**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to honor a resident's preference regarding personal care by assigning a male certified nursing assistant (CNA) to provide showers to one of eight sampled residents (Resident 86) when the resident requested to have female CNAs assigned on her shower days. This failure resulted in a violation of Resident 86's personal dignity and right to make decisions about her care. Findings: During a review of Resident 86's admission Record, the admission Record indicated Resident 86 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included schizophrenia (a mental illness that is characterized by disturbances in thought), hypertension ([HTN] - high blood pressure), metabolic encephalopathy (brain dysfunction), diabetes mellitus ([DM]- a disorder characterized by difficulty in blood sugar control and poor wound healing), and muscle weakness (loss of muscle strength). During a review of Resident 86's Minimum Data Set ([MDS]- a resident assessment tool), dated 3/18/2025, the MDS indicated Resident 86's cognition (ability to think and reason) was intact. The MDS indicated Resident 86 required supervision or touching assistance (helper provides verbal cues and/or touching assistance as resident completes activity) from staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During an interview on 6/2/2025 at 11:41 a.m., with Resident 86, Resident 86 stated her scheduled shower days were twice a week, on Mondays and Thursdays. Resident 86 stated she repeatedly informed staff that she did not want a male staff to assist her with showers. Resident 86 stated despite her request male CNAs continue to be assigned to her. Resident 86 stated the most recent incident occurred two weeks ago and again on 6/2/2025. Resident 86 stated she felt uncomfortable and embarrassed. Resident 86 stated the facility did not respect her wishes or her privacy. During a concurrent observation and interview on 6/5/2025 at 7:30 a.m., with Resident 86, in Resident 86's room, Resident 86 was observed siting on her bed, visibly upset. Resident 86 stated she had once again been assigned a male CNA on her shower day. Resident 86 stated she felt embarrassed and experienced a loss of dignity due to the facility's continued disregard for her expressed preferences. During a concurrent observation and interview on 6/5/2025 at 7:35 a.m., with CNA 2, who was male, stated he had been assigned to assist Resident 86 on her most recent shower days and on 6/5/2025. CNA 2 stated he was not aware Resident 86 was uncomfortable receiving assistance from a male CNA during her showers. CNA 2 stated if the resident preferred a female CNA, it was the responsibility of the Director of Staff Development (DSD) to ensure such preferences were reflected in the daily assignment. During a concurrent interview and record review on 6/5/2025 at 7:50 a.m., with the DSD, the facility's staff assignment records titled Nursing Staffing Assignment and Sign in Sheet, dated 5/1/2025 through 6/5/2025, were reviewed. The staff assignment records indicated on 5/19/2025, 6/2/2025, and 6/5/2025, a male (CNA 2) was assigned to assist Resident 86 with her shower. The DSD stated she was aware of Resident 86's preference for female CNAs during showers, which had been communicated verbally by the resident, however she overlooked the CNA assignment and did not include any instructions or notations in the daily assignment sheet to ensure that the resident's preference was followed. The DSD stated this failure to honor the resident's preferences could lead to emotional distress and loss of dignity. During an interview on 6/5/2025 at 9:30 a.m., with the Director of Nursing (DON), the DON stated resident's preferences such as care preferences should be honored and clearly communicated during staff assignments. The DON stated repeated exposure to the male CNA, against the resident's preferences, could lead to emotional discomfort and that the resident's personal care preferences were not valued or respected. The DON stated this compromised the resident's well-being and quality of life. During a review of the facility's policy and procedure (P&P) titled Privacy and Dignity, revised 5/1/2018, the P&P indicated To ensure that care and services provided by the Facility promote and/or enhance privacy, dignity and overall quality of live. During a review of the facility's P&P titled Resident Rights, revised 5/1/2023, the P&P indicated the facility would protect the right of all residents at the facility. The P&P indicated The Facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment, that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to timely submit the referral for probate conservatorship (referral to the court to appoint a conservator [an appointed person to act or make decisions for a person who cannot make decisions for themselves]) for one of three sampled residents (Resident41), who did not have the capacity to make decisions. This deficient practice resulted in the delay in the process of obtaining a conservator, which resulted in the Interdisciplinary Team ([IDT], a coordinated group of experts from several different fields) overseeing Resident 41's care. Findings: During a review of Resident 41's admission Record (Face Sheet), the Face Sheet indicated Resident 41 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included encephalopathy (damage or disease that affects the brain), cerebral infarction (loss of blood flow to a part of the brain), and schizophrenia (a mental illness that is characterized by disturbances in thought). The Face Sheet indicated the clinical IDT was Resident 41's responsible party. During a review of Resident 41's Minimum Data Set ([MDS], a resident assessment tool), dated 4/29/2025, the MDS indicated Resident 41's cognition (process of thinking) was severely impaired. The MDS indicated Resident 41 was dependent on staff's assistance with toileting, bathing, and putting on/taking off footwear. During a concurrent interview and record review on 6/3/2025 at 2:48 p.m., with the Social Services Director (SSD), Resident 41's History and Physical (H&P), dated 11/26/2024, was reviewed. The SSD stated Resident 41 did not have the capacity to understand and make decisions. The SSD stated Resident 41 did not have any family or friends involved in her care. The SSD stated since Resident 41 was assessed by their physician to not having the capacity to make medical decisions and no other person was involved in their care, the Resident 41 was supposed to be referred for probate conservatorship. The SSD stated while the referral was processed, the Resident 41's care would be overseen by the clinical IDT until a conservator was appointed. The SSD stated the process for appointing a conservator was a lengthy process and it was important to initiate the referral timely. During a concurrent interview and record review on 6/3/2025 at 2:54 p.m., with the SSD, Resident 41's IDT Conference Meeting, dated 2/27/2025, was reviewed. The SSD stated Resident 41's referral for probate conservatorship was made that day after the IDT met to discuss Resident 41's need for conservator. The SSD stated the process for appointing a conservator could be lengthy and the referral should be sent as soon as possible. The SSD stated three months was too long to wait to submit the referral for probate conservatorship. The SSD stated due to delaying the referral, the rest of the process for probate conservatorship was delayed, therefore the clinical IDT had overseen Resident 41's care for potentially a longer than necessary. During an interview on 6/4/2025 at 2:13 p.m., with the Director of Nursing (DON), the DON stated Resident 41 was unable to make medical decisions for herself, therefore was currently under the care of the clinical IDT. The DON stated Resident 41 was deemed to not having decision making capacity in November 2024 and should have been referred for probate conservatorship at that time. The DON stated once the social services department determined Resident 41 did not have any family or friends involved in her care, the process should have immediately started. The DON stated waiting three months to submit Resident 41's referral was too long and during those three months, Resident 41's referral could have been processed. The DON stated due to the delay; Resident 41 could have had a conservator appointed but instead stayed under the care of the clinical IDT. During a review of the facility's policy and procedure (P&P) titled, Bioethics Committee, revised 1/31/2025, the P&P indicated, A personal representative must be appointed for each resident lacking decision-making capacity and without a surrogate decision-maker. If the resident has no family or friends willing to participate in the Bioethics Committee meeting on his/her behalf, the Facility must find another person unaffiliated with the nursing home to serve as the resident's representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) from the residents prior to treatment with psychotropic (medications that affect brain activities associated with mental processed and behavior) medications for two of six sampled residents (Residents 77 and 86) by failing to: 1. Obtain informed consent from Resident 77, for the use Chlorpromazine (an antipsychotic medication [a medication that effects the mind, emotion, and behavior]). 2. Ensure Resident 86's informed consent for Risperidone (an antipsychotic medication), and Seroquel (an antipsychotic medication) was renewed every six months. The deficient practice of failing to obtain informed consent prior to initiating treatment with psychotropic medications could have prevented Residents 77 from exercising the right to decline treatment with psychotropic medications. This increased the risk that Residents 86 could have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) leading to impairment or decline in their mental or physical condition or functional or psychosocial status. Findings: During a review of Resident 77's admission Record, the admission Record indicated Resident 77 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included schizophrenia (a mental illness that is characterized by disturbances in thought), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 77's Minimum Data Set (MDS - a resident assessment tool), dated 3/31/2025, the MDS indicated Resident 77 cognition (process of thinking) was moderately impaired. The MDS indicated Resident 77 required moderate assistance (helper does less than half the effort) from staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 77 received antipsychotic medication. During a review of Resident 77's Order Summary Report, dated 6/4/2025, the Order Summary Report indicated on 3/26/2025, Resident 77's attending physician prescribed Chlorpromazine 25 milligrams ([mg]- metric unit of measurement, used for medication dosage and/or amount) via gastrostomy ([G-tube]-a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems)every six hours as needed for HICCUPS (involuntary spasms of the diaphragm [muscle that separates the chest from the abdomen]). During a review of Resident 77's available informed consent documentation and clinical record, the informed consent documentation and clinical record did not indicate there was documentation Resident 77 received education regarding the risks and benefits of Chlorpromazine prior to initiation on 3/26/2025. During an interview on 6/5/2025 at 3:10 p.m., with the Director of Nursing (DON), the DON stated the facility failed to obtain informed consent related to Resident 77's Chlorpromazine. The DON stated even though this medication was being used to treat HICCUPS for Resident 77, it was still a psychotropic medication which affects the brain and needed informed consent prior to initiation. The DON stated there was a risk that Resident 77 would not be able to exercise their right to opt out of the treatment with Chlorpromazine if the informed consent was not done. The DON stated this increased the risk that Resident 77 could have experienced adverse effects related to the treatment with Chlorpromazine. b. During a review of Resident 86's admission Record, the admission Record indicated Resident 86 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included schizophrenia and metabolic encephalopathy (brain dysfunction). During a review of Resident 86's MDS, dated [DATE], the MDS indicated Resident 86's cognition was intact. The MDS indicated Resident 86 required supervision or touching assistance (helper provides verbal cues and/or touching assistance as resident completes activity) from staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 86 received antipsychotic medications. During a review of Resident 68's Order Summary Report, dated 6/4/2025, the Order Summary Report indicated to give: 1. Risperidone 0.25 mg, one tablet by mouth, one time a day for schizophrenia as manifested by (m/b) verbal aggression and angry outbursts. 2. Seroquel 50 mg, one tablet by mouth, at bedtime for schizophrenia as m/b auditory (hearing) hallucination (sensory experiences that a person perceives as real, but are not actually present in the environment). During a concurrent interview and record review on 6/4/2025 at 9:50 a.m., with Registered Nurse (RN) 2, Resident 86's Psychotherapeutic Drugs Informed Consent Form, dated 10/27/2024, was reviewed. The Psychotherapeutic Drugs Informed Consent Form indicated consent was obtained for Risperidone 0.25 mg and Seroquel 50 mg for schizophrenia. RN 2 stated Resident 86's psychotherapeutic drugs informed consent form for Risperidone and Seroquel were outdated. RN 2 stated current regulation required the psychotherapeutic drugs informed consent to be renewed every six months. RN 2 stated Resident 86's psychotherapeutic drugs informed consent should have been renewed for Risperidone and Seroquel on 4/2025. RN 2 it was important to ensure informed consents were renewed every six months so the resident would be aware of the medication's continued use, risks, or benefits. During a review of the Health and Human Services Agency California Department of Public Health All Facilities Letter (AFL), dated 2/28/2024, the AFL indicated the following: 1. All facilities were to obtain a resident's written informed consent for treatment using psychotherapeutic drugs, and consent renewal every six months. 2. Before prescribing a psychotherapeutic drug, the prescriber must personally examine the resident and obtain informed written consent signed by the resident or the resident's representative along with, the signature of the health care professional declaring the required material information has been provided. 3. The signed written consent must be recorded in the resident's medical record. Before initiating treatment with psychotherapeutic drugs, facility staff must verify that the resident's health record contains written informed consent with the required signatures. During a review of the facility's policy and procedure (P&P) titled Informed Consent, revised 1/1/2012, the P&P indicated the facility would ensure a resident's informed consent would be obtained for the use of psychotherapeutic drugs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the call light was kept within reach for two of 25 sampled residents (Resident 23 and Resident 34). This deficient practice removed Resident 23's and Resident 34's ability to exercise their right to request assistance from staff and created the potential for accidents and/or delays in care. Findings: a. During a review of Resident 23's admission Record, the admission Record indicated Resident 23 was originally admitted on [DATE] and most recently readmitted on [DATE]. Resident 23's admitting diagnoses included generalized muscle weakness, hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) following cerebral infarction (when blood flow to the brain is interrupted, leading to a lack of oxygen and nutrients to brain tissue) affecting left non-dominant side, symptoms and signs involving the musculoskeletal system, and dementia (progressive state of decline in mental abilities). During a review of Resident 23's Minimum Data Set (MDS, a resident assessment tool), dated 5/8/2025, the MDS indicated Resident 23 had severe cognitive impairments (a decline in mental processes like memory, attention, language, and reasoning). The MDS indicated Resident 23 had upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hips, knees, ankles, feet) impairments on one side of the body. The MDS indicated Resident 23 was dependent on staff for getting dressed and putting on/taking off footwear. The MDS indicated Resident 23 required partial assistance from staff for movement while in bed. During an observation on 6/2/2025 at 10:35 a.m., at Resident 23's bedside, Resident 23's call light was observed on the ground, behind the head of his bed, tangled in the bed frame. During an observation on 6/2/2025 at 12:41 p.m., at Resident 23's bedside, Resident 23's call light was observed on the ground, behind the head of his bed, tangled in the bed frame. During a concurrent interview and record review, on 6/4/2025 at 10:46 a.m., with Registered Nurse (RN) 1, the facility's policy and procedure (P&P) titled Communication - Call System, revised 10/2022, was reviewed. The P&P indicated all residents were to be provided with a call system to enable them to alert nursing staff. RN 1 stated this was for the safety of the resident, and to allow the resident to call for help if needed. RN 1 stated an out of reach call light created the potential for delayed provision of care. During an interview on 6/5/2025 at 11:07 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated CNAs did room rounds (visual check-ins on the residents) every hour or more frequently. CNA 1 stated the purpose of room rounds was to ensure the residents' needs were met, and to ensure their environment was safe and equipped to meet their needs. CNA 1 stated call light placement was part of the room rounds. CNA 1 stated if a call light was observed out of reach, the CNAs should have placed it within reach of the resident. b. During a review of Resident 34's admission Record, the admission Record indicated Resident 34 was admitted to the facility on [DATE] with diagnosis which included hemiplegia and hemiparesis (total paralysis of the arm, leg, and trunk on the same side of the body), dysphagia (difficulty swallowing), schizophrenia (a mental illness that is characterized by disturbances in thought), and diabetes mellitus ([DM]- a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 34's MDS, dated [DATE], the MDS indicated Resident 34's cognition was severely impaired. The MDS indicated Resident 34 was totally dependent (helper does all the effort) on staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 34's care plan titled Resident at high risk for falls and injuries ., initiated 6/17/2021, the care plan indicated the facility would ensure the call light was within reach for the resident to use to request assistance. During an observation on 6/2/2025 at 10:05 a.m., in Resident 34's room, observed Resident 34 lying in bed. Resident 43's call light was observed on the floor behind the resident's bed. Resident 34's call light was not within reach. During a concurrent observation and interview on 6/2/2025 at 1:40 p.m., with Certified Nursing Assistant (CNA) 3, in Resident 34's room, Resident 34 was observed lying in bed in a semi-Fowler's position (lying on the back with head and upper body raised). CNA 3 stated the call light was observed on the floor behind the resident's bed, not within reach. CNA 3 stated Resident 34's call light should have been attached to the resident's bed and within reach. CNA 3 stated it was important the resident was able to reach and use the call light when needed and for an emergency. During an interview on 6/5/2025 at 9:15 a.m., with Registered Nurse (RN) 1, RN 1 stated the call light should be placed within resident reach and near the resident's bedside. RN 1 stated the call light was important for resident's to be able to communicate with the staff. RN 1 stated the facility's licensed staff were responsible for checking the residents' call light and placing it within resident reach at the bedside. RN 1 stated if the call light not within the resident's reach, the residents would not be able to use the call light and would not be able to call for help and assistance when needed. RN 1 stated the call light not within reach was a resident safety issue and placed residents at risk for falls and injury. During a review of the facility's policy and procedure (P&P) titled Communication-Call System, revised 10/24/2022, the P&P indicated the facility would provide a call system to enable residents to alert the nursing staff from their beds. The P&P indicated the call cords would be placed within the resident's reach in the resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the Minimum Data Sets (MDS, a resident assessment tool) for three of 25 sampled residents (Residents 72, 76, and 83) accurately reflected the care and services they received. This deficient practice resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS) regarding the above residents' health status and unique healthcare needs. This deficient practice also created the potential for Residents 72, 76, and 83 to not receive the interventions needed monitor the effectiveness of the care received. Findings: 1. During a review of Resident 76's admission Record, the admission Record indicated Resident 76 was originally admitted on [DATE] and was most recently readmitted on [DATE]. Resident 76's admitting diagnoses included dementia (a progressive state of decline in mental abilities) and epilepsy (a condition causing recurring seizures [sudden, uncontrolled electrical disturbances in the brain causing uncontrolled jerking, blank stares, and loss of consciousness]). During a review of Resident 76's MDS, dated [DATE], the MDS indicated Resident 76 had severe cognitive impairments (ability to think and reason). The MDS indicated Resident 76 was dependent on staff for activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). The MDS did not indicate Resident 76 received oxygen therapy while a resident. During an interview on 6/4/2025 at 9:18 a.m., with Minimum Data Set Nurse (MDSN) 1, MDSN 1 stated it was important to ensure the MDS was coded correctly because it guided the resident's individualized plan of care. During a concurrent interview and record review, on 6/4/2025 at 9:22 a.m., with MDSN 1, Resident 76's MDS dated [DATE] was reviewed. MDSN 1 stated the MDS did not indicate Resident 76 received oxygen therapy while a resident. During a concurrent interview and record review, on 6/4/2025 at 9:23 a.m., with MDSN 1, Resident 76's physician order, dated 4/19/2025 was reviewed. MDSN 1 stated the order indicated Resident 76 had orders for oxygen therapy. During a concurrent interview and record review, on 6/4/2025 at 9:25 a.m., with MDSN 1, Resident 76's vital sign (measurement of the body's most basic functions) flowsheet for oxygen saturation (level of oxygen in the blood), dated 5/2025, MDSN 1 stated the flowsheet indicated Resident 76 was receiving oxygen therapy. MDSN 1 stated Resident 76's MDS dated [DATE] was not accurate. MDSN 1 stated it was important for Resident 76's MDS to accurately reflect her use of oxygen therapy because there were special precautions required when a resident was on oxygen therapy.2. During a review of Resident 72's admission Record (Face Sheet), the Face Sheet indicated Resident 72 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (a mental illness that is characterized by disturbances in thought) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 72's MDS, dated [DATE], the MDS indicated Resident 72's cognition was intact. The MDS indicated Resident 72 required setup or clean-up assistance with oral hygiene, toileting, bathing, dressing, and personal hygiene. During a review of Resident 72's History and Physical (H&P), dated 3/10/2025, the H&P indicated Resident 72 had the capacity to understand and make decisions. During an interview on 6/4/2025 at 9:49 a.m., with MDSN 1, MDSN 1 stated the purpose of the MDS was to assess each resident to create an individualized plan of care to manage the resident's diagnoses or problems. MDSN 1 stated the MDS had to be accurate to ensure the resident received the best care possible. MDSN 1 stated a resident's medical diagnoses were included into the MDS upon admission to the facility based on their hospital paperwork and interview with the resident. During a concurrent interview and record review on 6/4/2025 at 9:53 a.m., with MDSN 2, Resident 72's MDS, dated [DATE], was reviewed. MDSN 2 stated Resident 72's MDS indicated he had Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities) as a diagnosis. MDSN 2 stated Resident 72's MDS was inaccurate because Resident 72 was not medically diagnosed with Alzheimer's Disease and did not have any issues with his mental abilities. MDSN 2 stated due to Resident 72's inaccurate MDS, Resident 72 was at risk for unnecessary treatment and prescribed medications to treat Alzheimer's Disease. 3. During a review of Resident 83's admission Record, the admission Record indicated was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included malignant neoplasm (cancer) of liver (organ in the body), schizophrenia. During a review of Resident 83's MDS, dated [DATE], the MDS indicated Resident 83's cognition was severely impaired. The MDS indicated Resident 83 was totally dependent (helper does all the effort) on staff for ADLs. The MDS indicated Resident 83 was assessed as not having any oral and/or dental issues. During a concurrent observation and interview on 6/3/2025 at 10:43 a.m., in Resident 83's room, was observed Resident 83 did not have any natural teeth. Resident 83 stated, I do not have any real teeth left, and I do not have dentures either. I just eat soft food. During a concurrent interview and record review on 6/5/2025 at 7:40 a.m., with MDSN 1, Resident 83's MDS, dated [DATE], was reviewed. MDSN 1 stated she was aware that the resident did not have any natural teeth. MDSN 1 stated Resident 83's MDS oral/dental assessment was coded incorrectly and did not reflect the resident's actual oral and/or dental status. MDSN 1 stated because Resident 83 did not have natural teeth, the MDS should have been coded correctly. MDSN 1 stated inaccuracy of the MDS assessment had the potential to result in not meeting the resident's care needs and services. During a review of the facility's policy and procedure (P&P) titled Resident Assessment Instrument (RAI) Process, revised 5/2025, the P&P indicated each MDS section was to be completed and all information within the MDS assessment was to reflect the resident's status at the time of the Assessment Reference Date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a care plan for five of 25 sampled residents (Resident 94, 101, 121, 83 and 77) by failing to: 1. Develop a care plan to address Resident 94's use of valproic acid (an anticonvulsant medication, a medication used to prevent or treat seizures and can be used to treat behavioral disorders). 2. Develop a care plan for Resident 101's wearable external heart defibrillator (a device that provides an electric shock to the heart to allow it to treat a potentially fatal abnormal heart rhythm). 3. Develop a care plan for the refusal for Restorative Nurse Aid services (nursing interventions that promote a person's ability to adapt and adjust to living as independently and safely as possible) for Resident 121, a resident diagnosed with an extremely painful bone disorder that severely affected his mobility. 4. Develop a care plan for Resident 83's missing natural teeth. 5. Develop a care plan to address Resident 77's use of chlorpromazine (an antipsychotic medication [a medication that affects the mind, emotions, and behavior]). These deficient practices had the potential to negatively affect Residents 94, 101, 121, 83, and 77's physical, mental, and psychosocial well-being and had the potential to delay the delivery of necessary care and services. Findings: 1. During a review of Resident 94's admission Record (Face Sheet), the Face Sheet indicated Resident 94 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event), and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 94's Minimum Data Set ([MDS], a resident assessment tool), dated 4/4/2025, the MDS indicated Resident 94's cognition (process of thinking) was moderately impaired. The MDS indicated Resident 94 required supervision with toileting, dressing, and personal hygiene. During a review of Resident 94's History and Physical (H&P), dated 1/6/2025, the H&P indicated Resident 94 had the capacity to understand and make decisions. During a review of Resident 94's Order Summary Report, dated 6/4/2025, the Order Summary Report indicated to give valproic acid 5 milliliters (ml, unit of measurement) by mouth, once time a day for schizoaffective disorder as manifested by verbal angry outburst. During an interview on 6/4/2025 at 9:58 a.m., with Minimum Data Set Nurse (MDSN) 1, MDSN 1 stated care plans were developed to dictate the individualized plan of care for each resident. MDSN 1 stated care plans should be developed for residents who received medications to treat behaviors. MDSN 1 stated the manifested behavior, and the medication had to be care planned. During a concurrent interview and record review on 6/4/2025 at 10 a.m. with MDSN 1, Resident 94's Care Plan titled, Risk for aggression, dated 3/24/2022, was reviewed. MDSN 1 stated the Care Plan indicated Resident 94 had schizoaffective disorder manifested by verbal angry outbursts. MDSN 1 stated the Care Plan did not address Resident 94's use of valproic acid to treat his behaviors. MDSN 1 stated the purpose of addressing Resident 94's use of valproic acid was to provide guidance on how to properly monitor, assess, and treat for any potential side effects of the medication. MDSN 1 stated without a care plan, the staff may not know how to properly care for Resident 94. During an interview on 6/4/2025 at 2:20 p.m., with the Director of Nursing (DON), the DON stated care plans were used as a communication tool between the staff to dictate the care each resident received in the facility. The DON stated Resident 94 should have had a care plan that addressed his use of valproic acid due to the potential side effects that could occur. The DON stated the care plan would indicate the staff's interventions to monitor for potential side effects and for the efficacy of the medication to treat Resident 94's behaviors. The DON stated these interventions would then allow the psychiatrist to determine if any changes to the medication was required. The DON stated without a care plan for Resident 94's use of valproic acid, the staff may not be informed of the necessary care Resident 94 had to receive. 2. During a review of Resident 101's admission Record, the admission Record indicated Resident 101 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included coronary angioplasty (procedure to open narrowed or blocked coronary arteries, which supply blood to the heart), tachycardia (fast heart rate), congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and anxiety (an overwhelming feeling of uneasiness). During a review of Resident 101's MDS, dated [DATE], the MDS indicated Resident 101's cognitive skills for daily decision making were intact. The MDS indicated Resident 101 required partial moderate assistance (helper does less than half of the effort) for bathing, toileting, lower body dressing, putting on footwear, and bed mobility. The MDS indicated Resident 101 had an active diagnosis of a stroke (when blood supply to part of the brain is interrupted). During a review of Resident 101's Order Summary Report, dated 6/3/2025, there were no orders for Resident 101 to physically wear an external defibrillator (a device that provides an electric shock to the heart to allow it to treat a potentially fatal abnormal heart rhythm) vest, no specified parameters that outlined how long the vest should be worn, and there were no orders to monitor, check the functionality of, and assess the cardiac device. During observations made on 6/2/2025 at 10:00 a.m.,11:56 a.m., and 6/3/2025 at 1:42 p.m., in Resident 101's room, Resident 101 was observed wearing a gray external defibrillator vest. During a concurrent interview and record review on 6/4/2025 11:49 a.m. with Registered Nurse (RN) 1, Resident 101's care plan titled, Cardiac Distress, dated 5/2/2025, and all of Resident 101's active care plans, dated 5/2025, were reviewed. The care plan did not indicate interventions specific to the care and monitoring of Resident 101's wearable defibrillator. There were no other care plans that outlined specific interventions for the care of Resident 101's defibrillator. RN 1 stated it was very important to know the functionality, brand of the device, and how often a cardiologist (a physician that specializes in treating conditions of the heart) appointment should be scheduled for the maintenance of Resident 101's defibrillator to ensure proper care was rendered. RN 1 stated the lack of a care plan for Resident 101's defibrillator placed Resident 101 at risk for an adverse cardiac-related emergency. During an interview on 6/4/2025 at 12:10 p.m. with the DON, the DON stated care plans were important to ensure a proper plan of care was in place for a resident. The DON stated proper nursing interventions for the care of Residents 101's defibrillator were to know how to operate the defibrillator and to ensure that the defibrillator operated correctly. The DON stated a care plan specific to the care of Resident 101's defibrillator was necessary to ensure proper nursing interventions were communicated and implemented. 3. During a review of Resident 121's admission Record, the admission Record indicated Resident 121 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included disorder of bone, diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet), and muscle weakness. During a review of Resident 121's MDS, dated [DATE], the MDS indicated Resident 121's cognitive skills were intact. The MDS indicated Resident 121 was entirely dependent on staff for toileting, bathing, upper and lower body dressing, and performing personal hygiene. During a review of Resident 121's Order Summary Report, dated 6/4/2025, the Order Summary Report indicated Resident 121 was ordered for the restorative nurse aid (RNA) to perform ambulation (walking) every day three times a week using the front wheeled walker to maintain current levels of mobility. During a review of Resident 121's RNA Progress Note, dated 5/30/2025, the Progress Note indicated Resident 121 refused all (three) RNA sessions that week. During a concurrent observation and interview on 6/2/2025 at 10:10 a.m., in Resident 121's room, Resident 121 was in his bed, positioned on his right side. Resident 121 stated he had bone issues that caused him pain all over his body, predominantly in his hip and arms. Resident 121 stated this affected his overall mobility and limited his ability to participate in physical activities. During a concurrent interview and record review on 6/4/2025 at 11:20 a.m. with RN 2, Resident 121's care plans, dated 5/2025 to 6/2025, were reviewed. There were no care plans for Resident 121's refusals for RNA therapy. RN 2 stated it was important for a refusal care plan to be developed and implemented for Resident 121 to ensure proper interventions were in place to prevent physical decline and to ensure reasons for Resident 121's refusals, like pain, were addressed. RN 2 stated nursing interventions for RNA refusals typically included notifying the physician, identifying the reason why the resident refused the RNA session, and implementing care plan interventions to prevent any functional decline. During an interview on 6/4/2025 at 12:10 p.m. with the Director of Nursing (DON), the DON stated care plans were important to ensure a proper plan of care was in place for a resident. The DON stated Resident 121 should have had an At High Risk for Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) Decline Secondary to RNA Therapy Refusals care plan after Resident 121 had persistent episodes of refusals. The DON stated the lack of a care plan that addressed the risk of ADL decline secondary to RNA therapy refusals placed Resident 121 at risk for ADL decline due to a lack of communicated interventions amongst the departments involved in his care. 4. During a review of Resident 83's admission Record, the admission Record indicated was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included malignant neoplasm (cancer) of the liver (organ in the body), schizophrenia (a mental illness that is characterized by disturbances in thought), and muscle weakness (loss of muscle strength). During a review of Resident 83's MDS, dated [DATE], the MDs indicated Resident 83's cognition was severely impaired. The MDS indicated Resident 83 was totally dependent (helper does all the effort) on staff for ADLs. The MDs indicated Resident 83 was assessed as not having any oral and/or dental issues. During a concurrent observation and interview on 6/3/2025 at 10:43 a.m., in Resident 83's room, observed Resident 83 without any natural teeth. Resident 83 stated, I do not have any real teeth left, and I do not have dentures either. I just eat soft food. During a concurrent interview and record review on 6/3/2025 at 3:20 p.m., with MDSN 1, Resident 83's care plans, dated 2024 through 2025, were reviewed. MDSN 1 stated she was aware that the resident did not have any natural teeth. MDSN 1 stated there was no care plan addressing the resident's edentulous (absence of the natural teeth) status. MDSN 1 stated a care plan should have been initiated upon resident's admission to the facility to address oral care needs. MDSN 1 stated care planning serves as a communication tool among facility staff to ensure consistent and effective care. MDSN 1 stated without a care plan in place, staff would not be able to provide care that meets the resident's individualized needs. During an interview on 6/5/2025 at 9:15 a.m., with the DON, the DON stated developing a care plan based on a resident's oral/dental status it was essential to ensure the resident received the appropriate care. The DON stated that without a comprehensive care plan to guide staff in managing the resident's oral care, the resident would be at increased risk for discomfort and decreased quality of life. The DON stated it was important to develop a care plan with individualized interventions to help support or maintain each resident's overall health. 5. During a review of Resident 77's admission Record, the admission Record indicated Resident 77 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included schizophrenia, encephalopathy (disease that affects the brain), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 77's MDS, dated [DATE], the MDS indicated Resident 77 cognition was moderately impaired. The MDS indicated Resident 7 required moderate assistance from staff for ADLs. The MDS indicated Resident 77 received antipsychotic (a medication that affects the mind, emotions, and behavior) medication. During a review of Resident 77's Order Summary Report, dated 6/4/2025, the Order Summary Report indicated on 3/26/2025, Resident 77's attending physician prescribed Chlorpromazine 25 milligrams ([mg]- metric unit of measurement, used for medication dosage and/or amount) via gastrostomy ([G-tube]- a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) one tablet every six hours as needed for HICCUPS (involuntary spasms of the diaphragm [muscle that separates the chest from the abdomen]). During a concurrent interview and record review on 6/3/2025 at 3:21 p.m., with RN 1, Resident 77's care plans, dated 3/2025 through 6/2025, were reviewed. RN 1 stated there was no care plan addressing the resident's use of Chlorpromazine. RN 1 stated it was important to include Chlorpromazine medication in Resident 77's care plan to ensure appropriate monitoring for potential side effects such sedation (sleepiness), extrapyramidal symptoms (tremors), and guide overall resident care. RN 1 stated without a person-centered care plan addressing this medication the facility would not be able to monitor Resident 77's response to treatment, prevent avoidable complications, and provide quality care. During a review of the facility's policy and procedure (P&P) titled, Care Planning, revised 12/10/2009, the P&P indicated, It is the policy of this facility that the interdisciplinary team (IDT, a group of different disciplines working together towards a common goal for a resident) shall develop a comprehensive care plan for each resident. During a review of the facility's P&P, titled, Care and Services, dated 5/1/2018, the P&P indicated the facility staff were to ensure residents were provided with the necessary care and services to maintain the highest level of practicable functioning in an environment that enhances quality of life in the scope of a long term care facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise one of five sampled resident's (Resident 5) care plan and interventions after Resident 5 had an unwitnessed fall on 11/24/2025. This deficient practice had the potential to result in Resident 5 sustaining a major injury after another fall. Findings: During a review of Resident 5's admission Record (Face Sheet), the Face Sheet indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included parkinsonism (brain conditions that cause slowed movements, stiffness, and tremors), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 5's Minimum Data Set ([MDS], a resident assessment tool), dated 5/25/2025, the MDS indicated Resident 5's cognitive skills (ability to think and reason) for daily decision making was moderately impaired. The MDS indicated Resident 5 had impairment on one side of her upper extremities (limbs of the upper body such as shoulder, elbow, wrist, and hand). The MDS indicated Resident 5 was dependent on staff's assistance with toileting, bathing, and personal hygiene. During a review of Resident 5's History and Physical (H&P), dated 11/26/2024, the H&P indicated Resident 5 had the capacity to understand and make decisions. During a review of Resident 5's Fall Risk Evaluation, dated 11/24/2024, the Fall Risk Evaluation indicated Resident 5 was a high risk for falls. During a review of Resident 5's Situation, Background, Assessment, Recommendation (SBAR, communication tool used by healthcare workers when there is a change of condition among the residents) form, dated 11/24/2024, the SBAR indicated Resident 5 was found on her left side, lying on the floor on the left side of the bed. The SBAR indicated Resident 5 stated she was trying to go to the other side. During an interview on 6/4/2025 at 10:03 a.m., with Minimum Data Set Nurse (MDSN) 1, MDSN 1 stated after a fall, a short-term care plan was developed to address the current situation and acute interventions for 72 hours, however, the long-term care plan had to be revised to address the ongoing interventions to help prevent further falls and/or injuries from a fall. During a concurrent interview and record review on 6/4/2025 at 10:03 a.m., with MDSN 1, Resident 5's Care Plan titled, High Risk for Falls, dated 9/10/2024, was reviewed. MDSN 1 stated Resident 5's care plan was not revised after her fall on 11/24/2025. MDSN 1 stated an Interdisciplinary Team ([IDT], a coordinated group of experts from several different fields) meeting was conducted after Resident 5's fall where the IDT consulted other departments to determine additional interventions to address Resident 5's fall and risk for falls. MDSN 1 stated new interventions were put into place to help prevent Resident 5 from falling again and those interventions should have been added to Resident 5's care plan. During an interview on 6/4/2025 at 10:17 a.m., with the Quality Assurance (QA) Nurse, the QA Nurse stated the IDT would meet after a resident fall incident to determine the root cause and develop additional interventions to prevent further falls. The QA Nurse stated additional interventions had to be included into the resident's care plan to communicate to the rest of the staff. During a concurrent interview and record review on 6/4/2025 at 11:20 a.m., with the QA Nurse, Resident 5's Post Fall Assessment and Investigation, dated 11/24/2025, was reviewed. The QA Nurse stated the social services, rehab, nursing, and activities department made up the IDT who conducted Resident 5's Post Fall Assessment and Investigation. The QA Nurse stated the IDT recommended bed rails (short rails on one or both sides of the bed) for safe bed mobility. The QA Nurse stated Resident 5's use of bed rails should have been included into a revised care plan. During an interview on 6/4/2025 at 2:26 p.m., with the Director of Nursing (DON), the DON stated once the IDT recommended new interventions after Resident 5's fall, Resident 5's care plan should have been revised. The DON stated revising the care plan was important to communicate to the staff of the interventions to properly care for Resident 5. The DON stated revising the care plan was essential to reevaluate whether Resident 5's goals were met in relation to the interventions set forth in the care plan. During a review of the facility's policy and procedure (P&P) titled, Fall Prevention and Management, revised 2018, the P&P indicated, The IDT will initiate, review, and update resident fall risks and Plan of Care at the following intervals: Admission, Quarterly, Annually, upon Significant Change of Condition Identification, and post fall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of seven sampled residents (Resident 76) had floor mats (cushioned floor pads designed to help prevent injury should a person fall) placed appropriately to prevent injury related to potential falls. This deficient practice placed Resident 76 at risk of experiencing injuries related to falls, such as bruises and/or broken bones. Findings: During a review of Resident 76's admission Record, the admission Record indicated Resident 76 was originally admitted on [DATE] and was most recently readmitted on [DATE]. Resident 76's admitting diagnoses included epilepsy (a brain condition that causes recurring seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) and dementia (a progressive state of decline in mental abilities). During a review of Resident 76's Minimum Data Saet (MDS, a resident assessment tool), dated 5/13/2025, the MDS indicated Resident 76 had severely impaired cognition (a significant decline in a person's ability to think, learn, and remember, resulting in a substantial impact on their daily life and independence). The MDS indicated Resident 76 had impairments to her upper extremities (shoulders, elbows, wrists, and hands) and lower extremities (hips, knees, ankles, feet) on both sides of her body. The MDS indicated Resident 76 was dependent on staff for all activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) and movement while in bed. During a review of Resident 76's physician order, dated 6/3/2025, the order indicated Resident 76 was to have floor mats at bedside to prevent injury related to a behavior of rolling out of bed and/or placing herself on the floor. The order also indicated staff were to check placement of the floor mats every shift. During a review of Resident 76's care plan titled [Resident 76] has need for floor mats at bedside to prevent injury related to behavior of sliding and rolling out of bed and/or placing self on the floor, poor safety awareness, and high risk for fall, dated 6/3/2025, the care plan indicated goals of care were for Resident 76 to have no significant injuries. The care plan interventions included checking placement of the floor mats every shift. During an observation on 6/3/2025 at 10:45 a.m., at Resident 76's bedside, Resident 76 was observed lying in bed. One fall mat was observed to the left side of her bed, and the other was underneath the bed, and not at the bedside. During an observation on 6/4/2025 at 8:39 a.m., at Resident 76's bedside, Resident 76 was observed lying in bed. One fall mat was observed to the left side of her bed, and the other was underneath the bed, and not at the bedside. During a concurrent interview and record review, on 6/4/2025 at 8:41 a.m., with Registered Nurse (RN) 1, Resident 76's physician order dated 6/4/2025 was reviewed. The order indicated Resident 76 required floor mats at the bedside to prevent injury related to the behavior of rolling out of bed and/or placing herself on the floor. RN 1 stated the order indicated staff were to check placement of the floor mats every shift. RN 1 stated staff were to start this at 7:00 a.m. on 6/3/2025. RN 1 stated the purpose of the floor mats was to prevent injury. RN 1 stated if the floor mats were not in place, Resident 76 could sustain fall-related injuries. During a concurrent interview and record review, on 6/4/2025 at 8:45 a.m., with RN 1, the photo taken on 6/3/2025 at 10:45 a.m. was reviewed. RN 1 stated Resident 76 had one functional floor mat, and stated the other was under the bed. RN 1 stated this was not effective because if Resident 76 were to fall, she would fall directly onto the floor which could cause injury. During a concurrent observation and interview, on 6/4/2025 at 8:46 a.m., with RN 1, at Resident 76's bedside, Resident 76's floor mats were observed. RN 1 stated the floor mat was still under the bed and was not placed effectively. During a review of the facility's policy and procedure (P&P) titled Fall Prevention and Management, revised 2018, the P&P indicated it was the facility's policy to provide a safe environment that minimizes complications associated with falls. The P&P indicated staff were to develop a plan of care according to the identified risk factors and root causes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to change the nasal cannula (device used to deliver supplemental [extra] oxygen placed directly on a resident's nostrils) and humidifier (water used to increase the moisture while providing oxygen therapy) weekly and store an oxygen mask (mask placed over the nose and mouth and connected to a supply of oxygen) inside a plastic bag in accordance to the facility's policy and procedure for one of three sampled residents (Resident 29). This deficient practice had the potential to result in an increased the risk for Resident 29 to acquire a respiratory infection. Findings: During a review of Resident 29's admission Record (Face Sheet), the Face Sheet indicated Resident 29 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), generalized muscle weakness (lack of strength in many muscles throughout the body), and neuromuscular dysfunction of the bladder (lacking bladder control leading to difficulty empty the bladder). During a review of Resident 29's Minimum Data Set (MDS, a resident assessment tool), dated 5/8/2025, the MDS indicated Resident 29 had moderately impaired cognition (ability to think, remember and use judgement), and was dependent on staff's assistance with toileting, bathing, and lower body dressing. During an observation on 6/2/2025 at 9:36 a.m., in Resident 29's room, Resident 29 had a nasal cannula at two liters. The humidifier bottle and tubing were dated 5/24/2025 (one week and two days prior) and the oxygen mask hung from Resident 29's bed, almost touching the floor. During a concurrent observation on 6/3/2025 at 8:58 a.m., in Resident 29's room, Resident 29 was observed lying in bed with the nasal cannula, at two liters. The humidifier bottle and tubing were dated 5/24/2025 and the oxygen mask hung from Resident 29's nightstand. During a concurrent interview, Resident 29 stated his nasal cannula and humidifier were changed when the humidifier bottle was empty. During a review of the Physician's Order Summary Report, dated 6/4/2025, the Order Summary Report indicated Resident 29 was to receive two liters (L, unit of measurement) of oxygen via nasal cannula for oxygen saturation (the percentage of oxygen in a person's blood, normal oxygen saturation level between 95 and 100 percent [%]) of 92 percent (%) or below. May increase to 4L to keep saturation levels at 92% or higher, as needed for shortness of breath. The Physician's Order Summary Report indicated to give albuterol sulfate (medication used to relax and open air passages to the lungs to make breathing easier), 3 (mL, milliliters), inhaled orally via nebulizer (drug delivery device to administer medication in the form of a mist inhaled into the lungs), every six hours as needed for shortness of breath and/or wheezing. During an interview on 6/4/2025 at 10:49 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated nasal cannulas and humidifiers were to be changed weekly or if they become dirty. LVN 2 stated she changed Resident 29's nasal cannula and humidifier because they were being used longer than a week. LVN 2 stated Resident 29 received nebulizer treatments and when the oxygen mask was not in use, the oxygen mask should be stored inside a plastic bag. During an interview on 6/4/2025 at 11:51 a.m., the Infection Preventionist Nurse (IPN) stated all oxygen tubing and humidifiers had to be changed weekly or when visibly dirty. The IPN stated changing the oxygen tubing and humidifier weekly would prevent the resident from breathing in old secretions or dirt accumulated into the oxygen tubing. The IPN stated the oxygen tubing had the potential to grow bacteria that could enter the resident via their nose. The IPN stated keeping the oxygen tubing and humidifier in use longer than a week placed the resident at risk for respiratory infection. The IPN stated all unused oxygen tubing and masks had to be stored inside a plastic bag to protect the device from collecting dust and prevent it from touching the floor. The IPN stated if oxygen devices were kept exposed when unused, dirt and bacteria could enter the oxygen device, thus entering the resident once it was back in use. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, revised 5/1/2018, the P&P indicated, All oxygen tubing, humidifiers, masks, and cannulas used to deliver oxygen are for single resident use only and will be changed weekly and when soiled. Oxygen items will be stored in a plastic bag at the resident's bedside to protect the equipment from dust and dirt when not in use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Registered Nurse (RN) 1, RN 2, and Licensed Vocational Nurse (LVN) 4 practiced the necessary competencies when providing care and services when the following occurred: 1. RN 1 did not correctly interpret or carry out Resident 115's physician order to change the resident's urinary catheter (thin tube inserted into the bladder) drainage bag (a medical device used to collect urine that is drained from the bladder). 2. RN 2 and LVN 4 did not know the facility policy and procedure (P&P) for replacing a resident's humidifier bottle (a device that adds moisture to the oxygen being delivered). These deficient practices placed the residents at risk for infection and illness. Findings: 1. During a review of Resident 115's admission Record, the admission Record indicated Resident 115 was originally admitted on [DATE] and most recently readmitted on [DATE]. Resident 115's admitting diagnoses included urinary retention (the inability to fully or partially empty the bladder, leaving urine trapped inside), acute kidney failure (a sudden and significant loss of kidney function), and benign prostatic hyperplasia (BPH, a condition in which the prostate gland grows larger than normal) with lower urinary tract (bladder and urethra in both males and females, and the prostate in males) symptoms. During a review of Resident 115's Minimum Data Set (MDS, a resident assessment tool), dated 4/19/2025, the MDS indicated Resident 115 had moderate cognitive impairments (a stage of cognitive decline where individuals experience more noticeable problems with thinking, learning, and memory compared to normal aging). The MDS indicated Resident 115 was dependent on staff for toileting hygiene (a set of practices that are necessary to prevent the spread of disease and preserve health related to urination and defecation). During a review of Resident 115's physician order, dated 1/11/2025, the order indicated staff were to change Resident 115's urinary catheter drainage bag every two (2) weeks and as needed every day shift every 14 day(s). During a review of Resident 115's care plan titled Risk for infection related to indwelling catheter, dated 1/12/2025, the care plan indicated the goal of care was that Resident 115 would not have signs or symptoms of a urinary tract infection. The care plan indicated staff were to change Resident 115's catheter drainage bag as ordered. During a concurrent interview and record review, on 6/3/2025 at 3:30 p.m., with RN 1, Resident 115's physician order dated 1/11/2025 was reviewed. RN 1 stated the physician order indicated staff were to change Resident 115's urinary catheter drainage bag every two weeks if needed. RN 1 stated the order did not indicate staff were to change the urinary catheter drainage bag every two weeks and as needed. During an interview on 6/4/2025 at 10:59 a.m., with RN 1, RN 1 stated she spoke with the Director of Nursing (DON) and clarified Resident 115's physician order, dated 1/11/2025. RN 1 stated she now understood staff were to change Resident 115's urinary catheter drainage bag every two weeks and as needed. RN 1 stated she was not previously following the order to change the urinary catheter drainage bag every two weeks. RN 1 stated the purpose of changing the drainage bag at least every two weeks was to prevent infection. During a concurrent interview and record review, on 6/4/2025 at 1:41 p.m., with the Director of Nursing (DON), Resident 115's physician order, dated 1/11/2025, was reviewed. The DON stated the order indicated the drainage bag was to be changed every two weeks and as needed. The DON stated the order was written clearly and licensed nursing staff, including RNs and licensed vocational nurses (LVNs) should have the competency to interpret and carry out the order. The DON stated it was a competency issue if licensed nursing staff could not interpret the order as it was written. During an interview on 6/5/2025 at 1:38 p.m., with the Infection Preventionist Nurse (IPN), the IPN stated unchanged drainage bags could harbor bacteria and lead to infection. The IPN stated this was why it was important to ensure the urinary catheter drainage bags were changed the frequency ordered. During a review of the facility's job description for Registered Nurse Supervisor, undated, the job description indicated RNs were to be able to demonstrate knowledge of and ability to apply basic principles of nursing care. During a review of the facility's P&P titled Catheter - Care Of, revised 5/2018, the P&P indicated staff were to ensure residents with a catheter received appropriate care and services to prevent infections to the extent possible. 2. During a review of Resident 76's admission Record, the admission Record indicated Resident 76 was originally admitted on [DATE] and was most recently readmitted on [DATE]. Resident 76's admitting diagnoses included dementia (a progressive state of decline in mental abilities). During a review of Resident 76's MDS, dated , the MDS indicated Resident 76 had severely impaired cognition (a significant decline in a person's ability to think, remember, learn, and use judgment). The MDS indicated Resident 76 was dependent on staff for activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 76's physician order, dated , the physician order indicated Resident 76 was to receive oxygen therapy (a medical treatment that involves administering supplemental oxygen to individuals who have difficulty getting enough oxygen through normal breathing). During an observation on 6/3/2025 at 11:05 a.m., at Resident 76's bedside, Resident 76 was observed lying in bed receiving oxygen therapy via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen). Resident 76's nasal cannula was connected to a humidifier bottle dated 5/2/2025. During an observation on 6/4/2025 at 8:48 a.m., at Resident 76's bedside, Resident 76 was observed lying in bed receiving oxygen therapy via nasal cannula. Resident 76's nasal cannula was connected to the same humidifier bottle. The date read 6/2/2025, and the previous month of 5 (May), had been written over. During an interview on 6/4/2025 at 8:50 a.m., with Registered Nurse (RN) 1, RN 1 stated humidifier bottles were to be changed every week. During a concurrent interview and record review, on 6/4/2025 at 8:53 a.m., with RN 1, a photo of Resident 76's humidifier bottle, taken on 6/3/2025 at 11:05 a.m., was reviewed. RN 1 stated the humidifier bottle was dated 5/2/2025. RN 1 stated the humidifier bottle should have been changed multiple times since 5/2/2025. RN 1 stated the purpose of replacing the humidifier bottle weekly was to prevent infection. During a concurrent interview and record review, on 6/4/2025 at 9:14 a.m., with LVN 4, a photo taken of Resident 76's humidifier bottle taken on 6/3/2025 at 11:05 a.m. was reviewed. LVN 4 stated the initials on the humidifier bottle were hers, and stated the date on the humidifier bottle was 5/2/2025. When asked how frequently the humidifier bottle was to be changed, LVN 4 stated she was not sure. During a concurrent interview and record review, on 6/4/2025 at 9:16 a.m., with LVN 4, a photo taken of Resident 76's humidifier bottle taken on 6/4/2025 at 8:49 a.m., was reviewed. LVN 4 stated the initials on the humidifier bottle were hers and stated the date on the humidifier now read 6/2/2025. LVN 4 stated she wrote over the previous month of 5 (May) and made it a 6 (June). During an interview on 6/4/2025 at 9:44 a.m., with LVN 4, LVN 4 stated the facility policy was to change humidifier bottles as needed. LVN 4 stated this meant the bottles would be changed once nearly empty or empty. LVN 4 stated she received this guidance from RN 2. During an interview on 6/4/2025 at 12:56 p.m., with the IPN, the IPN stated that weekly replacement of humidifier bottles was for infection control. The IPN stated that failure to change the humidifier bottle in accordance with the facility policy created the potential for respiratory infections. During an interview on 6/5/2025 at 10:16 a.m., with the DON, the DON stated staff were trained on facility policies and procedures. During a concurrent interview and record review, on 6/5/2025 at 10:17 a.m., with the DON, RN 2's and LVN 4's signed job descriptions dated 3/30/2023 and 12/2/2024, were reviewed. The DON stated RN 2's job description indicated she should be able to remember and recall facility policies and procedures. The DON stated LVN 4's job description indicated she should be able to remember, recall, and implement facility policies and procedures. During a concurrent interview and record review, on 6/5/2025 at 10:19 a.m., with the DON, the facility's P&P titled Oxygen Administration, revised 2018, was reviewed. The DON stated the P&P indicated humidifier bottles were to be to be changed weekly and as needed. The DON stated the purpose of this practice was for infection control. The DON stated failure to implement this policy created the potential for respiratory infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services and routine medications for two of six sampled residents (Resident 23 and Resident 60). Resident 23 and Resident 60 did not receive medications per Physician's Order, nor did the pharmacy have the medication available for Resident 23. These deficient practices had the potential to cause adverse outcomes to the residents such as low blood pressure and cerebral hypoperfusion (inadequate blood flow to the brain) for Resident 23, and gastric upset for Resident 60. Findings: a. During a review of Resident 23's admission Record, the admission Record indicated Resident 23 was re-admitted to the facility on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (an interruption in blood flow to the brain), dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), schizophrenia (a mental illness that is characterized by disturbances in thought), and gastrostomy (g-tube-a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 23's Minimum Data Set (MDS, a resident assessment tool), dated 5/8/2025, the MDS indicated Resident 23's cognitive skills (ability to think and reason) for daily decision making was severely impaired. The MDS indicated Resident 23 was entirely dependent on staff for activities of daily living. During a review of the Physician's Order Summary Report, dated 6/3/2025, the Order Summary Report indicated Resident 23 was originally ordered isosorbide mononitrate (a medication used to prevent chest pain [angina] caused by coronary artery disease) oral tablet 30 milligrams (mg, unit of measurement) via g-tube one time a day for hypertensive (high blood pressure) heart disease on 5/20/2025. During a concurrent observation, interview, and record review on 6/3/2025 at 8:43 a.m. with LVN 1, Resident 23's isosorbide bubble pack was observed, Resident 23's isosorbide bubble pack medication label was reviewed and Resident 23's Physician Orders, dated 5/20/2025, were reviewed. The bubble pack had 11 tablets remaining out of the 31 doses dispensed. The bubble pack label indicated the contents of the bubble pack contained doses of isosorbide mononitrate oral tablet 30 mg extended release. The Physician's Orders indicated Resident 23 was ordered isosorbide mononitrate oral tablet 30 mg via g-tube one time a day on 5/20/2025. LVN 1 stated she did not notice the bubble pack contained doses of isosorbide mononitrate oral tablet 30 mg extended release and stated extended-release medication was not to be crushed and administered via g-tube unless prescribed by the physician. LVN 1 stated the order should have been clarified by the physician and the pharmacy should have been made aware. LVN 1 stated Resident 23's physician medication order of isosorbide mononitrate oral tablet 30 mg was not prepared or ordered as prescribed, which could have placed Resident 23 at risk for a sudden drop in blood pressure and, or decreased heart rate. During a concurrent interview and record review at 6/3/2025 at 8:45 a.m. with LVN 1, Resident 23's eMAR, dated 5/20/2025 to 6/3/2025, was reviewed. The eMAR indicated Resident 23 received 14 doses of isosorbide mononitrate oral tablet 30 mg via g-tube. LVN 1 stated the only supply of isosorbide mononitrate oral tablet 30 mg was the extended-release dose. LVN 1 stated she was Resident 23's assigned nurse the day before (6/2/2025) and stated she crushed and administered Resident 23's isosorbide mononitrate oral tablet 30 mg extended-release dose via g-tube. LVN 1 stated she did not notice the physician orders did not match the labeling on the bubble pack supply of isosorbide for the five times she had administered it since 5/20/2025. During a concurrent interview and record review on 6/4/2025 at 11:11 a.m. with LVN 2, Resident 23's eMAR, dated 5/20/2025 to 6/3/2025, was reviewed. The eMAR indicated LVN 2 administered six doses of the 14 doses of Resident 23's isosorbide mononitrate oral tablet 30 mg via g-tube. LVN 2 stated she crushed and administered the medication that was dispensed by the pharmacy (isosorbide mononitrate oral tablet 30 mg extended release) and did not notice the physician's orders did not match the labeling on the bubble pack supply for the six times she had administered it since 5/20/2025. LVN 2 stated by not comparing the bubble pack supply to the physician's order, and by crushing the extended-release dose of isosorbide, this placed Resident 23 at risk for death or hospitalization. During an interview on 6/3/2025 at 11:42 a.m. with Pharmacist 1, Pharmacist 1 stated the pharmacy had not delivered Resident 23's bubble pack supply of isosorbide mononitrate oral tablet 30 mg (immediate release) to the facility. Pharmacist 1 stated isosorbide mononitrate oral tablet 30 mg was only available in ER form and not in immediate release form. Pharmacist 1 stated the pharmacy delivered isosorbide mononitrate oral tablet 30 mg ER to the facility and the error was not noticed by the pharmacy technicians or the licensed nursing staff. During an interview on 6/4/2025 at 12:10 p.m. with the Director of Nursing (DON), the DON stated she expected the pharmacy to communicate with the licensed nursing staff to make them aware the isosorbide mononitrate oral tablet 30 mg (immediate release) was not available so that the licensed nursing staff could call the physician. The DON stated she expected the licensed nurse to compare the medication bubble pack with the physician's order prior to the administration of medications. The DON stated if any issues were identified, then the licensed staff would have to communicate with the physician and the pharmacy. The DON stated once an ER medication was crushed, the medication was immediately released into the blood stream and the effects of the medication would start right away. The DON stated an ER medication was intended to be released slowly (over 12-24 hours) into the blood stream throughout the day. The DON stated this placed Resident 23 at risk for a hypotensive (low blood pressure) or bradycardic (slow heart rate) event because medication was crushed and not administered per the physician's order. b. During a review of Resident 60's admission Record, the admission Record indicated Resident 60 was re-admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), gastrointestinal hemorrhage, and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 60's MDS, dated [DATE], the MDS indicated Resident 60's cognitive skills for daily decision making were moderately impaired. During a concurrent observation and interview on 6/3/2025 at 7:45 a.m. with LVN 3, LVN 3's medication pass was observed. LVN 3 dispensed one metformin oral tablet 1000 mg in a medication cup. LVN 3 entered Resident 60's room and attempted to administer Resident 60 the tablet without his breakfast tray or food. During a concurrent interview and record review on 6/3/2025 at 7:50 a.m. with LVN 3, Resident 60's eMAR, dated 6/3/2025, was reviewed. The eMAR indicated Resident 60 was to receive the dose of metformin with food or a meal. LVN 3 stated she should have waited until Resident 60's breakfast tray was delivered to administer the medication. LVN 3 stated the administration of the metformin would have placed Resident 60 at risk for gastric upset and it did not align with the physician's order. During a review of Resident 60's Order Summary Report, dated 6/4/2025, the Order Summary Report indicated Resident 60 was ordered metformin oral tablet 1000 mg one time a day by mouth and to give with food or meal. During an interview on 6/4/2025 at 12:10 p.m., the DON stated she would have expected the licensed nurses to compare the medication bubble pack with the physician's order prior to administering medications. The DON stated metformin was usually administered with food because some medications were sensitive to gastric acid. During a review of the facility's Policy and Procedure (P&P) titled, Medication Administration, dated 5/1/2018, the P&P indicated the licensed nurse was to administer medications per the order of the attending physician or licensed independent practitioner. The P&P indicated the licensed nurses were to keep in mind the seven rights of medication when administering medication: a. The right medication b. The right amount c. The right resident d. The right time e. The right route f. Right indication g Right outcome The P&P also indicated the licensed nurse were to perform three checks [which include]: comparing the physician's order, pharmacy label and the medication administration record. The P&P indicated if any discrepancies were identified during the first, second and third check, it must be resolved prior to the administration of any medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide one of one sampled resident (Resident 5) with weighted utensils (eating tools designed to be heavier, providing added weight to help stabilize shaking hands and reduce hand tremors) in accordance with the physician's order. This deficient practice had the potential for Resident 5 to become discouraged in self-feeding due to difficulty handling regularly weighted utensils. Findings: During a review of Resident 5's admission Record (Face Sheet), the Face Sheet indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included parkinsonism (brain conditions that cause slowed movements, stiffness, and tremors), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 5's Minimum Data Set ([MDS], a resident assessment tool), dated 5/25/2025, the MDS indicated Resident 5's cognitive skills (ability to think and reason) for daily decision making was moderately impaired. The MDS indicated Resident 5 had impairment on one side of her upper extremities (limbs of the upper body such as shoulder, elbow, wrist, and hand). The MDS indicated Resident 5 was dependent on staff's assistance with toileting, bathing, and personal hygiene. The MDS indicated Resident 5 was a mechanically altered diet (change in texture of food or liquid). During a review of Resident 5's History and Physical (H&P), dated 11/26/2024, the H&P indicated Resident 5 had the capacity to understand and make decisions. During a review of Resident 5's Order Summary Report, dated 6/4/2025, the Order Summary Report indicated the following: 1. Serve Resident 5 a fortified (food that has added nutrients to increase calories), mechanical soft (foods that are easily chewed and swallowed due to their soft texture), pureed (cooked food that has been ground, pressed, blended or sieved to the consistency of a creamy paste or liquid) meat texture, and double portion of protein. 2. Resident 5 to use adaptive feeding equipment (specialized devices and tools designed to make eating easier and more independent) such as a divided plate (dish designed with separated compartments with raised dividers to assist with mobility and coordination issues) and weighted utensils for every meal. During a review of Resident 5's Care Plan titled, Difficulty with Self-Feeding, dated 5/13/2025, the care plan's goal indicated to increase Resident 5's independence with self-feeding. The care plan indicated staff interventions were to provide adaptive feeding equipment such as a divided plate and weighted utensils for every meal. During an observation on 6/2/2025 at 12:37 p.m., in Resident 5's room, Resident 5 received her lunch tray. Observed a weighted fork, a regular spoon, and a regular knife. Resident 5 attempted to use the spoon to scoop Jello from the cup to her mouth. Resident 5's hand shook while Resident 5 brought the spoon to her mouth. During an observation on 6/3/2025 at 12:40 p.m., in Resident 5's room, Resident 5 received her lunch tray. Observed a weighted fork, a regular spoon, and a regular knife. During an interview on 6/3/2025 at 3:24 p.m., with Director of Rehab (DOR) 1, DOR 1 stated adaptive utensils were used to make eating easier for residents, whether it be with a thicker handle for easier grabbing or weighted handle to help stabilize their hand from tremors. DOR 1 stated Resident 5 had an order for weighted utensils due to her hand tremors. DOR 1 stated all utensils provided to Resident 5 during her meals should be weighted. DOR 1 stated the weight assisted in stabilizing her hand which would result in Resident 5 having an easier time self-feeding. DOR 1 stated Resident 5 had the tendency to hold the utensils with her elbow bent and arm parallel to the ground. DOR 1 stated without the weighted utensils; Resident 5 would drop the food before the food could enter her mouth. DOR 1 stated Resident 5 was very motivated to self-feed, however, without the ordered weighted utensils, Resident 5 could become frustrated and discouraged. DOR 1 stated this could lead to Resident 5 not wanting to feed herself and require assistance from another staff member. During an interview on 6/3/2025 at 3:33 p.m. with the Dietary Supervisor (DS), the DS stated when a resident had an order for adaptive feeding equipment, the kitchen was responsible for providing the equipment to the resident. The DS stated Resident 5 had an order for weighted utensils, therefore Resident 5 should receive weighted utensils instead of regular ones. The DS stated the kitchen was responsible for preparing the correct utensils for the residents to ensure they can reach their highest practicable level in eating. During a review of the facility's policy and procedure (P&P) titled, Restorative Dining Program, revised 5/1/2018, the P&P indicated the facility was to provide the opportunity for residents to attain their highest level of independence in feeding, improve appropriate mealtime behavior, self-image, and socialization skills. The P&P indicated indications to use adaptive equipment include when a Resident spills food or liquid from utensils or cup, Resident exhibits trouble holding onto utensils while eating, [and] Resident exhibits difficulty scooping, bringing utensil from plate to mouth or bringing cup to mouth. The P&P indicated, Special adaptive equipment may be recommended by the Occupational Therapist and will be provided by the Facility. The P&P indicated adaptive equipment may include built-up handled utensils, weighted utensils, and divided plates. The P&P indicated, The equipment will be the responsibility of the Dietary Department and will be distributed on the meal trays.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, infection control measures were not maintained for two of 25 sampled residents (Resident 13 and Resident 78) when Certified Nursing Assistant (CNA) 5 failed to implement enhanced barrier precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] that employs targeted gown and glove use during high-contact resident care activities that are associated with a high risk of MDRO colonization, such as presence of a gastrostomy tube) and failed to perform hand hygiene (hand washing with soap or using alcohol-based hand rubs) while providing direct patient care. These deficient practices placed the residents at risk for infection and illness. Findings: a. During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was originally admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Resident 13's admitting diagnoses included generalized muscle weakness and dementia (progressive state of decline in mental abilities). During a review of Resident 13's Minimum Data Set (MDS, a resident assessment tool), dated 3/28/2025, the MDS indicated Resident 13 had severely impaired cognition (a significant decline in a person's ability to think, learn, and remember, resulting in a substantial impact on their daily life and independence). The MDS indicated Resident 13 required partial to moderate assistance from staff for personal hygiene and was dependent on staff for bed mobility. b. During a review of Resident 78's admission Record, the admission Record indicated Resident 78 was originally admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Resident 78's admitting diagnoses included presence of a gastrostomy tube (a feeding tube that is inserted directly into the stomach through the skin and abdominal wall). During a review of Resident 78's MDS, dated [DATE], the MDS indicated Resident 78 had severely impaired cognition. The MDS indicated Resident 78 had impairments to his upper extremities (shoulders, elbows, wrists, and hands) and lower extremities (hips, knees, ankles, feet) on both sides of his body, and was dependent on staff for personal hygiene and dressing and required substantial to maximal assistance from staff for bed mobility. During a review of Resident 78's physician order, dated 5/14/2025, the physician order indicated staff were to place Resident 78 on enhanced barrier precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] that employs targeted gown and glove use during high-contact resident care activities that are associated with a high risk of MDRO colonization, such as presence of a gastrostomy tube). During a review of Resident 78's care plan titled [Resident 78] on Enhanced Barrier Precautions secondary to presence of .gastrostomy tube, dated 9/17/2024, the care plan indicated the goal of care was to prevent Resident 78 from acquiring any healthcare-associated infections. Care plan interventions indicated staff were to perform hand hygiene when entering and leaving the room, and in between each residents' care. Care plan interventions also indicated staff were to wear gown and gloves in the resident room when providing high contact resident care activities such as changing linens and providing hygiene. During an observation on 6/3/2025 at 10:03 a.m., in the doorway of Resident 13 and Resident 78's room, CNA 5 was observed at the bedside assisting Resident 78 with activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily), then was observed adjusting and tucking in his bedsheets. CNA 5 was not wearing a gown or gloves. CNA 5 was then observed going to Resident 13's bedside to provide ADL assistance. CNA 5 did not perform hand hygiene following Resident 78's care or before Resident 13's care. During an observation, on 6/3/2025 at 10:08 a.m., in the doorway of Resident 13 and Resident 78's room, CNA 5 exited the room without performing hand hygiene. CNA 5 walked down the hall and retrieved plastic bags from the housekeeping cart. CNA 5 then re-entered the room without performing hand hygiene and proceeded to continue providing care to Resident 13. During an interview on 6/3/2025 at 2:03 p.m., with CNA 5, CNA 5 stated hand hygiene was required whenever staff entered and exited a resident's room. CNA 5 stated staff were also required to perform hand hygiene between care of multiple residents. CNA 5 stated it was important for infection control. CNA 5 stated that if hand hygiene was not performed, infection could spread from one resident to another. During an interview on 6/3/2025 at 3:36 p.m., with the Infection Preventionist Nurse (IPN), the IPN stated performing hand hygiene was the best intervention for the prevention of the spread of infection. The IPN stated hand hygiene was to be performed between the care of two different residents to prevent transmission of infection between residents. The IPN stated if hand hygiene was not performed between residents, there was the potential for illness and disease outbreak (a sudden increase in occurrences of a disease when cases are in excess of normal expectancy). The IPN stated that when providing ADL care to someone with orders for EBP, staff should be wearing a gown and gloves. The IPN stated that after removing the gloves, hand hygiene should be performed. The IPN stated the purpose of EBP was to prevent healthcare-associated infections in the facility. During a review of the facility's policy and procedure (P&P) titled Standard and Enhanced Precautions, dated 4/2024, the P&P indicated staff were to implement EBP when performing high-contact resident care activities such as providing hygiene and changing linens. During a review of the facility's P&P titled Hand Hygiene, revised 2/2025, the P&P indicated the facility considered hand hygiene the primary means to prevent the spread of infections. The P&P indicated staff were to perform hand hygiene immediately upon entering and/or exiting a resident occupied area and before moving to another resident in the same room or exiting the room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure one of 25 sampled residents (Resident 6) had a functioning call light. This deficient practice resulted in Resident 6's inability to call for staff assistnace or express his needs, and placed him at risk for delayed care and/or accidents. Findings: During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was originally admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Resident 6's admitting diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) affecting his left side, generalized muscle weakness, and dysphagia (difficulty swallowing). During a review of Resident 6's Minimum Data Set (MDS, a resident assessment tool), dated 3/13/2025, the MDS indicated Resident 6 had severely impaired cognition (ability to think and reason). The MDS indicated Resident 6 was dependent on staff for personal hygiene, and required substantial to maximal assistance from staff for repositioning while in bed. During a review of Resident 6's care plan titled [Resident 6] has an activities of daily living (ADL, activities such as bathing, dressing and toileting a person performs daily) self-care performance deficit ., dated 1/15/2025, the care plan indicated staff were to ensure Resident 6's call light was within reach and explain to him the importance of utilizing the call light for assistance. During a concurrent observation and interview, on 6/3/2025 at 10:12 a.m., at Resident 6's bedside, Resident 6 was observed lying in bed. Resident 6 stated he wanted to have the head of his bed elevated for comfort. Resident 6 pressed his call light. The indicator light outside of the room did not turn on. During an observation on 6/3/2025 at 10:15 a.m., at Resident 6's bedside, Resident 6 pressed his call light a second time. The indicator light outside of the room did not turn on. During an observation on 6/3/2025 at 10:16 a.m., at Resident 6's bedside, Resident 6 pressed his call light a third time. The indicator light outside of the room did not turn on. During a concurrent observation and interview on 6/3/2025 at 10:17 a.m., with Certified Nursing Assistant (CNA) 6, CNA 6 stated Resident 6's call light was not functional. CNA 6 stated Resident 6's call light should be functional to allow him to call for help. During an interview on 6/4/2025 at 10:56 a.m., with Registered Nurse (RN) 1, RN 1 stated call lights should always be functional. RN 1 stated that if the call light was not functional, there was a potential for delays in care and attending to the needs of the resident. During a review of the facility's policy and procedure (P&P) titled Communication - Call System, revised 10/2022 , the P&P indicated it was the facility's policy to provide a mechanism for residents to promptly communicate with nursing staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain good grooming and personal hygiene for two of 25 sampled residents (Resident 29 and 68) by failing to: 1. Ensure Resident 29 was bathed. 2. Keep Resident 68's fingernails clean and trimmed. These deficient practices had the potential to negatively impact Resident 29 and 68's quality of life and self-esteem. These deficient practices also had the potential to result in the development of infection. Findings: 1. During a review of Resident 29's admission Record (Face Sheet), the Face Sheet indicated Resident 29 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), generalized muscle weakness (lack of strength in many muscles throughout the body), and neuromuscular dysfunction of the bladder (lacking bladder control leading to difficulty empty the bladder). During a review of Resident 29's Minimum Data Set ([MDS], a resident assessment tool), dated 5/8/2025, the MDS indicated Resident 29's cognition (process of thinking) was moderately impaired. The MDS indicated Resident 29 was dependent on staff's assistance with toileting, bathing, and lower body dressing. The MDS indicated Resident 29 had an indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine). During a review of Resident 29's History and Physical (H&P), dated 5/6/2025, the H&P indicated Resident 29 had the capacity to understand and make decisions. During a review of Resident 29's Care Plan titled, Activities of Daily Living (ADL) Self-Care Performance Deficit, dated 5/14/2025, the care plan indicated staff were to encourage Resident 29 to shower as scheduled and per Resident 29's preference. During an interview on 6/3/2025 at 8:58 a.m., with Resident 29, Resident 29 stated with the exception of two times, the certified nursing assistants (CNAs) did not bring him to the shower room nor give him a proper bed bath. Resident 29 stated the bed baths he received would not be considered an actual bed bath because the CNA would lightly wet the washcloth and wipe the washcloth on his body. Resident 29 stated the CNAs would not have a basin of water to rewet the washcloth nor would the CNAs rewet the washcloth in the sink. During an interview on 6/4/2025 at 8:28 a.m., with CNA 4, CNA 4 stated the residents follow a shower schedule, however, they can request to shower on any day. CNA 4 stated residents have the option to take a shower in the shower room or a bed bath in their room. CNA 4 stated when giving a bed bath, the CNA was responsible for grabbing a basin of water, fresh towels, and the resident's preferred soap. CNA 4 stated throughout the bed bath, new towels would be used in each section of the body being washed. CNA 4 stated providing perineal care (cleaning and maintenance of the genital and anal area) was very important, especially for a resident with an indwelling urinary catheter. CNA 4 stated perineal care was provided every day and during a resident's shower day. CNA 4 stated after a shower or bed bath was provided to a resident, the CNA was responsible for documenting on the resident's Task sheet on the electronic health record (eHR). During a concurrent interview and record review on 6/4/2025 at 8:39 a.m., with CNA 4, Resident 29's Bathing Task, dated May and June 2025 were reviewed. The Bathing Task indicated Resident 29 only had one documented shower on 5/13/2025. CNA 4 stated without documented showers, there was no way to prove Resident 29 received a shower or a bed bath. CNA 4 stated this was in issue because Resident 29 was at risk for infection due to the presence of the indwelling urinary catheter and bathing was essential to keep Resident 29 clean and free of dirt and bacteria. CNA 4 stated not only are showers essential for infection prevention, but showers were also important for Resident 29's self-esteem by feeling clean and not malodorous (smelling unpleasant). During an interview on 6/4/2025 at 2:34 p.m., with the Director of Nursing (DON), the DON stated all CNAs were expected to provide routine showers or bed baths to the residents. The DON stated a bed bath consisted of a water filled basin and towels to ensure the resident was clean. The DON stated the CNA was responsible for documenting in the resident's eHR after completing the bed bath to communicate to other staff members the date of the bath and the level of assistance the resident required. The DON stated Resident 29 should have been bathed either in the shower room or in his room. The DON stated bathing Resident 29 was essential for cleanliness, self-esteem, and infection prevention. The DON stated perineal care would also be provided during a bath and perineal care was essential for Resident 29 due to the presence of an indwelling urinary catheter. The DON stated not only was Resident 29 at risk for self-esteem issues, Resident 29 was also at risk for developing an infection. During a review of the facility's policy and procedure (P&P) titled, Showering a Resident, revised 5/1/2018, the P&P indicated, A shower bath is given to the residents to provide cleanliness, comfort, and to prevent body odors. 2. During a review of Resident 68's admission Record, the admission Record indicated Resident 68 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included schizophrenia (a mental illness that is characterized by disturbances in thought), and muscle weakness. During a review of Resident 68's MDS, dated [DATE], the MDS indicated Resident 68's cognition was intact. The MDS indicated Resident 83 required moderate (helper does less than half the effort) assistance from staff for ADLs. During a concurrent observation and interview of 6/2/2025 at 9:52 a.m., in Resident 68's room, with Resident 68, the resident was observed with visibly long, irregular in shape fingernails. The fingernails had dark brown debris underneath and curled over the fingertips. Resident 68 stated her nails were dirty and too long. Resident 68 stated no one had cut and/or cleaned her nails in a while. During a concurrent observation and interview on 6/2/2025 at 3:30 p.m., in Resident 68's room, with CNA 3, Resident 68 was observed with a dark brown substance underneath her fingernails. CNA 3 stated Resident 68's fingernails were dirty and required cleaning and trimming. CNA 3 stated nail care was one of the CNA's responsibilities, which included observing the resident's nails and trimming and cleaning when long and dirty. CNA 3 stated residents' nails should be checked daily to ensure nails remain clean and neat. CNA 3 stated residents sometimes scratch their skin, and if they scratch hard enough, they could break the skin and create an open wound. CNA 3 stated if a resident had dirty fingernails and scratched themselves, this increased the risk of infection. CNA 3 stated having dirty fingernails was unsanitary because the residents use their hands to eat, and any bacteria present could be transferred to their mouth. CNA 3 stated if Resident 68 was to touch shared objects, bacteria from under her fingernails could be transferred to those items and potentially to other residents. During an interview on 6/5/2025 at 9:30 am., with the DON, the DON stated fingernail care was a part of the resident's ADLs routine. The DON stated if a resident had long and dirty fingernails, CNAs were expected to clean and trim them. The DON stated dirty fingernails was not acceptable, as they increase the risk of infection, especially if residents touch food or share items. During a review of P&P titled Grooming Care of the Fingernails and Toenails, revised 5/1/2018, the P&P indicated facility would provide nail care to keep residents' nails clean and trim. The P&P indicated CNAs would trim residents' fingernails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 29's admission Record (Face Sheet), the Face Sheet indicated Resident 29 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), generalized muscle weakness (lack of strength in many muscles throughout the body), and neuromuscular dysfunction of the bladder (lacking bladder control leading to difficulty empty the bladder). During a review of Resident 29's MDS, dated [DATE], the MDS indicated Resident 29's cognition was moderately impaired, and the resident was dependent on staff's assistance for toileting, bathing, and lower body dressing. The MDS indicated Resident 29 had an indwelling urinary catheter. During an interview on 6/4/2025 at 8:54 a.m., Resident 29 stated the urinary catheter was not secured to his leg and that he often felt the tubing go under his genital area and his leg. Resident 29 stated when the tubing went underneath him, he would feel it poking him and would be very uncomfortable. Resident 29 stated at times the tubing felt like it was pulling, and he would have to try to readjust it. During a concurrent observation and interview on 6/4/2025 at 9:02 a.m., with TN 1 in Resident 29's room, Resident 29 was observed lying in bed with his urinary catheter exposed. Resident 29's indwelling urinary catheter exited from Resident 29's urethra (the tube that carries urine from the bladder out of the body) and the tubing was not secured to Resident 29's leg. TN 1 stated Resident 29's urinary catheter tubing should always be secured to his leg. TN 1 stated securing the tubing to Resident 29's leg offered protection from accidental pulling and dislodgement. TN 1 stated securing the tubing offered protection to Resident 29's genital area and legs to prevent any unnecessary pressure and poking. During an interview on 6/4/2025 at 2:42 p.m., the Director of Nursing (DON) stated indwelling urinary catheters should always be secured to the resident's leg. The DON stated Resident 29 was able to move around in bed and his urinary catheter could move under him or get stuck. The DON stated without the proper urinary catheter securement, Resident 29 was at risk of the urinary catheter pulling and dislodging which could be very painful. During a review of the facility's P&P titled, Catheter- Care of, revised 5/1/2018, the P&P indicated, Anchor the catheter with a leg strap to protect excessive tension on the catheter, which can lead to urethral tears or dislodging the catheter. Based on observation, interview, and record review, the facility failed to ensure two of five sampled residents (Residents 89 and 29) received the necessary care and services to maintain normal bladder function. Resident 89 did not receive daily urinary catheter care and Resident 29's urinary catheter was not secured with a leg strap. These deficient practices had the potential to result in a urinary tract infection (UTI- an infection in the bladder/urinary tract), urethral injury and / or unnecessary discomfort for Resident 89 and Resident 29. Findings: a. During a review of Resident 89's admission Record, the admission Record indicated Resident 89 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including retention of urine, gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) status, severe sepsis (a life-threatening blood infection) with septic shock ( a near-fatal condition that occurs with sepsis), and paranoid schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 89's Care Plan titled, Resident Requires Use of Foley Catheter, dated 10/18/2024, the care plan indicated the facility's interventions were to cleanse the foley catheter and urethral opening with normal saline daily or as needed. During a review of Resident 89's Minimum Data Set (MDS, a resident assessment tool), dated 5/16/2025, the MDS indicated Resident 89's cognitive skills (ability to think and reason) for daily decision making were moderately impaired. The MDS indicated Resident 89 was entirely dependent on staff for Activities of Daily Living and the resident had an indwelling catheter. During an observation made on 6/2/2025 at 10 a.m., in Resident 89's room, Resident 89 was in bed with his urinary catheter in place. During a concurrent interview and record review on 6/4/2025 at 9:41 a.m., with the Treatment Nurse (TN) 1, Resident 89's Physician's Orders, dated 4/2025 to 6/4/2025, and Resident 89's Treatment Administration Record (TAR), dated 4/2025 to 6/2/2025, were reviewed. The Physician's Orders indicated Resident 89 had a urinary catheter in place from 4/2025 to 6/4/2025. The Physician's Orders indicated there was no order for daily urinary catheter care since 4/2025. The TAR indicated there was no documentation of daily urinary catheter care since 4/2025. TN 1 stated the facility's normal practice to prevent the occurrence of UTI's was to ensure urinary catheter care was provided daily. This included the catheter bag was changed twice a week or as needed, and the resident's output was monitored and documented. TN 1 stated there was no documentation to indicate Resident 89 received daily urinary catheter care since 4/2025. TN 1 stated it was important to maintain documentation of daily urinary catheter care because the documentation served as proof that the task was completed. TN 1 stated if the care was not done daily, then there was potential for Resident 89 to develop a urinary catheter associated infection or a UTI. During a review of the facility's Policy and Procedure (P&P), titled, Catheter- Care Of, dated 5/1/2018, the P&P indicated the facility was to prevent catheter-associated urinary tract infections. The P&P indicated documentation of catheter care would be maintained in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that its medication error rate was less than five percent (%). There were two medication errors out of 31 total opportunities which contributed to an overall medication error rate of 6.45% affecting two of five residents observed for medication administration (Resident 23 and Resident 60). Resident 23 and Resident 60 did not receive medications per Physician's Order, nor did the pharmacy have the medication available for Resident 23. The deficient practice of failing to administer medications in accordance with the physician's orders, including pharmacy not having the prescribed medication available, increased the risk that Residents 23 and 60 may have experienced medical complications possibly resulting in hospitalization. Cross Reference F755 Findings: a. During a review of Resident 23's admission Record, the admission Record indicated Resident 23 was re-admitted to the facility on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (an interruption in blood flow to the brain), dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), schizophrenia (a mental illness that is characterized by disturbances in thought), and gastrostomy (g-tube-a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 23's Minimum Data Set (MDS, a resident assessment tool), dated 5/8/2025, the MDS indicated Resident 23's cognitive skills (ability to think and reason) for daily decision making was severely impaired. The MDS indicated Resident 23 was entirely dependent on staff for activities of daily living. During a review of the Physician's Order Summary Report, dated 6/3/2025, the Order Summary Report indicated Resident 23 was ordered isosorbide mononitrate (a medication used to prevent chest pain [angina] caused by coronary artery disease) oral tablet 30 milligrams (mg, unit of measurement) via g-tube one time a day for hypertensive (high blood pressure) heart disease on 5/20/2025. During a concurrent observation, interview, and record review on 6/3/2025 at 8:43 a.m. with LVN 1, Resident 23's isosorbide bubble pack was observed, Resident 23's isosorbide bubble pack medication label was reviewed and Resident 23's Physician Orders, dated 5/20/2025, were reviewed. The bubble pack had 11 tablets remaining out of the 31 doses dispensed. The bubble pack label indicated the contents of the bubble pack contained doses of isosorbide mononitrate oral tablet 30 mg extended release. The Physician's Orders indicated Resident 23 was ordered isosorbide mononitrate oral tablet 30 mg via g-tube one time a day on 5/20/2025. LVN 1 stated she did not notice the bubble pack contained doses of isosorbide mononitrate oral tablet 30 mg extended release and stated extended-release medication was not to be crushed and administered via g-tube unless prescribed by the physician. LVN 1 stated the order should have been clarified by the physician and the pharmacy should have been made aware. LVN 1 stated Resident 23's physician medication order of isosorbide mononitrate oral tablet 30 mg was not prepared or ordered as prescribed, which could have placed Resident 23 at risk for a sudden drop in blood pressure and, or decreased heart rate. During a concurrent interview and record review at 6/3/2025 at 8:45 a.m. with LVN 1, Resident 23's eMAR, dated 5/20/2025 to 6/3/2025, was reviewed. The eMAR indicated Resident 23 received 14 doses of isosorbide mononitrate oral tablet 30 mg via g-tube. LVN 1 stated the only supply of isosorbide mononitrate oral tablet 30 mg was the extended-release dose. LVN 1 stated she was Resident 23's assigned nurse the day before (6/2/2025) and stated she crushed and administered Resident 23's isosorbide mononitrate oral tablet 30 mg extended-release dose via g-tube. LVN 1 stated she did not notice the physician orders did not match the labeling on the bubble pack supply of isosorbide for the five times she had administered it since 5/20/2025. During a concurrent interview and record review on 6/4/2025 at 11:11 a.m. with LVN 2, Resident 23's eMAR, dated 5/20/2025 to 6/3/2025, was reviewed. The eMAR indicated LVN 2 administered six doses of the 14 doses of Resident 23's isosorbide mononitrate oral tablet 30 mg via g-tube. LVN 2 stated she crushed and administered the medication that was dispensed by the pharmacy (isosorbide mononitrate oral tablet 30 mg extended release) and did not notice the physician's orders did not match the labeling on the bubble pack supply for the six times she had administered it since 5/20/2025. LVN 2 stated by not comparing the bubble pack supply to the physician's order, and by crushing the extended-release dose of isosorbide, this placed Resident 23 at risk for death or hospitalization. During an interview on 6/3/2025 at 11:42 a.m. with Pharmacist 1, Pharmacist 1 stated the pharmacy had not delivered Resident 23's bubble pack supply of isosorbide mononitrate oral tablet 30 mg (immediate release) to the facility. Pharmacist 1 stated isosorbide mononitrate oral tablet 30 mg was only available in ER form and not in immediate release form. Pharmacist 1 stated the pharmacy delivered isosorbide mononitrate oral tablet 30 mg ER to the facility and the error was not noticed by the pharmacy technicians or the licensed nursing staff. During an interview on 6/4/2025 at 12:10 p.m. with the Director of Nursing (DON), the DON stated she expected the pharmacy to communicate with the licensed nursing staff to make them aware the isosorbide mononitrate oral tablet 30 mg (immediate release) was not available so that the licensed nursing staff could call the physician. The DON stated she expected the licensed nurse to compare the medication bubble pack with the physician's order prior to the administration of medications. The DON stated if any issues were identified, then the licensed staff would have to communicate with the physician and the pharmacy. The DON stated once an ER medication was crushed, the medication was immediately released into the blood stream and the effects of the medication would start right away. The DON stated an ER medication was intended to be released slowly (over 12-24 hours) into the blood stream throughout the day. The DON stated this placed Resident 23 at risk for a hypotensive (low blood pressure) or bradycardic (slow heart rate) event because medication was crushed and not administered per the physician's order. b. During a review of Resident 60's admission Record, the admission Record indicated Resident 60 was re-admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), gastrointestinal hemorrhage, and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 60's MDS, dated [DATE], the MDS indicated Resident 60's cognitive skills for daily decision making were moderately impaired. During a concurrent observation and interview on 6/3/2025 at 7:45 a.m. with LVN 3, LVN 3's medication pass was observed. LVN 3 dispensed one metformin oral tablet 1000 mg in a medication cup. LVN 3 entered Resident 60's room and attempted to administer Resident 60 the tablet without his breakfast tray or food. During a concurrent interview and record review on 6/3/2025 at 7:50 a.m. with LVN 3, Resident 60's eMAR, dated 6/3/2025, was reviewed. The eMAR indicated Resident 60 was to receive the dose of metformin with food or a meal. LVN 3 stated she should have waited until Resident 60's breakfast tray was delivered to administer the medication. LVN 3 stated the administration of the metformin would have placed Resident 60 at risk for gastric upset and it did not align with the physician's order. During a review of Resident 60's Order Summary Report, dated 6/4/2025, the Order Summary Report indicated Resident 60 was ordered metformin oral tablet 1000 mg one time a day by mouth and to give with food or meal. During an interview on 6/4/2025 at 12:10 p.m., the DON stated she would have expected the licensed nurses to compare the medication bubble pack with the physician's order prior to administering medications. The DON stated metformin was usually administered with food because some medications were sensitive to gastric acid. During a review of the facility's Policy and Procedure (P&P) titled, Medication Administration, dated 5/1/2018, the P&P indicated the licensed nurse was to administer medications per the order of the attending physician or licensed independent practitioner. The P&P also indicated the licensed nurse were to perform three checks [which include]: comparing the physician's order, pharmacy label and the medication administration record. The P&P indicated if any discrepancies were identified during the first, second and third check, it must be resolved prior to the administration of any medication. The P&P also indicated the licensed nurse were to perform three checks [which include]: comparing the physician's order, pharmacy label and the medication administration record. The P&P indicated if any discrepancies were identified during the first, second and third check, it must be resolved prior to the administration of any medication. The P&P indicated the licensed nurses were to keep in mind the seven rights of medication when administering medication: a. The right medication b. The right amount c. The right resident d. The right time e. The right route f. Right indication g Right outcome

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the licensed nursing staff failed to ensure a resident was free from significant medication errors when staff failed to ensure the following for one of six sampled residents (Resident 23): 1. Resident 23's blood pressure medication was administered as ordered when the licensed nursing staff crushed and administered isosorbide mononitrate (a blood pressure medication) oral tablet 30 milligrams (mg- a unit of measurement) extended-release (ER- a medication that is formulated so that the drug is released slowly over time) in place of the prescribed isosorbide mononitrate 30 mg immediate release (IR- medication that allows for immediate absorption) on 14 occasions. 2. The pharmacy supplied the facility the correct form and dose of isosorbide mononitrate oral 30 mg for Resident 23, as ordered. These failures resulted in 14 instances of improper administration over a two-week period, which had the potential to cause rapid release of the drug, leading to hypotension (low blood pressure) dizziness, and other adverse cardiovascular effects for Resident 23. Findings: 1a. During a review of Resident 23's admission Record, the admission Record indicated Resident 23 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (an interruption in blood flow to the brain), dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), schizophrenia (a mental illness that is characterized by disturbances in thought), and gastrostomy (g-tube- a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 23's Minimum Data Set ([MDS], a resident assessment tool), dated 5/8/2025, the MDS indicated Resident 23's cognitive skills (ability to think and reason) for daily decision making was severely impaired. The MDS indicated Resident 23 was entirely dependent on staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 23's Order Recap Report, dated 6/3/2025, the Order Recap Report indicated on 5/20/20205 Resident 23 was ordered isosorbide mononitrate (a blood pressure medication) oral tablet 30 milligrams (mg- a unit of measurement) via g-tube one time a day for hypertensive (high blood pressure) heart disease. During a concurrent observation and interview on 6/3/2025 at 8:40 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1's medication pass was observed. LVN 1 compared Resident 28's bubble pack, which was labeled as isosorbide mononitrate oral tablet 30 mg ER to Resident 28's Electronic Medication Administration Record (eMAR) and proceeded to place one pill from the bubble pack into a medication cup. LVN 1 proceeded to place the medication in a plastic medication bag to prepare to crush the tablet of isosorbide mononitrate oral tablet 30 mg ER. During a concurrent observation, interview, and record review on 6/3/2025 at 8:43 a.m. with LVN 1, Resident 23's isosorbide bubble pack was observed, Resident 23's isosorbide bubble pack medication label was reviewed and Resident 23's Physician Orders and eMAR, dated 6/3/2025, were reviewed. The bubble pack had 11 tablets remaining out of the 31 doses dispensed. The bubble pack label indicated the contents of the bubble pack contained doses of isosorbide mononitrate oral tablet 30 mg ER. The Physician Orders and eMAR indicated Resident 23 was ordered isosorbide mononitrate oral tablet 30 mg via g-tube one time a day. LVN 1 stated she did not notice the bubble pack contained doses of isosorbide mononitrate oral tablet 30 mg ER and stated ER medication was not to be crushed and administered via g-tube unless prescribed by the physician. LVN 1 stated the order should have been clarified by the physician and the pharmacy should have been made aware. LVN 1 stated Resident 23's physician medication order of isosorbide mononitrate oral tablet 30 mg was not prepared or ordered as prescribed, which could have placed Resident 23 at risk for a sudden drop in blood pressure and, or decreased heart rate. During a concurrent interview and record review at 6/3/2025 at 8:45 a.m. with LVN 1, Resident 23's eMAR, dated 5/20/2025 to 6/3/2025, was reviewed. The eMAR indicated Resident 23 received 14 doses of isosorbide mononitrate oral tablet 30 mg via g-tube. LVN 1 stated the only supply of isosorbide mononitrate oral tablet 30 mg was the ER dose. LVN 1 stated she was Resident 23's assigned nurse on 6/2/2025 and stated she crushed and administered Resident 23's isosorbide mononitrate oral tablet 30 mg ER dose via g-tube. LVN 1 stated she did not notice the physician orders did not match the labeling on the bubble pack supply of isosorbide for the total of five times she administered the medication since 5/20/2025. During a concurrent interview and record review on 6/4/2025 at 11:11 a.m. with LVN 2, Resident 23's eMAR, dated 5/20/2025 to 6/3/2025, was reviewed. The eMAR indicated LVN 2 administered six doses of the 14 doses of Resident 23's isosorbide mononitrate oral tablet 30 mg via g-tube. LVN 2 stated she crushed and administered the medication that was dispensed by the pharmacy (isosorbide mononitrate oral tablet 30 mg ER) and did not notice the physician orders did not match the labeling on the bubble pack supply for the total of six times she administered the medication since 5/20/2025. LVN 2 stated this placed Resident 23 at risk for death or hospitalization by not comparing the bubble pack supply to the physician order and crushing the ER dose of isosorbide. 2a. During an interview on 6/3/2025 at 11:42 a.m. with Pharmacist 1, Pharmacist 1 stated the pharmacy had not delivered Resident 23's bubble pack supply of isosorbide mononitrate oral tablet 30 mg (IR) to the facility. Pharmacist 1 stated isosorbide mononitrate oral tablet 30 mg was only available in ER form and not in IR form. Pharmacist 1 stated the pharmacy delivered isosorbide mononitrate oral tablet 30 mg ER to the facility and the error was not noticed by the pharmacy technicians or the licensed nursing staff. During an interview on 6/4/2025 at 12:10 p.m. with the Director of Nursing (DON), the DON stated she expected the pharmacy to communicate with the licensed nursing staff to make them aware the isosorbide mononitrate oral tablet 30 mg (IR) was not available so that the licensed nursing staff could call the physician. The DON stated she expected the licensed nurse to compare the medication bubble pack with the physician's order prior to the administration of medications. The DON stated if any issues were identified, then the licensed staff would have to communicate with the physician and the pharmacy. The DON stated once an ER medication was crushed, the medication was immediately released into the blood stream and the effects of the medication would start right away. The DON stated an ER medication was intended to be released slowly (over 12-24 hours) into the blood stream throughout the day. The DON stated this placed Resident 23 at risk for a hypotensive (low blood pressure) or bradycardic (slow heart rate) event because medication was crushed and not administered per the physician's order. During a review of the facility's Policy and Procedure (P&P), titled, Medication Administration, dated 5/1/2018, the P&P indicated the licensed nurse was to administer medications per the order of the attending physician or licensed independent practitioner. The P&P indicated the licensed nurse were to perform three checks [which include]: comparing the physician's order, pharmacy label and the medication administration record. The P&P indicated if any discrepancies were identified during the first, second and third check, it must be resolved prior to the administration of any medication. The P&P indicated the licensed nurses were to keep in mind the seven rights of medication when administering medication: a. The right medication b. The right amount c. The right resident d. The right time e. The right route f. Right indication g Right outcome

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage practices in the kitchen that affected 123 residents out of 125 sampled residents when: 1. One container that contained margarine, one opened bottle of whipped cream, one opened bottle of chocolate syrup, one box of dairy creamer, and one bag of parmesan cheese with no use by date (date the food item must be consumed by), were stored in the refrigerator. 2. The can opener was not maintained in a sanitary manner. These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 123 of 125 residents who received food from the kitchen. Findings: During an observation during the initial kitchen tour on 6/2/2025 at 8:35 a.m., observed food items in the refrigerator with no opened date or use by date. Observed one container of margarine, one opened bottle of whipped cream, one opened bottle of chocolate syrup, one box of dairy creamer, and one bag of parmesan cheese with no label indicating the date those items were placed in the refrigerator and the date of when items must be used by. During an observation during the initial kitchen tour on 6/2/2025 at 9:00 a.m., observed a can opener attached to the food preparation table in the kitchen. The surface of the can opener was blackened and covered with black stains and dried residue. The area surrounding the can opener blade and gear were heavily stained with dark, hardened food debris. During an interview on 6/2/2025 at 9:10 a.m. with the Dietary Supervisor (DS), in the kitchen, the DS stated food items should be labeled with three dates. The DS stated food was labeled with a received date, opened date, and expiration date. The DS stated food items were labeled to identify if food was safe to consume. The DS stated when a food item was not labeled, the dietary staff would not know if the food was safe to consume. The DS stated refrigerators were checked daily. The DS stated when dietary staff checked the refrigerators, they were supposed to make sure all items were properly labeled, check the condition of the food, and check for expired items. During an interview on 6/2/2025 at 9:25 a.m. with the DS, the DS stated the can opener should be clean and kept in sanitary condition to prevent contamination and growth of harmful bacteria. The DS stated this had the potential for foodborne illness, placing residents at risk for harm. During a review of Food Code 2017, Food Code 2017 indicated 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be clean to sight and touch. (B) Nonfood-Contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris. During a review of the facility's policy and procedure (P&P) titled Labeling and Dating of Foods, undated, the P&P indicated all food items in the refrigerator need to be labeled and dated. The P&P indicated food delivered to the facility needs to be marked with a received date. The P&P indicated newly opened food items need to be labeled with an open date and use by date. During a review of the facility's P&P titled Can Opener and Base, undated, the P&P indicated proper sanitation and maintenance of the can opener was important to sanitary food preparation. The P&P indicated The can opener must be thoroughly cleaned each work shift and when necessary, more frequently.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) was offered and provided showers and baths, who required assistance with Activities of Daily Living (ADLs). This failure had the potential to cause skin irritation, infections and negatively affect the residents' psychosocial well-being. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. The admission Record indicated Resident 1's diagnoses included heart failure (a heart disorder which causes the heart to not pump the blood efficiently, Diabetes Mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and cellulitis (a skin infection that causes swelling and redness). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 12/11/2024, the MDS indicated Resident 1 had no cognitive (the ability to think and reason) impairment. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) to perform ADLs such as shower/bathing self and personal hygiene. The MDS indicated that Resident 1 was at risk for developing pressure ulcers/injuries (localized damage to the skin and/or underlying tissue usually over a bony prominence). During a review of Resident 1's History and Physical (H&P) dated 3/11/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During an observation on 5/1/2025 at 10:02 a.m. Resident 1 was observed wheeling herself from her room. Resident 1 was observed with oily, unwashed hair. During an interview on 5/1/2025 at 11:32 a.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated, staff should offer residents shower every day. CNA 1 stated, if a resident refused to shower, CNAs would inform the Charge Nurse and document the refusal in the medical records. During an interview on 5/2/2025 at 11:21 a.m. with CNA 3, CNA 3 stated not providing showers or baths to residents could cause skin breakdown and dry skin for the residents. During a concurrent interview and record review on 5/2/2025 at 1:13 p.m. with the Director of Staff Development (DSD), Resident 1's ADL Sheet for Bathing dated 4/2025 was reviewed. The DSD stated there's no documentation to indicate Resident 1 received or was offered a shower or bath on 4/1/2025- 4/10/2025 and 4/12/2025-4/16/2025, 4/20/2025-4/22/2025 and 4/24/2025- 4/28/2025. The DSD stated the risk of not offering a shower or bath to a resident could cause harm to the resident's skin integrity. During an interview on 5/2/2025 at 3:11 p.m. with the Director of Nursing (DON), the DON stated residents should be offered a shower or bath every day and any refusals should be reported to the Charge Nurse. During a review of facility's policy and procedure (P&P) titled, Showering a Resident, dated 5/1/2018, P&P stated, A shower bath is given to the residents to provide cleanliness, comfort, and to prevent body odors and Residents are offered a shower at a minimum of once weekly and given per resident request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of five residents (Resident 1) received treatment and care in accordance with professional standards of practice by failing to ensure Resident 1's Primary Care Provider (PCP) was notified of the resident's refusals of showers/baths and wound care treatment. This failure had the potential to place Resident 1 at risk for worsening skin conditions and complications from wound care noncompliance such as sepsis (a life-threatening blood infection), hospitalization and death. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. The admission Record indicated Resident 1's diagnoses included heart failure (a heart disorder which causes the heart to not pump the blood efficiently, Diabetes Mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and cellulitis (a skin infection that causes swelling and redness). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 12/11/2024, the MDS indicated Resident 1 had no cognitive (the ability to think and reason) impairment. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) to perform Activities of Daily Living (ADLs) such as shower/bathing self and personal hygiene. The MDS indicated that Resident 1 was at risk for developing pressure ulcers/injuries (localized damage to the skin and/or underlying tissue usually over a bony prominence). During a review of Resident 1's History and Physical (H&P) dated 3/11/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Order Summary Report dated 4/17/2025, the Report indicated the following treatment orders for Resident 1: On 12/13/2024, the physician ordered to apply dermaphor (medication used to treat or prevent dry, rough, scaly, itchy skin and minor skin irritation) moisturizing ointment to the resident's dry skin on the left and right foot every day shift. On 4/1/2025, the physician ordered to wipe the resident's right lower leg cellulitis with exudate (wound drainage) with normal saline (NS- a saltwater solution) pat try, apply xeroform sheets (dressing designed to provide non-adherent packing for wounds and create an environment that facilitates wound healing) and wrap leg with dry dressing every day shift for 30 days. During a review of Resident 1's Treatment Administrator Record (TAR) dated 4/2025, the TAR indicated Resident 1 refused wound care treatments on 4/3/2025, 4/5/2025, 4/12/2025, 4/16/2025, 4/17/2025, 4/19/2025, and 4/20/2025. During a review of Resident 1's Progress Notes dated 4/2025, the Notes did not indicate Resident 1's PCP was notified of the wound care treatment refusals on 4/3/2025, 4/5/2025, 4/12/2025, 4/16/2025, 4/17/2025, 4/19/2025, and 4/20/2025. During a review of Resident 1's ADL Sheet for Bathing dated 4/2025, the ADL Sheet indicated Resident 1 refused showers/baths on 4/17/2025, 4/18/2025, 4/19/2025, and 4/23/2025. During an interview on 5/2/2025 at 11:21 a.m. with Certified Nursing Assistant (CNA) 3, CNA 3 stated, CNAs performed skin checks on residents during showers, bathing and ADL care. CNA 3 stated, CNAs could identify new skin issues that should be reported to the Charge Nurse during showers. CNA 3 stated that if a resident did not shower, staff could miss any changes to the resident's skin. During an interview on 5/2/2025 at 12:36 p.m. with LVN 4, LVN 4 stated, nurses should inform the PCP if a resident refused to shower after three attempts. LVN 4 stated if a resident had cellulitis, refused to shower, there was a potential for new problems to develop. During an interview on 5/2/2025 at 2:26 p.m. with the Director of Staff Development (DSD), the DSD stated, licensed nurses should notify the resident's PCP for any refusals of wound care and document it under the progress notes and change of condition (COC). During a concurrent interview and record review on 5/2/2025 at 3:33 p.m. with the Director of Nursing (DON), the facility's Policy and Procedure (P&P) titled, Care and Service, dated 5/1/2018 was reviewed. The P&P indicated, The licensed nurse or designee documents and notifies the resident's physician and responsible party of Resident refusal of care or services. The DON stated the facility was not following the P&P by not informing the PCP of Resident 1's refusals to shower and receive wound care. During a review of facility's P&P titled, Wound Management dated 5/1/2018, the P&P indicated, The Attending Physician and Interdisciplinary Team (IDT)-Skin Committee will be notified of residents refusing treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure weekly skin checks were documented timely for one out of five sampled residents (Resident 1). This failure had the potential to result in inaccurate information communicated between healthcare providers and a delay in the provision of care or interventions for Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. The admission Record indicated Resident 1's diagnoses included heart failure (a heart disorder which causes the heart to not pump the blood efficiently, Diabetes Mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and cellulitis (a skin infection that causes swelling and redness). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 12/11/2024, the MDS indicated Resident 1 had no cognitive (the ability to think and reason) impairment. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) to perform Activities of Daily Living (ADLs) such as shower/bathing self and personal hygiene. The MDS indicated that Resident 1 was at risk for developing pressure ulcers/injuries (localized damage to the skin and/or underlying tissue usually over a bony prominence). During a review of Resident 1's History and Physical (H&P) dated 3/11/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Weekly Skin Check dated 3/18/2025, 3/25/2025, 4/1/2025, 4/15/2025, 4/22/2025 and 4/29/2025, were reviewed. The weekly skin checks indicated Skin Assessments charted to have been performed on 3/18/2025, 3/25/2025, 4/1/2025, 4/15/2025, 4/22/205 and 4/29/2025 were created on 5/1/2025. During a concurrent interview and record review on 5/1/2025 at 5:00 p.m. with LVN 3, Resident 1's weekly skin checks dated 3/18/2025, 3/25/2025 and 4/2025, were reviewed. LVN 3 stated she created and added the documentation for the skin checks she performed on 3/18/2025, 3/25/2025 and 4/2025, on 5/1/2025 based on what she remembered seeing on the resident's skin. During a concurrent interview and record review on 5/2/2025 at 4:01 p.m. with the Director of Nursing (DON), Resident 1's weekly skin checks for 3/18/2025, 3/25/2025 and 4/2025 were reviewed. The DON stated residents with existing skin issues must be assessed every seven days by the licensed nurse. The DON stated skin assessments should have been charted the same day it was completed to ensure accuracy because the nurse could forget important information. The DON stated there was potential that Resident 1's skin assessments were not accurately documented for 3/18/2025, 3/25/2025 and 4/2025. During a review of facility's Policy and Procedure (P&P) titled, Record Content: Documentation Principles, dated 11/2017, the P&P indicated, Resident health record shall be current and kept in detail consistent with good medical and professional practice based on the service provided to each patient. The P&P also indicated, Complete entries must be accurate and timely - recorded within the required time period. During a review of facility's P&P titled, Wound Management, dated 5/1/2018, the P&P indicated, A licensed nurse will perform a skin assessment upon admission, readmission, weekly, and as needed for each resident and stated, Licensed nurses will document effectiveness of current treatment in the resident's medical record on a weekly basis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents was free from physical abuse for one of four sampled residents (Resident 1). This deficient practice resulted in Resident 1 being hit with a wet floor sign cone ([12 inch wide and 36-inch height 36 between 5-10 pounds] a safety measure used to notify of a slippery surface) by Resident 2, and left Resident 1 feeling threatened (the sense that something bad might happen) and scared for his life. Findings: During a review of Resident 1 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), schizophrenia (a mental illness that can affect thoughts, mood, and behavior), major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and hypertension (HTN-high blood pressure). During a review of Resident 1 ' s Minimum Data Set ([MDS] – a federally mandated resident assessment tool), dated 9/21/2024, the MDS indicated Resident 1 ' s cognitive (the ability to think and process information) skills for daily decisions making was intact. The MDS indicated Resident 31 required supervision assistance (helper sets up or cleans up; resident completes activity) from staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1 ' s progress note, dated 10/5/2024 at 7:55 a.m., the progress note indicated Resident 1 was hit with a wet floor sign cone by roommate (Resident 2) and caused Resident 1 to sustain a bruise (skin discoloration) and cut on the right elbow. During an interview on 10/21/2024 at 1:10 p.m., with Resident 1, Resident 1 stated on 10/5/2024 in the early morning hours, (was not able to recall the time), his roommate (Resident 2) was passing gas and was acting very unpleasant. Resident 1 stated he (Resident 1) asked Resident 2 to stop passing gas and go into the restroom. Resident 1 stated, Resident 2 was upset, ran out of the room, grabbed a wet floor sign cone, and threw it at Resident 1. Resident 1 stated, he was hit on his right elbow. Resident 1 stated he had a right elbow skin cut and bruise. Resident 1 stated he felt threatened and scared for his life. During a review of Resident 2 ' s Face Sheet, the Face Sheet indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizophrenia, anxiety (feeling of fear, dread, and uneasiness), and hypertension. During a review of Resident 2 ' s MDS, dated [DATE], the MDS indicated Resident 2 ' s cognitive skills for daily decisions making was moderately impaired. The MDS indicated Resident 2 was independent for ADLs. During a review of Resident 2 ' s situation, background, recommendation ([SBAR]-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 10/5/2024 at 8:15 a.m., the SBAR indicated Residents 1 and 2 had an altercation. The SBAR indicated Resident 2 hit Resident 1 with a wet floor sign cone and Resident 1 sustained a right elbow skin cut. During a telephone interview on 10/22/2024 at 2:17 p.m., with Registered Nurse (RN 1), RN 1 stated on the morning of 10/5/2024, he (RN 1) was in the facility ' s conference room and heard yelling and screaming coming from the hallway. RN 1 stated he (RN 1) came out of the conference room right way and observed Resident 2 who appeared agitated, holding a wet floor sign cone, and running after Resident 1. RN 1 stated, Resident 1 looked scared. RN 1 stated, Resident 1 told him (RN 1) that Resident 2 threw the wet floor sign cone and hit him (Resident 1) on the right elbow. RN 1 stated Resident 1 sustain right elbow skin cut and a bruise. RN 1 stated the wet floor sign cone was left unattended in front of Residents 1 and 2 room. RN 1 stated physical abuse could have been prevented if the wet floor sign cone was not left unattended in front of the residents ' room. During a concurrent observation and interview on 10/22/2024 at 2:52 p.m., with RN 2 in the hallway, a wet floor sign cone was observed placed and left unattended in front of a resident ' s room. RN 2 stated that sign cones left unattended was a safety issue and had the risk for resident-to-resident physical harm, abuse, and injury. During a review of the facility ' s policy and procedure (P&P) titled Policy on patient abuse and mistreatment, dated 10/2022, the P&P indicated facility would uphold resident ' s rights to be free from physical abuse (defined as the willful infliction of injury, unreasonable confinement or punishment with resulting physical harm or pain or mental anguish or derivation by an individual). The P&P indicated residents would not be subjected to abuse by another resident. During a review of the facility ' s P&P tilted Safety of Residents revised 5/1/2023, the P&P indicated the facility would provide a safe environment for residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents ' environment remained free of accident hazards by keeping housekeeping cones (wet floor signs) unattended in residents ' rooms. This deficient practice resulted in Resident 1 being hit by Resident 2 with a wet floor sign-cone ([12 inch wide and 36-inch height 36, and between 5-10 pounds] a safety measure used to notify of a slippery surface) and had the potential to cause physical harm to other residents in the facility. Findings: During an observation on 10/22/2024 at 1:40 p.m., 2:00 p.m., and 2:40 p.m., in the facility ' s hallway, a wet floor sign cone and housekeeping cart was observed unattended and placed in front of a residents ' room. During a review of Resident 1 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), schizophrenia (a mental illness that can affect thoughts, mood, and behavior), major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and hypertension (HTN-high blood pressure). During a review of Resident 1 ' s Minimum Data Set ([MDS] – a federally mandated resident assessment tool), dated 9/21/2024, the MDS indicated Resident 1 ' s cognitive (the ability to think and process information) skills for daily decisions making was intact. The MDS indicated Resident 31 required supervision assistance (helper sets up or cleans up; resident completes activity) from staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1 ' s progress note, dated 10/5/2024 timed 7:55 a.m., the progress note indicated Resident 1 was hit with a wet floor sign cone by roommate (Resident 2) and caused Resident 1 to sustain a bruise (skin discoloration) and cut on the right elbow. During an interview on 10/21/2024 at 1:10 p.m., with Resident 1, Resident 1 stated on 10/5/2024 in the early morning hours, (unable to remember the time), his roommate (Resident 2) was passing gas. Resident 1 stated he told Resident 2 to stop passing gas and go into the restroom. Resident 1 stated, Resident 2 became upset, ran out of the room, and grabbed a wet floor sign cone and threw at Resident 1. Resident 1 stated was hit on his (Resident 1) right elbow. Resident 1 stated he sustained a right elbow skin cut and bruise. Resident 1 stated he felt threatened and scared for his life. During a review of Resident 2 ' s Face Sheet, the Face Sheet indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizophrenia, anxiety (feeling of fear, dread, and uneasiness), and hypertension. During a review of Resident 2 ' s MDS, dated [DATE], the MDS indicated Resident 2 ' s cognitive skills for daily decisions making was moderately impaired. The MDS indicated Resident 2 was independent for ADLs. During a review of Resident 2 ' s situation, background, recommendation ([SBAR]-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 10/5/2024 at 8:15 a.m., the SBAR indicated Residents 1 and 2 had an altercation. The SBAR indicated Resident 2 hit Resident 1 with a wet floor sign cone and Resident 1 sustained right elbow cut. During a telephone interview on 10/22/2024 at 2:17 p.m., with Registered Nurse (RN 1), RN 1 stated on the morning of 10/5/2024, he (RN 1) was in the facility ' s conference room and heard yelling and screaming coming from the hallway. RN 1 stated he (RN 1) came out of the conference room right way and observed Resident 2 who appeared agitated, holding a wet floor sign cone, and running after Resident 1. RN 1 stated, Resident 1 looked scared. RN 1 stated, Resident 1 told him (RN 1) that Resident 2 threw the wet floor sign cone and hit him (Resident 1) on the right elbow. RN 1 stated Resident 1 sustain right elbow skin cut and a bruise. RN 1 stated the wet floor sign cone was left unattended in front of Residents 1 and 2 room. RN 1 stated physical abuse could have been prevented if the wet floor sign cone was not left unattended in front of the residents ' room. During a telephone interview on 10/22/2024 at 2:17 p.m., with Registered Nurse (RN 1), the RN 1 stated on the morning of 10/5/2024 he (RN 1) was in the facility ' s conference room and heard yelling and screaming coming from the hallway. RN 1 stated he (RN 1) came out of the conference room right way and observed Resident 2 was agitated holding a wet floor sign cone and running after Resident 1. RN 1 stated Resident 1 was visibly (can be seen by the eye) scared. RN 1 stated Resident 1 told him (RN 1) that Resident 2 threw the wet floor cone and hit him (Resident 1) on the right elbow. During an interview on 10/22/2024 at 2:35 p.m., with housekeeping (HK1), t HK 1 stated, residents ' room were cleaned every 20 minutes throughout the day. HK 1 stated she would clean one residents ' room floor and would place wet floor sign cone and then go and clean another residents ' room floor. HK 1 stated she would leave the wet floor sign cone in place unattended for about 10 to 20 minutes until the floor was dry then remove it. HK 1 stated she was cleaning multiple residents ' room at the facility during her shift and did not have time to stay in the residents ' room and wait until the floor was dry. During a concurrent observation and interview on 10/22/2024 at 2:52 p.m., with RN 2 in the hallway, a wet floor sign cone was observed placed and left unattended in front of residents ' rooms. RN 2 stated that cleaning equipment left unattended was a safety issue, and placed residents at risk for physical harm, and injury. During a review of the facility ' s policy and procedure (P&P) titled Safety Committee- Composition and Duties, revised 5/1/2018, the P&P indicated: a) Facility would monitor the quality of resident care and safety practices. b) Facility safety committee (SC) would oversee safety practices on the grounds of the facility and environmental factors related to safety. c) Facility would maintain facility grounds in a manner to allow the safety of residents and facility staff. During a review of the facility ' s P&P titled Housekeeping- General, revised 5/1/2018, the P&P indicated housekeeping staff while performing job duties (tasks that an employee performs) would watch cleaning equipment carefully and keep it out the way of the residents. During a review of the facility ' s P&P titled Housekeeping job description, dated 12/16/2022, the P&P indicated housekeeping responsibilities and duties included keep cleaning equipment out of the residents ' way.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to ensure one out of two sampled residents (Resident 1) was informed about her medical coverage during her stay at the facility by: 1. Not informing Resident 1 that she did not have a secondary coverage (insurance that pays after primary coverage, it will cover the remaining costs that the primary insurance did not cover) for the length of her stay at the facility. 2. Not assisting Resident 1 with the process of applying for a secondary coverage. These deficient practices resulted in Resident 1 to live at the facility without being informed she had no medical coverage and Resident 1 received a medical bill for the uncovered amount. Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including depression (a common and serious medical illness that negatively affects how a person feels, thinks, and acts) and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations). During a review of Resident 1's History and Physical (H&P) dated 3/19/2021, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 2/25/2021, the MDS indicated Resident 1's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact. The MDS indicated Resident 1 required supervision for oral hygiene, toileting hygiene, dressing, and shower/bathing. During a review of Resident 1's electronic medical record, the electronic medical record indicated there was no documentation indicating Resident 1 was informed of no secondary coverage for her stay at the facility. The electronic medical record did not indicate the staff attempted to discuss Resident 1's medical coverage. During a review of Resident 1's Medicare Eligibility form, dated 2/19/2021, the Medicare Eligibility form indicated there was no recorded eligibility for requested date of service 2/1/2021. During an interview on 8/28/2024 at 1:12 p.m. with the Administrator, the Administrator stated Resident 1's last day of medical coverage was on 3/18/2021. The administrator stated Resident 1 was charged for her stays between 3/18/2021 - 4/28/2021. During an interview on 8/28/2024 at 1:32 p.m. with Resident 1, Resident 1 stated no one from the facility informed her that she did not have secondary coverage. Resident 1 stated the facility staff did not assist her in applying for a secondary coverage. Resident 1 stated if someone told her she did not have a secondary coverage she would have not stayed at the facility. Resident 1 stated she wanted to leave the facility because she completed her rehabilitation for her arm and was ready to live independently. Resident 1 stated she expected the facility staff to inform her of her medical benefits and to assist her with any issues but they did not. During an interview on 8/28/2024 at 2:28 p.m. with the Business Office Manager (BOM), the BOM stated a resident ' s medical benefits were verified before a resident was admitted to the facility. The BOM stated when the resident arrived to the facility their medical benefits were checked again to make sure they continue to have coverage. The BOM stated on admission staff must verify if a resident has a secondary coverage. The BOM stated within two weeks of admission to the facility a resident must be notified that they need secondary coverage. The BOM stated she never had a conversation with Resident 1 about not having a secondary coverage. The BMO stated the facility did not have any documentation that indicated Resident 1 was informed that she had an outstanding bill at the time of discharge. During an interview on 8/28/2024 at 3:14 p.m. with the BOM, the BOM stated during the admission process, all residents must be informed what their insurance covers and what it did not. The BOM stated on admission everything must be explained to the resident. During an interview on 8/28/2024 at 3:28 p.m. with the BOM, the BOM stated Resident 1 ' s medical benefits were checked in February 2024 and the resident did not have eligibility for Medicare (federal health insurance for anyone age [AGE] and older). The BOM stated residents' medical benefits should be checked monthly and the resident must be informed if they did not have a secondary coverage. The BOM stated facility staff must assist residents to apply for a secondary coverage. The BOM stated the facility did not have any documentation to indicate they attempted to assist Resident 1 with applying for a secondary coverage. The BOM stated it was important for residents not to have issues with their medical coverage because they need the reassurance that all services would be provided to them. The BOM stated if a resident did not have a secondary coverage, the resident might have issues with continuous care and would be responsible for paying the uncovered portion of care. During an interview on 8/28/2024 at 3:54 p.m. with the Director of Nursing (DON), the DON stated staff from the business office and from admissions should have knowledge on residents ' medical coverage. The DON stated those staff were responsible for talking to the residents on admission about their medical benefits and if they needed a secondary coverage. The DON stated it was the residents right to be informed abut their status on a secondary coverage. The DON stated if a resident was not informed that they did not have a secondary coverage they would receive a bill for the uncovered portion. The DON stated it was the responsibility of the facility staff to assist the residents with applying for Medicare. The DON stated if a resident did not receive the assistance needed to apply for Medicare services, they would not have a secondary coverage and would be responsible to pay for the uncovered portion. The DON stated she expected her staff to continuously check on resident benefit eligibility and inform the residents if they needed a secondary coverage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure, one of three residents (Resident 1), received treatment and care in accordance with professional standards of practice by failing to ensure: 1. The license nurse notified the attending physician (MD) for Resident 1's blood sugar (BS) level of 55 milligrams/ deciliter ([mg/dl] unit of measurement, normal BS level 70 to 99 mg/dL) on 1/24/2024 at 11:30 a.m. 2. Administer Glucagon 1 mg. Intramuscular ([IM] injection of medicine into the muscles) on 1/24/2024 at 11:30 a.m. when Resident 1 had a blood sugar level of 55 mg/dl as indicated in Resident 1's physician order to administer Glucagon 1 mg. IM, if BS was less than 60 mg/dl. 3. Resident 1, who was diabetic and on multiple medications to lower blood sugar levels, was assessed when Resident 1 became nonverbally responsive on 1/24/2024 at 11:41 p.m. 4. Notify the MD promptly on 1/24/2024 at 11:41 p.m. when Resident 1 was nonresponsive. 5. Implement its Nursing Manual – Dietary & Dining titled, Hypoglycemia, (low blood sugar levels) which indicated the facility should notify the attending physician (MD) of any blood sugar levels below 70 mg/dl. These failures placed Resident 1 at risk for severe medical complications, hospitalization, and death. Findings: During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included aftercare following joint replacement surgery and Type 2 Diabetes Mellitus ([DM] a long-term condition in which the body has trouble controlling blood sugar) without complications. During a review of Resident 1's order summary report dated 1/25/2024, Resident 1's physician's order indicated the following: 1. Controlled Carbohydrate Diet, mechanical soft. 2. Hold regular diet for 24 hours. Clear liquid diet for 24 hours. 3. Insulin Lispro (medicine for DM) to be injected per sliding scale (the amount of insulin to be administered would depend on the BS level ) before meals and at bedtime. If BS is less than 60 milligrams per deciliter ([mg/dl] unit of measurement), give Glucagon (a hormone that pancreas makes to help regulate blood glucose (sugar) levels and increases blood sugar levels, preventing it from dropping too low) 1 mg IM and call the MD. 4. Glipizide (medicine for DM) oral tablet extended release 24-hour 10 milligram ([mg] a unit of measurement), one (1) tablet by mouth twice a day before breakfast. 5. Januvia oral tablet 50 mg. (medicine for DM), 1 tablet twice a day. During a concurrent interview and record review on 7/25/2024 at 2:34 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's progress notes dated 1/24/2024 at 3:52 p.m. were reviewed. LVN 1 stated the notes indicated Resident 1 had a blood sugar level of 55 (time not specified), however, the progress notes did not indicate the MD was notified of the BS level of 55 mg/dl as per physician's order. LVN 1 stated the licensed nurse should have administered glucagon to Resident 1 due to BS level of 55 mg/dl. LVN 1 stated the BS level should have been reported to MD because if resident have not received glucagon, Resident 1's blood sugar would have dropped lower. During a concurrent interview and record review on 7/25/2024 at 3:42 p.m. with Registered Nurse (RN) Supervisor 1, Resident 1's Medication Administration Record (MAR) dated January 2024 was reviewed. The RN Supervisor stated the MAR on 1/24/2024 at 11:30 a.m., indicated Resident 1 had a BS level of 55 mg/dl. The RN Supervisor stated MAR did not indicate Glucagon 1 mg. was administered to Resident 1 as indicated in the MD order which indicated to administer Glucagon 1 mg. IM if BS was less than 60 mg/dl. During a review of Resident 1's Nursing Progress Notes dated 1/24/2024, the progress notes dated 1/24/2024 at 10:44 p.m. indicated Resident 1 was on a clear liquid diet. The progress notes indicated blood sugar was monitored. During a review of Resident 1's Situation, Background, Assessment, and Recommendation ([SBAR] a structured way to communicate to the care team about a resident's change in condition) dated 1/25/2024 at 12:32 a.m., the SBAR indicated a Certified Nurse Assistant (CNA) called for help in Resident 1's room on 1/24/2024 at 11:41 p.m. The SBAR indicated Resident 1 was nonverbally responsive, awakened when touched, heart rate was 48 beats per minute (normal 60-100 beats per minute), oxygen saturation (the amount of oxygen in the bloodstream with normal range of 95-100%) was 88 percent (%) on room air (without use of oxygen). The SBAR indicated oxygen via simple mask was administered and 911 (emergency phone number) was called. The SBAR indicated Resident 1 was transferred to general acute care hospital (GACH) on 1/25/2024 at 12 midnight. During an interview on 7/26/2024 at 2:26 p.m. with the Director of Nursing (DON), the DON stated the facility should have given Resident 1 the Glucagon 1 mg IM as ordered, rechecked the blood sugar level and notified the MD. The DON stated if MD was not notified of the blood sugar level of 55 mg/dl., corrective actions could not be received. The DON stated, administering glucagon is part of a nursing intervention and is part of change of condition. During a review of the facility's Nursing Manual – Dietary & Dining titled, Hypoglycemia, dated 1/1/2012, the manual indicated residents on hypoglycemic medications should be monitored for signs and symptoms of hypoglycemia during routine daily basis. The manual indicated, unless otherwise documented on the MAR per attending physician order, the nurse should notify the attending physician of any blood sugar levels of below 70 mg/dl. During a review of the facility's undated P&P titled, Change of Condition Notification, the P&P indicated the facility should promptly consult with the resident's attending physician when a resident has a significant change in condition. The P&P indicated the facility should immediately call the attending physician in emergency situations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 88's admission Record, dated 6/12/2024, indicated Resident 88 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 88's diagnoses included schizophrenia and MDD. A review of Resident 88's H&P, dated 7/4/2023, indicated Resident 88 did not have the capacity to understand and make decisions. A review of Resident 88's Physician Order Summary (a monthly summary of all active physician orders), dated 6/12/2024, indicated Resident 88 was prescribed buspirone (a medication used to treat anxiety) 5 mg by mouth once daily for anxiety on 4/24/2024. A review of Resident 88's Psychiatric Progress Note (a note recording the findings from a psychiatrist's periodic assessment), dated 6/5/2024, indicated Resident 88 had psychiatric diagnoses including schizophrenia, MDD, and anxiety disorder. A review of Resident 88's MDS Section I, dated 3/22/2024, indicated Resident 88 did not have anxiety disorder as an active diagnosis. During an interview on 6/12/24 at 9:41 a.m. with the DON, the DON stated Resident 88's MDS assessment Section I for 3/22/2024 was inaccurate as it did not include anxiety disorder in his active diagnoses. The DON stated because this diagnosis was included on Resident 88's psychiatric consult note dated 6/5/2024 and the resident had been receiving medication for anxiety disorder since well before the MDS assessment was completed, it should have been included in the MDS assessment on 3/22/2024. The DON stated inaccurate MDS assessments could negatively impact care planning which increased the risk that a resident's needs were not fully met, leading to a decline in their quality of life. A review of the facility's policy and procedure (P&P) titled, Resident Assessment Instrument Process- MDS Assessment, Processing, and Documentation, revised 1/1/2012, indicated, to provide residents assessments that accurately depict and identify resident-specific issues and objectives as required, while meeting state and federal submission requirements. Based on interview and record review, the facility failed to ensure the assessment entries on the Minimum Data Set (MDS, a standardized resident assessment care screening tool) were accurate for two of seven sampled residents (Resident 17 and 88) when the facility failed to: 1. Include the presence of hallucinations (an experience involving the apparent perception of something not present) for Resident 17. 2. Include a diagnosis of anxiety disorder per information in the medical record for Resident 88. Theses deficient practices had the potential to negatively affect Resident 17 and Resident 88's plan of care and delivery of necessary care and services. Findings: a. A review of Resident 17's admission Record (Face Sheet), indicated Resident 17 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 17's diagnoses included chronic obstructive pulmonary disease (COPD, a lung disease characterized by long-term poor airflow), schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), major depressive disorder (MDD, a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety disorder (a group of mental disorders characterized by significant feelings of fear). A review of Resident 17's Minimum Data Set (MDS, a standardized resident assessment and care screening tool) dated 6/2/2024, indicated Resident 17 was able to understand and be understood by others. The MDS indicated Resident 17's cognition (process of thinking) was intact. The MDS indicated Resident 17 had delusions (misconceptions of beliefs that are firmly held, contrary to reality). The MDS indicated Resident 17 required setup or clean-up assistance with eating, oral hygiene, toileting, showering, dressing, and personal hygiene. The MDS indicated Resident 17 received antipsychotic (medication to treat psychosis [severe mental condition involving abnormal thinking, perceptions, and loss of contact with reality], antianxiety (medication to treat anxiety [feeling of unease, excessive worry]), and antidepressant (medication to treat depression) medication. A review of Resident 17's History and Physical (H&P), dated 2/19/2024, indicated Resident 17 had the capacity to understand and make decisions. A review of Resident 17's Order Summary Report, dated 2/9/2024, indicated to administer Risperdal (an antipsychotic medication) 2 milligrams (mg, a unit of measurement) two times a day for paranoid schizophrenia, manifested by auditory hallucinations (an experience involving the apparent perception of something not present) by hearing voices to internal stimuli. A review of Resident 17's Monthly Psychotropic Drug Management, dated 6/3/2024, indicated between 5/1/2024 through 5/31/2024, Resident 17 exhibited the behavior of auditory hallucinations by hearing voices to internal stimuli a total of 5 times. A review of Resident 17's Medication Administration Record (MAR), dated 5/1/2024 through 5/31/2024, indicated Resident 17 exhibited the behavior of auditory hallucinations by hearing voices to internal stimuli on 5/16/2024 and 5/21/2024. A review of Resident 17's Psychiatric Note, dated 5/2/2024, indicated Resident 17 was seen in her room presenting with auditory hallucinations, angry outbursts, and verbalized sadness. During an interview on 6/12/2024 at 9:41 a.m., with the Director of Social Services (DSS), the DSS stated she was responsible for assessing the behavior portion of the MDS. The DSS stated she was responsible for reviewing the residents' H&P from the hospital to see if there were any history of the presence of hallucinations or delusions. The DSS stated during the assessment period, she would monitor and observe the resident to see if they were talking to someone that was not there or responding to internal stimuli. During a concurrent interview and record review on 6/12/2024 at 9:44 a.m., with the DSS, Resident 17's MDS, dated [DATE], was reviewed. The MDS indicated Resident 17 only experienced delusions. The DSS stated Resident 17's MDS did not indicate that Resident 17 experienced hallucinations. The DSS stated the MDS was incorrect because Resident 17 experienced hallucinations during the review period and was on antipsychotic medication for that behavior. The DSS stated the MDS assessment had to be accurate to monitor the resident, especially when they are on medications for the specific behavior and could prompt the team to decrease the dose or discontinue the medication entirely if the assessment indicated no hallucinations. The DSS stated because the MDS assessment for Resident 17's behavior was inaccurate; the assessment could mislead the healthcare team and could negatively affect Resident 17's plan of care. During an interview on 6/13/2024 at 10:06 a.m., with the Director of Nursing (DON), the DON stated when the MDS assessment was inaccurate, the resident's plan of care could be negatively affected. The DON stated the error on Resident 17's behavior could affect the decision making whether her antipsychotic medication had to be adjusted or continued.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure that individuals with a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) assessments were accurate, and that determination for the necessity of potential necessary services was completed for two of 25 sampled residents (Resident 109 and Resident 25). This deficient practice had the potential for Resident 109 and Resident 25 to not receive the required services and care needed for their diagnosed mental disorders. Findings: 1. A review of Resident 109's admission Record indicated the facility admitted Resident 109 on 1/19/2024. Resident 109's admitting diagnoses included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A review of Resident 109's Minimum Data Set (MDS, a comprehensive care-screening and care-planning tool), dated 4/27/2024, indicated Resident 109 had diagnoses of schizophrenia and depression. A review of Resident 109's PASRR Level I Screening, dated 1/19/2024, indicated the assessment was completed at the facility upon Resident 109's admission. A review of Resident 109's untitled record, dated 1/19/2024, indicated a PASRR Level II Mental Health Evaluation could not be completed because Resident 109 already had a duplicate PASRR Level I Screening on file. During a concurrent interview and record review, on 6/12/2024 at 10:06 a.m., with Registered Nurse Supervisor (RNS) 2, Resident 109's untitled record, dated 1/19/2024 was reviewed. RNS 2 stated the record indicated a Level II Mental Health Evaluation was required, and stated the facility did not follow up to ensure it was completed. RNS 2 stated the purpose of the PASRR screenings and evaluations was to ensure that residents with mental illness received the appropriate services. RNS 2 stated that failure to ensure Resident 109's Level II Mental Health Evaluation was completed created the potential for Resident 109 to not receive recommended mental health services. 2. A review of Resident 25's admission Record indicated the facility originally admitted Resident 25 on 4/15/2011, and most recently readmitted Resident 25 on 5/8/2024. Resident 25's admitting diagnoses included schizophrenia and depression. A review of Resident 25's MDS, dated [DATE], indicated Resident 25 had diagnoses of schizophrenia and depression. A review of Resident 25's PASRR Level I Screening, dated 5/10/2024, indicated the individual completing the screening was supposed to mark yes or no to indicate if Resident 25 had a serious diagnosed mental disorder such as depressive disorder, .and schizophrenia. The PASRR was marked no, indicating Resident 25 did not have a serious mental disorder. During a concurrent interview and record review on 6/12/2024 at 10:21 a.m., with RNS 2, Resident 25's admission Record and MDS dated [DATE] were reviewed. RNS 2 stated the admission Record and MDS dated [DATE] indicated Resident 25 had diagnoses of schizophrenia and depression. The RNS then reviewed Resident 25's PASRR Level I Screening, dated 5/10/2024, and stated the PASRR Level I Screening, dated 5/10/2024, was not accurate. RNS stated a Level II Mental Health Evaluation was not required due to the inaccurate assessment, and stated that without the Level II Mental Health Evaluation, there was potential for Resident 25 to miss out on any recommended mental health services. A review of the facility policy and procedure (P&P) titled Pre-admission Screening and Resident Review (PASRR), dated 7/1/2023, indicated it was the facility's policy to ensure that all facility applicants are screened for mental illness and to ensure coordination with the appropriate state agencies, if indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent the development of a pressure ulcer (a wound that develops from prolonged pressure depriving the tissue from receiving oxygen) for one out of three residents (Resident 58). The deficient practice had the potential to cause serious infection, tissue injury, and extreme discomfort to Resident 58. Findings: A review of Resident 58's admission Record indicated the facility originally admitted Resident 58 on 2/11/2021, and most recently re-admitted Resident 58 on 4/12/2024. Resident 58's admitting diagnoses included carcinoma (cancer) of the anus (the opening at the far end of the digestive tract through which stool leaves the body) and anal canal (a channel connecting the rectum to the anus), chronic ulcerative proctitis (an inflammatory disease involving only the rectum), and adult failure to thrive (a weight syndrome with decreased appetite, poor nutrition, and inactivity). A review of Resident 58's History and Physical (H&P), dated 4/12/2024, indicated Resident 58 had the capacity to understand and make decisions. A review of Resident 58's baseline (a minimum starting point used for comparison) assessment titled Light Comprehensive Assessment, dated 4/12/2024, indicated Resident 58 had no skin break down (opening of the skin) or pressure ulcers upon admission. A review of Resident 58's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 4/24/2024, indicated Resident 58 required total assistance with all activities of daily living (self care activities performed daily) such as eating, oral hygiene, toileting hygiene, showering/bathing, dressing, and personal hygiene. A review of Resident 58's Light Wound Weekly Observation Tool, dated 5/11/2024, indicated Resident 58 developed a wound on the sacrum (lower back) which measured 3 centimeters (cm, unit of measurement) (in length) by (x) 3 cm (in width) x 0.1 cm (in depth) in size. A review of Resident 58's Light Wound Weekly Observation Tool, dated 5/15/2024, indicated Resident 58 wound on the sacrum had increased in width and the new measurements were 2.4 cm x 4.5 cm. A review of Resident 58's Light Wound Weekly Observation Tool, dated 6/5/2024, indicated Resident 58 wound on the sacrum had increased in overall size, measuring 5.4 cm x 6.4 cm x 1.2 cm. A review of Resident 58's care plan for Pressure Ulcers, dated 5/15/2024, indicated Resident 58 had an unstageable (unable to determine the depth, degree, and severity of the wound) pressure ulcer to the sacrum. The care plan indicated Resident 58's health goal was to heal the wound and remain free from infection by turning and repositioning Resident 58 at least once every two (2) hours and more often as needed. A review of Resident 58's Physicians Orders, dated 6/5/2024, indicated Resident 58's unstageable pressure ulcer was to be treated with Santyl ointment (a topical wound care treatment that breaks down unhealthy tissue that prevents wound healing) daily. The order further indicated to clean Resident 58's wound with normal saline, and to cover with a dry dressing. The physician orders for Resident 58 did not include a skin barrier or protectant cream for incontinence related moisture of urine and feces. A review of Resident 58's care plan titled Stage 4 (a wound so deep it reaches the bone) Pressure Ulcer of the Sacrum dated 6/6/2024, indicated for staff to monitor for effectiveness of treatments and to inform the physician for wound improvements and declines. A review of Resident 58's care plan titled Poor Healing of Stage 2 (a pressure ulcer that exceeds the dermis with partial thickness loss) dated 6/11/2024, indicated Resident 58's health goal was to show signs of healing on the sacral (sacrum) wound. There were no staff interventions/approaches indicated on the care plan. During an observation on 6/10/2024 at 10:12 a.m., Resident 58 was observed bedbound and asleep on an air mattress (a mattress used to relieve pressure for bedbound residents). During an interview on 6/12/2024 at 9:52 a.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated Resident 58 was last admitted to the facility on [DATE] without wounds. RNS 1 stated a wound was discovered on Resident 58 on 5/11/2024 while under the facility's care. RNS 1 stated Resident 58 constantly had feces coming out of her anus which made it hard to keep the resident skin clean and dry. RNS 1 stated Resident 58's care plan did not indicate any interventions for increased frequency of incontinence care or any moisture barrier creams. RNS 1 stated due to Resident 58's situation more frequent skin checks and cleaning was warranted. During an interview on 6/12/2024 at 2:10 p.m., with the Director of Nursing (DON), the DON stated Resident 58 developed a wound under the facility's care. The DON stated due to Resident 58's situation the resident should be turned and skin checked more frequently, however it was not part of their plan of care. The DON was not able to determine what stage Resident 58's wound was due to care plan discrepancies (one care plan indicated a Stage 4 and another indicated a Stage 2). During an interview on 6/12/2024 at 2:36 p.m., with the Treatment Nurse (TXN), the TXN stated Resident 58's sacral wound was currently a Stage 3 (full thickness loss with a depth that can reach the fat tissue layer) because she was able to see subcutaneous (fat) tissue. During an interview on 6/13/2024, at 8:51 a.m., with Certified Nursing Assistant (CNA) 7, CNA 7 stated Resident 58 had a small amount of blood and liquid feces constantly coming out of her anus. CNA 7 stated as soon as she changed and repositioned Resident 58, the resident would become wet from a combination of blood and feces. CNA 7 stated she changed and repositioned Resident 58 every 2 hours. A review of the facility's policy and procedure (P&P) titled Pressure Ulcer Management Protocol, dated 3/2010, indicated to primarily prevent ulcers by: a. Risk Assessment b. Relieve Pressure c. Good Skin Care d. Nutritional Assessment e. Incontinence Assessment d. Resident Mobility F. Resident & Family Education. The P&P indicated for pressure ulcers that are a Stage II (2), Stage III (3), and Stage IV (4) interventions should include: a. Repositioning in bed every 1-2 hours and chair every 30 minutes to 2 hours. b. Hydrotherapy (a method that uses water to treat a variety of conditions) and/or showers up to 3 times a week unless contraindicated. c. Lubrication of the skin with body lotions to enhance pliability of skin and minimize risk. d. Dietary interventions with particular attention to protein, vitamin C, fluid intake, and nutritional supplements as indicated. The P&P further indicated a bowel and bladder management regime, good perineal (private region) care, and use of protective moisture barrier creams as indicated are part of the interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to keep the environment free from hazardous maintenance tools and nails in the room for two out of eight residents (Resident 10 and Resident 51). The deficient practice had the potential to cause injury to Resident 10 and 51 by coming into direct contact with sharp objects. Findings: a. A review of Resident 10's admission Record indicated the facility originally admitted Resident 10 on 7/22/2016, and most recently re-admitted Resident 10 on 12/21/2022. Resident 10's admitting diagnoses included dementia (a brain disease that effects memory and cognitive function, interfering with daily life), schizophrenia (a mental disorder characterized by disorganized and delusional thinking, and auditory or visual hallucinations), and bipolar disorder (a mood disorder with manic and depressive episodes). A review of Resident 10's History and Physical (H&P), dated 12/19/2022, indicated Resident 10 did not have the capacity to understand and make decisions. A review of Resident 10's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 5/1/2024, indicated Resident 10 was mildly cognitively impaired (ability to think and reason). The MDS indicated Resident 10 required total assistance with toileting hygiene, showering/bathing, and personal hygiene. b. A review of Resident 51's admission Record indicated the facility originally admitted Resident 51 on 11/07/2017, and most recently re-admitted Resident 51 on 5/23/2024. Resident 51's admitting diagnoses included multiple sclerosis (a progressive disease in which the immune system eats away at the protective covering of nerves causing weakness and immobility). A review of Resident 51's H&P, dated 5/24/2024, indicated Resident 51 had the capacity to understand and make decisions. A review of Resident 51's MDS, dated [DATE], indicated Resident 51 was cognitively intact. The MDS indicated Resident 51 had required total assistance with all activities of daily living such as eating, oral hygiene, toileting hygiene, showering/bathing, dressing, and personal hygiene. During an observation on 6/10/2024, at 10:49 a.m., inside Resident 51 and Resident 10's shared room, Resident 51 and Resident 10 were observed asleep. There was a rolling cart with used nails, screws, a wood [NAME], and other unidentifiable sharp objects exposed and within reach. During an interview on 6/10/2024 at 10:55 a.m., with Maintenance Assistant (MA) 1, MA 1 stated his tools were in Resident 10 and Resident 51's room because the floor needed to be fixed, but he had to step away for 5 minutes. MA 1 stated leaving unattended tools and sharp objects was a safety concern for the residents. During an interview on 6/12/2024 at 10:26 a.m., with Registered Nurse (RN) 1, RN 1 stated when maintenance staff performed work in a resident room, they must remove their tools and not leave them in the room unattended, even for short periods because it was unsafe for residents. RN 1 stated a resident could take the instrument and use it on themselves, hide or, or use it on others. During an interview on 6/12/2024 at 10:32 a.m., with the Maintenance Supervisor (MS), the MS stated when maintenance staff worked in resident areas or in resident rooms, they must take their tools with them, and put it somewhere safe and inaccessible to residents to prevent possible resident injury. During an interview on 6/12/2024 at 1:55 p.m., with the Director of Nursing (DON), the DON stated when maintenance staff performed work inside a resident room they could not leave tools in the room because it could cause an injury to residents. A review of the facility's policy and procedure (P&P) titled Safety Committee - Composition and Duties, dated 5/1/2018, indicated the purpose of the policy was to promote the quality of resident care and safety by monitoring safe practices. The P&P indicated that staff are to: a. Maintain facility grounds in a manner to allow for the safety of residents and facility risks. b. Identify hazardous areas and unsafe work practices and recommend corrective action.

Based on observation, interview, and record review, the facility failed to implement the Registered Dietician's (RD, a health professional who has special training in diet and nutrition) recommendations for one of 25 sampled residents (Resident 66), when staff were unaware of recommendations for Resident 66 to be initiated on a Restorative Nursing Aid (RNA, a certified nursing assistant primarily assigned to perform therapeutic exercises and activities to maintain or re- establish a resident's optimum physical function and abilities) feeding program (a medical and nutritional treatment regimen to aid those with nutritional concerns). This deficient practice increased the risk for Resident 66 to sustain further weight loss and not meet his nutritional needs. Findings: A review of Resident 66's admission Record indicated the facility originally admitted Resident 66 on 7/9/2021, and most recently re-admitted the Resident 66 on 1/27/2023. Resident 66's admitting diagnoses included generalized muscle weakness and dysphagia (difficulty swallowing). A review of Resident 66's History and Physical (H&P), dated 2/5/2024, indicated Resident 66 had the capacity to understand and make decisions. A review of Resident 66's Minimum Data Set (MDS, a standardized assessment and care screening/planning tool), dated 5/26/2024, indicated Resident 66 had moderate cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 66 required set-up or clean-up assistance from staff to eat. A review of Resident 66's care plan, dated 4/5/2024 and revised 5/31/2024, indicated Resident 66 was at risk for complications in health status due to his history of weight loss and fluctuating weight. The care plan indicated the goals of care included minimization of repeat significant weight loss. The staff interventions indicated dietary consultations as needed, assessment of Resident 66's need for further nutritional support, and to assist with meals to encourage increased meal intake. A review of Resident 66's Dietary Progress Note, dated 6/10/2024, indicated Resident 66 sustained a 39 pound (lb.) weight loss in the last six months due to variable oral intake (nutrition consumed by mouth). The progress note indicated the Registered Dietician (RD) recommended Resident 66 be initiated on a RNA feeding program for breakfast and lunch to promote increased oral intake and weight stabilization. A review of Resident 66's active physician orders did not indicate any orders for RNA feeding program. During an interview on 6/11/2024 at 8:54 a.m., with Certified Nursing Assistant (CNA) 4, CNA 4 stated Resident 66 was receiving a pureed diet (a diet where the food has been ground, pressed, and/or strained to a soft, smooth consistency, like a pudding) and fed himself. CNA 4 stated she set-up Resident 66's breakfast tray in the morning and did not assist with or supervise Resident 66 for breakfast. During a concurrent observation and interview, on 6/11/2024 at 1:02 p.m., in Resident 66's room, Resident 66 was observed sitting up in bed, with his lunch tray on his bedside table, placed directly in front of him. Resident 66 stated he was feeding himself. No staff were observed at the bedside to assist Resident 66 to eat, or to supervise the resident while eating. During an interview on 6/11/2024 at 1:04 p.m. with CNA 4, CNA 4 stated Resident 66 was not on a feeding program and stated Resident 66 fed himself. During a concurrent interview and record review on 6/11/2024 at 1:13 p.m., with Registered Nurse Supervisor (RNS) 1, Resident 66's dietary progress note dated 6/10/2024 was reviewed. RNS 1 stated the progress note indicated Resident 66 was supposed to be on a RNA feeding program. RNS 1 stated she was not aware of this progress note, or the RD's recommendations. RNS 1 stated that if Resident 66 was not on an RNA feeding program as recommended by the RD, Resident 66 was at risk for further weight loss. During an interview on 6/11/2024 at 1:19 p.m., CNA 1, CNA 1 stated she worked as a RNA in the facility and was responsible for implementing the RNA feeding program for any residents that required it. CNA 1 stated Resident 66 was not included in the residents seen for the RNA feeding program for breakfast or lunch. During a concurrent interview and record review, on 6/11/2024 at 2:18 p.m., with the Director of Nursing (DON), Resident 66's dietary progress note, dated 6/10/2024, and the current physician orders were reviewed. The DON stated that when the RD recommended to start a resident on a RNA feeding program, the recommendation was entered as an order to be carried out by the staff. The DON stated she was unaware of the recommendations made by the RD and stated there were no orders for Resident 66 to be started on an RNA feeding program. The DON stated the RNA feeding program was an intervention utilized when a resident had experienced weight loss and poor oral intake. The DON stated the RNA feeding program required RNAs to provide supervision to the residents during meals, encourage oral intake, and/or feed the residents if needed. The DON stated the RNA program was to aid in the prevention of further weight loss. During an interview on 6/12/2024 at 11:00 a.m., with the RD, the RD stated that timeliness in following up on the dietary recommendations made for the facility residents could make a difference in the residents' outcomes, including their nutritional status. A review of the facility's job description titled Job Descriptions Job Title: [Registered Nurse] Supervisor, dated 12/14/1998, indicated the RNS was responsible for monitoring all documentation necessary for quality patient care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled Behavior - Management, which indicated when a resident displayed new behavioral symptoms, staff would use effective verbal and non-verbal communication techniques to manage the behavior problems, prior to initiating psychotropic medications (medications used to treat anxiety) for one of one sampled residents (Resident 107), who was deaf and visually impaired. The facility failed to ensure: 1. Resident 107's behavior was assessed using a communication board, writing pad, or American Sign Language (ASL, a language expressed by movements of the hands and face), to meet the resident's needs, prior to diagnosing Resident 107 with anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), and administering lorazepam ([Ativan], a drug used to treat anxiety) to Resident 107 on 4/20/2024, 4/25/2024, and 5/3/2024. This deficient practice placed Resident 107 at risk for unnecessary medication and side effects associated with Ativan including headache, muscle weakness, sleep problems and loss of balance and coordination. Findings: A review of Resident 107's History and Physical (H&P) from a general acute care hospital (GACH) 1, dated 4/8/2024, indicated Resident 107 had a history of deafness, visual impairment/blindness, and dementia. The H&P did not indicate a diagnosis of anxiety disorder. A review of Resident 107's admission Record indicated Resident 107 was admitted to the facility on [DATE]. Resident 107's admitting diagnoses included dementia (loss of memory, language, problem-solving and other thinking abilities), deaf, nonspeaking (lacking the power of hearing, or having impaired hearing), history of falling, and generalized muscle weakness. The admission Record did not indicate a diagnosis of anxiety or anxiety disorder. A review of Resident 107's H&P, dated 4/17/2023, indicated Resident 107 did not have the capacity to understand and make decisions. A review of Resident 107's Minimum Data Set (MDS, a standardized care-planning and care-screening tool), dated 4/19/2024, indicated Resident 107 had moderate cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 107 had highly impaired hearing, did not speak, and had moderately impaired vision requiring the use of corrective lenses. The MDS indicated Resident 107 was unable to respond when asked how often she needed to have someone help her read instructions or written material. The MDS indicated Resident 107 exhibited rejection of care necessary to achieve goals for health and well-being for one (1) to three (3) days over a period of seven (7) days. The MDS indicated Resident 107 required partial to moderate assistance from staff for hygiene after toileting, dressing her upper body, personal hygiene activities, mobility while in bed, and transitioning between surfaces (bed to chair, getting on and off the toilet). The MDS indicated Resident 107 required verbal cues and/or touching/steadying assistance from staff when eating, brushing her teeth, dressing her lower body, putting on/taking off her shoes, and walking. A review of Resident 107's Progress Note, dated 4/12/2024 at 10:59 p.m., indicated Resident 107 had an episode of aggressive behavior due to frustration from inability to communicate her needs. A review of Resident 107's physician order, dated 4/12/2024, indicated to administer one (1) mg of lorazepam to be taken by mouth every four (4) hours as needed for anxiety for 14 days. This order was discontinued on 4/19/2024. A review of Resident 107's admission summary, dated [DATE], indicated Resident 107 was admitted from GACH 1, was deaf and used American Sign Language (ASL, a language expressed by movements of the hands and face) to communicate. The admission summary dated [DATE], indicated due to frustration from being unable to talk, Resident 107 spat water at the nursing staff who were attempting to assess her. A review of Resident 107's Progress Note, dated 4/14/2024, at 8:20 a.m., indicated Resident 107 was agitated (irritable, easily annoyed), displayed restlessness, walked up and down the hallway, and saying no one could understand her. The progress note did not indicate any attempts to assess Resident 107's preferred method of communication, or staff's attempts to communicate with the resident in her preferred method of communication. A review of Resident 107's Progress Note, dated 4/14/2024 at 9:59 p.m., indicated Resident 107 was observed with episodes of restlessness, wandering, and continuously trying to leave the facility. The progress notes further indicated Resident 107 was exhibiting increased frustration evidenced by her facial expressions. The progress note indicated Resident 107 was redirected to her room and placed under direct supervision. The progress note did not indicate any attempts to assess Resident 107's preferred method of communication, or staff's attempts to communicate with her in her preferred method of communication. A review of Resident 107's Progress Note, dated 4/15/2024 at 12:29 p.m., indicated Resident 107's family member (FM 1) notified staff that the effective way to communicate with Resident 107 was through ASL. A review of Resident 107's Progress Note, dated 4/15/2024 9:29 p.m., indicated Resident 107 was agitated, restless, and communicating through hand gestures and no one could understand her. The progress note did not indicate any staff intervention to address Resident 107's agitation, restlessness, or any attempts to communicate with Resident 107 in her preferred method of communication, to meet her needs. A review of Resident 107's Progress Note, dated 4/17/2024 at 4:06 p.m., indicated Resident 107 wrote on pen and paper and indicated she wanted to go home. A review of Resident 107's Change in Condition Evaluation (COC), dated 4/18/2024 at 9:23 p.m., indicated Resident 107 was non-verbal and communicated in sign language. The COC indicated Resident 107 attempted to leave the facility. The COC indicated Resident 107 had episodes of restlessness and agitation. The COC indicated attempts to redirect the resident were less effective due to a communication barrier between Resident 107 and the staff. The COC indicated Resident 107 refused to go back to her room and continued to try to communicate in sign language and gestures. The COC did not indicate that attempts were made to communicate with Resident 107 in her preferred method of communication, or address Resident 107's restlessness and attempts to leave the facility. A review of Resident 107's physician order, dated 4/19/2024, indicated to administer one (1) mg of lorazepam to be taken by mouth every 14 hours as needed for anxiety for 14 days. This order was discontinued on 5/3/2024. A review of Resident 107's physician order, dated 4/13/2024 to 4/27/2024, indicated staff were to monitor Resident 107 for anxiety manifested by fidgeting or restlessness. A review of Resident 107's Progress Note, dated 5/2/2024 at 1:45 p.m., indicated Resident 107 was seen by Physician Assistant (PA) 1 on 4/18/2024. The progress note indicated Resident 107 presented as anxious and verbalized wanting to go home. The note further indicated PA 1's assessment indicated Resident 107 had anxiety disorder, and the plan of care included lorazepam (Ativan) 1 milligram (mg, a unit of measuring) every 12 hours as needed for anxiety for 14 days. A review of Resident 107's Progress Note, dated 5/5/2024 at 8:56 p.m., indicated Resident 107 was seen by PA 1 on 5/2/2024. The progress note indicated PA 1's assessment indicated Resident 107 had anxiety disorder and was to receive lorazepam 1 mg every 12 hours as needed for anxiety for 14 days. A review of Resident 107's Medication Administration Records (MAR), dated 4/1/2024 to 4/30/2024, and 5/1/2024 to 5/31/2024, indicated staff documented 16 episodes of anxiety manifested by fidgeting or restlessness, and administered four (4) doses of lorazepam to Resident 107 for anxiety on 4/20/2024, 4/25/2024, and twice on 5/3/2024. During an observation on 6/10/2024 at 10:10 a.m., in the doorway of Resident 107's room, Resident 107 was observed sitting up at the right edge of her bed with her back towards the door. Resident 107 did not respond to vocalized questions. Upon entering the room, Resident 107 vocalized unintelligible sounds, and pointed to her ears and her eyes. No communication board, writing pad, or other communication devices were observed readily available at Resident 107's bedside. During an observation on 6/10/2024 at 10:18 a.m., in Resident 107's room, Resident 107 was observed pacing at her bedside and pointing to her eyes and ears. During an interview on 6/12/2024 at 12:12 p.m., with FM 1, FM 1 stated she was Resident 107's responsible party. FM 1 stated the facility contacted her through video calls whenever they need to and maybe once or twice a month. FM 1 stated Resident 107's preferred communication method was ASL, and the facility informed her they were used a relay service to communicate with Resident 107 during daily provision of care. FM 1 stated Resident 107's vision was very bad, she could not read small print, and wore reading glasses. FM 1 stated Resident 107 could write but was unable to write or spell well. FM 1 stated she recommended the use of a Telecommunications Relay Service (a service that allows persons who are deaf, hard of hearing, deafblind, or with speech disabilities to communicate by telephone in a way equivalent to telephone services used by persons without such disabilities) to the facility as a method for communicating with Resident 107. FM 1 stated during her video calls with Resident 107, Resident 107 used ASL to notify FM 1 that the staff did not understand what she was saying to them each time she tried to explain her needs. FM 1 stated she could tell Resident 107 was frustrated based on her facial expressions. FM 1 stated Resident 1 asked her multiple times if she could go home, and FM 1 stated she had to change the subject because Resident 107 felt bad and appeared to be in distress during the conversations. During a telephone interview on 6/13/2024 at 8:41 a.m., with PA 1, PA 1 stated he was asked to assess Resident 107's behaviors and review and manage her psychotropic medications (medications that affect the mind, emotions, and behavior). PA 1 stated Resident 1 had dementia, deafness, and was non-verbal with periods of confusion. PA 1 stated Resident 107 attempted to leave the facility. PA 1 stated he was not trained or certified in ASL, and stated he assessed Resident 107 on 4/18/2024 and 5/2/2024. PA 1 stated on 4/18/2024 he was accompanied by an unspecified nursing staff who used an interpreter via video call to assist with interpreting Resident 107's responses. PA 1 stated he did not verify the identity or qualifications of the interpreter to ensure the assessment data collected was accurate. PA 1 stated he conducted the assessment on 5/2/2024 without the use of an interpreter. PA 1 stated he conducted the assessment by writing simple questions on a piece of paper, and asked Resident 107 to write yes or no in response to the questions. PA 1 stated he did not verify if Resident 107 could read or understand the questions. PA 1 stated his assessments were used to guide Resident 107's plan of care, and stated his assessments were supposed to be accurate, but he was unable to verify if the assessment data collected was accurate. PA 1 stated he should have used an interpreter, but he did not. PA 1 stated Resident 107 continued to receive Ativan to treat an anxiety disorder. PA 1 stated anxiety disorder can be an acute condition (a condition that is severe and sudden in onset) and likely caused by Resident 107's inability to communicate with others. PA 1 stated he was unsure if staff addressed the cause of Resident 107's anxiety prior to the administration of Ativan. During an interview on 6/13/2024 at 11:41 a.m., with the MDS Nurse (MDSN), the MDSN stated she was responsible for the admission process, including ensuring required services for each resident were readily available prior to admitting the resident to the facility. The MDSN stated prior to Resident 107's admission to the facility, staff were aware of Resident 107's hearing impairment, and the facility did not have interpreter services available. The MDSN stated the facility planned to rely on FM 1 as an interpreter, though it was not the facility's policy to rely on family members as interpreters. The MDSN stated interpreter services should have been available prior to accepting Resident 107 to the facility, and Resident 107 should not have been admitted without the necessary services available. The MDSN stated the facility was currently working on obtaining interpreter services, but there was still no service in place at the time of the interview. During a concurrent interview and record review, on 6/13/2024 at 12:12 p.m., with the Director of Nursing (DON), Resident 107's admission Record, undated, nursing progress notes dated 4/12/2024 to 6/13/2024, COC, dated 4/18/2024, and Resident 107's current and discontinued care plans, and Resident 107's discontinued physician orders for lorazepam, dated 4/12/2024 to 4/19/2024, and 4/19/2024 to 5/3/2024, were reviewed. The DON stated the admission Record indicated Resident 107 was admitted on [DATE] and did not indicate a diagnosis of anxiety disorder. The DON stated the progress notes indicated staff were aware of Resident 107's preference to communicate using ASL, and Resident 107 displayed signs of frustration, agitation, and restlessness due to her inability to communicate with the staff. The DON stated there were no current or discontinued care plans to address Resident 107's anxiety. The DON stated there were no non-pharmacological (any type of healthcare intervention which is not primarily based on medication) interventions in place or previously attempted to address the cause of Resident 107's anxiety. The DON stated the COC, dated 4/18/2024, indicated Resident 107 attempted to leave the facility and attempts to redirect Resident 107 were less effective due to communication barriers. The DON stated she was aware when Resident 107 was admitted to the facility on [DATE], that staff had difficulty communicating with her (Resident 107). The DON stated it was reasonable that Resident 107 wanted to elope (when a person leaves unsupervised and undetected) due to an inability to communicate or understand others. The DON stated if Resident 107 could not communicate her needs, staff would not be able to meet the resident's needs. The DON also stated lack of clear communication could lead to inaccurate assessments of Resident 107's clinical condition, and negatively impact the plan of care. The DON stated Resident 107's psychosocial well-being could also be negatively affected, and Resident 107 could suffer anxiety and frustration. A review of the facility policy and procedure (P&P) titled Behavior - Management, dated 1/1/2012, indicated staff were supposed to perform an appropriate assessment of the resident's behavioral symptoms and implement appropriate interventions. The P&P indicated when a resident displayed new behavioral symptoms, staff would implement non-pharmacologic interventions to alleviate possible causative factors and use effective verbal and non-verbal communication techniques to manage the behavior problems, prior to initiating psychotropic medications. The P&P indicated possible interventions included addressing psychosocial stressors and medical conditions. A review of the facility P&P titled Psychotherapeutic Drug Management, dated 5/17/2024, indicated the purpose of the policy was to implement the most desirable and effective interventions to eliminate behaviors that were distressing to the resident, and/or decreasing or negatively impacting the resident's quality of life. The P&P indicated nursing staff's responsibilities included considering other factors that may be causing expressions or indications of distress before initiating psychotropic medications, such as an underlying medical condition, or psychosocial stressors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one bottle of Gabapentin (a medication used to treat nerve pain) 250 milligrams (mg - a unit of measure for mass) per 5 milliliters (ml - a unit of measure for volume) was stored in the refrigerator in one of three inspected medication carts (Station 2 Medication Cart 2) for Resident 62. The deficient practice of failing to store medications per the manufacturers' requirements increased the risk that Resident 62 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications. Findings: During a concurrent observation and interview on [DATE] at 1:45 p.m. of Station 2 Medication Cart 2, with Licensed Vocational Nurse (LVN 1), the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications: 1. One bottle of Gabapentin 250 mg per (/) 5 ml solution for Resident 62 was found stored at room temperature. According to the manufacturer's product labeling, Gabapentin 250 mg/5 ml solution should be stored in the refrigerator. LVN 1 stated the Gabapentin solution for Resident 62 was stored at room temperature but was supposed to be stored in the refrigerator according to the pharmacy label. LVN 1 stated because the resident needed the medication multiple times per day, it was likely not returned to the refrigerator after each dose as it should be. LVN 1 stated if the medication was not stored properly, there was a risk that it may not be effective when used for the resident. LVN 1 stated Resident 62 used this medication to treat nerve pain and could experience increased pain if the Gabapentin was ineffective due to improper storage. A review of the facility's undated policy and procedure (P&P) titled Storage of Medications, indicated medications and biologicals are stored safely, securely, and properly, and following the manufacturer's recommendations or those of the supplier. The P&P indicated medications requiring refrigeration are kept in a refrigerator with a thermometer to allow temperature monitoring.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide food that accommodated residents' preferences and offer meal substitutes of the same nutritive values for one of six sampled residents (Resident 112). These deficient practices had the potential to alter Resident 112's nutritional status. Findings: During a concurrent observation and interview on 6/10/2024 at 12:58 p.m., with Resident 112, in Resident 112's room, Resident 112's lunch meal tray was observed on top of the resident's bedside table. Resident 112's lunch meal tray included meatloaf, steamed vegetables, mashed potatoes, corn bread, and milk. Resident 112 was observed eating ice cream, and stated she was not going to eat her lunch because she did not like beef. Resident 112 stated that she was still being served beef even though she told the dietary staff that she did not like beef. A review Resident 112's meal tray ticket on 6/10/2024 at 1:05 p.m., indicated Resident 112 was receiving a regular, mechanical soft diet (texture-modified diet that restricts foods that are difficult to chew or swallow) with thin liquids. Resident 112's meal tray ticket indicated the resident disliked beef, coffee, pork, salad, and pasta. A review of Resident 112's Face Sheet, indicated Resident 112 was admitted to the facility on [DATE] with diagnoses including schizophrenia (serious mental health condition which affects the way one thinks, behaves, and feels clearly) and seizures (abnormal electric activity in the brain). A review of Resident 112's Minimum Data Set (MDS, a standardized resident assessment and care screening tool) dated 5/16/2024, indicated Resident 112's cognitive skills for daily decision making was intact (ability to think and reason). The MDS indicated Resident 112 required supervision (the helper provides verbal cues, touching contact as resident completes activity) for toileting hygiene, dressing, showering, and personal hygiene. During a concurrent observation and interview on 6/10/2024 at 1:15 p.m., with the Dietary Supervisor (DS), in Resident 112's room, the DS confirmed Resident 112's meal tray contained meatloaf. The DS stated he asked each individual resident about their food preferences. The DS stated there were three checks before the tray left the kitchen. The DS stated the tray line staff checked the menu cards with the tray. The DS stated he, himself, did a final check before the trays left the kitchen. The DS stated the third and final check was performed by the licensed nurse who helped pass out the trays to the residents. During an interview on 6/13/2024 at 9:57 a.m., with the Director of Nursing (DON), the DON stated it was important to honor residents' food preferences. The DON stated disliked food may affect the residents' intake and placed residents at risk for malnutrition (lack of proper nutrition). A review of the facility's Policy and Procedure (P&P) titled Food substitutions during tray line and alternate for food item resident does not like that is recorded on the tray card, undated, indicated the cook will provide a food substitute at each meal for food items that a resident may dislike, which has been noted on their tray card. A review of the facility's P&P titled Food preferences, undated, indicated, substitutes for all foods disliked will be given from the appropriate food group.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d. A review of Resident 88 admission Record, the admission Record indicated Resident 88 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 88's diagnoses included encephalopathy, schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A review of Resident 88's MDS, dated [DATE], indicated Resident 88 was able to sometimes understand and sometimes be understood by others. The MDS indicated Resident 88's cognition was moderately impaired. The MDS indicated Resident 88 had impairments on both sides of his lower extremities (lower part of the body that includes the hip, knee, ankle, and foot). The MDS indicated Resident 88 was dependent on staff for eating, oral hygiene, toileting, bathing, dressing, and personal hygiene. A review of Resident 88's H&P, dated 7/4/2023, indicated Resident 88 did not have the capacity to understand and make decisions. A review of Resident 88's Comprehensive Assessment, dated 10/13/2023, indicated Resident 88 had left and right side rails on his bed that was indicated for safety and to promote independence with bed mobility. There was no indication that consent was received for bilateral (both sides) side rails. A review of Resident 88's active physician orders did not indicate any orders for the use of bedrails or the placement of Resident 88's bed against the wall. During an observation on 6/10/2024 at 10:57 a.m. and on 6/11/2024 at 9:25 a.m., in Resident 88's room, Resident 88 was observed lying in bed, with his bed against the wall and with the upper bilateral side rails up. During an interview on 6/11/2024 at 2:17 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated restraints were considered any device used to restrict the residents' movements. LVN 2 stated to use restraints appropriately, the resident's physician would have to determine if restraints were warranted and would place an order. LVN 2 stated the physician would then inform the resident or their responsible party regarding the indication for the restraint and to obtain informed consent on whether they agreed to its use. During a concurrent observation and interview on 6/11/2024 at 2:22 p.m., with LVN 2, inside Resident 88's room, Resident 88 was observed lying in bed, with his bed against the wall and with the upper bilateral side rails up. LVN 2 stated the use of side rails and the bed against the wall restricted Resident 88's movement and should not be used unless needed. During a concurrent interview and record review on 2/11/2024 at 2:25 p.m., with LVN 2, Resident 88's Informed Consents were reviewed. The Informed Consents did not indicate informed consent was obtained from Resident 88's responsible party. LVN 2 stated when restraints were indicated for a resident, the resident's responsible party should be contacted and the risks and benefits for the use of restraints should be explained. LVN 2 stated the responsible party should then be able to decide on the use the restraints. e. A review of Resident 16's admission Record, indicated Resident 16 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 16's diagnoses included encephalopathy, epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), and dementia. A review of Resident 16's MDS, dated [DATE], indicated Resident 16 was usually able to understand and be understood by others. The MDS indicated Resident 16's cognition was moderately impaired. The MDS indicated Resident 16 had impairments on both sides of his upper extremities and on one side of the lower extremities. The MDS indicated Resident 16 was dependent on staff for eating, oral hygiene, toileting, bathing, dressing, and personal hygiene. A review of Resident 16's H&P, dated 1/16/2024, indicated Resident 16 did not have the capacity to understand and make decisions. A review of Resident 16's Comprehensive Assessment, dated 2/8/2024, indicated Resident 16 had left and right side rails. The Comprehensive Assessment indicated there was no indication for the use of the side rails nor indication that consent was received for bilateral side rails. During an observation on 6/10/2024 at 10:23 a.m. and on 6/11/2024 at 9:27 a.m., in Resident 16's room, Resident 16 was observed lying in bed, with his bed against the wall and with the upper bilateral side rails up. During a concurrent observation and interview on 6/11/2024 at 2:20 p.m., with LVN 2, inside Resident 16's room, Resident 16 was observed lying in bed, with his bed against the wall and with the upper bilateral side rails up. LVN 2 stated the use of side rails and the bed against the wall restricted Resident 16's movement and should not be used unless needed. During a concurrent interview and record review on 2/11/2024 at 2:24 p.m., with LVN 2, Resident 16's Informed Consents were reviewed. The Informed Consents did not indicate informed consent was obtained from Resident 16's responsible party. LVN 2 stated when restraints were indicated for a resident, the resident's responsible party should be contacted and provide the risks and benefits for the use of restraints and allow the responsible party to decide if the facility could use the restraint on the resident. During an interview on 6/13/2024 at 10:15 a.m., with the Director of Nursing (DON), the DON stated the Interdisciplinary Team (IDT, a group of healthcare professionals with various areas of expertise who work together towards the goals of the residents) would discuss the necessity of the restraint for the resident. The DON stated if the IDT approved the necessity, they would inform the resident's physician of the recommendation and discuss how the resident would benefit from the device. The DON stated the IDT would include the resident's responsible party in the discussion so they could be aware of the situation. The DON stated the physician would obtain informed consent from the resident and/or their responsible party to explain the risks and benefits of the restrictive device to allow the resident and/or the responsible party to decline its use. A review of the facility P&P titled Restraints, dated 5/1/2018, indicated that before any type of restraint is used, the licensed nursing staff were supposed to verify that informed consent had been obtained from the resident or their RP. The P&P indicated that restraints included any physical device or equipment attached or adjacent to the resident's body that restricted freedom of movement, including bed rails or beds against the wall. Based on observation, interview, and record review, the facility failed to ensure the residents and/or responsible party were informed in advance, of the risks and benefits of the use of physical restraints (manual method or device used to restrict freedom of movement or normal access to one's body) for five of 12 sampled residents (Resident 66, Resident 71, Resident 15, Resident 88, and Resident 16). These deficient practices resulted in the violation of Resident 66, 71, 15, 88, and 16's and/or responsible party's right to make an informed decision regarding the use of physical restraints. Findings: a. A review of Resident 66's admission Record indicated Resident 66 was originally admitted to the facility on [DATE], and most recently re-admitted on [DATE]. Resident 66's admitting diagnoses included unspecified abnormalities of gait (manner of walking) and mobility, generalized muscle weakness, and anxiety disorder (mental health disorder characterized by feelings of worry, or fear that are strong enough to interfere with one's daily activities). A review of Resident 66's History and Physical (H&P), dated 2/5/2024, indicated Resident 66 had the capacity to understand and make decisions. A review of Resident 66's Minimum Data Set (MDS, a standardized assessment and care screening/planning tool), dated 5/26/2024, indicated Resident 66 had moderate cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 66 required supervision or touching/steadying by staff to reposition himself in bed, transition from sitting to lying position and vice versa, transition from sitting to standing, and transfer from bed to chair and vice versa. The MDS did not indicate the use of bedrails. A review of Resident 66's active physician orders did not indicate any orders for the use of bedrails or the placement of Resident 66's bed against the wall. During an observation on 6/11/2024 at 8:39 a.m., at Resident 66's bedside, Resident 66's bed was observed placed against the wall, with the left side of the bed touching the wall. There were bed rails to the right and left side of Resident 66's bed. During an interview with 6/13/2024 at 11:04 a.m., with the Director of Medical Records (DMR), the DMR stated Resident 66 did not have an informed consent for use of bedrails, or placement of the resident's bed against the wall. b. A review of Resident 71's admission Record indicated Resident 71 was originally admitted to the facility on [DATE], and most recently re-admitted on [DATE]. Resident 71's admitting diagnoses included unspecified abnormalities of gait and mobility, generalized muscle weakness, and encephalopathy (a broad term for any brain disease that alters brain function or structure). A review of Resident 71's H&P, dated 4/17/2024, indicated Resident 71 had the capacity to understand and make decisions. A review of Resident 71's MDS, dated [DATE], indicated Resident 71 had severe cognitive impairment. The MDS indicated Resident 71 required partial to moderate assistance from staff to roll left and right in bed, transition from a sitting to lying position and vice versa, transition from a sitting to standing position and vice versa, and transfer from a chair to bed and vice versa. The MDS did not indicate the use of bedrails. A review of Resident 71's active physician orders did not indicate any orders for the use of bedrails or the placement of Resident 71's bed against the wall. During an observation on 6/11/2024 at 9:14 a.m., at Resident 71's bedside, Resident 71's bed was observed placed against the wall, with the left side of the bed touching the wall. There were bed rails to the right and left side of Resident 71's bed. During an interview with 6/13/2024 at 11:04 a.m., with the DMR, the DMR stated Resident 71 did not have an informed consent for use of bedrails, or placement of the resident's bed against the wall. c. A review of Resident 15's admission Record indicated Resident 15 was originally admitted to the facility on [DATE], and most recently re-admitted on [DATE]. Resident 15's admitting diagnoses included unspecified abnormalities of gait and mobility, generalized muscle weakness, anxiety disorder, and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 15's H&P, dated 11/8/2023, indicated Resident 15 did not have the capacity to understand and make decisions. A review of Resident 15's MDS, dated [DATE], indicated Resident 15 had moderate cognitive impairment. The MDS indicated Resident 15 had upper extremity impairment on one side of his body and required the use of a wheelchair. The MDS indicated Resident 15 required partial to moderate assistance from staff to transition from a sitting to standing position and vice versa, and to transition from a sitting to lying position and vice versa. The MDS indicated Resident 15 was dependent on staff to transfer from bed to chair and vice versa. A review of Resident 15's active physician order, dated 11/8/2023, indicated to apply lap tray (a tray with a cushioned underside, designed to rest in a person's lap) when up in wheelchair to prevent resident from sliding off the chair and maintain proper posture. During an observation on 6/10/2024 at 11:26 a.m., outside of Resident 15's room, Resident 15 was observed sitting in his wheelchair with a tray across his lap. The tray was fastened in the rear of the wheelchair, behind the back of the seat. During a concurrent observation and interview, on 6/11/2024 at 9:25 a.m., outside of Resident 15's room, with Licensed Vocational Nurse (LVN) 1 and Resident 15, LVN 1 observed Resident 15's lap tray. Resident 15's lap tray was across his lap and fastened in the rear of the wheelchair. Resident 15 stated the buckle to fasten the lap tray was behind him and he could not reach it. LVN 1 stated that if Resident 15 wanted to get up, staff assisted him. During a concurrent interview and record review, on 6/11/2024 at 1:25 p.m., with Registered Nurse Supervisor (RNS) 1, Resident 15's active physician orders and care plans were reviewed. RNS 1 stated the physician order dated 11/8/2023 indicated to apply the lap tray to prevent Resident 15 from sliding off the chair. RNS 1 stated Resident 15 had a history of falls, and stated the lap tray was being used as a restraint for fall prevention. A review of Resident 15's record titled Restraint Physical, dated 10/3/2021, indicated the use of restraints was discussed with Resident 15's emergency contact and responsible party (RP). During an interview on 6/12/2024 at 2:03 p.m., with Resident 15's responsible party (RP 1), RP 1 stated she was unaware Resident 15's lap tray was being used as restraint. RP 1 stated, I would not have allowed anything that prevents him from getting out of the chair. RP 1 stated she would never approve anything that restricted Resident 15's movement, and stated she had seen the lap tray applied when she visited Resident 15 in the past, and stated she thought it was for his food. RP 1 stated she did not know the lap tray was to keep him bound. RP 1 stated she never consented to use of the lap tray as restraint, and stated the facility staff had never discussed the use of restraints with her. During a concurrent observation and interview on 6/13/2024 at 10:33 a.m., with Resident 15, in the hallway outside of Resident 15's room, Resident 15 was observed sitting in his wheelchair in the hallway, with a lap tray attached to the wheelchair and placed across his lap. Resident 15 stated he fell out of his wheelchair a while ago, and facility staff applied the lap tray to his wheelchair following the fall. Resident 15 stated he wanted to get up on his own, but he could not because of the lap tray. Resident 15 stated he walked in the morning, but wanted to walk more, and stated he sometimes wished he could remove the tray. Resident 15 stated he did not try to get up unassisted and stated I know I can't do it. I call for help. During a concurrent interview and record review, on 6/13/2024 at 9:31 a.m., with the Director of Nursing (DON), the facility policy and procedure (P&P) titled Informed Consent, dated 4/12/2022 was reviewed. The DON stated the P&P dated 4/12/2022 was the current facility policy for informed consent. The DON stated the purpose of informed consent was to inform the resident or their responsible party about the use of restraints, and to provide them the opportunity to decline. The DON stated informed consent needed to be obtained by the physician, and stated there was no documentation that Resident 15's physician discussed the use of a lap tray restraint with RP 1. The DON stated the facility did not obtain informed consent for the use of a lap tray restraint on Resident 15.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. During an observation on 6/10/2024 at 10:36 a.m., in Resident 93's room, Resident 93 was observed lying in bed. Resident 93's bed was observed against the wall, and bilateral siderails upper position. A review of Resident 93's admission Record, indicated Resident 93 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 93's diagnoses included chronic obstructive pulmonary disease ([COPD] a chronic lung disease that causes obstructed airflow from the lungs) and chronic kidney disease (loss of kidney function). A review of Resident 93's MDS, dated [DATE], the MDS indicated Resident 93's cognitive skills for daily decision making was intact. The MDS indicated Resident 93 required moderate assistance (helper does less than half the effort) from staff for toileting hygiene, shower, and personal hygiene. 6. During an observation on 6/10/2024 at 10:47 a.m., in Resident 40's room, Resident 40 was observed lying in bed watching television. Resident 40's bed was observed against the wall, and the bilateral siderails in the up position. A review of Resident 40's admission Record, indicated Resident 40 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 40's diagnoses included muscle weakness, schizophrenia, and anxiety. A review of Resident 40's MDS, dated [DATE], indicated Resident 40's cognitive skills for daily decision making was impaired. The MDS indicated Resident 40 required moderate assistance (helper does less than half the effort) from staff for toileting hygiene, and shower. The MDS indicated Resident 40 required supervision (the helper provides verbal cues, touching contact as resident completes activity) for oral hygiene, and personal hygiene. During a concurrent observation and interview on 6/11/2024 at 12:00 p.m., in Resident 40's room, Resident 40 was observed seating on the bed and watching television. Resident 40's bed was observed against the wall, and the bilateral siderails up. Resident 40 stated he would like to have more space around the bed to be able to sit by the window and enjoy the view on the outside patio. Resident 40 stated he was not aware why there were siderails. Resident 40 stated he did not the siderails. 7. During and observation on 6/10/2024 at 11:21 a.m., in Resident 13's room, Resident 13's bed was observed with the bilateral siderails up. A review of Resident 13's Face Sheet, indicated Resident 13 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 13's diagnoses included dementia, dysphagia (difficulty swallowing), and Parkinson's disease (a brain disorder that cause uncontrollable movements, such as shaking, and difficulty with balance). A review of Resident 13's MDS, dated [DATE], indicated Resident 13 had moderate impairment in cognitive skills. The MDS indicated Resident 13 required assistance from staff for activities of daily living (ADLs, self-care activities performed daily such as dressing, personal hygiene, and toileting). 8. During an observation on 6/10/2024 at 12:06 a.m., in Resident 36's room, Resident 36's bed was observed against the wall with the bilateral siderails up. A review of Resident 36's Face Sheet, indicated Resident 36 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 36's diagnoses included dementia, anxiety, epilepsy, and diabetes (high blood sugar). A review of Resident 36's MDS, dated [DATE], indicated Resident 36 cognitive skills for daily decision making was impaired. The MDS indicated Resident 36 required moderate assistance from staff for toileting hygiene, shower, and personal hygiene. 9. During a concurrent observation and interview on 6/10/2024 at 12:58 p.m., in Resident 112's room, Resident 112 was observed sitting on the bed. Resident 112's bed was observed against the wall with the bilateral siderails in the up position. Resident 112 stated she did not need siderails and was not aware why her bed had siderails. A review of Resident 112's Face Sheet, indicated Resident 112 was admitted to the facility on [DATE]. Resident 112's diagnoses included schizophrenia, and seizures. A review of Resident 112's MDS, dated [DATE], indicated Resident 112 cognitive skills for daily decision making was intact. The MDS indicated Resident 112 required supervision for toileting hygiene, dressing, showering, and personal hygiene. During a concurrent observation and interview on 6/11/2024 at 12:04 p.m., in Resident 112's room, with Certified Nursing Assistant (CNA) 3. CNA 3 confirmed Resident 112's bed was observed against the wall, with the bilateral siderails in the up position. CNA 3 stated the resident's bed against the wall, and the siderails were considered a physical restraint. CNA 3 stated that prior to the use of physical restraints, the facility should have a physician order and informed consent. During a concurrent interview and record review on 6/12/2024 at 11:15 a.m., with RNS 1, Resident 93, Resident 40, Resident 13, Resident 36, and Resident 112's Electronic Medical Record (EMR) were reviewed. RNS 1 stated the facility placed residents' bed against the wall to provide more open space inside the residents' room. RNS 1 stated the siderails were for residents' safety and mobility. RNS 1 stated the bed against the wall, and the use of siderails should have a physician order and informed consent. RNS 1 stated there was no documentation that least restrictive measures were performed, physician orders, or informed consents were obtained prior to the use of siderails and prior to placing the residents' beds against the wall. 10. A review of Resident 15's admission Record indicated the facility originally admitted Resident 15 on 12/9/2018, and most recently re-admitted Resident 15 on 4/11/2021. Resident 15's admitting diagnoses included unspecified abnormalities of gait and mobility, generalized muscle weakness, anxiety disorder, and dementia. A review of Resident 15's H&P, dated 11/8/2023, indicated Resident 15 did not have the capacity to understand and make decisions. A review of Resident 15's MDS, dated [DATE], indicated Resident 15 had moderate cognitive impairment. The MDS indicated Resident 15 had upper extremity impairment on one side of his body and required the use of a wheelchair. The MDS indicated Resident 15 required partial to moderate assistance from staff to transition from a sitting to standing position and vice versa, and to transition from a sitting to lying position and vice versa. The MDS indicated Resident 15 was dependent on staff to transfer from bed to chair and vice versa. A review of Resident 15's active physician order, dated 11/8/2023, indicated to apply lap tray (a tray with a cushioned underside, designed to rest in a person's lap) when up in wheelchair to prevent resident from sliding off the chair and maintain proper posture. A review of Resident 15's care plans did not indicate a care plan was developed for the use or monitoring of Resident 15's lap tray. During an observation on 6/10/2024 at 11:26 a.m., outside of Resident 15's room, Resident 15 was observed sitting in his wheelchair with a tray across his lap. The tray was fastened in the rear of the wheelchair, behind the back of the seat. During a concurrent observation and interview, on 6/11/2024 at 9:25 a.m., outside of Resident 15's room, with LVN 1 and Resident 15, LVN 1 observed Resident 15's lap tray. Resident 15's lap tray was observed across his lap and fastened in the rear of the wheelchair. Resident 15 stated the buckle to fasten the lap tray was behind him and he could not reach it. LVN 1 stated that if Resident 15 wanted to get up, staff assisted him. During a concurrent interview and record review, on 6/11/2024 at 1:25 p.m., with RNS 1, Resident 15's active physician orders dated 11/8/2023 and care plans were reviewed. RNS 1 stated the physician order indicated to apply the lap tray to prevent Resident 15 from sliding off the chair. RNS 1 stated Resident 15 had a history of falls, and stated the lap tray was being used as a restraint for fall prevention. RNS 1 stated she was not sure of the facility's policy for the use of restraints, or whether the resident needed to be monitored. RNS 1 also stated there was no care plan for Resident 15's use of a lap tray as a restraint. During a concurrent interview and record review with the DON, on 6/11/2024 at 2:36 p.m., Resident 15's assessment titled Restraint - Physical, dated 9/15/2023, was reviewed. The DON stated Resident 15's continued need for restraints was supposed to be assessed quarterly (every three months). The DON stated the assessment dated [DATE] was the last time Resident 15's use of restraints was assessed, and stated the facility was way overdue for the next assessment. The DON stated the assessment indicated Resident 15's lap tray restraint was continued because Resident 15 continued to get up unassisted. The DON stated there were less restrictive measures that staff could implement to prevent Resident 15 from getting up unassisted and falling. The DON stated there was no documentation to indicate that less restrictive measures had been attempted since 9/2023. The DON stated facility staff were not routinely documenting the frequency of Resident 15's attempts to get up unassisted. During a concurrent observation and interview on 6/13/2024 at 10:33 a.m., with Resident 15, in the hallway outside of Resident 15's room, Resident 15 was observed sitting in his wheelchair in the hallway, with a lap tray attached to the wheelchair and placed across his lap. Resident 15 stated he fell out of his wheelchair a while ago. Resident 15 stated facility staff applied the lap tray to his wheelchair following the fall. Resident 15 stated he wanted to get up on his own but could not because of the lap tray. Resident 15 stated he walked in the morning, but wanted to walk more, and stated he sometimes wished he could remove the tray. Resident 15 stated he did not try to get up unassisted and stated I know I can't do it. I call for help. A review of the facility P&P titled Restraints, dated 5/1/2018, indicated it was the facility policy to provide residents with an environment that was restraint free, and that the least restrictive measures would be used if a restraint was necessary to treat a medical symptom. The P&P defined a physical restraint as any physical or mechanical device attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement including bedrails and beds against the wall. The P&P indicated: a. Alternative methods of behavioral control must be attempted and documented in the resident's medical record before a physical restraint is used. b. The Facility will not use restraints as needed PRN or as necessary basis. c. Informed consent will be obtained from the resident or responsible party if a restraint will be used. d. Restrained residents will be reviewed regularly (at a minimum of quarterly by the IDT to determine the continued need for restraints. e. The IDT will consider the elimination of restraints, or a less restrictive device whenever possible. f. Bed rail use will be addressed in the same manner as any other device that has the potential to risk movement. g. If the Facility is utilizing bed rails, the Bed Rail Entrapment Risk Assessment will be completed by a Licensed Nurse prior to the installation of bed rails. h. To determine if a bed rail is being used as an enabler, the resident must be able to easily and voluntarily get in and out of bed when the equipment is in use. If the resident cannot easily and voluntarily release the bed rails and/or use the bed rails to reposition, the use of the bed rails may be considered a restraint. i. The IDT will discuss with the resident and/or resident representative the risk and benefits involved with bed rails and described alternatives that may be feasible prior to installing bed rails. j. Care plans for restraints are to be developed and implemented. A review of facility's P&P tilted Siderails, revised 3/2010, the P&P indicated: a. Facility to use siderails based on residents assessed medical needs. b. Used for treatment of medical symptoms or condition. c. A physician's order and signed release by resident is required. d. Used for resident's mobility and /or transfer. e. To protect the resident from falling out of bed. f. A physician's order and signed release by resident is required. 3. A review of Resident 88 admission Record, indicated Resident 88 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 88's diagnoses included encephalopathy, schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A review of Resident 88's MDS, dated [DATE], indicated Resident 88 was able to sometimes understand and sometimes be understood by others. The MDS indicated Resident 88's cognition was moderately impaired. The MDS indicated Resident 88 had impairments on both sides of his lower extremities (lower part of the body that includes the hip, knee, ankle, and foot). The MDS indicated Resident 88 was dependent on staff for eating, oral hygiene, toileting, bathing, dressing, and personal hygiene. A review of Resident 88's H&P, dated 7/4/2023, indicated Resident 88 did not have the capacity to understand and make decisions. A review of Resident 88's Comprehensive Assessment, dated 10/13/2023, indicated Resident 88 had left and right side rails. The Comprehensive Assessment indicated the side rails were indicated for safety and to promote independence with bed mobility. There was no indication that consent was received for the use of side rails. A review of Resident 88's active physician orders did not indicate any orders for the use of bedrails or the placement of Resident 88's bed against the wall. During an observation on 6/10/2024 at 10:57 a.m. and on 6/11/2024 at 9:25 a.m., in Resident 88's room, Resident 88 was observed lying in bed, with his bed against the wall and with the upper bilateral (pertaining to both sides) side rails up. During an interview on 6/11/2024 at 2:17 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated restraints were considered any device used to restrict the residents' movements. LVN 2 stated to use restraints appropriately, the resident's physician would have to determine if restraints were warranted and write an order. During a concurrent observation and interview on 6/11/2024 at 2:22 p.m., with LVN 2, inside Resident 88's room, Resident 88 was observed lying in bed, with his bed against the wall and with the upper bilateral side rails up. LVN 2 stated the use of side rails and the bed against the wall restricted Resident 88's movement and should not be used unless needed. 4. A review of Resident 16's admission Record, indicated Resident 16 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 16's diagnoses included encephalopathy, epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), and dementia (a condition characterized by progressive or persistent loss of intellectual functioning). A review of Resident 16's MDS, dated [DATE], indicated Resident 16 was usually able to understand and be understood by others. The MDS indicated Resident 16's cognition was moderately impaired. The MDS indicated Resident 16 had impairments on both sides of his upper extremities and on one side of the lower extremities. The MDS indicated Resident 16 was dependent on staff for eating, oral hygiene, toileting, bathing, dressing, and personal hygiene. The MDS indicated Resident 16 used bed rails daily. A review of Resident 16's H&P, dated 1/16/2024, indicated Resident 16 did not have the capacity to understand and make decisions. A review of Resident 16's Comprehensive Assessment, dated 2/8/2024, the Comprehensive Assessment indicated Resident 16 had left and right side rails. The Comprehensive Assessment indicated there was no indication for the use of the side rails nor indication that consent was received for bilateral side rails. During an observation on 6/10/2024 at 10:23 a.m. and on 6/11/2024 at 9:27 a.m., in Resident 16's room, Resident 16 was observed lying in bed, with his bed against the wall and with the upper bilateral side rails up. During a concurrent observation and interview on 6/11/2024 at 2:20 p.m., with LVN 2, inside Resident 16's room, Resident 16 was observed lying in bed, with his bed against the wall and with the upper bilateral side rails up. LVN 2 stated the use of side rails and the bed against the wall restricted Resident 16's movement and should not be used unless needed. During an interview on 6/11/2024 at 2:29 p.m., with LVN 2, LVN 2 stated Resident 16 and 88's use of bed rails and their beds against the wall were not appropriate for them because it restricted their movements. LVN 2 stated these were mainly used for safety purposes, however, they should only be used as a last resort after utilizing less restrictive interventions such as closer monitoring. During an interview on 6/12/2024 at 10:46 a.m., with RNS 2, RNS 2 stated least restrictive methods should be utilized for residents, such as redirecting, assisting them with their needs, changing their surrounds, providing more supervision, or providing additional activities. RNS 2 stated the use of bed rails and the beds against the wall could be seen as a restraint because they restricted the resident's movement. RNS 2 stated Residents 16 and 88 did not have an order or assessment for the use of those devices or restrictive methods. RNS 2 stated these restrictive methods could be used for resident's safety, to prevent falls or injury. RNS 2 stated the use of these restrictive methods could put the residents in harm's way due to the lack of monitoring, supervision, and assessment for the appropriateness of those devices. During an interview on 6/13/2024 at 10:15 a.m., with the Director of Nursing (DON), the DON stated a restraint was anything that restricted the residents' movement. The DON stated restraints could be utilized for residents that were at high risk for falls or injury, however, restraints should be the last resort. The DON stated prior to utilizing restraints, they would have to assess the resident for their behavior that put their safety at risk and determine if a different intervention could be done to address the issue. The DON stated the IDT would discuss the necessity of the restraint for the resident. The DON stated if the IDT approved the necessity, they would inform the resident's physician of the recommendation and discuss how the resident would benefit from the device. The DON stated per their policy, an Entrapment Risk Assessment would be completed prior to the installation of bed rails. The DON stated this process was not done for Residents 16 and 88. Based on observation, interview, and record review, the facility failed to ensure 10 of 25 sampled residents (Resident 66, Resident 71, Resident 16, Resident 88, Resident 40, Resident 93, Resident 36, Resident 13, Resident 112, and Resident 15) were free from restraint by failing to: 1. Ensure there was a physician order, care plan, and informed consent obtained prior to use of bedrails for Residents 66, 71, 16, 88, 40, 93, 36, 13, and 112. 2. Ensure the bed was not placed against the wall for Residents 66, 71, 16, 88, 40, 93, 36, 13, and 112. 3. Ensure the implementation of less restrictive measures prior to use was performed for Residents 93, 40, 13, 36, and 112. 5. Ensure the Interdisciplinary Team (IDT, a group of different disciplines working together towards a common goal of a resident) performed quarterly assessments to ensure the least restrictive measures were taken in preventing Resident 15's attempts of getting up unassisted. These deficient practices reduced the ability for Residents 66, 71, 16, 88, 40, 93, 36, 13, and 112 to get out of bed freely, increased their risk for entrapment, and potential subsequent injuries. This deficient practice also increased Resident 15's risk to be restrained without an indication, leading to potential physical and psychosocial harm. Findings: 1. A review of Resident 66's admission Record indicated Resident 66 was originally admitted to the facility on [DATE], and most recently re-admitted on [DATE]. Resident 66's admitting diagnoses included unspecified abnormalities of gait (manner of walking) and mobility, generalized muscle weakness, and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). A review of Resident 66's History and Physical (H&P), dated 2/5/2024, indicated Resident 66 had the capacity to understand and make decisions. A review of Resident 66's Minimum Data Set (MDS, a standardized assessment and care screening/planning tool), dated 5/26/2024, indicated Resident 66 had moderate cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 66 required supervision or touching/steadying by staff to reposition himself in bed, transition from sitting to lying position and vice versa, transition from sitting to standing, and transfer from bed to chair and vice versa. The MDS did not indicate the use of bedrails. A review of Resident 66's active physician orders did not indicate any orders for the use of bedrails or the placement of Resident 66's bed against the wall. A review of Resident 66's care plans did not indicate a care plan was developed for the use of bed rails or placement of the resident's bed against the wall. During an observation on 6/11/2024 at 8:39 a.m., at Resident 66's bedside, Resident 66's bed was observed placed against the wall, with the left side of the bed touching the wall. There were bed rails observed to the right and left side of Resident 66's bed. During a concurrent observation and interview on 6/11/2024 at 1:22 p.m., at Resident 66's bedside, with Registered Nurse Supervisor (RNS) 1, RNS 1 observed the placement of Resident 66's bed and bed rails. RNS 1 stated Resident 66 had bed rails on both sides of the bed, and stated the bed was also placed against the wall. RNS 1 stated Resident 66 could not get out of the bed on the left side because it was against the wall, and stated the bed placement was a form of a restraint. 2. A review of Resident 71's admission Record indicated Resident 71 was originally admitted to the facility on [DATE], and most recently re-admitted on [DATE]. Resident 71's admitting diagnoses included unspecified abnormalities of gait and mobility, generalized muscle weakness, and encephalopathy (a broad term for any brain disease that alters brain function or structure). A review of Resident 71's H&P, dated 4/17/2024, indicated Resident 71 had the capacity to understand and make decisions. A review of Resident 71's MDS, dated [DATE], indicated Resident 71 had severe cognitive impairment. The MDS indicated Resident 71 required partial to moderate assistance from staff to roll left and right in bed, transition from a sitting to lying position and vice versa, transition from a sitting to standing position and vice versa, and transfer from a chair to bed and vice versa. The MDS did not indicate the use of bedrails. A review of Resident 71's active physician orders did not indicate any orders for the use of bedrails or the placement of Resident 71's bed against the wall. A review of Resident 71's care plans did not indicate a care plan was developed for the use of bed rails or placement of the resident's bed against the wall. During an observation on 6/11/2024 at 9:14 a.m., at Resident 71's bedside, Resident 71's bed was observed placed against the wall, with the left side of the bed touching the wall. There were bed rails to the right and left side of Resident 71's bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 11. During an observation on 6/10/2024 at 10:36 a.m., in Resident 93's room, Resident 93's bed was observed against the wall. The bilateral siderails were in the up position. A review of Resident 93's admission Record indicated Resident 93 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 93's diagnoses included COPD, chronic kidney disease (loss of kidney function). A review of Resident 93's MDS, dated [DATE], indicated Resident 93's cognitive skills for daily decision making was intact. The MDS indicated Resident 93 required moderate assistance from staff for toileting hygiene, shower, and personal hygiene. 12. During an observation on 6/10/2024 at 10:47 a.m., in Resident 40's room, Resident 40 was observed lying in bed. Resident 40's bed was against the wall, with the bilateral siderails in the up position. A review of Resident 40's admission Record indicated Resident 40 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 40's diagnoses included COPD, epilepsy, schizophrenia, and anxiety. A review of Resident 40's MDS, dated [DATE], indicated Resident 40's cognitive skills for daily decision making was impaired. The MDS indicated Resident 40 required moderate assistance from staff for toileting hygiene, and showering. The MDS indicated Resident 40 required supervision for oral hygiene, and personal hygiene. 13. During an observation on 6/10/2024 at 11:21 a.m., in Resident 13's room, Resident 13's bilateral siderails were observed in the up position. A review of Resident 13's Face Sheet, indicated Resident 13 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 13's diagnoses included dementia, Parkinson's disease (a brain disorder that cause uncontrollable movements, such as shaking, and difficulty with balance), and schizophrenia. A review of Resident 13's MDS, dated [DATE], indicated Resident 13 had mild impairment in cognitive skills. The MDS indicated Resident 13 required assistance from staff for activities of daily living (ADLs, self care activities performed daily such as dressing, toileting hygiene, and personal hygiene). 14. During an observation on 6/10/2024 at 12:06 a.m., in Resident 36's room, Resident 36's bed was observed against the wall with the bilateral siderails in the up position. A review of Resident 36's Face Sheet, indicated Resident 36 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 36's diagnoses included dementia, anxiety, epilepsy, and diabetes (high blood sugar). A review of Resident 36's MDS, dated [DATE], indicated Resident 36 cognitive skills for daily decision making was impaired. The MDS indicated Resident 36 required moderate assistance from staff for toileting hygiene, shower, and personal hygiene. 15. During an observation on 6/10/2024 at 12:58 p.m., in Resident 112's room, Resident 112 was observed sitting on the bed. Resident 112's bed was against the wall with the bilateral siderails in the up position. A review of Resident 112's Face Sheet, indicated Resident 112 was admitted to the facility on [DATE] with diagnoses including schizophrenia and seizures. A review of Resident 112's MDS, dated [DATE], indicated Resident 112 cognitive skills for daily decision making was intact. The MDS indicated Resident 112 required supervision for toileting hygiene,dressing, showering, and personal hygiene. During a concurrent interview and record review on 6/12/2024 at 11:15 a.m., with RNS 1, Residents 93, 40, 13, 36, and 112's Electronic Medical Records (EMR) were reviewed. RNS 1 stated the facility implemented siderails for residents' safety and mobility. RNS 1 stated the beds against the wall provided more open space in the residents' room. RNS 1 stated there were no care plans to address the use of siderails or addressing the beds against the wall. A review of facility's P&P tilted Restraints, revised 5/1/2018, indicated residents shall be provided an environment that is restraint-free, unless a restraint is necessary to treat a medical symptom in which case the least restrictive measures shall be used. The P&P indicated a physical restraint is defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body, including bed rails, beds against walls, restrictive clothing, etc. If the facility is utilizing bed rails, Bed Rail Entrapment Risk Assessment will be completed by a Licensed Nurse prior to the installation of bed rails. A review of facility's P&P tilted Care Planning, revised 5/12/2018, indicated a comprehensive person-centered care plan is developed for each resident based on their individual assessed needs. The P&P indicated the care plan serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and Interdisciplinary Team ([IDT] a group of healthcare professionals who work together to provide resident with the care they need) work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs. The P&P indicated a Licensed Nurse will initiate the care plan, and the plan will be finalized and updated as indicated for change in condition, onset of new problems resolution of current problems, and as deemed appropriate by clinical assessment and judgment on an ass needed bases. 9. A review of Resident 16's admission Record indicated Resident 16 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 16's diagnoses included encephalopathy, epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), and dementia. A review of Resident 16's MDS, dated [DATE], indicated Resident 16 was usually able to understand and be understood by others. The MDS indicated Resident 16's cognition was moderately impaired. The MDS indicated Resident 16 had impairments (the state of function being weakened or damaged) on both sides of his upper extremities (upper part of the body that includes the shoulder, elbow, wrist, and hand) and on one side of the lower extremities (lower part of the body that includes the hip, knee, ankle, and foot). The MDS indicated Resident 16 was dependent on staff for eating, oral hygiene, toileting, bathing, dressing, and personal hygiene. A review of Resident 16's H&P, dated 1/16/2024, indicated Resident 16 did not have the capacity to understand and make decisions. A review of Resident 16's Comprehensive Assessment, dated 2/8/2024, indicated Resident 16 had left and right siderails. There was no indication for the use of the side rails nor indication that consent was received for the use of bilateral (pertaining to both sides) siderails. A review of Resident 16's active physician orders did not indicate any orders for the use of bedrails or the placement of Resident 16's bed against the wall. During an observation on 6/10/2024 at 10:23 a.m. and on 6/11/2024 at 9:27 a.m., in Resident 16's room, Resident 16 was observed lying in bed. The bed was against the wall and the upper bilateral siderails in the up position. During a concurrent observation and interview on 6/11/2024 at 2:20 p.m., with LVN 2, inside Resident 16's room, Resident 16 was observed lying in bed. The bed was against the wall and with the upper bilateral siderails in the up position. LVN 2 stated the use of siderails and the bed against the wall restricted Resident 16's movement and should not be used unless needed. During a concurrent interview and record review on 6/11/2024 at 2:25 p.m., with LVN 2, Resident 16's Care Plans were reviewed. There were no care plans that addressed the use of side rails or the bed positioned against the wall. LVN 2 stated care plans were used to reflect what was currently happening with the residents. LVN 2 stated the use of bed rails and the bed against the wall should be included in Resident 16's care plans to communicate to the rest of the staff the indication of use and how to monitor the use of the devices to ensure Resident 16's safety. 10. A review of Resident 88's Comprehensive Assessment, dated 10/13/2023, the Comprehensive Assessment indicated Resident 88 had left and right side rails on his bed that was indicated for safety and to promote independence with bed mobility. There was no indication that consent was obtained for bilateral side rails. A review of Resident 88's active physician orders did not indicate any orders for the use of bedrails or the placement of Resident 88's bed against the wall. During an observation on 6/10/2024 at 10:57 a.m. and on 6/11/2024 at 9:25 a.m., in Resident 88's room, Resident 88 was observed lying in bed. The bed was against the wall and with the upper bilateral siderails in the up position. During a concurrent observation and interview on 6/11/2024 at 2:22 p.m., with LVN 2, inside Resident 88's room, Resident 88 was observed lying in bed. The bed was against the wall with the upper bilateral siderails in the up position. LVN 2 stated the use of side rails and the bed against the wall restricted Resident 88's movement and should not be used unless needed. During a concurrent interview and record review on 6/11/2024 at 2:25 p.m., with LVN 2, Resident 88's Care Plans were reviewed. There were no care plans that addressed the use of side rails or the bed positioned against the wall. LVN 2 stated care plans were used to reflect what was currently happening with the residents. LVN 2 stated the use of bed rails and the bed against the wall should be included in Resident 88's care plans to communicate to the rest of the staff the indication of use and how to monitor the use of the devices to ensure Resident 88's safety. During an interview on 6/12/2024 at 11 a.m., with RNS 2, RNS 2 stated the use of side rails and placing the resident's bed against the wall should be care planned. RNS 2 stated the interventions in the care plan would dictate how to monitor and care for Resident 88 to ensure his safety. During an interview on 6/13/2024 at 10:44 a.m., with the DON, the DON stated any device used on the residents should be included in their care plan. The DON stated the use of side rails, regardless of the indication as a restraint, for safety, or for mobility, should be included in the care plan. The DON stated positioning the residents' bed against the wall should be care planned to properly care for the resident. 4. A review of Resident 66's admission Record indicated the facility originally admitted Resident 66 on 7/9/2021, and most recently re-admitted the Resident 66 on 1/27/2023. Resident 66's admitting diagnoses included generalized muscle weakness, dysphagia (difficulty swallowing), unspecified abnormalities of gait (manner of walking) and mobility, and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). A review of Resident 66's H&P, dated 2/5/2024, indicated Resident 66 had the capacity to understand and make decisions. A review of Resident 66's MDS, dated [DATE], indicated Resident 66 had moderate cognitive impairment. The MDS indicated Resident 66 required set-up or clean-up assistance from staff to eat. The MDS indicated Resident 66 required supervision or touching/steadying by staff to reposition himself in bed, transition from sitting to lying position and vice versa, transition from sitting to standing, and transfer from bed to chair and vice versa. The MDS did not indicate the use of bedrails. a. During a concurrent observation and interview on 6/11/2024 at 8:37 a.m., with Resident 66, at Resident 66's bedside, Resident 66 was observed sitting up in bed, with no apparent upper or lower dentition. Resident 66 stated he had dentures. During a concurrent observation and interview, on 6/11/2024 at 1:04 p.m., with CNA 4, at Resident 66's bedside, CNA 4 was observed looking through Resident 66's belongings. CNA 4 stated Resident 66 did not have any dentures at the bedside. CNA 4 stated she did not know if Resident 66 had dentures or required dentures. CNA 4 stated she had never seen Resident 66 wearing dentures. CNA 4 stated she should know if the resident required dentures to ensure he did not choke on his food. During a concurrent interview and record review, on 6/13/2024 at 9:48 a.m., with the DON, the Resident 66's care plans were reviewed. The DON stated Resident 66 did not have a care plan for dentures or denture use. The DON stated that the care plans would be where staff would check to determine if the Resident 66 required dentures to eat. The DON stated it could affect Resident 66's ability to speak clearly and ability to chew if he required dentures and staff did not ensure they were available to him. During an interview on 6/13/2024 at 9:59 a.m., with CNA 1, CNA 1 stated Resident 66 told her on 6/12/2024 that he did not want to eat because he choked on his food, and stated he only wanted liquids. CNA 1 stated Resident 66 was not using dentures while eating. During a concurrent observation and interview on 6/13/2024 at 10:04 a.m., with the Director of Social Services (DSS), at Resident 66's bedside, the DSS was at looking Resident 66's dentures. The DSS located Resident 66's dentures and stated they were not stored in a proper denture container. The DSS stated the dentures were buried deep in the dresser. During a concurrent observation and interview on 6/13/2024 at 10:05 a.m., with Resident 66, at Resident 66's bedside, Resident 66 was observed without dentures on. Resident 66 stated he had breakfast that morning and he choked on his food. Resident 66 stated he did not choke on liquids, so he only wanted liquids. Resident 66 stated he was afraid to choke on his food. Resident 66 stated the last time he used his dentures was four months ago. Resident 66 was observed with dried food on his shirt. During an interview on 6/13/2024 at 10:27 a.m., with RNS 1, RNS 1 stated that if Resident 66 required dentures, he needed to wear them to prevent aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident). b. During an observation on 6/11/2024 at 8:39 a.m., at Resident 66's bedside, Resident 66's bed was observed against the wall, with the left side of the bed touching the wall. There were bed rails to the right and left side of Resident 66's bed. A review of Resident 66's active physician orders did not indicate any orders for the use of bedrails or the placement of Resident 66's bed against the wall. A review of Resident 66's care plans did not indicate a care plan had been developed for the use of bed rails or placement of the resident's bed against the wall. During a concurrent interview and record review on 6/13/2024 at 10:22 a.m., with RNS 1, Resident 66's physician orders were reviewed. RNS 1 stated Resident 66 did not have a care plan for the use bed rails, or for placement of his bed against the wall. 5. A review of Resident 109's admission Record indicated the facility admitted Resident 109 on 1/19/2024. Resident 109's admitting diagnoses included schizophrenia and depression. A review of Resident 109's MDS, dated [DATE], indicated Resident 109 had diagnoses of schizophrenia and depression. During a concurrent interview and record review on 6/12/2024 at 10:15 a.m., with RNS 2, Resident 109's admission record and care plans were reviewed. RNS 2 stated Resident 109 had a diagnosis of schizophrenia, and stated there were special care considerations and specific interventions required for residents with schizophrenia. RNS 2 stated these care considerations and interventions would be in Resident 109's care plans. RNS 2 there were no care plans in place for Resident 109's diagnosis of schizophrenia. RNS 2 stated there should be a care plan in place to indicate the current plan of care for facility staff to follow related to Resident 109's diagnosis of schizophrenia. 6. A review of Resident 11's admission Record indicated the facility originally admitted Resident 11 on 9/5/2017, and most recently readmitted Resident 11 on 5/1/2024. Resident 11's admitting diagnoses included paranoid schizophrenia, major depressive disorder, and anxiety disorder. A review of Resident 11's MDS, 5/8/2024, indicated diagnoses of paranoid schizophrenia, major depressive disorder, and anxiety disorder. During a concurrent interview and record review, on 6/12/2024 at 9:57 a.m., with RNS 2, Resident 11's admission Record and care plans were reviewed. RNS 2 stated the admission Record indicated Resident 11 had diagnoses of paranoid schizophrenia, major depressive disorder, and anxiety disorder, and stated there were special considerations for care of residents with these diagnoses. RNS 2 stated the resident might need special interventions to address certain behaviors or the cause of the behaviors. RNS 2 stated any behaviors also needed to be monitored, especially if medications were being administered to treat the behaviors. RNS 2 stated these interventions would be found in the care plan, and stated Resident 11 did not have any care plans in place for her diagnoses of paranoid schizophrenia, major depressive disorder, and anxiety disorder. RNS 2 stated the care plan indicated the care being provided to the resident, and instructions for the nurses to know the specific care required of the resident. 7. A review of Resident 15's admission Record indicated the facility originally admitted Resident 15 on 12/9/2018, and most recently re-admitted Resident 15 on 4/11/2021. Resident 15's admitting diagnoses included unspecified abnormalities of gait and mobility, generalized muscle weakness, anxiety disorder, and dementia. A review of Resident 15's H&P, dated 11/8/2023, indicated Resident 15 did not have the capacity to understand and make decisions. A review of Resident 15's MDS, dated [DATE], indicated Resident 15 had moderate cognitive impairment. The MDS indicated Resident 15 had upper extremity impairment on one side of his body and required the use of a wheelchair. The MDS indicated Resident 15 required partial to moderate assistance from staff to transition from a sitting to standing position and vice versa, and to transition from a sitting to lying position and vice versa. The MDS indicated Resident 15 was dependent on staff to transfer from bed to chair and vice versa. A review of Resident 15's active physician order, dated 11/8/2023, indicated to apply lap tray (a tray with a cushioned underside, designed to rest in a person's lap) when up in wheelchair to prevent resident from sliding off the chair and maintain proper posture. A review of Resident 15's care plans did not indicate a care plan had been developed for the use or monitoring of Resident 15's lap tray. During an observation on 6/10/2024 at 11:26 a.m., outside of Resident 15's room, Resident 15 was observed sitting in his wheelchair with a tray across his lap. The tray was fastened in the rear of the wheelchair, behind the back of the seat. During a concurrent observation and interview, on 6/11/2024 at 9:25 a.m., outside of Resident 15's room, with Licensed Vocational Nurse (LVN) 1 and Resident 15, LVN 1 observed Resident 15's lap tray. Resident 15's lap tray was across his lap and fastened in the rear of the wheelchair. Resident 15 stated the buckle to fasten the lap tray was behind him and he could not reach it. LVN 1 stated that if Resident 15 wanted to get up, staff assisted him. During a concurrent interview and record review, on 6/11/2024 at 1:25 p.m., with RNS 1, Resident 15's active physician orders and care plans were reviewed. RNS 1 stated the physician order dated 11/8/2023 indicated to apply the lap tray to prevent Resident 15 from sliding off the chair. RNS 1 stated she was not sure of the facility's policy for the use of restraints, or whether they needed to be monitored. RNS 1 also stated there was no care plan for Resident 15's use of a lap tray as a restraint. During a concurrent interview and record review with the DON, on 6/11/2024 at 2:36 p.m., Resident 15's care plans were reviewed. The DON stated Resident 15 did not have any care plans in place related to use of a lap tray restraint. The DON stated a care plan for restraint use should have been developed to indicate specific interventions, including monitoring Resident 15 for complications related to use of restraints. 8. A review of Resident 71's admission Record indicated the facility originally admitted Resident 71 on 1/10/2013, and most recently re-admitted Resident 71 on 4/12/2024. Resident 71's admitting diagnoses included unspecified abnormalities of gait and mobility, generalized muscle weakness, and encephalopathy (a broad term for any brain disease that alters brain function or structure). A review of Resident 71's H&P, dated 4/17/2024, indicated Resident 71 had the capacity to understand and make decisions. A review of Resident 71's MDS, dated [DATE], indicated Resident 71 had severe cognitive impairment. The MDS indicated Resident 71 required partial to moderate assistance from staff to roll left and right in bed, transition from a sitting to lying position and vice versa, transition from a sitting to standing position and vice versa, and transfer from a chair to bed and vice versa. The MDS did not indicate the use of bedrails. A review of Resident 71's care plans did not indicate a care plan had been developed for the use of bed rails or placement of the resident's bed against the wall. During an observation on 6/11/2024 at 9:14 a.m., at Resident 71's bedside, Resident 71's bed was observed against the wall, with the left side of the bed touching the wall. There were bed rails to the right and left side of Resident 71's bed. During an observation on 6/13/2024 at 9:57 a.m., at Resident 71's bedside, Resident 71's bed was observed against the wall, with the left side of the bed touching the wall. There were bed rails to the right and left side of Resident 71's bed. During a concurrent interview and record review on, 6/13/2024 at 10:18 a.m., with RNS 1, Resident 71's care plans were reviewed. RNS 1 stated Resident 71 did not have a care plan in place for the use of bed rails, or for placement of Resident 71's bed against the wall. During an interview on 6/13/2024 at 10:41 a.m., with the DON, the DON stated Resident 71 was at risk for entrapment and getting caught between the bed mattress and the bedrails. The DON stated interventions for bedrail safety would be in the care plan, and stated bedrail use was supposed to be included in Resident 71's care plans. 3. A review of Resident 10's admission Record indicated the facility originally admitted Resident 10 on 7/22/2016, and most recently re-admitted Resident 10 on 12/21/2022. Resident 10's admitting diagnoses included dementia (a brain disease that effects memory and cognitive function, interfering with daily life), schizophrenia, and bipolar disorder (a mood disorder with manic and depressive episodes). A review of Resident 10's H&P, dated 12/19/2022, indicated Resident 10 did not have the capacity to understand and make decisions. A review of Resident 10's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 5/1/2024, indicated Resident 10 was mildly cognitively impaired (ability to think and reason). The MDS indicated Resident 10 had required total assistance with toileting hygiene, showering/bathing, and personal hygiene. A review of Resident 13's admission Record indicated the facility originally admitted Resident 13 on 5/18/2016, and most recently re-admitted the Resident 13 on 12/12/2022. Resident 13's admitting diagnoses included dementia and schizophrenia, A review of Resident 13's H&P, dated 12/19/2022, indicated Resident 13 had the capacity to understand and make decisions. A review of Resident 13's MDS, dated [DATE], indicated Resident 13 was severely cognitively impaired. The MDS indicated Resident 13 was had required partial assistance (helper does less than half the effort) for personal hygiene only. A review of Resident 13's care plan for At Risk for Aggression to Others dated 5/28/2024, indicated Resident 13 was at risk for aggression to others. The care plan indicated Resident 13 was seen with another female resident in his room. The care plan interventions indicated to assess other residents visiting Resident 13's room to ensure their safety. During a concurrent observation and interview, on 6/11/2024 at 9:50 a.m., with Resident 10, Resident 10 was observed awake and alert. Resident 10 stated she did not know Resident 13 and denied ever going into his room. During a concurrent observation and interview, on 6/11/2024 at 10:08 a.m., with Resident 13, Resident 13 was observed awake and alert, sitting in his wheelchair outside on the patio. Resident 13 denied knowing Resident 10 and denied her ever being in his room. During an interview on 6/11/2024 at 10:54 a.m., with Certified Nursing Assistant (CNA) 5, CNA 5 stated on 5/18/2024 around 4:00 p.m., she had heard a door slam in Resident 13's room so she rushed in there to make sure everyone was safe. CNA 5 stated when she opened Resident 13's room door she saw Resident 13 naked next to Resident 10, who had her top unbuttoned and her bra showing. CNA 5 separated Resident 10 and Resident 13 and reported the sexual activity to Licensed Vocational Nurse (LVN) 3 and Registered Nurse Supervisor (RNS) 3. During an interview on 6/11/2024 at 12:34 a.m., with Resident 10's Responsible Party (RP) 2, RP 2 stated she received a phone call from RNS 4 who informed her staff found Resident 10 in Resident 13's room undressed. RP 2 stated she was upset because she believed Resident 10 was molested since she did not have capacity to make decisions, had dementia, and was confused. RP 2 stated she told the staff in the past Resident 10 needed to be monitored more since she had fallen one year ago. During a concurrent interview and record review, on 6/11/2024 at 2:12 p.m., with RNS 1, Resident 10's Resident Behavior Care Plan, dated 5/27/2024 was reviewed. RNS 1 verified the care plan indicated Resident 10 went into another resident's room (Resident 13) and had forgetfulness. The care plan further indicated to check Resident 10's whereabouts and to not allow Resident 10 into male residents' rooms. RNS 1 stated prior to 5/18/2024, when Resident 10 was witnessed going into Resident 13's room, the resident was on monitoring for and had a history of going into male residents' rooms. RNS 1 stated there should have been a care plan in place for Resident 10 wandering into male residents' rooms prior to 5/18/2024, but the care plan was created on 5/27/2024. RNS 1 stated Resident 10 needed full assistance with dressing and did not understand how she could have unbuttoned her blouse herself when she was found in Resident 13's room with an unbuttoned shirt. During an interview on 6/12/2024 at 1:27 p.m., with the Director of Nursing (DON), the DON stated Resident 10 had a history of dementia, forgetfulness, and wandering into residents' rooms, but it was not care planned. The DON stated Resident 10's wandering into rooms should have been care planned due to her history. Based on observation, interview, and record review, the facility failed to develop, implement, and update the comprehensive care plan for 15 out of 25 residents (Resident 88, 10, 13, 66, 109, 11, 71, 15, 16, 17, 93, 40, 13, 36, and 112) by failing to: 1. Develop a comprehensive care plan for Resident 88's use of Buspirone (a medication used to treat mental illness) and to address the problematic behavior of auditory hallucinations (hearing voices to harm self or others), and Resident 17's use of Ativan (a medication used to treat anxiety [feeling of unease, excessive worry]). 2. Develop a comprehensive care plan for Resident 10's behavior of wandering into Resident 13's room. 3. Develop a comprehensive care plan for Resident 66's use of dentures. 4. Develop a comprehensive care plan for Resident 109's diagnosis of schizophrenia (mental disorder that affects a person's ability to think, feel, and behave clearly), and Resident 11's diagnoses of paranoid schizophrenia, major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). 5. Develop a comprehensive care plan for Resident 15's use of a lap tray restraint. 6. Develop a comprehensive care plan for the use of physical restraints for Residents 71, 16, 88, 93,40, 13, 36, and 112. These deficient practices of failing to create a resident-centered care plan for Residents 88 and 17 to address problematic behaviors increased the risk that psychotropic medications (medications that affect brain activities associated with mental processes and behavior) used to manage those behaviors would not be periodically reevaluated as intended. This increased the risk that Residents 88 and 17 may have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to psychotropic medications possibly leading to impairment or decline in his mental or physical condition or functional or psychosocial status. These deficient practices of failing to create a resident-centered care plan placed Residents 10 and 13 at risk for harm. These deficient practices also had the potential to result in weight loss and choking hazards for Resident 66, placed Residents 109 and 11 at risk of not having their mental and psychosocial needs met, and also had the potential to negatively affect Resident 93, 40, 13, 36, 112, 66, 16, 88, 71, and 15's physical wellbeing, and placed the residents at risk for unnecessary physical restraints. Findings: 1. A review of Resident 88's admission Record (a document containing a resident's diagnostic and demographic information), dated 6/12/2024, indicated Resident 88 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 88's diagnoses included schizophrenia (a mental illness characterized by seeing and hearing things that are not there) and major depressive disorder (MDD - a mental disorder characterized by depressed mood, poor appetite, difficulty sleeping, and lack of interest in normally enjoyable activities). A review of Resident 88's History and Physical (H&P), dated 7/4/2023, indicated Resident 88 did not have the capacity to understand and make decisions. A review of Resident 88's Physician Order Summary (a monthly summary of all active physician orders), dated 6/12/2024, indicated Resident 88 was prescribed the following psychotropic medications on 4/24/2024: 1. Buspirone (a medication used to treat anxiety) 5 milligrams (mg - a unit of measure for mass) by mouth once daily for anxiety. 2. Risperidone (a medication sued to treat schizophrenia) 1.5 mg by mouth every morning and 2 mg by mouth every evening for schizophrenia. A review of Resident 88's Medication Administration Record (MAR) indicated Resident 88 was being monitored for auditory hallucinations: hearing voices to harm self or others related to the use of Risperidone. A review of Resident 88's available care plans indicated there was no care plan addressing the use of Buspirone or the problematic behavior of auditory hallucinations: hearing voices to harm self or others. During an interview on 6/12/2024 9:41 a.m. with the Director of Nursing (DON), t[TRU

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. A review of Resident 47's admission Record (Face Sheet), the admission Record indicated Resident 47 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease ([COPD] a group of diseases that cause airflow blockage and breathing-related problems), heart failure (heart condition in which the heart muscle is unable to pump enough blood to meet the body's needs), cerebral infarction (disrupted blood flow to the brain), diabetes (abnormal blood sugar), and muscle weakness. A review of Resident 47's MDS, dated [DATE], indicated Resident 47 was totally dependent (helper does all of the effort) on staff for toileting hygiene, shower, and moderate assistance (helper does less than half) for oral hygiene, and personal hygiene. The MDS indicated Resident 47 was self-understood and had the ability to understand others. During an observation on 6/10/2024 at 3:57 p.m., Resident 47 was observed sitting in a wheelchair in the facility's hallway, with long and black substance under all ten fingernails. During an observation on 6/11/2024 at 11:44 a.m., Resident 47 was observed sitting in a wheelchair in the facilities lobby room watching television, with long and black substance under all ten fingernails. During an interview on 6/12/2024 at 9:10 a.m., with CNA 3, CNA 3 stated CNAs were responsible to clean residents' fingernails daily and trim as needed. CNA 3 stated keeping Resident 47's fingernails clean and trimmed was important to prevent the growth of bacteria (infection) and hospitalization. d. A review of Resident 13's admission Record (Face Sheet), the admission Record indicated Resident 13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia, dysphagia (difficulty swallowing), Parkinson's disease (a brain disorder that cause uncontrollable movements, such as shaking, and difficulty with balance), and schizophrenia (mental health condition that effects how person think, feel, and behave). A review of Resident 13's MDS, dated [DATE], indicated Resident 13 had impairment in cognitive skills. The MDS indicated Resident 13 required assistance from staff for activities of daily living (ADL). During a concurrent observation and interview on 6/10/2024 at 11:21 a.m., in Resident 13's room, Resident 13 was observed with long and fingernails with black substance under all ten fingernails. Resident 13 stated he does not remember when last time his fingernails were cleaned or cut. Resident 13 stated he would like to have his fingernails cleaned and cut by staff. During a concurrent observation and interview on 6/12/2024 at 8:03 a.m., in Resident 13's room, with RNS 1, RNS 1 stated Resident 13's fingernails were long and dirty. RNS 1 stated CNAs were responsible to clean fingernails daily and trim as needed. RNS 1 stated it was important for Resident 13's fingernails clean and trim to prevent infection, cuts, and injury. During an interview on 6/13/2024 at 9:57 a.m., with the DON, the DON stated was CNA's responsibility to make sure the residents' fingernails were cleaned daily and trimmed as needed. The DON stated residents' dirty fingernails was an issue because residents could touch their eyes and could cause an eye infection, could scratched themselves and create skin breakouts, or injure themselves, or other residents. The DON stated residents should be provided with care and services necessary to maintain good personal hygiene. A review of facility's P&P titled Nail Care, revised 3/2010, indicated, the facility was to promote cleanliness, safety, and neat appearance of residents. A review of facility's P&P titled Certified Nursing Assistant Job Description, dated 12/8/1998, indicated, under Responsibilities and Duties included assists residents to ensure their cleanliness grooming, nourishment, rest, activity, and elimination in a manner conductive to the resident's comfort and safety. b. A review of Resident 16's admission Record indicated Resident 16 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 16's diagnoses included encephalopathy (a broad term for any brain disease that alters brain function or structure), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), and dementia (a condition characterized by progressive or persistent loss of intellectual functioning). A review of Resident 16's MDS dated [DATE], indicated Resident 16 was usually able to understand and be understood by others. The MDS indicated Resident 16's cognition was moderately impaired. The MDS indicated Resident 16 had impairments (the state of function being weakened or damaged) on both sides of his upper extremities (upper part of the body that includes the shoulder, elbow, wrist, and hand) and on one side of the lower extremities (lower part of the body that includes the hip, knee, ankle, and foot). The MDS indicated Resident 16 was dependent on staff for eating, oral hygiene, toileting, bathing, dressing, and personal hygiene. A review of Resident 16's H&P, dated 1/16/2024, indicated Resident 16 did not have the capacity to understand and make decisions. During observations on 6/10/2024 at 10:23 a.m. and on 6/11/2024 at 9:28 a.m., in Resident 16's room, Resident 16 was observed with a black substance undernath his right thumb and right index fingernails. During a concurrent observation and interview on 6/12/2024 at 8:41 a.m., with CNA 2, in Resident 16's room, Resident 16 was observed with black substance underneath his right thumb and right index fingers. CNA 2 stated Resident 16's right thumb and index fingernails were dirty. CNA 2 stated nail care was one of the duties that the CNAs had to attend to daily. CNA 2 stated the CNAs were allowed to clean underneath the resident's fingernails and to clip them if they were too long. CNA 2 stated Resident 16's nails should have been cleaned sooner before there was a buildup of the black substance. CNA 2 stated ensuring the residents' fingernails were clean was essential to prevent infection. CNA 2 stated Resident 16 was prone to scratching himself and others, therefore, keeping clean fingernails would help prevent the spread of germs. CNA 2 stated if Resident 16 were to scratch his skin too hard, he may have developed a cut which could get infected due to his dirty fingernails. During an interview on 6/12/2024 at 9:08 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated if Resident 16's nails had the black substance underneath them for three days, that would indicate that no one was cleaning the resident's nails. LVN 2 stated the nursing staff were responsible for keeping the residents' nails clean, especially for the residents that were dependent on the nurses for personal hygiene. LVN 2 stated dirty fingernails placed Resident 16 at risk for infection because any germs or bacteria that were underneath his fingernails could enter his bloodstream. During an interview on 6/12/2024 at 9:21 a.m., with the Infection Preventionist (IP), the IP stated keeping residents' fingernails clean was important because the fingernails could harbor bacteria that could make the residents sick. The IP stated a resident could suck on their thumb and ingest any bacteria on their hands and could cause some kind of infection and cause them to fall ill. The IP stated it was important for the staff to be very vigilant for the residents' personal hygiene to prevent infection. During an interview on 6/12/2024 at 10:39 a.m., with RNS 2, RNS 2 stated the nursing staff should assess the residents' nails daily to see if they need to be cleaned or trimmed. RNS 2 stated Resident 16's unkept nails were an issue because that could affect the resident's comfort, dignity, and cleanliness. During an interview on 6/13/2024 at 10:10 a.m., with the DON, the DON stated the when the CNAs provide their daily care to the residents, part of their responsibilities was to look at their nails and clean or trim them, if needed. The DON stated anyone who provided care to Resident 16 should have looked at his nails and coordinated to clean them if they needed assistance. The DON stated dirty fingernails could lead to the resident scratching themselves and could cause skin breakdown and infection of the skin. Based on observation, interview, and record review, the facility failed to provide care and services to maintain good grooming and personal hygiene for four of 14 residents (Resident 13, Resident 16, Resident 47, and Resident 98) by failing to: 1. Check Resident 98's soiled diaper in a timely manner per facility policy and professional standards. 2. Keep Residents 13, 16, and 47's nails clean and neat. These deficient practices had the potential to result in a negative impact on Resident's 98, 13, 16, and 47's quality of life and self-esteem, and had the potential for the development of infection. Findings: a. A review of Resident 98's admission Record indicated Resident 98 was originally admitted to the facility on [DATE], and most recently re-admitted on [DATE]. Resident 98's admitting diagnoses included hemiplegia (paralysis on one side) and hemiparesis (weakness or the inability to move on one side) following a cerebral vascular infarction (brain tissue death resulting from disrupted blood flow to the brain) affecting the right dominant side, and epilepsy (abnormal electrical brain activity and is also known as a seizure). A review of Resident 98's History and Physical (H&P), dated 4/13/2024, indicated Resident 98 was able to make needs known but did not have the capacity to make medical decisions. A review of Resident 98's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 5/15/2024, indicated Resident 98 was severely cognitively impaired (ability to think and reason). The MDS indicated Resident 98 required total assistance with toileting hygiene, showering/bathing, dressing, and personal hygiene. A review of Resident 98's care plan titled, At Risk for Skin Breakdown dated 3/20/2024, indicated to wash Resident 98's skin with soap and water every diaper change, and to encourage to reposition every 2 hours and as needed to prevent skin breakdown (an opening of the skin in various degrees which occurs because of pressure and/or moisture). During an observation on 6/10/2024 at 9:54 a.m., in Resident 98's room, Resident 98 was observed lying in bed, bedbound, awake, but was unable to speak. During an interview on 6/10/2024 at 12:31 p.m., with Resident 98's Responsible Party (RP) 3, RP 3 stated she was concerned about Resident 98 because he was hospitalized [DATE] for a urinary tract infection (UTI, an infection of any part of the urinary tract). RP 3 stated the hospital physician told her the infection occurred because Resident 98 needed to be changed more frequently. RP 3 stated since Resident 98 could not walk or talk he relied on the nurses to change him. During a concurrent observation and interview on 6/10/2924 at 12:45 p.m., with Certified Nursing Assistant (CNA) 6 and Resident 98, Resident 98 was obseved lying in bed face up. CNA 6 stated she last changed Resident 98 at 9:45 a.m. but planned to change the resident after the food trays were passed out to all the residents. CNA 6 stated staff were supposed to check on bedbound residents every 2 hours for a soiled diaper and to reposition them. During an interview on 6/11/2024 at 2:39 p.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated residents should be checked at least once every 2 hours or as needed to change soiled residents, and also to reposition them to prevent skin break down. During an interview on 6/12/2024 at 1:59 p.m., with the Director of Nursing (DON), the DON stated if residents were not turned or cleaned within 2 hours, they could be uncomfortable and at risk for breakdown. A review of the facility's policy and procedure (P&P) titled Perineal Care, dated 5/1/2018, indicated the purpose of the policy was to maintain cleanliness of the genital area, to reduce odor, and to prevent infection or skin breakdown. The P&P indicated to provide perineal care a minimum once daily and per resident need.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess the medical need, obtain a physician order, and informed consent for the use of bed side rails for nine of nine sampled residents (Resident 93, Resident 40, Resident 13, Resident 36, Resident 112, Resident 66, Resident 71, Resident 88, and Resident 16). These deficient practices had the potential to place Residents 93, 40, 13, 36, 112, 66, 71, 88, and 16 at risk for accidents, injury, and hazards such as entrapment and falls. Findings: a. During an observation on 6/10/2024 at 10:36 a.m., in Resident 93's room Resident 93's bed was observed with the bilateral (pertaining to both sides) siderails up. A review of Resident 93's admission Record indicated Resident 93 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 93's diagnoses included chronic obstructive pulmonary disease ([COPD] a chronic lung disease that causes obstructed airflow from the lungs) and chronic kidney disease (loss of kidney function). A review of Resident 93's Minimum Data Set ([MDS] a standardized assessment and care planning tool), dated 3/14/2024, indicated Resident 93's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact. The MDS indicated Resident 93 required moderate assistance (helper does less than half the effort) from staff for toileting hygiene, shower, and personal hygiene. b. During an observation on 6/10/2024 at 10:47 a.m., in Resident 40's room, Resident 40 was observed lying in bed. Resident 40's bed had bilateral siderails in the up position. A review of Resident 40's admission Record indicated Resident 40 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 40's diagnoses included COPD, epilepsy (abnormal electrical brain activity), muscle weakness (loss of muscle strength), schizophrenia (serious mental illness that effects how a person thinks, feels, and behaves), and anxiety (feeling of fear, restlessness, and excessive worry). A review of Resident 40's MDS, dated [DATE], indicated Resident 40's cognitive skills for daily decision making was impaired. The MDS indicated Resident 40 required moderate assistance (helper does less than half the effort) from staff for toileting hygiene, and shower. The MDS indicated Resident 40 required supervision (the helper provides verbal cues, touching contact as resident completes activity) for oral hygiene, and personal hygiene. During a concurrent observation and interview on 6/11/2024 at 12:00 p.m., in Resident 40's room, Resident 40 was observed sitting on the bed and watching television. Resident 40's bilateral siderails were in the up position. Resident 40 stated he would like to have more space around the bed and be able to sit by the window and enjoy the view on the outside patio. Resident 40 stated he was not aware why his bed had siderails and stated he did not need siderails. c. During an observation on 6/10/2024 at 11:21 a.m., in Resident 13's room, observed Resident 13's bed with the bilateral (pertaining to both sides) siderails up. A review of Resident 13's admission Record indicated Resident 13 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 13's diagnoses included dementia (a loss of brain function such as memory, language, thinking), dysphagia (difficulty swallowing), Parkinson's disease ( a brain disorder that cause uncontrollable movements, such as shaking, and difficulty with balance), and schizophrenia. A review of Resident 13's MDS, dated [DATE], indicated Resident 13 had moderate impairment in cognitive skills for daily decision making. The MDS indicated Resident 13 required assistance from staff for activities of daily living (ADLs, self care activities performed daily such as dressing, toileting, personal hygiene, and bathing). d. During an observation on 6/10/2024 at 12:06 a.m., in Resident 36's room, Resident 36's bed was observed with the bilateral siderails up. A review of Resident 36's admission Record indicated Resident 36 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 36's diagnoses included dementia, anxiety, epilepsy, and diabetes (high blood sugar). A review of Resident 36's MDS, dated [DATE], indicated Resident 36 cognitive skills for daily decision making was impaired. The MDS indicated Resident 36 required moderate assistance from staff for toileting hygiene, shower, and personal hygiene. e. During a concurrent observation and interview on 6/10/2024 at 12:58 p.m., in Resident 112's room, Resident 112 was observed sitting on the bed. Resident 112's bed was had bilateral siderails in the up position. Resident 112 stated she did not need siderails and was not aware why her bed had siderails. A review of Resident 112's admission Record indicated Resident 112 was admitted to the facility on [DATE]. Resident 112's diagnoses included schizophrenia and seizures (a medical condition caused by abnormal electric activity in the brain). A review of Resident 112's MDS, dated [DATE], indicated Resident 112's cognitive skills for daily decision making was intact. The MDS indicated Resident 112 required supervision (the helper provides verbal cues, touching contact as resident completes activity) for toileting hygiene, dressing, showering, and personal hygiene. During a concurrent interview and record review on 6/12/2024 at 11:15 a.m., with Registered Nurse Supervisor (RNS) 1, Residents 93's, 40's, 13's, 36's, and 112's Electronic Medical Record (EMR) was reviewed. RNS 1 stated the facility implemented siderails for residents' safety and mobility. RNS 1 stated siderails use should have a physician order and informed consent. RNS 1 stated Residents 93, 40, 13, 36, and 112's EMR indicated there were no assessments of the medical need for the siderails prior to the use of the siderails. RNS 1 stated there were no physician order's or informed consent obtained for the use of siderails. h. A review of Resident 88 admission Record indicated Resident 88 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 88's diagnoses included encephalopathy, schizophrenia, and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A review of Resident 88's MDS, dated [DATE], indicated Resident 88 was able to sometimes understand and sometimes be understood by others. The MDS indicated Resident 88's cognition was moderately impaired. The MDS indicated Resident 88 had impairments on both sides of his lower extremities (lower part of the body that includes the hip, knee, ankle, and foot). The MDS indicated Resident 88 was dependent on staff for eating, oral hygiene, toileting, bathing, dressing, and personal hygiene. A review of Resident 88's H&P, dated 7/4/2023, indicated Resident 88 did not have the capacity to understand and make decisions. A review of Resident 88's Comprehensive Assessment, dated 10/13/2023, the Comprehensive Assessment indicated Resident 88 had left and right side rails which were indicated for safety and to promote independence with bed mobility. There was no indication that consent was received for bilateral (both sides) side rails. A review of Resident 88's active physician orders did not indicate any orders for the use of bedrails. During an observation on 6/10/2024 at 10:57 a.m. and on 6/11/2024 at 9:25 a.m., in Resident 88's room, Resident 88 was observed lying in bed, with the upper bilateral side rails up. During a concurrent observation and interview on 6/11/2024 at 2:22 p.m., with LVN 2, inside Resident 88's room, Resident 88 was lying in bed, with the upper bilateral side rails up. LVN 2 stated the use of side rails restricted Resident 88's movement and should not be used unless needed. i. A review of Resident 16's admission Record indicated Resident 16 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 16's diagnoses included encephalopathy, epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), and dementia. A review of Resident 16's MDS, dated [DATE], indicated Resident 16 was usually able to understand and be understood by others. The MDS indicated Resident 16's cognition was moderately impaired. The MDS indicated Resident 16 had impairments on both sides of his upper extremities (upper part of the body that includes the shoulder, elbow, wrist, and hand) and on one side of the lower extremities (lower part of the body that includes the hip, knee, ankle, and foot). The MDS indicated Resident 16 was dependent on staff for eating, oral hygiene, toileting, bathing, dressing, and personal hygiene. The MDS indicated Resident 16 used bed rails daily. A review of Resident 16's H&P, dated 1/16/2024, indicated Resident 16 did not have the capacity to understand and make decisions. A review of Resident 16's Comprehensive Assessment, dated 2/8/2024, indicated Resident 16 had left and right-side rails. There was no indication for the use of the side rails nor indication that consent was received for bilateral side rails. During observations on 6/10/2024 at 10:23 a.m. and on 6/11/2024 at 9:27 a.m., in Resident 16's room, Resident 16 was observed lying in bed, with the upper bilateral side rails up. During a concurrent observation and interview on 6/11/2024 at 2:20 p.m., with Licensed Vocational Nurse (LVN) 2, inside Resident 16's room, Resident 16 was observed lying in bed, with the upper bilateral side rails up. LVN 2 stated the use of side rails restricted Resident 16's movement and should not be used unless needed. During an interview on 6/11/2024 at 2:29 p.m., with LVN 2, LVN 2 stated Resident 16 and 88's use of bed rails was not appropriate because it restricted the resident's movements. LVN 2 stated these were mainly used for safety purposes, however, they should only be used as a last resort after utilizing less restrictive interventions such as closer monitoring. LVN 2 stated when a resident had side rails on their beds, they should be assessed for the appropriateness of the device and closely monitored to ensure their safety was upheld. LVN 2 stated if the bed rails were inappropriate for the resident and they were not closely monitored, the resident's were at risk of getting caught between the side rails and the bed which could cause injury or suffocation (death caused by not having enough oxygen). During an interview on 6/12/2024 at 10:46 a.m., with RNS 2, RNS 2 stated least restrictive methods should be utilized for residents, such as redirecting, assisting them with their needs, changing their surrounds, providing more supervision, or providing additional activities. RNS 2 stated when bed rails were utilized, the resident must be assessed that it was appropriate to use, and the residents must be monitored. RNS 2 stated if the residents were not properly monitored, complications, such as getting caught in the side rails and injury, could occur. During an interview on 6/13/2024 at 10:35 a.m., with the DON, the DON stated the Interdisciplinary Team (IDT, a group of healthcare professionals with various areas of expertise who work together towards the goals of the residents) would discuss the necessity of bed rails for the resident. The DON stated if the IDT approved the necessity for the use of bed rails, they would inform the resident's physician of the recommendation and discuss how the resident would benefit from the device. The DON stated prior to utilizing bed rails, the facility should be aware of the entrapment risk, and assess the space between the side rail and the bed to ensure there was no risk of the resident getting stuck in that space. The DON stated per their policy, an Entrapment Risk Assessment would be completed prior to the installation of bed rails. The DON stated this process was not done for Residents 16 and 88 for the utilization of bed rails which placed them at risk for injury. A review of the facility's policy and procedure (P&P) tilted Siderails, revised 3/2010, indicated the facility was to use siderails based on the residents assessed medical needs. The P&P indicated a physician's order and signed release by resident is required. The P&P indicated the siderails were to be used for resident's mobility and /or transfer, and to protect the resident from falling out of bed. A review of the facility's P&P tilted Restraints, revised 5/1/2018, indicated a physical restraint is defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. This may include bed rails, beds against walls, restrictive clothing, etc. The P&P indicated residents shall be provided an environment that is restraint-free, unless a restraint is necessary to treat a medical symptom in which case the least restrictive measures shall be used. The P&P indicated informed consent will be obtained from the resident or responsible party if a restraint will be used. The P&P indicated if the facility is utilizing bed rails, a Bed Rail Entrapment Risk Assessment will be completed by a Licensed Nurse prior to the installation of bed rails. The P&P indicated the Interdisciplinary Care Team ([IDT] a group of healthcare professionals who work together to provide residents with the care they need) will discuss with the resident and/or resident representative the risk and benefits involved with bed rails and described alternatives that may be feasible prior to installing bed rails. f. A review of Resident 66's admission Record indicated the facility originally admitted Resident 66 on 7/9/2021, and most recently re-admitted the Resident 66 on 1/27/2023. Resident 66's admitting diagnoses included unspecified abnormalities of gait (manner of walking) and mobility, generalized muscle weakness, and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). A review of Resident 66's H&P, dated 2/5/2024, indicated Resident 66 had the capacity to understand and make decisions. A review of Resident 66's MDS, dated [DATE], indicated Resident 66 had moderate cognitive impairment. The MDS indicated Resident 66 required supervision or touching/steadying by staff to reposition himself in bed, transition from sitting to lying position and vice versa, transition from sitting to standing, and transfer from bed to chair and vice versa. The MDS did not indicate the use of bedrails. A review of Resident 66's active physician orders did not indicate any orders for the use of bedrails. A review of Resident 66's care plans did not indicate a care plan had been developed for the use of bed rails. During an observation on 6/11/2024 at 8:39 a.m., at Resident 66's bedside, Resident 66's bed was observed with bed rails to the right and left side of Resident 66's bed. During a concurrent observation and interview on 6/11/2024 at 1:22 p.m., at Resident 66's bedside, with RNS 1, RNS 1 observed Resident 66's bed rails. RNS 1 verified Resident 66 had bed rails on both sides of the bed. During a concurrent interview and record review, on 6/13/2024 at 10:22 a.m., with RNS 1, Resident 66's assessments were reviewed. RNS 1 stated Resident 66 did not have a Bed Rail Entrapment Risk Assessment. g. A review of Resident 71's admission Record indicated the facility originally admitted Resident 71 on 1/10/2013, and most recently re-admitted the Resident 71 on 4/12/2024. Resident 71's admitting diagnoses included unspecified abnormalities of gait and mobility, generalized muscle weakness, and encephalopathy (a broad term for any brain disease that alters brain function or structure). A review of Resident 71's H&P, dated 4/17/2024, indicated Resident 71 had the capacity to understand and make decisions. A review of Resident 71's MDS, dated [DATE], indicated Resident 71 had severe cognitive impairment. The MDS indicated Resident 71 required partial to moderate assistance from staff to roll left and right in bed, transition from a sitting to lying position and vice versa, transition from a sitting to standing position and vice versa, and transfer from a chair to bed and vice versa. The MDS did not indicate the use of bedrails. A review of Resident 71's active physician orders did not indicate any orders for the use of bedrails. A review of Resident 71's care plans did not indicate a care plan had been developed for the use of bedrails. During an observation on 6/11/2024 at 9:14 a.m., at Resident 71's bedside, Resident 71's bed was observed with bed rails to the right and left side of Resident 71's bed. During a concurrent interview and record review, on 6/13/2024 at 10:18 a.m., with RNS 1, Resident 71's assessments were reviewed. RNS 1 stated Resident 71 did not have a Bed Rail Entrapment Risk Assessment. During a concurrent interview and record review, on 6/13/2024 at 10:41 a.m., with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled Restraints, dated 5/1/2018 was reviewed. The DON stated the P&P indicated all residents were at risk for entrapment if bedrails were used and the residents should be assessed for risk of entrapment. The DON stated this assessment was not currently being done. The DON stated entrapment meant a resident was caught between the bed and the bedrail, and stated residents could sustain injuries if entrapment occurred.

Based on observation, interview, and record review, the facility failed to ensure staff followed food production recipes and fortified diet (diet to increase caloric intake) guidelines during lunch service when: 1. Fortified diets (diet enriched to increase caloric content) were not prepared and served to 10 residents who were receiving a fortified diet. 2. 17 residents who were prescribed a pureed diet (foods that do not require chewing and are easily swallowed in which all foods should be smooth and pureed to the consistency of pudding) received pureed vegetables (carrots and green beans) that were lumpy, not smooth, and had chunks which required chewing before swallowing. 3. [NAME] 1 used a small scoop size to serve meatloaf for residents receiving a mechanical soft and finally chopped diet (includes moist foods in bit sized pieces for residents who have chewing and or swallowing difficulty). 29 residents prescribed a mechanical soft diet and four residents prescribed a finally chopped diet received 1/3 cup of meat loaf instead of 1/2 cup per the menu. These deficient practices had the potential to result in meal dissatisfaction, decreased caloric intake, weight loss, and increased choking risk for residents requiring a pureed diet. Findings: 1. During the lunch service tray line observation on 6/10/2024 at 11:50 a.m., for residents who were prescribed a fortified diet, [NAME] 2 did not communicate to [NAME] 1 the fortified diet orders written on the meal tickets during tray line. [NAME] 1 did not add any additional food items per the fortified menu to the meal trays. During a concurrent observation and interview with [NAME] 1 and [NAME] 2 on 6/10/2024 at 12:00 p.m., regarding the diet fortification process, [NAME] 1 stated when there was a fortified diet, butter was added to the vegetables during lunch. [NAME] 2 stated during lunch he reads and communicated the different diets based on the meal ticket indicated on the trays. Subsequently, [NAME] 2 did not read and communicate residents likes and dislikes or the fortified diet orders written on the meal tickets. During a concurrent interview on 6/10/2024 at 12:45 p.m., with [NAME] 2 and the Dietary Supervisor (DS), [NAME] 2 stated he did not read and communicate the fortified diets during lunch service. The DS stated fortified diets were for residents who were losing weight or not eating enough calories. The DS stated butter was added to vegetables during lunch service to increase calories. The DS stated residents receiving a fortified diet did not receive the fortified foods. A review of the facility's policy and procedure (P&P) titled Therapeutic Diets, revised 5/1/2018, indicated, therapeutic diets are diets that deviate from the regular diet and require a physician order. The P&P indicated the dietary manager will observe meal preparation and serving to ensure that food portions served are equal to the written portion sizes. The P&P indicated the dietary manager will periodically review the residents tray card and the physicians' dietary orders to ensure that the information is consistent. A review of the facility's P&P titled Fortification of food: Increasing Calories and or protein in the Diet, dated 2023, indicated, the goal is to increase the calorie and or protein density of the foods commonly consumed by the resident to promote improvement in their nutrition status. The P&P indicated extra margarine may be added to one food item at breakfast, two food items at lunch, and one food item at dinner. 2. During an observation on 6/10/2024 at 10:35 a.m., in the kitchen, [NAME] 1 was observed adding frozen mixed vegetables (carrots, green beans, cauliflower) inside a large pot. [NAME] 1 added water and stated after the vegetables boiled for 30 minutes he would remove some of the vegetables to blend for the pureed diet. During an observation of the lunch tray line service on 6/10/2024 at 11:50 a.m., the pureed vegetables were chunky and not smooth. During the serving of the pureed vegetables, observed pieces of vegetables on the plate. During a concurrent observation and interview with the DS and [NAME] 1 on 6/10/2024 at 1:00 p.m., [NAME] 1 stated pureed food should be the consistency of pudding, hold its shape and not require chewing so the residents could not easily swallow. [NAME] 1 stated the pureed vegetables he served had a chunky consistency. [NAME] 1 stated he was rushing for lunch service and did not blend the pureed vegetables well until smooth. [NAME] 1 stated it was important for pureed food to be soft and not chunky so there was no chewing before swallowing. The DS tasted the pureed food and stated there was some chewing needed before swallowing. The DS stated [NAME] 1 would need to blend the pureed food longer. A review of the facility's P&P titled Regular Pureed Diet, dated 2023, indicated, pureed diet is a regular diet that has been designed for residents who have difficulty chewing and or swallowing. The P&P indicated the texture of the food should be of a smooth and moist consistency. A review of the recipe for pureed vegetables indicated to puree the cooked vegetables to a paste consistency before adding liquids. The recipe indicated to gradually add warm liquid if needed. The recipe indicated the puree should reach the consistency of applesauce. A review of the International Dysphagia Diet (foods that are soft textured and moist, making them easy to swallow) Standardization Initiative guidelines for pureed diet (www.IDDSI.org) indicated, pureed food does not require chewing and have a smooth texture with no lumps. 3. A review of the facility lunch menu for mechanical soft and finally chopped diet, dated 6/10/2024, indicated the following items would be served: Old fashioned meatloaf 4 ounces (oz., unit of measurement) or 1/2 cup mashable and moist with gravy; herb mashed potatoes 1/2 cup; seasoned fresh vegetables soft or chop 1/2 inch; pan biscuit; margarine; plain ice cream; and milk. During a concurrent observation of the lunch tray line service and interview with [NAME] 1 and the DS on 6/10/2024 at 11:50 a.m., for residents who were receiving a mechanical soft and finally chopped diet, [NAME] 1 served meatloaf using the #12 scoop yielding 2.5 oz. or 1/3 of cup instead of 1/2 cup per the menu. [NAME] 1 stated he used the smaller scoop to serve the mechanical soft meatloaf. [NAME] 1 stated he made a mistake and did not realize the scoop size. The DS stated the residents receiving a mechanical soft and finally chopped diet received less protein than the menu indicated. A review of the facility spreadsheet (portion and serving guide) dated 6/10/24, indicated old fashioned meatloaf regular portion for mechanical soft diet was 4 oz. or 1/2 cup. A review of the recipe for Old Fashioned Meatloaf indicated the portion size was 4 oz. A review of the facility's P&P titled Menu Planning, dated 2023, indicated, menus are planned to meet nutritional needs of residents in accordance with established national guidelines, physicians' orders, and recommended dietary allowances. The P&P indicated standardized recipes adjusted to appropriate yield shall be maintained and used in food preparation.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and preparation practices when: 1. One package of ready to eat ham was stored in the walk-in refrigerator with no thaw date. One large tray of breaded fish, two large packages of diced pork and six logs of ground beef were thawing in the walk-in refrigerator with no pulled out of the freezer or thaw date. One plastic storage bag with a breaded food item stored in the reach in freezer had no label or date. 2. The ice machine was not maintained in a clean manner and the inside compartment of the ice machine was observed with black residue. 3. Dietary Aide 1 did not follow cleaning and sanitizing procedures when there was raw ground beef in the food preparation sink, and when [NAME] 1 used the same sink to drain ready to eat cooked vegetables. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 108 out of 114 residents who received food and ice from the kitchen. Findings: During an observation on 6/10/2024 at 8:45 a.m., in the kitchen, there was one large tray of breaded fish with no thaw date stored in the walk in refrigerator. There was one package of ready to eat previously frozen and thawed sliced ham stored in the walk-in refrigerator with no thaw date. During a subsequent concurrent observation and interview with the Dietary Supervisor (DS), there were two large packages of raw diced pork and six logs of ground beef thawing on the bottom shelf in the walk-in refrigerator with no thaw or pulled out of the freezer date. The DS stated the ground beef was going to be used that day (6/10/2024). The DS stated the meat was usually taken out of the freezer 3 days prior to preparation. The DS agreed that meat thawing in the refrigerator should be labeled to ensure the food items did not exceed the thawing and storing period. During a concurrent observation and interview with the DS on 6/10/2024 at 9:00 a.m., in the reach in refrigerator, there was one brown bag sack lunch with a ham sandwich and juice dated 6/7/2024. The DS stated the lunch bag included snacks for residents receiving dialysis treatment (process of filtering waste from the blood in place of kidneys that no longer function). The DS stated the sack lunch had been in the refrigerator for 3 days and must be discarded. The DS was observed removing the sack lunch from the refrigerator. During a subsequent concurrent observation and interview with the DS, in the reach in freezer, there was one plastic bag with a breaded food item. The bag was not labeled or dated. The DS stated everything that was out of the original box must be labeled and dated. A review of the facility's policy and procedure (P&P) titled, Procedure for refrigerator storage, dated 2023, indicated, individual packages of refrigerated or frozen food taken from the original packing box needed to be labeled and dated. A review of the facility's P&P titled Meat Cookery and storage, revised 5/1/2018, indicated, meat to be defrosted will be pulled three days prior to service and defrosted in a dry, cool area at 41 degrees Fahrenheit (F) or lower. The P&P indicated to date the meat when pulled for defrosting and date the meat for meal service. A review of the facility's P&P titled Thawing of meats, dated 2023 indicated, allow 2 to 3 days to defrost, depending on quantity and total weight of the meat. The P&P indicated to label defrosting meat with pull and use by date. 2. During an observation of the facility's ice machine on 6/10/2024 at 9:15 a.m., located in the kitchen, a clean paper towel was used to swipe the ice storage bin ceiling and behind the plastic covering the ice dispensing area. A gray and black residue was residue was observed on the paper towel. The residue was located under the baffle (plastic board that hold the ice from falling out of the ice storage bin). Observation of the ceiling of the ice machine and where the ice was dispensed was covered with the gray and black color residue. During a subsequent interview with the DS, the DS stated the maintenance staff was responsible for cleaning the ice machine's internal compartment. During a concurrent observation, interview, and review of the Ice Machine cleaning log, with Maintenance Supervisor (MS), on 6/10/2024 at 9:20 a.m., the MS stated he cleaned the ice machine every month and the last cleaning was on 5/4/2024. The MS stated during the cleaning process, the ice was removed and the internal storage bin and tubing was cleaned. The MS stated he did not remove the plastic (baffle) covering during the last cleaning. The MS agreed that there are some black residues and stated the ice machine was due for a cleaning. The MS stated the dirty ice machine compartment could contaminate the ice. A review of facility's P&P titled Ice Machine Cleaning Procedures, dated 2023, indicated, the ice machine needs to be cleaned and sanitized monthly. The P&P indicated to be sure special attention was paid to cleaning the door molding and the lid of the machine. A review of the 2022 U.S. Food and Drug Administration Food Code titled Equipment Food-Contact Surfaces and Utensils Code# 4-602.11, indicated, surfaces of utensils and equipment contacting food that is not time/temperature control for safety food such as iced tea dispensers, carbonated beverage dispenser nozzles, beverage dispensing circuits or lines, water vending equipment, coffee bean grinders, ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. 3. During a concurrent food preparation observation and interview with [NAME] 1, on 6/10/2024 at 10:00 a.m., [NAME] 1 finished mixing the raw ground beef with spoons and then placed the used spoons in the food preparation sink. [NAME] 1 stated the food preparation sink was for washing vegetables, fruits and that sometimes he placed the cooking pots and pans there until it was washed by the dishwasher. [NAME] 1 stated he did not use the sink to wash or thaw any raw meat products. [NAME] 1 stated DA 1 assisted with the cleaning and sanitizing of the counters and sinks during the cooking preparation. [NAME] 1 stated it was important to sanitize the food prep sink with sanitizer to prevent cross contamination of food. During an observation of the cleaning and sanitizing of the counters and sink on 6/10/2024 at 10:25 a.m., DA 1 picked up the spoons that was used to mix ground beef and placed them in the dishwashing machine. DA 1 then started to clean the food preparation sink. DA 1 filled a red bucket with a sanitizer solution and poured it out in and around the counters and sink. Then with her hands DA 1 was collecting the sanitizer solution from the counter and into the sink. DA 1 completed the cleaning with pouring water in the sink and dried it with a clean cloth. There were pieces of raw ground beef from the spoons at the bottom of the sink, near the drain and in the sieve (a strainer) that collects food waste. During a subsequent interview with DA 1, DA 1 stated she added a sanitizer and scrubbed the sink with the sanitizer, then rinsed it with water and dried it with a cloth stored in the sanitizer solution. When asked if the sink was clean with the raw ground beef at the bottom, DA 1 stated Yes, it's clean. During a food preparation observation on 6/10/2024 at 11:00 a.m., [NAME] 1 used the sink to drain the water from the cooked ready to eat vegetables. A review of the facility's P&P titled Shelves, Counters, and Other Surfaces Including Sinks (Handwashing, Food Preparation, Etc.), dated 2023, indicated, remove any large debris and wash surface with a warm detergent solution, and rinse with clear water using a clean sponge or cloth. The P&P indicated to wipe dry with a clean cloth and spray with a sanitizer. The P&P indicated to not rinse. A review of the facility's undated Dietary Aide Job Description indicated, responsibilities and duties included to wash and sanitize dishes, utensils and equipment as prescribed by standard procedure.

Based on interview and record review, the facility failed to ensure the Infection Preventionist (IP), who was responsible for the facility's Infection Prevention Control Program, completed ten hours of continuing education training on an annual basis. This deficient practice had the potential for the IP to be unaware and be unable to educate the facility's staff of updated information regarding Infection Prevention and Control. Findings: During an interview on 6/13/2024 at 7:40 a.m., with the Infection Preventionist (IP), the IP stated he was unable to find documentation that he completed ten hours of continuing education for the year of 2023. The IP stated he completed continuing education hours when he renewed his nursing license, however, those hours were not completed in the year of 2023. The IP stated he was responsible for completing ten hours of continuing education annually to ensure he was aware of any new guidelines or studies that were released and to be up to date with current infection prevention and control practices. During an interview on 6/13/2024 at 10 a.m., with the Director of Nursing (DON), the DON stated the IP was responsible for educating the staff on current infection prevention and control practices. The DON stated for the IP to educate others, he was responsible for being updated on current news and training sources. The DON stated if the IP did not complete the ten hours of continuing education annually, there was the potential that he could miss any changes that would need to be implemented and could possibly not be up to date on current infection control practices. A review of the California Department of Public Health All Facilities Letter (AFL), dated 11/4/2020, indicated, The IP should complete 10 hours of continuing education in the field of [Infection Prevention and Control] on an annual basis. Facilities should provide encouragement and support for IP staff to stay abreast of current news and training sources through a nationally recognized infection prevention and control association.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement the care plan by providing a two staff assist when turning and repositioning one of 4 sampled residents (Resident 2). This deficient practice had the potential for Resident 2 to be at risk for a fall or injury. Findings: A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included muscle weakness and unspecified abnormalities of gait (walking pattern) and mobility. A review of Resident 2's Minimum Data Set [MDS- a comprehensive assessment and screening tool] dated 2/8/2024, indicated the resident was moderately impaired in decision making (ability to reason, understand, remember, judge, and learn). The MDS indicated Resident 2 required substantial/maximal assistance (helper does more than half the effort) rolling left and right, and was dependent on staff for chair/bed to chair transfer and tub/shower transfer. A review of Resident 2 ' s care plan, dated 3/28/23, indicated the resident was at high risk for falls and injuries. The care plan approaches indicated to use 2 staff members to assist in turning and repositioning the resident. A review of Resident 2 ' s Bed Mobility: Self Performance Task, dated 4/2024, indicated the certified nurse assistants (CNA) have been documenting that Resident 2 was totally dependent and required full staff performance in how the resident moved to and from a lying position, turning side to side, and positioning of the body while in bed. The document further showed the CNA ' s have been documenting they had been using only one person to achieve these tasks. During a concurrent interview and record review on 4/30/24 at 1:11 PM, with Registered Nurse (RN) 1, Resident 2 ' s care plan, dated 3/28/23, and Bed Mobility: Self Performance Task, dated 4/2024, was reviewed. RN 1 stated if there was anything regarding a resident, the CNAs needed to be aware of how to care for a resident. RN 1 stated it could be communicated to the CNA through word of mouth, during morning huddle, or in the communication function in their charting system. RN 1 stated it was the responsibility of the licensed vocational nurses (LVN), director of staff development (DSD) or the RN to do so because the CNAs did not have the ability to look through the resident ' s health record or care plan. RN 1 reviewed the Bed Mobility: Self Performance Task documentation done by the CNAs and acknowledged the CNAs have been documenting the tasks performed by just 1 staff member. RN 1 was shown Resident 2 ' s care plan where it stated to use 2 staff members to assist in turning and repositioning the resident. RN 1 further stated the LVN or RN should have communicated to the CNA ' s the resident required 2 staff assist and not 1 staff member because it was important for the safety of the resident and could prevent injuries. During an interview on 5/1/24 at 10:07 AM, with CNA 2, CNA 2 stated she has taken care of Resident 2 before and the resident was unable to turn or reposition herself in bed and the staff needed to do it for her. CNA 2 stated she turned and repositioned the resident without the assist of a second staff member unless the resident was being combative. CNA 2 stated she was not aware the resident required 2 staff members to turn and reposition the resident. CNA 2 further stated that if the resident required 2 staff members to assist but only 1 staff member has been providing the care, it could be very risky because the resident may experience a fall, or the staff could injure the resident. A review of the facility policy and procedure (P&P), titled Care Planning, dated 5/1/2018, indicated the care plan serves as a course of action where the resident and the interdisciplinary team (IDT, group of healthcare workers that work together to treat a patient) work to move a resident toward specific goals that address the resident ' s medical, nursing, mental and psychosocial needs. A review of the facility's P&P titled Positioning and Body Alignment, dated 5/1/2018, indicated positioning and body alignment activities are individualized to resident ' s needs, planned, monitored, evaluated, and documented in the resident ' s medical record. The P&P indicated general preparation steps to position the resident include to check the care plan first and to be aware of limitations the resident has in positioning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately obtain blood pressure readings to determine if two of four sampled residents (Resident 1 and Resident 2) have orthostatic hypotension (a form of low blood pressure that happens when standing after lying down or sitting). This deficient practice had the potential for Resident 1 and Resident 2 to experience delayed medical interventions, falls, and injuries due to not having their orthostatic blood pressures (taken while lying, sitting, and standing to determine orthostatic hypotension) taken appropriately to determine orthostatic hypotension. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included muscles weakness, schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves), epilepsy (seizures, burst of uncontrolled electrical activity between brain cells), cerebral infarction (disrupted blood flow to the brain), heart failure, and difficulty walking. A review of Resident 1 ' s Minimum Data Set ([MDS]), a standardized assessment and care planning tool), dated 2/10/24 indicated Resident 1 had severe cognitive impairment (ability to reason, understand, remember, judge, and learn). The MDS indicated Resident 1 required supervision or touching assistance when walking 50 feet (ft.) and 150 ft. A review of Resident 1 ' s care plan, dated 4/8/24, indicated Resident 1 was at high risk for falls and injuries related to generalized weakness, psychotropic medications, having lack of awareness, poor judgement of safety, gait (manner of walking) instability, and being able to ambulate (walk) without use of assistive devices. Interventions included instructing Resident 1 and staff to change position slowly from sitting to standing. A review of Resident 1 ' s Medication Administration Record (MAR), dated 4/2023, indicated Resident 1 was to have their orthostatic blood pressure monitored on Wednesdays during the 7:00 AM – 3:00 PM shift. A review of Resident 1 ' s Weights and Vitals Summary, dated 4/2023, showed 3 blood pressure readings on Wednesday, 4/10/2024, on the 7:00 AM – 3:00 PM shift, as follows : 10:50 AM - Blood pressure reading of 110/74 millimeters of mercury (mmHg, unit of measurement). 11:12 AM - Blood pressure reading of 134/81 mmHg, while standing. 11:13 AM - Blood pressure reading of 134/81 mmHg, while sitting. A review of Resident 2 ' s admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included muscle weakness, unspecified abnormalities of gait and mobility, paranoid schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves), and chronic obstructive pulmonary disease (COPD, a chronic lung disease that affects the way someone breathes). A review of Resident 2's MDS dated [DATE], indicated Resident 1 was moderately impaired in decision making (ability to reason, understand, remember, judge, and learn). The MDS indicated Resident 2 required substantial/maximal assistance (helper does more than half the effort) rolling left and right, and was dependent on staff for chair/bed to chair transfer and tub/shower transfer. A review of Resident 2 ' s care plan, dated 3/28/23, indicated Resident 1 was at high risk for falls and injuries due to generalized weakness, confinement to bed, and being unable to walk. A review of Resident 2 ' s Order Summary Report, dated 4/2023, indicated Resident 2 was to have orthostatic blood pressure monitoring on Saturdays, during the 3:00 PM – 11:00 PM shift. A review of Resident 2 ' s Weights and Vitals Summary, dated 4/2023, showed 3 blood pressure readings on Saturday, 4/6/2024 and 4/13/2024, on the 3:00 PM – 11:00 PM shift, as follows: On 4/6/2024 at 3:29 PM - Blood pressure reading of 122/68 mmHg. On 4/6/2024 at 5:26 PM - Blood pressure reading of 112/78 mmHg while lying. On 4/6/2024 at 11:13 PM - Blood pressure reading of 117/75 mmHg. On 4/13/2024 at 3:25 PM - Blood pressure reading of 117/67 mmHg. On 4/13/2024 at 5:22 PM - Blood pressure reading of 112/74 mmHg while lying. On 4/13/2024 at 11:49 PM - Blood pressure reading of 116/72 mmHg. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 1, on 4/30/23 at 10:45 AM, Resident 1 and Resident 2's Weights and Vitals Summary for April 2024, was reviewed. LVN 1 stated the procedure to obtain orthostatic blood pressure would be to take the blood pressure when the resident was lying down first. LVN 1 stated then have the resident sit up and then take another blood pressure reading. LVN 1 stated if the resident was able to, staff would have the resident stand up and take another blood pressure reading. LVN 1 stated the purpose of doing it that way was to determine if the resident had a drop in blood pressure from a lying to an upright position. LVN 1 stated the blood pressure readings would not be useful if the nurse took the blood pressures out of order or if too much time passed between each blood pressure reading. LVN 1 stated staff would usually wait 3-5 minutes between each change in position to take a blood pressure. LVN 1 stated Resident 1 and Resident 2's orthostatic blood pressures were done incorrectly and there were issues with the documentation. LVN 1 stated because the nurse did not specify what position the residents were in, and that the time between each reading was either too close together or too far apart to give an accurate reading. LVN 1 further stated it was an issue because it was not an accurate reading, and the nurse would not know if there was a change in blood pressure that needed to be reported to the physician. During an interview with the Director of Nursing (DON) on 5/1/2024 at 3:05 PM, the DON stated orthostatic blood pressures should first be taken with the resident lying down, then sitting up, and then standing up if they were able to. The DON stated during each change in position, you must wait 3-5 minutes before taking the blood pressure. The DON stated if there was a 20 mmHG drop of the systolic blood pressure, that indicated the resident may have orthostatic hypotension and which needed to be alerted the physician. The DON stated if there was no documentation what position the resident was in when the blood pressure was taken, or the time between each blood pressure reading was taken either too short or too long, it meant the orthostatic blood pressure was not taken appropriately and the physician would not be able to intervene appropriately if the resident did have orthostatic hypotension. A review of the facility's policy and procedure (P&P) titled, Orthostatic Hypotension, dated 1/1/2012, indicated the procedure for taking orthostatic blood pressure is to take the blood pressure with the resident lying down first and then have them stand up or sit if unable to stand, and then take another blood pressure. The P&P indicated that orthostatic hypotension is 20 millimeters of mercury ([mmHg]- a unit of measurement) in the systolic blood pressure (top number of the blood pressure reading) or a 10 mmHG drop in the diastolic blood pressure (bottom number of the blood pressure reading) within 3 minutes of standing up.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to notify the physician of behavior changes for one out of four sampled residents (Resident 2). This deficient practice had the potential to result in harm for Resident 1 by not informing the physician of Resident 2's mental health decline. Findings: a. During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included dementia (a disease of cognitive impairment that effects memory and the cognition required for daily living), anxiety (feeling of unease, exvessive worry), and paranoid schizophrenia (a mental disorder with hallucinations and delusions accompanied by being distrustful and suspicious of people). During a review of Resident 1's History and Physical (H&P), dated 12/14/2023, the H&P indicated Resident 1 did not have the capacity to make medical decisions. During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 2/21/2024, the MDS indicated Resident 1 was severely cognitively impaired (ability to think and reason). b. During a review of Resident 2's admission Record, the admisison record indicated Resident 2 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 2's diagnoses included schizophrenia, homicidal ideations (thoughts of killing others), and suicidal ideations (thoughts of killing self). During a review of Resident 2's H&P, dated 2/19/2023, the H&P indicated Resident 2 had the capacity to understand and make medical decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident21 was moderately cognitively impaired. During a review of Resident 2's Nursing Progress Note, dated 3/17/2024, the note indicated Resident 2 was on one-to-one (1:1) monitoring (close supervision) for striking out at staff and other residents during the shift. During a review of Resident 1 and Resident 2's Abuse Investigation Reporting Form, the form indicated on 3/23/2024 at 8:00 a.m., there was an unwitnessed incident where Resident 2 attacked Resident 1 in self-defense, after witnessing Resident 1 ball his fists. During a review of Resident 2's Discharge summary, dated [DATE], the Discharge Summary indicated Resident 2 was picked up by the police. During an observation on 4/9/2024, at 9:10 a.m., Resident 1 was observed lying in bed and was able to make eye contact but did not respond to verbal stimuli. During an interview on 4/9/2024, at 9:31 a.m., with the Activities Director (AD), the AD stated if staff witnessed any resident-to-resident abuse, the charge nurse and abuse coordinator (Administrator) should be informed immediately. During an interview on 4/9/2024, at 10:09 a.m., with Resident 1's Responsible Party (RP) 1, RP 1 stated a few weeks prior she received a phone call from the facility informing her that they were sending Resident 1 to the hospital because he was attacked by Resident 2 and had sustained facial injuries. During a concurrent interview and record review on 4/9/2024, at 1:24 p.m., with Registered Nurse (RN) 2, RN 2 stated Resident 2 always had behavior issues that presented as agitation. RN 2 stated Resident 2 would walk around the halls, hit doors, and scream at people, which was why he was on close monitoring. RN 2 stated prior to the altercation between Resident 1 and Resident 2, Resident 2 was just taken off monitoring for hitting a certified nursing assistant (CNA) on 3/17/2024, but she was not sure who. RN 2 stated there was no documentation that the physician was notified. RN 2 stated there should be a Situation Background Assessment Recommendation ([SBAR] a technique that can be used to facilitate prompt and appropriate communication) note documenting the notification to the physician because there was a change in condition. RN 2 stated per the notes in Resident 2's chart it was not clear what happened and who was involved on 3/17/2024 when Resident 2 hit staff. During a review of the facility policy and procedure (P&P) titled, Change of Condition Notification , dated 5/2018, the P&P indicated the purpose of the P&P was to ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner. The P&P further indicated that: a. Behavioral deviations are considered an acute change in condition. b. The physician will be notified of incidents or accidents involving the resident. c. A licensed nurse will document the date, time, pertinent details of the incident, and the time the physician was contracted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement its abuse prevention policy by failing to report the unusual occurrence of a resident-to-resident altercation to the State Survey Agency (SA) within 2 hours after the allegation occurred for one of four sampled residents (Resident 1). This deficient practice had the potential to place Resident 1 at risk for elder abuse. Findings: a. During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included dementia (a disease of cognitive impairment that effects memory and the cognition required for daily living), anxiety (feeling of unease, excessive worry), and paranoid schizophrenia (a mental disorder with hallucinations and delusions accompanied by being distrustful and suspicious of people). During a review of Resident 1's History and Physical (H&P), dated 12/14/2023, the H&P indicated Resident 1 did not have the capacity to make medical decisions. During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 2/21/2024, the MDS indicated Resident 1 was severely cognitively impaired (ability to think and reason). b. During a review of Resident 2's admission Record, the record indicated Resident 2 was intially admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 2's diagnoses included schizophrenia, homicidal ideations (thoughts of killing others), and suicidal ideations (thoughts of killing self). During a review of Resident 2's H&P, dated 2/19/2023, the H&P indicated Resident 2 did had the capacity to understand and make medical decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 1 was moderately cognitively impaired. During a review of Resident 1 and Resident 2's Abuse Investigation Reporting Form, the form indicated on 3/23/2024 at 8:00 a.m., there was an unwitnessed incident where Resident 2 attacked Resident 1 in self-defense, after witnessing Resident 1 ball his fists. During a review of Resident 2's Discharge summary, dated [DATE], the Discharge Summary indicated Resident 2 was picked up by the police. During an observation on 4/9/2024, at 9:10 a.m., Resident 1 was observed lying in bed and was able to make eye contact but did not respond to verbal stimuli. During an interview on 4/9/2024, at 9:31 a.m., with the Activities Director (AD), the AD stated if staff were to witness any resident-to-resident abuse the charge nurse and abuse coordinator (Administrator) should be informed immediately. During an interview on 4/9/2024, at 10:09 a.m., with Resident 1's Responsible Party (RP) 1, RP 1 stated a few weeks prior she had received a phone call from the facility informing her that they were sending Resident 1 to the hospital because he was attacked by Resident 2 and had sustained facial injuries. During an interview on 4/9/2024, at 10:25 a.m., with the Administrator (Admin), the Admin stated the incident between Resident 1 and Resident 2 was discovered on 3/23/2024 at 8:00 a.m. and he faxed over the report to the SA within two (2) hours, but the fax did not go through. The Admin stated he sent the SA another fax of the report on 3/27/2024 when he sent the 5-day investigative report. During an interview on 4/9/2024, at 1:50 p.m., with Registered Nurse (RN) 1, RN 1 stated abuse had to be reported to the SA within 2 hours. During a review of the facility policy and procedure (P&P) titled, Policy on Patient Abuse and Mistreatment , dated 10/2022, the P&P indicated the following: a. Facility Administrator shall be responsible for ensuring that all alleged and substantiated violations are reported to the state agency, and other agencies as required. b. Facility shall report the incident to state agency within the required timeframes (2-24 hours).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an incident of a resident-to-resident altercation between two of two sampled residents (Resident 1 and Resident 2) within two hours from the time the altercation occurred. The above failure had the potential to cause a delay in the notification of necessary agencies and the timeliness of their investigations, and the potential for additional altercations between Resident 2 and other facility residents and staff. Findings: During a review of Resident 1 ' s admission Record, the record indicated the facility admitted Resident 1 on 8/10/2018 and re-admitted Resident 1 on 8/9/2021. Resident 1 ' s admitting diagnoses included unspecified abnormalities of gait (way of walking) and mobility, generalized weakness. During a review of Resident 1 ' s History and Physical (H&P), dated 2/12/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care screening/planning tool), dated 3/12/2024, the MDS indicated Resident 1 had no cognitive impairments (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS further indicated Resident 1 required a wheelchair and required supervision or touching assistance to walk distances of 10 to 150 feet (ft., a unit to measure distance). During a review of Resident 1 ' s medical record titled IDT ([Interdisiciplinary Team] group of different disciplines working together towards a common goal of a resident) Care Conference Meeting Revised, dated 2/28/2024, the record indicated Resident 1 had been hit on the arm by Resident 2 and this incident was witnessed by activity staff. During a review of Resident 2 ' s admission Record, the record indicated the facility admitted Resident 2 on 1/25/2019, and most recently re-admitted Resident 2 on 2/24/2024. Resident 2 ' s admitting diagnoses included hemiplegia (inability to move one side of the body) and hemiparesis (weakness to one side of the body) following a stroke (damage to the brain from interruption of its blood supply), paranoid schizophrenia (a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly), and anxiety disorder (Intense, excessive, and persistent worry and fear about everyday situations). During a review of Resident 2 ' s H&P, dated 2/26/24, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2 ' s MDS, dated [DATE], the MDS indicated Resident 2 had mild cognitive impairments. The MDS indicated Resident 2 also had hallucinations (the perception of seeing, hearing, touching, tasting, or smelling something that wasn't actually there) and delusions (a false belief or judgment about external reality). The MDS further indicated Resident 2 exhibited verbal behavioral symptoms (e.g., threatening others, screaming at others, cursing at others) that were directed toward others, and other behavioral symptoms not directed at others (e.g., physical symptoms such as hitting or scratching self, pacing, or verbal/vocal symptoms like screaming, disruptive sounds). The MDS indicated these behaviors occurred four to six a days a week. During a review of Resident 2 ' s care plans (a summary of a person's health conditions, specific care needs, and current treatments), dated 2/24/2024, the care plan indicated Resident 2 had risk for aggression with other residents due to paranoid delusion . and cursing or verbal aggressiveness. During a review of Resident 2 ' s medical record titled IDT Care Conference Meeting Revised, dated 2/28/2024, the record indicated staff met with Resident 2 to discuss the resident-to-resident altercation that occurred between her and Resident 1. The record indicated Resident 2 stated she hit Resident 1 ' s arm, and when asked why, Resident 2 stated because [Resident 1] did this to me. The record further indicated that during the staff ' s interview of Resident 2 demonstrated aggression such as kicking and hitting the floor, stating they did this to me. During an interview on 3/13/2024 at 11:30 AM, with the Director of Social Services (DSS), the DSS stated that Resident 2 had not been physically aggressive with other residents before but had verbally expressed paranoia (an unrealistic distrust of others or a feeling of being persecuted). The DSS stated that Resident 2 stated that she meant to hit Resident 1 and that it was not an accident. The DSS stated resident-to-resident altercations were considered an allegation of abuse and stated it needed to be reported within two hours. The DSS stated it was important to report within the two-hour timeframe because late reporting was important in decreasing the risk of harm to other facility residents. During an interview on 3/13/2024 at 12:02 PM, with the Activities Assistant (AA), the AA stated she was the staff member who witness the resident-to-resident altercation between Resident 1 and Resident 2. The AA stated the altercation occurred on 2/27/2024. The AA stated she was provided with the facility Administrator ' s (ADM) phone number to notify him because he was the abuse coordinator. The AA stated she did not call him because she didn ' t want to bother him. The AA stated that allegations of abuse, including resident-to-resident altercations, were supposed to be reported as soon as possible and stated she did not report it to the necessary agencies. During a concurrent interview and record review, on 3/13/2024 at 12:16 PM, with the DSS, the DSS reviewed the document titled, Report of Suspected Dependent Adult/Elder Abuse, 2/28/2024. The DSS stated the form indicated the altercation occurred on 2/27/2024 at 6:30 PM, and that she faxed the form on 2/28/2024. The DSS stated the altercation should have been reported on 2/27/24 by 8:30 PM. The DSS stated all staff were responsible for reporting and stated there should not have been a delay. During an interview on 3/13/2024 at 12:28 PM, with the Director of Nursing (DON), the DON stated resident-to-resident altercations were considered a type of abuse and stated that all allegations of abuse were supposed to be reported within two hours. The DON stated it was important to report within the required timeframe to have prompt intervention and investigation from outside agencies. The DON further stated that the purpose was to keep facility staff and residents safe. The DON stated that all facility staff were mandated reporters and that the altercation should have been reported by 8:30 PM the day that it occurred. During a review of the facility policy and procedure (P&P) titled, Policy on Patient Abuse and Mistreatment, dated 10/2022, the P&P indicated residents shall not be subjected to abuse by anyone, including but not limited to .other resident . The P&P further indicated When an incident has been determined to have satisfied the definition of abuse or suspected abuse: Facility staff shall report the incident by notifying CDPH [California Department of Public Health] .of such an incident within the required timeframes (i.e., 2/24 hours).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Physician Orders for Life-Sustaining Treatment ([POLST] a written medical order that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) for one of three sampled residents (Resident 1) was honored. The deficient practice resulted in Resident 1's end of life care wishes, not being followed, and had violated her preference and residents' rights. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including spondylosis without myelopathy (a condition where wear and tear accumulate in your neck, without putting pressure on the spinal cord), type 2 diabetes mellitus (a disease that occurs when your blood glucose is too high), and quadriplegia (paralysis of the arms and legs caused by neurological damage). During a review of Resident 1's History and Physical (H&P), dated [DATE], the H&P indicated, Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Order Summary Report, the Order Summary Report indicated Resident 1 has an active order of Do Not Attempt Resuscitation/DNR, Comfort-Focused Treatment, No Artificial Means of Nutrition, including Feeding Tubes. During a review of Resident 1's last quarterly Minimum Data Set assessment ([MDS] standardized assessment and care screening tool), dated [DATE], indicated Resident 1 had the ability to express ideas and wants and in making self-understood. During a review of Resident 1's POLST, dated [DATE], the POLST indicated, Do Not Attempt Resuscitation/DNR (allow natural death). During a telephone interview on [DATE] at 3:06 p.m., with Registered Nurse 1 (RN 1), RN 1 stated on [DATE] at around 5:30 a.m., he went to Resident 1's room and found Resident 1 unresponsive to all forms of stimuli, no pulse, and no respiration. RN 1 stated he did administer Cardiopulmonary resuscitation ([CPR] is an emergency lifesaving procedure performed when someone is not breathing, or their heart is not beating) immediately to Resident 1. RN 1 stated he gave instructions to other staff to call 911 and get the physical chart of Resident 1. RN 1 stated he stopped CPR when he found out Resident 1 POLST was DNR. RN 1 stated he did CPR to Resident 1 for about 1 to 2 minutes. RN 1 stated he made a mistake by not following Resident 1's DNR order. During a concurrent interview and record review on [DATE] at 3:40 p.m., with Director of Nursing (DON), Resident 1's Progress Notes Dated [DATE] was reviewed. DON confirmed Resident 1 was given CPR by RN 1. DON stated RN 1 should have not initiated CPR to Resident 1 and it does not matter how long he performed CPR to Resident 1. DON stated the standard of practice was to check the code status first before giving chest compression and initiating life emergency measure to all residents. DON stated Resident 1's POLST should be fulfilled, as Resident 1 instructed, because it was Resident 1's right to determine what her end-of-life care should be. DON stated Resident 1's preference and rights had been violated by not honoring her medical wishes. During a review of the facility's policy and procedure (P&P), titled Do Not Resuscitate Orders and the Withholding/Withdrawal of Life Support and Life Sustaining Treatment, dated [DATE], the P&P indicated, The facility will follow federal and state law and resident preferences with regard to the withdrawal of or withholding of treatment and Do Not Resuscitate (DNR) orders. A DNR order, also called a No Code order, is a physician order that directs that resuscitative efforts will not be initiated in the event of cardiac or respiratory arrest. It authorizes the withholding of life sustaining procedures. Resident's rights will be respected regarding withdrawal or withholding of life support and DNR orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow infection control measures and the prevention of COVID-19 (a highly contagious infection that easily spreads from person to person) when: 1. Resident 1, who was COVID-19 positive (confirmed infected or sick), was not isolated from other residents (Resident 2 and Resident 3) from 12/5/2023 to 12/12/2023, while other rooms were empty. 2. Resident 2 and Resident 3, who were exposed to COVID-19 (close contacts) but negative (not confirmed infected or sick), were kept in the same room of a COVID-19 positive resident from 12/5/2023 to 12/12/2023, while other rooms were empty. 3. Resident 2 and Resident 3 were not wearing a face mask before or after eating in the room. 4. Resident 2 left her room without a mask. 5. Resident 2 and Resident 3 were not tested for COVID-19 using a more sensitive test called Polymerase chain reaction (PCR) test within or after five days of exposure. 6. Certified Nurse Assistant (CNA) 3 did not wear proper personal protective equipment (PPE, protective clothing designed to protect the wearer from the spread of infection or illness) before entering and providing care to COVID-19 positive and exposed residents (Resident 1, 2 and 3) who were still under transmission-based precautions (strict infection control measures to prevent transmission or spread of infection). 7. CNA 3 did not perform hand hygiene after exiting and providing care to COVID-19 positive and exposed residents (Resident 1, 2 and 3) who were still under transmission-based precautions and before getting straws from a medication cart for Resident 3. 8. Administrator and Director of Nursing misread and misinterpreted the guidelines for isolation, transmission-based precautions and cohorting (grouping of residents with the same confirmed infection) of COVID-19 positive and exposed roommates. Theses failures had the potential to result in an increase of COVID-19 cases in the facility and placed residents, staff, and the community at risk for contracting COVID-19. Findings: During a concurrent interview and record review on 12/12/2023, at 9:53 a.m., with Registered Nurse (RN) 2, Facility ' s Daily Room Roster (Census), dated 12/12/2023, was reviewed. RN 2 stated the facility had one COVID-19 positive resident (Resident 1) and there were two COVID-19 exposed (close contacts) but negative residents (Resident 2 and 3) in the same room. The Census indicated, Resident 1, 2 and 3 resided in the same room together. During an interview on 12/12/2023, at 10:02 a.m., with the Director of Nursing (DON), the DON stated Resident 1 was coughing and tested positive for COVID-19 on 12/5/2023. The DON stated Resident 1 refused to be transferred to the hospital as ordered by her physician. The DON stated Resident 1 told the facility she was not sick and her runny nose was from her allergies. The DON stated Resident 1 did not have the mental capacity to differentiate a change in condition to her health and her usual allergy symptoms. The DON stated the facility did not move Resident 2 and Resident 3 from the room based on the new recommendations they read and interpreted from the California Department of Public Health (CDPH) All Facilities Letter (AFL) 23-36 and the facility's public health nurses' (PHN) email and documents sent to them via email. The DON stated Resident 1, Resident 2, and Resident 3 were tested for COVID-19 using an antigen (a less sensitive test or less likely to detect a virus) test and all three residents were negative on 12/10/2023. During an interview on 12/12/2023, at 10:41 a.m., with the DON, the DON stated the COVID-19 positive and exposed residents were on contact or transmission-based precautions to prevent the spread of COVID-19 infection. The DON stated the staff assigned or who went into those rooms must perform hand hygiene, and wear complete PPE including a surgical (loose fitting) mask or N95 (very close fitting mask) mask, gown, gloves, and face shield to prevent the spread of infection and as recommended by the PHN. During a telephone interview on 12/12/2023, at 12:03 p.m., with the PHN, the PHN stated COVID-19 positive residents must be isolated in a designated COVID-19 room with transmission-based precautions for at least ten (10) days or until 12/15/2023, and if symptoms have improved while the COVID-19 exposed residents or close contacts were in a separate room to prevent further exposure. The PHN stated staff must perform hand hygiene before entering and after exiting a COVID-19 positive room and wear proper PPE that included a mask, gown, gloves, and face shield to protect the staff while inside the same room taking care of the positive and exposed residents to prevent the spread of COVID-19. The PHN stated COVID-19 exposed but negative residents must wear a surgical mask while outside of their rooms to prevent exposing other residents in case they became COVID-19 positive. The PHN stated COVID-19 exposed but negative residents were tested after 24 hours, 3-days, and 5-days after exposure, with an antigen test and at least with one polymerase chain reaction (PCR, a more sensitive test that can detect small amounts of the virus that the antigen test could not detect) test within or after five days. During an observation on 12/12/2023, at 12:33 p.m., in COVID-19 positive and exposed residents ' room, Certified Nursing Assistant (CNA) 3 was observed inside the room receiving meal trays from another staff outside of the room and passing the meal trays to Resident 1, 2, and 3 while wearing a mask and gloves. CNA 3 was not wearing a gown or face shield. CNA 3 was observed within 1 feet of Resident 3 while repositioning the resident in the wheelchair. Resident 3 was talking to CNA 3 without a mask. Resident 1 and 2 were sitting on the edge of their beds eating their lunch without a mask. CNA 3 left the room without performing hand hygiene. CNA 3 went to a medication cart in front of the closest nurse ' s station, got straws from the medication cart and went back to the COVID-19 positive and exposed room without hand hygiene before entering the room. During a concurrent observation and interview on 12/12/2023, at 12:38 p.m., with CNA 3, outside of the COVID-19 positive and exposed residents ' room, there were two posted signs on the right side of the doorway. One of the signs had pictures of PPE and was titled, Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19. The other sign were instructions on how to put on and take off the PPE. CNA 3 stated she did not wear complete PPE in the COVID-19 positive and exposed residents ' room because she read a communication that Resident 1, 2, and 3 were COVID-19 negative. CNA 3 stated she did not know if it was the antigen or PCR test. CNA 3 stated Resident 1 may still have a runny nose and Resident 1 could not tell if it was from allergies or still part of COVID-19 disease. During a concurrent interview and record review on 12/12/2023, at 1:03 p.m., with CNA 3, the facility ' s electronic communication (Communications) document, dated 12/10/2023 was reviewed. The document indicated Resident 1, 2 and 3 were all negative for COVID-19. CNA 3 stated she thought she did not need to wear complete PPE because the residents were negative even though there was still a sign outside of the room indicating to wear complete PPE. CNA 3 stated the document did not indicate what test was used or whether or not to stop wearing complete PPE when entering the room or taking care the residents. During an interview on 12/12/2023, at 1:06 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated COVID-19 could be transmitted or spread to others through contact (touching contaminated or exposed residents or objects) and/or droplets (coughing or sneezing). LVN 2 stated some of the signs or symptoms of COVID-19 were fever, coughing, sneezing, headache, nausea, diarrhea, shortness of breath, and fatigue that may lead to hospitalization even for a healthy person. LVN 2 stated the communications document indicated Resident 1, 2 and 3 were negative for COVID-19 but did not indicate which test was used or to stop wearing complete PPE. LVN 2 stated staff entering into a resident room with signage must continue transmission-based precautions until the PHN cleared the isolation precautions. LVN 2 stated if there was no hand hygiene and/or complete PPE, there was a chance for the staff to get COVID-19 and spread it to other staff and residents. During a concurrent observation and interview on 12/12/2023, at 1:21 p.m., with LVN 2, in the hallway near the nurse ' s station and dining room, Resident 2 was observed walking in the hallway without a mask. LVN 2 stated Resident 2 was exposed to COVID-19. LVN 2 stated Resident 2 came out of the COVID-19 positive room without a mask and may potentially be positive for COVID-19 and spread it to staff or other residents. During a concurrent observation, interview, and record review on 12/12/2023, at 2:21 p.m., with the Administrator (ADM) and DON, the CDPH AFL 23-36, dated 12/5/2023, was reviewed. The AFL 23-36 indicated symptomatic (showing signs or symptoms of being sick) and exposed residents should generally remain in their current room and wear a mask for source control when outside their room. The AFL 23-36 indicated to avoid movement of symptomatic and exposed residents that could lead to new exposures (for example, roommates of symptomatic residents, who have already been potentially exposed, should not be placed with new roommates, if possible). The AFL 23-36 indicated residents with confirmed COVID-19 should be placed in a single room, if available, or a designated COVID-19 isolation area or cohort. The AFL 23-36 indicated multiple residents with confirmed respiratory viruses may be cohorted together in shared rooms with the same confirmed virus infection. The ADM and DON stated they misread avoid movement of residents and misinterpreted that a confirmed COVID-19 resident and non-confirmed COVID-19 exposed residents can stay in the same room for the duration of the isolation. During a concurrent interview and record review on 12/12/2023, at 2:21 p.m., with the ADM and the DON, the PHN COVID-19 Outbreak Notification (Notification) document, dated 12/7/2023, was reviewed. The document indicated to initiate COVID-19 transmission-based precautions while continuing standard precautions for all residents with confirmed and suspect COVID-19. The Isolation and Quarantine section of the document indicated to isolate COVID-19 confirmed cases in a designated COVID-19 isolation area while close contacts or exposed residents were not routinely quarantined. The document indicated exposed residents should wear well-fitting masks when they were outside of their rooms. During a review of Resident 1 ' s admission Record, dated 12/12/2023, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE], and was re-admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, a group of disease that causes breathing problems) and dementia (a condition that may cause memory loss, poor judgment, and confusion). The admission Record indicated Resident 1 had a conservator or public guardian that made healthcare decisions on behalf of the resident. During a review of Resident 1 ' s History and Physical (H&P), dated 9/11/2023, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/31/2023, the MDS indicated Resident 1 was unable to complete the interview which assessed the resident's ability to think and understand. During a review of Resident 1 ' s Change in Condition Evaluation (COC), dated 12/5/2023, the COC indicated Resident 1 had a cough, congestion, and was positive for COVID-19. The COC indicated the physician ordered to transfer the resident to the hospital for further evaluation and treatment. During a review of Resident 1 ' s Care Plan titled, Resident is Positive for COVID-19, dated 12/5/2023, the care plan indicated the facility would assess and observe the resident for signs of respiratory changes. During a review of Resident 1 ' s Progress Note, dated 12/6/2023, the Progress Note indicated Resident 1 refused to go to the hospital for further treatment of her cough. During a review of Resident 1 ' s COVID-19 Point of Care Testing Form, dated 12/10/2023, the form indicated Resident 1 was negative for COVID-19 using an antigen test kit. The form did not indicate a PCR test was used. During a review of Resident 2 ' s admission Record, dated 12/12/2023, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE], and was re-admitted on [DATE] with diagnoses that included COPD and paranoid schizophrenia (a mental illness of being suspicious and having hallucinations). The admission Record indicated Resident 2 had a durable power of attorney (POA, person appointed to make decisions on behalf of another person) that could make healthcare decisions on the resident's behalf. During a review of Resident 2 ' s H&P, dated 3/27/2023, the H&P indicated Resident 2 did not have the capacity to understand and make medical decisions. During a review of Resident 2 ' s MDS, dated [DATE], the MDS indicated Resident 2 ' s cognition (ability to think and understand) was severely impaired. During a review of Resident 2 ' s Progress Note, dated 12/5/2023, the Progress Note indicated Resident 2 was being monitored for possible exposure to COVID-19. During a review of Resident 2 ' s Care Plan titled, At Risk for Exposure to COVID-19, dated 9/28/2022, revised on 11/30/2023, the care plan indicated the facility would assess and observe the resident for signs of respiratory changes. The care plan indicated If Resident 2 was having signs of COVID-19, the resident would be tested and quarantined per the public health recommendation. During a review of Resident 2 ' s COVID-19 Point of Care Testing Form, dated 12/5/2023, the form indicated Resident 2 was negative for COVID-19 using an antigen test kit. The form did not indicate a PCR test was used. During a review of Resident 2 ' s COVID-19 Point of Care Testing Form, dated 12/6/2023, the form indicated Resident 2 was negative for COVID-19 using an antigen test kit. The form did not indicate a PCR test was used. During a review of Resident 2 ' s COVID-19 Point of Care Testing Form, dated 12/8/2023, the form indicated Resident 2 was negative for COVID-19 using an antigen test kit. The form It did not indicate a PCR test was used. During a review of Resident 2 ' s COVID-19 Point of Care Testing Form, dated 12/10/2023, the form indicated Resident 2 was negative for COVID-19 using an antigen test kit. The form did not indicate a PCR test was used. During a review of Resident 3 ' s admission Record, dated 12/12/2023, the admission Record indicated, Resident 3 was originally admitted to the facility on [DATE] with diagnoses of parkinsonism (a brain condition that cause slowed movements, stiffness and tremors). The admission Record indicated Resident 3 had a guardian who could make healthcare decisions on behalf of the resident. During a review of Resident 3 ' s H&P, dated 8/3/2023, the H&P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3 ' s MDS, dated [DATE], the MDS indicated Resident 3 ' s cognition was severely impaired. During a review of Resident 3 ' s Progress Note, dated 12/5/2023, the Progress Note indicated Resident 3 was being monitored for possible exposure to COVID-19. During a review of Resident 3 ' s Care Plan titled, Exposure to COVID-19 Secondary to Roommate COVID-19 Positive, dated 12/6/2023, revised on 12/12/2023, the care plan indicated the facility would assess and observe the resident for signs of respiratory changes. The care plan indicated the facility would remove the resident to another room to avoid further exposure. During a review of Resident 3 ' s COVID-19 Point of Care Testing Form, dated 12/5/2023, the form indicated Resident 3 was negative for COVID-19 using an antigen test kit. The form did not indicate a PCR test was used. During a review of Resident 3 ' s COVID-19 Point of Care Testing Form, dated 12/6/2023, the form indicated Resident 3 was negative for COVID-19 using an antigen test kit. The form did not indicate a PCR test was used. During a review of Resident 3 ' s COVID-19 Point of Care Testing Form, dated 12/8/2023, the form indicated Resident 3 was negative for COVID-19 using an antigen test kit. The form did not indicate a PCR test was used. During a review of Resident 3 ' s COVID-19 Point of Care Testing Form, dated 12/10/2023, the form indicated Resident 3 was negative from COVID-19 using an antigen test kit. The form did not indicate a PCR test was used. During a review of the facility ' s policy and procedure (P&P) titled, 'COVID-19 Testing and Quarantine, dated 6/5/2023, the P&P indicated close contact means someone who has been within six feet of a COVID-19 positive person for a cumulative total of 15 minutes or more over a 24-hour period. The P&P indicated residents who are identified as close contact should wear source control while outside of their rooms. The P&P indicated,residents who test positive and are symptomatic with mild to moderate illness should be isolated (separated from other residents) at least five to ten days following the date of their positive test and symptoms have improved. During a review of the facility ' s P&P titled, Resident Isolation-Categories of Transmission-Based Precautions, dated 7/1/2023, the P&P indicated transmission-based precautions are used when caring for residents with communicable disease or transmittable infections. The P&P indicated contact precautions are implemented for residents known or suspected to be infected or colonized with COVID-19 that are transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident ' s environment. The P&P indicated gloves are removed before leaving the room and hand hygiene is performed immediately. The P&P indicated gown is worn for interactions that may involve contact with the resident or potentially contaminated items in the resident 's environment. The P&P indicated clothing is not allowed to contact potentially contaminated environmental surfaces. The P&P indicated droplet precautions are implemented for residents known or suspected to be infected or colonized with COVID-19 that are transmitted by droplets (large-particle droplets [larger than 5 microns in size] that can be generated by individual coughing, sneezing, or talking). The P&P indicated gloves are removed before leaving the room and hand hygiene is performed immediately. The P&P indicated a gown is worn for interactions that may involve contact with the resident or potentially contaminated items in the resident ' s environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Interdisciplinary Team (IDT, group of different disciplines working together towards a common goal for a resident) was involved in developing a discharge plan that reflected the resident's discharge needs, goals, and treatment preferences for one of two sampled residents (Resident 1). This deficient practice has the potential to result in incomplete or ineffective discharge planning and could lead to lack of necessary care for Resident 1 after being discharged from the facility. Findings: During a record review of Resident 1's admission Record dated 1/24/2023, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included anemia (lack of red blood cells or dysfunctional red blood cells in the body), hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following an unspecified cerebrovascular disease affecting the right dominant side (refers to a severe or complete loss of strength, whereas hemiparesis refers to a relatively mild loss of strength), schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly). During a review of Resident 1's MDS (MDS, a standardized assessment and care-screening tool), dated 1/4/2023, the MDS indicated Resident 1 was usually able to make self-understood and usually able to understand others. The MDS indicated Resident 1 required limited assistance with one staff for bed mobility, locomotion off and on the unit, extensive assistance with transfer, total assistance with personal hygiene, dressing, toilet use and bathing, and supervision with eating. During a record review of Resident 1's Interdisciplinary Team (IDT) Meeting Note dated 10/21/2022, the IDT note did not indicate any planning discharge. During a telephone interview on 1/19/2023 at 9:35 a.m. with Resident 1's Responsible Party (RP), the RP stated he was not aware how to transfer the resident because he was out of state. The RP stated he felt bad no one could visit Resident 1 at the facility since he was too far. The RP stated if he were closer to the facility he would visit the resident at least two times a week which would help in the resident's recovery. The RP stated he called the facility multiple times, but no one was helping him with the discharge process. The RP stated he tried to have Resident 1 transfer to a facility that was close to his place. During an interview on 1/19/2023 at 10:20 a.m. with the Social Services Assistant (SSA), the SSA stated she and the Social Services Director (SSD) divided the whole facility regarding the ancillary services, care planning or discharges. The SSA stated whatever the social services role was they divided the assignments by room numbers. The SSA stated she received a call, and she emailed documents to the RP's facility of choice. The SSA stated she did not try to look for other facility's around the RP's area. The SSA stated there was no IDT meeting done. During a record review of the December 2022 and January 2023 IDT Meeting calendar schedule, there was documentation Resident 1 was scheduled for a IDT meeting on either calendar. During an interview on 1/19/2023 at 11:15 a.m. with the SSD, the SSD stated the IDT met up if there were changes in a resident's plan of care like a discharge to the community or a lateral transfer so everyone in the team would be on the same page. The SSD stated she was not aware Resident 1's RP requested the resident to be discharged . The SSD stated communication was important to know other team members input to facilitate a proper discharge. During an interview on 1/19/2023 at 12:39 p.m. with the Administrator (Admin), the Admin stated a IDT meeting should have been initiated to be in the same goal and for appropriate discharge. The Admin stated he was not aware an IDT meeting was not done. During a record review of the facility's policy and procedure (P&P) titled, Admission, 24 Hour, dated 3/2010, the P&P indicated the discharge planning process begins with field evaluation prior to admission. This assessment includes a review of services, financial resources, and family support systems already in place or which could be made available. Once the assessment is completed, a preliminary discharge plan is formulated. This discharge plan is fluid and will be continuously changed and updated as the resident progresses through the program. Discharge planning is not a static activity. The P&P indicated the discharge Plan is created and altered with input from the IDT composed of the Registered Nurse, medical Director(MD), Psychiatrist, Physical Therapy, Occupational Therapy(OT), Speech Therapy, Dietician, Social Worker, Activities Director(AD) Respiratory Therapy, family members and the Resident. Together this group composes a plan to best meet the ever changing needs of the Resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure a resident who was receiving an anticoagulant medication (a blood thinning medication used to prevent blood clots [a mass of blood that forms when blood platelets {a component of blood} proteins and cells stick together) and who hit and injured their head during a fall episode was transferred to a general acute care hospital (GACH) for a CT scan ([computerized tomography] a medical imaging technique used to obtain detailed internal images of the body) to rule out an intracranial hemorrhage (bleeding between the brain tissue and skull or within the brain tissue itself; can cause brain damage and be life-threatening) for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1's delay in evaluation, diagnosis, care, and treatment. After obtaining a physician's order to transfer Resident 1 to a GACH, Resident 1 remained at the facility for over 10 hours before being transferred. At the GACH Resident 1 was admitted to the intensive care unit ([ICU] unit where critically ill patients are cared for) where he was diagnosed with a subdural hemorrhage (a type of bleeding that occurs outside the brain as a result of a severe head injury) and acute blood loss anemia (occurs when there is an abrupt drop in red blood cells most often by hemolysis [the breakdown of red blood cells] or acute hemorrhage [bleeding]) due to head trauma. Findings: During a review of the admission Record (face sheet) the face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with a diagnosis of traumatic subdural hemorrhage and dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). During a review of the Minimum Data Set ([MDS], a standardized assessment and care screening tool) dated 9/14/2022, the MDS indicated Resident 1's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision- making were severely impaired. The MDS indicated Resident 1 required limited assistance with locomotion on/off the unit and extensive one-person physical assist with activities of daily living ([ADLs] task such as eating, bathing, dressing, grooming and toileting). During a review of Resident 1's Nurse Progress Notes (NPN), dated 10/10/2022 and timed at 10:50 p.m., the NPN indicated Licensed Vocational Nurse 1 (LVN 1) notified a nurse practitioner (NP) of Resident 1's fall. The NPN indicated to transfer Resident 1 to a GACH for a CT scan to rule out intracranial bleeding. During a review of Resident 1's SBAR ([Situation Background Assessment Recommendation] a form of communication between members of a health care team), dated 10/1/2022 and timed at 12 a.m., the SBAR indicated a certified nursing assistant (CNA) found Resident 1 on the floor next to his wheelchair, with blood and a laceration on the left side above his eye measuring 0.5 centimeters ([cm] a unit of measurement) x 12 cm by 0.5 cm x 1.5 cm. The NP was made aware and ordered Resident 1 transferred to a GACH for a CT scan. During a review of Resident 1's Physicians Orders, dated 10/11/2022 and timed at 00:01 a.m., the Physician ' s Orders indicated to transfer Resident 1 to a GACH for a CT scan to rule out an intracranial hemorrhage. During a review of Resident 1's NPN dated 10/11/2022 and timed at 7:19 a.m., the NPN indicated Resident 1 had not been transferred to the GACH and was still at the facility. During a review of Resident 1's Physician ' s Orders, dated 10/11/2022 and timed at 8:53 a.m., the Physician's Order indicated Resident 1 was transferred to a GACH at 8:53 a.m. (10 hours following the order to transfer Resident 1 to the GACH). During a review of Resident 1's Admission/Registration (AR), from the GACH, dated 10/11/2022, the AR indicated Resident 1 arrived at the GACH' s emergency department on 10/11/2022 at 9:18 a.m. During a review of Resident 1's Trauma Consult Notes (TCN), from the GACH, dated 10/11/2022 and timed at 12:35 p.m., the TCN indicated Resident 1 was evaluated and found to have a small head bleed. During a review of Resident 1's CT scan, from the GACH, dated 10/11/2022, the CT scan indicated evidence of a minimal subdural hemorrhage in the anterior (front) aspect of the interhemispheric (a deep groove within the midline separating both cerebral hemispheres (the cerebrum [largest part of the brain] is divided into the left and right hemispheres) falx (part of the brain shaped like a C), measuring approximately 4 millimeters (mm) in thickness. During a review of Resident 1's Neurosurgery Progress Notes (NSPN), from the GACH dated 10/13/2022 and timed 1:47 p.m., the NSPN indicated Resident's diagnoses included traumatic subdural hemorrhage and bleeding in the head following an injury with loss of consciousness. The NSPN indicated Resident 1 was cleared for discharge back to the facility and to monitor him for any new or worsening neuro deficits. During an interview with Resident 1 on 10/28/2022 at 11:45 a.m., Resident 1 stated he fell during the night and was not transferred to the GACH until the next day in the morning. During an interview with the Director of Nursing (DON) on 10/28/2022 at 2:40 p.m., the DON stated if a doctor places an order, the nurse must follow up with the order. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 10/28/2022 at 3:45 p.m., LVN 1 stated Resident 1 fell between 10:30 p.m., and 10:40 p.m., and he (LVN 1) called the doctor (NP) to notify him of Resident 1's fall. LVN 1 stated the NP ordered Resident 1 transferred to the GACH to check him for a possible intracranial bleed. LVN 1 stated the NP said Resident 1 needed x-rays as soon as possible. LVN 1 stated Resident 1 was transferred to the GACH during the morning shift. During an interview with the NP on 11/09/2022 at 11:13 a.m., the NP stated the facility contacted him on 10/10/2022 a little past 11 p.m., to notify him that Resident 1 had fallen. The NP stated the nursing staff informed him that Resident 1 hit his head and had a laceration over his left eye. The NP stated he ordered to transfer Resident 1 to the GACH for a CT scan to rule out an intracranial injury. The NP stated Resident 1 should have been transferred to the GACH within four hours of falling. The NP stated he was not aware the facility waited that long to transfer Resident 1 to the GACH. During an interview and concurrent record review with the DON on 11/9/2022 at 12:40 p.m., the DON stated the nurse should notify the doctor if transportation to the hospital is taking too long. The DON stated transportation waiting time for a resident that experiences a fall with a head injury is four to six hours. The DON stated staff should follow doctor ' s orders in a timely manner. During an interview and concurrent record review with LVN 2 on 11/9/2022 at 2:05 p.m., LVN 2 stated Resident 1 was transferred to the GACH between 8 a.m., and 9 a.m. LVN 2 stated the night shift nurse informed her that Resident 1 would be transferred to the GACH at 8 a.m., (10/11/2022). LVN 2 stated after receiving the doctor ' s order and waiting a couple of hours, the nurse should have followed up and informed the doctor that Resident 1 was still in the facility. LVN 2 stated after reviewing Resident 1's clinical record that she did not documentation indicating when Resident 1 was transferred to the GACH, and she should have documented the time Resident 1 was transferred. LVN 2 stated it was important for Resident 1 to be transferred as soon as possible so any complications could be ruled out. LVN 2 stated an early transfer could have made a difference to Resident 1's care. The Facility did not develop a policy and procedure (P/P) indicating the urgency of transferring a resident to the GACH after a head injury, there was no P/P available for review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 105) had the right to be informed of, and participate in their care by not: 1. Obtaining informed consent (process in which residents were given important information, including possible risks and benefits, about a medical procedure or treatment) for Resident 105 prior to administering her with Remeron (medication used to treat depression [mental health disorder characterized by persistent sadness or loss of interest in daily life]) on 3/26/2022. 2. Updating and implementing the facility policy for treating residents without a decision-making capacity and without a representative to include the following, as per all facilities letter (AFL 20-83.1): i. Defined process for verbal and written notice ii. Process for identification, selection, and participation of a resident representative not affiliated with the facility on the interdisciplinary team ([IDT] group of different disciplines working together towards a common goal of a resident), whose interests are aligned with the resident who may receive the written notice. iii. Process for reasonable opportunity for residents to undertake objection with a proposed medical intervention or with the physician's determination of the resident's inability to consent iv. Process for emergency IDT medical treatment interventions, subsequent verbal, and written notice to the resident representative on the IDT after administration of emergency interventions. This deficient practice violated Resident 105's rights be informed and had the potential to result in facility negligence (failure to take proper care in doing something) to provide for the needs of affected residents. Findings: During a record review of the Resident 105's admission record (face sheet), the face sheet indicated Resident 105 was readmitted to the facility on [DATE]. Resident 105's diagnoses included fracture (broken bones) of left femur (thigh) , pneumonitis (inflamed lung because of infection), mild protein calorie malnutrition (reduced availability of nutrients leads to changes in body composition and function ), adult failure to thrive (decline seen in older adults - typically those with multiple chronic medical conditions - resulting in a downward spiral of poor nutrition, weight loss, inactivity, depression[mental health problem characterized by prolonged sadness and loss of interest in daily life] and decreasing functional ability), and muscle weakness. Face sheet further indicated Resident 105 was self-responsible and no family was listed under emergency contacts. During a review of Resident 105's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 2/26/2022, the MDS indicated Resident 105 expressed ideas and wants and usually understood verbal content. MDS indicated Resident 105 had moderately impaired cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making. Resident 105 needed limited assistance with eating; needed extensive assistance with bed mobility; and was totally dependent with transfer, dressing, toilet use and personal hygiene. During an interview with the Director of Social Services (DSS) on 4/27/2022 at 9:02 a.m., DSS explained that in cases where a resident was self-responsible , have no family or responsible party, have no probate conservatorship (court proceeding where a judge appoints a responsible person [conservator] to care for another adult who cannot care for him/herself or his/her finances) the Interdisciplinary Team ([IDT] group of different disciplines working together towards a common goal of a resident) team makes the medical decisions for the resident. Per DSS, when the IDT made decisions for residents, no written notice to resident or the ombudsman (representative assists residents in long term care facilities with issues related to day-to-day care, health, safety, and rights of individuals. was given. Per DSS, the facility IDT process and policy needed to be updated as per AFL 20-83.1. During a follow up interview with the DSS and record review of Resident 105's history and physical (H and P dated 3/3/2022) and informed consent for Remeron (dated 3/25/2022), on 4/27/2022 at 10:15 a.m., DSS confirmed Resident 105's H and P indicated she had no capacity to understand and make medical decisions. Per DSS, Resident 105's consent for Remeron indicating resident gave informed consent was not valid. Per DSS, Resident 105 needed a referral to probate conservatorship. During an interview with Registered Nurse 1 (RN 1) and a record review of Resident 105's medical records on 4/27/2022 at 2:02 p.m., RN 1 confirmed Resident 105's records indicated the following information: 1. History and Physical (H&P) authored by the physician, dated 3/3/2022, Resident 105 does not have the capacity to understand and to make medical decisions. 2. Informed consent for Remeron dated 3/25/2022 was obtained from Resident 105. Per RN 1, since the informed consent was obtained from a resident who did not have the capacity to understand and make decisions, the informed consent was not valid and resident rights were violated. During an interview with the Director of Nursing (DON) and record review of facility's policy titled, Treating residents without decision making capacity (revised 1/1/2021), DON confirmed Resident 105's H&P indicated that the resident was unable to understand and unable to make decisions then Resident 105 cannot consent to the Remeron. DON also confirmed that the ombudsman and resident do not receive written notice when the IDT made clinical decisions for residents with no capacity to consent. Per DON, the policy needed to be updated to follow current regulation. During a review of facility policy titled, Consents (revised 2021), indicated in accordance with state and federal regulations, and in adherence with patient's bill of rights, facility shall obtain consent, whereby applicable and indicated, from resident and/or responsible party and/or family member for administration of treatment and/or procedure. During a review of the facility policy titled, Treating residents without decision making capacity (revised 1/1/2021), the policy did not indicate the following: i. Defined process for verbal and written notice ii. Process for identification, selection, and participation of a resident representative not affiliated with the facility on the interdisciplinary team (IDT), whose interests are aligned with the resident who may receive the written notice. iii. Process for reasonable opportunity for residents to undertake objection with a proposed medical intervention or with the physician's determination of the resident's inability to consent iv. Process for emergency IDT medical treatment interventions, subsequent verbal, and written notice to the resident representative on the IDT after administration of emergency interventions. During a review of All facility letter (AFL 20-83.1) under the authority of Health and Safety Code (HSC) section 1418.8, AFL indicated, except in cases of emergency, skilled nursing facilities (SNFs )must complete before administering any IDT authorized medical treatment requiring informed consent: (1) Provide written and verbal notice to the resident that incorporates effective communication methods with residents, such as providing notice in the resident's preferred language. (2) Provide written notice to a person whose interests are aligned with a resident or to a local ombudsman. (3) Include a patient representative on the IDT unaffiliated with the facility must be found. (4) Process for reasonable opportunity for residents to communicate or undertake objection or disagreement with a proposed medical intervention or with the physician's determination of the resident's inability to consent to a proposed medical intervention judicial adjudication of the physician's or the IDT's determinations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the nursing staff failed to provide personal privacy for one of three residents (Resident 71) by not closing the privacy curtain or door while cleaning the private area of the resident. This deficient practice violated the resident's right to personal privacy. Findings: During a review of the admission record, the record indicated Resident 71 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that include COVID-19 (a highly infectious disease caused by a virus), generalized muscle weakness, type 2 diabetes mellitus (irregular blood sugar), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A review of the Minimum Data Set (MDS- a comprehensive assessment and screening tool), dated 2/12/2022, MDS indicated Resident 71 required total assistance from staff members for bed mobility, dressing, eating, toilet use, personal hygiene, and bathing. A review of Resident 71's History and Physical (H&P) dated 2/6/2022, indicated the resident does not have the capacity to understand and make decisions. During an observation on 4/25/2022, at 9:19 a.m., Certified Nurse Assistant 1 (CNA 1) and Certified Nurse Assistant 2 (CNA 2) were observed from the hallway providing peri care (cleaning the private areas) of Resident 71. Resident 71's entrance door and privacy curtain were opened, and visible in the hallway. Resident 71 was turned to the side and the resident's buttocks area was exposed. Once this surveyor entered the room one of the CNA closed the curtain. During an interview on 4/25/2022, at 9:25 a.m., with CNA 2, CNA 2 stated, we were changing the resident's soiled brief. The resident's privacy curtain was open because it was stuck. CNA 2 stated, she should have closed the door when the curtain was not working to provide privacy and dignity for the Resident 71. During an interview on 4/29/2022, at 9:02 a.m., with Registered Nurse Supervisor 1 (RN 1). RN 1 stated providing residents' privacy is an important issue because it is a part of dignity and residents rights. RN 1 stated staff are supposed to close the privacy curtain completely when providing care so resident's body parts would not be exposed. During a review of the facility's policy and procedure (P/P) titled, Resident Rights: Dignity and Respect, [undated, the P/P indicated residents shall be examined and treated in a manner that maintains the privacy of their bodies. A closed door or drawn curtain shields the Resident from passers-by .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow up with the status of the Pre-admission Screening and Resident Review ([PASRR] a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) Level II (a comprehensive evaluation by the appropriate state-designated authority and determines whether the individual has a Mental Disorder (MD), Intellectual Disability (ID) or a related condition, determines the appropriate setting for the individual and recommends what, if any, specialized services and/or rehabilitative services the individual needs) required evaluation and integrate the level of care into a plan of care for one (1) of one (1) sample resident (Resident 61). This deficient practice led to not incorporating the results of the Level II mental health evaluation into Resident 61's plan of care. This deficient practice may have potentially resulted in the facility not providing Resident 61 the appropriate services and care to attain or maintain her highest practicable quality of life. Findings: During a review of Resident 61's admission Record (Facesheet), the Facesheet indicated Resident 61 was admitted to the facility on [DATE] with diagnosis including Type 2 diabetes mellitus (a long-term condition that affects the way the body processes blood sugar; the body either does not produce enough insulin [a hormone that lowers the level of blood sugar in the body], or it resists insulin), schizophrenia (a disorder characterized by thoughts that seem out of touch with reality and affects a person's ability to think, feel, and behave clearly), and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows, which may include symptoms such as low energy, low motivation, and loss of interest in daily activities to manic highs, which may include symptoms such as high energy, reduced need for sleep, and loss of touch with reality. Mood episodes last days to months at a time and may also be associated with suicidal thoughts). During a review of Resident 61's History and Physical (H/P), dated 3/3/2022, the H/P indicated Resident 61 did not have the capacity to understand and make decisions. During a review of Resident 61's Minimum Data Set ([MDS], a standardized resident assessment and care screening tool), dated 2/24/2022, the MDS indicated Resident 61 had the ability to express ideas and wants and usually had the ability to understand others. The MDS indicated Resident 61 required supervision and setup for bed mobility and eating and required limited, one-person assistance for transfers out of bed, walking, dressing, toilet use, and personal hygiene. During a review of the Department of Health Care Services PASRR form, dated 2/17/22, the form indicated Resident 61 had a positive (indicating further action is required) Level I PASRR for suspected mental illness and a Level II mental health evaluation was required. There was No record of a Level II mental health evaluation found in Resident 61's chart. During a review of Resident 61's care plan, dated 2/18/2022, the care plan indicated the intervention to discuss Level II recommendations to resident/responsible party, assist with proper placement whether in the community or in a nursing facility based on Level II recommended services. During an interview on 4/27/2022, at 10:22 a.m., with Registered Nurse (RN) 1 in the conference room, RN 1 stated Resident 61 was referred to have a Level II mental health evaluation on 2/17/2022 due to a positive Level 1 PASRR. RN 1 stated Resident 61's Level II mental health evaluation was still pending to be done. RN 1 stated she had not followed up with the mental health agency regarding the pending Level II mental health evaluation. RN 1 stated two to three months was a long time for the Level II mental health evaluation to be done. RN 1 stated it was important for a Level II evaluation to be done to ensure the resident was placed in the proper mental health program/facility and ensure the resident received the proper care and services. RN 1 stated someone should have followed up on Resident 61's pending Level II PASRR. During a review of facility policy titled, Pre-admission Screening Resident Review (PASRR), dated 5/1/2018, the policy indicated Preadmission screening and Resident Review was a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care. The policy indicated if the Level I screening results indicate that the applicant should receive the Level II screening, the facility shall contact the appropriate state agency for additional screening. The policy indicated the Level II screening must be completed prior to admission. The policy indicated recommendations from the Level II screening would be incorporated into the residents' care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent the range of motion ([ROM] movement of the joints) decline of one (1) of three (3) sampled residents (Resident 22) when: a. The facility failed to provide RNA services for Resident 22 upon return to the facility on 1/3/2022. b. The Rehabilitation (services help people return to daily life and live in a normal or near-normal way) department did not re-attempt to reassess Resident 22 after she refused the initial attempt to screen for needed services upon re-admission to the facility on 1/3/2022. c. The Director of Rehabilitation (DOR) did not notify nursing services or the interdisciplinary team (IDT) team that Resident 22 refused the joint mobility assessment (JMA) on 1/4/2022. d. The IDT failed to identify that Resident 22 needed to resume Restorative Nursing Assistant (RNA) services she was receiving prior to being hospitalized on [DATE]. e. The facility failed to develop and implement a comprehensive care plan that addressed Resident 22's limited ROM. As a result, upon readmission on [DATE], Resident 22 did not receive the RNA services for approximately 3 months. By the time Resident 22 was screened on 4/25/2022, the ROM of her left upper extremity (LUE) contractures (permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) worsened. Resident 22's left wrist had a minimal (less than or equal to twenty-five (25) percent (%) loss) impairment on 10/31/2021 to moderate (26 percent to 50 percent loss) impairment on 4/25/2022. Resident 22's left shoulder and elbow joints indicated moderate impairment on 10/31/2021 to severe (more than or equal to 50 percent loss) impairment on 4/25/2022. Findings: During a review of the Resident 22's admission record (face sheet), the face sheet indicated the facility originally admitted Resident 22 on 11/7/2017. Resident 22 was most recently readmitted to the facility on [DATE]. Resident 22's diagnoses included covid-19 (highly contagious infection), dermatitis (skin problem), noncompliance with other medical treatment and regimen, anxiety disorder (mental health disorder characterized by pervasive worry or fear) , multiple sclerosis (a chronic disease affecting the brain and spinal cord causes many different symptoms, including vision loss, pain, fatigue, and impaired coordination), contractures of the left hand, muscle weakness, polyneuropathy (simultaneous malfunction of many peripheral nerves throughout the body), and pain. During a review of Resident 22's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 1/31/2022, the MDS indicated Resident 22 expressed ideas and wants and usually understood verbal content. MDS also indicated Resident 22 had intact cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making. Resident 22 needed extensive assistance with dressing; and was totally dependent with eating, bed mobility, toilet use, and personal hygiene. During a record review of Resident 22's restorative nursing program referral/ care plan dated 9/24/2021, therapist indicated Resident 22 had decreased mobility. The goal was to maintain mobility and per therapist the approach for Resident 22 was for RNA for BLE PROM five times a week or as tolerated, RNA to apply hand roll to left hand every day five times a week for 4- 6 hours or as tolerated, and RNA for LUE PROM five times a week or as tolerated. During a record review of Resident 22's physician orders for 8/22/2021 to 12/25/2021, orders indicated: i. RNA for Bilateral lower extremities (BLE) passive range of motion ([PROM] when someone is moving or stretching a part of the body for the resident) five (5) times a week or as tolerated. ii. RNA for Bilateral upper extremities (BUE) PROM five (5) times a week or as tolerated. iii. RNA to apply hand roll (device that comfortably extends fingers to position hand correctly) of left hand every day five (5) times a week for four (4) to six (6) hours or as tolerated. iv. RNA to apply hand roll of the left hand at 8:30 a.m. v. RNA to remove hand roll of the left hand at 2:30 p.m. During a record review of Resident 22's restorative nursing administration record for 12/2021, records indicated Resident 22 received the RNA services ordered and Resident 22 did not refuse RNA services. During an observation and interview with Resident 22 on 4/25/2022 10:10 a.m., Resident 22 was noted with a contractures in the LUE. Resident 22 stated her LUE was now more contracted. Per Resident 22, she used to get help with exercises on her arms and hands, but they stopped when she came back from the hospital. Per Resident 22, exercises would have been helpful. During an interview with Licensed Vocational Nurse 7 (LVN 7) and record review with Resident 22's physician orders on 4/26/2022 at 12:44 p.m., LVN 7 stated staff used to do ROM exercises for Resident 22 before she was hospitalized . Per LVN 7, RNA order restarted on 4/25/2022, 113 days after Resident 22 was admitted . Order indicated RNA for BLE and BUE, PROM five (5) times a week or as tolerated. During a record review of Resident 21's physician orders as of 4/28/2022, orders indicated no documented evidence of an order for RNA to apply hand roll to left hand every day five (5) times a week for four (4) to six (6) hours or as tolerated. During an interview with Restorative Nurse Assistant 1 (RNA 1) on 4/27/2022 at 11:25 a.m., RNA 1 stated she assisted Resident 22 with ROM exercises in the upper and lower extremities even before she was hospitalized last year. Per RNA 1, Resident 22 was compliant when exercises were offered. Per RNA 1, Resident 22 stopped receiving RNA services due to being hospitalized on [DATE] and it has not been resumed until 4/26/2022. Per RNA 1, RNA exercises were given only if ordered. During an interview with the Director of Rehabilitative Services (DOR) and record review of rehabilitation screening and JMA (dated 1/4/2022) on 4/27/2022 at 12:36 p.m., DOR confirmed Resident 22 refused JMA upon return to the facility. Per DOR, there was no documented evidence that she attempted to assess the resident's joint mobility more than once. Per DOR, Resident 22 would have benefited from RNA services, but she refused secondary to pain. During a follow up interview with the DOR and record review of Resident 22's JMA (dated 9/2021 and 4/25/2022) on 4/28/2022 at 9:16 a.m., DOR confirmed she did not notify nursing of the refusal and no documented evidence of the notification existed. Per DOR, she also did not notify the IDT team and she did not participate in the IDT team meeting for the resident. Per DOR, there was a decrease in mobility from 10/31/2021 to 4/25/2022 assessments. DOR confirmed Resident 22's LUE JMA indicated loss of range of motion mobility as follows: i. On 10/31/2021, left wrist indicated minimal (less than or equal to twenty-five (25) percent (%) loss), left elbow and left shoulder joint indicated moderate (twenty-six (26) percent to fifty (50) percent loss). ii. On 4/25/2022, Resident 22's left wrist indicated moderate loss of ROM; left shoulder and elbow joints indicated loss of ROM was severe (more than or equal to 50 percent loss). Per DOR, resuming the RNA services sooner than 4/25/2022 could have been beneficial for Resident 22. During an interview with registered nurse 1 (RN 1) and record review of Resident 22's medical records on 4/28/20222 at 11:32 a.m., RN 1 confirmed: i. DOR did not participate in the IDT meeting for Resident 22. IDT conference notes dated 2/10/222 indicated DOR did not attend the IDT meeting. ii. IDT team was not notified that Resident 22 refused the JMA upon admission. iii. IDT team thought Resident 22 was in the RNA program when she returned to the facility on 1/3/2022 and it was noted in the IDT conference notes on 2/10/2022 that Resident 22 was receiving RNA services five times a week. Per RN 1, no documented evidence existed that Resident 22 had an order for RNA services upon admission. Per RN 1, no documented existed that Resident 22 received RNA services from the RNA on admission till 4/26/2022. During the continued interview with RN 1 and record review of Resident 22's care plans on 4/28/2022 at 11:32 a.m., RN 1 confirmed no documented evidence of a comprehensive care plan addressing Resident 22's limited ROM existed. Per RN 1, Resident 22 did not receive services for about 3 months and per RN 1 there was a notable decline from the JMA on 10/31/2021 and the JMA on 4/25/2022. During a record review of the facility's policy and procedure (P/P) titled, Restorative Nursing Program Guidelines, (undated), the P/P indicated this program focused on achieving and maintaining optimal physical, mental, and psychosocial functioning. Residents will be reviewed by the interdisciplinary Team (IDT) upon admission, readmission, quarterly, and as needed to identify any decline in activity of daily living (ADL) function. The director of nursing (DON) or their designee, managed and directed the restorative nursing program. In conjunction with the attending physician and staff, therapists proposed a rehabilitation restorative care plan that provided an appropriate intensity, frequency, and duration of interventions to help achieve anticipated goals and expected outcomes. The DON or designee reviewed RNA weekly summary notes on a regular basis. During a review of the job description of the Director of Rrehabilitation Services (undated), the DOR responsibilities included: i. Attend care plan meetings as indicated by facility and regional manager ii. Ensure evaluations and treatments were done in a timely manner iii. Act as a representative for the rehabilitation department to communicate with the facility and members of the IDT team. During a review of the facility's P/P titled, Specialized Rehabilitative Services, (5/1/2018), the P/P indicated the facility shall meet the assessed needs of any resident to assisting them in obtaining or maintaining their highest practicable level of functional well-being. A resident will be assessed by a licensed nurse or the DOR for indications related to the provision of skilled rehabilitative services during the admission/re- admission process. Licensed nursing staff will refer residents assessed to have a clinical need for rehabilitative therapy for a screening by the appropriate discipline.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to identify, evaluate, and implement accident risks and hazard interventions for one of two sampled residents (Resident 94), who was identified as a high risk for falls and assessed on the Minimum Data Set ([MDS] resident assessment and care-screening tool) as having moderate visual impairment and requiring supervision, by failing to: 1. Provide supervision to prevent Resident 94 from having three fall incidents on 12/17/2021, 1/20/2022, and on 2/8/2022. 2. Comprehensively assess and follow up after each of Resident 94's fall incidents. 3. Ensure Resident 94's room was free from trip hazards. These deficient practices resulted in Resident 94 tripping and falling three times on 12/17/2021, 1/20/2022, and 2/8/2022. During the third fall, Resident 94 tripped over his bedside table, hitting the back of his head sustaining swelling to the crown of his head measuring 2 centimeters ([cm] unit of measurement) by 2 cm. Findings: During a review of Resident 94's admission Record, the admission Record indicated Resident 94 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 94's diagnoses included encephalopathy (any brain disease that alters brain function or structure), diabetes mellitus (high blood sugar), hypertensive heart disease without heart failure (heart problems that occur because of high blood pressure that is present over a long time). During a review of Resident 94's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 11/21/2021, the MDS indicated Resident 94 had severely impairment cognitive (ability to think and reason) skills for daily decision making. The MDS indicated Resident 94 required limited assistance with one person assist with bed mobility, extensive assistance with dressing, transfer, personal hygiene, and total assistance with locomotion on and off the unit (how residents move to and return off unit locations), toilet use, and bathing. The MDS indicated Resident 94's vision was moderately impaired, and the resident was unable to identify objects. During a record review of Resident 94's progress note dated 12/17/2021 at 11:25 a.m., the progress note indicated Resident 94 was noted on the floor lying on his left side. The note indicated Resident 94 was assisted back to bed, assessed and monitoring was initiated. The note indicated Resident 94 had no injuries. During a review of Resident 94's Post Fall Risk Evaluation dated 12/17/2021, the evaluation indicated Resident 94 was a high risk for falls and was intermittently confused. The evaluation indicated Resident 94 was chair-bound, requiring restraints and assistance with elimination. The evaluation indicated Resident 94 had poor vision with or without glasses and had balance problems while standing and walking. Resident 94 also had decreased muscular coordination, was unstable when making turns and required assistive devices (cane, walker, or wheelchair). The evaluation indicated Resident 94 was receiving three (3) to four (4) medications that put him at high risk for falls and had one (1) to two (2) predisposing diseases that makes him a high risk for falls. During a record review of Resident 94's progress note dated 1/20/2022 at 3:49 p.m., the progress note indicated Resident 94 was noted on the floor in a lying position on the left side next to the restroom door. The note indicated Resident 94 slipped and fell. According to the note, Resident 94 denied dizziness and weakness and was assisted back to bed. The note indicated no injuries were noted. During a review of Resident 94's Fall Risk Evaluation dated 1/20/2022, the evaluation indicated Resident 94 was at risk for falls. The evaluation indicated Resident 94 had poor vision with or without glasses, and he had balance problems while standing and walking. The evaluation indicated Resident 94 was receiving three (3) to four (4) medications that put him at high risk for falls and had one (1) to two (2) predisposing diseases that makes him a high risk for falls. During a record review of Resident 94's progress note dated 2/8/2022 at 12:21 p.m., the progress note indicated Resident 94 tripped over the bedside table and fell to the floor and hit the back of his head. Resident 94 had swelling to the crown of the head measuring 2 centimeters ([cm] unit of measurement) by 2 cm. The note indicated Resident 94 stated he had to go to the restroom. During a concurrent interview and record review on 4/27/2022 at 2:31 p.m. with Registered Nurse 1 (RN 1), RN 1 stated Resident 94 had multiple fall incidents while in the facility. RN 1 stated the fall incidents were care planned, but there was no change of condition completed. RN 1 stated nurse progress notes were completed for the fall incidents on 12/17/2021, 1/20/2022 and 2/8/2022. RN 1 stated there was no change of condition and/or situation background assessment recommendation ([SBAR] internal document) initiated and no follow up noted on Resident 94's condition after his falls. RN 1 stated if the fall risk assessment of the resident was scored 10 and above, it meant the facility should be more pro-active with the resident's plan of care to avoid repeat fall incidents. During an interview with the Director of Nursing (DON) on 4/27/2022 at 2:56 p.m. with the DON, the DON stated the SBAR was the way licensed nurses communicate and follow up with any medical concerns. The DON stated that some nurses were not following up and not documenting via SBAR and some just documented on the progress notes. The DON stated without a SBAR or COC documentation, a follow up cannot be done. The DON stated it was important to assess the resident if they are high fall risk to prevent or avoid any fall incidents. The DON stated the SBAR was like a tool to identify and prevent future fall incidents. The DON stated that if it was a resident's first fall was unavoidable but multiple falls should have been avoidable. The DON stated that Resident 94's repeated falls were due to the resident's moderately impaired vision. The DON stated if the facility was more aggressive with fall interventions to prevent further falls in Resident 94's plan of care, subsequent falls on 1/20/2022 and 2/8/2022 could have been avoided. During a record review of the facility's policy and procedure (P/P), dated 3/2010 and titled, Falls, the P/P indicated to evaluate the extent of injury after a fall and prevent complications. The P/P indicated all appropriate information should be completed. During a record review of the facility's document titled, Facility Assessment, dated 6/6/2021, the document indicated the facility was to ensure care was provided to improve the resident's quality of life. During a record review of the facility's P/P, dated 2/2022 and titled, Fall Program, the P/P indicated that the goal was to reduce the incidence of falls/injury for each resident in the program. The P/P indicated to establish a profile for each resident in the fall program using the current Fall Risks Evaluation Tool and reviewing the history of previous fall(s) or injury. This profile would serve as a guide for staff in individualizing interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility's staff failed to ensure a Gradual Dose Reduction ([GDR] an attempt to decrease or discontinue) for a psychotropic (acting on the mind) medication was done after no more than three months, after starting on a psychotropic medication, unless clinically contraindicated for one of one sampled residents (Resident 100). This deficient practice had the potential to result in Resident 100 receiving unnecessary medications. Findings: During a review of Resident 100's admission record, the admission Record indicated the resident was originally admitted to the skilled nursing facility on [DATE] and was readmitted on [DATE]. Resident 100's diagnoses included type two diabetes mellitus (high blood sugar), muscle weakness and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). During a review of Resident 100's Minimum Data Set (MDS), a comprehensive standardized assessment and care plan screening tool) dated 3/12/2022, indicated Resident 100 had unclear speech, was able to make himself usually understood and was able to understand others. The MDS further indicated Resident 100 required extensive assistance with a two- person assistance with bed mobility, walking in the room and walking in the corridor with extensive assistance with dressing, locomotion on and off unit (how residents move to and return off unit locations), total assistance with toilet use, bathing, personal hygiene and transfers. During an interview on 4/28/2022 at 8:49 a.m. with Registered Nurse 1 (RN 1), RN 1 stated that the facility performed a gradual dose reduction (GDR), if they notice some changes with the residents like getting sleepier or any changes in the level of cognition, they will perform GDR. According to RN 1, Pharmacy would perform a GDR if the changes were warranted. During a concurrent interview and record review on 4/28/2022 at 9:30 a.m. with RN 1 of the Physician's Summary order for April 2022, indicated that Resident 100 was taking valproic acid 1500 mg (milligrams) for schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly) since 2020. There was no attempt made for a GDR for the whole year of 2020. According to this record there was a GDR for April 2021, which decrease the valproic acid to 1000 mg two times a day and since then, there was no further GDR attempted. RN 1 stated the only time they do GDR the pharmacy would recommend or if again staff will notice some changes with the Resident. During an interview on 4/28/2022 at 9:41 am, with the Director of Nursing (DON), the DON stated that they did not do GDR for Resident 100. The DON stated it was important to do a GDR because some medications are hepatotoxic (causes damage to the liver), can cause abdominal pain and anorexia. A GDR is done to prevent having a medication adverse reaction. The DON stated the GDR should have been done sooner because of the regulation. During a record review of the Monthly Medication Review record (MMR) for the year 2021, a note from the facility's pharmacist indicated that Resident 100 had been on Valproic acid since 04/2021 as part of the annual assessment GDR, is appropriate or clinically contraindicated and that the MD had disagreed in November of 2021 (7 months after it was recommended by the pharmacist). During a record review of the Consultant Pharmacist services provider requirements indicated, that the consultant pharmacist perform includes but it is not limited to reviewing the medication regimen of each resident at least monthly or more frequently under certain conditions, incorporating federally mandated standards of care in addition to other applicable professional standards as outlined in the procedure for MMR and document the review and findings in the resident's medical record. During a review of the facility's policy and procedure (P/P) dated 5/1/2018 indicated, the P/P that during the first year if receiving an antipsychotic or psychopharmacologic medication, at least one attempt at GDR or dose tapering is attempted. A second attempt, in subsequent quarter the same year (12-month period) unless the first attempt demonstrated that GDR or tapering was clinically contraindicated. The attempts should be at least a month apart. After the first year, GDR should be attempted once a year.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility's staff failed to properly dispose of one of three sampled residents (Resident 56) tube feeding bag which was labeled with the resident's medical information. This failure had the potential outcome of residents' personal medical information being released to the public without the resident's knowledge or consent. Findings: During a review of Resident 56's admission record indicated, the resident was initially admitted to the skilled nursing facility on [DATE] and was readmitted on [DATE]. Resident 56's diagnoses include, schizoaffective disorder (a mental health condition, including schizophrenia and mood disorder symptoms) of schizophrenia bipolar type (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), adult failure to thrive (a state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments) and dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage). During a review of Resident 56's Minimum Data Set record [(MDS), a comprehensive assessment and care plan screening tool] dated 3/5/21, indicated Resident 56's cognitive (mental action or process of acquiring knowledge and understanding) function was mildly impaired. The MDS further indicated, Resident 56 was totally dependent on transfers, eating and required extensive assistance with bed mobility, dressing, toilet use and personal hygiene. During a review of Resident 56's Physician's Order summary report for the month of April 2022 indicated, Resident 56 had an enteral feed order for diabetic source AC at 85 milliliters (ml, a unit of measure) per hour over 12 hours to provide 1020 ml per 1224 kilocalories (kcal, a unit of measure) over 24 hours. The order further indicated to turn the pump on at 6 p.m., off at 6 a.m. or until the volumetric dose was completed. During an observation on 4/25/22 at 11:11 a.m., Resident 56's tube feeding machine was turned off. A used tube feeding bag was found in the regular trash bin with the label including information of the resident's name, room number, tube feeding order, date and time. During an observation on 4/26/22 at 12:13 p.m., Resident 56's tube feeding bag was found in the regular trash bin and the tube feeding bag label had Resident 56's name, room number, tube feeding order, date and time. During an interview on 4/26/22 at 12:13 p.m., with the Director of Staff Development (DSD), the DSD stated the Health Insurance Portability and Accountability Act ([HIPAA] a federal law that protects sensitive patient health information from being disclosed without the patient's consent or knowledge) needed to be protected and if there is resident information it needs to be discarded, it should be shredded to not expose one's information. During a concurrent observation and interview Licensed Vocational Nurse 4 (LVN 4) on 4/26/22 at 12:34 p.m., LVN 4 stated, Today, I discarded tube feeding bag for the resident. The tube feeding bag had resident information including name, room number, type of bag, and time. The surveyor showed LVN 4 the tube feeding bag label in a trash bin. LVN 4 stated, it was a mistake .that resident information on the tube feeding bag label should have been crossed out with a permanent marker because it would be a HIPAA violation. During a review of the facility's policy and procedure (P/P) titled, Privacy dated 11/17, the P/ P indicated, HIPAA privacy- basic do's and don'ts to remember: Do .10. Shred any papers with any Personal Health Information (PHI) prior to discarding or place these or disks in a locked bin (for proper destruction and disposal later per policy). Report papers with PHI you might find in the trash container to the health information department. They will review and take appropriate action .Do not .10. Discard any papers with any PHI in the trash in readable form. Shred or destroy these papers you might find in the trash container yourself. It may have been inadvertently discarded. During a review of Summary of the HIPAA Privacy Rule from U.S. Department of Health and Human Services, it indicated a major goal of the Privacy Rule is to assure that individuals' health information is properly protected while allowing the flow of health information needed to provide and promote high quality health care and to protect the public's health and well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect for two of 45 sampled residents (Resident 17 and 62) when the facility did not: a. Use a dignity bag (blue nonwoven material that conceals fluid in the drainage bag to improve resident dignity) for Resident 62's Foley catheter drainage bag (device that holds the urine that drains from the resident's body). b. Serve Resident 17's meal at the same time with the roommates. These deficient practices had the potential to negatively affect Resident 17 and 62's 's self-esteem and self-worth and to cause psychosocial harm or decline to the residents and violates residents' right to be treated with dignity. Findings: a. During a record review of the Resident 62's admission record (face sheet), the face sheet indicated Resident 62 was readmitted to the facility on [DATE]. Resident 62's diagnoses included dehydration (a harmful reduction in the amount of water in the body), muscle weakness, peripheral vascular disease (narrowing and blockage of blood vessels causing leg pain), anemia (not enough health red blood cells that circulate to deliver oxygen all over the body), bipolar disorder (mental health problem causes extreme mood swings that include emotional highs [mania] or lows [depression-- pervasive sadness or loss of interest in daily life]), obstructive and reflux uropathy (urine cannot flow through to exit the body and urine flows backward from the bladder to the kidney instead of going from the kidneys to the bladder) During a review of Resident 62's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 3/10/2022, the MDS indicated Resident 62 usually expressed ideas and wants and usually understood verbal content. MDS indicated Resident 62 had severely impaired cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making. Resident 62 needed extensive assistance with eating, bed mobility; and was totally dependent with transfer, dressing, toilet use and personal hygiene. During a review of Resident 62's physician orders as of 4/26/2022, an order on 11/23/2021 indicated Foley catheter to drainage bag. During a review of Resident 62's care plan for catheter, initiated 8/10/2021, intervention indicated to position catheter bag away from the entrance room door. During an observation and interview with Licensed Vocational Nurse 6 (LVN 6) on 4/25/2022 at 10:45 a.m., LVN 6 confirmed Resident 62's Foley drainage bag was not concealed with a dignity bag. Per LVN 6, the Foley bag should have been covered to promote residents' dignity. During an interview with Registered Nurse Supervisor 1 (RN 1) on 4/27/2022 at 2:02 p.m., RN 1 stated Foley drainage bags should be covered with a dignity bag to promote resident self-respect. During an interview with the Director of Nursing (DON) on 4/27/2022 at 3:54 p.m., the DON confirmed a dignity bag should be used to cover Foley drainage bag for resident's dignity. b. During a review of Resident 17's admission record, the record indicated Resident 17 was admitted on [DATE] with diagnoses including quadriplegia (paralysis caused by illness or injury that results in the partial or total loss of use of all four limbs and torso), spondylosis (age-related wear and tear affecting the spinal disks in the neck), and type 2 diabetes mellitus (a disease in which blood sugar levels are irregular). During a review of Resident 17's MDS dated [DATE], MDS indicated the resident's cognition was intact. Resident 17 required full staff assistance for bed mobility, dressing, eating, toilet use, and personal hygiene. During a record review of the order summary report for the month of April 2022, the report indicated that Resident 17 has a physician's order dated 10/23/2020, for a controlled carbohydrate diet with regular texture. During a record review of the facility's meal schedule, the schedule indicated breakfast was served at 7:30 a.m., lunch was served at 12:15 a.m., and dinner was served at 5:15 p.m. During an observation on 4/26/2022, at 12:40 p.m., in the hallway in front of nursing station 2, resident 17's lunch tray was in a tray cart. Resident 17's two roommates received their lunch tray at 12:49 p.m. and started eating the lunch. During an interview on 4/26/2022, at 1:03 p.m., with Certified Nurse Assistant 5 (CNA 5), CNA 5 stated, there is no set schedule for residents who need with eating meals. CNA 5 stated assignments for each shift are made by the charge nurse of the station, and CNA 5 had two to three residents need to be assisted with eating their meals. CNA 5 stated, the facility should set it up in a way that everyone in a room could eat at the same time for dignity. During an interview on 4/26/2022, at 1:11 p.m., with Resident 17, Resident 17 stated, They just bring the trays whenever and sometimes food is cold .it would be nice if I can have a lunch tray like my roommates. During an observation on 4/26/2022, at 1:19 p.m., 30 minutes after Resident 17's roommates were served, CNA 5 brought the lunch tray to Resident 17, set the table, raised the resident's head of the bed, and started to assist with eating the meal. During an interview on 4/26/2022, at 1:26 p.m., with the Director of Staff Development (DSD), DSD stated, DSD assigned the CNAs to each station and the charge nurse assigned the CNAs to assist residents. There was no set schedule for residents that needed assistance with feeding. DSD stated, waiting for the lunch tray for 30 minutes is considered late and it should not happen. During an interview on 4/26/2022, at 3 p.m., with DON, DON stated, meals should be served at the same time in each room, however the facility did not have a systemic approach to serve the resident including those in need of assistance. During a review of the facility's P&P titled, Resident Rights: Dignity and Respect [undated], indicated It is the policy of this facility that all residents be treated with kindness, dignity, and respect in full recognition of his or her individuality. During a review of the facility's P&P titled, Dignity and Respect (undated), the P&P indicated the facility shall treat all residents with kindness, dignity, and respect in full recognition of his or her individuality. The P&P indicated privacy of a resident's body shall be maintained during toileting, bathing, and other activities of personal hygiene. During a review of the facility's P&P titled, Resident Rights: Dignity and Respect [undated], the P&P indicated It is the policy of this facility that all residents be treated with kindness, dignity, and respect in full recognition of his or her individuality.

Based on interview and record review, the facility failed to ensure the residents' medical records were updated to show documentation clarifying if a resident had an advance directive (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) or not for one (1) out of the 23 sampled residents (Resident 95). This deficient practice had the potential to result in confusion in the care and services for Resident 95 and placed the resident at risk of receiving unwanted treatment and not receiving appropriate care based on her wishes. Findings: During a review of Resident 95's admission Record, dated 1/09/2022, the record indicated, Resident 95 was admitted to the facility, with diagnoses of but not limited to, acute respiratory failure with hypoxia (not enough oxygen in the blood stream), encephalopathy (a disease that affect the function and structure of the brain), paranoid schizophrenia (a mental disorder characterized by abnormalities in the perception or expression of reality), and chronic ischemic heart disease (narrowing of the heart's arteries). During review of Resident 95's Minimum Data Set (MDS- a standardized assessment and screening tool) dated March 30, 2022, the MDS indicated, Resident 95 had moderately impaired cognitive skills for making daily decisions. The MDS indicated, Resident 95 needed assistance with bed mobility, transfer, locomotion, dressing, toilet use and personal hygiene. During a review of Resident 95's Progress Notes dated 9/25/2020, The progress Notes indicated Resident 95 did not have the capacity to make healthcare decisions and no available Responsible Party. During a review of Resident 95's Advance Directive acknowledgement form, dated 2/23/2022, the Advanced Directive Acknowledge form indicated Resident 95 or the Resident's Representative had not signed the Advance Directive Acknowledgement form. On 4/27/22 at 9:34 am during an interview with the Director of Nursing (DON), the DON stated, Resident 95 did not have the capacity to make decisions. The DON stated an incomplete Advance Directive Acknowledgement form with no signature meant it was not offered. During a review of the facility's policy and procedure (P&P) titled, Advanced Directive dated January 1, 2012, the P&P indicated As part of the admission process, Facility Staff will inform the resident that they have the right to execute an Advance Directive. If no Advance Directive exists, the Facility provides the resident with an opportunity to complete the Advance Directive Form. Upon admission, admission Staff will provide the resident with the Advance Health Care Directive Form. The Form informs the resident about his or her rights to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that two of two residents (Resident 105 and 100) were free from physical restraints (any manual method adjacent to the resident's body, that cannot be removed easily by the resident, and restricts the resident's freedom of movement) by failing to: a. Identify position change alarms (alerting devices emit an audible signal when the resident moves in certain ways) as physical restraints. b. Assess the residents (Resident 100 and 105) prior to use of position change alarm. c. Ensure documentation of a medical symptom that warrant the use of position change alarm. d. Ensure the alarms were not used for staff convenience. e. Ensure individualized care planning by the Interdisciplinary team (IDT) that addressed: 1) Direct monitoring and supervision provided during use of the alarm, 2) Ongoing re-evaluation for the need of the alarm and its efficacy in treating the medical symptom, and 3) The development and implementation of interventions to prevent and address any risks related to the use of position change alarms; and f. Ensure the resident/ representative was informed of potential risks and benefits of all options under consideration including its use and alternatives to alarm use. This deficient practice had the potential to result in a decline in physical functioning and negatively impact residents' psychosocial wellbeing because an alarm is triggered whenever the residents move a certain way . Findings: a. During a review of the Resident 105's admission record (face sheet), the face sheet indicated the facility originally admitted Resident 105 on 1/7/2013. Resident 105 was most recently readmitted to the facility on [DATE]. Resident 105's diagnoses included fracture (broken bones) of left femur (thigh) , pneumonitis (inflamed lung because of infection), mild protein calorie malnutrition (reduced availability of nutrients leads to changes in body composition and function ), adult failure to thrive (decline seen in older adults - typically those with multiple chronic medical conditions - resulting in a downward spiral of poor nutrition, weight loss, inactivity, depression and decreasing functional ability), and muscle weakness. During a review of Resident 105's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 2/26/2022, the MDS indicated Resident 105 expressed ideas and wants and usually understood verbal content. MDS also indicated Resident 105 had moderately impaired cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making. Resident 105 needed limited assistance with eating; needed extensive assistance with bed mobility; and was totally dependent with transfer, dressing, toilet use and personal hygiene. Section P of the MDS for restraints and alarm also indicated Resident 105 used the bed and chair alarms daily. During a record review of Resident 105's physician orders as of 4/26/2022, orders started on 2/22/2022 indicated bed pad alarm for Resident 105 was to be used. Order indicated placement of bed pad alarm to alert staff when resident attempted to get out of bed unassisted. Monitor placement and functionality of bed pad alarm every shift. Another order started on 3/20/2022 indicated to apply wheelchair pad alarm when resident attempted to get up unassisted. Monitor placement and functionality every shift. During a record review of Resident 105's Medication Administration Record (MAR), for the months of February, March, and April 2022, the MAR indicated Resident 105 started using the bed pad alarm on 2/22/2022 and used it until 4/26/2022, of those days the alarm was used a total of sixty-four (64) out of sixty-four (64) days. Another order indicated wheelchair alarm use was used from 3/22/2022 until 4/26/2022, of those days the wheelchair alarm was used a total of thirty-five (35) out of thirty-six (36) days. Both orders did not specify what medical symptom or diagnosis was to justify the use of bed alarms. During an observation on 4/25/2022 at 2:29 p.m., Resident 105 was observed sitting on the wheelchair with an attached wheelchair alarm on. Resident 105 got out of the wheelchair and transferred herself to the bed and the wheelchair alarm made noise and staff went to check on the resident. During an interview with Medical Records Staff (MR) and record review of Resident 105's medical records on 4/27/2022 at 9:37 a.m., MR confirmed the facility did not obtain consent before applying the bedside alarm because the bedside alarm was not considered a restraint. During an interview with Certified Nurse Assistant 9 (CNA 9) on 4/27/22 9:56 a.m., CNA 9 confirmed Resident 105 sustained a hip fracture due to fall so wheelchair/ bed alarm was used to help notify the staff when Resident 105 was getting up. Per CNA 9, the alarm was never turned off and always was on. Per CNA 9, the bed and wheelchair alarms were not restraints. Per CNA 9, the alarm helped Resident 105 because every time she heard it, she stopped moving instantly and it reminded the resident to call staff for assistance. Per CNA 9, the alarm also helped the staff and was used with most fall risks residents. Per CNA 9 hearing the alarms prompted staff to stop their task to check on the resident with the triggered alarm. During an interview with Licensed Vocational Nurse 2 (LVN 2) and record review of Resident 105's medical records on 4/27/2022 at 10:21 a.m., LVN 2 confirmed Resident 105 recently fell and sustained a hip fracture. Per LVN 2, Resident 105 kept attempting to get out of bed unassisted, so the alarm helped the staff by making noise every time she moved a certain way. Per LVN 2, the alarms were not considered restraints because residents can move but with the noise. Per LVN 2, staff did not document monitoring of residents' behaviors and evaluate residents' response to the alarm. Per LVN 2, no consent or assessment was completed prior to initiating the alarm because it was not a restraint. Per LVN 2 no specific alarms care plan was made, alarms were only noted as interventions in the fall care plan. Per LVN 2, there was no specific diagnosis or medical symptom identified in the order to justify restraint use. During a concurrent observation and interview with LVN 2 on 4/27/2022 at 10:21 a.m., LVN 2 confirmed hearing Resident 105's alarm triggered while the resident was in her room in room [ROOM NUMBER] (room [ROOM NUMBER] was adjacent to nursing station 1)and LVN 2 was sitting in nursing station 2. Per LVN 2, the alarm was never off and always activated to beep whenever she moved a certain way. Per LVN 2, it was convenient, because the alarm was loud enough so staff can hear it from her room to nursing station 2. b. A review of the admission record indicated Resident 100 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included type two diabetes mellitus (high blood sugar), muscle weakness, anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). A review of Resident 100's Minimum Data Set (MDS - a comprehensive standardized assessment and screening tool), dated 3/12/2022, indicated Resident 100 had unclear speech, able to make himself usually understood and was able to understand others. The MDS indicated Resident 100 required extensive assistance with two- person assist on bed mobility, walking in the room, and corridor, extensive assistance with dressing, locomotion on and off unit (how residents move to and return off unit locations), total assistance with toilet use, bathing, personal hygiene, and transfer. During an initial tour of the facility on 4/25/2022 at 2:00p.m. Resident 100 was observed with a lap buddy tray (a positioning device when the resident is unable to maintain upright position in the chair and is used to provide trunk and upper arm/body support for wheelchair mobility or self-feeding) attached to his wheelchair. During an interview on 4/25/2022 at 2:02 p.m. Resident 100 stated that staff attach the lap buddy to his wheelchair, Resident 100 stated that he could not remove it, Resident further stated he did know how to remove the lap buddy. During a review of the physician's order for the month of March 2022 , an order dated 6/3/2021, indicated that Resident 100 had a lap tray when up in wheelchair to prevent resident from sliding off the chair and maintain proper posture. Monitor placement of lap tray when up in wheelchair every shift. Another order dated 4/11/2021 indicated, may apply bed pad alarm to alert staff when resident attempts to get out of bed unassisted ordered 4/11/2021. During a record review of the care plan for Resident 100, the record indicated that use of physical restraint related to physical and psychological condition initiated on 6/4/2021. During an interview on with 4/27/2022 at 3:54 p.m. with the Director Of Nursing (DON), DON stated that restraints were a physical device attached to residents' body that they could not easily remove and restricted movement. DON stated that assessment, consent, order, IDT, and care plan are needed when initiating use of a restraint, DON further stated that one full side rails is considered a restraint because the side rails restricted residents from getting out of bed on the side of the bed they preferred. DON further acknowledged that the psychological effect of not wanting to move due resident fear of the loud sound of the alarm was considered a restraint and needed to have an assessment, DON further stated that alarms in the facility were not assessed but considering negative psychological, and physical effect can potentially restrict freedom of movement making it type of restraint. During an interview on 4/28/2922 at 1:26 p.m. with Minimum Data Set Nurse (MDSN2), MDSN2 stated that restraint is any material or equipment that restrict movement of the resident, that the resident could not remove themselves if they wanted. During a concurrent interview and record review of Resident 100's medical record with RN 1 on 4/27/2022 at 2:25 p.m., RN 1 stated that no monitoring or end date for release of the lap tray that was specified in the care plan. RN 1 stated that alarms are considered a type of restraint so all residents that are on an alarm would be assessed for psychological harm from the loud sound of the alarm that also restricted their movements. RN 1 stated that no assessment was ever done for any alarms in the facility. During a review of facility's policy titled, Physical Restraints, dated 2/15/2010, policy indicated residents had the right to be free from any physical or chemical restraints (medication used to subdue sedate an individual) imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. Physical restraint is defined as using devices in conjunction with a chair, such as trays, tables, bars, or belts that the resident cannot remove easily, that prevent the resident from rising, placing a resident in a chair that prevents a resident from rising. Policy was to ensure residents can attain and maintain his/her highest practicable well-being in an environment that prohibited the use of restraints for discipline or convenience and limited restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. Per policy: 1. A physician's order is necessary for the use of a physical restraint. 2. The use of the restraining device must first be explained to the resident, family member, or legal representative. Each resident requiring physical restraints shall have the restraint released for at least ten (10) minutes every two (2) hours. During this time, the resident shall be re-positioned. Each resident requiring physical restraints shall be checked by a staff member at least every thirty (30) minutes. 3. The facility must explain, in the context of the individual resident' s condition and circumstances, the potential risks and benefits of all options under consideration including using a restraint, not using a restraint, and alterative to restraint use. 4. Explain the potential negative outcomes of restraint use which include, but are not limited to, declines in the resident's physical functioning (ability to ambulate) and muscle condition, contractures, increased incidence of infections and development of pressure ulcers, delirium, agitation, and incontinence. Resident may also face a loss of autonomy, dignity and self respect, and may show symptoms of withdrawal, depression, or reduced social contact. 5. Use of side rails as restraints is prohibited unless they are necessary to treat a resident's medical symptoms. 6. Medical symptoms that warrant the use of restraints must be documented in the resident's medical record, ongoing assessments, and care plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the minimum data set ([MDS] a comprehensive standardized assessment and screening tool) assessment accurately reflected resident's medical status for three of three sampled Residents (Residents 81,100 and 94). This deficient practice had the potential to negatively affect Residents 81,100 and 94's plan of care and cause delay of necessary care and services. Findings: a. During a review of the admission record, the record indicated Resident 81 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included fracture of left femur (partial or complete break in the bone), muscle weakness, chronic obstructive pulmonary disease (group of diseases that cause airflow blockage and breathing-related problems). A review of Resident 81's MDS, dated [DATE], indicated Resident 81 had unclear speech, able to make himself usually understood and was usually able to understand others. The MDS indicated Resident 81 required limited assistance with one person assist on bed mobility, extensive assistance with dressing, transfer, personal hygiene, locomotion on and off unit (how residents move to and return off unit locations), toilet use, and total dependence with two staff assist on bathing. During a record review of Resident 81's progress notes dated 2/21/2022 at 5:45 a.m., the notes indicated that Resident 81 tried to go to the bathroom independently and felt weak and fell on the floor and complained of left hip pain. During a record review of a hospital record dated 2/24/2022, the record indicated that Resident 81 fell in the facility and sustained a fracture of the left hip. During an interview on 4/27/2022 at 1:37 p.m. with Licensed Vocational Nurse 9 (LVN 9), LVN 9 stated that she does remember Resident 81 fell but not during her shift, LVN 9 stated that Resident 81 complained of pain at the left hip, so she gave pain medicine, and that Resident 81 was transferred to the hospital the next day. LVN 9 further stated that Resident 81 came back with hip surgery and needed assistance with activities of daily living (ADL). During a record review of MDS dated [DATE] for the section regarding falls; has the resident had any falls since admission/ entry or reentry on the prior assessment whichever is more recent it was coded 0 or no. During a concurrent interview and record review on 4/28/2022 at 1:19 p.m. with Minimum Data Set Nurse 2 (MDSN), MDSN2 stated that to code in minimum data set it must be within the assessment reference date (ARD - look back from date) period and has a certain look back that Resident Assessment Instrument (RAI) indicated for every section, MDSN2 stated that fall has 180 days of look back, MDSN stated that she missed to code the fall and will modify the assessment to make sure it reflected the correct information on Resident 81's medical condition. b. A review of the admission record indicated Resident 100 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included type two diabetes mellitus (high blood sugar), muscle weakness, anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) A review of Resident 100's MDS dated [DATE], indicated Resident 100 had unclear speech, was able to make himself usually understood and was able to understand others. The MDS indicated Resident 100 required extensive assistance with two- person assist on bed mobility, walk in the room and walk in the corridor, extensive assistance with dressing, locomotion on and off unit (how residents move to and return off unit locations), total assistance with toilet use, bathing, personal hygiene and transfer. During an initial tour of the facility on 4/25/2022 at 2:00p.m. Resident 100 was observed with lap buddy tray attached to his wheelchair. During an interview on 4/25/2022 at 2:02 p.m. Resident 100 stated that staff attached it to his wheelchair. Resident 100 stated he did not know how to take it out During a review of the physician's order for the month of March 2022, the orders indicated that Resident 100 has a lap tray when up in wheelchair to prevent resident from sliding off the chair and maintain proper posture. Monitor placement of lap tray when up in wheelchair every shift order 06/03/2021. During a record review of the care plan for Resident 100, the care plan indicated that use of physical restraint related to physical and psychological condition initiated on 6/4/2021. During a record review of the Resident 100's MDS, MDS indicated on section P (Restraints and Alarms) dated 3/12/2022 indicated no coded restraints or alarms. During a concurrent interview and record review on 4/28/2022 at 1:25 p.m. MDSN2 and MDSN 1 stated that it should have been coded, that the restraints were used daily, but MDSN 2 stated that she does not know how she missed that. MDSN 2 she will modify the assessment to reflect Resident's 100 restraints. c. A review of the admission record indicated Resident 94 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included encephalopathy (A broad term for any brain disease that alters brain function or structure), diabetes mellitus (irregular blood sugar), hypertensive heart disease without heart failure (Hypertensive heart disease refers to heart problems that occur because of high blood pressure that is present over a long time. A review of Resident 94's MDS, dated [DATE], indicated Resident 94's had clear speech, was able to make himself understood and was able to understand others. The MDS indicated Resident 94 required limited assistance with one person assist on bed mobility, extensive assistance with dressing, transfer, personal hygiene, total assistance with locomotion on and off unit (how residents move to and return off unit locations), toilet use, and bathing. During a record review of Resident 94's fall notes on 12/17/2021 at 11:25 a.m., the notes indicated that Resident 94 was noted on the floor lying oh his left side to bed. On 1/20/2022 at 3:49 p.m. indicated that Resident noted on floor in lying position on left side next to the restroom door documented that he slipped and fell. A fall note, dated 2/8/2022 at 12:21 p.m., indicated that Resident 94's foot tripped over the bedside table and noted falling to floor and hitting back of his head. Resident 94 had a swelling to crown area of the head measuring 2 cm by 2 cm. During an interview on 4/27/2022 at 2:31 p.m. with Registered Nurse 1 (RN 1), RN 1 confirmed that Resident 94 had had multiple fall incidents in the facility. During a concurrent interview and record review on 4/28/2022 at 1:30 p.m. with MDSN 2 and MDSN 1, MDSN 1 stated that Resident 94 she could not recall that he fell in the facility, MDSN 2 stated that department head usually will have stand up meeting and discuss what's going on to the facility especially with Residents that had a change of condition or any recent incidents like falls. MDSN 1 and 2 stated that Resident 94 had a fall in the facility within the look back period during Assessment Reference Date (ARD), MDSN 2 stated it was not coded or reflected in but she would modify the assessment because it was not coded. During a record review of the facility's policy and procedure (P/P) dated 3/2010 and titled, Resident Assessment Comprehensive Assessment, the P/P indicated that facility complete a comprehensive assessment of the resident's needs which are based on the state's specific RAI and the facility's interdepartmental assessment form. The nursing administrative body of the facility will assure the completion of resident assessment process enabling the development of an individualized comprehensive care plan for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a person-centered care plan to meet the preferences and goals, and address the residents' medical, physical, mental, and psychosocial needs for three of three sampled residents (Resident 1, 81, and 90 ). This deficient practice may potentially result in the facility not providing the residents' individual needs, services, and care to attain or maintain his or her highest practicable quality of life. Findings: a. During a review of Resident 90 admission record, the record indicated Resident 90 was admitted to the facility on [DATE], with diagnoses that included but not limited to metabolic encephalopathy (changes to the structure and function of the brain caused by an underlying condition), type 2 diabetes mellitus (irregular blood sugar), and depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). During a review of resident 90's quarterly Minimum Data Set (MDS), a standardized assessment and care planning tool), dated 3/26/2022, the MDS indicated Resident 90's cognition (ability to think, understand, and reason) was severely impaired. The MDS indicated Resident 90 required supervision with bed mobility, dressing, eating, toilet use, personal hygiene, and bathing. During a review of Resident 90's progress note dated 4/22/2022, written by Licensed Vocational Nurse 8 (LVN 8), the progress note indicated, at 11:25 p.m. the resident was noted with skin tear to the lateral side of left forearm, cleansed with normal saline (a solution that can be used to clean wounds), pat dry, applied triple antibiotic ointment and covered with dry dressing. When asked what and how it happened, the resident stated she did not know. continue to monitor. During a concurrent observation and interview on 4/25/2022 at 10:31 a.m., Resident 90 had a left forearm with dry dressing that was labeled applied 4/22/2022. Resident 90 stated, I cannot remember when or how it happened. During an interview on 4/25/2022 at 11 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated, she was not aware of the resident's skin tear issue. LVN 1 stated, when there is a change of condition on a resident, a care plan needed to be made as soon as possible. There was no care plan made for Resident 90's skin tear problem. During an interview on 4/27/2022 at 11:10 a.m., with Registered Nurse Supervisor 1 (RN 1), RN 1 stated a care plan should have been developed immediately for Resident 90's skin tear on her left arm, not initiating a care plan could delay care and present a greater risk of infection. b. A review of the admission record indicated Resident 81 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included fracture of left femur (a partial or complete break in the bone), muscle weakness, chronic obstructive pulmonary disease (group of diseases that cause airflow blockage and breathing-related problems). A review of Resident 81's MDS, dated [DATE], indicated Resident 81 had unclear speech, was able to make himself understood and was usually able to understand others. The MDS indicated Resident 81 required limited assistance with one person assist on bed mobility, extensive assistance with dressing, transfer, personal hygiene, locomotion on and off unit (how residents move to and return off unit locations), toilet use, and total dependence with two staff assist on bathing. During an initial tour and interview on 4/25/2022 at 9:17 a.m. Resident 81 was in the wheelchair and stated that he used to ambulate independently and that he fell and had surgery. During an interview on 4/27/2022 at 10:07 a.m. with Certified Nurse Assistant 7 (CNA 7), CNA 7 stated that Resident 81 used to be in station 1 where he fell, CNA 7 further stated Resident 81 used to walk around the facility and was independent with activities of daily living but after the fall he needed two-person assist, and is now in wheelchair. During a record review of the progress notes dated 2/21/2022 at 05:45 am; the notes indicated that Resident 81, fell to the floor at the bathroom and complained of left hip pain. During an interview on 4/27/2022 at 1:37 p.m., with LVN 9, LVN 9 stated that she did remember hearing Resident 81 fell but not during her shift, LVN 9 stated that Resident 81 complained of pain at the left hip, so I gave pain medicine, LVN 9 stated that she documented on the Medication administration record (MAR) when she gave medicine and assessed for pain before and after pain medicine administration to check for effectivity. LVN 9 stated that she gave the pain medicine but it's not the medicine that should manage the 5 out of 10 (moderate pain). During an interview on 4/27/2022 at 12:01 p.m., with RN 1, RN 1 stated that after the fall at around 5:45 a.m. on 2/21/2022 Resident 81 complained of pain and pain medicine was given one time towards the end of the shift on 2/21/2022 at 2:34 p.m. RN 1 stated that pain was not manage properly because when Resident 81 complained of pain 5/10 the facility should have administered a stronger pain medication prescribed for moderate pain. RN further added that pain should have been managed right away if Licensed Nurses are more aggressive with regards to pain. RN 1 stated no care plan was made or updated to help manage Resident 81's pain from the fracture. c. During a review of Resident 1's admission Record, the record indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with a diagnosis of cellulitis (a bacterial infection involving the inner layers of the skin) of the right arm. During a review of Resident 1's History and Physical (H/P), dated 4/12/2022, the H/P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1 had the ability to express ideas and wants, and usually had the ability to understand others. The MDS indicated Resident 1 required supervision and setup assistance for bed mobility and drinking, and required limited, one-person assistance for transfers out of bed, walking, dressing, toilet use, and personal hygiene. During a review of Resident 1's Order Summary Report, dated 4/27/2022, the report indicated Resident 1 had a physician order, dated 4/15/2022, for treatment of a right elbow abscess cavity. The order was to cleanse with normal saline, pat dry, loosely pack with ¼ iodoform (used as an antiseptic component of medications for minor skin diseases) and cover with dry dressing daily for 21 days. During a review of Resident 1's care plan, the care did not include an individualized plan of care and interventions for Resident 1's right elbow abscess. During a concurrent interview and record review on 4/27/2022, at 2:54 p.m., with LVN 5 in the hallway, LVN 5 stated she developed the care plan for residents with wounds and skin issues. LVN 5 stated Resident 1 had an abscess on his right elbow. LVN 5 confirmed that there was no care plan initiated for Resident 1's right elbow abscess. LVN 5 stated the purpose and importance of the care plan was to have a plan of care for a problem, to have a goal, and the interventions to reach the goal. LVN 5 stated a care plan guided the care for the resident and stated the plan of care was revised as needed to meet the goal. During an interview on 4/28/2022, at 4:12 p.m., with the Director of Nursing (DON) in her office, the DON stated the licensed nurse was responsible for developing an individualized care plan for the residents. Reviewed Resident 1's care plan with the DON and the DON verified Resident 1 did not have a care plan for his right elbow abscess and stated that Resident 1 should have a care plan addressing the wound. The DON stated it was important for Resident 1 to have a care plan because the care plan served as a tool of communication as well as a guide for the licensed nurses to work as a team and provide individualized care for the residents. During a review of the facility's policy and procedure (P&P) titled, Wound management [undated] indicated, A licensed nurse will develop a care plan for the resident based on recommendations from dietary, rehabilitation and the attending physician. During a review of facility policy titled, Care Planning, dated 1/1/2012, the policy indicated the care plan served as a course of action where the resident (resident's family and/or guardian or other legal authorized representative), resident's attending physician, and IDT (interdisciplinary team) work to help the resident move toward resident-specific goals . The policy indicated a licensed nurse would initiate the care plan. The policy indicated the care plan would describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The policy indicated the care plan must be completed within seven (7) days after completion of the comprehensive admission Assessment and must be periodically reviewed and revised by a team of qualified persons after each assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure five of seven sampled residents (Resident 22, 105, 94, 81, and 67) received treatment and necessary care in accordance with professional standards and in accordance with the plan of care (provides direction for type of nursing care to be rendered) by failing to: a. Comprehensively assess and report 126 bowel movements with a consistency of diarrhea/loose to the physician and manage Resident 67's diarrhea/loose bowel movements. As a result of this deficient practice Resident 67 experienced 126 diarrhea/loose bowel movements which led to Resident 67's suffered the discomfort of constantly having loose/diarrhea and needing to be changed frequently. Resident 67 was isolated to his room and did not want to go outside due to fear of having stool leak out of his adult brief. Resident 67 also endured feeling frustrated that his bowel condition was left untreated from 12/6/2021-4/26/2022. b. Follow up with Resident 22 after she had refused the initial attempt to be screened for needed Rehabilitation (services help people return to daily life and live in a normal or near-normal way) services upon re- admission to the facility on 1/3/2022; and the interdisciplinary team (IDT) failed to identify that Resident 22 was not receiving Restorative Nursing Assistant (RNA) exercises. Prevent the range of motion ([ROM] movement of the joints) decline of one (1) of one (1) sampled resident (Resident 22) by not resuming Restorative Nursing Assistant (RNA) services upon readmission on [DATE]. As a result of this deficient practice Resident 22 did not receive the RNA exercises she was receiving prior to being hospitalized and by the time she was screened on 4/25/2022, the range of motion ([ROM] movement of the joints) of her left upper extremity contractures (permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) worsened. c. Supervise Resident 94 who has moderately impaired vision and ambulated independently around the room and in the hallway and Resident 81 independently went for toilet use felt weak and fell on the floor sustaining fracture at the left hip. As a result of this deficient practice Resident 81 sustained a fall with injuries which included a left femur fracture (a broken thighbone, also known as a femur fracture, is a serious and painful injury and Resident 94 sustaining an avoidable repeat fall, (found on the floor). d. Ensure Resident 105's pain was relieved on 1/16/2022 after she fell at approximately 10:00 a.m. Documented pain relief was noted after ten and half (10 ½) hours after the fall incident occurred. As a result of this deficient practice Resident 105 had to endure unnecessary pain for ten and half (10 ½) hours. Findings: a. During a review of Resident 67's admission Record (Facesheet), the Facesheet indicated Resident 67 was admitted on [DATE] with a diagnosis of COVID-19 (a highly contagious viral infection), Type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar), and neuromuscular dysfunction of bladder (condition when a person loses control of the bladder due to a problem in the brain, spinal cord, or central nervous system which results a person urinating too much or too little). During a review of Resident 67's History and Physical (H/P), dated 12/5/2021, the H/P indicated Resident 67 had the capacity to understand and make decisions. During a review of Resident 67's Minimum Data Set ([MDS], a standardized resident assessment and care screening tool), dated 12/9/2021, the MDS indicated Resident 67 had the ability to express ideas and wants and usually had the ability to understand others. The MDS indicated Resident 67's activity preferences included that it was somewhat important to go outside to get fresh air. The MDS indicated Resident 67 required limited, one-person assistance for bed mobility and required extensive, one-person assistance for transfers out of bed and dressing. The MDS indicated Resident 67 was completely dependent on one-person assistance for toilet use and personal hygiene and required supervision and setup for meals. The MDS indicated Resident 67 was always bowel incontinent (the inability to control bowel movements, causing stool to leak unexpectedly from the rectum). During a review of Resident 67's Order Summary Report, dated 4/28/2022, the report indicated Bismuth Subsalicylate (medication to treat diarrhea) was not ordered until 4/27/2022 as needed every four hours. During a review of Resident 67's care plan, noted the care plan was not individualized to include interventions to manage Resident 67's diarrhea. During a review of resident 67's Documentation Survey Reports for bowel and bladder elimination, dated December 2021-April 2022, the report indicated Resident 67 had 126 entries that described the consistency of his bowel movements as loose/diarrhea. During an interview on 4/25/2022, at 9:07 a.m., with Resident 67 in his room, Resident 67 stated he has had diarrhea for a long time. Resident 67 stated he gets diarrhea every time he eats. Resident 67 stated he asked the nurses for Pepto Bismol (medication used to treat diarrhea, heartburn, nausea, and upset stomach) because it was what helped him at home when he had diarrhea. Resident 67 stated he had not been given anything to help treat the diarrhea. During an interview on 4/27/2022, at 12:08 p.m., in Resident 67's room, Resident 67 stated he had diarrhea today. Resident 67 stated he was just changed, and he had to go again. Resident 67 stated it makes him feel very frustrated to always have diarrhea. Resident 67 stated he would like to go outside but he cannot go outside because he is afraid, he will have an accident and that would be very embarrassing for him. Resident 67 stated he does not want that to happen, so he stays in his room, and that he feels lonely and sad. During an interview on 4/27/2022, at 12:37 p.m., with Certified Nurse Assistant 9 (CNA 9) in the hallway, CNA 9 stated Resident 67's bowel movements were always very loose. CNA 9 stated she changed Resident 67's adult brief with diarrhea/loose stool 2-3 times a day during her 8-hour shift and on bad days she changed him 3-4 times during her shift. CNA 9 stated she had reported Resident 67's diarrhea/loose bowel movements to LVN 9. CNA 9 stated Resident 67 had requested Pepto Bismol very often. CNA 9 stated Resident 67 would tell her his stomach was hurting and that he wished he was home so he could take his Pepto Bismol. CNA 9 stated she reported to Licensed Vocational Nurse 9 (LVN 9) that Resident 67 wanted Pepto Bismol to treat the diarrhea. During an interview and record review on 4/27/2022, at 2:08 p.m., with LVN 9 at Nurse Station 1, LVN 9 stated CNA 9 reported to her that Resident 67 had diarrhea/loose stools. LVN 9 stated she did not report Resident 67's diarrhea/loose bowel movements to his primary physician because she wanted to assess the bowel movements herself to determine if it was diarrhea. LVN 9 stated she had not seen Resident 67's diarrhea/loose bowel movements because when she had gone to see Resident 67, he would tell her he had just been changed by the CNA. LVN 9 stated she did not ask Resident 67 if he had diarrhea. LVN 9 stated she had not checked any of Resident 67's soiled adult briefs to assess the consistency of the bowel movements. During a concurrent observation and interview on 4/27/2022, at 2:34 p.m., CNA 9 changed the Resident 67's soiled adult brief. Observed with LVN 9 and CNA 9 Resident 67's adult brief with watery yellow-brown stool. LVN 9 confirmed the stool was watery diarrhea. During a follow up interview and record review on 4/28/2022, at 10:26 a.m., with LVN 9 at Nurse Station 1, reviewed the Documentation Survey Report for bowel and bladder elimination with LVN 9. Reviewed with LVN 9 the 97 loose/diarrhea bowel movements documented from 12/27/2021-4/27/2022. LVN 9 stated she was not aware Resident 67 had so many loose/diarrhea bowel movements. LVN 9 stated she had not previously looked at the bowel and bladder documentation entered by the CNAs. LVN 9 stated she should have reported Resident 67's diarrhea to the doctor. LVN 9 stated it would be unusual for Resident 67 to have diarrhea because he was not taking anything to cause diarrhea; stated Resident 67 was not prescribed any stool softeners. LVN 9 stated it was important to report diarrhea to the primary physician because untreated diarrhea may lead to dehydration, hospitalization, and it may cause discomfort to the resident. During an interview with the Director of Nursing (DON) on 4/28/2022, at 1:30 p.m., the DON stated when a resident reported having diarrhea to a CNA, the CNA would report it to the LVN for the LVN to assess the stool. The DON stated the LVN should clarify with the CNA the description of the stool to determine if it was diarrhea. The DON stated the LVN should educate the CNA that every time they change the resident, the LVN should be called to assess the stool. The DON stated there was a delay in care for Resident 67 due to the lack of communication and education between the LVN and the CNA. The DON stated diarrhea may affect a resident's electrolytes, may lead to dehydration, and possibly hospitalization. The DON stated a resident with diarrhea may feel uncomfortable leaving their room because they may have an accident if they lose control of their bowels, and the stool leaks out. The DON stated if a resident were to have an accident the resident's self-esteem would be negatively affected. The DON stated it was important for a resident with diarrhea to be further assessed and for the primary physician to be made aware so they may order necessary tests to determine the cause of the diarrhea and possibly refer the resident for a consult to address the issue. During a review of the facility's policy and procedure (P/P) titled, Physician Notification Policy and Procedure, dated 2019, the P/P indicated federal and state requirements mandate that the resident's physician must be notified of changes in a resident's condition that affect health, new admission to and discharge from the facility. The policy indicated the physician must be immediately notified of a change in condition including three or more loose stools in 24 hours. b. During a review of the Resident 22's face sheet, the face sheet indicated Resident 22 was admitted on [DATE]. Resident 22 was most recently readmitted to the facility on [DATE]. Resident 22's diagnoses included covid-19, dermatitis (skin problem), noncompliance with other medical treatment and regimen, anxiety disorder (mental health disorder characterized by pervasive worry or fear) , multiple sclerosis (a chronic disease affecting the brain and spinal cord causes many different symptoms, including vision loss, pain, fatigue, and impaired coordination), contractures of the left hand, muscle weakness, polyneuropathy (simultaneous malfunction of many peripheral nerves throughout the body), and pain. During a review of Resident 22's Minimum Data Set MDS, dated [DATE], the MDS indicated Resident 22 expressed ideas and wants and usually understood verbal content. MDS also indicated Resident 22 had intact cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making. Resident 22 needed extensive assistance with dressing; and was totally dependent with eating, bed mobility, toilet use, and personal hygiene. During a record review of Resident 22's physician orders for 8/22/2021 to 12/25/2021, orders indicated: i. RNA for Bilateral lower extremities (BLE) passive range of motion ([PROM] passive range of motion, when someone is moving or stretching a part of the body for the resident) five (5) times a week or as tolerated. ii. RNA for Bilateral upper extremities (BUE) PROM five (5) times a week or as tolerated. iii. RNA to apply hand roll to left hand every day five (5) times a week for four (4) to six (6) hours or as tolerated. iv. RNA to apply hand roll of the left hand at 8:30 a.m. v. RNA to remove hand roll of the left hand at 2:30 p.m. During a record review of Resident 22's Restorative Nursing Administration Record for 12/2021, records indicated Resident 22 received the RNA services ordered and there was no documented evidence of Resident 22 refusal of services offered by RNA. During an observation and interview with Resident 22 on 4/25/2022 10:10 a.m., Resident 22 was noted with a contractures in the LUE. Resident 22 stated her LUE was now more contracted. Per Resident 22, she used to get help with exercises on her arms and hands, but they had stopped. Per Resident 22, exercises would have been helpful. During an interview with LVN 7 and record review with Resident 22's physician orders on 4/26/2022 at 12:44 p.m., LVN 7 stated the staff used to do ROM exercises for Resident 22. Per LVN 7,there was new RNA order on started 4/25/2022, 113 days after Resident 22 was admitted . Order indicated RNA for BLE and BUE, PROM five (5) times a week or as tolerated. During an interview with Restorative Nurse Assistant 1 (RNA 1) on 4/27/2022 at 11:25 a.m., RNA 1 stated she assisted Resident 22 with ROM exercises in the upper and lower extremities even before she was hospitalized last year. Per RNA 1, Resident 22's left upper arm was already stiff and already contracted. Per RNA 1, Resident 22 was compliant when exercises were offered last year. Per RNA 1, Resident 22 stopped receiving RNA services due to being hospitalized on [DATE] and it has not been resumed until 4/26/2022. Per RNA 1, RNA exercises were given only if ordered. During an interview with the Director of Rehabilitative Services (DOR) and record review of rehabilitation screening and joint mobility assessment (JMA) (dated 1/4/2022) on 4/27/2022 at 12:36 p.m., DOR confirmed that Resident 22 refused joint mobility assessment([JMA] on upon return to the facility from the hospital. Per DOR, there was no documented evidence that she attempted to assess the resident's joint mobility more than once. Per DOR, Resident 22 would have benefited from RNA services, but she refused secondary to pain. During a follow up interview with the DOR and record review of Resident 22's JMA (dated 9/2021 and 4/25/2022) on 4/28/2022 at 9:16 a.m., Per DOR, she did not notify nursing of the refusal and no documented evidence of the notification existed. Per DOR, she did not notify the IDT team and she did not participate in the IDT team meeting for the resident. Per DOR, if she tried to do the JMA sooner than the quarterly required assessment, it might have been beneficial for the resident. Per DOR, there was a decrease in mobility from 10/31/2021 to 4/25/2022 assessments. DOR confirmed Resident 22's LUE JMA indicated loss of range of motion mobility as follows: i. On 10/31/2021, left wrist indicated minimal (less than or equal to twenty-five (25) percent (%) loss); left elbow joint indicated moderate (twenty-six (26) percent to fifty (50) percent loss); and left shoulder joint also indicated moderate (26 percent to 50 percent loss). ii. On 4/25/2022, Resident 22's left wrist at moderate (26 percent to 50 percent loss), left shoulder and elbow joints indicated severe (more than or equal to 50 percent loss). iii. Per DOR, resuming the RNA services sooner than 4/25/2022 could have been beneficial for Resident 22. During an interview with registered nurse 1 (RN 1) and record review of Resident 22's medical records on 4/28/2022 at 11:32 a.m., RN 1 confirmed: i. IDT team was unaware Resident 22 refused the JMA upon admission. ii. IDT team thought Resident 22 was in the RNA program when she returned to the facility on 1/3/2022 and it was noted in the IDT conference notes on 2/10/2022 that Resident 22 was receiving RNA services five times a week. Per RN 1, no documented evidence existed that Resident 22 had an order for RNA services upon admission. Per RN 1, no documented existed that Resident 22 received RNA services from the RNA on admission till 4/25/2022. iii. DOR did not participate in the IDT meeting for Resident 22 and the IDT was not notified of refusal for JMA on 1/4/2022. IDT conference notes indicated DOR did not participate in the IDT meeting. During the continued interview RN 1 and record review of Resident 22's care plans on 4/28/2022 at 11:32 a.m., RN 1 confirmed there was no documented evidence of a comprehensive care plan addressing Resident 22's limited ROM existed. Per RN 1, Resident 22 did not receive services for about 3 months and per RN 1 there was a notable decline from the JMA on 10/31/2021 and the JMA on 4/25/2022. During a record review of the facility's P/P titled, Restorative Nursing Program Guidelines, (undated), the P/P indicated this program actively focused on achieving and maintaining optimal physical, mental, and psychosocial functioning. Residents will be reviewed by the interdisciplinary Team (IDT) upon admission, readmission, quarterly, and as needed to identify any decline in activity of daily living (ADL) function. The director of nursing (DON) or their designee, manages and directs the restorative nursing program. In conjunction with the attending physician and staff, therapists will propose a rehabilitation restorative care plan that provided an appropriate intensity, frequency, and duration of interventions to help achieve anticipated goals and expected outcomes. The DON or designee reviewed RNA weekly summary notes on a regular basis. During a review of the facility's Specialized Rehabilitative Services P/P (5/1/2018), P/P indicated the facility shall meet the assessed needs of any resident admitted assisting residents in obtaining or maintaining their highest practicable level of functional well-being. A resident will be assessed by a licensed nurse or the DOR for indications related to the provision of skilled rehabilitative services during the admission/re- admission process. Licensed nursing staff will refer residents assessed to have a clinical need for rehabilitative therapy for a screening by the appropriate discipline. c. During a review of the admission record, the record indicated Resident 81 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included fracture of left femur (fracture is a partial or complete break in the bone), muscle weakness, chronic obstructive pulmonary disease (group of diseases that cause airflow blockage and breathing-related problems). During a review of Resident 81's MDS, dated [DATE], MDS indicated Resident 81's had unclear speech, be able to make himself usually understood and was usually able to understand others. The MDS indicated Resident 81 required limited assistance with one person assist on bed mobility, extensive assistance with dressing, transfer, personal hygiene, locomotion on and off unit (how residents move to and return off unit locations), toilet use, and total dependence with two staff assist on bathing. During an initial tour to the facility on 4/25/2022 at 9:24 a.m. Resident 81 in his wheelchair stated that he used to be independent and walks around but he fell and had recent surgery. During a record review of Resident 81's progress notes dated 2/21/2022 at 5:45 a.m., indicated that Resident 81 tried to go to the bathroom independently and felt weak and fell on the floor and complaining of pain at the on the left hip. During a record review of the hospital record dated 2/24/2022 indicated that Resident 81 fell in the facility and sustained a fracture of the left hip. During an interview on 4/27/2022 at 1:37 p.m. with LVN 9, LVN 9 stated that she does remember Resident 81 had a fall incident but not during her shift, LVN 9 stated that Resident 81 complain of pain at the left hip, so I gave pain medicine, LVN 9 stated that she documented at the Medication administration record (MAR) and when LVN's give medicine especially for pain assessment for pain before and after medicine was given to check for effectivity of pain medicine. LVN 9 stated that she gave the pain medicine but it's not the medicine that should manage the 5 out of 10 (moderate pain). LVN 9 stated that she should have given the stronger pain medicine to help in Resident 81's pain after the fall because Resident 81 had a fracture and can't move his leg. During a record review of the X-ray result dated 2/21/2022 at 11:10 a.m., reason for test is pain in left hip status, indicated that sub capital left hip fracture with mild impaction. During an interview on 4/27/2022 at 12:01 p.m., with Registered Nurse 1, RN 1 stated that after fall at around 5:45 a.m. on 2/21/2022 Resident 81 complain of pain and pain medicine was given one time towards the end of the shift on 2/21/2022 at 2:34 p.m. RN 1 stated that pain was not managed properly because Tylenol 650 mg was the one given even when the order for was for treating fever not pain and when Resident 81 complained of 5/10 Ultram should have been administered for moderate pain. RN further added that pain should have been manage right away if Licensed Nurses should have been more aggressive with managing pain because it is one of the vital signs. During a review of the admission record, the record indicated Resident 94 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included encephalopathy (A broad term for any brain disease that alters brain function or structure), diabetes mellitus (high blood sugar), hypertensive heart disease without heart failure (Hypertensive heart disease refers to heart problems that occur because of high blood pressure that is present over a long time. A review of Resident 94's, MDS dated [DATE], indicated Resident 94's has clear speech, be able to make himself understood and was able to understand others. The MDS indicated Resident 94 requires limited assistance with one person assist on bed mobility, extensive assistance with dressing, transfer, personal hygiene, total assistance with locomotion on and off unit (how residents move to and return off unit locations), toilet use, and bathing. During a concurrent interview and record review on 4/27/2022 at 2:31 p.m. with RN 1, RN 1 stated that Resident 94 has multiple fall incident in the facility, RN 1 stated that it was care plan, but no change of condition started for Resident 100 progress notes was done for fall on 12/17/2021, 1/20/2022 and 2/8/2022. During a record review of Resident 94's fall notes on 12/17/2021 at 11:25 a.m. indicated that Resident 94 was noted on floor lying on his left side to bed. On 1/20/2022 at 3:49 p.m. indicated that Resident noted on floor in lying position on left side next to the restroom door documented that he slipped and fell. On 2/8/2022 at 12:21 p.m. fall note indicated that Resident 94-foot trip over the bedside table and noted falling to floor and hitting back of his head. Resident 94 has a swelling to crown area of the head measuring 2 cm by 2 cm. During an interview with RN 1 on 4/27/2022 at 2:31 p.m., RN 1 stated that Resident 94 fell but no change of condition and or situation background assessment recommendation (SBAR-internal document) that was initiated and no followed up noted on Resident's condition. RN 1 stated that if the fall risk assessment of the Resident in the facility are high 10 and above meaning facility should be more pro- active with plan of care to avoid Residents repeat fall incident. RN 1 stated that fall with fracture they don't report it to state agency or ombudsman. RN 1 stated that unusual occurrences in the facility are as follow: fall with fracture, choking episodes, resident-resident altercation, or staff-resident altercation. During an interview on 4/27/2022 at 2:56 p.m. with the DON, the DON stated SBAR are the way they communicate and follow up any medical concerns for license nurses, DON stated that some nurses are not following and not documenting through SBAR and some just document at the progress notes so we could follow up timely. DON further stated that it is important to assess the Resident if they are high fall risk or not to prevent or avoid any fall incident, it is like a tool to identify and prevent future fall incidents. DON stated that if it is first fall it is unavoidable fall but with multiple falls it should have been avoidable. DON further stated that Resident 94 repeat falls was due to Resident's 94 moderately impaired vision, DON further stated that it could have been stringent with our plan of care and could have been avoided especially if we identify that there is a vision impairment for the Resident. DON stated that unusual occurrences in the facility are choking, bruise of unknown cause, major injury like fracture of unknown cause, excessive bleeding, fire, or earthquake. During a record review of the facility's P/P dated 3/2010 titled Falls, P/P indicated that facility to evaluate extent of injury after a fall and prevent complications. During a record review of the facility's P/P dated 02/2022 titled Fall program indicated that the goal to the program is to reduce the incidence of falls/injury for each resident in the program. Establish a profile for each resident in the fall program using the current Fall Risks Evaluation Tool and reviewing the history of previous fall(s) or injury. This profile would serve as a guide for staff in individualizing interventions. d. During a review of the Resident 105's face sheet, the face sheet indicated the facility originally admitted Resident 105 on 1/7/2013. Resident 105 was most recently readmitted to the facility on [DATE]. Resident 105's diagnoses included fracture (broken bones) of left femur (thigh) , pneumonitis (inflamed lung because of infection), mild protein calorie malnutrition (reduced availability of nutrients leads to changes in body composition and function ), adult failure to thrive (decline seen in older adults - typically those with multiple chronic medical conditions - resulting in a downward spiral of poor nutrition, weight loss, inactivity, depression and decreasing functional ability), and muscle weakness. During a review of Resident 105's MDS, a standardized assessment and care screening tool, dated 12/17/2021, the MDS indicated Resident 105 expressed ideas and wants and usually understood verbal content. MDS also indicated Resident 105 had moderately impaired cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making. Resident 105 needed supervision with bed mobility, walking, dressing, eating, toilet use and personal hygiene. During a review of Resident 105's physician orders, orders indicated starting on 10/19/2021 Resident 105 had orders of Tylenol extra strength (pain medication) one (1) tablet five hundred (500) milligrams (mg)every eight (8) as needed for moderate pain. Resident 105 also had an order for Tylenol one (1) tablet 325 mg every twelve (12) hours as needed for mild pain. During a review of Resident 105's progress notes dated 1/16/2022 at 1:12 p.m., note indicated at around 10:00 a.m., Resident 105 fell on her left hip at the patio during smoke break when she was looking for her cigarette and lost her balance. Per director of nursing (DON),Resident 105 complained of pain of 6 and was given Tylenol extra strength 1 tablet 500 mg with no relief. During a record review of Resident 105's progress notes dated 1/16/2022 at 7:55 p.m., note indicated during x- ray on left hip and knee, Resident 105 continued to be in pain with difficulty repositioning side to side with assistance. No documented scale level was noted. No documented evidence of comfort measures including pharmaceutical measures were rendered to the resident. During a record review of Resident 105's pain assessment dated [DATE] at 8:15 p.m., record indicated Resident 105 had a continuous throbbing pain in the left hip that was rated at a 7 (severe pan). Per document, pain affected Resident 105's activities of daily living ([ADL] term used to refer to people's daily self-care activities). It affected Resident 105's sleep and rest, social activities, appetite, and physical activity and mobility. Per document, the pain medication given to her helped a little bit. During a record review of Resident 105's progress notes on 1/16/2022 at 8:35 p.m., notes indicated Resident 105 still complained of left hip pain of 7 (severe pain) and was unable to raise leg but was relieved after pain medication was administered. First documented pain relief was noted in the records ten and half (10 ½) hours after the fall incident occurred. During a review of Resident 105's progress notes dated 1/16/2022 at 10:28 p.m., note indicated pain scale follow up after medication was administered was a zero (0). During an interview with DON and a record review of Resident 105's medical records on 4/29/2022 at 9:28 a.m., DON confirmed after Resident 105 received pain medication on 1/16/2022 at 10:00 a.m. and after documented evidence of no pain relief was noted, no further documented evidence of additional comfort measures to address the unrelieved pain was noted. Per DON pain was not further addressed and it should have been addressed further. During a record review of the facility's P/P titled Pain management, dated 5/1/2018, policy indicated a licensed nurse will assess residents for pain on admission and routinely as indicated by the resident's health and functional status. Staff was responsible for helping resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain. The pain assessment flowsheet will be completed every shift for new residents, for the first seventy-two (72) hours following admission; after medications/interventions were implemented, re-evaluate the resident's level of pain within one (1) hour. Nurses will complete the Pain Flow Sheet for residents receiving pain medication to evaluate the effectiveness of the medication regimen. If there was a new onset of pain, if the pain has changed in nature, or the pain has not been relieved with current medication, the nurse will notify the physician for a review of medications and the interdisciplinary team (IDT)-Pain Committee. Nursing Staff will implement timely interventions to reduce the increase in severity of pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to manage and re-assess two of two sampled residents' (Resident 105 and 81) pain after the residents fell and sustained major injuries. a. Resident 105 fell and complained of pain six out of 10 ([moderate pain] 6/10) on a pain scale, the resident was medicated with no pain relief noted. There was no documented evidence the resident's pain was re-assessed after the pain medication was given. b. Resident 81 fell in the bathroom and complained of pain 5/10 on a pain scale to the left hip, the resident was given Tylenol 650 milligrams ([mg] unit of measurement). There was no documented evidence the resident's pain was re-assessed. This deficient practice resulted in Resident 105 and 81 experiencing necessary pain and lack of proper management of pain. Findings: a. During a review of the Resident 105's admission record (face sheet), the face sheet indicated the facility originally admitted Resident 105 on 1/7/2013. Resident 105 was most recently readmitted to the facility on [DATE]. Resident 105's diagnoses included fracture (broken bones) of left femur (thigh) , pneumonitis (inflamed lung because of infection), mild protein calorie malnutrition (reduced availability of nutrients leads to changes in body composition and function ), adult failure to thrive (decline seen in older adults - typically those with multiple chronic medical conditions - resulting in a downward spiral of poor nutrition, weight loss, inactivity, depression and decreasing functional ability), and muscle weakness. During a review of Resident 105's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 12/17/2021, the MDS indicated Resident 105 expressed ideas and wants and usually understood verbal content. MDS also indicated Resident 105 had moderately impaired cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making. Resident 105 needed supervision with bed mobility, walking, dressing, eating, toilet use and personal hygiene. During a review of Resident 105's physician orders, orders indicated starting on 10/19/2021 Resident 105 had orders of Tylenol extra strength (pain medication) one (1) tablet five hundred (500) milligrams (mg)every eight (8) as needed for moderate pain. Resident 105 also had an order for Tylenol one (1) tablet 325 mg every twelve (12) hours as needed for mild pain. During a review of Resident 105's progress notes dated 1/16/2022 at 1:12 p.m., note indicated at around 10:00 a.m., Resident 105 fell on her left hip at the patio during smoke break when she was looking for her cigarette and lost her balance. Per director of nursing (DON), Resident 105 complained of pain of 6 and was given Tylenol extra strength 1 tablet 500 mg with no relief. During a record review of Resident 105's progress notes dated 1/16/2022 at 7:55 p.m., note indicated during x- ray on left hip and knee, Resident 105 continued to be in pain with difficulty repositioning side to side with assistance. No documented scale level was noted. No documented evidence of comfort measures including pharmaceutical measures were rendered to the resident. During a record review of Resident 105's pain assessment dated [DATE] at 8:15 p.m., record indicated Resident 105 had a continuous throbbing pain in the left hip that was rated at a 7 (severe pan). Per document, pain affected Resident 105's activities of daily living ([ADL] term used to refer to people's daily self-care activities). It affected Resident 105's sleep and rest, social activities, appetite, and physical activity and mobility. Per document, the pain medication given to her helped a little bit. During a record review of Resident 105's progress notes on 1/16/2022 at 8:35 p.m., notes indicated Resident 105 still complained of left hip pain of 7 (severe pain) and was unable to raise leg but was relieved after pain medication was administered. First documented pain relief was noted in the records ten and half (10 ½) hours after the fall incident occurred. During a review of Resident 105's progress notes dated 1/16/2022 at 10:28 p.m., note indicated pain scale follow up after medication was administered was a zero (0). During an interview with DON and a record review of Resident 105's medical records on 4/29/2022 at 9:28 a.m., DON confirmed after Resident 105 received pain medication on 1/16/2022 at 10:00 a.m. and after documented evidence of no pain relief was noted, no further documented evidence of additional comfort measures to address the unrelieved pain was noted. Per DON pain was not further addressed and it should have been addressed further. b. A review of the admission record indicated Resident 81 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included fracture of left femur (fracture is a partial or complete break in the bone), muscle weakness, chronic obstructive pulmonary disease (group of diseases that cause airflow blockage and breathing-related problems). A review of Resident 81's MDS dated [DATE], indicated Resident 81 had unclear speech, be able to make himself usually understood and was usually able to understand others. The MDS indicated Resident 81 requires limited assistance with one person assist on bed mobility, extensive assistance with dressing, transfer, personal hygiene, locomotion on and off unit (how residents move to and from off unit locations), toilet use, and total dependence with two staff assist on bathing. During an initial tour on 4/25/2022 at 9:17 a.m. Resident 81 was in the wheelchair and stated that he used to ambulate and that he fell and had recent surgery. During an interview on 4/27/2022 at 10:07 a.m. with Certified Nurse assistant 7, CNA 7 stated that Resident 81 use to be in station 1 where he fell, CNA 7 further stated he used to walk around the facility and independently with ADL's but after the fall he needed a two-person assist, and he is now in wheelchair. During a record review of the progress notes dated 2/21/2022 at 05:45 am indicated that Resident 81, fell to the floor at the bathroom and complaining of left hip pain. During an interview on 4/27/2022 at 1:37 p.m. with Licensed Vocational Nurse 9, LVN 9 stated that she does remember Resident 81 had a fall incident but not during her shift, LVN 9 stated that Resident 81 complain of pain at the left hip, so I gave pain medicine, LVN 9 stated that she documented at the Medication administration record (MAR) and when LVN's give medicine especially for pain assessment for pain before and after medicine was given to check for effectivity of pain medicine. LVN 9 stated that she gave the pain medicine but it's not the medicine that should manage the 5 out of 10 (moderate pain). LVN 9 stated that she should have given the stronger pain medicine to help in Resident 81's pain after the fall because Resident 81 had a fracture and can't move his leg. During a record review of the Medication Administration Record (MAR), the MAR indicated Resident 81's pain level was documented as zero ([0] no pain) on all shifts. During a record review of the physician's order for month of April 2022, the order indicated that Resident 81 had several pain medication since January of 2022, Ultram 50 mg one tablet every 6 hours as needed for moderate pain (level 4-6) and Percocet 5-325 mg(Oxycodone-Acetaminophen) 1 tablet as needed for severe pain (7 to 10) Tylenol 325 mg 1 tablet as needed for mild pain (1 to 3). During a record review of the progress note dated 2/21/2022 at 3:18 p.m., the note indicated that Resident 81 complaining of pain all over 5/10, PRN (as needed) Tylenol administered as ordered. During a record review of the X-ray result dated 2/21/2022 at 11:10 a.m. reason for test is pain in left hip status, indicated that sub capital left hip fracture with mild impaction. During an interview on 4/27/2022 at 12:01 p.m. with Registered Nurse 1, RN 1 stated that after fall at around 5:45 a.m. on 2/21/2022 Resident 81 complain of pain and pain medicine was given one time towards the end of the shift on 2/21/2022 at 2:34 p.m. RN 1 stated that pain was not manage properly because it was Tylenol 650 mg was the one given even when the order for fever not pain and when Resident 81 complain of 5/10 it should have been Ultram for moderate pain. RN further added that pain should have been manage right away if Licensed Nurses are more aggressive with regards to pain. During a record review of the facility's policy and procedure (P/P) titled, Pain Management, dated 5/1/2018, the P/P indicated a licensed nurse will assess residents for pain on admission and routinely as indicated by the resident's health and functional status. Staff was responsible for helping resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain. The pain assessment flowsheet will be completed every shift for new residents, for the first seventy-two (72) hours following admission; after medications/interventions were implemented, re-evaluate the resident's level of pain within one (1) hour. Nurses will complete the Pain Flow Sheet for residents receiving pain medication to evaluate the effectiveness of the medication regimen. If there was a new onset of pain, if the pain has changed in nature, or the pain has not been relieved with current medication, the nurse will notify the physician for a review of medications and the interdisciplinary team (IDT)-Pain Committee. Nursing Staff will implement timely interventions to reduce the increase in severity of pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility's staff failed to ensure the spreadsheet menu for a regular diet on 4/26/2022 was followed. This deficiency had the potential to result in residents receiving the wrong protein and caloric intake prescribed when not following the menu, which could result in undernutrition and further compromise the resident's medical status. Findings: During tray line observation and interview with the [NAME] (CK) on 4/26/2022 at 12:05 p.m., it was observed that the CK confirmed the regular diet had 1 scoop of corned beef casserole, 1 scoop of carrots, beet salad, hash, and low-fat milk. During an interview with the Dietary Manager (DM) and a record review of the facility's daily menu for spring 2022 spreadsheet for week 4 on 4/27/2022 at 2:15 p.m., the DM confirmed the regular diet lunch meal included corned beef casserole, tangy beet salad, parslied noodles, zesty carrots, low fat milk and [NAME] hash. According to the DM, there was no parslied noodles served during the lunch menu on 4/26/2022. The DM stated there was a recipe for corned beef casserole and another separate recipe for parslied noodles. The DM stated he should have double checked with the dietician to make sure it was both needed because it did not seem right to put both items on the menu since the casserole already came with noodles. During an interview with the Registered Dietician (RD) and record review of the facility's daily menu for spring 2022 spreadsheet, for week 4 on 4/28/2022 at 12:29 p.m., the RD confirmed the spreadsheet menu should have been clarified to ensure it was correct. The RD said, she contacted the author to clarify the spreadsheet. According to the RD it seemed like, it was an error. During a record review of the facility's policy and procedure (P/P) titled, Menus (2012), the P/P indicated menus were planned to meet the guidelines as established by the most current federal/ state regulations and the dietary reference intakes from the Food and Nutrition Board of the Institute of Medicine. All menus will be evaluated for nutritional adequacy by a registered dietician.

Based on observation, interview and record review, the facility failed to: a. Ensure two of three residents (Residents 35 and 13) unvaccinated residents or partially vaccinated (received only one dose and needed another dose of the COVID-19 [a highly contagious viral infection] vaccine ) residents did not attend indoor communal dining during the COVID-19 outbreak (presence of least one confirmed COVID-19 resident) in the facility. b. Ensure Licensed Vocational Nurse (LVN) 2 wore personal protective equipment ([PPE] equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) per recommended guidelines. These deficient practices had the potential to expedite the transmission of Covid-19 to the residents and staff of the facility; and thereby the community. Findings: a. During a review of the Resident 35's admission record (face sheet), the face sheet indicated the facility admitted Resident 35 to the facility on 2/1/2019. Resident 35's diagnoses included covid 19, chronic obstructive pulmonary disease ([COPD]group of lung diseases that block airflow and make it difficult to breath), encephalopathy (brain disease), muscle weakness, bipolar disorder ( mental disorder characterized by episodes of mood swings that include emotional highs [mania] and lows [depression-- pervasive sadness or loss of interest in daily life]), and tobacco use. During a review of Resident 35's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 2/16/2022, the MDS indicated Resident 35 usually expressed ideas and wants and usually understood verbal content. MDS also indicated Resident 105 had severely impaired cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making. Resident 35 needed supervision with eating, bed mobility, transfer, dressing, toilet use and personal hygiene. During a record review of Resident 35 immunization record dated 9/2/2021, notes indicated responsible party refused the covid vaccine for the resident. During a review of the Resident 13's admission record (face sheet), the face sheet indicated the facility admitted Resident 13 to the facility on 1/4/2021. Resident 13's diagnoses included COPD, epilepsy (abnormal electrical activity in the brain resulting in sudden recurrent episodes of sensory disturbance, loss of consciousness, convulsions[episode of rigidity and uncontrolled muscle spasms]), kidney failure (body cannot remove waste and balance fluids), encephalopathy, muscle weakness, tobacco use, anemia (not enough healthy red blood cells to carry oxygen to the body), and schizophrenia (mental disorder in which people interpret reality abnormally). During a review of Resident 13's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 4/10/2022, the MDS indicated Resident 13 expressed ideas and wants and usually understood verbal content. MDS also indicated Resident 105 had moderately impaired cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making. Resident 35 needed supervision with eating; and extensive assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. During a record review of Resident 13's immunization record dated 9/3/2021, the record indicated the resident's responsible party refused the COVID 19 vaccine for the resident. During an interview with Infection Preventionist (IP) on 4/28/2022 at 11:36 a.m., IP confirmed communal dining was open for all the residents in the green zone and unvaccinated residents were not exempt from this activity. During an observation in the lobby area and interview with Licensed Vocational Nurse 9 (LVN 9) on 4/28/22 at 3:17 p.m., LVN 9 confirmed Resident 13 was using his wheelchair in the hallway and roaming freely in the lobby area. Per LVN 3 there was an outbreak in the facility and Resident 13 was allowed to roam around in the green zone. During an observation in the hallway by the patio area and an interview with Activities Assistant 1 (AA 1) on 4/28/2022 at 3:23 p.m., AA 1 confirmed Resident 35 was in line with other residents waiting to go out on a smoke break. Per AA 1, during the outbreak everyone allowed to go activities except yellow zone. During the continued interview with AA 1 and record review of the list of residents who ate lunch in the dining room on 4/28/2021 at 3:23 p.m., AA 1 confirmed Resident 13 ate lunch in the dining room today. AA 1 confirmed seventeen (17)other residents ate in the communal dining area as well. During a review of resident 13's care plan, initiated on 2/19/2022, for at risk for exposure to covid-19, intervention indicated to inform resident to minimize staying outside room as much as possible. During a review of resident 35's care plan, initiated on 2/23/2022, for at risk for exposure to covid-19, intervention indicated to inform resident to minimize staying outside room as much as possible. During a record review of facility's COVID-19 mitigation plan (revised 3/23/2022), the plan indicated the facility with continue with best practices of infection prevention and control. Per plan, the facility will stay up to date with the current guidelines from the local health departments such as public health and California department of public health. During a record review of Los Angeles County department of public health, Guidelines for Preventing & Managing Covid-19 in Skilled Nursing (updated 3/31/2022) indicated if there was a covid-19 outbreak in the facility residents who were not up to date with vaccines must cease participation in indoor communal activities. b. During an observation on 4/25/22, at 9:17 a.m., LVN 2 at the nursing station one was wearing N95 mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) and a surgical mask on top of N95 mask. During an interview on 4/28/22, at 11:40 a.m., with IP, IP stated, I noticed some staff wearing double mask and I advised them not to do that because it could affect the fit and seal of the N95 mask, and expose staff to Covid-19 virus During a review of the facility's policy and procedure (P/P) titled, Policy and procedure for N95 respirator mask [undated], the P/P indicated, 1. The N95 respiratory face mask can't protect employee if it doesn't fit the face correctly. 2. N95 must be tight-fitting and form a tight seal with the face and neck to work properly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based an observation, interview, and record review, the facility failed to label three (3) insulin (a medication used to regulate blood sugar levels) pens with an open date in accordance with the facility's policy in two (2) of three (3) inspected medication carts for Resident 4, 20, and 100. This deficient practice increased the risk for Resident 4, 20, and 100 to potentially receive medication that may have become ineffective or toxic due to the failure of not labeling medication with an open date which may have potentially resulted in harmful side effects, hospitalization, and death. Findings: During a review of admission record (Facesheet), the Facesheet indicated Resident 4 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnosis including chronic obstructive pulmonary disease ([COPD] a group of diseases that cause airflow blockage and breathing problems) and type 2 diabetes mellitus (a long-term condition that affects the way the body processes blood sugar; the body either does not produce enough insulin [a hormone that lowers the level of blood sugar in the body]). During a review of the History and Physical (H/P), dated [DATE], the H/P indicated Resident 4 had the capacity to understand and make decisions. During a review of the Minimum Data Set ([MDS], a standardized resident assessment and care screening tool), dated [DATE], the MDS indicated Resident 4 had the ability to express ideas and wants and usually had the ability to understand others. The MDS indicated Resident 4 required supervision and setup for bed mobility, transfers out of bed, walking, dressing, eating, toilet use, and personal hygiene. During a review of the Facesheet, the Facesheet indicated Resident 20 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnosis including chronic obstructive pulmonary disease and type 2 diabetes mellitus. During a review of the H/P, dated [DATE], the H/P indicated Resident 20 did not have the capacity to understand and make decisions. During a review of the MDS, dated [DATE], the MDS indicated Resident 20 sometimes had the ability to understand others and make herself understood. The MDS indicated Resident 20 required extensive assistance for bed mobility, dressing, eating, toilet use, and personal hygiene and was completely dependent on staff for transfers out of bed and locomotion on and off the unit. During an inspection of medication cart two (2) on [DATE], at 2:13 p.m., located in nurse station two (2), observed Resident 4 had a Basaglar insulin (a type of medication used to regulate blood sugar) pen and Resident 20 had a Novolog insulin (a type of medication used to regulate blood sugar) pen stored in the medication cart without an open date. During a review of the admission record (Facesheet), the Facesheet indicated Resident 100 was originally admitted to the facility on [DATE] and was readmitted on [DATE], with diagnoses that included Type 2 diabetes mellitus, muscle weakness, and anxiety disorder (mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities). During a review of the MDS, dated [DATE], the MDS indicated Resident 100 had unclear speech and usually had the ability to make himself understood and was able to understand others. The MDS indicated Resident 100 required extensive assistance, two-person assistance for bed mobility and walking and required extensive assistance with dressing, locomotion on and off unit (how residents move to and return off unit locations), and required total assistance with toilet use, bathing, personal hygiene and transfers out of bed. During an inspection of the medication cart on [DATE], at 3:17 p.m., located in nurse station two (2), observed Resident 100 had a Novolog insulin (a type of medication used to regulate blood sugar) pen stored in the medication cart without an open date. During an interview on [DATE], at 3:17 p.m., with Licensed Vocational Nurse (LVN) 8 at nurse station two (2), LVN 8 stated insulin pens removed from the refrigerator and placed in the medication cart were supposed to be labeled with the open date. LVN 8 stated it was important to label an insulin pen with the open date to ensure the insulin was not used past its expiration date. LVN 8 noted Resident 100's Novolog insulin pen was not labeled with the open date and stated it should be labeled with an open date. LVN 8 stated she was unsure when the insulin pen was opened. LVN 8 stated an open insulin pen expired after 30 days from the open date. LVN 8 stated administering insulin past its expiration date may lead to not managing blood sugar effectively due to the insulin not having full potency past its expiration date which may potentially result in having high blood sugar which may lead to diabetic coma, hospitalization, and death. During an interview on [DATE], at 3:31 p.m., with LVN 1 at nurse station two (2), LVN 1 verified and stated the insulin pens for Residents 4 and 20 were not labeled with an open date. LVN 1 stated it was important to label insulin pens with an open date to know the accurate expiration date and you do not administer expired insulin to a resident. LVN 1 stated the risk of administering expired insulin may lead to adverse reactions including high blood sugar, diabetic coma, hospitalization, and death. LVN 1 stated the facility policy indicated insulin pens should be labeled with an open date once opened and placed in the medication cart. During an interview on [DATE], at 2:55 p.m., with the Director of Nursing (DON) in her office, the DON stated insulin pens were stored in the refrigerator to preserve the potency of the medication. The DON stated when an insulin pen was opened, it must be labeled with the open date and that it was good for 28-30 days according to the manufacturer. The DON stated it was important to label an opened insulin pen to avoid using insulin past its expiration date. The DON stated expired insulin did not have the same potency and may not manage blood sugar levels effectively which may lead to high blood sugar, diabetic coma, hospitalization, and death. During a review of the facility's undated policy and procedure titled, Med Storage, the P/P indicated the facility, in keeping with good pharmaceutical practice, maintained proper storage, and monitored expiration of insulin. The P/P indicated all insulin vials, cartridge and pen of insulin must be dated when opened.

Based on observation, interview, and record review, the facility's kitchen staff failed to demonstrate the correct calibration technique (process of validating the thermometer was working properly) for a food thermometer. This deficiency had the potential to result in food being held at unsafe temperatures, thus potentially compromising food safety and contaminating foods that facility residents consume. Findings: During an observation and interview with the [NAME] (CK) on 4/26/2022 at 11:50 a.m., the facility's cook demonstrated the process of calibrating a digital thermometer using a hot water method. Using water from the hot water dispenser, the CK measured the temperature using the digital thermometer. The Ck stated, the thermometer reading indicated the hot water was at 185 degrees Fahrenheit. According to the CK the thermometer was safe for use. Per CK the calibration method using ice water was only used with the analog thermometers. During an interview with the Dietary Manager (DM) on 4/26/2022 at 11:58 a.m., the DM confirmed they typically use the ice water method to calibrate the thermometers. According to the DM ,it was also acceptable to use the hot water method. The DM said, if using the hot water method to calibrate the thermometer the read out should be at 220 degrees Fahrenheit. The DM stated, the dietary aides were not instructed on how to calibrate a thermometer, only the cooks and the DM knew how to do it. During a record review of the facility's policy and procedure (P/P) titled, Calibrating and sanitizing thermometers (2012), the P/P indicated thermometers will be calibrated weekly to ensure accurate temperatures were obtained and meeting appropriate guidelines for safe food preparation and service. Procedure indicated to calibrate a bimetallic stemmed thermometer by a) placing in a cup full of ice water, thermometer should read 32 degrees Fahrenheit or b) placing a cup of boiling water, reaching 212 degrees Fahrenheit. Per policy, digital thermometers can be checked for accuracy using either method and if temperatures were inaccurate, they must be discarded if unable to calibrate. During a review of the Food and Drug Administrations (FDA) Food Code, dated 2017, the document indicated: 1. Temperature measuring devices must be appropriately scaled per Code requirements to ensure accurate readings. 2. Food temperature measuring devices shall be calibrated in accordance with manufacturer's specifications as necessary to ensure their accuracy. 3. Calibrated temperature measuring devices must be used for determining internal product temperatures, equipment must be properly used and in proper adjustment such as calibrated food thermometers. 4. The inability to accurately read a thermometer could result in food being held at unsafe temperatures.

Based on observations, interviews and record reviews, the facility's staff failed to store and prepare food under sanitary conditions in the kitchen, by failing to: a. Ensure the ice machine was clean. b. Remove the rubber object in the bottom shelf of the walk-in refrigerator. c. Monitor the temperature in the dry storage area and date the bags of hamburger buns and loaves of bread. These deficient practices had the potential to result in the transmission of infectious agents that can lead to food born illness. Findings: a. During the initial kitchen tour observation and interview with the Dietary Manager (DM) on 4/25/2022 at 8:30 a.m., the DM confirmed seeing dark greenish unidentified substances approximately three (3) inches in length on the metal surface in the upper inner left corner of the interior of the ice machine. This finding was photographed and shared with the DM. According to the DM, that should not be there. During a follow up interview with the Maintenance Director (MD) on 4/25/2022 at 1:56 p.m., the MD confirmed that the ice machine cleaning was due for the month of April. The MD stated the ice machine should be clean and cannot have a dark green substance in it. During a record review of the facility's policy and procedure (P/P) titled, Ice machines and Ice storage chests, dated 5/1/2018, the P/P indicated ice machines were used and maintained in a manner that provided a safe and sanitary supply of ice. Accordingly, the U.S. Food and Drug Administration Food Code defined ice as food. This mandates ice to the same handling and cleanliness standards as everything else in food. Ice itself falls under 40 C.F.R. 141 governing drinking water purity. Ice machine cleaning is governed by Food Law 2009 Chapter 4-part 602.11 section (E) item (4a and b), which states that the machines must be cleaned at a frequency specified by the manufacturer, which in most instances ranges from two to four times per year, or at a frequency necessary to preclude accumulation of soil or mold. b. During an observation and interview with the DM on 4/25/2022 at 8:35 a.m., the DM confirmed finding a long, black, flexible rubber strip on the bottom shelf of the walk-in refrigerator. The DM stated he would dispose of it since it does not belong there. During a review of the facility's P/P titled, Proper Storage Foods in Refrigerator and Freezer, dated 2021, the P/P indicated the refrigerator will be cleaned as scheduled and as needed. c. During an observation, interview with the DM and record review of a temperature log for the dry storage area on 4/25/2022 at 8:40 a.m., the DM confirmed there was no thermometer that read the temperature of the dry storage areas. The DM stated there was no log of temperature monitoring for both areas. The DM said, he would check the policy to see if he needed one. During an continued observation and interview with the DM on 4/25/2022 at 8:40 a.m., there were unopened and opened loaves of bread and hamburger buns found with no dates on the packages. The DM stated he would ensure that all items were dated. During a record review of the facility's P/P titled, Canned and Dry Goods Storage (2012), the P/P indicated a thermometer should be placed in the storeroom to ensure proper temperature control, maintained at less than or equal to 85 degrees Fahrenheit. The P/P indicated products should be dated to assure that older products are used before newer ones were used.