearing problem, post fall with left humerus surgery. The initial interventions included to anticipate and meet needs, be sure call light within reach and encourage calling for assistance as needed, and place the bed in the lowest position. Review of Resident 1's Fall Risk assessment dated [DATE], showed Resident 1 was at high risk for falls and had one or two falls in the past 90 days. Review of Resident 1's SBAR Communication Form dated 5/11/23 at 2015 hours, showed Resident 1 had an unwitnessed fall at 1915 hours. Resident 1 was found lying on the right side of the bed. Resident 1 stated he wanted to go home and tried to get up and slipped out from the bed. Resident 1 was assessed, denied pain or hitting his head, and had no bleeding, bruises, or open wounds. The nurse practitioner was notified with no new order. The family member was notified and requested the facility to give Resident 1 Tylenol 650 mg. Review of Resident 1's MDS dated [DATE], showed Resident 1 had severe cognitive impairment, and required one person's extensive assistance for bed mobility and transfers. Review of Resident 1's MAR in May 2023 showed the following physician's orders: - dated 5/8/23, for hydrocodone acetaminophen 5-325 mg one tablet by mouth every eight hours as needed for pain management and was discontinued on 5/12/23. - dated 5/13/23, for hydrocodone acetaminophen 5-325 mg one tablet by mouth every four hours as needed for moderate pain management. - dated 5/13/23, for hydrocodone acetaminophen 5-325 mg two tablets by mouth every four hours as needed for severe pain management. On 7/6/23 at 1120 hours, an interview and closed medical record review were conducted with LVN 1. LVN 1 stated a CNA notified her that Resident 1 was on the floor. LVN 1 went to Resident 1's room around 1915 hours (on 5/11/23). Resident 1 was on the floor, lying on his back on the right side of his bed. Resident 1 had the left arm sling on. Resident 1 was asked if he hit his head or left shoulder. Resident 1 said no. Resident 1 denied pain and had no injury. LVN 1 stated Resident 1's family member was notified and wanted to give him Tylenol for pain. The nurse practitioner was notified with the order for monitoring the resident and neuro checks, but no order for the x-ray of Resident 1's left shoulder. LVN 1 stated Resident 1 could not walk, tried to get out of bed, and was incontinent and confused. The family member usually was there until 1900 hours, but the family member went home earlier on that day. LVN 1 stated she last saw Resident 1 in bed round 1840 to 1845 pm. On 7/10/23 at 1500 hours, a telephone interview was conducted with LVN 2 about Resident 1. LVN 2 stated Resident 1 tried to get out of bed a few times when Resident 1 was admitted . The family was there with him, but not all the time. LVN 1 was asked about why Resident 1's pain medication was increased in frequency on 5/13/23. LVN 1 stated Resident 1 seemed to be in distress, had more pain from the left arm injury site. The family member asked to increase the pain medication. LVN 1 stated Resident 1 was confused, tried to move but he could not move much, and stayed in bed all the time. When asked if Resident 1 had any change in condition, LVN 2 stated he was not aware of the resident having any change in condition. On 7/10/23 at 1520 hours, a telephone interview was conducted with CNA 1. CNA 1 stated she changed Resident 1 around 1800 hours, while the family member was there. CNA 1 stated she took her break at 1900 to 1930 hours when Resident 1 was found on the floor. CNA 1 was asked if Resident 1 tried to get out of bed. CNA 1 stated Resident 1 was confused, tried to get out of bed and move his leg off the bed. CNA 1 stated she put Resident 1 in the middle of the bed with pillows on both sides for comfort and not sliding out of bed. CNA 1 adjusted the bed to the low position. The bed was a little high when Resident 1 fell, no floor mat on both side of the resident's bed when Resident 1 fell. 2. Review of Resident 1's Order Summary Report showed the following physician's orders: - dated 5/8/23, for NWB (non-weight bearing) on the left upper extremity. - dated 5/9/23, for wearing the left arm sling at all times, may remove on shower days and during patient care. Review of Resident 1's Progress Note date 5/9/23 at 0222 hours, showed Resident 1 had the left shoulder sling (immobilizer) in place with episodes of removing it. Resident 1 was difficult to redirect at times. Review of Resident 1's MAR failed to show the physician's order for NWB on the left upper extremity was monitored by the nursing staff and failed to show Resident 1's usage of arm sling was monitored from 5/9 to 5/21/23. Review of Resident 1's OT Notes dated 5/9/23 at 1549 hours, showed Resident 1 was found with arm sling removed. Review of Resident 1's OT Notes dated 5/16/23 at 1401 hours, showed Resident 1 had poor overall safety awareness with poor carryover. Resident 1 was found in bed without the arm sling on. Review of Resident 1's Orthopedic Progress Note dated 5/19/23 at 1211 hours, showed Resident 1 came to the orthopedic office following the ORIF of the left proximal humerus. According to the family member, Resident 1 fell on his arm in the facility a week ago, and Resident 1 was now coming in for the follow-up with the physician. The x-ray of Resident 1's left shoulder demonstrated displacement of the fracture with extension of the fracture down the humerus which required a revision ORIF of the left proximal humerus. Review of Resident 1's care plan updated 5/22/23, showed the care plan problem addressing Resident 1's noncompliance with wearing the left arm sling. On 7/10/23 at 1500 hours, a telephone interview was conducted with LVN 2. During an interview, LVN 2 confirmed Resident 1 took off his left arm sling and had told the family member to tell Resident 1 not to take off his arm sling. On 7/11/23 at 1106 hours, a telephone interview was conducted with Family Member 1. Family Member 1 stated he found Resident 1 sliding to the right side of the resident's bed and was not wearing the arm sling during his visit. Family Member 1 stated Resident 1 did not wear the arm sling for a few days. When asked about the resident's pain on the left arm, Family Member 1 stated the next day after Resident 1 fell, Resident 1 had more pain, and the pain medication was increased. On 7/11/23 at 1324 hours, a follow-up interview and concurrent closed medical record review was conducted with LVN 1. LVN 1 stated Resident 1 spoke foreign language, was alert, confused and hard of hearing. LVN 1 was asked if Resident 1 tried to get out of bed by himself. LVN 1 stated Resident 1 tried to get out of bed at least three to five times a shift. LVN 1 stated the nurse did frequent visual check once every 30 minutes. When asked if Resident 1 removed his left arm sling. LVN 1 stated Resident 1 took off his arm sling five times a day and did not refuse when the nurse put the left arm sling back on. LVN 1 was asked if the nurses notified the physician when Resident 1 tried to get out of bed and took off his left arm sling. LVN 1 stated she was not sure. On 7/11/23 at 1420 hours, an interview and record review were conducted with LVN 3. LVN 3 stated she helped put in the physician's order, report the resident's change of condition, and notify the laboratory results to the physician. LVN 3 stated the physician's order for Resident 1's NWB to the left arm and to wear the left arm sling at all times were not shown in the MAR for the nurse staff to monitor, but the orders were shown for the physical therapy. LVN 1 stated the nurse should see the physician's orders, and the physical therapist should question if the Resident 1 did not wear the left arm sling. LVN 1 verified no documented evidence showed Resident 1's removal of the left arm sling was reported to the physician. On 7/11/23 at 1518 hours, an interview and closed medical record review were conducted with the OT. The OT stated the left arm sling was on and off the resident's left arm. Sometimes, Resident 1 was not wearing the left arm sling in the morning, and the OT put it back on. Resident 1 would let the staff put his arm sling on. The OT stated he informed the nursing staff and educated the family to keep the arm sling on. On 7/11/23 at 1550 hours, an interview was conducted with the DON. The DON verified the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview,medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) and six nonsampled residents (Residents A, B, C, D, E, and F) had the rights to receive reasonable accommodation of needs and preferences. * The facility failed to ensure Residents 1, A, B, C, D, E and F's call lights were answered in a timely manner. This failure had the potential to negatively impact the residents' well-being. Findings: Review of the facility's P&P titled Call lights/Bell dated 5/2007 showed to answer the light or bell within reasonable time. 1. Medical record review for Resident 1 was initiated on 5/22/23. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's H&P examination dated 5/19/23, showed Resident 1 had the capacity to understand and make decisions. On 5/22/23 at 1015 hours, a concurrent observation and interview was conducted with Resident 1. Resident 1 was observed lying in bed. Resident 1 expressed the concern regarding the call light response at nighttime. Resident 1 stated on the night when she fell, she pressed the call light and waited more than 30 minutes. Resident 1 statedno one came so she got up on her own to go to the restroom because she could not hold it anymore. Resident 1 further stated sometimes at night, she needed assistance and had waited more than 30 minutes for toileting assistance. She had informed acouple staff about it. On 5/22/23 at 1130 hours, an interview was conducted with LVN 1. LVN 1 was asked if Resident 1 had expressed any concerns regarding the call light. LVN 1 stated Resident 1 had complained about waiting a long time for her call light at night shift. LVN 1 stated she informed the DSD. On 5/22/23 at 1200 hours, an interview was conducted with CNA 1. CNA 1 was asked if Resident 1 had expressed any concerns regarding the call light. CNA 1 stated Resident 1 told her that the night staff took a longer time to help her. On 5/22/23 at 1500 hours, an interview was conducted with the DSD. The DSD stated they were in the process of hiring more staff and asking the other shift staff to work on the night shifts. The DSD was not aware of Resident 1's concerns about the call light. On 5/23/23 at 1230 hours, an interview was conducted with CNA 2. CNA 2 stated it was challenging to answer the call lights if the residents called at the same time. CNA 2 could not help them right away. 2. Medical Record review for Resident A was initiated on 5/22/23. Resident A was admitted on the facility on 4/19/18. On 5/22/23 at 1050 hours, a concurrent observation and interview was conducted with Resident A. Resident A was sitting up in bed. Resident A stated sometimes, the night staff took 35 to 45 minutes to attend to the residents. Resident A asked her night shift CNA and was told they had to help around 18 to 20 residents. They werefriendly to her but so busy. 3. Medical record review for Resident B was initiated on 5/22/23. Resident B was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident B's H&P examination dated 9/13/22, showed Resident B had the capacity to understand and make decisions. On 5/22/23 at 1030 hours, a concurrent observation and interview was conducted with Resident B. Resident B was sitting up in the wheelchair. Resident B stated she felt upset that she had to wait more than 45 minutes to get help for a change of diaper at nighttime. The staff was nice to her but so busy to help other residents. 4. Medical record review for Resident C was initiated on 5/22/23. Resident C was admitted to the facility on [DATE]. Review of Resident C's H&P examination dated 10/21/22 showed Resident [NAME] the capacity to understand and make decisions. On 5/22/23 at 1030 hours, a concurrent observation and interview was conducted with Resident C. Resident C was sitting up in wheelchair. Resident C stated she felt upset that she had to wait more than 30 minutes for a change of diaper. They turned off the call light, and it took a long time to get help. The CNAs were trying their best to help but worked so hard to help a lot of residents. They needed more staff. 5. Medical record review for Resident D was initiated on 5/22/23. Resident D was admitted to the facility on [DATE] Review of Resident D's H&P examination dated 9/8/24, showed Resident D had the capacity to understand and make decisions. On 5/22/23 at 1015 hours, a concurrent observation and interview was conducted with Resident D. Resident D was observed lying in her bed. Resident D stated she hadto wait for more than 45 minutes to get assistance. The staff answered the call light in 10 minutes but turned it off, then would get someone to help, but it took a long time. Resident D stated a couple of times during the night shift, Resident D had a bowel movement and waited one hour for diaper change. Resident D felt frustrated about it. Resident D asked staff why it took a long time and was told that they were short staffed. 6. Medical record Review for Resident E was initiated on 5/23/23. Resident E was admitted to the facility on [DATE], and readmitted on [DATE]. On 5/23/23 at 1500 hours, an interview was conducted with Resident E. Resident E stated she had concerns with the night shift. There was a time when shehad to wait 30 minutes when she had bowel movement and waiting for diaper change in the morning. She could not hold it anymore and laid soiled with feces. Resident E verified she looked at the clock on the wall to check how long the staff took to answer the call light. 7. Medical record Review for Resident F was initiated on 5/22/23. Resident F was admitted to the facility on [DATE]. On 5/22/23 at 1030 hours, a concurrent observation and interview was conducted with Resident F. Resident F was sitting up in bed. There was an occasion during the night shift that Resident F had to wait 45 minutes to one hour for a blanket, and the room temperature was very cold. The staff tried their best. They workedhard but needed more people to help them out.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to protect one of two sampled resident's (Resident 1) rights to be free from physical abuse by another resident (Resident 2). This had the potential for Resident 1 to be injured or have psychosocial harm. Findings: Review of the SOC 341 Report of Suspected Dependent Adult/Elder Abuse dated 3/21/23, showed Resident 2 yelled at and punched Resident 1 on the face. a. Closed medical record review for Resident 1 was initiated on 4/18/23. Resident 1 was admitted to the facility on [DATE] and was discharged on 4/6/23. Review of Resident 1's Initial History and Physical examination dated 3/5/23, showed Resident 1 had the capacity to understand and make decisions. Review of Resident 1's Progress Notes dated 3/21/23 at 2210 hours, showed Resident 1 was involved in a resident-to-resident altercation which resulted in Resident 1 sustaining redness and a right temporal bump that measured 4 cm (length) x 5 cm (width). Review of Resident 1's Progress Notes dated 3/21/23 at 2358 hours, showed the staff responded to yelling coming from Residents 1 and 2's room and found Resident 2 standing over Resident 1 yelling and cussing. Resident 1 was observed with redness and a bump on the right side of his face while Resident 2 did not have any injuries. Resident 1 stated he had asked Resident 2 to stop smoking in the bathroom. Resident 2 then yelled at Resident 1 and punched him on the right side of the face. b. Medical record review for Resident 2 was initiated on 4/18/23. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's Initial History and Physical examination dated 11/28/22, showed Resident 2 had the capacity to understand and make decisions. Review of Resident 2's Progress Notes dated 3/22/23, showed the Interdisciplinary Team had met with Resident 2 regarding the altercation he had with Resident 1. Resident 2 stated he hit Resident 1 on his face because Resident 1 called him a cuss word. On 4/18/23 at 1059 hours, an interview was conducted with Resident 2. Resident 2 was asked about the altercation involving Resident 1. Resident 2 stated he had an argument with Resident 1 and punched Resident 1 in the face. On 4/18/23 at 1454 hours, an interview was conducted with RN 1. RN 1 stated when the staff responded to the commotion coming from Residents 1 and 2's room, they witnessed Resident 2 standing over Resident 1 whose face was red and swollen. RN 1 stated the residents were separated and when questioned, Resident 2 admitted to hitting Resident 1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to maintain the infection control practices to help prevent the transmission of diseases and infections. * The facility failed to ensure the staff practiced the enhanced barrier precautions when entering the room of one nonsampled resident (Resident A) who was on the enhanced barrier precautions. This failure posed the risk of infection and the transmission of disease-causing microorganisms. Findings: Review of the facility's P&P titled IPCP Standard and Transmission-Based Precautions dated 10/2022 showed Enhanced Barrier Precaution (EBP) expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs (Multi-drug Resistant Organisms) to staff hands and clothing then indirectly transferred to residents or from resident-to-resident (e.g. residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs). a. PPE: The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with: i. Wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents ii. [NAME] infection or colonization. b. Multi-drug Resistant Organisms ([NAME]) - the MDROs for which the use of EBP applies are based on local epidemiology. At a minimum, they should include resistant organisms targeted by CDC but can also include other epidemiologically important MDROs. i. Examples of MDROs targeted by CDC include .Carbapenemase-producing carbapenem-resistant Enterobacterales (CRE) . Medical record review for Resident A was initiated on 2/17/23. Resident was admitted on [DATE]. Review of the physician's order dated 1/16/23, showed to implement the enhanced barrier precautionsfor CRE in urine. On 2/17/23 at 1022 hours, Resident A's room was observed with an enhanced barrier precaution sign posted by the Resident A's door. The sign showed Enhanced Barrier Precautions, everyone must clean their hands, including before entering and when leaving the room. The providers and staff must wear gloves and gown for the following high-contact resident care activities: dressing, bathing/ showering, transferring, changing linens providing hygiene, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, and wound care: any skin opening requiring a dressing. CNA 1 was observed entering Resident A's room wearing surgical mask, face shield, and gloves but did not wear a gown, and closed Resident A's door. On 2/17/23 at 1031 hours, a concurrent observation and interview was conducted with CNA 1. CNA 1 was observed exiting Resident A's room. CNA 1 was asked what she did in Resident A's room when she closed the door and stated she performed a bed bath to Resident A. CNA 1 verified there was a sign by the wall showing Resident 4 was on the enhanced barrier precautions. CNA 1 stated she missed the sign and should have worn the mask, gloves, and gown. On 2/17/23 at 1230 hours, an interview was conducted with the IP. The IP verified for enhanced barrier precautions, the staff should perform handwashing before and after care, wear gloves and gown for high-contact resident care activities such as shower or bed bad. On 3/14/23 at 1400 hours, an interview was conducted with the DON. The DON verified Resident A was on enhanced barrier precaution staff for CRE in the urine. The DON further stated for enhanced barrier precaution, the staff should wear gloves and gown for care activities that may cause splash.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to arrange the post-discharge needs for one of two sampled residents (Resident 1). Resident 1, whose diagnoses included diabetes (a chronic disease that occurs when a person's blood sugar is too high), dysphasia (a disorder that affects how a person speaks or understands language due to brain disease or damage),and end-stage renal disease (also known as ESRD; a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis), was discharged without proper resources and medical support. The facility failed to arrange home health services and DME for Resident 1 as ordered by the physician. This failure created the risk of unsafe discharge for Resident 1. Findings: Review of the facility's P&P titled Preparing Resident for Transfer or Discharge revised 12/16 showed a post-discharge plan is developed for each resident prior to his or her transfer or discharge. This plan will be reviewed with the resident, and/or his or her family, at least twenty-four (24) hours before the resident's discharge or transfer from the facility. Nursing services is responsible for: · obtaining orders for discharge or transfer, as well as the recommended discharge services and equipment; · preparing the discharge summary and post-discharge plan; · preparing the medications to be discharged with the resident (as permitted by law); · providing the resident or representative (sponsor) with required documents (i.e., discharge summary and plan); · packing and collecting personal possessions (if the resident is not expected to return); · assisting with transportation as applicable (i.e., calling for an ambulance); and · escorting the resident to transportation. Closed medical record for Resident 1 was initiated on 12/19/22. Resident 1 was admitted to the facility on [DATE], readmitted on [DATE], and discharged to a private home or apartment with home health serviceson 12/8/22. Review of the acute care hospital's physician H&P examination dated 11/18/22, showed Resident 1 was discharged from the acute care hospital to the facility on [DATE], for rehabilitation and woundcare, with diagnoses including diabetes, ESRD on hemodialysis (a procedure where a machine and a special filter are used to clean a person's blood), and unsteady gait. Review of Resident 1's MDS dated [DATE], showed Resident 1 was cognitively intact. The document also showedResident 1 required extensive assistance from one person for bed mobility (how the resident moves to and from lying position, turns side to side, and positions body while in bed), transfers (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position), and basic daily care needs such as hygiene, dressing and toilet use. Review of Resident 1's Progress Notes dated 11/23/22 at 1057 hours, showed the discharge plan was initiated forResident 1. The document showed Resident 1 would stay for long term care. Resident 1's family member was unable to provide care to the resident. Review of Resident 1's Order Summary Report showed a physician's order dated 12/7/22, to discharge Resident 1 tohome on [DATE], with the home health RN for medication management, home health PT for home safety evaluation, follow up with Resident 1's primary care physician in one to two weeks, and DME that included a walker, wheelchair and a commode. The order also showed Resident 1's last covered date (LCD) was on 12/8/22. Review of Resident 1's OT Discharge summary dated [DATE], showed the discharge recommendations included assistance with IADL, assistive device for safe functional mobility, home health services, and remove throw rugs. Review of Resident 1's PT Discharge summary dated [DATE], showed Resident 1 could walk 100 feet with a CGA at discharge. The discharge recommendation including home exercise program, home health services, and 24 hours care. Review of Resident 1's Discharge Instruction dated 12/8/22, showed Resident 1 was discharged home and a home health agency will follow up on her care. However, upon further review, the facility failed to show documented evidence of the following: - There was no documented evidence to show which specific home health agency would provide care for Resident 1. The document also failed to show any contact information for the home health agency arranged to care for Resident 1 after discharged home. - There was no documented evidence to show a follow-up appointment with Resident 1's physician was arranged. The document failed to show Resident 1's primary care physician's contact information and thespecific date or time for an appointment. - There was no documented evidence to show Resident 1 or her responsible party was provided training or education on any of her medical conditions or the administration of medications. Further review of Resident 1's closed medical record failed to show documented evidence a list of her current medications was provided to Resident 1 or her responsible party. The facility failed to show Resident 1 had any home health services, DME or follow-up appointments arranged prior to discharge. On 12/19/22 at 1115 hours, a concurrent interview and closed medical record review was conducted with the Case Manager. The Case Manager stated Resident 1 had CalOptima with HMO contract group A that would arrange her home health services follow-up with her primary care physician and DME. However, the contract group A had ended on 11/30/22. The Case Manager stated she had met Family Member 1 at the resident's bedside to inform him of the LCD on 12/8/22,and home health arrangement. Resident 1 and Family Member 1 both agreed to discharge home. Family Member 1 confirmed the home address. The Case Manager stated Home Health B was supposed to accept the resident and usually should follow up with the resident. The Case Manager stated she did not receive a confirmation from Home Health B that they accepted Resident 1 as a patient. The Case Manager confirmed she sent Resident 1 home without home health services and DME as ordered by the physician. The Case Manager was asked how she could have helped Resident 1 to attain the home health services and DME. The Case Manager stated she or the social services staff should have contacted CalOptima to get a new contract group to cover continued medical services Resident 1 needed. On 12/19/22 at 1115 hours, a concurrent interview and closed medical record review was conducted with the SSD. The SSD stated she did not know Resident 1's HMO group had ended on 11/30/22. The SSD stated she or the Case Manager should have contactedCalOptima to get the new contract group to arrange the home health services for Resident 1. The SSD stated she did not call CalOptima and did not know the resident needed DME. On 12/19/22 at 1400 hours, a concurrent interview and closed medical record review was conducted with the DON. The DON was asked if she was aware Resident 1 was sent home without home health services and DME as ordered by the physician. The DON she did not know Resident 1 did not have home health servicesand DME arranged prior to the discharge. The DON was asked about Resident 1's discharge medications. The DON stated she gave Family Member 1 the discharge instructions and medications upon discharge. The DON stated the routine medications left in the bubble cards were sent home with the resident, not the PRN (as needed) or insulin medication. The DON stated the discharge medication list was sent home with the resident, and the facility did not keep a copy of discharge medication list. The DON was asked if Resident 1 was to continue the insulin at home. The DON stated she was not sure if the resident was on insulin at home, but Resident 1 had an accu-check and needed a home health RN for medication safety. On 1/12/23 at 1045 hours, a concurrent telephone interview and closed medical record review was conducted with LVN 1. When asked about the facility's discharge process. LVN 1 stated she got thedischarge orders to discontinue heparin (blood thinner), and Resident 1 would take the rest of her medication including insulin home. LVN 1 stated when aresident continued insulin at home, the nurse would teach the resident and family for the insulin injection before sending the resident home. LVN 1 verified there was no documentation to show Resident 1 knew how to check her blood sugars and administer insulin injections.