Based on observation, interview and record review, the facility failed to ensure resident's right to dignity and privacy was honored for one of one sampled resident (Resident 38) using indwelling urinary catheter (flexible tube inserted in the bladder through the urethra to drain urine), when Resident 38's indwelling urinary catheter drainage bag was not covered to ensure privacy. This deficient practice had the potential for Resident 38 to be embarrassed and affect their self-esteem. Findings: During a review of Resident 38's admission Record (Face Sheet), the Face Sheet indicated the facility admitted Resident 38 on 11/25/2024 with diagnosis including respiratory failure (lungs are not working well causing difficult breathing). During a review of Resident 38's History and Physical (H&P), dated 11/26/2024, the H&P indicated Resident 38 had a medical history of cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain), hypertension (HTN-high blood pressure), and urinary bladder neurogenic dysfunction (loss of bladder control due to brain, spinal cord, or nervous system problems). During a review of Residents 38's Minimum Data Set (MDS - a resident assessment tool), dated 2/27/2025, indicated the cognitive (ability to think and process information) skills for daily decision making was severely impaired, and required assistance of two-person physical assist for activities of daily living. Resident 38 rarely to never had the ability to make self-understood and understand others. The MDS indicated Resident 38 had an indwelling catheter. During a review of Resident 38's Care Plan titled, Altered Urinary Elimination/At Risk for UTI (urinary tract infection - bladder infection)/At Risk for Skin Breakdown, initiated on 8/29/2024, the care plan indicated an intervention to Provide privacy bag as required. During a concurrent observation and interview on 3/24/2025 at 10:53 a.m., with Licensed Vocational Nurse (LVN) 1, in Resident 38's room, Resident 38's uncovered urinary catheter drainage bag was visible from the hallway. LVN 1 stated the bag should be covered with a dignity bag (bag used to cover the urinary catheter drainage bag for privacy). During an interview on 3/27/2025 at 5:04 p.m., with Registered Nurse (RN) 5, RN 5 stated dignity was part of a resident's rights. RN 5 stated dignity also meant protecting a resident's privacy, such as covering the urinary drainage bag with a dignity bag. RN 5 stated a resident could have felt embarrassed or sad if anyone saw a urinary drainage bag uncovered. During a review of the facility's policy and procedure (P&P) titled, Standards of Care - Sub Acute, dated 3/2024, the P&P indicated, An individualized plan of care is implemented for residents requiring an indwelling catheter that includes use of a dignity cover to protect the resident's privacy and dignity. During a review of the facility's P&P titled, System-wide Patient Rights and Responsibilities Policy, dated 5/2022, the P&P indicated, You have the right to receive considerate, compassionate, confidential and respectful care. You will be treated with dignity.

Based on interview and record review, the facility failed to ensure to obtained informed consent (voluntary agreement to accept treatment or procedures after receiving education regarding the risks, benefits, and alternatives offered) for one of five sampled resident (Resident 25) reviewed for informed consent, prior to increasing the dose of Seroquel (medication used to help relax someone who is restless [unable to stay calm or still] or agitated [irritated]) from 50 milligrams (mg - a unit of measure) nightly dose to 75 mg. This failure had the potential to prevent Resident 25 and his responsible party from exercising their right to decline increasing the dose of Seroquel and could have increased the risk that Resident 25 could experience adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to psychotropic medications (medication that affect brain activities associated with mental processes and behavior.) Findings: During a review of Resident 25's admission Record (Face Sheet), dated 1/2/2024, the facility admitted Resident 25 on 1/2/2024 for respiratory failure (lungs are not working well causing difficulty breathing). During a review of Resident 25's History and Physical (H&P), dated 5/29/2024, the H&P indicated Resident 25 was re-admitted from the hospital to the facility on 5/28/2024. Resident 25 had a medical history of respiratory failure, tracheostomy (surgical incision in the windpipe for air and oxygen to enter the lungs), hypertension (HTN-high blood pressure), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 25's Minimum Data Set (MDS - a resident assessment tool), dated 3/14/2025, indicated the cognitive (the ability to think and process information) skills for daily decision making was severely impaired, and required assistance of two or more people for physical assist for activities of daily living. The MDS also indicated Resident 25 had anxiety (feeling worried or nervous) and psychotic disorder (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and was taking antipsychotic (group of medications used to treat mental health conditions) medications. During a concurrent interview and record review on 3/27/2025 at 1:35 p.m., with Registered Nurse (RN 7) of Resident 25's Medication Order, dated 10/21/2024, the record indicated Resident 25 had an order for Seroquel 75 milligrams (mg-a unit of measure) nightly for psychosis (type of mental health condition affecting the ability to think and be aware of reality) manifested by pulling out medical devices, agitation. RN 7 stated Resident 25's Seroquel dose was increased from 50 mg to 75 mg nightly. During a concurrent interview and record review on 3/27/2025 at 1:35 p.m., with RN 7, RN 7 stated Resident 25's last Facility Verification of Informed Consent, for Seroquel was in May 2024 and it was for Seroquel 50 mg nightly. RN 7 stated Resident 25 did not have a consent for Seroquel 75 mg. RN 7 stated a consent for a psychotropic drug was needed for a new drug or for an increase in the dose. During an interview on 3/27/2025 at 3:04 p.m., with RN 5, RN 5 stated psychotropic drugs were used for behavioral problems such as anxiety, restlessness (unable to stay calm) or agitation (irritable). RN 5 stated once there was an order to give a psychotropic medication, consent needed to be verified (confirmed) with the family to make sure they know what the risks and benefits were: such as becoming sleepier, getting a reaction from the medication, and to know that the goal was to improve behavior. RN 5 stated knowing what care was provided was part of respecting the resident's rights. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Drugs (Sub Acute), dated 2/2024, the P&P indicated, Informed consent is obtained prior to use of psychotropic medications from resident or family member . A psychotropic consent form is completed when any (routine or PRN) psychotropic agent is ordered. During a review of the facility's P&P titled, System-wide Patient Rights and Responsibilities, dated 5/2022, the P&P indicated, You have the right to be informed by your doctor of your diagnosis, treatment and prognosis in a way that you understand, so that you can make informed decisions regarding your care.

Based on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach for one (1) of 1 sampled resident (Resident 35) reviewed under the Environment task. This deficient practice had the potential to result in the delay of care and services and possible injury to residents when they are unable to call for assistance. Findings: During a review of Resident 35's Face Sheet (admission Record), the Face Sheet indicated the facility originally admitted the resident on 11/27/2023 and readmitted in the facility on 7/10/2024 with diagnoses including craniotomy (type of brain surgery where the surgeon will remove and replace part of the skull to access and treat a problem within the brain), hypertension (HTN - high blood pressure), and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). During a review of Resident 35's History and Physical (H&P), dated 7/12/2024, the H&P indicated Resident 35 had the presence of tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck) and was non-verbal (not speaking). During a review of Resident 35's Minimum Data Set (MDS - a resident assessment tool), dated 2/28/2025, the MDS indicated Resident 35 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 35's Morse Fall Risk Level (an assessment tool that determines a resident's likelihood of falling), dated between 3/23/2025 to 3/26/2025, the Morse Fall Risk Level indicated the resident has a low risk for falls. During an observation, on 3/24/2025, at 11:10 a.m., inside Resident 35's room, Resident 35's call light hung on the enteral feeding (EF - also known as tube feeding, a method of supplying nutrients directly into the stomach) pole. During a concurrent observation and interview, on 3/24/2025, at 11:27 a.m., inside Resident 35's room, with Licensed Vocational Nurse (LVN) 1, LVN 1 confirmed and stated Resident 35's call light was hanging on the EF pole. LVN 1 stated staff are supposed to ensure the call lights are within reach prior to leaving a resident's room so they would be able to call if they need assistance and attend to their needs timely. LVN 1 stated Resident 35's call light should have been placed within reach so the resident would be able to call for assistance and prevent a delay in meeting Resident 35's needs During an interview, on 3/24/2025, at 11:35 a.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated she must have forgotten to place the call light within the resident's reach after providing morning care to Resident 35 and prior to leaving the room. CNA 2 stated staff are supposed to place the call light within reach prior to leaving the room for the residents to be able to call for assistance. CNA 2 stated she should have placed Resident 35's call light within the resident's reach prior to leaving the room to prevent a delay in answering the resident's needs. During an interview, on 3/27/2025, at 5:00 p.m., with the Infection Preventionist (IP), the IP stated staff are supposed to place residents' call lights within reach at all times prior to leaving the room so the residents would be able to call for assistance to prevent a delay in attending to the resident's needs. The IP stated Resident 35's call light should have been placed within reach for him to be able to call for assistance and prevent delay in meeting the resident's needs. During a review of the facility's policy and procedure (P&P) titled, Standards of Care (Sub Acute), last reviewed on 3/10/2025, the P&P indicated to ensure safety, special attention should be paid to ensure call light is within resident's reach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body, cannot be removed easily by the resident, and restricts the resident's freedom of movement or normal access to his/her body) for two (2) of four (4) sampled residents (Residents 24 and 42) reviewed for restraints by: 1. Failing to complete a restraint assessment prior to application of peek-a-boo mitten (a padded mitten restraint used to prevent patients from pulling out tubes, lines, or other medical devices) on the right hand for Resident 24. 2. Failing to complete a restraint assessment and attempt least restrictive interventions prior to application of bilateral soft wrist restraint and peek-a-boo mitten on both hands for Resident 42. These deficient practices had the potential to result in the restriction of residents' freedom of movement, a decline in physical functioning, psychosocial harm, physical harm from entrapment (a state in which a person is trapped by the bed rail in a position that they cannot move from), and death of residents. Findings: a. During a review of Resident 24's Face Sheet, the Face Sheet indicated the facility originally admitted the resident on 7/16/2020, and readmitted the resident on 3/31/2022, with diagnoses including acute respiratory failure (a condition where the respiratory system is unable to function properly, which can lead to a failure of gas exchange), traumatic brain injury (TBI - a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 24's History and Physical (H&P), dated 11/11/2024, the H&P indicated the resident was unable to make medical decisions. During a review of Resident 24's Minimum Data Set (MDS, a resident assessment tool), dated 1/28/2025, the MDS indicated Resident 24 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 24 had a limb restraint. During a review of Resident 24's physician's order dated 2/26/2025, the physician's order indicated: - May apply right peek-a-boo mitt to prevent self-harm or injury by pulling tubes or medical devices for 30 days. Release and check every two hours and monitor for skin integrity, sensation, circulation, and range of motion. During a review of Resident 24's care plan (CP) titled, Restraint/Seclusion Use for Patient Safety, initiated on 1/17/2024 and last revised on 3/25/2025, the CP indicated to apply device or restraint as ordered, and reassess for continued use of device, restraint and consider reduction or discontinuation quarterly and as needed as a few of the interventions to minimize and prevent injury. During a concurrent observation and interview on 3/24/2025 at 9:16 a.m., inside Resident 24's room with Registered Nurse (RN) 8, RN 8 stated Resident 24 had a right-hand mitten, and the resident moves her right arm a lot and accidentally pulls at the life sustaining tubes and lines at times. During a concurrent interview and record review on 3/26/2025 at 3:30 p.m. with the Minimum Data Set Nurse (MDSN), reviewed Resident 24's medical record including restraint assessment, physician orders, and informed consents with the MDSN. The MDSN stated there was no restraint assessment completed prior to application of the right-hand peek-a-boo mitten for Resident 24. The MDSN stated restraint assessments are supposed to be completed prior to application of a restraint or device and at least quarterly per federal regulations but the facility did not have a pre-restraint assessment. The MDSN stated the licensed nurses only complete a restraint assessment every two hours to monitor for skin integrity, sensation, circulation, and range of motion, after obtaining a physician's order and informed consent. The MDSN stated there should have been a restraint assessment completed prior to application of right-hand peek-a-boo mitten on Resident 24 to ensure appropriateness of the restraint or device use and that least restrictive measures attempted have been unsuccessful. The MDSN stated failing to complete a restraint assessment prior to application of the right-hand mitten placed Resident 24 at risk for restriction of movement which may lead to decline in physical functioning. During an interview on 3/27/2025 at 5 p.m. with the Nurse Manager (NM), the NM stated the facility did not have a restraint assessment prior to application of any device/restraints to document any least restrictive measures attempted that were unsuccessful. The NM stated there should have been a restraint assessment completed prior to application of right-hand peek-a-boo mitten on Resident 24 to ensure appropriateness of the restraint or device use and that least restrictive measures attempted have been unsuccessful. The NM stated failing to complete a restraint assessment prior to application of the right-hand mitten placed Resident 24 at risk for restriction of movement and can possibly lead to a decline in physical functioning of the right hand. During a review of the facility's recent policy and procedure (P&P) titled, Restraint Use (Sub Acute), last revised on 3/10/2025, the P&P indicated the following: - It is the policy of general acute care hospital 1(GACH 1) to guide care givers on appropriate and safe management of residents with restraints and utilization of least restrictive alternatives. - Ensure safe and ethical practice for the use of physical restraints, that no person will be restrained against their will for any period of time longer than necessary. - Restrains use shall not cause any physical injury and to ensure the least possible discomfort to the resident - The licensed nurse will assess the patient and attempt to find less restrictive alternatives to restraint. - One time documentation is made in the electronic health record (EHR) upon initiation of restraints and includes less restrictive alternatives, resident's response, and clinical justification for restraint. b. During a review of Resident 42's Face Sheet, the Face Sheet indicated the facility originally admitted the resident on 9/4/2024 and readmitted in the facility on 12/20/2024 with diagnoses including history of stroke (loss of blood flow to a part of the brain), tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck, and ventilator-dependent respiratory failure (condition when a patient's lungs cannot breath on their own and required a machine to help breathe). During a review of Resident 42's H&P, dated 12/22/2024, the H&P indicated Resident 42 was awake and alert but did not indicate the resident's capacity to understand and make decisions. During a review of Resident 42's MDS, dated [DATE], the MDS indicated Resident 42 was able to make his needs known and able to understand others. The MDS further indicated Resident 42 had severely impaired cognition and required substantial/maximal assistance to total assistance from staff with all activities of daily living. The MDS indicated Resident 42 had limb restraint. During a review of Resident 42's physician's order, dated 12/20/2024, the physician's order indicated right upper extremity (RUE) and left upper extremity (LUE) soft wrist restraint and mittens due to elevate risk for interruption of treatment or unintentional injury and to release when originating behavior is no longer evident. During a concurrent observation and interview on 3/24/2025 at 10:25 a.m. inside Resident 42's room with Registered Nurse (RN) 2, RN 2 stated Resident 42 removed his tracheostomy in the past; hence, the need to apply RUE and LUE peek-a-boo mitten and soft wrist restraint. During a concurrent interview and record review on 3/26/2025 at 4 p.m. with the MDSN, reviewed Resident 42's medical record including restraint assessment, physician orders, and informed consents with the MDSN. The MDSN stated there was no restraint assessment completed prior to application of the RUE and LUE peek-a-boo mitten and soft wrist restraint for Resident 42. The MDSN stated restraint assessments are supposed to be completed prior to application of a restraint or device and at least quarterly per federal regulations but the facility did not have a pre-restraining assessment. The MDSN stated the licensed nurses only complete a restraint assessment every two hours to monitor for skin integrity, sensation, circulation, and range of motion, after obtaining a physician's order and informed consent. The MDSN stated there should have been a restraint assessment completed prior to application of the RUE and LUE peek-a-boo mitten and soft wrist restraint on Resident 42 to ensure appropriateness of the restraint or device use and that least restrictive measures attempted have been unsuccessful. The MDSN stated failing to complete a restraint assessment prior to application of the RUE and LUE peek-a-boo mitten and soft wrist restraint placed Resident 42 at risk for restriction of movement which may lead to decline in physical functioning. During an interview on 3/27/2025 a 5 p.m. with the NM, the NM stated the facility did not have a restraint assessment prior to application of any device/restraints to document any least restrictive measures attempted that were unsuccessful. The NM stated the purpose of completing a restraint assessment is to ensure the restraint/device use was appropriate and least restrictive measures have been unsuccessful. The NM stated there should have been a restraint assessment completed prior to application of RUE and LUE peek-a-boo mitten and soft wrist restraint on Resident 42 to ensure appropriateness of the restraint or device use and that least restrictive measures attempted have been unsuccessful. The NM stated failing to complete a restraint assessment prior to application of the RUE and LUE peek-a-boo mitten and soft wrist restraint placed Resident 42 at risk for restriction of movement and can possibly lead to a decline in physical functioning of the resident's both upper extremities. During a review of the facility's recent P&P titled, Restraint Use (Sub Acute), last revised on 3/10/2025, the P&P indicated the following: - It is the policy of general acute care hospital 1(GACH 1) to guide care givers on appropriate and safe management of residents with restraints and utilization of least restrictive alternatives. - Ensure safe and ethical practice for the use of physical restraints, that no person will be restrained against their will for any period of time longer than necessary. - Restrains use shall not cause any physical injury and to ensure the least possible discomfort to the resident - The licensed nurse will assess the patient and attempt to find less restrictive alternatives to restraint. - One time documentation is made in the electronic health record (EHR) upon initiation of restraints and includes less restrictive alternatives, resident's response, and clinical justification for restraint.

Based on observation, interview, and record review, the facility failed to ensure residents with a urinary catheter (also known as an indwelling catheter, a hollow tube inserted into the bladder to drain or collect urine) received appropriate care and services to prevent urinary tract infections (UTI - an infection in the bladder/urinary tract) for one (1) of 1 sampled resident (Resident 2) reviewed for urinary catheter or UTI by failing to ensure Resident 2's urinary catheter tubing did not have a loop while hanging on the side the bed. This deficient practice had the potential for the resident's urine not to flow freely which may lead to development of UTI. Findings: During a review of Resident 2's Face Sheet, the Face Sheet indicated the facility originally admitted the resident on 6/7/2022 and readmitted in the facility on 1/30/2025 with diagnoses including gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), neurogenic bladder (lack of bladder control due to brain, spinal cord or nerve problems), and tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck). During a review of Resident 2's History and Physical (H&P), dated 2/2/2025, the H&P indicated Resident 2 was awake and oriented but did not indicate if the resident had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 12/18/2024, the MDS indicated Resident 2 had intact cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). The MDS further indicated Resident 2 had an indwelling catheter. During a review of Resident 2's physician's order, dated 1/31/2025, the physician's order indicated: - Suprapubic catheter (a thin tube inserted directly into the bladder through a small incision in the lower abdomen to drain urine) French (Fr - a unit of measurement) 16 care every shift and as needed. Change every 45 days and as needed for neurogenic bladder. During an observation, on 3/24/2025, at 9:58 a.m., inside Resident 2's room, Resident 2's urinary drainage bag hung on the left side of the bed with a loop on the tubing. During a concurrent observation and interview, on 3/24/2025, at 10:10 a.m., inside Resident 2's room with Registered Nurse (RN) 8, RN 8 confirmed and stated Resident 2's urinary drainage bag was hanging on the side of the bed and the tubing had a dependent loop. RN 8 stated urinary drainage bags should be positioned properly so the tubing would not have a dependent loop which prevents the urine from flowing freely into the bag. RN 8 stated Resident 2's indwelling catheter tubing should not have a dependent loop as the urine will not flow freely and can back up into the bladder which may lead to UTI. During an interview, on 3/27/2025, at 5 p.m., with the Infection Preventionist (IP), the IP stated one of the practices to prevent UTI related to indwelling catheter use is to ensure the urine flow is not obstructed by keeping the tubing free of kinks or loops. The IP stated the staff are supposed to ensure the urinary catheter tubing should not have a loop. The IP stated Resident 2's urinary catheter tubing should have been positioned to prevent loops or kinks to prevent the urine from back up and cause urine infection. During a review of the facility's policy and procedure (P&P) titled, Urinary Catheter Care (Sub Acute), last reviewed 3/10/2025, the P&P indicated a purpose to provide guidelines for routine care of indwelling and suprapubic urinary catheters and should be followed by all caregivers to reduce the incidence of catheter associated UTI. The P&P further indicated the catheter urinary collection bag is always positioned below the patient's bladder without dependent loops or kinks.

Based on interview and record review, the facility failed to specify an indication (the reason) for the use of a hypoglycemic medication (lowers blood sugar) for one of five sampled residents (Resident 41) during a review of unnecessary medications when insulin (a hormone that removes excess sugar from the blood) lispro (fast-acting insulin) did not have an indication. This deficient practice had the potential to result in not medically necessary treatments potentially leading to ineffective diabetes management. Findings: During a review of Resident 41's Face Sheet, the Face Sheet indicated the facility admitted the resident on 12/11/2024 with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 41's Minimum Data Set (MDS-a resident assessment tool), dated 2/25/2025, the MDS indicated the resident had no speech, hearing was highly impaired, rarely/never made self understood, and rarely/never understood The MDS indicated the resident was taking medications in high-risk drug classes which includes hypoglycemics. During a concurrent interview and record review on 3/25/2025 at 3:50 p.m. with Registered Nurse (RN) 2, Resident 41's physician orders were reviewed. RN 2 stated Resident 41 received the following insulins: - Glargine (long-acting insulin) 100 unit per milliliter (ml-a unit of measurement), 25 units (0.25 ml) subcutaneous (SQ- situated or applied under the skin) for diabetes, routine, order dated 12/22/2024. - Lispro 0-12 units, SQ, two times daily, order dated 12/11/2024. RN 2 stated there was no indication noted on the use of Lispro. During an interview on 3/27/2025 at 5:35 p.m., with RN 7, RN 7 stated medication order components would need to have the medication name, dose, route, timing, blood sugar levels, and diagnosis. RN 7 stated the purpose of the diagnosis is to know what it is they are giving it for and if the primary nurse is not familiar about the medication they should ask and clarify with the physician what they are giving it for. RN 7 stated this is part of the medication rights. During a review of the facility's policy and procedure (P&P) titled, Medication Administration and Monitoring (Sub Acute), last revised and approved on 3/10/2025, the P&P indicated before administering the medication, the eMAR is reviewed and to always observe the seven-rights of medication administration: the right drug, the right patient, the right time, the right dose of the drug, the right route, the right reason (indication), and the right documentation.

Based on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services during the inspection of one (1) of three (3) medication carts (Medication Cart 1) reviewed during the Medication Storage and Labeling task by failing to discard Resident 1's medication in the bubble pack (a packaged container with compartments that can contain medications) with a broken seal and covered with paper tape. This deficient practice had the potential for medication error and contaminate medications stored inside the medication cart. Findings: During a concurrent observation and interview, on 3/26/2025, at 8:33 a.m., during an inspection of Medication Cart 1, in the presence of Registered Nurse (RN) 8, RN 8 confirmed and stated Resident 1's cyanocobalamin (a manufactured version of vitamin B12 used to treat and prevent vitamin B12 deficiency anemia [low levels of this vitamin in the body]) had a broken seal and was stored in Medication Cart 1. RN 8 stated the process prior to dispensing a medication from a bubble pack includes the licensed nurses (LNs) comparing the medication label in the bubble pack with the medication administration record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) first. RN 8 stated if a medication was dispensed by accident from the bubble pack, the medication should be discarded immediately at the designated bin inside the medication room and not taped back in the bubble pack. RN 8 stated the seal from Resident 1's bubble pack was broken and covered with clear plastic tape. RN 8 stated the medications for slot numbers 5 and 13 should have been discarded once removed from the bubble pack and not taped back as the medication had been contaminated. RN 8 stated it could not be the right medication that was placed back in the bubble pack and placed the Resident 1 at risk for receiving the incorrect medication which can be a medication error. During an interview, on 3/27/2025, at 5:30 p.m., with the Nurse Manager (NM), the NM stated she was made aware by RN 8 of the issue with the cyanocobalamin. The NM stated the cyanocobalamin should have been discarded in the designated bin inside the medication room if dispensed by accident. The NM stated the LN are supposed to compare the medication label in the bubble pack with the MAR first prior to dispensing a medication from the bubble pack. The NM stated dispensing a medication and taping it back to the bubble pack is not an acceptable practice as the medication was already contaminated, the nurses would not know if the correct medicine was placed back in the bubble pack, and the resident receives the correct medication. During a review of the facility's policy and procedure (P&P) titled, Storage of Medications, last reviewed 3/10/2025, the P&P indicated: - Medications and biologicals are stored safely, securely, and properly. - 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. - Medication storage conditions are monitored on a routine basis and corrective action are taken if problems are identified.

Based on interview and record review, the facility failed to fully develop and implement an antibiotic (antimicrobial, medicine that inhibits the growth of or destroys microorganisms) stewardship program (ASP- a coordinated program that promotes the appropriate use of drugs used to treat infections, including antibiotics as a part of its overall Infection Prevention and Control Program (IPCP) for one of six sampled residents (Resident 3) reviewed under Infection Control facility task by: 1. Failing to establish protocols to identify signs and symptoms of infections among residents to assess whether they met evidence-based national standard criteria for initiating antibiotic treatment 2. Failing to identify Resident 3's use of levofloxacin (antibiotic) indicated for urinary tract infection (UTI- an infection in the bladder/urinary tract). These deficient practices had the potential to result in increased risk of inappropriate antibiotic use, potentially leading to adverse outcomes (complications arising from an intervention or condition) such as antibiotic resistance (the acquired ability of bacterial pathogens to withstand the effects of antimicrobial agents, reducing treatment efficacy). Cross Reference F835 Findings: During a review of Resident 3's Face Sheet, the Face Sheet indicated the facility readmitted the resident on 2/17/2025 with diagnoses including acute hypoxic respirator (a condition where the lungs cannot get enough oxygen into the blood) and hyperlipidemia (abnormally high fat). During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool), dated 2/5/2025, the MDS indicated the resident's initial start date at the facility on 10/29/2024. The MDS indicated the resident had adequate hearing and unclear speech. The MDS indicated the resident made self understood and sometimes understood others. The MDS indicated the resident was dependent on staff with toileting, oral hygiene, shower/bathing self, lower body dressing, and personal hygiene. The MDS indicated the resident was taking antibiotics. During a review of Resident 3's physician order, dated 3/4/2025, the physician order indicated levofloxacin (Levaquin) tablet 500 milligrams (mg-a unit of measurement) per gastrostomy tube (g-tube- a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) for UTI, daily, end date 3/10/2025. During a concurrent interview and review on 3/27/2025 at 10:41 a.m. with the Infection Preventionist (IP), Resident 3's physician order, nursing progress notes, and registered nurses' plan of care, antibiotic tracking sheet (a document or tool used to monitor and record prescribed antibiotics and usage patterns [how often, how much, and what reason it's prescribed]), and Loeb's minimum criteria (evidence-based national standard criteria for initiating antibiotic treatment designed to reduce inappropriate prescribing by outlining minimum clinical signs and symptoms suggesting an infection) for initiating antibiotic therapy were reviewed. The Plan of Care indicated, on 3/1/2025 at 11:25 a.m., Resident 3 was noted with increased heart rate and had a temperature of 101.1 degrees Fahrenheit (F - a unit of measurement). The IP stated she uses the antibiotic tracking sheet and the Loeb's minimum criteria for initiating antibiotic therapy as a guide to monitor and review new or changes in antibiotic orders and uses Loeb's criteria, but this is not indicated in their policy. The IP stated they do not have a standard protocol in using the Loeb's criteria that shows which residents have met or have not met the criteria. The IP stated when Loeb's criteria is used for Resident 3's use of levofloxacin for UTI without urinary catheter, the resident would not have met the criteria because the resident only have increased heart and fever as signs and symptoms of infection. The IP stated the Loeb's minimum criteria for UTI includes either one of the following criteria: acute dysuria (discomfort or pain when urinating) or temperature greater than 100 F, and one or more of the following new or worsening symptoms: urgency, suprapubic pain (pain above pelvic bone), urinary incontinence, frequency, gross hematuria (visible blood in the urine), and costovertebral angle tenderness (pain in the upper back near the ribs). During a concurrent interview and record review on 3/27/2025 at 10:50 a.m. with the IP, the facility's policy and procedure (P&P) titled, Antimicrobial Stewardship (AMS) Program, last reviewed and approved on 3/10/2025, was reviewed. The IP stated the P&P did not indicate the protocol on the use of antibiotic tracking sheet and the use of Loeb's criteria to assess the residents for any infection. The IP stated she should have mentioned to the Manager of Infection Prevention (MIP) about the use of antibiotic tracking sheet and the use of Loeb's minimum criteria in initiating antibiotic therapy when they reviewed their P&Ps. During an interview on 3/27/2025 at 1:57 p.m. with the IP, the IP stated when the resident does not meet the Loeb's minimum criteria, she would notify the resident's physician that the resident did not meet the criteria to initiate the antibiotic then document on the resident's chart what she did and what the physician's response was. During a concurrent interview and record review on 3/27/2025 at 2:12 p.m. with Registered Nurse (RN) 2, Resident 3's nursing progress notes, plan of care, and physician orders were reviewed. RN 2 stated he was covering for the IP when Resident 3 had the order for levofloxacin for UTI. RN 2 stated he notified the primary nurse about the resident's laboratory results that were ordered, and he (RN 2) does not use any standardized criteria when reviewing antibiotics. During an interview on 3/27/2025 at 3:17 p.m. with the MIP, the MIP stated she was not aware of the Centers of Medicare and Medicaid Services (CMS- a federal agency that administers major healthcare programs) of the regulation antibiotic stewardship regulation requirements to be implemented. The MIP stated they have an ASP which they collaborate with the antimicrobial stewardship pharmacist. The MIP stated the purpose of the ASP is to administer antibiotics in the least amount of duration, and to make sure the antibiotic ordered had the appropriate frequency and dose to prevent multidrug resistance organisms. During a review of the facility's P&P titled, Antimicrobial Stewardship (AMS) Program, last reviewed and approved on 3/10/2025, the P&P indicated it is the facility's policy to implement a comprehensive AMS program to evaluate judicious use of antimicrobials. The P&P indicated the purpose of the P&P is to optimize antibiotic therapy to improve clinical outcomes while minimizing unintended consequences of antimicrobial use, such as drug toxicity (drug causing harm) and emergence of resistance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document that pneumococcal vaccine was offered for the resident and education was provided to the family/decision-maker per its pneumococcal vaccine (an injected medicine that can protect against and often prevent pneumococcal [a type of bacteria] infections [when the immune system fights off the bad germs to get better]) policy and procedures (P&P) for one of five sampled residents (Resident 19) reviewed for immunizations under Infection Control facility task. This deficient practice had the potential to result in increased risk for pneumococcal infections which may lead to serious health complications such as pneumonia (an infection that inflames the lungs' air sacs), meningitis (inflammation of brain and spinal cord membranes, typically caused by an infection), and bloodstream infections. Findings: During a review of Resident 19's Face Sheet, the Face Sheet indicated the resident was admitted on [DATE] with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe on your own) and seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of Resident 19's Minimum Data Set (MDS- a resident assessment tool), dated 1/30/2025, the MDS indicated the resident rarely/never made self understood and rarely/never understood others. During a concurrent interview and record review on 3/27/2025 at 9:37 a.m. with the Infection Preventionist (IP), Resident 19's Immunization Summary, plan of care, and nursing progress notes were reviewed. The IP stated there was no documentation that pneumococcal vaccine was offered for the resident, and that education was provided to the resident's family/decision-maker. The IP stated Registered Nurse (RN) 2 was covering for her during the time they were reviewing residents eligible to receive pneumococcal vaccines. During a concurrent interview and record review on 3/27/2025 at 2:12 p.m. with RN 2, Resident 19's plan of care and nursing progress notes were reviewed. RN 2 stated he missed documenting the discussion he had with Resident 19's family member where she (Resident 19's family member) consented for the resident to receive the pneumonia vaccine. RN 2 stated he was supposed to document and enter the order on the same day after the discussion with the family member. During an interview on 3/27/2025 at 5:57 p.m. with RN 7, RN 7 stated the purpose for offering and providing education of pneumococcal vaccine is for prevention especially many residents in their facility are at a higher risk of contracting pneumonia. During a review of the facility's P&P titled, Vaccines (Influenza and Pneumococcal) - (Sub Acute), last reviewed and approved on 3/10/2025, the P&P indicated it is the facility's policy to reduce potential for transmitting and/or contracting influenza and/or pneumonia among Sub-Acute (for residents needing services that are more intensive than those typically received in long-term care but less intensive than acute care) residents. The P&P indicated before offering the pneumococcal immunization, each resident or the resident's legal representative receives education regarding the benefits and potential side effects of the immunization; offer each resident a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized; indicate in the resident's medical record, includes documentation indicating, minimum, of the following: provide resident or resident's legal representative education regarding benefits and potential side effects of pneumococcal immunization.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide care in accordance with professional standards for two of two sampled residents (Residents 35 and 42) reviewed for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) and anticoagulant (a substance that is used to prevent and treat blood clots in blood vessels and the heart) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin for Resident 42, and heparin (an anticoagulant) for Resident 35. The deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin and heparin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross Reference F760 Findings: a. During a review of Resident 35's Face Sheet, the Face Sheet indicated the facility originally admitted the resident on 11/27/2023 and readmitted in the facility on 7/10/2024 with diagnoses including craniotomy (a major type of brain surgery where the surgeon will remove and replace part of the skull to access and treat a problem within the brain), hypertension (HTN - also known as high blood pressure), and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). During a review of Resident 35's H&P dated 7/12/2024, the H&P indicated Resident 35 had the presence of tracheostomy and was non-verbal (not speaking). During a review of Resident 35's MDS, dated [DATE], the MDS indicated Resident 35 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS further indicated Resident 35 received anticoagulant. During a review of Resident 35's physician's order, the physician's order dated 1/8/2025 indicated heparin sodium injection (porcine) solution 5000 units per milliliter (units/ml - a unit of measurement) 5000 units subcutaneously every 12 hours for DVT (deep vein thrombosis - a blood clot that forms in one or more of the deep veins in the body, usually in the legs causing leg pain or swelling) prophylaxis. During a review of Resident 35's care plan (CP) on thrombolytic therapy (the use of medications to dissolve blood clots) last revised on 3/2/2025 with a target date of 5/28/2025, the CP indicated to frequently monitor peripheral perfusion to address complications early as one of the interventions to prevent and manage risk of bleeding. During a concurrent interview and record review on 3/25/2025 at 11:05 am., reviewed Resident 35's physician's order, subcutaneous administration sites for heparin from 1/8/2025 to 3/25/2025, and the MDS with the Minimum Data Set Nurse (MDSN). The MDSN stated Resident 35 received heparin, had a physician's order for heparin, and were administered as follows: Heparin 5000 units/ml injection 5000 units: - 1/20/2025 5:51 a.m. left upper quadrant - LUQ - 1/20/2025 5:03 p.m. LUQ - 3/2/2025 6:22 p.m. LUQ - 3/3/2025 5:14 a.m. LUQ - 3/7/2024 6:58 a.m. right upper quadrant - RUQ - 3/7/2025 5:39 a.m. RUQ - 3/23/2025 5:15 a.m. LUQ - 3/23/2025 17:32 LUQ The MDSN stated administration sites for anticoagulants such as heparin should be rotated per standards of practice and manufacture's guideline to prevent hardening or lumps in the skin. The MDSN stated the list of administration sites for the heparin were not rotated. The MDSN stated Resident 35's administration sites should have been rotated to prevent pain, redness, irritation, and lumps on the resident's skin. During a concurrent interview and record review on 3/27/2025 at 5:00 p.m. with Registered Nurse (RN) 8, RN 8 stated the location of administration sites for Resident 35's heparin were not rotated. RN 8 stated the nurses are supposed to rotate heparin administration sites according to standards of practice, and as indicated in the manufacturer's guideline. RN 8 stated Resident 35's administration sites for heparin should have been rotated to prevent adverse effects such as bruising, skin irritation, skin pits, lipodystrophy and amyloidosis which can affect absorption of the medication. During a review of the facility-provided manufacturer's guideline for heparin sodium injection solution dated 1/2022, the manufacturer's guideline indicated to use a different site for each injection. The manufacturer's guideline further indicated injection site irritation is one of the most common adverse reactions for the use of heparin. During a review of the facility's P&P titled, Medication Administration and Monitoring (Sub Acute), last reviewed on 3/2025, the P&P indicated the following: - Healthcare providers administering medications are responsible for knowing and understanding the dosage, indications, side effects and precautions/warnings of the medications being administered. - Injection sites for subcutaneous and intramuscular administration must be rotated. b. During a review of Resident 42's Face Sheet, the Face Sheet indicated the facility originally admitted the resident on 9/4/2024 and readmitted in the facility on 12/20/2024 with diagnoses including history of stroke (loss of blood flow to a part of the brain), tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck, and ventilator-dependent respiratory failure (condition when a patient's lungs cannot breath on their own and required a machine to help breathe). During a review of Resident 42's H&P dated 12/22/2024, the H&P indicated Resident 42 was awake and alert but did not indicate the resident's capacity to understand and make decisions. During a review of Resident 42's MDS, dated [DATE], the MDS indicated Resident 42 was able to make his needs known and able to understand others. The MDS further indicated Resident 42 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required substantial/maximal assistance to total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 42 received insulin. During a review of Resident 42's physician's order, the physician's order dated 2/24/2025 indicated insulin glargine-yfgn (a long-acting insulin) injection vial eight (8) units (a unit of measurement) at bedtime for diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 42's CP on hyperglycemia last revised on 3/2/2025 with a target date of 7/31/2025, the CP indicated to provide pharmacologic therapy (drug or medication therapy) to maintain blood sugar levels within targeted range. During a concurrent interview and record review on 3/25/2025 at 11:05 am., reviewed Resident 42's physician's order, subcutaneous administration sites for insulin glargine from 2/24/2025 to 3/25/2025, and the MDS with the Minimum Data Set Nurse (MDSN). The MDSN stated Resident 42 received heparin, had a physician's order for insulin glargine, and were administered as follows: Insulin glargine-yfgn injection 8 units: - 3/12/2024 5:35 p.m. left lower quadrant - LLQ - 3/13/2025 5:34 p.m. LLQ - 3/17/2025 5:27 p.m. left upper arm - LUA - 3/18/2025 5:51 p.m. LUA The MDSN stated administration sites for insulin should be rotated per standards of practice and manufacture's guideline to prevent hardening or lumps in the skin. The MDSN stated the list of administration sites for Resident 42's insulin glargine were not rotated. The MDSN stated Resident 42's administration sites should have been rotated to prevent pain, redness, irritation, and lumps on the resident's skin. During a concurrent interview and record review on 3/27/2025 at 5:00 p.m. with RN 8, RN 8 stated the location of administration sites for Resident 42's insulin glargine was not rotated. RN 8 stated the nurses are supposed to rotate insulin administration sites according to standards of practice, and as indicated in the manufacturer's guideline. RN 8 stated Resident 42's administration sites for insulin glargine should have been rotated to prevent adverse effects such as bruising, skin irritation, skin pits, lipodystrophy and amyloidosis which can affect absorption of the insulin. During a review of the facility-provided manufacturer's guideline for insulin glargine (rDNA origin) 100 units/ml three (3) ml pen dated 8/26/2022, the manufacturer's guideline indicated to change (rotate) the injection site for each injection and to inject under the skin of the stomach area, buttocks, upper legs or upper arms. During a review of the facility's P&P titled, Medication Administration and Monitoring (Sub Acute), last reviewed on 3/2025, the P&P indicated the following: - Healthcare providers administering medications are responsible for knowing and understanding the dosage, indications, side effects and precautions/warnings of the medications being administered. - Injection sites for subcutaneous and intramuscular administration must be rotated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents receiving enteral feeding (also known as tube feeding, a method of supplying nutrients directly into the gastrointestinal tract) received the appropriate care and services to prevent complications for three of three sampled residents (Resident 2, 35, and 41) reviewed under the tube feeding care area by failing to: 1. Change Resident 35's water flush bag according to the manufacturer's guideline. 2. Indicate the date for Resident 2's medication syringe replacement. 3. Ensure Resident 41 the accurate amount of tube feeding formula was delivered to the resident as ordered. These deficient practices had the potential to result in altered nutritional status, such as dehydration and malnutrition, and complications associated with enteral feeding, such as gastrointestinal (GI - relating to stomach and intestines) problems, such as abdominal pain and diarrhea, and for residents to experience unmet nutritional needs and place residents at risk for unintended weight loss. Findings: a. During a review of Resident 2's Face Sheet (admission Record), the Face Sheet indicated the facility originally admitted the resident on 6/7/2022 and readmitted in the facility on 1/30/2025 with diagnoses including gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), neurogenic bladder (lack of bladder control due to brain, spinal cord or nerve problems), and tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck). During a review of Resident 2's History and Physical (H&P), dated 2/2/2025, the H&P indicated Resident 2 was awake and oriented but did not indicate if the resident had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 12/18/2024, the MDS indicated Resident 2 had intact cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). The MDS further indicated Resident 2 had a feeding tube (a soft, flexible tube inserted into the stomach or small intestine to deliver nutrition and fluids when someone can't eat or drink normally). During a review of Resident 2's physician's order, dated 10/28/2024, the physician's order indicated cyclic tube feeding Tube Feeding Formula (TFF - a liquid nutrition delivered directly into the stomach or small intestine via a feeding tube) 4 at 70 milliliter (ml - a unit of measurement for volume) per (/) hour (hr - a unit of measurement for time) start feeding at 5 p.m. until 6 a.m. During an observation, on 3/24/2025, at 9:58 a.m., inside Resident 2's room, Resident 2's medication syringe affixed with a sticker did not indicate a date of when to change the syringe. During a concurrent observation and interview, on 3/24/2025, at 10:10 a.m., inside Resident 2's room, with Registered Nurse (RN) 8, RN 8 stated Resident 2's medication syringe sticker did not indicate the date of when it should be changed. RN 8 stated the medication syringes are supposed to be changed every day and label the sticker with the date it would be changed. RN 8 stated Resident 2's medication syringe should have been labeled with the date it would be changed to ensure the syringe is clean and not contaminated as it placed the resident at risk for acquiring infection from a contaminated medication syringe. During an interview, on 3/27/2025, at 5 p.m., with the Infection Preventionist (IP), the IP stated medication syringes are changed every day and should indicate in the sticker the date it would be replaced. The IP stated Resident 2's medication syringe should have been labeled with the date it would be replaced as it was an infection issue and placed the resident at risk for acquiring infection from a contaminated medication syringe. During a concurrent interview and record review, on 3/26/2025, at 4:30 p.m., with the Nurse Manager (NM), the facility provided procedure titled, Enteral Tube Feeding, continuous, Gastrostomy, and Jejunostomy, last revised on 11/18/2024, was reviewed and the NM stated the facility follows the procedure for any enteral feeding related issues. The NM stated the procedure did not specifically indicate labeling of the medication syringe. The NM stated per facility practice, medication syringes are supposed to be changed every day and should indicate the date it will be replaced so the staff would know if it was old or new. b. During a review of Resident 35's Face Sheet, the Face Sheet indicated the facility originally admitted the resident on 11/27/2023 and readmitted in the facility on 7/10/2024 with diagnoses including craniotomy (a type of brain surgery where the surgeon will remove and replace part of the skull to access and treat a problem within the brain), percutaneous endoscopic gastrostomy tube (PEG - a feeding tube inserted directly into the stomach allow a person to receive nutrition through the stomach) dependent, and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). During a review of Resident 35's H&P, dated 7/12/2024, the H&P indicated Resident 35 had the presence of tracheostomy. During a review of Resident 35's MDS, dated [DATE], the MDS indicated Resident 35 had severely impaired cognition and required total assistance from staff with all ADLs. The MDS further indicated Resident 35 had a feeding tube. During a review of Resident 35's physician's order, dated 10/28/2024, the physician's order indicated continuous tube feeding renal Nepro (a therapeutic nutrition designed to meet the nutritional needs of people with kidney disease) at 35 ml/hr. During an observation, on 3/24/2025, at 11:07 a.m., inside Resident 35's room, Resident 35's water flush bag and label indicated a date of 3/23/2025 at 4 a.m. During a concurrent observation and interview, on 3/24/2025, at 11:27 a.m., inside Resident 35's room with Licensed Vocational Nurse (LVN) 1, LVN 1 confirmed and stated Resident 35's water flush bag indicated a date of 3/23/2025 at 4 a.m. LVN 1 stated water flush bags are changed by the nurse assigned to the resident as the water flush bags were only good for 24 hours. LVN 1 stated Resident 35's water flush bag had been hanging for more than 24 hours and should have been changed according to the manufacturer's guideline as it can already be contaminated, and Resident 35 can get infection. During a concurrent observation and interview, on 3/24/2025, at 11:50 a.m., inside Resident 35's room with RN 9, RN 9 stated Resident 35's water flush bag indicated a date and time of 3/23/2025, at 4 a.m., and it had already been more than 24 hours since the bag was last changed. RN 9 stated water flush bags are changed by the nurse assigned to the residents every 24 hours according to the manufacturer's guidelines. RN 9 stated Resident 35's water flush bag should have been changed as it can already be contaminated which placed the resident at risk for acquiring infection. During an interview, on 3/27/2025, at 5 p.m., with the IP, the IP stated water flush bags are supposed to be changed every 24 hours as indicated in the manufacturer's guideline. The IP stated Resident 35's water flush bag should have been changed as the bag can already be contaminated from being used for more than 24 hours and Resident 35 can get infection from the contaminated water flush bag. During a review of the facility provide manufacturer's guideline for the Water Flush Bag (WFB) 1, undated, the manufacturer's guideline indicated the device is intended for enteral feeding only and recommended to be replaced every 24 hours. During a review of the facility provided procedure titled Enteral Tube Feeding, continuous, Gastrostomy, and Jejunostomy, last revised 11/18/2024, the procedure indicated to change the administration set according to the manufacturer's instructions to prevent bacterial growth. c. During a review of Resident 41's Face Sheet, the Face Sheet indicated the facility admitted the resident on 12/11/2024 with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe) and dementia (a progressive state of decline in mental abilities). During a review of Resident 41's MDS, dated [DATE], the MDS indicated the resident had no speech, hearing highly impaired, rarely/never makes self-understood, and rarely/never had the ability to understand others. The MDS indicated the resident had function limitation in range of motion (full movement of a joint) on both sides of upper and lower extremities. The MDS indicated the resident with feeding tube while a resident of the facility. During a review of Resident 41's physician order, dated 2/26/2025, the physician order indicated TFF 3; 70 ml/hr, continuous 22 hours daily, gastrostomy, free water amount 100 ml, free water frequency every six hours. During a review of Resident 41's Follow-Up Nutrition Assessment, dated 2/22/2025, the Follow-Up Nutrition Assessment indicated the dietitian recommendations to continue TFF 3 1.2 to 70 milliliters for 22 hours daily to slow down weight loss. During a review of Resident 41's Flowsheet, dated 3/24/2025 to 3/25/2025, the Flowsheet indicated the following tube feeding intake: - 3/24/2025 at 6 a.m., 794 ml - 3/24/2025 at 6 p.m., 770 ml - 3/25/2026 at 6 a.m., 776 ml. During a review of Resident 41's care plan focusing on enteral nutrition, dated 12/17/2024, the care plan indicated interventions including minimizing unnecessary disruptions to feeding and using enteral nutrition protocol to optimize delivery. During a concurrent observation and interview, on 3/25/2025, at 8:34 a.m., with RN 9, inside Resident 41's room, the tube feeding connected to Resident 41 indicated TFF 3 labeled with the date 3/25/2025, start time 2 a.m., and set at 70 ml/hr in a one-liter container. RN 9 stated about 750 ml of fluid was left in the TFF 3 container. RN 9 stated 146 ml of formula was administered. RN 9 stated the next shift clears the amount in the tube feeding machine when they start their shift. RN 9 stated the start date and time was when the new TFF 3 was started, 3/25/2025 at 2 p.m. RN 9 stated the total time from 2 a.m. to 8:30 a.m. is 6 hours and 30 minutes. RN 9 stated when the tube feeding formula rate is set to 70 ml/hr, there should be about 455 ml delivered and should have about 545 ml left in the bag. RN 9 stated they also account for pausing the tube feeding during ADLs or repositioning which takes about 10 to 15 minutes. During a concurrent interview and record review, on 3/25/2025, at 8:38 a.m., with RN 9, Resident 41's Flowsheet, dated between 3/24/2025 to 3/25/25, nursing notes, dated between 3/24/2025 to 3/25/2025, and physician orders were reviewed. RN 9 stated there was no documentation to account for the 205 ml difference left in the bag. RN 9 stated there should have been a documentation why TFF 3 still had that much formula left in the bag. RN 9 stated there were no new orders to hold Resident 41's tube feeding formula. During an interview, on 3/27/2025, at 5:42 p.m., with RN 7, RN 7 stated at the start of the primary nurse's shift they check the tube feeding machine regarding the timing, the rate, and clear the amount delivered and monitor how much the resident's intake is. RN 7 stated the primary nurse can set up the machine to deliver the amount of formula at a set time and once the time has been reached, the machine will alarm. RN 7 stated if there is discrepancy with the amount left in the formula bag the primary nurse should have documented the reason why it has that much left and should have notified the resident's physician and the resident's family about it. RN 7 stated they should have notified the physician because there is no order for bolus or to increase the rate to catch up to the amount the resident is supposed to receive. RN 7 stated they can hold it for a short amount of time when the staff is providing ADLs or repositioning the resident. RN 7 stated the importance of following the order is to ensure the resident receives the amount of nutrients and vitamins as ordered to keep the resident in a healthy condition. RN 7 stated when the set amount of tube feeding formula is not received by Resident 41, the resident could potentially lose weight and may not get enough vitamins, minerals, or calories which can lead to malnutrition. During a review of the facility's Reference (Ref) 1 titled, Enteral tube feeding, continuous, gastrostomy and jejunostomy, last reviewed and approved on 3/10/2025, the Ref 1 indicated implementation included the following: - Verify the practitioner's order including administration method, volume, rate, and type, volume, and frequency of water flushes. - Make sure the enteral formula container is labeled with the date and time that the formula was hung, administration route, rate, and duration. - Frequently monitor the gravity drip rate or enteral feeding pump infusion rate to ensure accurate delivery of the enteral formula. During a review of the facility's policy and procedure (P&P) titled, Enteral Feedings, last reviewed and approved on 3/10/2025, the P&P indicated it is the purpose of this policy to provide nourishment to residents who are unable to meet their nutritional needs orally. The P&P indicated enteral formulas/supplements are ordered by the physician or dietitian when directed by the physician. The P&P indicated enteral formula administration and handling guidelines are found in the Ref 1 Procedures for nursing to follow tube feeding administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure three of five sampled residents (Resident 24, Resident 38, and Resident 40) investigated under the respiratory care area oxygen (type of gas our body needs in order to function) therapy equipment was maintained, and standard infection control practices were followed by failing to ensure: 1. Resident 24 and Resident 38's oxygen tubing did not touch the floor. 2. Resident 40's humidification bottle was labeled and changed per the facility established schedule. 3. Resident 38's Yankauer suction tool (long plastic tool used to remove secretions [thick or thin sticky fluids from the mouth and throat]) was labeled with the date when it was opened. These deficient practices had the potential for Resident 24, Resident 38, and Resident 40 to develop complications such as infection. Findings: 1a. During a review of Resident 24's Face Sheet (admission Record), the Face Sheet indicated the facility originally admitted the resident on 7/16/2020, and readmitted the resident on 3/31/2022, with diagnoses including acute respiratory failure (a condition where the respiratory system is unable to function properly, which can lead to a failure of gas exchange), traumatic brain injury (TBl - a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 24's History and Physical (H&P), dated 11/11/2024, the H&P indicated the resident is unable to make medical decisions. During a review of Resident 24's Minimum Data Set (MDS - a resident assessment tool), dated 1/28/2025, the MDS indicated Resident 24 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). The MDS indicated Resident 24 had tracheostomy (a surgical procedure that creates an opening in the trachea [windpipe] in the front of the neck) and was on continuous oxygen therapy (a treatment that supplies oxygen at higher levels than normal room air). During a review of Resident 24's physician's orders, dated 12/30/2024, the Order Summary Report indicated an order of may suction resident for increase secretion three times a day (TID) as needed. During an observation, on 3/24/2025, at 9:16 a.m., inside Resident 24's room, Resident 24 laid in bed with the resident's tracheostomy connected to oxygen at two (2) liters per minute (liters/min - a unit of measurement) via tracheostomy mask with the oxygen tubing touching the floor. During a concurrent observation and interview, on 3/24/2025, at 9:40 a.m., with the Infection Preventionist (IP), inside Resident 24's room, the IP confirmed and stated Resident 24's oxygen tubing was touching the floor. The IP stated oxygen tubing is not supposed to be touching the floor. The IP stated the tubing is supposed to be changed to a shorter one if the tubing is too long to prevent the tubing from touching the floor. The IP stated Resident 24's oxygen tubing should not be touching the floor as the floor is dirty and contaminated and can place the resident at risk for acquiring an infection. During a review of the facility's policy and procedure (P&P) titled, Standards of Care (Sub Acute), last reviewed on 3/10/2025, the P&P indicated the licensed nurse will carry out safety procedures for proper infection control practices, isolation techniques, use of restraints and side rails and care of the environment should be followed as indicated. 1b. During a review of Resident 38's Face Sheet, the Face Sheet indicated the facility admitted Resident 38 on 11/25/2024 with a diagnosis including respiratory failure (lungs are not working well causing difficult breathing). During a review of Resident 38's, dated 11/26/2024, the H&P indicated Resident 38 had a medical history of tracheostomy, cerebrovascular accident (CVA - stroke, loss of blood flow to a part of the brain), hypertension (HTN - high blood pressure), and urinary bladder (stores urine) neurogenic (brain, spinal cord, and/or nervous system) dysfunction (not working properly). During a review of Residents 38's MDS, dated [DATE], the MDS indicated Resident 38 had severe cognitive impairment and required assistance of two-person physical assist for ADLs. The MDS indicated Resident 38 received oxygen therapy, suctioning, and tracheostomy care. During a review of Resident 38's Care Plan (CP) titled, Device-Related Complication Risk (Artificial Airway), initiated on 8/29/2024, the CP interventions included: Provide oral (mouth) care regularly, evaluate need for suctioning to minimize risk of airway obstruction (blockage), and apply O2 (oxygen)/ventilation (moving air in and out of lungs). During a concurrent observation and interview, on 3/24/2025, at 1:45 p.m., with Licensed Vocational Nurse (LVN) 1, in Resident 38's room, the oxygen tubing from Resident 38's tracheostomy site at the neck to the oxygen humidifier (adds moisture to oxygen) on the wall, coiled on the floor. LVN 1 stated the oxygen tubing should not touched the floor because the floor was contaminated (dirty). During an interview, on 3/27/2025, at 8:38 a.m., with Registered Nurse (RN) 4, RN 4 stated it was important to keep oxygen tubing off the floor for infection control. RN 4 stated we need to prevent tubing from being on the floor because the resident could get an infection such as ventilator (breathing machine) associated pneumonia ([NAME] - lung infection from using the ventilator through a tube inside the mouth and throat, or through a tracheostomy). During a review of the facility's P&P titled, Standards of Care - Sub Acute, dated 3/2024, the P&P indicated, Licensed nurse will carry out safety procedures as outlined in the P&P for proper infection control practices, isolation techniques, use of restraints and side rails, and care of the resident's environment should be followed as indicated. 2. During a review of Resident 40's H&P, dated 9/27/2024, the H&P indicated the facility originally admitted the resident on 9/26/2024 with diagnoses including squamous cell carcinoma (a type of cancer) of the neck, chronic respiratory failure (serious condition that slowly develops when the lungs cannot get enough oxygen into the blood) with hypoxia (low oxygen in the tissues), tracheotomy, and ventilator dependence. During a review of Resident 40's MDS, dated [DATE], the MDS indicated the facility originally admitted the resident on 9/26/2024 and most recently admitted on [DATE]. The MDS further indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident used a mechanical ventilator and received oxygen therapy. During a review of Resident 40's Order Report, dated 3/26/2025, the Order Report indicated a physician's order for humidified O2 via T-piece (a device use to help tracheostomy breathing) during waking hours as tolerated with supervision and family on bedside (start at 60 minutes, increase duration daily if possible). Place back on ventilator support if in distress. Titrate (adjust) O2 to maintain 92 percent (%, a measurement), add humidifier, dated 11/15/2024. During a review of Resident 40's CP on presence of an artificial airway, initiated 9/27/2024, the CP indicated to provide humidification. During an observation, on 3/24/2025, at 10:30 a.m., inside Resident 40's room, supplemental oxygen via oxygen tubing and a humidifier bottle connected to Resident 40. Resident 40's oxygen humidifier bottle did not indicate the date it was last changed. During a concurrent observation and interview, on 3/24/2025, at 10:35 a.m., with RN 8, RN 8 entered Resident 40's room, turned on the light, and stated humidification bottles are changed by the night shift and should be labeled with the date the bottle was changed. RN 8 stated Resident 40's humidification bottle was not labeled, and RN 8 did not know when the bottle was last changed. During a concurrent observation, interview, and record review, on 3/24/2025, at 10:40 a.m., with Respiratory Therapist (RT) 1, the Subacute Supply Change and Equipment Check Schedule was reviewed. RT 1 confirmed and stated oxygen humidification bottles are changed every three days and the bottles are labeled with the date the bottle was last changed. RT 1 assessed Resident 40's oxygen humidification bottle and stated the bottle did not indicate the date it was last changed. RT 1 stated there was no documentation indicating Resident 40's humification bottle was changed within the last three days. RT 1 stated if Resident 40's humidification bottle was not labeled with the date, then RT 1 did not know when the bottle was last changed. During an interview, on 3/27/2025, at 8:35 a.m., with the Nurse Manager (NM), the NM stated oxygen humidification bottles are changed every three days and must be labeled with the date last changed. The NM stated it was important to label with the date to communicate when the bottles were last changed and to identify when the bottle needs to be changed next. The NM stated when Resident 40's oxygen humidification bottle did not indicate the date it was last changed, there was a risk the bottle was used for an extended amount of time causing an infection control issue. The NM stated Resident 40 is connected to a ventilator system and when the humidification bottle was not changed, there was a potential for the resident to develop a respiratory infection. The NM stated the facility policy and procedures regarding infection control were not followed. During a review of the facility provided, Subacute Supply Change and Equipment Check Schedule, last reviewed 4/2024, the Subacute Supply Change and Equipment Check Schedule indicated the RT is responsible for ventilator patients. The bubble humidifier (humidification bottle) is changed by the day shift when the water level is 25 % or every three days. During a review of the facility's policy and procedure (P&P) titled, Standard Precautions and Transmission-Based Precautions, last reviewed 3/10/2025, the P&P indicated standard precautions is the primary practice used for the prevention of the spread of disease and infections. Standard precautions are used in the care of all patients regardless of their diagnosis or presumed infection status. All caregivers including clinical and non-clinical caregivers are expected to follow appropriate precautions. Ensure single use items are discarded properly. 3. During a concurrent observation and interview on 3/24/2025 at 1:45 p.m., with LVN 1, in Resident 38's room, Resident 38's Yankauer suction tool was opened and had yellow secretions inside. LVN 1 stated the Yankauer did not have a date of when it was opened or needed to be changed. LVN 1 stated I don't know when it was opened. LVN 1 stated the Yankauer should be changed every day and as needed and should be dated when it was opened or needed to be changed. During an interview on 3/27/2025 at 8:38 a.m., with Registered Nurse (RN) 4, RN 4 stated if oxygen equipment was not changed on the right date or time, it could cause an infection for the resident. During a review of the facility's policy and procedure (P&P) titled, Standards of Care - Sub Acute, dated 3/2024, the P&P indicated, licensed nurse will carry out safety procedures as outlined in the P&P for proper infection control practices, isolation techniques, use of restraints and side rails, and care of the resident's environment should be followed as indicated. During a review of the facility's procedure titled Subacute (more specialized care than a general skilled nursing facility) Supply Change and Equipment Check Schedule, undated, the procedure indicated to change the Yankauer weekly and PRN (as needed) when soiled (caking [dried or hardened substance] present).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents are free of any significant medication errors for two of two sampled residents (Residents 35 and 42) reviewed for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) and anticoagulant (a substance that is used to prevent and treat blood clots in blood vessels and the heart) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin and heparin (an anticoagulant) administration sites. The deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin and anticoagulants (a substance that is used to prevent and treat blood clots in blood vessels and the heart) such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a rare disease that occurs when a protein called amyloid builds up in organs). Cross Reference F658 Findings: a. During a review of Resident 35's Face Sheet, the Face Sheet indicated the facility originally admitted the resident on 11/27/2023 and readmitted in the facility on 7/10/2024 with diagnoses including craniotomy (a major type of brain surgery where the surgeon will remove and replace part of the skull to access and treat a problem within the brain, hypertension (HTN - also known as high blood pressure), and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). During a review of Resident 35's History and Physical (H&P) dated 7/12/2024, the H&P indicated Resident 35 had the presence of tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck and was non-verbal (not speaking). During a review of Resident 35's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/28/2025, the MDS indicated Resident 35 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS further indicated Resident 35 received anticoagulant. During a review of Resident 35's physician's order, the physician's order dated 1/8/2025 indicated heparin sodium injection (porcine) solution 5000 units per milliliter (units/ml - a unit of measurement) 5000 units subcutaneously every 12 hours for DVT (deep vein thrombosis - a blood clot that forms in one or more of the deep veins in the body, usually in the legs causing leg pain or swelling) prophylaxis. During a review of Resident 35's care plan (CP) on thrombolytic therapy (the use of medications to dissolve blood clots) last revised on 3/2/2025 with a target date of 5/28/2025, the CP indicated to frequently monitor peripheral perfusion to address complications early as one of the interventions to prevent and manage risk of bleeding. During a concurrent interview and record review on 3/25/2025 at 11:05 am., reviewed Resident 35's physician's order, subcutaneous administration sites for heparin from 1/8/2025 to 3/25/2025, and the MDS with the Minimum Data Set Nurse (MDSN). The MDSN stated Resident 35 received heparin, had a physician's order for heparin, and were administered as follows: Heparin 5000 units/ml injection 5000 units: - 1/20/2025 5:51 a.m. left upper quadrant - LUQ - 1/20/2025 5:03 p.m. LUQ - 3/2/2025 6:22 p.m. LUQ - 3/3/2025 5:14 a.m. LUQ - 3/7/2024 6:58 a.m. right upper quadrant - RUQ - 3/7/2025 5:39 a.m. RUQ - 3/23/2025 5:15 a.m. LUQ - 3/23/2025 17:32 LUQ The MDSN stated administration sites for insulin and anticoagulants such as heparin should be rotated per standards of practice and manufacture's guideline to prevent hardening or lumps in the skin. The MDSN stated the list of administration sites for the heparin were not rotated. The MDSN stated Resident 35's administration sites should have been rotated to prevent pain, redness, irritation, and lumps on the resident's skin. The MDSN stated not rotating the administration sites for the insulin is not following the standards of practice and manufacturer's guideline and can be considered a medication error which may lead to an adverse reaction to the medicine. During a concurrent interview and record review on 3/27/2025 at 5:00 p.m. with Registered Nurse (RN) 8, RN 8 stated the location of administration sites for Resident 35's heparin were not rotated. RN 8 stated the nurses are supposed to rotate heparin administration sites according to standards of practice, and as indicated in the manufacturer's guideline. RN 8 stated Resident 35's administration sites for heparin should have been rotated to prevent adverse effects such as bruising, skin irritation, skin pits, lipodystrophy and amyloidosis which can affect absorption of the medication. RN 8 stated not rotating the administration sites for the heparin is not following the standards of practice and manufacturer's guideline and can be considered a medication error. During a review of the facility-provided manufacturer's guideline for heparin sodium injection solution, dated 1/2022, the manufacturer's guideline indicated to use a different site for each injection. The manufacturer's guideline further indicated injection site irritation is one of the most common adverse reactions for the use of heparin. During a review of the facility's policy and procedure (P&P) titled, Medication Administration and Monitoring (Sub Acute), last reviewed on 3/2025, the P&P indicated the following: - Healthcare providers administering medications are responsible for knowing and understanding the dosage, indications, side effects and precautions/warnings of the medications being administered. - Injection sites for subcutaneous and intramuscular administration must be rotated. During a review of the facility's P&P titled, Medication Error Reporting, last reviewed on 3/10/2025, the P&P indicated a medication event/error is defines as any preventable event (actual/potential) that may cause or lead to inappropriate medication use and/or patient harm while medication is in the control of health care professional, patient or consumer. Medication errors can occur within any of the following steps in the medication management process including prescribing, order communication, product labeling, packaging and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use. b. During a review of Resident 42's Face Sheet, the Face Sheet indicated the facility originally admitted the resident on 9/4/2024 and readmitted in the facility on 12/20/2024 with diagnoses including history of stroke (loss of blood flow to a part of the brain), tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck, and ventilator-dependent respiratory failure (condition when a patient's lungs cannot breath on their own and required a machine to help breathe). During a review of Resident 42's History and Physical (H&P) dated 12/22/2024, the H&P indicated Resident 42 was awake and alert but did not indicate the resident's capacity to understand and make decisions. During a review of Resident 42's MDS, dated [DATE], the MDS indicated Resident 42 was able to make his needs known and able to understand others. The MDS further indicated Resident 42 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required substantial/maximal assistance to total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 42 received insulin. During a review of Resident 42's physician's order, the physician's order dated 2/24/2025 indicated insulin glargine-yfgn (a long-acting insulin) injection vial eight (8) units (a unit of measurement) at bedtime for diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 42's care plan (CP) on hyperglycemia last revised on 3/2/2025 with a target date of 7/31/2025, the CP indicated to provide pharmacologic therapy (drug or medication therapy) to maintain blood sugar levels within targeted range. During a concurrent interview and record review on 3/25/2025 at 11:05 am., reviewed Resident 42's physician's order, subcutaneous administration sites for insulin glargine from 2/24/2025 to 3/25/2025, and the MDS with the Minimum Data Set Nurse (MDSN). The MDSN stated Resident 42 had a physician's order for insulin glargine, and were administered as follows: Insulin glargine-yfgn injection 8 units: - 3/12/2024 5:35 p.m. left lower quadrant - LLQ - 3/13/2025 5:34 p.m. LLQ - 3/17/2025 5:27 p.m. left upper arm - LUA - 3/18/2025 5:51 p.m. LUA The MDSN stated administration sites for insulin and anticoagulants should be rotated per standards of practice and manufacture's guideline to prevent hardening or lumps in the skin. The MDSN stated the list of administration sites for Resident 42's insulin glargine were not rotated. The MDSN stated Resident 42's administration sites should have been rotated to prevent pain, redness, irritation, and lumps on the resident's skin. The MDSN stated not rotating the administration sites for the insulin is not following the standards of practice and manufacturer's guideline and can be considered a medication error. During a concurrent interview and record review on 3/27/2025 at 5:00 p.m. with Registered Nurse (RN) 8, RN 8 stated the location of administration sites for Resident 42's insulin glargine were not rotated. RN 8 stated the nurses are supposed to rotate insulin administration sites according to standards of practice, and as indicated in the manufacturer's guideline. RN 8 stated Resident 42's administration sites for insulin glargine should have been rotated to prevent adverse effects such as bruising, skin irritation, skin pits, lipodystrophy and amyloidosis which can affect absorption of the insulin. RN 8 stated not rotating the administration sites for the insulin is not following the standards of practice and manufacturer's guideline and can be considered a medication error. During a review of the facility-provided manufacturer's guideline for insulin glargine (rDNA origin) 100 units per milliliter (units/ml - a unit of measurement) three (3) ml pen dated 8/26/2022, the manufacturer's guideline indicated to change (rotate) the injection site for each injection and to inject under the skin of the stomach area, buttocks, upper legs or upper arms. During a review of the facility's P&P titled, Medication Administration and Monitoring (Sub Acute), last reviewed on 3/2025, the P&P indicated the following: - Healthcare providers administering medications are responsible for knowing and understanding the dosage, indications, side effects and precautions/warnings of the medications being administered. - Injection sites for subcutaneous and intramuscular administration must be rotated. During a review of the facility's P&P titled, Medication Error Reporting, last reviewed on 3/10/2025, the P&P indicated a medication event/error is defines as any preventable event (actual/potential) that may cause or lead to inappropriate medication use and/or patient harm while medication is in the control of health care professional, patient or consumer. Medication errors can occur within any of the following steps in the medication management process including prescribing, order communication, product labeling, packaging and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen by failing to: 1. Ensure towels were stored in clean towel bins, sanitation buckets, or dirty towel bins when not in use. 2. Ensure food items in the walk-in Refrigerators #2 and #5 were labeled according to facility policy. 3. Ensure the personal property of staff was not stored in the kitchen area next to an uncovered serrated knife and food items. 4. Ensure Refrigerator #10 and the Subacute Resident Refrigerator/Freezer temperatures were maintained per facility policy and procedure. These deficient practices had the potential to result in harmful bacterial growth and cross contamination (the process by which bacteria, microorganisms, or chemicals are unintentionally transferred from one substance or object to another, with harmful effect) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 10 of 45 medically compromised residents who received food and ice from the kitchen. Findings: a. During an Initial Kitchen Tour, on 3/24/2025, at 8 a.m., with the Interim Director of Hospitality Services (IDHS) and Food Service Attendant 1 (FSA 1), the IDHS stated the facility uses white towels to sanitize the kitchen. The IDHS stated all towels should only be stored in clean towel bins prior to use, red sanitizer buckets when in use, or dirty towel bins after use. The IDHS stated no towels should be left out in the tray line area to prevent cross contamination from one surface to another while staff is performing tasks in the kitchen. Observed the following in the tray line area: 1. A white towel placed on the top of FSA 1's black rolling cart. The IDHS stated the towel was used and should not be on the cart. FSA 1 stated at approximately 6:30 a.m., FSA 1 used the towel and placed the dirty towel on the cart. FSA 1 stated she should not have placed the dirty towel on the cart. FSA 1 stated dirty towels should not be left on carts because the towel could be soiled with bacteria that could potentially contaminate the tray line area. FSA 1 stated there was no reason why she left the towel on the cart and stated she should not have. 2. Two white towels placed on an unattended black rolling cart. The IDHS stated she did not know if the towels were used. The IDHS stated the towels should not be placed on the unattended cart. The IDHS removed the towels and placed them in the dirty towel bin. The IDHS stated the towels could be dirty and cause cross contamination resulting in foodborne illness in residents. During a concurrent interview and record review, on 3/27/2025, at 1:35 p.m., with the Clinical Nutrition Manager (CNM), the facility provided Health and Safety Code (HSC) regarding equipment, utensils, and linens was reviewed. The CNM stated the facility does not have a specific policy regarding the use of towels in the kitchen, but it is a standard of practice to never keep towels in the kitchen area unless they are in a sanitization bucket. The CNM reviewed the HSC and stated the kitchen staff did not follow the HSC when towels were left out in the kitchen. During a review of the facility provided HSC document titled, Article 5. Linens, dated effective 1/1/2007, the HSC indicated wiping cloths that are used repeatedly are held in a sanitizing solution of an approved concentration. Working containers of sanitizing solutions for storage of in-use wiping cloths shall be used in a manner to prevent contamination of food, equipment, utensils, and linens. Soiled linens shall be kept in receptacles and transported to prevent contamination of food, clean equipment, and clean utensils. During a review of the facility policy and procedure (P&P) titled, Safety and Sanitation Standards, effective date 6/12/2024, the P&P indicated safety and sanitation standards are followed to ensure the provision of safe food to the customers. Each employee is responsible for maintaining a clean and safe work area throughout their shift. b. During an Initial Kitchen Tour, on 3/24/2025, at 8 a.m., with the IDHS and FSA 1, the IDHS stated staff have a locker to store their personal belongings and personal knives when not in use. The IDHS stated no personal items should be in the kitchen because there is a potential of cross contamination resulting in foodborne illness in residents. The top shelf of FSA 1's black rolling cart contained a box of substitute sugar packets, a box of seasoning packets, a cellphone, a wireless headphone case, and a serrated knife. The IDHS stated FSA 1 should have stored the cell phone and headphone case in FSA 1's locker. The IDHS stated FSA 1's knife should have been covered and securely stored in the designated storage area when not in use, but FSA 1 stored the uncovered knife on the cart next to FSA 1's personal items. FSA 1 stated the cell phone and headphone case belonged to her and personal items should not be stored in the kitchen. FSA 1 stated she uses the knife to cut fruit and the knife should not be stored uncovered and next to personal items because the phone and headphone case could contaminate the knife and other food items with bacteria. FSA 1 stated there was no reason why she stored the knife and personal items in the cart. During a concurrent interview and record review, on 3/27/2025, at 1:35 p.m., the CNM reviewed the facility provided HSC regarding personal belongings. The CNM stated some kitchen staff bring personal knives to use in the facility kitchen and the knives should be stored properly when not in use. The CNM stated all cell phones and headphone cases should always be stored in the staff members locker and not in the kitchen or tray line area. The CNM stated the facility did not have a specific policy regarding personal items and uncovered knives in the kitchen, but it was a standard of practice based on the HSC. The CNM stated FSA 1 did not follow the facility practice when the knife, cell phone, and headphone case were stored on the cart in the tray line area. During a review of the facility provided HSC document titled, Article 4. Employee Storage Areas dated effective 1/1/2007, the HSC indicated lockers or other suitable facilities shall be located in a designated room or area where contamination of food, equipment, utensils, and linens cannot occur. No personal effects are stored in any area used for the storage or preparation of food. A safety knife holder shall be provided to avoid loose storage of knives. During a review of the facility P&P titled, Dress Code, effective date 6/12/2024, the P&P indicated the purpose of the P&P was to avoid contamination of food. As appropriate and available, a locker will be assigned for employee use. Cell phones are not permitted at workstations. During a review of the facility P&P titled, Safety and Sanitation Standards, effective date 6/12/2024, the P&P indicated safety and sanitation standards are followed to ensure the provision of safe food to the customers. Each employee is responsible for maintaining a clean and safe work area throughout their shift. c. During an Initial Kitchen Tour, on 3/24/2025, at 8 a.m., with the IDHS, observed the facility walk in refrigerators with the IDHS. The IDHS stated the facility labels food items that are stored in the refrigerators to facilitate the first in, first out method (rotation method used to minimize waste and ensure food safety by preventing spoilage) and to ensure expired food is discarded and not served to residents. The IDHS stated it was important to label and discard expired food because there is a potential that expired foods served to resident may cause foodborne illness. Observed the following: 1. In Refrigerator #5, two unopened, prepackaged egg salad sandwiches by Manufacture 1(Mfr. 1), labeled 3/19. The IDHS stated the sandwiches expired on 3/19/2025 and should not have been stored in the refrigerator available to be served to residents. The IDHS stated the staff should have discarded the expired sandwiches and they did not. The IDHS stated when the expired sandwiches were left in the refrigerator, there was a potential that the expired sandwiches could be served to residents causing illness. 2. In Refrigerator # 5, there was one unlabeled large pan of cooked meat that was partially uncovered with the contents exposed to air. The IDHS stated the pan contained leftover chicken breasts and was unlabeled. The IDHS stated she did not know when the pan was placed in the fridge because it was not labeled. The IDHS stated it was important to label leftovers with the item contents and date of expiration to ensure staff knows what the food is and to ensure expired food is not served to residents. 3. In Refrigerator #2, one opened container labeled sour cream. The IDHS stated the expiration date on the container was not legible. The IDHS stated the facility uses the expiration on the container to know when to discard the sour cream. The IDHS stated because the expiration date was not legible, she did not know if the sour cream was expired. The IDHS stated if an expiration date is not legible then the sour cream should be thrown out. During a concurrent interview and record review, on 3/27/2025, at 1:35 p.m., the CNM reviewed the facility P&P regarding food storage labeling and leftovers. The CNM stated the kitchen floor stocking staff should discard any unlabeled, illegibly labeled, or expired foods from the refrigerators to ensure expired food that may be sour, rotted, or moldy is not served to residents. The CNM stated when expired food is served to residents it may affect the nutritional value of food and cause the residents to not feel well. During a review of the facility P&P titled, Label and Dating, effective date 3/20/2025, the P&P indicated the Food and Nutrition Services shall ensure that foods are labeled, dated, and stored appropriately. The purpose of the P&P was to ensure proper storage and safety of the department's food supply. The following procedures and checks are done regularly to prevent any possible contamination or spoilage of food: i. Caregivers are to remove any expired item and ensure that foods are safely stored. ii. All food supplies shall be rotated on a first-in, first-out, basis. This will ensure the oldest product is used first. iii. The pull date, is the last date that an item can be used. The product will be pulled on the morning following its pull date, and disposed of. Items prepared on premises, will carry a pull date to ensure maximum freshness. Where items are pull-dated by the manufacture, items will be pulled accordingly. iv. Products will be dated via the following acceptable mechanisms. a) Label with the following information will be used to label and date foods for holding and storage: i) Item name ii) Use by date (pull date) iii) Employee signature v. All prepared items will receive a three day pull date. During a review of the facility P&P titled, Label and Dating, Attachment A; Pull Dates, effective date 3/20/2025, the P&P attachment indicated the following pull dates: Product: sour cream has a pull date of the date on the container. Product: cooked chilled chicken has a pull date of three days. Product: Mfr. 1 Sandwiches have a pull date of two days. During a review of the facility P&P titled, Leftovers, effective date 6/10/2024, the P&P indicated leftover food is given a three day pull date to ensure proper usage, storage, and safety of the department leftover's food. Food portions not utilized in the service of a meal will be refrigerated in a shallow covered container labeled and dated with a three day pull date. d.1. During an Initial Kitchen Tour, on 3/24/2025, at 8 a.m., with the IDHS, observed the facility walk in refrigerators with the IDHS. The IDHS stated the facility maintains refrigerators at an acceptable temperature range of 32 to 41 degrees Fahrenheit (°F, a unit of measurement for temperature) to ensure the quality of the food and to prevent food borne illness in residents . The IDHS stated refrigerator # 10 is used during tray line and the thermometer indicated the refrigerator was 41 degrees. The IDHS reviewed Refrigerator #10's Temperature Log for 3/2025 and noted the refrigerator was out of the acceptable temperature range for the p.m. shift (evening shift) on the following dates: - On 3/1/2025, the temperature was 42 °F, no corrective actions/comments are indicated. - On 3/2/2025, the temperature was 48 °F, no corrective actions/comments are indicated. - On 3/4/2025, the temperature was 42 °F, no corrective actions/comments are indicated. - On 3/5/2025, the temperature was 42 °F, no corrective actions/comments are indicated. - On 3/7/2025, the temperature was 44 °F, no corrective actions/comments are indicated. - On 3/8/2025, the temperature was 44 °F, no corrective actions/comments are indicated. - On 3/9/2025, the temperature was 44 °F, no corrective actions/comments are indicated. - On 3/10/2025, the temperature was 44 °F, no corrective actions/comments are indicated. - On 3/11/2025, the temperature was 44 °F, no corrective actions/comments are indicated. - On 3/12/2025, the temperature was 45 °F, no corrective actions/comments are indicated. - On 3/13/2025, the temperature was 44 °F, no corrective actions/comments are indicated. - On 3/14/2025, the temperature was 44 °F, no corrective actions/comments are indicated. - On 3/15/2025, the temperature was 42 °F, no corrective actions/comments are indicated. - On 3/16/2025, the temperature was 46 °F, no corrective actions/comments are indicated. - On 3/17/2025, the temperature was 52 °F, no corrective actions/comments are indicated. - On 3/18/2025, the temperature was 50 °F, no corrective actions/comments are indicated. - On 3/19/2025, the temperature was 50 °F, no corrective actions/comments are indicated. - On 3/20/2025, the temperature was 42 °F, no corrective actions/comments are indicated. - On 3/21/2025, the temperature was 42 °F, no corrective actions/comments are indicated. - On 3/22/2025, the temperature was 44 °F, no corrective actions/comments are indicated. - On 3/23/2025, the temperature was 42 °F, no corrective actions/comments are indicated. The IDHS further stated she did not know why Refrigerator #10 was out of the acceptable temperature range only on the p.m. shift. During a concurrent interview and record review, on 3/25/2025, at 10:45 a.m., with the CNM, the facility provided Work Order email, dated 3/10/2025, and Refrigerator #10's Temperature Log, for 2/2025, were reviewed. The CNM noted Refrigerator #10 was out of the acceptable temperature range for the p.m. shift (evening shift) on the following dates: - On 2/13/2025, the temperature was 44 °F, no corrective actions/comments are indicated. - On 2/14/2025, the temperature was 42 °F, no corrective actions/comments are indicated. - On 2/18/2025, the temperature was 42 °F, no corrective actions/comments are indicated. - On 2/23/2025, the temperature was 44 °F, no corrective actions/comments are indicated. - On 2/27/2025, the temperature was 42 °F, no corrective actions/comments are indicated. The CNM further stated, on 3/9/2025, at 6:43 p.m., the evening kitchen supervisor entered a work order indicating Refrigerator #10 was out of the temperature control limits and needed service. The CNM stated there was no follow up to the work order. The CNM stated the refrigerator was taking too long to reach acceptable temperature ranges after the evening tray line and should have been removed from the kitchen service, but it was not removed. The CNM stated a refrigerator should consistently provide an acceptable temperature range for food safety. The CNM stated the food safety temperature zone is below 41 degrees to prevent bacterial growth. The CNM stated when Refrigerator #10 was not maintained at a temperature between 32 to 41 °F, it could have potentially resulted in bacterial growth causing food borne illnesses in residents. During a review of the facility P&P titled, Refrigerator/Freezer Temperature Logs, effective date 3/20/2025, the P&P indicated all refrigerators and freezers must be monitored and the temperature documented to ensure the proper storage of food. The purpose of the policy was to ensure that food is safe and is being held n compliance with public health regulations. Temperatures will be checked daily in the main kitchen and patient units. All temperatures are documented on the appropriate temperature log with the recorder's initials. Acceptable temperature ranges are 32 to 41 °F for refrigerators and below 0°F for freezers. When refrigerators and freezer temperatures are out of range, the following action step occur: a) Circle the out-of-range temperature in red ink b) Check the internal temperature of the food contained in the affected refrigerator and/or freezer, if the foods' temperature is out of the acceptable range, discard. c) Write an action plan on the temperature log, if more room is needed, turn the temperature log over and record the date and remainder of the action plan. d) Contact plant operations for repair as indicated e) Follow up to ensure the action plan has been completed. d.2. During a Subacute Kitchen Tour, on 3/27/2025, at 9 a.m., with the Clinical Educator (CE), observed the subacute refrigerators with the CE. The CE stated the Subacute refrigerator was maintained and monitored by the facility kitchen staff. The CE stated the acceptable temperature range for the refrigerator was between 32 and 41 °F. The CE reviewed the Subacute Refrigerator's Temperature Log for 3/2025 and noted the refrigerator was out of the acceptable temperature range on the following dates: - On 3/1/2025, the temperature was 20 °F, no corrective actions/comments are indicated. - On 3/2/2025, the temperature was 24 °F, no corrective actions/comments are indicated. - On 3/4/2025, the temperature was 25 °F, no corrective actions/comments are indicated. - On 3/5/2025, the temperature was 30 °F, no corrective actions/comments are indicated. - On 3/6/2025, the temperature was 28 °F, no corrective actions/comments are indicated. - On 3/7/2025, the temperature was 30 °F, no corrective actions/comments are indicated. - On 3/8/2025, the temperature was 25°F, no corrective actions/comments are indicated. - On 3/9/2025, the temperature was 30 °F, no corrective actions/comments are indicated. - On 3/10/2025, the temperature was 30 °F, no corrective actions/comments are indicated. - On 3/11/2025, the temperature was 30 °F, no corrective actions/comments are indicated. - On 3/12/2025, the temperature was 30 °F, no corrective actions/comments are indicated. - On 3/13/2025, the temperature was 30 °F, no corrective actions/comments are indicated. - On 3/14/2025, the temperature was 30 °F, no corrective actions/comments are indicated. - On 3/15/2025, the temperature was 25 °F, no corrective actions/comments are indicated. - On 3/16/2025, the temperature was 25 °F, no corrective actions/comments are indicated. - On 3/17/2025, the temperature was 25 °F, no corrective actions/comments are indicated. - On 3/18/2025, the temperature was 30 °F, no corrective actions/comments are indicated. - On 3/20/2025, the temperature was 30 °F, no corrective actions/comments are indicated. - On 3/21/2025, the temperature was 30 °F, no corrective actions/comments are indicated. - On 3/22/2025, the temperature was 30 °F, no corrective actions/comments are indicated. - On 3/23/2025, the temperature was 30 °F, no corrective actions/comments are indicated. During a concurrent interview and record review, on 3/27/2025, at 1:35 p.m., with the CNM, the CNM reviewed the Subacute Refrigerator's Temperature Log for 3/2025. The CNM stated the CNM was made aware the Subacute refrigerator was out of acceptable temperature range with no corrective actions indicated. The CNM stated the Subacute freezer log also indicated the freezer was out of the acceptable temperature range of below 0 °F on the following dates: - On 3/16/2025, the temperature was +10 °F, no corrective actions/comments are indicated. - On 3/17/2025, the temperature was +10 °F, no corrective actions/comments are indicated. The CNM further stated the importance of reporting when the temperature is out of range is to ensure the refrigerator/freezer is checked and functioning properly. The CNM stated when the subacute refrigerator's temperature was too low it could have potentially resulted in quality issues like the liquids freezing. The CNM stated residents must be served the intended appropriate texture and consistency of foods. The CNM stated when the items do not remain frozen in the freezer, it may result in quality issues from foods defrosting and refreezing. During a review of the facility P&P titled, Refrigerator/Freezer Temperature Logs, effective date 3/20/2025, the P&P indicated all refrigerators and freezers must be monitored and the temperature documented to ensure the proper storage of food. The purpose of the policy was to ensure that food is safe and is being held in compliance with public health regulations. Temperatures will be checked daily in the main kitchen and patient units. All temperatures are documented on the appropriate temperature log with the recorder's initials. Acceptable temperature ranges are 32 to 41 °F for refrigerators and below 0°F for freezers. When refrigerators and freezer temperatures are out of range, the following action step occur: a) Circle the out-of-range temperature in red ink b) Check the internal temperature of the food contained in the affected refrigerator and/or freezer, if the foods' temperature is out of the acceptable range, discard. c) Write an action plan on the temperature log, if more room is needed, turn the temperature log over and record the date and remainder of the action plan. d) Contact plant operations for repair as indicated e) Follow up to ensure the action plan has been completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement and maintain an infection control program by failing to ensure Registered Nurse (RN) 9, accompanied by the Nurse Practitioner (NP) and Medical Doctor (MD), implemented Contact Precautions (an infection control measure aimed to prevent spread of infection by direct or indirect contact by the use of personal protective equipment [PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments]) during rounding in the residents room for one of five sampled residents (Resident 39) reviewed under the Infection Control task area. This deficient practice had the potential to result in the spread of infectious microorganisms amongst staff, residents, and visitors. Findings: During a review of Resident 39's History and Physical (H&P), dated 3/27/2025, the H&P indicated the resident was re-admitted to the facility on [DATE] with diagnoses that included prostate (a gland in the male reproductive system) cancer, chronic respiratory failure (serious condition that slowly develops when the lungs cannot get enough oxygen into the blood) with tracheostomy (opening surgically created through the front of the neck and into the trachea [windpipe]), and percutaneous endoscopic gastrostomy (PEG or GT - a tube placed directly into the stomach to give direct access for supplemental feeding, hydration or medicine) placement. During a review of Resident 39's Minimum Data Set (MDS - a resident assessment tool), dated 1/24/2025, the MDS indicated the resident was originally admitted to the facility on [DATE]. The MDS further indicated the resident sometimes had the ability to make self-understood and sometimes understood others. The MDS indicated the resident was dependent on staff for oral and personal hygiene, bathing, dressing, toileting, and mobility. During a review of Resident 39's Physician Orders, dated 11/18/2024, the Physician Orders indicated a physician's order for contact isolation for Carbapenem-resistant pseudomonas aeruginosa (CRPA - an infectious bacteria spread through contact with contaminated surfaces, healthcare workers, or equipment); multidrug-resistant pseudomonas aeruginosa (MDRA - infectious bacteria that are resistant to the effects of multiple types of antibiotics [medication used to treat bacteria]) During an observation, on 3/24/2025, at 10:55 a.m., Resident 39's entry to the room had a contact isolation sign posted. The sign indicated before entering the room, all staff and visitors must put on a gown and gloves. RN 9, Resident 39's NP and MD were inside Resident 39's room not wearing gowns. RN 9, the NP, and the MD exited the resident's room after speaking with Resident 39's family member. During an interview, on 3/24/2025, at 11 a.m., with RN 9 upon exiting Resident 39's room, RN 9 stated Resident 39 had a contact isolation sign at the entry to the room because the resident was on contact isolation. RN 9 stated gloves and a gown should be donned (put on) before entering the resident's room. RN 9 stated that RN 9, the NP, and the MD did not don gowns prior to entering or while inside the resident's room because they were not touching the resident. During an interview, on 3/27/2025, at 11:44 a.m., with the facility Infection Preventionist (IP), the IP stated Resident 39 was diagnosed with CRPA. The IP stated CRPA can be spread amongst staff, residents, and visitors by touching surfaces contaminated with secretions or when secretions unexpectedly exit a resident's mouth or tracheostomy tubing during a cough. The IP stated to prevent the spread of CRPA, anyone entering the resident's room must don a disposable gown to prevent contamination of the staff or visitor's clothing. The IP stated staff and visitors should don a gown even if they do not intend to touch the resident or any environmental surfaces. The IP stated the gown prevents any cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) from Resident 39 to any of the other residents that the NP, MD, or RN 7 visit during their rounds. During an interview, on 3/27/2025, at 8:35 a.m., with the Nurse Manager (NM), the NM stated facility residents are at increased risk of infection and wearing a gown prevents the spread of infection between residents. The NM stated when RN 9, the NP, and the MD did not don gowns while inside Resident 39's room, the facility policy and procedures regarding contact isolation were not followed. During a review of the facility's policy and procedure (P&P) titled, Standard Precautions and Transmission-Based Precautions, last reviewed 3/10/2025, the P&P indicated standard precautions are the primary practice used for the prevention of the spread of disease and infections. Standard precautions are used in the care of all residents regardless of their diagnosis or presumed infection status. All caregivers including clinical and non-clinical caregivers are expected to follow appropriate precautions. Contact precautions are used in addition to standard precautions. Use contact precautions for residents known or suspected to be infected or colonized with epidemiologically important / significant microorganisms that can be transmitted, by direct / indirect contact. For the resident who appears to have a disease requiring contact precautions, it is important to institute the appropriate precautions immediately. The appropriate sign should be posted on the resident's door. In addition to standard precautions, wear a gown providing 360-degree coverage to protect skin and prevent soiling and / or contamination of clothing. [NAME] PPE when entering a resident's room based on the anticipated interaction with the resident and environment. Remove / doff PPE before leaving the resident's room. During a review of the facility's P&P titled, [Regional] Standard Precautions and Transmission-Based Precautions, Appendix A last reviewed 3/10/2025, the P&P indicated contact precautions are recommended in long term care facilities for carbapenem resistant organisms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to fully develop and implement an antibiotic (antimicrobial, medicine that inhibits the growth of or destroys microorganisms) stewardship program (ASP- a coordinated program that promotes the appropriate use of drugs used to treat infections, including antibiotics as a part of its overall Infection Prevention and Control Program (IPCP) for one of six sampled residents (Resident 3) reviewed under Infection Control facility task by: a. Failing to establish protocols to identify signs and symptoms of infections among residents to assess whether they met evidence-based national standard criteria for initiating antibiotic treatment b. Failing to identify Resident 3's use of levofloxacin (antibiotic) indicated for urinary tract infection (UTI- an infection in the bladder/urinary tract). These deficient practices had the potential to result in increased risk of inappropriate antibiotic use, potentially leading to adverse outcomes (complications arising from an intervention or condition) such as antibiotic resistance (the acquired ability of bacterial pathogens to withstand the effects of antimicrobial agents, reducing treatment efficacy) to Resident 3. Cross-reference F881 Findings: During a review of Resident 3's Face Sheet, the Face Sheet indicated the facility admitted the resident on 2/17/2025 with diagnoses including acute hypoxic respirator (a condition where the lungs cannot get enough oxygen into the blood) and hyperlipidemia (abnormally high fat). During a review of Resident 3's MDS, dated [DATE], the MDS indicated the resident's initial start date at the facility on 10/29/2024. The MDS indicated the resident had adequate hearing and unclear speech. The MDS indicated the resident made self understood and sometimes understood others. The MDS indicated the resident was dependent on staff with toileting, oral hygiene, shower/bathing self, lower body dressing, and personal hygiene. The MDS indicated the resident was taking antibiotics. During a review of Resident 3's physician order, dated 3/4/2025, the physician order indicated levofloxacin (Levaquin) tablet 500 milligrams (mg-a unit of measurement) per gastrostomy tube (g-tube- a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) for UTI, daily, end date 3/10/2025. During a concurrent interview and review on 3/27/2025 at 10:41 a.m. with the Infection Preventionist (IP), Resident 3's physician order, nursing progress notes, and registered nurses' plan of care, antibiotic tracking sheet (a document or tool used to monitor and record prescribed antibiotics and usage patterns [how often, how much, and what reason it's prescribed]), and Loeb's minimum criteria (evidence-based national standard criteria for initiating antibiotic treatment designed to reduce inappropriate prescribing by outlining minimum clinical signs and symptoms suggesting an infection) for initiating antibiotic therapy were reviewed. The Plan of Care indicated, on 3/1/2025 at 11:25 a.m., Resident 3 was noted with increased heart rate and had a temperature of 101.1 degrees Fahrenheit (F - a unit of measurement). The IP stated she uses the antibiotic tracking sheet and the Loeb's minimum criteria for initiating antibiotic therapy as a guide that she uses to monitor and review new or changes in antibiotic orders and uses Loeb's criteria, but this is not indicated in their policy. The IP stated they do not have a standard protocol in using the Loeb's criteria that shows which residents have met or have not met the criteria. The IP stated when Loeb's criteria is used for Resident 3's use of levofloxacin for UTI without urinary catheter, the resident would not have met the criteria because the resident only have increased heart and fever as signs and symptoms of infection. The IP stated the Loeb's minimum criteria for UTI includes either one of the following criteria: acute dysuria (discomfort or pain when urinating) or temperature greater than 100 F, and one or more of the following new or worsening symptoms: urgency, suprapubic pain (pain above pelvic bone), urinary incontinence, frequency, gross hematuria (visible blood in the urine), and costovertebral angle tenderness (pain in the upper back near the ribs). During a concurrent interview and record review on 3/27/2025 at 10:50 a.m. with the IP, the facility's P&P titled, Antimicrobial Stewardship (AMS) Program, last reviewed and approved on 3/10/2025, was reviewed. The IP stated the P&P did not indicate the protocol on the use of antibiotic tracking sheet and the use of Loeb's criteria to assess the residents for any infection. The IP stated she should have mentioned to the Manager of Infection Prevention (MIP) about the use of antibiotic tracking sheet and the use of Loeb's minimum criteria in initiating antibiotic therapy when they reviewed their P&Ps. During an interview on 3/27/2025 at 1:57 p.m. with the IP, the IP stated when the resident does not meet the Loeb's minimum criteria, she would notify the resident's physician that the resident did not meet the criteria to initiate the antibiotic then document on the resident's chart what she did and what the physician's response was. During a concurrent interview and record review on 3/27/2025 at 2:12 p.m. with Registered Nurse (RN) 2, Resident 3's nursing progress notes, plan of care, and physician orders were reviewed. RN 2 stated he was covering for the IP when Resident 3 had the order for levofloxacin for UTI. RN 2 stated he notified the primary nurse about the resident's laboratory results that were ordered, and he (RN 2) does not use any standardized criteria when reviewing antibiotics. During an interview on 3/27/2025 at 3:17 p.m. with the MIP, the MIP stated she was not aware of the Centers of Medicare and Medicaid Services (CMS- a federal agency that administers major healthcare programs) of the regulation antibiotic stewardship regulation requirements to be implemented. The MIP stated they have an ASP which they collaborate with the antimicrobial stewardship pharmacist. The MIP stated they purpose of the ASP is to administer antibiotics in the least amount of duration, and to make sure the antibiotic ordered had the appropriate frequency and dose to prevent multidrug resistance organisms. During a review of the facility's P&P titled, Antimicrobial Stewardship (AMS) Program, last reviewed and approved on 3/10/2025, the P&P indicated it is the facility's policy to implement a comprehensive AMS program to evaluate judicious use of antimicrobials. The P&P indicated the purpose of the P&P is to optimize antibiotic therapy to improve clinical outcomes while minimizing unintended consequences of antimicrobial use, such as drug toxicity (drug causing harm) and emergence of resistance. During a review of the facility P&P titled, Department Policy Guidelines, last reviewed and approved on 3/10/2025, the P&P indicated the policy's purpose was to provide guidelines for the creation and/or review of policies, and to outline the approval process. Departmental policies and procedures are created, approved, maintained and archived in a consistent and timely manner, following a standardized approval and maintenance process. The ''Policy Owner is the Director/Manager of each department, as they are responsible for the creation, review, revision, removal, and/or archive of their department's policies. The Policy Owner is responsible for updating policy. All clinical content is to be reviewed and revised by licensed caregivers and/or department Directors/Managers. Ensure policy content and formatting accuracy. Check that policy content is correct and applies to the department/unit's current practices. Ensure the policy is within scope of practice, and in accordance with Nurse Practice Act. Confirm that the policy contains the most current and evidence-based information. All departments are required to review their departmental policies according to the following timelines, and as needed for regulatory purposes. It is the responsibility of the department manager to ensure that appropriate documentation is maintained for any Standardized Procedures used in their department/area.

**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 honor the resident's right to a dignified existence to two of two sampled residents (Resident 23 and 238) investigated during review of dignity care area by: 1. Failing to ensure Resident 23's indwelling urinary catheter (flexible tube inserted in the bladder through the urethra to drain urine) drainage bag was covered with a dignity bag (a bag used to cover the urinary catheter drainage bag, so it is not visible). 2. Failing to ensure Certified Nursing Assistant 1 (CNA 1) was not standing over Resident 238 while assisting the resident with feeding. These deficient practices had the potential to affect the residents' self-esteem and self-worth. Findings: 1. A review of Resident 23's Face Sheet indicated the facility admitted the resident on 3/13/2024, with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe). A review of Resident 23's History and Physical (H&P), dated, 4/3/2024, indicated the resident had a history of hyperuricemia (too much uric acid in the blood) and status post (s/p) septic shock (a life-threatening condition that happens when the blood pressure drops to a dangerously low level after an infection). The H&P indicated the resident was on a ventilator (a machine that helps a person breathe) with occasional grunting. A review of Resident 23's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/20/2023, indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident had an indwelling catheter. The MDS indicated the resident had an active diagnosis of renal insufficiency (poor function of the kidneys), urinary tract infection (UTI, a bacterial infection of the bladder and associated structures), and depression. A review of Resident 23's Care Plan titled, Altered Urinary Elimination/At Risk for UTI/At Risk for Skin Breakdown, initiated on 8/26/2020, indicated interventions that included providing privacy bag as required and applying leg strap to secure catheter tubing. During a concurrent observation and interview on 4/13/2024, at 11:15 a.m., with Licensed Vocational Nurse 1 (LVN 1), in Resident 23's room, observed the resident's urinary catheter drainage bag hanging on the left lower part of the bed, visible from the doorway and without a dignity bag. LVN 1 stated the urinary catheter drainage bag should have been covered with dignity bag to protect the privacy of the resident and to promote the resident's right to a dignified existence. During an interview on 4/14/2024, at 7:37 p.m., with the Nurse Manager (NM), the NM stated staff should have placed a dignity bag on the resident's urinary catheter drainage bag to provide dignity to Resident 23. The NM stated without the dignity bag, the resident's urine in the drainage bag is visible to visitors and other residents' family members. A review of the facility's policy and procedure titled, Standards of Care- Sub Acute (is intensive, but to a lesser degree than acute care), last revised on 3/2024, indicated an individualized plan of care is implemented for residents requiring an indwelling catheter that includes use of a dignity cover to protect the resident's privacy and dignity. 2. A review of Resident 238's Face Sheet indicated the facility admitted the resident on 2/4/2024, with diagnoses including of respiratory failure. A review of Resident 238's H&P, dated 2/5/2024, indicated the resident had a history of cerebrovascular accident (CVA, an interruption in the flow of blood to cells in the brain) and pulmonary embolism (a sudden blockage of a blood vessel in the lung). The H&P indicated the resident moves all extremities, no focal deficits (is not specific to a certain area of the brain), and non-verbal. A review of Resident 238's MDS, dated [DATE], indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident had hemiplegia (one-sided muscle paralysis or weakness) or hemiparesis (weakness of one entire side of the body). During a concurrent observation and interview on 4/13/2024, at 8:49 a.m., in Resident 238's room, observed the resident's head of bed (HOB) elevated 80 to 90 degrees and Certified Nursing Assistant 1 (CNA 1) standing over the resident, while assisting the resident with feeding. CNA 1 stated he should have sat on an eye level with the resident to provide the resident dignity. CNA 1 stated standing over the resident while feeding the resident conveys disrespect to the resident. During an interview on 4/14/2024, at 7:37 p.m., with the Nurse Manager (NM), the NM stated CNA 1 should have sat on a chair within eye level with Resident 238 while assisting the resident to eat to convey respect to the resident. The NM also stated sitting at an eye level keeps the staff aware when the resident was choking or not swallowing the food. A review of the Lippincott procedure Manual provided by the facility titled, Feeding, last revised on 12/11/2023, indicated meeting such patient's nutritional needs requires determining the patient's food preferences; feeding the patient in a friendly, unhurried manner; encouraging self-feeding whenever possible to promote independence and dignity; and documenting intake and output. Position a chair next to the patient's bed so you can sit comfortably if you need to assist with feeding. Face the patient during feeding, make eye contact, and use a gentle tone of voice.

Based on observation, interview, and record review the facility failed to ensure residents resident receive care and services for the provision of parenteral fluids (medicines or fluids that go directly into the vein) consistent with professional standards of practice to two out of two sampled residents (Residents 21 and 238) investigated during random observations of residents receiving parenteral/intravenous (IV, within a vein) fluids by failing to label the peripheral IV (indwelling single-lumen plastic conduits that allow fluids, medications and other therapies such as blood products to be introduced directly into a peripheral vein) dressing with the date of when the IV was inserted or when the dressing was changed and the licensed nurse's initials who inserted the IV or changed the dressing. The deficient practice had the potential for complications related to intravenous fluid administration such as infiltration, bruising, phlebitis (inflammation of a vein), and infections. Findings: 1. A review of Resident 21's Face Sheet indicated the facility admitted the resident on 12/1/2021, with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe). A review of Resident 21's History and Physical (H&P), dated 1/24/2024, indicated the resident had a history of sepsis (the body's extreme response to an infection), on a ventilator (a machine that helps a person breathe) via tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow air to fill the lungs). The H&P indicated the resident does not follow commands. A review of Resident 21's All Active Orders, dated 2/19/2022, indicated an order for hypoglycemia (low blood sugar) management until discontinued. If unable to eat, gastrointestinal (GI) tract unavailable of the patient is unconscious: -if a large bore intravenous (IV) or central line (a tube that doctors place in a large vein in the neck, chest, groin, or arm to give fluids, blood, medications or to do medical tests quickly) is already in place, infuse 25 grams (a unit of weight) (50 cubic centimeter [cc, a unit of volume]) of D50 (50% dextrose injection indicated in the treatment of low blood sugar) IV push within 3 to 9 minutes. During a concurrent observation and interview on 4/13/2024, at 10:39 a.m., with Respiratory Therapist 1 (RT 1), in Resident 21's room, observed an unlabeled peripheral IV line, gauge 22 (needle gauge size) on the resident's right arm. RT 1 stated the peripheral IV was not labeled with a date and was not initialed by the licensed nurse who inserted or changed the dressing of the peripheral IV. During an interview on 4/13/2024, at 10:42 a.m., with Registered Nurse 6 (RN 6), RN 6 stated the peripheral IV should have been labeled with the insertion date or when the dressing was changed so that staff will know when to start a new line or when to change the dressing. RN 6 stated not dating the peripheral IV can result in staff not knowing when to change the dressing or start a new line which had the potential to lead to an infection. 2. A review of Resident 238's Face Sheet indicated the facility admitted the resident on 2/4/2024, with diagnoses including respiratory failure. A review of Resident 238's H&P, dated 2/5/2024, indicated the resident had a history of pulmonary embolism (a sudden blockage of a blood vessel in the lung) and septic shock (a life-threatening condition that happens when the blood pressure drops to a dangerously low level after an infection). The H&P indicated the resident moves all extremities, no focal deficits (not specific to a certain area of the brain), and non-verbal. A review of Resident 238's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/8/2023, indicated the resident rarely to never hand the ability to make self-understood and understand others. A review of Resident 238's All Active Orders, dated 2/4/2024, indicated an order for hypoglycemia management until discontinued. If unable to eat, GI tract unavailable of the patient is unconscious: -if a large bore IV or central line is already in place, infuse 25 grams (50 cc) of D50 IV push within 3 to 9 minutes. During a concurrent observation and interview on 4/13/2024, at 8:49 a.m., with Certified Nursing Assistant 2 (CNA 2), in Resident 238's room, observed a peripheral IV line, gauge 24 on Resident 238's right hand. CNA 2 stated the IV dressing did not have a date and did not have the licensed nurse's initials. CNA 2 stated the IV line was not dated. CNA 2 stated she knew that IV lines should be dated for infection control purposes, so the licensed nurses knew when to start a new IV or change the dressing. During an interview on 4/13/2024, at 11:38 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 328's peripheral IV line should be dated and initialed, so they know when to change the line, to prevent infection. During an interview on 4/14/2024, at 7:58 p.m., with the Nurse Manager (NM), the NM stated the peripheral IV line should be dated and initialed by the nurse who started the line or changed the dressing, so the licensed nurses know when to reinsert a new line or change the dressing. The NM stated not labeling the peripheral IV lines could potentially result in missed dressing care or new insertions which can lead to phlebitis (vein flammation) and cellulitis (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin). A review of the facility's recent policy and procedure titled, Comprehensive Vascular Access Management, last reviewed on 5/2023, indicated frequency of dressing changes: a. Dressings are to be changed every seven (7) days or earlier if soiled, damp, or loose. b. Gauze dressings are to be changed every 48 hours and as needed. The dressing will be labeled, indicating the date of insertion.

Based on observation, interview, and record review the facility failed to provide residents with necessary respiratory care and services that is in accordance with professional standards of practice to one out of one sampled resident (Resident 34) investigated during review of respiratory care by failing to connect the trach collar (used to hold a tracheostomy tube [a tube constructed of polyvinyl chloride that is placed between the vocal cords through the wind pipe] in place) to the oxygen humidifier (medical devices used to humidify supplemental oxygen) and oxygen regulator to ensure delivery of oxygen required to keep the resident's oxygen saturation (O2 sat, measures what percentage of the blood is saturated with oxygen) above 92%. The deficient practice had a potential to cause Resident 34 hypoxia (absence of enough oxygen in the tissues to sustain bodily functions) resulting in respiratory problems. Findings: A review of Resident 34's Face Sheet indicated the facility admitted the resident on 11/8/2023, with diagnose including respiratory failure (a serious condition that makes it difficult to breathe). A review of Resident 34's History and Physical (H&P), dated 11/10/2023, indicated the resident had a fall and sustained traumatic brain injury (TBI, a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain). The H&P indicated the resident was awake but non-communicative. A review of Resident 34's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/1/2023, indicated the resident rarely to never had the ability to make self-understood and understand others. A review of Resident 34's All Active Orders, dated 3/21/2024, indicated an order for: -Oxygen therapy until discontinued. Via trach mask or t-piece (allows for the delivery of oxygen therapy to residents who have had a tracheostomy [an opening surgically created through the neck into the windpipe to allow air to fill the lungs]), keep oxygen saturation (O2 sat, measures what percentage of the blood is saturated with oxygen) greater than (>) 92. A review of Resident 34's Care Plan titled, Problem: Device-Related Complication Risk (Artificial Airway), no date, indicated an intervention to assess and monitor airway and breathing for effective oxygenation and ventilation; maintain close surveillance for deterioration due to airway swelling or obstruction; signs may be subtle and provide humidification and evaluate need or suctioning to minimize risk of airway obstruction; regularly replace closed suction equipment. During an observation and interview on 4/13/2024, at 9:04 a.m., with Registered Nurse 1 (RN 1), in Resident 34's room, observed the resident's t-piece (an instrument used in weaning of a resident from a ventilator) not connected to the oxygen regulator. RN 1 stated the t-piece should be connected to the oxygen regulator with the humidifier to administer the prescribed oxygen concentration. RN 1 stated failure to connect the t-piece to the oxygen regulator could lead to respiratory distress. During an interview on 4/14/2024, at 7:59 p.m., with the Nurse Manager (NM), the NM stated the respiratory therapist who provided the breathing treatment should have checked if the t-piece was connected back to the oxygen regulator to ensure delivery oxygen to the resident. The NM stated not reconnecting the t-piece to the oxygen regulator was unsafe and can result in respiratory compromise. A review of the facility's recent policy and procedure titled, Respiratory Protocol to Evaluate and Treat (Adult), last reviewed on 6/2019, indicated the purpose of this policy is to define the scope and process of assessments on patient's ordered under Respiratory Protocol to Evaluate and Treat (RT to Evaluate and Treat).

Based on observation, interview, and record review, the facility: 1.Failed to ensure licensed nurse did not leave an insulin pen (an injection device that you can use to deliver preloaded insulin [controls the amount of sugar in the blood by moving it into the cells, where it can be used by the body for energy]) unattended on top of a computer on wheels (WOW). This deficient practice had the potential to result in unwanted serious side effects if placed in undesired hands which can lead to harm. 2.Failed to ensure licensed nurses' account of a controlled drug record (accountability record of medications that are considered to have a strong potential for abuse) was accurately documented per facility policy for one of two sampled residents. This deficient practice had the potential for medication errors. Findings: a. During an observation on 4/13/2024 at 12:09 p.m., observed Licensed Vocational Nurse 3 (LVN 3) place an insulin pen on top of a computer on wheels (wow). Observed LVN 3 walked away from the wow entering a resident's room, leaving the insulin pen unattended. During an observation and concurrent interview on 4/13/2024 at 12:23 p.m., Licensed LVN 3 stated that she left the insulin pen unattended on top of the wow while she entered a resident's room. LVN 3 stated that she should always have all medication with her at all times for safety. LVN 3 further stated that she should not have left the insulin pen on top of the wow unattended. A review of the facility's policy and procedure titled, Medication Administration and Monitoring (Sub Acute), revised 3/2024, indicated medications are removed from the medication cart for one resident at a time. Once removed, medications must remain with the administering staff at all times and not left unattended. b. A review of Resident 11's admission Record indicated the facility admitted the resident on 12/8/2023 with diagnosis that included respiratory failure (a serious condition that makes it difficult to breathe on your own) and seizure disorder (a sudden, uncontrolled burst of electrical activity in the brain). A review of Resident 11's Physician's Order dated 12/11/2023 indicated Lacosamide (Vimpat- to treat partial-onset seizures) 10 milligram (mg - unit of measurement)/milliliter (mL - unit of measurement) liquid 150 mg. Per g-tube (gastrostomy tube -a tube inserted through the belly that brings nutrition directly to the stomach) every morning. A review of Resident 11's Physician's Order, dated 12/11/2023, indicated Lacosamide (Vimpat) 10mg/mL liquid 200 mg. Per g-tube nightly. A reviewed of Resident 11's controlled-drug record for Lacosamide (Vimpat) 10mg/mL solution indicated: - Date: 3/8/2024; Administered Time: 8:15 p.m.; Administered Amount: 20; Amount Remaining: 20 - Date: 3/9/2024; Administered Time: 9:00 a.m.; Administered Amount: 15; Amount Remaining: 5 During an interview and concurrent record review with Registered Nurse 3 (RN 3) on 4/13/2024 at 3:56 p.m., RN 2 reviewed Resident 11's controlled-drug record and stated that Resident 11's controlled drug record for Lacosamide (Vimpat) not accurate. RN 3 stated that on 3/8/2024 20 mL was administered and on 3/9/2024 15 mL was administered, remaining should have been 10 mL, not 5 mL. RN 3 stated that licensed nurses should have checked the bottle and levels carefully to ensure that the accurate amount in the bottles matches what is documented on the controlled drug record at the start of every shift. During an interview and concurrent record review with the Nurse Manager (NM) on 4/13/2023 at 7:01 p.m., the NM reviewed Resident 11's controlled drug record and stated that Resident 11's controlled drug record for Lacosamide (Vimpat) count is wrong. Amount remaining should have been 10 mL not 5 mL. Staff should have identified the discrepancy in the beginning of the shift and reported the discrepancy per the facility's policy. A review of the facility's policy and procedure titled, Controlled Medication Storage, dated 8/2014, indicated medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal, state, and other applicable laws and regulations. At each shift change, physical inventory of all controlled medications, including the emergency supply is conducted by two licensed nurses and is documented on the controlled medication accountability record. Any discrepancy in controlled substance medication count is reported to the director of nursing immediately. The director or designee investigates and makes every reasonable effort to reconcile all reported discrepancies. The director of nursing documents irreconcilable discrepancies in a report to the administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure if needed (PRN) orders for psychotropic medications (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, and behavior) were only used when the medication was necessary and PRN use was only limited to two of five residents (Residents 23 and 5) selected for unnecessary medications review. The deficient practice had the potential to result in the use of unnecessary psychotropic drugs for residents and can lead to side effect and adverse (unwanted) consequence such as a decline in quality of life and functional capacity. Findings: 1. A review of Resident 23's Face Sheet (admission Record) indicated the facility admitted the resident on 3/13/2024, with a diagnosis of respiratory failure (a serious condition that makes it difficult to breathe). A review of Resident 23's History and Physical (H&P), dated 4/3/2024, indicated the resident had a history of post traumatic cervical-spine injury (involves damage to any part of the spinal cord), quadriplegia (a life-altering condition that results in a loss of control of both arms and both legs), and septic shock (a life-threatening condition that happens when the blood pressure drops to a dangerously low level after an infection). The H&P indicated the resident was on a ventilator (a machine that helps a person breathe) with occasional grunting. A review of Resident 23's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/20/2023, indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated Resident 23 had an active diagnosis of depression. A review of Resident 23's All Active Orders, dated 3/14/2024, indicated an order for lorazepam (Ativan, used to treat anxiety) tablet 0.5 milligrams (mg, a unit of weight) per gastrostomy tune (g-tube, a tube inserted through the wall of the abdomen directly to the stomach) every 6 hours PRN. PRN reasons: Anxiety Admin instructions: diagnosis (Dx) Anxiety monitor for behavior (m/b) hyperventilation (rapid or deep breathing) leading to shortness of breath (SOB). A review of Resident 23's Consultant Pharmacist's Medication Regiment Review (MRR) between 1/1/2024 and 1/30/2024, indicated the medications were reviewed by the consultant pharmacist. The MRR created between 2/1/2024 and 2/29/2024, indicated a recommendation from the pharmacist the resident has an order for PRN Ativan 0.5 mg. Please, specify the stop date. A new order can be written if the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication and documents their rationale in the resident's medical record and indicates the duration for the PRN order. During a concurrent interview and record review on 4/14/2024, at 7:55 p.m., with the Nurse Manager (NM), reviewed the Active Orders and the Medication Regimen Review pharmacist recommendations for Resident 23 with the NM. The NM confirmed the following orders for Resident 23, 3/14/2024 lorazepam (Ativan) tablet 0.5 mg per g-tube every 6 hours PRN without an end date. The NM also reviewed the MMR created between 2/1/2024 and 2/29/2024 for Resident 23 indicating a recommendation from the pharmacist the resident has an order for PRN Ativan 0.5 mg, please specify the stop date. The NM stated the lorazepam order for Resident 23 did not have a stop date and the pharmacist recommendation was not followed up. The NM stated psychotropic drugs such as the lorazepam should only be good for 14 days duration. The NM stated prolonged use of psychotropic medications can result in the use of unnecessary psychotropic drugs for residents and can lead to unwanted side effects, dependency on the drug that can lead to a decline in quality of life and functional capacity. A review of the Consultant Pharmacist's Medication Regiment Review between 1/1/2024 and 1/30/2024, indicated the medications were reviewed by the consultant pharmacist. Recommendations created between 2/1/2024 and 2/29/2024 indicated Resident 23 has an order for PRN Ativan 0.5 mg. Please, specify the stop date. A new order can be written if the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication and documents their rationale in the resident's medical record and indicates the duration for the PRN order. A review of the Pharmacist Consultant Summary Report for February 2024, indicated on E. Psychotropic Medications (F-tag 758), PRN Antipsychotic orders are always only x 14 days. A review of the facility's recent policy and procedure titled, Psychotropic Drugs (Sub Acute), last reviewed on 2/2024, indicated PRN psychotropic medications will have a start and stop date for 14 days initially then re-evaluated by MD. If needed to be continued, medication will be ordered for three months. The residents will have a monthly review documenting all behavior episodes for that month. 2. A review of Resident 5's Face Sheet indicated the facility admitted the resident on 8/28/2021, with a diagnosis of gastrointestinal (GI, relating to, or including both the stomach and intestine) bleed. A review of Resident 5's H&P, dated 8/18/2023, indicated the resident had agitation and delirium (a mental state in which a person is confused and has reduced awareness of their surroundings) being followed up by a psych specialist. The H&P indicated the resident was awake and interactive. A review of Resident 5's MDS, dated [DATE], indicated the resident sometimes had the ability to make self-understood and understand others. A review of Resident 5's All Active Orders, dated 1/24/2024, indicated an order for lorazepam (Ativan) 1 tablet per g-tube every 12 hours PRN, with a start date of 1/24/2024 and stop date of 4/23/2024. PRN reasons: Anxiety Admin instructions: Dx; Anxiety m/b throwing objects on the floor, pulling out medical devices. During a concurrent interview and record review on 4/14/2024, at 7:55 p.m., with the Nurse Manager (NM), reviewed the Active Orders and the Medication Regimen Review pharmacist recommendations for Resident 5 with the NM. The NM confirmed for Resident 5, lorazepam (Ativan) 1 tablet per g-tube every 12 hours PRN, with a start date of 1/24/2024 and stop date of 4/23/2024 more than 14 days of effectivity. The NM stated the lorazepam order for Resident 5 had more than 14 days effectivity of the order. The NM stated psychotropic drugs such as the lorazepam should only be good for 14 days duration. The NM stated prolonged use of psychotropic medications can result in the use of unnecessary psychotropic drugs for residents and can lead to unwanted side effects, dependency on the drug that can lead to a decline in quality of life and functional capacity. A review of the Consultant Pharmacist's Medication Regiment Review between 1/1/2024 and 1/30/2024, indicated the medications was reviewed by the consultant pharmacist. Recommendations created between 2/1/2024 and 2/29/2024 indicated the resident had an order for PRN Ativan 0.5 mg. Please, specify the stop date. A new order can be written if the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication and documents their rationale in the resident's medical record and indicates the duration for the PRN order. A review of the Pharmacist Consultant Summary Report for 2/2024, indicated on E. Psychotropic Medications (F-tag 758), PRN Antipsychotic orders are always only x 14 days. A review of the facility's recent policy and procedure titled, Psychotropic Drugs (Sub Acute), last reviewed on 2/2024, indicated PRN psychotropic medications will have a start and stop date for 14 days initially then re-evaluated by MD. If needed to be continued, medication will be ordered for three months. The residents will have a monthly review documenting all behavior episodes for that month.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility staff failed to implement its infection control program to two out of 23 sampled residents (Residents 5 and 3) during resident screening by failing to ensure: 1. The suction canister (a temporary storage container for secretions or fluids removed from the body) of Resident 5, labeled 4/5/2024 was discarded and replaced per facility policy. 2. The urinal bottle (frequently used in healthcare for residents who find it impossible or difficult to get out of bed) was labeled with the name, date, and room number of Resident 3. These deficient practices had to potential to spread infection among residents. Findings: 1. A review of Resident 5's Face Sheet indicated the facility admitted the resident on 8/28/2021, with a diagnosis of gastrointestinal (GI, relating to, or including both the stomach and intestine) bleed. A review of Resident 5's History and Physical (H&P), dated 8/18/2023, indicated the resident had a history of coronary artery bypass graft (CABG, a medical procedure to improve blood flow to the heart), craniotomy (a surgical procedure in which a part of the skull is temporarily removed to expose the brain), and tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs). The H&P indicated the resident was awake and interactive. A review of Resident 5's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/23/2024, indicated the resident sometimes had the ability to make self-understood and understand others. During a concurrent observation and interview on 4/13/2024, at 10:55 a.m., with Licensed Vocational Nurse 2 (LVN 2), inside Resident 5's room, observed the suction canister of the resident dated 4/5/2024. LVN 2 stated the suction canister should be changed weekly to prevent the growth and transmission of infection among residents. During an interview on 4/14/2024, at 8 p.m., the Nurse Manager (NM) stated the suction canister should have been changed on 4/12/2024. The NM stated the suction canisters were changed weekly to prevent growth of bacteria on the suction canisters that could cause infection to vulnerable residents. A review of the facility's recent policy and procedures titled, Mechanical Ventilation, Monitoring and Care, Long-term Care, last reviewed on12/11/2023, indicated for suction canister, replacement schedule was weekly and when three quarters full and the supply should be dated and initialed. 2. A review of Resident 3's Face Sheet indicated the facility admitted the resident on 8/2/2023, with a diagnosis of respiratory failure (a serious condition that makes it difficult to breathe). A review of Resident 3's H&P, dated 5/10/2023, indicated the resident had history of status post (s/p) tracheostomy and stage 1 sacral pressure injury (observable, pressure-related redness of a localized area usually over a bony prominence such as the sacrum [tailbone]). The H&P indicated the resident was awake, interactive, moves all extremities, with generalized weakness. A review of Resident 3's MDS, dated [DATE], indicated the resident had the ability to make self-understood and understand others. During a concurrent observation and interview on 4/13/2024, at 9:30 a.m., with Certified Nursing Assistant 3 (CNA 3), inside Resident 3's room, observed two unlabeled urinal bottles hanging at the left side rail of the resident's bed. CNA 3 stated the urinals should be labeled with the name, date, and room number of the resident so they know when to change them and to prevent interchanging urinals that could cause infection. During an interview on 4/14/2024, at 8 p.m., the Nurse Manager (NM) stated the staff should label the urinal with date, room number, and the name of the resident to know when to change the urinals and to prevent switching urinals with other residents to prevent infection. A review of the facility's recent policy and procedure titled, General Acute Care Hospital 1 (GACH 1) Department of Epidemiology & Infection Prevention 2024 Scope of Service, Surveillance Plan, Risk Assessment, and 2023 Program Evaluation, undated, indicated infection control is multi-disciplinary, systemic approach to quality patient care that emphasizes risk reduction of disease transmission in a health care environment. It can further be defined as the establishment of a program or a plan of action to prevent disease transmission in those cases that cannot be prevented. This is accomplished by setting controls or standards that have been proven to be effective in minimizing those infections that cannot be prevented, preventing those that can be, and providing early diagnosis and appropriate treatment of all infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 23's Face Sheet indicated the facility admitted the resident on 3/13/2024, with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe). A review of Resident 23's History and Physical (H&P), dated 4/3/2024, indicated the resident had a history of post traumatic cervical-spine injury (involves damage to any part of the spinal cord) and quadriplegia (a life-altering condition that results in a loss of control of both arms and both legs). The H&P indicated the resident was on a ventilator (a machine that helps a person breathe) with occasional grunting. A review of Resident 23's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/20/2023, indicated the resident rarely to never had the ability to make self-understood and understand others. A review of Resident 23's Fall Risk Assessment (FRA), dated 4/14/2024, indicated the resident was a medium risk for fall and at high risk for falls with injury. The FRA included the documentation of the application of the bed alarms. The FRA did include documentation of the resident using four side rails up in bed. A review of Resident 23's Care Plan titled, Problem: Fall Injury Risk, undated, indicated an intervention to avoid use of devices that minimize mobility such as restraints. During a concurrent observation and interview on 4/13/2024, at 11:15 a.m., with Licensed Vocational Nurse 1 (LVN 1), in Resident 23's room, observed Resident 23 in bed with four SR in raised position and a bed alarm in place. LVN 1 stated the resident's bed had all four side rails up and a bed alarm in place to prevent injuries resulting from falls. LVN 1 stated placing all 4 side rails up is considered use of a restraint. LVN 1 stated she is unsure if placement of bed alarm is considered a restraint. LVN 1 stated the bed alarm is to alert the staff if the resident is getting out of bed. LVN 1 stated a physician's order and consent from the resident's representative should be obtained prior to SR use. During a review of Residents 23's Physical Chart on 4/13/2024, at 4:37 p.m., there was no documented evidence a consent for use of four side rails up and bed alarm was obtained from the resident and or the resident's representative. During an interview on 4/14/2024, at 1:17 p.m., with the Nurse Manager (NM), the NM stated placing the resident's all four SR up is considered use of a restraint. The NM stated a physician's order, an assessment for entrapment risk, and consent from the resident or the resident representative (RR) should be in place prior to use of side rails. The NM stated the resident, or the RR should be informed of the risk and the benefits of using the restraints prior to application. The NM stated the bed alarms are used to notify the nurse if the resident is getting out of the bed and is not considered a restraint. The NM stated the application of four side rails up prevents the resident from getting out of bed thus hindering the resident from moving freely. The NM stated hindering the resident movement could potentially cause debilitation and injuries. A review of the facility's recent policy and procedure titled, Restraint Use (Sub Acute), last revised on 2/2024, indicated in keeping with the mission and values of General Acute Care Hospital 1 (GACH 1) to guide care givers on appropriate and safe management of residents with restraints and utilization of least restrictive alternatives. To ensure safe and ethical practice for the use of physical restraints in the Sub-Acute Unit and that no person will be restrained against their will for any period of time longer than necessary. Restraints are considered medical devices and are only used in the event that the patient is a danger to self or others. Consent for restraint is signed by legal representative/decision-maker. The licensed nurse will assess the patient and attempt to find less restrictive alternatives to restraint. Licensed healthcare practitioner order is required; orders for restraints obtained by telephone will be signed by the physician within five days; restraints are reordered every 30 days if continued need is assessed. Documentation on restraints will include device(s): a. Bed rails X 4 b. Mittens, including Peek-a-Boo mitts c. Mittens d. Soft wrist restraints e. Assessment for continued need 3. A review of Resident 5's Face Sheet indicated the facility admitted the resident on 8/28/2021, with diagnoses including gastrointestinal (GI, relating to, or including both the stomach and intestine) bleed. A review of Resident 5's H&P, dated 8/18/2023, indicated the resident had a history of alcohol abuse, and had a pedestrian accident sustaining bilateral subarachnoid hemorrhage (SAH, a bleeding in the space below one of the thin layers that cover and protect the brain), left subdural hemorrhage (SDH, a buildup of blood on the surface of the brain), with multiple facial bone fracture (partial or complete break in the bone). The H&P indicated the resident was awake and interactive with agitation and delirium (a mental state in which a person is confused and has reduced awareness of their surroundings). A review of Resident 5's MDS, dated [DATE], indicated the resident sometimes makes self-understood and understand others. The MDS indicated the resident had behavioral symptoms not directed towards others. The MDS indicated the resident was on a bed alarm. A review of Resident 5's FRA, dated 4/14/2024, indicated the resident was assessed as medium risk for fall and use of bed alarm was in place, The FRA did not indicate use of all four side rails up. A review of Resident 5's Care Plan titled, Problem: Fall Injury Risk, initiated on 8/2/2023, indicated the resident had a fall episode, found resident sitting on the floor at the right side of the bed on 8/2/2023. The Care Plan indicated the resident had lack of safety awareness/judgment due to impaired cognition (a term for mental processes that take place in the brain, including thinking, attention, language, learning, memory, and perception) and needed assistance during transfer from bed to shower gurney or vice versa. During a concurrent observation and interview on 4/13/2024, at 10:55 a.m., with Licensed Vocational Nurse 2 (LVN 2), in Resident 5's room, observed Resident 5 in bed with four SR in raised position and a bed alarm in place. LVN 2 stated the resident's bed had all four side rails up and a bed alarm is in place to prevent the resident from falling. LVN 2 stated use of side rails and bed alarm do not need a physician's and consent from the resident's representative. LVN 2 stated he does not consider use of four side rails up and bed alarms as restraints. LVN 2 stated the side rails are up so the resident will not be able to get out of bed and the bed alarms are to alert the staff if the resident is getting out of bed, to prevent falls. During a concurrent interview and record review on 4/13/2024, at 2:13 p.m., with Registered Nurse 4 (RN 4), reviewed Resident 5's All Active Orders, Flow Sheet, and Media. RN 4 stated there was no documented evidence of informed consent for side rails and entrapment risk assessment for side rail use. RN 4 stated the resident's bed had all four side rails up and a bed alarm is in place to prevent falls. During a review of Residents 5's Physical Chart on 4/13/2024, at 4:37 p.m., there was no documented evidence a consent for use of four side rails up and bed alarm was obtained from the resident and or the resident's representative. During an interview on 4/14/2024, at 1:15 p.m., with the Nurse Clinician (NC), the NC stated use of four side rails up is considered use of a restraint and required an order from the physician. The NC also stated the resident should have an assessment for side rail use to ensure safety. The NC stated use of four side rails up and bed alarm was implemented to prevent Resident 5 from getting out of the bed and to alert the staff if the resident was getting out of bed. The NC stated the use of bed alarm is not considered use of a restraint. During an interview on 4/14/2024, at 1:17 p.m., with the Nurse Manager (NM), the NM stated placing the resident's all four SR up is considered use of a restraint. The NM stated a physician's order, an assessment for entrapment risk, and consent from the resident or the resident representative (RR) should be in place prior to use of side rails. The NM stated the resident, or the RR should be informed of the risk and the benefits of using the restraints prior to application. The NM stated the bed alarms are used to notify the nurse if the resident is getting out of the bed and is not considered a restraint. The NM stated the application of four side rails up prevents the resident from getting out of bed thus hindering the resident from moving freely. The NM stated hindering the resident movement could potentially cause debilitation and injuries. A review of the facility's recent policy and procedure titled, Restraint Use (Sub Acute), last revised on 2/2024, indicated in keeping with the mission and values of General Acute Care Hospital 1 (GACH 1) to guide care givers on appropriate and safe management of residents with restraints and utilization of least restrictive alternatives. To ensure safe and ethical practice for the use of physical restraints in the Sub-Acute Unit and that no person will be restrained against their will for any period of time longer than necessary. Restraints are considered medical devices and are only used in the event that the patient is a danger to self or others. Consent for restraint is signed by legal representative/decision-maker. The licensed nurse will assess the patient and attempt to find less restrictive alternatives to restraint. Licensed healthcare practitioner order is required; orders for restraints obtained by telephone will be signed by the physician within five days; restraints are reordered every 30 days if continued need is assessed. Documentation on restraints will include device(s): a. Bed rails X 4 b. Mittens, including Peek-a-Boo mitts c. Mittens d. Soft wrist restraints e. Assessment for continued need Based on observation, interview, and record review the facility failed to ensure the residents were free from any physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) to three out of four sampled residents (Residents 24, 23, and 5) investigated during review of physical restraints care area by: 1. Failing to complete an assessment for risk of entrapment prior to use of four bed siderails (SR) up (raised [up] position on bilateral [two sides] upper [area including arms, shoulders, and head] and bilateral lower [area including legs]). 2. Failing to obtain a physician's order for the use of four bed SR up and bed alarms (warn caregivers when residents leave or attempt to leave their beds). 3. Failing to obtain an informed consent prior to use of four bed SR up while in bed and bed alarms. These deficient practices placed the resident at risk for restriction from freedom of movement, decline in physical functioning, psychosocial harm, physical harm from entrapment, and death. Cross reference F700 Findings: 1. A review of Resident 24's Face Sheet indicated the facility originally admitted the resident on 7/16/2020 and readmitted the resident on 3/31/2022 with diagnoses including traumatic brain injury (a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain which may result to disability or death), dysphagia (a condition in which swallowing is difficult or painful), percutaneous endoscopic gastrotomy (PEG - also known at GT, a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube) placement, and chronic respiratory failure (a long-term condition in which the lungs have a hard time loading the blood with oxygen which may result to low oxygen level). A review of Resident 24's History and Physical (H&P), dated 11/3/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 24's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 1/29/2024, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and totally dependent on staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 24's Morse Fall Risk Assessment every shift dated 4/11/2024, 4/12/2024, 4/13/2024, and 4/14/2024, indicated the resident was a medium risk for falls and a high risk for injury. A review of Resident 24's Order Reports did not indicate an order for four bed SR up. A review of Resident 24's every shift assessment by licensed nurses did not indicate the resident was assessed for possible entrapment with the use of four bed SR up prior to use. During a concurrent observation and interview on 4/13/2024 at 10:15 a.m., with Licensed Vocational Nurse 3 (LVN 3), observed Resident 24 in bed with four SR up. LVN 3 stated the resident places her right leg over the SR most of the time and placing four SR in raised up position is for the safety of the resident. LVN 3 stated the resident is at risk for falls and the SR prevent the resident from falling. During a concurrent observation and interview on 3/13/2024 at 10:39 a.m., with Registered Nurse 2 (RN 2), RN 2 stated Resident 24's four bed SR were placed in raised position while in bed for the resident's safety, to prevent falls and possibly injury as resident moves a lot in the bed. During a concurrent interview and record review on 4/13/2024 at 4:00 p.m., with the Infection Preventionist (IP), Resident 24's medical record including assessments, physician orders and informed consents were reviewed. The IP verified the resident did not have an assessment, physician's order, and consent for the use of four bed SR up while in bed because the facility does not consider SR as restraints. During an interview on 4/14/2024 at 1:15 p.m., with the Nurse Clinician (NC), the NC stated the use four SR up while the resident is in bed is considered use of a restraint. The NC stated there should have been an order from the physician and assessment for entrapment risk for SR use prior to use of four SR up. During an interview on 4/14/2024 at 1:17 p.m., with the Nurse Manager (NM), the NM stated placing the resident's all four SR up is considered use of a restraint and there should have been an order from the physician and assessment for entrapment risk for SR use. The NM stated it is important to notify the Resident 24's representative of the risks and benefits of using four SR up so they (representative) would be aware of the potential risks from using the SR such as restriction of movement, decline in functioning and entrapment which may lead to injuries. A review of the facility's recent policy and procedure titled, Restraint Use (Sub Acute), last revised on 2/2024, indicated the following: - It is the policy of general acute care hospital 1(GACH 1) to guide care givers on appropriate and safe management of residents with restraints and utilization of least restrictive alternatives. - Ensure safe and ethical practice for the use of physical restraints, that no person will be restrained against their will for any period of time longer than necessary. - Restraints are considered medical devices and are only used in the event that the patient is a danger to self or others. Consent for restraint is signed by legal representative/decision-maker. - The licensed nurse will assess the patient and attempt to find less restrictive alternatives to restraint. - Licensed healthcare practitioner order is required; orders for restraints obtained by telephone will be signed by the physician within five days; restraints are reordered every 30 days if continued need is assessed. - Documentation on restraints will include device(s): a. Bed rails X 4 b. Mittens, including Peek-a-Boo mitt. c. Mittens d. Soft wrist restraints e. Assessment for continued need

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to: 1. Develop and implement a care plan for bed alarm (device that warns caregivers when residents leave or attempt to leave their beds) use to two of four sampled residents investigated during review of restraints (Residents 23 and 5). 2. Develop and implement a comprehensive person-centered care plan for use of four bed siderails (SR) to three of four sampled residents (Resident 23, 24 and 5) investigated during review of restraints. These deficient practices had the potential for residents to not receive the proper and necessary care regarding SRs and bed alarm use with the potential to result in injury of the resident by failing to provide ongoing assessment, monitoring, and re-evaluation of SRs and restraints. 3. Ensure Resident 37 had a care plan addressing the use of apixaban (Eliquis-a FDA-approved to treat and prevent certain types of dangerous blood clots that can block blood vessels in your body) to one out of two sampled residents investigated during review of closed records. 4. Ensure Resident 37 had a care plan addressing the use of an indwelling catheter (a hollow flexible tube inserted in the bladder through the urethra to drain urine) to one out of one sampled resident being investigated during review of review of closed records. These deficient practices had the potential to result in inconsistent implementation of the care plan that may lead to a delay in or lack of delivery of care and services. Findings: 1. A review of Resident 23's Face Sheet indicated the facility admitted the resident on 3/13/2024, with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe). A review of Resident 23's History and Physical (H&P), dated 4/3/2024, indicated the resident had a history of post traumatic cervical-spine injury (involves damage to any part of the spinal cord) and quadriplegia (a life-altering condition that results in a loss of control of both arms and both legs). The H&P indicated the resident was on a ventilator (a machine that helps a person breathe) with occasional grunting. A review of Resident 23's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/20/2023, indicated the resident rarely to never had the ability to make self-understood and understand others. A review of Resident 23's Fall Risk Assessment (FRA), dated 4/14/2024, indicated the resident was a medium risk for fall and at high risk for falls with injury. The FRA included the documentation of the application of the bed alarms. The FRA did include documentation of the resident using four side rails up in bed. A review of Resident 23's Care Plan titled, Problem: Fall Injury Risk, undated, indicated an intervention to avoid use of devices that minimize mobility such as restraints or indwelling urinary catheter (a catheter that drains urine from the bladder into a bag outside of the body). During a concurrent observation and interview on 4/13/2024, at 11:15 a.m., with Licensed Vocational Nurse 1 (LVN 1), in Resident 23's room, observed Resident 23 in bed with four SR in raised position and a bed alarm in place LVN 1 stated there was no care plan created for SR and bed alarm use. During an interview on 4/14/2024, at 7:47 p.m., with the Nurse Manager (NM), the NM stated a care plan should have been developed and implemented for Resident 23's SR and bed alarm use. The NM stated care plan establishes goals and treatment of care that serves as their guide on how to care for the residents. The NM stated a care plan is needed to achieve quality of life. A facility's recent policy and procedure titled, Documentation, Clinical (Sub Acute), last revised on 3/2024, indicated an interdisciplinary care plan is constructed within 7 days of admission. This care plan outlines focused problems and interventions selected review of the by the health care team. For residents staying longer than 7 days, see procedure for Minimum Data Set (MDS). 2. A review of Resident 5's Face Sheet indicated the facility admitted the resident on 8/28/2021, with diagnoses including gastrointestinal (GI, relating to, or including both the stomach and intestine) bleed. A review of Resident 5's H&P, dated 8/18/2023, indicated the resident had a history of alcohol abuse, and had a pedestrian accident sustaining bilateral subarachnoid hemorrhage (SAH, a bleeding in the space below one of the thin layers that cover and protect the brain), left subdural hemorrhage (SDH, a buildup of blood on the surface of the brain), with multiple facial bone fracture (partial or complete break in the bone). The H&P indicated the resident was awake and interactive with agitation and delirium (a mental state in which a person is confused and has reduced awareness of their surroundings). A review of Resident 5's MDS, dated [DATE], indicated the resident sometimes makes self-understood and understand others. The MDS indicated the resident had behavioral symptoms such not directed towards others. The MDS indicated the resident was using a bed alarm. A review of Resident 5's FRA, dated 4/14/2024, indicated the resident was assessed as medium risk for fall and use of bed alarm was in place, The FRA did not indicate use of all four side rails up. During a concurrent observation and interview on 4/13/2024, at 10:55 a.m., with Licensed Vocational Nurse 2 (LVN 2), in Resident 5's room, observed Resident 5 in bed with four SR in raised position and a bed alarm in place. LVN 2 stated there was no care plan created for SR and bed alarm use. During a concurrent interview and record review on 4/13/2024, at 2:13 p.m., with Registered Nurse 4 (RN 4), reviewed Resident 5's care plans. RN 4 stated care plans help the licensed nurses to communicate the plan of care to the healthcare team. RN 4 stated without the care plan they will not be able to evaluate the effectivity of the interventions provided to the resident. During an interview on 4/14/2024, at 7:47 p.m., with the Nurse Manager (NM), the NM stated a care plan should have been developed and implemented for SR and bed alarm use. The NM stated care plan establishes goals and treatment of care that serves as their guide on how to care for the residents. The NM stated a care plan is needed to achieve quality of life. A facility's recent policy and procedure titled, Documentation, Clinical (Sub Acute), last revised on 3/2024, indicated an interdisciplinary care plan is constructed within 7 days of admission. This care plan outlines focused problems and interventions selected review of the by the health care team. For residents staying longer than 7 days, see procedure for Minimum Data Set (MDS). 3. A review of Resident 24's Face Sheet indicated the facility originally admitted the resident on 7/16/2020 and readmitted the resident on 3/31/2022 with diagnoses including traumatic brain injury (a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain which may result to disability or death), dysphagia (a condition in which swallowing is difficult or painful), percutaneous endoscopic gastrotomy (PEG - also known at GT, a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube) placement, and chronic respiratory failure (a long-term condition in which the lungs have a hard time loading the blood with oxygen which may result to low oxygen level). A review of Resident 24's History and Physical (H&P), dated 11/3/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 24's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 1/29/2024, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and totally dependent on staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 24's care plan did not indicate a care plan was developed for SR and bed alarm use. During a concurrent observation and interview on 4/13/2024 at 10:15 a.m., with Licensed Vocational Nurse 3 (LVN 3), observed Resident 24 in bed with four SR up. LVN 3 stated the resident is at risk for falls and the SR prevent the resident from falling. During a concurrent interview and record review on 4/13/2024 at 4:00 p.m., Resident 24's medical record was reviewed with the Infection Preventionist (IP). The IP verified the there was no care plan for SR use. During an interview on 4/14/2024 at 1:15 p.m., the Nurse Clinician (NC), stated a care plan should have been developed for the use of SRs. During an interview on 4/14/2024 at 8:45 p.m., the Nurse Manager (NM) verified there was no care plan addressing the use of SRs. The NM stated a care plan is important because it provides instructions to the healthcare team on how to properly care for Resident 24. A review of the facility's recent policy and procedure titled, Documentation, Clinical (Sub Acute), last reviewed and approved on 3/2024, indicated the following: - General acute care hospital 1 (GACH 1) ensures accurate clinical documentation in the resident's electronic health record. - GACH 1 ensures all information pertinent to each resident's individual care are accurately and effectively communicated. - An interdisciplinary care plan is constructed within seven (7) days of admission and outlines focused problems and interventions selected by the health care team. For residents staying longer than 7 days, the facility follows the procedure for MDS. 4. A review of Resident 37's admission Record indicated the facility admitted Resident 37 on 12/27/2023 with diagnoses including ischemic stroke (when a blood clot, known as a thrombus, blocks or plugs an artery leading to the brain), paroxysmal atrial fibrillation (when a person has an irregular heartbeat in the upper chambers of the heart), and acute respiratory failure (a serious condition that makes it difficult to breathe on your own). Resident 37 was dependent on a ventilator (a machine used to help a patient breathe). A review of Resident 37's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/3/2024 indicated Resident 37 cognitive (involving conscious intellectual activity such as thinking, reasoning, or remembering) skills for daily decision making were severely impaired (never/rarely made decisions). The MDS indicated Resident 37 was dependent on oral hygiene, toileting hygiene, showering, upper and lower body dressing and putting on and taking off footwear. The MDS further indicated Resident 37 was admitted to the facility with an indwelling urinary catheter (a hollow flexible tube inserted in the bladder through the urethra to drain urine). A review of Resident 37's Physician Order, dated 12/27/2023, indicated Apixaban (Eliquis, blood thinner [anticoagulant] used to treat and prevent blood clots and to prevent stroke) 5 milligram (mg - unit of measurement) tablet 5 mg twice daily for atrial fibrillation. A review of Resident 37's Physician Order, dated 1/2/2024, indicated to hold (not to administer) Eliquis. A review of Resident 37's Physician Order dated 12/27/2023 indicated insert indwelling urinary catheter one time due to critically ill with need for accurate input and output. A review of Resident 37's Physician Order dated 12/28/2023 indicated: -Insert indwelling urinary catheter time for acute urinary retention and or obstruction. - indwelling urinary catheter care 16 French for retention until discontinued. A review of Resident 37's Physician Order dated 1/10/2024 indicated continuous bladder irrigation management. -run continuous bladder irrigation (CBI) at a rate to keep pink or clearer at all times. -Do not let CBI run out. -Do not let blood clots form in bladder or tubing. -Do not remove catheter without physician's order. -if new onset of heavy or uncontrolled blood in urine appears notify provider. During a concurrent interview and record review on 4/14/2024 at 6:36 p.m. with the Nurse Manager (NM), the NM stated there was no care plan for Resident 37's indwelling urinary catheter. The NM stated there should be a care plan addressing the resident's indwelling catheter because the care plan determines the plan, interventions, evaluation, and assessments regarding treatment. The NM stated without a care plan, they are unable to set the goals of treatment and implement interventions. During a concurrent interview and record review on 4/14/2024 at 8:35 p.m. with the Nurse Manager (NM), Resident 37's care plans were reviewed. The NM stated there was no care plan for the use of Eliquis. The NM stated without a care plan there is no guidelines or goals for treatment. The NM stated not having a care plan for the use of Eliquis had the potential for not monitoring the resident for bleeding. A review of the current facility-provided policy and procedure (P&P) titled, Documentation, Clinical (Sub Acute), last revised on 3/2024 indicated all clinical documentation reflects a systemic, interdisciplinary approach to resident care. Care is based on outcome/goals listed in the care plan. An interdisciplinary care plan is constructed within 7 days of admission. This care plan outlines focused problems and interventions selected by the health care team. For residents staying longer than 7 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcer/injury (ulcers that happen on areas of the skin that are under pressure from lying in bed, sitting in a wheelchair, or wearing a cast for a long period) to three of three sampled residents (Residents 23, 27, and 14) being investigated under pressure ulcers by failing to consistently: 1. Assess and follow facility's policy and procedure of taking pictures and documenting the measurement of the stage 4 pressure injury (full thickness tissue loss with exposed bone, tendon, or muscle) of Resident 23 on the sacrum (a triangular bone at the base of the spine) and the occipital area (the back of the head). 2. Assess and follow facility's policy and procedure of taking pictures and documenting the measurement of the stage 4 pressure injury of Resident 27 on the sacrum. 3. Assess and follow facility's policy and procedure of taking pictures and documenting the appearance of the moisture related skin damage (MASD, caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, saliva, and their contents) on the sacral area of Resident 14. These deficient practices had the potential for development and worsening of pressure ulcers/injuries to residents. Findings: 1. A review of Resident 23's Face Sheet (admission Record) indicated the facility admitted the resident on 3/13/2024, with a diagnosis of respiratory failure (a serious condition that makes it difficult to breathe). A review of Resident 23's History & Physical (H&P), dated 4/3/2024, indicated the resident had history of sacral decubiti ulcers (damage to an area of the skin caused by constant pressure on the area for a long time) and venous insufficiency (a condition in which the veins have problems sending blood from the legs back to the heart). The H&P indicated the resident was on a ventilator (a machine that helps a person breathe) with occasional grunting. A review of Resident 23's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/20/2023, indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated Resident 23 was incontinent of bowel (feces). The MDS also indicated Resident 23 was at risk of developing pressure ulcers/injuries and had two unhealed stage 4 pressure injuries with pressure ulcer/injury care. A review of Resident 23's Braden Scale Assessment (BSA), dated 4/14/2024, indicated the resident was bedfast, completely immobile, and high risk for pressure ulcer/injury. A review of Resident 23's All Active Orders, dated 3/16/2024, indicated an order for: -Wound care sacrococcyx (the tailbone) pressure injury stage 4 until discontinued. Comments: Cleanse with normal saline (NS, mixture of water and salt commonly used for wound irrigation) pack with puracol (collagen dressing with the flexibility of application), moist gauze and cover with mepilex (foam dressing) every (q) shift and if needed (prn) if loose or soiled. Re-evaluate weekly. Associated wounds: wound 11/21/2022 pressure injury sacral spine. -Wound care occipital healing pressure injury stage 4 until discontinued. Comments: Cleanse with NS, apply plurogel (a burn and wound dressing) to wound bed, cover with moist gauze and mepilex dressing daily and prn if loose or soiled. Re-evaluate weekly. Associated wounds: wound 11/21/2022 pressure injury occipital region. A review of Resident 23's Care Plans titled, Problem: Impaired Wound Healing, initiated on 8/25/2020, and Problem: Skin Injury Risk Increased, undated, indicated interventions to assess and monitor wound for signs of impaired healing (e.g., drainage or purulent exudate [fluid that leaks out of blood vessels into nearby tissues], absence of healing ridge, prolonged inflammatory response) and reassess skin (injury risk, full inspection) frequently (e.g., schedule interval, with change in condition) to provide optimal early detection and prevention. During a concurrent interview and record review on 4/14/2024, at 8:42 a.m., with Registered Nurse 1 (RN 1), reviewed the Lines/Drain/airway (LDA) flowsheet of Resident 23 with RN 1. RN1 stated she does weekly wound assessment, including taking pictures, wound measurements, reviewing and updating of the pressure injury care plan documented in the multidisciplinary care progress notes. RN 1 stated there were missing assessments and documentations on the following weeks: -3/24/2024 to 3/30/2024- wound assessment, measurement, picture, and care plan review documentation. -1/1/2024, 4/4/2024, and 4/10/2024 - care plan review and revision on the multidisciplinary care progress notes. RN 1 stated she was on vacation from 3/24/2024 to 3/30/2024 and she did not know why the wound assessments were not done. RN 1 stated that it was important to follow the weekly wound assessments and documentations to see if the wound was progressing, and to inform the doctor or the wound specialist to intervene if there was a worsening of the pressure injury. During an interview on 4/14/2024, at 7:49 p.m., the Nurse Manager (NM) stated the treatment nurses should make sure they perform weekly wound assessment, including taking pictures, wound measurements, reviewing and updating of the pressure injury care plan documented in the multidisciplinary care progress notes to monitor the wound for worsening or healing of the wound. The NM stated if there was worsening of pressure injury, timely assessment and reporting was very crucial so the interdisciplinary team can be informed, and the attending physician and the wound specialist can step in. The NM stated between 3/24/2024 to 3/30/2024 they were short staffed, their wound nurse was on vacation, they had a float nurse, and they got an acute nurse rehab float, and she did not do it. A review of the facility's recent policy and procedure titled, Pressure Injury and Skin Breakdown Assessment and Prevention, last revised on 12/2022, indicated under wound assessment, complete a wound assessment for all identified wounds including: 8. Size in centimeters. A Wound certified Registered Nurse will review and validate all pressure injuries in the following categories: hospital-acquired pressure injuries (HAPIs), Stages 3 (full thickness tissue loss) and 4, deep tissue injury (DTIs, persistent non-blanchable deep red, purple or maroon areas of intact skin, non-intact skin or blood-filled blisters), Unstageable (obscured full-thickness skin and tissue loss), and any pressure injury that progresses/worsens from initial staging. The wound care RN upon consult will evaluate the wound(s) and develop a treatment plan of care and perform assessments as needed. Photographs will be taken of each wound weekly. Documentation to accompany photographs includes: a. Wound dimensions b. Wound descriptors as noted in the wound assessment. 2. A review of Resident 27's Face Sheet indicated the facility admitted the resident on 8/23/2023, with a diagnosis of respiratory failure. A review of Resident 27's H&P, dated 8/25/2023, indicated the resident had a history of diabetes mellitus (DM, occurs when the blood glucose, also called blood sugar is too high), obesity, and had a sacral decubitus stage 4. The H&P indicated Resident 27 was not following commands, had a weak cough and gag reflex. A review of Resident 27's MDS, dated [DATE], indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated Resident 27 was always incontinent of bowel. The MDS indicated Resident 27 was at risk for developing pressure ulcer/injuries and had one stage 4 pressure injury with pressure ulcer/injury care. A review of Resident 27's BSA, dated 4/14/2024, indicated the resident was bedfast and completely immobile. The BSA indicated Resident 27 was high risk for pressure injury development. A review of Resident 27's All Active Orders, dated 8/24/2023, indicated an order for wound care sacrococcyx pressure injury stage 4 until discontinued. Comments: Cleanse with NS. Pat dry, pack wound cavity with as many as can fit puracol, then moist gauze, cover with mepilex every Monday/Wednesday/Friday and prn if loose or soiled. Re-eval weekly. A review of Resident 27's Care Plan titled, Skin Injury Risk Increased, undated, indicated an intervention to reassess skin (injury risk, full inspection) frequently (e.g., scheduled interval, with change in condition) to provide optimal early detection and prevention. During a concurrent interview and record review on 4/14/2024, at 8:42 a.m., with RN 1, reviewed the LDA flowsheet of Resident 27 with RN 1. RN 1 stated there were missing assessments and documentations on the following weeks: -4/7/2024 to 4/13/2024- wound assessment, measurement, and care plan review documentation. -3/17/2024 to 3/23/2024, 3/10/2024 to 3/16/2024, 3/18/2024 to 3/24/2024, 1/21/2024 to 1/27/2024, and 12/31/2023 to 1/6/2024- care plan review and revision on the multidisciplinary care progress notes. RN 1 stated that it was important to follow the weekly wound assessments and documentations to see if the wound was progressing, and to inform the doctor or the wound specialist to intervene if there was a worsening of the pressure injury. During an interview on 4/14/2024, at 7:49 p.m., with the Nurse Manager (NM), the NM stated the treatment nurses should make sure they perform weekly wound assessment, including taking pictures, wound measurements, reviewing and updating of the pressure injury care plan documented in the multidisciplinary care progress notes to monitor the wound for worsening or healing of the wound. The NM stated if there was worsening of pressure injury, timely assessment and reporting was very crucial so the interdisciplinary team can be informed, and the attending physician and the wound specialist can step in. The NM stated between 3/24/2024 to 3/30/2024 they were short staffed, their wound nurse was on vacation, they had a float nurse, and they got an acute nurse rehab float, and she did not do it. A review of the facility's recent policy and procedure titled, Pressure Injury and Skin Breakdown Assessment and Prevention, last revised on 12/2022, indicated under wound assessment, complete a wound assessment for all identified wounds including: 8. Size in centimeters. A Wound certified Registered Nurse will review and validate all pressure injuries in the following categories: hospital-acquired pressure injuries (HAPIs), Stages 3 (full thickness tissue loss) and 4, deep tissue injury (DTIs, persistent non-blanchable deep red, purple or maroon areas of intact skin, non-intact skin or blood-filled blisters), Unstageable (obscured full-thickness skin and tissue loss), and any pressure injury that progresses/worsens from initial staging. The wound care RN upon consult will evaluate the wound(s) and develop a treatment plan of care and perform assessments as needed. Photographs will be taken of each wound weekly. Documentation to accompany photographs includes: a. Wound dimensions b. Wound descriptors as noted in the wound assessment. 3. A review of Resident 14's Face Sheet indicated the facility admitted the resident on 3/24/2024, with a diagnosis of respiratory failure. A review of Resident 14's H&P, dated 3/25/2023, indicated the resident had a history of DM, and massive intraparenchymal hemorrhage in the left basal ganglia (bleeding into the brain parenchyma [functional tissue in the brain]). The H&P indicated Resident 14 had extensor posturing (an involuntary flexion or extension of arms and legs) on both upper extremities and withdraws on both lower extremities and was nonverbal. A review of Resident 14's MDS, dated [DATE], indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated Resident was incontinent of urine and bowel. The MDS indicated Resident 14 was at risk for developing pressure ulcer/injuries and had a moisture associated skin damage (MASD) with pressure ulcer/injury care. A review of Resident 14's BSA, dated 4/14/2024, indicated the resident was bedfast with very limited mobility. The BSA indicated Resident 14 was high risk for pressure injury development. A review of Resident 14's All Active Orders, dated 8/26/2023, indicated an order for wound care, wound sacral MASD until discontinued. Comments: Cleanse with NS, pat dry, apply aquacel ag (a silver foam dressing), cover with mepilex daily and prn if loose or soiled. Re-eval weekly. A review of Resident 14's Care Plan titled, Problem: Skin Injury Risk Increased, last reviewed on 3/16/2024, indicated an intervention to reassess skin (injury risk, full inspection) frequently (e.g., scheduled interval, with change in condition) to provide optimal early detection and prevention. During an interview and record review on 4/14/2024, at 9:30 a.m., with RN 1, reviewed the Media of Resident 14 with RN 1. RN 1 stated they do not measure the wound, but they take pictures weekly for MASD. RN 1 stated there were missing assessment and picture on the week of 3/4/2024 to 3/30/2024. During an interview on 4/14/2024, at 7:49 p.m., the Nurse Manager (NM) stated the treatment nurses should make sure they perform weekly wound assessment, including taking pictures, wound measurements, reviewing and updating of the pressure injury care plan documented in the multidisciplinary care progress notes to monitor the wound for worsening or healing of the wound. The NM stated if there was worsening of pressure injury, timely assessment and reporting was very crucial so the interdisciplinary team can be informed, and the attending physician and the wound specialist can step in. The NM stated between 3/24/2024 to 3/30/2024 they were short staffed, their wound nurse was on vacation, they had a float nurse, and they got an acute nurse rehab float, and she did not do it. A review of the facility's recent policy and procedure titled, Pressure Injury and Skin Breakdown Assessment and Prevention, last revised on 12/2022, indicated under wound assessment, complete a wound assessment for all identified wounds including: 8. Size in centimeters. A Wound certified Registered Nurse will review and validate all pressure injuries in the following categories: hospital-acquired pressure injuries (HAPIs), Stages 3 (full thickness tissue loss) and 4, deep tissue injury (DTIs, persistent non-blanchable deep red, purple or maroon areas of intact skin, non-intact skin or blood-filled blisters), Unstageable (obscured full-thickness skin and tissue loss), and any pressure injury that progresses/worsens from initial staging. The wound care RN upon consult will evaluate the wound(s) and develop a treatment plan of care and perform assessments as needed. Photographs will be taken of each wound weekly. Documentation to accompany photographs includes: a. Wound dimensions b. Wound descriptors as noted in the wound assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding (EF - a form of nutrition that is delivered into the digestive system as a liquid) for three of three sampled residents (Residents 24, 26, and 191) investigated under the tube feeding care area by: 1. Failing to ensure Resident 24's EF bottle indicated the correct date and time the current bottle was started, and the water flush bag indicated the date and time started and the rate prescribed by the physician. 2. Failing to ensure Resident 26's and 191's EF bottle indicated the rate as prescribed by the physician. 3. Failing to ensure Resident 26' and 191's water flush bag indicated the date and time started and the rate prescribed by the physician. These deficient practices had the potential to place Residents 24, 26, and 191 at risk for complications of enteral feeding such as diarrhea (loose, watery stools when you poop) or vomiting which may lead to dehydration (loss or removal of water). Findings: a. A review of Resident 24's Face Sheet (admission Record) indicated the facility originally admitted the resident on 7/16/2020 and readmitted the resident on 3/31/2022 with diagnoses including traumatic brain injury (a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain which may result to disability or death), dysphagia (a condition in which swallowing is difficult or painful), percutaneous endoscopic gastrotomy (PEG - also known at GT, a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube) placement, and chronic respiratory failure (a long-term condition in which the lungs have a hard time loading the blood with oxygen which may result to low oxygen level). A review of Resident 24's History and Physical (H&P), dated 11/3/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 24's Minimum Data Set (MDS- a standardized assessment and screening tool), dated 1/29/2024, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and totally dependent on staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 24's physician's order, dated 11/29/2023, indicated the following order: -Hydration/water tube feeding (TF) amount 200 milliliters (ml - a unit of measurement for liquids) every six (6) hours. -Continuous TF carbohydrate controlled: Diabetisource AC (a tube feeding formula made with a unique blend of carbohydrates that includes pureed fruits and vegetables to help with nutritional management of patients with diabetes); rate: 55 ml per hour for 22 hours per day. During a concurrent observation and interview on 4/13/2024 at 10:18 a.m., Registered Nurse 2 (RN 2) verified Resident 24's EF bottle indicated a date of 4/14/2024 10 p.m. and the water flush bag did not indicate the date it was started. RN 2 stated the water flush bag and EF bottle should have been labelled properly so the staff would know when they were started and ensure the formula was not expired. During a concurrent interview and interview on 4/14/2024 at 2:30 p.m., the Nurse Manager (NM) verified that the package insert for the water flush bag indicated not to use the bag for more than 24 hours. The NM stated the water flush bag should have been labeled with the date and time the formula was hung, and the rate prescribed by the physician so the staff would know when it was started and need to discard the bag after 24 hours. The NM stated the EF bottle should have been labeled with the correct date and time it was hung for other staff to know and ensure the formula was not expired. A review of the facility's procedure titled, Enteral Tube Feeding, continuous, gastrostomy, jejunostomy, last revised 12/11/2023, indicated the following: -Verify the practitioner's order, including the patient's identifiers; prescribed route based on the enteral tube tip's location; enteral feeding device; prescribed enteral formula; administration method, volume, rate; and type, volume, and frequency of water flushes. -The procedure indicated to compare the enteral formula container label with the order in the patient's medical record. -Make sure the enteral formula container is labeled with the date and time the formula was hung; administration route, rate, and duration (if cycled or intermittent); initials of the person who prepared, hung, and checked the enteral formula against the orders. b. A review of Resident 26's Face Sheet indicated the facility originally admitted the resident on 6/9/2021 and readmitted the resident on 1/2/2024 with diagnoses including cardiac arrest (a condition that occurs when the heart suddenly and unexpectedly stops pumping and unable to deliver blood to the body), PEG placement, and chronic respiratory failure. A review of Resident 26's H&P, dated 1/4/2024, indicated the resident was non-verbal and unable to follow commands. A review of Resident 26's MDS, dated [DATE], indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and totally dependent on staff with all ADLs. A review of Resident 26's physician's order, dated 1/10/2024, indicated the following order: -Hydration/water tube feeding (TF) amount 200 milliliters (ml - a unit of measurement for liquids) every four (4) hours. -Continuous TF concentrated 1.5 kilocalories per milliliter (Kcal/ml - a food calorie): Nutren (calorically dense complete tube feeding formula for the nutritional management of those with limited fluid tolerance and increased energy needs); rate: 65 ml per hour for 22 hours per day. During a concurrent observation and interview on 4/13/2024 at 11:40 a.m., Licensed Vocational Nurse 3 (LVN 3) verified Resident 26's EF bottle did not indicate the rate prescribed by the physician. LVN 3 verified the water flush bag did not have a label indicating the resident's name, room number, rate prescribed by the physician, and the date and time the water flush bag was hung. LVN 3 stated all TF formulas and water flush bags should be labeled with the resident's name, room number, rate prescribed by the physician, and the date and time they were hung. so, everyone would know the correct amount of feeding and amount of water flushes the resident was receiving. During an interview on 4/14/2024 at 2:30 p.m., the Nurse Manager (NM) stated EF formula label should match the prescribed order by the physician. The NM stated the water flush bag should have been labeled with the date and time the formula was hung, and the rate prescribed by the physician so the staff would know when it was started and need to discard the bag after 24 hours. Th NM stated the EF bag should have the rate prescribed rate by the physician so other staff would know to ensure the resident was receiving the correct amount of feeding. A review of the facility's procedure titled, Enteral Tube Feeding, continuous, gastrostomy, jejunostomy, last revised 12/11/2023, indicated the following: -Verify the practitioner's order, including the patient's identifiers; prescribed route based on the enteral tube tip's location; enteral feeding device; prescribed enteral formula; administration method, volume, rate; and type, volume, and frequency of water flushes. -The procedure indicated to compare the enteral formula container label with the order in the patient's medical record. -Make sure the enteral formula container is labeled with the date and time the formula was hung; administration route, rate, and duration (if cycled or intermittent); initials of the person who prepared, hung, and checked the enteral formula against the orders. c. A review of Resident 191's Face Sheet indicated the facility admitted the resident on 6/6/2022 with diagnoses including traumatic brain injury (a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain which may result to disability or death), gastrotomy tube (GT, a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube) placement, and chronic respiratory failure. A review of Resident 191's H&P, dated 2/28/2024, indicated the resident was unable to follow commands and opened eyes only intermittently. A review of Resident 191's MDS, dated [DATE], indicated the resident had severely impaired cognition and totally dependent on staff with all ADLs. A review of Resident 191's physician's order, dated 1/10/2024, indicated the following order: - Tube feeding adult formula standard Fibersource HN (a nutritionally complete, tube feeding formula with fiber for patients with normal or high calorie and/or protein requirements; 60 ml/hr; free water amount: 150 ml; free water frequency: every 4 hours. During a concurrent observation and interview on 4/13/2024 at 11:40 a.m., Licensed Vocational Nurse 3 (LVN 3) verified Resident 191's EF bottle did not indicate the rate prescribed by the physician. LVN 3 verified the water flush bag did not have a label indicating the resident's name, room number, rate prescribed by the physician, and the date and time the water flush bag was hung. LVN 3 stated all TF formulas and water flush bags should be labeled with the resident's name, room number, rate prescribed by the physician, and the date and time they were hung. so, everyone would know the correct amount of feeding and amount of water flushes the resident was receiving. During an interview on 4/14/2024 at 2:30 p.m., the Nurse Manager (NM) stated EF formula label should match the prescribed order by the physician. The NM stated the water flush bag should have been labeled with the date and time the formula was hung, and the rate prescribed by the physician so the staff would know when it was started and need to discard the bag after 24 hours. Th NM stated the EF bag should have the rate prescribed rate by the physician so other staff would know to ensure the resident was receiving the correct amount of feeding. A review of the facility's procedure titled, Enteral Tube Feeding, continuous, gastrostomy, jejunostomy, last revised 12/11/2023, indicated the following: -Verify the practitioner's order, including the patient's identifiers; prescribed route based on the enteral tube tip's location; enteral feeding device; prescribed enteral formula; administration method, volume, rate; and type, volume, and frequency of water flushes. -The procedure indicated to compare the enteral formula container label with the order in the patient's medical record. -Make sure the enteral formula container is labeled with the date and time the formula was hung; administration route, rate, and duration (if cycled or intermittent); initials of the person who prepared, hung, and checked the enteral formula against the orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 23's Face Sheet indicated the facility admitted the resident on 3/13/2024, with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe). A review of Resident 23's History and Physical (H&P), dated 4/3/2024, indicated the resident had history of post traumatic cervical-spine injury (involves damage to any part of the spinal cord), and quadriplegia (a life-altering condition that results in a loss of control of both arms and both legs). The H&P indicated the resident was on a ventilator (a machine that helps a person breathe) with occasional grunting. A review of Resident 23's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/20/2023, indicated the resident rarely to never had the ability to make self-understood and understand others. A review of Resident's Fall Risk Assessment (FRA), dated 4/14/2024, indicated the resident was medium risk for fall and high risk for injury. The FRA did include documentation of the resident using four side rails up in bed. A review of Resident's Care Plan titled, Problem: Fall Injury Risk, undated, indicated an intervention to avoid use of devices that minimize mobility, such as restraints. During a concurrent observation and interview on 4/13/2024, at 11:15 a.m., with Licensed Vocational Nurse 1 (LVN 1), in Resident 23's room, observed Resident 23 in bed with four SR in raised position. LVN 1 stated the resident's bed had all four side rails up to prevent injuries resulting from falls. LVN 1 stated a physician's order and consent from the resident's representative should be obtained prior to SR use. LVN 1 further stated the resident was not assessed for risk of entrapment and there was no documentation that the risks and benefits of using a SR was reviewed with the resident or the resident representative. LVN 1 stated failure to assess the resident for risk of entrapment can result to accidents such as strangulation from the SR. A review of the facility provided manufacturer's guideline for Hospital Bed 1 (HB 1), undated, indicated a Warning- Evaluate patients for entrapment and fall risk according to facility protocol, and/or healthcare provider directives, and monitor patients appropriately. Make sure all siderails are fully latched when in the raised position. Failure to do either of these could cause serious injury or death. A review of the facility provided manufacturer's user manual for Hospital Bed 2 (HB 2), copyright 2005, indicated evaluate patients for entrapment risk according to facility protocol, and monitor patients appropriately. Make sure that all siderails are fully latched when in the raised position. Failure to do either of these could result in serious injury or death. A review of the facility's recent policy and procedure titled, Restraint Use (Sub Acute), last revised on 2/2024, indicated in keeping with the mission and values of Providence of Providence Health & Services, it is the policy of Providence Holy Cross Medical Center (PHCMC) to guide care givers on appropriate and safe management of residents with restraints and utilization of least restrictive alternatives. To ensure safe and ethical practice for the use of physical restraints in the Sub-Acute Unit and that no person will be restrained against their will for any period longer than necessary. Restraints are considered medical devices and are only used in the event that the patient is a danger to self or others. Consent for restraint is signed by legal representative/decision-maker. The licensed nurse will assess the patient and attempt to find less restrictive alternatives to restraint. Licensed healthcare practitioner order is required; orders for restraints obtained by telephone will be signed by the physician within five days; restraints are reordered every 30 days if continued need is assessed. Documentation on restraints will include device(s): a. Bed rails X 4 b. Mittens, including Peek-a-Boo mitt. c. Mittens d. soft wrist restraints e. Assessment for continued need 3. A review of Resident 5's Face Sheet indicated the facility admitted the resident on 8/28/2021, with diagnoses including gastrointestinal (GI, relating to, or including both the stomach and intestine) bleed. A review of Resident 5's H&P, dated 8/18/2023, indicated the resident had pedestrian accident sustaining bilateral subarachnoid hemorrhage (SAH, a bleeding in the space below one of the thin layers that cover and protect the brain), left subdural hemorrhage (SDH, a buildup of blood on the surface of the brain), with multiple facial bone fracture (partial or complete break in the bone). The H&P indicated the resident was awake and interactive. The H&P also indicated the resident had agitation and delirium (a mental state in which a person is confused and has reduced awareness of their surroundings) being evaluated by a psych specialist. A review of Resident 5's MDS, dated [DATE], indicated the resident sometimes had the ability to make self-understood and understand others. A review of Resident 5's FRA, dated 4/14/2024, indicated the resident was assessed as medium risk for fall and use of bed alarm was in place, The FRA did not indicate use of all four side rails up. A review of Resident 5's Care Plan titled, Problem: Fall Injury Risk, initiated on 8/2/2023, indicated the resident had a fall episode found resident sitting on the floor, at the right side of the bed. The Care Plan had an intervention to use side rail pad to both rails as needed. During a concurrent observation and interview on 4/13/2024, at 10:55 a.m., with Licensed Vocational Nurse 2 (LVN 2), in Resident 5's room, observed Resident 5 in bed with four SR in raised position. LVN 2 stated the resident's bed had all four side rails up to prevent the resident from falling. LVN 2 stated there was no physician's order, assessment for entrapment risk and consent from the resident's representative prior to SR use. During a concurrent interview and record review on 4/13/2024, at 2:13 p.m., with Registered Nurse 4 (RN 4), reviewed Resident 5's All Active Orders, Flow Sheet, and Media. RN 4 stated there was no documented evidence of informed consent for side rails and entrapment risk assessment for side rail use. RN 4 stated the resident's bed had all four side rails up to prevent falls. During an interview on 4/14/2024, at 1:15 p.m., with the Nurse Clinician (NC), the NC stated use of four side rails up is considered use of a restraint and required an order from the physician. The NC also stated the resident should have an assessment for side rail use to ensure safety. During an interview on 4/14/2024, at 1:17 p.m., with the Nurse Manager (NM), the NM stated placing the resident's all four SR up is considered use of a restraint. The NM stated a physician's order, an assessment for entrapment risk, and consent from the resident or the resident representative (RR) should be in place prior to use of side rails. The NM stated the resident, or the RR should be informed of the risk and the benefits of using the restraints prior to application. The NM stated failure to assess the resident for risk of entrapment had the potential to result in entrapment from SRs. A review of the facility's recent policy and procedure titled, Restraint Use (Sub Acute), last reviewed on 2/2024, indicated restraints are considered medical devices and are only used in the vent that the patient is a danger to self or others. Consent for restraint is signed by legal representative/decision maker. Documentation on restraints will include device(s): a. Bed rails X 4 A review of the facility provided manufacturer's guideline for Hospital Bed 1 (HB1), undated, indicated a Warning- Evaluate patients for entrapment and fall risk according to facility protocol, and/or healthcare provider directives, and monitor patients appropriately. Make sure all siderails are fully latched when in the raised position. Failure to do either of these could cause serious injury or death. A review of the facility provided manufacturer's user manual for Hospital Bed 2 (HB 2), copyright 2005, indicated evaluate patients for entrapment risk according to facility protocol, and monitor patients appropriately. Make sure that all siderails are fully latched when in the raised position. Failure to do either of these could result in serious injury or death. Based on observation, interview, and record review the facility failed to ensure the safe and appropriate use of four (4) bed side rails (SR) for three of four sampled residents (Resident 24, 23, and 5) investigated during review of physical restraints by: 1. Failing to conduct an assessment including the risk for entrapment (occurs when a resident is caught between the mattress and bed rail or within the bed rail itself) from side rails. 2. Failing to review the risk and benefits of side rails with the resident or resident representative and obtain informed consent (process in which residents or resident representatives are given important information, including possible risks and benefits, about a procedure or treatment). These deficient practices had the potential to result in psychosocial harm and physical harm from entrapment and death of residents. Cross Reference F604 Findings: 1. A review of Resident 24's Face Sheet indicated the facility originally admitted the resident on 7/16/2020 and readmitted the resident on 3/31/2022 with diagnoses including traumatic brain injury (a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain which may result to disability or death), dysphagia (a condition in which swallowing is difficult or painful), percutaneous endoscopic gastrotomy (PEG - also known at GT, a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube) placement, and chronic respiratory failure (a long-term condition in which the lungs have a hard time loading the blood with oxygen which may result to low oxygen level). A review of Resident 24's History and Physical (H&P), dated 11/3/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 24's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 1/29/2024, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and totally dependent on staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 24's Morse Fall Risk Assessment every shift dated 4/11/2024, 4/12/2024, 4/13/2024, and 4/14/2024, indicated the resident was a medium risk for falls and a high risk for injury. A review of Resident 24's Order Reports did not indicate an order for use of four side rails. A review of Resident 24's care plan did not indicate any plan of care for the use 4 bed SR up. A review of Resident 24's electronic every shift assessment by licensed nurses dated 03/01/2024-04/14/2024, did not indicate the resident was assessed for risk of entrapment prior to use of four side SRs. During a concurrent observation and interview on 4/13/2024 at 10:15 a.m., with Licensed Vocational Nurse 3 (LVN 3), observed Resident 24 in bed with four SR up. LVN 3 stated the resident places her right leg over the SR most of the time and placing four SR in raised up position is for the safety of the resident. LVN 3 stated the resident is at risk for falls and the SR prevent the resident from falling. During a concurrent observation and interview on 3/13/2024 at 10:39 a.m., with Registered Nurse 2 (RN 2), RN 2 stated Resident 24's four bed SR were placed in raised position while in bed for the resident's safety, to prevent falls and possibly injury as resident moves a lot in the bed. During a concurrent interview and record review on 4/13/2024 at 4:00 p.m., with the Infection Preventionist (IP), Resident 24's medical record including assessments, physician orders and informed consents were reviewed. The IP verified the facility did not have an assessment, physician's order, and consent for the use of four bed SR up while in bed because the facility does not consider SR as restraints. During an interview on 4/14/2024 at 1:15 p.m., with the Nurse Clinician (NC), the NC stated the use four SR up while the resident is in bed is considered use of a restraint. The NC stated there should have been an order from the physician and assessment for entrapment risk for SR use prior to use of four SR up. During an interview on 4/14/2024 at 1:17 p.m., with the Nurse Manager (NM), the NM stated placing the resident's all four SR up is considered use of a restraint and there should have been an order from the physician and assessment for entrapment risk for SR use. The NM stated it is important to notify the Resident 24's representative of the risks and benefits of using four SR up so they (representative) would be aware of the potential risks from using the SR such as restriction of movement, decline in functioning and entrapment which may lead to injuries. A review of the facility provided manufacturer's guideline for Hospital Bed 1 (HB 1), undated, indicated a Warning- Evaluate patients for entrapment and fall risk according to facility protocol, and/or healthcare provider directives, and monitor patients appropriately. Make sure all siderails are fully latched when in the raised position. Failure to do either of these could cause serious injury or death. A review of the facility provided manufacturer's user manual for Hospital Bed 2 (HB 2), copyright 2005, indicated evaluate patients for entrapment risk according to facility protocol, and monitor patients appropriately. Make sure that all siderails are fully latched when in the raised position. Failure to do either of these could result in serious injury or death. A review of the facility's recent policy and procedure titled, Restraint Use (Sub Acute), last revised on 2/2024, indicated in keeping with the mission and values of Providence of Providence Health & Services, it is the policy of Providence Holy Cross Medical Center (PHCMC) to guide care givers on appropriate and safe management of residents with restraints and utilization of least restrictive alternatives. To ensure safe and ethical practice for the use of physical restraints in the Sub-Acute Unit and that no person will be restrained against their will for any period longer than necessary. Restraints are considered medical devices and are only used in the event that the patient is a danger to self or others. Consent for restraint is signed by legal representative/decision-maker. The licensed nurse will assess the patient and attempt to find less restrictive alternatives to restraint. Licensed healthcare practitioner order is required; orders for restraints obtained by telephone will be signed by the physician within five days; restraints are reordered every 30 days if continued need is assessed. Documentation on restraints will include device(s): a. Bed rails X 4 b. Mittens, including Peek-a-Boo mitt. c. Mittens d. soft wrist restraints e. Assessment for continued need

Based on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices by: 1. Failing to ensure food service attendant wore a hair restraint while working in the food production line. 2. Failing to ensure food items not in their original package were labeled and dated. 3. Failing to ensure an open food product that is in its original packaging was labeled and dated. These deficient practices had the potential to place six out of 43 residents at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). 1.During an initial observation of the kitchen on 4/13/2023 at 8:14 a.m., observed a Food Service Attendant (FSA) working in the food production line placing food on meal trays, not wearing a hair restraint. During an observation and concurrent interview with the FSA on 4/13/2024 at 8:16 a.m., the FSA stated that he was not wearing a hair restraint. When asked when he is supposed to wear a hair restraint, the FSA stated that once he clocks in for work at 5:00 a.m. and upon entering the kitchen, the FSA is supposed to wear a hair restraint. The FSA further stated that hair restraints are important to wear so that hair does not fall into the food. The facility policy and procedure titled Dress Code, revised on 10/8/2019. Indicated it is the policy of Providence Holy Cross Medical Center Food and Nutrition Services Department that all employees are required to dress accordingly to the approved dress code at all times. Purpose: To avoid contamination of food, establish departmental identification and present a professional appearance. Under universal Dress Requirements: A. In food production, storage and serving areas, hair restraints must be worn: a hairnet, skull cap, or beret. 2. During an observation of refrigerator 1-2 on 4/13/2023 at 8:25 a.m., observed open food items not in its original packaging placed in a clear storage bag without a label or date. During observation an observation and concurrent interview with the Kitchen Supervisor (KS) on 4/13/2024 at 8:29 a.m., the KS stated that the open food items were not in its original packaging placed in a clear storage bag without a label or date. When asked what the food item was, the KS stated there were multiple pieces of cheddar cheese. The KS stated that when a food item is not in its original packaging the food item must be labeled with the specific name of the food item, the date when the food item was opened, and the initials of the food service attendant that opened the product. When asked about the importance of accurate labeling the KS stated that it is important to accurately label food items to make sure that the food item is what is and for the safety of our residents. 3.During an observation of refrigerator 1-2 on 4/13/2023 at 8:33 a.m., observed an open package of low moisture part-skim mozzarella cheese open without an open date. During observation an observation and concurrent interview with the KS on 4/13/2024 at 8:35 a.m., the KS stated that the open package of low moisture part-skim mozzarella cheese is not labeled with an open date. The KS stated that once a food item is open the food item should be labeled with an open date to make sure we use the food item before it expires. This is to ensure resident safety. A review of the facility provided policy and procedure titled Label and Dating, 1/9/2019, indicated the Food and Nutrition Services shall ensure that foods are label, dated and stored appropriately. Purpose: To ensure the proper storage and safely of the department's food supply. Products will be dated via the following acceptable mechanisms: A Label with the following information will be used to label and date foods for holding and storage. 1). Item name; 2) Use by date (pull date); 3) Employee Signature.

Based on interview and record review, the facility failed to implement its policy and procedures for antimicrobial stewardship (AMS- a coordinated program that promotes the appropriate use of antimicrobials [including antibiotics, drugs used to treat infections caused by bacteria and other microorganisms], improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms) for one of six sampled residents (Resident 2) when clindamycin (an antibiotic) was ordered on 1/29/2024 as indefinite and the facility failed to monitor the antibiotic use for 77 days. This deficient practice had the potential for the resident to receive an inappropriate antibiotic and develop antibiotic resistance (when bacteria/germs change in some way that reduces or eliminates the effectiveness of drugs, chemicals, or other agents designed to cure or prevent infections). Findings: A review of Resident 2's admission Record indicated the facility admitted the resident on 12/28/2023. Resident 2's diagnoses included history of multidrug resistant pseudomonas proteus (bacteria that have become resistant to certain antibiotics) and methicillin-resistant staphylococcus aureus (MRSA- is a cause of staph infection that is difficult to treat because of resistance to some antibiotics), quadriplegia (a form of paralysis that affects all four limbs, plus the torso), and multiple sclerosis (MS-a long-lasting [chronic] disease of the central nervous system). A review of Resident 2's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 12/22/2023, indicated the resident's cognitive (involving conscious intellectual activity such as thinking, reasoning, or remembering) skills for daily decision-making was intact. A review of the Physician's Orders for Resident 2 dated 1/29/2024 indicated clindamycin 1% gel two times a daily for chronic respiratory failure (a condition in which not enough oxygen passes from the lungs into the blood) unspecified whether with hypoxia (deficiency in the amount of oxygen reaching the tissues) or hypercapnia (elevation of carbon dioxide in the blood). Length of therapy indicated indefinite. A review of Resident 2's Medication Administration Record (MAR- is a report detailing the drugs administered to a patient by a healthcare professional at a treatment facility) for clindamycin 1% gel two times a daily for chronic respiratory failure unspecified whether with hypoxia or hypercapnia indicated: January 2024: given 5 times (9 a.m. and 9 p.m.). February 2024: given 58 times (9 a.m. and 9 p.m.). March 2024: given 62 times (9 a.m. and 9 p.m.). April 2024: given 27 times (9 a.m. and 9 p.m.). During a concurrent interview and record review, on 4/14/2024 at 2:41 p.m., with the Infection Preventionist (IP) of Resident 2's Physician Orders, the IP stated Resident 2 was on clindamycin topically (to the skin). The IP stated the order indicated clindamycin was ordered indefinitely by the dermatologist on 1/29/2024 for folliculitis (skin condition that happens when hair follicles become inflamed). The IP stated antibiotics should not be used indefinitely, antibiotics should have a stop date. The IP stated antibiotics require a stop date to ensure the resident does not develop a resistance to the antibiotics. The IP stated Resident 2's clindamycin should have been included in the antibiotic stewardship program, and that if its use had been documented, they could have caught the indefinite length of treatment. During an interview, on 4/14/2024 at 6:28 p.m., the Nurse Manager (NM) stated Resident 2 should not have any antibiotic with an indefinite order; the use of antibiotic should have a time frame to determine the efficacy (effectiveness). The NM stated there is a concern with the antibiotic drug resistance when the antibiotic order does not have an end date. The NM stated the antibiotic stewardship was created to monitor antibiotic use. A review of the current facility-provided policy and procedure (P&P) titled, Antimicrobial Stewardship (AMS) Program, last revised in 06/2023, indicated to implement a comprehensive antimicrobial stewardship program to evaluate judicious use of antimicrobials. The purpose of the policy is to achieve the following AMS program goals and objectives: 1. Optimize antibiotic therapy to improve clinical outcome while minimizing unintended consequences of antimicrobial use, such as drug toxicity and emergence of resistance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure for one sampled resident (Resident 1), Resident 1's oxygen delivery via tubing was secured and maintained. This deficient practice had the potential to result in Resident 1 suffering from hypoxemia (low level of oxygen in the blood) and may lead to the resident's deterioration of medical condition. Findings: A review of Resident 1's History and Physical (H&P), dated [DATE], indicated Resident 1 was found down by family members. Cardiopulmonary Resuscitation ([CPR] is an emergency lifesaving procedure performed when the heart stops beating) was initiated prior to Emergency Medical Services ([EMS] is a system that responds to emergencies in need of highly skilled pre-hospital clinicians) arrival. The patient was intubated (a tube has been placed inside a patient's trachea through the mouth to keep airways open in an emergency setting) for airway protection. In addition the H&P indicated Resident 1's Computed Tomography ([CT] scan is an imaging test that helps healthcare providers detect diseases and injuries) scan of the head showed a large intracranial (Within the cranium, the bony dome that houses and protects the brain) and intraventricular (within the ventricles of the brain) hemorrhage (bleeding) with developing hydrocephalus (the buildup of fluid in cavities called ventricles deep within the brain). During an interview on [DATE], at 8:24 A.M., with the Nurse Manager (NM), the NM confirmed that on [DATE], Resident 1's oxygen tubing was found disconnected by the resident's family member (FM). Resident 1's FM immediately informed Staff Nurse 1 (SN1), who was with another patient in the same room. The NM stated SN1 was not sure why oxygen tubing was disconnected. The NM added there was a similar event in the past involving Resident 1, where the oxygen tubing was found disconnected. These incidents may have been the result of how staff reposition residents. During an interview on [DATE], at 9:12 A.M., with the NM, the NM stated Resident 1 was brought back from activity room to bed by Certified Nurse Assistant 1 (CNA 1) on [DATE] between the hours of 12:30 p.m. and 1:00 p.m. CNA 1 went back around 4:30 p.m. to 5:00 p.m. to reposition Resident 1. Resident 1's FM found the oxygen tubing disconnected sometime after 5:00 p.m. In the same interview, the NM stated on investigation CNA 1 did not check if oxygen tubing was connected to Resident 1 after repositioning Resident 1. The NM stated the staff should do environmental check before leaving the patient. The NM stated CNA 1 informed her that after repositioning Resident 1, CNA 1 did not check if the oxygen tubing was connected to the patient. A review of the facility's policy and procedure (P&P), titled Standards of Care - Sub Acute indicated Licensed nurse will carry out safety procedures as outlined in the Policies and Procedures for proper infection control practices, isolation techniques, use of restraints and side rails, and care of the resident's environment should be followed as indicated.

Based on observation, interview, and record review, the facility failed to provide an environment that is restraint-free by failing to consistently monitor and document the use of restraint for one (Resident 11) out of one resident reviewed for restraint use. This deficient practice had the potential to place the residents at risk for unnecessary prolonged use of restraints and can lead to a decline in physical functioning and skin injuries and severe injuries such as strangulation or entrapment. Findings: A review of Resident 11's face sheet indicated the facility admitted the resident on 2/3/2023 with diagnoses including respiratory failure (a condition that makes it difficult to breathe on your own) and deep vein thrombosis (a condition that occurs when a blood clot forms in a deep vein usually in the lower leg, thigh, and arm). A review of Resident 11's History and Physical (H&P) dated 2/9/2023, did not indicate the resident's capacity to understand and make decisions. The H&P indicated the resident had tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help with breathing), psychosis (a mental condition characterized by a disconnection from reality), and diabetes mellitus II (a condition characterized by high levels of sugar in the blood). A review of Resident 11's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 1/10/2023, indicated the resident had severely impaired cognition ((mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated use of limb restraint. A review of Resident 11's order report dated 2/4/2023, indicated the following orders: 1. Apply bilateral soft wrist restraint (a device placed on the wrist used to prevent patients from harming themselves) to prevent pulling tubing and medical devices, scratching scalp wound. Monitor every two hours, check for circulation, skin integrity and movement. 2. Apply bilateral hand peek a boo (hand mitt - a soft large glove that covers the hand used to prevent patients from harming themselves) to prevent pulling tubing and medical devices, scratching scalp wound. Monitor every two hours, check for circulation, skin integrity and movement. A review of Resident 11's care plan on restraint use for patient safety dated 2/4/2023, indicated the resident uses bilateral soft wrist restraint and bilateral hand peek a boo with goals including resident shall not sustain injury while using restraints. The interventions included to monitor for episodes of agitation (a feeling of irritability or severe restlessness) or anxiety (a feeling of fear and uneasiness), monitor for pulling lines or tubes, keep resident clean and dry, assess less restrictive measures or device prior to restraint use, check for proper placement, release and check for redness, circulation, hygiene, and impaired skin integrity every two hours and as needed. During an observation on 3/24/2023 at 8:15 p.m., observed Resident 11 in bed asleep with padded upper siderails and with hand mitten and wrist restraints on both arms and wrists. During a concurrent observation and interview on 3/24/2023 at 8:20 p.m., Licensed Vocational Nurse 4 (LVN 4) stated that Resident 11 has soft wrist restraints and hand mittens on both hands. LVN 4 stated the restraints had been applied since admission due to agitation and multiple attempts to pull out tube, lines, and scratching the scab on her scalp wound that had reopened. During a concurrent interview and record review on 3/25/2023 at 6:35 p.m. with Minimum Data Set Coordinator (MDSC), Resident 11's medical records were reviewed including physician orders, care plan, and restraint flowsheet (a form to document the assessment, teaching, observation, and care of a patient who requires the use of a restraint, including the use of a least restrictive device). The MDSC stated there were missing documentation of monitoring for the wrist and hand mitten restraint on the following dates and time: 1. 3/16/2023 from 1:00 p.m. to 3:00 p.m. 2. 3/16/2023 from 3:00 p.m. to 5:00 p.m. 3. 3/16/2023 from 5:00 p.m. to 7:00 p.m. 4. 3/20/2023 from 1:00 p.m. to 3:00 p.m. 5. 3/20/2023 from 3:00 p.m. to 5:00 p.m. 6. 3/20/2023 from 5:00 p.m. to 7:00 p.m. The MDSC stated it is important to monitor the use of restraint to ensure the resident maintains their range of motion, (ROM - refers to how far a part of the body can be moved or stretched such as a joint or a muscle) ensure the resident's skin is intact, and ensure use of least restrictive measure were used, and appropriateness of continued use. A review of the facility's policy and procedure titled, Restraint Use (Sub Acute), last revised 12/2022, indicated a purpose to ensure safe and ethical use of physical restraints that no person will be restrained against their will longer than necessary. The policy also indicated restraint monitoring is documented in the electronic health record (EHR) and completed each day every two hours for each resident in restraint.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan for one of three residents (Resident 33) by failing to: 1. Ensure there was a care plan addressing Resident 33's Restorative Nursing Assistance (RNA, a program designed to ensure each resident maintains their physical and functional abilities) therapy. 2. Ensure there was a care plan addressing Resident 33's use of an anticoagulant (Eliquis, used to prevent serious blood clots from forming due to a certain irregular heartbeat). This deficient practice had the potential to result in a delay of nursing care and medical interventions for the residents. Findings: A review of Resident 33's face sheet indicated that the facility admitted the resident on 2/15/2023, with diagnoses including respiratory failure (a condition that occurs due to a disease or injury that interferes with the ability of the lungs to deliver oxygen) and hypertension (high blood pressure). A review of Resident 33's History and Physical (H&P), dated 2/17/2023, indicated the resident had histories of chronic atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart), heart failure (a condition that develops when the heart does not pump enough blood for the body's needs), and progressive neuromuscular disorder (progressive weakness due to degeneration of the muscles that control movement). A review of Resident 33's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/28/2023, indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident had impaired vision. The MDS also indicated the resident was totally dependent on bed mobility and transfer, dressing, eating, toilet use, and personal hygiene. A review of Resident 33's Active Orders indicated: -RNA Physical Therapy (PT, a medical treatment used to restore functional movements, such as standing, walking, and moving different body parts) until discontinued. Perform left extremity (LE) passive range of motion (PROM, the range of motion that is achieved when an outside force exclusively causes movement of a joint and is usually the maximum range of motion that a joint can move) daily to bilateral hip, knee, ankle, and foot daily 6 days/week on 2/24/2023. -RNA Occupational Therapy (OT, rehabilitation that focuses on improving the resident's ability to perform activities of daily living) until discontinued. Perform OT upper extremity (UE) daily to bilateral shoulder, elbow, forearm, wrist, and hand 6 days/week on 2/16/2023. -Apixaban (Eliquis) tablet 5 milligrams (mg, a unit of mass or weight) two times daily via gastrostomy tube (G-tube, a tube inserted through the wall of the abdomen directly into the stomach) on 2/15/2023. During a concurrent interview and record review on 3/26/2023, at 9:56 a.m., reviewed Active Orders and Care Plan with the Nurse Manager (NM). The NM stated that there was no order for monitoring of the side effects on the use of anticoagulant (Eliquis) on Resident 33. The NM also stated that there was not care plan developed for the use of the anticoagulant on the resident. The NM further stated that they should have monitored the resident for bleeding. The NM stated that the care plan is important because it indicates the resident's plan of care, and it must be reassessed on a regular basis to find out if there is a need to adjust the treatment based on the reassessment. During a concurrent interview and record review on 3/26/2023, at 5:45 p.m., reviewed Resident 33's Active Orders and the Care Plan with the NM. The NM stated there was no care plan for RNA therapy. A review of the facility's recent policy and procedure titled Plan of Care- Post Epic (2014) (an electronic health records system for hospitals and large practices), last revised on 1/2014, indicated all healthcare professionals are expected to review and contribute to the plan within their scope of practice. The Registered Nurse (RN) is accountable to assure the development of a patient-centric, interprofessional individualized plan of care. Initiate Plan of Care (POC) within 4 hours and completion within 24 hours following admission, the interprofessional team initiates a focused Plan of Care (Based on a focused assessment), to include: Patient care needs and preferences; Clinical practice guideline (CPG)- Medical/Treatment/Procedure CPG (reflects the patient's diagnosis or treatment/procedures as written by the healthcare provider) and/or Human Response CPG (reflects the human response of the patient and/or family to illness/treatment and requires no healthcare provider order)- that will support patient stabilization by recommending additional screening and assessment. Within 24 hours following admission, the RN assures completion of a comprehensive interprofessional Plan of Care (based on a comprehensive assessment) informed by admission data and identification of diagnostic statements to include: Prioritized problem identification; Goals/outcomes set in collaboration with patient and interprofessional healthcare team; Therapeutic interventions and actions; Learning and education needs. A review of the facility's recent policy and procedure titled Anticoagulation Management, last revised on 7/2022, indicated that RN's direct oral anticoagulants (DOACs) responsibilities is to monitor patient for any adverse reactions to medication, including signs/symptoms of bleeding. Document DOAC administration on the Electronic Medication Administration Record (eMAR) and monitoring in progress notes in the Electronic Health Record (HER). A review of the facility's recent policy and procedure titled Assessment (Functional) Prior to Restorative Therapy (Sub Acute), last revised on 12/2019, indicated if the resident would benefit from a restorative nursing program, the therapist obtains an RNA order from the physician and gives hand off communication with the RNA about the following: a. Type of program b. Resident's diagnoses c. Resident's diagnoses d. Resident's ROM/strength/splinting/mobility/activities of daily living (ADL's) Restorative Nursing Assistant (RNA) carries out the established treatment plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide Restorative Nursing Assistance (RNA, a program designed to ensure each resident maintains their physical and functional abilities) services for two of three sampled residents (Residents 33 and 25). This deficient practice had the potential to result in a decline in mobility and range of motion for the residents. Findings: a. A review of Resident 33's face sheet indicated the facility admitted the resident on 2/15/2023, with diagnoses including respiratory failure (a condition that occurs due to a disease or injury that interferes with the ability of the lungs to deliver oxygen) and hypertension (high blood pressure). A review of Resident 33's History and Physical (H&P), dated 2/17/2023, indicated the resident has histories of progressive neuromuscular disorder (progressive weakness due to degeneration of the muscles that control movement) with amyotrophic lateral sclerosis (ALS, a rare neurological disease that affects motor neurons [nerve cells in the brain and spinal cord that control voluntary muscle movement]), peripheral neuropathy (a nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness in different parts of the body) and was intubated (placing a breathing tube through the mouth and down the throat into the lungs) for airway protection. A review of Resident 33' Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/28/2022, indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident had impaired vision. The MDS also indicated the resident was totally dependent on bed mobility and transfer, dressing, eating, toilet use, and personal hygiene. A review of Resident 33's Active Orders indicated: -RNA Physical Therapy (PT, a medical treatment used to restore functional movements, such as standing, walking, and moving different body parts) until discontinued. Perform left extremity (LE) passive range of motion (PROM, the range of motion that is achieved when an outside force exclusively causes movement of a joint and is usually the maximum range of motion that a joint can move) daily to bilateral hip, knee, ankle, and foot daily 6 days/week on 2/24/2023. -RNA Occupational Therapy (OT, an allied health profession that involves the therapeutic use of everyday activities) until discontinued. Perform OT upper extremity (UE) daily to bilateral shoulder, elbow, forearm, wrist, and hand 6 days/week on 2/16/2023. A review of Resident 33's Restorative Nurse Aide Activity Flow Sheet 1/1/2023 to 3/25/2023 indicated: -1/3/2023, resident had high blood pressure, and has pain, therapy was not done. -1/16/2023, no RNA. -1/24/2023, no RNA. -1/30/2023, no RNA. -2/7/2023 to 2/15/2023 Resident was [NAME] to General Acute Care Hospital (GACH) due to gastrointestinal bleed (GIB, bleeding in the gastrointestinal system). -2/22/2023, resident had x-ray procedure. -2/28/2023, resident had low blood pressure. -3/4/2023 therapy was not done, instead it was done the following day 3/5/2023. -3/13/2023, no RNA. -3/15/2023, no RNA. During an interview on 3/26/2023, at 5:23 p.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated that stated that they were down one full time RNA, the facility was still in the process of replacing the vacated position. During a concurrent interview and record review on 3/26/2023, at 5:45 p.m., reviewed Active Orders and Restorative Nurse Aide Activity Flow Sheet with Nurse Manager (NM). The NM stated that the resident was in the hospital due to GIB on 2/7/2023 to 2/15/2023. The NM further stated that the therapy was reordered on 2/16/2023 around 4 p.m. and the therapy resumed on 2/17/2023. The NM Stated that on 1/13/2023, resident had high blood pressure and has pain, therapy was not done. The NM stated that on 1/16/2023, 1/24/2023, and 1/30/2023 there was no RNA. The NM stated that the therapy for 3/4/2023, was done on 3/5/2023. The NM stated that on 2/22/2023 resident had x-ray procedure. The NM stated that on 2/28/2023 resident had low blood pressure. Lastly, the NM stated that the 3/13/2023 and 3/15/2023 there was no RNA. The staff should have communicated to the DON or Nursing Supervisors that there was no RNA coverage that day to find a replacement so that the therapy can be provided as ordered. The NM stated that failure to perform RNA therapy to residents could cause decline in function. A review of the facility's recent policy and procedure titled Assessment (Functional) Prior to Restorative Therapy (Sub Acute), last revised 12/2019, indicated if the resident would benefit from a restorative nursing program, the therapist obtains an RNA order from the physician and gives hand off communication with the RNA order from the physician and gives hand off communication with the RNA about the following: a. Type of program b. Resident's diagnoses c. Resident's ROM/strength/splinting/mobility/activities of daily LIVING (ADL's) d. Recommended frequency of the RNA Program Restorative Nursing Assistant (RNA) carries out the established treatment plan. b. A review of Resident 25's face sheet indicated the facility admitted the resident on 2/9/2023 with diagnoses including acute respiratory failure (sudden inability of the lungs to maintain normal respiratory function) and constipation (a condition of inability to pass stools regularly). A review of Resident 25's MDS, dated [DATE], indicated the resident was in a persistent vegetative state/no discernible consciousness. The MDS indicated the resident was totally dependent with bed mobility, locomotion on unit, dressing, bathing, and personal hygiene with one or more person's physical assist. The MDS indicated the resident had impairment on both sides of the upper and lower extremities. A review of Resident 25's Active Orders, dated 12/5/2022 indicated: - RNA OT upper extremity passive range of motion (PROM, an exercise provided by therapist or the RNAs who will have to do full range of motion [ROM, the extent or limit to which a part of the body can be moved around a joint or a fixed point] for the person without any help from the resident) daily, six days /week. - RNA PT lower extremity PROM daily, six day/week. A review of Resident 25's Range of Motion Impairment Care Plan, dated 9/29/2020, expected end date 5/13/2023, indicated an intervention for passive range of motion to both upper and lower extremities six days per week. During a concurrent interview and record review of Resident 25's Restorative Nurse Aide Activity Flow Sheet from 2/19/2023 to 3/25/2023, on 3/26/2023 at 8:51 p.m., the NM confirmed Resident 25 did not receive RNA ROM as ordered by the physician. The NM stated RNAs should document once ROM was provided and if not documented, it means it was not done. The NM stated it is important that the residents received the RNA treatment exercises as ordered to prevent any contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) and should help improve and prevent decline in the resident's range of motion. The NM stated when RNA treatments are provided to the resident, the RNAs document it on the Restorative Nurse Aide Activity Flow Sheet. The RNA Weekly Summary did not indicate that the RNA PROM for both upper and lower extremities order for six days were provided. The NM confirmed the Restorative Nurse Aide Activity Flow Sheet documentation did not indicate reason why the facility did not provide the six treatment days per week.The flowsheet only indicated the following: - Weekly summary dated 2/24/2023: Resident 25 was only seen five days. - Weekly summary dated 3/3/2023: the resident was only seen four days. - Weekly summary dated 3/17/2023: the resident was only seen five days. A review of the facility's recent policy and procedure titled Assessment (Functional) Prior to Restorative Therapy (Sub Acute), last revised 12/2019, indicated if the resident would benefit from a restorative nursing program, the therapist obtains an RNA order from the physician and gives hand off communication with the RNA order from the physician and gives hand off communication with the RNA about the following: a. Type of program b. Resident's diagnoses c. Resident's ROM/strength/splinting/mobility/activities of daily living (ADL's) d. Recommended frequency of the RNA Program. Restorative Nursing Assistant (RNA) carries out the established treatment plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an environment free from accidents and hazards by failing to ensure: 1. Resident 33's bed was left in the lowest position. 2. Resident 17's left arm splint (an immobilizer for limbs to protect self-injury) was in place to prevent the resident from pulling out tubes and lines. These deficient practices had a potential for Resident 33 sustaining a fracture (a partial or complete break in the bone) or death due to a fall and Resident 17 to pull out tubes or lines necessary for the resident's wellbeing. Findings: a. A review of Resident 33's face sheet indicated the facility admitted the resident on 2/15/2023, with diagnoses including respiratory failure (a condition that occurs due to a disease or injury that interferes with the ability of the lungs to deliver oxygen) and hypertension (high blood pressure). A review of Resident 33's History and Physical (H&P), dated 2/17/2023, indicated the resident's diagnoses included amyotrophic lateral sclerosis (ALS, a rare neurological disease that affects motor neurons [nerve cells in the brain and spinal cord that control voluntary muscle movement]), atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart), and peripheral neuropathy (a nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness in different parts of the body). A review of Resident 33's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/28/2023, indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident had impaired vision. The MDS also indicated the resident was totally dependent on bed mobility and transfer, dressing, eating, toilet use, and personal hygiene. A review of Resident 33's Active Orders indicated: -Fall precautions until discontinued. Implement precautions per departmental/hospital protocol on 2/15/2023. -Nursing communication: Side rails up times four while in bed for safety and protection due to poor safety awareness. A review of Resident 33's Morse Fall Risk Assessment (type of fall risk assessment), dated 3/25/2023, indicated the resident was at high risk for fall with injury. During a concurrent observation ad interview on 3/25/2023, at 9:23 a.m., with RN 1(RN 1), observed the resident's bed at the high position. Measured the bed height with a measuring tape and recorded the bed height at 31 inches off the floor to the mattress surface. RN 1 stated that the resident's bed was not on the lowest position. RN 1 stated that the resident could fall and sustain a fracture due to the bed height. During an interview on 3/26/2023, at 9:10 a.m., the Director of Nursing (DON) stated that the bed should be at the lowest position because of the potential for fall with injury. A review of the facility's recent policy and procedure titled, Fall Risk Assessment and Prevention, last revised on 4/2021, indicated general fall precautions to consider for all patients: Bed locked and in low position with upper side rails up. Bed/chair alarm on. b. A review of Resident 17's face sheet indicated the facility admitted the resident on 1/17/2023, with diagnoses including respiratory failure (a condition that occurs due to a disease or injury that interferes with the ability of the lungs to deliver oxygen) and muscle spasm. A review of Resident 17's H&P, dated 1/18/2023, indicated the resident was contracted (to shorten or to reduce in size) in all extremities except the left upper extremity which she moves freely. A review of Resident 17's MDS, dated [DATE], indicated the resident never had the ability to make self-understood and understand others. The MDS indicated that the resident had severely impaired vision. The MDS also indicated the resident was totally dependent on bed mobility and transfer, dressing, eating, toilet use, and personal hygiene. A review of Resident 17's Active Orders indicated: -Nursing communication. Apply left hand peek a boo (a restraint that covers the hands and fingers) to prevent pulling tubings and medical devices. Monitor every two hours, check for circulation, skin integrity, and movement on 3/13/2023. -Nursing communication. Apply left hand soft wrist restraint (a device that is placed on the wrist or ankle with velcro to prevent from inadvertently dislodging medical equipment) to prevent pulling tubings and medical devices. Monitor every two hours, check for circulation, skin integrity, and movement on 3/13/2023. -Nursing communication. Apply Posey splint (restricts arm movement without rigid arm splints) to left arm on 3/17/2023. A review of Resident 17's Nursing Progress Notes, dated 1/17/2023, indicated the resident was received form a rehabilitation center with a Posey splint on the left upper extremity, upon removing posey splint for skin assessment, noted patient actively pulling tracheostomy tube (a tube inserted through the hole and secured in place with a strap around the neck). During a concurrent observation and interview on 3/25/2023, at 9:22 a.m., with Certified Nursing Assistant 2 (CNA 2), observed the resident with a left hand peek a boo, and a left-hand soft wrist restraint on, left Posey arm splint was not applied on Resident 17. CNA 2 stated that the left arm splint should have been placed to prevent the resident from pulling tracheostomy tube and other medical devices. During an interview on 3/26/2023, at 8:40 a.m., the Nurse Manager (NM), stated that the resident kept pulling the trach. The NM stated that they should have applied the Posey left arm restraint or communicated to the doctor that it is not working and discontinue the order. The NM stated that there will be a potential repeated pulling of tracheostomy tune and other medical devices. A review of the facility's recent policy and procedure titled Restraint Use (Sub Acute), last revised on 12/2022, indicated if a resident is deemed to be a danger to themselves or others there may be a need for restraints. When restraints are deemed necessary for the protection of the resident or others. One time documentation is made in the electronic record upon initiation of restraints and includes: a. Less restrictive alternatives i. Bed alarm ii. Companionship iii. Distraction/Activities/Diversion iv. Modification of environment for safety v. Physical comfort measures vi. Reality orientation/coaching or reorientation vii. Other b. Resident's response- look up with the ability to type in a response: i. Agitation ii. Uncooperative iii. Confused iv. Combative c. Clinical justification for restraints- look up with the ability to type in: i. pulling lines/tubes/trach ii. Self-harm iii. Harm to others iv. Other type (type in)

Based on observation, interview and record review, the facility failed to administer Cefepime (a drug used to treat infection) 2 grams (g- a unit of measurement used to measure very light objects) as prescribed for one of one sampled resident (Resident 37). This deficient practice had the potential to result in ineffectively managing Resident 37 infection. Findings: A review of Resident 37's face sheet indicated the facility admitted the resident on 1/20/2023 with diagnoses that included chronic respiratory failure and dysphagia (difficulty swallowing). A review of Resident 37's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/27/2023 indicated Resident 37 rarely and or never understand other and rarely and or never is understood by others. The MDS indicated Resident 37 was totally dependent on bed mobility, transferring, dressing, eating, and toilet use. A review of Resident 37's Physician's Orders dated 3/19/2023 to 3/26/2023 indicated cefepime (Maxipime) 100 milligram (mg- A measure of weight)/ milliliters (ml- a metric unit of volume equal to a thousandth of a liter) intravenous (IV-into or within a vein) syringe 2 grams, two times per day. During an observation on 3/25/2023 at 9:54 a.m. in Resident 37's room, observed IV bag dated 3/24/2023 at 9 p.m. labeled cefepime 2 gm with liquid medication in the vial; bag and IV tubing are hung and disconnected from an IV pump. During a concurrent observation and interview on 3/25/2023 at 9:59 a.m. with Licensed Vocational Nurse 2 (LVN 2), at Resident 37's bedside, LVN 2 stated IV cefepime 2 gm was administered on 3/24/2023 at 9 p.m., LVN 2 stated pump is off, and IV line is disconnected indicating antibiotic infusion is complete. LVN 2 stated that there was approximately five (5) ml of medication in the vial and approximately 40 ml of normal saline left in the IV bag. LVN 2 stated the resident did not get full dose of the antibiotics. LVN 2 stated Resident 37 should have been given the full dose because not getting the full dose of antibiotics increases the risk for infection. During an interview on 3/26/2023 at 4:10 p.m. with the Nurse Manager (NM), the NM stated if antibiotic is not given in its entirety it is almost like an omission of treatment. The NM stated not getting full dose of antibiotics would disrupt the antibiotic treatment course. The NM stated the nurse did not follow doctors' orders. A review of facility's policies and procedures, titled Medication Administration and Monitoring, last revised on 12/2022 indicated medications are administered exactly as ordered. Dosages are not altered in any way, without a written change of order. A review of facility's policies and procedures, titled Medication Storage in the Facility, last revised on 12/2022 indicated medications rooms, carts, and medication supplies are locked or attended by persons with authorized access.

Based on interview and record review the facility failed to ensure residents drug regimen were free of unnecessary medications for two of three sampled residents (Resident 2 and 33) by failing to: 1. Monitor and document the adverse (unwanted) effects of anticoagulant use (Eliquis, used to prevent serious blood clots from forming due to a certain irregular heartbeat) for Resident 33. This deficient practice had the potential for adverse reactions including bleeding easily and bruising. 2. Monitor a resident for any adverse reaction (any unexpected or dangerous reaction to a drug) upon initiation of intravenous (IV - given through a vein) antibiotic and succeeding doses as instructed by the physician for Resident 2. This deficient practice had the potential to result in Resident 2 experiencing an adverse reaction from the medication. Findings: a. A review of Resident 33's face sheet indicated the facility admitted the resident on 2/15/2023, with diagnoses including respiratory failure (a condition that occurs due to a disease or injury that interferes with the ability of the lungs to deliver oxygen) and hypertension (high blood pressure). A review of Resident 33's History and Physical (H&P), dated 2/17/2023, indicated the resident had a past medical histories of chronic atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart) (on Eliquis), heart failure (a condition that develops when the heart does not pump enough blood for the body's needs), and bradycardia (slow heart rate). A review of Resident 33's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/28/2023, indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated that the resident was on anticoagulant. A review of Resident 33's Active Orders, dated 2/15/2023, indicated an order for apixaban (Eliquis) tablet 5 milligrams (mg, a unit of mass or weight) per gastrostomy tube (G-tube, a tube inserted through the wall of the abdomen directly into the stomach) two times daily. During an interview and record review on 3/26/2023, at 9:56 a.m., reviewed the Active Orders with the Nurse Manager (NM). The NM stated that there was no order for monitoring of adverse reaction on the use of the anticoagulant (Eliquis) and there was no monitoring for side effects on the use of the anticoagulant. The NM further stated that the staff should have called the doctor to place on order for monitoring for adverse effects of anticoagulant use and monitored the resident for bleeding. A review of the facility's recent policy and procedure titled Anticoagulation Management, last revised on 7/2022, indicated that Registered Nurses (RN's) direct oral anticoagulants (DOACs) responsibilities is to monitor patient for any adverse reactions to medication, including signs/symptoms of bleeding. Document DOAC administration on the Electronic Medical Record (eMAR) and monitoring in progress notes in the Electronic Health Record (HER). b. A review of Resident 2's face sheet indicated the facility admitted the resident on 9/12/2022 with diagnosis including respiratory failure (a condition that makes it difficult to breathe on your own). A review of Resident 2's History and Physical (H&P) dated 9/14/2022 indicated the resident had tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help with breathing) tube placement, multiple sclerosis (a condition that can affect the brain and spinal cord that may cause serious disability), and seizure (a sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain). A review of Resident 2's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 1/3/2023, indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and was able to make her needs known. The MD indicated Resident 2 required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of the Resident 2's Order Report, indicated an order for cefepime 1 gram (gm - a unit of measurement IV every twelve hours for fourteen doses for urinary tract infection (UTI - infection in the urinary system) ordered on 2/28/2023. During a concurrent interview and record review on 3/26/2023 at 11:06 a.m., the nurses' notes were reviewed with the Infection Preventionist (IP). The IP stated the nurses' notes dated 2/28/2023 at 3:10 p.m. indicated the physician was aware of the Resident 2's multiple allergies with antibiotics and asked to closely monitor resident and to discontinue antibiotic if resident develops severe allergic reaction. The IP verified that there was no documented evidence that Resident 2 was monitored for adverse reaction upon initiation of the antibiotic. The IP verified that the resident was monitored only for adverse reaction on the following days and times: 1. 3/5/2023 at 4:04 p.m. 2. 3/7/2023 at 3:21 p.m. 3. 3/8/2023 at 2:14 p.m. The IP stated that Resident 2 should have been monitored for any adverse reaction every shift for the duration of antibiotic infusion as the resident had multiple allergies to antibiotics as instructed by the physician and per facility policy. During an interview on 3/26/2023 at 1:07 p.m., the Nurse Manager (NM) stated that Resident 2 should have been monitored for adverse reactions every shift for the duration of the antibiotic infusion as instructed by the physician and per facility policy. A review of the facility's policy and procedure titled, First Dose Administration, dated 6/2018, indicated allergic may not manifest until the second or later dose of medications is administered. The policy also indicated that residents must be monitored closely during subsequent dosing. A review of the facility's policy and procedure titled, Infusion Therapy Products, dated 4/2008, indicated the resident's medical record is checked for know allergies and monitored closely for any signs of adverse reactions after each dose of the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide physical therapy services (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) as ordered for two of two sampled residents (Resident 140 and 240) investigated addressing functional mobility (describes a person's ability to move around in his or her environment, such as walking and standing). This deficient practice had the potential to result in a decline in the residents' progress in physical endurance and mobility and at risk for developing contractures (abnormal shortening of muscle tissue). Findings: a. A review of Resident 140's face sheet indicated the facility admitted the resident on 3/8/2023 with diagnoses that included seizures (change in a person's behavior that comes from abnormal electrical activity in the brain), tracheostomy (a hole that surgeons make through the front of the neck and into the windpipe, to help someone breath), and dysphagia (difficulty swallowing). A review of Resident 140's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 3/15/2023 indicated Resident 140 rarely understand other and rarely is understood by others. The MDS indicated Resident 140 required extensive assistance with bed mobility, transferring, and dressing, and was totally dependent on eating. A review of Resident 140's Physician Orders, dated 3/8/2023, indicated Physical Therapy evaluation and treatment until discontinued. A review of Resident 140's Physical Therapy Plan of Care initial Evaluation, Treatment Note dated 3/10/2023 indicated the recommended frequency of five times a week. During an interview on 3/24/2023 at 8:02 p.m., Resident 140's Family Member (FM 1) stated that she was told Resident 140 would be getting physical therapy five times a week, but the resident was not getting physical therapy as ordered. FM 1 stated he Resident 140 had missed many therapies due to short staffing. A review of Resident 140's Physical Therapy Plan of Care indicated Resident 140 was seen on 3/10/2023, 3/13/2023, 3/15/2023, 3/16/2023, 3/21/2023, 3/23/2023, and 3/26/2023. During an interview on 3/26/2023 at 10:45 a.m., Physical Therapist 1 (PT 1) stated he works a rotation shift where he will work at the hospital and subacute (comprehensive inpatient care designed for someone who has an acute illness, injury, or exacerbation of a disease process). PT 1 stated that physical therapist will try to come to subacute at least three times a week but the physical therapist will mostly be at the hospital. PT 1 stated Resident 140 had a physician's order to receive physical therapy five times a week and the physical therapy department will prioritize Resident 140 when they go to subacute and ensure to see the resident at least three times a week. PT 1 stated staff are trying to follow frequency as ordered five times a week but are not able to due to staffing, PT 1 stated staff should be following the physician's order and would benefit from the ordered frequency. PT 1 also stated Resident 140 may have some decline with activities of daily living (ADL) if they do not follow the physician's order. During an interview on 3/26/2023 at 4:44 p.m. the Physical Therapist Supervisor (PTS) stated therapy staff are short staffed and they were not able to do the recommended visits. The PTS stated Resident 140 was recommended to be seen five (5) times a week, but physical therapy can only see him three (3) times a week. The PTS stated not following the ordered physical therapy to residents can potentially affect residents' progress. The PTS also stated not providing the ordered physical therapy services would affect a resident's endurance and balance which can lead to a decline in a resident's ADLs. A review of the facility's policies and procedures titled, Physical Therapy and Occupational Therapy Evaluation and Treatment, last revised on 8/2022 indicated if skilled individuals' therapy is indicated, formal, individualized therapy is initiated, and a care plan summary is sent to the physician for signature. b. A review of Resident 240's face sheet indicated the facility admitted the resident on 2/9/2023 with diagnoses including ventilator dependent (dependent upon mechanical life support because of inability to breathe effectively) and deep vein thrombosis (DVT, a condition in which the blood clots form in veins located deep inside the body). A review of Resident 240's Pulmonary Progress Note, dated 3/10/2023, indicated the resident was confused, non-verbal, and unable to make decisions. A review of Resident 240's MDS, dated [DATE], indicated the resident had severely impaired cognition (a condition that can lead to losing the ability to understand the meaning or importance of something and the ability to talk or write, resulting in the inability to live independently). The MDS indicated the resident was totally dependent with bed mobility, transfer, dressing, eating, toilet use, personal hygiene, and bathing with physical assistance from one or more persons. During a concurrent interview and record review of Resident 240's clinical record on 3/26/2023 at 2:50 p.m., the MDS Coordinator (MDSC) confirmed the following: - Physician's Order indicated physical therapy evaluation and treatment, dated 3/10/2023. - Physical Therapy Plan of Care (PTPOC), Initial Evaluation and Treatment Note, dated 3/13/2023, indicated treatment plan - balance training, bed mobility, three times per week. - PTPOC-Treatment Note, 3/14/2023 spent 25 minutes. - PTPOC-Treatment Note, 3/16/2023, spent 30 minutes. - PTPOC-Treatment Note 3/23/2023, spent 25 minutes. - PTPOC-Treatment Note 3/24/2023, spent 25 minutes. The MDSC confirmed Resident 240 was not seen three times per week as ordered from 3/10/2023 to 3/26/2023. During an interview on 3/26/2023 at 4:46 p.m., the PTS stated when a resident is admitted to the subacute unit (inpatient care and rehabilitation for patients with an acute illness, injury or disease or complex health problems), the attending physician (AP) will write a physical therapy evaluation and treatment order. The PTS stated within three days from the date the order was placed, one of the physical therapy staff will evaluate and create a plan of care and the resident's AP will co-sign the PTPOC. The PTS stated in the past three weeks, they were not able to send a physical therapist to see the residents in the subacute unit consistently because of staffing issues and had to prioritize which residents gets to be seen. The PTS stated the rehabilitation department covers the hospital inpatients and subacute residents. During an interview on 3/26/2023 at 4:58 p.m., the PTS stated Resident 240 was not seen three times a week. The PTS stated they prioritize residents who has potential for rehabilitation and catch them at their prime. The PTS stated for Resident 240 he was only seen twice per week. During an interview on 3/26/2023 at 5:05 p.m., the PTS stated Resident 240 not being seen consistently would potentially affect and lower the resident's endurance, sitting tolerance, and walking endurance. The PTS stated Resident 240 may have a decline with endurance but should not be as much. During an interview on 3/26/2023 at 9:03 p.m., the Nurse Manager (NM) stated nursing staff do not keep track of the physical therapy visits and how often the physical therapists come and see the residents. The NM stated if recommended, there should be some tracking for continuity of care. A review of the facility's policy and procedure titled, Physical Therapy and Occupational Therapy Evaluation and Treatment, last revised on 8/2022, indicated if skilled individuals' therapy is indicated, formal, individualized therapy is initiated, and a care plan summary is sent to the physician for signature.

Based on observation, interview, and record review, the facility failed to promote the resident rights to examine the results of the most recent survey (a survey to determine compliance with state and federal regulations) of the facility by failing to: 1. Ensure two (Residents 4 and 19) of two residents knew where to locate the most recent survey results. 2. Post the most recent survey results in a place that are prominent and accessible (a place where individuals wishing to examine survey results do not have to ask to see them) to residents, family members, and legal representatives of residents. These deficient practices had the potential to impede the resident rights and negatively affect residents' psychosocial wellbeing. Findings: A review of Resident 4's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 1/14/2023, indicated the facility admitted the resident on 5/4/2020 and had an intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated the resident was independent with eating, supervision with locomotion, and required extensive assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 19's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 12/15/2022, indicated the resident had moderately impaired cognition ((mental action or process of acquiring knowledge and understanding) and required extensive assistance from staff with bed mobility and total assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During an observation on 3/25/2023 at 1:30 p.m., the most recent survey results were not posted in a readily accessible location in the facility. Observed survey results in an unlabeled binder adjacent to the communication board. During the Resident Council task interview on 3/25/2023 at 1:00 p.m., two of two residents shook their head to indicate they did not know where to find the most recent survey results when asked by the surveyor, Without having to ask, were the results of the state inspection available to read?. During an interview on 3/25/2023 at 1:32 p.m., the Activities Coordinator (AC) stated that residents were reminded during the resident council meeting where to find the most recent survey results. During a concurrent observation and interview on 3/25/2023 at 1:33 p.m., Licensed Vocational Nurse 2 (LVN 2) stated if the surveyor did not ask where the survey results were, he would not know where it was located. LVN 2 stated that the survey results were on a metal rack without a label next to the communication board adjacent to the nurse station. LVN 2 stated the survey result was not clearly labeled and was not readily accessible. LVN 2 stated residents or their representatives should not have to ask for assistance to locate the survey result. During a concurrent observation and interview on 3/25/2023 at 1:35 p.m., Registered Nurse 4 (RN 4) stated the survey result was not at the nurse station. RN 4 stated he did not know where the survey results were located. RN 4 stated residents or their representatives should not have to ask for assistance to locate the survey result.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d. A review of Resident 3's face sheet indicated the facility admitted the resident on [DATE] with diagnoses including respiratory failure (a condition that makes it difficult to breathe on your own), and diabetes mellitus II (a condition characterized by high levels of sugar in the blood). A review of Resident 3's History and Physical (H&P) dated [DATE], indicated the resident had tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help with breathing) tube placement, and seizure (a sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain). A review of Resident 3's Minimum Data Set (MDS- a standardized assessment and screening tool) dated [DATE], indicated the resident had severely impaired cognition ((mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 3's electronic health record (EHR) on [DATE] at 9:00 a.m., there was no documented evidence that the AD was discussed and offered to the representative or their representative. The EHR also indicated the Power of Attorney (legal authorization for a designated person to make decisions about another person's property, finances, or medical care) status was unknown. During an interview on [DATE] at 6:19 p.m. with Registered Nurse (RN 4), RN 4 stated there was no advance directive acknowledgement form for Resident 3. During an interview on [DATE] at 10:51 a.m. with Clinical Social Worker (CSW), the CSW stated advance directives are always offered during admission and the admitting nurse goes over the paperwork with the family. The CSW stated there should have been a document that indicates it was offered upon admission. The CSW stated the reason for acknowledgement form is to document the presence of an advance directive and offer assistance if they do not have one. The CSW stated if the resident or resident representative wanted more information, the licensed nurses would help them with that. During an interview on [DATE] at 9:16 a.m., the Admissions Coordinator (AC) stated she meets with resident and family to go over the admission packet. The AC stated she will ask resident if they have an advance direct and will request a copy and or mark no indicating the resident does not have an advance directive. The AC stated she does not go over the advance directive and the CSW is responsible to follow up with the resident or their representatives. The AC stated the purpose of advance directives is to follow residents' decision if they are not able to communicate and to assign someone to follow their wishes. The AC stated there can be a risk of not respecting resident's wishes in case they become incapacitated to make decisions if the AD was not followed up on. The AC stated based on policy they are not following residents' rights to an advance directive. The AC was unable to provide documented evidence that the AD was discussed with Resident 3 or their representative. During an interview on [DATE] at 9:40 a.m., the Admitting Supervisor (AS) stated the admitting department provide information on how to complete an AD but there is no documented evidence that information was provided to residents or their representatives or if they declined assistance. The AS stated the importance of formulating an AD is that in case a resident is not able to make decisions regarding their care, they have the option to select someone who can decide for them. During an interview on [DATE] at 6:30 p.m., the Nurse Manager (NM) stated the facility is required to ask residents if they have an advance directive upon admission. The NM stated the importance of an AD, honors resident's wishes in case of emergency, and they are unable to decide for themselves. e. A review of Resident 11's face sheet indicated the facility admitted the resident on [DATE] with diagnoses including respiratory failure (a condition that makes it difficult to breathe on your own), deep vein thrombosis (a condition that occurs when a blood clot forms in a deep vein usually in the lower leg, thigh, and arm). A review of Resident 11's History and Physical (H&P) dated [DATE] indicated the resident had tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help with breathing), psychosis (a mental condition characterized by a disconnection from reality), and diabetes mellitus II (a condition characterized by high levels of sugar in the blood). A review of Resident 11's Minimum Data Set (MDS- a standardized assessment and screening tool) dated [DATE], indicated the resident had severely impaired cognition ((mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 11's electronic health record (EHR) on [DATE] at 9:00 a.m., there was no documented evidence that the AD was discussed and offered to the representative or their representative. The EHR also indicated the Power of Attorney (legal authorization for a designated person to make decisions about another person's property, finances, or medical care) status was unknown. During an interview on [DATE] at 6:19 p.m. with Registered Nurse (RN 4), RN 4 stated there was no advance directive acknowledgement form for Resident 11. During an interview on [DATE] at 10:51 a.m. with Clinical Social Worker (CSW), the CSW stated advance directives are always offered during admission, stated the admitting nurse goes over the paperwork with the family. The CSW stated there should have been a document that indicates it was offered upon admission. The CSW stated the reason for acknowledgement form is to document the presence of an advance directive and offer assistance if they do not have one. The CSW stated if the resident or resident representative wanted more information, the licensed nurses would help them with that. During an interview on [DATE] at 9:16 a.m., the Admissions Coordinator (AC) stated she meets with resident and family to go over the admission packet. The AC stated she will ask resident if they have an advance direct and will request a copy and or mark no indicating the resident does not have an advance directive. The AC stated she does not go over the advance directive and the CSW is responsible to follow up with the resident or their representatives. The AC stated the purpose of advance directives is to follow residents' decision if they are not able to communicate and to assign someone to follow their wishes. The AC stated there can be a risk of not respecting resident's wishes in case they become incapacitated to make decisions if AD was not followed up on. The AC stated based on policy they are not following residents' rights to an advance directive. The AC was unable to provide documented evidence that the AD was discussed with Resident 11 or their representative. During an interview on [DATE] at 9:40 a.m., the Admitting Supervisor (AS) stated the admitting department provide information on how to complete an AD but there is no documented evidence that information was provided to residents or their representatives or if they declined assistance. The AS stated the importance of formulating an AD is that in case a resident is not able to make decisions regarding their care, they have the option to select someone who can decide for them. During an interview on [DATE] at 6:30 p.m., the Nurse Manager (NM) stated the facility is required to ask residents if they have an advance directive upon admission. The NM stated the importance of an AD, honors resident's wishes in case of emergency, and they are unable to decide for themselves. A review of the facility's policy and procedure titled, Advance Directive, last reviewed 7/2018 indicated a policy statement to support patients and families' rights to participate in healthcare decision-making and to ensure those rights are addressed and the patient's wishes are followed if they become incapacitated. The policy also indicated the following: 1. Patient Registration will ask the patient or their family member for an AD or would like information and based on the response, the appropriate selection will be entered into the EHR for the AD status. 2. Nursing Staff will review and update the AD information during the initial assessment and document in the EHR the appropriate selection. Based on interview and record review, the facility failed to provide documented evidence that information about an advance directive (AD - written statement of a person's wishes regarding medical treatment made to ensure those wishes were carried out should the person be unable to communicate to a doctor) was discussed to the residents and/or their responsible parties for eight of eight sampled residents (Resident 26, 37, 140, 3, 11, 13, 36, and 240). This deficient practice had the potential to delay emergency treatment or the potential to force emergency, life-sustaining procedures against the resident's personal preferences and or violated the resident's rights and/or representative's right to be fully informed of the option to formulate their advance directives. Findings: a. A review of Resident 26's face sheet indicated the facility admitted the resident on [DATE] with diagnoses including congestive heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), carbapenem resistant bacteria carrier (multidrug-resistant organisms that that can cause serious infections and require interventions in healthcare settings to prevent spread), and quadriplegia (paralysis below the neck that affects all of a person's limbs). A review of Resident 26's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated [DATE] indicated Resident 26 rarely and or never understand other and rarely and or never is understood by others. The MDS indicated Resident 26 was totally dependent on bed mobility, transferring, dressing, eating, and toilet use. During a record review of Resident 26' medical records on [DATE] at 11:05 a.m., there was no advance directive noted in the chart or the electronic medical chart. During an interview on [DATE] at 6:19p.m. with Registered Nurse (RN 4), RN 4 stated there was no advance directive acknowledgement form for Resident 26. During an interview on [DATE] at 10:51 a.m. with Clinical Social Worker (CSW), the CSW stated advance directives are always offered to residents during admission by the nurse. The CSW stated there should have been a document that indicates it was offered to the resident upon admission. The CSW stated the reason for the acknowledgement form is to document the presence of an advance directive and if they do not have one, it will be offered to them. The CSW stated she assist by providing information to the residents if they request assistance with formulating one. During an interview on [DATE] at 9:16 a.m. with the Admissions Coordinator (AC), the AC stated she meets with resident and family to go over the admission packet. The AC stated she will ask resident if they have an advance direct and will request a copy and or mark no indicating the resident does not have an advance directive. The AC stated it is not her role to offer advance directive and will redirect resident to social worker. The AC stated the purpose of advance directives is to follow residents' decision if they are not able to communicate and to assign someone to follow their wishes. During an interview on [DATE] at 9:35 a.m. with Admitting Supervisor (AS), the AS stated that the facility does have an advance directive acknowledgement form and once completed it is scanned. The AS stated there is no documentation of education provided to Resident 26 or family. During an interview on [DATE] at 4:33 p.m., with the Nurse Manager (NM), the NM stated the facility is required to ask residents if they have an advance directive upon admission. The NM stated advance directive tell staff what the resident wants for their end of life and facility need to honor residents request because without it may not respect the resident wishes and could possibly start cardiopulmonary resuscitation (CPR- an emergency life-saving procedure that is done when someone's breathing or heartbeat has stopped) on a resident who does not want one. A review of the facility's policies and procedures, titled, Advance Directives, last revised on 7/2018 indicated Patient Registration will ask the patient/family if the patient has an Advance Health Care Directive (AHCD) or would like information regarding Advance Directives. Nursing staff will: Review and update the patient's Advance Directive information during the initial assessment and document in the electronic medical record the appropriate selection for the patient's Advance Directive status. b. A review of Resident 37's face sheet indicated the facility admitted the resident on [DATE] with diagnoses including chronic respiratory failure and dysphagia (difficulty swallowing). A review of Resident 37's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated [DATE] indicated Resident 37 rarely and or never understand other and rarely and or never is understood by others. The MDS indicated Resident 37 was totally dependent on bed mobility, transferring, dressing, eating, and toilet use. During a record review of Resident 37' medical records on [DATE] at 11:40 a.m., there was no advance directive noted in the chart or the electronic medical chart. During an interview on [DATE] at 6:19p.m. with Registered Nurse (RN 4), RN 4 stated there was no advance directive acknowledgement form for Resident 37. During an interview on [DATE] at 10:51 a.m. with Clinical Social Worker (CSW), the CSW stated advance directives are always offered to residents during admission by the nurse. The CSW stated there should have been a document that indicates it was offered to the resident upon admission. The CSW stated the reason for the acknowledgement form is to document the presence of an advance directive and if they do not have one, it will be offered to them. The CSW stated she assist by providing information to the residents if they request assistance with formulating one. During an interview on [DATE] at 9:16 a.m. with the Admissions Coordinator (AC), the AC stated she meets with resident and family to go over the admission packet. The AC stated she will ask resident if they have an advance direct and will request a copy and or mark no indicating the resident does not have an advance directive. The AC stated it is not her role to offer advance directive and will redirect resident to social worker. The AC stated the purpose of advance directives is to follow residents' decision if they are not able to communicate and to assign someone to follow their wishes. During an interview on [DATE] at 9:35 a.m. with Admitting Supervisor (AS), the AS stated that the facility does have an advance directive acknowledgement form and once completed it is scanned. The AS stated there is no documentation of education provided to Resident 37 or family. During an interview on [DATE] at 4:33 p.m. with the Nurse Manager (NM), the NM stated the facility is required to ask residents if they have an advance directive upon admission. The NM stated advance directive tell staff what the resident wants for their end of life and facility need to honor residents request because without it may not respect the resident wishes and could possibly start cardiopulmonary resuscitation (CPR- an emergency life-saving procedure that is done when someone's breathing or heartbeat has stopped) on a resident who does not want one. A review of the facility's policies and procedures, titled, Advance Directives, last revised on 7/2018 indicated Patient Registration will ask the patient/family if the patient has an Advance Health Care Directive (AHCD) or would like information regarding Advance Directives. Nursing staff will review and update the patient's Advance Directive information during the initial assessment and document in the electronic medical record the appropriate selection for the patient's Advance Directive status. c. A review of Resident 140's face sheet indicated the facility admitted the resident on [DATE] with diagnoses that included seizures (change in a person's behavior that comes from abnormal electrical activity in the brain), tracheostomy (a hole that surgeons make through the front of the neck and into the windpipe, to help someone breath), and dysphagia (difficulty swallowing). A review of Resident 140's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated [DATE] indicated Resident 140 rarely and or never understand other and rarely and or never is understood by others. The MDS indicated Resident 140 requires extensive assistance with bed mobility, transferring, and dressing, and is totally dependent on eating. During a record review of Resident 140' medical records on [DATE] at 11:32 a.m., there was no advance directive noted in the chart or the electronic medical chart. During an interview on [DATE] at 6:19 p.m. with Registered Nurse (RN 4), RN 4 stated there was no advance directive acknowledgement form for Resident 140. During an interview on [DATE] at 10:51 a.m. with Clinical Social Worker (CSW), the CSW stated advance directives are always offered to residents during admission by the nurse. The CSW stated there should have been a document that indicates it was offered to the resident upon admission. The CSW stated the reason for the acknowledgement form is to document the presence of an advance directive and if they do not have one, it will be offered to them. The CSW stated she assist by providing information to the residents if they request assistance with formulating one. During an interview on [DATE] at 9:16 a.m. with the Admissions Coordinator (AC), the AC stated she meets with resident and family to go over the admission packet. The AC stated she will ask resident if they have an advance direct and will request a copy and or mark no indicating the resident does not have an advance directive. The AC stated it is not her role to offer advance directive and will redirect resident to social worker. The AC stated the purpose of advance directives is to follow residents' decision if they are not able to communicate and to assign someone to follow their wishes. During an interview on [DATE] at 9:35 a.m. with Admitting Supervisor (AS), the AS stated that the facility does have an advance directive acknowledgement form and once completed it is scanned. The AS stated there is no documentation of education provided to Resident 37 or family. During an interview on [DATE] at 4:33 p.m. with the Nurse Manager (NM), the NM stated the facility is required to ask residents if they have an advance directive upon admission. The NM stated advance directive tell staff what the resident wants for their end of life and facility need to honor residents request because without it may not respect the resident wishes and could possibly start cardiopulmonary resuscitation (CPR- an emergency life-saving procedure that is done when someone's breathing or heartbeat has stopped) on a resident who does not want one. A review of the facility's policies and procedures, titled, Advance Directives, last revised on 7/2018 indicated Patient Registration will ask the patient/family if the patient has an Advance Health Care Directive (AHCD) or would like information regarding Advance Directives. Nursing staff will review and update the patient's Advance Directive information during the initial assessment and document in the electronic medical record the appropriate selection for the patient's Advance Directive status f. A review of Resident 13's face sheet indicated the facility admitted the resident on [DATE] with diagnoses including ventilator dependent (dependent upon mechanical life support because of inability to breathe effectively) and deep vein thrombosis (DVT, a condition in which the blood clots form in veins located deep inside the body). A review of Resident 13's Physician admission Note, dated [DATE], indicated the resident's neurological was nonresponsive. A review of Resident 13's MDS dated [DATE], indicated the resident in persistent vegetative state/no discernible consciousness. g. A review of Resident 36's face sheet indicated the facility admitted the resident on [DATE] with diagnosis including respiratory failure and hypertension (a condition in which the blood vessels have persistently raised pressure). A review of Resident 36's H&P, dated [DATE], indicated the resident neurologic status was awake, interactive, episodic agitation, and moves all extremities. A review of Resident 36's MDS, dated [DATE], indicated the resident with moderate cognitive impairment. The MDS indicated the resident was able to make self-understood and understood others. The MDS indicated that the California Physician Orders for Life-Sustaining Treatments (POLST, medical order form stating what kind of medical interventions a person wants or does not want in case they become very ill) Section D-Advance Directives was not completed. h. A review of Resident 240's face sheet indicated the facility admitted the resident on [DATE] with diagnoses including ventilator dependent and DVT. A review of Resident 240's Pulmonary Progress Note, dated [DATE], indicated the resident confused, non-verbal, unable to make decisions. A review of Resident 240's MDS, dated [DATE], indicated the resident with severely impaired cognition. The MDS indicated the resident required total dependence with bed mobility, transfer, dressing, eating, toilet use, personal hygiene, and bathing with physical assistance from one or more persons. During an interview on [DATE] at 9:16 a.m., the AC stated she meets with resident and family to go over the admission packet. The AC stated she will ask resident if they have an advance direct and will request a copy and or mark no indicating the resident does not have an advance directive. The AC stated she does not go over the advance directive and the CSW is responsible to follow up with the resident or their representatives. The AC stated the purpose of advance directives is to follow residents' decision if they are not able to communicate and to assign someone to follow their wishes. The AC stated there can be a risk of not respecting resident's wishes in case they become incapacitated to make decisions if AD was not followed up on. The AC stated based on policy they are not following residents' rights to an advance directive. During an interview on [DATE] at 9:40 a.m., the AS stated the admitting department provide information on how to complete an AD but there is no documented evidence that information was provided to residents or their representatives or if they declined assistance. The AS stated the importance of formulating an AD is that in case a resident is not able to make decisions regarding their care, they have the option to select someone who can decide for them. During an interview [DATE] at 12:40 p.m., the AC was unable to provide documented evidence that the AD was discussed with Resident 13, 36, and 240 or their representative. During an interview on [DATE] at 6:30 p.m., the NM stated the facility is required to ask residents if they have an advance directive upon admission. The NM stated the importance of an AD, honors resident's wishes in case of emergency, and they are unable to decide for themselves. A review of the facility's policy and procedure titled, Advance Directive, last reviewed 7/2018 indicated a policy statement to support patients and families' rights to participate in healthcare decision-making and to ensure those rights are addressed and the patient's wishes are followed if they become incapacitated. The policy also indicated the following: 3. Patient Registration will ask the patient or their family member for an AD or would like information and based on the response, the appropriate selection will be entered into the EHR for the AD status. 4. Nursing Staff will review and update the AD information during the initial assessment and document in the EHR the appropriate selection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the necessary treatment and services to prevent formation and progression of a pressure injury (an injury to skin and underlying tissue due to prolonged pressure over a bony structure) to three of three sampled residents (Residents 33, 31, and 32) by: 1. Failing to provide documented evidence that dressing change to the Sacro coccyx (pertaining to the sacrum [large, curved, triangular-shaped bone at the base of the spine] and coccyx [tailbone]) wound was performed on the following days: 12/27/2022, 1/10/2023, 1/18/2023, 1/28/2023, 1/29/2023, 2/24/2023, and 2/25/2023 to Resident 33. 2. Failing to apply bilateral heel protectors (a unique product designed specifically to minimize the risk of pressure damage to heels) per physician's order to Resident 31. 3. Failing to complete weekly wound pressure ulcer reassessment for Resident 32. These deficient practices had the potential to result in the development of worsening and newly acquired pressure injuries for the residents. Findings: a. A review of Resident 33's face sheet indicated the facility admitted the resident on 2/15/2023, with diagnoses including respiratory failure (a condition that occurs due to a disease or injury that interferes with the ability of the lungs to deliver oxygen) and hypertension (high blood pressure). A review of Resident 33's History and Physical (H&P), dated 2/17/2023, indicated the resident had stage 3 pressure injury (full thickness skin loss involving damage ore necrosis [tissue death] of subcutaneous tissue that may extend down to, but not through, underlying fascia [a sheath of stringy connective tissue that surrounds every part of the body]) , present on admission, transitioned to unstageable (an ulcer that has full thickness tissue loss but is either covered by extensive necrotic tissue or by eschar [dead tissue that sheds or falls off from the skin]) as of 1/2023. A review of Resident 33's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/28/2023, indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident was totally dependent on bed mobility and transfer. The MDS also indicated the resident had unstageable pressure ulcer of the sacral region. A review of Resident 33's Braden Scale Assessment (an assessment tool for predicting the risk of pressure injury), dated 3/25/2023, indicated the resident was at high risk for developing pressure injuries. A review of Resident 33's Active Orders indicated: -Wound care to Sacro coccyx pressure injury transitioned to unstageable until discontinued. Cleanse with normal saline (NS, a sterile solution of sodium chloride in water), apply Santyl (an FDA [Food and Drug Administration}-approved prescription medicine that removes dead tissue from wounds to heal), moist gauze and cover with mepilex (a soft and highly conformable antimicrobial foam dressing that absorbs exudate [fluid that leaks out of blood vessels into nearby tissues] and maintains wound environment) daily and if necessary (PRN) if loose or soiled. Re-evaluate weekly. A review of Resident 33's Wound Eval and Treatment Flow Sheet dated 12/2022 to 2/2023 indicated missing entries on: 12/27/2022, 1/10/2023, 1/18/2023, 1/28/2023, 1/29/2023, 2/24/2023, and 2/25/2023. A review of Resident 33's Care Plan, dated 3/5/2023, indicated the resident had impaired wound healing. The care plan indicated to provide good skin care and assess skin integrity daily and prn, report any impaired skin integrity to MD. During an interview on 3/25/2023, with Registered Nurse 4 (RN 4), RN 4 stated it is important to follow the treatment regimen as ordered and document it to prevent the wound from getting worse and infected. During an interview and record review on 3/26/2023, at 9:34 a.m., reviewed Resident 33's Active Orders and Wound Eval and Treatment Flow Sheet with the Nurse Manager (NM). The NM stated that even if there was no dedicated wound nurse present, the assigned licensed staff should have done the wound dressing. The NM stated if there was no documentation, it was not done. b. A review of Resident 31's face sheet indicated the facility admitted the resident on 9/15/2023, with diagnoses including respiratory failure and fever. A review of Resident 31's H&P, dated 3/18/2022, indicated the resident was confused at baseline, and had weakness. The MDS indicated the resident was totally dependent on bed mobility. A review of Resident 31's Braden Scale Assessment, dated 3/25/2023, indicated the resident was high risk for developing pressure injuries. A review of Resident 31's Active Orders, dated 9/15/2022, indicated an order nursing communication until discontinued, to apply bilateral heel protectors and check for skin integrity every two hours and notify MD of any changes. A review of Resident 31's Care Plan, with expected end date of 5/23/2023, indicated the resident had skin injury risk increased. The care plan indicated interventions including relieve and redistribute pressure (e.g., scheduled position changes, weight shifts, use of support surface, medical device repositioning, protective dressing application, use of positioning device, microclimate control, use of pressure-injury-monitor). During a concurrent observation and interview on 3/25/2023, at 9:02 a.m., with Registered Nurse 1, observed Resident 31 without bilateral heel protectors. RN 1 stated that the resident should have had heel protectors to prevent pressure injuries on both heels. During a concurrent interview and record review on 3/26/2023, at 10:08 a.m., reviewed Resident 31's Active Orders and Repositioning every two hours flow sheet with the Nurse Manager (NM). The NM stated that the staff should have applied the heel protectors on because the resident is at risk for developing skin breakdown on the heels. A review of the facility's recent policy and procedure titled Pressure Injury and Skin Breakdown Assessment and Prevention, last revised on 12/2022, indicated documentation is completed in the Electronic Health Record (EHR) by nursing and or ancillary staff as appropriate for the intervention, including but not limited to: Intervention/prevention strategies implemented, including safe patient mobilization equipment used. Guidelines for skin breakdown prevention and early intervention for at risk patients may include but not limited to: Offload heels using pillows under the calves or off-loading devices. A review of the facility's recent policy and procedure titled Pressure Injury Prevention (2021), last revised on 5/2021, indicated relieve pressure (float heels) by using pillows lengthwise under the legs or other device. All assessments and skin inspection findings will be documented in the medical record as outlined in the Plan of Care- Assessment and Documentation Guideline. Interventions related to prevention of skin breakdown will be documented every shift. c. A review of Resident 32's face sheet indicated the facility admitted the resident on 10/6/2021. A review of Resident 32's H&P, dated 3/22/2023, indicated the resident with diagnoses including chronic hypoxemic (a condition of lower-than-normal range of oxygen levels in the blood) respiratory failure (an ongoing condition when the airways that carry air to the lungs become narrow and damaged limiting air movement through the body) and sacral decubitus stage four (a deep wound reaching the muscles, ligaments, or bones). A review of Resident 32's MDS, dated [DATE], indicated the resident rarely/never understood others and rarely/never made self-understood. The MDS indicated the resident was totally dependent with bed mobility, transfer, toilet use, and personal hygiene from one or more person's physical assist. The MDS indicated the resident at risk of developing pressure ulcers with one stage four pressure ulcer. A review of Resident 32's Active Orders indicated, dated 8/7/2022, indicated wound care sacrococcyx transitioned to stage four pressure injury , daily, cleanser normal saline, in to the hole place puracol (collagen wound dressing) cover with gauze .to the hypertrophic (excessive growth) granulation (a type of new connective tissue) wound, apply silver aquacel (antimicrobial dressing) cut to size so the silver can calm down granulation, mepilex (a spongey grey foam pad) or equivalent, A review of Resident 32's Care Plan for Wound, dated 6/9/2021, indicated sacrum transitioned to stage four with interventions including treatment as ordered on affected area and monitor for effectiveness and notify MD accordingly. During a concurrent interview and record review of Resident 32's Wound Eval on 3/26/2023 at 11:56 a.m., the RN 3 stated that on 3/22/2023, the weekly pressure ulcer wound was done but there were no measurements documented. RN stated if it was not done the licensed nurse should have documented the reason why it was not completed. RN stated weekly wound reassessments are done to check if the wound is responding to the treatments and if it is improving or getting worse. During a concurrent interview on 3/26/2023 at 9:04 p.m., the NM stated weekly wound pressure ulcer assessment should be done weekly. The NM stated weekly wound pressure assessment is part of the treatment plan and it is how they monitor if the wound getting worse or getting better. The NM stated the eyes cannot measure accurately so the wounds must be measured in order to have a precise and accurate assessment. A review of the facility's recent policy and procedure titled Pressure Injury and Skin Breakdown Assessment and Prevention, last revised on 12/2022, indicated documentation is completed in the Electronic Health Record (EHR) by nursing and or ancillary staff as appropriate for the intervention, including but not limited to: Intervention/prevention strategies implemented, including safe patient mobilization equipment used.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to position the residents head of bed at 30 degrees while receiving enteral feeding (a form of nutrition that is delivered into the digestive system as a liquid) consistent with the facility's policy and procedure for three of three sampled residents who are dependent on staff for positioning (Resident 13, 36, and 240). This deficient practice had the potential to place the residents at risk for aspiration (occurs when food or liquid is breathed into the airways or lungs, instead of being swallowed) pneumonia (inflammation or infection of the lungs or large airways). Findings: a. A review of Resident 32's face sheet indicated the facility admitted the resident on 10/6/2021. A review of Resident 32's History and Physical (H&P), dated 3/22/2023, indicated the resident with diagnoses including chronic hypoxemic (a condition of lower-than-normal range of oxygen levels in the blood) respiratory failure (an ongoing condition when the airways that carry air to the lungs become narrow and damaged limiting air movement through the body) and sacral decubitus stage four (a deep wound reaching the muscles, ligaments, or bones). A review of Resident 32's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/12/2023, indicated the resident rarely/never understood others and rarely/never made self-understood. The MDS indicated the resident was totally dependent with bed mobility, transfer, toilet use, and personal hygiene from one or more person's physical assist. The MDS indicated the resident feeding tube was performed while the resident was residing in the facility. A review of Resident 32's active orders dated 10/5/2022, indicated, adult tube feeding (TF, a way to provide nutrition when you cannot eat or drink safely by mouth) carbohydrate-controlled rate 65 milliliters (ml, a unit of measure)/hour (hr), continuous. During an observation on 3/26/2023 at 8:17 a.m., observed Licensed Vocational Nurse 5 (LVN 5) adjusted Resident 32's head of bed (HOB) at 23 degrees and resumed tube feeding. During an observation on 3/26/2023 at 9:28 a.m., observed Resident 23's HOB at 23 degrees with tube feeding running. During a concurrent observation and interview on 3/26/2023 at 9:41 a.m., observed LVN 5 at Resident 32's bedside. LVN 5 confirmed the resident's HOB was at 23 degrees. LVN 5 stated the HOB should be always at or above 30 degrees. LVN 5 adjusted the resident's HOB to 30 degrees. b. A review of Resident 17's face sheet indicated that the facility admitted the resident on 1/17/2023, with diagnoses including respiratory failure (a condition that occurs due to a disease or injury that interferes with the ability of the lungs to deliver oxygen) and muscle spasm. A review of Resident 17's H&P, dated 1/18/2023, indicated the resident was contracted in all extremities except the left upper extremity which she moves freely. A review of Resident 17's active orders, dated 1/17/2023, indicated adult tube carbohydrate-controlled tube feeding start rate at 45ml/hr, continuous. A review of Resident 17's MDS, dated [DATE], indicated the resident never had the ability to make self-understood and understand others. The MDS also indicated the resident was totally dependent on bed mobility and transfer, dressing, eating, toilet use, and personal hygiene. The MDS indicated the resident feeding tube was performed while the resident was residing in the facility. During a concurrent observation and interview on 3/26/2023 at 9:36 a.m., LVN 5 stated she had just finished Resident 17's medication pass. LVN 5 stated Resident 17's HOB was at 24 degrees and will elevate Resident 17's HOB to 30 degrees. LVN 5 stated she had to put the resident's HOB down because she had difficulty with administering the resident's gastrostomy (g-tube, a flexible tube inserted through the abdominal wall that directly delivers nutrition to the stomach) medications. LVN 5 stated she should have elevated the resident's HOB at 30 degrees. c. A review of Resident 25's face sheet indicated the facility admitted the resident on 2/9/2023 with diagnosis including acute respiratory failure (sudden inability of the lungs to maintain normal respiratory function) and constipation (a condition of inability to pass stools regularly). A review of Resident 25's MDS, dated [DATE], indicated the resident is in a persistent vegetative state/no discernible consciousness. The MDS indicated the resident was totally dependent with bed mobility, locomotion on unit, dressing, bathing, and personal hygiene with one or more person's physical assist. The MDS indicated the resident with impairment on both side of upper and lower extremities. A review of Resident 25's active orders, dated 2/9/2023, indicated adult tube feeding carbohydrate-controlled goal rate 80 ml/hr, continuous. A review of Resident 25's Care Plan, Absence of Aspiration Signs/Symptoms, expected end date 5/13/2023, indicated the resident is at risk for aspiration due to TF with interventions including keeping HOB elevated at least 30-45 degrees at all times. During an observation on 3/26/2023 at 7:54 a.m., observed Resident 25 in bed, with tube feeding Fibersource High Nitrogen (tube feeding formula) running at 50 ml/hr, fed 100 ml, and HOB elevated at 27 degrees. During a concurrent observation and interview on 3/26/2023 at 9:41 a.m., with LVN 5 at Resident 25's bedside, LVN 5 stated the resident's HOB was elevated at 27 degrees. LVN 5 stated the HOB should have been elevated at 30 degrees. During an interview on 3/26/2023 at 9:01 p.m., the Nurse Manager (NM) stated the HOB should be at least 30 degrees while the resident is receiving tube feeding. The NM stated that when the HOB is less than 30 degrees, it places the resident at risk for aspiration pneumonia and vomiting. The NM the LVNs and registered nurses (RNs), should make sure the HOB should be elevated at least 30 degrees at all times while the resident is receiving tube feeding. A review of the facility's policy and procedure titled, Enteral Tube Care: Administration of Nutrition, Fluids, and Medications (Sub Acute), reviewed 12/2022, indicated that the HOB is elevated at least 30 degrees at all times when resident is receiving tube feeding, fluid or medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. A review of Resident 37's face sheet indicated the facility admitted the resident on [DATE] with diagnoses that included chronic respiratory failure (an ongoing condition when the airways that carry air to the lungs become narrow and damaged limiting air movement through the body) and dysphagia (difficulty swallowing). A review of Resident 37's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated [DATE] indicated Resident 37 rarely and or never understand other and rarely and or never is understood by others. The MDS indicated Resident 37 was totally dependent on bed mobility, transferring, dressing, eating, and toilet use. A review of Resident 37's Physician Orders dated [DATE] to [DATE] indicated to apply nystatin powder to bilateral fingernails two times per day. During an observation on [DATE] at 9:59 a.m. in Resident 37's room, observed Resident 37's nystatin powder located on top of a medication locker (a locked box in resident room, that is only accessed by licensed staff). During a concurrent observation and interview on [DATE] at 10:04 a.m. Licensed Vocational Nurse (LVN 2) stated Resident 37's nystatin should be in a locked container. LVN 2 stated the medication needs to be locked for safety reasons During an interview on [DATE] at 4:19 p.m., the Nurse Manager (NM) stated for Resident 37 the nystatin should be locked in resident locker. The NM stated leaving medication out is a risk as someone can take it. The NM stated since the medication was labeled with confidential information, patient information can be used. A review of the facility's policies and procedures, titled Medication Administration and Monitoring, last revised in 12/2022 indicated once removed, medications must remain with the administering staff at all times and not left unattended. d. During a concurrent observation of Med Storage 1 and interview, on [DATE] at 2:43 p.m., observed the following with Licensed Vocational Nurse 4 (LVN 4): 1. Enoxaparin sodium 40 milligrams (mg- measure of weight) with expiration date of 9/2022 (total 1). 2. Enoxaparin sodium 30 mg with expiration date of 2/2023 (total of 4). LVN 4 stated that Enoxaparin sodium 40 mg and Enoxaparin sodium 30 mg were expired. LVN 4 stated the medications should have been discarded. LVN 4 stated there is a risk for harm to residents if the medications were administered as the efficacy of the medications were not accurate anymore. During an interview on [DATE] at 4:05 p.m., the Nurse Manager (NM) stated there should not have been any expired supplies or medications in the medication storage room as those meds will not be effective as ordered. A review of the facility's policies and procedures, titled Medication Storage in the Facility, last revised in 12/2022 indicated outdated, contaminated, or deteriorated medications, and those in containers that are cracked, soiled, or without secure closure are immediately removed from room stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. e. During a concurrent observation of Med Storage 1 and interview, on [DATE] at 2:43 p.m., observed a Shiley Tracheostomy Tube Cuffed (name of a trachestomy tube) with inner cannula with expiration date of 2/2019. LVN 4 stated the tracheostomy cannula was expired. LVN 4 stated the tracheostomy cannula should have been discarded because it was no longer sterile which can lead to infection if used. During an interview on [DATE] at 4:05 p.m., the Nurse Manager (NM) stated there should not have been any expired supplies or medications in the medication storage room. The NM stated the cleanliness or infection control aspect of the tracheostomy cannula would be questioned because if expired, it can cause an infection. A review of the facility's policies and procedures, titled Medication Storage in the Facility, last revised on 12/2022 indicated outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closure are immediately removed room 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 ensure safe handling of medications and maintain a safe and secure storage by: 1. Failing to date Resident 31's levalbuterol (breathing treatment medication) with an open date according to manufacturer's instructions. This deficient practice had the potential to administer ineffective medications. 2. Failing to discard four of four sampled residents' (Resident 17, 31, 240, and 26) medications in bubble packs (a packaged container with compartments that can contain medications) with a broken seal and covered with tape. This deficient practice had the potential to contaminate medications stored inside the medication cart. 3. Failing to ensure licensed nurses did not leave nystatin (drug used to treat fungal infections [a type of microorganism]) powder not locked up and left unattended for one out of four sampled residents (Resident 37). This deficient practice had the potential to result in Resident 37's nystatin being available to unauthorized personnel. 4. Failing to dispose of expired enoxaparin sodium (used to prevent blood clots) in one out of two medication rooms (Med Storage 1). This deficient practice had the potential to result in the use of ineffective of the medications. 5. Failing to remove expired tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe [trachea] to help you breathe) inner cannula (a small tube for insertion into a body cavity or into a duct or vessel) from one out two medication rooms (Med Storage 1). This deficient practice had the potential to result in the use of ineffective medical device for the residents. Findings: a. During a concurrent observation of Medication Cart 1 (Med Cart 1) and interview on [DATE] at 5:41 p.m., Licensed Vocational Nurse 1 (LVN 1) confirmed Resident 31's vials of levalbuterol 1.25 milligram (mg, a unit of measure)/ 3 milliliter (ml, a unit of measure) was stored in an opened and undated box and foil pouch. LVN 1 confirmed the manufacturer indicated that once the foil pouch is opened, the vials should be used within two weeks. LVN 1 stated she will discard it and put an opened date when she opens a new one for Resident 31. A review of the Manufacturer's Instructions levalbuterol, revised 02/2020, indicated the following: - When a levalbuterol inhalation solution, USP foil pouch is opened, use the vials within two weeks. - When the vials are removed from the foil pouch, use them right away or within one week. b. During a concurrent observation and interview on [DATE] at 5:53 p.m., LVN 1 confirmed the following residents' medications with broken seal were stored in Medication Cart 1: - Resident 17's clonazepam (antianxiety medication) bubble pack, slot number 1 - Resident 31's lorazepam (antianxiety medication) bubble pack, slot number 30 - Resident 240's hydrocodone/acetaminophen (medication used to treat moderate to severe pain) bubble pack, slot number 26. During an interview on [DATE] at 6:03 p.m., LVN 1 stated when the medication seal is broken in the bubble pack, the medication/s should have been discarded right away and witnessed by another licensed nurse (registered nurse or LVN) because it was already exposed and contaminated. During a concurrent observation and interview on [DATE] at 6:20 p.m., LVN 2 confirmed Resident 26's lorazepam bubble pack, slot number 5 with a broken seal was stored in Medication Cart 2. LVN 2 stated the lorazepam should have been discarded right away and not placed back inside the bubble pack. During an interview on [DATE] at 8:45 p.m., the Nurse Manager (NM) stated when a medication bubble pack has a broken seal, the licensed nurses should have wasted the medication right away. The NM stated the licensed nurses should indicate the reason for discarding the medication and another licensed nurse cosigning it because it is a safety issue. The NM stated this is done to ensure the resident receives the right medication. A review of the facility's policy and procedure titled, Storage of Medications, revised in 3/2019, indicated that contaminated or deteriorated mediations 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. A review of the facility's policy and procedure titled, Controlled Medication Disposal, revised in 3/2019, indicated that when a dose of controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility staff failed to implement infection control program by failing to: 1. Date the tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe to help breathe) collar tubings (a soft plastic mask that fits over and around the tracheostomy tube to provide humidified oxygen) of Residents 17 and 31, and date the suction canisters (a temporary storage container that is used to collect infectious medical waste until it is disposed of properly) of Residents 17, 33, and 31. 2. Failing to keep the tracheostomy collar tubing of Resident 31 attached to the wall oxygen regulator off the floor. 3. Sanitize the hands of Registered Nurse 5 (RN 5) in between changing of gloves while performing dressing change of the sacrococcyx (pertaining to the sacrum [large, curved, triangular-shaped bone at the base of the spine] and coccyx [tailbone]) pressure injury (breakdown of skin integrity due to pressure) of Resident 33. 4. Ensure the suction canister indicated the date and initial of staff on when they were last changed per facility procedure for four (Residents 11, 29, 3, and 2) out of seven sampled residents investigated addressing infection control. 5. Ensure the Attending Physician 1 (AP 1) donned on (put on) a gown, gloves, and eye protection prior to entering Resident 26's isolation (denoting ward for patients with infectious diseases) room. 6. Ensure that Registered Nurse 5 (RN 5) washed her hands in between glove changes during Resident 26's wound care. The deficient practices had to potential to spread infection among residents. Findings: a. A review of Resident 17's admission Record indicated the facility admitted the resident on 1/17/2023, with a diagnosis of respiratory failure (a condition that occurs due to a disease or injury that interferes with the ability of the lungs to deliver oxygen). A review of Resident 17's History and Physical (H&P), dated 1/18/2023, indicated the resident had a vehicular accident and suffered an intracerebral hemorrhage (bleeding in the brain caused by the rupture of a damaged blood vessel in the head) and underwent left decompressive craniectomy (a removal of a piece of bone of the skull to reduce intracranial pressure) and had tracheostomy. The H&P indicated the resident moves her left arm but does not communicate or was able to move the other extremities as they were contracted (abnormally shortened muscle tissue). A review of Resident 17's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/24/2023, indicated the resident did not have the ability to make self-understood and understand others. A review of Resident 17's Active Orders, dated 1/17/2023, indicated tracheostomy care (a care that is done to keep your tracheostomy tube clean) by Respiratory Therapist (RT) and Registered Nurse (RN) per facility standard of care. During an observation on 3/24/2023, at 7:53 p.m., observed Resident 17's tracheostomy collar tubing with a sticker indicating to change on Monday but the date and time fields were left blank. Observed an undated suction canister containing yellow fluids (halfway full) at the bedside. During an observation and interview on 3/24/2023, at 8:19 p.m., Licensed Vocational Nurse 5 (LVN 5) stated that the trach collar tubing and the suction canister should be dated and initialed by the staff who changed the equipment to prevent the growth of bacteria that can cause infection to residents. A review of the facility's provided resource Lippincott procedures Manual titled Mechanical ventilation, monitoring and care, long-term care, revised 11/28/2022, indicated: Respiratory Supply Replacement Schedule Date and initial supply 1. Ventilator circuit Monthly and when soiled YES 2. Ventilator bacterial filter Monthly and when soiled YES 3. Suction Canister Weekly and when three quarters-full YES 4. Oxygen Supply Tubing/ Tracheostomy Collar Tubing Monthly and when soiled YES b. A review of Resident 31's admission Record indicated the facility admitted the resident on 9/15/2022, with a diagnosis of respiratory failure. A review of Resident 31's H&P, dated 3/18/2023, indicated the resident had past medical history atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart), hypertension (high blood pressure) and pneumonia (an infection that inflames the air sacs in one or both lungs). Due to inability to wean from ventilator (the process of abruptly or gradually withdrawing ventilatory support), patient was trached (paced a tube on the windpipe) on 3/10/2021. A review of Resident 31's Active Orders, dated 9/15/2022, indicated an order for: - Contact isolation (used when a patient has an infectious disease that may be spread by touching either the patient or other objects the patient has handled) for carbapenem resistant enterobacteriaceae (CRE, strains of bacteria that are resistant to an antibiotic class [carbapenem] used to treat severe infections). - Tracheostomy (trach) management until discontinued, trach care every shift and if necessary. Trach care by RT or RN per facility standard of care. During an observation on 3/24/2023 at 8:10 p.m., observed Resident 31's tracheostomy collar tubing with a sticker indicating to change on Monday but the date and time fields were left blank. Observed an undated suction canister containing yellow fluids (more than halfway full) at the bedside. Also observed the tracheostomy tubing attached to the wall regulator touching the floor. During an observation and interview on 3/24/2023, at 8:19 p.m., Licensed Vocational Nurse 5 (LVN 5) stated that the trach collar tubing and the suction canister should be dated and initialed by the staff who changed the equipment to prevent the growth of bacteria that can cause infection to residents. LVN 5 further stated that the trach collar tubing attached to the wall oxygen regulator should be off the floor to prevent tripping on the tube and to prevent infection. During an interview on 3/26/2023, at 9:05 a.m., the Nurse Manager (NM) stated staff should have labeled the tracheostomy collar tubing with the date and time it was changed. The NM further stated that if the tracheostomy collar tubing was not dated, they will not know when the last time it was changed and could also cause potential infection to the residents. The NM also stated that the trach collar tubing attached to the wall oxygen regulator should be off the floor to prevent tripping on the tube and to prevent infection. A review of the facility's provided resource Lippincott procedures Manual titled Mechanical ventilation, monitoring and care, long-term care, revised 11/28/2022, indicated: Respiratory Supply Replacement Schedule Date and initial supply 1. Ventilator circuit Monthly and when soiled YES 2. Ventilator bacterial filter Monthly and when soiled YES 3. Suction Canister Weekly and when three quarters-full YES 4. Oxygen Supply Tubing/ Tracheostomy Collar Tubing Monthly and when soiled YES c. A review of Resident 33's admission Record indicated that the facility admitted the resident on 2/15/2023, with a diagnosis of respiratory failure. A review of Resident 33's H&P, dated 2/17/2023, indicated the resident was on acute on chronic hypoxemic respiratory failure (acute or chronic impairment of gas exchange between the lungs and the blood causing hypoxia [low levels of oxygen in your body tissues] with or without hypercapnia [buildup of carbon dioxide in the bloodstream]) with tracheostomy and ventilator (a machine that helps a person breathe). A review of Resident 33's MDS, dated [DATE], indicated the resident had sometimes the ability to make self-understood and understand others. The MDS also indicated that the resident was on oxygen therapy, suctioning, tracheostomy care, and invasive mechanical ventilator. A review of Resident 33's Active Orders indicated: - Tracheostomy management, trach care every shift and if necessary. Trach care by RT or RN per facility standard of care on 2/15/2023. -Wound care sacrococcyx pressure injury transitioned to unstageable (an ulcer that has full thickness tissue loss but is either covered by extensive necrotic tissue or by eschar [dead tissue that sheds or falls off from the skin]) until discontinued. Cleanse with normal saline (NS-cleaning solution), apply Santyl (medication used to remove dead tissue from wounds so they can start to heal), moist gauze and cover with mepilex (a soft and highly conformable antimicrobial foam dressing that absorbs exudate [fluid that leaks out of blood vessels into nearby tissues] and maintains wound environment) daily and if necessary (prn) if loose or soiled. During an observation on 3/24/2023, at 7:48 p.m., observed Resident 33's undated suction canister with yellowish fluid more than half filled. During a concurrent observation and interview on 3/15/2023 at 12:35 p.m., observed RN 5 changed gloves without sanitizing hands while performing pressure injury dressing change to Resident 33. RN 5 stated that she should have washed her hands or used alcohol sanitizer after removing the gloves and before placing a new pair to prevent infection. During an interview on 3/26/2023, at 9:05 a.m., the Nurse Manager (NM) stated staff should have labeled the tracheostomy collar tubing with the date and time it was changed. The NM further stated that if the tracheostomy collar tubing was not dated, they will not know when the last time it was changed and could also cause potential infection to the residents. A review of the facility's provided resource Lippincott procedures Manual titled Mechanical ventilation, monitoring and care, long-term care, revised 11/28/2022, indicated: Respiratory Supply Replacement Schedule Date and initial supply 1. Ventilator circuit Monthly and when soiled YES 2. Ventilator bacterial filter Monthly and when soiled YES 3. Suction Canister Weekly and when three quarters-full YES 4. Oxygen Supply Tubing/ Tracheostomy Collar Tubing Monthly and when soiled YES A review of the facility's recent policy and procedure titled Hand Hygiene Policy, last reviewed on 9/2019, indicated gloves are removed when the need for protection no longer exists and hand hygiene should be practiced immediately after removal of gloves. Change gloves during patient care if moving from a contaminated body site to a clean body site. d. A review of Resident 11's face sheet indicated the facility admitted the resident on 2/3/2023 with diagnoses including respiratory failure (a condition that makes it difficult to breathe on your own), deep vein thrombosis (a condition that occurs when a blood clot forms in a deep vein usually in the lower leg, thigh, and arm). A review of Resident 11's H&P, dated 2/9/2023, indicated the resident had tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help with breathing), psychosis (a mental condition characterized by a disconnection from reality), and diabetes mellitus II (a condition characterized by high levels of sugar in the blood). A review of Resident 11's MDS, dated [DATE], indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During an observation on 3/24/2023 at 8:15 p.m., observed Resident 11's suction canister (a temporary storage container that's used to collect secretions [liquids produced the body] until it is disposed of properly) did not indicate the date when it was last changed. During a concurrent observation and interview on 3/24/2023 at 8:25 p.m., Licensed Vocational Nurse 4 (LVN 4) verified the suction canister did not indicate the date when it was last changed. LVN 4 stated suction canisters are changed when full and should indicate the date it was changed. LVN 4 stated it was an infection control issue. A review of the facility's Lippincott procedure titled, Mechanical ventilation, monitoring and care, long term care, last revised 11/28/2022, indicated a respiratory supply checklist can help track supplies to ensure routine placement. The procedure indicated replacement schedule for suction canister was weekly and when three quarters full and should date and initial the supply. e. A review of Resident 29's face sheet indicated the facility admitted the resident on 2/10/2023 with diagnoses including respiratory failure (a condition that makes it difficult to breathe on your own) and pain. A review of Resident 29's H&P, dated 2/12/2023, indicated the resident had tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe [trachea] to help with breathing) tube placement, coronary artery disease (a condition that affects your heart caused by plaque [fat deposits] build up on the wall of the arteries [tubelike structures responsible for transporting fluid to and from every organ in the body]), and stroke (a condition that occurs when the blood supply to part of the brain is interrupted or reduced). A review of Resident 29's MDS, dated [DATE], indicated the resident was in a persistently vegetative [a state of brain dysfunction in which a person shows no signs of awareness] state). The MDS indicated required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 29 required suctioning. A review of Resident 29's Order Reports indicated the resident is on contact enteric isolation (used when a patient has an infectious disease that may be spread by touching either the patient or other objects the patient has handled for a bacteria that were resistant to a class of antibiotic used to treat severe infections). During an observation on 3/24/2023 at 8:20 p.m., observed Resident 29's suction canister (a temporary storage container that's used to collect secretions [liquids produced the body] until it is disposed of properly) did not indicate the date when it was last changed. During a concurrent observation and interview on 3/24/2023 at 8:25 p.m., Licensed Vocational Nurse 4 (LVN 4) verified the suction canister did not indicate the date when it was last changed. LVN 4 stated suction canisters are changed when full and should indicate the date it was changed. LVN 4 stated it was an infection control issue. During an interview on 3/26/2023 at 10:30 a.m., the Nurse Manager (NM) stated that suction canisters are changed weekly or when three quarters full and should indicate the date it was last changed and initials of the staff who changed the canisters per the Lippincott procedure the facility is following. The NM stated it is important to indicate the date when the canister was last changed as it is an infection control issue. A review of the facility's Lippincott procedure titled, Mechanical ventilation, monitoring and care, long term care, last revised 11/28/2022, indicated a respiratory supply checklist can help track supplies to ensure routine placement. The procedure indicated replacement schedule for suction canister was weekly and when three quarters full and should date and initial the supply. f. A review of Resident 3's Face Sheet indicated the facility admitted the resident on 4/20/2022 with diagnoses including respiratory failure (a condition that makes it difficult to breathe on your own), and diabetes mellitus II (a condition characterized by high levels of sugar in the blood). A review of Resident 3's H&P, dated 4/20/2022, indicated the resident had tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help with breathing) tube placement and seizure (a sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain). A review of Resident 3's MDS, dated [DATE], indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 3 required suctioning. A review of Resident 3's order report indicated a physician's order dated 4/20/2022 to suction patient as needed. During an observation on 3/24/2023 at 8:30 p.m., observed Resident 3's suction canister (a temporary storage container that's used to collect secretions [liquids produced the body] until it is disposed of properly) did not indicate the date when it was last changed. During a concurrent observation and interview on 3/24/2023 at 8:35 p.m., Licensed Vocational Nurse 4 (LVN 4) verified the suction canister did not indicate the date when it was last changed. LVN 4 stated suction canisters are changed when full and should indicate the date it was changed. LVN 4 stated it was an infection control issue. During an interview on 3/26/2023 at 10:30 a.m., the Nurse Manager (NM) stated that suction canisters are changed weekly or when three quarters full and should indicate the date it was last changed and initials of the staff who changed the canisters per the Lippincott procedure the facility is following. The NM stated it is important to indicate the date when the canister was last changed as it is an infection control issue. A review of the facility's Lippincott procedure titled, Mechanical ventilation, monitoring and care, long term care, last revised 11/28/2022, indicated a respiratory supply checklist can help track supplies to ensure routine placement. The procedure indicated replacement schedule for suction canister was weekly and when three quarters full and should date and initial the supply. g. A review of Resident 2's Face Sheet indicated the facility admitted the resident on 9/12/2022 with diagnosis including respiratory failure (a condition that makes it difficult to breathe on your own). A review of Resident 2's H&P, dated 9/14/2022, indicated the resident had tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help with breathing) tube placement, multiple sclerosis (a condition that can affect the brain and spinal cord that may cause serious disability), and seizure (a sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain). A review of Resident 2's MDS, dated [DATE], indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and was able to make her needs known. The MD indicated Resident 2 required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 2's Order Reports indicated the resident is on contact isolation (used when a patient has an infectious disease that may be spread by touching either the patient or other objects the patient has handled) for a multidrug resistant organism (bacteria that have become resistant to certain antibiotics). During an observation on 3/24/2023 at 8:55 p.m., observed Resident 3's suction canister (a temporary storage container that's used to collect secretions [liquids produced the body] until it is disposed of properly) did not indicate the date when it was last changed. During a concurrent observation and interview on 3/24/2023 at 9:05 p.m., Licensed Vocational Nurse 4 (LVN 4) verified the suction canister did not indicate the date when it was last changed. LVN 4 stated suction canisters are changed when full and should indicate the date it was changed. LVN 4 stated it was an infection control issue. During an interview on 3/26/2023 at 10:30 a.m., the Nurse Manager (NM) stated that suction canisters are changed weekly or when three quarters full and should indicate the date it was last changed and initials of the staff who changed the canisters per the Lippincott procedure the facility is following. The NM stated it is important to indicate the date of when the canister was last changed as it is an infection control issue. A review of the facility's Lippincott procedure titled, Mechanical ventilation, monitoring and care, long term care, last revised 11/28/2022, indicated a respiratory supply checklist can help track supplies to ensure routine placement. The procedure indicated replacement schedule for suction canister was weekly and when three quarters full and should date and initial the supply. h. A review of Resident 26's face sheet indicated the facility admitted the resident on 11/28/2022 with diagnoses that included congestive heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), carbapenem resistant bacteria carrier (multidrug-resistant organisms that that can cause serious infections and require interventions in healthcare settings to prevent spread), and quadriplegia (paralysis below the neck that affects all of a person's limbs). A review of Resident 26's MDS, dated [DATE] indicated Resident 26 rarely and or never understand other and rarely and or never is understood by others. The MDS indicated Resident 26 was totally dependent on bed mobility, transferring, dressing, eating, and toilet use. A review of Resident 26's Physician Orders dated 3/8/2023 indicated Resident 26 is on isolation contact; contact enteric until discontinued. During a concurrent observation and interview on 3/25/2023 at 9:46 a.m. in Resident 26 room observed AP 1 enter Resident 26's room wearing a surgical mask, AP 1 did not don gown, gloves and or eye protection. Observed AP 1 placing a stethoscope (a medical instrument for listening to the action of someone's heart or breathing) on Resident 26 and touching the resident with ungloved hands. AP 1 stated Resident 26 was on isolation and he must take precautions; AP 1 stated he was cautious. Observed AP 1 washed his hands and exited Resident 26's room. During an interview on 3/25/2023 at 10:05 a.m. with Licensed Vocational Nurse (LVN 2), LVN 2 stated AP 1 did not don the proper personal protective equipment (PPE- specialized clothing or equipment worn by an employee for protection against infectious materials). LVN 2 stated AP 1 should have worn a gown, gloves, and eye protection before entering Resident 26 room. LVN 2 stated AP 1 was aware and has been educated on wearing the appropriate PPE. LVN 2 stated AP 1placed the facility at risk for spread of infection to other residents. During an interview on 3/26/2023 at 3:48 p.m. with the Infection Preventionist (IP), the IP stated Resident 26's room was an isolation room and staff should be observing contact precautions (must wear a mask, gown, and gloves). The IP stated AP 1 was aware of the isolation precautions and has been educated on requirement of PPE for isolation, but AP 1 was not compliant. The IP stated not wearing the appropriate PPE is a concern for cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another). A review of facility's policy and procedure titled Donning and Doffing (taking off) Personal Protective Equipment (PPE), revised in 5/2021, indicated PPE is to be properly donned and doffed tn the proper sequence, and adjusted and worn properly in order to reduce the risk of contamination. i. A review of Resident 26's face sheet indicated the facility admitted the resident on 11/28/2022 with diagnoses that included congestive heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), carbapenem resistant bacteria carrier (multidrug-resistant organisms that that can cause serious infections and require interventions in healthcare settings to prevent spread), and quadriplegia (paralysis below the neck that affects all of a person's limbs). A review of Resident 26's MDS, dated [DATE] indicated Resident 26 rarely and or never understand other and rarely and or never is understood by others. The MDS indicated Resident 26 was totally dependent on bed mobility, transferring, dressing, eating, and toilet use. A review of Resident 26 Physician Orders dated 11/29/2022 indicated Resident 26 required wound care to sacral/coccyx for stage 4 (ulcers are deep wounds that may impact muscle, tendons, ligaments, and bone) until discontinued. During a concurrent observation and interview on 3/25/2023 at 11:58 with RN 5, observed RN 5 performed wound care for Resident 26. Observed RN 5 cleaning Resident 26's wound, removed her gloves, and applied new gloves. Did not observe RN 5 perform hand washing in between glove changes. RN 5 completed Resident 26's wound care and then washed her hands. RN 5 stated she did not wash her hands in between glove changes. RN 5 stated she should have washed her hands in between glove changes because it was a risk for infection control. During an interview on 3/26/2023 at 3:54 p.m. with the Infection Preventionist (IP), the IP stated if hands are not visibly soiled, staff can use hand sanitizer. The IP stated RN 5 should have washed her hands in between glove changes as it can be a risk for contamination of clean area and it can be a risk for infection. A review of facility's policy and procedure titled Hand Hygiene Policy, revised in 9/2019, indicated compliance with the proper hand hygiene procedure before and after patient contact is an expectation of all healthcare disciplines. The policy further indicated gloves are removed when the need for protection no longer exists and hand hygiene should be practiced immediately after removal of gloves, change gloves during patient care if moving from a contaminated body site to a clean body site.