Based on interview and record review, for one of one sampled resident (Resident 6), the facility failed to notify a physician of an abnormal potassium level (electrolyte in the body that regulates heart muscle contractions and maintaining proper electrical signals within the heart) level of 5.6 (milliquivalent per liter (mEq/L - unit of measurement. Reference range 3.5 to 5.1 mEq/L) on 6/6/2025 at 11:26 P.M. Resident 6's physician was not notified of the abnormal potassium level until 6/7/2025, at 5:50 P.M. This deficient practice had the potential to result in Resident 6 suffering palpitations (a noticeably rapid, strong, or irregular heartbeat due to agitation, exertion, or illness), chest pain, hypertension (elevated blood pressure) and a heart attack ( myocardial infarction (MI), occurs when blood flow to the heart muscle is suddenly blocked, depriving it of oxygen), which could result in death. Findings: During a record review, Resident 6's admission Record indicated the facility admitted Resident 6 on 6/16/2020 and readmitted Resident 6 on 5/6/2025 with diagnoses including hypertension, chronic kidney disease (when kidneys, that filter waste from the blood become damaged and don't work as well as they should), and diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing. During a record review, Resident 6's Minimum Data Set (MDS - a resident assessment tool) dated 5/13/2025, indicated Resident 6 was cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 6 required substantial/maximal staff assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a record review, Resident 6's laboratory results collected on 6/6/2025 at, 4:32 A.M., and resulted on 6/6/2025, at 11:26 PM., indicated Resident 6's blood Potassium was 5.6 mEq/L and flagged as high. During a record review, Resident 6's change of condition (COC -a noticeable and significant shift in someone's health or circumstance), dated 6/7/2025, at 5:50 P.M., indicated hyperkalemia (abnormally high level of potassium in the blood). During a concurrent interview and record review, on 6/13/2025, at 11:28 AM, with the Registered Nurse Supervisor (RNS) 2, Resident 6's laboratory (lab) results collected on 6/6/2025 at, 4:32 A.M., and resulted on 6/6/2025, at 11:26 P.M., were reviewed. RNS 2 stated Resident 6's laboratory results were abnormal, including a potassium level of 5.6 mEq/L). RNS 2 stated laboratory results needed to be reported to the physician or nurse practitioner (NP - a licensed, advanced practice registered nurse [APRN] who has completed graduate-level education and advanced clinical training) as soon as the facility receives the laboratory results. RNS 2 stated that Resident 6's physician was not notified of Resident 6's abnormal potassium level of 5.6 mEq/L until 6/7/2025, at 5:50 P.M. RNS 2 stated, Resident 6's lab results of potassium level of 5.6 mEq/L could have affected the resident's heart and that Resident 6 needed to receive medication promptly to lower the potassium level as a level that high could lead to a heart attack. During an interview, on 6/13/2025, at 12:55 PM, with the Director of Nursing (DON), the DON stated, abnormal lab results must be reported to the physician or NP as soon as the facility recieves the abnormal results. The DON stated hyperkalemia could lead to Resident 6 having palpitations, chest pain, hypertension and a heart attack. During a record review, the facility Policy and Procedures (P&P), titled, Laboratory Services revised 1/27/2025, indicated, The licensed nurse promptly notifies the attending physician of the laboratory test findings and reports the results according to the following guidelines: II. Results abnormal -Telephone/page attending physician and fax to attending physician with date and time noted on the results.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Follow the doctors orders by covering sacral wound for Resident 32. 2. Ensure facilities identify and provide needed care and services that are resident centered, in accordance with the resident's goals for care and professional standards of practice that will meet each resident's need by puttying a dressing on the resident's sacral pressure (refers to the pressure exerted on the sacrum [the bony area at the base of the spine) due to prolonged sitting or lying down]) injury. These failures had the potential to cause further injury and infection to the Resident 32's sacral pressure injury. Findings: During a record review, Resident 32's admission Record indicated Resident 32 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with a diagnoses including sepsis (a dangerous and potentially life-threatening condition where the body's response to an infection goes into overdrive), pressure ulcer of the sacral region, stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle. It is the most severe type of pressure ulcer also known as a bedsore). During a record review, the Minimum Data Set (MDS-resident assessment tool) dated 5/22/2025, indicated Resident 32's cognitive (mental process of acquiring knowledge and understanding through thought, and understanding) skills for daily decision making were intact. It further indicated Resident 32 needed substantial/maximal assistance with putting on her shoes, upper and lower body dressing, showering, toileting, and personal hygiene. During a record review, a document titled Skilled Nursing Facility Follow-up Visit for Resident 32 dated 6/2/2025, indicated, Assessment/plan indicated Resident 32 has osteomyelitis of the sacrum and coccyx, stage 4 sacrococcyx pressure ulcer, status post (s/p-after) skin graft to sacrococcyx pressure ulcer on 4/13/2025. During a record review, a document titled Order Summary Report for Resident 32 dated 6/11/2025, indicated Resident 32 had an order for Silvadene External Cream 1% (is a prescription-only topical medication for treating and preventing severe burn wounds). Apply to sacralcoccyx topically everyday shift every 3 days for pressure injury, cleanse with NS (normal saline), pat dry, apply Silvadene and Santyl ointment (a medication used to remove damaged or burned skin, aiding in wound care and the growth of healthy skin), apply foam dressing (wound care material used to create and maintain a moist wound environment, particularly in wounds with moderate to heavy drainage). During a record review, care plan for Resident 32 initiated on 8/16/2024 and revised on11/16/2024 indicated Resident 32 has a coccyx (is the small bone located at the very bottom of the spine) pressure injury. Update: Site reclassified as sacrum. The care plan goal included, Will have no s/s (signs and symptoms) of infection. The care plan target date is 8/15/2025 During a record review, the Treatment Administration Record for Ressdent 32 dated from 6/1/2025 to 6/30/2025, indicated cleanse with NS (normal saline), pat dry, apply Santyl ointment, apply foam dressing every day shift. During a wound care observation of Resident 32's sacralcoccyx and right foot wound care with Treatment Nurse (TN) 1 and TN 2 on 6/12/2025 at 9:19 AM, Resident 32's sacral pressure injury did not have a dressing in place. Resident 32 tolerated wound care well. Resident 32 did not complain of pain during wound care. During a concurrent interview with TN 1, TN 1 stated there should always a dressing on the sacral wound to prevent infection and interference of wound healing. TN 1 stated if the sacral wound dressing comes off or get soiled, the charge Nurse or the Registered Nurse (RN) Supervisor is supposed to replace the dressing. During an interview on 6/12/2025 at 10:26 AM, Certified Nursing Assistant (CNA) 2 stated Resident 32 did not have a dressing to the sacral wound during Activities of Daily Living (ADL) care in the morning and reported to TN 2 that Resident 32 did not a dressing to the sacral wound. CNA 2 stated she do not remove the resident's dressings from pressure injury sites because it is not in her job description. During an interview on 6/12/2025 at 2:16 PM, the Director of Nursing (DON) stated Resident 32 should always have a dressing to his sacral pressure injury. DON stated she has instructed all the CNA's to never remove a dressing from any of the resident's pressure injuries. DON stated if a resident's pressure injury is not covered with a dressing the resident could get an infection, and the pressure injury could get worse. During a record review, the facility policy and procedures (P&P) titled Skin and Wound Management, with a reviewed date of 1/27/2025, indicated: Purpose: To maintain and /or improve resident's tissue tolerance in order to prevent injury and/or infection, skin breakdown, the potential for skin breakdown, and the risk for the development of pressure ulcers and/or other skin conditions. During a record review, the facility document titled Treatment Nurse Job Description, indicated: Position Description: Under the direction and supervision of the Director of Nursing Services, the Treatment Nurse is responsible for all the treatments that are prescribed by the attending physician for all residents in the facility.

Based on interview and record review, the facility failed to provide intravenous catheter (IV -a thin, flexible tube inserted into the vein to deliver fluids, medications, or other treatments directly into the blood stream) treatment in accordance with professional standards for one of one sampled resident (Resident 6) by failing to remove Resident 6's IV catheter on 6/8/2025 when ordered IV hydration was completed. This deficient practice had the potential to result in infection and possible hospitalization for Resident 6. Findings: During a record review, Resident 6's admission Record indicated the facility admitted Resident 6 on 6/16/2020 and readmitted Resident 6 on 5/6/2025 with diagnoses including hypertension (elevated blood pressure), chronic kidney disease (when kidneys, that filter waste from the blood become damaged and don't work as well as they should), and diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing. During a record review, Resident 6's Minimum Data Set (MDS - a resident assessment tool) dated 5/13/2025, indicated Resident 6 was cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 6 required substantial/maximal staff assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a record review, Resident 6's physician orders dated 6/7/2025 with an end date of 6/8/2025, indicated sodium chloride solution (Salt water) 0.9 percent (% -unit of measure as a part of one hundred), use 1 liter (unit of measure for fluids) intravenously one time a day for hydration until 6/8/2025 0:00 A.M.(midnight), at 75 cubic centimeters per hour (cc/h -unit of volume in liquid). During an observation on 6/10/2025, at 9:12 A.M., in Resident 6's room, a peripheral IV line was observed on Resident 6's left forearm dated 6/8/2025. During an interview on 6/11/2025, at 9:04 A.M., with Licensed vocational Nurse (LVN) 1), LVN 1 stated, Resident 6 had an IV access for hydration that was discontinued the day prior (6/10/2025). During an interview, on 6/13/2025, at 12:55 P.M., with the Registered Nurse Supervisor (RNS) 1, RNS 1 stated resident IV access are discontinued as soon as the hydration is done to prevent infection. During an interview, on 6/13/2025, at 12:55 P.M., with the Director of Nursing (DON), the DON stated, IV access was only kept in place if there was an order from the physician to maintain the IV access in place, other wise the IV access was to be discontinued to prevent infection and possible skin breakdown. The DON stated there was no documented evidence that the physician ordered Resident 6's IV remain in place. The DON stated the IV should have been discontinued after the hydration was complete. During a record review, the facility Policy and Procedures (P&P), titled, Removal of a Peripheral (Over the needle, peripheral short) Catheter revised 1/27/2025, indicated, Peripheral IV catheters will be removed safely and aseptically by a nurse with demonstrated competency in this procedure . when therapy is completed .

Based on observations, interviews, and record reviews, the facility failed to provide necessary respiratory care services for one of one sampled resident (Resident 19), by failing to: 1. Ensure Resident 19's oxygen tubing was changed weekly in accordance with the facility's policy and procedures (P&P) titled Oxygen Therapy revised 1/27/2025. 2. Ensure a physician's order for oxygen was complete and accurate in accordance with the facility's P&P titled Physician Orders revised 1/27/2025. This deficient practice had the potential to result in infection, medication error and possibly hospitalization for Resident 19. Findings: During a record review, Resident 19's admission Record indicated the facility admitted Resident 19 on 11/27/2018 and readmitted Resident 19 on 12/2/2024 with diagnoses including congestive heart failure (CHF - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), Acute respiratory failure with hypoxia (when the lungs are having a hard time getting enough oxygen into the blood and body), and diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a record review, Resident 19's Minimum Data Set (MDS - a resident assessment tool) dated 3/26/2025, indicated Resident 19 was cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 19 required partial/moderate staff assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a record review of the physician's order dated 4/14/2025, the physician's orders indicated Oxygen at 2 liter per minute (l/min) (Liters-unit of measure for liquids) via nasal cannula (a thin, flexible tube that has two prongs that fit into the nostril used to give extra oxygen for people who need it) to keep saturation acute respiratory failure. During a concurrent observation in Resident 19's room and interview on 6/10/2025, at 11:58 AM, with the Licensed Vocational Nurse (LVN 1), Resident 19 was observed with oxygen nasal cannula on, the cannula had a label on it dated 6/2/2025. LVN 1 stated nasal cannula tubing was required to be changed weekly, and that the date on Resident 19's nasal cannula tubing was 6/2/2025. LVN 1 stated the nasal cannula tubing should have been changed for infection control and to make sure that the tubing was nice and clean. LVN 1 stated not changing the nasal cannula tubing could lead to infection. During a concurrent interview and record review on 6/13/2025 at 12:39 PM, with the Registered Nurse Supervisor (RNS 1), Resident 19's oxygen physician order was reviewed. RNS 1 stated that the oxygen order did not specify if the order was as needed or routine. RNS 1 stated Resident 19's oxygen order did not have parameters (specific, measurable instructions or guidelines that ensure medications are given safely and effectively.) and the order was incomplete. RNS 1 stated the incomplete order could compromise the resident's respiratory condition and if too much oxygen was given it could be a potential medication error. During a concurrent interview and record review on 6/13/2025, at 1:14 PM, with the Director of Nursing (DON), Resident 19's oxygen physician order was reviewed. The DON stated that physicians order was incomplete. The DON stated Resident 19 had an order for oxygen, however, the oxygen order had no parameters so that the facility staff could know when the oxygen could be stopped or when Resident 19 required supplemental oxygen. The DON stated oxygen was considered a medication and an incomplete order of the oxygen could lead to a possible medication error. The DON stated that oxygen tubing needed to be changed every seven days to prevent infection. During a record review, the facility P&P, titled, Oxygen Therapy revised 1/27/2025, indicated, Purpose: To ensure the safe storage and administration of oxygen in the facility . Oxygen is administered under safe and sanitary conditions to meet resident needs. Licensed Nursing staff will administer oxygen as prescribed . II. Oxygen -storage, maintenance, and handling C. Oxygen tubing, mask, and cannula will be changed no more than every seven (7) days and as needed. The supplies will be dated each time they are changed. During a record review, the facility P&P, titled, Oxygen Therapy revised 1/27/2025, indicated, Physician Orders revised 1/27/2025, indicated, .Orders will include a clear and complete description to provide clarity on the physician's plan of care.

Based on record review and interview the facility failed to ensure one of three sampled residents (Resident 59) who required dialysis (a medical treatment that cleans the blood when the kidneys are unable to do so) received services consistent with professional standards. By failing to assess the resident's current vital signs (body temperature, blood pressure, pulse [heart rate], and breathing rate to help assess the general physical health of a person) prior to transporting the resident to the dialysis center. This deficient practice had the potential for Resident 59 to experience adverse complications that would not be identified by facility staff in a timely manner. Findings: During a record review, Resident 59's admission record indicated the facility admitted the resident on 2/3/2025 and readmitted the resident on 5//52025 with diagnoses including but not limited to ESRD (End Stage Renal Disease-irreversible kidney failure), dependence on renal dialysis and kidney transplant failure. During a record review, Resident 59's Minimum Data Stet (MDS - a resident assessment tool) dated 5/12/2025, indicated the resident's cognition (ability to think, read, learn, remember, reason, express thoughts, and make decisions) moderately impaired. The MDS indicated Resident 59 required substantial assistance from facility staff to set up assistance with all activities of daily living. The MDs indicated Resident 59 was receiving dialysis treatment. During a record review, Resident 59's dialysis care plan, initiated 2/4/2025, indicated the resident required hemodialysis (HD) due to ESRD and a history of kidney transplant rejection. A review of the care plan indicated the goal was for the resident to have immediate intervention should any sign or symptom of complications from dialysis occurred. The interventions included to monitor vital signs as ordered and to notify the physician of significant abnormalities, monitor/document/report signs of bleeding, hemorrhage, bacteremia and septic shock and to monitor/document/report as needed new/worsening peripheral edema. During a record review, Resident 59's physician orders, dated 5/5/2025 indicated the resident was to receive dialysis treatment at an outside dialysis clinic on Tuesdays, Thursday and Saturday at 3:45 PM. The physician order indicated Resident 59's pick up time was 3:20 PM. During a record review, Resident 59's Pre-Dialysis Evaluation forms indicated that: - On 5/27/2025, the resident's pre- dialysis vital signs were blood pressure 130/72, respirations 18, pulse 79 and temperature 97.8. The Pre-Dialysis Evaluation form also indicated these vital signs were taken at 7:12 AM on 5/27/2025. The Pre-Dialysis Evaluation Form indicated Resident 59 left the facility and was transported to the dialysis center at 3:30 PM. - On 6/5/2025 -the resident's pre- dialysis vital signs were blood pressure 134/72, pulse 76, resp 18 and temp 97.2 at 9:42 am. The form further indicated Resident 59 left the facility at 3:30 PM. During an interview on 6/10/2025 at 8:30 AM, Resident 59 confirmed having been receiving dialysis treatments for the past 25 years. During an interview on 6/12/2025 at 11:14 AM, Licensed Vocational Nurse (LVN) 2 stated Resident 59's dialysis schedule was Tuesday, Thursday, Saturday and the resident usually leaves for dialysis at around 3:30 or 4 PM. During a concurrent interview and record review on 6/13/2025 at 8:36 AM, Resident 59's dialysis communication forms were reviewed with Registered Nurse Supervisor 1 (RNS 1). RNS 1 stated on 6/5/2025 and 5/27/2025, the charge nurse took Resident 59's vitals more than 4 hours prior to the resident leaving for dialysis. RNS 1 stated nursing staff were to take the resident's vital signs within 2 hours of leaving for the dialysis center. RNS 1 stated vitals were taken prior to leaving for dialysis in order to know the resident's status and prevent an adverse outcome. During an interview on 6/13/2025 at 10:34 AM, the Director of Nursing (DON) stated staff were to assess the resident's appropriateness to leave for dialysis. The DON stated part of assessing the resident prior to leaving the facility was taking the resident's vital signs. The DON stated based on the resident vital signs, the resident might not be appropriate to go for dialysis and the resident's physician would have to be contacted and/or the resident might need to go to a general acute care hospital (GACH). During a record review, the facility's Long Term Care Facility Outpatient Dialsys Services Care Coordination Agreement, dated 10/13/2023, under the section Transportation indicated, the Long Term Care Facility shall be responsible for ensuring that residents are (I ) medically stable to undergo such transportation, to medically suitable to receive treatment at the hospital facility and three timely transport to and from dialysis facility. During a record review, the facility policy and procedures titled, Dialysis Care, dated 1/29/2024, indicated under the section Communication and Collaboration, nursing staff will communicate the following information in writing to the dialysis staff: a. The resident's current vital signs b. Weight; and c. Any changes of conditions specific to the resident with each treatment.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen by failing to ensure: 1. Food is labelled with expiration date 2. Discard expired foods 3. Food refrigerator(s) and freezers were clean. 4. Implement food cooling down method according to the facility policy and procedures titled Hazardous Foods Cooling Monitor dated 1/27/2025. 5. The Ice machine and the water fountain are not dirty These failures had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses and other toxins) medically compromised residents who received food from the kitchen. Findings: During the initial tour of the kitchen on 6/10/2025 at 8 AM, with the Dietary Supervisor (DS), the kitchen refrigerator the following were noted. -Expired pudding dated 6/10/2025 -A container of strawberries with used by date of 6/9/2025. -A container of cooked fish sticks -3 containers of cream soup, cooked meatloaf. -The ice machine tray noted to be dirty, water machine tray noted to be dusty and dirty. -The residents outside food storage refrigerator freezer temperature was less than (<) 4 degrees, the freezer and refrigerator were dirty with old and dried food, The refrigerator temperature was greater than (>) 40 degrees. Two open bottles of yogurt were not labelled with expiration date. A clear container without no name, room number, of expiration date on the container. 3 boxes of sausages in the refrigerator with a use within 2 days or use by date of 7/2/2025 and must be frozen. During an interview on 6/10/2025 at 8:36 AM, DS stated the residents can get sick if they consume foods that have expired. DS stated the dietary cooks are supposed to follow the cooling down method of any cooked foods stored in the refrigerator. DS stated the license nurses are responsible to receive residents' food from the outside and are also responsible to label and date the residents' food. DS stated it is the responsibility of the Maintenance Supervisor (MS) to discard expired foods from the resident's refrigerator and to clean the outside food storage refrigerator. DS stated the MS is responsible to clean the resident's refrigerator. ice machine, and water machine. During an interview on 6/10/2025 at 8:56 AM, with Dietary [NAME] (DC) stated she cooked the meatloaf two days ago and did not follow the cool down method prior to storing the leftovers in the refrigerator. DC stated she prepared the tuna 3 days ago and did not follow the cool down method. DC stated she has attended in-services and is aware on how to properly follow the cool down method. DC stated she do not know why she did not follow the cool down method prior to storing the meatloaf, soup and the tuna. DC stated if she does not follow the cool down method prior to storing left over foods in the refrigerator the residents can get very sick. During a concurrent record review on 6/10/2025 at 9:22 AM, of the cool down method record with the DS, there was no record of the cooked leftover meat load, 3 containers of soups, or the 17 cooked fish sticks. During an observation and interview on 6/10/2025 at 10:03 AM, with the Maitenance Supervisor (MS) of the ice machine, water dispenser, and residents outside food storage refrigerator was dirty. During an interview MS stated he clean the ice machine, water dispenser daily, and he clean the residents outside food storage refrigerator every three days so that he can remove all the old foods. MS stated it is the nurse's responsibility to make sure the residents food brought in from the outside is labeled and stored properly. MS stated if the ice machine, water dispenser, or the resident's refrigerator is not cleaned, and the residents consume expired foods that are bought in from the outside, the residents can get very sick. MS stated he do not have a monthly log for cleaning the ice machine and there was no log for cleaning the water dispenser. MS stated there is no manual for cleaning the water dispenser, and that the facility does not have a policy for cleaning the water dispenser. During an interview on 6/13/2025 at 9:17 AM, with the Registered Dietician (RD), RD stated the dietary cooks are supposed to follow the cooling down method whenever cooking and storing left over foods in the refrigerator. RD stated the dietary cooks are supposed to follow the cool down method when preparing tuna because they are supposed to check the temperature prior to storing the tuna in the refrigerator. RD stated if the dietary cooks are not following the cool down method the residents can get sick. RD stated if the residents consume expired foods, they can get really sick. RD stated she completes in-service for the cool down method quarterly and as needed for the dietary staff. RD stated that the MS is responsible for discarding expired foods in the residents refrigerator. During a record review, the facility policy and procedures (P&P) titled Policy and Procedure Implementation Form dated 5/22/2025, indicated: Policy and procedure Revision: 4. When refrigerated, it will be labeled, dated, and discarded after 48 hours if not consumed 5. Unopened/sealed foods must be discarded by the manufacture's printed best buy or used by date. During a record review, the facility P&P titled Hazardous Foods Cooling Monitor with a reviewed date of 1/27/2025, indicated: Purpose: To provide the dietary department with guidelines for service, storage and reheating of hazardous foods. Procedure: ll. Label and date the containers. lll. Place the container in the refrigerator or freezer for cooling. A. Leave the container uncovered of loosely covered during the cooling process. lV. Hot food should be cooled from 140 degrees to 70 degrees within two hours and cooled from 70 degrees to 41 degrees or lower in an additional four hours. V. Cool food prepared from ambient temperature (such as tuna salad) must be cooled to 41 degrees or lower within fours. Vl. Record food every hour. During a record review, the facility P&P titled Ice Machine-Operation and Cleaning with a reviewed date of 1/27/2025, indicated Policy: The dietary staff will operate the ice machine according to the manufactures guidelines. The ice machine will be cleaned routinely. Procedure: 11. F. On no less than monthly basis, remove the ice to wash the inside of the machine. During a record review, the facility Instruction Manual for Ice Dispenser Models DB-130H and DB-200H indicated: B. Cleaning and Sanitizing Instructions: The ice dispenser must be cleaned and sanitized at least once a year. More frequent cleaning and sanitizing may be required in some water conditions. For icemaker cleaning and sanitizing instructions, see the icemaker instruction manual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement and maintain infection control measures by failing to ensure the end of a gastric tube (GT- is a tube inserted through the abdomen into the stomach for nutrition, hydration, and medication) that is connected to a resident was secured, capped, and was not on the floor for one of two sampled residents (Resident 4). This deficient practices had the potential to result in infection and hospitalization for Resident 4. Findings: During a record review, the admission Record indicated Resident 4 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with a diagnoses including urinary tract infection (an infection in your urinary system, which includes your bladder, urethra, and kidneys, gastrostomy (a surgical procedure where a doctor makes an opening in the stomach, usually to access its interior). During a record review, the Skilled Nursing Facility Follow-up Visit dated 6/3/2025, indicated, Resident 4 has GT. During a record review, the Order Summary Report for Resident 4 dated 6/12/2025, indicated Enteral Feed (a method of providing nutrition directly into the gastrointestinal (GI) tract through a tube) every evening and night shift Jevity (a brand name for a medical product that provides nutritional support for people who are unable to eat or have difficulty eating) 1.5 at 40 milliliters (ml-unit of measurement) per (/hr) via pump x 10 hour=400 ml/24 hour 600 calories/24 hours via G-tube for dysphagia. The Order summary Report indicated Jevity to be turned on 8 pm, off at 6 am, or until dose is reached. During a record review, the Minimum Data Set (MDS - resident assessment tool) dated 5/15/2025, indicated Resident 4's cognitive (mental process of acquiring knowledge and understanding through thought, and understanding) skills for daily decision making were intact. It further indicated Resident 4 needed substantial/maximal assistance with putting on her shoes, upper and lower body dressing, and toileting hygiene. During a record review of Resident 4's care plan titled Enteral Feeding initiated on 8/9/2024 and revised on 4/15/2025, indicated Resident 4 is on feeding tube. During an observation on 6/11/2025 at 11:28 AM, Resident 4 noted to be clean, well groomed, and dressed appropriately for the weather, hair noted to be well groomed. The GT feeding machine was turned off and disconnected from Resident 4. The GT bottle (Jevity) was connected to the feeding tube pump and was lying on floor uncapped (not covered) and a moderate amount of the Jevity was leaking on the floor. During an Interview with Licensed Vocational Nurse (LVN) 1 stated when disconnecting the GT from the resident, the tip of the was supposed to place a cap to cover the gastric tubbing to prevent it from getting contaminated and it is a infection control issue. LVN 1 stated if a nurse uses a contaminated feeding tubing that was on the floor uncovered and reconnect the tubing back to the resident, the resident can get very sick and inquire an infection. During an interview on 6/13/2025 at 9:55 AM, with LVN 2 stated if a cap is not placed on the GT once disconnected from the residents the resident can get an infection and become septic (a serious condition in which the body responds improperly to an infection). During an interview on 6/13/2025 at 1:16 PM, with the Director of Nursing (DON), stated the licenses nurses are always supposed to cap the G-tube tubbing whenever they disconnect it from the resident to prevent infection control. The DON stated if the GT falls on the floor and the nurse reconnects it back to the resident the resident, the resident could inquire a bad infection and get very sick. During a record review, the facility policy and procedures titled Infection Control-Policy and Procedure with a reviewed date of 1/27/25, indicated, Purpose: To provide infection control policies and procedures required for a safe and sanitary environment. Policy: The facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment. Procedure: ll. Objectives: A. Prevent, detect, investigate, and control infections in the facility. B. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public. lV. Staff are trained on the infection control policies and procedures upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. Based on interview and record review, the facility failed to implement and/or maintain infection control measures for when: 1. the facility failed remove intravenous catheter (IV -a thin, flexible tube inserted into the vein to deliver fluids, medications, or other treatments directly into the blood stream) when IV therapy was completed for one of one sampled resident (Resident 6). 2. Prevent g-tube feeding tube from falling on the floor. 3. Place a cap on g-tube feeding tube when not in use. These deficient practices had the potential to result in infection and possible hospitalization for Resident 4 and Resident 6. Findings: A review of Resident 6's admission Record indicated the facility admitted Resident 6 on 6/16/2020 and readmitted Resident 6 on 5/6/2025 with diagnoses including hypertension (elevated blood pressure), chronic kidney disease (when kidneys, that filter waste from the blood become damaged and don't work as well as they should), and diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing. A review of Resident 6's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 5/13/2025, indicated Resident 6 was cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 6 required substantial/maximal staff assistance with 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 6's physician orders dated 6/7/2025 with an end date of 6/8/2025, indicated sodium chloride solution (Salt water) 0.9 percent (% -unit of measure as a part of one hundred), use 1 liter (unit of measure for fluids) intravenously one time a day for hydration until 6/8/2025 0:00 A.M., at 75 cubic centimeters per hour (cc/h -unit of volume in liquid). During an observation on 6/10/2025, at 9:12 A.M., in Resident 6's room, a peripheral iv line gauge 24 was observed on Resident 6's left forearm dated 6/8/2025. During an interview on 6/11/2025, at 9:04 A.M., with Licensed vocational Nurse (LVN 1), LNV 1 stated, Resident 6 had an IV access for hydration that was discontinued yesterday (6/10/2025). During an interview, on 6/13/2025, at 12:55 P.M., with the Registered Nurse Supervisor (RNS 1), RNS 1 stated, Resident IV access are discontinued as soon as the hydration is done to prevent infection. During an interview, on 6/13/2025, at 12:55 P.M., with the Director of Nursing (DON), the DON stated, IV access are kept in place only if there is an order from the physician to maintain it in place, other wise the IV access is discontinued to prevent infection and possible skin breakdown. DON stated there was no documented evidence that the physician ordered for then IV access to remain in place otherwise, the IV needs to be discontinued after the hydration is complete. A review of the facility's Policy and Procedure (P&P), titled, Removal of a Peripheral (Over the needle, peripheral short) Catheter revised 1/27/2025, indicated, Peripheral IV catheters will be removed safely and aseptically by a nurse with demonstrated competency in this procedure . when therapy is completed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain one of two laundry service rooms (laundry room [ROOM NUMBER]) in good repair. By failing to ensure the floors were free of cracks, buckets holding chemicals were free of cracks and holes, the ceiling was clean, and the door leading to the trash area was intact. These deficient practices had the potential to result in an infestation of rodents, and or pests such as ants and roaches due to holes and substantial cracks found in the floor, and open pipes, including a broken door leading to the trash area of the laundry room. Findings: During observation of the laundry service area on 6/10/2025 at 11:03 AM the second room used for laundry services; had multiple areas in disrepair. In the second laundry services room that housed the washers, behind the washers the floor and wall were extremely dirty with cracks and one open pipe, under laundry chemical buckets the wooden platform that held the buckets of chemicals had holes and cracks in the base of the platform that stood about three inches off the floor. The floor area under the platform that supported the laundry chemicals was cracked and had a hole in the floor about 10 to 12 inches long. The ceiling had dark spots that looked to be a substance of unknown origin other than dirt, the ceiling in various places had peeling paint coming of in flakes. The door that led to the trash area was broken at the bottom area and the floor was several different colors. During concurrent observation of laundry room [ROOM NUMBER] and interview on 6/10/2025 at 11:12 AM Maintenance Supervisor (MS) stated that he was the acting supervisor for laundry services as well as the supervisor for maintenance of the building. During observation of the laundry room [ROOM NUMBER], it was noted that the wooden platform that supported the chemicals used to wash the linen and resident clothes was rotted or has suffered water damage. The floors behind the washing machine were cracked, with small holes, including one large hole about 10 to 12 inches in length. The wall just behind the washing machine had an open pipe. The door inside the laundry room leading to the trash area was broken at the bottom. In addition, the ceiling had a black discoloration in the corner and the ceiling paint was peeling and cracked. MS stated that he would have to perform some repairs and get estimates for other repairs and stated the repairs needed to be completed immediately. During concurrent observation and interview on 6/10/2025 at 11:25 AM the Administrator (ADM) stated the floor in laundry room [ROOM NUMBER] had to be repaired and it would be done as soon as an estimate was presented by the maintenance supervisor. The ADM stated the door in laundry room [ROOM NUMBER] would be repaired or replaced, and the ceiling appeared to have dirt, and it would be cleaned. The ADM stated all the other repairs such as paint removal and cleaning the ceiling could be done by the maintenance supervisor immediately. During a record review, the facility's Policy and Procedures (P&P) titled Maintenance Service dated revised 1/27/2025, indicated Policy: The Maintenance Department maintains all areas of the building, grounds, and equipment Procedure 1. The Maintenance Department is responsible for maintain the building, grounds, and equipment in a safe and operable manner at all times. 2. Functions of the Maintenance Department may include, but are not limited to: A. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines; B. Maintaining the building in good repair and free from hazards;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that 13 out of 34 rooms (room [ROOM NUMBER], 4, 8, 9, 11, 14, 15, 16, 17, 18, 20, 22, and 33) met the 80 square feet (sq. ft.) per resident This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for 39 Residents. Findings: The room waiver request and Client Accommodation analysis indicated the following rooms contained three residents and: RM# RM. Size (sq.ft) SQ.FT/Resident 3 209 69.7 4 209 69.7 8 220 73.3 9 220 73.3 11 220 73.3 14 220 73.3 15 220 73.3 16 216.66 72.2 17 209 69.7 18 209 69.7 20 209 69.7 22 209 69.7 33 220 73.3 The minimum requirement for a three bedroom should be at least 240 sq. ft. During general observations from 6/10/2025 to 6/13/2025, both residents and staff had enough space to move about freely inside the rooms. The nursing staff had adequate space to safely provide care to the residents with the side tables, dressers, and resident care equipment in rooms. During an interview on 6/13/2025 at 8:34 AM, Restorative Nurse Aide 1 (RNA 1) stated rooms 17, 18, 20 and 22 provided adequate space to provide care for the residents. During a record review, the facility policy and procedures, Resident Rooms and Environment, dated 1/27/2025, indicated, It was the facility policy to provide residents with a safe, clean, comfortable and home like environment. The staff facility staff will provide residents with their pleasant environment and person-centered care that emphasizes the residents comfort, independence, and personal needs and preferences.

Based on observation, interview, and record review the facility failed to ensure closet doors were functional in nine of nine resident rooms (Rooms 17, 18, 20, 21, 22, 23, 24, 25, and 26). This failures had the potential to cause harm to the residents. Findings: During an interview on 6/12/2025 at 11:30 AM, Family Member (FM) 1 stated Resident 32's space in his room is too small. Stated the closet door is broken. Stated she reported to one of the head nurses, but she cannot remember her name. FM 1 stated she followed up with the head nurse and she stated that she reported the broken closet door to the MS and as of today the closet door remains broken. During an observation and concurrent interview on 6/13/2025 at 11:54 AM, with the Maintenance Supervisor (MS), the closet doors were not attached at the bottom in resident rooms 17, 18, 20, 21, 22, 23, 24, 25, and 26. The closet doors were noted to swing open from the bottom. The MS stated the nurses unhook the closet sliding doors at the bottom so that they can store the resident's wheelchairs in the closet because there is not enough space in the resident's rooms to store the wheelchairs. During a concurrent record review on 6/13/2025 at 12:16 PM, with the MS, the facility request for repair log wa reviewed. The repair request log indicated that there was no logged in request for the repair of the closet doors for rooms 17, 18, 20, 21, 22, 23, 24, 25, and 26. During an interview on 6/13/2025 at 2:06 PM, Director of Nursing (DON) stated that the nurses are not supposed to be unhooking the resident's closet doors at the bottom to store the resident's wheelchairs. DON stated residents can get injured if the resident closets are being unhooked at the bottom and is swinging open at the bottom. During an interview and concurrent record review on 6/13//2025 at 3:16 PM, Medical Records Designee stated the document titled Director of Environment Services is the job description for the Maintenance Supervisor. During a record review, the facility policy and procedures titled Director of Environmental Services indicated, Principle Responsibilities: Technical: Ensure a safe, comfortable, sanitary environment for residents, staff and visitors in accordance with Federal, State, and Corporate requirements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident's right to be informed were honored and implemented accordingly to her decision on health care treatment for one of five sampled residents (Resident 43). This deficient practice violated resident's right to make an informed decision and resulted to failure in the delivery of necessary care and services. Findings: A review of Resident 43's admission Record indicated Resident 43 was admitted to the facility on [DATE] with diagnosis including urinary tract infection (UTI- an infection in any part of the urinary system, including the kidney, bladder or urethra), sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), and paroxysmal atrial fibrillation (afib- a sudden irregular and very rapid heart rhythm that and can lead to blood clots in the heart). A review of Resident 43's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 5/6/2024, indicated Resident 43's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were mildly impaired and required moderate to maximal assistance from staff for activities of daily livings (ADLs- toileting hygiene, shower/bathing self, upper and lower body dressing, repositioning from sit to lying and sit to stand). A review of Resident 43's Care Plan (CP) for at risk for Multidrug-resistant organisms (MDROs - are microorganisms, mainly bacteria, that are resistant to one or more classes of antimicrobial agents), and other transmissible infectious pathogens due to presence of indwelling foley catheter (a device that drains urine [pee] from urinary bladder into a collection bag outside of the body when a person can't pee on their own or for various medical reasons), initiated on 5/25/2024, the CP indicated an intervention to educate resident (Resident 43), and resident family/representatives regarding the use and purpose of enhanced standard precaution (ESP - involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices), , educate staff regarding the use and purpose of ESP and initiate ESP. During a concurrent observation and interview with Resident 43 on 5/25/2024 at 6:47 p.m., Resident 43 was observed with an ESP signage posted outside the door. Resident 43 asked the surveyor why staff wear gowns while changing diapers and doing care for her. Resident 43 stated, what is going on? Am I sick? I know nurses wear gowns when a patient is sick. Resident 43 further stated, no one explained it to her, they just come in her room with gowns and did not explain when she asked the nurses. During a concurrent observation with Licensed Vocational Nurse 2 (LVN2), on 5/25/2024 at 6:50 p.m., LVN 2 went inside Resident 43's room and Resident 43 asked LVN2 why staff wears gown and gloves when they come in her room, with Resident 43 stating, am I sick?. LVN2 answered Resident 43 and stated, we do not need to wear gowns, don't worry. During an interview with LVN 2 on 5/25/2024 at 6:52 p.m., LVN 2 stated, Resident 43 is not on any ESP, LVN 2 further stated, she told Resident 43 that they don't need to wear any gowns and gloves when doing care for her (Resident 43). During an interview with Infection Preventionist Nurse 1 (IPN1), on 5/27/2024 at 5:34 p.m., IPN1 stated, staff should be educating residents regarding any transmission-based precautions. IPN1 stated, they are still learning about ESP and in process of finalizing their protocols on ESP. A review of the facility's policy and procedures (P&P) titled, Resident Rights, reviewed on 1/29/2024, the P&P indicated that State and Federal laws guarantee certain basic rights to all residents of the facility. These rights include, but not limited to, a resident's right to: be informed about what rights and responsibilities he or she has. In order to facilitate resident choices, facility staff will inform (and regularly remind) the resident and family members of the resident's right to self-determination and participation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to enhance a resident's dignity and respect by failing to provide personal hygiene and assistance to one of five sampled residents (Resident 1). This deficient practice had the potential to negatively affect the residents' psychosocial well-being. Findings: A review of Resident 1's admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including unspecified dementia (loss of cognitive functioning-thinking, remembering, and reasoning), moderate protein-calorie malnutrition (lack of sufficient nutrients in the body), and heart failure (a condition in which the heart does not pump blood as well as it should). A review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 5/2/2024, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were severely impaired and required moderate assistance to clean-up assistance from staff for activities of daily livings (ADLs- eating, toileting hygiene, repositioning from sit to stand, bed to chair transfer). A review of Resident 1's Care Plan (CP) for ADL self-care performance deficit, initiated on 2/20/2024, the CP indicated an intervention that Resident 1 requires set up assistance by one staff to each and Resident 1 required extensive assistance by staff with personal hygiene and oral care. A review of Resident 1's ADL log, dated 5/25/2024, the ADL log did not indicate any record that ADL care and assistance was provided to Resident 1 during dinner. During an observation of Resident 1 on 5/25/2024 at 6:44 p.m., Resident 1 was observed laying on the bed, eyes closed with pieces of food all over his clothes and all his bed. During an interview and a concurrent observation with Certified Nursing Assistant 8 (CNA 8), on 5/25/2024 at 6:46 p.m., CNA 8 observed Resident 1 was observed with having food all over his clothes and on his bed. CNA 8 stated, Resident 1 eats on his own. When asked if Resident 1 was assisted after eating and when food tray was removed, CNA 8 stated, no. CNA 8 was then observed removing pieces of food from Resident 1's clothes and bed. CNA 8 further stated, she does not think Resident 1 was comfortable sleeping with food all over his clothes and bed. A review of the facility's policy and procedures (P&P) titled, Resident Rights - Quality of Life, reviewed on 1/29/2024, the P&P indicated that each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, individuality and receives services in a person-centered manner, as well as those that support the resident in a attaining or maintaining his/her highest practicable well-being. A review of the facility's P&P titled, Resident Rooms and Environment, reviewed on 1/29/2024, the P&P indicated that facility provides residents with a safe, clean, comfortable, and homelike environment. Facility Staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. Facility staff aim to create a personalized, homelike atmosphere, paying close attention to the following: . cleanliness and order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a safe, comfortable, and homelike environment by failing to ensure residents' rooms were kept with comfortable sound levels maintained for two of five sampled residents (Residents 18 and 53). This deficient practice had the potential to negatively impact the resident's quality of life and placing Residents 18 and 53 an increased level of discomfort and inability to sleep during the night. Findings: 1. A review of Resident 18's admission Record indicated that Resident 18 was admitted to the facility on [DATE] with diagnosis including monoplegia (paralysis limited to a single limb [arm/leg]) of lower leg, spinal stenosis (narrowing of the spaces within the spine, which can put pressure on the nerves that travel through the spine) and generalized muscle weakness. A review of Resident 18's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 3/27/2024, MDS indicated Resident 18 has a moderately intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and requiring moderate assistance from staff for activities of daily living (ADL-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). 2. A review of Resident 53's admission Record indicated Resident 53 was admitted to the facility on [DATE] with diagnosis including diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), acute respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide) and generalized muscle weakness. A review of Resident 53's MDS dated [DATE], indicated Resident 53 had a moderately intact cognition for daily decision-making and requiring minimal assistance from staff for ADLs. During the resident council meeting on 5/26/2024 at 12:14 p.m., both Residents 18 and 53 stated that staff were heard shouting and yelling across the hallway during the night. Both residents stated that they are unable to sleep during the night. A review of resident council minutes dated 4/4/2024, resident council minutes indicated that residents complained of needing to promote quiet time during the night to enhance quality of sleep and facilitate resident's recovery process. A review of resident council department response form dated, 4/9/2024, form indicated that nursing was made aware of the noise issues. Form also indicated no other information that issue was addressed. During an interview with the Activity Director (AD), on 5/27/2024 at 12:02 p.m., AD stated that the noise issue was addressed to the nursing department and in-service was supposed to be completed. During an interview with the Director of Staff and Development (DSD), on 5/27/2024 at 4:35 p.m., DSD stated he (DSD) was made aware about the noise issue and added that he (DSD) has not done any in-services to the staff regarding the issues. DSD also stated that staff should be courteous and tone their voices down. A review of the facility's policy and procedures (P&P), titled, Resident Rooms and Environment, reviewed on 1/29/2024, P&P indicated that facility provides residents with a safe, clean, comfortable and homelike environment and facility staff will provide residents with a pleasant environment and person-centered care plan that emphasizes the resident's comfort, independence and personal needs and preferences; paying close attention to the comfortable noise levels.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review the facility failed to identify and notify the Medical Director (MD) about a change in condition for Resident 62's noncompliance of not using a humidifier (are devices that add moisture to the air to prevent dryness that can cause irritation in many parts of the body) for his oxygen. This deficient practice had the potential to place Resident 62 at a risk of having dry mucus membranes mucus membranes which could lead to break in skin resulting in bacteria entering through the broken skin. Findings: A review of Resident 62 admission record indicated the resident was initially admitted to the facility on [DATE] with diagnoses that included hemiplegia (loss of strength in the arm, leg, and sometimes the face on one side of the body) and hemiparesis (loss of use in the arm, leg, and sometimes the face on one side of the body) following cerebral infarction (stroke), diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), and dependence on renal dialysis (a treatment for people whose kidneys are failing. When you have kidney failure, your kidneys don't filter blood the way they should. As a result, wastes and toxins build up in your bloodstream. Dialysis does the work of your kidneys, removing waste products and excess fluid from the blood). A review of Resident 62's Minimum Data Set (MDS- standardized data collection tool used to assess cognitive and functional status, and care needs) dated 4/5/24, indicated the Resident 62 was moderately impaired (a slight decline in cognitive function, such as memory, language, and thinking) and required between supervision or touching assistance to setup or clean-up assistance for Activities of Daily Living (ADL- Eating, oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing). During a concurrent observation and interview with Resident 62 on 5/25/2024 at 11: 30 am., Resident 62 was observed lying down on his bed with the oxygen concentrator (a medical device that separates nitrogen from the air around you so you can breathe up to 95% pure oxygen) completely turned off and the humidifier. Resident 62 stated that he had turned off the oxygen because it was causing his nose to feel dry and that the nursing staff were all aware. Resident 62 stated that he especially did not like the white container with water. Resident 62 admitted that he did not know much about it because he was not offered any education on the importance of keeping the humidifier on. During an interview with the Infection Preventionist Nurse 2 (IPN 2), on 5/26/24 10 am, IPN 2 stated that she had noted that Resident 62 was not using the humidifier this morning and a Change of Condition (COC) was completed. IPN 2 admitted that the other nursing staff working directly with Resident 62 should have reported the change sooner for timely treatment. IPN 2 stated that the oxygen Resident 62 could be drying to the mucous membranes to his nose which may cause cracking of the skin. The cracked skin may serve as a portal for infection. A review of a Policy and Procedure titled Change of Condition Notification, revised 1/29/2024 indicated, To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner. The same P&P indicated the following: I. The Facility will promptly inform the resident, consult with the resident's Attending Physician, and notify the resident's legal representative or an interested family member, if known, when the resident endures a significant change in their condition caused by, but not limited to: A. An accident; B. A significant change in the resident's physical, mental or psychosocial status; and/or C. A significant change in treatment. II. Change of Condition related to Attending Physician notification is defined as when the Attending Physician must be notified when any sudden and marked adverse change in the resident's condition which is manifested by signs and symptoms different than usual denote a new problem, complication or permanent change in status and require a medical assessment, coordination and consultation with the Attending Physician and a change in the treatment plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an environment free from risks and hazards for one of six sampled residents, (Resident 48) by failing to ensure Resident 48's Desitin cream (used as a moisturizer to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations [such as diaper rash, skin burns from radiation therapy]) inside the resident's bedside drawer and [NAME] tears eyedrops (used to help relieve dryness of the eyes) were not left on top of the resident's bedside table by facility staff without a proper physician's order and per facility's policy and procedures (P&P) titled Self-Administration of Medications with a review date of 1/29/2024. This deficient practice increased the risk for accidents, under or overdosing, medication diversion (medication used for a purpose or on a person not prescribed for), and jeopardized residents' health and safety. Cross Reference F656 Findings: A review of Resident 48's admission Record indicated resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), acute respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood) and pneumonia (lung infection that inflames air sacs with fluid or pus). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 4/10/2024, indicated Resident 48's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were moderately impaired and the resident required maximal to total assistance from staff for eating, toileting hygiene, shower/bathing self, upper and lower body dressing, repositioning from sit to lying and rolling left to right. A review of Resident 48's Self-Administration of Medication form dated 4/14/2024, indicated Resident 48 was not approved for self-administration of medications and the resident was not allowed to keep medications at bedside. During a concurrent observation of Resident 48's room and interview on 5/26/2024 at 11:16 a.m., Resident 48 was observed with an opened Desitin cream inside the resident's bedside drawer and [NAME] tears eyedrops on top of the bedside table. Resident 48 stated the Desitin cream was brought in from the hospital and the eyedrops was from the facility and facility staff left the eyedrops on the bedside. During a concurrent observation of Resident 48's room and interview on 5/26/2024 at 7:45 p.m., the DON observed Resident 48's Desitin cream and [NAME] tears eyedrops at bedside. The DON stated and confirmed that Resident 48 was not allowed to keep medications at bedside. The DON stated she (DON) would have to store the medications in the facility's locked cabinet. The DON stated the medications left at the bedside put Resident 48 at risk of accidents due to not being able to properly administer the medications and put other residents at risk of accidents by allowing other residents to access medications that were not prescribed for them. A review of the facility's P&P titled, Self-Administration of Medications, reviewed on 1/29/2024, indicated bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the rooms of, or room with, residents who self-administer. When the interdisciplinary team determines that bedside or in-room storage of medications would be a safety risk to other residents, the medications of residents permitted to self-administer are stored in the central medication cart or medication room. A review of the facility's P&P titled, Storage of Medications, reviewed on 1/29/2024, the P&P indicated, that medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide intravenous (IV, insertion of a cannula or catheter into a vein to provide access to the bloodstream) access care consistent with professional standards of practice and as per facility policy and procedures (P&P) titled Central Venous Catheter Dressing Changes dated May 2022, for two of two sampled residents (Residents 277 and Resident 278). By failing to ensure: 1. A care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) was developed and implemented for Resident 277's IV therapy. 2. Resident 278's peripherally inserted central catheter (PICC, a thin, soft tube inserted into a vein in the arm, leg, or neck for long-term intravenous antibiotics) was labeled with date and time the dressing was changed and the initials of the staff member changing the dressing. 3. Registered nurse 1 (RN 1) wore the required personal protective equipment (PPE, protective clothing for the eyes, head, ears, hands, respiratory system, body, and feet used to protect employee and resident against infectious materials) when providing the resident PICC line care. These failures had the potential to result improper treatment and care for Resident 277's IV therapy placed the resident at risk for sepsis (a life-threatening medical emergency that occurs when the body's immune system has an extreme response to an infection. Can also be called septicemia, which is the medical term for blood poisoning caused by bacteria, viruses, or fungi) which could result in organ failure and death. Cross reference F656 and F880. Findings: 1. A review of Resident 277's admission Record indicated Resident 277 was originally admitted to the facility on [DATE], with diagnoses including hypertensive (high blood pressure) heart disease with heart failure (disease when heart doesn't pump enough blood for your body's needs), muscle weakness, difficulty walking and anemia (not enough oxygen carrying red blood cells in the blood). A review of Resident 277's Minimum Data Set (MDS- standardized data collection tool used to assess cognitive brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions] and functional status, and care needs), dated 5/9/2024, indicated Resident 277 had mild cognitive (ability to think, read, learn, remember, reason, express thoughts, and make decisions) impairment and required supervision or touching assistance from staff for eating, oral hygiene, and upper body dressing, and moderate and maximum assistance from staff for toileting, bathing, lower body dressing and personal hygiene. A review of Resident 277's prescription order sheet dated 5/21/2024, indicated the resident had an order for Venofer intravenous solution (iron sucrose - an IV iron medication) 100 milligrams (mg) intravenously in the evening for iron deficiency. A record review of Resident 277's care plans, indicated no care plan created for the resident's Venofer IV therapy. During an observation on 5/26/24 at 10:00 a.m., Registered Nurse 1 (RN 1) was observed caring or Resident 277's IV access. During an interview on 5/28/2024 at 2:11 p.m., with the Infection Prevention Nurse 1 (IPN 1), IPN 1 confirmed by stating Resident 277 did not have a care plan for IV therapy and stated there should have been a care plan for a resident on IV therapy. 2. A review of Resident 278's admission Record indicated Resident 278 was originally admitted to the facility on [DATE], with diagnoses including diabetes mellitus (a disease in which your body does not produce enough insulin needed to control sugar levels in the blood), muscle weakness, discitis (inflammation of the intervertebral [area between bones of the spine] disc space) lumbar (lower back) region, and malignant neoplasm (cancerous tumor) of the breast. A review of Resident 278's MDS, dated [DATE], indicated Resident 278 had moderate cognitive impairment and required supervision or touching assistance from staff for toileting, bathing, dressing and personal hygiene. The MDS indicated Resident 278 was on IV antibiotic therapy and had a PICC line. A review of Resident 278's physician order summary report (POSR), dated 5/27/2024, indicated on 5/8/2024 the resident's physician orders the PICC line dressing and cap (disinfecting cap placed on ports of PICC line to help prevent the transmission of infections) be changed every day shift every seven days until 6/20/2024. During a concurrent observation in Resident 277's room and interview on 5/26/2024 at 9:48 a.m., RN 1 observed the resident's PICC line dressing with a date of 5/25/2024 and initials. RN 1 was observed providing PICC line care without donning (putting on) a gown as indicated on the Enhanced Standard Precautions (a resident-centered and activity-based approach of care for preventing multi drug resistant organisms [MDRO, germs that are not ablet be treated with most medications available] transmission in skilled nursing facilities) sign posted outside the resident's room door. RN 1 stated she was supposed to have donned a gown and along with her gloves while providing PICC care and stated the dressing should have been labeled with the time changed, not just the date and initials. During an interview and concurrent record review on 5/26/2024 at 10:05 a.m., RN 1 reviewed the Enhanced Standard Precautions signage on Resident 277's door dated September 2021. The sign indicated providers and staff were required to clean hands upon entering and exiting the resident's room. The sign indicated providers and staff were to wear gloves and a gown for high-contact resident care activities or when caring for devices and giving medical treatments. RN 1 stated she should have put on a gown when caring for the resident's PICC. A review of the facility's P&P titled Central Venous Catheter Dressing Changes dated May 2022, indicated To apply sterile dressing . 6. Apply sterile transparent dressing (no gauze) to area, making sure to center the dressing over the insertion site . Label with initials, date and time. A review of the facility's P&P titled, Resident Isolation - Categories of Transmission-Based Precautions, reviewed on 1/29/2024, the P&P indicated that transmission-based precautions are used accordingly when caring for residents who are documented or are suspected of having communicable diseases or infection that can be transmitted to others. A review of the facility's P&P titled, Compliance with Laws and Professionals Standards reviewed on 1/29/2024, indicated that facility policies and procedures were developed and maintained in accordance with local, state, and federal laws and with currently accepted professional standards and principles that apply to professionals providing services in a skilled nursing facility. A. Policies and procedures are reviewed at least annually and updated as necessary. B. Facility staff perform their duties in accordance with the policies and procedures adopted by the Facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide necessary respiratory care services for two of two sampled residents (Resident 3 and Resident 10) by failing to ensure: 1. Resident 3 received oxygen at 2 liters per minute (l/min - unit of measurement) via nasal cannula (NC - a device used to deliver supplemental oxygen that should be placed directly on the resident's nostrils) to keep oxygen saturation (O2 sat) above 93 percent (% - unit of measurement) every shift for shortness of breath (SOB)/desaturation (the condition of a low blood oxygen concentration) as per physician's order dated 1/17/2024. 2. Resident 10 received oxygen at 2l/min via NC to keep O2 sat above 93 percent every shift for SOB every shift, as per physician's orders dated 8/18/2023. This deficient practice had the potential to deny Resident 3 and Resident 10's the oxygen needed to ensure brain and organ health and function. Cross Reference: F656 Findings: 1. A review of Resident 3's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis (loss of the ability to move in one side of the body) following cerebral infarction (stroke: lack of blood flow resulting in severe damage to some of the brain tissue) affecting right dominant side, Parkinson's disease (a disorder in the brain that affects movement, often including tremors), Alzheimer's disease (a progressing brain disorder that destroys memory and other important mental function), hypertension (HTN - elevated blood pressure) and hyperlipidemia (abnormally high levels of fats in the blood) A review of Resident 3's Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 2/16/2024, indicated Resident 3's cognitive skills for daily decision-making were moderately impaired and the resident was totally dependent on staff for eating, toileting hygiene, repositioning from sit to stand, bed to chair transfer. A review of Resident 3's Physician's History and Physical (H&P), dated 3/19/2024, indicated Resident 3 was unable to be fully assessed by the physician and did not follow commands. A review of Resident 3's Order Summary Report dated 1/17/2024, indicated the resident had an order for oxygen at 2 liters per minute via NC to keep the resident's O2 sat above 93 % every SOB/desaturation. A review of Resident 3's care plan for altered cardiovascular (pertaining to the heart and blood vessels that make up the circulatory system) status related to (r/t) HTN, hyperlipidemia, revised on 5/2/2024, indicated a goal for the resident to be free from complications of cardiac problems. The care plan indicated on 5/25/2024 and intervention to provide O2 via N/C per order was not added until 5/25/2024. A review of Resident 3's vital sign (VS - measurements of the body's most basic functions) dated 5/26/2024 at 8:16 a.m., indicated Resident 3's O2 sat was 92%. During an observation of Resident 3 on 5/25/2024 at 11:03 a.m., Resident 3 was observed in bed, eyes closed, and no oxygen machine or NC were observed in the room. During a follow-up observation with Resident 3 on 5/26/2024 at 11:52 a.m., Resident 3 was observed in bed, and no oxygen machine or NC were observed in the room. During a concurrent interview and record review of Resident 3's Order Summary on 5/27/2024 at 12:23 p.m., the Minimum Data Set Nurse 1 (MDSN1) stated confirmed Resident 3 had a physician's order for O2 supplement and stated the physician's order had to be followed. During an interview on 5/27/2024 at 12:31 p.m., the DON confirmed by stating there was no oxygen machine set-up for Resident 3. The DON stated the facility was not implementing Resident 3's care plan regarding oxygen therapy. 2. A review of Resident 10's admission Record indicated resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including acute respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide) with hypoxia (low levels of oxygen in the body tissues), heart failure (a condition in which the heart does not pump blood as well as it should) and toxic encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood). A review of Resident 10's MDS dated [DATE], indicated Resident 10's cognitive skills for daily decision-making were severely impaired and the resident was totally dependent on staff for oral hygiene, toileting hygiene, shower/bathing, upper and lower body dressing, and personal hygiene. A review of Resident 10's Order Summary Report dated 8/18/2023 indicated physician's order was in place for oxygen at 2l/min via NC to keep O2 sat above 93 percent every shift for SOB every shift. A review of Resident 10's CP for altered respiratory status/difficulty breathing r/t acute hypoxic respiratory failure revised on 5/8/2024, indicated a goal for the resident to be free from complications r/t SOB, with interventions including to provide oxygen as ordered. During an observation of Resident 10 on 5/25/2024 at 11:56 a.m., Resident 10 was observed on O2 supplement via NC. Resident 10's oxygen machine was observed at 1.5 l/min. During an interview on 5/27/2024 at 12:35 p.m., the DON stated physician's orders for O2 supplement had to be followed. The DON stated she (DON) would check Resident 10's O2 supplement machine and would call physician to update the order. During a follow-up interview on 5/27/2024 at 5:51 p.m., the DON confirmed by stating Resident 10's O2 machine was less than 2 l/min which was not what was indicated on the physician's order or care plan. A review of the facility's policy and procedure (P&P) titled, Oxygen Therapy, reviewed on 1/29/2024, the P&P indicated to administer oxygen per physician's orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 46) received the care and services consisted with professional standards of practice for hemodialysis (HD-filtering the blood of a person whose kidneys are not working normally) by failing to assess and documented resident 46's condition for complications after hemodialysis treatment. This deficient practice had the potential to allow for unidentified malfunctioning AV shunt, infections and bleeding from the AV shunt site which could all lead to serious harm and/or death. Findings: A review of Resident 46's admission Record indicated Resident 46 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), end stage renal failure (ESRD-a medical condition in which a person's kidney [organ in the body that lifters waste and excess fluid from the blood] function stop functioning on a permanent basis), hemodialysis (HD-filtering the blood of a person whose kidneys are not working normally) dependence and generalized muscle weakness. A review of Resident 46's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 3/28/2024, indicated Resident 46's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making was moderately impaired and the resident required maximal assistance from staff for activities of daily living (ADLs- bed mobility, transfer, dressing, and toilet use). The MDS indicated Resident 46 was receiving hemodialysis treatment. A review of Resident 46's order summary report dated 1/12/2024, indicated the resident was to have hemodialysis every Monday, Wednesday, and Friday. A review of Resident 46's pre-dialysis evaluation form dated 5/24/2024, indicated an assessment was to be done before and during hemodialysis. A review of Resident 46's post dialysis evaluation form for5/24/2024, indicated the post dialysis evaluation form was missing. During an interview on 5/27/2024 at 12:05 p.m., Licensed Vocational Nurse 3 (LVN 3) stated residents who were scheduled for HD were required to have an assessment before leaving the facility, during the HD treatment which would be done by the HD staff, and when the resident returned to the facility. LVN 3 stated the nursing staff had to assess the resident and document the assessment to make sure the resident tolerated the HD with no complications. A review of facility policy and procedure (P&P) titled, Dialysis Care, reviewed on 1/29/2024, indicated that all documentation concerning dialysis services and care of the dialysis resident would be maintained in the resident's medical record.

Based on observation, interview and record review, the facility failed to post the federally required daily actual hours worked by the facility staff in an area accessible to the public for one of four days (5/25/2024) for the month of May 2024. As a result, the actual hours worked by the staff was not readily accessible to residents, family, or visitors. And had the potential to cause inadequate staffing. Findings: During an observation of the nurse's station on 5/25/2024 at 9:55 a.m., nurse staffing hours information was observed posted with a date of 5/23/2024. During an interview with on 5/27/2024 at 4:35 p.m., the Director of Staff and Development (DSD) stated since he (DSD) had been in vacation, the facility was not able to update and post the nursing hours. The DSD stated nurse posting was to be done daily. A review of a facility's policy and procedures (P&P) titled Nursing Department-Staffing, Scheduling & Posting reviewed on 1/29/2024, indicated the facility will post the following information on a daily basis: i. Facility name ii. Current date iii. Total number and the actual hours worked of all the licensed and unlicensed nursing staff directly responsible for resident care per shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to communicate the consultant pharmacist's recommendation, in the Medication Regimen Review (MRR), to the attending physician for two of five sampled residents (Resident 15 and 53). This deficient practice had the potential for unnecessary medication use, resulting in an adverse drug reaction to affect the health and wellbeing of Resident 15 and Resident 53. Findings: A review of Resident 15's admission Record indicated the resident was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including dementia (a chronic or persistent disorder of the mental processes caused by brain disease), osteoarthritis (inflammation of the bone) and anxiety disorder. A review of Resident 15's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 3/28/2024, indicated Resident 15 had moderately intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and required moderate assistance from staff for activities of daily living (ADL-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). A review of Resident 15's Consultant Pharmacist's Medication Regimen Review (CPMRR) dated 3/23/2024, indicated a recommendation to re-evaluate cetirizine (antihistamine medication) and loratadine (antihistamine medication) due to a possibility of duplicate therapy. The CPMRR indicated to document rationale if medication needed to be continued. During a concurrent interview and record review with the Director of Nursing (DON) on 5/28/2024 at 2:41 p.m., Resident 15's order summary was reviewed by the DON. The order summary indicated the resident had a physician's order for loratadine dated 5/21/2024 and cetirizine dated on 2/1/2024. The DON reviewed and confirmed Resident 15's progress notes had no documentation regarding CPMRR. The DON stated facility staff had to relay and document pharmacy recommendations to the physician. During an interview with the Nurse Practitioner 1 (NP 1) on 5/28/2024 at 4:37 p.m., NP 1 stated she (NP 1) was not aware Resident 15 was taking two different kinds of antihistamine. NP 1 stated that she was also not aware that Resident 15 had a pharmacy recommendation. NP 1 stated facility staff should have notified the physician for any pharmacy recommendations. A review of Resident 53's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), acute respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide) and generalized muscle weakness. A review of Resident 53's MDS dated [DATE], indicated the resident had moderately intact cognition for daily decision-making and required minimal assistance from staff for ADLs. A review of Resident 53's order summary report (OSR) dated 3/28/2024, indicated Resident 53 had an order for Fosamax (medication that slows bone loss and prevents fractures) 70 milligrams (mg) by mouth one time a day every Saturday on an empty stomach. The OSR indicated facility staff could crush medications and mix with apple sauce. A review of Resident 53's CPMRR, dated 4/26/2024, CPMRR indicated a recommendation by the pharmacist to add do not crush to the Fosamax order. During a concurrent interview and record review with the Director of Nursing (DON) on 5/28/2024 at 2:33 p.m., Resident 53's medical record was reviewed. The DON confirmed by stating do not crush was missing from the active physician's orders and the pharmacist recommendation was not documented in Resident 53's progress notes. The DON stated all the licensed nurses could notify the physician regarding CPMRR recommendations and the recommendations and notification of the physician had to be documented in the progress notes. A review of a facility's policy and procedures (P&P) titled Consultant Pharmacist Reports: Medication Regimen Review, reviewed on 1/29/2024, indicated recommendations were to be acted upon and documented by the facility staff and/or the prescriber.

Based on observation, interview, and record review, the facility failed to provide fortified diet (diet enhanced to increase caloric content) as ordered by the physician to one of 21 sampled residents (Resident 36) who was on a kosher (food that complies with a strict set of dietary rules in the Jewish religion) and fortified diet. This deficient practice had the potential to result in decreased caloric intake and lead to undesirable weight loss for the resident. Findings: During an observation of lunch service in the kitchen on 5/25/2024 at 12:00 p.m., residents who were kosher diet received prepacked kosher meal. The prepackaged kosher meal was heated for 2 minutes in the microwave and then placed on resident tray. During the same observation and interview in the kitchen with [NAME] 1 and [NAME] 2, [NAME] 2 was communicating the fortified diet orders written on the resident's meal tickets during tray line for lunch service and [NAME] 1 was adding butter on the vegetables for residents on fortified diet. [NAME] 1 stated fortified diet means add butter for more calories. A review of resident 36's tray or meal tickets on the cart indicated the orders for fortified diets. However, [NAME] 2 did not read out loud the fortified diet and [NAME] 1 did not add butter on Resident 36's food. During an observation on 5/25/2024 at 1:00 p.m., Resident 36's tray on the bedside table had sliced roasted turkey, sweet potato, peas in a disposable plastic container that was opened and a cup of nutrition supplement. There was no butter on the tray or on the food. During a concurrent interview with Resident 36 on 5/25/2024 at 1:00p.m, the resident stated she eats kosher food, and the food comes prepackaged and sealed and the nurse assists in removing the cover. During an observation of lunch service in the kitchen on 5/25/2024 at 11:55 a.m., Resident 36 prepacked kosher food was heated in the microwave then placed on the tray. During the same observation [NAME] 2 did not communicate the fortified diet for resident 36 and [NAME] 1 did not add any butter on Resident 36's tray. During an observation on 5/25/2024 at 1:00 p.m., Resident 36's tray on the bedside table had spaghetti and meatballs and peas. Resident only ate the meatballs. There was no butter on the tray or on the food. During an interview with Dietary Supervisor (DS) on 5/26/2024 at 3:30 p.m., DS stated fortified diet orders are for residents who are losing weight or have decreased intake. DS stated for during lunch meal, butter is added on vegetables to add extra calories. DS stated when residents did not get the fortified diet then they did not receive the extra calories. DS stated they did not add butter to Resident 36's food. DS stated the food comes in prepackaged and sealed container and they don't open it because it is Kosher. DS stated they could not add butter on the food because it was sealed. DS said Resident 36 did not get the extra calories from fortified diet as ordered. A review of the Order Summary Report for Resident 36 indicated diet order: Fortified Diet regular texture for weight loss start date 4/30/2024. A review of the Dietary Profile dated 3/6/2024 indicated diet order is regular texture fortified food, resident likes kosher food and dislikes pork. A review of facility policy and procedures titled Therapeutic Diets (Revised 6/1/2014) indicated, Therapeutic diets are diets that deviate from the regular diet and require a physician order. Per the physician order, therapeutic diets are planned, prepared, and served in consultation with the Dietitian. A review of facility policy and procedures titled Fortified Diet (dated 2020) indicated, fortified diet is designed for residents who cannot consume adequate amounts of calories and or protein to maintain their weight or nutritional status .the goal is to increase calorie for the foods .calorie increase should be approximately 300-400per day .examples adding extra margarine or butter to food, extra gravy etc.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain patient care equipment in safe working condition when one of six sampled residents (Resident 3) had an uncovered overhead light with exposed bulb. This deficient practice had a potential to cause incidental accidents to the resident, which could result in injuries. Findings: A review of Resident 3's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis (loss of the ability to move in one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting right dominant side, Parkinson's disease (a disorder in the brain that affects movement, often including tremors), dysphagia (difficulty swallowing food or liquid), and Alzheimer's disease (a progressing brain disorder that destroys memory and other important mental function). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 2/16/2024, indicated Resident 3's cognitive (relating to mental action or process of acquiring knowledge and understanding) skills for daily decision-making were moderately impaired. Resident 3 required total dependence from staff for activities of daily livings (ADLs-eating, toileting hygiene, shower/bathing self, upper and lower body dressing, repositioning from sit to lying and sit to lying). During an observation in Resident 3's room on 5/25/2024 at 11:03 a.m., Resident 3's overhead light with no cover and a long light bulb was exposed. During a concurrent interview and observation of Resident 3 with Maintenance Supervisor 1 (MS1) on 5/25/2024 at 7:11 p.m., MS1 stated and confirmed Resident 3's overhead light did not have a cover. MS1 stated the overhead light should always have a protective cover; if not, it may cause an avoidable electrical accident as the lightbulb might fall on resident's head. A review of the facility's policy and procedures (P&P) titled, Resident Rooms and Environment reviewed on 1/29/2024, indicated that the facility provides comfortable and adequate lighting throughout the facility to promote a safe, comfortable, and homelike environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were informed, offered or followed up regarding Advance Directive (ACHD - 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) in a timely manner for four of 18 sampled residents (Residents 48, 43, 3, and 58). This deficient practice had the potential to cause conflict with resident's wishes regarding health care. Findings: 1. A review of Resident 43's admission Record indicated Resident 43 was admitted to the facility on [DATE] with diagnosis including urinary tract infection (UTI- an infection in any part of the urinary system, including the kidney, bladder or urethra), sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), and paroxysmal atrial fibrillation (afib- a sudden irregular and very rapid heart rhythm that and can lead to blood clots in the heart). A review of Resident 43's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 5/6/2024, indicated Resident 43's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were mildly impaired and required moderate to maximal assistance from staff for activities of daily livings (ADLs- toileting hygiene, shower/bathing self, upper and lower body dressing, repositioning from sit to lying and sit to stand). The same MDS indicated, Resident 43 Advance Directive was not completed. A review of Resident 43's Advance Directive form assessment during admission, dated 5/2/2024, indicated that Resident 43 chose the option that she (Resident 43) has executed an ACHD. A review of Resident 43's Baseline Care Plan, dated 5/1/2024 indicated, Social Services documentation with what was provided to Resident 43 was blank. A review of Resident 43's Progress Notes as of 5/26/2024, there were no notes by the Social Services Department regarding obtaining a copy of Resident 43's Advance Directive. During a concurrent interview and record review with Social Services Director (SSD) on 5/26/2024 at 5:23 p.m., SSD stated, residents were inquired if they have an ACHD and/or if they would like to execute an ACHD upon admission by the admission Coordinator (AC). SSD reviewed Resident 43's electronic record with surveyor and stated, according to ACHD assessment form upon admission indicated Resident 43 have an ACHD but there was no copy of Resident 43's ACHD. SSD stated, if a resident has executed an ACHD, SSD is to follow-up with a copy, and it should be filed. SSD stated, she did not follow-up with Resident 43's regarding her actual ACHD. SSD further stated, she did not document that she followed-up with Resident 43's actual ACHD. SSD stated, ACHD is important so that they know what resident's wishes are when they are no longer able to make decision. 2. A review of Resident 3's admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnosis including hemiplegia and hemiparesis (loss of the ability to move in one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting right dominant side, Parkinson's disease (a disorder in the brain that affects movement, often including tremors), dysphagia (difficulty swallowing food or liquid), and Alzheimer's disease (a progressing brain disorder that destroys memory and other important mental function). A review of Resident 3's MDS dated [DATE], indicated Resident 3's cognitive skills for daily decision-making were moderately impaired and required total dependence from staff for ADLs-eating, toileting hygiene, shower/bathing self, upper and lower body dressing, repositioning from sit to lying and sit to lying. The same MDS also indicated, Resident 3's Advance Directive was not completed. A review of Resident 3's Advance Directive form assessment during admission, dated 5/26/2023, indicated that Resident 3/family representative chose the option that she (Resident 3) has executed an ACHD. A review of Resident 3's Baseline Care Plan, dated 5/17/2023 indicated, SSD documented that, ancillaries offered and provided as needed. A review of Resident 3's Progress Notes as of 5/26/2024, there was no notes by the Social Services Department regarding obtaining a copy of Resident 3's Advance Directive and what are the ancillaries that SSD offered and provided. During a concurrent interview and record review with SSD on 5/26/2024 at 5:25 p.m., SSD stated, residents were inquired if they have an ACHD and/or if they would like to execute an ACHD upon admission by the AC. SSD reviewed Resident 3's electronic record with surveyor and stated, according to ACHD assessment form upon admission indicated Resident 3 have an ACHD but there was no copy of Resident 43's ACHD. SSD stated, if a resident has executed an ACHD, SSD is to follow-up with a copy, and it should be filed. SSD stated, she did not follow-up with Resident 43's regarding her actual ACHD. SSD further stated, she did not document that she followed-up with Resident 43's actual ACHD. SSD stated, ACHD is important so that they know what resident's wishes are when they are no longer able to make decision. 3. A review of Resident 48's admission Record indicated resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), acute respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood) and pneumonia (lung infection that inflames air sacs with fluid or pus). A review of Resident 48's MDS dated [DATE], indicated Resident 48's cognitive skills for daily decision-making were moderately impaired and required maximal to total dependence ADLs-eating, toileting hygiene, shower/bathing self, upper and lower body dressing, repositioning from sit to lying and rolling left to right. The same MDS also indicated, Resident 48 does not have Advance Directive. A review of Resident 48's Advance Directive form assessment during admission, dated 4/9/2024, indicated that Resident 48 chose the option that she (Resident 48) will bring in a copy of the Advance Directive for the medical record. A review of Resident 48's Baseline Care Plan, dated 4/29/2024 indicated, SSD documented that, discharge planning was discussed, home health services and psychosocial wellbeing and support. There were no notes indicating about AHCD. A review of Resident 48's Progress Notes as of 5/26/2024, there was no notes by the Social Services Department regarding obtaining a copy of Resident 3's Advance Directive. During a concurrent interview and record review with SSD on 5/26/2024 at 5:28 p.m., SSD stated, residents were inquired if they have an ACHD and/or if they would like to execute an ACHD upon admission by the AC. SSD reviewed Resident 48's electronic record with surveyor and stated, according to ACHD assessment form upon admission indicated Resident 48 have an ACHD and resident's representative will bring a copy for their record but there was no copy of Resident 48's ACHD. SSD stated, if a resident has executed an ACHD, SSD is to follow-up with a copy, and it should be filed. SSD stated, she did not follow-up with Resident 43's regarding her actual ACHD. SSD further stated, she did not document that she followed-up with Resident 43's actual ACHD. SSD stated, ACHD is important so that they know what resident's wishes are when they are no longer able to make decision. 4. A review of Resident 58's admission Record indicated resident was admitted to the facility on [DATE] with diagnosis including metabolic encephalopathy, hypertension (HTN - elevated blood pressure), history of falling and muscle weakness. A review of Resident 58's MDS dated [DATE], indicated Resident 58's cognitive skills for daily decision-making were moderately impaired and required moderate to maximal assistance from staff for ADLs- toileting hygiene, shower/bathing self, upper and lower body dressing, repositioning from sit to lying and sit to stand). The same MDS also indicated, Resident 48's Advance Directive was not completed. A review of Resident 58's Advance Directive form assessment during admission, dated 4/17/2024, indicated that Resident 58 chose the option that she (Resident 48) was interested in executing an Advance Directive (refer to Social Services). A review of Resident 58's Baseline Care Plan, dated 4/29/2024 indicated, SSD documented that, discharge planning was discussed, home health services, ancillaries offered and psychosocial wellbeing support. There were no notes indicating about a referral for AHCD. A review of Resident 58's Progress Notes as of 5/26/2024, there was no notes by the Social Services Department regarding following up with Resident 58's request to execute an Advance Directive and what are the ancillaries that were offered. During a concurrent interview and record review with SSD on 5/26/2024 at 5:31 p.m., SSD stated, residents were inquired if they have an ACHD and/or if they would like to execute an ACHD upon admission by the AC. SSD reviewed Resident 58's electronic record with surveyor and stated, according to ACHD assessment form upon admission, it indicated Resident 58 was interested in executing an ACHD. Resident 58's had a power of attorney (POA) financial on file, dated 4/26/2024 which indicated, that this form is not valid for healthcare decisions. SSD stated, if a resident requested to execute an ACHD, SSD is to follow-up with a referral. SSD further stated, she did not document that she followed-up with Resident 58's request. SSD stated, ACHD is important so that they know what resident's wishes are when they are no longer able to make decision. During an interview with Director of Nursing (DON) on 5/27/2024 at 2:58 p.m., DON stated, the POA for on file for Resident 58 was for financial decisions and it was not valid for health care decisions. During a follow-up interview with SSD and AC on 5/26/2024 at 8:07 p.m., AC stated, residents are inquired about ACHD upon admission, and they document it, but surveyor does not have access to their documentation in the electronic charting. AC stated, if resident would like to execute an ACHD and/or they have executed an ACHD, they must follow-up with residents. AC stated, they don't document for any follow-up and/or education that was provided with residents. SSD stated and agreed with stating, they don't need to document any follow-up and education that was provided to residents. SSD stated, all they need to do is document it during admission process. A review of the facility's policy and procedures (P&P) titled, Advance Directive, reviewed on 1/29/2024, the P&P indicated, the facility will respect a resident's advance directive and will comply with the resident's wishes expressed in an advance directive. Upon admission, the admission Staff or designee will obtain a copy of a resident's advance directive. A copy of the resident's advance directive will be included in the resident's medical record. If a resident does not have an Advance Directive, the facility will provide the resident and/or resident's next of kin with information about advance directives upon request . During the Social Services Assessment process, the Director of Social Services or designee will also ask the resident whether he or she has a written advance directive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physician when the resident continued to refuse to take her medications for one of two sampled residents (Resident 58). This deficient practice had the potential to result in delayed provision of necessary care, treatment and services. Cross Reference F656 Findings: A review of Resident 58's admission Record indicated resident was admitted to the facility on [DATE] with diagnosis including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), hypertension (HTN - elevated blood pressure), history of falling and muscle weakness. A review of Resident 58's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 4/21/2024, indicated Resident 58's cognitive skills for daily decision-making were moderately impaired and required moderate to maximal assistance from staff for activities of daily livings (ADLs- toileting hygiene, shower/bathing self, upper and lower body dressing, repositioning from sit to lying and sit to stand). During an interview with Resident 58 on 5/25/2024 at 11:28 a.m., Resident 58 stated, she has multiple of vitamins and medications that nurses bring in every morning, but she does not like taking them. Resident 58 stated, she likes to take the medications with food or after eating so she would ask the nurses to put it on an empty bottle of medication. Resident 58 stated, nurses does not inform her of what the risks of not taking the medications. During a review of Resident 58's Medication Administration Record (MAR) for the month of May 2024, the MAR indicated the following: i. amlodipine (can treat high blood pressure and chest pain) oral tablet 5 milligram (mg - unit of measurement) - give 1 tablet by mouth one time a day for HTN. ii. arginaid oral packet (nutritional supplements) - give 1 packet by mouth one time a day for wound healing. iii. atorvastatin calcium (medication use to lower cholesterol and triglycerides [fats] levels) oral tablet 20 mg - give 1 tablet by mouth in the evening. iv. docusate sodium (prevents and treats occasional constipation) oral tablet 100 mg - give 1 tablet by mouth one time a day for bowel management. v. Enoxaparin sodium (used to prevent deep venous thrombosis, [a condition in which harmful blood clots] form in the blood vessels of the legs) injection prefilled syringe 40mg/0.4 millimeter (ml) - inject 40 mg subcutaneously (SQ - the injection is given in the fatty tissue, just under the skin) one time a day for blood clots. vi. Multivitamins-minerals oral tablet - give 1 tablet by mouth one time a day. vii. Zinc sulfate (supplemental for growth and for the development and health of body tissues) capsule 200 mg - give 1 capsule by mouth one time a day. viii. Pro-stat (indicated for increased protein needs) oral liquid - give 30 ml by mouth two times a day. ix. Vitamin C (used for growth and repair of tissues in parts of body) oral tablet 500 mg - give 1 tablet by mouth two times a day. Resident 58's MAR indicated, there were multiple consecutive days of refusals documented for the medications listed above. A review of Resident 58's Progress Notes as of 5/27/2024, indicated, there was no documentation that physician was notified, and if any education was provided to Resident 58 upon refusals of medications. During an interview with Director of Nursing (DON) on 5/27/2024 at 11:34 a.m., DON stated, physician should be notified for refusals of medications, it should be documented the reason of refusals and if any educations was provided to residents. A review of the facility's policy and procedure (P&P) titled, Medication Administration - General Guidelines, reviewed on 1/29/2024, the P&P indicated, that medication refusal must be reported to the prescriber after (XX) number of doses are refused and there must be a documentation of prescriber notification of such. A review of the facility's P&P titled, Refusal of Treatment, reviewed on 1/29/2024, the P&P indicated that the Attending Physician will be notified of refusal of treatment in a time frame determined by the resident's condition and potential serious consequences of the refusal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1g. A review of Resident 36's admission Record, dated 5/28/2024, indicated Resident 36 was originally admitted to the facility on [DATE], and was re-admitted on [DATE], with diagnoses including DM, major depressive disorder (depressed mood or loss of interest in activities, causing significant impairment in daily life), abnormal posture, and generalize muscle weakness. A review of Resident 36's MDS, dated [DATE], indicated Resident 36's had moderate cognitive impairment, and required substantial/maximal assistance from staff for toileting, bathing, dressing, personal hygiene and bed mobility. A review of Resident 36's POSR, as of 5/28/2024, POSR indicated no orders or consent for side rails. During an observation on 5/25/2024 at 12:48 p.m., Resident 36 was observed in bed with bilateral upper side rails up. During an observation on 5/26/2024 at 9:48 a.m., Resident 36 was observed in bed with bilateral upper side rails up. During an observation on 5/27/2024 at 11:01 a.m., Resident 36 was observed in bed with bilateral upper side rails up. 1h. A review of Resident 40's admission Record, dated 5/28/2024, indicated Resident 40 was originally admitted to the facility on [DATE], with diagnoses including, depressive disorder (depressed mood or loss of interest in activities, causing significant impairment in daily life), heart failure (a medical condition where the heart muscle doesn't pump blood as well as it should), hypertension (high blood pressure) and chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breath). A review of Resident 40's MDS, dated [DATE], indicated Resident 40's had mild cognitive impairment, and required moderate to maximal assistance from staff for toileting, bathing, dressing, personal hygiene, and bed mobility. A review of Resident 40's POSR, as of 5/28/2024, POSR indicated no orders or consent for side rails. During an observation on 5/25/2024 at 12:56 p.m., Resident 40 was observed in bed with bilateral upper side rails up. During an observation on 5/26/2024 at 9:49 a.m., Resident 40 was observed in bed with bilateral upper side rails up. During an observation on 5/27/2024 at 3:00 p.m., Resident 40 was observed in bed with bilateral upper side rails up. 1i. A review of Resident 277's admission Record indicated Resident 277 was originally admitted to the facility on [DATE], with diagnoses including hypertensive (high blood pressure) heart disease with heart failure (disease when heart doesn't pump enough blood for your body's needs), muscle weakness, difficulty walking and anemia (not enough oxygen carrying red blood cells in the blood). A review of Resident 277's MDS, dated [DATE], indicated Resident 277 had mild cognitive impairment and required supervision or touching assistance from staff for eating, oral hygiene, and upper body dressing, and moderate and maximum assistance from staff for toileting, bathing, lower body dressing and personal hygiene. A review of Resident 277's POSR, as of 5/28/2024, POSR indicated no orders or consent for side rails. During an observation on 5/25/2024 at 11:06 a.m., Resident 277 was observed in bed with bilateral upper side rails up. During an observation on 5/26/2024 at 10:00 a.m., Resident 277 was observed in bed with bilateral upper side rails up. During an observation on 5/27/2024 at 11:05 a.m., Resident 277 was observed in bed with bilateral upper side rails up. 1j. A review of Resident 278's admission Record indicated Resident 278 was originally admitted to the facility on [DATE], with diagnoses including diabetes mellitus, muscle weakness, discitis (inflammation of the intervertebral [area between bones of the spine] disc space) lumbar (lower back) region, and malignant neoplasm (cancerous tumor) of the breast. A review of Resident 278's MDS, dated [DATE], indicated Resident 278 had moderate cognitive impairment and required supervision or touching assistance from staff for toileting, bathing, dressing and personal hygiene. A review of Resident 278's POSR, as of 5/28/2024, POSR indicated no orders or consent for side rails. During an observation on 5/25/2024 at 5:28 p.m., Resident 278 was observed in bed with bilateral upper side rails up. During an observation on 5/26/2024 at 9:42 a.m., Resident 278 was observed in bed with bilateral upper side rails up. During an observation on 5/27/2024 at 11:05 a.m., Resident 278 was observed in bed with bilateral upper side rails up. Based on observation, interview, and record review, the facility failed to ensure nine out of nine sampled residents (Residents 48, 43, 50, 178, 44, 40, 36, 277, 278 and 227) were free from physical restraint by failing to: 1. Obtain a physician's order and informed consent from residents/responsible party for the use of bilateral bed side rails according to facility's policy and procedures (P & P) titled, Bed Rails, for Residents 50, 178, 44, 40, 36, 277, and 278 2. Obtain a physician's order for the use of bilateral bed siderails for Resident 48. 3. Obtain a physician's order and informed consent from residents/responsible party for the use of the bilateral bed side rails and bed side rails assessment were accurate for Resident 43. These deficient practices had the potential to result in entrapment, injury, and residents not being treated with respect and dignity with the use of restraints. Cross Reference F656 Findings: 1a. A review of Resident 43's admission Record indicated Resident 43 was admitted to the facility on [DATE] with diagnosis including urinary tract infection (UTI- an infection in any part of the urinary system, including the kidney, bladder or urethra), sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), and paroxysmal atrial fibrillation (afib- a sudden irregular and very rapid heart rhythm that and can lead to blood clots in the heart). A review of Resident 43's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 5/6/2024, indicated Resident 43's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were mildly impaired and required moderate to maximal assistance from staff for activities of daily livings (ADLs- toileting hygiene, shower/bathing self, upper and lower body dressing, repositioning from sit to lying and sit to stand). A review of Resident 43's physician order summary report (POSR), as of 5/27/2024, POSR indicated no orders for side rails. A review of Resident 43's informed consent as of 5/27/2024 indicated, there was no informed consent signed from resident/responsible party for the use of bilateral bed siderails. A review of Resident 43's Bed Rail Assessment, dated 4/29/2024 indicated, side rails/assist bar are not indicated at this time. A review of Resident 43's Care Plan (CP) as of 5/27/2024 indicated, there was no CP developed for the use of bilateral bed siderails. During a concurrent observation and interview with Resident 43 on 5/25/2024 at 12:00 p.m., Resident 43 was observed with a bilateral upper bed siderails up. Resident 43 stated, she is unable to get up on her own and needs assistance with getting out of bed and walking. Resident 43 was observed unable to move the bilateral bed siderails down on her own. During a concurrent observation of Resident 43 and interview with Director of Nursing (DON), on 5/26/2024 at 7:25 p.m., DON stated and confirmed, Resident 43 is on bilateral bed side rails. During a follow-up interview with DON, on 5/26/2024 at 11:50 a.m., DON stated, the use of bilateral bed siderails does not need a physician's order and no informed consent needed as they were not utilizing it for restraints. When asked regarding Resident 43's bed rails assessment which indicated, side rails/assist bar are not indicated at this time, DON was unable to answer. When asked if Resident 43 is able to move the siderails on her own, DON stated, no. 1b. A review of Resident 48's admission Record indicated Resident 48 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), acute respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood) and pneumonia (lung infection that inflames air sacs with fluid or pus). A review of Resident 48's MDS dated [DATE], indicated Resident 48's cognitive skills for daily decision-making were moderately impaired and required maximal to total dependence from staff for activities of daily livings (ADLs-eating, toileting hygiene, shower/bathing self, upper and lower body dressing, repositioning from sit to lying and rolling left to right). A review of Resident 48's POSR, as of 5/27/2024, POSR indicated no orders for side rails. A review of Resident 48's care plan (CP), indicated Resident 48 was at risk for fall related to gait/balance problems initiated on 4/29/2024. The CP indicated an intervention that facility will provide siderails for turning and repositioning. During a concurrent observation and interview with Resident 48 on 5/26/2024 at 11:16 a.m., Resident 48 was observed with a bilateral bed siderail up. Resident 48 stated, she is unable to get up on her own and unable to move herself up from bed to sitting position. Resident 48 was observed unable to move the bilateral bed side rails down on her own. During a concurrent observation of Resident 48 and interview with DON, on 5/26/2024 at 7:27 p.m., DON stated and confirmed, Resident 48 is on bilateral bed side rails and bed siderails does not need a physician's order because it is a nursing scope of practice. During a follow-up interview with DON on 5/27/2024 at 11:53 a.m., DON stated, the use of bilateral bed siderails does not need a physician's order and no informed consent needed as they were not utilizing it for restraints. When asked if Resident 48 is able to move the bed siderails on her own, DON stated, no. 1c. A review of Resident 50's admission Record indicated resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including surgical aftercare following surgery on the skin, congestive heart failure (CHF- a progressive condition that affects the pumping power of the heart muscle) and paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease) A review of Resident 50's MDS dated [DATE], indicated Resident 50's cognitive skills for daily decision-making were mildly impaired and required total dependence from staff for ADLs- toileting hygiene, shower/bathing self, lower body dressing, repositioning from sit to lying and lying to sitting on side of bed. A review of Resident 50's POSR, as of 5/27/2024, POSR indicated no orders for side rails. A review of Resident 50's informed consent as of 5/27/2024 indicated, there was no informed consent signed from resident/responsible party for the use of bilateral bed siderails. A review of Resident 50's CP, indicated Resident 50 was at risk for fall related to gait/balance problems initiated on 4/26/2024. The CP indicated an intervention that facility will provide siderails for turning and repositioning. During a concurrent observation and interview with Resident 50 on 5/26/2024 at 9:25 a.m., Resident 50 stated, he is unable to get up on his own and needs assistance to get up from bed to wheelchair. Resident 50 was asked if he's able to put his bed siderails down on his own and Resident 50 stated, he cannot. During a concurrent observation of Resident 50 and interview with DON on 5/26/2024 at 7:30 p.m., DON stated and confirmed, Resident 50 is on bilateral bed side rails for mobility and bed siderails does not need a physician's order because it is a nursing scope of practice. During a follow-up interview with DON on 5/27/2024 at 11:53 a.m., DON stated, the use of bilateral bed siderails does not need a physician's order and no informed consent needed as they were not utilizing it for restraints. When asked if Resident 50 is able to move the bed siderails on her own, DON stated, no. A review of the facility's P&P titled, Bed Rails, reviewed on 1/29/2024, the P&P indicated that facility will attempt alternatives prior to the installation of bed rails, prior to installation, assess the resident's risk of entrapment with bed rails. Review the risks and benefits of bed rails with the resident or resident's representative and obtain informed consent prior to installation. The same P&P also indicated that, a bed rails is an assistive device and must be used in accordance with the following regulations: a. Only permissible if they are used to treat a Resident's medical symptoms b. Are classified as a physical restraint when bed rails are used to limit a Resident's freedom of movement (i.e., prevent the Resident from leaving the bed) c. The length of the bed rail (quarter, half, full, etc.) does not determine if the bed rail is a restraint or an enabler d. Bed rails cannot be used for staff convenience or as discipline, such as prevention of falls when less restrictive methods have not been attempted or ruled out e. A detailed order by a healthcare provider (e.g., a physician, nurse practitioner) is required before any restraints can be utilized. A review of the facility's P&P titled, Informed Consent, reviewed on 1/29/2024, the P&P indicated that Informed consent is required for any medical intervention that is not emergency care or routine nursing care; When informed consent is required, the physician who orders or performs the intervention is required to obtain informed consent. 1d. A review of Resident 44's admission Record indicated Resident 44 was originally admitted to the facility on [DATE], and was re-admitted on [DATE], with diagnoses including injury of head, dementia (loss of cognitive functioning-thinking, remembering, and reasoning), generalized weakness, history of falling and epilepsy (a disorder in which a nerve cell activity in the brain is disturbed causing seizure [a sudden, uncontrolled electrical disturbance in the brain]). A review of Resident 44's MDS dated [DATE], indicated Resident 44's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making was moderately impaired and requiring maximal assistance from staff for activities of daily living (ADLs- bed mobility, transfer, dressing, and toilet use). A review of Resident 44's physician order summary report (POSR), as of 5/27/2024, POSR indicated no orders for side rails. A review of Resident 44's care plan, indicated Resident 44 was at risk for fall related to gait/balance and history of falls, reviewed on 3/15/2024. Care plan also indicated interventions that facility will provide siderails for turning and repositioning. During an observation on 5/26/2024 at 10:02 a.m., Resident 44 was observed in bed with padded bilateral upper side rails up. During an interview with the LVN 3 on 5/27/2024 at 11:50 a.m., LVN 3 stated that Resident 44 needed to have padded bilateral upper side rails up when in bed for safety. LVN 3 stated that since according to the care plan that bilateral upper side rails up are supposed to be for turning and repositioning, side rails should only be used when Resident 44 was being turned and repositioned. LVN 3 also stated that she was unsure if side rails as enabler needs to have a physician order. During an interview with the DON, on 5/27/2024 at 5:23 p.m., DON stated not needing a physician order for having bilateral upper side rails up for turning and repositioning. DON also stated that as long as there was a care plan in the intervention indicating that a resident needs a side rail for turning and repositioning, resident should be okay to have the side rails up at all times when in bed. 1e. A review of Resident 178's admission Record indicated Resident 178 was originally admitted to the facility on [DATE], and was re-admitted on [DATE], with diagnoses including diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), end stage renal failure (ESRD-a medical condition in which a person's kidney [organ in the body that lifters waste and excess fluid from the blood] function stop functioning on a permanent basis), hemodialysis (HD-filtering the blood of a person whose kidneys are not working normally) dependence and generalized muscle weakness. A review of Resident 178's MDS, dated [DATE], indicated Resident 178's cognitive skills for daily decision-making was moderately impaired and requiring maximal assistance from staff for ADLs. MDS also indicated Resident 178 was on hemodialysis since admission. A review of Resident 178's POSR, as of 5/27/2024, POSR indicated no orders for side rails. A review of Resident 178's care plan, indicated Resident 178 has an ADL self-care performance deficit, reviewed on 5/6/2024. Care plan also indicated interventions that facility will provide siderails for repositioning. During an observation on 5/25/2024 at 11:23 a.m., Resident 178 was observed in bed with bilateral upper side rails up. During an observation on 5/26/2024 at 10:02 a.m., Resident 178 was observed in bed with bilateral upper side rails up. During an observation on 5/26/2024 at 4:20 p.m., Resident 178 was observed in bed with bilateral upper side rails up. During an interview with the LVN 3 on 5/27/2024 at 11:41 a.m., LVN 3 stated being unsure if Resident 178 needed to have bilateral upper side rails up when in bed. LVN 3 stated that since according to the care plan that bilateral upper side rails up are supposed to be used for turning and repositioning, side rails should only be used when Resident 178 was being turned and repositioned. LVN 3 also stated that she was unsure if side rails as enabler needs to have a physician order. During an interview with the DON, on 5/27/2024 at 5:23 p.m., DON stated not needing a physician order for having bilateral upper side rails up for turning and repositioning. DON also stated that as long as there was a care plan in the intervention indicating that a resident needs a side rail for turning and repositioning, resident should be okay to have the side rails up at all times when in bed. A review of facility's P&P, titled, Restraints, reviewed on 1/29/2024, P&P indicated that facility will honor resident's right to be free from any restraints that are imposed for reasons other than that of treatment of the resident's medical symptoms. P&P also indicated that restraints require a physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. A review of Resident 330's admission Record indicated Resident 330 was originally admitted to the facility on [DATE], and was re-admitted on [DATE], with diagnoses including toxic encephalopathy, anemia, and chronic kidney disease stage 3 (kidneys have mild to moderate damage, and they are less able to filter waste and fluid out of the blood). A review of Resident 330's MDS dated [DATE], indicated Resident 330's cognitive skills for daily decision-making were severely impaired and the resident required supervision or touching assistance to partial/moderate assistance for ADLs. During a concurrent interview and record review of Resident 330's Change in Condition (COC) Evaluation dated 5/26/2024 at 4:23 pm, IPN 2 reviewed the COC which indicated the resident was noted to have 2 raised redness spots with pustule to the right upper buttock The COC indicated the resident possibly had shingles (also called herpes zoster, is a disease that triggers a painful skin rash. It is caused by the same virus as chickenpox). Resident 330's physician orders dated 5/26/2024 were reviewed and indicated, Contact isolation precaution for shingles for 7 days. IPN 2 confirmed by stating there was no documented evidence that there was a care plan in place for the contact precautions and that a care plan should have been developed to ensure continuity of care for Resident 330. IPN 2 stated the importance of developing a care plan was to help staff know what interventions were needed to care for Resident 330. A review of facility's P&P titled Comprehensive Person-Centered Care Planning, reviewed on 1/29/2024, indicated all care plans will be developed and implemented, using the necessary combination of problem specific care plans since resident's admission to properly care for the resident. Based on observation, interview and record review, the facility failed to develop and implement individualized (resident-specific) comprehensive care plans (plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) for 12 out of 12 sampled residents (Residents 36, 40, 227, 277, 278, 48, 43, 50, 3, 178, 330 and 44) by: 1. Failing to develop and implement care plans for bilateral upper bed side rails as mobility enabler (assist in turning and transferring in and out of bed) for residents 36, 40, 277, and 278. 2. Failing to develop and implement a care plan for Resident 277's Venofer (iron sucrose - an IV iron medication) intravenous (IV, medical technique that administers fluids, medications, and nutrients directly into a person's vein) solution 100 milligrams (mg) intravenously in the evening for iron deficiency. 3. Failing to implement a care plan for transmission-based precautions (a set of infection control measures used in addition to standard precautions for patients who may be infected with pathogens that can transmit disease) for Resident 178. 4. Failing to implement care plans for side rails for turning and repositioning for Residents 48, 50, 44 and 178. Residents 48, 50, 44 and 178 required the bilateral (both sides) upper bed side rails to be in the up position when in bed. 5. Failing to develop and implement a comprehensive care plan for the Resident 48's Desitin cream (used as a moisturizer to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations [such as diaper rash, skin burns from radiation therapy]) inside the resident's bedside drawer and [NAME] tears eyedrops (used to help relieve dryness of the eyes) left on top of the bedside table by facility staff. 6. Failing to develop and implement a comprehensive care plan for the use of oxygen supplement therapy for Resident 3 and Resident 10. 7. Failing to develop and implement a care plan for the use of bilateral bed side rails for Resident 43. 8. Failing to develop and implement a care plan for Contact Precautions (intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or the patient's environment) for Resident 330. The deficient practices placed Residents 36, 40, 277, 278, 43, 48, 50, 3, 178, 330, and 44 at risk for missed care and treatment, worsening of current medical conditions, infections, organ failure, and death. Findings: 1. A review of Resident 36's admission Record, dated 5/28/2024, indicated Resident 36 was originally admitted to the facility on [DATE], and was re-admitted on [DATE], with diagnoses including diabetes (a disease in which your body does not produce enough insulin needed to control sugar levels in the blood), major depressive disorder (depressed mood or loss of interest in activities, causing significant impairment in daily life), abnormal posture, and generalize muscle weakness. A review of Resident 36's Minimum Data Set (MDS- standardized data collection tool used to assess cognitive brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions] and functional status, and care needs) dated 3/25/2024, indicated Resident 36's had moderate cognitive (ability to think, read, learn, remember, reason, express thoughts, and make decisions) impairment, and required substantial/maximal assistance from staff for toileting, bathing, dressing, personal hygiene and bed mobility. A review of Resident 36's physician order summary report (POSR) as of 5/28/2024, indicated there were no orders for side rails. A review of Resident 36's care plans indicated Resident 36 had no care plan for side rails to be utilized as enablers for mobility. During an observation on 5/25/2024 at 12:48 p.m., Resident 36 was observed in bed with bilateral upper side rails up. During an observation on 5/26/2024 at 9:48 a.m., Resident 36 was observed in bed with bilateral upper side rails up. During an observation on 5/27/2024 at 11:01 a.m., Resident 36 was observed in bed with bilateral upper side rails up. A review of Resident 40's admission Record, dated 5/28/2024, indicated Resident 40 was originally admitted to the facility on [DATE], with diagnoses including, depressive disorder, heart failure (a medical condition where the heart muscle doesn't pump blood as well as it should), hypertension (high blood pressure) and chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breath). A review of Resident 40's MDS, dated [DATE], indicated Resident 40's had mild cognitive impairment, and required moderate to maximal assistance from staff for toileting, bathing, dressing, personal hygiene, and bed mobility. A review of Resident 40's POSR as of 5/28/2024, indicated there were no orders for side rails. A review of Resident 40's care plans indicated Resident 40 had no care plan for side rails to be utilized as enablers for mobility. During an observation on 5/25/2024 at 12:56 p.m., Resident 40 was observed in bed with bilateral upper side rails up. During an observation on 5/26/2024 at 9:49 a.m., Resident 40 was observed in bed with bilateral upper side rails up. During an observation on 5/27/2024 at 3:00 p.m., Resident 40 was observed in bed with bilateral upper side rails up. A review of Resident 277's admission Record indicated Resident 277 was originally admitted to the facility on [DATE], with diagnoses including hypertensive (high blood pressure) heart disease with heart failure (disease when heart doesn't pump enough blood for your body's needs), muscle weakness, difficulty walking and anemia (not enough oxygen carrying red blood cells in the blood). A review of Resident 277's MDS, dated [DATE], indicated Resident 277 had mild cognitive impairment and required supervision or touching assistance from staff for eating, oral hygiene, and upper body dressing, and moderate and maximum assistance from staff for toileting, bathing, lower body dressing and personal hygiene. A review of Resident 277's POSR as of 5/28/2024, indicated there were no orders for side rails. A review of Resident 277's care plans, indicated Resident 277 had no care plan for side rails to be utilized as enablers for mobility. During an observation on 5/25/2024 at 11:06 a.m., Resident 277 was observed in bed with bilateral upper side rails up. During an observation on 5/26/2024 at 10:00 a.m., Resident 277 was observed in bed with bilateral upper side rails up. During an observation on 5/27/2024 at 11:05 a.m., Resident 277 was observed in bed with bilateral upper side rails up. A review of Resident 278's admission Record indicated Resident 278 was originally admitted to the facility on [DATE], with diagnoses including diabetes mellitus, muscle weakness, discitis (inflammation of the intervertebral [area between bones of the spine] disc space) lumbar (lower back) region, and malignant neoplasm (cancerous tumor) of the breast. A review of Resident 278's MDS, dated [DATE], indicated Resident 278 had moderate cognitive impairment and required supervision or touching assistance from staff for toileting, bathing, dressing and personal hygiene. A review of Resident 278's POSR as of 5/28/2024, indicated there were no orders for side rails. A review of Resident 278's care plans, indicated Resident 278 had no care plan for side rails to be utilized as enablers for mobility. During an observation on 5/25/2024 at 5:28 p.m., Resident 278 was observed in bed with bilateral upper side rails up. During an observation on 5/26/2024 at 9:42 a.m., Resident 278 was observed in bed with bilateral upper side rails up. During an observation on 5/27/2024 at 11:05 a.m., Resident 278 was observed in bed with bilateral upper side rails up. 2. A review of Resident 277's admission Record indicated Resident 277 was originally admitted to the facility on [DATE], with diagnoses including hypertensive, heart disease with heart failure muscle weakness, difficulty walking and anemia. A review of Resident 277's MDS, dated [DATE], indicated Resident 277 had mild cognitive impairment and required supervision or touching assistance from staff for eating, oral hygiene, and upper body dressing, and moderate and maximum assistance from staff for toileting, bathing, lower body dressing and personal hygiene. A review of Resident 277's prescription order sheet dated 5/21/2024, indicated an order for Venofer intravenous solution (iron sucrose - an IV iron medication) 100 milligrams (mg) intravenously in the evening for iron deficiency. A record review of Resident 277's care plans, indicated no care plan created for the resident's Venofer IV therapy. During an observation on 5/26/24 at 10:00 a.m., Registered Nurse 1 (RN 1) was observed caring or Resident 277's IV access. During an interview on 5/28/2024 at 2:11 p.m., with the Infection Prevention Nurse 1 (IPN 1), IPN 1 confirmed by stating Resident 277 did not have a care plan for IV therapy and stated there should have been a care plan for a resident on IV therapy. 4. A review of Resident 48's admission Record indicated resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), acute respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood) and pneumonia (lung infection that inflames air sacs with fluid or pus). A review of Resident 48's MDS dated [DATE], indicated the resident's cognitive skills for daily decision-making were moderately impaired and the resident required maximal to total assistance from staff for eating, toileting hygiene, shower/bathing self, upper and lower body dressing, repositioning from sit to lying and rolling left to right. A review of Resident 48's POSR as of 5/27/2024, indicated there were no orders for side rails. A review of Resident 48's care plan initiated on 4/29/2024, indicated the resident was at risk for falls related to gait/balance problems. The care plan indicated interventions included the facility was to provide siderails for turning and repositioning. During a concurrent observation in Resident 48's room and interview on 5/26/2024 at 11:16 a.m., Resident 48 was observed with a bilateral bed siderail in the up position. Resident 48 stated she was unable to get up independently and unable to move independently from bed to a sitting position. Resident 48 was observed unable to move the bilateral bed side rails from the up to down position. During a concurrent observation of Resident 48 and interview on 5/26/2024 at 7:27 p.m., the DON stated and confirmed Resident 48 had bilateral bed side rails in the up position and the bed siderails did not need a physician's order because the side rails were in the nursing scope of practice. During a follow-up interview on 5/27/2024 at 11:53 a.m., the DON stated the use of bilateral bed siderails did not need a physician's order or informed consent (the process of providing people with information so they can make their own decisions about accepting or refusing treatment or services) since the facility was not utilizing the bed rails as restraints (devices used to limit or obstruct independent movement in and out of bed). When asked if Resident 48 was able to move the bed siderails on independently the DON stated, no. The DON stated that if there was a care plan with an intervention indicating a resident needed side rails for turning and repositioning it was okay to always have the side rails in the up position when in bed. A review of Resident 50's admission Record indicated resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including surgical aftercare following surgery on the skin, congestive heart failure (CHF- a progressive condition that affects the pumping power of the heart muscle) and paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease). A review of Resident 50's MDS dated [DATE], indicated the resident's cognitive skills for daily decision-making were mildly impaired and the was resident was totally dependent on staff for toileting hygiene, shower/bathing self, lower body dressing, repositioning from sit to lying, and lying to sitting on side of bed. A review of Resident 50's POSR, as of 5/27/2024, indicated there were no orders for side rails. A review of Resident 50's informed consents as of 5/27/2024 indicated, there was no informed consent signed by the resident or the resident's responsible party for the use of bilateral bed siderails. A review of Resident 50's care plan initiated on 4/26/2024, indicated Resident 50 was at risk for falls related to gait/balance problems. The care plan indicated interventions included the facility was to provide siderails for turning and repositioning. During a concurrent observation of Resident 50's room and interview on 5/26/2024 at 9:25 a.m., Resident 50 stated he was unable to get up independently and needed assistance to get up from bed to wheelchair. Resident 50 was asked if he was able to put the side rails in the down position independently and Resident 50 stated he could not. During a concurrent observation of Resident 50 on 5/26/2024 at 7:30 p.m., the DON stated and confirmed Resident 48 had bilateral bed side rails in the up position and the bed siderails did not need a physician's order because the side rails were in the nursing scope of practice. During a follow-up interview with DON on 5/27/2024 at 11:53 a.m., the DON stated the use of bilateral bed siderails did not need a physician's order or informed consent (the process of providing people with information so they can make their own decisions about accepting or refusing treatment or services) since the facility was not utilizing the bed rails as restraints (devices used to limit or obstruct independent movement in and out of bed). When asked if Resident 50 was able to move the bed siderails on independently the DON stated, no. The DON stated that if there was a care plan with an intervention indicating a resident needed side rails for turning and repositioning it was okay to always have the side rails in the up position when in bed. 5. A review of Resident 48's admission Record indicated resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy, acute respiratory failure, acute kidney failure and pneumonia. A review of the MDS dated [DATE], indicated Resident 48's cognitive skills for daily decision-making were moderately impaired and the resident was totally dependent on staff for eating, toileting hygiene, shower/bathing self, upper and lower body dressing, and personal hygiene. A review of Resident 48's Self-Administration of Medication form dated 4/14/2024, indicated Resident 48 was not approved for self-administration of medications and the resident was not allowed to keep medications at bedside. A review of Resident 48's care plans as of 5/27/2024, indicated there was no care plan in place for medications to be left at bedside. During a concurrent observation of Resident 48's room and interview on 5/26/2024 at 11:16 a.m., Resident 48 was observed with an opened Desitin cream inside the resident's bedside drawer and [NAME] tears eyedrops on top of the bedside table. Resident 48 stated the Desitin cream was brought in from the hospital and the eyedrops was from the facility and facility staff left the eyedrops on the bedside. During a concurrent observation of Resident 48's room and interview on 5/26/2024 at 7:45 p.m., the DON observed Resident 48's Desitin cream and [NAME] tears eyedrops at bedside. The DON stated and confirmed that Resident 48 was not allowed to keep medications at bedside. The DON stated she (DON) would have to store the medications in the facility's locked cabinet. The DON stated the medications left at the bedside put Resident 48 at risk of accidents due to not being able to properly administer the medications and put other residents at risk of accidents by allowing other residents to access medications that were not prescribed for them. The DON stated and confirmed there was no care plan developed for Resident 48's medication to be left at the bedside. 6. A review of Resident 3's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis (loss of the ability to move in one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting right dominant side, Parkinson's disease (a disorder in the brain that affects movement, often including tremors), Alzheimer's disease (a progressing brain disorder that destroys memory and other important mental function), hypertension, and hyperlipidemia (abnormally high levels of fats in the blood) A review of the MDS dated [DATE], indicated Resident 3's cognitive skills for daily decision-making were moderately impaired and the resident was totally dependent on staff for eating, toileting hygiene, repositioning from sit to stand, bed to chair transfer. A review of Resident 3's Physician's History and Physical (H&P), dated 3/19/2024, indicated Resident 3 was unable to be fully assessed by the physician and did not follow commands. A review of Resident 3's POSR dated 1/17/2024, indicated a physician order was in place for oxygen at 2 liters per minute (l/min - unit of measurement) via nasal cannula (NC - a device used to deliver supplemental oxygen that should be placed directly on the resident's nostrils) to keep oxygen saturation (O2 sat) above 93 percent (% - unit of measurement) every shift for shortness of breath (SOB)/desaturation (the condition of a low blood oxygen concentration). A review of Resident 3's care plan for altered cardiovascular (pertaining to the heart and blood vessels that make up the circulatory system) status related to (r/t) HTN, hyperlipidemia, revised on 5/2/2024, indicated a goal for the resident to be free from complications of cardiac problems. The care plan indicated on 5/25/2024 and intervention to provide O2 via N/C per order was not added until 5/25/2024. A review of Resident 3's vital sign (VS - measurements of the body's most basic functions) dated 5/26/2024 at 8:16 a.m., indicated that Resident 3's O2 sat was 92%. During an observation of Resident 3 on 5/25/2024 at 11:03 a.m., Resident 3 was observed in bed, eyes closed, and no oxygen machine or NC were observed in the room. During a follow-up observation with Resident 3 on 5/26/2024 at 11:52 a.m., Resident 3 was observed in bed, and no oxygen machine or NC were observed in the room. During a concurrent interview and record review of Resident 3's Order Summary on 5/27/2024 at 12:23 p.m., the Minimum Data Set Nurse 1 (MDSN1) stated confirmed Resident 3 had a physician's order for O2 supplement and stated the physician's order had to be followed. During an interview on 5/27/2024 at 12:31 p.m., the DON confirmed by stating there was no oxygen machine set-up for Resident 3. The DON stated the facility was not implementing Resident 3's care plan regarding oxygen therapy. A review of Resident 10's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including acute respiratory failure with hypoxia (low levels of oxygen in the body tissues), heart failure and toxic encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood). A review of the MDS dated [DATE], indicated Resident 10's cognitive skills for daily decision-making were severely impaired and the resident was totally dependent on staff for oral hygiene, toileting hygiene, shower/bathing, upper and lower body dressing, and personal hygiene. A review of Resident 10's POSR dated 8/18/2023, indicated physician's order was in place for oxygen at 2l/min via NC to keep O2 sat above 93 percent every shift for SOB every shift. A review of Resident 10's CP for altered respiratory status/difficulty breathing r/t acute hypoxic respiratory failure revised on 5/8/2024, indicated a goal for the resident to be free from complications r/t SOB, with interventions including to provide oxygen as ordered. During an observation of Resident 10 on 5/25/2024 at 11:56 a.m., Resident 10 was observed on O2 supplement via NC. Resident 10's oxygen machine was observed at 1.5 l/min (not the ordered 2l/min). During an interview on 5/27/2024 at 12:35 p.m., the DON stated physician's orders for O2 supplement had to be followed. The DON stated she (DON) would check Resident 10's O2 supplement machine and would call physician to update the order. During a follow-up interview on 5/27/2024 at 5:51 p.m., the DON confirmed by stating Resident 10's O2 machine was less than 2 l/min which was not what was indicated on the physician's order or care plan. A review of the facility's policy and procedures (P&P) titled, Oxygen Therapy, reviewed on 1/29/2024, indicated to administer oxygen per physician's orders. 7. A review of Resident 43's admission Record indicated resident was admitted to the facility on [DATE] with diagnoses including urinary tract infection (UTI- an infection in any part of the urinary system, including the kidney, bladder or urethra), sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), and paroxysmal atrial fibrillation (afib- a sudden irregular and very rapid heart rhythm that and can lead to blood clots in the heart). A review of Resident 43's MDS dated [DATE], indicated the resident's cognitive skills for daily decision-making were mildly impaired and the resident required moderate to maximal assistance from staff for toileting hygiene, shower/bathing self, upper and lower body dressing, repositioning from sit to lying, and sit to stand. A review of Resident 43's POSR as of 5/27/2024, indicated there were no orders for side rails. A review of Resident 43's informed consents as of 5/27/2024 indicated, there was no informed consent signed by the resident or the resident's responsible party for the use of bilateral bed siderails. A review of Resident 43's Bed Rail assessment dated [DATE], indicated the use of side rails or assist bars were not indicated. A review of Resident 43's care plans as of 5/27/2024 indicated, there was no care plan developed or implemented for the use of bilateral bed siderails. During a concurrent observation of Resident 43 on 5/25/2024 at 12:00 p.m., Resident 43 was observed with bilateral upper bed siderails in the up position. Resident 43 stated she was unable to get up independently and needed assistance from staff to get out of bed and with walking. Resident 43 was observed unable to move the bilateral bed siderails down independently. During a concurrent observation of Resident 43 and interview on 5/26/2024 at 7:25 p.m., the DON confirmed by stating Resident 43 had bilateral side rails in the up position. During a follow-up interview on 5/26/2024 at 11:50 a.m., the DON stated the use of bilateral bed siderails did not need a physician's order and an informed consent was not needed as the side rails were not utilized as restraints. When asked regarding Resident 43's bed rails assessment which indicated side rails/assist bar are not indicated at this time, the DON was unable to answer. When asked if Resident 43 was able to move the siderails independently, the DON stated, no. The DON stated if there was a care plan with an intervention indicating that a resident needed a side rail for turning and repositioning, it was okay to always have the side rails up when the resident was in bed. 3. A review of Resident 178's admission Record indicated Resident 178 was originally admitted to the facility on [DATE], and was re-admitted on [DATE], with diagnoses including diabetes mellitus, end stage renal failure (ESRD-a medical condition in which a person's kidney [organ in the body that lifters waste and excess fluid from the blood] function stop functioning on a permanent basis), hemodialysis (HD-filtering the blood of a person whose kidneys are not working normally) dependence and generalized muscle weakness. A review of Resident 178's MDS dated [DATE], indicated Resident 178's cognitive skills for daily decision-making was moderately impaired and the resident required maximal assistance from staff for activities of daily living (ADLs- bed mobility, transfer, dressing, and toilet use). The MDS also indicated Resident 178 was on hemodialysis since admission. A review of Resident 178's POSR as of 5/28/2024, indicated there were no orders for enhanced standard precaution. A review of Resident 178's care plan created on 5/25/2024, indicted Resident 178 was at risk for MDRO (multi drug resistant organism-bacteria that have become resistant to certain antibiotic medications). The care plan indicated interventions (specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition) included to initiate enhance standard precautions and educate staff regarding the use and purpose of the precaution. During an observation of Resident 178's room on 5/25/2024 at 12:49 p.m., Resident 178's signage was observed indicating Resident 178 did not need to be on transmission-based precautions. During an observation on 5/26/2024 at 10:04 a.m., Certified Nursing Assistant 4 (CNA 4) was observed not wearing any personal protective equipment (PPE) while providing Resident 178's care. CNA 4 stated Resident 178 was not on transmission-based precautions; therefore CNA 4 did not need any PPE. During an observation of Resident 178's room door and interview on 5/27/2024 at 11:41 a.m., Licensed Vocational Nurse 3 (LVN3) observed the signage on the front door of Resident 178's room indicating the resident did not need to be on enhanced standard precaution. LVN 3 stated and verified that Resident 178 was supposed to be in enhanced standard precaution since re-admission [DATE]). During an interview on 5/27/2024 at 4:56 p.m., IPN 1 confirmed by stating Resident 178 was supposed to be on enhanced standard precautions since re-admission [DATE]). IPN 1 stated the signage was not updated and that Resident 178 was at risk for infection if staff was not wearing proper PPE when caring for the resident. 4. A review of Resident 44's admission Record indicated Resident 44 was originally admitted to the facility on [DATE], and was re-admitted on [DATE], with diagnoses including injury of head, dementia (loss of cognitive functioning-thinking, remembering, and reasoning), generalized weakness, history of falling and epilepsy (a disorder in which a nerve cell activity in the brain is disturbed causing seizure [a sudden, uncontrolled electrical disturbance in the brain]). A review of Resident 44's MDS dated [DATE], indicated Resident 44's cognitive skills for daily decision-making were moderately impaired, requiring maximal assistance from staff for activities of daily living (ADLs- bed mobility, transfer, dressing, and toilet use). A review of Resident 44's POSR as of 5/27/2024, indicated there were no orders for side rails. A review of Resident 44's care plan reviewed on 3/15/2024, indicated Resident 44 was at risk for falls related to gait/balance and history of falls. The care plan indicated interventions included the facility was to provide siderails for turning and repositioning. During an observation in Resident 44's room on 5/26/2024 at 10:02 a.m., Resident 44 was observed in bed with padded bilateral upper side rails in the up position. During an interview on 5/27/2024 at 11:50 a.m., LVN 3 stated Resident 44 needed to have padded bilateral upper side rails in the up position when in bed for safety. LVN 3 stated according to the care plan bilateral upper side rails were supposed to be in the up position for turning and repositioning. LVN 3 stated the side rails were to only be used when Resident 44 was being turned and repositioned. LVN 3 stated she was unsure if using side rails as enabler required a physician order. A review of Resident 178's admission Record indicated Resident 178 was originally admitted to the facility on [DATE], and was re-admitted on [DATE], with diagnoses including DM, ESRD, HD dependence and generalized muscle weakness. A review of Resident 178's MDS dated [DATE], indicated Resident 178's cognitive skills for daily decision-making were moderately impaired and the resident required maximal assistance from staff for ADLs. The MDS also indicated Resident 178 was on hemodialysis since admission. A review of Resident 178's POSR, as of 5/27/2024, indicated there were no orders for side rails. A review of Resident 178's care plan reviewed on 5/6/2024, indicated Resident 178 had an ADL self-care performance deficit. The care plan indicated interventions included the facility was to provide siderails for turning and repositioning. During an observation of Resident 178's room on 5/25/2024 at 11:23 a.m., Resident 178 was observed in bed with bilateral upper side rails in the up position. During an observation of Resident 178's room on 5/26/2024 at 10:02 a.m., Resident 178 was observed in bed with bilateral upper side rails in the up position. During an observation Resident 178's room on 5/26/2024 at 4:20 p.m., Resident 178 was observed in bed with

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide the necessary care and services to attain or maintain the highest practical emotional/physical well-being and pain management for two of two sampled residents (Resident 9 and Resident 58), by: 1. Failing to administer Resident 9's Lidocaine External Patch 5 percent (% - unit of measurement)- apply to affected area topically one time a day for pain management leave on for only 12 hours only within a 24-hour period at the scheduled time (9:00 a.m.). 2. Failing to remove Resident 9's lidocaine patch (a prescription-only topical local anesthetic) 12 hours after application as per physician's order and timely administered medications per physician's order. 3. Failing to ensure Resident 58's lidocaine patch was labeled according to facility's policy and procedure, titled Transdermal Drug Delivery System (Patch) Application reviewed on 1/29/2024. This deficient practice placed Resident 9 and Resident 58 at risk for experiencing untreated pain and discomfort, insomnia, impaired healing, and physical and emotional harm. Findings: 1. A review of Resident 9's admission Record indicated resident was admitted to the facility on [DATE] with diagnoses including aftercare following joint replacement surgery (a procedure in which a surgeon removes a damaged joint and replaces it with a new, artificial part), polyneuropathy (a condition in which a person's peripheral nerves are damaged), and major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 4/28/2024, indicated Resident 9's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were intact and the resident required moderate supervision from staff for activities of daily livings (ADLs-oral hygiene, toileting hygiene, shower/bathing self, upper and lower body dressing, repositioning from sit to lying and sit to lying). A review of Resident 9's Order Summary Report dated 4/21/2024, indicated the resident had an order for Lidocaine External Patch 5 %, apply to affected area topically one time a day for pain management leave on for only 12 hours only within a 24-hour period, scheduled at 9:00 a.m. A review of Resident 9's Care Plan for at risk for pain related to (r/t) recent hospitalization, recent surgery, disease process, initiated on 4/22/2024, indicated a goal of the resident not having discomfort related to side effects of analgesia (a class of drugs, designed to relieve pain). The care plan indicated interventions (specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition) including to administer medication as ordered. During a concurrent observation in Resident 9's room and interview on 5/24/2024 at 12:20 p.m., Resident 9 was observed with a patch on the left knee, there was no label with a date and time the patch was applied. Resident 9 stated it was a lidocaine patch the nurses applied once a day. Resident 9 stated the nursed kept the patch on the resident the whole day and applied a new patch in the morning. A review of Resident 9's Medication Administration Record (MAR) for the month of May 2024, indicated there was no documentation indicating the time the lidocaine patch was removed from 5/1/2024 - 5/28/2024. The MAR indicated on 5/24/2024, the lidocaine patch was applied at 3:45 p.m. not at the scheduled time of 9:00 a.m. 2. A review of Resident 58's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), hypertension (HTN - elevated blood pressure), a history of falling and muscle weakness. A review of Resident 58's MDS dated [DATE], indicated the resident's cognitive skills for daily decision-making were moderately impaired and the resident required moderate to maximal assistance from staff for toileting hygiene, shower/bathing self, upper and lower body dressing, repositioning from sit to lying and sit to stand. A review of Resident 58's Order Summary Report, dated 5/6/2024, indicated the resident had an order for Lidocaine External Patch 4% - apply to affected area topically one time a day for pain management on 12 hours, off 12 hours, scheduled at 9:00 a.m. A review of Resident 58's care plan for at risk for pain r/t recent hospitalization, disease process, physical limitation initiated on 4/17/2024, indicated a goal of the resident not having any discomfort related to side effects of analgesia with interventions including to administer medication as ordered. During a concurrent observation of Resident 58 and interview on 5/24/2024 at 11:28 a.m., Resident 58 was observed with patches on the left and right knee, no labels indicating the date and time the patches were applied were observed. Resident 58 stated she has also had a patch on her back. Resident 58 stated she didn't remember when the patches were applied or if the patches were to be removed at night. Resident 58 stated she believed the patch on her back was put on the day prior (5/23/2024). Resident 58 reported having a lot of pain on the right knee and right side of the body because of a fall sustained at home (the resident fell on the right side). A review of Resident 58's MAR for the month of May 2024, indicated that there was no documentation when the lidocaine patch was removed from 5/6/2024 - 5/25/2024. The MAR indicated the following: Lidocaine patch 4%, scheduled at 9:00 a.m.: On 5/13/2024, the lidocaine patch was applied at 12:26 p.m., on 5/19/2024, the lidocaine patch was applied at 1:56 p.m., and on 5/24/2024, the lidocaine patch was applied at 3:02 p.m. During a concurrent interview and record review of Resident 9 and Resident 58's order summary report and MAR, the Director of Nursing (DON) reviewed the resident's order summary reports and MARs and stated the medication order had to be specific on where to apply the patch and a time should have been documented when the patch was removed. A review of the facility's P&P titled, Pain Management reviewed on 1/29/2024, indicated that the licensed nurse would administer pain medication as ordered and document medication administered on the MAR. A review of the facility's P&P titled, Transdermal Drug Delivery System (Patch) Application reviewed on 1/29/2024, indicated the purpose of the Transdermal Drug Delivery System (Patch) Application was to administer medication through the skin through proper placement of the patch and care of the application site(s) . Write the date and nurse's initials on a sticker and place the sticker on the back of the patch before application.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide sufficient staffing to accommodate resident needs by not answering call lights (device(s) with a button or touch pad a resident uses to set off an alarm that flashes/rings to alert the facility staff the resident needs assistance) in a timely manner for four of five sampled residents (Resident 8, 18, 50 and 53). This deficient practice resulted in Resident 8, 18, 50 and 53 not receiving needed services timely and efficiently and had the potential to affect the quality of life and treatment given to all 72 facility residents. Findings: A review of Resident 8's admission Record indicated Resident 8 was originally admitted to the facility on [DATE], and was re-admitted on [DATE], with diagnoses including obesity (a disorder involving excessive body fat that increases the risk of health problems), osteoarthritis (inflammation of the bone) and generalized muscle weakness. A review of Resident 8's Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 3/11/2024, indicated Resident 8's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making was intact and the resident required moderate assistance from staff for activities of daily living (ADLs- bed mobility, transfer, dressing, and toilet use). A review of Resident 18's admission Record indicated Resident 18 was admitted to the facility on [DATE] with diagnoses including monoplegia (paralysis limited to a single limb [arm/leg]) of lower leg, spinal stenosis (narrowing of the spaces within the spine, which can put pressure on the nerves that travel through the spine) and generalized muscle weakness. A review of Resident 18's MDS dated [DATE], indicated Resident 18 had moderately intact cognition for daily decision-making and required moderate assistance from staff for ADLs. A review of Resident 50's admission Record indicated Resident 50 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including bronchitis (inflammation of the bronchi [airways in the lungs] of the lungs), obesity and congestive heart failure (CHF-a chronic condition in which the heart does not pump blood as well as it should). A review of Resident 50's MDS dated [DATE], indicated Resident 50 had moderately intact cognition for daily decision-making and required moderate assistance from staff for ADLs. A review of Resident 53's admission Record indicated Resident 53 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), acute respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide) and generalized muscle weakness. A review of Resident 53's MDS dated [DATE], indicated Resident 53 had moderately intact cognition for daily decision-making and required minimal assistance from staff for ADLs. During the resident council (an organized group of residents who meet regularly to discuss and address concerns about their rights, quality of care, and quality of life) meeting on 5/26/2024 at 12:08 p.m., Resident 8, 18, 50 and 53 stated that they had to wait 30 minutes to an hour to get assistance when using the call light system. Resident 8, 18, 50 and 53 stated that they had to wait until their assigned certified nursing assistant (CNAs) were done with lunch breaks before getting any assistance since no other CNAs would assist them. Resident 8, 18, 50 and 53 stated they could hear the staff talking to one another outside their (Resident 8, 18, 50 and 53) rooms and would still not answer the call lights. During an interview on 5/27/2024 at 4:54 p.m., the Director of Staff and Development (DSD) stated any staff could answer the call lights and call lights had to be answered within two minutes. The DSD stated waiting for 30 minutes to an hour was unacceptable. A review of a facility's policy and procedures (P&P) titled Communication-Call System reviewed on 1/29/2024, indicated facility staff were to provide a mechanism for residents to promptly communicate with Nursing Staff. The P&P indicated nursing staff were to answer call bells promptly and in a courteous manner.

Based on observation, interview and record review, the facility failed to ensure facility staff possessed the appropriate competencies to provide nursing and related services to assure resident safety four of nine sampled nursing staff (Registered Nurse 1-RN 1, Infection Prevention Nurse 1-IPN 1, Certified Nursing Assistant 4-CNA 4 and Certified Nursing Assistant 7-CNA 7) had the specific competencies and skills sets necessary to care for the residents. This deficient practice had the potential to lead to inadequate care and a delay resident's care. Findings: During a concurrent interview and record review of employee files on 5/27/2024 at 4:35 p.m., the Director of Staff and Development (DSD) reviewed nine sampled nursing staff files and confirmed by stating there were missing skills competencies (verification of the ability to perform a task with the necessary knowledge, skills, and abilities to provide safe and effective care to residents) for RN 1, IPN 1, CNA 4 and CNA 7. The DSD stated nursing skills competencies were required to be verified upon hire, yearly, and as needed. A review of a facility's policy and procedures (P&P) titled Staff Competency Assessment reviewed on 1/29/2024, indicated competency assessments would be performed upon hire during the 90-day employment period, annually or anytime new equipment or a procedure was introduced and as needed. The P&P indicated the competency assessments would be kept in the employee file for current employees and for seven years from the last date of employment.

Based on observation, interview, and record review, the facility failed to ensure pharmaceutical services included procedures to ensure the emergency kit (e-kit - secured container or secured electronic system containing drugs which are used for either immediate administration to residents or in an emergency or as a starter dose) was securely sealed and medciation used from the E-kit was reordered. By failing to: 1. Ensure the Intravenous (IV, insertion of a cannula or catheter into a vein to provide access to the bloodstream) E-kit located in one of one sampled medication storage closet (medication storage closet 1) was properly resealed, had an open date documented, and medication used was reordered. 2. Ensure the narcotic (any psychoactive compound with numbing or paralyzing properties) E-kit located in one of two sampled medication carts (medication cart 1B) was properly resealed and medication used was reordered. This deficient practice had the potential for harm to residents due to a lack of availability of medications leading to delays in the timely administration of medications in the event of an emergency. Findings: 1. During a concurrent observation and interview on 5/26/2024 9:48 a.m., with Director of Nursing (DON), one used IV E-kit was observed stored inside the medication storage closet 1, the E-kit was dated filled 4/17/2024. The E-kit had a red zip-tie (indicating the E-kit had been opened, unopened box would have green zip-tie) to reseal box, that was improperly applied because the box was opened by DON without cutting the zip-tie. The DON stated the E-kit was not properly secured and the E-kit should have been picked up by the pharmacy for replacement within 48 hours after opening. During a concurrent interview and record review on 5/26/2024 9:48 a.m., with Director of Nursing (DON), a yellow carbon copy of the Emergency Kit Pharmacy Log from inside the E-kit was reviewed. The log indicated NS (normal saline, mixture of salt and water, used to treat dehydration [insufficient water in the body]) 0.9%, 1 bag removed on 4/9/2024. The log had missing entries in columns for Pharmacist taking order and Serial #. The DON verified the missing entries on the log and stated al sections of the log should have been filled out by the nurse when removing the medication from the E-kit. A review of the facility Emergency Kit Pharmacy Log, dated 4/9/2024, indicated Instructions: 1. Submit orders to the pharmacy. 2. Contact pharmacy to obtain authorization from the pharmacist before removing item from the E-kit. 3. Enter information on E-kit log. 4. Place white copy in E-kit binder and return yellow copy with E-kit to the pharmacy. 5. Reseal E-kit. 2. During a concurrent observation and interview on 5/26/2024 10:14 a.m., with Registered Nurse 2 (RN 2), observed a narcotic E-kit located inside the medication cart with a red zip tie. Upon opening the narcotic E-kit, an E-kit pharmacy log was inside the narcotic E-kit, indicated that on 5/15/2024, the E-kit was opened and a medication was removed. RN 2 stated that once they opened an E-kit, the licensed nurse was supposed to re-order a new E-kit as soon as possible via phone call and fax to the pharmacy, needing to have it refilled within 72 hours of opening. A review of the facility's policy and procedures titled Emergency Pharmacy Service and Emergency Kits, revised January 2018, indicated, G. When an emergency or stat order is received, the nurse follows the procedure for order documentation . 3) The nurse records the medication use from the emergency kit on the [medication/use form] and [calls the pharmacy for replacement of the kit/dose and/or flags the kit with a color-coded lock to indicate need for replacement of kit/dose] as soon as possible after the medication has been administered . 6) Before going off duty, the charge nurse indicates the opened status of the emergency kit at the shift change report, and transfers the new medication orders to oncoming staff . I. If exchanging kits, when the replacement kit arrives the receiving nurse gives the used kit to the pharmacy personnel for return to the pharmacy . K. The kits are monitored/inventoried by the [consultant pharmacist/provider pharmacy] at least [every thirty (30) days] for completeness and expiration dating of the contents. The date of inventor is noted [on the outside of the kit].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide pharmaceutical services to meet the needs of residents in the facility by failing to: 1. Ensure proper disposal of an open sterile central line (a small, soft tube called a catheter is put in a vein that leads to your heart, used for delivering fluids or medications for a longer period of time) dressing kit, and expired sterile (completely clean and free from germs) needles, alcohol pads (small gauze pads saturated with alcohol used as an disinfectant), and saliva collection kit (syringe used to collect saliva for a lab test). 2. Ensure opened medication bottles/containers for acidophilus (prebiotic medication) and bismuth subsalicylate (medication that relieves symptoms of upset stomach) were dated when opened. 3. Ensure ipratropium Bromide and albuterol sulfate solution (medication being given via inhalation [inhaling medication in the form of gas or vapor] used to treat or prevent bronchospasm [when muscles that line the airways in the lungs becomes tighten) was properly used when opened within two weeks or disposed after the timeframe per manufacturer's policy. 4. Ensure pill cutter was clean every after use. 5. Ensure medication cart was clean at all times. These deficient practices had the potential to compromise the safety and effectiveness of medications which could result in medication administration error and place residents at risk for unsafe, improper medication administration use. Findings: 1. During a concurrent observation and interview on [DATE] 10:42 a.m., with Registered Nurse 3 (RN 3), the IV (intravenous which means in the vein) medication storage closet was observed. There was one open sterile central line dressing kit, and 45 expired sterile needles (expiration date [DATE]), five expired alcohol pads (expiration date 8/2023), and one expired saliva collection kit (expiration date 9/2023). RN 3 verified the expiration dates of the supplies, gathered the supplies to throw them out and stated they (expired supplies) should not be there. A review of the facility's policy and procedures (P&P), titled Equipment and Supplies for Administering Medications, reviewed on [DATE], indicated, The facility maintains equipment and supplies necessary for the preparation and administration of medications to residents . A. The following equipment and supplies are acquired and maintained by the facility for proper storage, preparation and administration of mediations: 5) Oral syringes, parenteral (without passing through the digestive system, usually by injection or IV) syringes, needles, droppers . alcohol wipes, . labels for date opened/date expires . B. The charge nurse on duty ensures that equipment and supplies relating to medication administration are clean and orderly . C. The consultant pharmacist monitors medication storage conditions on a [quarterly] bases and reports any irregularities and recommendations for improvement to the [director of nursing]. 2. During a concurrent observation and interview with RN 2 on [DATE] at 10:30 a.m., medication cart 1 was observed. There were opened bottles of acidophilus (prebiotic medication) and bismuth subsalicylate (medication that relieves symptoms of upset stomach) with missing date to indicate the date opened. RN 2 stated when opening a medication bottle and or container, they (nurses) have to make sure that they put the date when it was opened. A review of the facility's P&P, titled, Medication Storage in the Facility, reviewed on [DATE], indicated that when the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated by placing a date opened sticker on the medication. 3. During a concurrent observation and interview with RN 2 on [DATE] at 10:34 a.m., medication cart 2 was observed. There was a fully opened foil pack of ipratropium Bromide and albuterol sulfate solution inside the opened box dated [DATE]. RN 2 validated the open foil inside the open box and stated that per manufacturer's policy, the medication was supposed to use within 2 weeks from the time package was opened. A review of the facility's P&P, titled, Medication Storage in the Facility, reviewed on [DATE], indicated that the nurse will check the expiration date of each medication before administering it. P&P also indicated that all expired medication will be removed from the active supply and destroyed in the facility. A review of the manufacturer's guidelines for ipratropium Bromide and albuterol sulfate solution, undated, indicated that the medication should be protected from light, should remain stored in the protective foil pouch at all times and once open, it should be used within two weeks. 4. During a concurrent observation and interview with RN 2 on [DATE] at 10:27 a.m., a pill cutter inside the medication cart 1 was observed with whitish and greenish particles. RN 2 stated the pill cutter should be cleaned after each use, so it does not cause of mixing with medications. During a concurrent observation and interview with the Licensed Vocational Nurse 3 (LVN 3) on [DATE] at 11:28 a.m., a pill cutter inside the medication cart 2 was observed with whitish and greenish particles. LVN 3 stated the pill cutter should be cleaned after each use since it will have some residues from other medications. 5. During a concurrent observation and interview with LVN 3 on [DATE] at 11:28 a.m., there were cluttered items including bandages, nail cutter, alcohol wipes, etc. inside the left top drawer of medication cart 2. LVN 3 stated the charge nurses was supposed to keep the medication cart clean at all times. During an interview with Infection Preventionist Nurse 1 (IPN 1) on [DATE] at 5:02 p.m., IPN 1 stated that it was the charge nurses' duty to make sure medication carts and pill cutter are being cleaned due to possible transmission of infection. A review of the facility's P&P, titled, Medication Administration-General Guidelines, reviewed on [DATE], indicated that medications are administered in accordance with good nursing principles.

Based on observation, interview and record review, the facility failed to follow the menu and provide resident a variety of food options when: 1.One resident (Resident 48) who was on a renal diet (a diet aimed at keeping levels of fluids, electrolytes, and minerals balanced in the body in individuals with kidney disease or who are on dialysis) received chicken jambalaya (mixed rice, chicken, and tomato dish) instead of Baked chicken and rice per menu. 2. Residents who were on vegetarian and vegan diets (Resident 69, Resident 61 and Resident 9) complained that the menu does not have variety of vegetarian options and Resident 61 complained that last week fish sticks were served every day for lunch. This deficient practice had the potential to result in inadequate nutrition status and meal dissatisfaction when the menu is not updated to reflect the needs of the residents. Findings: According to the facility dinner menu for regular diet on 5/24/2024, the following items will be served on the regular diet: Chicken Jambalaya (a casserole type dish with mixed rice, chicken, sausage, tomato and spices) 1 cup; seasoned zucchini ½ cup, 1 wheat roll, margarine, applesauce and milk. Renal Diet: Baked chicken with gravy 2 ounces, brown rice with margarine ½ cup, seasoned zucchini ½ cup, 1 wheat roll, margarine, and applesauce. During a concurrent observation and interview with [NAME] 2 and Dietary Supervisor (DS) in the kitchen on 5/25/2024, at 9:45a.m., there was a medium size plastic container of red colored rice, labeled chicken jambalaya stored in the reach in refrigerator with date 5/24/24 and use by date of 5/25/24. [NAME] 2 stated chicken jambalaya was from yesterday dinner (5/24/24). [NAME] 2 stated there were rice, sausage, chicken, tomato, onions, and spices. [NAME] 2 stated for residents on renal there was baked chicken and rice with no sausage and no tomato. According to the facility lunch menu for regular diet on 5/26/2024, the following items will be served on the regular diet: Baked pork chop with gravy 3 oz, 1 baked potato, margarine, mixed vegetables ½ cup, wheat roll margarine. Renal diet will receive pork chop, rice ½ cup and mixed vegetables. A review of Resident 48's meal ticket (physician ordered diet with resident food preferences) for lunch dated 5/26/24 indicated renal diet 80 grams protein, low salt, low potassium, no coffee, no milk, no pork. During an observation the tray line service for lunch on 5/26/204 at 11:55 a.m., for Resident 48 who dislikes pork and is on renal diet, [NAME] 3 served regular chicken jambalaya with mixed vegetables and wheat roll instead of the baked pork chop. During a concurrent interview with [NAME] 2 and [NAME] 3, [NAME] 3 stated the chicken jambalaya was left over from previous day's dinner and is used as an alternative for residents who don't like pork. [NAME] 2 stated she prepared the chicken jambalaya on 5/24/24 for dinner. She stated the ingredients were chicken, sausage, tomatoes, onions and rice. [NAME] 2 stated the same day residents on renal diet received baked chicken and rice instead of the chicken jambalaya per menu. During a dining observation on 5/26/2024 at 12:50 p.m., Resident 48 was on her bed and lunch was set up in front of her. Resident 48 stated the food is terrible and did not want to eat it. Resident 48's family who was present stated the food looked very bad and not appropriate for the renal diet. During an interview with [NAME] 2 and DS on 5/26/2024 at 3:30p.m., [NAME] 2 stated the residents on renal diet should not get tomatoes, potatoes, spinach, beans, and milk. When asked if the chicken jambalaya had tomatoes, [NAME] 2 replied yes. During the same interview, DS stated Resident 48 does not like pork and that's why [NAME] 3 served chicken jambalaya as the alternative. DS stated the regular chicken jambalaya was not a renal diet. DS stated, we should've served something else because jambalaya was not for renal diet. DS stated renal diet is low in salt and potassium foods such tomato to maintain normal electrolyte levels. A review of the recipe for the chicken jambalaya indicated the ingredients included chicken, sausage, onion, celery, diced tomatoes with juice and rice. For Renal diet, the recipe indicted to serve baked chicken with gravy, brown rice with margarine. A review of facility policy, titled renal diet, dated 2020, indicated, this diet is used for the resident with renal insufficiency .this diet regulates the dietary intake of sodium, potassium, and protein to lighten the work of the diseased kidney. 2. During a dining observation on 5/25/2024 at 1:15p.m., Resident 69 stated he is on a vegan diet. Resident 69 stated he does not eat any meats, dairy, eggs or fish. Resident 69's tray included fish sticks, brussel sprouts and pasta. Resident 69 stated he thought all the meals that was provided for him was plant based. During a dining observation on 5/25/2024 at 1:25 p.m., Resident 9 was in her room and on her bed. Resident 9 stated she is vegetarian, does not eat any meat but eats eggs, and dairy products. Resident 9 stated the facility gives her grilled cheese sandwich, cheese quesadilla (cheese in tortilla), fruit platter and fish sticks. Resident 9 stated she refused her meal today because a visitor brought her lentil soup. She stated the vegetarian options are limited in the facility, but her friends bring her vegetarian options. During a dining observation on 5/25/2024 at 2:00 p.m., Resident 61 was in her room on her bed. Resident 61 stated she is vegetarian, and eggs and dairy are ok. Resident 61 stated that they serve fish sticks as one of the vegetarian options. She states last week she received fish sticks every day for lunch. She stated she receives 3 fish sticks with side of vegetables and either rice, pasta, or potato. She stated there is very poor selection of vegetarian options. Resident 61 stated her family brings her vegetarian options. During an interview with DS on 5/26/2024 at 3:30 p.m., DS stated the options for vegetarian diets are grilled cheese sandwich, cheese quesadilla, salad, fruits, and fish sticks. DS stated they (facility) replace the meat with fish sticks or grilled cheese on the regular menu, but they don't have a special menu for vegetarian diet with recipes. DS stated she purchased plant-based meatballs and served as a substitute for meat and the residents did not like it. She stated she served platter of vegetables; garbanzo beans and corn and residents did not like it either. During an interview with facility administrator (ADM) on 5/26/2024 at 3:30p.m., ADM stated facility will work with the registered dietitian to evaluate and reassess residents' needs. A review of facility policy and procedure, titled, Menus dated 4/1/2014, indicated, the purpose to ensure that the facility provides meals to residents that meet the requirement of the food and nutrition board of the national research council of the national academy of sciences. the dietary manager will develop menus in collaboration with the dietitian. Menus are to be designed in consideration of resident preference, dietary department resourced .when a substation is requested, the substitute item should be compatible with the rest of the meal taking into consideration color, texture, and flavor, comparable in nutritional value taking into consideration vitamins, minerals and calories.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the residents were served the food with preferences listed on the lunch meal ticket (physician ordered diet with resident food preferences) and received substitute meal options of similar nutritive value when: 1.One resident (Resident 69) food preferences were not honored by serving fish sticks during lunch, despite Resident 69's diet order indicated Vegan. 2. Two residents (Resident 61 and Resident 9) who are vegetarians and do not eat meat, received 3 fish sticks for alternate protein choice that had lower protein content than the beef paprika (diced beef and spices) and the roasted pork chop that was on the regular menu. This deficient practice had the potential to result in decreased meal satisfaction, decreased nutritive value for the meal, which could lead weight loss and other health issues. Findings: 1. A review of admission Record indicated Resident 69 was admitted to the facility on [DATE] with diagnoses including epidural hemorrhage without loss of consciousness (bleeding between the inside of the skull and the outer covering of the brain), dysphagia oropharyngeal phase (difficulty swallowing) and cognitive communication deficit. A review of Resident 69's meal ticket (physician ordered diet with resident food preferences) for lunch dated 5/25/24 indicated Regular texture diet and vegan (A diet based on plants such as vegetables, grains, soy products tofu, nuts and fruits, vegans do not eat foods that come from [NAME] including dairy products and eggs.) During an observation of lunch service in the kitchen on 5/25/2024 at 12:00 p.m., cook 1 served 3 fish sticks with tartar sauce, brussels sprouts, and pasta for Resident 69. During a concurrent observation and interview with [NAME] 1 and [NAME] 2 on 5/25/2024 at 12:00p.m., Cook2 stated for the vegan and vegetarian get fish instead of the beef paprika. [NAME] 2 stated resident 69 likes the fish sticks. During a dining observation on 5/25/2024 at 1:15 p.m., resident 69 was seated on wheelchair and food on the bed side table Infront of him. Resident 69 stated he has been vegan for more than 5 years. He stated he does not eat animal products including fish. When asked if the lunch is vegan, he replied yes, adding I believe it is vegan. The resident further stated that the facility knows I am vegan, and I trust everything they provide and place Infront of me is vegan. During an interview with Cook1 and Cook2 on 5/25/2024 at 1:35 p.m., Cook1 stated vegan food should not have any meats, cheese, eggs, butter, and no fish. [NAME] 1 stated Resident 69 eats the fish sticks so we serve him the fish sticks. [NAME] 2 stated vegan meatballs were served but Resident 69 refused them but then the resident eats fish sticks. During the same interview with dietary supervisor (DS) on 5/25/2024 at 1:35 p.m., DS stated Resident 69 keeps asking for fish stick and that is the reason we give him fish sticks. DS stated she made vegie burger and put regular cheese on it and the resident ate the regular cheese. A review of the dietary profile for Resident 69 dated 4/10/2024 indicated the resident likes vegetables, salads, fruits, plant-based food, soy milk or almond milk and dislikes all meats, cheese, milk, and soups. A review of the same dietary profile for Resident 69 dated 4/10/2024 indicated the resident's family stated, brother is Vegan as much as possible no meats plant-based food and resident is able to tell what he likes and for snacks he likes crackers, chips, Sherbert. A review of Nutrition/Dietary Progress note for Resident 69 dated 4/29/2024 indicated the resident had a significate weight loss x 2 weeks, resident with variable intake and is likely not meeting estimated nutrient needs. Plan to add snacks TID in between meals at 10am, 2 pm and 8pm for variable intake, wound healing and wight loss. A review of the ingredients of the tartar sauce indicated the product has eggs. A review of the ingredients of the fish sticks indicated the product has [NAME] and type of fish. A review of facility policy, titled, Dietary profile and resident Preference interview revised 4/21/2022, indicated, The dietary manager will complete a dietary profile for residents to reflect current nutritional needs and food preferences. The dietary department will provide resident with meals consistent with their preferences and physician order as indicated on the tray card. If a preferred item is not available a suitable substitute should be provided. The dietary manager may update food preferences as often as necessary. A review of facility document titled Vegetarian and Vegan diet dated 2020, indicated, Vegans use vegetables, salads, legumes (beans, peas and lentils), tofu, fruits, whole grains, nuts and seeds and exclude all animal products. To maintain energy intake, increase the use of leavened bread, cereals, legumes, nuts, and seeds, use a fortified soy milk, use of green leafy vegetables, dried fruits etc. 2. A review of Resident 9's meal ticket (physician ordered diet with resident food preferences) for lunch dated 5/25/24 indicated No added salt regular texture, vegetarian, fish ok. A review of Resident 61's meal ticket for lunch dated 5/25/24 indicated CCHO diet (diet for individuals who have high blood sugar), regular texture and vegetarian (Diet consists of no meats and fish, vegetables, nuts, seeds, and fruits and sometimes eggs and dairy are included). During a concurrent observation and interview on 5/25/2024 at 12:00 p.m., [NAME] 1 served 3 fish sticks for residents 9 and resident 61 who were on vegetarian diet. [NAME] 1 stated the vegetarians like the fish stick and instead of the 3 ounces (oz.) beef paprika (diced beef with spices) vegetarians will get 3 fish sticks (frozen fish product breaded and shaped into sticks). Cook1 stated 3 fish sticks is 3 ounces of protein and usually for lunch it's 3 ounces of protein. During a review of the nutritional information on the packaging of the frozen fish sticks used as an alternative meal for the vegetarians indicated 4 fish sticks provide 12 grams of protein and facility served only 3 fish sticks even less protein. A review of the United States Department of Agriculture (USDA) USDA National Nutrient Database for Standard Reference Legacy dated (2018) Nutrients: Protein (g), The protein content of 3 ounces (oz) of cooked beef is 21-25 grams of protein. https://www.nal.usda.gov/sites/default/files/page-files/Protein.pdf The vegetarian alternative 3 fish sticks provided significantly less protein than the 3 ounces of the beef paprika (diced beef with spices) served on the regular menu. During a concurrent observation and interview on 5/26/2024 at 11:55 a.m., Cook3 served 3 fish sticks for residents 9 and resident 61 who were on vegetarian diet as an alternative meal for the boneless baked pork chop served on the regular menu. The protein content of the 3 ounces boneless pork chop is 20-25 grams and according to the nutrition information on the package of the frozen fish sticks, 4 fish sticks provide 12 grams of protein which is less than the pork chops. Cook3 stated the vegetarians like the fish sticks. Cook3 doesn't know how much protein fish sticks have. During a dining observation on 5/25/2024 at 1:25 p.m., Resident 9 was in her room and on her bed. Resident 9 stated that she is vegetarian, does not eat any meat but eats eggs, and dairy products. Resident 9 stated the facility gives her grilled cheese sandwich, cheese quesadilla (cheese in tortilla), fruit platter and fish sticks. Resident 9 stated she refused her meal today because a visitor brought lentil soup. She stated the vegetarian options are limited in the facility, but her friends bring her vegetarian options. During a dining observation on 5/25/2024 at 2:00 p.m., Resident 61 was in her room on her bed. Resident 61 stated she is vegetarian, and eggs and dairy are ok. Resident 61 stated that they serve fish sticks as one of the vegetarian options. She states last week she received fish sticks every day for lunch. She stated she receives 3 fish sticks with side of vegetables and either rice, pasta, or potato. She stated there is very poor selection of vegetarian options. Resident 61 stated her family brings her vegetarian options. During an interview with Dietary supervisor (DS) on 5/26/2024 at 3:30 p.m., DS stated the options for vegetarian diets are grilled cheese sandwich, cheese quesadilla, salad, fruits, and fish sticks. DS stated the facility replaced the meat with fish sticks or grilled cheese, but they (facility) did not have a set menu for vegetarian diet. DS stated the facility serves 3 fish sticks for 3 ounces of meat. During the same interview, DS stated the regular diet on 5/26/24 was 3 ounces of boneless baked pork chop and the vegetarians received 3 fish sticks. A concurrent review of the nutritional information on the package of the frozen and breaded fish sticks indicated 4 fish sticks is 4 ounces and provided 12 grams of protein. The nutrition content of 3 ounces of boneless baked pork chop is 20-25grams of proteins. DS stated if residents did not receive comparable amount of protein and calories, they would receive less nutrition and would have weight loss. During an interview with facility administrator (ADM) on 5/26/2024 at 3:30p.m., ADM stated 3oz of pork or meat provides anywhere between 21-27 grams of protein per information available on the internet, more protein than the 3 fish sticks. A review of Resident 9's diet order dated 4/29/2024 indicated No added salt diet, regular texture, low fat milk, vegetarian ok with fish. A review of Resident 61's diet order dated 5/10/2024 indicated CCHO regular texture (diabetic diet), vegetarian. A review of Resident 61's Dietary Profile dated 3/21/2024 indicated per residents (family) prefer vegetarian food, per family for snacks likes fresh fruits, apples, pears, oranges, watermelon, carrots celery, peanut butter. For main meal likes lentil soup, fresh vegetables, fruits hard boiled eggs or scrambled eggs and fish sticks are ok. Resident dislikes carbohydrates, cereal, pasta, bread, meats, spinach kale, fish fillet, turkey, and chicken. Family will also bring food. A review of the recipe for the beef paprika indicted portion size is (3 oz of beef and 1 oz of sauce). A review of the recipe for the baked pork chop indicated portion size is 1 pork chop boneless 3 ounces. A review of the nutrition information for Oven ready par fried whole grain breaded [NAME] sticks, indicated 4 fish sticks are 4 ounces and provide 12 grams of protein. A review of facility policy titled Vegetarian and Vegan diet (dated 2020) indicated, nutrition breakdown for protein 78-85 grams of protein per day. Vegetarians use vegetables, salads, legumes, tofu fruits, whole grains, nuts, and seeds and sometimes will use dairy item and eggs. A review of facility policy and procedures, titled, Menus dated 4/1/2014 indicated, the dietary manager will develop menus in collaboration with the dietitian. Menus are to be designed in consideration of resident preference, dietary department resourced .when a substation is requested, the substitute item should be compatible with the rest of the meal taking into consideration color, texture, and flavor, comparable in nutritional value taking into consideration vitamins, minerals and calories.

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation when: Food brought to resident from outside of the facility, including leftovers stored in the resident food refrigerator were not dated. There was no monitoring system for the refrigerator temperatures and expired food was not discarded. This deficient practice 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 food borne illness in 67 out of 70 residents who received food from facility including the residents who had their food stored in the resident refrigerator. Findings: During an observation in the resident refrigerator located in a room in the common hallway on 5/25/2024 at 11:00 a.m., there was no thermometer inside the freezer, no refrigerator/freezer temperature documentation log. There were three plastic bags containing food with no date. There was one large brown bag with food for a resident with no date. There was one lunch box with no label or date. One plastic to-go food container with date 5/21/24 and another container of food for resident with date 5/19/24 exceeded storage period for outside food. There was one small container of leftover strawberry flavor yogurt with no open date and one glass food storage container with white soupy food item with no label or date. The freezer contained frozen dinner boxes with no date, one large plastic cup of leftover coffee color drink with no label and date, one open leftover of chocolate bar with no label. During the same observation and interview with Dietary Supervisor (DS) and Administrator (ADM) on 5/25/2024 at 11:00 a.m., DS stated the nursing staff are responsible to check the food label and date. ADM stated everyone is responsible for maintaining the food in the refrigerator and to discard expired products. ADM stated when family brings food from outside, nurses should label and date the food item before storing in the refrigerator to know when to discard. ADM and DS didn't explain why there was no thermometer in the freezer. ADM stated they (facility) will make sure the refrigerator is organized, food is dated and expired items are discarded. A review of facility policy titled Food Brought in by Visitors (revised June 2018) indicated, When food is brought into a nursing home prepared by others, the nursing home is responsible for ensuring that the food container is clearly labeled with the resident's name and date received and stored in a refrigerator .perishable food requiring refrigeration will be discarded after two (2) hours at bedside, and if refrigerated it will then be labeled, dated, and discarded after 48 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the facility's Administrator (ADM) who was responsible for providing effective leadership, oversight, safe access to residents, staff, and visitors, policies, and procedures throughout the recertification process-maintained professionalism and appropriate behavior. This deficient practice impeded the completion of an investigation, placing facility residents at risk for the spread of infections, delays in care, and had the potential to make residents, visitors, and staff feel threatened. Findings: A review of Resident 278 admission record indicated the resident was initially admitted to the facility on [DATE] with diagnoses that included chronic kidney disease stage 4 (kidneys are moderately or severely damaged and are not working as well as they should to filter waste from your blood. Waste products may build up in your blood and cause other health problems), type 2 diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), and chronic obstructive disease (COPD- is a common lung disease causing restricted airflow and breathing problems). A review of Resident 278's Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 5/9/24 indicated, Resident 278 was moderately impaired cognitively (ability to think, read, learn, remember, reason, express thoughts, and make decisions) and required supervision and/or touching assistance to setup or clean-up assistance for activities of daily living (ADL's: activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). A review of the care plan titled At risk for MDRO and other transmissible infectious pathogens due to peripherally inserted central catheter (PICC line -presence of a long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart), history of MRSA (Methicillin-resistant Staphylococcus aureus is an infection of Staphylococcus (staph) bacteria. This germ is resistant to some antibiotics. It can spread in hospitals, other healthcare facilities, and in the community), ESBL (Extended-spectrum beta-lactamases are enzymes that confer resistance to most beta-lactam antibiotics, including penicillin, cephalosporins, and the monobactam aztreonam. Infections with ESBL-producing organisms have been associated with poor outcomes), and VRE (Vancomycin-resistant Enterococci are bacteria (germs) that commonly live in the gastrointestinal tract (bowels) of most people [colonization] can be spread from person to person through direct contact with an infected or colonized person), was initiated on 5/25/24 with interventions which included to educate resident, and resident family/representatives regarding the purpose of Enhanced Standard Precaution (ESP-transmission based precaution that refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). A review of Resident 278's physician order summary report (POSR) as of 5/27/202, indicated there was no physician's order for ESP. During a concurrent observation of Resident 278's room and interview on 5/27/2024 at 5:15 p.m., Resident 278's room door was observed to have signage indicating the resident was on Enhanced Standard Precaution (ESP-transmission based precaution that refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). Visitors/family were observed entering Resident 278's room without putting on the indicated Personal protective equipment (PPE: specialized gowns, gloves, masks, or equipment worn to create a barrier between the wearer and germs, reducing the chance of exposure and spread of infections). The visitors/family were then observed hugging and kissing Resident 278 with no PPE on. Registered Nurse 4 (RN4) was asked if resident family members and visitors were educated regarding ESP, PPE, and the importance of protecting residents who were on ESP. RN 4 stated that visitors were notified over the phone before visiting the facility regarding isolations/precautions and what type of PPE to wear. RN 4 stated all visitors were re-educated when arriving to the facility's lobby to ensure understanding and were then directed to go to the nursing station to collect the required PPE for infection control. During the same concurrent observation of Resident 278's room and interview 5/27/2024 at 5:15 p.m., the ADM approached the surveyor in the hallway and started talking loudly over the surveyor, not allowing the surveyor to speak, while vigorously pointing out at a paper with facility policies. The ADM held the paper within 4-5 inched of the surveyor's face, with the level of voice getting louder, in front of facility staff, residents, and visitors. The ADM stated, where in our policy does it state that touching is included in the isolation?. The surveyor kindly informed the ADM that she (the surveyor) was unable to speak with the ADM at that moment as the surveyor was in the middle of the interview. The ADM walked away angrily. Visitor 1 (V1) for Resident 278 then approached the surveyor angrily yelling at the surveyor asking why the surveyor was trying to prevent the visitors/family from visiting with the resident. V1 stated no one in the facility had spoken to her (V1) about the type of precautions Resident 278 was on. V1 stated she (V1) was not happy that the facility had not even placed any type of container by Resident 278's room containing PPE which would serve as a cue for anyone entering the room. V1 stated placing the PPE at the nursing station where guests had no access was unacceptable and denied V1 and others the opportunity to put on PPE. The surveyor was unable to continue the investigation as the surveyor felt threaten and left the facility. During a telephone interview on 5/28/2024 at 9:31am, the district office supervision (DOS) called the ADM and [NAME] President of Operations (VPO) to ensure the recertification process could continue safely. The ADM continuously interrupted the DOS in a loud voice throughout the call stating she (ADM) was very passionate. The ADM was asked if professionalism and respect could be maintained, the ADM agreed. During the formal exit conference on 5/28/2024 at 7:29 p.m., with the ADM, [NAME] President of Operations (VPO), Director of Nursing (DON), and Regional Quality Management Consultant 1 (RQMC1), the ADM was observed entering the conference wearing a blue overall onesie in a monster ([NAME]/[NAME]) character. During the required reading of the exit conference script reading, the surveyor was interrupted by ADM who sarcastically declared and uttered, that's an understatement, after reading the script paragraph, we understand that the survey process can be stressful. The surveyor had to stop throughout the exit as the ADM was constantly interrupting. A review of the policy and procedures (P&P) titled Enhanced Standard Precautions revised 1/29/24 indicated, the facility will reduce the potential for transmissions of pathogens including MDROs and viruses through the use of enhanced standard and transmission-based precautions. The same P&P indicated the purpose was to provide guidelines for infection control practices to reduce the potential for transmission of pathogens including MDROs and viruses which included: MRSA, VRE, ESBL, any infection when the organism is sensitive to two or fewer antibiotics. Under admission and placement, the P&P indicated to ensure that the appropriate instructions (signage) are communicated to staff, visitors and others entering the facility. A review of the facility's job description, titled, Administrator, undated, it indicated that principal responsibilities and duties (of ADM) includes maintaining strong positive relationships with resident, families, personnel, physicians, and the community . Maintain neat, well-groomed, and professional appearance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of Resident 278 admission record indicated the resident was initially admitted to the facility on [DATE] with diagnoses that included chronic kidney disease stage 4 (kidneys are moderately or severely damaged and are not working as well as they should to filter waste from your blood. Waste products may build up in your blood and cause other health problems), type 2 diabetes mellitus, and chronic obstructive disease (COPD- is a common lung disease causing restricted airflow and breathing problems). A review of Resident 278's MDS dated [DATE] indicated Resident 278 was moderately impaired cognitively and required between supervision or touching assistance to setup or clean-up assistance for ADLs. A review of the care plan titled At risk for MDRO and other transmissible infectious pathogens due to: Presence of PICC line, history of MRSA (Methicillin-resistant Staphylococcus aureus is an infection of Staphylococcus (staph) bacteria. This germ is resistant to some antibiotics. It can spread in hospitals, other healthcare facilities, and in the community), ESBL (Extended-spectrum beta-lactamases are enzymes that confer resistance to most beta-lactam antibiotics, including penicillin, cephalosporins, and the monobactam aztreonam. Infections with ESBL-producing organisms have been associated with poor outcomes), and VRE (Vancomycin-resistant Enterococci are bacteria (germs) that commonly live in the gastrointestinal tract (bowels) of most people [colonization] can be spread from person to person through direct contact with an infected or colonized person), initiated on 5/25/24, indicated interventions which included to educate resident, and resident family/representatives regarding the purpose of ESP. During a concurrent observation and interview with Registered Nurse (RN) 4 on 5/27/24 at 5:15 p.m., two visitors (V1 and V2) went into Resident 278's room without receiving education regarding the type of precaution the resident was on and any offer for PPE. RN 4 stated that guests were notified over the phone before they visited the facility regarding isolations/precautions and what type of PPE to don. RN 4 stated that all visitors should be re-educated at the lobby to ensure understanding and directed to go to the nursing station to collect the required PPE for infection control. During an interview with V1 on 5/27/24 at 5:18 p.m., at the nurse's station, V1 stated that no one in the facility had spoken to her about the type of precautions Resident 278 was on. V 1 stated that she was not happy that the facility had not placed any type of container by Resident 278's room containing PPE which would serve as a cue for anyone entering the room. V1 stated that placing the PPE at the nursing station where guests had no access was unacceptable because it denied herself and others from being offered the opportunity. A review of the P&P titled Enhanced Standard Precautions, revised 1/29/24, indicated, the facility will reduce the potential for transmissions of pathogens including MDROs and viruses through the use of enhanced standard and transmission-based precautions. The same P&P indicated the purpose was to provide guidelines for infection control practices to reduce the potential for transmission of pathogens including MDROs and viruses which included: MRSA, VRE, ESBL, any infection when the organism is sensitive to two or fewer antibiotics. Under admission and placement, the P&P indicated to ensure that the appropriate instructions (signage) are communicated to staff, visitors and others entering the facility. 6. A review of Resident 278's admission Record indicated Resident 278 was originally admitted to the facility on [DATE], with diagnoses including diabetes mellitus, muscle weakness, discitis (inflammation of the intervertebral [area between bones of the spine] disc space) lumbar (lower back) region, and malignant neoplasm (cancerous tumor) of the breast. A review of Resident 278's MDS, dated [DATE], indicated Resident 278 had moderate cognitive impairment and required supervision or touching assistance from staff for toileting, bathing, dressing and personal hygiene. The same MDS further indicated Resident 278 was on intravenous (IV, medical technique that administers fluids, medications, and nutrients directly into a person's vein) antibiotic therapy and had a PICC. A review of Resident 278's physician order summary report (POSR), dated 5/27/2024, indicated Resident 278 had an order dated 5/8/2024 of PICC line: change dressing and cap every day shift every seven days until 6/20/2024. During an observation with concurrent interview with Registered Nurse 1 (RN 1) on 5/26/2024 at 9:48 a.m., RN 1 was observed providing PICC line care for Resident 278 without donning (putting on) a gown as indicated on the Enhanced Standard Precautions (a resident-centered and activity-based approach of care for preventing multi drug resistant organisms [MDRO, germs that are not ablet be treated with the majority of the medications available] transmission in skilled nursing facilities) sign posted outside the residents room door. RN 1 stated she was supposed to have donned a gown along with gloves while providing PICC care. RN 1 also stated the dressing should be labeled with the time changed, not just the date and initials. During an interview with concurrent record review with RN 1 on 5/26/2024 at 10:05 a.m., the Enhanced Standard Precautions sign, dated September 2021, and posted outside the resident's room door was reviewed. The sign indicated providers and staff must clean hands-on room entry and when exiting, and wear gloves and gown for the high-contact resident care activities . Caring for devices and giving medical treatments. RN 1 stated she should have put on a gown when caring for the resident's PICC. A review of the facility's policy and procedures titled Central Venous Catheter Dressing Changes, dated May 2022, indicated, To apply sterile dressing . 6. Apply sterile transparent dressing (no gauze) to area, making sure to center the dressing over the insertion site . Label with initials, date and time. 4a. A review of Resident 48's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), bloodstream infection (an infection caused by bacteria entering the bloodstream) due to central venous catheter (a long, flexible tube your inserted into a vein in the neck, chest, arm or groin), acute respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), pneumonia (lung infection that inflames air sacs with fluid or pus) and dependence on renal dialysis (a treatment for people whose kidneys are failing). A review of the MDS dated [DATE], indicated Resident 48's cognitive skills for daily decision-making were moderately impaired and required maximal to total dependence from staff for ADLs-eating, toileting hygiene, shower/bathing self, upper and lower body dressing, and personal hygiene. A review of Resident 48's POSR, as of 5/27/2024 indicated, there was no order for ESP. During a concurrent observation and interview with Resident 48 on 5/26/2024 at 11:16 a.m., Resident 48's did not have any ESP signages posted outside the door and there were no PPE carts available upon exiting Resident 48's room. Resident 48 stated she was just hospitalized because of an infection and blockage of her dialysis access (Permacath - a central line catheter used for hemodialysis [HD-a process of filtering the blood of a person whose kidneys are not working normally]). During an interview with Infection Preventionist Nurse 1 (IPN 1) on 5/27/2024 at 4:56 p.m., IPN1 stated they did not access Resident 48's Permacath, therefore the resident did not need to be on ESP. IPN1 stated Resident 48's dialysis Permacath is an indwelling catheter. IPN1 further stated they are in process of learning what an ESP is. During an interview with Medical Director (MD) on 5/28/2024 at 5:24 p.m., MD stated, a Permacath for the resident on HD is considered an indwelling catheter. MD stated he thinks it's important to ensure these residents are protected from infection and Resident 48 should be placed in an ESP. MD stated he was not aware of who were the residents placed in ESP, but physicians should be notified when residents are to be placed in ESP as a physician's order could help implement the process. During a follow-up interview with MD on 5/28/2024 at 7:20 p.m., MD stated that he wanted to correct himself to the surveyor to clarify that it is not necessary to have a physician's order to place resident for ESP. A review of the facility's P&P titled, Resident Isolation - Categories of Transmission-Based Precautions, reviewed on 1/29/2024, indicated that transmission-based precautions are used accordingly when caring for residents who are documented or are suspected of having communicable diseases or infection that can be transmitted to others. A review of the facility's P&P titled, Compliance with Laws and Professionals Standards, reviewed on 1/29/2024, indicated that facility policies and procedures are developed and maintained in accordance with local, state, and federal laws and with currently accepted professional standards and principles that apply to professionals providing services in a skilled nursing facility. A. Policies and procedures are reviewed at least annually and updated as necessary. B. Facility staff perform their duties in accordance with the policies and procedures adopted by the Facility. A review of Centers for Medicare & Medicaid Services (CMS), Quality, Safety & Oversight (QSO - oversight for compliance with the Medicare health and safety standards for laboratories, acute and continuing care providers [including hospitals, nursing homes, home health agencies (HHAs), end-stage renal disease (ESRD) facilities, hospices, and other facilities serving Medicare and Medicaid beneficiaries], made available to beneficiaries, providers/suppliers, researchers and State surveyors information about these activities), reference letter: QSO-24-08-NH, dated 3/20/2024 indicated that in July 2022, the Centers for Disease Control and Prevention (CDC - serves as the national focus for developing and applying disease prevention and control, environmental health, and health promotion and health education activities designed to improve the health of the people of the United States) released updated EBP recommendations for Implementation of PPE Use in nursing homes to prevent spread of MDROs, and therefore, CMS is updating its infection prevention and control guidance accordingly. The recommendations now include the use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status. Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. A review of the CDC's Implementation of PPE in Nursing Homes to prevent spread of MDROs, updated 7/12/2022, indicated that Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. When implementing Contact Precautions or Enhanced Barrier Precautions, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies. To accomplish this: . make PPE, including gowns and gloves, available immediately outside of the resident room . Provide education to residents and visitors. 4b. A review of Resident 62's admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction (stroke), DM and dependence on renal dialysis. A review of Resident 62's MDS dated [DATE], indicated the Resident 62 was moderately impaired (a slight decline in cognitive function, such as memory, language, and thinking) and required between supervision or touching assistance to setup or clean-up assistance for ADL- Eating, oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing. A review of Resident 62's orders dated 3/29/24 indicated, (to) observe Permacath (a special catheter used for short-term dialysis treatment) site right chest for redness, vascular access, tenderness, bleeding, and drainage every shift. During a concurrent observation and interview of Resident 62's room with IPN2 on 5/26/24 at 10:38 a.m., there was no signage at the door to indicate type of isolation. The IPN2 stated that Resident 62 should be on isolation given the fact that he had a central line. IPN2 stated that any type of opening in the body is a possible portal for infection. IPN2 also stated that Resident 62 should have been on isolation for that reason. 5a. During a concurrent observation and interview with RN 2 on 5/26/2024 at 10:27 a.m., the pill cutter inside the medication cart 1, was observed with whitish and greenish particles. RN 2 stated the pill cutter should be cleaned after each use, so it does not mix with any other medications left on the cutter. During a concurrent observation and interview with LVN 3 on 5/27/2024 at 11:28 a.m., the pill cutter inside the medication cart 2, was observed with whitish and greenish particles. LVN 3 stated the pill cutter should be cleaned after each use since it would have some residues from other medications. 5b. During a concurrent observation and interview with LVN 3 on 5/27/2024 at 11:28 a.m., cluttered items such as bandages, nail cutter, alcohol wipes, etc. were observed inside the left top drawer of medication cart 2. LVN 3 stated that the charge nurses were supposed to keep the medication cart clean at all times. During an interview with IPN 1 on 5/27/2024 at 5:02 p.m., IPN 1 stated that it is the charge nurses' duty to make sure medication carts and pill cutter are being cleaned due to possible transmission of infection. A review of facility's P&P, titled, Medication Administration-General Guidelines, reviewed on 1/29/2024, indicated that medications are administered in accordance with good nursing principles. A review of facility's P&P, titled, Infection Control, reviewed on 1/29/2024, indicated that facility will provide infection control policies and procedures required for a safe and sanitary environment. Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to implement their infection control policy and procedures (P&P) for five of 19 by failing to: 1. [NAME] (put on) appropriate personal protective equipment (PPE) when disconnecting Resident 3 from the gastrostomy tube (GT- a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration) and while assisting Resident 3. 2. [NAME] appropriate PPE when Certified Nursing Assistant 4 (CNA 4) was assisting Resident 178 during basic care. Enhanced Standard Precaution (ESP-transmission based precaution that refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) signage was not updated in Resident 178's door. 3. Provide education about ESP and offer PPE use to the visitors of Resident 278. 4. Ensure hemodialysis (HD-filtering the blood of a person whose kidneys are not working normally) residents with indwelling catheter were placed in ESP for Residents 48, and 62. 5. Ensure medication cart and pill cutters were clean at all times. 6. Ensure RN 1 donned (put on) gown before providing peripherally inserted central catheter (PICC, a thin, soft tube inserted into a vein in the arm, leg, or neck for long-term intravenous antibiotics [medication to fight bacterial infections]) care for Resident 278. These deficient practices had the potential to cross contamination and the spread of infection to the residents, visitors, and the community. Findings: 1a. A review of Resident 3 admission record indicated the resident was initially admitted to the facility on [DATE] with diagnoses that included hemiplegia (loss of strength in the arm, leg, and sometimes the face on one side of the body) and hemiparesis (loss of use in the arm, leg, and sometimes the face on one side of the body) following cerebral infarction (stroke), encounter for attention to gastrostomy and essential hypertension (elevated high blood pressure not caused by another disease). A review of Resident 3's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 2/16/24 indicated, Resident 3 was moderately impaired cognitively (relating to mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 3 was dependent for all activities of daily living (ADLs- bed mobility, transfer, dressing, and toilet use). A review of the care plan titled At risk for MDRO (multidrug resistant organism [MDRO] is a germ that is resistant to many antibiotics. If a germ is resistant to an antibiotic, it means that certain treatments will not work or may be less effective), and other transmissible infectious pathogens due to: Presence of Gtube, initiated 5/25/24. The interventions included to educate staff regarding the use and purpose of ESP. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 1 on 5/26/24 at 12 p.m., LVN 1 was observed wearing gloves without gown while disconnecting Resident 3 from the Gtube who was on ESP. LVN 1 was unable to verbalize the reason why it was important to include an isolation gown while working with a resident who had an indwelling medical device. During an interview with Infection Preventionist Nurse 2 (IPN 2), IPN 2 stated that when providing care such as connecting or disconnecting a Gtube, staff must don a gown and gloves for infection prevention. 1b. A review of Resident 3's Physician Order Summary Report (POSR), as of 5/27/2024, indicated there was no physician's order for ESP. During an observation Certified Nursing Assistant 2 (CNA 2) on 5/24/2024 at 6:33 p.m., Resident 3 was observed with an ESP signage posted outside the door with no PPE and PPE cart provided. CNA 2 went inside Resident 3's room and pull up Resident 3's gown to access Resident 3's g-tube catheter. CNA2 did not perform hand hygiene and did not don gown and gloves before touching Resident 3. CNA 2 did not do any hand hygiene after leaving Resident 3's room. During a follow-up interview with CNA 2 on 5/24/2024 at 6:39 p.m., CNA 2 stated Resident 3 was on ESP according to the signage posted outside the door. CNA 2 acknowledged she did not put on PPE such as gown and gloves before touching Resident 3 which put residents at risk of acquiring infection. CNA 2 further stated they(staff) got their PPE from the linen cart which is down in the basement, and it was hard for them to use PPE because PPE was not readily available for them to use if needed. During an interview with Infection Preventionist Nurse 1 (IPN 1) on 5/27/2024 at 4:56 p.m., IPN1 stated staff are to don PPE if doing high-contact care with residents. IPN1 stated, if staff pulled up resident's gown to access a g-tube, that did not mean it was a high-contact activity. When asked if staff should wear gloves and do hand hygiene before and after touching resident, IPN answered yes. IPN 1 stated, placing residents on ESP is a nursing scope of practice and does not need a physician's order. IPN1 further stated, they are in process of learning what an ESP is. 2. A review of Resident 178's admission Record indicated Resident 178 was originally admitted to the facility on [DATE], and was re-admitted on [DATE], with diagnoses including diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), end stage renal failure (ESRD-a medical condition in which a person's kidney [organ in the body that lifters waste and excess fluid from the blood] function stop functioning on a permanent basis), hemodialysis dependence and generalized muscle weakness. A review of Resident 178's MDS dated [DATE], indicated Resident 178's skills for daily decision-making were moderately impaired. Resident 178 required maximal assistance from staff for activities of daily living (ADLs- bed mobility, transfer, dressing, and toilet use). MDS also indicated Resident 178 was on hemodialysis since admission. A review of Resident 178's POSR, as of 5/27/2024, indicated no orders for enhanced standard precaution. A review of Resident 178's care plan, created on 5/25/2024, indicted Resident 178 was at risk for MDRO with interventions to initiate enhance standard precautions and educate staff regarding the use and purpose of the precaution. During an observation on 5/25/2024 at 12:49 p.m., transmission-based precaution signage and PPE cart were not observed to be provided for Resident 178. During an observation on 5/26/2024 at 10:04 a.m., Certified Nursing Assistant 4 (CNA 4) did not wear any PPE while providing Resident 178's basic care. CNA 4 stated Resident 178 was not on a transmission-based precaution, therefore no PPE was needed or required. During a concurrent observation and interview with Licensed Vocational Nurse 3 (LVN 3) on 5/27/2024 at 11:41 a.m., there was no signage to indicate Resident 178 was on enhanced standard precaution. LVN 3 stated Resident 178 was supposed to be on enhanced standard precaution since re-admission on [DATE] and staff should wear proper PPE when caring for the resident. During an interview with IPN 1, on 5/27/2024 at 4:56 p.m., IPN 1 stated that Resident 178 was supposed to be on enhanced standard precaution since re-admission, dated 5/21/2024. IPN 1 stated the signage was not updated and that Resident 178 was at risk for infection if staff was not wearing proper PPE when caring for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 278's admission Record indicated Resident 278 was originally admitted to the facility on [DATE], with diagnoses including diabetes mellitus, muscle weakness, discitis (inflammation of the intervertebral [area between bones of the spine] disc space) lumbar (lower back) region, and malignant neoplasm (cancerous tumor) of the breast. A review of Resident 278's MDS, dated [DATE], indicated Resident 278 had moderate cognitive impairment and required supervision or touching assistance from staff for toileting, bathing, dressing and personal hygiene. The same MDS further indicated Resident 278 was on IV antibiotic therapy and had a peripherally inserted central catheter (PICC, a thin, soft tube inserted into a vein in the arm, leg, or neck for long-term intravenous antibiotics). A review of Resident 278's POSR, dated 5/27/2024, the POSR indicated, Resident 278 was prescribed daptomycin intravenous solution 500 mg IV every two days for spinal abscess (buildup of pus) on 5/2/2024 until 6/20/2024. A review of Resident 278's ISE, dated 5/2/2024, the ISE indicated missing infection analysis result of that if antibiotic usage criteria was met. During a concurrent interview and record review with IPN 1 on 5/28/2024 at 2:10 p.m., Resident 278's daptomycin order and ISE were reviewed. IPN 1 stated Resident 278's ISE for the daptomycin medication was not acceptable due to missing infection analysis result indicating whether the antibiotic usage criteria were met or not met. Based on interview and record review, the facility failed to implement facility's protocol for Antibiotic Stewardship (the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients/resident) for three of three sampled residents (Resident 13, 178, and 278). This deficient practice had the potential for Resident 13, 178, and 278, to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use, which could lead to adverse events including allergic reactions. Findings: 1. A review of Resident 178's admission Record indicated Resident 178 was originally admitted to the facility on [DATE], and was re-admitted on [DATE], with diagnoses including diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), end stage renal failure (ESRD-a medical condition in which a person's kidney [organ in the body that lifters waste and excess fluid from the blood] function stop functioning on a permanent basis), hemodialysis (HD-filtering the blood of a person whose kidneys are not working normally) dependence and generalized muscle weakness. A review of Resident 178's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/9/2024, indicated Resident 178's cognitive (relating to mental action or process of acquiring knowledge and understanding) skills for daily decision-making was moderately impaired. Resident 178 required maximal assistance from staff for activities of daily living (ADLs- bed mobility, transfer, dressing, and toilet use). MDS also indicated Resident 178 was on hemodialysis since admission. A review of Resident 178's Physician Order Summary Report (POSR), dated 5/21/2024, indicated that Resident 178 was prescribed with ceftriaxone sodium (antibiotic [antibiotic] medication) 2 grams (GM) intravenously (IV-administering fluid medication through a needle or tube inserted into a vein) every 24 hours for osteomyelitis (bone infection). POSR also indicated daptomycin (antibiotic medication) 350 milligrams (mg) via IV every 2 days for osteomyelitis was also ordered on 5/22/2024. A review of Resident 178's Infection Screening Evaluation (ISE), dated 5/21/2024, indicated missing infection analysis result of that if ceftriaxone sodium was met or not met antibiotic usage criteria. A review of Resident 178's ISE, dated 5/4/2024, indicated missing infection analysis result of that if daptomycin was met or not met antibiotic usage criteria. During a concurrent interview and record review with the Infection Preventionist Nurse 1 (IPN 1) on 5/28/2024 at 2:10 p.m., Resident 178's antibiotic orders and ISE were reviewed. IPN 1 stated that Resident 178's ISE for both antibiotic medications were not acceptable due to missing infection analysis result to indicate if antibiotic usage criteria were met. During an interview with the Director of Nursing (DON) on 5/28/2024 at 2:25 p.m., DON stated that it is important to have a correct and complete system for antibiotic stewardship to minimize and prevent antibiotic resistant to all residents. 3. A review of Resident 13's admission Record indicated Resident 13 was originally admitted to the facility on [DATE], and was re-admitted on [DATE], with diagnoses including diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and essential hypertension (elevated blood pressure not caused by another disease). A review of Resident 13's MDS dated [DATE], indicated Resident 13's cognitive skills for daily decision-making were severely impaired, requiring maximal assistance from staff for ADLs. A review of the Change in Condition Evaluation dated 5/16/2023 at 4:10 pm indicated, Resident 13 was noted to be difficult to arouse but responsive to stimuli. A urine sample was collected as ordered to check for a Urinary Tract Infection (UTI- when bacteria get into your urine and travels up to your bladder). A review of physician's orders dated 5/17/2024, indicated Ciprofloxacin (Cipro-type of antibiotics) 250 mg tablets, take 1 tablet by mouth twice a day for 5 days for UTI. During a concurrent interview and record review of Resident 13's medical record with IPN 1 on 5/28/2024 at 2:10 p.m., IPN 1 stated Resident 13's ISE for the Cipro medication was not acceptable due to missing infection analysis result indicating whether the antibiotic usage criteria was met or not met. A review of facility's policy and procedures (P&P), titled, Antibiotic Stewardship, reviewed on 1/29/2024, indicated that the facility will implement an Antibiotic Stewardship Program (ASP) to promote appropriate use of antibiotics optimizing the treatment of infection, reducing the threat of antibiotic resistance, reducing adverse events associated with antibiotic use and improve outcomes for Residents. P&P also indicated that IPN is responsible for tracking the following antibiotic stewardship processes by whether or not the Resident's condition met McGeer's Criteria (clinical criteria used to inform resident care decisions regarding initiation of antibiotics) when the antibiotic was ordered.

Based on interview and record review, the facility failed to provide copies of personal and medical records within two working days for one of two residents (Resident 1) in accordance with the rfacility's policy and procedures titled, Resident Access to protected Information, last reviewed on 2022. This deficient practice denied Resident 1 and/or her Representative the right to access personal and medical records. Findings: A review of Residenty 1's admission Record indicated the facility admitted Resident 1 on 10/24/2022 with diagnoses including hypertension (HTN - elevated blood pressure), unspecified dementia (decline in mental ability severe enough to interfere with daily functioning/life), and muscle weakness. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 2/20/2023, indicated Resident 1's cognition (thought process) was moderately impaired (decisions poor; cues/supervision required). The MDS indicated Resident 1 required limited assistance with one person assist for activities of daily living including bed mobility, eating, and dressing. A review of the facility's Log of Resident Requests for Access to Protected Health Information document indicated that on 3/21/2023, the facility received Requestor 1's request for the medical records request for Resident 1. The log indicated the facility provided the requested records on 3/27/2023. A review of the United States Postal Service receipt, indicated the facility mailed the aforementioned medical records to Requestor 1 on 3/27/2023 at 10:31 AM. During an interview on 4/18/2023 at 12:03 PM, the Medical Records Director (MRD) stated according to her [MRD] documentation, the request for medical record for Resident 1 was received on 3/21/2023 and was provided on 3/27/2023. The MRD stated she spoke with Requestor 1 on 3/27/2023, however, the MRD was unable to provide any email or any documentation that indicated Requestor 1 approved for the facility to delay in providing requested medical records for Resident 1. The MRD further stated the facility was required to provide requested medical records within two working days. The MRD stated the facility did not provide requested medical records for Resident 1 within the two days. The MRD stated the potential outcome for not releasing requested medical records within the two days was that the resident or representative could be denied timely access to requested medical records. During an interview on 4/18/2023 at 2:09 PM, the Administrator (Admin) stated the facility received the request for Resident 1 ' s medical record on 3/21/2023. The Admin stated Resident 1's medical records were not provided until 3/27/2023. The Admin stated the facility failed to provide Resident 1 ' s medical records within two days per facility policy and procedure. The Admin stated the potential outcome was that Resident 1 or representative would not have timely access to requested medical records. A review of the facility's policy and procedures titled, Resident Access to Protected Health Information, reviewed 2022, indicated, if the resident and/or their personal representative requests a copy of the resident ' s medical record, the Health Insurance Portability and Accountability Act (HIPAA - Is a federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge) Privacy Officer will provide the resident and/or their personal representative with a copy of a medical record within two working days after receiving the written request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect the resident ' s rights by not closing the privacy curtain to ensure a resident would not be visually exposed to visitors, staff, and/or other residents while staff were providing care for one of two sampled residents (Resident 1), when Licensed Vocational Nurse 1 (LVN 1) was observed applying an abdominal binder to Resident 1 without pulling the privacy curtain or closing the door to Resident 1 ' s room. This deficient practice violated the resident ' s right for privacy. Findings: A review of Resident 1 ' s admission Record, dated 3/31/2023, indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including nontraumatic intracerebral hemorrhage (bleeding into the brain tissue), essential primary hypertension (high blood pressure), and dysphagia (difficulty swallowing). A review of Resident 1 ' s Minimum Data Set (MDS – an assessment and care screening tool), dated 3/19/2023, indicated Resident 1 had mild cognitive impairment (difficulty understanding, remembering, making decisions) and is totally dependent with activities of daily living (ADLs – self-care activities such as personal hygiene, toileting, transferring from surface to surface, etc.). A review of Resident 1 ' s Order Summary Report, dated 3/29/2023, indicated Resident 1 was ordered enteral feed (form of nutrition that is delivered into the digestive system as a liquid) order via gastrostomy tube (GT – a tube inserted through the wall of the abdomen directly into the stomach) for indication of dysphagia. During an observation on 3/31/2023, at 11:29 AM, LVN 1 was observed applying an abdominal binder on Resident 1 from the hallway. The door to Resident 1 ' s room was observed open, and the privacy curtain was not pulled closed around Resident 1. Resident 1 ' s GT and abdomen was observed from the hallway. During an interview with LVN 1, on 3/31/2023, at 11:47 AM, LVN 1 stated Resident 1 has a GT, and her nurse practitioner (NP) came in and saw Resident 1 was touching her GT and ordered her an abdominal binder. LVN 1 stated she was applying the abdominal binder on Resident 1. LVN 1 stated that the privacy curtain was not closed while applying the abdominal binder on Resident 1. LVN 1 further stated it is important to close the curtain or door prior to providing care to protect the privacy of residents. During an interview with Certified Nursing Assistant 3 (CAN 3), on 3/31/2023, at 1:07 PM, CNA 3 stated prior to providing care to residents, he makes sure to close the privacy curtain. CNA 3 further stated it is important to close the privacy curtain to maintain privacy for residents. During an interview with CNA 1, on 3/31/2023, at 1:16 PM, CNA 1 stated prior to providing care to residents, she closes the privacy curtain. CNA 1 further stated it is important to close the privacy curtain prior to providing care to maintain privacy and so that no one can see what is being done for the resident. During an interview with CNA 2, on 3/31/2023, at 1:31 PM, CNA 2 stated prior to providing care to residents, she closes the privacy curtain. CNA 2 further stated it is important to close the privacy curtain prior to providing care to provide privacy for the residents. During an interview with LVN 3, on 3/31/2023, at 1:45 PM, LVN 3 stated it is important to close the privacy curtain prior to providing care to maintain a resident ' s dignity since the resident may feel uncomfortable if someone else sees them. LVN 3 further stated residents have a right to have privacy. During an interview with the Administrator, on 3/31/2023, at 2:00 PM, the Administrator stated during care, the privacy curtains are pulled, and the window shutters are closed to maintain the resident ' s privacy. A review of the facility ' s policy and procedures titled, Resident Rights – Quality of Life, revised on 3/2017, indicated facility staff promotes, maintains, and protects resident ' s privacy, including bodily privacy, when assisting with personal care and during treatment procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 2), was provided a safe environment to prevent falls or mitigate (to move from one country, place, or point to another) harm from falls as indicated in the resident ' s care plan, when Resident 2 was observed in bed not set in the lowest height position and floor mats were not observed in place. This deficient practice had the potential to place Resident 2 at risk for harm from potential falls. Findings: A review of Resident 2 ' s admission Record, dated 3/31/2023, indicated Resident 2 was originally admitted to the facility on [DATE] with diagnoses including heart failure (condition in which the heart does not pump blood as well as it should) and generalized muscle weakness. A review of Resident 2 ' s Minimum Data Set (MDS – an assessment and care screening tool), dated 1/19/2023, indicated Resident 2 has severe cognitive impairment (unable to understand and make decisions) and requires extensive assistance, with one-person assist, for activities of daily living (ADLs - self-care activities such as personal hygiene, toileting, transferring from surface to surface, etc.). A review of Resident 2 ' s Fall Risk Evaluation, dated 1/12/2023, indicated Resident 2 was at risk for falls. A review of Resident 2 ' s Change in Condition Evaluation, dated 3/15/2023, indicated Resident 2 had a fall with no major injury. A review of Resident 2 ' s Care Plan, dated/initiated 1/16/2023, indicated Resident 2 is at risk for falls or injuries from falls. A revision to the care plan, dated 3/15/2023, indicated Resident 2 was found sleeping on the floor. The care plan indicated interventions include providing Resident 2 with floor mats and a low bed. A review of Resident 2 ' s Care Plan, dated/initiated 3/15/2023, indicated Resident 2 was found sleeping on the floor. The care plan indicated interventions included providing Resident 2 with floor mats and a low bed. During an observation, on 3/31/2023, at 12:10 PM, inside Resident 2 ' s room, the base of Resident 2 ' s bed was observed at a height of approximately 20 inches. Further observation indicated Resident 2 did not have floor mats placed adjacent to the resident ' s bed. During a concurrent interview and record review with Licensed Vocational Nurse 2 (LVN 2), on 3/31/2023, at 12:21 PM, Resident 2 ' s Care Plan, dated 3/15/2023, was reviewed. Resident 2 ' s Care Plan indicated Resident 2 was found sleeping on the floor and interventions included providing floor mats and providing a low bed. LVN 2 confirmed Resident 2 ' s care plan interventions. During a concurrent observation and interview with LVN 2, on 3/31/2023, at 12:25 PM, the base of Resident 2 ' s bed appeared to be approximately 20 inches from the ground and there were no floor mats observed adjacent to Resident 2 ' s bed. LVN 2 confirmed and stated Resident 2 does not have floor mats next to their bed. LVN 2 was asked to demonstrate if the height of Resident 2 ' s bed could be lowered and LVN 2 was observed using the bed controls to lower the base of Resident 2 ' s bed to approximately 10 inches. LVN 2 confirmed and stated Resident 2 ' s bed was not in the lowest position. LVN 2 stated that the interventions in Resident 2 ' s care plan were not implemented. LVN 2 further stated it is important to implement the care plan interventions to prevent the resident from getting injuries from falls. During an interview with LVN 1, on 3/31/2023, at 1:23 PM, LVN 1 stated it is important to implement interventions such as floor mats and low beds to prevent injury in the event there is a fall. During an interview with Certified Nursing Assistant 2 (CAN 2), on 3/31/2023, at 1:31 PM, CNA 2 stated she was assigned to Resident 2. CNA 2 stated she removed Resident 2 ' s floor mats because they were dirty, and she cleaned it and left it in the sun to dry. CNA 2 stated Resident 2 ' s fall interventions include floor mats and the bed in low position. CNA further stated it is important to keep Resident 2 ' s bed in a low position to prevent injury as opposed to a bed in a higher position, which can lead to possible major injury. During an interview with LVN 3, on 3/31/2023, at 1:45 PM, LVN 3 stated Resident 2 ' s interventions include keeping the bed in the lowest position and floor mats. LVN 3 further stated it is important to have Resident 2 ' s interventions in place to help prevent another fall and help prevent major injuries from occurring. During an interview with Physical Therapist Assistant 1 (PTA 1), on 3/31/2023, at 1:52 PM, PTA 1 stated Resident 2 is weak and is a high risk for falls. PTA 1 stated Resident 2 ' s interventions include using floor mats and having the height of the bed in the lowest position. PTA 1 stated it is important to implement the interventions to provide padding from a possible fall and having the bed at the lowest position decreases the distance between the floor and the bed. During an interview with the Administrator, on 3/31/2023, at 2:00 PM, the Administrator stated Resident 2 ' s interventions include the bed in the lowest position and floor mats. The Administrator further stated it is important to implement the interventions to prevent a serious injury and the use of floor mats and having the bed in the lowest position would mitigate or minimize injury damage from a possible fall. A review of the facility ' s policy and procedures titled, Resident Safety, revised 4/15/2021, indicated after a risk evaluation is completed, a resident-centered care plan will be developed to mitigate safety risk factors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to re-admit one of three sampled residents (Resident 1) from General Acute Care Hospital (GACH) 1. The facility also failed to respect their Bed Hold Policy and procedures. This deficient practice resulted in the denial of Resident 1 ' s rights to return to the facility. Findings: A review of Resident 1 ' s admission record indicated the facility admitted the resident on 4/20/22, with diagnoses that included paraplegia (Paralysis of the lower half of your body, including both legs), Stage 4 pressure ulcer (deep wound reaching the muscles, ligaments, or bones) and anxiety. A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 9/8/22, indicated his cognition was intact (decisions consistent/reasonable) and indicated the resident was totally dependent on one-person physical assist with transfer, eating , toileting and personal hygiene. A review of Resident 1 ' s Change in Condition Evaluation form dated 9/13/22, indicated he was not having urine output from his suprapubic catheter (a urinary catheter that is inserted through a hole in the abdomen and then directly into the bladder). A review of the Physician ' s Order dated 9/13/22, indicated to transfer Resident 1 to GACH 1 for evaluation due to minimal hematuria (presence of blood in urine) output. A review of the GACH face sheet indicated Resident 1 was admitted to the GACH on 9/13/22. During an interview on 10/17/22, at 1:56 PM., with the Registered Nurse Case Manager (RNCM) 1 from the GACH, stated Resident 1 has been admitted for 34 days. RNCM 1 stated Resident 1 was ready to be discharged back to the facility on [DATE]. RNCM 1 her colleague spoke with the Administrator (ADM), who told her that the facility have given away Resident 1's bed out because the resident refused to sign the bed hold upon transferred to GACH 1. During an interview on 10/18/22, at 2:06 PM., the Administrator (ADM) stated, Resident 1 went to the hospital on 9/13/22. Administrator stated the resident refused to sign the bed hold. ADM stated Resident 1 was told that if no one will take him the (the hospital) are going to call here. ADM further said Resident 1 was not readmitted because he was off the bed hold and did not want to come back. Administrator stated, the day GACH 1 called the resident was in isolation, and the facility did not have an isolation bed at that time and was never charged for a bed hold. Administrator further stated the facility did not put him on a bed hold because he did not ask for a bed hold and the resident stated that he did not want a bed-hold. Administrator stated as long as the facility can take care of him, the facility can readmit him today. Administrator stated the GACH 1 had not called the facility again. During an interview on 10/18/22, at 2:23 PM., with the admission Coordinator (AC) stated, on 9/13/22, Resident 1 was transferred to the hospital and refused to sign for the bed hold. AC stated they understood that the resident did not want to come back here. AC further stated, when he was transferred out, the facility's staff wanted to make sure he had the bed waiting for him, but he refused and at that time we had limited bed availability and if he had signed the bed hold, we would not have given away his bed. Today right now we have available rooms. During an interview on 11/7/22 at 2:00 PM, Infection Preventionist (IP) stated Facility nurses are able to effectively care for a resident with klebsiella. Have you provided care to contact isolation residents? Yes, What kind of contact isolation residents ESBL and depending on the organism. MRSA, COVID contact with droplet. During an interview on 11/10/22 at 4:06 PM, RNCM 3 stated that the facility put the patient on the wait list. We (the GACH) paid for the patient for two months at a board and care. She also stated that at first, Resident 1 did not want to go back there but when we said no one else was accepting he wanted to go back there. She further stated she called the facility on 9/22/22 around 4 PM and spoke with AC. She stated that the facility kept saying that they did not have beds and they could not take the patient back. During an interview on 11/18/22 at 10:28 AM, AC stated The hospital called and said that the patient is ready to come back and I said that the patient did not want to come back here. They kept calling if we had available rooms. When I spoke with the administrator about it, we said we respect the patient ' s wants and he did not want to come back. When asked if the GACH ' s case manager ever stated Resident 1 did not want to come back, AC stated No, she just asked do we have room for him. I just said that the patient did not want to come back here, and I kept telling her she had to ask the patient if she wanted to come back here. For patients, even after the 7 days, if we have a room available, we take the patient back. We take many patients back after they pass the bed hold. When asked if she ever spoke to Resident 1 while he was hospitalized about his wishes, AC said, We never spoke to him while he was in the hospital because he specifically told us that he did not want to come back here when he was leaving. During an interview on 11/18/22 at 10:42 a. m., with the business office manager stated that when Resident 1 left the facility he still had skilled Medicare days. During an interview on 11/18/22 at 10:45 AM, ADM stated Resident 1 did not want to come back and that is what we told the case manager. She further stated, if a resident wants to come back of course, the resident has the right to be re-admitted to the facility. A review of the facility ' s California Standard admission Agreement for Skilled Nursing and Intermediate Care Facilities, provided to the resident, under the section, Bed hods and readmission, indicated if the resident is hospitalized for more than seven days, the facility will readmit the resident to the first available bed. It also indicated if a resident of the facility has been hospitalized in an acute care hospital and asserts his or her rights to readmission pursuant to bed hold provisions or readmission rights of either state or federal law and the facility refuses to readmit him, the resident may appeal the facility ' s refusal. Under attachment 2, Notice of Bed Hold Policy, it indicated if Resident ' s hospitalization or therapeutic leave exceeds the number of days indicated on the Bed Hold Notification Form Resident will be readmitted to the Center immediately upon the first availability of a bed in a semi-private room, if Resident continues to require the services provided by Center and is still eligible for benefits under Resident ' s Managed Care Plan. A review of the facility ' s policy and procedures titled, Bed Hold, revised 7/2017, indicated that if the bed hold period expires and the resident does not elect to pay to hold the bed, but wishes to return to the facility, the facility will provide the resident with the first available bed covered by the resident ' s payer source.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to adhere to infection control practices as evidenced by: -Failing to perform N95 respirator (a face mask designed to achieve a very close facial fit and very efficient filtration of airborne particles) fit testing for a facility staff member. -Failing to initiate the timely quarantine for one of three sampled residents (Resident 1) who exhibited symptoms of Coronavirus (COVID-19, a virus that causes respiratory illness and symptoms such as fever, sore throat, coughing, shortness of breath, muscle aches, fatigue, loss of taste, and loss of smell; that can spread from person to person). These deficient practices had the potential to result in the spread of COVID-19 to facility residents and staff. Findings: a. During an observation and concurrent interview on 11/21/2022 at 10:54 a.m., the Physical Therapist Assistant (PTA) 1 was observed wearing a Honeywell N95 face mask. PTA 1 stated he had gone into the red zone (area of the facility where COVID-19 positive residents reside) of the facility to give treatment to residents. PTA 1 stated he used the Honeywell N95 face mask but indicated he had not been fit tested for the Honeywell N95 face mask he was wearing. A review of the facility's N95 fit test log indicated there was no N95 fit test record for PTA 1. During an interview and concurrent record review on 11/21/2022 at 3:53 p.m., with the Infection Preventionist (IP), the facility's N95 fit test log was reviewed. The IP stated and confirmed PTA 1 did not have a N95 fit test record. The IP stated PTA 1 did not have a N95 fit test done and staff should be fit tested for the N95 mask before using one and before entering the red zone. The IP stated if staff used a N95 mask prior to being fit tested and either have COVID-19 or go into the red zone infection control can become an issue, and COVID-19 can spread from the staff to other staff or residents. A review of the facility's policy and procedure titled, Respiratory Protection Program (RPP), dated 9/9/2021 indicated fit testing was required for tight fitting respirators. Fit tests will be conducted: prior to an employee being allowed to wear any respirator, if the facility changes the respirator product or model, if the employee's body weight changes by 10% or more or if the employee had changes in facial structure, if the employee reports that a respirator that previously passed a fit test was no longer providing an adequate fit, or if the RPPA, supervisor, or physican notices a change in the employee that would require an additional fit test as Cal/OSHA standards require. A review of the Center of Disease Control (CDC) document titled, Types of Masks and Respirators, updated 9/8/2022 indicated when using a N95 mask it was important to wear the respirator properly, so it forms a seal to your face. Gaps can let air with respiratory droplets leak in and out around the edges of the respirator. Gaps can be caused by choosing the wrong size or type of respirator or when a respirator was worn with facial hair. b. A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including cerebral infarction (a lack of adequate blood supply to brain cells leading to a lack of oxygen to the brain), traumatic hemorrhage of cerebrum (bleeding in the brain caused by trauma), and dysarthria (difficulty speaking caused by brain damage). A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 10/17/2022, indicated Resident 1 was cognitively intact (able to understand) and required extensive assistance and one-person physical assistance for activities of daily living (ADL- such as bed mobility, dressing, and toilet use). A review of Resident 1's eInteract Change in Condition (COC) Evaluation dated 11/20/2022 at 1:42 p.m., indicated around 1:30 p.m. the resident and Certified Nursing Assistant (CNA) verbalized that the resident was hot/warm to touch. Resident 1's temperature was checked and was 102 degrees Fahrenheit. Tylenol was given and the IP nurse was notified. the eInteract COC indicated a rapid test for COVID was done and result was negative. Resident 1 for PCR test tomorrow. Resident 1 was alert, no pain, no shortness of breath (SOB), skin was intact. Doctor was notified. A review of Resident 1's Weights and Vitals Summary indicated on 11/20/2022 at 1:43 p.m., Resident 1 had a temperature of 103 degrees Fahrenheit. A review of the Physician's Order dated 11/21/2022 at 12:33 p.m., indicated Resident 1 was to be placed on contact/droplet isolation for COVID-19 quarantine (isolation) every shift for 10 days. During an observation and concurrent interview on 11/21/2022 at 2:05 p.m. Resident 1 was observed being placed on isolation and contact/droplet precautions. The IP stated Resident 1 became symptomatic of COVID-19 with a fever, so he was placed on isolation precautions in a room by himself. During an interview and concurrent record review on 11/22/2022 at 2:02 p.m., Resident 1's medical record was reviewed with the IP. The IP stated when a resident was symptomatic of COVID-19, the assigned physician was notified, but it was a facility-driven protocol to conduct testing and initiate isolation or quarantine precautions. The IP reviewed Resident 1's eInteract COC Evaluation dated 11/20/2022 at 1:42 p.m. and confirmed that she was notified Resident 1 was symptomatic with fever; and that the resident was then rapid tested and pending PCR test. The IP also reviewed Resident 1's physician's orders and confirmed that contact/droplet precautions were not ordered and implemented until 11/21/2022. The IP stated that this delay in implementation of droplet and contact precautions posed a transmission risk to staff and residents and potential for spread of infection. A review of the facility's COVID-19 Mitigation Plan revised 10/8/2022, indicated symptoms of COVID-19 infection were fever, chills, cough, shortness of breath, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, diarrhea and/or nausea or vomiting. When a resident become symptomatic of COVID-19 infection, regardless of vaccination status, they will be placed on droplet and contact precautions, placed on quarantine, and immediately tested for COVID-19.

Based on interview and record review, the facility failed to implement their policies and procedures in tracking the Coronavirus 2019 (COVID-19, a respiratory infection disease that is highly contagious though to spread mainly from person to person through respiratory droplets produced when an infected person coughs, sneezes, or talks) immunization status of each staff member. The infection preventionist failed to ensure that four active employee's (Physical Therapy Aide (PTA), Certified Nursing Assistant (CNA) 3, Registered Nurse (RN) 1 and, CNA 4) COVID-19 immunizations were organized and accurately documented. This deficient practice had the potential for the facility to fail to identify the COVID-19 immunization status of each staff member that works in the facility. Findings: A review of CNA 3's California Immunization Registry record indicated she received COVID-19 vaccine doses on 1/6/2021 and 1/29/2021 and she received her booster dose on 12/22/2021. A review of the PTA's COVID-19 Vaccination Record Card indicated he received one dose of the one dose COVID-19 vaccine on 4/8/2021 and a booster dose on 1/20/2022. A review of RN 1's COVID-19 Vaccination Record Card indicated RN 1 received doses of the COVID-19 vaccine on 6/30/2021 and 8/2/2021 and received a booster dose on 3/4/2022. A review of CNA 4's COVID-19 vaccination documentation indicated she received doses of the COVID-19 vaccine on 8/9/2021 and 9/6/2021 and received her booster dose on 1/24/2022. A review of the facility staff vaccination matrix indicated that PTA, CNA 3, RN 3, and CNA 4's vaccination status was not listed. During an interview on 11/22/2022 at 9:06 a.m., the PTA stated he was fully vaccinated for COVID-19 and had received a booster dose. During an interview on 11/22/2022 at 1:09 p.m., the Payroll staff stated that PTA, CNA 3, RN 3, and CNA 4 were all active employees at the facility. During an interview and concurrent record review of the facility staff vaccination matrix on 11/22/2022 at 2:02 p.m., the Infection Preventionist (IP) stated that PTA, CNA 3, and RN 3's COVID-19 vaccination status was not logged. She also stated CNA 4 had received her booster although the log showed that CNA 4 had not received one. The IP stated that tracking of the employee's vaccination status was important because vaccination was the best defense we have against COVID and the higher the vaccination rate the less infections there will be. The IP further stated that accurate reporting and keeping of records was essential. During a record review and concurrent interview with the IP on 10/6/2022 at 3:01 p.m., the facility's COVID-19 Staff Vaccination Status for Providers was reviewed. The IP stated the log revealed nine out of 106 employees had not received their COVID-19 booster. the IP stated the matrix indicated Licensed Vocational Nurse (LVN) 2 had not received a booster and that she had not spoken to those employees regarding why they have not received their boosters. A review of the California Department of Public Health All Facilities Letter 21-28.3 dated 2/22/2022, titled, Coronavirus Disease 2019 (COVID-19) Testing, Vaccination Verification and Personal Protective Equipment (PPE) for Health Care Personnel (HCP) at Skilled Nursing Facilities (SNF), indicated that SNFs were to develop and implement a process for verifying the vaccination status of all HCP. A review of the facility's policy and procedure titled, COVID-19 Staff Vaccination Program, revised 5/31/2022, indicated the facility will use a spreadsheet to document all COVID-19 vaccine doses received by health care personnel. It also indicated in addition to the facility internal tracking of employee vaccination information, vaccination data of employees was reported to NHSN (National Healthcare Safety Network) by facility designee. A review of the facility's mitigation plan, revised 10/8/2022, indicated the facility must maintain records of the vaccination status of all workers or their exemption status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an indwelling catheter (a tube left in the bladder that drains urine) drainage bag was placed in a dignity bag (a concealment device used to block the view of the contents of a urinary catheter bag, a collection bag connected to a tube inserted into the body to collect urine) to provide privacy for one of three sampled residents (Resident 17). This deficient practice had the potential for resulting to psychosocial harm and violating Resident 17's right to be treated with dignity. Findings: During an initial tour of the facility on 5/10/2022 at 9:45 A. M., Resident 17 was observed lying in bed with the urinary catheter bag anchored to the side of the bed without a privacy bag cover in place. A review of Resident 17's admission record, dated 5/24/2021, indicated the resident was admitted to the facility on [DATE], with diagnoses that included but were not limited to Multiple sclerosis (a disease that can affect the brain and spinal cord, and can cause vision, balance, muscle control problems an neuromuscular dysfunction of bladder (lose control of your bladder), retention of urine (the action of absorbing and continuing to hold a substance)and muscle weakness. A review of Resident 17's Order Summary Report, dated 4/1/2021, indicated to provide treatments for urinary catheter care daily. A review of Resident 17's care plan dated 4/1/2022, indicated the resident had a foley indwelling catheter due to neurogenetic bladder. Foley catheter care daily. Position catheter bag and tubing below the level of the bladder and away from the entrance room door. During an interview on 5/10/2022, at 9:48 A. M., with Certified Nursing Assistant (CNA) 1 stated it was the policy of the facility to place all the residents' with indwelling catherter bag in a privacy bag to promote dignity and respect for the resident. CNA 1 stated that she would place the indwelling catheter bag in a privacy bag immediately. During an interview on 5/13/2022, at 11:35 A. M., the Director of Nursing (DON) stated residents with indwelling foley catheters should have their indwelling foley catheter drainage bag placed in dignity bags to provide the residents' with privacy. A review of the facility policy and procedure titled, Resident Rights-Quality of Life, dated March 2017, indicated each resident shall be cared for in manner that promotes and enhanced the quality of life, dignity, respect, individuality and receives services in a person-centered manner, as well as those that support the resident in attaining or maintaining his/her highest practicable wellbeing. Facility staff promote dignity and assist residents as needed by helping the resident to keep urinary catheter bags covered. A review of the facility policy and procedure titled, Catheter-Care of, dated 6/10/2021 indicated the after the bag was emptied, the drainage bag protector will be replaced.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have the call light (device used to alert the facility staff that a resident requires assistance) within reach in the resident's room for two of 17 sampled residents (Resident 35 and 48). This deficient practice had the potential to result in the delay of provision of services and not allow the resident to call for help when needed or emergencies which could lead to harm to Resident 35 and 48. Findings: a. A review of Resident 35's Facesheet (admission record) indicated the facility admitted the resident on 2/15/2022, with diagnoses that included cerebral infarction (damage to brain tissues caused by lack of oxygen to the area), epilepsy (a seizure disorder) and a cognitive communication deficit (a disorder resulting in difficulty with thinking and how someone uses language). A review of Resident 35's Minimum Data Set (MDS - a standardized assessment and care -screening tool), dated 2/22/2022, indicated Resident 35 cognitive skills of daily decision making were intact and required extensive assistance and one-person physical assist with activities of daily living which include bed mobility and dressing and was totally dependent with one-person physical assist with eating and toileting. During an observation and interview in Resident 35's room on 5/10/2022, at 8:50 A. M,, Resident 35's call bell was observed clipped to the corked board behind Resident 35's bed out of the resident's reach. Resident 35 stated call bell is always pinned behind her and she can never reach it. The surveyor pressed the call bell and Certified Nursing Assistant (CNA) 2 came to the room. During an observation and interview on 5/10/2022, at 8:55 A. M,, with CNA 2, confirmed that Resident 35's call light was clipped behind the resident's bed on the message board and stated Resident 35 could not reach the call light. CNA 2 stated the call bell should be within the resident's reach and that the facility staff are supposed to check and make sure that the call bell is next to the resident to prevent accident and to immediateely attend to the resident when in need of services. During an interview with director of nursing (DON) on 5/12/2022, at 11:06 A. M., stated all call lights should be within the reach of all residents so that we can attend to their needs as soon as possible. DON further stated there is a risk for fall or injury risk of harmful incidents to the residents when the call bell is out of reach. b. A review of Resident 48's Facesheet, dated 5/11/2022, indicated Resident 48 was originally admitted to the facility on [DATE], and readmitted to the facility on [DATE], with diagnoses that included but were not limited to generalized muscle weakness and heart failure (a chronic condition in which the heart does not pump blood as well as it should and can cause symptoms such as shortness of breath and/or swollen legs). A review of the History and Physical (H&P), dated 3/4/2022, indicated Resident 48 had the capacity to understand and make decisions and had diagnoses including muscle weakness, heart failure, and gait (manner of walking) impairment. A review of the MDS, dated [DATE], indicated Resident 48 required supervision to extensive assistance with activities of daily living (ADL - bed mobility, surface to surface transfers, dressing, toileting use, personal hygiene). During an observation and interview on 5/10/2022, at 12:41 PM, Resident 48 was observed lying in bed and the call light was observed on the floor behind Resident 48's bed. When the resident was asked, Resident 48 stated she could not find her call light. During an observation and interview on 5/10/2022, at 1 PM, with CNA 7, Resident 48's call light was observed on the floor behind Resident 48's bed. CNA 7 stated Resident 48's call light was on the floor and should always be in bed and within reach of the resident. CNA 7 was observed placing the call light back onto Resident 48's bed. CNA 7 further stated it was important for call lights to be on the bed or within reach so residents can call for help when they need it. A review of the facility's policy and procedures (P&P) titled, Communication - Call System, dated 1/1/2012, indicated the purpose was to provide a mechanism for residents to promptly communicate with nursing staff. The P&P indicated call cords will be placed within the resident's reach in the resident's room. The P&P further indicated when the resident was out of bed, the call cord will be clipped to the bedspread in such a way as to be available to a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 advanced 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 two of three sampled resident (Residents 5 and 22) Findings: a. A review of the admission Record indicated Resident 5 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included generalized muscle weakness, unsteadiness on feet, and anxiety. A review of the Minimum Data Set (MDS - a standardized assessment and screening tool), dated 4/15/2022, indicated Resident 5 had severe cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). A review of Resident 5's Advance Healthcare Directive Acknowledgement Form, undated, was found to have a signature under the section for resident signature and a blank space under the date. Resident 5's Advance Healthcare Directive Acknowledgement Form did not indicate whether Resident 5 received information regarding the resident's right to make an Advance Healthcare Directive, did not have an Advance Healthcare Directive, would like to receive more information, did not have an Advance Healthcare Directive and did not want information, or did have an Advance Healthcare Directive. Resident 5's Advance Healthcare Directive Acknowledgement Form further indicated blank spaces under facility staff name, title, facility staff signature, and date. During an interview and record review with the Social Services Director (SSD), on 5/12/2022, at 11:00 AM, Resident 5's Advance Healthcare Directive Acknowledgement Form, undated, was reviewed. Resident 5's Advance Healthcare Directive Acknowledgement Form indicated to have a signature under the section for resident signature and a blank space under the date. Resident 5's Advance Healthcare Directive Acknowledgement Form did not indicate whether Resident 5 received information regarding the resident's right to make an Advance Healthcare Directive, did not have an Advance Healthcare Directive, would like to receive more information, did not have an Advance Healthcare Directive and did not want information, or did have an Advance Healthcare Directive. Resident 5's Advance Healthcare Directive Acknowledgement Form further indicated blank spaces under facility staff name, title, facility staff signature, and date. The SSD stated Resident 5's Advance Healthcare Directive Acknowledgement Form was incomplete with no date or to what Resident 5 agreed to on the form. The SSD confirmed that Resident 5 had been a resident of the facility since 2020. During an interview and record review with the Director of Nursing (DON), on 5/12/2022, at 11:25 AM, Resident 5's Advance Healthcare Directive Acknowledgement Form, undated, was reviewed. Resident 5's Advance Healthcare Directive Acknowledgement Form indicated to have a signature under the section for resident signature and a blank space under the date. Resident 5's Advance Healthcare Directive Acknowledgement Form did not indicate whether Resident 5 received information regarding the resident's right to make an Advance Healthcare Directive, did not have an Advance Healthcare Directive, would like to receive more information, did not have an Advance Healthcare Directive and did not want information, or did have an Advance Healthcare Directive. Resident 5's Advance Healthcare Directive Acknowledgement Form further indicated blank spaces under facility staff name, title, facility staff signature, and date. The DON stated the Advance Healthcare Directive Acknowledgement Form should be completed within 48 hours. The DON stated a resident with severe cognitive impairment would not be able to make decisions on their own and the Advance Healthcare Directive Acknowledgement Form should be signed by a resident who had the ability to make decisions. The DON stated the Advance Healthcare Directive Acknowledgement Form should be completely filled out. The DON confirmed that Resident 5's Advance Healthcare Directive Acknowledgement Form was incomplete. b. A review of the admission Record indicated, Resident 22 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included Sepsis (potentially life-threatening condition that occurs when the body's response to an infection damages its own tissues), Escherichia Coli (a bacteria, this bacterium is harmless. It helps digest the food you eat. However, certain strains of E. coli can cause symptoms including diarrhea, stomach pain and cramps and low-grade fever), Pressure Ulcers (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) of the left hip, left ankle, left buttock and right hip. A review of Resident 22's MDS dated [DATE], indicated the resident had intact cognition. The MDS indicated the resident needed extensive assistance with bed mobility, transfer, locomotion, dressing, toilet use and personal hygiene. A review of Resident 22's Advance Directive Acknowledgment Form located in the resident's chart was found to be blank. On 5/12/2022 at 11 AM, during an interview, the SSD indicated Resident 22 was self-responsible and confirmed that the Advance Directive was not completed on 5/10/2022. The SSD stated the Advance Directive was completed on 5/11/2022. On 5/12/2022 at 11:35 AM, during an interview, the DON stated that an advance directive should be completed within 48 hours of admission to the facility and was unsure why Resident 22's advance directive was not completed upon admission. A review of the facility's policies and procedures (P&P) titled, Advance Directives, dated 7/2018, indicated the facility will respect a resident's advance directive and will comply with the resident's wishes expressed in the advance directive. Upon admission, the admission staff or designee will obtain a copy of the resident's advance directive. A copy of the resident's advance directive will be included in the resident's medical record. The P&P further indicated upon admission, the Admissions Staff or designee will provide written information to the resident concerning his or her right 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 interview and record review, the facility failed to ensure Beneficiary Protection and Notification forms were given to one of three sampled residents (Resident 3). This deficient practice had the potential to result in Resident 3 incurring an unknown financial liability to the facility or Resident 3 not being able to exercise his right to an appeal. Findings: A review of Resident 3's admission Record indicated the facility originally admitted the resident on 7/18/2018 and he was readmitted on [DATE]. A review of the Notice of Medicare Non-coverage (NOMNC) form indicated Resident 3's coverage for Medicare Part A Skilled Services would end on 2/15/2022. A further review of the form indicated that on page two of the NOMNC, the section, additional information, where one can document speaking to a resident representative, was blank and where the resident's signature/RP signature could go, unable to sign was written. A review of Resident 3's Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) form indicated the resident may have to pay out of pocket for custodial care beginning on 2/16/2022. A review of the form indicated there was no patient or patient representative (RP) signature on the form or any indication the form had been mailed to the representative for a signature. Further review of the SNFABN indicated that on the resident / RP signature line, unable to sign was written followed by a signature of a facility staff member. A review of Resident 3's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 4/14/2022, indicated Resident 3's cognition was severely impaired (never/rarely makes decisions). During an interview and record review on 5/13/22 at 9:47 AM with Business Office Manager (BOM), Resident 3's SNFABN and NOMNC forms were reviewed. The BOM stated that his assistant was not able to talk to Resident 3's family and they were not given the forms. The BOM stated Resident 3's spouse should have received the notices. A review of the Form Instructions for the NOMNC CMS-10123 indicated a Medicare provider must deliver a completed copy of the NOMNC to beneficiaries/enrollees receiving covered skill nursing. It further indicated that the NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily. A review of the facility's policy and procedures titled, Medicare Denial Process, revised 3/2018, indicated the beneficiary or representative will sign and date the NOMNC acknowledging that it was received and if the facility was unable to personally deliver the Notice to a person legally acting on behalf of the beneficiary, then the Facility must contact the representative via telephone and advise the representative when the beneficiary's services were no longer covered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to review and revise care plan for one of five sampled resident (Resident 28) who was receiving furosemide (Laxis - a medication used to treat fluid retention (holding) by increasing the amount of urine voided by the body). This deficient practice had the potential for Resident 28 not to receive the appropriate care treatment and/or services. Findings: A review of Resident 28's Facesheet (admission Record), dated 5/12/2022, indicated Resident 28 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE], with diagnoses that included but were not limited to Stage III chronic kidney disease (mild to moderate damage to the kidneys that causes the kidneys not to work as well as they should to filter waste and extra fluid out of the blood) and heart failure (a chronic condition in which the heart does not pump blood as well as it should and can cause symptoms such as shortness of breath and/or swollen legs). A review of Resident 28's Order Summary Report, dated 12/10/2021, indicated Resident 28 had an order for furosemide 40 milligrams (mg), one tab, by mouth, daily before breakfast for treatment of heart failure. A review of Resident 28's Minimum Data Set (MDS - a standardized assessment and care -screening tool), dated 2/25/2022, indicated Resident 28's cognitive skills of daily decision making were intact and required supervision with activities of daily living (ADLs - surface to surface transfer, eating, locomotion), and was always continent of bowel and bladder. A review of Resident 28's care plan, dated 4/6/2022, indicated the goal was for Resident 28 to attempt to comply with medication regimen. The care plan intervention indicated to monitor for edema (swelling caused by excess fluid trapped in the body's tissues) and shortness of breath, monitor for non-compliance with treatment, and promote the importance of participation/compliance in treatment regimen. The care plan did not indicate interventions to address Resident 28's periods of incontinence caused by medication use. During an interview on 5/10/2022, at 9:40 AM, Resident 28 stated she wears adult incontinence briefs because she had episodes of incontinence due to her furosemide medication. During an interview on 5/12/2022, at 1:13 PM, Certified Nursing Assistant (CNA) 8 stated Resident 28 was continent and was able to go to the restroom by herself, but she sometimes had episodes of incontinence due to her furosemide medication and wears adult incontinent briefs. CNA 8 further stated Resident 28 was independent and can help herself, but sometimes needs help with changing her incontinence briefs. A review of the Care Plan, dated 4/6/2022 indicated Resident 28 was non-compliant with medication regimen of furosemide 40mg every day and that Resident 28 verbalized not wanting to take the medication every day because the resident did not like having to eliminate fluid frequently. The care plan goal indicated Resident 28 will attempt to comply with medication regimen. The care plan intervention indicated to monitor for edema (swelling caused by excess fluid trapped in the body's tissues) and shortness of breath, monitor for non-compliance with treatment, and promote the importance of participation/compliance in treatment regimen. The care plan did not indicate interventions to address Resident 28's periods of incontinence caused by medication use. During an interview the MDS Coordinator stated Resident 28s care plan interventions do not include bowel and bladder elimination or anticipation of bowel and bladder needs. A review of the facility's policy and procedures (P&P) titled, Comprehensive Person-Centered Care Planning, dated 11/2018, indicated it was the policy of this facility to provide person-centered, comprehensive, and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being. The P&P further indicated the comprehensive care plan will also be reviewed and revised at the following times: onset of new problems, change of condition, to address changes in behavior and care, and other times as appropriate or necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure, for a resident who had an indwelling catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage), the indwelling catherter bag was anchored (secure) below the resident's bladder for one of two sampled residents (Resident 6). This deficient practice had the potential to result in recurrence of urinary tract infection (UTI-an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney) and had a potential to lead to urosepsis (a potentially life-threatening complication of urinary tract infection) or harm to the resident. Findings: A review of Resident 6's admission record indicated the resident was admitted to the facility on [DATE], and readmitted to on 3/21/2022, with diagnoses that included but were not limitted to Urinary Tract Infection and Type II Diabetes (High blood sugar). A review of Resident 6's care plan for Indwelling Catheter dated 3/23/2022, indicated the resident will be/remain free from catheter-related trauma through the review date that was not indicated. The care plan intervention indicated to position the catheter bag and tubing below the level of the bladder and away from the entrance room door and also check tubing for kinks and leakes each shift. During an initial tour of the facility on 5/10/2022 at 9 AM, Resident 6 was observed with an indwelling catheter with a drainage bag with approximately 600 milliliter of urine. The indwelling catherter bag was observed anchored above the resident's bladder that may cause a backflow of urine that could lead to bladder infection. During an interview with Licensed Vocational Nurse (LVN) 3 on 5/10/2022 at 9:03 AM, LVN 3 stated and confirmed Resident 6's indwelling foley catheter drainage bag was anchored above the resident's bladder. LVN 3 anchored the indwelling catheter drainage bag to the bed below Resident 6's bladder. During an interview with the director of nursing (DON) on 5/13/2022 at 11:25 AM, the DON stated the indwelling foley catheter bag should be secured to the resident's bed and anchored below the level of the resident's bladder to prevent the black flow of the urine andthat could cause infection. A review of facility's policy and procedures titled, Catheter-Care of, dated 6/10/2021, indicated the catheter will be anchored to prevent excessive tension on the catheter. The catheter tubing, bag or spigot will be anchored to prevent it from touching the floor and backflow.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow through on one recommendation from the consultant pharmacist (a professional responsible for reviewing each resident's medication profile monthly to identify and report irregularities) from February 2022 to consider a gradual dosage reduction (GDR - a periodic attempt to lower the dosage of a medication to the lowest effective dose) on Depakote (a medication used to treat mental illness) in one of five sampled residents (Resident 48.) The deficient practice could have resulted in Resident 48 experiencing preventable complications from her medication therapy, possibly leading to a diminished quality of life. Findings: A review of Resident 48's admission Record dated 5/12/22, indicated she was readmitted to the facility on [DATE] with diagnoses including bipolar disorder (a mental illness associated with mood swings ranging from depressive lows to manic highs). A review of the consultant pharmacist's Medication Regimen Review, dated 2/25/22, indicated the consultant pharmacist made a recommendation to Resident 48's attending physician to consider an attempt of a GDR on the Depakote due to minimal behaviors. A review of Resident 48's Order Summary Report, dated 5/2/22, indicated the attending physician prescribed Depakote 250 milligrams (mg - a unit of measure for mass) by mouth twice daily for bipolar disorder manifested by angry outbursts toward staff. A review of Resident 48's clinical record indicated the facility did not document any response from the attending physician regarding the consultant pharmacist's recommendation to perform a GDR on Depakote. During an interview on 5/11/22, the DON stated the facility must address any pharmacist recommendations for GDR with the physician directly rather than assuming the physician's response from previous records. The DON stated the failure to address the pharmacist's recommendations with the physician when required could cause complications due to drug therapy which could diminish the resident's quality of life. On 5/12/22 at 12:01 PM, during an interview, the DON stated the facility failed to address the consultant pharmacist's recommendation for the GDR on Depakote dated 2/25/22 for Resident 48. A review of the facility's policy titled, Pharmacist Medication Regimen Review, dated 2/23/15, indicated the consultant pharmacist medication regimen review and nursing medication documentation review reports were processed as follows: Medication regimen review recommendation to physician . the physician provides a written response to the report to the facility within two weeks after the report is sent . a copy of the report is kept by the facility until the physician's signed response is returned.

Based on observation interview and record review, the facility failed to provide appropriate monitoring of Heparin (a medication used to prevent blood from clotting in the heart or blood vessels) for one of five sampled residents (Resident 35). This deficient practice had the potential to result in complications from the use of heparin such as bruising and bleeding to Resident 35. Findings: A review of Resident 35's admission Record indicated the facility admitted the resident on 2/15/2022 with a medical history including cerebral infarction (damage to brain tissues caused by lack of oxygen to the area), epilepsy (a seizure disorder) and a cognitive communication deficit (a disorder resulting in difficulty with thinking and how someone uses language). A review of the Physician's Order, dated 2/15/2022, indicated Resident 35 was to receive Heparin Sodium 5000 units per one (1) milliliter (ml) solution subcutaneously (applied under the skin) every eight hours for deep vein thrombosis (DVT - a blood clot in a deep vein, usually in the legs) prophylaxis (action taken to prevent disease). A review of the physician order, dated 2/17/2022, indicated Resident 35 was to be monitored for bruising or unusual bleeding every shift secondary to anti-coagulant use. A review of the Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 2/22/2022, indicated Resident 35 had intact cognition (decisions consistent/ reasonable), required extensive assistance and one-person physical assist with bed mobility and dressing, and was totaly dependent with one-person physical assist with eating and toileting. According to a review of the March, April and May 2022 medication administration records (MAR), Resident 35 received Heparin Sodium (an anticoagulant medication injection-used to treat and prevent harmful blood clots) every eight hours. A review of these MARs also indicated no documented evidence the licensed nurses monitored for side effects of Heparin. A review of the Consultant Pharmacist's Medication Regimen Review, dated April 2022, indicated there was a recommendation for the facility to monitor for signs and symptoms of bruising and bleeding every shift as the resident recieved Heparin. A review of the care plan titled, Risk for alteration in hematological status, anticoagulant, dated 5/12/2022 indicated Resident 35 was at risk due to the use of Heparin. The care plan interventions included monitor/ document/ report as needed the symptoms of anemia, including pallor, fatigue and palpitations. According to the Nursing Drug Handbook, 2021, Heparin side effects included bleeding and thrombocytopenia (a condition in which one's ability to clot is impaired). The Nursing Drug Handbook indicated to monitor for bleeding from gums, minor cuts and in urine. During an interview with the Director of Nursing (DON) on 5/13/2022 at 8:56 AM, the DON stated there was a physician's order to monitor for bruising and bleeding, order dated 2/17/2022 due to the administration of heparin for Resident 35. The DON stated the order was not placed on the MAR due to a data entry error and that there was no documentation of the resident being monitored for bruising or unusual bleeding every shift. A review of the facility policy and procedure titled, Heparin subcutaneous injection, dated 1/1/2012, indicated the resident should be observed for bleeding and bruising. A review of the facility policy and procedure titled, Drug Regimen Review, dated 12/2016, indicated all resident's drug regimen must be free from unnecessary drug and an unnecessary drug was any drug when used without adequate monitoring.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure standard infection control practices were followed for two of 16 sampled residents (Residents 26 and 36) by: -Failing to ensure Resident 26's oxygen nasal cannula tubing (nc - a device used to deliver supplemental oxygen placed directly on a resident's nostrils) and humidification bottle was dated. -Failing to ensure Resident 36's gastric drainage tubing and the attached cannister were off the floor. These deficient practices caused an increased risk in contamination with the potential for infections for Residents 26 and 36. Findings: a. A review of admission Record indicated Resident 26 was readmitted to the facility on [DATE], with diagnoses that included acute respiratory failure with hypoxia (a condition when one does not have enough oxygen in their blood), anemia (a condition marked by a deficiency of red blood cells or of hemoglobin-a protein responsible for transporting oxygen in the blood) and heart failure (condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen. A review of Resident 26's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 4/25/2022, indicated Resident 26's cognition was moderately impaired (decision poor; cues/supervision required). The resident was totally dependent on staff in transfer, bed mobility, and dressing and toileting. A review of Resident 26's Physician's Order dated 4/18/2022, indicated to administer oxygen two liters per minute (LPM) via nasal cannula (nc - medical device to provide supplemental oxygen therapy through the nostrils) continuously. During an observation on 5/10/2022 at 10:05 AM, Resident 26 was observed lying in her bed sleeping, receiving oxygen via nasal cannula. The nasal cannula and humidification bottle were both observed undated. During an interview on 5/10/2022 at 10:19 AM, Licensed Vocational Nurse (LVN) 1 stated Resident 26 was receiving oxygen at 2 LPM and that neither the oxygen tubing nor the humidifier tubing was labeled with a date. LVN 1 stated it was important to indicate the date for infection control purposes. During an interview with the Infection Preventionist (IP) on 5/11/2022 at 9:49 AM, The IP stated the oxygen tubing was to be changed every seven days. During an interview with Director of Nursing (DON) on 5/13/2022 at 8:59 AM, the DON stated the oxygen tubing should be dated and changed once a week. The DON further stated that not changing the tubing was a risk factor for infection and that the tubing should be dated to know when to change it. A review of the facility's policy and procedure titled, Oxygen Therapy, revised 11/2017, indicated the humidifier and tubing should be changed no more than every seven days and labeled with the date of change. A review of the facility's policy and procedure titled, Infection Control - Policies and Procedures, revised 1/1/2012, indicated the objectives of the infection control policies and procedures were to maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public. b. A review of Resident 36's admission Record indicated the facility readmitted the resident to the facility on 5/2/2022 with a medical history including dysphagia (difficulty swallowing), gastro-esophageal reflux disease (GERD- frequent heartburn) and gastrostomy malfunction. A review of the MDS dated [DATE], indicated Resident 36's cognition was severely impaired (never/rarely made decisions), was totally dependent in bed mobility, transfer, eating, toileting and personal hygiene. During an observation on 5/10/2022 at 10:48 AM, Resident 36 was observed lying in bed with a drainage tube connecting the gastrostomy to a cannister on the floor. Both the tubing and cannister were on the floor and neither the tubing nor the cannister were dated. During an observation on 5/10/2022 at 1:19 PM,the tubing from Resident 36's gastrostomy to a cannister was observed on the floor. The cannister was also on the floor. During an interview with LVN 3 on 5/11/2022 at 12:16 PM, LVN 3 stated Resident 36 was sent out multiple times for g-tube malfunctions and Resident 36 was having a lot of gas and bloating. LVN 3 further stated that the drain was in place to decompress the stomach of gas and acid. During an interview on 5/11/2022 at 12:23 PM, LVN 1 stated the drainage tubing connected Resident 36's g-tube with the cannister was on the floor and that both the tubing and canister should be dated, and they were not. LVN 1 stated the tubing and canister should not be on the floor due to infection control because these actions can lead to an infection. During an interview on 5/12/2022 at 11:08 AM, the DON stated the drainage tubing on the floor instituted a risk for infection for Resident 36 and that the cannister and drainage tubing should be dated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to create a comprehensive care plan (a resident-specific plan with defined clinical goals and interventions used to manage identified medical issues or other areas of concern) to meet the needs of three of 16 sampled residents (Resident 26, Resident 28, and Resident 48) by failing to: -Develop a plan of care for Resident 26 who was using oxygen for shortness of breath. -Develop a plan of care with individualized approaches for Resident 28 who had diagnoses for bipolar disorder (a mental illness associated with mood swings ranging from depressive lows to manic highs), major depressive disorder ([MDD] a mental illness characterized by depressed mood, loss of appetite, lack of energy or interest in doing usually enjoyable activities), and schizophrenia (a mental disorder that affects a person's ability to think, feel, and behave clearly). -Develop a plan of care with individualized approaches for Resident 48 who had diagnoses of major depressive disorder and bipolar disorder. These deficient practices had the potential to result in a delay of nursing care and medical interventions for Resident 26 and increased the risk that Resident 28 and Resident 48 may have received suboptimal care from facility staff in these care areas leading to diminished physical, mental, and psychosocial well-being. Findings: a. During an observation on 5/10/2022 at 10:05 AM, Resident 26 was observed lying in bed sleeping with oxygen administered via a nasal cannula (NC - medical device to provide supplemental oxygen therapy through the nostrils). A review of Resident 26's admission record, indicated Resident 26 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included but were not limitted to acute respiratory failure with hypoxia (a condition when one does not have enough oxygen in their blood), anemia (a condition marked by a deficiency of red blood cells or of hemoglobin-a protein responsible for transporting oxygen in the blood) and heart failure (condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen. A review of Resident 26's physician's order dated 4/18/2022, indicated to administer oxygen two liters per minute (LPM) via NC continuously. A review of Resident 26's Minimum Data Set (MDS - a standardized assessment and care- screening tool) dated 4/25/2022, indicated Resident 26's cognitive skills of daily decision making were moderately impaired. The MDS indicated the resident was totally dependent on staff with activities of daily livings (transfer, bed mobility, and dressing and toileting). During an interview and observation with LVN 1 on 5/10/2022, at 10:19 AM, LVN 1 stated Resident 26 was receiving oxygen at 2 liters per minute (LPM) through a nasal cannula. During an interview and record review on 5/10/2022 at 11:45 a.m., the MDS nurse stated she could not find an oxygen care plan for Resident 26. MDS nurse and that the admitting nurse and/or the nurse who received the resident was responsible for developing the care plan and the MDS coordinator was responsible to review the care plan quarterly. The MDS nurse further stated that there should be an oxygen care plan and that a care plan was made to ensure the resident needs were met, and that the facility was able to address any needs that may arise. A review of the facility's policies and procedures titled, Comprehensive Person-Centered Care Planning, revised 11/2018, indicated an individualized comprehensive care plan will be developed within seven days of the completion of the comprehensive MDS assessment and the comprehensive care plan will be periodically reviewed and revised as necessary. b. A review of Resident 28's admission record indicated Resident 28 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including bipolar disorder, Major depressive disorder, and schizophrenia. A review of Resident 28's MDS, dated [DATE], indicated Resident 28's cognitive skills of daily decisions making were in intact. A review of Resident 28's Order Summary Report, dated 5/1/2022, indicated the physician prescribed the following medications on the following dates: -On 11/24/2021, escitalopram (a medication used to treat MDD) 10 mg by mouth one time a day for self-isolation related to MDD. -On 4/9/2022, quetiapine (a medication used to treat schizophrenia) 50 mg by mouth at bedtime for schizophrenia manifested by auditory (related to hearing) hallucinations as evidence by hearing voices. A review of Resident 28's care plans for escitalopram and quetiapine dated 5/11/2022, was reviewed with the MDS Coordinator. On 5/12/2022, at 11:55 AM, the MDS nurse Coordinator stated Resident 28's care plans for escitalopram and quetiapine were initiated on 5/11/2022, not when the medications were ordered. The MDS Coordinator stated care plans should be develped upon comprehensive assessment and when medications are ordered. The MDS Coordinator further stated it was important to create a care plan for the medications to monitor for side effects and take care of the residents in relation to the medications in use. c. A review of Resident 48's admission record indicated she was admitted to the facility originally on 6/11/20 and readmitted on [DATE] with diagnoses including MDD and bipolar disorder. A review of Resident 48' Order Summary Report, dated 5/2/2022, indicated the attending physician prescribed the following mediations on the following dates: -On 2/28/2022, Depakote (a medication used to treat bipolar disorder) 250 milligrams (mg - a unit of measure for mass) by mouth twice daily for bipolar disorder manifested by angry outbursts toward staff. -On 3/29/2022, escitalopram 5 mg by mouth at bedtime for depression manifested by verbalization of feeling sad. A review of Resident 48's MDS indicated comprehensive assessment was completed by the facility on 3/21/2022. A review on 5/11/2022 of Resident 48's undated care plans indicated the care plan for depression/mood swings did not list any resident specific behaviors, clinical goals, or medications used to treat the conditions listed as specific interventions. Further review of the care plan for depression/mood swings indicated all the interventions listed for this care area were regarding management of physical pain rather than behaviors of MDD or bipolar disorder. A review of Resident 48's clinical record indicated there was no other care plans available addressing MDD or bipolar disorder, related behaviors, or the use of Depakote or escitalopram used to treat these conditions. During an interview on 5/11/2022. at 2:30 PM., the MDS Coordinator stated she was responsible of developing the care plans and the facility failed to create care plans that were resident-specific or with clear clinical goals and specific interventions for Resident 48's diagnoses of MDD, bipolar disorder, or the Depakote and escitalopram used to treat them. The MDS Coordinator stated having resident-specific care plans to address identified care areas was important to ensure the facility staff provide the optimal care in the areas of concern identified for that resident. The MDS Coordinator stated failure to create resident-specific therapeutic goals and interventions may cause the resident to be unable to reach their highest level of physical, mental, or psychosocial well-being. A review of the facility's policy titled, Comprehensive Person-Centered Care Planning, dated November 2018, indicated to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, and environmental needs of residents in order to obtain or maintain the higher physical, mental and psychosocial well-being. Within seven days from the completion of the comprehensive MDS assessment, the comprehensive care plan will be developed.

Based on observation, interview, and record review, the facility failed to accurately account for the use of four doses of controlled substances (medications with a high potential for abuse) for four residents (Residents 23, 27, 57, and 213) in two of two inspected medication carts (Medication Carts 2A and 2B). This deficient practice increased the risk that Residents 23, 27, 57 and 213 could have received too much or too little medication due to lack of documentation, possibly resulting in serious health complications requiring hospitalization. Findings: During an observation of Medication Cart 2B, on 5/10/22 at 11:01 AM, with the Licensed Vocation Nurse (LVN 1), the following discrepancy was found between the Narcotic and Hypnotic Record (a log signed by the nurse with the date and time each time a controlled substance is given to a resident) and the medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses of the medication): -Resident 27's Narcotic and Hypnotic Record for hydrocodone/acetaminophen (a medication used to treat pain) 5/325 milligrams (mg - a unit of measure for mass) indicated there were 40 doses left, however, the medication card contained 39 doses. During a concurrent interview, LVN 1 stated she gave the missing dose of hydrocodone / acetaminophen 5/325 to Resident 27 earlier this morning, but failed to sign for the dose in the Narcotic and Hypnotic Log after it was given. LVN 1 stated it was the facility's policy to sign the log immediately after the dose was given to ensure the accountability of the narcotic medications and for resident safety to ensure he was not administered more medication than was allowed. LVN 1 stated if Resident 27 received hydrocodone/acetaminophen 5/325 more often than it was prescribed, it could cause medical complications that could affect his overall well-being. During an observation of Medication Cart 2A, on 5/10/22 at 11:17 AM, with LVN 2, the following discrepancies were found between the Narcotic and Hypnotic Record and the medication card: -Resident 213's Narcotic and Hypnotic Record for tramadol (a medication used to treat pain) 50 mg indicated there were 20 doses left, however, the medication card contained 19 doses. -Resident 57's Narcotic and Hypnotic Record for hydrocodone/acetaminophen 7.5/325 mg indicated there were 28 doses left, however, the medication card contained 27 doses. -Resident 23's Narcotic and Hypnotic Record for oxycodone/acetaminophen (a medication used to treat pain) 7.5/325 mg indicated there were 18 doses left, however, the medication card contained 17 doses. During a concurrent interview, LVN 2 stated she failed to sign for Resident 57's dose of hydrocodone/acetaminophen this morning and according to the Medication Administration Record (MAR), LVN 1 failed to sign for Resident 213's tramadol and Resident 23's oxycodone/acetaminophen from doses given last night. LVN 2 stated the narcotic doses were important to sign for right away to ensure accountability of the controlled substances and to ensure resident safety by making sure they were not given medication more often than was prescribed. A review of the facility's policy titled, Controlled Medication Storag,e dated 2/23/15, indicated at each shift change, a physical inventory of all controlled medications, including the emergency supply, was conducted by two licensed nurses and was documented on the controlled medication accountability record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two medications were labeled with an open date per the manufacturer's requirements in one of two inspected medication carts (Medication Cart 2A) affecting Residents 48 and 214, and the facility failed to remove one expired medication from one of two inspected medication carts (Medication Cart 2A) affecting Resident 57. These deficient practices increased the risk that Residents 48, 57, and 214 could have received medication that had become ineffective or toxic due to improper storage or labeling, possibly leading to health complications resulting in hospitalization or death. Findings: During an observation on [DATE] at 11:17 AM, of Medication Cart 2A with the Licensed Vocational Nurse (LVN 2), 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: -One open vial of latanoprost eye drops (a medication used to treat eye problems) for Resident 214 was found stored at room temperature unlabeled with an open date. Per the manufacturer's product labeling, once stored at room temperature, latanoprost eye drops should be used or discarded within six weeks. -One opened Symbicort inhaler (a medication used to treat breathing problems) for Resident 48 unlabeled with an open date. Per the manufacturer's product labeling, once removed from the protective foil pouch, Symbicort inhalers should be used or discarded within three months. -One opened Combivent Respimat inhaler (a medication used to treat breathing problems) for Resident 57 found labeled with an open date of [DATE]. Per the manufacturer's product labeling, Combivent Respimat should be discarded three months after the first use. During a concurrent interview, Licensed Vocational Nurse (LVN) 2 stated the latanoprost for Resident 214 does not have an open date labeled on it but needs one because the facility policy was to discard open eye drops 30 days after opening. LVN 2 stated the Symbicort inhaler for Resident 48 should be marked with an open date to ensure it was not used for more than three months after opening it. LVN 2 stated the Combivent Respimat for Resident 57 with an open date of [DATE] was expired as it must be used or discarded within three months of first use. LVN 2 stated that using breathing treatments or eye drops beyond their use date or when they have not been stored appropriately according to the manufacturer's requirements could cause health complications possibly leading to hospitalization. A review of the facility's policy titled, Storage of Medications, dated [DATE], indicated medications and biologicals are stored safely, securely, and properly, following the manufacturer's recommendations or those of the supplier. Outdated, contaminated, or deteriorated medications are immediately removed from stock.

Based on observation, staff interviews, record review, the facility failed to ensure safe and sanitary food storage and food preparation practices when: -Raw chicken stored on top of beef brisket and next to raw fish in the reach in refrigerator. -Ice machine ice dispenser and spout internal compartment was dirty. -Dishwahser staff did not wash hands or change gloves when removing the clean and sanitized dishes form the dish machine. -Food brought to residents from outside of the facility, including leftovers, stored in the resident refrigerator were not labeled. 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 66 of 67 residents who received food and ice from the facility. Findings: a. During an observation of the kitchen on 5/10/2022 at 9:30 AM, a large bowl of raw chicken was stored on top of raw beef brisket and on the same shelf as the raw fish. The raw chicken was in a stainless-steel bowl and loosely covered with plastic wrap. During a concurrent interview with the Dietary Supervisor (DS), she sated raw chicken should be on the lower shelf below the beef and fish. The DS stated, We have no space, all the different meat types are thawing together on same shelf. The DS stated she will rearrange the meats and put them on different shelf and that foods that take longer to cook should be on the lower shelf. A review of facility policy titled, Food Storage, revised 7/25/19 indicated raw meat, poultry and seafood should be stored in refrigerators/freezers in the following top to bottom order: 1.[top]Ready to eat food; 2.seafood; 3.whole cuts of beef and pork; 4.Ground meat and ground fish; 5.[bottom] whole and ground poultry; label and date all food items. The above storage order was based on the minimal internal cooking temperature of each food. b.During an observation of the facility ice machine on 5/10/2022 at 10:31 AM, located in the corridor outside of resident rooms, a clean paper towel swipe inside the ice dispenser (spout) produced a black color residue. During a concurrent observation and interview with the Maintenance Supervisor (MS), he stated he cleaned the ice machine according to manufactures instructions once a month and he turned off the machine and removed the ice. The MS stated then used the cleaning solutions from the kitchen to clean the ice storage bin and then he used the sanitizer solution from the kitchen (quaternary ammonia) from the dishwashing area to sanitize the ice storage bin in the ice machine. When asked if he cleaned inside the dispenser on the front panel of the ice machine, he stated he might have overlooked that area. During the same observation, the MS used a clean paper towel and swiped inside the ice dispenser produced a black color residue. The MS stated he did not clean and sanitize that area which was the ice dispenser area. The MS verified that ice drops from the dispenser and residents have access to the ice machine by pressing on the dispenser which releases ice. The MS stated he will clean and sanitize the dispenser. A review of facility policy titled, Ice machine - Operation and Cleaning, revised 10/1/2014 indicated maintenance staff will clean the ice making mechanism according to manufacturer's guidelines. A review of the manufacturer's instruction for the facility ice machine (revised 12/13/2003) indicated to scrub the inside of the bin, the agitator, the spout of the bin, the spout of the font panel and chute using pad, buses and cleaning solution. The instruction continues, for sanitizing procedure, following cleaning procedure- using the following sanitizing solution: ½ oz of chlorine bleach diluted in 1 gallon of water. Rinse all parts thoroughly with clean water. c. During an observation in the dish machine area on 5/10/2022 at 9:50 AM, the Dishwasher Staff (DW) had gloves on and rinsing soiled dishes. After rinsing soiled dishes the DW was loading the dirty dishes in the dish machine. Once the dish machine stopped the DW then rinsed gloved hands with water using hose next to dirty dishes sink, then dipped gloved hands in a bucket full of sanitizer solution located in the manual dishwashing sink adjacent to the dish washing machine. The DW proceeded to remove the clean and sanitized dishes from the machine and stored on rack for air drying. During a concurrent interview with the DW staff, he stated he should remove gloves, wash hands and put on new gloves when touching clean dishware. He stated he did not remove gloves and he did not wash hands. The DW staff stated he dipped his gloved hands in sanitizer solution because he was rushing to finish the dishwashing before it piles up. He added that he knows he should change gloves and wash hands in the hand washing sink every time he moves from dirty task to clean task. During an interview with Dietary Supervisor (DS) on 5/10/2022 at 11:50AM, the DS stated that staff should always remove gloves, wash hands then put on new gloves when touching clean dishes. She added that she will provide Inservice on handwashing. A review of facility policy titled, Dietary Department-Infection Control foe Dietary Employees, revised 11/9/2016 indicated proper handwashing by personnel will be done after handling soiled equipment or utensils. Kitchen sinks shall not be used for hand washing. Separate hand washing facilities with soap, running water and individual towels shall be provided. d. During an observation of the resident refrigerator on 5/11/2022 at 10:30AM located inside a small storage room, there were several food items brought in from outside stored in the freezer with no label. There was a cup with a left over pink drink and straw inside it that was half full stored in the freezer with no name or date, there was a cup of ice cream from an ice cream shop pre-scooped with no name or date, there were several store-bought frozen foods with no name stored in the resident refrigerator/freezer unit. During a concurrent interview with Infection prevention nurse (IP), she stated all food items brought in from outside should be labeled with resident name and date. She verified there were several food items including leftover pink drink and a cup of ice cream stored in the resident freezer with no label. The IP stated she will check and discard items per policy. A review of facility policy titled, Food Brought in by visitors, revised 6/2018, indicated when food is brought into a nursing home prepared by others, the nursing home is responsible for ensuring that the food container is clearly labeled with the resident name and date received and stored in a refrigerator designated for this purpose.