**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a safe environment and adequate supervision to prevent elopement ( a person left a place without anyone knowing or without permission) for 1 of 3 sampled residents (Resident 1), when the Wander Guard alarm system failed to activate when Resident 1 exited through a secured door and staff were not immediately alerted to the resident's departure.This failure resulted in Resident 1 leaving the facility unsupervised, placing Resident 1 at risk for serious injury, harm or death due to potential environmental hazards, including vehicular traffic.During a review of Resident 1's admission Record (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), and abnormalities of gait (walking) and mobility ( how easily a person could move their body when sitting, standing or using a wheelchair).During a review of Resident 1's Minimum Data Set (MDS-resident assessment tool which indicates physical and cognitive abilities), dated 5/20/25, the MDS indicated a Brief Interview for Mental Status (BIMS-an assessment of cognitive function) score of 8 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment) indicating Resident 1 had moderate cognitive impairment.During an interview on 7/16/25 at 12:11 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she heard Resident 1's Wander Guard did not sound when she left the facility, but was not on shift the day the incident happened. CNA 1 explained when a resident wearing a Wander Guard approaches an exit door, the system is supposed to trigger an alarm. CNA 1 stated it was important for the system to be working, because that was how they knew everyone was in the facility.During an observation on 7/16/25 at 12:18 p.m. in Resident 1's room, Resident 1 was observed sitting up in her bed. She was well groomed and dressed for the day. Resident 1 was oriented (person knew basic information such as who they are, the day, and what was happening around them) to self but displayed confusion regarding the day and the current situation. Resident 1's demeanor was calm. A Wander Guard device was observed on her left wrist.During an interview on 7/16/25 at 12:38 p.m. with CNA 2, CNA 2 stated there had been a recent elopement and they heard there was a possible malfunction of a Wander Guard. CNA 2 explained it was important for the alarm to sound, as it alerts staff when a high-risk resident is attempting to leave the facility. CNA 2 stated residents who wear a Wander Guard typically have dementia and stated the alarm has a distinct sound that differs from the call light.During an interview on 7/16/25 at 12:45 p.m. with Registered Nurse (RN) 1, RN 1 stated the alarm system notifies staff immediately when a resident wearing a Wander Guard attempt to leave the facility. RN 1 stated the system is a very important safety precaution, as elopements can result in falls, serious injuries and even death.During an interview on 7/16/25 at 1:19 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Wander Guards helped ensure resident safety, so it's important that the system functions properly. The LVN shared Resident 1 can be difficult to redirect.During a concurrent interview and review of Wander Guard Daily Functioning Log dated for month July 2025 with the Activities Director (AD), The AD stated Wander Guards system is checked daily, typically in the morning. The AD explained that the facility uses an approved system device that displays the Wander Guard number if it is active. If the number does not appear, the device is not active. The device only tests the Wander Guard that is placed on the resident wrist or ankle. The July 2025 log indicated on July 10, the day of the incident, Resident 1's Wander Guard was documented as active and had passed the daily check.During an interview on 7/16/25 at 2:24 p.m. with the Administrator (ADMIN), the ADMIN stated on the day of the incident, Resident 1 requested her medication around 10:35p.m. The nurse informed Resident 1 it was too early to administer her medication but assured her it would be given at the earliest appropriate time. Resident 1 then returned to her room. At 11:00p.m. the nurse went to administer the medication; Resident 1 was not there. Approximately thirty minutes later Resident 1 was found down the street in front of a Farmers Insurance building. Resident 1 was returned to the facility by staff. Upon reentry, Resident 1's Wander Guard alarm sounded. However, staff reported the alarm did not activate when Resident 1 initially exited the facility and they were not alerted to her departure. The ADMIN stated this may have been a potential system malfunction and emphasized that it is important to keep residents safe.During a review of Resident 1's Care Plan Report (CP), revised 1/3/25, the CP indicated, Resident 1 was identified as an elopement risk/wanderer and a fall risk. The goal was for Resident 1 to remain safely within the facility. Interventions included assessing Resident 1 for falls, identifying patterns of wandering and what they may indicate and checking the functionality of the Wander Guard.During a review of the facilities policy and procedure (P&P) titled, Elopement/Wandering, revised 2/2025, the P&P indicated, the maintenance department or designee tests the monitoring system (at alarmed exits) on a daily basis using the manufactured supplied device (as applicable) and documents the test.

Based on interview and record review, the facility failed to ensure the facility was free from accidents or hazards when one of three sampled residents (Resident 1) eloped (exited the facility without supervision or staff knowledge) from the facility when staff did not respond to a security alarm timely. This failure had the potential for Resident 1 to become lost, disoriented, physically injured from a fall or traffic collision, when he was found approximately 350 feet away from the facility. Findings: During a review of the facility document titled Subject: Unusual Occurrence, dated 7/9/25, the document indicated, On 7/8/25 at approximately 5:10 PM, [Resident 1] was seen ambulating in the south hallway. Approximately 10 minutes later he was reported to be in the [fast food restaurant] parking lot across the street from the back of the facility. Staff immediately responded and were able to guide [Resident 1] back to the facility. Nursing staff assessed [Resident 1] for any injuries and no injuries noted to him. [Security Alarm] system at the back door was in place and functioning. Nurse reported to hear alarm and responded at time of the event. During a review of Resident 1's admission Record (AR), dated 7/17/25, the AR indicated Resident 1 had been in the facility over one year. During a review of Resident 1's Minimum Data Sheet (MDS, a comprehensive, standardized assessment tool), dated 4/21/25, the MDS indicated at Question C0500 a score of 3 out of a possible 15, which indicated Resident 1's cognition (having sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the resident's environment) had severe impairment. During a review of Resident 1's Care Plan Report (CPR), dated 7/9/25, the CPR indicated Resident 1 had an episode of elopement on 7/8/25 [related to] impaired cognition. The CPR dated 4/5/24 indicted Resident 1 is an elopement risk/wanderer. Intervention/Tasks: [electronic security bracelet that activates an alarm whenever the bracelet comes near a sensor, usually installed next to exit doors] to left wrist to prevent resident from wandering outside unattended area. During a review of Resident 1's Elopement Risk Assessment (ERA), dated 4/2/25, the ERA indicated, Yes the resident is at risk for elopement. During an interview on 7/11/25, at 10:30 a.m., with the Administrator, the Administrator stated Resident 1 can walk and does not need the use of a wheelchair. The Administrator stated the staff person who first responded to the Security System alarm from Resident 1 on 7/8/25, was Licensed Vocational Nurse (LVN) 3. The Administrator stated, She is reporting that she didn't see [Resident 1] when she checked the alarm and opened the door to look for him. Ten minutes later, a former employee recognized him at [the nearby fast-food restaurant] and called an employee here and informed us of [Resident 1's] location. During an interview on 7/11/25, at 11:10 a.m., with the Administrator, the Administrator stated it is her expectation that, when a door alarm goes off, it gets checked by staff in one minute or less, as soon as they hear it. We have 15 residents with [security alarm bracelets]. During an interview on 7/23/25, at 8:55 p.m., with LVN 3, LVN 3 stated she recalled responding to a door alarm on 7/8/25. LVN 3 stated, I responded to one of the alarms at the back door on the south station [of the facility]. The alarm was going off, I was there within five minutes. I went outside and didn't see anyone, the alarm was going off. Then I went to the front door and looked there. I don't know why I went to the front door to look, the front door alarm was not going off. During a review of Google Maps, the distance from the South Station exit of the facility, to the fast-food restaurant, was measured to be approximately 350 feet (a standard football field is 300 feet). During a review of the facility's policy and procedure (P&P) titled, Elopement/Wandering, dated 2/25, the P&P indicated, Definitions: Elopement: The resident/patient exits the [facility] without staff knowledge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) had elopement (when a resident leaves the facility, or a designated safe area within the facility, without proper authorization or supervision, which potentially endangers themselves) risk factors assessed when he was admitted to the facility. This failure resulted in Resident 1 eloping from the facility. Findings: During a review of Resident 1 ' s admission Record (AR), dated 6/11/25, the AR indicated he was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (also known as a type of ' stroke ' which occurs when blood flow to a part of the brain is interrupted, leading to lack of blood supply and subsequent brain tissue death; symptoms can include sudden weakness or numbness on one side of the body, difficulty speaking or understanding speech, vision problems, dizziness, and loss of coordination), problems relate to life management difficulty, need for assistance with personal care, and alcohol abuse. During a review of Resident 1 ' s Minimum Data Sheet (MDS, a comprehensive, standardized assessment tool), dated 5/1/25, the MDS indicated at Question C0500 a score of 4 out of a possible 15, which indicated Resident 1 ' s cognition (having sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the resident ' s environment) was severely impaired. During a review of Resident 1 ' s Progress Notes (PN), dated 5/29/25, at 5:13 p.m., the PN indicated, Writer was on his way home when writer noticed an individual in a wheelchair heading towards [nearby street]. Writer pulled over and noticed that individual was actually [Resident 1]. Writer got out of vehicle and approached [Resident 1]. Writer asked resident where [sic] he was attempting to go and he stated ' I have family that lives around here. ' [Resident 1] currently in bed resting. The PN was written by Licensed Vocational Nurse (LVN) 1. During an interview on 6/11/25, at 11:50 a.m., with LVN 1, LVN 1 stated, I was leaving work in my car and I noticed [Resident 1] in his wheelchair [on a nearby sidewalk about 1,000 feet from the front door of facility, per Google Maps]. [Resident 1] stated, ' I have family near here. ' I got out of my car and wheeled him back to facility with no further incident. We applied a Wander guard [an electronic security bracelet, that sets off alarm when it activates a sensor, often placed by exit doors to alert staff that a resident may be attempting to leave the building without supervision] to him upon his return. There ' s been no further episodes of elopement. If I had to guess, he left the building via the front doors. During a review of Resident 1 ' s Order Summary Report (OSR), dated 6/11/25, the OSR indicated Resident 1 had a physician ' s order dated 5/29/25 for a Wander Guard to right ankle to prevent resident from wandering outside attended area. During an interview on 6/11/25, at 12:45 p.m., with LVN 2, LVN 2 stated she performs new admission paperwork for residents when they are admitted to the facility. LVN 2 stated, elopement risk assessments are usually done by the 2nd shift after the resident arrives in the facility. LVN 2 stated they are to be done certainly by 24 hours after admission. During a review of Resident 1 ' s admission – readmission Nursing Evaluation ([NAME]), the [NAME] indicated it was completed on 6/5/25. During a concurrent record review and interview on 6/11/25, at 12:50 p.m., with the Administrator, Resident 1 ' s clinical record was reviewed. The Administrator stated all residents admitted to the facility are to have a Nursing admission Evaluation done at admission. The Administrator stated Resident 1 ' s Nursing admission Evaluation was not done until 6/5/25 (41 days after Resident 1 ' s admission to the facility). The Administrator stated, This assessment captures his elopement risk, which was not done. I don ' t know why it was not done. This should have been done at admission. During a review of the facility ' s policy and procedure (P&P) titled, Nursing admission Evaluation, dated 7/14, the P&P indicated, The nurse completes the Nursing admission Evaluation at admission. Members of the IDT [Interdisciplinary Team, made up of representatives of different departments such as Nursing, Dietary, Activities, Social Services] review the Nursing admission Evaluation upon completion to facilitate a complete evaluation and plan of care for the resident. During a review of the facility ' s P&P titled, Elopement/Wandering, dated 2/25, the P&P indicated, The Center evaluates residents for wandering and/or exit seeking behavior and implements appropriate interventions as indicated via the evaluation process. At admission, the licensed nurse (LN) completes the Nursing admission Evaluation, to determine the resident ' s risk for wandering/elopement. The LN gathers as much information as possible at the time of admission from the family, significant other, or responsible party regarding previous elopement attempts or desire to leave the premises.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the safety and security of the residents when 15 of 15 sliding glass doors (located in resident rooms that exited to the exterior of the building) were noted to be unsecured, with no system to alert staff if a person entered or exited the facility via these 15 doors. This failure resulted in one resident (Resident 1) eloping (the act of leaving facility premises, or enters an unsafe area, without facility knowledge and/or supervision) via one of the 15 unsecured sliding glass doors twice in one day, and after the second elopement was found by staff 0.6 miles from the facility in a confused state. This placed Resident 1 at significant risk for injury, including trauma from a traffic collision; and, resulted in the potential for other ambulatory residents to elope via the 15 unsecured doors in the facility, and the potential for unknown visitors to enter the facility via the 15 unsecured doors. Findings: During a review of Resident 1 admission Record (AR) , dated [DATE], the AR indicated Resident 1 had diagnoses that included dementia (a progressive state of decline in mental abilities), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and disorientation (the condition of having lost one's sense of direction). During a review of Resident 1's Progress Notes (PN) , dated [DATE], at 4:04 p.m., the PN indicated, Resident [1] was spotted entering the building through the front door. Receptionist asked how she got out and she said through the back door. Writer walked around the side of the building where resident room has a sliding door. The door opens to a walkway that is open on both ends. A woman approached writer as I was examining the gate that leads to the front parking lot and was told that she saw a lady coming through the gate 10 minutes prior. During a review of Resident 1 PN dated [DATE], at 6:02 p.m., the PN indicated, Writer was notified by [Registered Nurse 1] that resident [1] was last seen at about 5:50 p.m. [Staff including Registered Nurse 1] were seen leaving the facility to look for resident and writer went through the back door in search of resident as well. Resident was found by [Registered Nurse 1] at . grocery store at 6:15 p.m. and redirected back to the facility at about 6:20 p.m. Resident [1] had the sliding back door of her room open and went out from there. Resident [1] was asked why she left the facility, resident stated, I am tired of being here, I want to go home, I was taking a walk to my house, my house is on the 16thstreet, I don't want to be here anymore, please allow me to go home. Writer educated resident [1] on the risks of leaving facility without a proper way of discharge, counselled on being hurt/injured/getting lost without the knowledge of the facility staff and family members. During a review of Resident 1 PN dated [DATE], at 6:32 p.m., the PN indicated, Resident [1] found by [Registered Nurse 1] and returned to facility around 6:30 p.m. Resident [1] ambulates independently with no problems. When resident asked why she left resident [1] stated, I wanted to go home so I left. Resident reports she left through her glass door in her room. Residents' doors don't have alarms. Gate outside doors don't have locks. During a review of Resident 1's Care Plan Report (CPR) dated [DATE], the CPR indicated Resident 1 is an elopement risk/wanderer related to History of attempts to leave facility unattended. During a concurrent observation and interview on [DATE] at 11:55 a.m., with Maintenance Supervisor, (MS ), a tour of the 15 rooms on the North facing hall (rooms 27, 29, 31, 33, 35,37, 39, 40, 41, 43, 44, 45, 47,49, and 51), each room was noted to have a sliding glass door leading to a sidewalk on the exterior of the facility. Both ends of the sidewalk led to a wooden gate which could be opened by pulling on a string. Each gate opened to a parking lot and city streets beyond. The MS confirmed that the 15 sliding glass doors provide 15 exits from the facility that residents have access to. The MS stated that there are no alarms or system to alert staff when any one of the 15 doors are opened and there are no alarms or system to alert staff when the two wooden gates are opened. The MS also stated that there are no alarms or system to alert staff when any one of the 15 doors are opened to gain entry into the building. The MS stated, I feel handcuffed, because I feel like I can't do anything to keep my residents safe. During an interview on [DATE] at 2:06 p.m., with the Administrator, the Administrator nodded her head in agreement that there were 15 sliding glass doors that ambulatory residents could leave the building without staff knowledge and that unknown visitors could enter the building without staff knowledge through the same 15 sliding glass doors. Administrator stated, I probably have less than five ambulatory residents right now. During an interview on [DATE] at 3:15 p.m. with Registered Nurse [RN] 1, RN 1 stated that on [DATE], that she went looking for Resident 1 in her car and found her in front of a store 0.6 miles from the facility. RN 1 stated she watched Resident 1 cross multiple lanes of traffic with busy streets. The address of the store was verified with RN 1 using Google Maps, and RN 1 agreed Google Maps indicated the walking distance between the facility and the store was 0.6 miles. RN 1 stated she spoke with Resident 1 and convinced her to return with her to the facility. During a review of the facility's policy and procedure (P&P) titled, Elopement/Wandering , dated 2/25, the P&P indicated, The [facility] evaluates residents for wandering and/or exit seeking behavior and implements appropriate interventions as indicated via the evaluation process. Definitions: Elopement: The resident/patient exits the [facility] without staff knowledge or the resident/patient enters an unsafe area without staff knowledge or presence. During a review of the Facility Assessment (FA), dated [DATE], the FA indicated the Resident Profile as having an average daily census as 102 residents. The FA indicated the facility averages 7 to 8 admissions and discharges per week. The FA indicated the facility admits and provides services to residents with Impaired cognition, Memory Loss, and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities) and other dementias .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide care in a manner that maintained dignity and respect for two of three sampled residents (Resident 25 and 47) when: 1.Resident 25's urinary catheter (flexible tube inserted into bladder to drain urine) bag was uncovered and visible to other residents and visitors. This failure had the potential to compromise Resident 25's dignity and privacy by exposing their foley catheter bag, leading to embarrassment or psychosocial harm. 2. A 20-minute time limit for morning Activities of Daily Living (ADL- tasks done on a daily basis to take care of your body, like bathing, brushing hair, brushing teeth, eating, and using the bathroom) care, for Resident 47, was implemented by using a timer, resulting in the resident feeling rushed and singled out. This failure resulted in the violation of resident 47's right to dignity leaving her feeling singled out by staff. Findings: 1. During a review of Resident 25's admission Record (AR) dated 3/19/25, the AR indicated, Resident 25 was initially admitted to the facility on [DATE] with diagnoses of cystitis (inflammation of the bladder), displacement of nephrostomy catheter (nephrostomy tube [a tube that is put into the kidney to drain urine directly from the kidney] tip positioned outside the renal collecting system [a series of tubules and ducts in the kidneys where urine flows and drains], diabetes mellitus (condition that happens when your blood sugar is too high), urinary tract infection (an infection in any part of the urinary system), presence of urogenital implants (artificial material in the urinary organs or genitals), obstructive and reflux uropathy (obstructive and reflux uropathy,), and calculus of kidney (kidney stones). During a review of Resident 25's Order Summary Report (OSR) dated 3/21/25, the OSR indicated, .change foley q (every) 3 weeks .enhanced barrier precautions r/t (related to) nephrostomy tube .foley catheter output every shift for foley . During a review of Resident 25's Minimum Data Set (MDS- a standardized assessment tool that measures health status in nursing home residents) dated 12/12/24, the MDS section C indicated, .cognitive skills for daily decision-making score of 3 .severely impaired . During an observation on 3/17/25 at 11:46 a.m. in Resident 25's room, Resident 25's foley catheter was not covered by a dignity bag (a bag used to the cover and hold the catheter drainage/collection bag, so it is not visible). During a concurrent observation and interview on 3/19/25 at 11:55 a.m. with Licensed Vocational Nurse (LVN) 1 in Resident 25's room, Resident 25's foley was not covered with a dignity bag. LVN 1 concurred, the foley catheter did not have a dignity bag. LVN 1 stated, the foley catheter drainage bag should have been covered. During an interview on 3/19/25 at 3:35 p.m. with the Director of Nursing (DON), the DON stated, she expected Resident 25's foley catheter bag to be covered with a dignity bag. The DON stated, a dignity bag always needed to cover the foley catheter bag. The DON stated, not having a dignity bag violated dignity, privacy, and HIPPA (Health Insurance Portability and Accountability Act- establishes federal standards protecting sensitive health information from disclosure without patient's consent) regulations. The DON stated, the dignity bag needed to be provided so other residents would not know Resident 25's condition. During a review Resident 25's Care Plan (CP) dated 12/30/24, the CP indicated, .[Resident 25] has a Foley catheter r/t (related to) calculus of kidney (kidney stone), obstructive uropath, (blocking of urine by an object such as a kidney stone) [Resident 25] is at risk for infection . During a review of the facility's policy and procedure (P&P) titled, Dignity, dated 02/21, the P&P indicated, .Residents are treated with dignity and respect at all times .Staff protect confidential clinical information .signs indicating the resident's clinical status or care needs are not openly posted .promote, maintain, and protect resident privacy . 2. During a review of Resident 47's admission Record (AR) dated 3/19/25, the AR indicated, Resident 47 was initially admitted to the facility on [DATE] with diagnoses of heart failure ( a condition in which the heart is unable to pump sufficient blood to meet the body's needs), supraventricular tachycardia (abnormally fast heart rhythm) and morbid obesity (overweight-weight is more than 80 to 100 pounds above the ideal body weight). During a review of Resident 47's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 1/9/25, the MDS section C indicated Resident 47 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 47 was cognitively intact. During a concurrent observation and interview on 3/17/25 at 10:52 a.m. with Resident 47, in Resident 47's room, Resident 47 was observed seated in a wheelchair in front of the television, dressed, and applying makeup. During the observation, Resident 47 stated that the facility only allows her 20 minutes to receive morning care. During an interview on 3/18/25 at 2:54 p.m. with Resident 47's Family Member (FM), FM stated his frustration regarding the facility's use of a 20-minute timer to limit his mother's morning care. FM stated he felt his mother was being singled out, as no other resident in the facility was known to be subjected to a timed limit for morning care. During a review of Resident 47's Progress note, dated 3/3/25, the Progress note indicated, . Administrator ordered a timer on 2/26/25 to be used by staff to decrease extensive time spent with resident . resident was informed that the use of the timer was being implemented on 3/1/25 and that the timer would be set for 20 minutes for morning care. Resident expressed dissatisfaction . During a concurrent observation and interview on 3/19/25 at 9:34 a.m. with Certified Nursing Assistant (CNA) 2 in Resident 47's room, CNA 2 was providing morning care to Resident 47. CNA 2 stated Resident 47 will take up a lot of time, the use of the timer was implemented to set a limit of 20 minutes for Resident 47's morning care. During a concurrent interview and record review on 3/19/25 at 10:01 a.m. with the Licensed Vocational Nurse (LVN) 4, Resident 47's Progress Note dated 3/3/25 was reviewed, LVN 4 stated Resident 47's Progress note was created by the Interdisciplinary Team (IDT - collaborative group of individuals who work together to achieve a common goal. ) who developed the use of the timer to help staff manage the time spent with Resident 47. LVN 4 stated that no other resident in the facility is using a timer to manage time spent. LVN 4 acknowledged the use of a timer would make Resident 47 feel singled out. During an interview on 3/20/25 at 11:38 a.m. with the Director of Nursing (DON) stated, On, paper, this looks like the first attempt at time management, The DON acknowledged implementing a 20-minute timer for Resident 47's ADL care was an extreme first step. The DON stated best practice is to have all proper documentation in the resident's clinical record. During a review of the facility's policy and procedure (P&P) titled, Dignity, dated 02/21, the P&P indicated, .Residents are treated with dignity and respect at all times .Residents may exercise their rights without .discrimination or reprisal from any person or entity associated with this facility .signs indicating the resident's clinical status or care needs are not openly posted .Demeaning practices and standards of care that compromise dignity are prohibited .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement a significant change of condition for Resident 42 when the resident was admitted to the facility on [DATE], was unable to make her needs known and be her own responsible party (RP- health care decision maker) Resident experienced a major improvement in mentation on 3/3/25 and no significant change of condition was completed. This failure had the potential to result in a lack of further improvement for Resident 72 when there were no updates in plan of care to reflect the change in mentation. Findings: During a record review of Resident 72's admission Record (AR) dated 3/20/25, the AR indicated Resident 72 was admitted into the facility on 2/17/25. The AR indicated, .Diagnosis Information . Cerebral Infarction (medical condition where blood flow to the brain is interrupted, leading to damage or death of brain tissue) . metabolic encephalopathy (condition where brain ' s function is impaired due to an imbalance in the body ' s metabolism) . bipolar disorder . During a record review of Resident 72's Minimum Data Set (MDS - define) section C (cognitive patterns) dated 2/24/25, the MDS section C indicated, . C0100 .0. No (resident is rarely/never understood) . No BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) was conducted at this time due to resident scoring a zero in section C0100. During a review of IDT [Interdisciplinary Team] Note dated 3/3/25, the IDT [Interdisciplinary Team] Note indicated, .Resident has a BIMS score of 99 as of 2/24/2025 . resident speaks but it is challenging to understand what she is trying to say . During a review of Social Services Discharge/Preparation Note dated 2/19/25, the Social Services Discharge/Preparation Note indicated, .Welcome Conference held with resident on 2/18/2025, brother and family at bedside. Resident was able to communicate in a limited manner with impaired speech. Resident was able to use a pad of paper and pen to communicate yes and no to some questions. Resident became agitated [related to] difficultly communicating . During a review of Social Services Follow Up Note dated 3/4/2025, the Social Services Follow Up Note indicated, . [Social Services Director] completed a new BIMS assessment due to change in condition, and resident scored a BIMS of 15 [score between 13 to 15 suggests the individual has intact cognitive function]. Writer performed a SLUMS [St. Louis University Mental Status - examination for detecting mild cognitive impairment and dementia] examination with resident, and the resident had a score of 18, which is indicative of dementia [a progressive state of decline in mental abilities] per the scoring guide . During a concurrent interview and record review on 3/20/25 at 4:57 p.m. with the Minimum Data Set (MDS) Coordinator, Resident 72 ' s Social Services Follow up Note dated 3/4/25 was reviewed. The Social Services Follow up Note indicated, . [Social Services Director] completed a new BIMS assessment due to change in condition, and resident scored a BIMS of 15 . The MDS Coordinator was unable to locate a BIMS assessment and a change of condition following this social services visit. The MDS Coordinator stated this change in BIMS can be considered a change of condition. During an interview on 3/21/25 at 2:00 p.m. with the MDS Coordinator, the MDS coordinator stated no formal IDT meeting for change of condition was done for this resident following the social services director's new BIMS scoring of 15. The MDS Coordinator stated, We probably just failed and sounds like we need to do a change of condition for her. During an interview on 3/21/25 at 2:18 p.m. with the Social Services Director (SSD), the SSD stated the IDT should have met on 3/4/25 to discuss the multiple changes in Resident 72's behavior and change in mentation from a BIMS of 99 to a BIMS of 15 and that should have been enough to trigger a change in condition. During an interview on 3/21/25 at 3:46 p.m. with the Director of Nursing (DON), the DON stated it would have been important to conduct a change of condition for Resident 72's change of BIMS from 99 to 15. The DON stated it is important to do a change of condition so new care plan interventions can be implemented to improve the resident's health. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status dated 2/2001, the P&P indicated, .1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): . d. significant change in the resident's physical/emotional/mental condition; . 2. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease relation clinical interventions (it is not self-limiting ); . d. ultimately is based on the judgement of the clinical staff and the guidelines outlined in the Resident Assessment Instrument .5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the residents medical/mental condition or status .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to administer parenteral fluids (Parenteral fluids administered by injection through the tissue and circulatory system) in accordance with professional standards of practice for two of three sampled residents (Resident 421 and 422), when: 1. Resident 421 was admitted to the facility on [DATE] with a peripherally inserted central catheter (PICC, tube that is inserted into a vein in the upper arm to the heart) for the purposes of administering intravenous (IV - through the vein) antibiotics (medicines that fight bacterial infections). The facility did not have an approved policy and procedure that followed the standards of practice to instruct and guide nurses on the care of the PICC line. Two of Two Registered Nurses (RN [RN 1 and RN 4]) and the Assistant Director of Nursing (ADON) were not trained and did not follow the standards of practice in the care of the PICC line. 2. Resident 422 was admitted to the facility on [DATE]/25 and a midline (a long, thin, flexible tube that is inserted into a large vein in the upper arm) was inserted on 03/20/25 for the purposes of administering intravenous antibiotics. The facility did not have an approved policy and procedure that followed the standards of practice to instruct and guide nurses on the care of the PICC line. Two of Two Registered Nurses (RN [RN 1 and RN 4]) and the Assistant Director of Nursing (ADON) were not trained and did not follow the standards of practice in the care of the Midline line. These failures had the potential to cause Resident 421 and Resident 422 to experience adverse outcomes such as life-threatening blood infection and an air emboli (a blood vessel blockage caused by one or more bubbles of air or other gas in the circulatory system) due to nursing staff not having the knowledge, training, and competency to safely care for Resident 421 and Resident 422's PICC line and administer their IV antibiotics. Findings: 1. During a review of Resident 421's, admission Records (AR) dated 3/20/25, the AR indicated Resident 421 was admitted to the facility on [DATE] with a primary diagnosis of late syphilitic oculopathy (an eye condition that can happen if syphilis isn't treated), type two diabetes mellitus (a condition where the body doesn't use insulin [a type of compound that regulates sugar levels in the blood] well and can't keep blood sugar at normal levels), epilepsy (brain disorder that causes recurring, unprovoked seizures [sudden, uncontrolled bursts of electrical activity in the brain that can cause temporary changes in behavior, consciousness, and body movements]), and essential hypertension (high blood pressure that is not due to another medical condition) During a review of Resident 421's Minimum Data Set (MDS-a standardized uniform comprehensive assessment of all residents) dated 3/11/25, the MDS indicated, Resident 421 had a BIMS (Brief Interview for Metal Status-a screening tool used to evaluate a person's cognitive [an individual's thinking, reasoning, and remembering process] ability) score of 15 (a BIMS score of 15 indicated Resident 421 had intact cognitive function). During a review of Resident 421's Order Summary Report (OSR) dated 3/20/25, the OSR indicated, .D/C (discontinue) PICC line after IV (intravenous-in the vein) Antibiotic (medicine to treat bacterial infection) therapy is completed . During a concurrent observation and interview on 3/17/25 at 3:30 p.m., with Resident 421 in his room, Resident 421 had a PICC line on his right upper arm. Resident 421 stated he was here for short term antibiotic therapy for an eye infection. During a concurrent observation and interview on 3/20/25 at 10:27 a.m. with Resident 421 in the facility's lobby, Resident 421 was sitting on a chair waiting for his ride to pick him up. Resident 421's PICC line was removed, and a brown band-aid covered the site where the PICC line had been removed. Resident 421 stated, Registered Nurse (RN) 1 removed his PICC line about 30 to 40 minutes ago and only put a band-aid to cover the site. Resident 421 stated RN 1 did not tell him to lay flat after the PICC line was removed. Resident 421 stated RN 1 did not provide instructions for post PICC line removal. During an interview on 3/20/25 at 10:38 a.m. with the Infection Preventionist (IP), the IP stated she was familiar with what a PICC and Midline were but was not responsible for the care and maintenance for PICC or Midlines. The IP stated, only RNs were allowed to provide care for patients with PICCs and Midlines. The IP stated, RNs must be trained on PICCs and Midlines by their preceptor (a teacher, or someone who trains people how to do a job) before being allowed to provide care and maintenance for PICCs and Midlines. During a phone interview on 3/20/25 at 11:02 a.m. with the Third-Party Vendor Chief Nursing Officer (TPVCNO), the TPVCNO stated the RN should have applied an occlusive dressing (an air and water tight dressing [a piece of material such as a pad applied to a wound]) consisting of petroleum-infused (mixed and saturated[full of]) 2x2 (two inches by two inches-unit of measure indicating size) gauze (a type of cotton cloth used for covering and protecting wounds) covered with a tegaderm (a thin clear sterile dressing that keeps out water, dirt and germs) to seal the site. The TPVCNO stated, the RN should have instructed the resident to remain flat for at least 30 minutes and provided post-removal instructions. The TPVCNO stated, the RN should have informed the resident to keep the dressing on for at least 24 hours. During an interview on 3/20/25 at 11:37 a.m. with the Minimum Data Set Registered Nurse (MDSRN), the MDSRN stated, Resident 421 was in the facility for short term antibiotics and was admitted from [acute care hospital name] with a PICC line on his right arm. The MDSRN stated, RNs were responsible in the care and management of central lines such as PICCs. The MDSRN stated new RNs were paired with experienced RNs to provide their central line management training. The MDSRN stated, there are no official training materials on paper and all training regarding PICCs were verbal in nature. The MDSRN stated, nurses who were not trained in PICC line management should not be allowed to provide care for residents with PICCs, Midlines or any other central lines. The MDSRN stated when a PICC line was removed, pressure and an occlusive dressing was needed to cover the site. The MDSRN stated, RN 1 should not have used a band aid to cover Resident 421's PICC line site.The MDSRN stated this was an incorrect practice and could have caused an air emboli to Resident 421 potentially leading to his death. The MDSRN stated, That's wrong .I've never put a band aid . The MDSRN stated RN 1 did not follow the correct procedure when she removed Resident 421' s PICC line. MDSRN stated RN 1 needed more training. During a concurrent interview and record review on 3/20/25 at 12:18 p.m. with RN 1, RN 1's LVN (Licensed Vocational Nurse)/RN Skills List Orientation (SLO) dated 2/28/25 was reviewed. The SLO indicated, no signatures were present from RN 2 that indicated RN 1 completed the training for .IV/Hydration therapy/antibiotic therapy . RN 1 stated she was trained by RN 2. RN 1 stated RN 2 was her preceptor and was responsible for training her in how to manage PICC lines. RN 1 stated, .there isn't training regarding central line care . RN 1 stated RN 2 should have signed the IV/Hydration therapy/antibiotic therapy as soon as she completed the training. RN 1 stated she was trained by the ADON to change PICC dressings but had to resort back to educational materials from nursing school to familiarize herself with removing a PICC line. RN 1 stated she thought residents should remain laying down for at least two minutes after a PICC was removed. RN 1 stated, .I think the normal is 2-5 minutes . RN 1 stated she made a guess on how long Resident 421 should have laid flat. RN 1 stated no one ever told her how long a resident should have laid flat. RN 1 stated when she removed Resident 421's PICC line, she used a band aid to cover the site. RN 1 stated she should have used an occlusive dressing. RN 1 stated a band aid could have potentially caused an air emboli to develop and could have resulted in Resident 421's death. During a concurrent interview and record review 3/20/25 at 12:48 p.m. with the Assistant Director of Nursing (ADON), RN 1's SLO dated 2/28/25 was reviewed. The SLO stated no signatures were present from RN 2 that indicated RN 1 completed the training for .IV/Hydration therapy/antibiotic therapy . The ADON stated the SLO was not signed by RN 2. The ADON stated she did not see any trainings that were specific to central line care and management. During an interview on 3/21/25 at 5:16 p.m. with the ADON, the ADON stated nurses had been insufficiently trained to care for residents receiving parenteral fluids in central lines and central line care and management. The ADON stated she had not received formal training in central line care and management from the facility. The ADON stated she had relied on her past job experiences to determine her own job competency in caring for residents with central lines and managing parenteral fluid administration. The ADON stated nurses should have been educated, trained, and required to perform a return demonstration to determine their competencies in the care and management of central lines. The ADON stated nurses should not have been assigned to residents with PICCs or central lines if they were not competent. During an interview on 3/21/25 at 5:38 p.m. with the Director of Nursing (DON), the DON stated the facility was not obligated (forced to) offer IV therapy services (a way to give fluids, medicine, nutrition, or blood directly into the bloodstream though a vein [blood vessels located throughout the body] using a central line such as a PICC or midline). The DON stated nurses needed to be competent in central line management. The DON stated nurses should have received trainings from the ADON or DON and completed a return demonstration to determine their competency. The DON stated inadequate training in managing and administering medications through central lines could potentially harm residents, leading to complications such as blood infections or air embolisms, which could have resulted in death. During a review of the facility's policy and procedure (P&P) titled, General Policies For IV Therapy dated 06/18, the P&P indicated, .Only an RN or IV Certified LVN may start intravenous infusion or administer approved IV solutions . During a review of the facility's P&P titled, PICC Removal dated 06/18, the P&P indicated, .to be performed by .RNs according to state law and facility policy .equipment .transparent dressing .sterile gloves .sterile gauze .antimicrobial solution .sterile tape .measuring tape .mask .don clean gloves assess the catheter site for evidence of local complication .remove the tape and dressing .done sterile gloves .apply pressure with sterile gauze until the bleeding stops .secure with sterile occlusive dressing .monitor resident for signs/symptoms of embolism .resident teaching . During a review of the facility's P&P titled, Nursing Personnel Education and Training dated 11/16, the P&P indicated, .nursing personnel education and competency validation is conducted to promote the provision of care and services consistent with professional standards of practice .Competency .means validating acceptable performance and knowledge associated with required skill .care competencies are determined through evaluation of center specific trends, resident populations served, and individual performance evaluation .education provided to new employees .provided as part of orientation and scheduled annually, includes .infection control .state and federal required education . During a review of the Journal of Infusion Nursing The Official Publication of the Infusion Nurses Society Infusion Therapy Standards of Practice, dated January/February 2016, indicated, . Standard 1.1 The Infusion Therapy Standards of Practice is applicable to any patient care setting in which vascular access devices (VADs) [a sterile tube that provides access to your veins for the delivery of intravenous (in the vein) medication such as a PICC (Peripherally inserted central catheter- external device placed in upper arm) line] are placed and/or managed and where infusion therapies are administered. 1.2 Infusion therapy is provided in accordance with laws, rules and regulations . federal and state regulatory and accrediting bodies . 1.3 Infusion therapy practice is established in organizational policies, procedures, practice guidelines, and/or standardized written protocols/orders . 3. SCOPE OF PRACTICE .Practice Criteria . D. Nursing Personnel . 5. Registered Nurse (RN) a. Complete an organized educational program on infusion therapy due to the lack and/or inconsistency of infusion therapy in basic nursing criteria . b. Do not accept assignments and tasks when one . is inadequately prepared to perform the assignment or task . d. Delegate tasks, activities, and components of care after determination of competency to perform the specific task . f. Use critical thinking and nursing judgement to apply the Five Rights of Delegation . 4. INFUSION TEAM . A. Assign vascular access device (VAD) . management and surveillance only to individuals and or teams with infusion therapy education, training, and validated competency . 5. COMPETENCY ASSESSMENT AND VALIDATION Standard . 5.2 The clinician is responsible and accountable for attaining and maintaining competence with infusion therapy administration . 5.3 Competency assessment and validation is performed initially and on an ongoing basis. 5.4 Competency validation is documented in accordance with organizational policy . C. Validate clinician competency by documenting the knowledge, skills, behaviors, and ability to perform the assigned job. 1. Validate initial competency before providing patient care . when the scope of practice changes, and with the introduction of new procedures, equipment, or technology. 2. Validate continuing competency on an ongoing periodic basis . 10. DOCUMENTATION IN THE MEDICAL RECORD Standard 10.1 Clinicians document their initial and ongoing assessments . 10.2 Documentation contains accurate, complete, chronological, and objective information in the patient's medical record regarding the patient's infusion therapy and vascular access with the clinician's name, licensure or credential to practice, date, and time. 10.3 Documentation is legible, timely, accessible to authorized personnel, and efficiently retrievable. 10.4 Documentation reflects the continuity, quality, and safety of care . Practice Criteria A. Documentation includes . 1. Patient . responses to therapy, interventions, and education. 2. Specific site preparation, infection prevention, and safety precautions taken, using a standardized tool for documenting . 3. The type, length, and gauge/size of the vascular access device (VAD) inserted . date and time inserted . 6. peripherally inserted central catheters (PICCs): a. External catheter length and length of catheter inserted. b. Arm circumference: before insertion of a PICC and when clinically indicated to assess the presence of edema [swelling] and possible deep vein thrombosis [DVT-blood clot] . 7. Condition of site, dressing, type of catheter stabilization, dressing change, site care, patient report of discomfort or any pain with each regular assessment of the access site, and patient report of changes related to the VAD or access site. 9. condition of the . access site prior to and after infusion therapy. 10. Results of VAD functionality assessment including patency, absence of signs and symptoms of complications, lack of resistance when flushing, and presence of a blood return upon aspiration. 41. VASCULAR ACCESS DEVICE (VAD) ASSESSMENT, CARE AND DRESSING CHANGES . H. Perform dressing changes . 1. Change transparent semipermeable membrane (TSM) dressings at least every 5 to 7 days and gauze dressing at least every 2 days . 4. Change the dressing . if dressing becomes loose/dislodges . 2. During a review of Resident 422's AR dated 3/21/25, the AR indicated Resident 422 was admitted to the facility on [DATE] with a primary diagnosis of pneumonia, unspecified organism (a disease that causes inflammation and fluid in the lungs caused by an unidentified organism), end stage renal disease (ESRD- a disease, your kidneys no longer work as they should) anemia in chronic kidney disease (a condition where there is not enough red blood cells due to malfunctioning kidneys), and chronic kidney disease (a disease characterized by progressive damage and loss of function in the kidneys). During a review of Resident 422's MDS dated 3/21/25, the MDS indicated, Resident 422 had a BIMS score of 15 which indicated Resident 422 had intact cognitive function. During a review of Resident 422's OSR dated 3/21/25, the OSR indicated, .Enhanced Barrier Precautions (EBP- infection control intervention designed to reduce transmission of multidrug-resistant organisms) .wound/IV atb (antibiotics) .may insert midline .midline dressing to right upper arm .order date . 03/20/2025 .change dressing every 7 days or prn (whenever necessary) .Midline IV Flush Protocol (manual injection of 0.9% (concentration) 5 ml (milliliter-a unit of measure) daily .Ceftazidime (an antibiotic) 1G (gram-a unit of measure) for 30 days . During a concurrent observation and interview on 3/20/25 at 4:55 p.m. with LVN 9 in Resident 422's room, Resident's midline dressing was saturated with blood. LVN 9 stated the dressing was dirty, bloody, and needed to be changed. LVN 9 stated the central line dressing needed to be clean or there was potential for infections to occur. LVN 9 stated RNs were responsible for managing central line care. During a concurrent observation and interview on 3/20/25 at 5:04 p.m. with the ADON, the ADON changed Resident 422's dirty bloody dressing. Resident 422 did not wear a face mask, the uncovered midline actively bled from the insertion site, and the line lay on the bed linens without a sterile barrier between the midline and the linens. The midline's length measured 17 cm (centimeter-a unit of measure). The ADON stated Resident 422 should have worn a mask during the dressing change. The ADON stated the uncovered midline touched the bed linen and was not sterile. The ADON stated she had initially measured the midline at 10cm. The ADON sated the midline was no longer in the proper placement and had to be removed. The ADON admitted to making multiple errors during the procedure which included, not putting a face mask on Resident 422, allowing the midline to touch the nonsterile linens and generally failed to follow appropriate sterile technique (use of practices that restrict microorganisms in the environment and prevent contamination of the procedural area). The ADON stated it was important to follow sterile technique while changing central line dressings so bacteria would not be introduced into the central line which leads directly into the heart, and potentially could have resulted in a life-threatening blood infection. During an interview on 3/21/25 at 8:24 a.m. with RN 1, RN 1 stated she served as the RN for Resident 422 that day and had to be retrained in central line management, including care for his midline, by the DON that morning. RN 1 stated the DON validated her training, and RN 4 provided the retraining for central line management. RN 1 sated she had to explain the procedure and perform a return demonstration to validate her competencies. During an interview on 3/21/25 at 9:13 a.m. with RN 4, RN 4 stated she retrained RN 1 in the central line management this morning. RN 4 stated nurses needed to be competent in central line management before being assigned to care for those residents. RN 4 stated she rarely encountered residents with central lines. RN 4 stated she was unaware of proper positioning for a resident during central line removal. RN 4 stated she was unsure how long a resident had to remain flat after central line removal and estimated about 15 minutes. RN 4 stated inadequate training or competency in dressing change or central line removal could have led to adverse consequences such as infections and air embolisms, both of which could have resulted in death. RN 4 stated her own knowledge in central line management was insufficient and needed to be re-enforced to assure competency. During an interview on 3/21/25 at 11:23 a.m. with the IP, the IP stated the expectation was nurses had to verbalize and had to provide a return demonstration for the trainings they have received to be considered competent. During an interview on 3/21/25 at 5:16 p.m. with the ADON, the ADON stated nurses had been insufficiently trained to care for residents receiving parenteral fluids in central lines and central line care and management. The ADON stated she had not received formal training in central line care and management from the facility. The ADON stated she had relied on her past job experiences to determine her own job competency in caring for residents with central lines and managing parenteral fluid administration. The ADON stated nurses should have been educated, trained, and required to perform a return demonstration to determine their competencies in the care and management of central lines. The ADON stated nurses should not have been assigned to care for residents with PICCs or central lines if they were not competent. During an interview on 3/21/25 at 5:38 p.m. with the Director of Nursing (DON), the DON stated the facility was not obligated (forced to) offer IV therapy services (a way to give fluids, medicine, nutrition, or blood directly into the bloodstream though a vein [blood vessels located throughout the body] using a central line such as a PICC or midline). The DON stated, nurses needed to be competent in central line management. The DON stated nurses should have received trainings from the ADON or DON and completed a return demonstration to determine their competency. The DON stated inadequate training in managing and administering medications through central lines could potentially harm residents, leading to complications such as blood infections or air embolisms, which could have resulted in death. The DON stated sterile technique was supposed to be followed during central line dressing changes. The DON stated if the procedure was not sterile, there was a potential for bacteria and other pathogens to be introduced to the central line which led directly into the heart and could have caused a life-threatening blood infection ultimately leading to death. During a review of the facility's P&P titled, PICC Dressing Change dated 06/18, the P&P indicated, .dressing changes using transparent dressings are performed .if the integrity of the dressing has been compromised (wet, lose or soiled) .equipment .clean gloves .antimicrobial disc .hand sanitizer .mask .antimicrobial solution .label, sterile gauze and tape .transparent dressing .sterile gloves .securement device .measuring tape .procedure .don sterile gloves . During a review of the facility's P&P titled, PICC Removal dated 06/18, the P&P indicated, .to be performed by .RNs according to state law and facility policy .equipment .transparent dressing .sterile gloves .sterile gauze .antimicrobial solution .sterile tape .measuring tape .mask .don clean gloves assess the catheter site for evidence of local complication .remove the tape and dressing .done sterile gloves .apply pressure with sterile gauze until the bleeding stops .secure with sterile occlusive dressing .monitor resident for signs/symptoms of embolism .resident teaching . During a review of the Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011 https://www.cdc.gov/infectioncontrol/pdf/guidelines/bsi-guidelines-H.pdf, dated October 2017, indicated, 1. Use either sterile gauze or sterile, transparent, semipermeable dressing to cover the catheter site 2. If the patient is diaphoretic (sweating heavily) or if the site is bleeding or oozing, use a gauze dressing until this is resolved. 3. Replace catheter site dressing if the dressing becomes damp, loosened, or visibly soiled. 4. Do not use topical antibiotic ointment or creams on insertion sites, except for dialysis catheters, because of their potential to promote fungal infections and antimicrobial resistance. 5. Do not submerge the catheter or catheter site in water. Showering should be permitted if precautions can be taken to reduce the likelihood of introducing organisms into the catheter (e.g., if the catheter and connecting device are protected with an impermeable cover during the shower). 6. Replace dressings used on short-term CVC sites every 2 days for gauze dressings. 7. Replace dressings used on short-term CVC sites at least every 7 days for transparent dressings, except in those pediatric patients in which the risk for dislodging the catheter may outweigh the benefit of changing the dressing. 8. Replace transparent dressings used on tunneled or implanted CVC sites no more than once per week (unless the dressing is soiled or loose), until the insertion site has healed 14. Monitor the catheter sites visually when changing the dressing or by palpation through an intact dressing on a regular basis, depending on the clinical situation of the individual patient. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or bloodstream infection, the dressing should be removed to allow thorough examination of the site. 15. Encourage patients to report any changes in their catheter site or any new discomfort to their provider. During a review of the Journal of Infusion Nursing The Official Publication of the Infusion Nurses Society Infusion Therapy Standards of Practice, dated January/February 2016, indicated, . Standard 1.1 The Infusion Therapy Standards of Practice is applicable to any patient care setting in which vascular access devices (VADs) [a sterile tube that provides access to your veins for the delivery of intravenous (in the vein) medication such as a PICC (Peripherally inserted central catheter- external device placed in upper arm) line] are placed and/or managed and where infusion therapies are administered. 1.2 Infusion therapy is provided in accordance with laws, rules and regulations . federal and state regulatory and accrediting bodies . 1.3 Infusion therapy practice is established in organizational policies, procedures, practice guidelines, and/or standardized written protocols/orders . 3. SCOPE OF PRACTICE .Practice Criteria . D. Nursing Personnel . 5. Registered Nurse (RN) a. Complete an organized educational program on infusion therapy due to the lack and/or inconsistency of infusion therapy in basic nursing criteria . b. Do not accept assignments and tasks when one . is inadequately prepared to perform the assignment or task . d. Delegate tasks, activities, and components of care after determination of competency to perform the specific task . f. Use critical thinking and nursing judgement to apply the Five Rights of Delegation . 4. INFUSION TEAM . A. Assign vascular access device (VAD) . management and surveillance only to individuals and or teams with infusion therapy education, training, and validated competency . 5. COMPETENCY ASSESSMENT AND VALIDATION Standard . 5.2 The clinician is responsible and accountable for attaining and maintaining competence with infusion therapy administration . 5.3 Competency assessment and validation is performed initially and on an ongoing basis. 5.4 Competency validation is documented in accordance with organizational policy . C. Validate clinician competency by documenting the knowledge, skills, behaviors, and ability to perform the assigned job. 1. Validate initial competency before providing patient care . when the scope of practice changes, and with the introduction of new procedures, equipment, or technology. 2. Validate continuing competency on an ongoing periodic basis . 10. DOCUMENTATION IN THE MEDICAL RECORD Standard 10.1 Clinicians document their initial and ongoing assessments . 10.2 Documentation contains accurate, complete, chronological, and objective information in the patient's medical record regarding the patient's infusion therapy and vascular access with the clinician's name, licensure or credential to practice, date, and time. 10.3 Documentation is legible, timely, accessible to authorized personnel, and efficiently retrievable. 10.4 Documentation reflects the continuity, quality, and safety of care . Practice Criteria A. Documentation includes . 1. Patient . responses to therapy, interventions, and education. 2. Specific site preparation, infection prevention, and safety precautions taken, using a standardized tool for documenting . 3. The type, length, and gauge/size of the vascular access device (VAD) inserted . date and time inserted . 6. peripherally inserted central catheters (PICCs): a. External catheter length and length of catheter inserted. b. Arm circumference: before insertion of a PICC and when clinically indicated to assess the presence of edema [swelling] and possible deep vein thrombosis [DVT-blood clot] . 7. Condition of site, dressing, type of catheter stabilization, dressing change, site care, patient report of discomfort or any pain with each regular assessment of the access site, and patient report of changes related to the VAD or access site. 9. condition of the . access site prior to and after infusion therapy. 10. Results of VAD functionality assessment including patency, absence of signs and symptoms of complications, lack of resistance when flushing, and presence of a blood return upon aspiration. 41. VASCULAR ACCESS DEVICE (VAD) ASSESSMENT, CARE AND DRESSING CHANGES . H. Perform dressing changes . 1. Change transparent semipermeable membrane (TSM) dressings at least every 5 to 7 days and gauze dressing at least every 2 days . 4. Change the dressing . if dressing becomes loose/dislodges .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents' food preferences for food brought in from the outside were met by warming food up when the facility microwave was removed from the resident food storage area and staff was instructed, they could no longer warm up food for residents. This failure resulted in residents' frustration and denial of food preferences not being warmed to acceptable temperatures for palatability. This failure resulted in residents not having the ability to warm up their frozen foods which lead to frustration and denial of food preferences not being warmed to acceptable temperatures for palatability. Findings: During a concurrent observation and interview on 3/17/25 at 11:33 a.m. with Resident 102 in Resident 102's room, a collection of canned and packaged food was on the top right side of Resident 102's counter. Resident 102 stated he has food brought in for evening snacks, or to eat if he did not want to eat what was on the menu from the kitchen. Resident 102 stated the Certified Nursing Assistant (CNA), would warm up the food for him. During an interview on 3/18/25 at 1:20 p.m. with Resident 102, Resident 102 stated he was no longer able to have his food warmed up and the facility microwave has been removed from the Resident Food Storage Room (RFSR). Resident 102 stated that he was frustrated and had spent a lot of his own money to buy food that he would normally eat at night at home. Resident 102 stated, . it is my right. Resident 102 stated this afternoon was the first time warming up the food from his room has been an issue since his admission on [DATE]. During a review of Resident 102's admission Record (AR) dated 3/20/25, the AC indicated Resident 102 was admitted on [DATE] with diagnosis of . Heart Failure (HF), Diabetes Mellitus (DM) Type II (body does not produce enough insulin or use it properly, leading to high blood sugar levels), Kidney Failure . During a review of Resident 102's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive, physical abilities and needs) assessment dated [DATE], the MDS assessment indicated Resident 102's Brief Interview for Mental Status (BIMS-screening tool used to assess resident cognition status on a scale of 015 [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit) assessment score was 15 out of 15 which indicated Resident 102 had no cognitive deficit. During an interview on 3/18/25 at 2:01 p.m. with Resident 47, Resident 47 stated the facility was violating her rights by not heating up the food her family brings her from home. Resident 47 stated that her family bought her food, and the staff refuse to heat it up. Resident 47 stated that staff used to heat up the food and now they no longer heat it for her, and she cannot eat the food frozen. Resident 47 stated this makes her feel upset During a review of Resident 47's admission Record (AR) dated 3/19/25, the AR indicated, Resident 47 was initially admitted to the facility on [DATE] with diagnoses of heart failure ( a condition in which the heart is unable to pump sufficient blood to meet the body's needs), supraventricular tachycardia (abnormally fast heart rhythm) and morbid obesity (overweight-weight is more than 80 to 100 pounds above the ideal body weight). During a review of Resident 47's Minimum Data Set (MDS- a standardized assessment tool that measures health status in nursing home residents) dated 1/9/25, the MDS section C indicated, .cognitive skills for daily decision-making score of 15 .cognitively intact . During an observation on 3/19/25 at 4:17 p.m. in the hall of the facility, Maintenance Assistant (MA), was observed removing the microwave from the resident food storage room and taking it down the hall to the Medical Records office. During a concurrent observation and interview on 3/19/25 at 5:26 p.m. with Certified Nursing Assistant (CNA) 3, in the resident food storage room, 11 frozen meals were noted in the resident freezer. CNA 3 stated, . residents are no longer able to have their food heated up as of approximately two weeks ago, the administration did not provide an explanation they just stated the staff was no longer able to warm up food for residents. The microwave was then removed from the resident food storage room . several residents have complained, but the facility has not come up with an alternative . During an interview on 3/21/25 at 1:54 p.m. with the Activities Director (AD), the AD stated, . the Administrator (ADM) told us to inform residents during the Resident Council Meeting on 3/6/25, staff will no longer be heating up food in the microwave. The residents were not happy but those were the instructions that were given . During an interview on 3/21/25 at 3:33 p.m. with the Registered Dietitian (RD), the RD stated she was not aware that staff was not warming up food for residents. The RD stated staff could have an in-service training regarding heating up food for residents or have a thermometer available to take the temperature of the food after it has been microwaved. The RD stated there were several options that the facility could look into to provide ways to heat up food for residents. During an interview on 3/21/25 at 5:26 p.m. with the Director of Staff Development (DSD), the DSD stated, the microwave was removed for resident safety. The CNA staff were not equipped with thermometers or trained on how to properly heat up food in the microwave. The facility did not come up with an alternate way to heat up food for residents. During an interview on 3/21/25 at 6:10 p.m. with the ADM, the ADM stated , . the reasons for stopping the staff from heating up resident food were, the time it takes for the staff to reheat the food, the staff are not trained to take the temperature of food, and there was not a thermometer or temperature log for staff to take the temperature of the food or log the temperatures . the facility needs to find a way to heat up food for residents .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to develop and implement a baseline care plan (a document which specified goals, interventions, and monitoring strategies for patients) for three of nine sampled residents (Residents 221, 222, and 421) when: 1. Residents 221 and 222 did not have their baseline care plans completed within 48 hours of their admission to the facility This failure had the potential to cause Residents 221 and 222 to not have their respiratory care needs met 2. Resident 421 did not have his baseline care plan for a PICC (peripherally inserted central catheter- a thin, flexible tube that is inserted into a vein in the upper arm used to deliver medications directly into the heart) completed within 48 hours of his admission to the facility. This failure had the potential to cause Resident 421 to not have his care needs met potentially leading to poor patient outcomes (adverse effects) such as developing infections that could lead to a decline in health. Findings: 1. During a review of Resident 221's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 3/21/25, the AR indicated, Resident 221 was admitted to the facility on [DATE] with a primary diagnosis of pleural effusion (buildup of excess fluid between the layers of tissue lining the lungs and chest cavity). During a review of Resident 222's AR, dated 3/21/25, the AR indicated, Resident 222 was admitted to the facility on [DATE] with diagnoses that included pneumonia (an infection of the lungs that causes the air sacs to become inflamed and fill with fluid), chronic obstructive pulmonary disease (COPD- an ongoing lung condition caused by damage to the lungs) and pleural effusion. During a concurrent interview and record review on 3/20/25 at 11:01 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 221 and 222's care plans, dated 3/20/22, were reviewed. Resident 221 and 222's care plan did not include any interventions for their admitting diagnoses or physician orders. LVN 1 stated both Resident 221 and 222 had orders for the use of oxygen and nurses at the facility were responsible for care planning the oxygen order upon admission. LVN 1 stated Residents 221 and 222 had respiratory conditions and staff needed to care plan goals and interventions which would help them breathe better. LVN 1 stated the care plan drives residents' care, and upon admission nurses needed be aware of the basic needs of each resident. During an interview on 3/21/25 at 1:46 p.m. with the Minimum Data Set Registered Nurse (MDSRN), the MDSRN stated the nurses caring for the residents were responsible for ensuring baseline care plans were created for newly admitted residents. The MDSRN stated Residents 221 and 222 should have had their diagnoses and physician's orders care planned. The MDSRN stated care planning was important because it ensured staff were aware of a resident's medical needs and what each resident required to help them feel better. Accurate care planning was also needed to better communicate with other nurses who might not know what the resident requires. During an interview on 3/21/25 at 3:03 p.m. with the Director of Nursing (DON), the DON stated baseline care planning should have been done for Residents 221 and 222. The DON stated care planning was important because it created interventions which staff could implement to try to get residents healthy enough to discharge home. During a review of the facility's policy and procedure (P&P) titled, Care Plans-Baseline dated 3/22, the P&P indicated, .A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission . The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: a. Initial goals based on admission orders and discussion with the resident/representative; b. physician orders 2. During a review of Resident 421's AR dated 3/20/25, the AR indicated Resident 421 was admitted to the facility on [DATE] with a primary diagnosis of late syphilitic oculopathy (an eye condition that can happen if syphilis isn't treated), type two diabetes mellitus (a condition where the body doesn't use insulin [a type of compound that regulates sugar levels in the blood] well and can't keep blood sugar at normal levels), epilepsy (brain disorder that causes recurring, unprovoked seizures (sudden, uncontrolled bursts of electrical activity in the brain that can cause temporary changes in behavior, consciousness, and body movements), and essential hypertension (high blood pressure that is not due to another medical condition). During a review of Resident 421's Minimum Data Set (MDS-a standardized uniform comprehensive assessment of all residents) dated 3/11/25, the MDS indicated, Resident 421 had a BIMS (Brief Interview for Metal Status-a screening tool used to evaluate a person's cognitive [an individual's thinking, reasoning, and remembering process] ability) score of 15 (a BIMS score of 15 indicated Resident 421 had intact cognitive function). During a review of Resident 421's Order Summary Report (OSR) dated 3/20/25, the OSR indicated, .D/C (discontinue) PICC line after IV (intravenous-in the vein) Antibiotic (medicine to treat bacterial infection) therapy is completed . During a concurrent observation and interview on 3/17/25 at 3:30 p.m. with Resident 421 in his room, Resident 421 had a PICC line on his right upper arm. Resident 421 stated, he was here for short term antibiotic therapy for an eye infection. During a concurrent observation and interview on 3/20/25 at 10:27 a.m. with Resident 421 in the facility's lobby, Resident 421 was sitting on a chair waiting for his ride to pick him up. Resident 421's PICC line was removed and was discharged . Resident 421 stated, Registered Nurse (RN) 1 removed his PICC line about 30 to 40 minutes ago. During a concurrent interview and record review on 3/20/25 at 2:14 p.m. with the Director of Nurses (DON), Resident 421's Care Plan (CP-a form where that summarizes a person's health conditions, specific care needs, and current treatments) dated 3/5/25 to 3/20/25 was reviewed. The CP did not indicate PICC line care plans were implemented. The DON stated, there were no CP for Resident 421's PICC line but should have had a baseline care plan implemented when he was admitted . During a concurrent interview and record review on 3/20/25 at 3:11 p.m. with Registered Nurse (RN) 1, Resident 421's CP dated 3/5/25 to 3/20/25 was reviewed. CP did not indicate PICC line care plans were implemented. RN 1 stated, Resident 421 did not have a baseline care plan for his PICC line and should have had one. RN 1 stated, baseline care plans should have been completed within 48 hours of admission. RN 1 stated, a CP was important because it guides resident care and offers a way to measure treatment outcomes. RN 1 stated, if no CP were implemented, the was a potential for Resident 421's health status to decline. During a concurrent interview and record review on 3/20/25 at 3:11 p.m. with RN 1, Resident 421's CP dated 3/5/25 to 3/20/25 was reviewed. The CP did not indicate PICC line care. RN 1 stated, Resident 421 should have had a care plan for his PICC line. RN 1 stated, a baseline care plan should have been completed within 48 hours of admission. RN 1 stated, CPs were important as they guided care and tracked progress of the treatment. RN 1 stated, without a CP, Resident 421's health could have declined. During an interview on 3/21/25 at 5:38 p.m. with the DON, the DON stated, she expected a baseline care plan to be implemented within 48 hours of a resident's admission. The DON stated, it was important because it created interventions which staff could implement to guide care and lead to the resident's optimal health before discharging. During a review of the facility's P&P titled, Care Plans-Baseline dated 3/22, the P&P indicated, .A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission . The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: a. Initial goals based on admission orders and discussion with the resident/representative; b. physician orders

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During a record review of Resident 223's admission Record (AR) dated 3/19/25, the AR indicated Resident 223 was admitted into the facility on [DATE]. The AR indicated, . Gangrene (the death of body tissue, typically due to lack of blood flow or a serious bacterial infection, often affecting limbs like toes, fingers, and feet), post amputation (the surgical removal) of left toes, Type II Diabetes (DM- body does not produce enough insulin or use it properly, leading to high blood sugar levels), End Stage Renal Disease (ESRD-kidneys can no longer adequately filter waste and excess fluid from the blood), Peripheral Vascular Disease (PVD-blood vessels outside the heart and brain narrow or become blocked, reducing blood flow and potentially causing pain, numbness and other issues), Hemodialysis (a treatment that cleans the blood to filter out waste and excess fluid) . During a review of Resident 223's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive, physical abilities and needs) assessment dated [DATE], the MDS assessment indicated Resident 223's Brief Interview for Mental Status (BIMS-screening tool used to assess resident cognition status on a scale of 0-15 [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit) assessment score was 15 out of 15 which indicated Resident 223 had no cognitive deficit. During a review of Resident 223's Order Summary (OS), dated 1/2/25, the OS indicated, . MWF dialysis at Satellite Healthcare Merced . pick up 1300 (1 p.m.), chair time 1500 (3 p.m.) . During a review of Resident 223's Medication Administration Record (MAR), dated 2/1/25, the MAR indicated, Resident 223 was prescribed Apaxiban Oral Tablet 5 MG (milligram-unit of measure), Give 1 tablet by mouth two times a day for DVT (Deep Vein Thrombosis - blood clot), prevention .Insulin Glargine Solostar Subcutaneous Solution Pen Injector 100 Unit/ML (milliliter-unit of measure), (Insulin Glargine) inject 5 units subcutaneously (into the skin), at bedtime for Diabetes . During a concurrent interview and record review on 3/21/25 at 6:38 p.m. with Director of Nurses (DON), Resident 223's Care Plans (CP) dated 2/1/25 were reviewed. The CP indicated, no Care Plan for anticoagulants, insulin, diabetic care, or hemodialysis were created. The DON stated, the care plan provides directions for staff to care for residents, without a care plan the resident may not get the care that is needed. During a review of the facility's policy and procedure (P&P) titled, Care Planning-Interdisciplinary Team, dated 09/13, the P&P indicated, .A comprehensive, person centered care plan that included measureable objectives and timetables to meet the resident'sphysical, psychosocial and functional needs is developed and implemented for each resident . Based on observation, interview and record review, the facility failed to develop and implement comprehensive care plans for four of 12 sampled residents (Resident 71 and Resident 72, Resident 47 and Resident 223) when: 1. Resident 71 had an incomplete care plan for anxiety medication, and no care plan for Sertraline (anti-depressant medication) and Olanzapine (antipsychotic medication that alters brain chemistry to help reduce symptoms of the mind where there has been some loss of contact with reality). 2. Resident 72 did not have individualized care plans for Quetiapine (antipsychotic [class of drugs used to treat psychotic disorders] medication used to treat schizophrenia [a chronic mental health conditional characterized by significant disruptions in thought processes, perceptions, emotions and behavior] and bipolar disorder [chronic mental health condition characterized by extreme shifts in mood, energy and behavior]), Buspirone (medication used to treat anxiety disorders), and Lorazepam (anti-anxiety medication). These failures had the potential to result in Resident 71 and Resident 72 not having their mental and psychosocial (relating to the interrelation of social factors and individual through and behavior) needs met. 3. Resident 223 did not have a care plan for Apaxiban, Insulin (regulates blood sugar levels in the body), diabetic (the body does not produce insulin resulting in high blood sugar levels), care, or hemodialysis (a treatment that cleans the blood to filter out waste and excess fluid). These failures put Resident 223 at risk for harm by not monitoring or identifying risk of uncontrolled bleeding and harmful side effects and by not monitoring effects of insulin on the Resident's blood sugar. 4. Resident 47 did not have a care plan for apixaban (anticoagulant - prevent blood clots from forming). This failure put Resident 47 at risk for harm by not monitoring or identifying risk of uncontrolled bleeding and harmful side effects. Findings: 1. During a record review of Resident 71's AR dated 3/21/25, the AR indicated resident 71 was admitted into the facility on 2/22/25. The AR indicated, . Diagnosis Information .bipolar disorder .post-traumatic stress disorder [PTSD - a disorder in which a person has difficultly recovering after experiencing or witnessing a terrifying event] . During a record review of Resident 71's Care Plan (CP) Report dated 2/23/25, the CP Report indicated, . Goal: The resident will show decreased number (SPECIFY) episodes or anxiety through the review date. Date initiated: 02/23/2025. Revision on 03/17/2025. Target Date: 03/24/2025 . Did not observe a care plan in place for the medications Sertraline and Olanzapine. During a concurrent interview and record review on 3/21/25 at 8:59 a.m. with LVN 3, Resident 71's CP Report for anti-anxiety medication was reviewed. The CP Report indicated, .Goal: The resident will show decreased number (SPECIFY) episodes or anxiety through the review date . LVN 3 stated this care plan is incomplete and specify was not edited. LVN 3 stated it is important to have a specific number included to know how many behaviors to observe for and to see if the medication is effective. LVN 3 was unable to locate care plans for the medications Sertraline and Olanzapine. LVN 3 stated there should be care plans for these medications because they are antipsychotics and staff need to monitor the resident for behaviors. 2. During a record review of Resident 72's admission Record (AR) dated 3/20/25, the AR indicated Resident 72 was admitted into the facility on 2/17/25. The AR indicated, .Diagnosis Information . Cerebral Infarction (medical condition where blood flow to the brain is interrupted, leading to damage or death of brain tissue) . metabolic encephalopathy (condition where brain's function is impaired due to an imbalance in the body's metabolism) . bipolar disorder . During a record review of Resident 72's Care Plan (CP) dated 3/20/25, the CP indicated, Focus: [Resident 72] uses psychotropic medications [substances that affect the brain and nervous system, altering mood, perception and behavior] (Quetiapine) for bipolar disorder m/b [manifested by] verbal and physical aggression towards staff. She is at risk for drug-related complications. Date initiated: 03/20/2025. Revision on: 03/20/2025 . During a record review of Residents 72's CP dated 3/20/25, the CP indicated, Focus: [Resident 72] uses anti-anxiety medication Buspirone r/t [related to] repetitive statements, I want to go home. She is at risk for drug-related complications. Date initiated: 03/20/2025. Revision on: 03/20/2025 . During a record review of Resident 72's CP dated 03/20/25, the CP indicated, Focus: [Resident 72] uses anti-anxiety medications [Lorazepam] r/t anxiety m/b inability to relax. She is at risk for drug-related complications. Date Initiated: 03/20/2025. Revision On: 03/20/2025 . During a concurrent interview and record review on 3/21/25 at 8:54 a.m. with Licensed Vocational Nurse (LVN) 3, the medication orders for Quetiapine, Buspirone, and Lorazepam and care plans for these medications were reviewed. LVN 3 stated the medication order for Seroquel indicated a start date of 2/18/25. LVN 3 stated the medication order for Buspirone indicated a start date of 2/18/25. LVN 3 stated the medication order for Lorazepam indicated a start date of 3/5/25. LVN 3 stated the care plans for Quetiapine, Buspirone, and Lorazepam were created on 3/20/25. LVN 3 stated the care plans for these medications should have been in place when the medications were ordered. LVN 3 stated it is important to have care plans for these medications because the resident needs to be monitored to determine if the medication is effective for the resident. During an interview on 3/21/25 at 3:23 p.m. with the Director of Nursing (DON), the DON stated the CP for Resident 71 is incomplete because it does not specify the number of episodes to observe for. The DON stated it is important to have specific number of episodes to observe for to see if medication is working or not and determine if the current dose of the medication needs to be adjusted. The DON acknowledged Resident 71's care plans for Quetiapine, Buspirone, and Lorazepam were missing and not created when the medication was ordered. The DON acknowledged for Resident 72 the care plans for Sertraline and Olanzapine were missing and should have been created. The DON stated it is important to have comprehensive care plans so interventions can be implemented, and this is especially important for short term residents so they can be healed and back to bassline prior to discharge. During a record review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered dated 12/2016, the P&P indicated, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident . The P&P indicated, . 12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS) . 4. During a review of Resident 47's admission Record (AR) dated 3/19/25, the AR indicated, Resident 47 was initially admitted to the facility on [DATE] with diagnoses of heart failure ( a condition in which the heart is unable to pump sufficient blood to meet the body's needs), supraventricular tachycardia (abnormally fast heart rhythm) and morbid obesity (overweight-weight is more than 80 to 100 pounds above the ideal body weight). During a review of Resident 47's Minimum Data Set (MDS- a standardized assessment tool that measures health status in nursing home residents) dated 1/9/25, the MDS section C indicated, .cognitive skills for daily decision-making score of 15 .cognitively intact . During a review of Resident 47's Order Summary Report (OSR) dated 12/3/24, the OSR indicated .apixaban 5 mg tablet twice a day for supraventricular tachycardia . During an interview on 3/19/25 at 5:45 p.m. with the Minimum Data Set Nurse (MDSN), The MDSN stated Resident 47 did not have a care plan for apixaban. The MDSN stated it is important to have a care plan for apixaban, apixaban is an anticoagulant (medication that is used to prevent blood clots). The MDSN stated Resident 47 is at risk for bleeding. During a concurrent interview and record review on 3/21/25 at 4:35 p.m. with LVN 5, Resident 47's Care Plan, dated 3/19/25 and OSR, dated 12/3/24 were reviewed. LVN 7 stated the order for apixaban was started on 12/3/25. LVN 7 stated Resident 47's care plan for apixaban should have been entered sooner. LVN 7 stated care plans are important because it provides a form of communication to care for each resident. During an interview on 3/21/25 at 4:55 p.m. with the DON, The DON stated it is the expectation of the facility to document completely and timely. DON stated care plans are resident centered. During a review of the facility's policy and procedure (P&P) titled, Care Planning-Interdisciplinary Team, dated 09/13, the P&P indicated, .The comprehensive, person-centered care plan is developed within seven days of the completion of the required comprehensive assessment .care plans are revised as information about the residents and residents' condition change .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to meet professional standards of quality for three of six sampled residents (Residents 4, 221, and 321) when 1. Resident 221's physician order for routine oxygen administration was not followed This failure had the potential to cause Resident 221 to experience negative health effects from lack of oxygen. 2. Resident 321 had an incorrect medication order for a Lidocaine Patch (medication that is used to relieve pain). This failure had the potential to result in incorrect placement of the Lidocaine Patch and the potential for the resident to experience ineffective pain control. 3. Resident 4's order for use of Pressure Reduction mattress for pressure redistribution was not being followed. This failure had the potential for Resident 4 to experience delayed healing of a wound, and to not receive necessary wound care. Findings: 1. During a review of Resident 221's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 3/21/25, the AR indicated, Resident 221 was admitted to the facility on [DATE] with a primary diagnosis of pleural effusion (buildup of excess fluid between the layers of tissue lining the lungs and chest cavity). During a concurrent observation and interview on 3/17/25 at 11:09 a.m. in Resident 221's room with Resident 221, Resident 221's nasal cannula (a thin, flexible tube with two prongs, used to deliver supplemental oxygen through the nostrils) was stored in a bag and her oxygen concentrator (a medical device that takes in air from the surrounding environment and delivers a concentrated, purified stream of oxygen to the resident) was turned off. Resident 221 stated she needed oxygen and did not know why it was turned off. During a concurrent interview and record review on 3/19/25 at 9:43 a.m. with Licensed Vocational Nurse (LVN) 6, Resident 221's Order Summary Report, dated 3/17/25 was reviewed. The Order Summary Report indicated Resident 221 was to receive one to four liters (L- a unit of measurement) of oxygen via her nasal cannula. LVN 6 stated Resident 221 had a pleural effusion which meant she had trouble breathing and needed more oxygen than a regular person. LVN 6 stated Resident 221's order was for continuous oxygen delivery and not a PRN (as needed) order. LVN 6 stated if nurses were choosing when to administer Resident 221's oxygen then they needed to call the doctor to get a new order. During an interview with the Director of Nursing (DON), the DON stated if Resident 221 did not need continuous oxygen then the nurses needed to call the doctor to obtain an order for the PRN use of oxygen. The DON stated Resident 221 may have received the inappropriate amount of oxygen if her order was not correct During a review of the facility's policy and procedure (P&P) titled, Medication Order dated 4/08, the P&P indicated, .(b) All drug orders shall be written, dated, and signed by the person lawfully authorized to give such an order. The name, quantity or specific duration of therapy, dosage and time or frequency of administration of the drug, and route of administration if other than oral shall be specified. P.R.N. order shall include the indication for use of a drug .1) Medication orders specify the following .c. Dosage and frequency of administration. 2. During an observation on 3/19/25 at 8:31 a.m. with Licensed Vocational Nurse (LVN) 2 at the South one medication cart in front of Resident 321's room, LVN 2 was observed referring to medication administration record (MAR - a report that details the medications to be administered to a resident) for a Lidocaine Patch order. LVN 2 proceeded to walk into Resident 321's room with the Lidocaine patch and explained to the resident the Lidocaine Patch was a pain medication and was to be placed behind the right shoulder. Resident 321 stated she needed the patch on her right shoulder and a Lidocaine patch on her stomach below the colostomy bag because that is where she felt pain. LVN 2 stepped out of the room and referred to the MAR for the order. LVN 2 re-entered Resident 321's room and explained the medication order was for the right shoulder and proceeded to place the Lidocaine patch. During a record review of admission Record (AR) dated 3/20/25, the AR indicated Resident 321 was admitted into the facility on 3/18/25. During a record review of Resident 321's Order Summary Report (OSR) dated 3/20/25, the OSR indicated, .Lidocaine External Patch 4% (Lidocaine) Apply to affected area topically [medication that is applied directly to the surface of the body] one time a day for pain . Order Date: 3/18/2025 . During a concurrent interview and record review on 3/20/25 at 9:10 a.m. with LVN 3, Resident 321's Lidocaine Patch order was reviewed. The Lidocaine Patch order indicated, .Lidocaine External Patch 4% (Lidocaine) Apply to affected area topically one time a day for pain . LVN 3 stated the medication order does not specify where the Lidocaine Patch should be placed. LVN 3 stated, I would not know where to put [the Lidocaine Patch] looking at this order. LVN 3 stated it is important for the order to state where to place the patch, so it is placed in the correct location, and it is effective for the resident. During an interview on 3/21/25 at 11:02 a.m. with the Pharmacy Consultant (PC), the PC stated the Lidocaine Patch order for Resident 321 is incomplete and does not state where the patch needs to be applied. The PC stated it is important to have a complete order to know where the medication should be placed and to relieve the resident of pain. During a concurrent interview and record review on 3/21/25 at 3:12 p.m. with the Director of Nursing (DON) the Lidocaine patch order for Resident 321 was reviewed. The DON stated the order should have clarified where to place the patch. The DON stated it is important for the medication order to have the affected site listed so the area of pain for the resident is addressed. The DON stated if the affected site is not listed and the Lidocaine patch is placed in the wrong location, the resident will have ineffective pain control. During a review of the facility's policy and procedure (P&P) titled, Medication Order dated 4/2008, the P&P indicated, .1) Medication orders specify the following .e. Route of administration (If facility policies allow, orders are assumed to be P.O. unless otherwise specified) . The P&P indicated, .Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe . The P&P indicated, . Procedures . c. The prescriber is contacted to verify or clarify an order ([example] when the resident has allergies to the medication, there are contraindications to the medication, the directions are confusing) . 3. During a concurrent observation and interview on 3/17/25 at 11:20 a.m. with Resident 4, in Resident 4's room, Resident 4 was observed lying in bed facing the entry way of his door. Resident 4 was alert and oriented. Resident 4 stated he has been lying in bed for months. During a review of Resident 4's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 3/19/25, the AR indicated Resident 4 was admitted to the facility on [DATE] with diagnoses of Paraplegia ( Condition causes partial or complete loss of function of the lower half of the body), Type 2 Diabetes Mellitus (condition where the body does not use insulin properly or does not produce enough insulin), and Pressure ulcer of the sacral region unstageable [ a full thickness [injury extends beyond the two outer layers of skin and into fat and muscle], to the bottom of the back. During a review of Resident 4's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 3/5/25, the MDS Section C indicated, Resident 4's Brief Interview for Mental Status (BIMS- an assessment to be used by facility to screen and Identify memory, orientation, and judgement status of the resident) assessment score was 15 out of 15, (0-15 scale- 0-6 severe cognitive deficit, 7-12 moderate cognitive deficit 13 -15 no cognitive deficit) indicating Resident 4 was cognitively intact. During a review of Resident 4's Braden scale- (a standardized clinical tool that assesses 6 risk areas for pressure ulcers), dated 1/15/25, indicated a total score of 12 which is high risk for developing pressures ulcers. With scoring ranging from 1-3 or 4 and total scoring ranging from 6 to 23. A lower Braden Scale indicates a lower level of functioning and, therefore, higher level of risk for pressure ulcer development. During review of Resident 4's Order Summary Report (OSR), dated 3/19/25, the OSR indicated, .Pressure Reduction mattress for Pressure redistribution every shift . During a concurrent observation and interview on 3/19/25 at 9:34 a.m. with Certified Nursing Assistant (CNA) 2, CNA 2 was observed helping Resident 4 change positions in bed. CNA 2 stated Resident 4 had a regular mattress and not a Pressure Reduction mattress for pressure redistribution. During a concurrent interview and record review on 3/19/25 at 10:01 a.m. with Licensed Vocational Nurse (LVN) 4, Resident 4's OSR, dated 3/19/25, was reviewed. LVN 4 stated the physician orders were to be followed. LVN 4 stated Resident 4 had refused the use of the mattress. LVN 4 stated Resident 4's refusal of Pressure Reduction Mattress was not documented. LVN 4 stated the use of the Pressure reduction mattress is important for Resident 4's wound healing. During an interview on 3/20/25 at 11:38 a.m. with the Director of Nursing (DON), the DON stated Resident 4 had no documentation of refusal of Pressure Reduction Mattress. The DON stated nurses should have informed the physician of Resident 4's refusal. The DON stated not following physician orders could result in Resident 4's wounds worsening. During a review of the facility's P&P titled, Pressure Injury Prevention, dated 4/2018, the P&P indicated, . document an individual's significant risk factors of developing pressure ulcers . evaluate and document the progress . despite existing interventions . During a review of facility's P&P titled, Requesting, Refusing and/or Discontinuing Care or Treatment, dated 2/2024, the P&P indicated, .Detailed information relating to the request, refusal, or discontinuation of treatment are documented in the resident's medical record . The healthcare practitioner must be notified of refusal or treatment .

Based on observation, interview, and record review the facility failed to properly store medication in three of five medication carts and one of two medication storage rooms when: 1. South one medication cart contained: a. An unopened insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) pen intended for refrigeration storage for Resident 56, and b. No open dates were placed on medications for Resident 78, Resident 99, Resident 322, Resident 222, and Resident 72. 2. South two medication cart contained: a. Six insulin pens with no open dates for Resident 68, Resident 53, Resident 5, and Resident 17. b. Expired medication for Resident 66, c. Four eye drop bottles did not have an open date, and d. Three respiratory medications did not have an open date. 3. North one medication cart contained: a. Discontinued medication for Resident 2, b. Two multi-dose (bottle or vial of liquid medication that contains more than one dose of medication) medications did not have open dates for Resident 15 and Resident 63, and c. One over the counter (OTC) medication was expired. 4. North medication storage room contained: a. Two expired medications, b. One medication bottle with an incorrect expiration date, c. Three opened bottles stored on the shelves for unopened OTC medications, and d. Medication refrigerator contained a discontinued medication for Resident 100. These failures had the potential to result in decreased medication potency that could compromise the therapeutic effectiveness of stored medications and result in adverse reactions from medications stored incorrectly, expired and improperly labeled. Findings: 1. During an observation on 3/19/25 at 9:25 a.m. at South one medication cart with Licensed Vocational Nurse (LVN) 2, observed: a. For Resident 56 an unopened Glargine (a long-acting synthetic insulin used to treat type 1 diabetes [condition where pancreas makes little or no insulin which leads to high blood sugar levels] and type 2 diabetes [long term condition where the body has trouble controlling blood sugar and using it for energy]) pen. Pen was not stored in refrigerator as recommended by manufacturer b. For Resident 78 and Resident 99, observed Insulin Glargine with no open date. For Resident 322 observed two eye drop medications, Brinzolamide ophthalmic (eye drop used to treat increased eye pressure caused by glaucoma [eye disease that damages the optic nerve, which connects the eye to the brain] or ocular hypertension [when pressure inside the eye is high than normal]) suspension (liquid medication prepared when the drug doesn't dissolve but is crushed into fine particles) and brimonidine tartrate (eye drop used to treat glaucoma and lower intraocular pressure), and one inhaler (a handheld medical device used to deliver medication directly into the lungs through inhalation), fluticasone propionate and salmeterol (combination of medication used to treat asthma and COPD), with no open date on the bottle. For Resident 222 observed four inhalers, that included albuterol sulfate (short acting medication that provides relief from an asthma attack by relaxing the smooth muscles in the airways), tiotropium bromide (bronchodilator medication breathed in through the mouth to help open up air passages in the lungs), levalbuterol (medication that can treat or prevent bronchospasm [sudden narrowing of the airways in the lungs resulting in difficulty breathing])and breztri aerosphere (medication used to treat long term chronic obstructive pulmonary disease [COPD- a chronic lung disease causing difficulty in breathing] ), with no open date. For Resident 72 observed a bottle of dabigatran (medication that can treat and prevent blood clots) with no open date. During a review of Resident 56's Order Summary Report (OSR) dated 3/20/25, the OSR indicated, Insulin Glargine Solution 100 UNIT/ML [milliliter- unit of volume] Inject 20 unit subcutaneously [under the skin] one time a day for diabetes [chronic disease where the body either doesn't produce enough insulin or cant effectively use the insulin in produces, leading to high blood sugar levels] . Order Status: Active . Start Date: 02/12/2025 . During a review of Resident 78's OSR dated 3/20/25, the OSR indicated .Insulin Glargine Subcutaneous Solution 100 UNIT/ML . Inject 30 unit subcutaneously two times a day for [diabetes] . Order Status: Active . Start Date: 06/18/2024 . During a review of Resident 99's OSR dated 3/20/25, the OSR indicated, . [Insulin Glargine] Subcutaneous Solution Pen-Injector 100 UNIT/ML .Inject 16 unit subcutaneously at bedtime for TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS .Order Status: Active . Start Date: 02/15/2024 . During a review of Resident 322's OSR dated 3/20/25, the OSR indicated, .Brimonidine Tartrate Ophthalmic Solution 0.2% (Brimonidine Tartrate) Instill 1 drop in both eyes every 12 hours for glaucoma . Order Status: Active . Start Date: 03/18/2025 . [Brinzolamide] . Instill 1 drop in both eyes every 12 hours for glaucoma . Order Status: active . Start Date: 03/18/2025 . The OSR indicated, .Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated 100-50 MCG/ACT . I puff inhale orally one time a day . Order Status: Active . Start Date: 03/19/2025 . During a review of Resident 222's OSR dated 3/20/25, the OSR indicated, .Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 base) MCG/ACT (Albuterol Sulfate) 2 puff inhale orally every 6 hours . Order Status: Active . Start Date: 03/13/2025 . Breztri Aerosphere Inhalation Aerosol 160-9-4.8 MCG/ACT (Budesonide-Glycopyrrolate-Formoterol Fumarate) 2 puff inhale orally two times a day . Order Status: Active . Start Date: 03/13/2025 . The OSR indicated, Tiotropium Bromide Monohydrate Inhalation Capsule 18 MCG (Tiotropium Bromide Monohydrate) . 1 capsule inhale orally one time a day . Order Status: Active . Start Date: 03/14/2025 .[Levalbuterol] 1.25 MG/3ML .3 ml inhale orally via nebulizer [a device for producing a fine spray of liquid] every 6 hours as needed for shortness of breath while awake . Order Status: Active . Start Date: 03/13/2025 . During a review of Resident 7's OSR dated 3/20/25, the OSR indicated, . [Dabigatran] oral capsule 150 MG Give 1 capsule by mouth every 12 hours for prevent blood clots . Order Status: Active . Start Date: 03/13/2025 . During an interview on 3/19/25 at 10:30 a.m. with LVN 2, LVN 2 stated it is important to have an open date on the medication itself because if the medication gets separated from the box, the nurse will be unaware when the medication was opened. 2. During an observation on 3/19/25 at 10:35 a.m. at South two medication cart with LVN 6, observed: a. Six insulin pens with no open date. These medications included Resident 68's Insulin glargine and lispro [short-acting human made insulin helps to control blood sugar levels], Resident 53's insulin glargine, Resident 5's Insulin glargine and insulin lispro, and Resident 17's Insulin glargine; b. For Resident 66, observed an expired Insulin glargine; c. For Resident 17, observed two eye drop medications, brimonidine 0.2% and latanoprost 0.005%, with no open date; and d. For Resident 66, observed two inhalers, Combivent Respimat inhaler and albuterol, with no open date and for Resident 20 a bag of levalbuterol with no open date. During a review of Resident 68's OSR dated 3/20/25, the OSR indicated, .Humalog Injection Solution 100 UNIT/ML . Inject 14 unit subcutaneously three times a day for [diabetes type 2] . Order Status: Active . Start Date: 12/25/2024 .Insulin Glargine Solution 100UNIT/ML Inject 45 unit subcutaneously at bedtime for [diabetes type 2] hold if [blood sugar] 150 [greater than] and notify [Medical Doctor] . Order Status: Active . Start Date: 04/01/2024 . During a review of Resident 53's OSR dated 3/20/25, the OSR indicated, . Insulin Glargine subcutaneous solution 100 UNIT/ML (Insulin Glargine) Inject 15 unit subcutaneously at bedtime for type 2 diabetes mellitus without complications . Order Status: Active . Start Date: 3/12/25 During a review of Resident 5's OSR dated 3/20/25, the OSR indicated, .[Humalog] Injection Solution 100 UNIT/ML .Inject as per sliding scale . Order Status: Active . Start Date: 10/13/2023 . [Insulin Glargine] subcutaneous solution 100 UNIT/ML . Inject 20 unit subcutaneously at bedtime . Order Status: Active . Start Date: 8/11/2024 . During a review of Resident 17's OSR dated 3/20/25, the OSR indicated, . [Insulin Glargine] Subcutaneous Solution Pen-Injector [device used to inject medication under the skin] 300 UNIT/ML .Inject 24 unit subcutaneously in the morning for diabetes hold for blood sugar [less than] 100 . Order Status: Active . Start Date: 10/07/2024 . During a review of Resident 66's Order Review undated, the Order Review indicated, .Insulin Glargine Subcutaneous Solution 100 UNIT/ML . Directions: Inject 10 unit subcutaneously one time a day for TYPE 2 DIABETES MELLITTUS WITHOUT COMPLICATIONS for 5 days . Status: Completed . End Date: 3/13/2025 . During a review of Resident 17's OSR dated 3/20/25, the OSR indicated, Brimonidine Tartrate Ophthalmic Solution 0.2% (Brimonidine Tartrate) Instill 1 drop in both eyes three times a day for Glaucoma . Order Status: Active . Start Date: 08/23/2024 .[Latanoprost] .Instill 1 drop in both eyes at bedtime for Glaucoma . Order Status: Active . Start Date: 06/17/2023 . During a review of Resident 66's OSR dated 3/20/2025, the OSR indicated, . Albuterol Sulfate Inhalation Nebulization Solution 1.25 MG/3ML .1.25 mg inhale orally every 4 hours as needed for shortness of breath or wheezing while awake . Order Status: Active . Start Date: 03/07/2025 . [Ipratropium-Albuterol] Inhalation Aerosol Solution 20-100 MCG/ACT .1 puff inhale orally two times a day . Order Status: Active . Start Date: 03/08/2025 . During a review of Resident 20's OSR dated 3/20/25, the OSR indicated, .Levalbuterol HCL Inhalation Nebulization Solution 1.25 MG/3ML (Levalbuterol HCL) ml inhale orally via nebulizer three times a day . Order Status: Active . Start Date: 03/05/2025 . During a concurrent interview and record review on 3/21/25 at 9:08 a.m. with LVN 1, the insulin order for Resident 66 was reviewed. The insulin order indicated, .Insulin Glargine Subcutaneous Solution 100 UNIT/ML . Directions: Inject 10 unit subcutaneously one time a day for TYPE 2 DIABETES MELLITTUS WITHOUT COMPLICATIONS for 5 days . Status: Completed . End Date: 3/13/2025 . LVN 1 stated this medication has been discontinued and the medication should not be in the medication cart. LVN 1 stated expired or discontinued medications should not remain in the medication cart because a medication error (preparation or administration of medication is not in accordance with prescriber's orders, manufacturers specifications or professional standards) could occur. 3. During an observation on 3/19/25 at 12:04 p.m. with LVN 8 at North one medication cart, observed: a. For Resident 2, observed a discontinued bubble pack (card that packages doses of medications within small, clear or light-resistant, amber-colored plastic bubbles) of Lorazepam; b. For Resident 15 observed a multi-dose Lactulose (medication to treat constipation) bottle with no open date, Resident 63 ' s multi-dose Sucralfate (medication that treats stomach ulcers) bottle with no open date; and c. Observed an expired cetirizine hydrochloride (antihistamine medication used to treat allergy symptoms like itchy eyes, sneezing, stuffy nose or hives). During a review of Resident 2's OSR dated 3/21/25, the OSR indicated, .[Lorazepam] Oral Tablet 0.5 MG .Give 1 tablet by mouth every 6 hours as needed for inability to relax for 14 days . Order Status: Discontinued . Revision Date: 03/12/2025 . During a review of Resident 15's OSR dated 3/20/25, the OSR indicated, .Lactulose oral solution 10 GM/15ML .45 mL by mouth every 6 hours . Order Status: Active .Start Date: 03/04/2025 . During a review of Resident 63's OSR dated 3/20/25, the OSR indicated, .Sucralfate Oral Suspension 1 GM/10ML .Give 10 mL by mouth before meals for [treatment] and prevention . Order Status: Active . Start Date: 03/07/2024 . During an interview on 3/19/25 at 12:21 p.m. with LVN 3, LVN 3 stated it is important to remove expired medication from the medication cart because the strength of the medication will not be as effective. 4. During an observation on 3/19/25 at 3:38 p.m. with the Infection Preventionist (IP) at the North medication storage room, observed: a. Three medication bottles, including Reguloid (medication used to treat constipation) with a written open date of 5/29/24, Fish oil (dietary source of omega-3 fatty acids) with a written open date of 4/24/24, and Nephro vitamins (medication used to treat or prevent vitamin deficiency) with a written open date of 1/8/25, stored on shelves designated for unopened OTC medications; b. Observed two packets of topical analgesics (medication applied directly to the skin to relieve pain) that were expired; c. Observed a bottle of unopened Famotidine with an incorrect expiration of 3/27 written on the bottle when manufacturer date was 01/2026; and d. Observed Resident 100's discontinued Latanoprost Ophthalmic Solution 0.005% in the medication refrigerator. During a review of Resident 100's Order Audit Report dated 3/21/25, the Order Audit Report indicated, .Latanoprost Ophthalmic Solution 0.005% .Instill 1 drop in both eyes at bedtime for glaucoma . Order Status: Discontinued . During an interview on 3/19/25 at 3:59 p.m. with the IP, the IP stated it is important to not have expired medication in the medication storage room because the potency (power) of the medication will not be what it needs to be, and the resident will not be receiving an accurate dose of medication. The IP stated if a medication is labeled incorrectly, like an incorrect expiration date, a nurse could be giving an expired medication. During a concurrent observation and interview on 3/20/25 at 8:29 a.m. with Central Supply (CS) in the North medication storage room, medications that were expired and medications with open dates were reviewed. CS stated the expiration date written on Famotidine was an incorrect date. CS stated only unopened OTC medications are to be placed in the medication room. CS stated when OTC medications are seen with an open date in the medication storage room, they should be placed in the bin labeled, Discontinued medication for destruction. CS stated for the topical analgesics that were expired, they should have been removed from the medication room. During an interview on 3/20/25 at 8:38 a.m. with LVN 9, LVN 9 stated open bottles should not be put back into the medication storage room because these medications can expire without staff being aware. LVN 9 stated open dates for medications should be placed directly onto the bottle and not just the packaging because the packaging can be thrown away and a medication could end up with no open date written on it. LVN 9 stated for OTC medications, such as eye drops, staff should place the resident's name and open date on the bottle. LVN 9 stated placing only the room number for a resident on the bottle should not be done because the resident may be moved, and the medication may be given to another resident. During an interview on 3/21/25 at 11:02 a.m. with the Pharmacy Consultant (PC), the PC stated for labeling medications, at a minimum an open date needs to be placed directly onto the medication, or on an open date sticker on the medication, and not just the packaging the medication comes in. The PC stated it is important to remove expired medications from the medication cart such as insulins and eye drops because expired medications may not be as effective and expired eye drops could be an infection control issue. The PC stated discontinued medications should be removed from the medication cart because these medications may continue to be administered without an order. During an interview on 3/21/25 at 3:33 p.m. with the Director of Nursing (DON), the DON stated it is important to put open dates on the medication itself because some medications have a shelf life (length of time an item remains usable) and expire when the medication is opened. The DON stated for the medication storage room, opened OTC medications should not be placed back onto the shelves because the medication could expire past its shelf life. The DON stated expired medications in the medication carts and the medication storage rooms should be removed because if they are not, they may be administered and lead to a medication error. During a review of the facility's policy and procedure (P&P) titled, Medication Storage in the facility: Storage of Medications dated 4/2008, the P&P indicated, .F. Except for those requiring refrigeration, medications intended for internal use are stored in a medication cart or other designated area .M. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists .

Based on observation, interview and record review, the facility failed to store and distribute food in accordance with professional standards for food service safety when: 1. The facility had a clear plastic bag of what appeared to be frozen chicken with no labels or closure device, stored in one of two freezers. 2. The chest freezer did not have a thermometer to monitor the internal freezer temperature. 3. The cook did not take the temperature of the tray of meat loaf or the tray of au gratin potatoes during the lunch tray line service. These failures had the potential to place residents in the facility at risk for food born illness. Findings: 1. During a concurrent observation and interview on 3/17/25 at 9:52 a.m. with the District Manager of the kitchen (DMK), in one of two freezers, a clear plastic bag of what appeared to be frozen, and frost bitten (the surface of frozen food dries out and becomes leathery or discolored due to moisture loss), chicken had no labels or closure device on the bag. The DMK stated the meat should be in a labeled, airtight container for food freshness and safety. The DMK stated without placing the meat in an airtight container, ice could form on the meat causing the meat to lose flavor and moisture. The DMK stated the food needs to have a label to prevent the residents from being served expired foods which could lead to food born illness. 2. During a concurrent observation and interview on 3/17/25 at 10:10 a.m. with the Dietary Aid (DA), there was not a thermometer in the chest freezer. The DA stated, there should be a thermometer in the freezer and the thermometer should be checked every day and recorded and put on a log. During a concurrent observation and interview on 3/17/25 at 10:11 a.m. with the DMK in the facility's kitchen, the DMK stated the freezer should have had an internal thermometer to monitor the temperature inside the freezer to ensure food is being kept at a temperature to prevent bacterial growth and food born illness. 3. During a concurrent observation and interview on 3/19/25 at 11:30 a.m. with the DMK during the lunch tray line observation, the Lead [NAME] (LC), did not take the temperature of the au gratin potatoes or the meat loaf before serving. The DMK stated the LC should have taken the temperature of the au gratin potatoes and meat loaf prior to serving. During a concurrent interview and record review on 3/19/25 at 2:41 p.m. with the DMK, the facility's policy and procedure (P&P) titled, Food and Storage dated 1/2022 was reviewed. The P&P indicated, . All food .shall be stored I in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption .Date and rotate items; first in first out .discard food past the use-by or expiration date . must be stored in containers that have tight fitting lids . The DMK stated all food should be handled following the food and safety codes to help prevent residents from food borne illness. During a review of California Code of Regulations (CCR), Title 22 Security, Division 5 - Licensing and Certification of Health Facilities, Home Health Agencies, Clinics, and Referral Agencies, Chapter 8.5 - Intermediate Care Facilities/Developmentally Disabled-Habilitative, Article 3 - Services Section 76888 - Food and Nutrition Services-Food Storage dated, 12/27/24, the CCR indicated, . All readily perishable foods or beverages shall be maintained at temperatures of 7°C (45°F) or below, or at 60°C (140°F) or above, at all times, except during necessary periods of preparation and service. Frozen foods shall be stored at minus 18°C (0°F) or below at all times. There shall be an accurate thermometer in each refrigerator and freezer and in any other storage space used for perishable food . Keep hot food hot-at or above 140 °F. Place cooked food in chafing dishes, preheated steam tables, warming trays, and/or slow cookers .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. During a review of Resident 371's AR, dated [DATE], the AR indicated, Resident 371 was admitted to the facility on [DATE] with diagnoses which included acute embolism and thrombosis of left lower extremity (a blood clot forming in a vein in the left leg, potentially blocking blood flow and leading to complications) and acquired absence of the left leg (surgical removal of the leg). During an observation on [DATE] at 4:20 p.m. in Resident 371's room, LVN 5 was changing resident 371's dressing. LVN 5 was not wearing a gown. LVN 5 stated Resident 371 had an amputated leg, and a wound had developed on it. LVN 5 stated Resident 371 was at risk for infection. LVN 5 stated Resident 371 was on enhanced barrier precautions (equipment such as gown and gloves, designed to reduce the transmission of multidrug-resistant organisms), and staff were required to wear a gown and gloves when entering the room to provide care. During an interview on [DATE] at 11:23 a.m. with the IP, the IP stated Resident 371 was on enhanced barrier precautions and nursing staff were required to wear gloves and a gown when providing care to him. The IP stated Resident 371 had a recent left leg amputation and had a wound to the surgical site, LVN 5 should have worn a gown when doing his dressing change because that helped protect the resident from infection and it helped protect the nurse from cross contaminating her own clothes. During an interview on [DATE] at 3:03 p.m. with the DON, the DON stated LVN 5 should not have gone into Resident 371's room without a gown. The DON stated not wearing the proper PPE when caring for residents could spread infections to other residents if any contamination attached to LVN 5's clothes. The DON stated LVN 5 not wearing the appropriate PPE did not follow the facility's infection control policy. During a review of the facility's P&P titled, Infection Control Policies and Practices dated [DATE], the P&P indicated, .This Center's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections .the objectives of our infection control policies and practices are to .maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public .the Governing Board .have adopted our infection control policies and procedures and practices as outlined herein, to reflect the Center's need and operational requirements for preventing transmission of infections and communicable diseases . During a review of the Professional Reference (PR) found on https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) dated [DATE], the PR indicated, . [Multi Drug Resistant organisms] (MDROs - germs which have become resistant to medications) 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. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply . Based on observation, interview, and record review, the facility failed to provide a safe, sanitary, and comfortable environment to prevent the development and transmission of communicable diseases and infections for four of 12 sampled residents (Residents 25, 20, 12, 371, and all residents who received medications from South one medication cart) when: 1. Resident 25's visibly soiled, uncovered, and unlabeled graduated cylinder (a plastic container with calibration marks [evenly spaced lines marked along the cylinder that indicate volume measurements] used for measuring volumes of liquids) was on top of a toilet shared by two residents. This failure had the potential to cause cross-contamination and the spread of bacteria and other pathogens (disease causing microorganisms) leading to the risk of infection for residents. 2. Resident 20's nasal canula (a device that delivers extra oxygen through a tube and into the nose) was touching the ground and nebulizer equipment (drug delivery device that turns liquid medicine into a fine mist that is breathed in through a mask or mouthpiece) was stored in the same bag where the nasal canula tubing was supposed to have been stored. These failures had the potential to increase the risk of cross-contamination and infections. 3. Resident 12's humidifier bottle and solution (a container filled with sterile [free of germs] or distilled [water is purified to remove contaminants] water that adds moisture to oxygen before it is delivered to a patient, preventing dryness in the airways) was expired and not replaced. This failure had the potential to lead to bacterial growth in the humidifier solution, increasing the risk of respiratory infections. 4. LVN 5 did not don appropriate personal protective equipment (PPE-specialized clothing, equipment, or devices worn to protect a person from hazards in the workplace or environment) when performing a dressing change for Resident 371's left leg wound. This failure had the potential to cause Resident 371's wound to become infected and lead to other residents becoming infected if LVN 5's clothing became cross contaminated (the physical movement or transfer of harmful bacteria from one person, object or place to another). 5. An envelope containing resident money was stored in the South one medication cart. This failure had the potential to result in transfer of infectious microorganisms (a living thing, such as bacterium, virus or fungus, that is so small it must be viewed with a microscope) onto the medications, equipment and surfaces inside the medication cart. Findings: 1. During a review of Resident 25's admission Record (AR) dated [DATE], the AR indicated, Resident 25 was initially admitted to the facility on [DATE] with diagnoses of cystitis (inflammation of the bladder), displacement of nephrostomy catheter (nephrostomy catheter a tube that is put into the kidney to drain urine directly from the kidney) tip positioned outside the renal collecting system (a series of tubules and ducts in the kidneys where urine flows and drains), diabetes mellitus (condition that happens when your blood sugar is too high), urinary tract infection (an infection in any part of the urinary system), presence of urogenital implants (artificial material in the urinary organs or genitals), obstructive and reflux uropathy (obstructive and reflux uropathy,), and calculus of kidney (kidney stones). During a review of Resident 25's Order Summary Report (OSR) dated [DATE], the OSR indicated, .change foley q (every) 3 weeks .enhanced barrier precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms) r/t (related to) nephrostomy tube .foley catheter (a device that drains urine [pee] from your urinary bladder into a collection bag). output every shift for foley . During a review of Resident 25's Minimum Data Set (MDS- a standardized assessment tool that measures health status in nursing home residents) dated [DATE], the MDS section C indicated, .cognitive skills for daily decision-making score of 3 .severely impaired . During a concurrent observation and interview on [DATE] at 11:55 a.m. with Licensed Vocational Nurse (LVN) 1 in Resident 25's bathroom, a visibly soiled, uncovered, and unlabeled graduated cylinder was on top of the toilet. LVN 1 stated the graduated cylinder was visibly soiled with brown stains with small amount of dried urine on the bottom of the container and was unlabeled. LVN 1 stated the graduated cylinder was used to measure Resident 25's urine output from her foley catheter. During an interview on [DATE] at 9:20 a.m. with the Infection Preventionist (IP), the IP stated a used and visibly soiled graduated cylinder should not have been stored atop the toilet in the bathroom. The IP stated the graduated cylinder should have been thoroughly cleaned after each use, free of stains and any other contents inside or outside, placed in a plastic bag, and stored in a separate location inside the resident's closet. The IP stated the graduated cylinder should have had resident identifiers written on it such as the resident's name. The IP stated there was a potential for cross-contamination if another resident touched the soiled graduated cylinder . The IP stated it was important to have resident identifiers written on the graduated cylinder so it would not be used on other residents, which posed a potential for cross-contamination and risk of infection. During an interview on [DATE] at 5:08 p.m. with the Assistant Director of Nursing (ADON), the ADON stated a container used to empty urine should not have been left on top of the toilet as it was not clean. The ADON stated the container should have been cleaned and labeled, stored in a bag, and placed in area where there was no risk for cross-contamination with other residents. The ADON stated there was a potential for cross-contamination that could have led to other residents getting sick. During an interview on [DATE] at 5:15 p.m. with the Director of Nursing (DON), the DON stated she expected the graduated cylinder to have been labeled with the resident's name, cleaned after each use, stored in separate bag, and stored away from contact with other residents. The DON stated there was a potential for cross-contaminations and the spread of infection if another resident or staff used the soiled and unlabeled graduated cylinder. During a review of Resident 25's Care Plan (CP) dated [DATE], the CP indicated, . monitor and document intake and output from right nephrostomy collection bag . During a review of the facility's policy and procedure (P&P) titled, Infection Control Policies and Practices dated [DATE], the P&P indicated, .This Center's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections .the objectives of our infection control policies and practices are to .maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public .the Governing Board .have adopted our infection control policies and procedures and practices as outlined herein, to reflect he Center's need and operational requirements for preventing transmission of infections and communicable diseases . During a review of the professional reference (PR) found on https://www.vumc.org/periop-services/sites/default/files/public_files/L-Care-of-the-Patient-with-Catheters-and-Drains.pdf titled, Overview Care Of The Patient With Catheters And Drains dated 2012, the PR indicated, .use a clean graduated cylinder that is only used for that patient . 2. During a review of Resident 20's AR dated [DATE], the AR indicated, Resident 20 was initially admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD-a common lung disease causing restricted airflow and breathing problems), acute on chronic systolic (congestive) hearth failure (refers to the heart being unable to pump enough blood around the body), covid 19 (a contagious disease caused by the coronavirus), and obstructive sleep apnea (a sleep disorder that affects breathing while you sleep). During a review of Resident 20's OSR dated [DATE], the OSR indicated, .change foley q (every) 3 weeks .enhanced barrier precautions r/t (related to) nephrostomy tube .foley catheter output every shift for foley . During a review of Resident 20s MDS dated [DATE], the MDS section C indicated, Resident 20 had a BIMS (Brief Interview for Mental Status (BIMS) is an assessment used in nursing homes and other long-term care facilities to monitor cognition) score of 10. A score of 10 indicated, Resident 20 had moderately impaired cognition (condition in which people have more memory or thinking problems than other people their age). During a review of Resident 20's OSR dated [DATE], the OSR indicated, .O2 (oxygen) at 4 liters (L-a unit of measure) via nasal canula every shift for COPD .oxygen 1-4 Liters continuous O2 via Nasal Canula or face mask to keep Oxygen above 90% .levalbuterol HCL (medication used to treat COPD) inhalation nebulization solution 1.25 mg/3ml (milligram/milliliter-a unit of measure) . During an observation on [DATE] at 2:50 p.m. in Resident 20's room, Resident 20 was asleep. Resident 20's oxygen concentrator (machines that take air from the surroundings, extract oxygen and filter it into purified oxygen for patients to breathe) was set to 2.5L. Resident 20's nasal canula was on the floor and nebulizer equipment was stored in a plastic bag hanging from the oxygen concentrator. During an interview on [DATE] at 9:34 a.m. with the IP, the IP stated the nasal canula tubing should not have been on the floor. The IP stated this put Resident 20 at risk for infection because the floor was not clean, and bacteria could have travelled up the nasal canula to Resident 20's nose. The IP stated the nasal canula delivered oxygen directly into the resident's mucosal membrane (the moist, inner lining of some organs and body cavities such as the nose) in her nose. The IP stated the nebulizer equipment should not have been stored in the bag used to store the nasal canula. The IP stated nasal canula and the nebulizer equipment should have been stored in their own dedicated bags. The IP stated there was a potential for cross-contamination with the nebulizer equipment being stored in the nasal canula bag because they were two completely different pieces of equipment and should have been stored separately. The IP stated the Central Supply Clerk (CSC) was responsible for ensuring the nasal canula and the nebulizer equipment were stored in different bags. During an interview on [DATE] at 10:09 a.m. with the CSC, the CSC stated she was responsible for replacing the nasal canula and nebulizer equipment every week. The CSC stated the nasal canula and nebulizer equipment should be stored in different bags to prevent cross-contamination. During an interview on [DATE] at 4:47 p.m. with the ADON, the ADON stated the nasal cannula should not have touched the floor, and the nebulizer equipment should not have been stored in the same bag as the nasal cannula. The ADON stated the nasal cannula on the ground posed an infection risk to Resident 12 because the dirty floor could have contained bacteria, which might have come into contact with Resident 12's mucosal membrane and caused an infection. The ADON stated staff were expected to store the nasal canula and nebulizer equipment in separate bags to prevent cross-contamination. During an interview on [DATE] at 4:57 p.m. with the DON, the DON stated she expected the nasal cannula tubing to remain off the floor and for the nebulizer equipment to be stored in its own bag. The DON stated, allowing the nasal cannula tubing to the touch the floor posed a risk of cross-contamination and infection due to the presence of pathogens (disease causing organisms). The DON stated the nasal cannula and nebulizer tubing were two different pieces of equipment used on different parts of the body, further increasing the risk of cross-contamination if improperly stored. During a review of Resident 20's CP dated [DATE], the CP indicated, . [Resident 20] has COPD. [Resident 20] is at risk for sob (shortness of breath) .the resident will have no s/sx (signs or symptoms) of poor oxygen absorption with oxygenation saturation greater than 90% .give aerosol or bronchodilators (medication that make breathing easier) as ordered . During a review of the facility's P&P titled, Infection Control Policies and Practices dated [DATE], the P&P indicated, .This Center's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections .the objectives of our infection control policies and practices are to .maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public .the Governing Board .have adopted our infection control policies and procedures and practices as outlined herein, to reflect he Center's need and operational requirements for preventing transmission of infections and communicable diseases . During a review of the facility's P&P titled, Respiratory Care; Oxygen Administration dated 12/17, the P&P indicated, .Oxygen equipment, tanks, humidifier bottles, cannulas, masks, and other related items are checked with administration .equipment that is soiled .is replaced . 3. During a review of Resident 12's AR dated [DATE], the AR indicated, Resident 12 was initially admitted to the facility on [DATE] with a diagnosis of mild intermittent asthma (a type of asthma [a chronic condition that inflames and narrows the airways in the lungs] wherein a person has symptoms on no more than 2 days per week), encounter for screening with other viral diseases (a routine test done to a population to identify unrecognized disease carrier state), muscle wasting and atrophy (the decrease in size and wasting of muscle tissue), personal history of transient (temporary) ischemic attack and cerebral infarction ( a temporary lack of blood flow to part of the brain). During a review of Resident 12's OSR dated [DATE], the OSR indicated, .Administer Oxygen 2-5 liter per min via NC (nasal canula) as needed for shortness of breath (SOB) of O2 sat <(above) 90% every shift for SOB .change oxygen tubing, concentrator bottle and clean filter every week every night shift every Sun (Sunday) . During a review of Resident 12s MDS dated [DATE], the MDS section C indicated, Resident 12 had a BIMS score of 08. A score of 08 indicated, Resident 12 had moderately impaired cognition. During an observation on [DATE] at 3:03 p.m. in Resident 12's room, Resident 12 was sitting in her wheelchair asleep. An oxygen humidifier bottle that was nearly full of humidifier solution was connected to her oxygen concentrator and had a date of 2/5. During a concurrent observation and interview on [DATE] at 3:16 p.m. with Certified Nursing Assistant (CNA) 1, Resident 12's humidifier bottle and solution had a date of 2/5. CNA 1 stated the humidifier bottle, and solution was dated 2/5 and was out of date. During an interview on [DATE] at 9:28 a.m. with the IP, the IP was shown a picture, taken by surveyor, of the humidifier bottle and solution taken in Resident 12's room. The IP stated the humidifier bottle and solution were dated 2/5. The IP stated the humidifier bottle and solution were out of date and should have been replaced. The IP stated, the humidifier bottle should have been changed weekly because stagnant (lack of movement or flow, becoming stale) humidifier solution could have potentially allowed bacteria and mold to grow that could have caused and worsened respiratory illnesses for Resident 12. The IP stated, the CSC was responsible for changing the humidifier bottle weekly and should have changed the bottle a week after 2/5. During an interview on [DATE] at 9:57 a.m. with the CSC, the CSC stated she was responsible for changing the supplies of residents on oxygen. The CSC stated she kept track of the rooms with oxygen concentrators. The CSC stated she was supposed to change the humidifier bottles every week. The CSC stated she failed to change Resident 12's humidifier bottle and solution. The CSC stated it was important to have changed the humidifier bottle and solution because if the solution runs out, the oxygen could potentially have dried out Resident 12's mucosal membrane leading to cracking, bleeding, and discomfort. The CSC stated bacteria could have potentially grown in the expired and stagnant humidifier solution and had the potential to cause infections to Resident 12. During an interview on [DATE] at 4:49 p.m. with the ADON, the ADON stated the humidifier solution with a date of 2/5 was three weeks out of date and should have been replaced. The ADON stated she expected the humidifier bottle and solution to have been changed every week by the CSC or nurse. The ADON stated it was important to change the humidifier bottle and solution weekly so the solution inside did not become stagnant and allowed bacteria to grow. The ADON stated bacteria in the solution could have potentially caused respiratory infections to Resident 12 and worsened her asthma. During an interview on [DATE] at 5:01 p.m. with the DON, the DON stated she expected the humidifier bottle and solution to be changed weekly. The DON stated an expired and potentially stagnant humidifier solution had the potential to cause bacteria to grow in the solution and cause respiratory infections to Resident 12. During a review of Resident 12's CP dated [DATE], the CP indicated, . [Resident 12] has oxygen therapy r/t mild intermittent Asthma AEB (as evidenced by) SOB .Administer 2-4 LPM (liters per minute) oxygen .monitor oxygen therapy every shift .Resident is on Oxygen Therapy . During a review of the facility's job description (JD) titled, Central Supply Clerk undated, the JD indicated, .determine if inventory quantities are sufficient .rotate stock using first in first out .stocking nursing stations with the appropriate nursing supplies .orders and maintains inventory of supplies and fills requests according to procedures . During a review of the facility's JD titled, Registered Nurse dated 2022, the JD indicated, .Registered Nurse .follow company policy and procedures to ensure a safe and comfortable environment .deliver and maintain optimum resident care and comfort by demonstrating knowledge and skills of current nursing practices . During a review of the facility's P&P titled, Infection Control Policies and Practices dated [DATE], the P&P indicated, .This Center's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections .the objectives of our infection control policies and practices are to .maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public .the Governing Board .have adopted our infection control policies and procedures and practices as outlined herein, to reflect he Center's need and operational requirements for preventing transmission of infections and communicable diseases . During a review of the facility's P&P titled, Respiratory Care; Oxygen Administration dated 12/17, the P&P indicated, .Oxygen equipment, tanks, humidifier bottles, cannulas, masks, and other related items are checked with administration .equipment that is soiled .is replaced . 5. During a concurrent observation and interview on [DATE] at 9:15 a.m. at South one medication cart with Licensed Vocational Nurse (LVN) 2, when inspecting the locked drawer for scheduled medications, a folder with two 10-dollar bills was found. The folder was labeled, Weekend and after hours trust $20.00 only for residents who have trust account. **See list inside folder. LVN 2 stated the money is kept in this cart for residents with a trust who ask for money after hours when the business office is closed or on the weekends. LVN 2 stated there is a list inside the envelope with residents who have a trust, and this gets updated daily by the business office and this list is given to the LVN responsible for the cart. During a concurrent observation and interview on [DATE] at 8:50 a.m. with LVN 3 at South one medication cart, an envelope containing money was observed in the locked drawer. LVN 3 stated she was unaware there was money in the cart. LVN 3 stated, I haven't been told about the money in this cart but if it is here, I am responsible for it. LVN 3 stated resident money should not be in the cart. LVN 3 stated money held in the medication cart could be an infection control issue because money is dirty, and medications are stored there . During an interview on [DATE] at 11:23 a.m. with the Infection Preventionist (IP), the IP stated she was unaware money was stored in the medication cart and stated money should not be stored in the medication cart. The IP stated money is one of the dirtiest things and having it near medications is not acceptable. The IP stated having money stored next to medication could make the medications dirty. During an interview on [DATE] at 11:42 a.m. with the Pharmacy Consultant (PC), the PC stated he was unaware money was being kept in the South one medication cart. The PC stated money should not be stored in the medication cart because of how dirty it is, and it is mixing with clean medications. During an interview on [DATE] at 3:33 p.m. with the Director of Nursing (DON), the DON stated she was unaware money was kept in the South one medication cart. The DON stated the money should not remain in the medication cart and should be moved. The DON stated money kept in the medication cart can be an infection control issue and everything in the medication cart needs to remain clean. During a review of the facility ' s policy and procedure (P&P) titled, Infection Control Policies and Practices dated 5/2025, the P&P indicated, .This Center ' s infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections .

Based on interview and record review, the facility failed to ensure an unknown number of residents' collective right to privacy was respected when Resident 3 frequently took photographs, with her smartphone, of an unknown number of residents without their consent. This failure resulted in an unknown number of residents having their privacy violated when Resident 1 frequently took their photographs without their consent. Findings: During a review of Resident 3's admission Record (AR) , dated 2/4/25, the AR indicated she was admitted to the facility in 2023 with diagnoses that included Paranoid Personality Disorder (a mental condition in which a person has a long-term pattern of distrust and suspicion of others). During a review of Resident 3's Care Plan (CP) , dated 1/20/25, the CP indicated, Resident 3 has a behavior of taking staff and other res[idents] pictures. Explain risks [versus] benefits of taking pictures of staff and other res[idents] without consent. During an interview on 1/21/25, at 2:10 pm., with the Social Services Director (SSD), the SSD stated Resident 3 has a smartphone and it appears Resident 3 was using it to take photographs in the facility. The SSD stated, You can see a light on it, it looks like she is taking photos. During an interview on 1/21/25, at 2:30 p.m., with the Assistant Director of Nursing (ADON), the ADON stated, I believe [Resident 3] is probably taking photos of other residents. Based on her behavior, she probably is. During a review of Resident 3's Progress Notes (PN) , dated 1/16/25, at 4:29 a.m., the PN indicated Resident 3 was Taking photos of staff and residents. taking photos of hallway and nurses station. Very agitated. Non-compliant and refusing to cooperate. [T]aking photos of patients names and room numbers and rooms. Verbally aggressive and unable to calm down and won't stop taking photos. During a review of Resident 3's PN dated 1/18/25, at 6:18 p.m., the PN indicated Resident 3 continued to yell and take pictures of everyone. The PN was written by Registered Nurse (RN) 1. During an interview on 1/21/25, at 2:45 p.m., with RN 1, RN 1 stated she recalled writing the PN dated 1/18/25 at 6:18 p.m. RN 1 stated Resident 3 has a cell phone, she takes photos of everything and everyone, staff and residents. I have seen her do this. I have seen her do this on a lot of days. Her phone must be full [of photos] now, I've seen her take a lot of photos. She says it is her right to take photos and she can do what she wants. During an interview on 2/4/25, at 12:40 p.m., with the Administrator, the Administrator stated, We see [Resident 3] holding and waving her phone around in her hand, occasionally you will see a flash go off from her phone, so it looks like she is taking a picture. We have talked to her about not taking pictures of other residents. During an interview on 2/4/25, at 1:09 p.m., with Resident 5, Resident 5 stated, Yeah, I have seen [Resident 3] come around and take pictures. Just the other day she was following me around and I came to my room and she followed me there to the doorway to take a picture. She does it all the time. Staff will try and redirect her, they can't do a lot, she gets aggressive. I didn't see the pictures, but she points [her smartphone] right at you, you know what she is doing. During a review of Resident 5's Minimum Data Sheet (MDS, a comprehensive, standardized assessment tool) , dated 12/9/24, the MDS indicated at Question C0500 a score of 15 out of a possible 15, which indicated Resident 5 was cognitively intact (having sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the resident's environment). During an interview on 2/11/25, at 1:50 p.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated she recalled working with Resident 3. CNA 2 stated, She took pictures of everyone that passed by her room. She did this every day. Every day, I'd see her in her doorway, taking photos and videos. She showed me the pictures she took, of other residents. I saw the photos, videos too, on her phone screen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 3) had a care plan intervention in place by not placing a non-skid mat on the seat of her wheelchair, in an effort to reduce her frequent falls. This failure had the potential to result in an increased risk for falls for Resident 3. Findings: During a review of Resident 3's admission Record (AR) , dated 11/22/24, the AR indicated Resident was admitted to the facility on [DATE]. The AR indicated Resident 3 had diagnoses that included anemia (a condition where the body doesn't have enough healthy red blood cells to carry oxygen throughout the body, often resulting in weakness and feeling tired), muscle weakness, difficulty in walking, abnormalities in gait and mobility, and dementia (a chronic, progressive disease affecting mood, memory, and judgement). During a review of Resident 3's Minimum Data Sheet (MDS, a comprehensive, standardized assessment tool) , dated 10/10/24, the MDS indicated at Question C0500 a score of 8 out of a possible 15, which indicated Resident 3's cognition (having sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the resident's environment) was moderately impaired . The MDS indicated at Question GG0170 – E, a score of 2 , which indicated Resident 3 needed Substantial/maximal assistance – Helper does MORE HAN HALF the effort when transferring to and from a bed to a chair (wheelchair). The MDS indicated at Question GG0170 – I, a score of 88 , which indicated Resident 3's ability to walk 10 feet was Not attempted due to medical condition or safety concerns. During a review of Resident 3's EVG - IDT Post Fall Meeting (IDT Post Fall Meeting) , dated 10/4/24, at 8:41 a.m., the IDT Post Fall Meeting indicated, IDT [Interdisciplinary Team, comprised of representatives of different disciplines of the healthcare team, such as nursing, activities, dietary, and social services] met to discuss residents unwitnessed fall that occurred on 10/3/24 [at] approximately [11:04 p.m.]. IDT RECOMMENDATIONS . Dycem [the brand name of a type of non-slip mat designed to hold the resident in place whilst they are in transit] to be placed on wheelchair. During a review of Resident 3's IDT Post Fall Meeting , dated 10/7/24, at 8:15 a.m., the IDT Post Fall Meeting indicated, IDT met to discuss residents unwitnessed fall that occurred on 10/6/24 [at] approximately 10:16 a.m. IDT RECOMMENDATIONS . Dycem to be placed on wheelchair. During a review of Resident 3's IDT Post Fall Meeting , dated 10/29/24, at 7:45 a.m., the IDT Post Fall Meeting indicated, IDT met to discuss residents unwitnessed fall that occurred on 10/28/24 [at] approximately 9:11 a.m. IDT RECOMMENDATIONS . Dycem to be placed on wheelchair. During a review of Resident 3's IDT Post Fall Meeting , dated 11/14/24, at 8:20 a.m., the IDT Post Fall Meeting indicated, IDT met to discuss residents unwitnessed fall that occurred on 11/13/24 [at] approximately 4:45 [a.m.] IDT RECOMMENDATIONS . Dycem to be placed on wheelchair. During a review of Resident 3's Care Plan , undated, the Care Plan indicated Resident 3 is at risk for falls related to Deconditioning, unaware of safety needs, dementia, muscle weakness, difficulty waking, use of psychotropic medications [a class of medications that can cause problems with balance, increased sleepiness and are known to increase the risk of falls]. The Care Plan indicated, Interventions . Dycem on wheelchair, blue information sheet above bed. During a review of Resident 3's Care Plan , undated, the Care Plan indicated Resident 3 is on the Fall Program, due to being high risk and recent falls. Interventions. Blue Information sheet above bed. Dycem on wheelchair. During a concurrent interview and record review, on 11/22/24, at 11:42 a.m., with LVN 2, Resident 3's clinical record was reviewed. LVN 2 stated Resident 3's clinical record indicated she was to have a Dycem non-skid mat on the seat of her wheelchair. During a concurrent observation, interview, and record review, on 11/22/24, at 11:44 a.m., in Resident 3's room, with LVN 2, Resident 3 was noted to be sitting in her wheelchair. No Dycem non-skid mat was noted to her wheelchair. LVN 2 stated she did not see any Dycem on Resident 3's wheelchair. LVN 2 reviewed a blue information sheet on the wall over Resident 3's bed, and confirmed the sheet indicated Resident 3's name and Dycem on w/c [wheelchair] for safety. During an interview on 11/22/24, at 11:45 a.m., with CNA 1, in Resident 3's room, CNA 3 stated, I just changed her [incontinent brief] a little while ago, and there was no Dycem in her wheelchair. During an interview on 11/22/24, at 12 p.m., with the Administrator, the Administrator stated there should have been Dycem on Resident 3's wheelchair. During a review of the facility Policy and Procedure (P&P), titled, Falls and Fall Risk, Managing , dated 9/23, the P&P indicated, Based on previous evaluation and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement physical interventions to reduce hazards and risks identified in their fall prevention program for 2 of 3 sampled residents (Resident 1 and Resident 2), and failed to ensure three of three sampled staff could not describe other key interventions of the fall prevention program when: 1. Resident 1 did not have non-skid socks (socks that have grips to prevent slipping when standing and walking) that were ordered by her physician as a fall prevention intervention. 2. Resident 2 had one transfer bar (bed rails attached to bed to aid resident when getting in and out of bed) attached to her bed when two transfer bars were ordered by her physician as a fall prevention intervention. 3. Three of three staff could not define what the 4 P's (1. Pain [address pain management] 2. Personal belongings [assure personal belongings are kept close to resident] 3. Personal care [assure residents ADL care is addressed] 4. Positioning [assure residents is positioned safe and comfortable]. were, indicated as interventions in the facility's fall prevention program.) These failures had the potential to result in falls for Resident 1 and Resident 2 when interventions of the facility's fall prevention program were not implemented, which increased their risk for serious injury, including bone fracture, pain, and reduced mobility. Findings: 1. During a review of Resident 1's admission Record (AR) , dated 11/8/24, the AR indicated diagnoses of dorsalgia (pain in the back that can affect the muscles, ligaments, bones, joints, and nerves of the spine), unspecified dementia (a general term for dementia, a decline in mental function that causes interference with daily life, mood disturbance (mental health condition that primarily affects emotional state) and anxiety (feeling of fear, dread, and uneasiness), muscle weakness, postural kyphosis (rounding or hunching of the back), and age-related osteoporosis (condition when bones become less dense and more likely to break). The AR indicated Resident 1 was admitted to the facility on [DATE]. During a review of the facility document titled, Monthly Fall Report – October (MFR) , dated 10/24, the MFR indicated Resident 1 had fallen in the facility nine times since she was admitted (on 4/25/24). During a review of Resident 1's Minimum Data Set (MDS, a comprehensive, standardized assessment tool) , dated 9/16/24, the MDS indicated Resident 1 was assessed at Question C0500 a score of 3 on a scale of 1 to 15 , which indicated Resident 1 was severely cognitively impaired (difficulty with thinking, learning, remembering, and making decisions). During a review of Resident 1's Care Plan (CP) (undated), the CP indicated Resident 1 was on the facility's Fall Program, due to being high fall risk and fall with major injury. Date Initiated 8/1/24. Interventions, Fall Program .Non-skid socks if indicated, Blue information sheet above the bed. During a review of Resident 1's Order Summary Report (OSR, a recap of Physician Orders) , dated 11/8/24, the OSR indicated a Physician's Order for Fall Interventions in place: .non skid socks, blue information sheet above bed. The Physician's Order was written on 8/6/24. During a review of EVG- IDT Post Fall Meeting, dated 10/21/2024, the EVG- IDT Post Fall Meeting indicated, .IDT [Interdisciplinary Team, comprised of health care professionals from different disciplines such as Nursing, Activities, Dietary and Social Services] Recommendations 2. IDT identified the root cause of the fall [Resident 1 had fallen on 10/19/24] as residents' cognitive impairment, poor safety awareness. Previous IDT recommendation for falls included: . - resident to be placed on the Fall Program . - 4P's monitoring . During an observation on 11/7/24 at 10:40 a.m., in Resident 1's room, Resident 1 was observed to be lying in bed, with eyes closed and no non-skid socks on her bare feet. A blue sheet of paper was attached to the wall behind resident's bed that indicated, Resident 1] - Fall Program Interventions: Non-skid socks.4 P's. During a concurrent observation and interview on 11/7/24 at 12:09 p.m., in Resident 1's room, Resident 1 was awake and alone, sitting on the edge of the bed with her bare feet resting on the fall mat. Certified Nursing Assistant (CNA) 1 walked into the resident's room and stated Resident 1 should always have non-skid socks on. CNA 1 looked throughout Resident 1's room and stated she was unable to locate any non-skid socks for the resident. During an observation on 11/7/24 at 1:20 p.m., Resident 1 was in the dining room. Resident 1 showed confusion when her son approached for a visit and the resident did not recognize who he was. Resident 1 then grabbed her son's walking stick and would not let go after provided direction several times by staff to remove her hand from the walking stick. During interview on 11/7/24 at 2:09 p.m., with the Director of Nursing (DON), the DON stated Resident 1 does not require one to one staff monitoring (when one designated staff person monitors one resident closely, at all times, in an effort to prevent certain behaviors such as those likely to result in injury to self or others) because she is not always anxious and there are times she is resting and does not require close monitoring. The DON stated Resident 1 should have been wearing non-skid socks. 2. During a review of Resident 2's AR , dated 11/8/24, the AR indicated diagnoses of epilepsy (chronic brain disorder that causes seizures, which are episodes of abnormal electrical activity in the brain), muscle weakness, other abnormalities of gait and mobility, other specified disorders of bone density and structure, unspecified convulsions (when body's muscles contract and relax rapidly and repeatedly, resulting in uncontrolled shaking), anxiety, and age related osteoporosis. During a review of Resident 2's Progress Notes (PN) dated 10/17/24, at 1:27 p.m., the PN indicated, . resident was calling for help CN [Certified Nurse] went to room. Found resident hanging off the bed c/o [complaining of] dizziness. Resident was placed back in the bed . During a review of Resident 2's PN dated 10/17/24, at 9:17 p.m., the PN indicated, .Resident worried about her bed's side rails. CNA notified writer resident stated I need bed's side rails. I might go to fall again . During review of Resident 2's Order Summary Report (OSR) dated 11/8/24, the OSR indicated a Physician's Order for Transfer bars x 2 for assistance with bed mobility and transfer. The Physican's Order were written on 10/18/24. During review of Resident 2's CP (undated) , the CP indicated, Focus, [Resident 2] is at risk for falls [related to] impaired safety awareness. Date initiated 01/29/2024 . Interventions . Transfer rails x2 for assistance with bed mobility and transfers. Date initiated: 10/18/2024. During an observation on 11/7/24 at 1:32 p.m., in Resident 2's room, her bed was observed to have one transfer bar in place on the right side of the bed. There was no transfer bar on left side of the bed. During a concurrent interview, observation, and record review on 11/7/24 at 1:34 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 2's physician orders were reviewed. LVN 1 stated Resident 2's physician's orders indicated Resident 2 was ordered to have two transfers bars on her bed. Upon entering Resident 2's room, LVN 1 stated there was only one transfer bar on Resident 2's bed but there should be two. During an interview on 11/7/24, at 2:09 p.m., with the DON, the DON was informed Resident 2 did not have two transfer bars on her bed that were ordered by her physician, and this was confirmed with LVN 1. The DON stated Resident 2 was moved to a different bed overnight and both transfers bars were not taken and placed on the Resident 2's new bed, and this will be corrected. 3. During an interview on 11/7/24, at 1:25 p.m., with CNA 3, CNA 3 stated she was unsure what the 4 P's , as indicated in the fall prevention program, stood for. CNA 3 stated she would have to ask a colleague to find out what that stood for. During an interview on 11/7/24 at 1:34 p.m., with LVN 1, LVN 1 stated the 4 P's stood for positioning and proximity but did not know what the additional 2 P's stood for. During an interview on 11/7/24 at 1:50 p.m., with LVN 2, LVN 2 did not know what the 4 P's stood for. LVN 2 stated that each resident's fall interventions are individualized but she did not know what the 4 P's within the fall prevention program meant. During an interview on 11/7/24 at 2:09 p.m., with the DON, the DON stated it was her expectation that staff were aware of what the 4 P's were. During a review of the facility document titled 4 P's, (undated), the 4 P's indicated, 1. Pain (address pain management) 2. Personal belongings (assure personal belongings are kept close to resident) 3. Personal care (assure residents ADL care is addressed) 4. Positioning (assure residents is positioned safe and comfortable). During a review of the facility's Policy & Procedure (P&P), titled Falls and Fall Risk, Managing, dated 9/23, the P&P indicated . 5. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable .8. The Fall Program identifies high fall risk residents by Blue arm bands, non-skid socks, Blue door tag, Blue information sheet . 11. The facility can use the following interventions but not limited to these interventions for the resident. Falling Star, 1:1 . Monitoring Subsequent Falls and Fall Risk . 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions .

Based on observation, interview, record review, and facility policy review, the facility failed to ensure 1 (Resident #84) of 2 resident's food choices were provided per the resident's request. Specifically, the facility failed to honor Resident #84's preference for fried or poached eggs with their breakfast. Findings included: A facility policy titled, Food Preparation revised in 02/2023, revealed, 8. Only pasteurized egg products will be used for soft cooked egg items. An admission Record revealed the facility admitted Resident #84 on 01/18/2023. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/28/2024, revealed Resident #84 had a Brief Interview of Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS indicated Resident #84 was on a therapeutic diet and had no signs or symptoms of a swallowing disorder. Resident #84's Diet Requisition Form, dated 12/28/2023, revealed Resident #84 was on a regular, fortified diet with thin liquids. The form revealed staff completed the diet form due to a diet change. The option for Food Preference Review (Dining Services Director) was not marked on the form, and the resident's preferences were not listed on the form. During an interview on 04/29/2024 at 10:51 AM, Resident #84 stated they asked for fried or poached eggs, but the facility never served them fried or poached eggs. An observation of Resident #84's breakfast meal on 04/30/2024 at 9:00 AM revealed Resident #84 was served scrambled eggs. Resident #84 stated they had talked to dietary staff, who told the resident they could not have fried eggs. During an interview on 05/01/2024 at 11:28 AM, Resident #84 stated they had mentioned receiving fried or poached eggs to staff before and had also requested fried or poached eggs in a resident council meeting. During an interview on 05/01/2024 at 2:12 PM, the Dietary Manager (DM) stated that because the facility was a skilled nursing facility, they could not serve poached or fried eggs to the residents. The DM said they had to utilize pasteurized eggs, which she said were liquid eggs that could not be poached or fried. After reviewing regulatory guidance, the DM said she now understood the facility could accommodate Resident #84's egg preference. During a follow-up interview on 05/01/2024 at 3:05 PM, the DM said she had reviewed the facility's policy and the regulations and acknowledged the facility should have honored Resident #84's preference for fried eggs. The DM said she would order the shelled eggs needed to accommodate the resident's food preference. During an interview on 05/02/2024 at 3:18 PM, the Director of Nursing (DON) stated she expected staff to notify nursing and dietary staff if a resident requested a specific food item, such as a fried egg, so dietary staff could follow-up with the resident and discuss their options. During an interview on 05/02/2024 at 3:22 PM, the Administrator stated she expected staff to honor residents' food preferences and choices.

Based on interview, record review, and facility policy review, the facility failed to ensure the designated interdisciplinary team member obtained the hospice plan of care specific to 1 (Resident #27) of 2 sampled residents reviewed for hospice services. Findings included: A facility policy titled, Hospice Program, revised in 07/2017, indicated 1. Our facility has an agreement in place with at least one Medicare-certified hospice to ensure that residents who wish to participate in a hospice program may do so. The policy revealed, 9. In general, it is the responsibility of the hospice to manage the resident's care as it relates to the terminal illness and related conditions, including the following: a. Determining the appropriate hospice plan of care. The policy revealed, 12. Our facility has designated [the facility's Director of Nursing] to coordinate care provided to the resident by our facility staff and the hospice staff. (Note: this individual is a member of the IDT [interdisciplinary team] with clinical and assessment skills who is operating within the state scope of practice act). He or she is responsible for the following, d. Obtaining the following information from the hospice: (1) The most recent plan of care specific to each resident. An admission Record revealed the facility admitted Resident #27 on 03/25/2016. According to the admission Record, the resident had a medical history that included diagnoses of stage four pressure ulcers of the left buttock, right buttock, and sacral region; colostomy status; dementia; type two diabetes mellitus with unspecified complications; hypothyroidism; open wound of the lower back and pelvis; chronic ulcer of the right foot; unspecified heart failure; personal history of other malignant neoplasm (cancer) of the rectum at the rectosigmoid junction (colon) and anus; personal history of a malignant neoplasm of the breast; and adult failure to thrive. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/09/2024, revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #27 received hospice services. Resident #27's comprehensive care plan included a Focus area, revised on 04/17/2024, that indicated the resident was admitted to hospice on 04/03/2024. Resident #27's electronic medical record (EMR) revealed no documented evidence the facility had obtained the hospice plan of care specific to Resident #27. Licensed Vocational Nurse (LVN) #1 was interviewed on 05/01/2024 at 10:48 AM. LVN #1 stated all hospice information should be included in the resident's EMR. Registered Nurse (RN) #2, who provided hospice services for Resident #27, was interviewed on 05/01/2024 at 3:22 PM. RN #2 stated the hospice plan of care was completed when a resident was admitted to hospice and given to the nurse prior to leaving the facility. RN #2 stated she had not admitted Resident #27 to hospice but provided the name of RN #3, who had completed Resident #27's hospice admission. A telephone interview was held with RN #3 on 05/02/2024 at 6:30 PM. RN #3 confirmed she completed admissions for the hospice agency but was unable to remember Resident #27 and was unable to verify if she admitted the resident. RN #3 stated when a resident was admitted to hospice, the hospice plan of care was left at the facility on the day of admission. The Medical Records Director (MRD) was interviewed on 05/02/2024 at 8:32 AM. The MRD stated the hospice agency brought her a packet of hospice records for Resident #27 the previous night (05/01/2024) and told her that the hospice plan of care for Resident #27 had already been left at the facility with a staff member; however, according the MRD, the facility had no copy of Resident #27's hospice plan of care prior to 05/01/2024. RN #4, one of the facility's nurse supervisors, was interviewed on 05/02/2024 at 12:19 PM. RN #4 stated she had not received a hospice plan of care for Resident #27 from the hospice agency. RN #4 stated any information that she received from any outside source, including hospice, was given to the facility's medical records staff, who scanned the documents into the resident's EMR. The Director of Nursing (DON) was interviewed on 05/01/2024 at 2:37 PM. The DON stated hospice agencies provided the facility with a hospice plan of care, and those documents were maintained in the resident's EMR under the document sections. The DON said the hospice plan of care was usually provided to the facility on the day of the resident's admission to hospice services. During a follow-up interview on 05/02/2024 at 4:12 PM, the DON stated she was unaware until 05/01/2024, when informed by the Administrator, that her name was listed in the facility's policy as the person designated as responsible for the coordination of hospice services, including the responsibility of ensuring the facility received each resident's hospice plan of care. The Administrator was interviewed on 05/02/2024 at 1:47 PM. The Administrator stated she was unaware until 05/01/2024 that Resident #27's hospice plan of care was not in the resident's EMR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were treated with respect and dignity for one of five sampled residents (Resident 1), when two Certified Nursing Assistants (CNA 3 and 4) did not stop providing care to the resident when the resident said to stop. This failure violated Resident 1 ' s right to be treated with respect and dignity and posed the risk to negatively impact Resident 1 ' s self-esteem. Findings: During a review of facility document Progress Notes, print dated 4/18/23, the progress note indicated Resident 1 was admitted to the facility on [DATE] and had diagnoses which included . MUSCLE WEAKNESS (GENERALIZED) (decreased strength of the muscles) . DIFFICULTY IN WALKING . During a review of Resident 1 ' s Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 2/27/23, the MDS indicated, Resident 1 ' s Brief Interview for Mental Status (BIMS- an evaluation of attention, orientation and memory recall) indicated a score of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 1 had no cognitive impairment. During an interview on 4/18/23 at 10:29 a.m., with Resident 1, Resident 1 stated, during a brief change by CNA 3 and CNA 4, he wanted them to stop providing care and he was yelling for them to stop. Resident 1 stated CNA 3 and CNA 4 did not stop. Resident 1 stated when he asks the staff to stop or slow down while providing care to him, he would have liked them to stop or slow down the care. During an interview on 4/18/23 at 1:52 p.m., with Licensed Vocational Nurse (LVN), LVN 3 stated, if a resident asked her to stop or slow down while providing care, she would stop her care, ask if the resident was okay, and see if the resident was experiencing pain or discomfort. LVN 3 stated the importance of listening to the resident and stopping care was to respect residents ' rights and dignity. During an interview on 4/18/23 at 1:56 p.m., with CNA 1, CNA 1 stated, if a resident asked her to stop or slow down with providing care, she would slow down, ask the resident what is going on and if anything hurts. CNA 1 stated these steps should have been done to make sure the resident was okay and not being hurt. During a phone interview on 4/24/23 at 2:11 p.m., with the Director of Nursing (DON), the DON stated, the staff had been educated to listen to resident ' s request and should have stopped care when the resident said to stop. DON stated the importance of listening to Resident 1 ' s request to stop and stopping care was to protect the resident ' s rights. During a review of facility document titled [Resident 1]: Interview, dated 4/13/23, the interview indicated Resident stated around 3:10-3:15 am on 4/13 2 CNAs came into his room changing his brief. He said it was ok but told both CNAs to go slow with him. Resident said male CNA said ' I know, I know ' .when it was time to rotate resident to middle. [Resident 1] said he reminded staff to go slow again. [Resident 1] said male CNA rotated him back to middle in a fast manner. [Resident 1] said room was ' shaking ' . [Resident 1] was telling male CNA to stop multiple times when male CNA rotated [Resident 1] to the middle . During a review of facility document titled Progress Notes, dated 4/13/23, the progress note indicated . Resident stated 2 CNA entered his room to changed him, while being changed he became dizzy from rolling back and forth and asked CNA to stop, wait ' . Resident stated CNA did not listen, so he grabbed CNA ' s arm and said stop . During a review of the facility's policy and procedure (P&P) titled, Residents Rights, dated 2/2021, the P&P indicated, . Employees shall treat all residents with kindness, respect, and dignity . Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to . a dignified existence . be treated with respect, kindness, and dignity . self-determination . communication with and access to people and services, both inside and outside the facility .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain infection and control practices to ensure a provision of a safe and sanitary environment for 103 out of 103 residents when: 1. One of two shower rooms had mold on the shower curtain. 2. Monitoring and tracking of deep cleaning for 52 of 52 resident rooms were not done as per policy. These failures had the potential to result in the development and transmission of communicable diseases, illness, and infections. Findings: During an interview on 9/7/23 at 8:55 a.m. with Resident 1, Resident 1 stated there was mold on the shower curtains in the shower room. Resident 1 stated he thought the mold was disgusting and made him feel like he wasn't really getting clean when he was showered. During a concurrent observation and interview on 9/7/23 at 9:15 a.m. with Certified Nurse Assistant (CNA) 2, in Shower room [ROOM NUMBER], a large amount of mold was observed on the bottom third of a shower curtain. CNA 2 stated there should be no mold in the shower. CAN 2 stated molds could lead to infection for the residents. CNA 2 stated approximately half of the residents showered each day were showered in shower room [ROOM NUMBER]. CNA 2 stated shower rooms were not assigned to residents, so all residents had the potential to be showered in Shower room [ROOM NUMBER]. During a concurrent observation and interview on 9/7/23 at 9:40 a.m., with the Administrator (ADM) in Shower room [ROOM NUMBER], there was the mold on the shower curtain. The ADM stated the mold on the shower curtain was not acceptable and should have been replaced right away. ADM stated mold exposure could cause infection or illness in the residents. During a concurrent interview and record review on 9/7/23 at 11:35 a.m., with the District Manager of House Keeping (DMHK), the policy & procedures (P&P) on 7-Step Daily Washroom Cleaning was reviewed. The P&P indicated, . PURPOSE: To teach . the proper method to sanitize a washroom or bathroom . The DMHK was unable to produce any evidence of shower curtains being replaced or the P&P addressing replacing shower curtains in the shower rooms. A review of the professional reference from Centers for Disease Control and Prevention (CDC) Basic Facts About Mold and Dampness , https://www.cdc.gov/mold/faqs.htm, indicated, Exposure to damp and moldy environments may cause a variety of health effects . Some people are sensitive to molds. For these people, exposure to molds can lead to symptoms such as stuffy nose, wheezing, and red or itchy eyes, or skin. Some people, such as those with allergies to molds or with asthma, may have more intense reactions . Severe reactions may include fever and shortness of breath. In 2004 the Institute of Medicine (IOM) found there was sufficient evidence to link indoor exposure to mold with upper respiratory tract symptoms, cough, and wheeze in otherwise healthy people; with asthma symptoms in people with asthma; and with hypersensitivity pneumonitis in individuals susceptible to that immune-mediated condition . People with allergies may be more sensitive to molds. People with immune suppression or underlying lung disease are more susceptible to fungal infections. Individuals with chronic respiratory disease (e.g., chronic obstructive pulmonary disorder, asthma) may experience difficulty breathing. Individuals with immune suppression are at increased risk for infection from molds . 2. During an interview on 9/7/23 at 8:55 a.m., with Resident 1, Resident 1 stated he felt like his room was dirty because of the dried reddish-brown droplets on his window blinds, the brown dried substance on the privacy curtain next to the bathroom. Resident 1 stated there were still personal items in the closet belonging to a previous resident. Resident 1 stated he had been moved from his previous room to room [ROOM NUMBER] on 8/21/23. During a concurrent observation and interview on 9/7/23 at 9:05 a.m., in Resident 1's room, there were personal items in the closet. CNA 1 stated there were items in the closet that were left from another resident. CNA 1 stated belongings from another resident were not supposed to be left in the rooms. CNA 1 stated there were dried reddish/brown substance on the blinds and dried brown substance on curtain. CNA 1 stated the curtains and window blinds should have been cleaned when the room was last deep cleaned between residents. CNA 1 stated residents could get infections if the rooms were not cleaned between residents. During an interview on 9/7/23 at 9:28 a.m., with the DMHK, the DMHK stated room [ROOM NUMBER] was cleaned every day. The DMHK stated the process of cleaning daily included taking out the trash, cleaning the bathroom, cleaning the overbed tables, and mopping the floor. The DMHK stated curtains should have been changed with every deep clean which was done once a month and as needed when residents were discharged or transferred. The DMHK stated the curtains had not been changed because the facility did not have enough curtains. The DMHK stated she did not have a record of when room [ROOM NUMBER] was last deep cleaned. The DMHK stated the privacy curtains in room [ROOM NUMBER] were dirty and needed to be changed. The DMHK said if room [ROOM NUMBER] had been deep cleaned, then it had not been deep cleaned well. During an interview on 9/7/23 at 9:40 a.m., with the ADM, the ADM stated the reddish-brown dried substance on the window blinds and dried brown substance on privacy curtain were not acceptable. The ADM stated the blinds should have been cleaned and the privacy curtain replaced. During an interview on 9/7/23 at 11:15 a.m., with the ADM, the ADM stated the facility should have monitored and tracked the cleaning done by housekeeping. The ADM stated the facility did not have a log to keep track of which rooms were deep cleaned. The ADM stated the expectation was for the housekeepers to be following the policy for deep cleaning. The ADM stated not keeping resident rooms clean could result to the spread of infection and a resident could get sick. During an interview on 9/7/23 at 11:25 a.m., with Resident 2, Resident 2 stated he had been admitted to the facility on [DATE]. Resident 2 stated the curtains in his room were dusty and had not been changed since he had been admitted . During a concurrent interview and record review on 9/7/23 at 11:35 a.m., with the DMHK, the 5-Step Daily Room Cleaning P&P was reviewed. The P&P indicated, . PURPOSE: To teach . the proper cleaning method to sanitize a patient room . The DMHK stated, resident rooms were to be deep cleaned at least monthly. The DMHK stated the Deep Clean Checkoff List was supposed to be filled out after each room deep clean. During an interview on 9/7/23, at 11:49 am, with the DMHK, the DMHK stated he was unable to find any completed Deep Clean Check off Lists for the facility. The DMHK stated that his expectation was for housekeeping to follow the 5-Step Daily Room Cleaning and 7-Step Daily Washroom Cleaning every day and to do a complete deep clean of every room once a month and on discharge/transfer as evidenced by the completed Deep Clean Checkoff List . The DMHK stated it was important to track and monitor the cleaning to make sure that all the steps were being performed to ensure a germ free, sanitary environment for the residents.

Based on interview and record review, the facility failed to develop and implement a person-centered care plan for one of the three sampled residents (Resident 1) when there was no care plan to address Resident 1 ' s refusal of meals and low food intake. This failure resulted in Resident 1 not receiving consistent and individualized care to ensure his nutritional status was being monitored and evaluated. Findings: During a review of Resident 1 ' s Administrative Record (AR-document with resident demographic and medical diagnosis) dated 6/7/23, the AR indicated Resident 1 was admitted to the facility 4/6/23. Resident 1 ' s AR included diagnoses . Sepsis (infection in the blood) . Acute Respiratory Failure with Hypoxia (low oxygen in the tissues to sustain bodily function) . pneumonia (lung inflammation), end stage renal disease (kidneys are unable to function properly) . During an interview on 6/7/23, at 10:26 a.m., with Certified Nurse Assistant (CNA 1), CNA 1 stated, she assisted Resident 1 with meals and recorded meal intake. CNA 1 stated, Resident 1 refused meals, several times. CNA 1 stated she reported Resident 1 ' s meal refusals to the Licensed Vocational Nurse (LVN). CNA stated she did not know if the LVN evaluated meal refusals and initiated a care plan for Resident 1. CNA 1 stated there was no care plan for Resident 1 ' s meal refusals. During a review of Resident 1 ' s Care Plan (CP), dated 4/7/23, the CP indicated, . The resident has nutritional problem or potential nutritional problem . dated initiated 4/7/23 . Provide, serve diet as ordered. Monitor intake and record q (every) meal . date initiated 4/7/23 . During a review of Resident 1 ' s Amount of Meal Eaten (AME), dated 5/1/23-5/23/23, the AME indicated, Resident 1 refused 18 meals, and ate 0-25% (percent) of 22 meals in May 2023. AME dated 4/1/23-4/30/23, indicated Resident 1 refused 10 meals, and ate 0-25% of 16 meals in April 2023. During a concurrent interview and record review on 6/7/23, at 10:46 a.m., with LVN 1, Resident 1 ' s Care Plan was reviewed. LVN 1 stated Resident 1 had been at the facility for approximately one month, was discharged on 5/23/23. LVN 1 stated Resident 1 needed assistance with meals and refused food. LVN 1 stated she documented Resident 1 ' s meal refusal and offered alternatives. LVN 1 was unable to find a care plan for Resident 1 ' s refusal of meals. LVN 1 stated there should have been a care plan for Resident 1 ' s meal refusals. LVN 1 stated it was important to have a care plan for meal refusals to ensure resident ' s meal intake was documented and evaluated so he received adequate nutrition. During a concurrent interview and record review on 6/7/23, at 11: 26 a.m., with Licensed Vocational Nurse, Wound Nurse (WN), Resident 1 ' s meal intake was reviewed. Resident 1 ' s meal intake indicated, 18 refusals during the month of May 2023. WN verified, Resident 1 had a low intake of food for May 2023. WN stated if a resident refused meals, the Interdisciplinary team (IDT) should have met and initiated a care plan for meal refusals. WN stated she was unable to locate IDT notes or a care plan regarding Resident 1 ' s meal refusals. WN stated a care plan should have been done for Resident 1 ' s meal refusals. WN stated not having a care plan for meal refusals could lead to Resident 1 not receiving the nutrition he needed. During a concurrent interview and record review on 6/7/23, at 1:42 p.m., with Minimum Data Set Registered Nurse (MDSRN), Resident 1 ' s meal intake for 4/2023 and 5/2023 was reviewed. MDSRN stated resident refused meals in April 2023 and May 2023. MDSRN stated CNAs and nursing staff should have notified the charge nurse if a resident was refusing meals. MDSRN stated the charge nurse should have notified the Registered Dietician. MDSRN stated the standard of practice, was that the interdisciplinary team should have discussed Resident ' s refusal and initiated a care plan. During a concurrent interview and record review on 6/7/23, at 1:47 p.m., with MDSRN, Resident 1 ' s care plan was reviewed. MDSRN v, Resident 1 ' s had no care plan to address meal refusals. MDSRN stated there should have been a care plan for Resident 1 meal refusals. MDSRN stated if resident ' s meal refusals were not care planned, there was a risk for a decline in health status. During a concurrent interview and record review on 6/8/23, at 12:20 p.m., with Registered Dietician (RD), Resident 1 ' s meal intake was reviewed. RD stated Resident 1 ' s meal intake was low in May 2023. RD stated he was unaware of Resident 1 ' s meal refusals and should have been notified. RD stated meal refusals should have been discussed during IDT meetings and addressed with a care plan. RD stated he was unable to find a care plan for Resident 1 ' s meal refusals. RD stated there should have been a care plan for Resident 1 ' s meal refusals. RD stated it was important to care plan meal refusals to ensure resident ' s preferences and goals were documented and evaluated. RD stated if residents refused their meals, it could lead to a decrease in nutrition, placing the resident at risk to deteriorate. During a concurrent interview on 6/8/23, at 12:38 p.m., with Assistant Director of Nursing (ADON), Resident 1 ' s care plan was reviewed. ADON stated there was no care plan for Resident 1 ' s meal refusals. The ADON stated care plans should have been initiated if a Resident was refusing meals. ADON stated if a resident was refusing meals it needed to be communicated to the IDT members so that goals and plan of care could be discussed. ADON stated having a care plan provided staff on how to address Resident 1 ' s meal refusals and prevent decline in health and nutrition. During a review of the facility ' s policy and procedure (P&P) titled, Food and Nutrition Services, dated 10/2017, the P&P indicated, . 9. Nursing personnel, with the assistance of the food and nutrition services staff, will evaluate (and document as indicated) food and fluid intake of residents with, or at risk for significant nutritional problems . a. Variations from usual eating or intake patterns will be recorded in the resident ' s medical record and brought to the attention of the nurse . b. A nurse will evaluate the significance of such information and report it, as indicated, to the attending physician and dietitian . During a review of the facility ' s policy and procedure (P&P) titled, Care Plan, Comprehensive Person-Centered, dated 3/2022, the P&P indicated, . 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents ' conditions change .

Based on interview and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for one of three sampled residents (Resident 2) when Resident 2 was found with smoking paraphernalia (materials for smoking like cigarette and lighter) in his room near an oxygen concentrator (device which takes air from the surroundings, extract oxygen and filter it into purified oxygen for use ) and caused a flame on 9/22/22. This failure placed Resident 2 at risk for skin burns from the flame which could lead to a fire in the room, causing harm to other residents. Findings: During a review of Resident 2 ' s admission Record (AR- a document which provides resident information, a brief medical history, level of functioning, preferences, and wishes), dated 9/26/22, the AR indicated, . admission Date 2/28/2017 . During a review of Resident 2's Minimum Data Set Section C Cognitive Patterns (MDS-a comprehensive, standardized assessment of residents' functional capabilities and health needs), dated 7/1/22, the MDS indicated, . BIMS (Brief Interview for Mental Status) Summary Score . 15 [indicating normal level of cognition] . During an interview on 10/3/22, at 9:24 a.m., with Resident 2, Resident 2 stated he did not know how the fire in his room began as he was not smoking. Resident 2 stated there was a small fire, but did not get burned from the flames. During an interview on 10/3/22, at 9:57 a.m., with Resident 1, Resident 1 stated on 9/22/22 he saw smoke coming out of Resident 2 ' s room. Resident 1 stated he heard Resident 2 yell fire! Resident 1 stated staff ran to see what was going on. Resident 1 stated he was concerned about Resident 2 smoking in his room. Resident 1 stated he feared Resident 2 was dangerous for the facility as he could potentially burn the facility down. During an interview on 10/3/22, at 11:20 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated on 9/22/22, he heard CNA 2 yelling there was a fire in Resident 2 ' s room. CNA 1 stated he went to retrieve the fire extinguisher to put out the fire. CNA 1 stated CNA 2 had removed the oxygen concentrator from Resident 2 ' s room. CNA 1 stated when he went into Resident 2 ' s room, the fire was out but the room was filled with smoke. CNA 1 stated he saw a lighter behind Resident 2 ' s pillow at the head of the bed. CNA 1 stated he saw ashes on Resident 2 ' s clothes. CNA 1 stated he suspected Resident 1 was smoking in his room and was the reason of the fire. CNA 1 stated he had noticed Resident 2 smell of smoke before and had suspected of him smoking in his room. CNA 1 stated he had seen lighters and cigarettes in his room before and told Resident 2 to hand over his smoking paraphernalia. CNA 1 stated all smoking articles needed to be locked in the nurse ' s cart for safe keeping and to ensure no resident could smoke in their rooms. During an interview on 10/10/22, at 11:35 a.m., with CNA 2, CNA 2 stated on 9/22/22 at approximately 9 p.m., Resident 2 had asked if he could get out of bed to go outside to smoke. CNA 2 stated she instructed Resident 2 she could not get him up in bed until she finished with resident care for other residents. CNA 2 stated Resident 2 threatened to smoke inside his room if she did not get him out of bed. CNA 2 stated she warned Resident 2 not to smoke in his room. CNA 2 stated several minutes later, she saw smoke coming out of his room and ran to see the oxygen concentrator lit with a flame. CNA 2 stated she went to remove the oxygen concentrator from Resident 2 ' s room and put out the fire. CNA 2 stated there was a partial cigarette wrapped in a napkin near Resident 2 ' s beside table along with a lighter in the room. CNA 2 stated Resident 2 denied smoking in his room. CNA 2 stated she suspected Resident 2 of smoking before the oxygen concentrator caught on fire. CNA 2 stated Resident 2 had history of being noncompliant with smoking rules in his room by the smell of smoke on his clothes and staff discovering cigarettes and lighters in his room. CNA 2 stated Resident 2 was not on a smoking schedule before the incident and was able to smoke in the patio on his own. During an interview on 10/10/22, at 12:10 p.m., with the Director of Nursing (DON), the DON stated Resident 2, had been non-compliant with the smoking policy. The DON stated Resident 2 had a history of staff catching him with smoking materials in his room. The DON stated Resident 2 was not on a smoking schedule prior to the incident on 9/22/22 because he was alert enough to smoke on his own in the outside patio where smoking was permitted. The DON stated all smoking articles needed to be locked in the nurse ' s cart outside the patio to ensure no residents had smoking articles in their possessions. The DON stated the smoking policy needed to be followed by the residents to ensure the safety of all residents and to prevent any fires from occurring in the facility. The DON stated Resident 2 should not have been smoking in his room and should not have started a fire. The DON stated Resident 2 could have gotten burned. The DON stated other residents could have been affected if the facility caught on fire. The DON stated because Resident 2 was non-compliant with smoking policies, he needed to be placed on a supervised smoking schedule, to ensure he did not smoke in his room and cause another fire. During a review of Resident 2 ' s Care Plan (CP), dated 3/2/17, the CP indicated, . [Resident 2] was at risk for accidentally injury related to smoking . cigarettes (or other smoking materials) and lighter are required to be stored in nurse ' s cart . [Resident 2] can smoke UNSUPERVISED . Notify charge nurse if it suspected [Resident 2] has violated facility smoking policy . During a review of Resident 2 ' s Smoking Screen (SS), dated 9/22/22, the SS indicated, . Risk for fire r/t [related to] non-compliance with facility policies . Fire was noted in pt (patient) room, by staff, found cigarettes and lighter by the pillow today, fire department was called, Pt is at risk for safety . During a review of the facility policy and procedure (P&P) titled, Smoking Safety Guideline dated 12/27/2011, the P&P indicated, . Facility residents will be allowed to smoke in designated areas only . The Nursing department/designee will manage and distribute smoking materials and supervise residents whose evaluation has demonstrated unsafe smoking practices upon staff observation. Facility staff will ensure appropriate supervision is provided . The Charge Nurse will ensure the safety of the resident and complete/update the Smoking Safety Evaluation . The DON/Designee and the IDT (interdisciplinary team-group of healthcare professionals who work together to provide the care a resident needs) will review the resident ' s Smoking Safety Evaluation and care plan and implement interventions as required . During a review of the facility P&P tilted, Quality of Care Accident Hazards/Supervision/Devices, dated July 2018, the P&P indicated, . 1. The facility will develop a culture of safety and commit to implementing systems that address resident risk and environmental hazards to minimize the likelihood of accidents . Resident Smoking . 1. The facility will assess the resident ' s capabilities and deficits to determine if the resident requires supervision while smoking. 2. The resident ' s care plan will reflect the extent of supervision, if any, is needed during smoking .

Based on observation, interview, and record review, the facility failed to ensure the food and nutrition services staff safely carried out the meal service functions according to facility policies and procedures when food substitutions which were not approved by the Registered Dietitian (RD) were served to residents. These failures had the potential to negatively affect food intake of residents which may result in altered nutrition status for 79 residents who consumed food from the kitchen. Cross reference F803 and F 804 Findings: During a concurrent observation, interview, and record review on 9/12/22, at 11:00 A.M., lunch meal was being prepared in the kitchen. The [NAME] (CK) was heating a large metal batch pan of cauliflower in the oven. CK stated, The food vendor sent us cauliflower because they didn't have broccoli florets or the capri vegetables blend in stock. CK stated she was substituting the Italian vegetable blend for the capri vegetable blend and cauliflower for the broccoli florets. A review of the facility's therapeutic menu spreadsheet titled, 2022 Diet Guide Sheet, dated 9/12/22, indicated, the lunch meal on 9/12/22 for a Regular diet was 3 ounces of encrusted pork loin or low sodium (LS) smothered turkey patty, 1/2 cup broccoli florets, 1/2 cup capri vegetable blend, 1/2 cup oven browned potatoes, 1/2 cup buttered noodles, 1 dinner roll. The CC-Renal lunch meal was LS smothered turkey patty, 1/2 cup broccoli florets, 1/2 cup capri vegetables, 1/2 cup buttered noodles, 1/2 mashed potatoes, 1 dinner roll, and 1 sugar cookie. CK stated all of the facility's food vendors have been out of stock of several food items for the last couple of years. CK stated she sometimes told the Nutrition Service Manager (NSM) about the meal substitutions but not all the time. During an interview on 9/12/22, at 3:35 P.M., with the Administrator (ADM) and Director of Nursing (DON), both the ADM and DON stated their expectation was the kitchen staff, including the Cooks, followed the facility's policies and procedures as well as relevant standards of practice for food safety. During a review of the facility document titled Healthcare Services Inc. Job Description, undated, indicated Cook: Position Summary: The [NAME] prepares and serves food including texture modified and therapeutic diets according to the facility menu. Prepares food in accordance with current applicable federal, state, and local standards . Food Preparation/Delivery: Prepares food for meals, including modified textures for restricted and therapeutic diets . Prepare and serve substitute foods to residents . Make only authorized food substitutions .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the food and nutrition services staff safely and correctly carried out the meal service functions according to facility policy and procedure when: 1. Menu substitutions served to residents with therapeutic diets were not approved by the kitchen Nutrition Services Manager (NSM) or the Registered Dietitian (RD) prior to serving the food item. 2. The renal therapeutic menu was not followed for 10 residents on a renal diet. These failures had the potential to decrease food intake, which may alter nutrition status and lead to weight loss in the 79 residents who received food from the kitchen. Cross reference F804 Findings: 1. During a concurrent observation and interview on 9/12/22, at 11:00 A.M., lunch meal was being prepared in the kitchen. The [NAME] (CK) was heating a large metal batch pan of cauliflower in the oven. CK stated the cauliflower was for the regular diet meals. CK stated the facility's food vendor sent some cauliflower and the capri vegetable blend with the food order because they didn't have any broccoli florets in stock. CK stated she switched out the broccoli florets for the cauliflower. CK stated she didn't always get permission from the kitchen manager or the RD to make food substitutions. CK stated, they understand when I need to make food substitutions. CK stated sometimes she told the NSM when she made meal food substitutions, but not all the time. During a review of the facility's therapeutic menu spreadsheet titled, 2022 Diet Guide Sheet, dated 9/12/22, the menu spreadsheet indicated, the lunch meal for a Regular diet was 3 ounces [0z - unit of measure] of encrusted pork loin or low sodium (LS) smothered turkey patty, 1/2 cup broccoli florets, 1/2 cup capri vegetable blend, 1/2 cup oven browned potatoes, 1/2 cup buttered noodles, 1 dinner roll. The CC (carbohydrate controlled)-Renal lunch meal was LS smothered turkey patty, 1/2 cup broccoli florets, 1/2 cup capri vegetables, 1/2 cup buttered noodles, 1/2 mashed potatoes, 1 dinner roll, and 1 sugar cookie. During an interview on 9/12/22, at 11:15 A.M., with the NSM, the NSM stated he was unaware the facility did not have the broccoli florets for the lunch meal and CK was substituting cauliflower for the broccoli florets. The NSM stated CK should have informed him and got approval from the Registered Dietitian when a food substitution was made. The NSM stated the expectation was for the kitchen staff to follow the facility's policy and procedures and receive approval before making meal substitutions. During an interview on 9/12/22, at 3:05 P.M., with the RD, the RD stated her expectation was for the kitchen staff, including the Cooks, to follow the menus as printed, and to receive her and the NSM's approval of any food substitutions prior to making them. The RD stated it was important for all residents to receive their appropriate therapeutic diet, especially those with renal diets who receive dialysis treatments because their health status was already fragile. The RD stated she expected all kitchen staff to follow the facility's policies and procedures, including facility menus, as well as relevant standards of practice for food safety. During an interview on 9/12/22, at 3:35 P.M., with the Administrator (ADM) and Director of Nursing (DON), both the ADM and DON stated their expectation was all kitchen staff, including the Cooks, follow the facility's policies and procedures and standards of practice for food and nutrition services. During a review of the facility document titled, Job Description: [NAME] Position Summary, undated, indicated, . [NAME] prepares and serves food including texture modified and therapeutic diets according to the facility menu. Prepares food in accordance with current applicable federal, state, and local standards . Food Preparation/Delivery: Prepares food for meals, including modified textures for restricted and therapeutic diets . Prepare and serve substitute foods to residents . Make only authorized food substitutions . During a review of the facility document titled, Job Description: Registered Dietician, dated 2022, indicated, . Dietary Services . Serve as a resource to the facilities regarding nutritional care through consultation and in-service education . Perform standard reviews and nutrition and food service audits in the facility . During a review of the facility document titled, Job Description: Nutrition Services Manager, dated 2022, indicated, . Supervise Food Preparation and Staffing: . Ensure food is nutritional, appetizing, and prepared as planned . Monitor food production maintaining use of standardized recipes and menus and ensuring proper preparation . Unit Supervision/Management: Interview, hire, train, supervise, evaluate, and discipline dietary personnel . Maintain records, manage budget, and supplies . During a review of the facility's policy and procedure titled, Menus, dated 9/2017, the policy and procedure indicated, . Menus will be planned in advance to meet the nutritional needs of the residents/patients in accordance with established national guidelines . 7. A menu substitution log will be maintained on file . 2. During a review of Resident 1's admission Record (AR), dated 9/12/22, the AR indicated, Resident 1 was admitted on [DATE], with the following diagnosis of protein-calorie malnutrition (a condition where there is a low availability of nutrients which leads to changes in body functioning), end stage renal disease (a condition affecting the ability of the kidneys to filter wastes out of blood), type 2 diabetes (inability to regulate blood sugar levels), and hyperkalemia (high level of the mineral potassium in the blood). During a review of the Resident 2's AR, dated 9/12/22, the AR indicated, Resident 2 was admitted on [DATE], with the following diagnosis of epilepsy (a brain disorder resulting in loss of consciousness and sensory disturbances) and dependence on renal dialysis (a condition where the body requires permanent filtering of wastes out of the blood). During a review of the Resident 3's AR, dated 9/12/22, the AR indicated, Resident 3 was admitted on [DATE], with the following diagnosis of type 2 diabetes (inability to regulate blood sugar levels), hypertension (high blood pressure), and hypoxemia (low oxygen in the blood). During a review of the facility document titled, Consistency Census Report (diet list), dated 9/12/22, the report indicated, Resident 1 had a diet consistency of CC-Renal and Diet Category/Meal of Fluid restriction- 8 ounces breakfast, lunch, and dinner; Resident 2 had a diet consistency of CC-Renal; and Resident 3 had a diet consistency of Reg D-Puree. During a review of the facility document titled, Menu Substitution Log (2022), dated 4/20/22- 9/12/22, indicated the column titled Initials of RD were blank and the last written initials were on 4/21/22. The food substituted for biscuits was toast. During an interview on 9/12/22, at 11:25 A.M., with Resident 1, Resident 1 stated he did not like the food at the facility because it was all processed, cold and did not have any flavor. Resident 1 stated the meat was all canned and pre-cooked. Resident 1 stated the food was not conducive to promote health because it was not fresh. Resident 1 stated he mentioned these food concerns to the kitchen manager but never met or spoke to the Registered Dietitian. Resident 1 stated the food on the meal tray tickets were always different from what was served for lunch on the menu. Resident 1 stated it (meal ticket and food served) never matched daily. Resident 1 stated the kitchen often ran out of food and several residents refuse their meals. During a concurrent observation, interview and document review on 9/12/22, at 1:05 P.M., in Resident 1's room, Resident 1's lunch meal tray ticket indicated CCD Renal; LS Smothered Turkey patty, buttered noodles, broccoli florets, dinner roll/bread, and sugar cookie. The meal tray contained cauliflower instead of broccoli florets. Resident 1 stated he did not like the lunch meal because he was expecting to eat broccoli florets but was served cauliflower instead. Resident 1 stated he did not receive the vegetable blend. During a concurrent observation, interview and document review on 9/12/22, at 12:30 P.M., in Resident 2's room Resident 2 stated she did not like or eat the food at the facility because it did not taste good. Resident 2's meal tray had a 3-ounce turkey patty with light brown tan gravy smothered on top, a third of the plate with macaroni egg noodles, a 1/2 cup of cauliflower, and a dinner roll. The meal tray ticket read CCD Renal; LS Smothered Turkey patty, buttered noodles, broccoli florets, dinner roll/bread, sugar cookie, and 4 ounces of cranberry juice. During a concurrent observation and interview on 9/12/22, at 12:45 P.M., with Resident 3, Resident 3 stated the food isn't good here because they serve the same thing all the time. Resident 3 stated the food was tasteless and did not have any flavor. During an interview on 9/12/22, at 3:05 P.M., with the RD, the RD stated her expectation was for the kitchen staff, including the Cooks, to follow the menus as printed, and to receive her and the NSM's approval of any food substitutions prior to making them. The RD stated it was important for all residents, especially those with therapeutic and renal diets on dialysis treatments, receive their appropriate diet because their health status was fragile and compromised. The RD stated she expected all kitchen staff to follow the facility's policies and procedures, including facility menus, as well as relevant standards of practice for food safety. During an interview on 9/12/22, at 3:35 P.M., with the ADM and DON, both the ADM and DON stated their expectation was all kitchen staff, including the Cooks, follow the facility's policies and procedures and standards of practice for food and nutrition services. During a review of the professional reference from the Journal of American Dietetic Association, dated 2010, the reference indicated, according to a study conducted by the Meals-on-Wheels Association of America community residing adults aged 60 to 90 years who had experienced weight loss were examined, and a test group that received three attractive meals and two snacks daily was compared with a group that received the traditional three meals a day. The study concluded weight loss was reversed in the test group (Journal of American Dietetic Association. 2010;110: 1554-1563). During a review of the facility's policy and procedure titled, Menus, dated 09/2017, the policy and procedure indicated. Menus will be planned in advance to meet the nutritional needs of the residents . in accordance with established national guidelines . 6. Menus will be served as written, unless a substitution is provided . 7. A menu substitution log will be maintained on file . During a review of the facility policy and procedure titled, Therapeutic Diets, dated 2017, the policy and procedure indicated . Therapeutic diet is defined as a diet ordered by a physician, or delegated registered dietitian . as part of the treatment for a disease or clinical condition. The purpose of a therapeutic diet is to eliminate or decrease specific nutrients in the diet . or to increase specific nutrients in the diet . to provide food that a resident is able to eat . During a review of the facility's document titled, Diet Manual, dated and approved on 1/26/22, the document indicated, . Renal Dialysis Diet- Individuals placed on this diet are often limited in the amount of sodium, fluid, potassium, and phosphorus they can consume. Protein and calorie needs may be increased depending on the individual's health .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were served attractive and nutritious meals in accordance with standards of practice and facility policy and procedure when the food served to residents during the lunch meal (9/12/22) was not palatable and appetizing. This failure resulted in residents receiving non-appetizing food, which had the potential to decrease food intake and affect nutrition and health status of the 79 residents in the facility. Cross reference F803 Findings: During a review of the Resident 1's admission Record (AR), dated 9/12/22, the AR indicated, Resident 1 was admitted on [DATE], with the following diagnosis of protein-calorie malnutrition (a condition where there is a low availability of nutrients which leads to changes in body functioning), end stage renal disease (a condition affecting the ability of the kidneys to filter wastes out of blood), type 2 diabetes (inability to regulate blood sugar levels), and hyperkalemia (high level of the mineral potassium in the blood). During a review of the Resident 2's AR, dated 9/12/22, the AR indicated, Resident 2 was admitted on [DATE], with the following diagnosis of epilepsy (a brain disorder resulting in loss of consciousness and sensory disturbances) and dependence on renal dialysis (a condition where the body requires permanent filtering of wastes out of the blood). During a review of the Resident 3's AR, dated 9/12/22, the AR indicated, Resident 3 was admitted on [DATE], with the following diagnosis of type 2 diabetes (inability to regulate blood sugar levels), hypertension (high blood pressure), and hypoxemia (low oxygen in the blood). During a review of the facility document titled, Consistency Census Report (diet list), dated 9/12/22, the report indicated Resident 1 had a diet consistency of CC-Renal and Diet Category/Meal of Fluid restriction- 8 ounces breakfast, lunch, and dinner; Resident 2 had a diet consistency of CC-Renal; and Resident 3 had a diet consistency of Reg D-Puree. During an interview on 9/12/22, at 11:25 A.M., with Resident 1, Resident 1 stated he did not like the food at the facility because it was all processed, not fresh food. Resident 1 stated food was cold and did not have any flavor. Resident 1 stated the meat was all canned and pre-cooked. Resdient 1 stated all residents in the facility receive the same food and meals, regardless of their medical condition and diet type. Resident 1 stated a week ago he received potato chips for lunch and potatoes were generally served twice a day with the meals. Resident 1 stated the food was not conducive to promote health. Resident 1 stated he mentioned his food concerns with the kitchen manager but had never met or spoke to the facility's RD (Registered Dietitian). Resident 1 stated every month at resident council meetings, the residents complained about the same types of food items being served daily and weekly. Resident 1 stated the food on the meal tray tickets never matched the food served. Resident 1 stated the kitchen often ran out of food and several residents refused their lunch meals daily. During a concurrent observation, interview and document review, on 9/12/22, at 1:05 P.M., with Resident 1, Resident 1 was served his lunch tray. Resident 1's lunch meal tray ticket indicated CCD Renal; LS Smothered Turkey patty, buttered noodles, broccoli florets, dinner roll/bread, and sugar cookie. The meal tray contained cauliflower instead of broccoli florets as indicated in the meal ticket. Resident 1 stated he did not like the lunch meal because he was expecting to eat broccoli florets but was served cauliflower instead. Resident 1 stated he did not receive the vegetable blend. During a concurrent observation, interview and document review on 9/12/22, at 12:30 P.M., with Resident 2, Resident 2 was served his lunch tray. Resident 2 stated she did not like or eat the food at the facility because it did not taste good. Resident 2's meal tray had a 3-ounce turkey patty with light brown tan gravy smothered on top, a third of the plate had macaroni egg noodles, a 1/2 cup of cauliflower, and a dinner roll. The meal tray ticket read CCD Renal; LS Smothered Turkey patty, buttered noodles, broccoli florets, dinner roll/bread, sugar cookie, and 4 ounces of cranberry juice. During an interview on 9/12/22, at 12:45 P.M., with Resident 3, Resident 3 stated the food isn't good here because they serve the same thing all the time. Resident 3 stated the food was tasteless and does not have any flavor. During a concurrent observation and interview on 9/12/22, at 1:10 P.M., in the kitchen, a test tray evaluation of the regular diet was done. The test tray meal included a 3-ounce pork chop patty with brown gravy, cauliflower, chopped potatoes, dinner roll and 4-ounce carton of milk. The temperature of the chopped potatoes was 120 degrees. The Nutrition Service Manager (NSM) stated the food tasted bland. The NSM stated the dinner roll was dry, hard and over cooked, and the entire meal needed more color and did not look attractive because all the foods were tan and white. The NSM stated the meal could have used some type of garnish. A review of the facility's ducument titled, Resident Council meeting minutes, dated June 2022-August 2022 were requested on 9/12/22 but were not provided. During an interview on 9/12/22, at 3:05 P.M., with the Registered Dietitian (RD), the RD stated her expectation was for the kitchen staff, including the Cooks, to follow the menus as printed and the residents be served attractive, nutritious, and palatable meals. The RD stated it was important for all residents, especially those with therapeutic and renal diets on dialysis treatments, receive their appropriate diet because their health status was fragile and compromised. The RD stated she expected all kitchen staff to follow the facility's policies and procedures, including facility menus, as well as relevant standards of practice for food safety. During an interview on 9/12/22, at 3:35 P.M., with the ADM and DON, both the ADM and DON stated their expectation was all kitchen staff, including the Cooks, follow the facility's policies and procedures and standards of practice for food and nutrition services. During a review of the professional reference from the Journal of American Dietetic Association, dated 2010, the reference indicated, according to a study conducted by the Meals-on-Wheels Association of America community residing adults aged 60 to 90 years who had experienced weight loss were examined, and a test group that received three attractive meals and two snacks daily was compared with a group that received the traditional three meals a day. The study concluded weight loss was reversed in the test group (Journal of American Dietetic Association. 2010;110: 1554-1563). During a review of the facility document titled, Job Description: [NAME] Position Summary, undated, indicated . [NAME] prepares and serves food including texture modified and therapeutic diets according to the facility menu . Food Preparation/Delivery: Prepares food for meals, including modified textures for restricted and therapeutic diets . Prepares food by methods that conserve nutritive value and flavor . Insures foods are palatable, attractive and in the proper form to meet the individual needs of the residents. Prepare and serve meals that are palatable and appetizing in appearance . During a review of the facility's policy and procedure titled, Food Preparation, dated 09/2017, the policy and procedure indicated . All foods are prepared in accordance with the FDA Food Code .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an effective infection prevention and control program designed to provide a safe, sanitary and comfortable environment for one of three sampled residents (Resident 1) when urine was found on the floor of Resident 1's room. This failure had the potential to result in spread of infection and cross contamination (transfer of germs from one surface to another) to residents and staff. During a concurrent observation and interview on 11/10/22, at 11:25 a.m., in Resident 1's room, Resident 1 was sitting up in bed. There was a yellow, wet area with a strong foul smell under Resident 1's bed. The flooring under the wet, yellow area was warped (bent or twisted out of shape) with the floor panels separating from each other. There was a fly flying around Resident 1. Resident 1 stated he did not urinate in the toilet. During a review of Resident 1's admission Record (AR), dated 11/10/22, the AR indicated, Resident 1 was admitted to the facility on [DATE]. The AR indicated Resident 1 had diagnoses of Cognitive Communication Deficient (difficulty in thinking and how someone uses language), Sepsis (the body's extreme response to infection which is a life-threatening medical emergency), Urinary Incontinence (loss of bladder control). During a review of Resident 1's Minimum Data Set (MDS - a comprehensive, standardized assessment of each residents' functional capabilities and health needs), dated 9/16/22, the MDS indicated Resident 1 had a BIMS (Brief Interview for Mental Status - a score of 0-7 suggests severe impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact, a score of 99 indicates the resident was unable to complete the interview) of 99. During a concurrent observation and interview on 11/10/22, at 11:33 a.m., in Resident 1's room, Resident 1's floor had a yellow, wet area and a strong foul smell. Certified Nursing Assistant (CNA) 1 stated the room smelled like urine. CNA 1 stated the wet, yellow area on the floor was urine. CNA 1 stated the floor was sticky from the urine. CNA 1 stated the floorboards had become warped underneath the urine. During a concurrent observation and interview on 11/10/22, at 11:39 a.m., in Resident 1's room, Resident 1's floor was wet with a yellow fluid and had a strong foul smell. There was a fly in the room. Licensed Vocational Nurse (LVN) 1 stated the floor was sticky and the room smelled like urine. LVN 1 stated the urine on the floor was not acceptable and should have been cleaned up right away. LVN 1 stated if the urine was not cleaned up there was a potential for the spread of infectious (of a disease-causing organism which can be transferred to people through the environment) diseases in the urine. LVN 1 stated a fly landed on Resident 1. During a concurrent observation and interview on 11/10/22, at 11:49 a.m., in Resident 1's room, Resident 1 was lying in bed. Resident 1's room had a strong, foul smell and a wet, yellow area on the floor. The Housekeeper (HK) stated the process at the facility was to clean up urine right away. The HK stated the process at the facility was the staff who saw the urine needed to clean it up then notify her so she could sanitize the area. The HK stated the floorboards were spreading apart and discolored from Resident 1's urine. The HK stated she had been trained on infection control processes. HK stated there was a potential to spread bacteria in the urine to other people in the facility if urine was not cleaned up right away. During a concurrent observation and interview on 11/10/22, at 12:05 p.m., in Resident 1's room, the floor had a wet, yellow area and a strong, foul smell. The Housekeeping and Laundry Manager (HLM) stated, Whew, it hit me, it's urine . The HLM stated the urine on Resident 1's floor should have been cleaned up immediately and then sanitized. The HLM stated the floors in Resident 1's room were damaged from the urine. During a concurrent observation and interview on 11/10/22, at 12:19 p.m., in Resident 1's room, the floor had a wet, yellow area and a strong, foul smell. The Maintenance Director (MD) stated the wet yellow area was urine. The MD stated the urine was seeping into the floorboards causing the adhesive to deteriorate. The MD stated when the flooring adhesive went bad the flooring needed to be removed. The MD stated the flooring needed to be replaced now . During an observation on 11/10/22, at 12:32 p.m., in Resident 1's room, the floor was wet with a yellow substance and had a strong foul smell. During an observation on 11/10/22, at 12:52 p.m., in Resident 1's room, the wet, yellow substance was starting to dry around the edges of the puddle. Resident 1's room had a strong, foul smell. During a concurrent observation and interview on 11/10/22, at 2:36 p.m., in Resident 1's room, Resident 1's floor had a wet, yellow area and a strong, foul smell. The Director of Nursing (DON) stated the process at the facility was whoever (staff) saw the urine on the floor would clean it up and notify housekeeping to sanitize the area. The DON stated urine should not sit on the floor for hours. The DON stated, The urine should be cleaned up as soon as possible, within an hour. During an interview on 11/10/22, at 3:20 p.m., with the DON, the DON stated Resident 1's floor should have been cleaned up right away. The DON stated the urine on the floor had the potential to be spread infection to other residents in the facility. The DON stated the urine needed to be cleaned up for infection control purposes. During an interview on 1/19/22, at 3:22 p.m., with the Infection Preventionist (IP), the IP stated urine should have been cleaned up immediately and sanitized. The IP stated it was important to clean up urine right away to prevent the spread of germs and cross contamination. The IP stated if urine was not cleaned up right away there was a potential for the germs in the urine to spread to other residents or staff. The IP stated infectious diseases can be spread by urine. During a review of the facility's policy and procedure (P&P) titled, Resident Rights Safe, Clean and Comfortable Environment, dated 7/2018, the P&P indicated, . The resident has the right to a safe, clean and comfortable environment . The facility will provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior . During a review of the facility's P&P titled, INFECTION PREVENTION and CONTROL PROGRAM , dated 11/2017, the P&P indicated, . The facility will establish and maintain an infection prevention and control program designated to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and Infections . The program will provide guidance related to: . avoiding transmission from staff to resident . Surveillance will be performed to assist identifying possible communicable diseases, infection risks or infections before they spread . Observation of practices by staff directly related to resident care, including, but not limited to: . Incontinence care . Cleaning and disinfection procedures . During a professional reference review retrieved from https://www.cdc.gov/infectioncontrol/spread/index.html, titled How Infections Spread , dated January 7, 2016, the professional reference indicated, . An infection occurs when germs enter the body, increase in number, and cause a reaction of the body. Three things are necessary for an infection to occur: Source: Places where infectious agents (germs) live (e.g., sinks, surfaces human skin) Susceptible (vulnerable) Person with a way for germs to enter the body Transmission: a way germs are moved to the susceptible person . Transmission refers to the way germs are moved to the susceptible person . Germs don't move themselves. Germs depend on people, the environment, and/or medical equipment to move in healthcare settings. A source is an infectious agent or germ and refers to a virus, bacteria, or other microbe. In healthcare settings, germs are found many places. People are one source of germs including .Germs are also found in the healthcare environment. Examples of environmental sources of germs include; Dry surfaces in patient care areas (e.g., bedrails, medical equipment, countertops, and tables) Wet surfaces, moist environments, and biofilms (e.g., cooling towers, faucets and sinks, and equipment such as ventilators) .

Based on interview, and record review the facility failed to implement an effective infection control and prevention program for one of three sampled residents (Resident 1), when the facility did not inform Resident 1's family member (FM 1) of Resident 1's positive Coronavirus (COVID-19- a contagious respiratory infection transmitted from person to person that was responsible for a worldwide pandemic that began in 2019) test result on 12/5/22 and an outbreak of COVID-19 in the facility. This failure had the potential to result in the spread and transmission of Covid-19 in the community. Findings: During a review of Resident 1's admission Record (AR), dated 12/15/22, the AR indicated, .Original admission Date 11/29/22 .Emergency Contact #2 [FM 1] . During review of Resident 1's Minimum Data Set Section C Cognitive Patterns (MDS-comprehensive, standardized assessment of residents' functional capabilities and health needs), dated 12/6/22, the MDS indicated, .BIMS (Brief Interview for Mental Status) Summary Score .03 (indicating impaired cognition) . During an interview on 12/15/22, at 9:10 a.m., with the Infection Preventionist (IP), the IP stated the facility had a COVID-19 outbreak (two or more linked cases of the same illness or the situation where the observed number of cases exceeds the expected number, or a single case of disease caused by a significant pathogen) that began on 11/25/22. The IP stated all residents were tested using a rapid COVID-19 test (Antigen test, frequently referred to as a rapid test. This test detects protein fragments specific to the Coronavirus). The IP stated there were 23 residents in the red zone for COVID-19 (designated area where residents are isolated in their rooms to prevent the spread of COVID-19 virus to other residents or staff). During a concurrent observation, and interview on 12/15/22, at 10 a.m., with Resident 1 (via FaceTime on cell phone), Resident 1 was in the COVID-19 red zone. Resident 1 could not recall when he had a positive result of COVID-19. During an interview on 12/15/22, at 1:50 p.m., with FM 1, FM 1 stated she and her family had visited Resident 1 on 12/3/22. FM 1 stated she was not aware of a COVID-19 outbreak when she visited. FM 1 stated no staff member at the entrance had told her the facility was in an outbreak. FM 1 stated the receptionist just instructed her and her family to wear an N95 mask, but did not explain why. FM 1 stated she became ill on 12/6/22 and tested positive for COVID-19 on that day. FM 1 stated she would not have visited Resident 1, if she knew the facility was in a COVID-19 outbreak to prevent from getting exposed and becoming ill. FM 1 stated the facility had called another family member of COVID-19 result but did not answer. FM 1 stated there was no communication nor notice sent to her about the facility being in an outbreak nor Resident 1 being positive for COVID-19. During a concurrent interview and record review on 12/15/22, at 2:30 p.m., with the IP, Resident 1's Progress Notes (NP), dated 12/5/22 and 12/12/22 were reviewed. The PN on 12/5/22 indicated Resident 1 was positive for COVID-19 on 12/5/22. The PN indicated on 12/12/22 indicated, . [FM 1] concerned that she was not aware that [Resident 1] was tested COVID-19 positive. Per [FM 1] she visited the resident last weekend with her daughter and she was not aware that the facility was in outbreak mode .the facility informed RP 1 (responsibility party) listed. [FM 1] informed the writer that she wanted to be informed as well for any changes of [Resident 1]. The IP stated when there was an outbreak of COVID-19, they would send letters to family members of an outbreak in the facility and call RP to inform them of their resident being positive for COVID-19. The IP stated they called RP 1 of Resident 1 but could not reach him. The IP stated there was no other documentation indicating FM 1 was notified of the positive result on 12/5/22. The IP stated it was important to notify family members and RPs of a positive COVID-19 result to make aware of what was occurring with a residents' health status. The IP stated it was important to notify family members of a COVID-19 outbreak for them to be aware of the possibility of being infected if they were exposed to the resident and prevent spread of the COVID-19 virus in the community. During an interview on 12/15/22, at 2:40 p.m., with the Administrator (ADM), the ADM stated the responsibility of notifying the RPs of resident COVID-19 status was on the ADM, IP and Director of Nursing. The ADM stated it was important to update RPs and other family members when the facility was in a COVID-19 outbreak so they could understand the risks of coming into the facility to visit residents. The ADM stated FM 1 should have been aware of Resident 1's positive COVID-19 result on 12/5/22, and the status of an outbreak when she visited on 12/3/22, as the outbreak had started on 11/25/22. During a review of the facility policy and procedure (P&P) titled Infection Control Reporting COVID-19 information to Residents/Representatives , dated 5/14/20, indicated, .1. The facility will keep residents/representatives and family members of residents informed as to the status of COVID-19 in the facility. 2. Notifications will take place by 5 pm on the following calendar day each time a confirmed COVID-19 case is identified or whenever three or more residents or staff are identified with new onset of respiratory symptoms occurring within 72 hours of each other .4. Notifications will .b. Include cumulative updates for residents, representatives, and families at least weekly or by 5 pm the next calendar day .5. Notifications may be made electronically through email or website posting, paper notification or recorded telephone messages .

Based on observation, interview and record review, the facility failed to provide services which met professional standards of quality when Licensed Nurse (LN) 1 administered a blood pressure (pressure of the blood with in the arteries and produced primarily by the contraction of the heart muscles) medication to Resident 37 without first checking Resident 37s heart rate and not following physicians order for one of two sampled residents. This failure had the potential risk for Resident 37 to receive medication with a possible side effect of a low heart rate. Finding: During a concurrent observation, interview and record review on 4/10/19, at 8:25 a.m., in Resident 37's room, LN 1 checked Resident 37's physicians order in the computer and read out loud, Metoprolol tartrate (medication use to treat high blood pressure) 50 mg (milligram) (dry unit of measurement) give 1 tablet by mouth two times a day, related to essential hypertension (high blood pressure) hold for SBP (Systolic Blood Pressure)(The top number is the systolic blood pressure, the highest level your blood pressure reaches when your heart beats) under 60. The lower number is the Diastolic Blood Pressure (DBP) (when the heart relaxes between beats) or under 60. LN 1 checked Resident 37's blood pressure and the reading was 134/82 mmhg (millimeters of mercury). LN 1 prepared the medication and started to administer it. During a concurrent observation, interview and record review with LN 1 on 4/10/19, at 9:02 a.m., the surveyor asked LN 1 to read again the physicians order and asked LN 1 if she had checked the resident's heart rate. LN 1 stated, I did not check the heart rate. LN 1 went back to Resident 37 and checked her heart rate for 1 minute which was 68 beats per minute. LN 1 stated the order read to not to give the medication if the heart rate was less than 60 beats per minute. LN 1 stated she should have checked the heart rate before preparing to give the medication. During a concurrent interview and record review with the Director of Nursing (DON), on 4/10/19, at 3:48 p.m., she reviewed the medication review report and the medication administration record (MAR) dated 4/1/19 to 4/10/19. She stated if she was the LN who administered the blood pressure medication she would check the B/P and the heart rate before giving the medication to eliminate a potential bradycardia (slow heart rate). The DON stated the LN's needed to follow the doctor's order. During a concurrent interview and record review with the Facility Nurse consultant (FNC) on 4/10/19, at 5:00 p.m., she reviewed the MAR dated 4/1/19 to 4/10/19 and stated the LN should have checked both blood pressure and heart rate. She stated, It (metoprolol) will cause a low heart rate and deteriorate Resident's 37 heart condition. During a concurrent interview and record review with the Facility Pharmacy Consultant (FPC), on 4/11/19, at 10:21 a.m., she reviewed medication review report and medication administration record dated 4/1/19 to 4/10/19. The FPC stated the B/P was recorded in the space provided on the form and on the pulse column was recorded an x which indicated it was not recorded in the MAR. The FPC stated the heart rate needed to be checked before administering the medication. The facility documents titled, Medication and Administration Record dated 4/1/19 to 4/10/19, indicated Metoprolol Tartrate Tablet 50 MG was to be given 1 tablet by mouth two times a day related to ESSENTIAL (primary) HYPERTENTION. The medication was to be held for a SBP under 100 and for a DBP under 60; and for a heart rate below 60 beats per minute. The facility document of the manufacture's specifications titled Metoprolol Tartrate undated, indicated . contraindications .Metoprolol tartrate is contraindicated in sinus (refers to sinus node, the heart's natural pacemaker which creates the normal regular heartbeat) bradycardia .Monitor heart rate and rhythm in patients receiving metoprolol tartrate . The policy and procedure titled, Medication and Treatment orders dated 7/2016, indicated, Policy Statement order for medication and treatments will be consistent with principles of safe and effective order writing. Policy Interpretation and Implementation .9. Orders for medications must include .e. Clinical condition or symptoms for which the medication is prescribed . The policy and procedure titled, Pharmacy Services Medication Administration dated 8/2018, indicated Purpose: To provide residents with safe, accurate medication administration .Guidelines: 1. Medications will be administered following the Six (6) rights of medication administration: a. The right order (valid prescriber order) . f. The right practices (correct, accepted standards of practice and manufacturer's specifications). 2. Medications will be prepared and administered in accordance with: a. prescriber's order . c. accepted professional standards and principles .

Based on interview and record review, the facility failed to ensure one of six sampled Certified Nursing Assistants (CNA) 2 received appropriate competencies and skills set training when CNA 2 had not received competency training on orientation in order to provide safe use of the mechanical lift (a device used to transfer non ambulatory residents) and sling (a hammock like cloth device used to hold the resident during transfer with a mechanical lift) on residents. This failure had the potential to place residents requiring the use of the mechanical lift for transfers at risk for falls and injuries. Findings: During an interview with the Director of Staff Development (DSD), on 4/10/19, at 3:14 p.m., the DSD stated [Resident 76] experienced a fall while CNAs were using the mechanical lift to transfer resident from wheelchair to bed. DSD stated the mechanical sling ripped and Resident 76 fell onto the floor which resulted in Resident 76's broken right foot fifth toe. The DSD stated she saw the sling that was ripped during Resident 76's transfer. The DSD stated it was the CNA's responsibility to inspect the slings prior to using the sling to transfer residents. The DSD stated she did not know the date when the sling was ordered and believed it was important for all the slings to be dated to ensure it was not past the manufacturer's recommended date of use (six months). The DSD stated, I did see the sling [that ripped during Resident 76's transfer]. It looked like it was cut in half . The DSD stated CNAs were required to receive competency mechanical lift and sling training upon hire and annually. During a concurrent employee file review for CNA 2 and interview with the DSD, on 4/11/19, at 9:55 a.m., the DSD reviewed CNA 2's new hire orientation competency skill set check list. The DSD stated CNA 2 was hired on 10/25/18. The DSD was unable to find documented competency skill set check list indicating CNA 2 was trained to use the mechanical lift and sling to safely transfer residents. The DSD stated, It [mechanical lift competency] should be in the employees file. It is important for all CNAs to be trained how to properly use the mechanical lift and the sling so it would be safe when they transfer the resident. The facility policy and procedure titled, Safe Lifting and Movement of Residents dated 12/13, indicated, . In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents . 1. Resident safety . will be incorporated into goals and decisions regarding the safe lifting and moving of residents . 6. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques . 8. Enough slings, in the sizes required by residents in need, will be available at all times. As an alternative, residents with lifting and movement needs will be provided with single-resident use disposable slings. 9. Maintenance staff shall perform routine checks and maintenance of equipment used for lifting to ensure that it remains in good working order. 10. All equipment design and use will meet or exceed guidelines and regulations concerning resident safety and the use of restraints .

2. During an observation in the kitchen, on 4/9/19, at 8:20 a.m., a whisk with white sticky substance was stored with clean utensils on the cart in the kitchen. During an interview with Dietary aide (DA) 1, on 4/9/19, at 8:25 a.m., she stated it's not clean, it's dirty, there's a white sticky stuff at the edges. DA 1 stated she would remove the dirty whisk and rewash the utensils. During an interview with Certified Dietary Manager (CDM), on 4/9/19, at 8:15 a.m., he stated, The whisk had dried food, probably dried oatmeal. During an interview with CDM, on 4/11/19, at 8:15 a.m., he stated he had given an in service to staff about cleaning all utensils, pots and pans to make sure no food was left especially on the whisker. The DS stated, It (whisk) could causes foodborne illness to residents if a dirty utensil were used by residents with the meal. The policy and procedure titled Ware washing dated 9/2017, indicated, Policy Statement: All dishware, service ware and utensils will be cleaned and sanitized after each use . Based on observation, interview and record review, the facility failed to maintain an effective infection prevention and control program when: 1. Registered Nurse (RN) 1 did not follow the facility policy and procedure titled Instillation of Eye Drops and administered eye drops without wearing gloves during the eye drop medication administration. 2. One whisk (wire kitchen utensil) was stored with the clean utensils on the cart in the kitchen. These failures had the potential for spread of infection and cause foodborne illness to residents. Findings: During a medication administration observation, on 4/10/19, at 8:22 a.m., on South station, RN 1 entered Resident 4's room and told Resident 4 she was giving her eye drops medication. RN 1 washed her hand in the sink then took the medicine eye drops and instilled to both eyes without wearing gloves. During an interview with the RN 1, on 4/10/19, at 8:33 a.m., she stated she washed her hand prior administering the eye drops and does not need to wear gloves unless it is antibiotic eye drops. During an interview with the Director of Nursing (DON), on 4/10/19, at 9:29 a.m., she stated RN 1 should wear gloves when administering eye drops medication. The facility policy and procedure titled Instillation of Eye Drops dated 1/2014, indicated .Steps in the Procedure . 3. Put on gloves .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure to store, prepare and serve food safely when: 1. An undated opened box of brown sugar, open bottle of ground spice pimiento, opened box of kosher salt were stored and ready for use in the condiments shelves in the kitchen. 2. An undated zip lock bag with 10 pieces of cooked pancake were stored and ready for use in the freezer 1 in the kitchen. 3. An undated and/or no use by date open boxes containing chicken, salami, pork [NAME] were stored and ready for use in freezer 2 in the kitchen. 4. Undated nutritional shakes were stored and ready for use in the kitchen walk in refrigerator and in the north nurse's station refrigerator. These failures to ensure effective dietetic service operations placed residents that received meal form the kitchen at risk for food borne illness and the growth of microorganisms. Findings: 1. During a concurrent observation and interview with the Certified Dietary Manager (CDM), on 4/9/19, at 8:25 a.m., in the kitchen, an undated opened box of brown sugar, opened bottle of ground spice pimiento and opened box of kosher salt were stored and ready for use in the condiments shelves in the kitchen. The CDM stated the items should all be dated with open date. 2. During concurrent observation and interview with the CDM, on 4/9/19, at 8:30 a.m., in the kitchen's freezer 1, an undated Ziploc bag containing 10 pieces of cooked pancakes was stored and ready for use. The CDM confirmed the bag was not dated and stated, These pancakes should be dated by use by date. 3. During a concurrent observation and interview with CDM in the kitchen's freezer 2, on 4/9/19, at 8:35 a.m., opened boxes containing chicken [NAME], salami [NAME] and pork [NAME] with were stored and ready for use without an open date or use by date. The CDM reviewed the items and was unable to locate open or used by dates and confirmed the boxes were not dated. 4. During concurrent observation and interview with CDM in the kitchen walk in refrigerator, on 4/9/19, at 8:40 a.m., there were opened boxes with 25 strawberry nutritional shakes, 50 chocolate nutritional shakes, and 25 of vanilla nutritional shakes with no dates to indicate when the shakes were thawed. The CDM stated once thawed the nutritional shake would expire within 14 days and validated there were no dates on the shakes. The facility policy and procedure titled Receiving dated 9/2017, indicated .Procedures .5. All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation . The facility policy and procedure titled Food Storage: Dry Goods dated 9/2017, indicated Storage areas . date marked as appropriate. The facility policy and procedure titled Food Storage: Cold Foods dated 4/2018, indicated Procedures: .5. All foods will be stored wrapped or in covered containers, labeled and dated and arranged in a manner to prevent cross contamination. The facility document dated 1/9/2018, indicated . the frozen shakes have a shelf life of one year from the date of manufacture when kept frozen. Once thawed, refrigerate and use within 14 days.

Based on interview and record review, the facility failed to ensure the facility assessment addressed the federal expectation to develop a water management program for the risk reduction of Legionella (a water borne bacteria which can cause life threatening pneumonia) and other water-borne pathogens (germs that cause disease) in accordance with CMS letter revision date 7/6/18. This failure resulted in the increased risk of not being prepared to address the risk of infections to residents for Legionella and/or other water-borne pathogens. Findings: During an interview with the Administrator (ADM), on 4/12/19, at 2:16 p.m., he stated he was aware of the facility's requirement to established a water management plan to reduce the risk of growth and spread of waterborne organisms (bacteria). During a concurrent interview and record review with the ADM, on 4/12/19 at 2:20 p.m., the facility document titled, Facility Assessment dated 2/1/19 did not have any information regarding the facility's need for a water management program. The ADM stated the water management plan was not addressed in the facility assessment. Review of the CMS QSO letter dated and revised 7/6/18 indicated Expectations for Healthcare Facilities:CMS expects Medicare and Medicare/Medicaid certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. Facilities must have water management plans and documentation that, at a minimum, ensure each facility: 1)Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system. 2) Develops and implements a water management program that considers the ASHRAE industry standard and the CDC toolkit. 3)Specifies testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. 4) Maintains compliance with other applicable Federal, State and local requirements.

Based on interview and record review, the facility failed to establish and implement a comprehensive antibiotic (ATB) stewardship (program designed to reduce unnecessary use of antibiotics and to limit the spread of antibiotic resistance in bacteria) and surveillance program to identify, track, and monitor resident antibiotic use when: 1. The Director of Staff Development (DSD) did not accurately monitor the use of antibiotic of resident infections on the monthly line listing surveillance logs for eight of eight sampled residents (Resident 74, Resident 92, Resident 79, Resident 6, Resident 34, Resident 91, Resident 48 and Resident 46). 2. The facility did not have documented monthly line listing surveillance logs for seven of 12 sampled months (June 2018, July 2018, August 2018, September 2018, October 2018, November 2018 and December 2018). These failures had the potential to result in the residents to be placed at risk for an adverse effect of antibiotics and/or develop an antibiotic-resistant (not effective to treat infection) organisms from unnecessary or inappropriate antibiotic use. Findings: 1. During a concurrent interview and record review with the DSD, on 4/11/19, at 1:50 p.m., the DSD reviewed the antibiotic surveillance logs and stated she did not know what happened to the monthly line listing surveillance logs for June 2018, July 2018, August 2018, September 2018, October 2018, November 2018 and December 2018. The DSD stated surveillance logs was very important to keep track of residents that were receiving ATB because it was part of the ATB stewardship program. The DSD stated, If it's not documented, it's not done. The DSD reviewed the surveillance line listing logs for January and February 2019 and stated the monthly surveillance for January 2019 and February 2019 were incomplete because the logs did not contain documented signs and symptoms indicating the purpose for the use of the antibiotic. The DSD stated the surveillance would provide the facility guidance to ensure residents met the criteria for an ATB to be started. The DSD stated the monthly line listing surveillance logs for January 2019 and February 2019 should also include the date when the infection was resolved to determine if the ATB was effective or not. The DSD stated the surveillance logs did not include it. The DSD stated she did not complete the documentation for the monthly line listing surveillance logs for March 2019. The DSD stated surveillance logs should have been completed especially when there was an influenza (a highly contagious viral infection of the respiratory passages causing fever, severe aching, and often occurring in epidemics) outbreak in the facility on March 2019 and she did not do that. During a review of the facility document titled, Infection Prevention and Control Surveillance Log dated 1/19/19, indicated, . [Resident 74] . Infection [Osteomyelitis- inflammation of the bones] . signs/symptoms [physician (MD) diagnosis] . Treatment . Rocephin Sodium Solution, 1 gram [Intravenous] [q-every] 24 hours . date ATB started . 1/22/19 . date infection resolved (blank) . During a review of the facility document titled, Infection Prevention and Control Surveillance Log dated 1/5/19, indicated, . [Resident 92] . Infection [Urinary Tract Infection] . signs/symptoms [urine culture and sensitivity] . treatment . Keflex 500 milligrams (mg- a unit of dry measurement) po [by mouth] TID [three times a day] x [for] 7 days . date ATB started [1/6/19] . dated ATB ended [1/13/19] . date infection resolved (blank) . During a review of the facility document titled, Infection Prevention and Control Surveillance Log dated 1/27/19, indicated, . [Resident 79] . Infection [ear] . signs and symptoms [MD diagnosis] . treatment [amoxicillin 1000 mg po q8hours for 10 days] . date ATB started [1/28/19], date ATB ended [2/7/19] . date infection resolved (blank) . During a review of the facility document titled, Infection Prevention and Control Surveillance Log dated 2/13/19, indicated, . [Resident 6] . Infection [left foot cellulitis] . signs and symptoms [MD diagnosis] . treatment [ciprofloxacin 250 mg po q12 hours for 7 days] . date ATB started [2/13/19], date ATB ended [2/20/19] . date infection resolved (blank) . During a review of the facility document titled, Infection Prevention and Control Surveillance Log dated 2/13/19, indicated, . [Resident 6] . Infection [left foot osteomyelitis] . signs and symptoms [MD diagnosis] . treatment [clindamycin 150 mg Po q6 hours for 7 days] . date ATB started [2/14/19], date ATB ended [2/20/19] . date infection resolved (blank) . During a review of the facility document titled, Infection Prevention and Control Surveillance Log dated 2/6/19, indicated, . [Resident 34] . Infection [UTI] . signs and symptoms Urine [UA] C&S [Culture and Sensitivity] . treatment [Amoxicillin 875-125 mg Po q12 hours for 4 days] . date ATB started [2/7/19], date ATB ended [2/11/19] . date infection resolved (blank) . During a review of the facility document titled, Infection Prevention and Control Surveillance Log dated 2/11/19, indicated, . [Resident 91] . Infection [GI- gastrointestinal] . signs and symptoms [stool specimen positive] . treatment [vancocin 125 mg po q6 hours for 14 days] . date ATB started [2/12/19], date ATB ended [2/26/19] . date infection resolved (blank) . During a review of the facility document titled, Infection Prevention and Control Surveillance Log dated 2/13/19, indicated, . [Resident 48] . Infection [Respiratory] . signs and symptoms [CXR- chest x-ray] . treatment [azithromycin 250 mg po once a day for 3 days] . date ATB started [2/13/19], date ATB ended [2/16/19] . date infection resolved (blank) . During a review of the facility document titled, Infection Prevention and Control Surveillance Log dated 2/13/19, indicated, . [Resident 48] . Infection [skin/wound] . signs and symptoms [MD diagnosis] . treatment [valacyclovir 1000 mg q8 hours for 7 days] . date ATB started [2/14/19], date ATB ended [2/21/19] . date infection resolved (blank) . During a review of the facility document titled, Infection Prevention and Control Surveillance Log dated 2/13/19, indicated, . [Resident 46] . Infection [respiratory] . signs and symptoms [CXR] . treatment [Levaquin 750 mg q48 hours], date ATB started [2/14/19], date ATB ended [2/19/19] . date infection resolved (blank) . During a concurrent interview and record review with the Director of Nursing (DON), on 4/11/19, at 2:45 p.m., the DON reviewed the monthly line listing surveillance logs for January 2019 and February 2019. The DON stated the DSD is responsible for completing the monthly infection line listing surveillance logs. The DON stated the monthly line listing surveillance log were incomplete because the residents signs and symptoms was not documented. The DON stated, The DSD should have put the signs and symptoms of infection and the [laboratory] results to ensure it met the criteria for ATB use and ATB stewardship. 2. During a concurrent interview and record review with the Facility Nurse Consultant (FNC), on 4/11/19, at 2:30 p.m., the FNC reviewed the monthly line listing surveillance logs for January 2019 and February 2019. The FNC stated the monthly line listing surveillance logs were incomplete because logs did not include the signs and symptoms of infection and the laboratory and culture results. The FNC stated, It is very important to have a complete line listing to track and monitor the use of ATB's in the facility and to make sure the Mc Geer's criteria (is an ABT surveillance tool) is being met and followed. The DSD is new in her position but we trained her to make sure the line listing was complete as it was part of the ATB stewardship. The FNC stated she did not know why the monthly line listing surveillance logs were not completed for June 2018, July 2018, August 2018, September 2018, October 2018, November 2018 and December 2018. The FNC stated, If it's not documented, it's not done. During a concurrent interview and record review with the Director of Nursing (DON), on 4/11/19, at 2:45 p.m., the DON reviewed the monthly line listing surveillance logs for January 2019 and February 2019. The DON stated the DSD is responsible for completing the monthly infection line listing surveillance logs. The DON stated the monthly line listing surveillance log were incomplete because the residents signs and symptoms was not documented. The DON stated, The DSD should have put the signs and symptoms of infection and the [laboratory] results to ensure it met the criteria for ATB use and ATB stewardship. The facility policy and procedure titled, Infection Prevention and Control Antibiotic Stewardship dated 3/19, indicated, . Purpose: to optimize the treatment of infections and reduce the risk of adverse events. Policy: The facility leadership is committed to safe and appropriate antibiotic usage. The Antibiotic Stewardship program will monitor antibiotic use and related resident outcomes to optimize the treatment of infections while reducing the adverse events associated with antibiotic use and to reduce antibiotic resistance . The program will validate that antibiotics are prescribed for the correct indication, the correct dose, the correct route and the correct duration. The program will implement a data gathering system and analyze the collected data . Guidelines . 1. The facility will identify a specific individual to oversee the antibiotic stewardship program within the facility. 2. The facility will develop protocols to describe how the program will be implemented and how antibiotic will be monitored. 3. Use of antibiotics will be based on recommendations from appropriate national, professional organizations . CDC definitions . updated from McGeer's criteria will be used as a guidance for assessing residents for infection and Loeb's criteria will be used as a guide for protocols for prescribing antibiotics . 5. When clinically indicated, laboratory testing will be used to identify organisms and sensitivity or resistance to antibiotics. These findings, in conjunction with guidelines from national, professional organizations, will be used in determining the need for antibiotics . CDC (Centers for Disease Control) Professional Reference titled, The Core Elements of Antibiotic Stewardship for Nursing Homes (found at www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html) indicated, . Leadership Commitment . Nursing home leaders commit to improving antibiotic use. Facility leadership, both owners and administrators, as well as regional and national leaders if the facility is part of a larger corporation, can demonstrate their support in the following ways . Communicate with nursing staff and prescribing clinicians the facility's expectations about use of antibiotics and the monitoring and enforcement of stewardship policies . Create a culture through messaging, education . which promotes antibiotic stewardship . Accountability . Nursing homes identify individuals accountable for the antibiotic stewardship activities who have the support of facility leadership . Empower the Director of Nursing to set the practice standards for assessing, monitoring and communicating changes in a resident's condition by front-line nursing staff. Nurses and nurse aides play a key role in the decision-making process for starting an antibiotic . Therefore, the importance of antibiotic stewardship is conveyed by expectations set by nursing leadership in the facility . Infection program coordinator . Infection program coordinators have key expertise and data to inform strategies to improve antibiotic use. This includes tracking of antibiotic starts, monitoring adherence to evidence-based published criteria during the evaluation and management of treated infections, and reviewing antibiotic resistance patterns in the facility . Tracking and Reporting Antibiotic Use and Outcomes . Process Measures: Tracking how and why antibiotics are prescribed . Perform reviews on resident medical records for new antibiotic starts to determine whether the clinical assessment, prescription documentation and antibiotic selection were in accordance with facility antibiotic use policies and practices. When conducted over time, monitoring process measures can assess whether antibiotic prescribing policies are being followed by staff and clinicians . Antibiotic use measures: tracking how often and how many antibiotics are prescribed . Track the amount of antibiotic used to review patterns of use and determine the impact of new stewardship interventions .