**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 and services for one of four sampled residents (Resident 4). * The facility failed to ensure Resident 4's suction canister was changed. This failure had the potential to affect the respiratory health and well-being of the resident. Findings: Review of the facility's P&P titled Suction Canister Disposal dated July 2014 showed the suction canisters will be changed weekly, ¾ full, and PRN. Medical record review for Resident 4 was initiated on 5/7/25. Resident 4 was readmitted to the facility on [DATE]. Review of Resident 4's H&P examination dated 8/13/24, showed Resident 4 had the capacity to make and understand his own decision. Review of Resident 4's RT- Continuous Ventilator Flow Sheet dated 5/2/25 at 1800 hours, showed the suction canister was changed. On 5/7/25 at 1223 hours, Resident 4 was observed on the ventilator (medical device used to assist or take over the function of breathing) with the tubing connected to the suction canister which was full. On 5/7/25 at 1234 hours, an observation and concurrent interview was conducted with RT 1. When asked when Resident 4's suction canister was last changed, RT 1 stated the facility had scheduled to change the suction canister two times a week on Wednesdays, Saturdays, and PRN. RT 1 stated Resident 4's suction canister was last changed on 5/2/25 at 1800 hours. RT 1 further stated it would be changed today in the evening shift. When asked when the suction canister would be changed PRN, RT 1 stated when it was full. RT 1 verified the above findings and stated she was going to change the suction canister now. On 5/7/25 at 1310 hours, an interview and concurrent medical record review was conducted with the RT Supervisor. The RT Supervisor stated the suction canister should be changed when it was full. When asked what would happen if the suction canister was not changed when it was full, the RT Supervisor stated the equipment would not be able to suction and it was a potential for infection. The RT supervisor was informed and acknowledged Resident 4's suction canister should have been changed when it was ¾ full.

Based on observation, interview, and facility P&P review, the facility failed to ensure the resident equipment was maintained in a safe operating condition. * An air fryer (countertop appliance used to cook food) and Keurig coffee machine were observed in Resident 4's room. This failure had the potential for the equipment to not function in the way it was intended and exposed to potential fire hazards. Findings: Review of the facility's P&P titled Electrical Appliance revised January 2019 showed the following: 1. Residents may not maintain any electrical appliance (i.e., heating irons, cooking utensils, etc ) within their living areas unless approved by the administrator or his/her designee. 2. Should the electrical appliances be permitted, each must be in good working order, free of frayed cords, and UL approved. On 5/7/25 at 0747 hours, during the initial tour of the facility, an air fryer was observed on the bedside table close to the patio door in Room A. On 5/7/25 at 1115 hours, a follow-up observation of Room A and concurrent interview was conducted with LVN 2 and Resident 4. An air fryer and a Keurig coffee machine were observed in Room A. LVN 2 verified the findings and stated the two items above belong to Resident 4. LVN 2 stated the facility staff heated up the food for Resident 4 and made coffee for the resident. Resident 4 stated he used the air fryer to heat up his food like French fries and grilled cheese and liked to drink his own coffee which the facility staff made for him. On 5/7/25 at 1150 hours, an interview was conducted with CNA 1. When asked if he used the air fryer to heat up the food and/or make coffee for Resident 4 using the Keurig coffee machine, CNA 1 stated no, and Resident 4 had never asked to. CNA 1 stated he did not receive any training or in-service from the facility on how to use the air fryer or Keurig coffee machine. On 5/7/25 at 1215 hours, a follow-up interview was conducted with LVN 2. When asked when Resident 4 had gotten the air fryer and coffee machine, LVN 2 stated the two appliances had already been in the resident's room before he started working in the facility. LVN 2 stated he did not receive any training or in-service from the facility on how to use the air fryer or Keurig coffee machine. LVN 2 stated he did not know the food temperatures when the food was heated up. On 5/7/25 at 1242 hours, an interview was conducted with the Maintenance Director. When the Maintenance Director was asked about the care of the equipment brought in by the residents, the Maintenance Director stated the Social Services staff would notify him and he would check the equipment. The Maintenance Director stated he or his staff checked Resident 4's refrigerator daily for the temperature. However, when asked if he checked Resident 4's air fryer and/or coffee machine, the Maintenance Director stated he did not see the appliances in the resident's room. When asked how he checked the electrical equipment, the Maintenance Director stated he used the electric tester to test the outlets to make sure they were compatible. The Maintenance Director stated if there was too much equipment plugged in, it might cause the electrical overload and potential for fire hazards. On 5/7/25 at 1600 hours, an interview was conducted with the DON and Administrator. The DON and Administrator were informed of the above findings and stated Resident 4 had his own TV, radio, air fryer, and coffee machine before they started working in the facility. The DON and Administrator further stated Resident 4 stayed in his room, so the facility tried to provide him with a home environment in his room. The DON and Administrator acknowledged the facility did not provide any in-service or training for the facility staff regarding the safe use and maintenance of the appliances in Resident 4's room.

Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of three sampled residents (Resident 1) attained and maintained the highest practicable physical well-being. * The facility failed to ensure the proper documentation was completed as per the facility's protocol for Resident 1 who had a change in condition. This failure had the potential for Resident 1 to not be provided with the appropriate care and monitoring. Findings: Review of the facility's P&P titled Change of Condition, under Section E, showed the documentation of the change in condition shall be performed by the Licensed Nurse accordingly: 1. Documenting for at least 72 hours, or longer if condition change warrants 2. Using appropriate form for daily charting 3. Documenting vital signs each shift 4. Care plan evident 5. Reassessing MDS (if change is significant) 6. IDT conference if indicated 7. Reassess resident condition as needed 8. COC/SBAR will be completed as indicated Medical Record review for Resident 1 was initiated on 3/25/25. Resident 1 was admitted to facility on 11/26/24. Review of Resident 1's physician's telephone orders dated 3/20/25, showed for the following orders: - Levofloxacin (antibiotic)tablet 500 mg, one tablet by mouth one time a day for fever and cough for five days, and for the first dose to be taken from E-kit. - Chest x-ray one time only on 3/20/25 - STAT CBC and BMP testson 3/20/25 - STAT Flu rapid test Review of Resident 1's Medication Administration Report for March 2025 showed Levofloxacin was documented as given on 3/20/25 at 1000 hours. Review of Resident 1's Facility Transfer Form dated 3/21/25, showed Resident 1 was experiencing cough and fever since 3/20/25. Resident 1 was prescribed Levofloxacin and transferred to the acute care hospital on 3/21/25. Further review of Resident 1's medical record failed to show documentation for a change of condition and the care plan to be developed to addressthe resident's cough and fever. Additionally, there were no nurse progress notes to show the resident was monitored for the cough and fever. On 3/26/25 at 1055 hours, an interview was conducted with LVN 3. LVN 3 stated Resident 1 should have had a change of condition report for new onset of coughing and low-grade fever, updated care plan, and conducted the nursing monitoring for 72 hours. On 3/26/25 at 1115 hours, an interview was conducted with ADON. The ADON acknowledged the findings and further stated the nurses should have the documentation related to a resident's change in condition, update the care plan and initiate the 72-hour monitoring of the resident per protocol.

**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 care was provided in a manner which promoted dignity and respect for one of four final sampled residents (Resident 84) reviewed for indwelling urinary catheter and one of 24 final sampled residents (Resident 71) reviewed for privacy. * The facility failed ensure Resident 84's indwelling urinary drainage bag was fully covered. * Resident 71's body parts were exposed while being transferred to a shower bed. These failures have the potential to negatively affect the resident's emotional well-being. Findings: 1. Review of the facility's P&P titled Dignity revised 2/2021 showed the staff are expected to promote dignity and assist the residents; for example: helping resident to keep urinary bags covered. The P&P also showed each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are treated with dignity and respect at all times. Medical record review for Resident 84 was initiated on 3/11/25. Resident 84 was readmitted to the facility on [DATE]. Review of Resident 84's MDS dated [DATE], showed Resident 84 was cognitively intact. Resident 84 needed extensive assistance from the staff with his ADL care. Review of Resident 84's Physician Order Summary dated 3/13/25, showed a physician's order dated 2/3/25, for the indwelling urinary catheter to attached to the bedside drainage bag. On 3/11/25 at 0829 and 1430 hours, and 3/13/25 at 0809 hours, Resident 84 was observed in bed. Resident 84 was observed to have the urinary drainage bag hanging to the left side of his bed. The urinary drainage bag was not fully covered and observed to have light yellow liquid. On 3/13/25 at 0821 hours, an observation and concurrent interview was conducted with the IP. The IP verified the above findings. The IP stated the urinary drainage bag had to be fully covered to protect the resident's dignity. The IP verified the urinary drainage bag for Resident 84 was not fully covered. On 3/14/25 at 0946 hours, the DON was informed and acknowledged the above findings. 2. Medical record review for Resident 71 was initiated on 3/11/25. Resident 71 was readmitted to the facility on [DATE]. Review of Resident 71's H&P examination dated 5/25/24, showed the resident had the capacity to understand and make decisions. Review of Resident 71's Order Summary Report dated 3/12/25, showed Resident 71 had a diagnosis of unspecified depression. On 3/11/25 at 1016 hours, an observation was conducted on Resident 71. Resident 71 was observed to be seated on a hoyer lift, being transferred from the bed to shower bed with his abdomen and bilateral legs exposed. Resident 71's transfer to the shower bed done by CNA 3 and the SLP could be seen from the hallway with Resident 71's door wide open. On 3/11/25 at 1020 hours, an interview was conducted with the SLP. The SLP stated she was helping CNA 3 and verified Resident 71's door should have been closed to provide privacy. On 3/11/25 at 1111 hours, an interview was conducted with LVN 3. LVN 3 verified the door should have been closed and respected Resident 71's right of dignity and privacy. On 3/11/25 at 1145 hours, an interview was conducted with Resident 71. Resident 71 was asked how he felt when the care was not provided with privacy. Resident 71 stated he felt it was disappointing and got used to it. On 3/14/25 at 1045 hours, an interview was conducted with the DON. The DON verified Resident 71's body parts should have not been exposed and Resident 71's door should have been closed to provide privacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Medical record review for Resident 44 was initiated on 3/11/25. Resident 44 was admitted to the facility on [DATE], and reamitted on 7/14/23. Review of Resident 44's Quarterly MDS dated [DATE], showed Resident 44 had a BIMS score of 12 which meant the resident was moderately cognitively impaired. Review of Resident 44's Order Summary Report for March 2025 showed a physician's order dated 10/29/24, for Abilify 5 mg one tablet via GT at bedtime for Bipolar disorder manifested by angry outburst. Review of Resident 44's Informed Consent for the Abilify nedication dated on 10/29/24, showed no documented evidence the physician had signed or dated the informed consent. On 3/13/25 at 1356 hours, a concurrent interview and medical record review was conducted with LVN 3. LVN 3 verified Resident 44's physician's order for the Abilify medication. LVN 3 further verified the resident received Abilify 5 mg at 2100 hours from 3/1 to 3/12/25, as documented on Resident 44's MAR for March 2025. Moreover, LVN 3 verified the informed consent for the use of the Abilify medication was not signed or dated by the physician. LVN 3 stated the informed consent should have been signed and dated by the physician. On 3/14/25 at 1320 hours, an interview was conducted with the Administrator and DON with the Regional Director of Operations present. The Administrator and DON were made aware and acknowledged the above findings. Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the informed consents for four of 24 final sampled residents (Residents 10, 44, 72, and 85) and one nonsampled resident (Resident 20) were completed as per the facility's P&P. * The facility failed to ensure the informed consents for Residents 10, 20, 72, and 85 were signed and dated by the physician. * The facility failed to ensure Resident 44's informed consent for the use of the Abilify (antipsychotic medication) was signed and dated by the physician. These failures posed the risk of residents and their responsible parties not to be informed of their treatments and the potential side effects. Findings: Review of the facility's P&P titled Informed Consent dated 12/2024 showed to ensure the residents and/or their representatives are fully informed of the benefits, risks, frequency/duration and alternatives before initiating the administration of the psychotherapeutic drugs or physical restraints. The physician and/or prescriber must sign an informed consent form after explaining all necessary information to the residents or representatives. 1. Medical Record review of Resident 10 was initiated on 3/11/25. Resident 10 was readmitted to the facility on [DATE]. Review of Resident 10's H&P examination dated 5/25/24, showed the resident had the capacity to understand and make decisions. Review of Resident 10's Informed Consents form dated 2/18/25, showed the physician had confirmed giving the information of the resident proposed treatment and nature and seriousness of illness, reasonable alternative treatment and/or possible non-pharmacological approaches and the rationale for the recommended treatment, nature of procedures involved in the proposed treatment, including probable frequency and duration, probable degree, duration and probability of significant risks commonly known by health professionals in person for the following:. - proposed treatment (non-restraint) for out of the bed to the gerichair as tolerated for the resident had poor trunk control. The resident benefits from being up in the gerichair for socialization, stimulation, and activities, and - proposed treatment (non - restraint) for the bilateral upper half side rails up and locked when in bed as an enabler for positioning and ease of mobility. Further review of the informed consents failed to show the date and signature of the physician who had obtained the informed consents. 2. Medical Record review of Resident 72 was initiated on 3/11/25. Resident 72 was readmitted to the facility on [DATE]. Review of Resident 72's H&P examination dated 10/18/24, showed the resident had no capacity to understand and make decisions. Review of Patient 72's Informed Consent forms showed the physician had confirmed that he/she had given information to the resident's representative by telephone call regarding the reason for the treatment and nature and seriousness of the illness, nature of procedures to be used in the proposed treatment, including probable frequency and duration, probable degree and duration of improvement or remission, nature, degree, duration and probability of known side effects and significant risks commonly known by health professionals, reasonable alternative treatment and risks and why the particular treatment is recommended and that the resident or resident's representative has the right to accept or refuse the proposed treatment and if/she consents, has the right to revoke his/her consent for any reason at any time for the following consents: - dated 10/28/24, for the left hand mitten for the prevention of pulling out of the life sustaining tubes per family preference. - dated 10/16/25, for out of the bed to the gerichair for socialization, stimulation, activities and shower days; - dated 10/16/24, for the bilateral upper side rails up for positioning due to gravity related to the involuntary movements secondary to the head of bed elevated for the management of the tracheostomy and GT feeding; and - dated 10/16/24, for the low bed with the floor pads/mats to minimize the potential for injury from the spontaneous/involuntary movement from bed to the floor mats/pads. Further review of the informed consents failed to show the dates and signature of the physician who had obtained the informed consents. On 3/14/25 at 0930 hours, an interview and concurrent medical record review for Residents 10 and 72 was conducted with RN 2. RN 2 verified the above findings. 3. Medical Record review of Resident 20 was initiated on 3/11/25. Resident 20 was readmitted to the facility on [DATE]. Review of Resident 20's Informed Consent forms dated 9/13/24, showed the physician had confirmed that he/she had given the information to the resident's representative by telephone call regarding the reason for the treatment and nature and seriousness of illness, nature of procedures to be used in the proposed treatment, including probable frequency and duration, probable degree and duration of improvement or remission, nature, degree, duration and probability of known side effects and significant risks commonly known by health professionals, reasonable alternative treatment and risks and why the particular treatment is recommended and that the resident or resident's representative has the right to accept or refuse the proposed treatment and if/she consents, has the right to revoke his/her consent for any reason at any time for the following: - for the bilateral upper side rails up for positioning due to the gravity related involuntary movements secondary to the head of the bed elevated for the management of the tracheostomy and GT feeding; - for out of the bed to the geri-chair as tolerated during shower days. The resident is immobile and had no ability to transfer independently and the resident would benefit from being up in geri-chair for socialization, stimulation and activities; and - for the low bed with the floor pads/mats to minimize the potential injury from spontaneous/involuntary movement from bed to floor mats/pads. Review of Resident 20's H&P examination dated 9/17/24, showed the resident had no capacity to understand and make decisions. Further review of the informed consents failed to show the date and signature of the physician who had obtained the informed consents. 4. Medical Record review of Resident 85 was initiated on 3/11/25. Resident 85 was readmitted to the facility on [DATE]. Review of Resident 85's H&P examination dated 12/19/24, showed the resident had no capacity to understand and make decisions. Review of Resident 85's Informed Consent forms dated 12/19/25, showed the physician had confirmed that he/she had given information to the resident by telephone call regarding the reason for the treatment and nature and seriousness of illness, nature of procedures to be used in the proposed treatment, including probable frequency and duration, probable degree and duration of improvement or remission, nature, degree, duration and probability of known side effects and significant risks commonly known by health professionals, reasonable alternative treatment and risks and why the particular treatment is recommended and that the resident or resident's representative has the right to accept or refuse the proposed treatment and if/she consents, has the right to revoke his/her consent for any reason at any time for the following: - for the bilateral upper side rails up for positioning due to gravity related to the involuntary movements secondary to HOB elevated for the management of the tracheostomy and GT feeding; - for the low bed with the floor pads/mats to minimize the potential injury from spontaneous/involuntary movement from bed to floor mats/ pads; and - for the out of the bed to the gerichair as tolerated during shower days. The resident is immobile and had no ability to transfer independently and the resident would benefit from being up in the gerichair for socialization, stimulation and activities. Further review of the informed consents failed to show the date and signature of the physician who had obtained the informed consents. On 3/14/25 at 0945 hours, an interview and concurrent medical record review for Residents 20 and 85 was conducted with RN 5. RN 5 verified the above findings. On 3/14/25 at 1554 hours, an interview was conducted with the DON. The DON verified all of the above 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 maintain a copy of an advance directive in the medical record for one of six final sampled residents (Resident 34) reviewed for advance directives. This failure had the potential for Resident 34's decisions regarding his healthcare and treatment options to not be honored. Findings: Review of the facility's P&P titled Advance Directive revised 9/2022 showed prior to or upon admission of a resident, the Social Service Director or designee will inquire of the resident, his/her family members and /or his or her legal representative about the existence of any written Advance Directives. Further review of the P&P showed if the resident or the resident's representative has executed one or more advanced directives, or executes one upon admission, copies of these documents are obtained and maintained in the same section of the residents' medical record and are readily retrievable by any facility staff. Medical record review for Resident 34 was initiated on 3/11/25. Resident 34 was readmitted to the facility on [DATE]. Review of Resident 34's POLST dated 2/24/25, showed Resident 34 had an advance directive. Review of Resident 34's H&P examination dated 5/2/24, showed Resident 34 had the capacity to understand and make decisions. Review of Resident 34's Advance Directive Acknowledgement dated 2/24/25, showed Resident 34 had executed an advance directive. Review of Resident 34's medical record failed to show a copy of the advance directive was maintained in Resident 34's medical record. On 3/12/24 at 1019 hours, an interview and concurrent medical record review for Resident 34 was conducted with the SSD. The SSD verified there was no copy of Resident 34's advance directive in the medical record, nor was it uploaded in Resident 34's EMR. The SSD stated Resident 34 had an advance directive, and the copy of the advance directive should have been maintained in the Resident 34's medical record and should be readily retrievable by the facility staff. On 3/14/25 at 0946 hours, 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 ensure the appropriate restraint use, including skin assessment, removal of restraint, and ROM exercises for three of three final sampled residents (Residents 41, 72, and 100) reviewed for the use of the restraints. * Resident 100 did not have a physician's order and consent for the use of the elbow restraint, and no documentation of the restraint removal, and if the arm was assessed and exercised every two hours. * Residents 41 and 72's medical records failed to show their hand mitten restraints were removed, and if their hands were assessed and exercised every two hours. These failures had the potential for the increased risk of resident's skin and soft tissue injury as well as the decrease in the ROM functions related to restraint use. Findings: Review of the facility's P&P titled Use of Restraints revised April 2017 showed the following: - Restraints will only be used with a physician's order and after consent is obtained, - The opportunity for motion and exercise for a period of not less than 10 minutes every two hours while the restraint is in use, and - Documentation will include the observations, range of motion and repositioning flowsheets. 1. On 3/11/25 at 0854 hours, an observation and concurrent interview was conducted at Resident 100's bedside. Resident 100 was observed lying in bed, with oxygen tubing connected to his tracheal tube. The resident had an elbow splint on his left arm, keeping the left arm extended and preventing the arm from bending. Resident 100's family member (Family Member 1) entered the room and went to the resident's bedside. Family Member 1 stated Resident 100 had the elbow splint to prevent him from pulling out his respiratory tubing. Family Member 1 stated she came in daily and would remove the resident's elbow splint when she was with him. Medical record review for Resident 100 was initiated on 3/11/25. Resident 100 was readmitted on [DATE]. Review of Resident 100's medical record failed to show for a physician's order and consent were obtained for an elbow splint. The record also failed to show documentation of an elbow splint removal, splint site observations and exercises performed as per the faiclity's P&P. On 3/12/25 at 0754 hours, Resident 100 was observed lying in bed, with the eyes closed; and the elbow splint was observed applied to the resident's left arm, keeping it extended. There were no visitors observed at the resident's bedside. On 3/13/25 at 0812 hours, an interview was conducted with CNA 6. CNA 6 stated Resident 100 had the elbow splint prior to the resident's readmission to the facility. CNA 6 stated the elbow splint was usually in placed every morning when he came in, and the resident's family would take it off when they were at the resident's bedside and put it back on when they leave. On 3/13/25 at 0823 hours, an interview and concurrent record review was conducted with the ADON and RN 3. The ADON stated Resident 100 had a previous order from a prior admission for the elbow splint. RN 3 verified there was no current physician's order and consent for the use of the left elbow splint, and no documentation to show the splint was removed every two hours. 2. Medical record review for Resident 41 was initiated on 3/11/15. Resident 41 was readmitted to the facility on [DATE]. Review of Resident 41's Order Summary Report showed the following physician's orders: - dated 2/1/25, for a right hand-mitten restraint to prevent from pulling out life sustaining tubes, and - dated 2/4/25, to release the restraint every two hours for 15 minutes for comfort, circulation, ROM exercises, repositioning, and monitoring of the skin integrity. Review of Resident 41's MAR for March 2025 showed the entry for the order to release the restraint every two hours for 15 minutes for comfort, circulation, ROM exercises, repositioning, and monitoring skin integrity and it was signed off per shift; however, it did not show what time it was performed, including the findings and outcome. On 3/13/25 at 1039 hours, an interview and concurrent medical record review was conducted with LVN 7. LVN 7 stated they would remove the splint every two hours and document on the MAR, with only one entry for the entire eight-hour shift. LVN 6 stated they did not document it anywhere else. LVN 7 further stated they used to document every two hours on a flowsheet, but the facility did not use the flow sheet anymore. 3. Medical record review for Resident 72 was initiated on 3/11/25. Resident 72 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 72's annual MDS dated [DATE], showed Resident 72's cognitive skills for the daily decision making was severely impaired. Review of Resident 72's Order Summary Report for March 2025, showed the following physician's orders: - dated 12/2/24, to monitor the episodes of pulling out the life sustaining tubes, tracheostomy or GT/NGT (nasogastric tube) and tally with hashmarks, and - dated 1/24/25, for the restraint left hand mitten for the prevention of pulling out the life sustaining tubes per the family's preference, and restraint may be released every two hours for 15 minutes to check for the circulation, movement, sensation, and skin integrity. Multiple observations of Resident 72 were conducted in the resident's room. Resident 72 was observed wearing the left hand mitten restraint on the following dates and times: - 3/11/25 at 0841, and 1010 hours; and - 3/12/25 at 1201, and 1525 hours. On 3/13/25 at 1039 hours, a concurrent interview and medical record review was conducted with LVN 13. LVN 13 verified Resident 72 had a physician's order for the left hand restraint. LVN 13 stated the restraint was to be removed every two hours to ensure the resident's skin was assessed for any skin breakdown. Further review of Resident 72's MAR for March 2025 showed no documented evidence for the removal of the hand mitten restraint was documented every two hours as per the facility's P&P. LVN 13 stated the MAR only showed the total number of times Resident 72 attempted to remove the hand mitten restraint during the shift. LVN 13 verified the MAR did not show when the left hand mitten restraint was removed. On 3/13/25 at 1049, 1300, and 1500 hours, a follow-up observation was conducted for Resident 72. Resident 72 was observed wearing the left hand mitten restraint. On 3/13/25 at 1527 hours, a concurrent interview and medical record review was conducted with RNA 1. RNA 1 verified Resident 72 wore the left hand mitten restraint. RNA 1 stated the documentation were electronically entered on the EMR. When RNA 1 was asked if the RNA documentation included when the left hand mitten restraint was released, RNA 1 stated she did not document the times when the left hand mitten restraint was released. RNA 1 further stated the left hand mitten restraints should be removed every two hours. On 3/14/25 at 1300 hours, a concurrent interview and medical record review was conducted with the DON. The DON verified Resident 72 had a physician's orders for the left hand mitten restraint. The DON further verified the facility did not have the paper medical record or documentation to show the left hand mitten restraint was released every two hours. The DON stated her expectations of the nurses were to remove the left hand mitten restraint every two hours to ensure hand circulation and assess the skin for dryness, infection, or discoloration. On 3/14/25 at 1320 hours, an interview was conducted with the Administrator and DON with the Regional Director of Operations present. The Administrator and DON were made aware 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 notify the resident and/or their representative of the transfer and reasons for the transfer in writing when the resident was transferred to the acute care hospital for two of three final sampled residents (final sampled residents, Residents 11 and 84) reviewed for hospitalization. This failure had the potential for the resident and their representative of not knowing about the appeal process and the circumstances of the resident's transfer/discharge should the resident and their representative believe the transfer or discharge was inappropriate or involuntary. Findings: 1. On 3/11/24 at 1010 hours, an interview was conducted with Resident 11. Resident 11 stated she was transferred to the acute acre hospital on or around 7/20/24. Resident 11 was asked if the facility provided the written Notice of Transfer/Discharge when she was transferred to the acute care hospital. Resident 11 stated the facility did not provide Resident 11 or her responsible party with the written Notice of Transfer/Discharge when she was transferred to the acute care hospital on 7/20/24. Medical record review for Resident 11 was initiated on 3/11/25. Resident 11 was readmitted to the facility on [DATE]. Review of Resident 11's Physician's Order dated 7/20/24, showed to transfer Resident 11 to the acute care hospital. Review of Resident 11's NC-COC/Interact Assessment Form (SBAR) dated 7/20/24, showed Resident 11 was transferred to the acute care hospital on 7/20/24 at 2200 hours, for left facial and perioral swelling (around the mouth). Review of Resident 11's Notice of Transfer/discharge date d 7/20/24, showed no signature in the section for the resident/resident representative's signature. Further review of the medical record for Resident 11 failed to show documentation if Resident 11 or their representative was notified of the transfer or discharge and reasons for the transfer in writing. Review of Resident 11's H&P examination dated 7/26/24, showed Resident 11 had the capacity to understand and make decisions. On 3/14/25 at 0811 hours, an interview and concurrent medical record review for Resident 11 was conducted with RN 2. RN 2 verified the above findings and stated Resident 11 was transferred to the acute care hospital on 7/20/24. RN 2 stated there was no documented evidence the written Notice of Transfer/Discharge was provided to Residents 11 or the resident's responsible party when the resident was transferred to the acute care hospital on 7/20/24. 2. Medical record review for Resident 84 was initiated on 3/11/25. Resident 84 was readmitted to the facility on [DATE]. Review of Resident 84's H&P examination dated 2/4/25, showed Resident 84 had the capacity to understand and make decisions. Review of Resident 84's Physician's Order dated 1/28/25, showed to transfer Resident 84 to the acute care hospital due to urinary retention (unable to empty bladder completely), hematuria (blood in urine) and bilateral flank (side of the back, below the ribs and above the hips) pain. Review of the NC-COC/Interact Assessment Form (SBAR) dated 1/28/25, showed Resident 84 was transferred to the acute care hospital on 1/28/25 at 1711 hours. Review of Resident 84's Notice of Transfer/discharge date d 1/28/25, showed no signature in the section for the resident/resident representative's signature. Further review of the medical record for Resident 84 failed to show a documentation if Resident 84 or the resident's representative was notified of the transfer or discharge and reasons for the transfer in writing. On 3/14/25 at 0836 hours, an interview and concurrent medical record review for Resident 84 was conducted with RN 2. RN 2 verified the above findings and stated Resident 84 was transferred to the acute care hospital on 1/28/25. RN 2 stated there was no documented evidence the written Notice of Transfer/Discharge was provided to Residents 11 and 84 or their responsible party when the residents were transferred to the acute care hospital. On 3/14/25 at 0946 hours, the DON was informed and acknowledged the above 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 resident and/or their representative were provided with the written information regarding the facility's bed-hold policy when the resident was transferred to the acute care hospital for two of three final sampled residents (Residents 11 and 84) reviewed for hospitalization. This failure had the potential for Residents 11 and 84 and/or their representative to be unaware of their rights to request a bed hold and return to the first available bed should the resident's hospital stay exceed the seven-day bed-hold period. Findings: Review of the facility's P&P titled Bed-Holds and Returns dated 3/2022 showed all the residents/representatives are provided written information regarding the facility bed hold policies, which address holding or reserving a resident's bed during period of absence (hospitalization or therapeutic leave). The residents are provided written information about this policy at least twice well in advance of any transfer (in the admission packet) and at the time of transfer (or if the transfer was emergency, within 24 hours). 1. On 3/11/24 at 1010 hours, an interview was conducted with Resident 11. Resident 11 stated she was transferred to the acute care hospital on or around 7/20/24. Resident 11 stated the facility did not provide her or her responsible party with a written bed hold policy when she was transferred to the acute care hospital on 7/20/24. Medical record review for Resident 11 was initiated on 3/11/25. Resident 11 was readmitted to the facility on [DATE]. Review of Resident 11's Physician's Order dated 7/20/24, showed to transfer Resident 11 to the acute care hospital and to provide a seven-day bed hold if the resident was admitted to the acute care hospital. Review of Resident 11's COC/Interact Assessment Form (SBAR) dated 7/20/24, showed Resident 11 was transferred to the acute care hospital on 7/20/24 at 2200 hours, for left facial and perioral (around the mouth) swelling. Review of Resident 11's Notification of Bed Hold dated 7/20/24, did not show the signature of the resident. Further review of the Notification of Bed Hold showed if a resident of the facility transferred to a general acute care hospital, the facility shall afford the resident a bed hold of seven days which may be exercised by the resident or resident's representative. Upon transfer to a general acute care hospital, the resident or resident's representative shall notify this facility within 24 hours after being informed of the right to have the bed hold, if the resident desires the bed hold. Resident who exercises the bed hold option shall be liable to pay reasonable charges not to exceed the resident's daily rate for care in the facility for bed hold days. Further review of the medical record for Resident 11 failed to show a documentation if Resident 11 or their representative was notified of the facility's bed hold policy in writing when Resident 11 was transferred to the acute care hospital on 7/20/24. Review of Resident 11's H&P examination dated 7/26/24, showed Resident 11 had the capacity to understand and make decisions. On 3/14/25 at 0811 hours, an interview and concurrent medical record review for Resident 11 was conducted with RN 2. RN 2 verified the above findings and stated Resident 11 was transferred to the acute care hospital on 7/20/24. RN 2 stated she was not able to find documented evidence to show Resident 11 or the resident's representative was provided with the facility's bed hold policy in writing when Resident 11 was transferred to the acute care hospital on 7/20/24. 2. Medical record review for Resident 84 was initiated on 3/11/25. Resident 84 was readmitted to the facility on [DATE]. Review of Resident 84's Physician's Order dated 1/28/25, showed to transfer Resident 84 to the acute care hospital due to urinary retention (unable to empty bladder completely), hematuria (blood in urine) and bilateral flank (side of the back, below the ribs and above the hips) pain. Review of the COC/Interact Assessment Form (SBAR) dated 1/28/25, showed Resident 84 was transferred to the acute care hospital on 1/28/25 at 1711 hours. Review of Resident 84's Notification of Bed Hold dated 1/28/25, did not show the signature of the resident. Further review of the document showed if a resident of this facility transferred to a general acute care hospital, this facility shall afford the resident a bed holds of seven days which may be exercised by the resident or resident's representative. Upon transfer to a general acute care hospital the resident or resident's representative shall notify this facility within 24 hours after being informed of the right to have the bed hold, if the resident desires the bed hold. Resident who exercises the bed hold option shall be liable to pay reasonable charges not to exceed the resident's daily rate for care in the facility for bed hold days. Further review of the medical record for Resident 84 failed to show a documentation if Resident 11 or the resident's representative was notified of the facility's bed hold policy in writing when Resident 11 was transferred to the acute care hospital on 1/28/25. Review of Resident 84's H&P examination dated 2/4/25, showed Resident 84 had the capacity to understand and make decisions. On 3/14/25 at 0836 hours, an interview and concurrent medical record review for Resident 84 was conducted with RN 2. RN 2 verified the above findings and stated Resident 84 was transferred to the acute care hospital on 1/28/25. RN 2 stated she was not able to find the documented evidence to show Resident 84 or the resident's representative was provided with the facility's bed hold policy in writing when Resident 84 was transferred to the acute care hospital on 1/28/25. On 3/14/25 at 0946 hours, the DON was informed and acknowledged 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 develop and implement the plan of care for one of 24 final sampled residents (Resident 100). * Resident 100's care plan failed to address the resident's ventilator use at night and left elbow restraint use. This failure had the potential for the resident's plan of care not being communicated to the interdisciplinary team. Findings: Medical record review for Resident 100 was initiated on 3/11/25. Resident 100 was readmitted on [DATE]. a. On 3/11/25 at 0854 hours, an observation was conducted at Resident 100's bedside. The resident had an elbow splint on his left arm, keeping the arm extended and preventing the arm from bending. On 3/12/25 at 0754 hours, Resident 100 was observed lying in bed, with their eyes closed. The elbow splint was observed applied to the resident's left arm, keeping it extended. On 3/13/25 at 0812 hours, an interview was conducted with CNA 6. CNA 6 stated Resident 100 had the elbow splint prior to the resident's readmission. CNA 6 stated the elbow splint was usually in place every morning when he came in, and Resident 100's family member took it off when they were at the facility and put it back on when they were leaving. On 3/13/25 at 0823 hours, an interview and concurrent medical record review was conducted with RN 3. RN 3 verified there was no care plan to address Resident 100's use of the elbow splint. b. Review of Resident 100's Order Summary Report showed the following physician's orders: - dated 1/22/25, for the resident to be on a ventilator at night, and specified the ventilator settings. - dated 1/22/25, for the resident to receive oxygen at 3 LPM via a tracheal piece/collar during AM and PM shifts, and to be on a ventilator at night. Review of Resident 100's plan of care failed to show the resident was being weaned off from the ventilator during the day and evening shifts, and on a mechanical ventilator during the night shift. On 3/12/25 at 1111 hours, an interview and concurrent record review was conducted with the Respiratory Lead. The Respiratory Lead stated Resident 100 was previously on a ventilator 24 hours a day, but the resident was currently only on the ventilator during the night shift from 2200 to 0600 hours, and was off from the ventilator and on supplemental oxygen for the rest of the day. The Respiratory Lead reviewed the resident's care plan and verified it did not address the resident being on the ventilator every night.

**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 24 final sampled residents (Resident 47) remain free from accident hazards. * The facility failed to apply the tab alarm (a fall prevention device designed to alert caregivers when a person attempts to get out of the bed, chair, or wheelchair) for Resident 47 as ordered by the physician. This failure had the potential to place Resident 47 at risk for serious injuries. Findings: Review of the facility's P&P titled Alarm Monitor (undated) showed the licensed nurse will complete the physical restraint assessment to determine whether the resident is a candidate for alarm monitor. The assessments will include but are not limited to : - The medical symptoms warrant the use of alarm monitor. - The less restrictive measures attempted prior to the alarm. - The type of alarm to be used: - Tab alarm; - Pad alarm (a fall prevention device designed to alert caregivers when a person attempts to get out of the bed, chair or wheelchair); - Alarm in wheelchair; and - Alarm in bed. The P&P further showed the staff will apply the alarm to the resident, following the manufacturer's instructions, to ensure its functionalists. Medical record review for Resident 47 was initiated on 3/11/25. Resident 47 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 47's Order Summary Report dated 3/14/25, showed a physician's order dated 1/14/25, to monitor the placement of the pad/tab alarm every shift. Review of Resident 47's Standard Assessments-Falls showed Resident 47 had fallen on the following dates: - on 10/16 and 10/20/24; and - on 1/8 and 1/14/25. Review of Resident 47's Change of Condition assessment dated [DATE], showed Resident 47 had lost her balance and fell backwards, hitting her head on the floor while trying to get up to go to the bathroom unassisted. Review of Resident 47's plan of care showed a care plan problem dated 1/14/25, addressing Resident 47's status post fall. The interventions included to apply the tab alarm in the bed and wheelchair. On 3/11/25 at 0906 hours, Resident 47 was observed in her room sitting in the wheelchair without the tab alarm. On 3/13/25 at 1004 hours, an observation and concurrent interview was conducted with LVN 1 for Resident 47. Resident 47 was observed in the dining room sitting in the wheelchair. Resident 47 was observed sitting on the tab alarm device and the tab alarm clip was not clipped onto the resident's clothing. When LVN 1 was asked if the resident should be sitting on the tab alarm device, LVN 1 stated the tab alarm should be hung on the wheelchair handle and the tab alarm clip should be clipped onto Resident 47's clothing. LVN 1 verified Resident 47's tab alarm was not properly applied on Resident 47. On 3/13/25 at 1056 hours, an observation and concurrent interview was conducted with CNA 5. Resident 47 was observed sitting in the wheelchair inside the bathroom. CNA 5 was observed wheeling Resident 47 out of the bathroom and handing the resident a cardigan sweater to wear. CNA 5 was asked if she had clipped the tab alarm onto Resident 47 after wheeling the resident out of the bathroom. CNA 5 verified she did not clip the tab alarm onto Resident 47 after assisting her. CNA 5 stated she knew Resident 47 was a high fall risk resident who benefited from the proper use of the tab alarm.

**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 verify the GT placement, patency, and gastric residuals prior to starting an enteral tube feeding for one of four residents investigated for tube feeding (final sampled resident, Resident 100). This failure had the potential for adverse outcome related to a dislodged GT or increased gastric residuals. Findings: Review of the facility's P&P titled Enteral Tube Feeding via Continuous Pump revised March 2023 showed to verify placement of the GT, and when placement has been verified, flush the tubing with at least 30 ml of water. Medical record review for Resident 100 was initiated on 3/11/25. Resident 100 was readmitted to the facility on [DATE]. Review of Resident 100's Order Summary Report showed the following physician's orders: - dated 1/3/25, to check the GT feeding residual every shift and hold the enteral feeding for one hour if the residuals are more than 100 ml. - dated 1/3/25, to run 40 ml of water every hour to provide 800 ml/day. - dated 2/18/25, for Peptamen AF 1.2 (feeding formula) to be administered at 70 ml/hr for 20 hours daily via GT. On 3/11/25 at 1302 hours, an observation and concurrent interview was conducted with LVN 5 at Resident 100's bedside. LVN 5 was observed connecting the enteral feeding formula and water flush tubing to the resident's GT, and then starting the feeding pump. LVN 5 was not observed checking the GT for placement, checking for patency or for gastric residuals prior to starting the enteral feeding formula and water flush. LVN 5 verified they did not check the GT for placement, patency, or residuals; and stated the staff checked them earlier in the shift when administering the morning medications. On 3/11/25 at 1310 hours, an interview was conducted with the ADON. The ADON stated when starting a GT feeding, the protocol was to check the tube placement using a stethoscope and an air bolus into the GT to check for the placement and check gastric residuals before starting the feeding and hold if needed as per the physician's order.

**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 three final sampled residents (Residents 52, 82, and 712) reviewed for respiratory care were provided the appropriate respiratory care. * The facility failed to ensure Residents 82 and 712's oxygen tubings were labeled and dated. * The facility failed to ensure Resident 52 was administered the oxygen as per the physician's order. These failures had the potential to affect the respiratory health and well-being of the residents in the facility. Findings: Review of the facility's P&P titled Oxygen Administration dated 10/2010 showed for the oxygen administration preparation, to verify that there is a physician's order for this procedure, review the physician's orders or facility protocol for oxygen administration, review the resident's care plan to assess for any special needs of the resident, and assemble the equipment and supplies as needed. Review of the facility's P&P titled Departmental (Respiratory Therapy) - Prevention of Infection dated 11/2011 showed to change the oxygen cannula and tubing every seven days or as needed. 1. Medical record review for Resident 82 was initiated on 3/11/25. Resident 82 was readmitted to the facility on [DATE]. Review of Resident 82's Order Summary Report for March 2025 showed a physician's order dated 1/23/25, to administer oxygen at a rate of 2 LPM via nasal cannula, may titrate up to 5 LPM for the oxygen saturation level less than 92% every shift. On 3/11/25 at 0923 hours, during the initial tour of the facility, an observation was conducted with Resident 82. Resident 82 was observed using the oxygen at 2 LPM via nasal cannula. The nasal cannula was unlabeled with the name and date on when it was changed. On 3/11/25 at 0926 hours, an observation and concurrent interview was conducted with LVN 3. When asked when Resident 82's nasal cannula was changed, LVN 3 stated he was not sure and would need to get a new nasal cannula tubing. LVN 3 verfied the nasal tubing should have been labeled with the name and date when it was changed for infection prevention and control. 2. Medical record review for Resident 712 was initiated on 3/11/25. Resident 712 was admitted to the facility on [DATE]. Review of Resident 712's Order Summary Report for March 2025 showed a physician's order dated 2/19/25, to administer the oxygen at a rate of 2 LPM via nasal cannula, may titrate up to 5 LPM for the oxygen saturation level less than 92% every shift. On 3/11/25 at 0914 hours, during the initial tour of the facility, an observation was conducted with Resident 712. Resident 712 was observed receiving the oxygen at a rate of 2 LPM via nasal cannula. The nasal cannula was unlabeled with name and date when it was changed. On 3/11/25 at 0919 hours, an observation and concurrent interview was conducted with LVN 3. When asked when the nasal cannula was last changed for Resident 712, LVN 3 stated he was not able to recall when it was last changed. LVN 3 verified Resident 712's nasal cannula tubing was unlabeled with the name and date when it was changed. On 3/14/25 at 1045 hours, an interview was conducted with the DON. The DON was made aware and acknowledged Residents 82 and 712's nasal cannula tubing should have been labeled and dated on when it was changed. 3. Medical record review for Resident 52 was initiated on 3/11/25. Resident 52 was readmitted to the facility on [DATE]. Review of Resident 52's H&P examination dated 5/14/24, showed Resident 52 had no capacity to understand and make decisions. Review of Resident 52's Order Summary Report showed a physician's order dated 5/28/24, for oxygen at a rate of 2 LPM continuously. On 3/11/25 at 0943 hours, during the initial tour of the facility, an observation was conducted for Resident 52. Resident 52 was observed lying in bed asleep with oxygen at a rate of 3 LPM via nasal cannula. On 3/12/25 at 1029 hours, a concurrent observation and interview was conducted with LVN 1. Resident 52 was observed lying in bed asleep with oxygen via nasal cannula. When asked to check Resident 52's oxygen rate, LVN 1 stated Resident 52's oxygen rate was set at 3 LPM. LVN 1 verified Resident 52's physician's order for the continuous oxygen was to be administered at a rate of 2 LPM. LVN 1 further stated the physician's order for Resident 52 's oxygen was not followed. On 3/14/25 at 1400 hours, an interview was conducted with the DON. The DON was asked regarding the importance of following physician's orders, the DON stated it was very important to follow physician's orders. The DON stated the licensed nurses must check the residents' oxygen saturation level, assess residents' color, and make sure to administer the oxygen as per the physician's order. 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 ensure the non-pharmacological interventions for pain management was provided when one of one final sampled resident (Resident 34) reviewed for pain management. This failure had the potential to negatively affect Resident 34's well-being. Findings: Review of the facility's P&P titled Pain - Clinical Protocol dated 3/2018 showed the physician will order appropriate non-pharmacologic and medication interventions to address the individual's pain. Further review of the P&P showed the staff will provide the elements of a comforting environment and appropriate physical and complementary interventions; for example, positioning/repositioning, local heat or ice, and the opportunity to talk about chronic pain. On 3/11/24 at 0904 hours, Resident 34 was observed lying in her bed. Resident 34 stated she had pain on the right side of her body. RN 1 was observed entering the room of Resident 34. Resident 34 reported having pain on the right side of her body to RN 1. RN 1 then stated she would look if Resident 34 had any pain medication. RN 1 was not observed offering the non-pharmacological interventions to manage Resident 34's pain. Medical record review for Resident 34 was initiated on 3/11/25. Resident 34 was readmitted to the facility on [DATE]. Review of the Resident 34's Care Plan Report dated 11/24/22, showed a care plan problem addressing Resident 34's pain with the goal of reducing episodes of pain or discomfort through appropriate interventions daily. The interventions included to provide non-pharmacological interventions: positioning for comfort, hot pack, cold pack, massage, and distraction. Review of Resident 34's H&P examination dated 5/2/24, showed Resident 34 had the capacity to understand and make decisions. Review of Resident 34 's Physician Order Summary showed an order dated 1/8/25, to administer tramadol (pain medicine) 50 mg one tablet by mouth every eight hours as needed for moderate to severe pain (pain level of 6-10, on a pain scale of 0 to 10, with 0 indicating no pain and 10 indicating the worst possible pain). Review of Resident 34's MAR dated 3/1- 3/31/25, showed Resident 34 had a pain level of 7 on 3/8/25 at 1700 hours, 3/9/25 at 1700 hours, 3/11/25 at 0742 hours, and 3/12/25 at 0959 hours. Further review of Resident 34's MAR showed the tramadol 50 mg medication was administered on the above dates and time. Further review of Resident 34's medical record did not show the non-pharmacological interventions were provided to Resident 34, when Resident 34 had a pain level of 7 on the above dates and times. On 3/12/24 at 1409 hours, an interview and concurrent medical record review for Resident 34 was conducted with RN 1. RN 1 verified the above findings and stated the non-pharmacological interventions should be provided to the residents to manage their pain. RN 1 stated there was no physician's order for the non-pharmacological interventions related to the use of the tramadol medication for Resident 34. RN 1 stated she was not able to find the documented evidence to show the non-pharmacological interventions were provided to Resident 34 when the resident had the pain level of 7 on the above dates and times. On 3/14/25 at 0946 hours, 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 provide the necessary care and services to attain or maintain the highest physical well-being for one of one final sampled resident (Resident 10) reviewed for hemodialysis care. * The facility failed to ensure the licensed staff have the competency to assess the hemodialysis access site of Resident 10. This failure had the potential for the delay in hemodialysis site assessment and resident's poor health outcomes. Findings: Review of the facility's P&P titled Care of Resident with End-Stage Renal Disease (undated) showed the following: - Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents; and - Education and training of staff includes, specifically the nature and clinical management of ESRD, the type of assessment data that is to be gathered about the resident's condition on a daily basis or per shift basis and the care of grafts and fistulas. Medical record review for Resident 10 was initiated on 3/12/25. Resident 10 was readmitted to the facility on [DATE]. Review of Resident 10's MDS dated [DATE], showed Resident 10's BIMS score was 14, indicating cognitively intact. Review of Resident 10's H&P examination dated 2/21/25, showed Resident 10 had the capacity to understand and make decisions. Review of Resident 10's Order Summary Report dated 3/13/25, showed the physician's order to monitor the shunt or graft for bruit (a whooshing sound heard with a stethoscope), and thrill (a buzzing vibration felt over the fistula) every shift. On 3/13/25 at 0904 hours, an interview was conducted with LVN 1. LVN 1 was asked how to check for the bruit and thrill. LVN 1 stated she would use the stethoscope to check for bruit and thrill. On 3/13/25 at 0929 hours, an interview was conducted with RN 3. RN 3 was asked how to assess Resident 10's Arteriovenous (AV) Fistula (a surgical procedure that creates a connection between an artery and a vein, typically in the forearm, to facilitate hemodialysis in patients with kidney failure) access site for dialysis and she stated check the lumen, sometimes it has two lumens. Furthermore, RN 3 stated the lumens should be intact and patent. On 3/13/25 at 1021 hours, an interview was conducted with LVN 2. LVN 2 was asked how to check for bruit and thrill on Resident 10's AV fistula access site. LVN 2 stated to listen to the flow for thrill and feel the vibrations for bruit. Review of facility's Dialysis In-Service dated 2/1/25, showed a lesson plan titled Care of Resident Receiving Renal Dialysis and licensed nurse attendees, included three out five licensed nurses who were interviewed. On 3/14/25 at 1400 hours, an interview was conducted with the DON. The DON was asked how to assess for bruit and thrill. The DON stated to listen using a stethoscope for the bruit and feel for the thrill. The DON was informed and acknowledged the above findings. Furthermore, the DON stated she would have an in-service for the licensed nurses on how to properly assess the access site of the hemodialysis residents.

**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 seven of eight final sampled residents (Residents 9, 45, 47, 51, 52, 89, and 99) reviewed for the side rail use remained free from the accident hazards associated with the use of the elevated side rails. * The facility failed to ensure the side rails assessment was accurate or completed, and/or the least restrictive measures were provided prior to the use of the side rails for Residents 9, 45, 47, 51, 52, 89, and 99. These failures had the potential to put the residents at risk for entrapment and serious injuries. Findings: Review of the facility's P&P titled Bed Safety and Bed Rails revised on 3/2023 showed the following: - The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for the use of bed rails have been met, including the attempts to use an alternatives, interdisciplinary evaluation, resident assessment, and informed consent; and - Alternatives to the use of side or bed rails are attempted. Alternatives may include roll guards, foam bumpers, lowering the bed and/or use of concave mattresses to reduce rolling off the bed. 1. On 3/12/25 at 0952 hours, an observation was conducted for Resident 51. Resident 51 was observed lying in bed, awake, alert, with the bilateral half upper side rails elevated. Medical record review for Resident 51 was initiated on 3/14/25. Resident 51 was admitted to the facility on [DATE]. Review of Resident 51's Order Summary Report showed a physician's order dated 10/4/23, for the bilateral upper half side rails up and locked when in bed as an enabler for positioning and ease of mobility. Review of Resident 51's NA-Restraint-Physical (Initial Evaluation) dated 10/4/23, did not show if the alternatives were attempted prior to the application of the bilateral half upper side rails. Review of Resident 51's H&P examination dated 10/9/24, showed Resident 51 had the capacity to understand and make decisions. Review of Resident 51's MDS dated [DATE], showed Resident 51's BIMS score was 14, indicating cognitively intact. On 3/14/25 at 1019 hours, a concurrent observation and interview was conducted with CNA 2. CNA 2 verified Resident 51's bilateral half upper side rails were elevated. CNA 2 stated Resident 51 was able to hold on the side rails during the repositioning with an extensive assistance from the staff. On 3/14/25 at 1025 hours, a concurrent observation and interview was conducted with LVN 1. LVN 1 verified Resident 51's bilateral half upper side rails were elevated. LVN 1 stated Resident 51 was able to use the side rails as an enabler for repositioning with assistance from the staff. On 3/14/25 at 1029 hours, a concurrent interview and medical record review was conducted with RN 2. RN 2 verified there were no documentation to show if the alternatives were attempted prior to the application of Resident 51's bilateral half upper side rails. RN 2 verified and stated the least restrictive interventions must be attempted prior to the application of the side rails. 2. On 3/11/25 at 0943 hours, during the initial tour of the facility, a concurrent observation and interview was conducted with CNA 2. Resident 52 was observed lying in bed asleep with the bilateral upper half side rails elevated. CNA 2 stated Resident 52's bilateral arms and hands were contracted and unable to grab or use the side rails. Medical record review for Resident 52 was initiated on 3/11/25. Resident 52 was readmitted to the facility on [DATE]. Review of Resident 52's H&P examination dated 5/14/24, showed Resident 52 had no capacity to understand and make decisions. In addition, Resident 52 had a history of Spastic Quadriplegic Cerebral Palsy (the most severe form of spastic cerebral palsy, affecting all four limbs, often the trunk and face, with increased muscle tone (spasticity) and resulting in challenges with movement, balance, and coordination), and contracture on the right wrist and both hands. Review of Resident 52's NA-Restraint-Physical (Initial Evaluation) dated 5/12/24, showed the summary of the IDT review for Resident 52 to have the bilateral upper half side rails as an enabler for repositioning and ease of mobility. Review of Resident 52's MDS dated [DATE], under the section for the Functional Abilities, showed Resident 52 had an impairment to both upper extremities and was dependent for staff assistance for the mobility. Review of Resident 52's Order Summary Report dated 3/12/25, showed a physician's order dated 5/13/24, for the bilateral upper half side rails up and locked when in bed as an enabler for positioning and ease of mobility. On 3/12/25 at 1029 hours, a concurrent observation and interview was conducted with LVN 1. LVN 1 verified Resident 52's bilateral upper half side rails were elevated. LVN 1 stated Resident 52's bilateral upper extremities were still and contracted. In addition, LVN 1 stated Resident 52 was a total care with the ADL care and unable to use the side rails. On 3/14/25 at 1044 hours, a concurrent interview and medical record review was conducted with RN 2. RN 2 stated Resident 52 was not appropriate to have the bilateral upper half side rails due to Resident 52 could not grab the side rails to help turn or reposition. On 3/14/25 at 1400 hours, an interview was conducted with the DON. The DON verified Resident 52 could not grab the side rails and stated she would inform the physician to obtain an order to discontinue the side rails. The DON was informed and acknowledged the above findings. 3. On 3/11/25 at 0844 hours, an observation was conducted for Resident 45. Resident 45 was observed lying in bed on his back with the bilateral upper half side rails elevated. Medical record review for Resident 45 was initiated on 3/11/25. Resident 45 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 45's NA-Restraint-Physical (Initial Evaluation) dated 10/31/24, showed the following alternatives were attempted prior to the application of the side rails: - anticipating hunger, pain, heat, cold; - acceptance of risk; - normal schedule/individual routine; - medication review; and - bloodwork/labs review. Review of Resident 45's Side Rail/Entrapment Assessment/Care Plan dated 10/31/24, showed the recommendation for the bilateral upper half side rails was due to Resident 45's generalized muscle weakness. Review of Resident 45's H&P examination dated 11/2/24, showed the resident had no capacity to understand and make decisions. Review of Resident 45's Order Summary Report showed a physician's order dated 3/1/25, for the bilateral upper half side rails up when in bed for positioning and ease of mobility. On 3/12/25 at 1411 hours, a concurrent observation and interview was conducted with LVN 1. LVN 1 verified Resident 45's bed had the bilateral upper half side rails elevated. On 3/12/25 at 1429 hours, an interview and concurrent medical record review for Resident 45 was conducted with the MDS RN. The MDS RN verified Resident 45's medical record failed to show the least restrictive alternatives were attempted prior to the installation of the bilateral upper half side rails. 4. Medical record review for Resident 47 was initiated on 3/11/25. Resident 47 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 47's NC-Side Rail/ Entrapment Assessment/Care Plan dated 4/13/24 and 1/11/25, showed the reason for Resident 47's use of the bilateral upper half side rails was due to the resident's generalized weakness. Review of Resident 47's Order Summary Report dated 3/14/25, showed a physician's order dated 1/12/25, for the bilateral upper half side rails up and locked when in bed as an enabler for positioning and ease of mobility. On 3/14/25 at 1308 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 stated Resident 47 should have an assessment completed for the physical restraint in her medical record prior the use of the bilateral upper half side rails. RN 2 was asked if a physical restraint assessment was initiated for Resident 47, RN 2 stated she did not see it in her medical record. Furthermore, RN 2 stated the least restrictive measure should have been implemented and tried for Resident 47 prior to ordering the bilateral upper half side rails for the resident. On 3/14/25 at 1335 hours, an interview and concurrent medical record review was conducted with the MDS RN. The MDS RN was asked if Resident 47 had a physical restraints assessment completed before the physician ordered the bilateral upper half side rails. The MDS RN stated, no and verified there was no physical restraint assessment documented for Resident 47. The MDS RN was asked if the least restrictive measures regarding the restraints were used for Resident 47. The MDS RN stated there was no way to know since the physical restraint assessment was not completed for Resident 47. 5. Medical record review for Resident 9 was initiated on 3/11/25. Resident 9 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 9's NA-Restraint-Physical (Initial Assessment) dated 1/29/25, the section for the History/Alternatives Attempted failed to show any alternative measures were attempted prior to Resident 9's use of the bilateral upper half side rails. Review of Resident 9's Order Summary Report dated 3/13/25, showed a physician's order dated 1/30/25, for the bilateral upper half side rails up and locked when in bed as an enabler for positioning and ease of mobility. On 3/14/25 at 1314 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 was asked what alternative measures were attempted and documented for Resident 9 prior to the use of the bilateral upper half side rails. RN 2 stated the restraint-physical assessment had no documentation if any alternative measures were provided prior to the use of the bilateral upper half side rails for Resident 9. On 3/14/25 at 1407 hours, an interview and concurrent medical record review was conducted with the MDS RN. The MDS RN was asked what alternative measures were attempted for Resident 9 prior to the use of the bilateral upper half side rails. The MDS RN stated the NA-Restraint-Physical assessment had no documented evidence if any alternative measures were provided prior to the use of the bilateral upper half side rails for Resident 9. 6. Medical record review for Resident 99 was initiated on 3/11/25. Resident 99 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 99's Order Summary Report dated 3/13/25, showed a physician's order dated 2/24/25, for the bilateral upper half side rails up and locked when in bed as an enabler for positioning and ease of mobility. Review of Resident 99's NA-Restraint- Physical (Initial Assessment) dated 2/24/25, the section for the History/Alternatives Attempted failed to show any alternative measures were attempted prior to Resident 99's use of the bilateral upper half side rails. On 3/14/25 at 1316 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 was asked what alternative measures were attempted prior to the use of the bilateral upper half side rails for Resident 99. RN 2 stated there was no documented evidence if any alternative measures were provided prior to the use of the bilateral upper half side rails for Resident 99. On 3/14/25 at 1350 hours, an interview and concurrent medial review was conducted with the MDS RN. The MDS RN was asked what alternative measures were attempted prior to the use of the bilateral upper half side rails for Resident 99. The MDS RN stated there was no documented evidence if any alternative measures were provided prior to the use of the bilateral upper half side rails for Resident 99 and detailed reason for the use of the side rails. 7. Medical record review for Resident 89 was initiated on 3/11/25. Resident 89 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 89's NA-Restraint-Physical (Initial Assessment) dated 8/27/24, the section for the History/Alternatives Attempted failed to show any alternative measures were attempted prior to Resident 89's use of the bilateral upper half side rails. Review of Resident 89's Order Summary Report dated 3/13/25, showed a physician's order dated 8/27/24, for the bilateral upper half side rails up and locked when in bed as an enabler for positioning and ease of mobility. Review of Resident 89's NA-Restraint-Physical (Initial Assessment) dated 8/27/24, the section for the History/Alternatives Attempted failed to show any alternative measures were attempted prior to Resident 89's use of the bilateral upper half side rails. On 3/14/25 at 1321 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 was asked what alternative measures were attempted and documented prior to the use of the bilateral upper half side rails for Resident 89. RN 2 stated there was no documentation if any alternative measures were provided prior to the use of the bilateral upper half side rails for Resident 89. On 3/14/25 at 1405 hours, an interview and concurrent medial review was conducted with the MDS RN. The MDS RN was asked what alternative measures were attempted prior to the use of the bilateral upper half side rails for Resident 89. The MDS RN stated there was no documentation if any alternative measures were provided prior to the use of the bilateral upper half side rails for Resident 89.

**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 physician's orders matched the medication label provided by the pharmacy and medication was administered as ordered by the physician for two of three residents (nonsampled residents, Residents 18 and 48) reviewed during the medication administration as evidence by the following: * The facility failed to ensure Resident 18's physician's order for the digoxin (heart medication) matched the instructions shown on the medication label of the bubble pack provided by the pharmacy. * The facility failed to ensure Resident 48's metoprolol tartrate (blood pressure medication) medication was administered with food as ordered by the physician. These failures posed the risk for negative health outcomes to the residents. Findings: Review of the facility's P&P titled Administering Medications revised 3/2023 showed the medications are administered in a safe and timely manner, and as prescribed. The medication are administered in accordance with prescriber orders, including any required time frame. Review of the facility's P&P titled Medication Orders revised 3/2023 showed when recording orders for the medication, to specify the type, route, dosage, frequency, and strength of the medication ordered. 1. Medical record review for Resident 18 was initiated on 3/11/25. Resident 18 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 18's H&P examination dated 6/18/24, showed Resident 18 had no mental capacity to understand and make decisions. Review of Resident 18's Order Summary Report for March 2025 showed a physician's order dated 6/17/24, for digoxin 125 mcg two tablets (250 mcg) via GT one time a day for atrial fibrillation (an abnormal heartbeat) and hold if the HR less than 60 beats per minute. Review of Resident 18's MAR for March 2025 showed Resident 18 was administered with two tablets of digoxin 125 mcg medication at 0900 hours, from 3/1 to 3/12/25. Review of Resident 18's digoxin medication label on the bubble pack provided by the pharmacy showed the instructions to administer one tablet of digoxin 250 mcg via GT one time a day for atrial fibrillation and hold if the HR less than 60 beats per minute. On 3/12/25 at 0914 hours, a concurrent medication administration observation and medical record review for Resident 18 was conducted with LVN 8. LVN 8 verified the medication label on the bubble pack from the pharmacy showed to administer one tablet of digoxin 250 mcg tablet medication. LVN 8 further verified he administered one tablet of digoxin 250 mcg to Resident 18. On 3/12/25 at 1409 hours, a follow-up interview and concurrent medical record review was conducted with LVN 8. LVN 8 verified Resident 18's physician's order for the digoxin medication showed to administer two tablets of the digoxin 125 mcg; however, the medication label on the bubble pack provided by the pharmacy showed to administer one tablet of digoxin 250 mcg medication. LVN 8 acknowledged the orders and instructions did not match and verified there was no evidence a change of direction label was placed on Resident 18's digoxin medication bubble pack. LVN 8 stated the instructions should match with the physician's orders to ensure the right dose of the medication was administered. 2. Medical record review for Resident 48 was initiated on 3/11/25. Resident 48 was admitted to the facility on [DATE]. Review of Resident 48's Order Summary Report for March 2025 showed a physician's order dated 2/3/25, for metoprolol tartrate 50 mg one tablet by mouth two times a day for hypertension (elevated blood pressure), hold if the SBP less than 110 mmHg or HR less than 60 beats per minute, and to administer with food. Review of Resident 48's H&P examination dated 2/6/25, showed Resident 48 had the capacity to understand and make decisions. On 3/12/25 at 1015 hours, a medication administration observation was conducted for Resident 48 with LVN 1. LVN 1 was observed administering the metoprolol tartrate medication to Resident 48 without food instead of with food as ordered by the physician. On 3/12/25 at 1346 hours, an interview was conducted with LVN 1. LVN 1 verified she did not administer Resident 48's metoprolol tartrate medication with food as ordered by the physician. LVN 1 stated she should have provided Resident 48 with food as instructed in the physician's order. LVN 1 further stated she could have provided Resident 48 with food such as crackers or pudding. On 3/14/25 at 1320 hours, an interview was conducted with the Administrator and DON with the Regional Director of Operations present. The Administrator and DON were made aware and acknowledged all of the above 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 two of five final sampled residents (Residents 34 and 44) were free from the unnecessary psychotropic drugs (any drug that affects brain activity associated with mental processes and behavior). * The facility failed to ensure non-pharmacological interventions were implemented for the depression and anxiety behaviors exhibited by Resident 34. * The facility failed to ensure non-pharmacological interventions were implemented for the bipolar behaviors exhibited by Resident 44. These failures had the potential to place the residents at risk for receiving the unnecessary medications and increased risk of serious medication adverse reactions. Findings: Review of the facility's P&P titled Use of Psychotropic Medication use dated 3/2023 showed in part, a psychotropic drug is any drug that affects the brain activities associated with the mental processes and behavior, which includes the antipsychotics, anxiolytics, hypnotics, and antidepressants .Facility should use non- pharmacological approaches (unless contraindicated to minimize the need for the medication, permit the lowest possible dose, and allow for the discontinuation of the medications when possible. 1. Medical record review for Resident 34 was initiated on 3/11/25. Resident 34 was admitted to the facility on [DATE]. Review of Resident 34's Order Summary Report dated 3/12/25, showed a physician's order dated 1/13/24, for the following: - buspirone HCL (antianxiety medication) 7.5 mg one tablet by mouth two times a day for anxiety as manifested by panicky feelings causing stress, and - escitalopram oxalate (antidepressant medication) 10 mg one tablet by mouth one time a day for depression as manifested by self-expression of sadness. Review of Resident 34's MAR for March 2025 showed from 3/1 to 3/11/25, Resident 34 had 24 episodes of depression as manifested by self-expression of sadness and anxiety as manifested by panicky feelings causing stress. Review of Resident 34's medical record showed the non-pharmacological interventions were not identified or documented as an option to be implemented when Resident 34 had the episodes of depression and anxiety. On 3/13/25 at 1440 hours, an interview and concurrent medical record review for Resident 34 was conducted with RN 1. RN 1 verified Resident 34 was receiving the buspirone HCL and escitalopram oxalate medications. RN 1 also verified Resident 34 had 24 episodes of depression as manifested by self-expression of sadness and anxiety as manifested by panicky feelings causing stress. RN 1 was not able to show the non-pharmacological interventions documentation. 2. Medical record review for Resident 44 was initiated on 3/11/25. Resident 44 was readmitted to the facility on [DATE]. Review of Resident 44's Order Summary Report dated 3/13/25, showed a physician order dated 10/29/24, for Abilify (antipsychotic medication) 5 mg one tablet via GT at bedtime for bipolar disorder as manifested by angry outburst. Review of Resident 44's MAR for March 2025 showed from 3/1 to 3/12/25, Resident 44 had 26 episodes of bipolar disorder as manifested by angry outburst. Review of Resident 44's medical record showed the non-pharmacological interventions were not identified or documented as an option to be implemented when Resident 44 had episodes of bipolar disorder. On 3/14/25 at 0811 hours, an interview and concurrent medical record review for Resident 44 was conducted with RN 2. RN 2 verified Resident 44 was receiving the Abilify medication. RN 2 also verified Residents 44 had 26 episodes of bipolar disorder as manifested by angry outburst. RN 2 was not able to show the non-pharmacological interventions documentation. On 3/14/25 at 0946 hours, the DON was 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 provide the necessary pharmacy services to ensure the proper storage and disposal of the medications. * The facility failed to store the external and internal medications separately in Medication Storage Room A and Medication Cart G. * The facility failed to ensure seven out of eight sampled Medication Carts (Medication Carts A, B, C, D, E, G, and H) were maintained in a clean and sanitary manner. * The facility failed to ensure Residents 19 and 98's Assure Platinum Meter Serial Number in the blood glucose monitoring system record were accurately documented. These failures had the potential to negatively impact the residents' well-being, and the potential for the medications to lose the stability and effectiveness. Findings: Review of the facility's P&P titled Storage of Medications dated 3/2023 showed the facility stores all the drugs and biologicals in a safe, secure, and orderly manner. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. 1.a. On 3/12/25 at 0926 hours, an inspection of Medication Storage Room A and concurrent interview was conducted with RN 1. Boxes of bisacodyl stimulant laxative suppository (medication to relieve constipation) were observed being stored together with the boxes of artificial tears lubricant eyedrops (medication to moisten dry eyes) on the second shelf. RN 1 acknowledged the rectal medications and eyedrops medications should not be stored together. b. On 3/12/25 at 1200 hours, an inspection of Medication Cart G and concurrent interview was conducted with LVN 6. An open box of loperamide hcl 2 mg tablets (medication to relieve diarrhea), an open spray bottle of fluticasone propionate 50 mg nasal spray (medication to reduce inflammation of nasal passages) and three boxes of artificial tears lubricant eyedrops were stored together in the left middle drawer of Medication Cart G. LVN 6 verified the medications should not be stored together. 2.a. On 3/12/25 at 1024 hours, an inspection of Medication Cart A and concurrent interview was conducted with RN 1. The following was observed: - A bag of disinfecting caps for intravenous ports had sticky yellow residue. - The top drawer compartment had a streak of sticky yellow brown residue. RN 1 verified the above findings. b. On 3/12/25 at 1033 hours, an inspection of Medication Cart B and concurrent interview was conducted with RN 1. The following was observed: - The drawer compartment containing the tuberculin syringes was not clean and had dried brown medication residue. - The drawer compartment containing scissors and tape for labeling had dried yellow brown medication residue. RN 1 verified the above findings. c. On 3/12/25 at 1047 hours, an inspection of Medication Cart C and concurrent interview was conducted with LVN 7. The following was observed: - The top drawer compartment was not clean and had dried brown residue. - A bottle of Lactulose Solution (medication to relieve constipation) medication had spilled medication residue on the top part of the bottle. LVN 7 verified the above findings and stated the cart should be clean for infection prevention and control. d. On 3/12/25 at 1108 hours, an inspection of Medication Cart D and concurrent interview was conducted with LVN 8. The following was observed: - The bottom drawer was not clean and had spilled dried yellow brown residue. - A bottle of liquacel concentrated liquid protein (protein supplement) had spilled sticky medication residue on the upper part of the bottle. - A bottle of milk of magnesia (medication to relieve constipation) medication had spilled medication residue on the upper part of the bottle. - A bottle of lactulose Solution medication had spilled medication residue on the upper part of the bottle. LVN 8 verified the above medication bottles should be clean for infection prevention and control. e. On 3/12/25 at 1135 hours, an inspection of Medication Cart E and concurrent interview was conducted with LVN 3. The following was observed: - The top drawer compartment was not clean and had dried brown residue. - The bottom drawer compartment was not clean and had dried brown medication residue. LVN 3 verified the medication cart drawers should be clean for infection prevention and control. f. On 3/12/25 at 1200 hours, an inspection of Medication Cart G and concurrent interview was conducted with LVN 6. The following was observed: - A bottle of milk of magnesia medication had spilled medication residue on the upper part of the bottle. - A bottle of liquacel concentrated liquid protein had spilled sticky medication residue on the upper part of the bottle. - A bottle of Lactulose Solution medication had spilled medication residue on the upper part of the bottle. - The bottom drawer was not clean and had brown residue. LVN 6 verified the above findings. g. On 3/12/25 at 1330 hours, an inspection of Medication Cart H and concurrent interview was conducted with LVN 9. The following was observed: - The top drawer compartment with the tongue depressors was not clean and had white powdered medication residue. - The compartment drawer with the antifungal ointment medication was not clean and had white powdered medication residue. LVN 9 verified the above findings. 3. On 3/12/25 at 1047 hours, an interview and concurrent medical record review of Resident 98's Assure Platinum Blood Glucose Monitoring System was conducted with LVN 7. Resident 98's recorded serial number on the Assure Platinum Blood Glucose Monitoring System was documented as 1070-4372514. However, the label on Resident 98's Assure Platinum Blood Glucose Meter Machine's serial number was 1040-4273532. LVN 7 verified the numbers needed to be corrected immediately. LVN 7 further stated the machine was used solely for Resident 98 and labeled with Resident 98's name. On 3/12/25 at 1135 hours, an interview and concurrent medical record review of Resident 19's Assure Platinum Blood Glucose Monitoring System was conducted with LVN 8. Resident 19's recorded serial number on the Assure Platinum Meter Serial Number was documented as 1040-4324799. However, the label on Resident 19's Assure Platinum Blood Glucose Meter Machine's serial number was 1040-4324798. LVN 8 verified the numbers were recorded incorrectly. LVN 8 stated Resident 19's Assure Platinum Blood Glucose Meter Machine was used solely for Resident 19 since the machine and labeled with Resident 19's name. On 3/14/25 at 1045 hours, an interview was conducted with the DON. The DON verified the above findings.

Based on observation, interview, and facility P&P review, the facility failed to ensure the nutrient content of pureed vegetables was preserved when pureed vegetables were prepared more than one hour prior to meal service and held in an oven at 500 degrees F. This failure posed the risk of 15 residents on a puree diet to not meet their nutritional needs. Findings: Review of the Order Listing Report dated 3/11/25, showed 15 residents had physician's orders for a pureed diet. During the review of the professional reference titled, https://www.healthline.com/nutrition/cooking-nutrient-content, dated 11/7/2019, the reference showed in part, . The following nutrients are often reduced during cooking: water-soluble vitamins: vitamin C and the B vitamins - thiamine (B1), riboflavin (B2), niacin (B3), pantothenic acid (B 5), pyridoxine (B6), folic acid (B9), and cobalamin (B12), fat-soluble vitamins: vitamins A, D, E, and K, and minerals: primarily potassium, magnesium, sodium, and calcium . On 3/12/25 at 1011 hours, an observation of the puree preparation and concurrent interview was conducted with [NAME] 1. [NAME] 1 stated he was preparing 13 portions of the puree stir fry vegetables. [NAME] 1 had placed 13 ½ cup servings of the stir fry vegetables previously cooked in chicken broth, into the Robot Coupe (RC, a device used to puree food). The stir fry vegetables were blended until a pudding consistency was obtained then placed in a pan and stored in the oven at 500 degrees fahrenheit (F) until the lunch meal tray line began at 1146 hours. On 3/13/25 at 1041 hours, an interview was conducted with the RD. The RD agreed that storing the pureed vegetables in an oven at 500 degrees F for more than one hour prior to the meal service was not the ideal way to preserve the nutrients of the pureed vegetables.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility document review, the facility failed to ensure two of 10 final residents reviewed for dining (Residents 11 and 85) received food prepared in a form to meet their individual dietary needs. * The facility failed to ensure Resident 11 was provided with the minced and moist diet as per physician's diet order. * The facility failed to ensure Resident 85 was provided with the mechanical soft snacks as per the resident's diet order. These failures placed Residents 11 and 85 at risk for aspiration (accidental breathing in of food or fluid into the lungs) or choking. Findings: 1. Medical record review for Resident 11 was initiated on 3/11/25. Resident 11 was readmitted to the facility on [DATE]. Review of Resident 11's SLP Evaluation and Plan of Treatment dated 3/12/24, showed Resident 11 was currently edentulous (toothless) per dentist recommendation and was awaiting a procedure on her gums to improve the ability to wear dentures. Further review of the SLP Evaluation and Plan of Treatment showed Resident 11 had difficulty chewing tough/fibrous material but refused to be downgraded to a puree diet. The recommendation showed for minced and moist textures, thin liquid and puree vegetables only per the residents' request. Review of Resident 11's Order Summary Report for March 2025 showed a physician order dated 3/12/25, for no added salt diet, minced and moist texture (foods must be soft, moist, and easily formed into a ball, with no hard lumps and pieces no larger than 4 mm), thin consistency, low purine diet, no beans, no nuts, oatmeal with breakfast lunch and dinner. Puree vegetables only. Review of Resident 11's H&P examination dated 7/26/24, showed Resident 11 had the capacity to understand and make decisions. On 3/11/25 at 0959 hours, an interview was conducted with Resident 11. Resident 11 stated she was in a process of getting an oral surgery and could not use her dentures. Resident 11 further stated the facility had been providing her with minced diet; however, sometimes she would get food in big pieces which was hard for her to swallow. On 3/11/25 at 1224 hours, Resident 11 was observed eating her lunch in the dining room. Resident 11's food on the tray was mashed potatoes, cooked green leaves, chicken in pieces, milk, dessert, puree salad, and a bowl of oatmeal. Resident 11's plate had dry pieces of chicken approximately more than 1 cm long and was not finely minced and moist. Resident 11 was observed taking lumps of the chicken pieces out of her plate and putting it aside. Resident 11 stated the pieces of the chicken in her plate were big for her to swallow. On 3/11/25 at 1232 hours, an observation and concurrent interview was conducted with the DSD. The DSD verified the above observation and stated the chicken Resident 11 received was not moist and was not minced properly. The DSD was observed offering Resident 11 another tray of the meal. On 3/11/25 at 1240 hours, an observation and concurrent interview was conducted with the DSS. The DSS verified the observation and stated the chicken in Resident 11's plate was not minced and moist. The DSS stated she would replace the meal for Resident 11. On 3/11/25 at 1245 hours, Resident 11 was observed receiving another replacement tray for her lunch which included finely minced and moist chicken. Resident 11 stated she was finally able to easily swallow the food served. On 3/11/25 at 1251 hours, an interview was conducted with the SLP. The SLP was informed and verified the above findings and stated the food Resident 11 receive should be finely minced and moist that required very little or no chewing. On 3/14/25 at 0946 hours, the DON was informed and acknowledged the above findings. 2. Medical record review for Resident 85 was initiated on 3/11/25. Resident 85 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 85's Order Summary Report for March 2025 showed a physician order dated 12/23/24, for an oral great diet. Puree texture, nectar/mildly thick consistency. Patient may have occasional soft and bite sized snacks/mechanical soft snacks upon request for per resident request only. Review of Resident 85's annual MDS dated [DATE], showed Resident 85 had a BIMS score of 14 which meant the resident was cognitively intact. On 3/11/25 at 0929 hours, during the initial tour observation, Resident 85 was in bed eating saltine crackers. There were three packets of saltine crackers on the resident's bedside table. On 3/11/25 at 1222 hours, a concurrent observation and interview was conducted with Resident 85 in her room. When asked if the resident eats the saltine crackers via her cellphone to communicate, Resident 85 replied it takes forever to eat the saltine crackers. On 3/11/25 at 1226 hours, a concurrent observation, interview, and medical record review was conducted with LVN 12. LVN 12 verified there were a total of eight saltine crackers at Resident 85's bedside table. LVN 12 stated Resident 85 was given saltine crackers; however, has a hard time eating them. LVN 12 further verified Resident 85's diet order showed she was allowed for a soft and bite sized snacks and/or mechanical soft snacks. LVN 12 acknowledged the saltine crackers were not appropriate snacks and Resident 85 was at risk for aspiration or choking. On 3/11/25 at 1233 hours, an interview with the DSS was conducted. The DSS verified the saltine crackers were not considered a mechanical soft snack. On 3/11/25 at 1235 hours, a concurrent interview and medical record review with the RD was conducted. The RD verified Resident 85's diet orders. When the RD was asked if the saltine crackers were offered for the residents on a mechanical soft snacks, the RD stated it was not. On 3/11/25 at 1244 hours, a concurrent interview with the SLP was conducted. The SLP stated Resident 85 can have soft and bite size snacks. The SLP stated Resident 85 can have saltine crackers if it was dipped in water first; however, verified instructions were not on the diet order and stated not all the nurses were aware of her instructions regarding the saltine crackers should be dipped in water first prior to the resident eating it. On 3/14/25 at 1320 hours, an interview was conducted with the Administrator and DON with the Regional Director of Operations present. The Administrator and DON was made aware 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 ensure the food preferences were honored for one of 24 final sampled residents (Resident 10). This failure had the potential for decreased meal intake, weight loss, and a negative impact on the resident's psychosocial wellbeing. Findings: Review of the facility's P&P titled Resident Food Preferences (undated) showed the DSS will meet with the resident or representative to go over food preferences, allergies, likes and dislikes upon admission and as needed. The DSS will visit the resident periodically to ensure food preferences are being honored. Medical record review for Resident 10 was initiated on 3/11/25. Resident 10 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the facility's Resident Council minutes dated 1/14/25, showed Resident 10 requested the collard greens with meals. Review of the the Resident Council Response Form dated 1/14/25, showed the DSS would order the collard greens and have them in the facility for Resident 10. Review of Resident 10's care plan dated 1/23/25, showed the resident had a risk for alteration in nutritional status and was at risk for weight loss and malnutrition. The care plan interventions included adhering to Resident 10's food preferences. Review of Resident 10's H&P examination dated 2/21/25, showed Resident 10 had the capacity to understand and make decisions. Review of Resident 10's Order Summary Report showed a physician's order dated 2/28/25, for CCHO, NAS diet, regular texture, thin liquids, no orange juice, no potatoes, and no banana. On 3/12/25 at 1106 hours, an interview was conducted with Resident 10. Resident 10 stated they requested collard greens at the Resident Council meeting in January 2025. Resident 10 stated the facility had not informed her of the status of her request or if the facility was able to order the collard greens. Resident 10 stated the collard greens had not been served with any meals. On 3/13/25 at 1101 hours, an interview and concurrent medical record review was conducted with the DSS for Resident 10. The DSS verified Resident 10's request for the collard greens was received by the facility. The DSS stated the facility had not purchased the collard greens. The DSS verified the facility has not accommodated Resident 10's request for collard greens. The DSS verified Resident 10's medical record failed to show documentation of a follow-up with Resident 10 regarding the request for the collard greens. On 3/14/25 at 1503 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed of and acknowleged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to ensure food brought from the outside was stored for three nonsampled residents (Residents 57, 65, and 70). Additionally, the facility failed to ensure the visitors and staff were educated on safe food handling guidelines. These failures had the potential to expose residents who received food brought from the outside to food borne illnesses. Findings: Review of the facility's P&P titled Food from Outside Sources (undated) showed the food from outside sources is discouraged due to concerns with food safety and infection control and maintaining control of therapeutic diet orders. 1. While it is preferred that families and/or friends do not bring foods or beverages into the facility, it is within the resident's right to allow the resident to eat outside food, especially if an individual is eating poorly. If outside food is brought in, the facility is not liable for safety and infection control concerns. a. Review of Resident 70's medical record showed Resident 70 was admitted to the facility on [DATE], with diagnoses which included cardiomegaly (enlargement of the heart), old myocardial infarction (heart attack) and acute kidney failure. A No Added Salt diet was ordered by the physician on 1/3/25. On 3/11/25 at 1158 hours, an observation of the lunch meal in the dining room and concurrent interview was conducted with Resident 70's family member. Resident 70's family member brought a piece of cake for Resident 70. Resident 70's family member stated the facility did not like the family member to bring food from the outside because Resident 70 was on a special diet. When Resident 70's family member asked if she had received information from the facility regarding safe food handling guidelines, she stated she was not sure. b. Review of Resident 65's medical record showed Resident 65 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (a disease that results with too much sugar in the blood), alcoholic liver disease (liver damage caused by long term excessive alcohol consumption), and hepatic failure (liver failure). On 3/11/25 at 1201 hours, an observation of the lunch meal in the dining room and concurrent interview was conducted with Resident 65 using CNA 3 as a translator. Resident 65 was observed eating BBQ ribs and macaroni salad. Resident 65 stated his friend brought the food from the outside for him. When asked if his friend received information from the facility regarding safe food handling guidelines, Resident 65 stated he told his friends what foods they were allowed to bring to the facility. c. Review of Resident 57's medical record showed Resident 57 was admitted to the facility on [DATE], with diagnoses which included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebrovascular disease (medical emergency that encompasses a range of conditions affecting the brain's blood vessels and blood flow), and diabetes mellitus. On 3/11/25 at 1206 hours, an observation of the lunch meal in the dining room and concurrent interview was conducted with Resident 57's family member using the Activities Director as a translator. Resident 57's family member had brought in pureed chicken and rice in a plastic container. When asked if Resident 57's family member had received information from the facility regarding safe food handling guidelines, Resident 57's family member stated she had received information regarding Resident 57's diet. On 3/12/25 at 8:26 hours, an interview was conducted with RN 1. RN 1 was asked to explain the facility process for food brought to the facility from the outside. RN 1 stated they made sure the food was appropriate for the resident. When asked where the food from the outside was stored, RN 1 stated storage of the food was not allowed; the food must be eaten in one sitting. RN 1 confirmed there was no refrigeration available for storage of outside food. RN 1 was asked how the food from the outside was heated. RN 1 showed two microwave ovens located in the dining room. One microwave oven was observed with excess food debris inside. RN 1 stated the housekeeping was responsible to clean the microwave. On 3/12/25 at 0929 hours, an interview was conducted with the DSD. The DSD confirmed there was no staff training given regarding safe food handling guidelines.

4. According to the USDA Food Code 2022, Section 5-501.113 Covering Receptacles: Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered. (B) With tight-fitting or doors if kept outside the food establishment. On 3/13/25 at 0924 hours, an observation and interview were conducted with the Maintenance Director outside by the side of the building. The following was observed: - More than 10 large plastic trash bags piled on the ground along the block wall; and two empty cardboard boxes (one flattened) laying on top of the bags in the rain. - A gray wheeled trash bin with clear plastic bunched up in the bin, with a portion hanging over the top of the bin, there was no lid. - A black plastic trash bag filled with trash next to the building, with an empty cardboard box on top of it, and a broom propped against it. - Two hand carts with stacked cardboard boxes. Most of the boxes were flattened. The Maintenance Director verified the above findings were all trash/refuse, and stated the dumpsters were already full. On 3/13/25 at 1054 hours, during a follow-up observation with the Maintenance Director, a pile of more than 20 large trash bags full and closed with a knot, was observed along the block wall next to a storage unit in the back corner of the facility. The Maintenance Director stated that was also trash. Based on observation, interview, and facility P&P review, the facility failed to ensure the facility's garbage and refuse was properly disposed as evidence by: * The facility failed to ensure the waste dumpsters were properly closed. * The facility failed to ensure the organic waste and recycling refuse were handled as per state mandate SB1383. * The facility failed to ensure trash was placed in the appropriate containers and not stored in the trash bags placed on the ground or stacked on hand carts. These failures had the potential to cause unsafe sanitary conditions and potential to harbor pests and rodents. Findings: 1. According to the USDA Food Code 2022, Section 5-501.113 Covering Receptacles: Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered. (B) With tight-fitting or doors if kept outside the food establishment, Review of the facility's P&P titled Waste Control and Disposal (undated) showed outside garbage bin should be keep closed at all times and surrounding area must be kept clean. On 3/11/25 at 0733 hours, during the initial tour of the facility, an observation of the facility's garbage dumpsters was conducted. One of the four dumpsters was observed with the lid open and garbage inside. Another dumpster was observed with the lid propped open by garbage, preventing the lid from fully closing. On 3/11/25 at 1122 hours, an interview was conducted with Maintenance Director. The Maintenance Director verified the findings (via a photograph taken of the findings). On 3/12/25 at 0638 hours, an observation of the facility's outside dumpster located in front of the facility was conducted. One of four dumpsters was observed with the lid open and garbage inside. On 3/12/25 at 0849 hours, an interview was conducted with Maintenance Director. The Maintenance Director verified the findings (via a photograph taken of the findings). 2. Review of the Senate [NAME] (SB) 1383 regulation dated 1/1/22, showed every jurisdiction was to provide organic waste collection services to all residents and businesses. Jurisdiction includes city, county, a city and county, or a special district that provides solid waste collection services. Organic waste includes food, green material, landscape and pruning waste, organic textiles and carpets, lumber, wood, paper products, printing and writing paper, manure, biosolids, digestate, and sludges. On 3/11/25 at 1122 hours, an observation and concurrent interview was conducted with Maintenance Director. One organic waste barrel was observed in the dumpster storage area with the regular trash inside. The Maintenance Director verified the findings. On 3/11/25 at 1146 hours, an interview was conducted with the Administrator. The Administrator verified the facility was not collecting the organic trash. On 3/12/25 at 0804 hours, an interview was conducted with the DSS. The DSS verified the kitchen was not collecting the organic trash. 3. Review of California State [NAME] AB 341, also called the Mandatory Commercial Recycling Regulation, requires businesses and multi-family residential dwellings of five units or more, that generate four or more cubic yards of commercial solid waste per week to implement recycling programs, on or after 7/1/12. https://calrecycle.ca.gov/recycle/commercial/ According to the USDA Food Code 2022, Section 5-501.11 Storing Refuse, Recyclables, and Returnables showed refuse, recyclables, and returnables shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. On 3/11/25 at 1146 hours, an interview was conducted with the Administrator. The Administrator verified the facility was not collecting the recycle trash. On 3/14/25 at 0947 hours, an interview was conducted with the Administrator, RD, and DSS. The Administrator, RD, and DSS were informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, document review, and facility P&P review, the facility failed to ensure the medical records were accurately maintained for eight of 24 final sampled residents (Residents 9, 40, 45, 47, 51, 52, 72, 89, and 99). * The facility failed to ensure the respiratory care documentation for Resident 72 were accurate. * The facility failed to ensure the side rails assessment for the risk for entrapment for Residents 9, 40, 45, 47, 51, 52, 89, and 99 were accurate. These failures posed the risk for residents not to receive the necessary care and services as their medical records were not accurate. Findings: 1. Review of the facility's P&P titled Charting and Documentation revised on 7/2017 showed all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Medical record review for Resident 72 was initiated on 3/11/25. Resident 72 as admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 72's annual MDS dated [DATE], showed Resident 72's cognitive skills for daily decision making was severely impaired. Review of Resident 72's Order Summary Report for March 2025 showed the following physician orders: - dated 11/17/24, for Trach tube type: Portex 8 uncuffed - dated 11/17/24, to change trach tube: Portex 8 uncuffed as needed Further review of Resident 72's Order Summary Report showed no documented evidence the resident was on a ventilator. Review of the Progress Notes showed the license nurses documented Resident 72 was on a ventilator on the following dates: - 3/7/25 at 1929 hours, - 3/6/25 at 1714 hours, - 3/5/25 at 1725 hours, - 3/4/25 at 1733 hours, - 3/3/25 at 1704 hours, and - 2/28/25 at 1711 hours. On 3/14/25 at 1000 hours, a concurrent observation and interview was conducted with LVN 8 in Resident 72's room. LVN 8 verified Resident 72 was not on a ventilator and stated the resident had not been on a ventilator since he started working at the facility. On 3/14/25 at 1036 hours, a concurrent interview and medical record review was conducted with RT 2. RT 2 reviewed Resident 72's discontinued orders and verified the resident's ventilator orders were discontinued on 10/16/24. RT 2 acknowledged Resident 72's progress notes showed the resident was still on a ventilator and verified the above findings. RT 2 stated Resident 72 was not on a ventilator; however, the progress notes showed the resident was on a ventilator and could be confusing. RT 2 further stated it was important to assess and document accurately. On 3/14/25 at 1300 hours, a concurrent interview and medical record review was conducted with the DON. The DON verified Resident 72 was not on a ventilator; however, the nurses' progress notes documentation showed the resident was still on a ventilator. The DON stated she expected the licensed nurses to have proper documentation and to assess their residents rather than assuming the subacute residents were on a ventilator. On 3/14/25 at 1320 hours, an interview with the Administrator and DON was conducted with the Regional Director of Operations present. The Administrator and DON acknowledged and verified the above findings. 2. The FDA issued a Safety Alert entitled Entrapment Hazards with Hospital Bed Side Rails (1995). 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. 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 and Bed Rails dated March 2023 showed regardless of the mattress type, width, length, and/or depth, the bed frame, bed rail and mattress will leave no gap wide enough to entrap a resident ' s head or body. Any gaps in the bed system are within the safety dimensions established by the FDA, and the Maintenance Staff routinely inspects all beds and related equipment to identify the risk and problems including potential entrapment risks. a. On 3/12/25 at 0952 hours, an observation was conducted for Resident 51. Resident 51 was observed lying in bed, awake, and alert with the bilateral half upper side rails elevated. Medical record review for Resident 51 was initiated on 3/14/25. Resident 51 was admitted to the facility on [DATE]. Review of Resident 51's Order Summary Report dated 3/12/25, showed the physician's order dated 10/4/23, for the bilateral upper half side rails up and locked when in bed as an enabler for positioning and ease of mobility. On 3/14/25 at 1025 hours, a concurrent observation and interview was conducted with LVN 1. LVN 1 observed and verified the bilateral half upper side rails were elevated. Review of Resident 51's NC - Side Rail/Entrapment/Care Plan dated 1/6/25, showed Zones 1-7 were assessed and marked as they were within the measurement guidelines of less than four and 3/4 (three quarters) of an inch. On 3/14/25 at 1029 hours, a concurrent interview and medical record review was conducted with RN 2. RN 2 verified the entrapment assessment was inaccurate, and Zone 5 should have not been assessed since it was not applicable when there were no split bed rails. b. On 3/11/25 at 0943 hours, during the initial tour of the facility, a concurrent observation and interview was conducted with CNA 2. Resident 52 was observed lying in bed asleep with the bilateral upper half side rails elevated. CNA 2 stated Resident 52's bilateral arms and hands were contracted and unable to grab or use the side rails. Medical record review for Resident 52 was initiated on 3/11/25. Resident 52 was readmitted to the facility on [DATE]. Review of Resident 52's Order Summary Report showed a physician's order dated 5/13/24, for the bilateral upper half side rails up and locked when in bed as an enabler for positioning and ease of mobility. On 3/12/25 at 1029 hours, a concurrent observation and interview was conducted with LVN 1. LVN 1 verified Resident 52's bilateral upper half side rails were elevated. Review of Resident 52's NC - Side Rail/Entrapment/Care Plan dated 8/6/24, showed Zones 1-7 were assessed and marked as they were within the measurement guideline of less than four and 3/4 (three quarters) of an inch. On 3/14/25 at 1044 hours, a concurrent interview and medical record review was conducted with RN 2. RN 2 reviewed and verified Resident 52's Entrapment assessment was inaccurate and stated Zone 5 should have not been assessed since it was not applicable when there were no split bed rails. On 3/14/25 at 1400 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. c. On 3/11/25 at 0844 hours, an observation was conducted for Resident 45. Resident 45 was observed lying in bed on his back with the bilateral upper half side rails elevated. Medical record review for Resident 45 was initiated on 3/11/25. Resident 45 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 45's Order Summary Report dated 3/14/25, showed a physician's order dated 3/1/25, for the bilateral upper half side rails up when in bed for positioning and ease of mobility. Review of Resident 45's NC - Side Rail/Entrapment Assessment/Care Plan dated 10/31/24, showed the recommendation for the bilateral upper half side rails was due to Resident 45's generalized muscle weakness. Additionally, the Side Rail/Entrapment Assessment showed Resident 45's bed was assessed for entrapment on Zones 1-7 and all the zones were within the measurement guidelines of less than four and 3/4 (three quarters) of an inch. On 3/12/25 at 1411 hours, a concurrent observation and interview was conducted with LVN 1. LVN 1 verified Resident 45's bed had the bilateral upper half side rails elevated. On 3/14/25 at 1308 hours, an interview and concurrent medical record review for Resident 45 was conducted with RN 2. RN 2 verified Resident 45's NC - Side Rail/Entrapment Assessment/Care Plan dated 10/31/24, showed the entrapment assessment was conducted for Zones 1-7. RN 2 verified the assessment was inaccurate and stated the entrapment assessment for Zone 5 should have not been assessed as it was not applicable when there were no split bed rails. d. Medical record review for Resident 40 was initiated on 3/11/25. Resident 40 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 40's Order Summary Report dated 3/14/25, showed a physician's order dated 2/10/25, for the bilateral upper side rails for positioning due to gravity related to involuntary movements. On 3/14/25 at 1308 hours, an interview and concurrent medical record review for Resident 40 was conducted with RN 2. RN 2 verified Resident 40's NC - Side Rail/Entrapment Assessment/Care Plan dated 2/10/25, showed the entrapment assessment was conducted for Zones 1-7. RN 2 verified the entrapment assessment was inaccurate, and stated the entrapment assessment for Zone 5 should have not been assessed as it was not applicable when there were no split bed rails. On 3/14/25 at 1503 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. e. Medical record review for Resident 47 was initiated on 3/11/25. Resident 47 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 47's Order Summary Report 3/14/25, showed a physician's order dated 1/12/25, for the bilateral upper half side rails up and locked when in bed as enabler for positioning and ease of mobility. Review of Resident 47's NC-Side Rail/ Entrapment Assessment/Care Plan dated 4/13/24 and 1/11/25, showed the side rails for Zones 1-7 were assessed for the entrapment and marked as they were within the guidelines of less than four and 3/4 (three quarters) of an inch. On 3/14/25 at 1308 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 was asked if all the seven zones should have the check marks on the side rail entrapment assessment. RN 2 verified all the seven zones should not have the check marks for Resident 47 who had an order for only the bilateral upper half side rails and not the split bed rails. On 3/14/25 at 1335 hours, an interview and concurrent medical record review was conducted with the MDS RN. The MDS RN was asked about Resident 47's NC-Side Rail/ Entrapment Assessment/Care Plan dated 4/13/24, and 1/11/25. When asked if all the zones should have been assessed for entrapment for Resident 47, the MDS RN stated no and only the zones that were applicable to the physician's order should have the check marks. f. Medical record review for Resident 9 was initiated on 3/11/25. Resident 9 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 9's Order Summary Report dated 3/13/25, showed a physician's order dated 1/30/25, for the bilateral upper half side rails up and locked when in bed as an enabler for positioning and ease of mobility. Review of Resident 9's NC-Side Rail/ Entrapment Assessment/ Care Plan dated 1/29/25, showed the side rails for Zones 1-7 were assessed for entrapment and marked as they were within the guidelines of less than four and 3/4 (three quarters) of an inch. On 3/14/25 at 1314 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 was asked if all the seven zones should have the check marks on the NC-Side Rail/Entrapment Assessment/Care Plan dated 1/29/25. RN 2 verified all seven zones should not have the check marks for Resident 9 who had an order only for the bilateral upper half side rails and not the split bed rails. On 3/14/25 at 1407 hours, an interview and concurrent medical record review was conducted with the MDS RN. The MDS RN was asked if all the seven zones for Resident 9 should have been assessed for entrapment on the NC-Side Rail/Entrapment Assessment/Care Plan dated 1/29/25. The MDS RN verified all the seven zones should not have the check marks for Resident 9. g. Medical record review for Resident 99 was initiated on 3/11/25. Resident 89 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 99's Order Summary Report 3/13/25, showed a physician's order dated 02/24/25, for the bilateral upper half side rails up and locked when in bed as an enabler for positioning and ease of mobility. Review of Resident 99's NC-Side Rail/ Entrapment Assessment/Care Plan dated 2/24/25, showed the side rails ' Zones 1-7 were assessed for entrapment and marked as they were within the guidelines of less than four and 3/4 (three quarters) of an inch. On 3/14/25 at 1316 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 was asked if all the seven zones for Resident 99 should have the check marks on the NC-Side Rail/Entrapment Assessment/Care Plan dated 2/4/25. RN 2 verified all seven zones should not have the check marks for Resident 99 who had an order only for the bilateral upper half side rails and not the split bed rails. On 3/14/25 at 1350 hours, an interview and concurrent medial review was conducted with the MDS RN. The MDS RN was asked if all the seven zones for Resident 99 should have the check marks on the NC-Side Rail/Entrapment Assessment/Care Plan dated 2/24/25. The MDS RN verified all seven zones should not have the check marked for Resident 99. h. Medical record review for Resident 89 was initiated on 3/11/25. Resident 89 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 89's Order Summary Report dated 3/13/25, showed a physician's order dated 8/27/24, for the bilateral upper half side rails up and locked when in bed as an enabler for positioning and ease of mobility. Review of Resident 89's NC-Side Rail/Entrapment Assessment/Care Plan dated 8/27/24, showed the side rails for Zones 1-7 were assessed for entrapment and marked as they were within the guidelines of less than four and 3/4 (three quarters) of an inch. On 3/14/25 at 1321 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 was asked if all the seven zones for Resident 89 should have the check marks on the NC-Side Rail/Entrapment Assessment/Care Plan dated 8/27/24. RN 2 verified all the seven zones should not have the check marks for Resident 89 who had an order only for the bilateral upper half side rails and for the split bed rails. On 3/14/25 at 1405 hours, an interview and concurrent medial review was conducted with the MDS RN. The MDS RN was asked if all the seven zones for Resident 89 should have the check marks on the NC-Side Rail/ Entrapment Assessment/Care Plan dated 8/27/24. The MDS RN verified all the seven zones should have not the check marks for Resident 89 who had an order only for the bilateral upper half side rails and not the split bed rails.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection control program and practices to help prevent the development and transmission of diseases and infections. * Two used mugs and a utensil were sitting on the laundry room's clean sink, and the clean linen shelf had staffs' personal belongings, hand sanitizers and lotion bottles next to the clean linen. * The facility was not cleaning and maintaining their decorative water feature, as well as maintaining logs per the facility's water management program. * Residents 28, 77, 88, and 98's (nonsampled residents) infections were incorrectly listed as meeting McGeer's Criteria on the facility's monthly infection control report. * The LVN failed to maintain infection control practices when initiating Resident 100's GT feeding. * Hand hygiene was not performed prior to the medication administration for Resident 6. * Basins were found in Rooms A, B and C's shared restrooms and were not labeled. These failures resulted in inaccurate infection surveillance and/or prevention which had the potential for spread of infection in the facility. Findings: 1. Review of the facility's P&P titled Work Practices revised 8/2008 showed the staff's belongings should not be stored in clean areas. a. On 3/13/25 at 0924 hours, a laundry room inspection and concurrent interview was conducted with the Maintenance Director and the Laundry Staff. Two stacked mugs and one metal utensil were observed on the sink located in the laundry room. The Laundry Staff stated the dishes were used and from the staff's break. The Maintenance Director stated the sink was considered a clean sink, and used dishes should not be placed in or on the sink. b. During the inspection, the following was observed on the clean linen shelves located in the clean linen area: - An umbrella was on top of the linen shelf, touching a clean blanket. - A tote bag, water bottle and drink tumbler were on top of the clean linen shelf. - Two hand-pump bottles of hand sanitizer and two bottles of skin moisturizer were on a shelf with clean linen. Two of the bottles were touching the clean linen. The Laundry Staff stated the umbrella, tote bag, water bottle, and drink tumbler were staff's personal belongings. The Maintenance Director stated the personal belongings and hand sanitizer, and skin moisturizers should not be stored with the clean linen. 2. Review of the facility's Water Management Program dated 2025 showed the program is designed to reduce the risk for Legionnaires' disease and other opportunistic pathogens associated with the facility's water systems and devices. The program showed the following control point areas to be monitored and tested: - HVAC vents will be checked monthly to ensure there is no water leaking from the vents, which could be aerosolized and inhaled by the residents. - The decorative water fountain will be monitored and cleaned monthly. - Water heaters and the HVAC will be checked quarterly to ensure there are no leaks, stagnant water, or biofilm collecting of fitting, in drip trays, and any other area where water can collect and stagnate. Review of the Water Management Program showed each time a control point was checked, the date and time should be entered on a log sheet, which must be kept in a central location. On 3/13/25 at 1054 hours, an observation, interview, and concurrent facility document review was conducted with the Maintenance Director. A water fountain feature was observed outside by the facility's front entrance. The feature was a raised rectangular pond lined with smooth rocks at the bottom, a decorative pot with rocks spilling out, and two additional decorative pots. [NAME] residue was observed on two of the pots, and on some of the rocks spilling out of a pot. The Maintenance Director stated he did not test the water fountain, but adds a disinfectant tablet to the water monthly. The Maintenance Director stated he did not perform any other cleaning of the water fountain. When reviewing the disinfectant container used, the Maintenance Director verified the container showed to use an automatic feeder, a float, or a skimmer designed for the product. The directions showed to add the disinfectant to reach a free available chlorine level between 1-4 ppm. The Maintenance Director stated he did not test the chlorine level. When asked to review the control logs for the cleaning, inspection and maintenance of the HVAC unit, vents, and the water fountain, the Maintenance Director was unable to locate any. 3. Review of the facility's P&P titled Surveillance for Infection revised 4/2023 showed the purpose of infection surveillance is to identify cases and trends of infection, to guide appropriate interventions, and prevent future infections. The IP will gather data to determine if the resident has a healthcare-associated infection, analyze the data trends and present the findings to the infection control committee. On 3/13/25 at 1536 hours, a concurrent interview, medical record review, and facility document review was conducted with the IP. The IP stated the facility used McGeer's criteria to identify true infections and the data was presented to the infection control committee. Review of the facility's Monthly Infection Surveillance Report for February 2025 showed there were 34 resident infections, with four of them not meeting criteria. The report showed Residents 28, 77, 88, and 98 had infections that not met criteria. a. Resident 28's NI - Surveillance Data Collection Form (Respiratory Tract Infections) effective 2/3/25, inaccurately showed the resident's condition met McGeer's criteria for a true infection. b. Resident 77's NI - Surveillance Data Collection Form (Respiratory Tract Infections) effective 2/25/25, inaccurately showed the resident's condition met McGeer's criteria for a true infection. c. Resident 88's NI - Surveillance Data Collection Form (Respiratory Tract Infections) effective 2/4/25, inaccurately showed the resident's condition met McGeer's criteria for a true infection. d. Resident 98's NI - Surveillance Data Collection Form (Respiratory Tract Infections) effective 2/6/25, inaccurately showed the resident's condition met McGeer's criteria for a true infection. The IP verified the above residents' (Residents 28, 77, 88, and 98) dates were inaccurately reported to the infection control committee as meeting criteria when their infections did not meet criteria. 4. On 3/11/25 at 1252 hours, an observation of Resident 100's enteral tubing (connected to the enteral formula and water flush hanging on the enteral pump pole) and concurrent interview was conducted with LVN 5. Resident 100's enteral tubing was observed lying on the floor until LVN 5 entered and came to the resident's bedside at 1302 hours. LVN 5 was observed retrieving the tubing from the floor, and proceeded to connect it to the resident's GT. LVN 5 verified the tubing tip was on the floor and they should have discarded the enteral set-up, and retrieved a new set-up before connecting it to the resident's GT. 5. Review of the facility's P&P titled Handwashing/Hand Hygiene revised 5/2023 showed the facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The P&P further showed to use an alcohol-based hand rub containing at least 62% alcohol or soap and water for the following situation including before preparing or handling medications. On 3/12/25 at 0939 hours, a concurrent medication administration observation and interview was conducted with LVN 1 in Resident 6's room. During the medication administration, LVN 1 did not perform hand hygiene prior to administering the oral medications to Resident 6. LVN 1 verified she did not perform hand hygiene prior to administering the medications to Resident 6. LVN 1 stated she should have performed hand hygiene. LVN 1 further stated hand hygiene would prevent contamination and ensures the cleanliness. On 3/14/25 at 1320 hours, an interview with the Administrator and DON was conducted with the Regional Director of Operations present. The Administrator and DON acknowledged and verified the above findings. 6. Review of the facility's P&P titled Personal Property dated 8/2022 showed the residents' belongings are treated with respect by facility staff, regardless of perceived value. On 3/11/25 at 0822 hours, an observation of Rooms A and B's shared restroom and concurrent interview was conducted with CNA 3. Residents 49 and 53 shared the restroom in Room A, while Residents 50 and 87 shared the restroom in Room B. In Room B's restroom, there was an unlabeled basin found on the shower floor. In Room A's restroom, there was an unlabeled basin on top of the sink. CNA 3 was asked what the basins were used for. CNA 3 stated the basins were used to clean up the residents. CNA 3 verified the basins should have been stored properly and labeled for infection prevention and control. On 3/11/25 at 0934 hours, an observation of Room C's shared restroom and concurrent interview was conducted with CNA 4. Residents 35, 75, and 101 shared the restroom in Room C. There were three unlabeled basins piled on top of each other on a bedside commode in Room C's shared restroom. CNA 4 verified all of the basins should be stored properly and labeled for infection prevention and control. On 3/14/25 at 1045 hours, an interview was conducted with the DON. The DON verified the basins should be labeled and stored properly.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the antibiotic stewardship program to reduce the risk of unnecessary or inappropriate antibiotic use when one closed record sampled resident (Resident 1) and four nonsampled residents (Residents 28, 77, 88, and 98) were being treated for conditions which did not meet the McGeer's criteria. These failures had the potential of not accurately identifying true infections and exposing the residents to unnecessary antibiotic use. Findings: Review of the facility's P&P titled Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes revised 4/2023 showed the IP, or designee will review all antibiotic utilization and identify specific situations that are not consistent with the appropriate use of antibiotics, and the physician will be notified of the review findings. Review of the facility's P&P titled Infections - Clinical Protocol revised 3/2018 showed based on clinical review, the physician and staff will identify whether antibiotics are warranted or whether antibiotics that have already been started should continue or change. On 3/13/25 at 1536 hours, a review of the facility's documents on antibiotic stewardship, medical record review, and concurrent interview was conducted with the IP. The IP stated the facility used the McGeer's criteria to identify for the true infections. The IP stated the process was to notify the physician to evaluate the antibiotic usage for suspected infections that did not meet the McGeer's criteria and were treated with the antibiotics. a. Review of Resident 1's NI - Surveillance Data Collection Form (UTI) with Indwelling Catheter - V1.1 effective 1/26/25, had UTI-DNMC handwritten on the printed form. The form showed the resident was started on Levaquin (an antibiotic) medication for a UTI. The additional notes section showed the results were relayed to the physician with no antibiotics for UTI. The IP stated DNMC meant it did not meet criteria for an infection. Review of Resident 1's medical record showed the urine culture results received on 1/29/25 at 1236 hours, showed organisms were present, with no clinical significance. Review of Resident 1's MAR for January 2025, showed the resident completed the ordered five days of Levaquin 250 mg by mouth four times a day for UTI. The IP verified Resident 1's medical record failed to show the physician was notified when the resident's condition did not meet the McGeer's criteria and to reevaluate the need for the use of the antibiotic medication. b. Review of Resident 28's NI - Surveillance Data Collection Form (Respiratory Tract Infections) effective 2/3/25, showed the resident's condition met McGeer's criteria for a true infection. The form failed to show the constitutional criteria needed to meet the McGeer's criteria. The form showed Resident 28 was treated with the cefepime (an antibiotic) medication. When the IP was asked to find where they had at least one of the constitutional criteria in Resident 28's medical records, the IP verified the resident's condition did not show at least one of the constitutional criteria, therefore, did not meet McGeer's criteria. The IP verified they incorrectly identified it as meeting the criteria. The IP stated the physician was not notified of Resident 28's condition not meeting the McGeer's criteria and would need to reevaluate the need for the use of the antibiotic medication. c. Review of Resident 77's NI - Surveillance Data Collection Form (Respiratory Tract Infections) effective 2/25/25, showed the resident's condition met McGeer's criteria for a true infection. The form showed the constitutional criteria needed to meet the McGeer's criteria. The form showed Resident 77 was treated with the Zosyn (an antibiotic) medication. When the IP was asked to find where they had at least one of the constitutional criteria in Resident 77's medical records, the IP verified the resident's condition did not show at least one of the constitutional criteria, therefore, did not meet the McGeer's criteria. The IP verified they incorrectly identified it as meeting the criteria. The IP stated the physician was not notified of Resident 77's condition not meeting the McGeer's criteria and would need to reevaluate the need for the use of the antibiotic medication. d. Review of Resident 88's NI - Surveillance Data Collection Form (Respiratory Tract Infections) effective 2/4/25, showed the resident's condition met the McGeer's criteria for a true infection. The form failed to show the constitutional criteria needed to meet the McGeer's criteria. The form showed Resident 88 was treated with the Zosyn (an antibiotic) medication. When the IP was asked to find where they had at least one of the constitutional criteria in Resident 88's medical records, the IP verified the resident's condition did not show at least one of the constitutional criteria, therefore, did not meet the McGeer's criteria. The IP verified they incorrectly identified it as meeting criteria. The IP stated the physician was not notified of Resident 88's condition not meeting the McGeer's criteria and would need to reevaluate the need for the use of the antibiotic medication. e. Review of Resident 98's NI - Surveillance Data Collection Form (Respiratory Tract Infections) effective 2/6/25, showed the resident's condition met the McGeer's criteria for a true infection. The form failed to show the constitutional criteria needed to meet the McGeer's criteria. The form showed Resident 98 was treated with the ciprofloxacin (an antibiotic) medication. When the IP was asked to find where they had at least one of the constitutional criteria in Resident 98's medical records, the IP verified the resident's condition did not show at least one of the constitutional criteria, therefore, did not meet the McGeer's criteria. The IP verified they incorrectly identified it as meeting the criteria. The IP stated the physician was not notified of Resident 98's condition not meeting the McGeer's criteria and would need to reevaluate the need for the use of the antibiotic medication.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to maintain the essential equipment in a clean and safe operating condition when: * The ice machine located in the kitchen was not clean and the manufacturer's guidelines for cleaning and sanitizing were not followed. * The walk-in refrigerator floor was not maintained in a clean/sanitary condition. * The microwave used to heat the resident's food was not maintained in a clean condition. These failures had the potential for the essential equipment to not function in the way it was intended and expose residents to unsafe practices, which could lead to food borne illnesses for the residents. Findings: 1. Review of the facility's P&P titled Ice Machine cleaning (undated) showed the ice machine bin will be cleaned and sanitized once a month. The maintenance staff will clean and sanitize the motor (evaporator) every three to six months, depending on manufacturer's recommendation. Review of the ice machine manufacturer guidelines titled [Hoshizaki] Model KML -325/500 Instruction Manual revised date 5/13/21, showed the following instructions for Cleaning: - Move the mode switch to the CLEAN position, then move the control switch to the ON position (one short beeps occurs, then three seconds later one long beep occur). - When the control board starts beeping (two beeps sequence), remove the front panel. Move the control switch to the OFF position. - Remove the front insulation panel, then pour [Hoshizaki] Scale away into the water tank. [Model KML -325/500 - 9 fluid ounces(266 ml) Scale away] - Move the control switch to the ON position (one short beep occurs, then three seconds later one long beep occurs). Replace the front panel. To avoid excessive foaming in the water tank, there is a one minute delay before circulation begins. After approximately 30 minutes of circulation, the ice maker performs three rinse cycle. - When the control board start beeping (five beep sequence), remove the front panel. Move the control switch to the OFF position. Sanitizing: - Confirm the mode switch is in the CLEAN position, then move the control switch to the ON position (one short beeps occurs, then three seconds later one long beep occur). Replace the front panel. The water tank drains and then fills. - When the control board starts beeping (two beeps sequence), remove the front panel. Move the control switch to the OFF position. - Remove the front insulation panel then pour 7.5% Sodium Hypochlorite solution (chlorine bleach) into the water tank. - Move the control switch to the ON position (one short beep occurs, then three seconds later one long beep occurs). Replace the front panel. To avoid excessive foaming in the water tank, there is a one minute delay before circulation begins. After approximately 30 minutes of circulation, the ice maker performs three rinse cycle. - When the control board start beeping (five beeps sequence), remove the front panel. Move the control switch to the OFF position - Clean the dispenser unit/ice storage bin liner using a neutral cleaner. Rinse thoroughly after cleaning. On 3/11/25 at 1043 hours, an observation of the ice machine and concurrent interview was conducted with the Maintenance Director, RD, and DSS. When the Maintenance Director was asked about the cleaning of the ice machine, the Maintenance Director stated he cleaned the ice machine once a month. The Maintenance Director stated he used [Nucalgon] cleaner to clean the ice machine. The Maintenance Director stated he put the [Nucalgon] cleaner into the machine and ran the clean cycle. The internal hose was removed and cleaned using a brush and hot water. The ice machine chute (the channel through which ice was dispensed) was cleaned and sanitized on 2/28/25, with Pure Bright Germicidal Ultra Bleach 6% Sodium Hypochlorite. Upon inspection of the ice machine internal components, the chute had a black residue (with picture taken). The Maintenance Director verified the findings. The DSS stated the ice machine storage bin was cleaned with the bleach and rinsed with water. 2. According to the USDA Food Code 2022 Annex 3 Section 4-201.11 Equipment and Utensils showed Equipment and utensils must be designed and constructed to be durable and capable of retaining their original characteristics so that such items can continue to fulfill their intended purpose for the duration of their life expectancy and to maintain their easy cleanability. If they cannot maintain their original characteristics, they may become difficult to clean, allowing for the harborage of pathogenic microorganisms, insects, and rodents. On 3/11/25 at 0800 hours, during the initial tour of the kitchen with DSS, the walk-in refrigerator floor was observed with gray paint that was excessively worn exposing the cement floor surface. On 3/12/25 at 0847 hours, an interview was conducted with the Maintenance Director. The Maintenance Director confirmed there was no communication log between the Dietary and Maintenance department for any Dietary concerns. Furthermore, the Maintenance Director confirmed there was no communication regarding the walk-in refrigerator floor condition. On 3/12/25 at 0859 hours, an observation of the kitchen walk-in refrigerator and concurrent interview was conducted with the Maintenance Director. The Maintenance Director confirmed the walk-in refrigerator floor was in need of repair, and he was not aware of the condition of the floor. The Maintenance Director agreed the walk-in refrigerator floor was not a cleanable surface. 3. On 3/12/25 at 0826 hours, an observation of one of two microwaves located in the dining room, used to heat the residents' food brought from the outside and concurrent interview was conducted with RN 1. The microwave was dirty with excess food debris. RN 1 verified the findings and stated she was not sure who was responsible to clean the microwave.

Based on observation, interview, facility document review, and P&P review, the facility failed to ensure the DSS was competent in the day-to-day supervision of the kitchen as evidenced by: 1. Fried eggs were not pasteurized or cooked thoroughly for one of three non-sampled residents (Resident 33). 2. The DSS did not know the correct procedure to calibrate a thermometer. 3. The DSS did not know the manufacturer guidelines for the health shakes. 4. The DSS did not ensure food preparation equipment was replaced when worn. 5. The DSS did not ensure beard coverings were available for kitchen staff with facial hair. 6. The DSS competency was not evaluated by the Administrator. These failures posed the risk for 62 vulnerable residents who received food prepared in the kitchen to be exposed to potential food borne illnesses. Findings: Review of the facility's document titled Order Listing Report dated 3/11/25, showed 62 residents received food prepared in the kitchen. Review of the job description titled Dietary Manager signed and dated by the DSS on 2/24/14, showed the Dietary Manager supervises the operations of the Dietary Department .the quality of meals meets the facility standards and ensuring all facility dietary and food handling standards are met. Essential Duties and Responsibilities include the following supervises the operation of the food service department. Responsible for knowing, understanding, and conveying to other dietary staff personnel the Federal and State rules and regulations regarding nursing home dietary requirements and is responsible for their enforcements within the scope of the Dietary Department. Inspects and evaluates the department regularly to ensure compliance with all state and federal guidelines. Review of the employee file for the DSS did not show a competency evaluation. 1. According to the CDC, Salmonella are bacteria (germs) that can make people sick with an illness called salmonellosis. Anyone can get a Salmonella infection. Some groups of people have an increased chance of infection, and some people may become seriously ill. These groups include: Adults who are 50 years and older with underlying medical problems, such as heart disease, adults who are 65 and older, and people who have a weakened immune system. https://www.cdc.gov/salmonella/about/index.html#:~:text=People%20at%20risk&text=These%20groups%20include%3A,who%20are%2065%20and%20older Review of the California Code, Health and Safety Code - HSC § 114091 showed in part, in a licensed health care facility the following shall apply . Pasteurized shell eggs or pasteurized liquid, frozen, or dry eggs or egg products shall be substituted for raw shell eggs in the preparation of foods. A reference review from the California Department of Food and Agriculture (CDFA) dated 7/1/13, showed California Shell Egg Food Safety Compliant or the abbreviated CA SEFS Compliant statement means that the eggs you're purchasing have gone through added measures to reduce the risk of Salmonella Enteritidis (SE) contamination, as specified in California Code of Regulation Title 3 Section1350 (3 CCR 1350). SE is the number one food borne illness associated to raw shell eggs. On 3/11/25 at 0756 hours, during the initial tour of the kitchen with the DSS, three cases of CA SEFS Compliant raw shelled eggs were observed in the walk-in refrigerator. The DSS confirmed she had not been able to order pasteurized eggs due to the current egg shortage. On 3/11/25 at 1121 hours, an interview was conducted with the RD. The RD stated the eggs stored in the walk-in refrigerator were safe for resident consumption because they were SEFS. On 3/11/25 at 11:35 AM an interview was conducted with the DSS. The DSS stated no residents were served under cooked eggs. On 3/12/25 at 0720 hours, during the breakfast meal service, the DSS was observed to be cooking fried eggs. An observation of Resident 33's breakfast meal was conducted with the RD. The fried egg on Resident 33's breakfast meal tray was not fully cooked, and the yolk was runny. The RD confirmed the findings and returned Resident 33's breakfast plate to the DSS to cook the fried egg until the yolk was fully cooked. The RD was asked how she would ensure all the fried eggs were completely cooked. The RD stated she would in-service the kitchen staff and nursing. Cross reference to F812, example #1. 2. A reference review from the Wisconsin Department of Agriculture titled Calibrating Thermometer dated 2/2021 showed thermometers should be calibrated regularly to ensure accurate temperatures. The ice-point method is the most widely used method to calibrate a dial or digital thermometer. Fill a large container with crushed ice, then add clean cold tap water until the container is full. Stir the mixture well. Place the thermometer stem or probe into the ice water. Make sure the thermometer is not touching the bottom or sides of the glass. Wait 30 seconds or until the reading stays steady. The attached picture of the reference shows the thermometer being held in the glass of ice and water, not touching the bottom or sides of the glass. Step three: Adjust the thermometer so it reads 32 degrees Fahrenheit (F). On 3/12/25 at 0700 hours, during the breakfast meal tray line, an observation and concurrent interview was conducted with [NAME] 1. One analog thermometer (a thermometer using a pointer or needle which moves across a dial to indicate temperature, rather than displaying a digital reading) was observed in a plastic cup with water and ice. The thermometer was resting on the side and bottom of the cup. [NAME] 1 stated this was the way he calibrated a thermometer. On 3/12/25 at 0705 hours, an interview was conducted with the DSS. The DSS was asked if it was correct for the thermometer to be resting on the side and bottom of the glass during the calibration process. The DSS stated it was ok for the thermometer to rest on the side and bottom of the cup and confirmed this was way the thermometers were calibrated every meal. On 3/12/25 at 1146 hours, during the lunch meal tray line, three analog thermometers were observed in a plastic cup with water and ice. All three analog thermometers were resting on the sides and bottom of the cup. The DSS stated, If this is not the correct way to calibrate a thermometer, can you tell us the correct way? [NAME] 1 used one of the analog thermometers that was in the ice/water mixture to take the lunch food temperatures. Using a digital thermometer, the surveyor also took the lunch food temperatures. The temperature for the puree vegetables was 180 degrees F per the facility's analog thermometer versus 208 degrees F per the surveyor's digital thermometer, a 28-degree difference. [NAME] 1 obtained a second thermometer from the ice/water mixture. The temperature for the puree chicken was 160 degrees F per the facility analog thermometer vs 210 degrees F per the surveyor's digital thermometer, a 50-degree difference. The RD confirmed the findings and asked if the facility was calibrating the thermometer incorrectly. 3. On 3/11/25 at 0756 hours, during the initial tour of the kitchen with the DSS, two cases of completely thawed health shakes (a nutritional supplement) were observed in the walk-in refrigerator. The DSS stated the health shakes were stored in the freezer then put in the refrigerator. One case of the health shakes was dated 3/3/25, when removed from the freezer, and the other case of health shakes was dated 2/12/25, when removed from the freezer. The DSS was asked how long the health shakes were allowed in the refrigerator once thawed. The DSS stated 30 days. The DSS was shown the manufacturer guidelines on the health shake carton which read the shakes are to be discarded after 14 days once thawed. The DSS confirmed the health shakes dated 2/12/25, were expired and would be discarded. Cross reference to F812, example #6.a. 4. According to the USDA Food Code Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces and Utensils, (A) Equipment, food-contact surfaces and utensils shall be clean to the sight and touch. On 3/11/25 at 0756 hours, during the initial tour of the kitchen with the DSS, the can opener blade stainless steel was observed to be excessively worn. The DSS confirmed the finding and stated she had another blade she could have the maintenance put on the can opener. Cross reference to F812, example #9. a. On 3/12/25 at 0955 hours, during an observation of the puree food preparation with [NAME] 1 and the DSS present, the Robot Coupe, a device used to puree food was observed with a brown residue on the blade assembly. The DSS confirmed the finding and stated the residue did not come off with cleaning because the blade assembly was old. The DSS stated she would need to order a new blade assembly. Cross reference to F812 example #9.a. 5. According to the USDA Food Code 2022, Section 2-402.11 Hair Restraints, Effectiveness, Food employees shall wear hair restraints such as hats, hair covering 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, and utensils. Review of the facility's P&P titled Sanitation and Infection Control (undated) showed beard and/or moustache should be closely trimmed or must be covered at all times. On 3/12/25 at 1355 hours, in the kitchen food preparation area, an observation and concurrent interview was conducted with DA 2 and [NAME] 2. Both employees had uncovered facial hair. When asked if their facial hair should be covered, [NAME] 2 stated the kitchen used to have beard restraints but not any longer. On 3/12/25 at 1359 hours, an interview was conducted with the DSS. The DSS was informed of DA 2 and [NAME] 2's uncovered facial hair. The DSS verified the findings and stated any facial hair must be covered with a hair restraint. The DSS stated she would order beard restraints. Cross reference to F812, example #8. 6. On 3/13/25 at 1044 hours, an interview was conducted with the Administrator. The Administrator was asked how she ensured her department directors were competent. For the kitchen, the Administrator stated she relied on the RD to assess the DSS competency. On 3/13/25 at 1107 hours, an additional interview was conducted with the Administrator. The Administrator stated the previous RD did not voice any concerns regarding the DSS or kitchen. On 3/13/25 at 1110 hours, an interview was conducted with the RD. The RD was asked about the competency evaluation of the DSS. The RD stated she did not do an actual competency checklist for the DSS; however, would communicate with the Administrator if there were any concerns with the kitchen or DSS. The RD stated however, she had only worked for the facility for two weeks and could not speak for the previous RD. On 3/14/25 at 0849 hours, a concurrent interview was conducted with the DSS and RD. The DSS was asked who assessed the DSS's competency. The DSS stated the Administrator was responsible to assess her competency. The DSS confirmed there was no competency evaluation in writing from the Administrator regarding her competency.

Based on observation, interview, facility document review, and P&P review, the facility failed to ensure two of 10 kitchen employees (Cook 1 and DA 1) were competent in their daily job duties when: 1. [NAME] 1 failed to perform the following: - Follow proper hand hygiene, - Take food temperatures correctly during meal service, - Prepare resident meals according to the facility recipes, - Accurately test the sanitizing solution used to sanitize food preparation surfaces, and - Utilize the manual dishwashing process correctly. 2. DA 1 was unable to read the temperature dial of the dish machine. These failures posed the risk for unsafe food handling practices which could expose the 62 residents who received food prepared in the kitchen to food borne illnesses. Findings: Review of the facility's document titled Order Listing Report dated 3/11/25, showed 62 residents received food prepared in the kitchen. 1. Review of the facility's job description titled [NAME] signed by [NAME] 1 (undated) showed the [NAME] is responsible for the preparation of all dietary components in accordance with the menu of the day utilizing sanitary standards established for the department by the facility and the appropriate regulatory agencies. Review of the facility's document titled Competency Checklist signed and dated by [NAME] 1 and the DSS dated 1/6/25, showed [NAME] 1 was competent in hand hygiene, able to identify the appropriate ppm of quaternary solution, and food temperature log. a. Review of the facility's P&P titled Hand Washing undated, showed wash hands after handling cart, soiled dishes and utensils. Before and after handling foods. Wash hands when changing gloves. Change disposable gloves when: * Gloves get ripped or torn * Beginning a different task. * After coughing or sneezing into hands, use of handkerchief or tissue, smoking, touching hair or face, and using the toilet. * After handling waste * During food preparation, as often as necessary when it get soiled and when changing task to prevent cross contamination. Review of the facility's document titled Record of In-service Training dated 4/18/24 and 8/7/24, showed the policy titled Sanitation and Infection Control was covered. [NAME] 1 was in attendance for both in-services. On 3/11/25 at 0756 hours, during the initial tour of the facility's kitchen with the DSS, [NAME] 1 was asked to discard two rubber spatulas and wash a dirty peeler. [NAME] 1 touched the trash can lid to throw away the rubber spatulas, then proceeded to wash the dirty peeler. [NAME] 1 did not change his gloves or wash his hands after touching the trash can. After washing the peeler, [NAME] 1 wiped his wet gloved hands on his apron and returned to food preparation. On 3/12/25 between 1002 hours and 1025 hours, an observation of the puree meal preparation was conducted with [NAME] 1. [NAME] 1 was observed preparing puree meat with gloved hands. [NAME] 1 removed his gloves to wash the RC in the automatic dish machine. [NAME] 1 touched the dish machine tray and dish machine handle then donned a new pair of gloves without washing his hands. [NAME] 1 proceeded with the puree meal preparation. During the puree meal preparation, [NAME] 1 rested his gloved hands on the counter. Without changing his gloves or washing his hands, [NAME] 1 continued to touch multiple objects in the kitchen; a cooking pan, a blender, and an oven handle while preparing the puree food for residents. [NAME] 1 washed the RC again in the automatic dish machine using the same gloved hands then he prepared the chicken broth which he added to the noodles and continued to puree the food for the facility residents. On 3/13/25 at 0837 hours, a concurrent interview was conducted with the DSS and RD. Both the RD and DSS agreed the Cooks should wash their hands and change gloves prior to starting a new task such as food preparation. Cross reference to F812, example #2. b. Review of a professional literature titled Food Safety Tips: Using a Food Thermometer dated 9/10/24, showed when using a thermometer to measure internal temperature, use these tips: - Insert the thermometer into the thickest part of the meat or the center of the casserole. - Make sure the thermometer is not touching the pan, bone or fat. Foodhero.org/healthy-food/food-safety-tips-using-food thermometer#:~:text=When%20using%20a%20thermometer%20to,the%20pan%2C%20bone%20or%20fat. Review of the facility's document titled In-service Daily Food Temperatures dated 5/10/24, showed [NAME] 1 was in attendance. The in-service reviewed the policy for thermometer calibration; however, did not include how to correctly take food temperatures. On 3/12/25 at 1146 hours, an observation of the lunch meal tray line and concurrent interview was conducted with [NAME] 1. [NAME] 1 was taking food temperatures using an analog thermometer. While taking the food temperatures, the thermometer was touching the hot pan. [NAME] 1 was asked if it was correct to touch the pan with the thermometer. [NAME] 1 did not answer. [NAME] 1 was asked to read the temperature on the food thermometer dial. [NAME] 1 stated he could not read the temperature on the thermometer because it was too small. On 3/13/25 at 0837 hours, a concurrent interview was conducted with the DSS and RD. When asked if a [NAME] should be proficient in taking food temperatures, the RD stated the [NAME] should be able to accurately take food temperatures and read the thermometer. The RD further stated she would order a digital thermometer that was easier to read. c. Review of the facility's P&P titled Menu (undated) showed the standard menu will ensure for the nutritional adequacy of all the diets, offer a variety of food in adequate amounts at each meal, and a standardized food production. On 3/12/25 between 1002 and 1021 hours, an observation of the puree preparation for the lunch meal and concurrent interview was conducted with [NAME] 1. The recipes for puree sweet and sour chicken, puree stir fry vegetables, and puree sesame noodles were not followed. On 3/13/25 at 0837 hours, a concurrent interview was conducted with the RD and DSS. The RD confirmed all recipes should be followed. Cross reference to F803, examples #1, #2, and #3. d. Review of the facility's P&P titled Sanitizing Equipment and Surfaces undated, showed sanitizer levels will be checked and recorded at least once per shift to ensure equipment and surfaces are sanitized appropriately. Procedure: 3. Test strip should read 200-400 ppm refer to manufacturer's recommendations. Review of the sanitizing test strip container showed: Dip paper in quat solution , for ten seconds, Don't shake. Review of the facility's document titled In-service titled Manual dishwashing; Quat bucket dated 3/4/25, showed [NAME] 1 was in attendance. On 3/12/25 at 0948 hours, an observation of the sanitizing solution and concurrent interview was conducted with [NAME] 1. [NAME] 1 was asked to test the ppm of the sanitizing solution. [NAME] 1 held the sanitizing test strip in the sanitizing solution for three seconds. The test strip read 100 ppm. [NAME] 1 obtained a second test strip and held it in the sanitizing solution for three seconds and stirred the test strip in the solution. [NAME] 1 was shown with the instructions on the sanitizing test strip container. [NAME] 1 was asked to test the strip a third time. Using the surveyor's phone stopwatch, the testing was monitored for ten seconds. [NAME] 1 held the sanitizing test strip in the sanitizing solution for ten seconds and the strip read 200 ppm. On 3/13/25 at 0837 hours, a concurrent interview was conducted with the RD and DSS. The DSS confirmed the kitchen employees should know how to test the sanitizing solution correctly. e. Review of the facility's P&P Manual Dish Washing - 2 or 3 compartment sink undated showed, two-compartment sink procedures: 1. Fill sink 1 with warm water and soap to proper level to complete wash process. Scrub all surfaces to clean and remove food and other debris. 2. Drain sink 1 and rinse walls with fresh water. 3. Refill sink 1 to proper level to freely rinse all items with fresh water only. 4. Fill sink 2 with fresh water to proper level with water from cold line and add Quaternary sanitizer. 5. Test to ensure paper solution of no less than 200 ppm to no more than 400 ppm is available with proper test strips. 6. Place all items in solution for no less than 1 minute. 7. Place on a clean surface and allow to dry clean. Review of the facility's document titled In-service titled Manual dishwashing; Quat (sanitizing solution) bucket dated 3/4/25, showed [NAME] 1 was in attendance. On 3/11/25 at 0756 hours, during initial tour of the facility's kitchen, an observation of [NAME] 1 and concurrent interview was conducted with the DSS. [NAME] 1 was asked to wash a dirty peeler. [NAME] 1 used the cleaning solution located in a green bucket by dipping the peeler in the bucket. [NAME] 1 then rinsed the peeler off with the faucet and dried the peeler using a paper towel. [NAME] 1 returned the peeler to the storage drawer. The DSS verified the findings and stated [NAME] 1 should have followed the manual dish washing procedure. Cross reference to F812, example #5. 2. Review of the facility's Job Description titled Dietary Aide/Dishwasher undated and unsigned by Diet Aide 1 showed essential duties and responsibilities: properly cleans, sanitizes and stores all dishes, utensils and cooking/food prep equipment. Review of the facility's document titled Competency Evaluation signed by DA 1 and the DSS on 1/6/25, showed DA 1 was competent in dish machine temperature and ppm log maintained. Review of the facility's P&P titled Dish Washing Procedures- dish machine (undated) showed to inform the Dietary Services Supervisor or Maintenance personnel if the dish machine is not reaching the proper temperature and chlorine levels. Manual Dish washing or disposables will be used if the dish machine is not working properly. Low temperature dish machine: temperature between 120-135 degrees F, Chlorine - 50 to 100 ppm. The DSS was unable to provide evidence of in-services on the dish machine operations for the past year. Review of the facility's document titled Dish Machine Temperature Log dated March 1-March 11 breakfast through dinner showed the automatic dishwashing machine temperature was 120-123 degrees F on every entry. On 3/11/25 at 0833 hours, an observation of the automatic dishwashing machine and concurrent interview was conducted with DA 1 using the DSS as a translator. As DA 1 was washing dishes, she was asked where she checked the temperature for the automatic dish washing machine. DA 1 was unable to state where she obtained the dish machine temperature. The surveyor showed DA 1 the dish machine temperature dial which was under the machine near the floor. DA 1 was unable to stoop down to read the dish machine temperature dial. The surveyor informed DA 1 and the DSS the temperature of the wash water was 100 degrees F. DA 1 agreed 100 degrees F was too low. Although the dish machine had been running for several cycles before DA 1 was interviewed, the DSS stated the dish machine needed to be run few times to get the water temperature to the correct range. Cross reference F812, example #2.

Based on observation, interview, and facility document review, the facility failed to ensure the menus were followed when the recipes for puree meat, vegetables, and starch were not adhered to. This failure had the potential for the nutritional needs to not be met for 15 residents who received a puree diet. Findings: Review of the Order Listing Report dated 3/11/25, showed 15 residents had the physicians' orders for the pureed diet. 1. Review of the facility's document titled Recipe: Puree (IDDSI Level 4) Meats dated 2024 showed 12 servings mix 12 to 24 oz (1 ½ to 3 cups) warm fluid such as gravy, or low sodium both. If the meat is moist, you can start with only a few ounces of liquid. These amounts are only an average and may vary. If needed: Stabilizer: for 12 serving to mix 6 to 12 Tbsp (3/8 - ¾ cup) instant potato, non -fat dry milk, breadcrumbs, toast, instant cream of rice or farina, or commercial instant food thickener. On 3/12/25 at 1002 hours, an observation of the puree meat preparation and concurrent interview was conducted with [NAME] 1. [NAME] 1 stated he was preparing 12 servings of puree sweet and sour chicken. [NAME] 1 added nine six-ounce servings of sweet and sour chicken to the Robot Coupe (RC, a device used to puree foods), then blended. The puree sweet and sour chicken had a runny consistency. [NAME] 1 stated he could use thickener to reach the appropriate consistency. [NAME] 1 pour an unmeasured quantity of thickener into a metal pitcher that held one quart (equivalent to four cups). The metal pitcher was approximately half full (two cups) with thickener. [NAME] 1 added the unmeasured thickener to the puree sweet and sour chicken and stirred it with a wire whisk. On 3/13/25 at 0837 hours, an interview was conducted with the RD and DSS. Both the RD and DSS agreed all recipes should be followed. 2. Review of the facility's document titled Recipe: Stir Fry Vegetables dated 2024 showed Ingredients: assorted vegetables, margarine, garlic powder, salt. Directions: 2. Pan fry vegetables with margarine or boil, steam vegetables until soft. Drain well. Add margarine, garlic and salt. Review of the facility's document titled Recipe: Pureed Vegetable (undated) showed 12 serving puree vegetables: mix vegetable with 2 to 6 oz (1/4 cup to ¾ cup) of warm fluid such as milk, or low sodium broth. These are suggested amounts and may vary from vegetable to vegetable. Some vegetables may not require any fluids at all. If needed: Stabilizer: for 12 serving to mix 6 to 12 Tbsp (3/8 - ¾ cup) instant potato, or commercial instant food thickener. Review of the chicken flavored bouillon nutritional information showed ¾ teaspoon chicken flavored bouillon mixed with one cup of water contained 620 mg sodium. On 3/12/25 at 1016 hours, an observation of the puree vegetable preparation and concurrent interview was conducted with [NAME] 1. [NAME] 1 took a large pan out of the oven with vegetables cooked in liquid. [NAME] 1 stated he cooked the stir fry vegetables in chicken broth in the oven. [NAME] 1 placed 13 ½ cup servings of the stir fry vegetable mixture into the RC. The product was blended and placed in the oven at 500 degrees. recipes should be followed. The stir fry vegetable recipe was reviewed with the RD. The RD confirmed the stir fry vegetable recipe did not specify what liquid to boil or steam the vegetables in. The RD stated she would prefer the vegetables to be boiled in water. The RD agreed using regular chicken broth with a high sodium content to cook the vegetables was not correct. 3. Review of the facility's document titled Recipe: Sesame Noodles dated 2024 showed Ingredients: Low sodium vegetable or chicken broth (200 mg or less per eight-ounce reconstituted broth). Review of the facility's document titled Recipe: Pureed Starch (Rice, Pasta, Potatoes) (undated) showed 12 servings mix 12 to 24 oz (1 ½ to 3 cups) warm milk, starting with the smaller amount and adding in more as needed to achieve the desired consistency. If needed: Stabilizer: for 12 serving to mix 6 to 12 Tbsp (3/8 - ¾ cup) instant potato, non -fat dry milk, breadcrumbs, toast, instant cream of rice or farina, or commercial instant food thickener. Review of the chicken flavored bouillon nutritional information showed ¾ teaspoon chicken flavored bouillon mixed with one cup of water contained 620 mg sodium. On 3/12/25 at 1021 hours, an observation of the puree noodle preparation and concurrent interview was conducted with [NAME] 1. [NAME] 1 pour an unmeasured quantity of chicken flavored bouillon into a metal pitcher that held one quart (equivalent to four cups). [NAME] 1 added water to the metal pitcher to equal approximately two cups (the metal pitcher was half full). [NAME] 1 added 13 ½ cup servings of sesame noodles and the chicken flavored bouillon mixture to the RC. The noodles were blended until smooth then placed in a pan and put in the oven at 500 degrees F. On 3/13/25 at 0837 hours, an interview was conducted with the RD and DSS. The RD confirmed all the recipes should be followed and the pureed starch should be pureed with milk per the recipe or low sodium broth.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility document and facility P&P review, the facility failed to ensure the food safety and sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the egg served was fully cooked when there were no pasteurized eggs were available. * The facility failed to ensure the proper hand hygiene was followed during the food preparation. * The facility failed to ensure the fish thawing process was followed. * The facility failed to the ensure the automatic dish washing water temperature reached the acceptable range. * The facility failed to ensure the manual dishwashing process was followed. * The facility failed to ensure the refrigerated food items were stored properly. * The facility failed to ensure the ice storage was in sanitary condition. * The facility failed to ensure the hair restraints were available and worn by staff in the kitchen. * The facility failed to ensure the kitchen equipment were maintained in a sanitary condition. * The facility failed to ensure the food item in the walk-in freezer was dated, label and not left open. * The facility failed to ensure the dry food was properly stored. * The facility failed to ensure the food preparation equipment was air dried. * The facility failed to ensure Resident 7's personal refrigerator was maintained. These failures had the potential to cause foodborne illnesses for Resident 7 and in the 62 residents who consumed food prepared in the kitchen. Findings: Review of the facility's document titled Order Listing Report dated 3/11/25, showed 62 of 109 residents received food prepared in the kitchen. 1. According to the Center for Disease Control (CDC) Salmonella are bacteria (germs) that can make people sick with an illness called salmonellosis. Anyone can get a Salmonella infection. But some groups of people have an increased chance of infection, and some people may become seriously ill. These groups include Adults who are 50 years and older with underlying medical problems, such as heart disease, Adults who are 65 and older and People who have a weakened immune system. https://www.cdc.gov/salmonella/about/index.html#:~:text=People%20at%20risk&text=These%20groups%20include%3A,who%20are%2065%20and%20older. A reference review from California Department of Food and Agriculture (CDFA) dated 7/1/13, showed California Shell Egg Food Safety Compliant or the abbreviated CA SEFS Compliant statement means that the eggs you're purchasing have gone through added measures to reduce the risk of Salmonella Enteritidis (SE) contamination, as specified in California Code of Regulation Title 3 Section 1350 (3 CCR 1350). SE is the number one food borne illness associated to raw shell eggs. Review of California Code, Health and Safety Code - HSC § 114091 showed in part, in a licensed health care facility the following shall apply . Pasteurized shell eggs or pasteurized liquid, frozen, or dry eggs or egg products shall be substituted for raw shell eggs in the preparation of foods. https://www.cdfa.ca.gov/ahfss/mpes/pdfs/CA_SEFS_Compliant.pdf On 3/11/25 at 0756 hours, during the initial tour of the facility's kitchen, observation and concurrent interview was conducted with the DSS. Three cases of CASEFS eggs were observed in the walk-in refrigerator. The DSS verified there were no pasteurized eggs and stated she was unable to purchase the pasteurized eggs from the provider. On 3/11/25 at 1121 hours, an interview was conducted with the RD. The RD stated the eggs were safe because they were CASEFS approved. On 3/12/25 at 0645 hours, a breakfast meal tray-line observation was conducted. The DSS was observed cooking the fried eggs for residents on the grill. On 3/12/25 at 0720 hours, an observation of Resident 33's breakfast meal tray and concurrent interview was conducted with the RD. Resident 33's breakfast meal tray ticket showed a daily standing order for two fried eggs. The two fried eggs were observed on the plate; however, one of the egg yolks was observed runny and not fully cooked. The RD verified the findings and stated she would have the DSS cook the eggs until the yolk was completely cooked. 2. Review of the facility's P&P titled Hand Washing (undated) showed to wash hands after handling the cart, soiled dishes and utensils, before and after handling foods, and wash hands when changing gloves. Change the disposable gloves when: - gloves get ripped or torn; - beginning a different task; - after coughing or sneezing into hands, use of handkerchief or tissue, smoking, touching hair or face, and using the toilet; - after handling waste and - during food preparation, as often as necessary when it get soiled and when changing task to prevent cross contamination. On 3/11/25 at 0756 hours, during the initial tour of the facility's kitchen, an observation and concurrent interview was conducted with the DSS. [NAME] 1 was asked to discard the two rubber spatulas and wash a dirty peeler. [NAME] 1 touched the trash can lid to throw away the rubber spatulas, then proceeded to wash the dirty peeler. [NAME] 1 did not change his gloves or wash his hands after touching the trash can. After washing the peeler, [NAME] 1 was observed wiping his wet gloved hands on his apron and returned to the food preparation. On 3/12/25 at 0859 hours, a follow-up observation was conducted of [NAME] 1. [NAME] 1 was observed placing her gloved hands in the trash can to remove a sticker from her gloves. [NAME] 1 did not remove her gloves or wash her hands prior to returning to the food preparation. On 3/12/25 between 1002 and 1025 hours, an observation of the puree meal preparation was conducted with [NAME] 1. The following was observed: - [NAME] 1 was observed preparing the puree meat with gloved hands, - [NAME] 1 removed his gloves to wash the Robot Coupe (RC) in the automatic dish machine, - [NAME] 1 touched the dish machine tray and dish machine handle then donned a new pair of gloves without washing his hands, - [NAME] 1 proceeded with the puree meal preparation. During the puree meal preparation, [NAME] 1 rested his gloved hands on the counter. Without changing his gloves or washing his hands, [NAME] 1 continued to touch multiple objects in the kitchen; a cooking pan, a blender, and oven handle while preparing the puree food for the residents, and - [NAME] 1 washed the RC again in the automatic dish machine using the same gloved hands, then he prepared the chicken broth which he added to the noodles and continued to puree the food for the facility residents. On 3/13/25 at 0837, an interview was conducted with the DSS and RD. Both the RD and DSS acknowledged the cooks should wash their hands and change gloves prior to starting a new task such as the food preparation. 3. Review of the facility's P&P titled Refrigerator /Freezer Storage (undated) showed all the items should be properly covered, dated, and labeled. The food items should have the following appropriate dates: - delivery date upon receipt, - open date for opened containers of the PHF (potentially hazardous food), and - thaw date of any frozen items. Review of the chart from the US Food & Drug Administration (USFDA) posted outside of the walk-in refrigerator titled Refrigerator and Freezer Storage Chart dated March 2018 showed the lean and fatty fish may be stored in the refrigerator safely for one to two days. On 3/11/25 at 0800 hours, an observation of the walk-in refrigerator and concurrent interview was conducted with the DSS. Two boxes of 10 pounds tilapia were observed in the walk-in refrigerator dated 3/5/25. The DSS was asked what the 3/5/25 date meant. The DSS verified the 3/5/25 was the delivery date and there was no date to indicate when the tilapia was removed from the freezer to thaw. 4. Review of the facility's P&P titled Dish Washing Procedures- Dish Machine (undated) showed to inform the DSS or Maintenance personnel if the dish machine is not reaching the proper temperature and chlorine levels. Manual dish washing or disposables will be used if the dish machine is not working properly. For the low temperature dish machine, the temperature should be between 120-135 degrees Fahrenheit (F), and Chlorine at 50 to 100 ppm. Review of the facility' s document titled Dish Machine Temperature Log for 3/1-3/11/25, the breakfast through dinner showed the automatic dishwashing machine temperature was 120-123 degrees F on every entry. On 3/11/25 at 0833 hours, an observation of the automatic dishwashing machine and concurrent interview was conducted with DA 1 using the DSS as a translator. As DA 1 was washing the dishes, she was asked where she checked the temperature for the automatic dish washing machine. DA 1 was unable to state where she obtained the dish washing machine temperature. DA 1 was shown where the dish machine temperature dial which was located at the bottom of the machine near the floor. DA 1 was unable to stoop down to read the dish machine temperature dial. DA 1 and the DSS was informed the temperature of the wash water was at 100 degrees F. DA 1 acknowledged the temperature of 100 degrees F was too low. Although the dish machine had been running for several cycles before DA 1 was interviewed, the DSS stated the dish machine needed to be run a few times to get the water temperature to the correct range. On 3/13/25 at 1134 hours, a follow-up observation of the automatic dish machine and concurrent interview was conducted with the RD. The RD stated the dish machine company had come out to check the machine and stated everything was fine. Upon the inspection of the dish machine temperature dial, the wash temperature was at 112 degrees F. The dish machine was then ran twice; however, the dish machine temperature remained at 112 degrees F. The RD stated she would notify the maintenance. 5. Review of the facility's P&P titled Manual Dish Washing - 2 or 3 Compartment Sink (undated) showed the two-compartment sink procedures as follows: - Fill sink 1 with warm water and soap to proper level to complete wash process. Scrub all surfaces to clean and remove food and other debris. - Drain sink 1 and rinse walls with fresh water. - Refill sink 1 to proper level to freely rinse all items with fresh water only. - Fill sink 2 with fresh water to proper level with water from cold line and add Quaternary sanitizer. - Test to ensure paper solution of no less than 200 ppm to no more than 400 ppm is available with proper test strips. - Place all items in solution for no less than 1 minute. - Place on a clean surface and allow to dry clean. On 3/11/25 at 0756 hours, during the initial tour of the facility's kitchen, an observation of [NAME] 1 and concurrent interview was conducted with the DSS. [NAME] 1 was asked to wash a dirty peeler. [NAME] 1 was observed dipping the peeler in the solution in a green bucket. [NAME] 1 then rinsed the peeler off with the water from the faucet and dried the peeler using a paper towel. [NAME] 1 returned the peeler to the storage drawer. The DSS verified the findings and stated [NAME] 1 should have followed the manual dish washing procedure. 6. Review of the facility's document titled Refrigerator and Freezer Storage Chart dated 3/2018 showed these short but safe time limits will help keep the refrigerated food at 40-degree F from spoiling or becoming dangerous. The section for the Hot Dogs and Lunch Meats (in freezer wraps), the opened package of the lunch meat can be stored in refrigerator for 3-5 days and 1-2 months in the freezer. Review of the facility's document Health Shake Nourishment Storage and Handling instruction: Store frozen showed to thaw under refrigeration (at 40 degree F or below), after thawing keep refrigerated, and use within 14 days after thawing. On 3/11/25 at 0800 hours, an observation and concurrent interview was conducted with the DSS. An opened package of turkey lunch meat dated 3/3/25, and one box of the health shakes dated 2/12/25, were observed inside the walk-in refrigerator. The DSS verified the finding and stated the turkey lunch meat should be discarded after seven days. When asked regarding the process for thawing of the health shakes, the DSS stated the health shakes can be used for 30 days after thawing. Upon the inspection of the health shake guidelines located on the health shake carton, the DSS verified the health shakes can only be used for 14 days once thawed. 7. Review of the USDA Food Code 2022, Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) Equipment, food-contact surface and utensils shall be clean to sight and touch. On 3/11/25 at 1102 hours, an observation and concurrent interview was conducted with the DSS. The DSS stated the ice cooler located near the kitchen door was used by the CNAs to get ice for the residents' water pitchers. The inside of the ice cooler was observed with a brown residue. The DSS was asked about the process on how to clean the ice cooler. The DSS stated the ice cooler was cleaned weekly with soap and water. The DSS verified the ice cooler was not clean and removed it to be cleaned. 8. According to the USDA Food Code 2022, Section 2-402.11 Hair Restraints, Effectiveness, Food employees shall wear hair restraints such as hats, hair covering 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, and utensils. Review of the facility's P&P titled Sanitation and Infection control (undated) showed the beard and/or moustache should be closely trimmed or must be covered at all times. On 3/12/25 at 1355 hours, an observation in the kitchen and concurrent interview was conducted with DA 2 and [NAME] 2. DA 2 and [NAME] 2 was observed with uncovered facial hair. When asked if their facial hair should be covered, [NAME] 2 stated the kitchen used to have beard restraints but not any longer. On 3/12/25 at 1359 hours, an interview was conducted with the DSS. The DSS was informed of DA 2 and [NAME] 2's uncovered facial hair. The DSS verified the findings and stated any kitchen staff with facial hair or beard need to use the hair restraints and she would need to order some hair restraint. 9. Review of the USDA Food Code 2022, Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) Equipment, food-contact surface and utensils shall be clean to sight and touch. a. On 3/11/25 at 0800 hours, during the initial tour of the facility's kitchen, an observation and concurrent interview was conducted with the DSS. The following was observed and verified by the DSS: - one peeler was not clean, - a plastic container used to store the silverware was not clean and observed with food debris, - two rubber spatula were chipped and no longer in a cleanable condition, - one can opener blade with excessive wear, and - one nonstick pan was unclean and the coating was coming off. b. On 3/12/25 at 0955 hours, a lunch meal puree preparation observation and concurrent interview was conducted with [NAME] 1 and the DSS. The Robot Coupe was observed with hard brown residue on the blade assembly. The DSS stated the Robot Coupe was old and the residue did not come off with cleaning. The DSS further stated she would order a new blade assembly. 10. Review of the facility's P&P titled Refrigerator /Freezer Storage (undated) showed all the items should be properly covered, dated and labeled. The food items should have the following appropriate dates: - delivery date upon receipt, - open date for opened containers of the PHF (potentially hazardous food), and - thaw date of any frozen items. On 3/11/25 at 0800 hours, during the initial tour of the facility's kitchen, an observation and concurrent interview was conducted with the DSS. One 20 pounds bag of peas was observed open with no date label in the walk-in freezer. The DSS verified the finding and stated all the food items should be dated and sealed once opened. 11. Review of the facility's P&P titled Storage of Canned and Dry Goods (undated) showed the plastic or metal containers (with tight fitting lids and NSF approved), or re-sealable plastic bags will be used for staples and opened packages (like pasta, rice, cereal, flour, etc.). The food items will be dated and labeled when placed in the containers. The scoops should not be left in the container and will be cleaned after each use. On 3/12/25 at 0649 hours, during the breakfast tray line observation, a scoop was observed inside the thickener container. On 3/12/25 at 0804 hours, an observation and concurrent interview was conducted with the DSS. The DSS verified the finding, and stated the scoop should not be kept in the thickener container. 12. According to the USDA Food Code 2017, Section 4-901.11, Equipment and Utensils, Air-Drying Required, items must be allowed to drain and to air-dry before being stacked or stored. Stacking of the wet items prevents them from drying and may allow an environment where microorganism can begin to grow. On 3/11/25 at 0800 hours, during the initial tour of the facility's kitchen, an observation and concurrent interview was conducted with the DSS. A clean blender was observed stored with the top lid on and wet inside. The DSS verified the blender was not air-dried. On 3/14/25 at 0947 hours, an interview was conducted with the Administrator, RD, and DSS. The Administrator, RD, and DSS were informed and acknowledged the above findings 13. Review of the facility's P&P titled Resident's Refrigerator/Freezer Storage (undated), showed the nursing staff or a designee to check and record temperatures of all refrigerators and freezers daily to ensure the equipment is within the appropriate temperature for food. The section for Procedure showed the following: 1. Nursing staff or designee will check the inside temperature of refrigerators and freezers. 2. Nursing staff or designee will record and initial the temperature log twice a day. 3. If the temperatures are not within appropriate range, nursing staff or designee will notify the Maintenance Supervisor and Administrator. - Refrigerator Temperature: 40 degrees F (Fahrenheit) or lower - Freezer Temperature: 0 degrees F or lower Medical record review for Resident 7 was initiated on 3/11/24. Resident 7 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 7's H&P examination dated 8/9/24, showed Resident 7 had the capacity to understand and make decisions. On 3/11/25 at 0930 hours, an observation and concurrent interview was conducted with Resident 7. Resident 7's room was observed with a personal refrigerator and the log titled Refrigerator Log March 2025 was posted on the outside of the refrigerator. Resident 7 verified the refrigerator inside the room was his personal refrigerator. Review of the Refrigerator Log for March 2025 showed the columns for the date, nurse's initials, and refrigerator temperatures for 0600 and 1800 hours. The daily refrigerator temperature log for Resident 7's personal refrigerator showed the following temperature at 0600 hours: - 48 degrees F on 3/2, and 3/3/25; - 49 degrees F on 3/8/25; - 50 degrees F on 3/1, 3/4, 3/5, 3/6, 3/7, 3/9, 3/11, and 3/12/25, and - 52 degrees F on 3/13/25. Further review of the refrigerator log failed to show the documentation of Resident 7's personal refrigerator temperature for the 1800 hours or documentation of the freezer temperature. On 3/13/25 at 0847 hours, an observation, interview, and concurrent facility document review for Resident 7's personal refrigerator was conducted with RN 3. RN 3 verified the refrigerator log showed the temperature for the refrigerator must be between 36 and 46 degrees F and the RN Supervisor and/or Maintenance Supervisor should be notified immediately for the temperatures not within range. RN 3 verified the refrigerator log showed the temperature for Resident 7's personal fridge was outside of the acceptable temperature range every day for March 2025. RN 3 verified the log showed no documentation if the RN Supervisor and/or Maintenance Supervisor was contacted when Resident 7's personal refrigerator temperature was outside of the acceptable range. RN 3 stated the RN Supervisor and/or Maintenance Supervisor should have been notified. RN 3 also verified the refrigerator log showed no documentation the temperature of Resident 7's personal refrigerator was checked daily at 1800 hours. Furthermore, RN 3 acknowledged the facility's policy for maintaining the personal refrigerator temperatures of less than 40 degrees F should be followed. RN 3 verified the refrigerator log showed an unacceptable temperature range that was inconsistent with the facility's policy for personal refrigerators. On 3/13/25 at 0912 hours, a follow-up observation and concurrent interview was conducted with RN 3. RN 3 verified the refrigerator log for Resident 7's personal refrigerator showed no documentation of the freezer temperatures for March 2025. The temperature of the freezer in Resident 7's personal refrigerator was observed at 10 degrees F. RN 3 verified and acknowledged the temperature of Resident 7's freezer was at 10 degrees F, and was out of the recommended range of zero degrees or lower per the facility's policy. On 3/13/25 at 0948 hours, an interview and concurrent facility document review was conducted with the Maintenance Director. The facility's P&P titled Resident's Refrigerator/Freezer Storage (undated) and maintenance department's Refrigerator Log for Resident 7's personal fridge for March 2025 was reviewed with the Maintenance Director. The Maintenance Director verified the Refrigerator Log posted outside Resident 7's personal refrigerator showed the refrigerator temperatures were outside of the acceptable range of 40 degrees F or less every day for March 2025. The Maintenance Director stated he was unaware the temperature of Resident 7's personal refrigerator was outside of the acceptable range every day in March 2025. The Maintenance Director verified he should have been notified when Resident 7's refrigerator temperature was outside of the acceptable range so the refrigerator temperature could have been adjusted. Review of the maintenance department's Refrigerator Log for Resident 7's personal refrigerator for March 2025 showed the following temperatures: - 39 degrees F on 3/5, and 3/11/25; - 40 degrees F on 3/1, 3/2, and 3/6/25; - 41 degrees F on 3/3, 3/4, 3/7, 3/8, 3/9, and 3/10/25, and - no entry on 3/12/25. The Maintenance Director verified the maintenance department checks the temperatures of all the personal refrigerators daily. The Maintenance Director verified the maintenance department's Refrigerator Log for Resident 7's personal refrigerator was incomplete and showed no documentation if the refrigerator's temperature was checked on 3/12/25. The Maintenance Director verified the facility's policy for maintaining the personal refrigerator temperatures of less than 40 degrees F should be followed and the refrigerator logs showed an unacceptable temperature range that was inconsistent with the facility's policy for personal refrigerators. The Maintenance Director verified the maintenance department's refrigerator log for Resident 7's personal refrigerator showed the temperature was outside of the acceptable range on 3/3, 3/4, and 3/7 to 3/10/25, and the log showed no documentation the refrigerator temperature was adjusted to ensure the refrigerator's temperature remained within the acceptable range. On 3/14/25 at 1503 hours, an interview was conducted with the Administrator and DON. The Administrator and the DON were 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 maintain the infection prevention and control program designed to provide thesafe, sanitary comfortable environment to help prevent the transmission of communicable diseasesand infection. * CNA 5 failed to properly perform the proper hand hygiene after removing and disposing the PPE. * The facility failed to ensure the proper disposal of used gowns and gloves in the trash in Room A. These failures had the potential risk to spread and control the infection to the residents, staff personnel, and visitors. Findings: 1. Review of the facility's P&P titled Handwashing/ Hand Hygiene revised April 2023 showed the facility considers hand hygiene the primary means to prevent the spread of infections, all personnel shall follow the handwashing/hand hygiene procedure to help prevent the spread of infections to other personnel, residents and visitors, and the hand hygiene is the final step after removing and disposing or personal protective equipment. Medical record review for Resident 2 was initiated on 3/25/24. Resident 2 was admitted to the facility on [DATE]. On 3/26/24 at 0824 hours, an observation was conducted with CNA 5 while taking care of Resident 2. CNA 5 removed her gown and gloves and disposed the PPE she was wearing in the trash bin. CNA 5 touched the trash bin while disposing the PPE. CNA 5 proceeded back to Resident 2's bedside, touched Resident 2's shoulders, and assisted Resident 2 with repositioning. However, CNA 5 was not observed performing the proper hand hygiene after disposing the PPE. On 3/26/24 at 0901 hours, an interview was conducted with LVN 4. LVN 4 stated the proper hand hygiene was required after touching something dirty and should be performed before attending to the resident. 2. On 3/26/24 at 1034 hours, a wound care observation was conducted with Treatment Nurse 4 in Room A. The resident in Room A was also observed with tracheostomy and GT site. Furthermore, the trash bin in Room A was observed overflowing with disposable gowns and gloves. On 3/26/24 at 1055 hours, an interview was conducted with Treatment Nurse 2. Treatment Nurse 2 stated the trash bin should not be overflowing and it should have been collected.

Based on record review, interviews, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure the accuracy of a Minimum Data Set (MDS) assessment for 1 (Resident #60) of 3 sampled residents reviewed for Preadmission Screening and Resident Review (PASSR) requirements. Specifically, the facility failed to ensure Resident #60's annual MDS, with an Assessment Reference Date (ARD) of 07/07/2023, reflected that the resident was considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or related condition. Findings included: A review of the CMS Long-Term Care Facility RAI 3.0 User's Manual, version 1.18.11, dated October 2023, Chapter 3: Overview to the Item-By-Item Guide to the MDS 3.0, A1500: Preadmission Screening an Resident Review (PASRR), revealed, Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD [intellectual disability/developmental disability] or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions. A review of an admission Record revealed the facility most recently admitted Resident #60 on 04/06/2022 with diagnoses that included schizoaffective disorder, anxiety disorder, paranoid schizophrenia, bipolar disorder, bipolar two disorder, and mental disorder not otherwise classified. A review of Resident #60's Care Plan, revealed a Focus area, initiated on 04/06/2022 and revised on 06/09/2022, that indicated the resident had behavior manifestations related to diagnoses of schizophrenia, mood disorder, and insomnia. Further review of Resident #60's Care Plan revealed multiple Focus areas that indicated the resident was at risk for adverse effects from psychotropic medications with black box warnings, including Haldol (an anti-psychotic medication), risperidone (an atypical anti-psychotic medication), Caplyta (an atypical anti-psychotic medications), and buspirone (an anti-anxiety medication). A review of a Preadmission Screening and Resident Review (PASRR) Individualized Determination Report, dated 06/17/2022, revealed a Level II PASRR review was completed, and specialized services were recommended, which included services and supports to supplement nursing facility care to address the resident's mental health needs. A review of an annual MDS, with an ARD of 07/07/2023, revealed Resident #60 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The MDS indicated the resident had active diagnoses that included anxiety disorder, bipolar disorder, schizophrenia, and a mental disorder not otherwise specified. Section A1500, for whether the resident was considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or related condition, was inaccurately coded 0, indicating no. According to Section Z Assessment Administration, MDS Licensed Vocational Nurse (LVN) #5 completed Section A1500. During an interview on 03/08/2024 at approximately 9:10 AM, MDS LVN #5 stated if a resident had a Level II PASRR it should be reflected on the comprehensive MDS in section A. After reviewing Resident #60's record, she confirmed that the MDS was not accurately coded for a Level II PASRR. During an interview on 03/08/2024 at 10:27 AM, the Director of Nursing (DON) stated if a resident had a Level II PASRR, it should be reflected on the MDS.

Based on observations, record review, interviews, and facility policy review, the facility failed to ensure the use of a bilevel positive airway pressure machine (BiPAP, a machine used to provide noninvasive ventilation) was reflected on the care plan for 1 (Resident #60) of 2 sampled residents reviewed for respiratory care. Findings included: A review of a facility policy titled, Care Plans, Comprehensive Person-Centered, revised in March 2023, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy specified, The comprehensive, person-centered care plan: a. includes measurable objective and timeframes; b. describes the services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being, including (3) which professional services are responsible for each element of care and e. reflects currently recognized standards of practice for problem areas and conditions. A review of an admission Record revealed the facility most recently admitted Resident #60 on 04/06/2022 with diagnoses that included obstructive sleep apnea. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/03/2024, revealed Resident #60 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. According to the MDS, the resident utilized a non-invasive mechanical ventilator while a resident of the facility. A review of Resident #60's Order Summary Report, listing active orders as of 03/08/2024, revealed the following orders dated 07/19/2022: - BiPAP with heated humidifier and tubing with fillers (large facemask) 8-15 centimeters (cm) water every evening and night shift; -Cleanse BiPAP mask before and after use, wipe mask with personal cleansing cloth every evening and night shift; and -Cleanse BiPAP tubing every week on Sunday, cleanse with soap and warm water, pat and hang dry. A review of Resident #60's Care Plan, last reviewed on 01/11/2024, revealed the resident had a care plan addressing impaired gas exchange related to obstructive sleep apnea; however, at the time of the review, the care plan did not address the resident's use of a BiPAP. The facility revised the resident's care plan on 03/07/2024 (during the survey) to include a Goal related to BiPAP use. The undated Interventions consisted of assessing the resident's respiratory function, checking the condition of the resident's skin under the BiPAP mask and securing band, frequent visual checks, and palpating the resident's abdomen for distention. None of the interventions were related to the resident's specific BiPAP orders, or to the ordered cleaning and maintenance of the equipment. Observations and interview on 03/07/2024 at 1:40 PM revealed a BiPAP machine on Resident #60's nightstand with the tubing still connected and the mask lying on top of the machine. There was dried debris on the inside of the mask. Resident #60 stated they had not seen the staff clean their BiPAP equipment and did not think it had been cleaned. Resident #60 stated the mask was usually sitting on the top of the machine. During an interview on 03/08/2024 at 9:15 AM, the MDS Registered Nurse (RN) stated that in general the overall condition of the resident should be reflected on the care plan, including what their function level was, any type of special equipment needed, and the general health of the resident. She stated the use of specialized equipment, including BiPAPs, should be addressed on the care plan. During an interview on 03/08/2024 at 10:27 AM, the Director of Nursing (DON) stated the care plan should include specialized treatments, including the use of a BiPAP. She stated Resident #60 previously had a care plan for the use of the BiPAP, but someone accidentally resolved it (a term meaning the care plan was no longer considered active and was no longer a current problem for the resident), so it needed to be reactivated. During an interview on 03/08/2024 at 11:01 AM, the Administrator stated Resident #60's care plan should have addressed the use of a BiPAP.

Based on observations, record review, interviews, and facility policy review, the facility failed to ensure staff assisted with oral care, including brushing teeth, for 1 (Resident #62) of 3 sampled residents reviewed for activities of daily living (ADLs). Findings included: A review of a facility policy titled, Activities of Daily Living (ADLs), Supporting, revised in March 2023, revealed, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). The policy specified, 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care). A review of an admission Record revealed the facility admitted Resident #62 on 03/25/2021 with diagnoses that included cerebral palsy, Rett syndrome (a rare genetic neurological disorder), scoliosis, and functional quadriplegia. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/28/2023, revealed a Staff Assessment for Mental Status (SAMS) determined Resident #62 had short- and long-term memory problems and severely impaired cognitive skills for daily decision making. According to the MDS, the resident was dependent on staff for oral hygiene. A review of Resident #62's Care Plan, revealed a Focus area, initiated on 03/31/2021 and revised on 11/30/022, that indicated the resident had self-care deficits and required total assistance of up to two people with personal hygiene. An undated intervention directed staff to provide dental/oral care twice daily and as needed and to assist as needed. An observation on 03/05/2024 at 11:20 AM revealed Resident #62's teeth were dirty and had debris stuck to them. The resident had halitosis (unpleasant odor from mouth). An observation on 03/06/2024 at 3:57 PM revealed Resident #62's teeth were dirty with brown and yellow debris stuck to them, and the resident had halitosis. An observation on 03/07/2024 at 10:13 AM revealed Resident #62's teeth were dirty and had debris stuck to them. During an interview on 03/08/2024 at 9:26 AM, Certified Nurses Aide (CNA) #3 stated she only used oral swabs and mouthwash to provide oral care for Resident #62 and had never tried to brush the resident's teeth since the resident did not eat food. She stated the resident did not refuse care, but she was unable to get the stuff off the resident's teeth. CNA #3 stated she had not had a chance to provide oral care yet that morning. During an interview on 03/08/2024 at 8:52 AM, Registered Nurse (RN) #2 stated oral care should be provided two times a day by the CNAs. She stated Resident #62 required total assistance with oral care and thought the CNAs could brush the resident's teeth but was not sure. RN #2 stated Resident #62 did not refuse care. During an interview on 03/08/2024 at 9:37 AM, Licensed Vocational Nurse (LVN) #1 stated oral care was provided every shift and the supplies were kept in the top drawer of the nightstand. LVN #1 entered Resident #62's room and confirmed there was no toothbrush or toothpaste in the resident's drawer of the nightstand, but there was a bottle of mouthwash and oral swabs in the drawer. LVN #1 confirmed Resident #62 had yellow and brown debris on their teeth and stated she thought it might be plaque (a sticky film that coats teeth and contains bacteria). During an interview on 03/08/2024 at 10:27 AM, the Director of Nursing (DON) stated oral care should be provided every shift or as needed. She stated a resident's personal toothbrush and toothpaste should be kept in a bag in the top drawer of their nightstand unless they were disposable. The DON stated Resident #62 required total care from staff for their ADLs. During an interview on 03/08/2024 at 11:01 AM, the Administrator stated oral care should be provided daily, at a minimum. The Administrator stated Resident #62 was dependent on staff and required assistance with oral care.

Based on observations, record review, and interviews, the facility failed to ensure respiratory equipment was cleaned and stored appropriately between uses for 1 (Resident #60) of 2 sampled residents reviewed for respiratory care. Specifically, Resident #60's bilevel positive airway pressure machine (BiPAP, a machine used to provide noninvasive ventilation) mask was cleaned and stored in a plastic bag after each use. Findings included: A review of an admission Record revealed the facility most recently admitted Resident #60 on 04/06/2022 with diagnoses that included obstructive sleep apnea. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/03/2024, revealed Resident #60 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. According to the MDS, the resident utilized a non-invasive mechanical ventilator while a resident of the facility. A review of Resident #60's Order Summary Report, listing active orders as of 03/08/2024, revealed the following orders dated 07/19/2022: - BiPAP with heated humidifier and tubing with fillers (large facemask) 8-15 centimeters (cm) water every evening and night shift; and -Cleanse BiPAP mask before and after use, wipe mask with personal cleansing cloth every evening and night shift A review of Resident #60's March 2024 Medication Administration Record (MAR) revealed documentation that staff administered the resident's BiPAP every evening and night. The MAR also reflected documentation each evening and night shift that staff cleansed the resident's BiPAP mask. There was no documentation for cleansing the BiPAP mask after use (in the morning). Observations on 03/05/2024 at 10:45 AM revealed a BiPAP machine on Resident #60's nightstand with the tubing still connected. The resident's BiPAP mask was lying on the bed next to the bed rail. Observations on 03/06/2024 at 10:16 AM revealed a BiPAP machine on Resident #60's nightstand with the tubing still connected. The resident's BiPAP mask was lying on top of clothes on the nightstand, and there was dried debris inside the mask. Observations and interview on 03/07/2024 at 1:40 PM revealed a BiPAP machine on Resident #60's nightstand with the tubing still connected and the mask lying on top of the machine. There was dried debris on the inside of the mask. Resident #60 stated they had not seen the staff clean their BiPAP equipment and did not think it had been cleaned. Resident #60 stated the mask was usually sitting on the top of the machine. During an interview on 03/08/2024 at 8:52 AM, Registered Nurse (RN) #2 stated BiPAP masks should be cleaned with wipes before and after use and stored in a plastic bag between uses. During an interview on 03/08/2024 at 9:37 AM, Licensed Vocational Nurse (LVN) #1 stated BiPAP masks should be stored in a plastic bag when not in use. She further stated masks were cleaned with personal wipes before bedtime by the evening shift. During an interview on 03/08/2024 at 10:03 AM, LVN #4 stated she worked with Resident #60 during the evening shift and assisted the resident with their BiPAP and turned the machine on. LVN #4 stated the day shift should clean the BiPAP mask after use when it was removed each morning. During an interview on 03/08/2024 at 10:27 AM, the Director of Nursing (DON) stated BiPAP equipment should be stored in a plastic bag in the room when not in use. The DON further stated the mask should be cleaned before and after use. She stated the nurse that removed the mask in the morning should clean and store it properly. During an interview on 03/08/2024 at 11:01 AM, the Administrator stated BiPAP equipment should be stored in a plastic bag when not in use. She stated the mask should be cleaned every day. She stated she saw Resident #60's BiPAP mask the day prior and acknowledged the mask was not stored properly.

Based on observations, record review, interviews, and facility policy review, the facility failed to ensure the medication error rate was less than 5 percent (%). Specifically, the facility had 2 errors out of 31 opportunities, resulting in a medication error rate of 6.45%, affecting 1 (Resident #6) of 5 residents reviewed during the medication administration task. Findings included: A review of a facility policy titled, Administering Medications, revised in March 2023, revealed, Medications are administered in a safe and timely manner, and as prescribed. The policy further indicated, 4. Medications are administered in accordance with prescriber orders, including any required time frame. A review of Resident #6's admission Record revealed the facility most recently admitted the resident on 09/22/2021 with diagnoses that included neuromuscular dysfunction of the bladder and calculus of the kidney. A review of Resident #6's March 2024 Medication Administration Record (MAR) revealed the transcription of an order started on 09/22/2021 for Florastor (a probiotic) capsule 250 milligrams (mg), two capsules by mouth one time a day, and the transcription of an order started on 10/14/2021 for cranberry capsule 425 mg, two capsules by mouth four times a day for urinary tract infection prophylaxis. According to the MAR, Resident #6 was scheduled to receive the Florastor and cranberry capsules each morning at 9:00 AM. On 03/07/2024 at 9:09 AM, Licensed Vocational Nurse (LVN) #1 was observed preparing and administering Resident #6's medications. LVN #1 administered one capsule of cranberry and one capsule of Florastor, instead of two capsules as ordered by the physician. During an interview on 03/07/2024 at 1:24 PM, LVN #1 confirmed that she only administered one capsule of Florastor and one capsule of cranberry. She stated she should have read the order better. She further stated she should have compared the label on the medication with the order, and she should have read the whole order to ensure that she was giving the right amount. During an interview on 03/08/2024 at 8:52 AM, Registered Nurse (RN) #2 stated that when passing medications, the nurse should check the order with the medication label three times. During an interview on 03/08/2024 at 10:27 AM, the Director of Nursing (DON) stated that when nurses were passing medications, they should compare the MAR to the medication labels three times before administering the medications. She stated LVN #1 should have read the whole order and checked to see how many capsules should have been given. During an interview on 03/08/2024 at 11:01 AM, the Administrator stated that when passing medications, the nurses should follow the rights of medication administration, including the right resident, right medication, right dose, right time, and right route.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility document review, the facility failed to provide the necessary care and services for one of three sampled residents (Resident 3) to ensure the resident maintained his highest physical well-being. * The facility failed to ensure the sling was applied appropriately to Resident 3's RUE as per the physician's order. This failure had the potential to affect Resident 3's well-being. Findings: Review of the facility's in-service titled Mobility Precautions, Right Shoulder Sling at All Times, No Right Shoulder Movement, 2 Person Assist, POP Precaution, Donning/Doffing RUE Sling provided by the DOR and DSD on 11/14 and 11/15/23, showed CNA 1 and LVN 2 were in attendance for the in-service. Medical record review of Resident 3 was initiated on 11/20/23. Resident 3 was readmitted to the facility on [DATE]. Review of Resident 3's Order Summary Report dated 11/22/23, showed a physician's order dated 11/14/23, to apply sling on the right shoulder for right proximal humeral shaft fracture at all times and may release sling every two hours to monitor for signs and symptoms of skin breakdown. On 11/20/23 at 1236 hours, an observation was conducted with Resident 3. Resident 3 was observed lying on a LAL mattress and positioned on his back. Resident 3 was observed without a sling on his RUE. On 11/20/23 at 1243 hours, an observation and concurrent interview was conducted with LVN 2. LVN 2 verified Resident 3 did not have a sling on his RUE. LVN 2 stated Resident 3 had a physician's order to apply a sling to his right arm but needed to recheck the physician's order for the frequency of the sling. On 11/20/23 at 1257 hours, a follow-up observation and concurrent interview was conducted with LVN 2. LVN 2 verified the physician's order showing to apply the sling at all times but may be released every two hours to monitor for skin breakdown. LVN 2 stated he did not know how long Resident 3 had his sling off and needed to ask CNA 1. On 11/20/23 at 1302 hours, an observation and concurrent interview was conducted with CNA 1 and LVN 2. CNA 1 stated the sling was on Resident 3's RUE and proceeded to show Resident 3's sling. Resident 3's sling was observed underneath his right shoulder. CNA 1 and LVN 2 verified the finding. LVN 2 stated Resident 3's sling was not applied properly and should be applied around Resident 3's right forearm, with the straps placed around Resident 3's posterior neck to provide support for his right arm. On 11/20/23 at 1317 hours, an interview was conducted with RN 1. RN 1 stated he was aware Resident 3 had a physician's order for a sling to be applied on his RUE. However, RN 1 stated he did not have the chance to check whether Resident 3's sling was on and applied properly on his RUE. On 11/22/23 at 0913 hours, an interview was conducted with the ADON. The ADON was informed and acknowledged the above finding. The ADON stated the licensed nurses were expected to apply the sling as ordered by the physician and to monitor for proper application and placement of the sling during their shift. On 11/22/23 at 1130 hours, an interview was conducted with the DON and Administrator. The DON and Administrator 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 ensure the necessary care and services were provided to prevent the worsening of pressure injuries (areas of damaged skin caused by staying in one position for a long time which reduces blood flow to the area and causes the skin to die and develop a sore) and promote the healing of existing pressure injuries for two of three sampled residents (Residents 1 and 2). * The facility failed to provide the appropriate and necessary nursing services to ensure Residents 1 and 2 had no more than two layers of linen between the residents and low air loss mattress. This failure had the potential of Residents 1 and 2 not receiving the appropriate care and services to promote healing or prevent the development of new pressure injuries. Findings: Review of the facility's P&P titled Pressure-reducing Mattresses (undated) showed the objective of the policy was to provide mattresses that will prevent and/or minimize pressure on the skin. Under the section for Steps showed to place a flat sheet over the mattress, while ensuring that no more than two layers of linen are between the resident and the pressure-reducing mattress. If the resident is incontinent, place protective pad in the center of the bed, this will count as one layer of linen. 1. During the initial tour of the facility on 11/20/23 at 1021 hours, Resident 1 was observed lying on a LAL mattress covered with a flat sheet and two protective pads were underneath Resident 1. Medical record review for Resident 1 was initiated on 11/20/23. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's MDS dated [DATE], showed Resident 1 had moderately impaired cognition and required maximal assistance from staff to roll left and right (the ability to roll from lying on back to left and right side, and return to lying on back on the bed). Review of Resident 1's Skin Progress Report dated 11/14/23, showed Resident 1 had a Stage 4 (full-thickness skin loss with exposed bone, tendon, or muscle) pressure injury to her sacrococcygeal (pertaining to both the sacrum and coccyx/tailbone) extending to the left and right buttocks and right ischium (forms the lower and back part of the hip bone). On 11/20/23 at 1209 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 verified Resident 1 was lying on a LAL mattress covered with a flat sheet and two protective pads were underneath the resident who was also wearing an incontinence brief. On 11/20/23 at 1425 hours, a wound care observation for Resident 1 was conducted with LVN 1 and the IP. The IP verified Resident 1 was lying on a LAL mattress covered with a flat sheet and one protective pad was underneath the resident who was also wearing an incontinence brief. The IP stated Resident 1 should only have either a protective pad or an incontinence brief when lying on a LAL mattress covered with a flat sheet. The IP stated there should only be two layers between the LAL mattress and resident. 2. On 11/20/23 at 1135 hours, an observation and concurrent interview was conducted with Resident 2. Resident 2 was observed lying on a LAL mattress covered with a flat sheet and two protective pads were underneath the resident who was also wearing an incontinence brief. Medical record review for Resident 2 was initiated on 11/20/23. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's H&P examination dated 10/4/23, showed Resident 2 had the capacity to understand and make decisions. Review of Resident 2's MDS dated [DATE], showed Resident 2 was at risk of developing pressure ulcers/injuries. The MDS showed Resident 2 had an unstageable (full thickness skin loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar/ dead tissue) pressure injury. On 11/20/23 at 1208 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 verified Resident 2 was lying on a LAL mattress covered with a flat sheet and two protective pads were underneath the resident who was wearing an incontinence brief. LVN 1 stated there should only be two layers between the resident and the LAL mattress. LVN 1 stated the protective pad and incontinence brief were considered one layer each. On 11/22/23 at 1130 hours, an interview was conducted with the DON and Administrator. The DON and Administrator 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, the facility failed to ensure one of three sampled residents (Resident 3) who received enteral feedings via GT were provided the appropriate treatment and services to prevent complications. * The facility failed to ensure Resident 3 was administered the correct enteral feeding formula as ordered by the physician. In addition, the facility failed to ensure the enteral feeding mechanical pump was operated by a licensed staff for Resident 3. These failures posed the potential risk for not meeting the Resident 3's nutritional needs and potential risk for aspiration during feeding. Findings: Review of the facility's P&P titled Enteral Feedings- Safety Precautions revised 11/2018 showed the purpose of the policy is to ensure the safe administration of enteral nutrition. Under the section Preparation showed all personnel responsible for preparing, storing, and administering enteral nutrition formulas will be trained, qualified and competent in his or her responsibilities. Under the section Preventing Errors in Administration showed to check the enteral nutrition label against the order before administration. a. Medical record review of Resident 3 was initiated on 11/20/23. Resident 3 was readmitted to the facility on [DATE]. Review of Resident 3's History and Physical examination dated 4/11/23, showed Resident 3 had dysphagia (difficulty swallowing) and GT feeding, and did not have the capacity to understand and make decisions. Review of Resident 3's MDS dated [DATE], showed Resident 3 was totally dependent on the staff for eating (including intake of nourishment through tube feeding). Review of Resident 3's Order Summary Report dated 11/22/23, showed a physician's order dated 8/3/23, to administer Glucerna 1.2 (a type of feeding formula) at 80 ml/hr for 20 hours via pump to provide 1600 ml or 1920 kcals. On 11/20/23 at 1236 hours, an observation was conducted with Resident 3. Resident 3 was observed lying on a LAL mattress, positioned on his back with his head of bed elevated. Resident 3 was observed receiving enteral feeding of Jevity 1.2 (a type of feeding formula) at 80 ml/hr via mechanical pump. However, the enteral feeding bottle was labeled with Resident A's name and room number. On 11/20/23 at 1243 hours, an observation and concurrent interview was conducted with LVN 2. LVN 2 verified Resident 3 was receiving Jevity 1.2 at 80 ml/hr via mechanical pump. LVN 2 verified the Jevity 1.2 formula bottle was labeled with Resident A's name and room number. On 11/20/23 at 1257 hours, a follow-up observation and concurrent interview was conducted with LVN 2. LVN 2 was observed checking Resident 3's physician's order. LVN 2 verified thephysician's order showed to administer Glucerna 1.2 at 80 ml/hr. LVN 2 stated the Jevity 1.2 formula bottle was hung by the previous licensed nurse. LVN 2 stated he turned on Resident 3's enteral mechanical pump with the Jevity 1.2 formula hanging at 1200 hours. However, LVN 2 stated he did not check if the correct enteral feeding formula was hanging prior to turning on the mechanical pump and administering the feeding to Resident 3. On 11/20/23 at 1313 hours, a follow-up interview was conducted with LVN 2. LVN 2 stated he turned off the enteral feeding pump, changed Resident 3's enteral feeding formula to Glucerna 1.2 as ordered by the physician and notified the physician of Resident 3 receiving the wrong feeding formula. b. On 11/20/23 at 1302 hours, an observation and concurrent interview was conducted with CNA 1. Resident 3 was observed lying in bed, positioned on his back with his head of bed elevated and receiving enteral feeding via mechanical pump. CNA 1 was observed pressing the hold button on the mechanical pump and lowering Resident 3's head of bed down to fix the placement of Resident 3's right arm sling. CNA 1 stated he was allowed to put the enteral feeding on hold when he provided care for the resident but would inform the licensed nurse when he was done providing care. On 11/20/23 at 1313 hours, an interview was conducted with LVN 2. LVN 2 stated he was unfamiliar about the facility's policy allowing CNAs to operate the enteral feeding mechanical pump. However, LVN 2 stated CNAs were not allowed to operate the enteral feeding mechanical pump. On 11/20/23 at 1317 hours, an interview was conducted with RN 1. RN 1 stated CNAs should not be operating the enteral feeding mechanical pump, including pressing the hold button when providing care for the resident. On 11/22/23 at 0913 hours, an interview was conducted with the ADON. The ADON was informed and acknowledged the above findings. The ADON stated the licensed nurses were expected to check the enteral feeding formula against the physician's order prior to hanging and administering an enteral feeding formula. The ADON stated CNAs must notify the licensed nurse to put the enteral feeding pump on hold because CNAs were not trained to operate the mechanical pump. On 11/22/23 at 1130 hours, an interview was conducted with the DON and Administrator. The DON and Administrator 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 ensure the nursing staff performed hand hygiene during the wound care treatment for two of three sampled residents (Residents 1 and 2). This failure posed the risk of infection and the transmission of disease-causing microorganisms. Findings: Review of the facility's P&P titled Hand Washing (undated) showed hand washing must be performed in between performance of routine procedures i.e., handling urinals, bedpans, catheters, changing dressings, collecting specimens, etc. Review of the facility's P&P titled Wound Care revised 3/2023 showed the purpose of the policy is to provide guidelines for the care of wounds to promote healing. Under the section Steps in the Procedures showed: (a) put on exam gloves, loosen tape, and remove dressing, (b) pull gloves over the dressing and discard into appropriate receptacle, (c) wash and dry hands thoroughly, and (d) put on gloves. 1. Medical record review for Resident 1 was initiated on 11/20/23. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's Order Summary Report dated 11/22/23 showed a physician's order dated 11/14/23, to cleanse the right ischium wound with normal saline, pat dry, apply hydrogel gel (gel that creates a moist wound environment and promotes wound healing) followed by collagen (used to help the body naturally restart the wound healing process) powder topically every day shift. Review of Resident 1's Order Summary Report dated 11/22/23 showed a physician's order dated 11/14/23, to cleanse the sacrococcyx wound extending to left and right buttock with normal saline, pat dry, apply collagen sheet, then cover with a dry dressing every day shift. On 11/20/23 at 1425 hours, a wound care observation for Resident 1 was conducted with LVN 1 and the IP. Resident 1 was observed awake and lying on a LAL mattress. LVN 1 and theIP were observed washing their hands with soap and water and donning a clean pair of gloves and gowns. Resident 1's sacrococcyx, left and right buttocks, and right ischium pressure injuries were observed not covered with a dressing. LVN 1 was observed cleaning Resident 1's wounds with normal saline, then patted them dry with a gauze. LVN 1 then proceeded to apply the collagen sheets to Resident 1's sacrococcyx and left and right buttock wounds without changing his gloves and performing hand hygiene. LVN 1 then covered and secured Resident 1's sacrococcyx extending to the left and right buttock wounds with a bordered dressing. LVN 1 was observed removing his gloves, washing his hands with soap and water, then donning a new pair of clean gloves. Finally, LVN 1 used a tongue depressor to apply hydrogel and collagen powder to Resident 1's right ischium wound. On 11/20/23 at 1440 hours, an interview was conducted with LVN 1 and the IP. LVN 1 and theIP verified the above findings. LVN 1 and the IP stated LVN 1 should have removed his old gloves, washed his hands with soap and water, and donned new gloves after cleaning Resident 1's wounds. 2. Medical record review for Resident 1 was initiated on 11/20/23. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's Order Summary Report dated 11/22/23, showed a physician's order dated 11/14/23, to cleanse status post mid abdominal opened surgical wound with three retention sutures with normal saline, apply wet to dry dressing, and cover with a bordered gauze. On 11/20/23 at 1145 hours, a wound care observation was conducted with LVN 1. Resident was observed being awake and lying on a LAL mattress. LVN 1 was observed washing his hands with soap and water and donning a clean pair of gloves. LVN 1 was observed removing the dressing from Resident 2's mid abdominal wound. LVN 1 then proceeded to clean Resident 2's wound with normal saline, then patted it dry with gauze, without changing his gloves and performing hand hygiene. LVN 1 was then observed changing to a clean pair of gloves, without performing hand hygiene, and used a cotton tipped swab to pack Resident 2's wound with gauze moistened with normal saline. Finally, LVN 1 changed to a clean pair of gloves without performing hand hygiene, and covered Resident 2's wound with a bordered dressing. On 11/20/23 at 1208 hours, an interview was conducted with LVN 1. LVN 1 verified the above findings and stated he should have washed his hands and changed to a clean pair of gloves after removing the old dressing and before donning clean each pair of gloves. On 11/22/23 at 1130 hours, an interview was conducted with the DON and Administrator. The DON and Administrator 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 ensure the informed consent was obtained prior to the initiation and administration of a psychotropic medication for one nonsampled resident (Resident 89). This failure had the potential to violate Resident 89's rights to be informed of the psychotropic medication use. Findings: Review of the facility's P&P titled Psychotropic Medication Use dated 6/2021 showed the informed consent will be obtained by the prescriber prior to initiation of the psychotropic medication. On 12/9/22 at 1348 hours, an observation, interview, and concurrent medical record review was conducted with LVN 1 at Medication Cart 1. LVN 1 was asked to select a random PRN controlled medication from the cart. LVN 1 showed a bubble pack dated 8/16/22, for Resident 89 for lorazepam (anti-anxiety medication) 1 mg, administer one tablet by mouth every eight hours PRN for anxiety. LVN 1 was asked to show the physician's order of lorazepam and informed consent obtained prior to the initiation and administration of lorazepam for Resident 89. LVN 1 was able to show the physician's order but was unable to provide documentation of the informed consent. LVN 1 asked LVN 6 for assistance. Medical record review for Resident 89 was initiated on 12/9/22. Resident 89 was admitted to the facility on [DATE]. Review of Resident 89's History and Physical examination dated 5/9/22, showed Resident 89 did not have the capacity to understand and make decisions and listed a surrogate decision maker. Review of Resident 89's Order Summary Report showed an order dated 8/16/22, for Ativan (its generic name is lorazepam) 1 mg, administer one tablet by mouth every eight hours PRN for anxiety manifested by restlessness and agitation. Review of Resident 89's MARs showed Resident 89 received three doses of Ativan in August 2022, 14 doses in September 2022, 11 doses in October 2022, four doses in November 2022, and two doses in December 2022. Cross reference to F758, example #3. On 12/9/22 at 1436 hours, an interview and concurrent medical record review was conducted with LVN 6. LVN 6 was asked to show the informed consent was obtained prior to the administration of a psychotropic medication for Resident 89. Review of Resident 89's Informed Consent form for Ativan 1 mg every eight hours PRN for anxiety showed the following: - The resident/resident's representative listed below had given the informed consent to treat. - Resident 89's name was listed on the form, but there was no responsible party listed, no facility staff's signature, no physician's signature, and no date.

Based on observation, interview, and medical record review, the facility failed to provide the reasonable accommodation to meet the needs of two of 25 final sampled residents (Residents 17 and 359) and two nonsampled residents (Residents 61 and 360). The facility failed to ensure the residents' call lights were within reach. This failure had the potential to negatively impact the resident's psychosocial well-being or result in delayed provision of care. Findings: 1. On 12/7/22 at 0829 hours, Resident 17 was observed in bed, awake. The call light was observed on the floor, and not within the resident's reach. On 12/7/22 at 0831 hours, the ADON was asked to go to Resident 17's room. The ADON observed Resident 17's call light on the floor and acknowledged the resident could not reach it. On 12/8/22 at 0922 hours, an observation and interview was conducted with Resident 17. Resident 17 was observed in bed, awake. The call light was observed hanging on the side rail. Resident 17 stated she needed her call light, but the staff took her call light away. Resident 17 further stated even if she pressed the call light button, the staff would not respond to the call light. On 12/8/22 at 0928 hours, the IP was asked to go to Resident 17's room. The IP observed Resident 17's call light was hanging on the side rail and acknowledged the resident could not reach it. 2. On 12/7/22 at 0840 hours, Resident 61 was observed in bed, asleep. The call light cord was wrapped around the side rail, and the call light button was not within the resident's reach. On 12/7/22 at 0842 hours, the ADON asked to go to Resident 61's room. The ADON observed Resident 61's call light cord was wrapped around the side rail and acknowledged the resident could not reach the call light. 3. On 12/7/22 at 0910 hours, Resident 360 was observed in bed, asleep. The call light was observed on the floor, and not within the resident's reach. On 12/7/22 at 0913 hours, the ADON asked to go to Resident 360's room. The ADON observed Resident 360's call light was on the floor and acknowledged the resident could not reach it. 4. On 12/7/22 at 0918 hours, Resident 359 was observed in bed, awake. The call light was observed on the floor, and not within the resident's reach. On 12/7/22 at 0929 hours, CNA 3 was asked to go to Resident 359's room. The CNA 3 observed Resident 359's call light on the floor and acknowledged the resident could not reach it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure one of 25 final sampled residents' (Resident 34) advance directive was in the medical record. This failure put Resident 34 at risk of not receiving the medical treatment or medical services in accordance with his wishes. Findings: Medical record review for Resident 34 was initiated on 12/7/22. Resident 34 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 34's History and Physical Examination dated 8/11/22, showed Resident 34 did not have the capacity to understand, make decisions, and was listed as a surrogate decisionmaker. Review of Resident 34's Advance Directive Acknowledgement form dated 10/25/21, showed Resident 34 had executed an advance directive on 12/6/05. Review of Resident 34's Physician Orders for Life-Sustaining Treatment (POLST) dated 3/10/20, showed Resident 34's advance directive was available and reviewed. However, the advance directive was not in the medical record. On 12/8/22 at 1423 hours, an interview and concurrent medical record review was conducted with LVN 5. LVN 5 reviewed Resident 34's medical record and verified Resident 34's advance directive was not in the medical record. On 12/8/22 at 1436 hours, an interview was conducted with the SSD. The SSD stated during admission of a resident to the facility, they would ask whether the resident had an advance directive and if the resident had an advance directive, a copy of the advance directive would be placed in the medical record. On 12/8/22 at 1440 hours, an interview and concurrent medical record review was conducted with the Medical Records Director. The Medical Records Director was asked to provide a copy of Resident 34's advance directive. The Medical Records Director reviewed Resident 34's medical record and was unable to find a copy of Resident 34's advance directive.

Based on observation and interview, the facility failed to ensure the visual privacy for one nonsampled resident (Resident 408) was provided during care. This had the potential to violate the resident's rights to privacy. Findings: On 12/7/22 at 0824 hours, LVN 1 was observed administering the medications to Resident 408 via GT. Resident 408 occupied the last bed of a room shared with another resident. Resident 408's abdomen and upper body were exposed during the medication administration. Resident 408's privacy curtain was partially drawn, leaving Resident 408 visible to other residents and staff. On 12/7/22 at 0830 hours, an interview was conducted with LVN 1. LVN 1 verified the findings and stated the privacy curtain should have been fully closed during care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 59's medical record review was initiated on 12/7/22. Resident 59 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 59's Order Summary Report showed the physician's order to administer Caplyta capsule 42 mg one capsule by mouth one time a day. Review of Resident 59's care plan showed no care plan problem was developed to address the use of Caplyta. On 12/9/22 at 0953 hours, an interview and concurrent medical record review was conducted with RN 2. When asked if Resident 59 had a care plan for the Caplyta medication, RN 2 stated there was no care plan developed for Resident 59's Caplyta medication use. On 12/14/22 at 0933 hours, an interview and concurrent medical record review was conducted with the ADON. When asked if Resident 59 had a care plan for Caplyta medication use before 12/9/22, the ADON stated no care plan had been developed for the resident. Based on observation, interview, medical record review, and facility P&P review, the facility failed to develop the plans of care to reflect the individual care needs for three of 25 final sampled residents (Residents 26, 48, and 59). * The facility failed to develop a care plan problem to address Residents 26 and 48's use of side rails. * The facility failed to develop a care plan problem for Resident 59's Caplyta (medication used to treat schizophrenia). These posed the risk of not providing appropriate, consistent, and individualized care to the residents. Findings: Review of the facility's P&P titled Side Rail Use When Not a Restraint (undated) showed to complete a care plan entry when side rails are used. 1. On 12/7/22 at 0845 and 1127 hours, and on 12/13/22 at 0831 and 0939 hours, Resident 48 was observed lying in bed with bilateral side rails elevated by the head of the bed. Medical record review for Resident 48 was initiated on 12/7/22. Resident 48 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 48's History and Physical examination dated 11/22/22, showed Resident 48 had diagnoses including spastic recurrent seizures (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain). Review of Resident 48's plan of care failed to show a care plan problem was developed to address the use of side rails. On 12/13/22 at 0949 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified the above information. RN 1 verified a care plan problem was not developed to address Resident 48's use of side rails but should have been. Cross reference to F700, example #3. 2. On 12/7/22 at 1027 hours, during an initial tour of the facility, Resident 26 was observed in bed with bilateral side rails elevated. Subsequent observations showed on 12/8/22 at 1153 hours and 12/8/22 at 1344 hours, Resident 26 in bed with bilateral side rails elevated. On 12/14/22 at 1103 hours, an observation and concurrent interview was conducted with LVN 5 at Resident 26's bedside. LVN 5 verified Resident 26 was in bed with bilateral 1/4 side rails elevated. Medical record review for Resident 26 was initiated on 12/7/22. Resident 26 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Review of Resident 26's Order Summary Report showed an order dated 7/31/18, for bilateral upper half side rails up when in bed secondary to involuntary movement by gravity due to elevated HOB (head of bed) for management and provision of enteral feeding (intake of food via the gastrointestinal [GI] tract). Review of Resident 26's plan of care failed to show a care plan problem for side rail use. On 12/14/22 at 1104 hours, an interview and concurrent medical record review for was conducted with RN 1. RN 1 was asked to show Resident 26's care plan for the use of side rails. RN 1 showed a care plan problem dated 12/14/22, for the use of side rails as a non-restraint. RN 1 stated she added a care plan problem for the use of side rails for Resident 26 today. RN 1 verified there was no care plan problem in place prior to the use of bilateral side rails for Resident 26. Cross reference to F700, example #1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide an ongoing in room activity program to meet the needs and interests of two of 25 final sampled residents (Residents 12 and 76). * Resident 12 was assessed to prefer watching television. However, Resident 12 was provided a television with a blurry display. * Resident 76 was assessed to prefer watching television and listening to music. However, Resident 76 was observed in bed with no sensory stimulation. These failures posed the risk for the residents to feel isolated. Findings: 1.a. On 12/8/22 at 0938 hours, an observation and interview was conducted with Resident 12. Resident 12 was observed in bed and awake. A television was observed hanging on the wall. The television was turned on but the display was blurred. The television was shared between Resident 12 and another resident. When asked what activities she did in the facility, Resident 12 stated she stayed in bed, watched television, and slept. Resident 12 stated she liked to watch television. Resident 12 acknowledged the television display was blurred. Resident 12 stated she wanted it to be clearer if possible. Resident 12 was observed attempted to reach the television remote control, but the television remote control cord was wrapped around the right side rail, and Resident 12 could not reach the television remote control. When asked how she felt about the blurred television display, Resident 12 stated I guess, all channels are like that. On 12/8/22 at 0940 hours, the ADON was asked to go into Resident 12's room to check the television display. The ADON did not enter the room but stated she did not know anything about television so she would call the maintenance. On 12/8/22 at 0950 hours, an observation of Resident 12 and concurrent interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor verified Resident 12's television display was blurred. The Maintenance Supervisor also verified Resident 12's television remote control cord was wrapped around the right side rail. The Maintenance Supervisor unwrapped the television remote control cord from the side rail. Resident 12 was able to reach the television remote control and changed the channels. All channels were blurred. The Maintenance Supervisor attempted to fix the television display, but the channels were still blurred. The Maintenance Supervisor stated they would probably have to buy a new television for the resident. Medical record review for Resident 12 was initiated on 12/7/22. Resident 12 was readmitted to the facility on [DATE]. Review of Resident 12's Activities assessment dated [DATE], showed Resident 12's current activity preferences included watching television and talking/conversing. The assessment form also showed Resident 12's preferred activity setting was in her own room and in day/activity room. Review of Resident 12's Progress Notes, under Activity Note dated 10/25/22, showed for quarterly review, Resident 12 continued to be alert, verbally responsive and able to make needs known. Resident 12 was assisted to group activities as tolerated, otherwise, provided 1:1 room visits. Review of Resident 12's plan of care showed a care plan problem revised 7/18/22, to address Resident 12's requiring assistance and encouragement in attending and/or participating with planned activities program and the resident preferred activities. The interventions included to invite and assist the resident to activities daily, room visits when not going to group activities to accommodate their needs, and to offer alternate choice of activities per the resident preferences within their level of activities. Further review of Resident 12's plan of care showed a care plan problem dated 10/25/22, to address Resident 12's activity participation challenged by behavioral symptoms, and need for 1:1 activities. The goal was for Resident 12 to participate in 1:1 activity without disruptive behavior three times per week for 90 days. b. Review of Resident 12's Documentation Survey Report showed the following: - In October 2022, Resident 12 was provided 11 room visits, and no group activity; - In November 2022, Resident 12 was provided 9 room visits, and one group activity; and - In December 2022, Resident 12 was provided group activity, independent activity, and room visit on 12/9/22. On 12/9/22 at 1456 hours, an interview and concurrent medical record review for Resident 12 was conducted with the Activities Assistant. The Activities Assistant verified the above findings. When asked about Resident 12's activities, the Activities Assistant stated Resident 12 was non-verbal and did not go out of the room for activities. The Activities Assistant stated Resident 12 mostly stayed in bed and watched television. The Activities Assistant was informed Resident 12 could actually talk and was assessed with clear speech; and talking/conversing was one of her preferred activity preferences. The Activities Assistant stated when the residents could not participate in group activities, the activities personnel would do room visits daily. The Activities Assistant verified Resident 12 was not provided activities per her in-room visits and group activities as per the assessment and plan of care. On 12/14/22 at 1147 hours, Resident 12 was observed in bed and awake. A different television observed hanging on the wall, the TV was turned on and the display had a clear reception. When asked about the television, Resident 12 smiled and gave a thumbs up. 2. On 12/7/22 at 0942, 1036, and 1232 hours; and 12/8/22 at 0830, 0950, 1040, 1135, 1331 and 1347 hours, Resident 76 was observed in bed, awake, and staring at the wall. There was no television, radio, or any sensory stimulation observed. On 12/8/22 at 1347 hours, an observation and concurrent interview for Resident 76 was conducted with CNA 3. When asked about Resident 76's activities, CNA 3 stated Resident 76 mostly stayed in bed, and Resident 76 was always awake during the day. CNA 3 stated Resident 76 did not do anything while in bed. When asked about any sensory stimulation such as television or radio, CNA 3 verified the TV was off, and there was no radio inside the resident's room. CNA 3 stated she plugged the TV in, but she forgot to turn it on for Resident 76. Medical record review for Resident 76 was initiated on 12/7/22. Resident 76 was readmitted to the facility on [DATE]. Review of Resident 76's Activity assessment dated [DATE], showed Resident 76's current activity preferences included music and watching television. The assessment form also showed Resident 76's preferred activity setting was in her own room. Review of Resident 76's plan of care showed a care plan problem revised date 11/16/22, to address Resident 76's activity participation challenged by impaired cognition, non-verbal, and need for 1:1 activities. The goal was for Resident 76 to respond by eye contact and follow simple tasks in 1:1 activity programs that would be provided three times per week for 90 days. Review of Resident 76's Documentation Survey Report showed the following: - In November 2022, Resident 76 was provided 10 room visits; and - In December 2022, Resident 76 was provided independent activities on 12/2 and 12/9/22, and room visits on 12/3 and 12/9/22. On 12/9/22 at 1448 hours, an interview and concurrent medical record review for Resident 76 was conducted with the Activities Assistant. The Activities Assistant verified the above findings. When asked about Resident 76's activities, the Activities Assistant stated Resident 76 was non-verbal; the resident's activities was mostly in her room, watching television and sensory stimulation. The Activities Assistant verified Resident 76 was not provided activities or her in-room visits as per the assessment and plan of care.

**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 25 sampled residents (Resident 85) received necessary care and services to help prevent the development or worsening of pressure ulcers. Over the course of four hours, Resident 85 was observed in the same position with pressure points directly on the mattress. Resident 85 was immobile, and had a history of pressure ulcers with interventions to reposition every two hours. This failure put Resident 85 at risk for the development or worsening of pressure ulcers. Findings: Review of the facility's P&P titled Policy: Pressure Sore Management (undated) showed all available measures shall be taken to reduce skin breakdown and pressure sores. The resident is to be repositioned as scheduled. Medical record review for Resident 85 was initiated on 12/7/22. Resident 85 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 85's History and Physical examination dated 4/25/22, showed Resident 85 did not have the capacity to understand and make decisions due to vegetative state (absence of responsiveness and awareness due to overwhelming dysfunction of the the brain) and encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition). Review of Resident 85's MDS dated [DATE], showed Resident 85 was totally dependent on staff and required assistance from two people for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture), and transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position). Review of Resident 85's Order Summary Report showed the following treatment orders: - An order dated 12/7/22, for left lateral (side) leg redness, cleanse with normal saline, pat dry, apply zinc oxide ointment, and cover with dry dressing every day shift until 1/7/23. - An order dated 11/1/22, for left lateral malleolus (ankle) fragile skin, cleanse with normal saline, pat dry, sure prep, and cover with hydrocolloid dressing every Monday for skin maintenance management until 2/5/23. - An order dated 11/1/22, for right lateral malleolus fragile skin, cleanse with normal saline, pat dry, sure prep, and cover with hydrocolloid dressing every Monday for skin maintenance management until 2/5/23. - An order dated 12/7/22, for right heel redness, cleanse with normal saline, pat dry, apply foam dressing daily for 30 days until 1/6/23. Review of Resident 85's wound risk assessment dated [DATE], showed Resident 85 was at high risk for skin breakdown. Review of Resident 85's wound management care plans dated 4/23/22, showed Resident 85 was readmitted to the facility with right and left buttock pressure ulcer DTI (deep tissue injury), and left and right heel pressure ulcer DTI. Review of Resident 85's skin progress reports, showed the left and right buttock was resolved on 5/4/22. Further review of Resident 85's skin progress reports, showed resident was noted with right heel redness measuring 3 cm by 2 cm on 12/7/22. On 12/8/22 at 1150 hours, Resident 85 was observed in bed, lying on his right side. Resident 85's right lateral heel was directly against the bed surface, with a pillow between his knees. Resident 85's left leg was on top of the pillow. On 12/8/22 at 1339, 1445, and 1533 hours, Resident 85 was again observed in the same position as above. On 12/8/22 at 1432 hours, an interview was conducted with the ADON. The ADON was asked about Resident 85's treatments. The ADON stated Resident 85 had treatments for left lateral leg and right heel redness, and also for right and left lateral malleolus fragile skin. When asked if Resident 85 was able to reposition himself, the ADON stated no. On 12/8/22 at 1336 hours, an interview was conducted with LVN 7. LVN 7 stated he was assigned to Resident 87 for the 0700 to 1500 hours shift on 12/8/22. When asked if LVN 7 turned or did any ADL care for Resident 87 today, he stated no. On 12/8/22 at 1537 hours, a follow-up interview and concurrent facility document review was conducted with the ADON. The ADON was asked who the assigned CNA was for Resident 85. The ADON checked the assignment sheet and stated Resident 85 was not included in the assignment that day for CNA coverage, therefore no CNA was assigned for the 0700 hours to 1500 shift. Review of the facility's Nursing Staffing Assignment and Sign-In Sheet dated 12/7/22, showed Resident 85 was not assigned a CNA for the 0700-1500 hours shift on 12/7/22. On 12/8/22 at 1544 hours, an observation and concurrent interview was conducted with LVN 7 and CNA 4 at Resident 85's bedside. Resident 85 was again observed lying in bed in the same position as the prior observations. LVN 7 and CNA 4 repositioned Resident 85 on to his back and removed the pillow between his legs. Resident 85 was observed to have deep indents on his left lateral calf where his skin had been against the sheet and mattress. Resident 85 was observed to have a hydrocolloid bandage on his right lateral malleolus and a bandage on his right heel. On 12/8/22 at 1603 hours, an interview was conducted with the DON. The DON was asked who was responsible for ensuring residents were repositioned as ordered. The DON stated the CNA, treatment nurses, and charge nurses were responsible for repositioning residents. The DON was asked to show documentation Resident 85 was repositioned on 12/8/22, from 1150 to 1530 hours. The DON was unable to provide such documentation. On 12/9/22 at 1304 hours, an interview and concurrent medical record review was conducted with LVN 4. LVN 4 stated she was the treatment nurse for Resident 85. LVN 4 stated Resident 85 was observed on 12/7/22, with a stage one pressure ulcer to the right heel. LVN 4 stated there was no wound consult for the wound due to it being stage one. LVN 4 stated Resident 85 was at high risk for wounds due to diagnoses of diabetes, obesity, lumbar stenosis (narrowing of the spinal canal in your lower back that may cause pain or numbness in the legs), and protein calorie malnutrition. LVN 4 stated interventions included treatments as ordered and offloading with no pressure on the heels. On 12/13/22 at 1029 hours, a telephone interview was conducted with the Wound Care Physician. The Wound Care Physician stated he first assessed Resident 85 in 4/22 when he was admitted to the facility with bilateral DTI to both heels. The Wound Care Physician stated he assessed Resident 85 again on 12/12/22, for a wound to the right heel and reclassified the wound as an arterial ulcer ( develops as the result of damage to the arteries due to lack of blood flow to tissue). The Wound Care Physician stated Resident 85 was at higher risk for development of a pressure ulcer due to having an existing arterial ulcer, and being diagnosed with diabetes and peripheral arterial disease (narrowing or blockage of the vessels that carry blood from the heart to the legs). The Would Care Physician stated he recommended offloading of the heels (every two hours) and iodine (a medication used to treat both acute and chronic wounds).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the splint and hand rolls for two of 25 final sampled residents (Residents 17 and 76) were applied per the physician's orders. * The facility failed to ensure the bilateral knee splints for Resident 76 were applied for three to six hours daily per the physician's order. * The facility failed to ensure the hand rolls for Resident 17 were applied for six hours daily per the physician's order. These failures had the potential for the residents' contractures (abnormal shortening of muscle tissue, rendering the muscle highly resistant to stretching; this can lead to permanent disability) and range of motion to worsen. Findings: 1. Medical record review for Resident 76 was initiated on 12/7/22. Resident 76 was readmitted to the facility on [DATE]. Review of Resident 76's Order Summary Report showed a physician's order dated 12/5/22, for the RNA program to apply bilateral knee splints for three to six hours daily. Review of Resident 76's Documentation Survey Report v2, under RNA program for application of bilateral knee splints for three to six hours daily, showed 15 on 12/7, 12/8, 12/9, 12/11, and 12/12/22, and 5 on 12/10/22. On 12/8/22 at 0830, 0950, 1040, 1135, 1331, and 1347 hours, Resident 76 was observed in bed without the bilateral knee splints applied. On 12/8/22 at 1347 hours, an observation for Resident 76 and concurrent interview was conducted with CNA 3. CNA 3 verified the above findings. CNA 3 stated she did not see the splints were applied to Resident 76 today. When asked to show where the splints were, CNA 3 was observed taking the splints from the closet. CNA 3 stated the splints were in the same place inside the closet as yesterday. When asked if she can apply the splints to the residents or remove the splints from the resident, CNA 3 stated no because she did not receive any training to apply or remove the splints. On 12/9/22 at 1021 and 1237 hours, Resident 76 was observed in bed without the bilateral knee splints applied. On 12/9/22 at 1257 hours, an interview and concurrent medical record review for Resident 76 was conducted with RNA 1 and RNA 2. When asked about Resident 76's bilateral knee splints, RNA 1 and 2 stated they have not applied the knee splints today. RNA 1 and 2 stated they applied the knee splints yesterday around 1400 hours and left the knee splints for the CNA to remove after three to six hours. RNA 1 and 2 were informed Resident 76 was observed without any knee splints yesterday, and the CNA who worked verified there were no knee splints applied to Resident 76 yesterday, and that same CNA worked 16 hours yesterday. RNA 1 and 2 stated they actually applied the knee splints to Resident 76 around 0900 to 1000 hours, and removed the knee splints around 1130 hours. RNA 1 and 2 verified the application was approximately one to two and a half hours, less than three to six hours per physician's order. When asked to provide documentation of the application of the knee splints to Resident 76 for three to six hours, RNA 1 and 2 showed their RNA documentation in PCC. RNA 1 and 2 stated the 5 or 15 on the Documentation Survey Report only showed the amount of minutes they spent in the application of the knee splints. RNA 1 and 2 verified there was no documentation the knee splints for Resident 76 was applied for three to six hours, as per the physician's order. On 12/14/22 at 0923 hours, an interview and concurrent medical record review for Resident 76 was conducted with the Rehabilitation Director. The Rehabilitation Director verified the above findings. The Rehabilitation Director stated the RNAs were responsible to apply the splints to the residents. The Rehabilitation Director stated the CNAs could remove the splints and the CNAs were expected to know how to remove the splints because that was taught in school. When asked about the documentation of the splint application, the Rehabilitation Director stated the RNAs document in PCC under Tasks. The Rehabilitation Director was informed the documentation only showed the minutes the RNAs spent in applying the splints but not the actual time Resident 76 had the splints on, the Rehabilitation Director stated the RNAs should put the actual time to show how long Resident 76 tolerated the bilateral splints. 2. Medical record review for Resident 17 was initiated on 12/7/22. Resident 17 was readmitted to the facility on [DATE]. Review of Resident 17's Order Summary Report showed a physician's order dated 12/7/22, for RNA to apply hand rolls for both hands for six hours daily. Review of Resident 17's Documentation Survey Report v2, under RNA program for application of hand rolls for both hands for six hours daily, showed 15 on 12/7, 12/8, and 12/9/22, 5 on 12/10/22, and 7.5 on 12/11 and 12/12/22. On 12/7/22 at 0829, 0831, and 0847 hours, on 12/8/22 at 0829, and 0922, 0928, 1220, and 1332 hours, and on 12/9/22 at 0840, 1244, 1247, and 1337 hours, Resident 17 was observed in bed without the hand rolls to both hands. On 12/9/22 at 1247 hours, an observation and concurrent interview for Resident 17 was conducted with CNA 4. CNA 4 verified Resident 17 did not have any of the hand rolls to both hands. CNA 4 stated he was not aware Resident 17 should have the hand rolls. On 12/9/22 at 1337 hours, a follow-up interview was conducted with CNA 4. CNA 4 verified Resident 17 did not have any hand rolls to both hands. CNA 4 stated Resident 17 had no hand rolls throughout his shift, and no one has come in to apply any of the hand rolls to Resident 17. On 12/14/22 at 0933 hours, an interview and concurrent medical record review for Resident 17 was conducted with the Rehabilitation Director. The Rehabilitation Director verified the above findings. The Rehabilitation Director stated the RNAs were responsible to apply the hand rolls to Resident 17 because the RNAs also provide exercises and stretch the resident's hands as they apply the handrolls, and also for accountability. When asked about the documentation of the hand roll application, the Rehabilitation Director stated the RNAs document in PCC under the Tasks section, and the RNAs should put the actual time to show how long Resident 17 had the hand rolls to both hands.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure one of 25 final sampled residents (Resident 33) remained free from accident hazards. * The facility failed to implement the bilateral floor mats and maintain the resident's bed in the low position as per the physician's order and plan of care. This failure had the potential to place the resident at risk for serious injury. Findings: On 12/7/22 at 0804 hours, during the initial tour of the facility, Resident 33 was observed lying in bed, with the bed high and not in the low position. One floor mat was in place on the left side; no floor mat was observed in place on the right side. Medical record review for Resident 33 was initiated on 12/7/22. Resident 33 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 33's Fall Risk assessment dated [DATE], showed the resident was at high risk for falls. Review of Resident 33's plan of care showed a care plan problem dated 12/22/21, addressing Resident 33's risk for falls/injury related to impaired cognition, poor safety awareness/judgement, seizure disorder, and use of the low air loss mattress. The interventions included to maintain the bed in the low position and to implement bilateral floor mats. Review of Resident 33's Order Summary Report showed a physician's order dated 2/11/22, to maintain the bed in the low position and to implement floor mats to minimize potential injury from spontaneous/involuntary movement from the bed to the floor. On 12/7/22 at 1430 hours, Resident 33 was observed lying in bed with the bed high and not in the low position. One floor mat was in place on the left side; no floor mat was observed in place on the right side. On 12/7/22 at 1433 hours, an observation of Resident 33 was conducted with LVN 4. LVN 4 verified Resident 33's bed was high and not in the low position and only one floor mat was in place. LVN 4 was able to lower the resident's bed further and into the lowest position. A subsequent interview and concurrent medical record review was conducted with LVN 4. LVN 4 verified they did not implement bilateral floor mats and maintain the resident's bed in the low position as per the physician's order and the resident's plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the medications were administered as ordered on dialysis (a treatment to rid the body of wastes and toxins when the kidneys fail to function) days for one of 25 final sampled residents (Resident 358). This had the potential for Resident 358 not being provided appropriate care and treatment, and the possibility of medical complications. Findings: On 12/7/22 at 1049 hours, a concurent observation and interview was conducted with Resident 358. Resident 358 was observed in bed and awake. Resident 358 stated he went to dialysis on Mondays, Wednesdays, and Fridays. Resident 358 stated he usually left the facility for dialysis around 0500 hours and came back at 1000 hours or after. Resident 358 stated he was concerned he was missing his medications for 0600, 0700, 0800, and 0900 hours when he was at the dialysis. Medical record review for Resident 358 was initiated on 12/7/22. Resident 358 was readmitted to the facility on [DATE]. Review of Resident 358's Order Summary Report showed the following physician's orders dated: - 11/29/22, Resident 358 had dialysis treatments scheduled at an outside dialysis center every Monday, Wednesday, and Friday; - 11/16/22, to administer aspirin (a nonsteroidal anti-inflammatory drug) EC 81 mg tablet one time a day; - 11/17/22, to administer cranberry oral capsule (supplement) 425 mg three times a day; - 11/16/22, to administer docusate sodium (stool softener) 100 mg one capsule two times a day - 11/17/22, to administer docusate sodium 100 mg capsule one time day; - 11/16/22, to administer famotidine (medication used to treat stomach or intestinal ulcers) 20 mg one time a day; - 11/16/22, to administer Florastor (probiotic medication) 250 mg one capsule two times a day; - 11/16/22, to administer folic acid (vitamin supplement) 1 mg one tablet by mouth one time a day; - 11/16/22, to administer gabapentin (medication used to treat nerve pain) 100 mg one capsule by mouth every eight hours; - 11/16/22, to administer regular insulin (medication used to treat diabetes) per sliding scale before meals; - 11/17/22, to administer multivitamin with mineral (supplement) one tablet by mouth one time a day; - 11/16/22, to administer pro-stat (supplement) 30 ml three times a day; -11/16/22, to administer Rena Vite (supplement) one tablet one time a day; - 11/29/22, to administer Renvela (medication used to control phosphorus levels) 800 mg one time a day; - 11/16/22, to administer Symbicort (medication used long-term to improve symptoms of chronic obstructive pulmonary disease) 160-4.5 mcg two puffs orally every 12 hours; - 11/16/22, to administer vitamin C (supplement) 500 mg one tablet one time a day; - 11/17/22, to administer vitamin D3 (supplement) 25 mcg one tablet one time day; and - 11/17/22, to administer zinc sulfate (supplement) 200 mg one capsule one time a day. Review of Resident 358's MAR for November 2022 showed Resident 358 was not administered the following medications: - aspirin, folic acid, multivitamin with mineral, vitamin D3, zinc, docusate sodium, Florastor, cranberry, and pro-stat, on 11/23, 11/28, and 11/30/22 at 0900 hours; - famotidine 20 mg on 11/18 and 11/28/22 at 0600 hours; - vitamin C on 11/21, 11/23, and 11/30/22 at 0900 hours; - Symbicort, Rena Vite, on 11/23, and 11/30/22 at 0900 hours; - gabapentin on 11/28/22 at 0600 hours; -insulin on 11/21, and 11/28/22 at 0630 hours; and - calcium on 11/21, 11/23, and 11/28/22 at 0715 hours. The MAR showed Resident 358 had an order dated 11/16/22, for calcium acetate (supplement) 667 mg by mouth with meals. The record showed this order was discontinued on 11/29/22. Review of Resident 358's MAR for December 2022 showed Resident 358 was not administered the following medications: - aspirin, docusate sodium, folic acid, multivitamin with minerals, Florastor, Symbicort, cranberry, pro-stat, and Renvela, on 12/5, and 12/7/22 at 0900 hours; and - famotidine on 12/8/22 at 0600 hours. Review of Resident 358's medical record failed to show the facility informed the dialysis center regarding any held medications, or obtained a physician's order to hold the medications during dialysis. On 12/9/22 at 1333 hours, an interview and concurrent medical record review for Resident 358 was conducted with LVN 2. LVN 2 verified the above findings. LVN 2 stated Resident 358 usually left the facility at 0530 hours and returned at 1100 hours. LVN 2 stated when Resident 358 arrived at 1000 hours, he was able to give the medications due at 0900 hours because he had the one-hour window. LVN 2 stated when Resident 358 returned after the one hour window then he would hold the medications and documented in the MAR. LVN 2 verified there was no physician orders for the medications to be held prior to dialysis. On 12/9/22 at 1346 hours, an interview and concurrent medical record review for Resident 358 was conducted with RN 2. RN 2 verified the above findings. RN 2 verified there was no physician's orders for the medications to be held during dialysis. On 12/9/22 at 1410 hours, an interview and concurrent medical record review for Resident 358 was conducted with the DON. The DON verified the above findings. The DON stated they would clarify with the physician regarding holding the medications during dialysis, or to change the medication administration times to when Resident 358 comes back from dialysis. Cross reference to F760.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the facility's P&P titled Side Rail Use When Not a Restraint (undated) showed the licensed nurse should obtain an order from the attending physician to include the resident may have both side rails up when in bed. On 12/7/22 at 0845 and 1127 hours, and on 12/13/22 at 0831 and 0939 hours, Resident 48 was observed lying in bed with bilateral side rails elevated by the head of the bed. Medical record review for Resident 48 was initiated on 12/7/22. Resident 48 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 48's History and Physical examination dated 11/22/22, showed Resident 48 had diagnoses including spastic recurrent seizures (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain). Review of Resident 48's Side Rail Safety/Entrapment assessment dated [DATE], showed side rails were not indicated for Resident 48. Review of Resident 48's Order Summary Report dated 12/13/22, failed to show a physician's order for the use of side rails. Medical record review for Resident 48 did not show informed consent was obtained for the use of the bilateral side rails. On 12/13/22 at 0949 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified the above information. RN 1 verified Resident 48's Side Rail Safety/Entrapment assessment dated [DATE], showed side rails were not indicated for Resident 48. RN 1 verified there was no physician's order for the use of side rails and verified informed consent was not obtained prior to the use of the bilateral side rails. Cross reference to F656, example #1. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure three of 25 residents (Residents 26, 57, and 48 ) were properly assessed for the use of side rails prior to the initiation of bilateral side rails. * The facility failed to assess Resident 26 for the use of bilateral side rails prior to use. * The facility assessed Resident 57 as not being indicated for the use of side rails, however bilateral side rails were in use. * The facility failed to obtain a physician's order, review the risks and benefits of the side rails with Resident 48 and/or resident representative, and failed to obtain informed consent for the use of the side rails. These failures had the potential to place the residents at risk of entrapment and serious injury. Findings: Review of the facility's P&P titled Policy: Side rail use when not a restraint (undated) showed when using the side rails not as a restraint, first complete physical restraint assessment form. If the physical restraint assessment form demonstrates that the resident is immobile and cannot voluntarily get out of bed due to a physical limitation, then proceed with the accompanying IDT for use of both side rails not as a restraint. The licensed nurse should obtain an order from the attending physician for the use of side rails. The FDA issued a Safety Alert entitled Entrapment Hazards with Hospital Bed 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, or 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. 1. On 12/7/22 at 1027 hours, during the initial tour of the facility, Resident 26 was observed in bed with bilateral side rails elevated. Subsequent observations showed Resident 26 in bed with bilateral side rails elevated. For example: - On 12/8/22 at 1153 hours. - On 12/8/22 at 1344 hours. Medical record review for Resident 26 was initiated on 12/7/22. Resident 26 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 26's Order Summary Report showed an order dated 7/31/18, for bilateral upper half side rails up when in bed secondary to involuntary movement by gravity due to elevated HOB for management and provision of enteral feeding. Review of Resident 26's medical record failed to show an assessment for the use of bilateral side rails. On 12/14/22 at 1103 hours, an observation and concurrent interview was conducted with LVN 5 at Resident 26's bedside. LVN 5 verified Resident 26 was in bed with bilateral 1/4 side rails elevated. On 12/14/22 at 1104 hours, an interview and concurrent medical record review for Resident 26 was conducted with RN 1. RN 1 was asked to show Resident 26's assessment for the use of side rails. RN 1 reviewed the record and was unable to find an assessment. Cross reference F656, example #2. 2. On 12/7/22 at 1030 hours, during an initial tour of the facility, Resident 57 was observed in bed with bilateral 1/2 side rails elevated. Subsequent observations showed Resident 57 in bed with bilateral 1/2 side rails elevated on multiple occasions. For example: - On 12/8/22 at 1156 hours. - On 12/9/22 at 0851 hours. - On 12/14/22 at 1021 hours. Medical record review for Resident 57 was initiated on 12/7/22. Resident 57 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of the side rail safety/entrapment assessment dated [DATE], failed to show whether side rail use was indicated for Resident 57. The section under recommendations was left blank. Review of the Side rail safety/entrapment assessment dated [DATE], showed side rail is not indicated at this time. On 12/14/22 at 1028 hours, an observation and concurrent interview was conducted with LVN 5 at Resident 57's bedside. LVN 5 verified Resident 57 was in bed with bilateral 1/2 side rails elevated. When asked who was responsible for assessing residents for side rail use, LVN 5 stated any admitting nurse could assess for the use of side rails. On 12/14/22 at 1029 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated residents were assessed upon admission for the use of side rails. RN 1 was asked to show Resident 57's assessment for the use of side rails. RN 1 stated the most recent side rail safety/entrapment assessment for Resident 57 was completed 10/9/21, and showed side rail use was not indicated at this time. Upon further review, the assessment showed side rail use is indicated was now selected. RN 1 stated she changed the recommendations to side rail use indicated as we were conducting the interview.

**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 a medication that was stored beyond pharmacy recommendations was not administered for one of 32 nonsampled residents (Resident 4). * Resident 4 was administered Latanoprost (an eyedrop medication) that was opened on 10/15/22, and stored beyond 28 days. This failure had a potential to place the resident at risk for adverse effects. Findings: According to the facility P&P titled Medication Storage in the Facility dated April 2008, medication and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from the stock, disposed of accordingly to procedures of medication disposal, and reordered from pharmacy if a current order exists. Review of the Lexicomp (clinical drug resource) guide updated 12/13/22, showed store Latanoprost solution intact bottles under refrigeration at two degrees Celsius to eight degrees Celsius (36 degrees Fahrenheit to 46 degrees Fahrenheit). Protect from light. May be maintained at temperatures up to 40 degrees Celsius (104 degrees Fahrenheit) for up to eight days during shipment. Once opened, the container may be stored at room temperature up to 25 degrees Celsius (77 degrees Fahrenheit) for 6 weeks. Medical record review for Resident 4 was initiated on 12/13/22. Resident 4 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 4's Order Summary Report showed a physician's order dated 7/1/11 to administer Latanoprost Solution 0.005 percent, instill one drop in both eyes at bedtime. On 12/9/22 at 1450 hours, a concurrent observation, interview, and medical record review was conducted with LVN 8. Resident 4's Latanoprost medication dated 10/15/22, was found in Medication Cart 2. Resident 4's Latanoprost medication was labeled: once bottle opened, discard unused medication after 28 days. LVN 8 verified Resident 4's Latanoprost medication was opened on 10/15/22 and acknowledged it was passed 28 days. Review of Resident 4's December 2022 MAR was conducted with LVN 8. LVN 8 verified Resident 4 received Latanoprost medication daily at bedtime. Review of Resident 4's Pharmacy Supplies Record conducted on 12/14/22 showed, Resident 4's Latanoprost medication was dispensed on 10/6 and 12/10/22. On 12/14/22 at 0933 hours, a concurrent interview and medical record review was conducted with the ADON. The ADON was made aware of Resident 4's Latanoprost medication opened 10/15/22, was found inside Medication Cart 2 and labeled to be discarded 28 days once opened. Review of Resident 4's November and December 2022 MAR showed, Resident 4 had been receiving the Latanoprost medication daily at bedtime. The ADON was unable to provide information on Resident 4's Latanoprost medication refill in November 2022. The ADON acknowledged Resident 4 received an old Latanoprost eyedrops medication that could invite growth of mold and bacteria. Cross reference to F761, 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 25 final sampled residents (Residents 17, 43, and 89) were free from the unnecessary psychotropic drugs (any drug that affects brain activity). * The facility failed to ensure Resident 17 was monitored for the behavior and side effects related to the use of Remeron (medication used to treat depression), and venlafaxine (medication used to treat depression) and clozapine (medication used to treat schizophrenia). In addition, the monthly behavior summary was not completed for Abilify (medication used to treat schizophrenia), clozapine, and venlafaxine. * The facility failed to ensure Resident 43 was monitored for the side effects of trazodone (medication used to treat depression). * The facility failed to ensure the physician's order for PRN lorazepam for Resident 89 was limited to a 14 days duration. These failures had the potential for Residents 17, 43, and 89 to have adverse complications from the medications. Findings: 1. Medical record review for Resident 17 was initiated on 12/7/22. Resident 17 was readmitted to the facility on [DATE]. Review of Resident 17's Order Summary Report showed the following physician's orders dated: - 10/30/22, to administer Abilify 10 mg one tablet one time a day for schizophrenia manifested by episodes of angry outburst causing harm to self or others; - 10/27/22, to administer Abilify 15 mg one tablet one time a day for schizophrenia manifested by episodes of angry outburst causing harm to self or others; - 10/30/22, to administer clozapine 100 mg one tablet two times a day for schizophrenia manifested by episodes of angry outburst causing harm to self or others; - 12/8/22, to administer Remeron 15 mg at bedtime for appetite stimulant; - 10/27/22, to administer risperidone (medication used to treat schizophrenia) 3 mg two times a day for schizophrenia manifested by irritable mood causing stress; - 10/27/22, to administer venlafaxine 75 mg one time a day for depression manifested by verbalization of feelings of hopelessness/ helplessness affecting daily living activities; - 10/27/22, to monitor for potential side effects for antipsychotic medications (clozapine, Aripiprazole, risperidone) every shift; - 10/27/22, to monitor episodes of schizophrenia manifested by episodes of angry outburst causing harm to self or others for Abilify use, every shift; - 10/27/22, to monitor episodes of schizophrenia manifested by episodes of angry outburst causing harm to self or others for risperidone use, every shift; and - 10/27/22, to monitor episodes of schizophrenia manifested by visual hallucinations causing fear for clozapine use, every shift. Review of Resident 17's MAR for November 2022 showed the following: - Resident 17 was administered Abilify, venlafaxine, clozapine and risperidone from 11/1 to 11/30/22; - Resident 17 was monitored for the side effects of antipsychotic medications (clozapine, Aripiprazole, risperidone) from 11/1 to 11/30/22, every shift; and - Resident 17 was monitored for the behavior related to the use of risperidone and Abilify from 11/1 to 11/30/22. However, there was no monitoring for the behavior and side effects related to the use of Remeron and venlafaxine. In addition, the behavior monitoring was not correct in relation to the use of clozapine. Review of Resident 17's MAR for December 2022 showed the following: - Resident 17 was administered Abilify, clozapine, risperidone and venlafaxine from 12/1 to 12/9/22 - Resident 17 was administered Remeron from 12/1 to 12/8/22 -Resident 17 was monitored for the side effects of antipsychotic medications (clozapine, Aripiprazole, risperidone) 12/1 to 12/9/22 every shift; and - Resident 17 was monitored for the behavior related to the use of risperidone and abilify from 12/1 to 12/9/22, every shift. a. However, there was no monitoring for the behavior and side effects related to the use of Remeron and venlafaxine. b. In addition, the behavior monitoring was not correct in relation to the use of clozapine. c. Review of Resident 17's Psychotropic Summary Sheets for clozapine, Abilify, risperidone, and venlafaxine were left blank. Further review of Resident 17's medical record did not show the behavior and side effects related to the use of Remeron and venlafaxine were monitored, and there was no documentation to show the behavior related to the use of clozapine was monitored. In addition, the monthly behavior summary sheets related to the use of Abilify, risperidone, and venlafaxine were not completed. On 12/13/22 at 1034 hours, an interview and concurrent medical record review for Resident 17 was conducted with LVN 2. LVN 2 verified the above findings. LVN 2 could not locate any documentation to show the side effects related to the use of venlafaxine was monitored, and the behavior related to the use of clozapine was monitored. On 12/13/22 at 1100 hours, an interview and concurrent medical record review for Resident 17 was conducted with LVN 6. LVN 6 verified the above findings. LVN 6 verified the monthly behavior summary sheets related to the use of Abilify, risperidone, and venlafaxine were not completed. LVN 6 stated the NOC shift nurses were supposed to complete the monthly behavior summary sheets at the end of each month. 2. Medical record review for Resident 43 was initiated on 12/7/22. Resident 43 was admitted to the facility on [DATE]. Review of Resident 43's Order Summary Report showed the following physician's orders dated: - 8/3/22, to administer fluoxetine (medication used to treat depression) 40 mg one capsule by mouth one time a day for depression manifested by verbalization of extreme sadness/ causing social withdrawal affecting daily living activities; - 8/3/22, to administer trazodone 100 mg one tablet by mouth at bedtime for depression manifested by inability to sleep; - 8/3/22, to monitor potential side effects of antidepressant fluoxetine, every shift; - 8/3/22, to monitor episodes of depression manifested by verbalization of extreme sadness causing social withdrawal affecting daily living activities for fluoxetine use, every shift. - 8/3/22, to monitor episodes of depression manifested inability to sleep. Monitor hours of sleep; and - 8/3/22, to monitor episodes of insomnia manifested by inability to sleep/ sleeplessness. Monitor hours of sleep Review of Resident 43's MAR for October 2022 showed the following: - Resident 43 was administered fluoxetine and trazodone from 10/1 to 10/31/22; - Resident 43 was monitored for the behavior and side effects related to the use of fluoxetine from 10/1 to 10/31/22; and - Resident was monitored for the behavior related to the use of trazodone from 10/1 to 10/31/22. Review of Resident 43's MAR for November 2022 showed the following: - Resident 43 was administered fluoxetine and trazodone from 11/1 to 11/30/22 - Resident 43 was monitored for the behavior and side effects related to the use of fluoxetine from 11/1 to 11/30/22 and - Resident was monitored for the behavior related to the use of trazodone from 11/1 to 11/30/22. Review of Resident 43's MAR for November 2022 showed the following: - Resident 43 was administered fluoxetine and trazodone from 11/1 to 11/30/22 - Resident 43 was monitored for the behavior and side effects related to the use of fluoxetine from 11/1 to 11/30/22 and - Resident 43 was monitored for the behavior related to the use of trazodone from 11/1 to 11/30/22. Review of Resident 43's MAR for December 2022 showed the following: - Resident 43 was administered fluoxetine from 12/1 to 12/8/22; - Resident 43 was administered trazodone from 12/1 to 12/7/22; - Resident 43 was monitored for the behavior and side effects related to the use of fluoxetine from 12/1 to 12/8/22; and - Resident 43 was monitored for the behavior related to the use of trazodone from 12/1 to 12/8/22. Further review of Resident 43's medical record did not show the side effects related to the use of trazodone was monitored. On 12/13/22 at 1057 hours, an interview and concurrent medical record review for Resident 43 was conducted with the ADON. The ADON verified the above findings. The ADON could not locate any documentation the side effects related to the use of trazodone was monitored. 3. On 12/9/22 at 1348 hours, an observation, interview, and concurrent medical record review was conducted with LVN 1 at Medication Cart 1. LVN 1 was asked to select a random PRN controlled medication from the cart. LVN 1 showed a bubble pack dated 8/16/22, for Resident 89 for lorazepam one mg tablet to administer one tablet by mouth every eight hours as needed for anxiety with no stop date. LVN 1 was unable to show any documentation as to why the order had no stop date. Medical record review for Resident 89 was initiated on 12/9/22. Resident 89 was admitted to the facility on [DATE]. Review of Resident 89's History and Physical examination dated 5/9/22, showed Resident 89 did not have the capacity to understand and make decisions and listed a surrogate decisionmaker. Review of Resident 89's Order Summary Report showed an order dated 8/16/22, for Ativan (lorazepam) oral tablet one mg to administer one tablet by mouth every eight hours as needed for anxiety manifested by restlessness and agitation. There was no stop date documented. Review of Resident 89's MAR showed Resident 89 received three doses of Ativan in 8/22, 14 doses in 9/22, 11 doses in 10/22, four doses in 11/22, and two doses in 12/22. Cross reference to F552.

Based on observation, interview, and medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 6.25%. Two of four licensed nurses (LVNs 1 and 7) who were observed during the medication administration were found to have made errors, when LVNs 1 and 7 failed to administer a prescribed medication to their residents. These failures had the potential to negatively affect the residents' health. Findings: 1. On 12/8/22 at 0818 hours, a medication administration observation for Resident 95 was conducted with LVN 1. LVN 1 stated Resident 95 was administered medications via the GT. LVN 1 prepared and administered the following medications to Resident 95: -one tablet of docusate sodium (stool softener) 100 mg, -7.5 ml of ferrous sulfate (iron supplement) 220 mg/5 ml, -one tablet of multivitamin with mineral, -5 ml of Vitamin C 500 mg/5 ml, and - one tablet of Vitamin D3 25 mcg. However, review of Resident 95's Order Summary Report showed a physician's order dated 10/8/22, to administer 30 ml of UTI- Stat (cranberry-Vitamin C-Inulin) three times a day at 0900, 1300, and 1700 hours for UTI (urinary tract infection, an infection that happen when bacteria enter the urethra and infect the urinary tract) prophylaxis. On 12/8/22 at 1018 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 verified the above findings. LVN 1 verified UTI-Stat was not administered to Resident 95 because the medication was not available. Cross reference to F842, example 1. 2. On 12/8/22 at 0857 hours, a medication administration observation for Resident 38 was conducted with LVN 7. LVN 7 stated Resident 38 was administered medications via the GT. LVN 7 prepared and administered the following medications to Resident 38: -one tablet of Apitom (medication used to treat seizure disorder) 800 mg, -one tablet of carvedilol (medication used to treat high blood pressure) 3.125 mg, -five tablets of Vitamin D3 1,000 unit, -two tablets of docusate sodium (stool softener) 100 mg, -7.5 ml of ferrous sulfate (iron supplement) 220 mg/5 ml, -12 ml of levetiracetam solution (medication used to treat seizure disorder) 100 mg/ml, - one tablet of multivitamin with mineral, and -5 ml of Vitamin C 500 mg/5 ml. However, review of Resident 38's Order Summary Report showed a physician's order dated 11/24/21, to administer 30 ml of UTI- Stat (cranberry-Vitamin C-Inulin) two times a day at 0900 and 1700 hours for UTI prophylaxis. On 12/8/22 at 1022 hours, an interview and concurrent medical record review was conducted with LVN 7. LVN 7 verified the above findings. LVN 7 verified UTI-Stat was not administered to Resident 38 because the medication was not available. Cross reference to F842, example #2.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure one of 25 final sampled residents (Resident 358) was free from significant medication errors. The facility failed to administer Resident 358's heparin (medication used to prevent blood clot) during dialysis days and failed to ensure a physician's order was obtained to hold the heparin medication as ordered on dialysis days. This failure placed Resident 358 at risk for medical complications. Findings: On 12/7/22 at 1049 hours, Resident 358 was observed in bed, awake. Resident 358 stated he went to dialysis on Mondays, Wednesdays, and Fridays. Resident 358 stated he usually left the facility for dialysis around 0500 hours and came back at 1000 hours or after. Resident 358 stated he was concerned he was missing his medications for 0600, 0700, 0800, and 0900 hours when he was at the dialysis. Medical record review for Resident 358 was initiated on 12/7/22. Resident 358 was readmitted to the facility on [DATE]. Review of Resident 358's Order Summary Report showed the following physician's orders dated: -11/29/22, Resident 358 had dialysis treatments scheduled at an outside dialysis center, every Monday, Wednesday, and Friday; and -11/16/22, to administer heparin injection 5000 unit/ml subcutaneously (under the skin) every 12 hours. Review of Resident 358's MAR for November 2022 showed Resident 358 was not administered heparin on 11/23, 11/28, and 11/30/22 at 0900 hours; Review of Resident 358's MAR for December 2022 showed Resident 358 was not administered heparin on 12/5 and 12/7/22 at 0900 hours. Review of Resident 358's medical record failed to show the facility informed the dialysis center regarding any held medications or obtained a physician's order to hold the medications during dialysis. On 12/9/22 at 1333 hours, an interview and concurrent medical record review for Resident 358 was conducted with LVN 2. LVN 2 verified the above findings. LVN 2 verified there was no physician's orders for the medications to be held prior to dialysis days. On 12/9/22 at 1346 hours, an interview and concurrent medical record review for Resident 358 was conducted with RN 2. RN 2 verified the above findings. RN 2 verified there was no physician's orders for the medications to be held during dialysis days. On 12/9/22 at 1410 hours, an interview and concurrent medical record review for Resident 358 was conducted with the DON. The DON verified the above findings. The DON stated they would clarify with the physician regarding holding the medications during the dialysis, or to change the medication administration times to when Resident 358 comes back from dialysis days. Cross reference to F698.

**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 store the medications and supplies safely according to the manufacturer or pharmacy recommendations. * Medication Cart 2 had two expired boxes of blood glucose strips (small, plastic strips that help to test and measure blood sugar levels). This had the potential for use of expired supplies. * Medication Cart 2 had Resident 4's bottle of Latanoprost (eyedrops medication) opened on [DATE] and labeled once opened, discard unused medication after 28 days. This failure had the potential for the administration of deteriorated medication. * Resident 459's discontinued Gabapentin (medication used to treat nerve pain) tablets were found in Medication Cart 2. This failure had the potential to negatively impact the resident's well-being. Findings: According to the facility P&P titled Medication Storage in the Facility dated [DATE], the medication and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from the stock, disposed of accordingly to procedures of medication disposal, and reordered from pharmacy if a current order exists. 1. On [DATE] at 1450 hours, a concurrent observation and interview was conducted with LVN 8 of Medication Cart 2. There were two unopened boxes of blood glucose test strips with expiration date of [DATE], in the left third drawer. LVN 8 verified the expired strips should not be in the cart and should have been discarded. On [DATE] at 0933 hours, an interview was conducted with the ADON. When ask regarding the expired supplies or medications inside medication cart, the ADON stated any expired supply or medication should be removed out of the medication cart right away and be placed in the medication room for disposal. 2. Review of the Lexicomp (clinical drug resource) guide updated [DATE], showed to store Latanoprost solution intact bottles under refrigeration at two degrees Celsius to eight degrees Celsius (36 degrees Fahrenheit to 46 degrees Fahrenheit). Protect from light. May be maintained at temperatures up to 40 degrees Celsius (104 degrees Fahrenheit) for up to eight days during shipment. Once opened, the container may be stored at room temperature up to 25 degrees Celsius (77 degrees Fahrenheit) for six weeks. Medical record review for Resident 4 was initiated on [DATE]. Resident 4 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE]. Review of Resident 4's Order Summary Report showed a physician's order dated [DATE] to administer Latanoprost Solution 0.005 percent, instill one drop in both eyes at bedtime. On [DATE] at 1450 hours, a concurrent observation and interview was conducted with LVN 8 of Medication Cart 2. Resident 4's Latanoprost medication was observed in a container dated [DATE] and labeled: once bottle opened, discard unused medication after 28 days. LVN 8 verified that Resident 4's Latanoprost medication was opened on [DATE], and acknowledged Resident 4's Latanoprost had passed 28 days and should have been discarded. On [DATE] at 0933 hours, an interview was conducted with the ADON. When ask on how to discard the Latanoprost medication, the ADON stated to follow pharmacy labeling on when to discard the medication. The ADON stated if pharmacy label indicated to discard after 28 days once opened, it should have been taken out of the medication cart right away. 3. Review of Resident 459's medical record was initiated on [DATE]. Resident 459 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 459's Order Summary Report showed a physician order dated [DATE] to administer gabapentin 300 mg two capsules by mouth in the afternoon and one capsule by mouth as needed for neuropathy (nerve pain). On [DATE] at 1450 hours, inspection of Medication Cart 2 was conducted with LVN 8. Resident 459's gabapentin 600 mg tablets medication pack was observed in the left bottom drawer. When asked about Resident 459's Gabapentin tablets, LVN 8 stated Resident 459's gabapentin tablets had been discontinued and the order was changed. LVN 8 further stated Resident 459's discontinued gabapentin tablets should have been taken out of the cart and brought to medication room for disposal. On [DATE] at 0933 hours, a concurrent interview and medical record review was conducted with the ADON. When asked regarding Resident 459's gabapentin medication, the ADON stated Resident 459's gabapentin 600 mg tablet were changed to gabapentin 300 mg capsule on [DATE]. The ADON further stated when a resident's medication was changed, the old medication had to be taken out of the medication cart right away to prevent accident of giving the wrong dose. Cross reference to F755.

Based on observation, interview, and facility document review, the facility failed to ensure the kitchen staff had the appropriate skill set to safely perform the daily operation of the Food and Nutrition Services Department. * Dietary Aide 1 was unable to correctly test the chemical concentration measured in parts per million of quaternary sanitizing solution used to sanitize food contact surfaces. This unsafe food practice had the potential to lead to foodborne illnesses in a highly susceptible population of residents who received food from the kitchen. Findings: Review of the Form CMS-672 Resident Census and Conditions of Residents completed by the facility dated 12/7/22, showed 57 of the 104 residents residing in the facility received foods prepared in the kitchen. According to the USDA Food Code 2017, 4-301.12, Manual Ware washing, sink compartment requirements, alternative manual ware washing equipment must provide accomplishment of the application of cleaners and the removal of soil, removal of any abrasive and removal or dilution of cleaning chemicals and sanitation. Review of the manufacturer's guidelines for the quaternary ammonium sanitizer test strips showed the testing instructions, to tear off a strip of test paper and dip it into room temperature sanitizing solution for ten seconds. On 12/9/22 at 0840 hours, an observation and interview was conducted with Dietary Aide 1. Dietary Aide 1 was asked to demonstrate how to check the sanitizing solution. Dietary Aide 1 was observed wearing gloves, and observed changing the sanitizing solution in the bucket. Dietary Aide 1 was observed tearing off a testing strip from the container with wet gloves on. Dietary Aide 1 was observed dipping the strip into a red bucket filled with sanitizer. When asked what the appropriate range was for the sanitizing solution, Dietary Aide 1 did not answer. When asked how long should the strips be in the solution, Dietary Aide answered five seconds. On 12/9/22 at 0858 hours, an interview was conducted with the DSS. When asked how competencies were evaluated, the DSS stated the staff have monthly in-services. The DSS was informed Dietary Aide 1 was not able to correctly demonstrate how to check the chemical concentration of the sanitizing solution. The DSS stated she would have to do an inservice immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of facility's P&P titled Med Pass (undated) under basic procedure Pour-Pass-Chart, showed prepare the med correctly, administer the med correctly, and chart the med pass correctly. Make sure that during the course of med pass: accountable meds are signed out when removed from stock. Review of Resident 5's medical record was conducted on 12/9/22. Resident was admitted to the facility on [DATE] and was readmitted to the facility on [DATE]. Review of Resident 5' Order Summary Report showed a physician order dated 9/18/18 to administer phenobarbital solution 20 mg (medication used to treat seizure) per five ml, give 50 mg by mouth in the morning and 25 ml (100 mg) every night at bedtime. On 12/9/22 at 1536 hours, a controlled medication reconciliation was conducted with LVN 8. Resident 5's Controlled Drug Records for phenobarbital showed the medication was last taken out on 12/8/22 at 2100 hours. LVN 8 stated Resident 5's phenobarbital medication was given 12/9/22 at 0900 hours but did not sign the controlled medication count sheet when the medication dose was removed. Review of Resident 5's December 2022 MAR showed the phenobarbital medication ordered was administered on 12/9/22 at 0900 hours. 5. Review of Resident 29's medical record was conducted on 12/9/22. Resident was admitted to the facility on [DATE]. Review of Resident 29's Order Summary Report showed a physician order dated 11/3/22, to administer hydrocodone-acetaminophen five-325 mg (pain medication) one tablet by mouth every six hours as needed for moderate to severe pain. On 12/9/22 at 1538 hours, a controlled medication reconciliation was conducted with LVN 8. Resident 29's Controlled Drug Record for hydrocodone/acetaminophen showed two tablets were remaining. Review of Resident 29's December 2022 MAR showed Resident 29's hydrocodone/APAP was administered at 0900 hours. 6. Review of Resident 50's medical record was conducted on 12/9/22. Resident was admitted to the facility on [DATE] and was readmitted to the facility on [DATE]. Review of Resident 50's Order Summary Report showed a physician order dated 8/15/22, to administer Lyrica capsule 75 mg (pregabalin) (medication used to treat nerve pain), give one capsule by mouth three times a day. On 12/9/22 at 1538 hours, a controlled medication reconciliation was conducted with LVN 8. Resident 50's Controlled Drug Records showed Resident 50's pregabalin medication was last taken out on 12/8/22 at 1700 hours. LVN 8 stated two doses of pregabalin was adminsitered to Resident 50 on 12/9/22 but did not sign the controlled medication count sheet right away. Review of Resident 50's December 2022 MAR showed pregabalin 75 mg was administered on 12/9/22 at 0900 and 1300 hours. On 12/14/22 at 0933 hours, an interview with the ADON was conducted. When asked regarding Resident 50's controlled medications administration, the ADON stated when the controlled medications was given, it has had to be signed right away in Controlled Drug Record to avoid missing medication or discrepancy in the controlled medication count sheet. 3. On 12/9/22 at 1330 hours, a laptop on top of a cart was left open and unattended in the hallway, displaying the resident information. A resident and a housekeeping staff were observed passing by the hallway. On 12/9/22 at 1333 hours, an interview was conducted with RN 2. RN 2 verified the laptop was left open and unattended. RN 2 acknowledged the laptop should have been locked to not display the resident information when left unattended. Based on observation, interview, and medical record review, the facility failed to ensure the medical records for five nonsampled residents (Residents 5, 29, 38, 50, and 95) were accurate or safeguarded. * Resident 38 and 95's medications were documented as administered although the medications were omitted and unavailable. This had the potential for the resident care needs not being met as their medical information was inaccurate. * The facility failed to ensure the resident-identifiable information and medical record information were safeguarded. The facility failed to ensure a laptop displaying the residents' medical record information were safeguarded when left unattended. This had the potential of unauthorized staff and/or visitors' access to residents' confidential medical or personal information. * The facility failed to document on Residents 5, 29, and 50's Controlled Drug Record when medications were removed from the medication supply pack. These had the potential for discrepancy in controlled medication count sheet. Findings: 1. Medical record review for Resident 95 was initiated on 12/8/22. Resident 95 was admitted to the facility on [DATE] and readmitted on [DATE]. On 12/8/22 at 0818 hours, a medication administration observation for Resident 95 was conducted with LVN 1. LVN 1 was found to have omitted administering 30 ml of UTI- Stat (cranberry-Vitamin C-Inulin) to Resident 95. However, review of Resident 95's Medication Administration Record dated December 2022 showed the 30 ml of UTI-Stat was documented as administered to Resident 95 on 12/8/22 at 0900 hours. On 12/8/22 at 1018 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 verified the above findings. LVN 1 verified UTI-Stat was not administered to Resident 95 because the medication was not available. Cross reference to F759, example #1. 2. Medical record review for Resident 38 was initiated on 12/8/22. Resident 38 was admitted to the facility on [DATE] and readmitted on [DATE]. On 12/8/22 at 0857 hours, a medication administration observation for Resident 38 was conducted with LVN 7. LVN 7 was found to have omitted administering 30 ml of UTI- Stat (cranberry-Vitamin C-Inulin) to Resident 38. However, review of Resident 38's Medication Administration Record dated December 2022 showed the 30 ml of UTI-Stat was documented as administered to Resident 38 on 12/8/22 at 0900 hours. On 12/8/22 at 1022 hours, an interview and concurrent medical record review was conducted with LVN 7. LVN 7 verified the above findings. LVN 7 verified UTI-Stat was not administered to Resident 38 because the medication was not available. Cross reference to F759, example #2.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 12/7/22 at 0845 hours, during the initial tour of the facility, an Enhanced Barrier Precautions sign was observed posted outside of Resident 92's room alerting anyone entering the room to don gloves and a gown for the following high contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting. CNA 5 was observed providing ADL care to Resident 92 without having donned a PPE gown. Following the observation, an interview was conducted with CNA 5. CNA 5 verified the findings. CNA 5 stated he cleaned Resident 92, changed the resident's gown and linen, and repositioned the resident. CNA 5 verified he should have donned a gown prior to providing ADL care to Resident 92. Medical record review for Resident 92 was initiated on 12/7/22. Resident 92 was admitted to the facility on [DATE]. Review of the physician's order dated 12/7/22, showed Resident 92 was in contact isolation for CRE (carbapenem-resistant Enterobacterales, strains of bacteria that are resistant to the antibiotic class carpabenem used to treat severe infections) in the sputum. On 12/13/22 at 0832 hours, an interview was conducted with the IP. The IP verified the staff should don the appropriate PPE when entering Resident 92's room. Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the infection control interventions to reduce the transmission of infectious diseases were followed for three residents (Residents 458, 67, and 92). This failure put the residents at risk for transmission of infection in an already highly susceptible population. Findings: Review of the facility's P&P titled Policy: Enhanced Standard Precaution (undated) showed the enhanced standard precaution is an infection control intervention designed to reduce transmission of multidrug organisms (MDROs). Enhanced barrier precautions involved gown and glove use during high contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk for MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Residents assessed for the need of enhanced barrier precaution include residents with MDRO, those with a feeding tube, and ventilator-dependent residents. Wear gowns and gloves while performing the following tasks associated with the greatest risk for MDRO contamination: - morning and evening care - device care, for exampled feeding tube - any activity where close contact with the resident is expected to occur such as bathing - changing bed linens Review of the facility's document (sign/poster) titled Enhanced Barrier Precautions showed the providers and staff must wear gloves and a gown for the following high contact resident care activities: - bathing, showering - changing linens - device care or use including feeding tube 1. On 12/8/22 at 0856 hours, a medication administration observation and concurrent interview was conducted with LVN 2. LVN 2 prepared the medications for Resident 458 to be administered via GT outside Resident 458's room. A sign showing Enhanced Barrier Precautions was posted near the resident's door. LVN 2 prepared each medication, and then donned gloves prior to administration of the medications. LVN 2 did not don a gown. LVN 2 checked the placement and residual of Resident 458's GT, and then administered all of the medications via the GT. When asked why the sign was posted outside Resident 458's room, LVN 2 stated because she had a GT. LVN 2 stated he should have worn a gown for the administration of the medications via resident's GT. Medical record review for Resident 458 was initiated on 12/8/22. Resident 458 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 458's History and Physical examination dated 9/17/22, showed Resident 458 had a GT in place. 2. On 12/8/22 at 0957 hours, a medication administration observation and concurrent interview was conducted with LVN 3. During the observation, CNA 1 was observed across the hall inside Resident 67's room. CNA 1 was changing the linens of the bed. CNA 1 was wearing a surgical mask and gloves, but no gown. An enhanced barrier precautions sign was posted next to the door. Resident 67 was observed inside the room in a shower chair, covered with blankets. After disposing the linens, CNA 1 began to push Resident 67 out of the room towards the hallway. CNA 1 was asked where she was going. CNA 1 stated she was taking Resident 67 to the shower room. CNA 1 was asked if she wore a gown while changing the linens or while being in contact with Resident 67, and she stated no, but she knows she was supposed to because Resident 67 had a GT. Medical record review for Resident 67 was initiated on 12/8/22. Resident 67 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 67's History and Physical examination dated 8/27/22, showed Resident 67 had a GT in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 14. Medical record review for Resident 62 was initiated on 12/7/22. Resident 62 was admitted to facility on 7/23/19 and was readmitted to the facility on [DATE]. Review of Resident 62's Order Summary Report showed a physician order dated 12/1/2022 to administered oxygen at two liters per minute continuously via nasal cannula, may titrate up to five liter per minute for oxygen saturation less than 94 percent and change nasal cannula/mask every night shift every Sunday and as needed when soiled. Review of Resident 62's Order Summary Report showed a physician order dated 1/13/22 to administer Ipratropium-Albuterol Solution (nebulizer medication) 0.5-2.5 three mg per three ml, one unit dose via mask every six hours and every three hours as needed for prevention of shortness of breath, wheezing and respiratory distress. Review of Resident 62's November and December 2022 MAR showed, Resident 62 received nebulizer treatments every six hours daily. Review of Resident 62's December 2022 MAR showed Resident 62 received oxygen continuously via nasal and the nasal cannula/mask was changed on 12/4/22. However, Resident 62 was not provided with a new storage bag. On 12/7/22 at 0827 and 1031 hours, a plastic bag was observed hanging on the oxygen concentrator dated 9/25/22. Resident 62's nebulizer mask was observed on top of the bedside table inside a hazy plastic bag dated 9/25/22. On 12/7/22 at 1049 hours, a concurrent observation and interview was conducted with LVN 8. When asked how often Resident 62's nebulizer mask, nebulizer bags and oxygen tubing were change, LVN 8 stated it should be changed once a week on Sundays and as need. LVN 8 verified Resident 62's oxygen tubing bag and nebulizer mask bags were dated 9/25/22. When LVN 8 was asked to check the date when Resident 62's nebulizer mask was changed, LVN 8 stated Resident 62's nebulizer mask was dated 9/25/22. LVN 8 stated Resident 62 uses the nebulizer mask daily for breathing treatments. LVN 8 acknowledged giving Resident 62's breathing treatments but did not check when nebulizer mask was changed. On 12/9/22 at 1334 hours, an interview was conducted with LVN 3. When asked how often oxygen tubing, nebulizer mask and plastic bags were changed, LVN 3 stated it should be change and dated weekly on Sundays and prn when dirty to decrease the risk of infection. 15. Medical record review for Resident 86 was initiated on 12/7/22. Resident 86 was admitted to the facility on [DATE]. Review of Resident 86's Order Summary Report showed a physician's order dated 4/2/22 to administer oxygen at two liter per minute via nasal canula and to administer Ipratropium-Albuterol Solution 0.5-2.5 three mg per 3 ml, inhale orally every six hours for shortness of breath or wheezing. Review of Resident 86's December 2022 MAR showed Resident uses oxygen treatment continuously and nebulizer treatments every six hours daily. Review of Resident 86's care plan problem for oxygen use had an intervention to change oxygen tubing weekly or as needed. On 12/7/22 at 0813 hours, Resident 86 was observed asleep using oxygen via nasal canula, a nebulizer mask on top of a plastic drawer and oxygen tubing coiled around a wheelchair handle. The tubing had no visible dates. On 12/7/22 at 1024 hours, an interview with Resident 86 was conducted. Resident 86 stated he uses oxygen all the time. When Resident 86 was asked about his oxygen tubing, Resident 86 stated he had it for more than a week. Resident 86 stated he used the oxygen tubing on the wheelchair when he went out of the room on 12/6/22. On 12/7/22 at 1059 hours, a concurrent observation and interview was conducted with LVN 8. When asked how often oxygen tubing, nebulizer masks and bags were changed, LVN 8 stated it should be changed every week on Sundays and as needed. LVN 8 verified Resident 86's oxygen tubing and nebulizer mask were not dated. LVN 8 verified Resident 86 was not provided with bags to store when the nebulizer mask and oxygen tubing were not in use. On 12/9/22 at 1334 hours, an interview was conducted with LVN 3. When asked how often oxygen tubing, nebulizer mask and plastic bag were changed, LVN 3 stated it should be change and dated weekly on Sundays and as needed when dirty to decrease the risk of infection. 9. Review of the facility's P&P titled Oxygen Administration (undated) showed the following: - The oxygen tubing should be changed weekly and as needed, including the mask, cannula, nebulizer equipment, etc. When not in use, the oxygen tubing should be stored in a clean bag for example, a Ziplock bag; - The date, time, and initials should be noted on oxygen equipment when it is initially used when changed; and - The oxygen tubing should be used in manner that prevents it from touching the floor. On 12/7/22 at 0942 hours, Resident 76 was observed in bed, receiving oxygen via nasal cannula. The oxygen nasal cannula was undated. A nebulizer mask dated 11/8/22 was observed on Resident 76's side table. There was no bag set-up for the oxygen and nebulizer mask. On 12/7/22 at 1232 hours, an observation and concurrent interview for Resident 76 was conducted with LVN 2. LVN 2 verified the above findings. LVN 2 acknowledged Resident 76 was on continuous oxygen. LVN 2 stated the oxygen nasal cannula, nebulizer mask and tubing were supposed to be changed every Sunday by the treatment nurse. Medical record review for Resident 76 was initiated on 12/7/22. Resident 76 was readmitted to the facility on [DATE]. Review of Resident 76's Order Summary Report showed the following physician's orders dated 12/1/22: -To administer oxygen at two liters per minute continuously via nasal cannula. May titrate up to five liters per minute for oxygen saturation less than 94% every shift; -To change nasal cannula/ mask as needed when soiled; and -To change nasal cannula/ mask every night shift every Sunday. Further review of Resident 76's Order Summary Report showed the following physician's orders dated 10/31/22: - budosemide (corticosteroid, medication used to control and prevent symptoms of asthma ( inhalation suspension 0.5 mg/2 ml every 12 hours; and - ipratropium-albuterol (anticholinergic, a combination medication used to treat chronic obstructive pulmonary disease) solution 0.5-2.5 mg one vial inhale every four hours as needed. 10. On 12/7/22 at 0918 hours, Resident 359 was observed in bed. An oxygen concentrator was observed near the resident's bed, and the nasal cannula attached to the oxygen concentrator was undated. A nebulizer mask dated 11/22/22 was observed on Resident 359's side table. There was no bag set-up for the oxygen and nebulizer mask. On 12/7/22 at 0948 hours, an observation and concurrent interview for Resident 359 was conducted with LVN 2. LVN 2 verified the above findings. LVN 2 stated Resident 359 used oxygen and nebulizer in the past, and Resident 359 was sent out and was just recently readmitted . LVN 2 stated the nasal cannula tubing and nebulizer mask should have been discarded. LVN 2 stated the oxygen nasal cannula, nebulizer mask and tubing were supposed to be changed every Sunday by the treatment nurse when these are being used or ordered routinely. LVN 2 stated if the oxygen and nebulizer were ordered as needed, the nasal cannula and nebulizer mask should be dated when it was first used and just changed when soiled. Medical record review for Resident 359 was initiated on 12/7/22. Resident 359 was readmitted to the facility on [DATE]. Review of Resident 359's Physician's Order showed the following physician's orders dated 2/15/19: -To administer oxygen at two liters per minute via nasal cannula as needed. May titrate up to five liters per minute for oxygen saturation less than 92 %; -To change oxygen tubing weekly (Sundays) 11-7 shift and as needed; -To change nasal cannula/ mask every seven days and as needed when soiled. Further review of Resident 359's medical record showed the physician's orders dated 11/20/22 to discontinue the following: - Oxygen at two liters per minute via nasal cannula as needed. May titrate up to five liters per minute for oxygen saturation less than 92%, and - ipratropium-albuterol solution 0.5 - 2.5 (3) mg/3ml, one vial inhale orally via nebulizer every six hours for congestion/ wheezing. 11. On 12/7/22 at 0829 hours, Resident 17 was observed in bed, receiving oxygen via nasal cannula. The oxygen nasal cannula was undated. An undated nebulizer mask was observed on Resident 17's side table. The end of the nebulizer mask tubing was touching the floor. There was no bag set-up for the oxygen and nebulizer mask. On 12/7/22 at 0831 hours, an observation and concurrent interview for Resident 17 was conducted with the ADON. The ADON verified the above findings. The ADON stated the nasal cannula tubing and nebulizer mask should be changed weekly. Medical record review for Resident 17 was initiated on 12/7/22. Resident 17 was readmitted to the facility on [DATE]. Review of Resident 17's Order Summary Report showed the following physician's orders dated: -12/1/22, to administer oxygen at two liters per minute continuously via nasal cannula. May titrate up to five liters per minute for oxygen saturation less than 94% every shift; -12/1/22, to change nasal cannula/ mask as needed when soiled; -12/1/22, to change nasal cannula/ mask every night shift every Sunday; and -12/4/22, to administer ipratropium-albuterol solution 0.5-2.5 mg one vial inhale every four hours as needed. 12. On 12/7/22 at 1002 hours, an observation and interview was conducted with Resident 43. Resident 43 was observed in bed, and awake. A nebulizer mask dated 8/6/22 was observed on Resident 43's side table. There was no bag set-up for nebulizer mask. When asked about the nebulizer mask, Resident 43 stated he no longer used a nebulizer and he did not know when was the last time he used it. On 12/7/22 at 1226 hours, an observation and concurrent interview for Resident 43 was conducted with LVN 2. LVN 2 verified the above findings. LVN 2 stated Resident 43 used nebulizer previously but the order has been discontinued. LVN 2 stated the nebulizer mask should have been discarded. Medical record review for Resident 43 was initiated on 12/7/22. Resident 43 was admitted to the facility on [DATE]. Review of Resident 43's physician's orders showed the following physician's orders dated -8/2/22, to administer ipratropium-albuterol solution every four hours as needed; and -12/4/22, to discontinue ipratropium-albuterol solution every four hours as needed. Review of Resident 43's medical record did not show any active orders for nebulizer treatment. 13. On 12/7/22 at 0910 hours, Resident 360 was observed in bed, receiving oxygen via nasal cannula. The oxygen nasal cannula was undated. There was no bag set-up for the oxygen tubing. On 12/7/22 at 0913 hours, an observation and concurrent interview for Resident 360 was conducted with the IP. The IP verified the above findings. The IP stated the oxygen tubing should have been dated when it was initially used. The IP stated she was not sure how often should they change the nasal cannula tubing, but she told the nurses they have to change it if it was soiled. The IP stated the NOC shift charge nurse was responsible to change the tubing. On 12/9/22 at 0940 hours, an interview, medical record review and facility P&P review was conducted with the DON. When asked how often the staff should change the oxygen tubing, and nebulizer mask, the DON stated the nasal cannula tubing and nebulizer masks should be changed weekly on Sunday by the NOC shift charge nurse, and will be checked by the treatment nurses on Mondays. The DON stated if the NOC shift charge nurse was not able to change the nasal cannula tubing and nebulizer masks, then the treatment nurses should change them. The DON also stated the nasal cannula and nebulizer masks should be changed whether these were being used routinely or as needed. Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide safe respiratory care to meet the needs of 10 of 25 final sampled residents (Residents 17, 39, 43, 48, 51, 62, 75, 76, 86, and 359 ) and five nonsampled residents (Residents 52, 81, 84, 360, and 409). * The facility failed to ensure qualified and trained staff responded to Resident 51's ventilator alarm. This failure had the potential to result in poor health outcomes for the resident. * The facility failed to ensure the mechanical ventilator low and high pressure alarms for Residents 39, 48, 52, 81, and 84 were set within safe parameters. This posed the risk for delayed care and interventions if the residents' ventilators did not alarm when they should have to alert the staff the residents were in distress or disconnected from their ventilators. * The facility failed to ensure Resident 409 had a manual resuscitation device (a hand-held device used to provide ventilation to residents who are not breathing or not breathing adequately) at the bedside. This posed the risk of delayed intervention in the event of an emergency. * The facility failed to ensure Resident 75's ventilator respiratory rate alarm was set within safe parameters. This failure put Resident 75 at risk for a delay in necessary care and services. * The facility failed to ensure Residents 17, 43, 62, 76, 359, and Resident 360's nasal cannulas (soft tubing used to deliver oxygen via the nostrils), nebulizer masks, nebulizer bags and tubing (a device which delivers medicated mist to a person via a mouth piece or a face mask) were changed every seven days in accordance with the physician's order and the facility's P&P. In addition, the facility failed to ensure the oxygen tubing and nebulizer masks were stored in a clean bag. These failures had the potential for increased risks of infection. * Resident 86's oxygen tubing and nebulizer mask were not labeled to show when it was changed. Resident 86's oxygen tubing and nebulizer mask were not storage in a bag when not in use. This failure had the potential for increased risk of infection. Findings: Review of the facility's P&P titled Ventilator Alarm Settings revised 11/2007 showed to maintain the high pressure alarm setting at a maximum of 30 cm of water pressure above the resident's peak airway/inspiratory pressure (PIP); and to maintain the low pressure alarm setting within a range of 10 cm of water pressure below the resident's PIP. According to the Clinical Application of Mechanical Ventilation 2014, Fourth Edition, the low pressure alarm is triggered if the PIP is less than the alarm setting. Conditions that may trigger the low pressure alarm may include circuit disconnection, exhalation valve driveline disconnection, endotracheal tube cuff leak, and a loose circuit connection. The high pressure alarm should be set at 10 to 15 cm H2O above the observed PIP. This alarm is triggered when the PIP is equal to or higher than the high pressure limit. The patient must be evaluated to determine the cause of the airflow obstruction. Common causes that trigger the high pressure alarm include water in the ventilator circuit, kinking or biting of the endotracheal tube, secretions in the airway, bronchospasm, mucus plugs, tension pneumothorax, decreases in lung compliance, increases in airway resistance, and coughing. Review of the facility's P&P titled Manual Resuscitation Device (Ambu-Bag) (undated) showed a manual resuscitator device will be placed at the bedside of each patient and on the emergency cart. 1. On 12/7/22 at 0804 hours, Resident 51 was observed in bed with a tracheostomy tube (breathing tube inserted through the neck into the airway to maintain an open airway) in place and connected to a mechanical ventilator. CNA 2 was at the bedside providing ADL care to Resident 51 with the privacy curtain drawn. Resident 51's ventilator started audibly alarming, and RT 1 responded to the ventilator alarm. However, RT 1 stood at the doorway and did not enter the resident's room to assess the resident nor check the ventilator or ventilator connection. RT 1, while standing at the doorway, asked CNA 2 if Resident 51 was disconnected from the ventilator and instructed CNA 2 to clear the alarm. On 12/7/22 at 0810 hours, an observation of Resident 51 was conducted with CNA 2 who was still at the resident's bedside. CNA 2 pointed to the exhalation line connected to the exhalation valve of the ventilator circuit and stated the exhalation line was disconnected. CNA 2 stated he reconnected the exhalation line to the exhalation valve. CNA 2 verified RT 1 did not enter the room to assess Resident 51 nor the ventilator or ventilator connection. On 12/7/22 at 0816 hours, an interview was conducted with RT 1. RT 1 verified she did not enter Resident 51's room to assess the resident when the resident's ventilator alarmed. When asked why the ventilator alarmed, RT 1 stated she did not know what triggered the ventilator to alarm, whether it was due to a disconnection, high or low pressure, or another ventilator alarm type. RT 1 verified she asked the CNA to clear the ventilator alarm even though it was not within the CNA's scope of practice to troubleshoot or make changes to the ventilator settings/alarms. Medical record review for Resident 51 was initiated on 12/7/22. Resident 51 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 51's plan of care showed a care plan problem dated 4/22/19, to address ventilator alarms. Flashing alerts and audible alarms may be a result of high or low pressure alarms and may be caused by the resident being turned; kinked tubing; the resident moving; coughing; increased pulmonary secretions the resident attempting to speak, bearing down, or straining; and a disconnected or leaking circuit/tubing. The goal was to provide monitoring and care for ventilator dependent residents to ensure their respiratory needs were met and to ensure respiratory distress was resolved or prevented. The interventions included for the staff to promptly enter the resident's room and assess the resident when there is an audible ventilator alarm. On 12/7/22 at 0926 hours, an interview was conducted with the Lead RT. The Lead RT verified it was not within the CNA's scope of practice to manipulate the ventilator settings or to silence ventilator alarms. The Lead RT verified the RTs should promptly enter the resident's room to assess the resident and the ventilator alarm when the ventilator alarmed. 2. On 12/7/22 at 0845 hours, Resident 48 was observed in bed with a tracheostomy tube in place and connected to a mechanical ventilator. The observed PIP on the ventilator was 46; the low pressure alarm was observed set at 6 and the high pressure alarm was observed set at 97. On 12/7/22 at 0906 hours, an interview was conducted with RT 2. RT 2 stated the low pressure alarm should be set 10 cm H2O below the resident's observed PIP and the high pressure alarm should be set up to 30 cm H2O above the resident's observed PIP. RT 2 stated the low pressure alarm was important because it alerted the staff if the resident was disconnected from the ventilator, and the high pressure alarm alerted the staff if the resident had an airway obstruction. RT 2 stated if the high pressure alarm was set too high it would take longer or take higher pressures for the ventilator to alarm and could potentially delay interventions. Following the interview, an observation of Resident 48's ventilator settings was conducted with RT 2. RT 2 stated she was not assigned to Resident 48 but would assist with checking the resident's ventilator settings. RT 2 verified how to check the ventilator settings. Resident 48's observed PIP on the ventilator was 32; the low pressure alarm was observed set at 6 and the high pressure alarm was observed set at 97. RT 2 verified Resident 48's low and high pressure alarms were not set according to the facility's P&P. 3. On 12/7/22 at 0855 hours, Resident 84 was observed in bed with a tracheostomy tube in place and connected to a mechanical ventilator. The observed PIP on the ventilator was 39; the low pressure alarm was observed set at 6 and the high pressure alarm was observed set at 99. On 12/7/22 at 0910 hours, a concurrent observation and interview of Resident 84's ventilator settings was conducted with RT 2. RT 2 verified the observed PIP on Resident 84's ventilator ranged from 35 to 45; the low pressure alarm was observed set at 6 and the high pressure alarm was observed set at 99. RT 2 verified both the low and high pressure alarms were not set within a safe limit based on Resident 84's observed PIP. 4. On 12/7/22 at 0854 hours, Resident 81 was observed in bed with a tracheostomy tube in place and connected to a mechanical ventilator. The observed PIP on the ventilator was 20; the low pressure alarm was observed set at 6 and the high pressure alarm was observed set at 99. On 12/7/22 at 0911 hours, a concurrent observation and interview of Resident 81's ventilator settings was conducted with RT 2. The observed PIP on Resident 81's ventilator was 21; the low pressure alarm was observed set at 6 and the high pressure alarm was observed set at 99. RT 2 verified the high pressure alarm was set too high. 5. On 12/7/22 at 0839 hours, Resident 52 was observed in bed with a tracheostomy tube in place and connected to a mechanical ventilator. The observed PIP on the ventilator was 35; the low pressure alarm was observed set at 8 and the high pressure alarm was observed set at 99. On 12/7/22 at 0913 hours, a concurrent observation and interview of Resident 52's ventilator settings was conducted with RT 2. The observed PIP on Resident 52's ventilator was 36; the low pressure alarm was observed set at 8 and the high pressure alarm was observed set at 99. RT 2 verified the findings and stated both the low and high pressure alarms were not set within a safe limit based on the resident's observed PIP. 6. On 12/7/22 at 0758 hours, Resident 39 was observed in bed with a tracheostomy tube in place and connected to a mechanical ventilator. The observed PIP on the ventilator was 32; the low pressure alarm was observed set at 6 and the high pressure alarm was observed set at 99. On 12/7/22 at 0919 hours, a concurrent observation and interview of Resident 39's ventilator settings was conducted with RT 2. The observed PIP on Resident 39's ventilator was 37; the low pressure alarm was observed set at 6 and the high pressure alarm was observed set at 99. RT 2 verified the findings and stated both the low and high pressure alarms were not set within a safe limit based on the resident's observed PIP. 7. On 12/7/22 at 0833 hours, Resident 409 was observed in bed with a tracheostomy tube in place and connected to a mechanical ventilator. A manual resuscitation device was not observed at Resident 409's bedside. On 12/7/22 at 0916 hours, RT 2 verified a manual resuscitation device was not available at Resident 409's bedside, but should be in case of an emergency and Resident 409 required manual resuscitation. On 12/7/22 at 0926 hours, an interview was conducted with the Lead RT regarding the above findings for Residents 48, 84, 81, 52, 39, and 409. The Lead RT stated all three of the RTs were assigned to these residents. The Lead RT verified the low pressure alarm should be set 10 cm H2O below the resident's observed PIP and the high pressure alarm should be set up to 30 cm H2O above the resident's observed PIP. The Lead RT verified a manual resuscitator device should be placed at the bedside of each resident in case of medical emergencies or ventilator failure. 8. Medical record review for Resident 75 was initiated on 12/7/22. Resident 75 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 75's Order Summary Report showed an order dated 11/20/22, for ventilator mode: SIMV, TV 450, RR 10, FIO2 5 lpm, PSV 10, and peep + 5. On 12/7/22 at 1027 hours, an observation and concurrent interview was conducted with RT 2 at Resident 75's bedside. RT 2 was asked to check Resident 75's ventilator settings and alarms. RT 2 verified Resident 75 was on the above ordered settings. When asked about the RR alarm, RT 2 stated Resident 75's RR was set to alarm at 100. RT 2 stated she did not know why it was set so high, and an alarm set that high meant the staff might not know if the resident's RR was at an unsafe range. RT 2 stated the normal alarm value for RR was 45.

Based on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the proper hand hygiene was used in between glove changes and when handling dirty to clean dishes. * The facility failed to ensure the proper labeling and dating of foods in the kitchen. * The facility failed to air dry the equipment. * The facility failed to ensure the plates were free from chip and cracks. * The facility failed to ensure the chlorine strips and pH sanitizer strips had not expired. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the Form CMS-672 Resident Census and Conditions of Residents completed by the facility and dated 12/7/22, showed 57 of the 104 residents residing in the facility received foods prepared in the kitchen. 1. According to the USDA Food Code 2017, Section 2-301, When to Wash, the food employees shall clean their hands before donning gloves to initiate a task involving working with food; and after engaging in other activities which contaminated the hands. Review of the facility's P&P titled Sanitation and Infection Control revised 2019 under the section for Handwashing, showed handwashing after handling carts, soiled dishes, and utensils and under the section for Use of Disposable Gloves, showed to wash hands when changing gloves. Review of the facility's P&P titled Dishwashing Procedures - Dish Machine revised 2019 showed to prevent cross-contamination, it is recommended that two employees handle dish washing. One employee will handle soiled dishes and the other employee will handle clean dishes. If only one employee is available to wash and handle clean and soiled dishes, the employee must wash hands thoroughly before handling clean dishes. On 12/9/22 at 0825 hours, Dietary Aide 2 was observed wearing gloves and washing the cups and bowls. Then Dietary Aide 2 was observed removing his gloves and donning new pair of gloves without washing his hands. Dietary Aide 2 proceeded to take a tray full of plates from the dishwasher. On 12/9/22 at 0846 hours, Dietary Aide 2 verified he did not wash his hands when he changed his gloves and between handling dirty and clean dishes. On 12/9/22 at 0858 hours, an interview was conducted with the DSS. The DSS stated Dietary Aide 2 should have washed his hands between handling dirty and clean dishes, and between glove changes. 2. Review of the facility's P&P titled Labeling: Food (undated) showed the following: - Food that is cooked or open and placed into refrigerator will be labeled with name of food item and date placed in the refrigerator; - Items in refrigerator opened will be properly covered, dated and labeled; - Other items that are in original container and opened will have open date labeled. On 12/7/22 at 0750 hours, an initial tour was conducted with the DSS. During the initial tour, the following items in the refrigerator were observed opened and no opened date: - A bottle of caramel sauce; - A bottle of white chocolate sauce; and - A bottle of chocolate sauce. The following items in the open storage area near the stove were observed opened and no opened date: - A bottle of red shade food color; - A bottle of kitchen bouquet browning and seasoning sauce; and - A container of grilling food release spray - opened, undated The DSS verified the findings and stated the food items should have been properly labeled and dated with open dates. 3. According to the USDA Food Code 2017, 4-901.11, Equipment and Utensils, Air- Drying Required, items must be allowed to drain and air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganism can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms. On 12/9/22 at 1000 hours, a pureed food preparation observation and concurrent interview was conducted with the Cook. After blending the beef goulash, the [NAME] was observed washing the blender. The blender was observed wet. The [NAME] placed the wet blender into the machine. The [NAME] stated he would prepare the pureed carrots. The [NAME] verified the blender was still wet, and stated the blender needed to be air-dried. 4. According to the USDA Food Code 2017, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. On 12/9/22 at 0825 hours, bowls and plates were observed stacked and stored on the shelf near the trayline area. Several plates were observed with chipped edges. The DSS verified the above findings. The DSS stated they do not use those plates but would discard the plates. 5. According to the USDA Food Code 2017, 4-501.18, Warewashing Equipment, Clean Solutions, failure to maintain clean wash, rinse, and sanitizing solutions adversely affects the warewashing operation. Equipment and utensils may not be sanitized, resulting in subsequent contamination of food. Review of the Product Technical Fact Sheet for the chlorine test papers showed the shelf-life of the test strip is two years from the date of manufacture when stored properly in the original packaging. According to https://www.preclaboratories.com/knowledge-base/knowledge-base-general-questions/, under Knowledge Based General Questions, the test strips have a minimum shelf-life of two years when stored and handled correctly. In reality, the strips are stable for much longer. We have experienced test strips over 3 years old that still perform to specification. We suggest the test strips be used within one year from the date of opening, given proper storage and handling. On 12/9/22 at 0846 hours, an observation of sanitation bucket test was conducted with Dietary Aide 2. Dietary Aide 2 checked the concentration of the sanitizer using a piece of paper strip taken from a container of chlorine test paper. The chlorine test paper container had an expiration date of 9/2022, with no opened date. Dietary Aide 2 verified the had expired and no opened date 6. According to the USDA Food Code 2017, 3-304.14, Wiping Cloths, Use Limitation, cloths in-use for wiping counters and other equipment surfaces shall be held between uses in a chemical sanitizer solution. According to the USDA Food Code 2017, 4-701.10, Food Contact Surfaces and Utensils, effective sanitization procedures destroy organisms of public health importance that may be present on wiping cloths, food equipment, or utensils after cleaning, or which have been introduced into the rinse solution. Review of the manufacturer's Safety Information on pH Test Papers/Strips (undated) showed the pH test papers have a shelf life of three years and should be stored dry and protected from sunlight. According to https://www.microessentiallab.com/help.aspx, under Frequently Asked Question, the shelf life of the pH test paper is three years from the date of manufacture. The color chart is marked with the expiration and lot number for that specific roll. The pH paper will remain accurate until the expiration date listed. On 12/9/22 at 0840 hours, an observation of sanitation bucket test was conducted with Dietary Aide 1. Dietary Aide 1 checked the concentration of the sanitizer using a paper strip taken from a roll of pH test strips. The pH test strip container had an expiration date of 3/1/22. On 12/9/22 at 0858 hours, an interview was conducted with the DSS. The DSS verified the chlorine test paper container had expired and had no opened date; and the pH test strip roll had expired. Cross reference to F802.

**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 regular inspection of all bed frames, mattresses, and side rails as part of the regular maintenance program to identify areas of possible entrapment. This had the potential to negatively impact the residents resulting to entrapment, serious injuries, and death. Findings: Review of the facility's P&P titled Policy for Resident's Bed Entrapment (undated) showed the following: - The facility will conduct inspection of all bed frames, mattresses, and bedrails to identify areas of possible entrapment to ensure safety; and - The facility will utilize 7-zone as reference for bed entrapment assessment. 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 document titled Bed Safety Checklist for Residents with Side Rails dated 12/7/22, showed there were 108 residents and Zones 1, 2, 3, 5, 6, and 7 were inspected. The column for Zone 4 showed N/A. The document showed Zone 4 was not inspected for possible entrapment. Further review of the residents' medical records and facility document showed the residents beds in the facility were not properly inspected for possible entrapment. For example: 1. On 12/7/22 at 0918, 0929, and 0948 hours, on 12/8/22 at 0827, 1335, and 1525 hours, and on 12/13/22 at 0935 hours, Resident 359 was observed in bed. Resident 359 had ¼ side rails up on the left side of the bed. Resident 359 was observed leaning towards the left, and his head was near the left side rail. Medical record review for Resident 359 was initiated on 12/7/22. Resident 359 initially admitted to the facility on [DATE], and was readmitted on [DATE]. Review of Resident 359's Order Summary Report showed a physician's order dated 11/21/22, for bilateral upper half side rails when in bed for safety and protection secondary to involuntary movement. Review of Resident 359's plan of care showed a care plan problem dated 2/20/19, to address safe bed, and to provide resident with a bed that reduces hazards such as entrapment associated with use of hospital beds and side rails. The interventions included to inspect all beds upon admission and/or bed changes, bed frame, side rails mattress type. 2. On 12/7/22 at 0829, 0831, and 0847 hours, on 12/8/22 at 0829, and 0922, 0928, 1220 and 1332 hours, and on 12/9/22 at 0840, 1244, 1247, and 1337 hours, Resident 17 was observed lying in bed with bilateral upper side rails elevated. Medical record review for Resident 17 was initiated on 12/7/22. Resident 17 was readmitted to the facility on [DATE]. Review of Resident 43's Order Summary Report showed the following physician's order dated 10/27/22, for bilateral upper half side rails up and locked when in bed as enabler for positioning and ease of mobility; and on 10/28/22, for low air loss mattress for wound care and management. On 12/14/22 at 0855 hours, an interview was conducted with the Maintenance Supervisor. When asked about the bed inspection, the Maintenance Supervisor stated bed inspections should be done monthly, however, they have not done the monthly bed inspection for this month. When asked what the process was for the monthly bed inspection, the Maintenance Supervisor stated he was new in the position, but the Maintenance Assistant Supervisor had done it before. The Maintenance Supervisor was asked to provide documentation of their recent bed inspection. On 12/14/22 at 1040 hours, an interview and concurrent facility document review for bed inspection was conducted with the Maintenance Assistant Supervisor. When asked about the bed inspection process, the Maintenance Assistant Supervisor stated he checked if there was a gap between the mattress and the side rails. When asked why it was necessary to check the beds prior to the installation of bed rails, the Maintenance Assistant Supervisor stated the resident could get stuck in between the bed and rail. When asked why zone 4 was documented as N/A on the Bed Safety Checklist form, the Maintenance Assistant Supervisor stated N/A meant not applicable, and he did not measure the zone 4 on the bed because the residents only used the upper bilateral side rails. When asked if he measured the different zones on the beds for 108 residents on 12/7/22, the Maintenance Assistant Supervisor stated he only visually inspected the beds. The Maintenance Assistant Supervisor stated the measurements were done three to four years ago based on a standard bed and a regular mattress. When asked if he inspected the bed when there was a change of bed or mattress or a new resident to determine if any areas of possible entrapment are present based on the change of the bed, or mattress, or user, the Maintenance Assistant Supervisor answered no. The Maintenance Assistant Supervisor stated he was not informed when a resident switched bed or mattress. The Maintenance Assistant Supervisor stated he did not know he had to inspect the bed for possible entrapment each time there was a change of bed, mattress or resident. 3. On 12/7/22 at 0845 and 1127 hours, and on 12/13/22 at 0831 and 0939 hours, Resident 48 was observed lying in bed with bilateral side rails elevated by the head of the bed. On 12/14/22 at 1041 hours, an interview and concurrent facility record review was conducted with the Maintenance Assistant Supervisor. Review of the Bed Safety Checklist for Residents with Side Rails dated 12/7/22, showed no measurements were obtained for entrapment Zone 4 (under the rail at the ends of the rail) for Resident 48 and all other residents with side rails. The Maintenance Assistant Supervisor verified the findings and stated he confused Zone 4 with Zone 5 (between two split side rails). The Maintenance Assistant Supervisor stated the measurements documented on the Bed Safety Checklist for Residents with Side Rails were obtained three years ago or so based on a standard sized mattress and the bed. When asked if new measurements were conducted when standard sized mattresses were switched to a different type of mattress like the low air low mattress, the Maintenance Assistant Supervisor stated no because they are not informed if or when the residents' mattress types were changed. On 12/14/22 at 1205 hours, an interview was conducted with LVN 9. LVN 9 stated the nurses did not inform the maintenance staff if or when the residents' mattresses were changed.