**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide the Restorative Nursing Assistant (RNA) services as ordered by the physician for two of 20 sampled residents reviewed for Range Of Motion (ROM) functions (Resident 2 and 69). This failure had the potential for decline in the resident's range of motion and mobility. Findings: 1. During a review of Resident 2's face sheet dated, 6/12/24, showed Resident 2 was admitted to the facility in 10/2020 with multiple diagnoses that included Brain Stem Stroke Syndrome (when a blood supply to the base of the brain is stopped which can potentially affect many functions in the body). During a review of Resident 2's Physical Therapy (PT) Discharge summary, dated [DATE], revealed under Assessment and Summary of Skilled Services: Prognosis to maintain Current Level of Functioning (CLOF) = Excellent with consistent staff support, excellent with participation in Restorative Nursing Program (RNP). Under Discharge Recommendations: Functional Maintenance Program/Restorative Nursing Program (FMP/RNP). During a review of Resident 2's Order Summary, dated 2/28/24, revealed RNA Program: Patient (Pt) to participate in RNP 2x/week x 90 days to address muscle weakness and lack of coordination status post (s/p) CVA with L side paresis (left side weakness). RNP to increase transfer to wheelchair (w/c) from bed, bed to w/c with two person assist and sit in w/c for at least 30 minutes. Reassess by PT/OT as necessary. During a review or Resident 2's Order Summary Report, dated 5/7/24, revealed RNA Program: Pt to participate in RNP 2x/week x 90 days to address muscle weakness and lack of coordination s/p CVA with L side paresis. Passive Range Of Motion (PROM)TO Left Upper Extremity (LUE ) 2 X A WEEK. During a review of Resident 2's care plan, dated, 2/28/24, revealed Resident 2 had ADL (Activities of Daily Living) Self Care Performance Deficit related to hemiplegia (paralysis on one side of the body). According to the care plan, one of the interventions was RNA Program: Patient (Pt) to participate in RNP 2x/week x 90 days to address muscle weakness and lack of coordination s/p CVA with L side paresis . 2. During a review of Resident 69's face sheet date, 6/12/24, showed Resident 69 was admitted to the facility in 5/22/23 with multiple diagnoses that included Hemiplegia and Hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting right dominant side and weakness. During a review of Resident 69's Order Summary, dated 3/19/24, revealed RNA Program: PROM to bilateral. Upper Extremity (UE) & Lower Extremity (LE) 3x/week to prevent decline in ROM & functional mobility. 3x/week every Mon, Wed, Fri for Prevent decline in ROM and functional mobility until 06/21/24. During a review of Resident 69's PT Discharge summary, dated [DATE], revealed under Discharge Recommendations and Status: Discharge Recommendations RNA services. During a review of Resident 69's care plan, dated, 3/20/24, revealed Resident 69 had limited physical mobility r/t Hemiplegia and Hemiparesis . Furthermore, the care plan indicated one of the interventions was RNA program for PROM to strengthen muscles and increase mobility status. During a concurrent interview and record review on 6/12/24, at 12:45 p.m., with Restorative Nurse Assistant (RNA), RNA could not show evidence Resident 2 and Resident 69 received ROM exercises. During a concurrent interview and record review on 6/12/24, at 2:00 p.m., with the Director of Nursing (DON), DON stated RNP was stopped during the period Resident 2 and 69 was supposed to receive RNA services. DON verified Resident 2 and Resident 69 did not receive ROM exercises as ordered by the physician. During an interview on 6/12/24, at 2:52 p.m., with the Director Of Rehabilitation (DOR), DOR stated, all residents had the potential for decline in functioning an mobility so it was important for residents to receive ROM exercises once done with physical therapy, to maintain range of motion and prevent decline in functioning. During a review of facility's policy and procedure (P&P), titled, Restorative Nursing Program Guidelines, dated 9/2019, showed under Purpose: .This program actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning . Under Procedure: .I. B. Frequency of the RNA program will be determined b the medical necessity and physician order.E. A Licensed Nurse must supervise the activities in the Restorative Nursing Program .members of the nursing staff are still responsible for overall coordination and supervision of the Restorative Nursing Program. II. A Restorative Nursing Program may include: A. Passive or active range of motion exercises.

Based on interview and record review, the facility failed to ensure there was Registered Nurse (RN) coverage eight hours a day, seven days a week. This failure had the potential to endanger the health and safety of residents. Findings: During a concurrent interview and record review on 6/13/24 at 9:54 a.m. with Payroll (PAYROLL), payroll data was reviewed from Q3/2023 (April 1 - June 30) until Q4/2023 (July 1 - September 30). Payroll confirmed there were no RN working for the following dates: 1. For the month of April 2023: 4/23/23 2. For the month of May 2023: 5/28/23 3. For the month of June 2023: 6/25/23 4. For the month of July 2023: 7/9/23 5. For the month of August 2023: 8/27/23 6. For the month of September 2023: 9/2/23 During a concurrent interview and record review on 6/13/24 at 10:17 a.m. with Central Supply/Scheduler (CS/S), staffing schedule was reviewed. CS/S confirmed a RN was not scheduled to work on 4/23/23, 5/28/23, 6/25/23, 7/9/23, 8/27/23, 9/2/23. During an interview on 6/12/24 at 3:56 p.m., with the Director of Nursing (DON), DON stated, it was important to have RN coverage eight hours a day. DON further added, resident safety were at risk without RN available.

Based on observation, interview and record review, the facility failed to store food in a safe and sanitary manner when: 1. Fresh lettuce stored inside the reach-in refrigerator was exposed and had no cover 2. A plastic container bin with single packs of graham crackers had no use by date or open dates Failure to store food in accordance with facility policy and/or professional standards had the potential to not meet food service safety standards and prevent food borne illnesses for 76 residents who received food from the kitchen out of a facility census of 76. Findings: 1.During an initial kitchen tour observation and concurrent interview on 6/10/24 at 10:13 a.m., with the Dietary Supervisor (DS), the contents of Refrigerator 1, were inspected. The bottom rack had a clear storage bin with fresh lettuce inside. The lettuce was exposed and had no cover. DS stated the lettuce should be covered with a plastic wrap to keep it fresh and to make sure spills do not get in contact the lettuce. During an interview on 6/13/23 at 1:10 p.m., with the Regional Registered Dietitian (RRD), when asked what the expectation was when storing fresh produce in the refrigerator, RRD stated, it [produce] should be covered to prevent anything from spilling into it. Review of the facility's policy and procedure (P&P) titled, Food Storage - Operation Manual -Dietary Services, revision dated 7/25/19, the P&P indicated, Purpose - To establish guidelines for storing . Policy - Food items will be stored . in accordance with good sanitary practice . Procedure .IX. Fresh Vegetable Storage Guidelines .E. Vegetables should be left in cartons, bags, or paper wrapping because it retards spoilage and loss of moisture . 2. During an observation and concurrent interview on 6/10/24 at 10:28 a.m., with the DS, the kitchen dry storage room was inspected. One of the storage shelving racks had a clear storage bin that contained multiple, individually packed graham crackers. The storage bin had no label and did not indicate open and use by dates for the graham crackers. DS stated the person who poured the items in the storage bin did not label and date the graham crackers. During an interview and concurrent record review on 6/13/24 at 12:40 p.m., with the DS, the facility's Dry Goods Storage Guidelines, dated 2023, was reviewed. The Dry Storage Guidelines indicated, This storage length is to be followed unless you have manufacturer's recommendation indicating otherwise . Food Item . [NAME] crackers . Unopened on shelf - 6 months, Opened on Shelf - N/A [not applicable]. DS explained that unopened on shelf referred to original packaging in box [of food item]. DS confirmed the graham crackers found in the dry storage room on 6/10/24 was in a clear storage bin and not in its original packaging in box. DS stated the graham crackers should have an open and use by dates indicated. Review of the facility's policy and procedure (P&P) titled, Food Storage - Operation Manual -Dietary Services, revision dated 7/25/19, the P&P indicated, Purpose - To establish guidelines for storing . Policy - Food items will be stored . All items will be correctly labeled and dated. Procedure .XIII. Dry Storage Guidelines .H. Label and date all storage products .

Based on observation, interview, and record review, the facility failed to ensure three of 78 sampled residents' (Resident 2, Resident 6, and Resident 8), call lights were within reach and easily accessible. This failure placed the Resident 2, Resident 6 and Resident 8 at risk of not being able to ask for assistance. Findings: Resident 2 was admitted to the facility in late 2020, with diagnoses which included cerebral infarction (disrupted blood flow does to the brain), stenosis (narrowing of the spinal cord) and convulsions (irregular movement of arms and legs). Resident 6 was admitted to the facility in late 2020 with diagnoses which included heart disease, bradycardia (slow heartbeat) and blindness of the right eye (vision loss). Resident 8 was admitted to the facility in mid-2022, with diagnoses which included seizure (irregular body movement), Parkinson (tremors, stiffness, and loss of balance) and repeated falls. During an observation on 4/11/24 at 1:15 p.m. in Resident 2's, Resident 6's and Resident 8's rooms, the call lights were on the floor behind or under the beds. During a concurrent observation and interview on 4/11/24 at 2 p.m. with Medical Records Director (MR), in Resident 2's, Resident 6's and Resident 8's rooms, the MR confirmed the call lights were on the floor behind the beds and out of reach of the Residents and stated, They should be within reach so they can call the staff. During an interview on 4/11/24 at 2:40 p.m. with the Administrator (ADM), the ADM stated, I would expect that everyone should have their call lights. Requested a copy of facility's policy and procedure for answering the call lights. The facility was not able to provide,

Based on interview and record review the facility failed to ensure one out of three residents (Resident 1) had written Informed Consent (a process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention to help them decide if they want to authorize the given procedure or intervention) before they were administered a psychoactive medication (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior). This failure had the potential to cause Resident 1 to take a psychoactive medication without knowledge of the medication ' s risks, benefits, and alternatives. A review of Resident 1's admission Record printed 3/21/24, indicated Resident 1 was admitted to the facility in 2022 with a diagnosis of Spastic Hemiplegia (a nerve and muscle condition that results in the muscles on one side of the body being in a constant state of contraction). The record indicated Resident 1 was their own Responsible Party (health care decision maker). During a concurrent interview and record review on 3/21/24 at 3:59 p.m., with Registered Nurse (RN) 1, Resident 1 ' s Doctors Orders, dated November through December 2023 and Informed Consents, were reviewed. RN 1 confirmed Resident 1 had multiple doctor ' s orders for Ativan (a psychoactive medication used to treat anxiety) that started on 11/28/2023. RN 1 stated they could not find Resident 1 ' s written Informed Consent for Ativan. RN 1 stated Resident 1 should have had an informed consent for Ativan. RN 1 stated Informed Consent for Ativan was important so Resident 1 could have known the medication risks, benefits, and alternatives and could have had the right to refuse the medication. During a concurrent interview and record review on 3/26/24 at 1:14 p.m., with Regional Director of Staff Development (RDSD), Residents 1 ' s Informed Consents were reviewed. RDSD stated nurses were supposed to ensure residents had Informed Consent for Ativan signed by the resident or their responsible party and the doctor before starting the medication. RDSD stated Resident 1 did not have written Informed Consent for Ativan. During an interview on 4/17/24, at 2:58 p.m., with Director of Nursing (DON), DON stated their policy for all psychoactive medications was to get informed consent before starting the medication. DON stated the doctor was responsible to get the Informed Consent, explain the medication risks, benefits, alternatives, and the right to refuse, to the resident or responsible party. DON stated the nurse was responsible to verify the Informed Consent was done. DON stated Informed Consent was important because Residents are entitled to know the risks and benefits of a medication before they take it, especially a psychoactive medication. DON stated when Informed Consent was not obtained, residents may not have been aware of the medication risks, benefits and alternatives. During a review on Resident 1 ' s History and Physical, (H&P) dated 12/5/22, the H&P indicated the resident had capacity (the ability to utilize information about an illness and proposed treatment options to make a choice that is fitting with one's own values and preferences). During a review of Resident 1 ' s Order Summary Report, dated 3/21/24, the report indicated Resident 1 had Physician ' s orders for Lorazepam (a generic name for Ativan) and Ativan. The report indicated Resident 1 had a Physician ' s Order for Lorazepam oral tablet 0.5mg (milligrams) . Give 1 tablet by mouth every 6 hours as needed for anxiety, dated 11/28/23. The report indicated Resident 1 had a Physician ' s Order for Ativan oral tablet 0.5mg . Give 2 tablet by mouth every 6 hours as needed for anxiety, dated 12/15/23. The report indicated Resident 1 had a Physician ' s Order for Ativan Oral Tablet 0.5mg . Give 2 tablet by mouth every 6 hours as needed for anxiety, dated 12/19/23. During a review of Resident 1 ' s Medication Administration Record (MAR), dated December 2023, the MAR indicated Resident 1 was given Ativan and Lorazepam nineteen times in December 2023. The MAR indicated Resident 1 received Lorazepam oral tablet 0.5mg .1 tablet, one time each day on 12/1/23, 12/2/23, 12/5/23 through 12/8/23, 12/11/23, 12/13/23, and 12/15/23 and two times each day on 12/12/23 and 12/14/23. The MAR indicated Resident 1 received Ativan oral tablet 0.5mg . 2 tablet, one time each day on 12/16/23, 12/22/23, and 12/25/23, and three times on 12/24/23. During a review of the facility ' s policy and procedure (P&P) titled, Informed Consent, revised December 2020, the P&P indicated, The ordering physician must obtain informed consent before the facility can administer new orders (or increased dosages) for psychoactive medication . The P&P indicated Physician documentation of informed consent should contain the date and who gave informed consent (Resident of surrogate decisionmaker). The P&P indicated Before administering the first dose or first increased dose of psychoactive medications . the licensed nurse will confirm that the physician obtained informed consent and will document the verification in the Resident ' s medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a summary of the baseline care plan for one of two sampled residents (Resident 1). This failure resulted in the lack of information regarding care. Findings: During a review of Resident 1's admission Record, the document indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included severe protein calorie malnutrition, gastroenteritis (lining of the stomach and intestines are inflamed) and colitis (inflammation of the inner lining of the large bowels), cachexia (marked weight and muscle loss), esophagitis (inflammation of the esophagus/swallowing tube), diarrhea, and gastric ulcer (open sores develop on the stomach lining). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 7/6/23 indicated Resident 1's Brief Interview for Mental Status (BIMS, an assessment tool for resident's orientation to time and capacity to remember) score of 11 out of 15, indicating Resident 1 is moderately impaired. During an interview on 7/21/23 at 10:25 a.m. with Resident 1, Resident 1 stated the discharge plan was to either go home or go to the hospital. Resident 1 added discussions are still ongoing where Resident 1 tried to advocate for self. During an interview on 7/21/23 at 10:40 a.m. with Director of Nursing (DON), DON stated there was confusion about Resident 1's discharge plan. DON stated the plan was for Resident 1 to stay in the facility for long term, but Social Services Director (SSD) communicated to Resident 1 and Case Manager (CM) that Resident 1 was going to be discharged soon. DON stated Resident 1's tube feeding was re-started on 7/19/23 following discussion with Resident 1's CM who stated Resident 1 used to receive bolus feeding prior to admission to the facility. During an interview with SSD on 7/21/23 at 11:45 a.m., SSD stated there was no active discharge date yet. SSD also stated the goal was for Resident 1 to gain tube feeding compliance and achieve weight gain before discharge date and arrangements could be started. During a concurrent joint interview and review of Resident 1's Baseline Care Plan, dated 7/1/23, with DON and Medical Records Director (MRD) on 8/1/23 at 1:13 p.m., DON stated Resident 1's baseline care plan was not completed and Resident 1 was not given a copy of it. MRD stated a request to print a copy of Resident 1's baseline care plan was made on 7/31/23 to be provided to Resident 1. Review of Resident 1's Baseline Care Plan, dated 7/1/23, indicated under Signature of Resident and Representative was signed with the name of the staff completing the care plan. During a review of the facility's policy and procedure titled Comprehensive Person-Centered Care Planning, last revised November 2018, the policy indicated a baseline care plan summary will be developed within 48 hours of a resident's admission to the facility, a copy will be provided to the resident and/or the resident representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), maintained acceptable desirable body weight range when: 1. G-tube (gastrostomy tube, a tune inserted through the stomach that brings nutrition directly to the stomach) feeding was discontinued despite Resident 1's inability to maintain adequate oral intake. 2. G-tube feeding was not provided as ordered by the physician. These failures potentially resulted in Resident 1's significant weight loss of 5.8 pounds from 58 pounds (lbs.) on 7/7/23 to 52.2 lbs. on 7/23/23 (10 %) over two weeks. Findings: During a review of Resident 1's admission Record, the document indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included severe protein calorie malnutrition, gastroenteritis (lining of the stomach and intestines are inflamed) and colitis (inflammation of the inner lining of the large bowels), cachexia (marked weight and muscle loss), esophagitis (inflammation of the esophagus/swallowing tube), diarrhea, and gastric ulcer (open sores develop on the stomach lining). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 7/6/23 indicated Resident 1's Brief Interview for Mental Status (BIMS, an assessment tool for resident's orientation to time and capacity to remember) score of 11 out of 15, indicating Resident 1 is moderately impaired. During an observation and concurrent interview with Resident 1 on 7/21/23 at 10:25 a.m., Resident 1 stated she was barely able to finish breakfast, and stated she is having a hard time swallowing food. Resident 1's bedside had puddles of fluid on the floor near the bed, on the over-the-bed table were cups and a basin. During an interview with Certified Nursing Assistant (CNA) 1 on 7/21/23 at 12:30 p.m., CNA 1 stated Resident 1 ate a lot all day, but not did not really consume everything that was served because food would be coming back out. CNA 1 stated Resident 1 would complain having a lot of acid in stomach and would spit saliva out into a cup. CNA 1 also stated there were cups and basins at the bedside because Resident 1 used them to spit into. During a review of Resident 1's Hospitalist Progress Note, dated 6/28/23, indicated Resident 1 has a history of esophageal stricture and currently depends on g-tube feeding for the majority of nutrition. The note also indicated Resident 1 chews and spits out any oral intake as a means to alleviate .anxiety, but is not getting any caloric intake from this. During a review of Resident 1's Inter-facility Transfer Report, signed and dated 6/29/23, indicated for Resident 1 to receive g-tube feeding Jevity 1.2 (liquid tube feeding formula as a sole-source of nutrition) continuously at 40 milliliters per hour (ml/hr.) to advance 10 ml/12 hr. with a goal rate of 60 ml/hr. During a review of Resident 1's Nutritional Risk Assessment, dated 7/6/23, indicated the goal was for Resident 1 to have gradual weight gain. The assessment also indicated Resident 1's desirable body weight (DBW) was 120 pounds (lbs.), as of 7/7/23, Resident 1 weighed 58 lbs. (48 percent [%] of DBW) and was 5 feet 4 inches tall. Resident 1 was Severely underweight. [Resident 1] would benefit from gradual weight gain at 4-8 [lbs.]/ month, if possible, towards 90 [lbs.]. The assessment also indicated Registered Dietician (RD) 1 ' s recommendations that included: - Discontinue current g-tube feeding order. - Provide Resident 1 with oral intake of a fortified regular double portions at breakfast, mechanical soft chopped texture regular consistency. - House shake 4 ounce (oz) three times daily with meals - House supplement 90 milliliters (ml) three times daily during medication pass. - Prostat (protein) 30 ml three times daily through 9/30/23. - Check CMP (complete metabolic panel that measures 14 different substances in the blood) and PAB (prealbumin screen, blood test to check if one has enough nutrition in their diet). - Weekly weights for 4 weeks. The RD Assessment indicated Resident 1's current g-tube feeding, Jevity 1.2 cal at 60 ml/hr. x 12 hours would provide 720 cc formula, 864 calories, 40 grams protein and 581 ml water. During a concurrent telephone interview and review of Resident 1's Medication Administration Record (MAR) for July 2023 with DON on 8/9/23 at 6:35 p.m., DON stated, Resident 1's current feeding order, dated 7/3/23, was Jevity 1.2 cal at 60 ml/hr. continuous and not for 12 hours as indicated in Nutritional Risk assessment dated [DATE]. During an interview with DON on 7/21/23 at 1:10 p.m., DON stated, Resident 1's g-tube feeding was discontinued on 7/14/23 because there were supplements recommended by RD 1. Review of Resident 1's MAR for July 2023 indicated Resident 1 did not receive g-tube feeding from 7/15/23 to 7/18/23 (4 days) and only received 90 ml house supplement three times daily with meals. During a concurrent interview and review of Interdisciplinary (IDT- a team of individuals representing different departments of the facility) Note, dated 7/19/23, on 7/21/23 at 10:40 a.m. with DON, DON stated new order to resume Resident 1's g-tube feeding was carried out after Resident 1's Case Manager (CM) had reached out and told DON that Resident 1 used to receive bolus tube feeding before being admitted to the hospital. During an interview and concurrent review of Resident 1's Weekly Evaluation, dated 7/24/23, and Weekly Weight on 7/21/23 at 1:10 p.m. with DON, DON stated Resident 1's weight on 7/13/23 was 57 lbs. Resident 1's Weekly Evaluation indicated weight on 7/23/23 was 52.2 lbs., a weight loss of 5.8 lbs. over 10 days. DON stated this was a significant weight loss. During a review of Resident 1's July 2023 MAR, the document indicated an order with start date of 7/26/23 for Resident 1 to receive Jevity 1.2 continuously via g-tube at 30 ml/hr. x 12 hours during sleeping hours from 9 p.m.- 9 a.m. the following day. During a telephone interview on 7/31/23 at 3:53 p.m. with CM, CM stated, on 7/28/23 at 8:30 a.m., CM arrived at facility to find Resident 1 at bedside without tube feeding. CM stated Resident 1 claimed not getting any g-tube feeding all night. During an interview on 8/1/23 at 11 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 7/28/23, at the start of the morning shift at 7 a.m., Resident 1's feeding was off, and the formula bottle was detached from the tubing. LVN 1 stated an empty formula bottle was on the floor next to the right side of Resident 1's bed. LVN 1 stated NOC shift nurse could not answer whether the tube feeding had been running or not. During a review of Resident 1's care plan related to tube feeding and weight, initiated on 7/10/23, the care plan indicated interventions that included giving Tube feeding as ordered Jevity 60 ml per hour.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the indwelling urinary catheter (a tube inserted into the bladder that drains urine into a bag outside your body) was securely placed and covered for privacy for one of three sample residents (Resident 1) when Resident 1's indwelling urinary catheter bag was on the floor and uncovered. This deficient practice had the potential to spread infection on the catheter bag, for Resident 1 to develop a urinary tract infection (an infection involving any part of the urinary system including urethra bladder uterus and kidney), and to not protect Resident 1's dignity. Findings: During a review of Resident 1's, admission Record , printed on 9/21/22, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Sepsis (an infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever). During a record review of Resident 1's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 9/12/22, the MDS assessment section G indicated Resident 1 needed staff's assistance to maintain his personal hygiene, showers, and grooming. The MDS assessment section C indicated Resident 1's Brief Interview of Mental Status (BIMS- an assessment for mental status) score was 15 out of 15 which indicated intact mental status. During a concurrent observation and interview on 9/21/22 at 10:40 a.m., with Resident 1, Resident 1 was observed lying in bed with his door opened. Resident 1's urinary bag was touching the floor and the urinary bag was uncovered. Resident 1 stated he cannot move and he cannot do anything on his own, and is dependent on staff for everything. Resident 1 stated he is tired of going to hospital due to infections. During a review of Resident 1's, Progress notes , dated 9/17/22 indicated, Resident 1 was transferred back from hospital with diagnosis of Sepsis, UTI Klebsiella (Infection of any part of the urinary system, including kidneys, ureters, bladder, and urethra caused by bacteria Klebsiella) etc. Progress notes indicated to ensure safety measures. During a concurrent observation and interview on 9/21/22 at 10:57 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1's urinary bag was not secured properly and was touching the floor. LVN 1 stated Resident 1's urinary drainage bag should not be touching the floor because there was risk of contamination. LVN 1 stated it can lead to kinks and breakage to tubing if it is not secured properly. LVN 1 also stated the privacy bag was not on for Resident 1's urinary bag. During an interview on 9/21/22 at 11:41 a.m., Infection preventionist (IP), stated the urinary bag should be attached to the side of the bed and cannot be on the floor. IP stated if urinary bag is not secured properly there is risk for back flow of urine and can lead to infection. During a review the facilities, Policy, and Procedures (P & P), titled, Indwelling catheter revised on 9/1/2014, indicated, II. Drainage . B. The catheter and collecting tube will be kept free from kinking and the collection container for each resident. III. Catheter Care .B. The resident's Privacy and dignity will be protected by placing cover over drainage bag.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed obtain a doctor's order and assess one of one resident (Resident 67) ability to self-administer medications when Resident 67 had a bottle of Sore Throat Oral Anesthetic Spray (medication to temporarily relieve sore throat pain) bottle at the bedside. This deficient practice had the potential to result in Resident 67 using the Sore Throat Oral Anesthetic Spray against safe dosing recommendations. It also had the potential to result in the use of the medication by other residents, who could potentially obtain Resident 67's medication from the bedside table where it was stored. Findings: During a concurrent observation and interview on 6/16/22, at 11:35 a.m., with Resident 67, at Resident 67's bedside, a bottle of Sore Throat Oral Anesthetic Spray was observed on Resident 67's overbed table. Resident 67 stated she used the Sore Throat Oral Anesthetic Spray whenever she felt throat pain. Resident 67 further stated she did not remember how often she used the spray, nor how much spray she used. During a review of Resident 67's admission Record, dated 5/19/22, indicated Resident 67 was admitted to the facility on [DATE] and has medical diagnoses including stenosis of larynx, anxiety disorder, and other specified diseases of upper respiratory tract. During a review of Resident 67's minimum data set (MDS, a comprehensive assessment tool to guide care), dated 4/22/22, indicated Resident 67 had a Brief Interview for Mental Status (BIMS, a screening tool to assess cognitive function) score of seven which indicated severe cognitive impairment. During an interview with Registered Nurse (RN) 1, on 5/16/22, at 11:55 a.m., RN 1 stated the bottle of Sore Throat Liquid may stay at Resident 67's bedside because Resident 67 was alert and oriented. RN 1 further stated she was not aware an assessment was needed prior to allowing residents to self-administer medication(s). During a concurrent interview and record review, with the Interim Director of Nursing (IDON), on 5/18/22, at 10:45 a.m., the IDON stated the interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their patients) must fill out the Assessment for Self-Administration of Medications form and review it prior to recommending a resident to self-administer medications. The IDON also stated the Assessment for Self-Administration of Medications form was not completed for Resident 67. During a review of the facility's policy and procedure (P&P) titled, Medication-Self Administration, dated 1/1/12, the P&P indicated, The Facility will allow a resident to self-administer medications when determined capable to do so by the IDT [Interdisciplinary Team] and the resident's Attending Physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of one sampled resident's (Resident 27) preferences for showers were followed, when Resident 27's scheduled shower days were missed from April through May 2022. This failure resulted in Resident 27's request and preference for showers not being honored. Findings: During an interview on 5/16/22, at 12:30 p.m., with Resident 27, Resident 27 stated he does not receive showers as scheduled. Resident 27 stated he told the Administrator (ADM) and the Interim Director of Nursing (IDON) about missed showers. Resident 27 stated he was scheduled to have showers twice a week on Tuesdays and Fridays and prefers to take them on his scheduled days. Resident 27 stated his scheduled shower last Friday was missed because of short staff and had to wait until Monday for a shower. Resident 27 further stated it makes him feel annoyed and agitated when his showers are missed because he wants to be clean. During a review of Resident 27's admission Record, dated 5/18/22, indicated Resident 27 was admitted on [DATE]. The admission Record indicated Resident 27 has medical diagnoses including hemiplegia (paralysis of one side of the body) of left non-dominant side, major depressive disorder, anxiety disorder, dependence on wheelchair, and traumatic arthropathy (arthritis or joint disease) of left shoulder. During a review of Resident 27's minimum data set (MDS, a comprehensive assessment tool to guide care), dated 3/16/22, indicated Resident 27 had a Brief Interview for Mental Status (BIMS, a screening tool to assess cognitive function) score of 15 which indicated intact cognition. During an interview on 5/17/22, at 11:52 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated there were days when the facility was short staffed, and showers were missed. CNA 1 stated residents receive showers twice a week. CNA 1 stated completed showers are recorded on the residents' Skin Assessment form and Activities of Daily Living (ADL, activities related to personal care) Flowsheet. During a review of Princeton Manor Shower Schedule PM Shift, updated 4/7/20, indicated Resident 27 has scheduled showers on Tuesday and Friday. During a record review of Resident 27's comprehensive health assessment, dated 9/7/21, indicated Resident 27 responded very important to the question How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? During a record review of Resident 27s comprehensive health assessment, dated 3/9/22, indicated Resident 27 has supervision for bathing. During a concurrent interview and record review on 5/19/22, at 10:30 a.m., in the IDON's office, with the IDON, Resident 27's ADL Flowsheet, dated April through May 2022, were reviewed. The IDON stated showers and sponge baths were documented in the ADL Flowsheets. The IDON stated Resident 27's scheduled showers were on Tuesdays and Fridays. The IDON stated the P indicated sponge bath and the S indicated shower on the ADL Flowsheet. The IDON confirmed there were no S's or showers documented for Resident 27 in the April and May 2022 ADL Flowsheets. The IDON stated she does not know why there were only sponge baths documented for Resident 27. The IDON stated there needs to be education on showers and documentation. During a review of the facility's policy and procedure (P&P), titled, Showering and Bathing, revised 1/1/12, the P&P indicated, A tub or shower bath is given the residents to provide cleanliness, comfort, and to prevent body odors.

Based on observation and interview, the facility failed to follow infection control policies and procedures when the Infection Preventionist (IP) did not properly disinfect and store reusable ice bags. This deficient practive had the potential to place residents at risk for spread of infection and cross contamination. Findings: During a concurrent observation and interview on 5/17/22, at 11:20 a.m., at the medication room in Nurses Station 1, with Licensed Vocational Nurse 1 (LVN 1), the Nurses Station 1 resident food refrigerator was observed. The refrigerator did not have food inside. There were four re-useable ice packs in the refrigerator compartment and five re-useable ice packs in the freezer compartment. LVN 1 stated the ice packs were for residents, for issues such as pain, and residents needed a doctors order for them. During an interview on 5/18/22, at 9:45 a.m., with LVN 1, LVN 1 stated the ice packs in the Nurses Station 1 fridge were from physical therapy. During an interview on 5/18/22, at 9:52 a.m. with Physical Therapist (PT), PT stated the ice packs were reusable, and shared between residents. PT stated the ice packs contained a chemical that kept them cold, longer. PT stated after residents used the ice packs, they were bleached for about five minutes, allowed to dry, wiped with alcohol, then placed in Nurses Station 1 refrigerator. PT stated the ice packs stored in the food refrigerator was a risk for cross contamination. During an interview and record review on 5/18/22, at 10:01 a.m., at the medication room in Nurses Station 1, with IP, IP stated after residents used the ice packs, they were rinsed in the sink, then placed back in the refrigerator. IP stated the Nurses Station 1 refrigerator was designated as a food refrigerator. The Medication Room Temperature Log, dated May 2002, posted on the Nurses Station 1 fridge was reviewed. IP stated staff took fridge temperatures to make sure it was the proper temperature for food. IP stated they must get another refrigerator for ice packs. During an interview on 5/18/22, at 1:03 p.m., with Physical Therapy Aide (PTA), PTA stated after residents used ice packs, they were sanitized for four minutes per manufacturer's instruction and placed back in the refrigerator. During an interview on 5/19/22, at 12:30 p.m., with Interim Director of Nursing (IDON), IDON stated the Nurses Station 1 refrigerator was designated for food only. IDON stated the ice packs were not supposed to be reused or kept in the refrigerator. IDON stated ice packs should not be in the refrigerator because of cross contamination. IDON stated all the ice packs were discarded. During a concurrent interview and record review on 5/20/22, at 10:24 a.m., with IP, the facility's policy and procedure (P&P) titled, Cleaning and Disinfection of Resident Care Equipment, revised 1/1/2012, was reviewed. The P&P indicated, Reusable items are cleaned and disinfected or sterilized between residents . IP stated reusable items were disinfected with a chemical and allowed to dry, according to manufacture's instruction to prevent cross contamination. During a review of the facility's job description titled Infection Control Coordinator, undated, the job description indicated, Principal Responsibilities . Promotes and maintains infection control guidelines and standards.

Based on interview, record review, and document review, the facility failed to ensure one of four staff (Dietary Aide 1 [DA 1]) followed the COVID-19 (an infectious respiratory disease) vaccination policies and procedures when DA 1 did not complete COVID-19 vaccine series with a booster dose. This failure had the potential to result in the spread of COVID-19 infections to residents, staff, and visitors in the facility. Findings: During a concurrent interview and document review on 5/18/22, at 10:55 a.m., the Employee COVID-19 Vaccination Log, was reviewed with Infection Preventionist (IP). The vaccination log indicated DA 1 received the Pfizer vaccine (a COVID-19 vaccine) on 8/13/21 and 10/20/21. A COVID-19 vaccine booster result was not recorded for DA 1. IP confirmed DA 1's booster was due and not logged. IP stated, DA 1 received the COVID-19 booster vaccine, however, DA 1 has not brought in the vaccine record for verification. IP stated DA 1 still worked in the facility and last worked sometime last week. During a follow-up interview and concurrent document review on 5/19/22, at 12:00 p.m., with IP, IP stated she was waiting for DA 1 to send a copy of the COVID-19 booster vaccination record. IP then provided DA 1's COVID-19 vaccination record card. DA 1's vaccination card indicated DA 1 received the booster on 5/19/21 (same day as the current interview). Review of the facility's policy and procedure (P&P), titled, COVID-19 Staff Vaccination Program, revised on 9/2/21, indicated all personnel providing services or performing work at the facility are required to be vaccinated against COVID-19. Only those who have a medical or religious reason will be granted an exemption. The P&P also indicated, If additional doses of COVID-19 vaccines (i.e., boosters) become recommended by federal, state, or local health authorities . the Facility may require personnel to receive additional vaccine doses in alignment with those recommendations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure the comprehensive care plan for falls were updated and implemented for one of one sampled resident (Resident 67), when Resident 67 was identified as a high risk for falls and experienced multiple falls. This failure resulted in Resident 67 experiencing a fractured left femoral neck (hip bone), requiring a left hemiarthroplasty (hip replacement surgery) from the fall, and was transferred to the acute care hospital for treatment. Findings: A review of Resident 67's admission Record, dated 5/19/22, indicated Resident 67 was admitted to the facility on [DATE] with diagnoses that included paralysis (the loss of the ability to move (and sometimes to feel anything) in part or most of the body and weakness of the left side of the body. A review of Resident 67's Minimum Data Set (an assessment tool to guide care), dated 7/21/21, indicated Resident 67's Brief Interview for Mental Status (BIMS, a screening tool to assess cognitive function) score was seven which indicated moderate impaired cognition. A review of Resident 67's Fall Risk Assessment, dated 10/21/21, indicated Resident 67's fall risk score was 18 which indicated a high risk for falls. The assessment also indicated Resident 67 experienced multiple falls within the last six months. The assessment further indicated Resident 67 exhibits loss of balance while standing, requires hands on assistance to move from place to place, uses an assistive device, and has decrease in muscle coordination. A review of Resident 67's medical records from 8/11/2021 through 4/8/3022 indicated Resident experienced a fall on 8/11/21, 10/21/21, and 4/8/22. A review of Resident 67's fall risk care plan, initiated 4/20/21, indicated Resident 67 is high risk for falls related to gait and balance problems, incontinence, and left sided hemiparesis. The care plan interventions included: -ensuring call light within reach -educating resident about safety reminders -encouraging resident to participate in activities -ensuring resident is wearing appropriate footwear -following facility fall protocol -evaluating and treating resident as ordered or as needed -reviewing information on past falls and attempt to determine cause of falls and record possible root causes. A review of Resident 67's fall care plan, initiated 8/11/21, indicated resident has had an actual fall with no injury, poor balance, unsteady gait on 8/9/21. The care plan interventions included: -Continue interventions on the at risk plan -Monitor, document, and report as needed to doctor for signs and symptoms of pain, bruises, and change in mental status, new onset of confusion, sleepiness, inability to main posture, and agitation for 72 hours -Neuro checks for 72 hours -PT [physical therapy] consult for strength and mobility -Vital signs every shift for 72 hours. A review of Resident 67's Progress Notes, dated 10/21/21, indicated [Resident 67] told staff that she fell and it's suspected that she was self transferring to her bedside commode .Her roommate reports that she heard a noise at night and woke up to see [Resident 67] on the floor . [Resident 67] was reporting leg pain . IDT [interdisciplinary team] will safety measures when she returns such as bed in low position, floor mat, side rail, etc . A review of Resident 67's acute care hospital (ACH) History and Physical record, dated 10/21/21, indicated Resident 67 Presents from SNF [skilled nursing facility] secondary to fall out of bed, found to have L [left] femoral neck fracture. Per patient she uses a wheelchair at baseline . L sided paresis [partial paralysis] but had a dream that she could walk and tried to step out of bed this morning .remembers nurse helping her off the floor and into bed . Per nursing staff at her SNF, her fall was unwitnessed. She had been complaining of pain to her L hip. Nursing staff did not document finding her out of her bed, and the nursing staff that I spoke with was unaware of the event. They state that she has otherwise seemed to be at her baseline mental status and with normal vitals. The only complaint that she has had is the pain to her L hip. A review of Resident 67's ACH imaging record, dated 10/21/21, indicated Resident's 67 left hip x ray indicated a left femoral neck fracture and There is a superior and lateral displacement of the distal fracture component. A review of Resident 67's ACH Orthopaedic Surgery Progress Note, dated 10/23/22, indicated Resident 67 presenting with L [left] femoral neck fx [fracture] now s/p [status/post, refers to a treatment and often a surgical procedure] L hemiarthroplasty [a surgical procedure that involves replacing half of the hip joint] on 10/21, pt [patient] remains stable since surgery. A review of Resident 67's ACH Discharge summary, dated [DATE] indicated resident was admitted to ACH from 10/21/21 to 10/26/21 due to a left displaced femoral neck fracture. A review of Resident 67's fall care plan initiated on 10/21/21, indicated Resident 67 has had an actual fall with L femur fx d/t [due to] poor balance, unsteady gait. The care plan interventions included: -bed in low position, call light in reach -continue interventions on the at risk plan for no apparent acute injury, determine and address causative factors of the fall -monitor, document, and report as needed to doctor for signs and symptoms of pain, bruises, and change in mental status, new onset of confusion, sleepiness, inability to main posture, and agitation for 72 hours -pharmacy consult to evaluate medications -provide activities that promote exercise and strength building where possible -PT consult for strength and mobility -vital signs every eight hours for 72 hours. During observations on 5/17/22, at 11:00 a.m. and 5/18/22, at 10:00 a.m., Resident 67 was observed using a wheelchair to propel herself throughout the facility. There was no fall mat observed located at Resident 67's bedside. During a concurrent interview and medical record review on 5/20/22 at 9:30 a.m., with Registered Nurse 1 (RN 1), Resident 67's fall history was discussed. RN 1 stated she was on morning duty on 10/21/22 when RN 1 received a phone call from an ACH doctor informing RN 1, Resident 67 was discovered with a fracture. RN 1 stated the assigned nurse for Resident 67 during the night shift did not report the fall incident to RN 1. RN 1 stated the night shift nurse reported to RN 1 that Resident 67 was transferred out to hospital. The multiple fall care plans were reviewed with RN 1 and RN 1 was requested to comment about Resident 67's nursing interventions. RN 1 stated a care plan was created after each fall incident, not revised, was vague and not detailed to appropriately care for Resident 67. RN 1 stated she would have added frequent monitoring, an example of a nursing intervention, to update or revise the care plan to prevent additional falls for Resident 67. A review of Resident 67's fall care plan, initiated on 4/8/22, indicated Resident 67 has had an actual fall (no injury) poor balance, unsteady gait on 4/8/22. The care plan interventions included: -continue interventions on the at risk plan for no apparent acute injury, determine and address causative factors of the fall -PT consult for strength and mobility -vital signs (FREQ). During an interview on 5/19/22, at 11:30 a.m., with the Interim Director of Nursing (IDON), the IDON stated she assessed Resident 67 and determined Resident 67 was independent. The IDON stated Resident 67 removed the armrest on her wheelchair and the wheel brake was not long enough to prevent Resident 67 from scooting out of the chair. The IDON stated she would notify the PT to evaluate the Resident 67 to add a longer handbrake to the wheelchair. The IDON stated the interdisciplinary team was going to implement frequent checks on the resident, every hour. The IDON further stated these interventions would be added to Resident 67's care plan. During a concurrent interview and record review, on 5/20/21, at 10:11 a.m., with the PT, the Therapy Post Fall Screen, dated 4/11/22 was reviewed. The Therapy Post Fall Screen, indicated Resident 67 did not require physical therapy. The PT stated he educated Resident 67 to use the call light to get out of bed and for assistance when items are out of reach. Review of the facility's policy and procedure (P&P), titled, Fall Management Program, revised on 3/13/21, indicated, The Facility will implement a Fall Management Program that supports providing an environment free from fall hazards .A .the licensed nurse will complete a fall risk evaluation. If a fall risk factor is identified, document interventions on the Resident's care plan .B. A licensed nurse will conduct a new fall risk evaluation .upon identification of a significant change of condition, post fall and as needed .C. The Interdisciplinary Team (IDT) and/or the licensed nurse will develop a care plan according to the identified risk factors and root cause(s) per Care Area Assessment (CAA) guidelines. The P&P further indicated, for a resident who is identified as high risk for falls, the IDT will meet monthly to review the fall risk interventions for appropriateness and effectiveness until the frequency of their falls diminishes and The Residents' care plans will be updated with the IDT's recommendations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that its medication error rate was not five percent or greater. During the medication pass (med pass) observation, there were six medication errors observed out of 36 opportunities which resulted to a med pass error rate of 16.6 percent. This failure had the potential for Resident 54 not getting the full therapeutic benefit of the medications. Findings: During a medication pass observation on 5/17/22 at 8:40 a.m., Registered Nurse 1 (RN1) crushed six medications of Resident 54: Metoprolol 25mg (used to treat high blood pressure), Lovastatin 20mg (used to lower cholesterol), Tamsulosin 0.4mg (for the treatment of enlarged prostate), Metformin 500mg (used to treat high blood sugar levels), Memantine 10mg (for dementia), Lisinopril 40mg (used to treat high blood pressure and heart failure). A review of Resident 54's admission Record, dated 5/19/22, indicated Resident 54 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills), high blood pressure and dysphagia (difficulty swallowing). During a concurrent interview and record review, with the Interim Director of Nursing (IDON) on 5/17/22, the IDON was not able to find physician's orders for the medications of Resident 54 to be crushed. The IDON stated there should be a physician's order stating nurses may crush the medications. The facility's policy and procedure titled: Medication Administration dated 1/1/12 indicated, if the resident has difficulty swallowing pills, the licensed nurse will notify the physician to discuss possibility of a different form of the medication i.e. crushed, liquid or suspension. If the medication is to be crushed, a physician's order is required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 54) was free of significant medication error, when Resident 54's oral medications were all crushed and administered together without a physician's order. This deficient practice had the potential for Resident 54 not receiving the full benefits of the medications. Findings: During a medication pass observation on 5/17/22, at 8:40 a.m., Registered Nurse 1 (RN1) crushed all of Resident 54's prescribed medication in a plastic pouch: Metoprolol 25mg (used to treat high blood pressure), Lovastatin 20mg (used to lower cholesterol), Tamsulosin 0.4mg (for the treatment of enlarged prostate), Metformin 500mg (used to treat high blood sugar levels), Memantine 10mg (for dementia), Lisinopril 40mg (used to treat high blood pressure and heart failure) poured them in a medicine cup, mixed it with apple sauce, then served it to Resident 54, followed by a teaspoonful of Medpass Plus 2.0 (a medication pass drink which delivers more nutrition than water). RN1 stated she crushed the medications because she feared Resident 54 might choke if given whole medication tablets. A review of Resident 54's admission Record, dated 5/19/22, indicated Resident 54 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills), high blood pressure and dysphagia (difficulty swallowing). During a concurrent interview and record review, with the Interim Director of Nursing (IDON) on 5/17/22, the IDON was not able to find physician's orders for the medications of Resident 54 to be crushed. The IDON stated there should be a physician's order stating nurses may crush the medications. During a review of the facility's policy and procedure (P&P) titled, Medication-Administration, dated 1/1/12, indicated, If the resident has difficulty swallowing pills, the licensed nurse will notify the physician to discuss the possibility of a different form of the medication i.e crushed, liquid or suspension. If the medication is to be crushed, a physician order is required.

Based on observation, interview and record review, facility failed to follow its policy and procedure on Oxygen Therapy when there was no date on the oxygen tubings of Resident 62. This deficient practice had the potential of delivering oxygen in an unsafe and unsanitary condition to resident. Findings: During the initial tour of the facility on 5/16/22 at 11:55 a.m., Resident 62 had two (2) oxygen concentrators ( a device that concentrates oxygen by removing nitrogen to supply oxygen-enriched gas), and two(2) small oxygen tanks in her room. The two(2) concentrators each had 25 feet tubings connected by a Y tube to deliver a high dose of oxygen to Resident 62. The two(2) oxygen tanks were set up with tubings and were a back up source of oxygen, in case of a power outage. The oxygen tubings connected to the two(2) concentrators and two(2) oxygen tanks were not dated. In an interview with Registered Nurse (RN)1 on 5/16/22 at 12:10 p.m., she stated she was not sure when the tubings were changed. She stated there were no labels indicating the date the tubings were changed. Review of the facility policy titled: Oxygen Therapydated November 2017 indicated:Oxygen tubing, mask, and cannulas will be changed no more than every seven (7) days and as needed. The supplies will be dated each time they are changed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for two of five (Resident 26 and 34) sampled resident vaccination record, the facility failed to follow their immunization policy and procedure when the pneumococcal vaccine was not offered or documented for Resident 26 and 24 as recommended by the Advisory Committee on Immunizations Practices (ACIP, group of medical public health experts). This deficient practice had the potential to increase the risk for Resident 26 and 34 to acquire, transmit or experience complications from pneumococcal disease. Findings: During a concurrent interview and vaccine record review, on 5/18/22, at 10:55 a.m., Resident 26 and 34's pneumococcal vaccination records were reviewed with the Infection Preventionist (IP). The vaccination record indicated Resident 26 received the pneumococcal vaccine on 6/10/16. The vaccination record did not indicate which pneumonia vaccine was administered to Resident 34. The newly appointed IP stated she would search through records for Resident 26 and 34. Review of Resident 26's admission Record, dated 5/19/22, indicated Resident 26 was [AGE] years old with an autoimmune disease (body does not make enough cortisol to help break down fats, proteins, and carbohydrates in the body). Review of Resident 34's admission Record, dated 5/19/22, indicated Resident 34 was [AGE] years old with diagnoses that included diabetes and high blood pressure. Review of the facility's policy and procedure (P&P), titled Pneumococcal Disease Prevention, revised on 2/18/21, indicated the pneumococcal vaccination is recommended for the following residents: adults [AGE] years old and older, anyone 2 - [AGE] years old who has long term health problems such as diabetes and residents of nursing homes or long-term care facilities and those who are immunocompromised. The Resident's medical record shall include documentation that indicates, at a minimum, a date vaccine was administered and whether the Resident received the PCV13 (Prevnar 13,Pfizer) or the PPSV23 (Pneumovax 23) vaccine, or did not receive either because of medical contraindications or refusal.

Based on observation, interview, and facility document review, the facility failed to provide adequate oversight of the kitchen when multiple issues were identified with kitchen safety and sanitation; equipment was not maintained; food was not served so it was palatable and cooked to maintain nutritive value; and staff were not trained and competent for calibrating thermometers and cooking food to a safe temperature. These failures had the potential to result in food being served to residents in a safe and sanitary manner resulting in food borne illness; attract pests to the kitchen resulting in contamination of food, utensils, and equipment; and decrease the amount of food intake for residents resulting in nutritional related medical issues, for 71 residents who received food from the kitchen out of a facility census of 71. Findings: Review of the undated job description provided for the Dietary Supervisor (DS), titled, Director of Nutritional Services, indicated this position ensured the preparation of nutritious meals to all residents, maintained a safe and sanitary work environment, and monitored staff performance through coaching, evaluated quality of services accomplished by staff. During the Federal Re-certification survey conducted from 5/16/22 to 5/20/22, multiple issues were identified, including: 1.) food was not stored in a safe and sanitary environment when food stored inside a freezer was not frozen; door screens had rips, holes, and were not securely fitted; pans used for cooking were in poor condition; an ice scoop used for scooping ice was not protected from pests and other contaminants; ice was not stored in an area where staff could wash their hands before scooping ice; staff did not demonstrate proper hand hygiene when serving food; and oven mitts were soiled and came into contact with food (Cross-reference F812); 2.) a leaking drainpipe from a 2-compartment sink was not fixed after staff reported it to the DS (Cross-reference F-809); and 3.) food was not prepared in a manner to conserve nutritive value and vegetables served were not palatable (Cross-reference F804). In addition, it was identified that a cook was not competent and not trained on 1.) safe cooking temperatures for meat; and 2.) calibrating thermometers. 1. An observation on 5/18/22, at 12:02 p.m., showed [NAME] 2 removed a pan with multiple meatloaves from the oven. She placed a thermometer in the meatloaf and stated the meatloaf had to be at least 140 degrees Fahrenheit (F). She continued to take the temperature of the meatloaf then stated the meatloaf should be 145 degrees F. Then she placed the thermometer in several other spots in the meatloaf and said the meatloaf had to be 150 degrees F. She showed the temperature of the meatloaf taken in the various spots were 142 degrees F, 155 degrees F, and 175 degrees F. [NAME] 3 and Diet Aide 1 (DA 1), told [NAME] 2 the temperature was not okay so [NAME] 2 placed the meatloaf back in the oven. After speaking with [NAME] 3 and DA 1, [NAME] 2 stated the temperature of the meatloaf had to be 165 degrees F. In an interview on 5/19/22, at 11:50 a.m., DS stated she did not know if [NAME] 2 was trained on cooking temperatures for meat and she did not have in-service documentation indicating she was trained. Review of the policy and procedure titled, Meat Cookery and Storage, dated July 1, 2014, showed ground beef had to be cooked to an internal temperature of 155 degrees F for at least 15 seconds. Review of the recipe titled, Garden Fresh Meatloaf, dated Week 3 Wednesday, and provided for the meatloaf served for lunch on 5/18/22, indicated ground beef was an ingredient and the internal temperature of the meatloaf must register at least 165 degrees for 15 seconds. 2. In an observation and concurrent interviews with [NAME] 2 and the DS, on 5/18/22, at 10:30 a.m., [NAME] 2 stated thermometers were usually calibrated by cooks on Mondays and she was one of the cooks that calibrated thermometers. [NAME] 2 demonstrated how to calibrate thermometers by placing two, bi-metallic food thermometers (dial thermometers) in a glass filled with ice and some water. The thermometers read 28- and 30-degrees F, and she said they were okay. [NAME] 2 said if thermometers were not at the correct reading, she just discarded them. [NAME] 2 stated she did not know the thermometers were calibratable. [NAME] 2 said she wanted to learn how to calibrate the thermometers, so the DS demonstrated. The DS took the thermometer out of the ice water and turned the dial, so it read 32 degrees Fahrenheit (F). Then the DS placed the thermometer back in the ice water and the thermometer read 5 degrees F. The DS said the temperature was not right. The DS repeated the steps by removing the thermometer from the ice water and turned the dial on the thermometer and placed it back in the ice water, this time the thermometer read 20 degrees F. Review of the policy and procedure titled, Calibrating a Thermometer, dated July 1, 2014, indicated how to calibrate a bi-metallic food thermometer. The procedure indicated to fill a glass with ice and add water then place the thermometer in the glass of ice water. Then wait until the thermometer stabilizes and the thermometer should be 32 degrees F. If the thermometer is not 32 degrees F, then leave it in the ice water and turn the thermometer dial until the needle reads 32 degrees F. In an interview on 5/19/22, at 11:50 a.m., DS stated she did not know if [NAME] 2 was trained on calibrating thermometers and she did not have in-service documentation showing she was trained. Review of an undated, written statement provided by the ADM, titled [Name of [NAME] 2] - Cook indicated, Competency evaluation was not done at the time of hire. However, the Dietary Supervisor will provide 90 days evaluation for the employee.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure vegetables were palatable and cooked in a manner to conserve nutritive value for 71 residents who received food from the kitchen out of a facility census of 71. This failure had the potential for residents to not consume the amount of nutrients planned for the menu. Findings: An observation and concurrent interview with [NAME] 1, on 5/16/22, at 10:30 a.m., [NAME] 1 was observed pureeing food in a food processor. [NAME] 1 stated she was pureeing the turkey for lunch. [NAME] 1 said she just put the pureed green beans and pureed bread on the oven. [NAME] 1 stated the regular green beans were in the oven too. Inside the oven, was one large pan covered with foil and two smaller pans covered with foil. [NAME] 1 lifted the foil off the large pan to show it held green beans. [NAME] 1 stated she had to heat them up and planned to take them out at 11:45 a.m. to place on tray-line which started at 12 p.m. [NAME] 1 confirmed the oven was set at 450 degrees F. Review of the recipe titled, Green Beans with Garlic, dated Week 3 Monday, and provided for the recipe used for the green beans served for lunch on 5/16/22, indicated the recipe called for frozen green beans and to heat green beans . The recipe did not indicate how long to cook the green beans for and at what temperature. In an interview on 5/16/22, at 11:30 a.m., Resident 15 stated the food was horrible and said the vegetables were too watery. A record review for Resident 15, indicated she was [AGE] years old, she had a Brief Interview of Mental Status (BIMS; a test used to get a quick snapshot of how well a person is functioning cognitively) score of 15 (a BIMS score of 15 indicates intact cognition meaning there is no sign of dementia or cognitive impairment), and she was on a Regular diet. In an interview on 5/18/22, at 2:20 p.m., Dietary Supervisor (DS) stated the green bean prepared for lunch on Monday, were canned green beans. DS stated the green beans might take 30 - 40 minutes to heat-up in an oven at 450 degrees Fahrenheit (F). In an interview on 5/19/22, at 10:19 a.m., Registered Dietitian 1 (RD 1) stated vegetables cooled too long could become too soft and mushy and might lose nutrients. RD 1 said residents might not think the overcooked vegetables were appealing and refuse to eat them. RD 1 stated sometimes canned green beans were substituted for frozen green beans if frozen green beans were not available from the supplier. RD 1 confirmed the cooking time and temperature for the green beans were not on the recipe. In an interview on 5/19/22, at 2:28 p.m., RD 1 stated cooking canned vegetables for over an hour was way too long. RD 1 said cooking the vegetables that long would make them too mushy and the residents may not like them, and it would likely decrease the nutrient value.

Based on observation, interview, and facility document review, the facility failed to ensure a safe and sanitary environment in the kitchen when: 1. Food was not frozen when stored in a reach-in freezer; 2. Two door screens were not intact and sealed properly to help prevent insects and rodents from entering the kitchen; 3. Cooking pans were in poor condition; 4. The ice machine was not stored in an area to help prevent contamination of the ice; 5. There were no air-gaps for the food preparation sink and the 2-compartment warewashing sink; 6. Staff did not practice appropriate hand hygiene; and 7. Soiled oven mitts came into contact with food. This failure had the potential to cause contamination of food resulting in food borne illness for 71 residents who received food from the kitchen out of a facility census of 71. Findings: 1. An observation and concurrent interview with the Dietary Supervisor (DS), on 5/16/22 at 10 a.m., showed food stored in the 2-door, reach-in freezer number 2 was not frozen solid when the food was pressed, and it was soft. Foods that were not frozen solid in the freezer included a plastic bag filled with plain doughnuts; a box of plain doughnuts, three loaves of packaged garlic bread, a large, full container of ice cream, over 20 frozen nutritional supplements, and three bags of packaged hashbrown potatoes. The built-in temperature display screen located on the outside of the freezer, read negative 1 degrees Fahrenheit (F). Two thermometers located on the shelves inside the freezer, read 10 degrees F. DS stated she recorded the temperatures of the freezer onto the temperature log the last two mornings. DS stated she used the thermometer reading located on the outside of the freezer to document the freezer temperature and did not look at the internal thermometers. In a concurrent observation and interview with DS, on 5/16/22, at 1:58 p.m., DS stated she figured out why the food was getting soft in the freezer. DS demonstrated when the right door was opened then pushed closed, the left door opened and stayed ajar a half inch. An observation and concurrent interview with DS, on 5/17/22, at 12:42 p.m., showed single serving plastic containers of ice cream served on the lunch trayline (a system of food preparation in which trays move along an assembly line). The ice cream cups were stored in a metal container filled with melting ice, so the cups were partially floating in the ice water. The ice cream cups were not solid and the sides of the plastic cups easily pressed in. DS confirmed the ice cream was melted. DS also stated it was difficult to keep the ice cream cups in freezer number 2 during trayline because the door was not closing properly to keep the food frozen. Review of the Refrigerator/Freezer Temperature Log, dated May 2022, indicated written instructions, . Freezer temperatures should be 0 degrees F or below. If temperature is not within this range, report to supervisor-on-duty immediately or contact Maintenance for correction. Document corrective actions taken in appropriate column as necessary. According to the 2017 Federal Food Code, frozen food is to be maintained frozen. 2. An observation and concurrent interview with [NAME] 1 and DS, on 5/16/22, at 10:35 a.m., showed the back doors were open and a magnetic bug screen was attached to the doors. The magnetic screens were two screen panels with a magnetic strip down the middle for the purpose of closing the two screen panels. On the door located closer to the stove, the screen magnets were not connected so the two sides of the screen door were not closed leaving an open gap to the outside. The bottom of the screen was not attached to anything, so it laid loose on the ground. In addition, the screen was ripped in the middle creating a hole over 1 inch by 3 inches long; and it was ripped at the bottom creating a hole over 3 inches by 5 inches long. [NAME] 1 stated she kept the back door open at times because the kitchen was hot due to the majority of the air conditioning vents in the kitchen not working. DS confirmed the magnetic screen door was open and was ripped. DS stated flies could come in through the holes. Three flies were flying around inside the kitchen. In an interview on 5/17/22, at 10:25 a.m., the Environmental Manager (EM) stated the procedure for communicating maintenance needs in the kitchen was for staff to log the issues in the maintenance logbook located in station 1. EM stated he was not aware of the ripped screen door because kitchen staff did not report it. EM confirmed the magnetic strips that held the two sides of the screen door together near the bottom of the screen door, did not connect which left a gap in the screen. EM stated flies could come in through the gaps and the rips in the screen. An observation on 5/18/22, at 12:15 p.m., showed the back door located next to the 2-compartment sink, was open. The two screen panels of the magnetic door screen were not closed, leaving a gap in the screen the entire height of the door. Toward the top, the gap between the screens was one inch and toward the bottom the gap was over four inches. The bottom of the screen was not attached to anything, so it laid loosely on the ground. Staff were preparing food at the food preparation table next to the open door. An observation and concurrent interview with EM and the Administrator (ADM), on 5/19/22, at 9:15 a.m., showed the back door near the 2-compartment sink was open and the magnetic screen was not fully closed which left a gap in the screen. The administrator agreed that rodents could potentially enter the kitchen because the bottom of the screen was not attached and laid loosely on the ground. According to the 2017 Federal Food Code, if doors of a food establishment are kept open for ventilation, or other purposes, the openings shall be protected against the entry of insects and rodents by mesh screens (16 mesh per 1 inch), properly installed air curtains, or other effective means. 3. An observation on 5/16/22, at 10:42 a.m. showed cooking pans hanging from a rack in the stove area. The cooking surface of one pan had black residue build-up on the inside cooking surface. The cooking surfaces of five pans had cooking surfaces with black and orange residue build-up, and scratches. [NAME] 1 stated she did not use the pan with the most orange residue build-up, but she did use the other pans. DS stated she ordered two new pans to replace the worst pans but did not receive them yet. DS stated she was going to replace all the pans eventually. According to the 2017 Federal Food Code, food-contact surfaces are to be easily cleanable, smooth and free of chips, inclusions, pits and similar imperfections. Also, food-contact surfaces are to be clean to sight and touch; and the food contact surfaces of cooking equipment and pans are to be kept free of encrusted grease deposits and other soil accumulation. 4. An observation and concurrent interview with Nourishment Staff 1 (NS 1), on 5/16/22, at 2:08 p.m., showed an ice machine located in an outdoor patio area outside of the activity room. An ice scoop was inside a scoop container attached to the wall. The lid on the scoop container was open, leaving the scoop uncovered. When the lid was closed, there was a gap at the area where there was a hole cut out for the scoop handle. NS 1 opened the door to the activity room, then unlocked the door to the patio and opened the door to the patio, then handled the lock on the ice machine. Then NS 1 removed the ice scoop from the container on the wall and scooped ice into an ice cooler. NS 1 stated the ice was for the kitchen and there was only one ice machine at the facility. There was no handwashing sink in the patio area where the ice machine was located to allow staff to clean their hands before scooping ice. In an interview on 5/17/22, at 8:18 a.m., DS stated a kitchen staff retrieved ice from the outdoor ice machine before each meal and the ice was used to keep milk and juices cold during meal service. DS stated nurses also retrieved ice from the outdoor ice machine which was used for ice water for residents. In an observation and interview with EM, on 5/17/22, at 10:14 a.m., EM stated he was responsible for cleaning the inside of the ice machine. EM opened the top of the machine, so the internal parts were visible. The plastic that covered the condenser had black residue on the surface. EM stated it was a little dust. In an interview on 5/18/22, at 10:45 a.m., Registered Nurse 1 (RN 1) stated some residents liked ice in their water. RN 1 said any nursing staff filled coolers with ice from the outside ice machine, to have ice available for residents. In an interview with the Registered Dietitian (RD) and a concurrent observation of the ice machine, on 5/19/22, at 10:58 a.m., RD stated staff could wash their hands in the kitchen before getting ice, but in order to get ice, they would contaminate their hands between the kitchen and scooping ice because they had to open doors and handle the lock on the ice machine. RD also agreed the ice scoop was not fully protected from insects even when the scoop container was closed since there was a gap in the lid when it was closed. RD said she thought the scoop was cleaned daily but insects could come into contact with the scoop between cleanings. According to the policy and procedure titled, Ice Machines & [and] Ice Storage Chests, dated October 1, 2014, indicated the ice scoop was to be in a covered container when not in use. According to the 2017 Federal Food Code, hand washing is to occur when working with exposed food, clean equipment and utensils, and after engaging in other activities that contaminate the hands. According to the 2017 Federal Food Code, cleaned equipment and utensils are to be stored where they are not exposed to dust or other contamination. In addition, during pauses in food dispensing, dispensing utensils such as ice scoops, are to be stored in a clean protected location. 5. During an observation on 5/17/22, at 8:32 a.m., in the facility kitchen, the Food Preparation and the 2-Compartment Ware Washing sinks were observed. Both sinks were plumbed directly to the floor without an air gap (space that separates a water line from a sink to a sewer). During an interview on 5/17/22, at 10:52 a.m., with Dietary Aid 1 (DA 1), DA 1 stated the 2-Compartment Ware Washing sink was for washing items used for food preparation. During an interview on 5/17/22, at 10:33 a.m., with EM, EM stated the Food Preparation and the 2-Compartment Ware Washing sinks were plumbed directly into the sewage system and did not have an air gap. According to the 2017 Federal Food Code, a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed. 6. During an observation on 5/17/11, at 12:00 p.m., in the facility Kitchen, [NAME] 2 was observed. Before [NAME] 2 started trayline, [NAME] 2 did not wash her hands before she put gloves on. During an observation on 5/17/11, at 12:33 p.m., in the facility Kitchen, [NAME] 2 was observed during trayline. [NAME] 2 prepared resident lunch plates and did not wash her hands after [NAME] 2 removed her gloves and before she put new gloves on. During an interview on 5/17/22, at 12:42 p.m., with DS, DS stated [NAME] 2 did not wash her hands when she changed gloves during trayline. DS stated staff need to wash their hands before they put on gloves. During a review of the facility's policy and procedure (P&P) titled, Hand Hygiene, dated 9/1/20, the P&P indicated, The following situations require appropriate hand hygiene . Before and after food preparation . Before donning (putting on) and after doffing (removing) Personal Protective Equipment (PPE). According to the 2017 Federal Food Code, food employees are to wash their hands and exposed portions of their arms before donning gloves to initiate a task that involves working with food. 7. During an observation on 5/17/22, at 11:51 a.m., in the facility Kitchen, [NAME] 2 was observed during trayline. [NAME] 2 poured two pans of cooked baked chicken into a container, on the steam table. [NAME] 2's oven mitts came into contact with the chicken and sauce that when into the pan on the steam table. [NAME] 2 placed the chicken and sauce from the pan onto plates for resident lunches. During a concurrent observation and interview on 5/18/22, at 9:28 a.m., in the facility Kitchen, with DS, 4 oven mitts were observed. The oven mitts were observed with orange residue on outer surface. DS stated the residue on the oven mitts were from food. DS stated oven mitts were not cleaned or laundered. DS stated that the oven mitts should not come into contact with food because it is a risk for cross contamination. During an observation on 5/18/22, at 12:19 p.m., in the facility Kitchen, [NAME] 3 picked up an oven mitt she dropped on the kitchen floor and placed it on the food preparation counter. The oven mitt came into contact with an opened bag of breadcrumbs, and a plastic container of onion powder. During an interview on 5/19/22, at 10:19 a.m., with RD, RD stated staff should not use an oven mitt that fell on the floor, they should use a clean oven mitt. RD stated oven mitts that fell on the floor should be washed because oven mitts have the potential to contact food. During an interview on 5/20/22, at 8:25 a.m. with Regional Registered Dietitian (RRD), RRD stated oven mitts that fell on the floor should immediately be placed in the soiled linen bin so housekeeping clean and sanitize it with chemicals. RRD stated If an oven mitt fell on the floor, it should not be placed on the counter or near the food prep area. RRD stated the floor is not sanitary and it is a risk for cross contamination. According to the 2017 Federal Food Code, cloth gloves may not be used in direct contact with food unless the food is subsequently cooked.

Based on observation, interview, and facility document review, the facility failed to ensure a drainpipe from the 2-compartment kitchen sink was in good repair. This had the potential to attract pests resulting in contamination of food and utensils for 71 residents who received food from the kitchen out of a facility census of 71. Findings: An observation and concurrent interview with Dietary Aide 1 (DA 1) and [NAME] 2, on 5/17/22, at 8:32 a.m., showed a drainpipe under the 2-compartment sink, used for manual warewashing, was plumbed into the floor. When the sink was drained, water leaked from the pipe, which was caught in a plastic dome plate cover on the floor under the sink and drainpipe. DA 1 and [NAME] 2 stated, there was a terrible odor that came from the drainpipe area under the sink, especially when the 2-compartment sink drained. [NAME] 2 said the drain was like that since she started working at the facility six months ago. In an interview on 5/17/22, at 10:25 a.m., Environmental Manager (EM) stated there was a maintenance logbook in station 1. EM said kitchen staff were supposed to log things in need of maintenance in the kitchen. EM said he was not aware of the leak or the smell from the drainpipe under the 2-compartment sink. EM said staff did not notify him. In an interview with EM and Administrator (ADM), on 5/19/22, at 1:02 p.m., EM stated the dripping pipe could be a possible contamination and ADM said it was a sanitation concern. In an interview on 5/20/22, at 12:04 p.m., Dietary Supervisor (DS) stated staff told her about the dripping drainpipe from the 2-compartment sink about two weeks ago. DS said she notified maintenance verbally and did not document it in the maintenance logbook. DS stated she was not aware staff were catching the water from the dripping pipe with plate dome covers. DS also said she did not follow-up with maintenance to find out if the dripping drainpipe was fixed. Review of the policy and procedure titled, Maintenance - Work Orders, dated January 1, 2012, indicated department directors/supervisors were responsible for completing work orders and forwarding them to the Director of Maintenance. According to the 2017 Federal Food Code, a plumbing system shall be maintained in good repair.

Based on observation, interview and record review, the facility failed to protect privacy and dignity for one (Resident 271) of 21 sampled residents when Resident 271's urinary catheter drainage bag was left uncovered on the floor where others could clearly see it. This failure resulted in Resident 271's feeling ignored by the facility. Findings: During an observation on 10/21/19, at 11:17 a.m., Resident 271's urinary catheter drainage bag was sitting on the floor by the bedside, while Resident 271 was laying in the bed. Drainage bag was clearly visible from the hallway outside Resident 271's room. During an interview on 10/21/19 at 11:25 a.m., Resident 271 stated he never received the privacy cover for the urinary drainage bag and felt ignored. During an interview on 10/21/19 at 11:24 a.m., Certified Nursing Assistant (CNA 1) stated Resident 271's urinary drainage bag should be covered with a blue bag to provide privacy. Review of facility's policy and procedure titled, Indwelling Catheter, dated 9/1/14, indicated .The resident's privacy and dignity will be protected by placing cover over drainage bag

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - an assessment tool used to guide care) represented the accurate status for two (Resident 41 and 73) of 21 sampled residents. 1. Resident 41's weight was not taken within 30 days before the MDS assessment, and; 2. Resident 73's discharge MDS indicated they were discharge to the hospital instead of to home. For Residents 41 and 73, these failures resulted in an inaccurate reflection of the residents' status. Findings: 1. During an interview and concurrent record review on 10/24/19 at 10:35 a.m., Minimum Data Set Coordinator (MDSC) reviewed Resident 41's Weights and Vitals Summary and stated Resident 41 had not been weighed since 9/3/18. During an interview and concurrent record review on 10/24/19 at 10:35 a.m., MDSC reviewed Resident 41's MDS dated [DATE] and stated Resident 41's weight was coded as 110 pounds (her last weight taken on 9/3/18). MDSC also stated the Dietary Manager (DM) was responsible for completing the weight section and DM could use only a weight that was taken within 30 days prior to the assessment date. During an interview on 10/24/19 at 11:06 a.m., Dietary Manager (DM) stated Resident 41's MDS, dated [DATE], was coded incorrectly because there was no weight available (taken within 30 days) prior to the assessment date. Review of Centers of Medicare and Medicaid Services (CMS's) Resident Assessment Instrument (RAI) Version 3.0 Manual, dated 10/2019, indicated directions to .Base weight on the most recent measure in the last 30 days. If a resident cannot be weighed, for example because of extreme pain, immobility, or risk of pathological fractures, use the standard no-information code (-) and document rationale on the resident's medical record 2. Review of Resident 73's discharge MDS assessment, dated 10/6/19, indicated Resident 73 was discharged to Code 03, Acute Hospital on 10/6/19. During an interview and concurrent review on 10/23/19 at 12:17 p.m., Resident 73's Progress notes, dated 10/6/19, indicated Resident 73 was discharged to home. MDSC stated Resident 73 was discharged to home on 10/6/19. MDSC stated Resident 73's discharge MDS was coded inaccurately for discharge disposition and needed to be modified. Review of Centers of Medicare and Medicaid Services (CMS's) Resident Assessment Instrument (RAI) Version 3.0 Manual, dated 10/2019, indicated directions to .Code 01, community (private home/apt., board/care, assisted living, group home): if discharge location is a private home, apartment, board and care, assisted living facility, or group home

Based on observation, interviews and record review, for of one (Resident 15) of twenty-one sampled residents the facility failed to ensure Resident 15 reached his highest practicable psychosocial wellbeing when Resident 15 physician's order for psychiatry support was not followed up. This failure resulted in Resident 15 not receiving psychiatry support to achieve his highest practicable psychosocial wellbeing. to provide psychiatry support for the emotional and mental illness when; Resident 15 did not received psychiatry support for schizophrenia and major depression as ordered by his physician. (Schizophrenia-a long-term mental disorder involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and a sense of mental fragmentation) Findings: Review of Resident 15's Minimum Data Set (MDS - a resident assessment tool used to guide care), dated 8/9/19, indicated Resident 15 did not have the ability to clearly think, reason, or remember. The MDS also indicated Resident 15 had diagnoses that included two severe chronic mental disorders manifested by depression and disorganized thinking, misconceptions or beliefs that are contrary to reality. Review of Resident 15's History and Physical (H&P), dated 3/1/16, indicated Resident 15 did not have the mental capacity to understand the nature and consequences of his diagnosis and treatment options. Review of Resident 15's undated care plan indicated Resident 15 had behaviors that included self isolation, non-interaction with peers and staff, resistance to care, continuous refusal of showers, and money hoarding. Interventions included educating resident/family of the possible outcomes of not complying with treatment and care. Review of the physician progress notes, dated 5/29/19, 8/14/19 and 10/16/19 indicated the physician ordered psychiatry support for Resident 15. In an interview on 10/25/19 at 7:51 a.m., Certified Nursing Assistant (CNA3), stated Resident 15 isolated himself and ate a little. During an interview and concurrent record review on 10/24/19, at 11:22 a.m., Director of Nursing (DON) stated she was not aware of Resident 15's physician ordered referral for psychiatry support and the facility had not referred Resident 15 for psychiatry evaluation.

Based on interview and record review, for one of five sampled residents (Resident 36) who had mood and behavioral issues, the facility failed to ensure Resident 36's medication regimen was free from unnecessary drugs when Resident 36 was not monitored for behaviors or adverse effects (includes nervousness and trouble sleeping) related to the use of Venlafaxine. For Resident 36, this failure resulted in unrecognized increase in behaviors and also had the potential to result in the unrecognized presence of adverse effects. Findings: Review of Resident 36's Face Sheet, printed 10/23/19, indicated Resident 36was admitted to the facility with diagnoses that included recurrent major depressive disorder (mental disorder characterized by persistent feeling of depressed mood, and loss of interest in life, symptoms include disturbed sleep and suicidal thoughts). Review of Resident 36's Minimum Data Set (MDS - an assessment tool used to direct resident care), dated 9/9/19, indicated Resident 36 had the ability to clearly think, reason, and remember. The MDS also indicated Resident 36 had been feeling down, depressed, or hopeless. The MDS further indicated Resident 36 was also feeling tired or having little energy for several days over a two-week period. Review of Resident 36's hospital stay on 7/26/19, indicated an order for Resident 36's Venlafaxine (medication to treat depression, generalized anxiety disorder, panic disorder, and social anxiety disorder) was to be reduced from 150 milligrams per day to 75 mg per day. Review of Resident 36's Medication Administration Record (MAR), dated September 2019, indicated Resident 36 had an order to receive 75 milligrams of Venlafaxine. The MAR did not indicate an order to monitor behaviors or the presence of adverse effects related to the use of Venlafaxine. During an interview and concurrent review on 10/24/19 at 12:33 p.m., there was no care plan that addressed monitoring Resident 36's symptoms of depression related to the decrease in Venlafaxine. During an interview on 10/25/19, at 10:36 a.m., Resident 36 stated that on 9/20/19 that was the day she had mental breakdown and her brain snapped. Resident 36 stated she woke up not knowing where she was. Resident 36 stated she heard voices that came from the two Certified Nursing Assistants (CNAs) that they were going to kill her. Resident 36 also stated Registered Nurse (RN) 3 with the plan to kill her by sticking a pill under her tongue. Resident 36 stated she got scared for her life because two nights prior to the incident, Resident 36 had nightmares about family members trying to kill her and the voices that she heard seemed to be part of the plot to kill her and so she had to call 911. Resident 36 stated she was taken to the hospital to get mental help. Resident 36 stated after being discharged from the hospital, the facility staff did not talk to her about the incident. Resident 36 also stated she did not get any room visits from SSD regarding the incident or her previous request to see a psychiatrist. Review of Resident 36's Progress Notes, dated 9/20/19, indicated .(Resident 36) called [Police Department] requesting to be transferred to ED (Emergency Department) because she feels unsafe because family and staff are attempting to poison her. (Resident 36) stated 'my sister poisoned the chicken' and 'you told her to poison my vitamins.' Review of Resident 36's Instructions from the acute hospital, dated 9/20/19, indicated Resident 36 was evaluated and treated for stress.

Based on interview and record review, for one of five sampled residents (Residents 36), the facility failed to ensure Resident 36 was free of a significant medication error when Resident 36 received Procrit (a man-made form of a protein that helps your body produce red blood cells) in contradiction to the physician's orders. This failure had the potential to jeopardize Resident 36's health and safety. Findings: Review of Resident 36's Face Sheet, printed 10/23/19, indicated Resident 36 was admitted to the facility with diagnoses that included chronic kidney disease (a longstanding disease in which the kidneys can no longer filter waste and excess fluid from the blood). Review of Resident 36's Medication Administration Record (MAR), dated September 2019, indicated an order dated 9/19/19 to hold Procrit if hemoglogin (Hgb) was greater than 10 grams per deciliter (g/dL). Review of Resident 36's laboratory results, dated 8/27/19, indicated Resident 36's hemoglobin level was (Hgb) 11.2 grams per deciliter (g/dL). Review of Resident 36's laboratory results, dated 9/29/19, indicated Resident 36's Hgb level was 11.9 g/dL. Review of Resident 36's MAR, dated September 2019, indicated Resident 36 received Procrit was on 9/23/19 and 9/30/19. In an interview on 10/23/19, at 2:40 p.m., Licensed Vocational Nurse (LVN) 1 stated that Resident 36 received Procrit every Monday. LVN 1 also stated Resident 36's Hgb labs indicated Resident 36's Hgb was 11.9 (g/dl) and therefore the Procrit should have been held (not given).

Based on interview and record review, the facility failed to ensure four (Resident 42, 271, 55 and 170) of 21 sampled residents received a written summary of their baseline care plan. This failure had the potential to result in Resident 42, 271, 55, and 170 to not be informed of their respective initial plans for delivery of care and services. Findings: 1. During an interview on 10/21/19 at 12:35 p.m., Resident 42 stated he had concerns about intolerable pain in both ankles. Resident 42 also stated he was not aware of a possible discharge disposition for him. Review Resident 42's Multidisciplinary Care Conference 1 (MCC), dated 9/3/19, indicated Resident 42 was admitted to the facility with diagnoses that included fractures to both ankles. The MCC included care concerns related to discharge needs related to homelessness. During an interview and concurrent record review on 10/24/19 at 3:30 p.m., Minimum Data Set Coordinator (MDSC) stated the facility conducted the Care conference with Resident 42 on 9/3/19, however the facility did not give a written summary of baseline care plan to Resident 42. 2. During an interview and concurrent record review on 10/23/19, at 12:19 p.m., MDSC stated the facility conducted a care conference meeting on 10/14/19 to discuss plan of care with Resident 271. During an interview and concurrent record review on 10/23/19 at 12:30 p.m., MDSC stated Resident 271 signed the blank Multidisciplinary Care Conference 1, dated 10/14/19. MDSC stated Resident 271 did not receive a copy of their baseline care plan summary. During an interview on 1/23/19, at 12:35 p.m., MDSC stated it was facility's practice for residents to sign a blank care conference form and then the Interdisciplinary team completed the care conference form. MDSC also stated facility did not give a baseline care plan summary to the residents and she was not aware of this regulation. 3. Review of Resident 55's Multidisciplinary Care Conference 1, dated 3/22/19, indicated the facility met to discuss care plan needs with Resident 55 on 3/22/19. Care Conference form indicated Resident 55 had diagnoses that included Stage 4 Chronic kidney disease (severe kidney disease) and had concerns regarding discharge disposition due to homelessness. During an interview on 10/23/19, at 12:25 p.m., MDSC stated the facility did not give a summary of baseline care plan to Resident 55. 4. During an interview on 10/25/19, at 9:19 a.m., the Director of Nursing (DON), stated facility did not discuss with or give Resident 170 a copy of their care plan instructions. DON also stated they were not aware a summary of baseline care plan was to be provided to Resident 170 and his representatives. Review of facility's policy and procedure titled Comprehensive Person-Centered Care Planning, dated 11/2018, indicated .The baseline care summary (Form NP-04-Form-B) will be developed within 48 hours of admission .A copy of the baseline care plan summary will be provided to the resident and/or resident representative

Based on interview and record review, for two of five sampled residents (Resident 16 and 36), the facility failed to ensure comprehensive care plans were developed when: 1. For Resident 16, there was no care plan developed to address use of Seroquel and Risperdal (medications to treat severe chronic mental disorders). For Resident 16, this failure had the potential to result in unmet mental and psychosocial needs. 2. For Resident 36, ADL (activities of daily living, such as transfers, personal hygiene, and bathing) care plan was not developed. This failure had the potential to result in unmet care needs. Findings: 1. Review of Resident 16's Medication Administration Record (MAR), dated 9/2019, indicated Resident 16 received Seroquel (medication to treat a severe chronic mental disorder) and Risperdal (medication to treat a severe chronic mental disorder manifested by symptoms of depression). During an interview and concurrent record review on 10/24/19, at 4:02 p.m., Minimum Data Set Coordinator (MDSC) stated there were no care plans initiated for Resident 16's use of Seroquel and Risperdal. MDSC stated the admitting nurse did initial assessment when Resident 16 returned from the hospital in August 2019 did not initiate care plans. 2. Review of Resident 36's Face Sheet, printed 10/23/19, indicated Resident 36 was admitted to the facility with diagnoses that included stroke and morbid obesity. Review of Resident 36's Minimum Data Set (MDS - an assessment tool used to direct resident care), dated 9/9/19, indicated Resident 36 had the ability to clearly think, reason, and remember. Resident 36's MDS also indicated Resident 36 was totally dependent on the physical assistance of one staff person for bathing. During an interview on 10/21/19, at 11:39 a.m., Resident 36 stated she had been getting bed baths after few falls during her staff assisted transfers to a shower chair. Resident 36 stated that staff told her they did not want to hurt their backs and they were afraid she might fall during transfers. During an interview on 10/25/19, at 9:48 a.m., Minimum Data Set Coordinator (MDSC) stated there was no care plan initiated to address Resident 36's need for ADL help.

Based on observation, interview and record review, facility failed to ensure their medication error rate was less than 5% when the facility's observed medication error rate was 12.12%. a. Licensed Vocational Nurse (LVN) 2 gave Resident 15 Senna Plus and Vitamin D instead of Senna and Vitamin D3; b. LVN 2 gave Resident 60 Calcium Carbonate 750 instead of Calcium Carbonate 1240, and; c. LVN 1 gave Resident 44 Vitamin D instead of Vitamin D3. This failure resulted in Resident 15, 60, and 44 receiving medications which were not prescribed by their physician. Findings: a. Review of Resident 15's Physician orders, dated 7/24/19, indicated Resident 15 was to receive one tablet of Senna 8.6 milligrams (mg) by mouth two times a day for constipation. A Physician's order, dated 7/24/19, indicated Resident 15 was also to receive one tablet of Vitamin D3 one time a day as a supplement. During an observation on 10/22/19, at 8:50 a.m., LVN 2 gave Resident 15 Senna plus (a stool softener containing Sennoside 8.6 mg and 50 mg of Docusate Sodium) and Vitamin D (containing Vitamin D3 and 55 mg of Calcium). During an interview and concurrent review on 10/22/19, at 12:45 p.m., LVN 2 reviewed Resident 15's physician's orders and stated she did not know Senna Plus also had Docusate. LVN 2 stated the facility's central supply closet had only Senna Plus. LVN 2 also stated she was giving Vitamin D when the order was to give Vitamin D3. b. Review of Resident 60's Physician orders, dated 10/8/18, indicated Resident 60 was to receive one tablet of 1250 mg of Calcium carbonate with 500 mg Calcium by mouth three times a day. During an observation on 10/22/19 at 9:05 a.m., LVN 2 gave Resident 60 one 750 mg tablet of Calcium Carbonate. During a concurrent interview and record review on 10/22/19 at 12:52 p.m., LVN 2 was unable to state if Resident 60 received the right dose of Calcium carbonate when she compared the administration record and manufacturer label for antacid calcium carbonate. LVN 2 stated she had given the same medication to Resident 60 for last six months. c. Review of Resident 44's Physician order, dated 4/4/19, indicated Resident 44 was to receive one table of Vitamin D3 one time a day. During an observation on 10/23/19, at 9:44 a.m., LVN 1 gave Resident 44 one tablet of Vitamin D. During an interview on 10/23/19 at 10:08 a.m., LVN 1 stated she was giving Vitamin D instead of Vitamin D3 to Resident 44 and was not aware that Vitamin D also contained Calcium. Review of facility's policy and procedure titled Medication Administration - General Guidelines, dated 10/2017, indicated .Medications are administered as prescribed in accordance with good nursing principles and practices .Prior to administration, the medication and dosage schedule on the resident's medication administration record (MAR) is compared with the medication label .Medications are administered in accordance with written orders of the attending physician

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the safe storage of medications and wound treatment supplies when there were multiple expired or outdated medications, medical supplies, rusted medical supplies stored with in use medications and medical supplies in the medication carts and medication rooms. This failure had the potential for contamination, and administration of expired and outdated medications. Findings: In an observation and concurrent interview with Registered Nurse (RN) 1 on 10/22/19 at 7:40 a.m., there were the following items in Medication room [ROOM NUMBER]: a. one Intravenous (IV) start kit that expired on 1/2019; b. one blood glucose monitor that expired on 12/31/17, and; c. one opened jar of petroleum jelly 100 milligrams (mg) with manufacturer date 7/2018 that was not labeled for a specific resident. RN 1 stated expired IV start kit should not be kept in medication room. RN 1 stated the blood glucose monitor belonged to Resident 272 who was discharged from the facility back in 2016. RN 1 stated facility should have given the blood glucometer to Resident 272 upon discharge. During an observation and concurrent interview with Licensed Vocational Nurse (LVN) 1 on 10/22/19, at 12:55 p.m., there were the following items in the Treatment Cart: a. Resident 64's Clobetasol propionate ointment 0.05% 30 milligrams (mg); b. Resident 273's Polysporin 14.2 grams (g); c. Resident 274's Lidocaine ointment 5% 35.44g; d. Resident 39's Debrox 6.5 drops expired on 2/22/19; e. Unlabeled and undated Econazle nitrate 1% 30g; g. unlabeled and undated Activon tube 25g; h. unlabeled and undated DermaSyn/ Silver 42g; i. unlabeled and undated Vaseline 49g; j. unlabeled and undated Calamine topical suspension 177 milliliters (ml), and; f. One pair of rusted tweezers and one pair of rusted scissors. LVN 1 stated if residents were discharged , then the facility should send the medications with the residents. LVN 1 stated if medication orders were discontinued facility should discard the medications. LVN 1 stated Resident 64 and Resident 39 did not have an active orders for those medications anymore. LVN 1 stated Resident 273 and Resident 274 were not at the facility anymore. LVN 1 stated the rusted tweezers and scissors should not be in the cart. During an observation and concurrent interview with LVN 1 on 10/22/19 at 1:38 p.m., there were the following items in Medication room [ROOM NUMBER]: a. one dressing change tray kit with expiry date 9/30/19; b. one dressing change tray kit with expiry date 07/2018; c. five Sodium Chloride injection 0.9% with expiry date 9/30/19, and; d. one catheter stabilization device with expiry date 04/2018 e. One unlabeled rusted electric shaving kit was in medication drawer. f. one rusted spatula tool was underneath treatment supplies. LVN 1 stated expired medications and supplies should not be kept in the medication storage room. LVN 1 stated she did not know who the rusted electric shaving kit belonged to. LVN 1 stated the rusty spatula tool was used to scrape the paint from the walls. LVN 1 stated she did not know why it was kept in the medication storage room. Review of facility's policy and procedure titled Medication storage in the facility, dated 04/2008, indicated .Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier .Outdated, contaminated or deteriorated medications .are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from pharmacy if a current order exists

5. During an observation accompanied by Certified Nursing Assistant (CNA 2) on 10/21/19, at 12:04 p.m., following items were found at Resident 55's bedside table: a. Two peanut butter and jelly sandwiches that were dated 10/20/19, and one peanut butter and jelly sandwich dated 10/19/19; b. One 8 ounce (oz) cup of undated and unlabeled white colored drink that had a thick cheese like material floating in upper half of the cup and milky water at the bottom half of the cup, and; c. One banana with dark black patches all over it and flying insects all around it. During an interview on 10/21/19, at 12:04 p.m., CNA 2 stated the white liquid was milk. CNA 2 was unable to confirm when the facility served the above food items to Resident 55. During an interview at Resident 55's bedside on 10/21/19, at 12:11 p.m., Dietary Manager (DM) stated the milk was not good anymore and the peanut butter and jelly sandwiches should be discarded if they were not consumed within an hour of being served. DM stated she could not confirm when the facility served the milk and the banana to Resident 55. DM stated that bacteria start to grow once food was at room temperature. DM also stated the food items should not be left at Resident 55's bedside. Review of facility's policy and procedure titled Food Storage, dated 7/25/19, indicated .All items will be correctly labeled and dated .Dairy items should be kept under refrigeration until use, store at temperatures below 41 degrees Fahrenheit .Fresh fruits should be checked and sorted for ripeness Based on observation, interview and record review, the facility failed to ensure food was stored and prepared in a sanitary manner when: 1. [NAME] 1 used an iodine test strip to check the sanitizer concentration of a dishwasher that used a chlorine-based sanitizer; 2. Kitchen Manager (KM) and Dietary Aide (DA 1) did not know how to perform manual dishwashing; 3. Multiple food preparation areas had dried food particles on them; 4. [NAME] 1 touched dinner rolls being removed from the oven with a pair of pot holders that were coated with blackish greasy residue, and; 5. There were multiple undated, unlabeled, and over ripe food items that were stored at Resident 55's bedside. These failures had the potential to result in food borne illnesses. Findings: 1. Review of the Dish Machine Temperature Log for October 2019 indicated previous temperature readings for all meals (breakfast, lunch and dinner) in October were at 100 ppm. During an observation on 10/21/19 at 8:20 a.m., [NAME] 1 took one test strip from a tube and dipped it in the dishes that had just come out of the dishwasher, [NAME] 1 stated the test strip indicated 50 parts per million (ppm - measure of concentration of chemical) which, [NAME] 1 stated, was the expected reading. Cook 1 stated they had been using the same test strip since Friday, 10/18/19. Further observation of the test strip that [NAME] 1 used indicated Precision Iodine Test Paper. [NAME] 1 stated the dishwasher used chlorine sanitizer. During an interview with concurrent observation of the iodine test paper with Kitchen Manager (KM) on 10/21/19 at 8:40 a.m., KM stated the test strip that [NAME] 1 used was for iodine sanitizer, which could only go up to 50 ppm. KM stated she did not know how it was possible to have readings of 100 ppm if the test paper that was used could only give a reading of 50 ppm. The iodine test paper indicated a color graph that showed the highest concentration was 50 ppm. KM stated she had ordered for the company to send chlorine test strips and they had to wait for them to be delivered while kitchen staff would do manual dishwashing. During an interview and concurrent review of the Dish Machine Temperature Log with DA 2 on 10/22/19 at 2:12 p.m., DA 2 stated MT was her initials. DA 2 stated she was told when she came in this morning they had to replace the test strips because they were the wrong ones. DA 2 stated they had been using the iodine strips for a while. 2. During an observation and concurrent interview with KM and Dietary Aide (DA 1) on 10/21/19 at 9:30 a.m., KM stated they use two-compartment sink to do manual dishwashing. KM filled both sink compartments with hot water up to the fill line. DA 1 rinsed the dishes of food debris and submerged the dishes in the first compartment (left side of the sink). After a few minutes, KM pulled out the dishes from the first compartment and transferred them onto the next compartment (right side of sink). KM stated the dishes would be left to soak for few minutes with the sanitizer. KM also stated the first sink should be used to rinse the dishes after they were sanitized on the second compartment. KM hesitated, and stated she did not know the process of manual dishwashing. DA 1 stated when washing dishes manually, the first compartment was used to wash the dishes, the second compartment to rinse. DA 1 also changed her answer and stated wash the dishes in the first compartment, sanitize on the second, then use an extra bin to rinse the dishes then air dry them on the racks. Both KM and DA 1 were looking at a manual that was posted on the wall just above the two-compartment sink. Review of the manual posted on the wall titled Scout Pot & Pan Wash Procedure, indicated use of a three-compartment sink to manually wash dishes. The manual indicated to fill the wash sink (first compartment) with water and solution (detergent), fill the rinse sink (middle compartment) with hot water, and fill the sanitizer sink (third compartment) with sanitizer up to fill line. Pre-scrape the pots and pans, soak for at least 5-10 minutes depending on soil level, scrub all surfaces and allow the excess water to run back into wash sink. Submerge the pots and pans in hot water rinse and allow excess water to run back into rinse sink. Submerge in sanitizer sink for one minute, or as specified by product label, and turn upside down to air dry. Review of an undated facility's policy and procedure titled, Dishwashing, indicated .a chlorine log will be kept and maintained by the dishwashers to assure that the dish machine is working correctly. This log will be completed each meal, prior to any dishwashing. The chlorine should read 50-100 ppm on the dish surface in final rinse. The proper chlorine level is crucial in sanitizing the dishes 3. During an observation on 10/22/19, at 11:30 a.m., [NAME] 1 prepared pureed food at the food preparation area. The area had dried up food debris, and white crumbs all over. The handle on the oven also had dried whitish debris. 4. During an observation and concurrent interview with KM on 10/22/19, at 11:47 a.m., [NAME] 1 opened the oven wearing pot holders that were covered in blackish greasy residue. [NAME] 1 pulled a pan of cooked dinner rolls out of the oven and touched the rolls that were on both edges of the pan. KM also stated the pot holders needed to be thrown away.

Based on observation, interviews and record review, for three (Resident 24 and 16) of twenty-one sampled residents the facility failed to ensure the accuracy of medical records when: 1. Resident 24 received clonazepam (a medication to treat anxiety) for a diagnosis of Adult Failure to Thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol), and; 2. Resident 16 received Seroquel (medication to treat a severe chronic mental disorder) for a diagnosis of Hemiplegia (paralysis on one side of the body). This failure had the potential to result in inaccurate representation of Resident 24 and 16's health status. Findings: 1. Review of the admission Minimum Data Set (MDS - a resident assessment tool used to guide care), dated 9/30/19, indicated Resident 50 was admitted to the facility with diagnoses that included anxiety and an Adult Failure to Thrive. Review of Resident 50's Medication Review Report, dated 10/9/19, indicated Resident 24 had an order to receive 1 milligram (mg) of clonazepam two times per day for Adult failure to Thrive. Review of the Medication Administration Record (MAR), date October 2019, indicated Resident 50 received 1 mg of clonazepam two times per day for quadriplegia 10/1/19 - 10/8/19) and adult failure to thrive (109/19 - 10/23/19). In an interview on 10/25/19, at 9:04 a.m., Director of Nursing (DON) stated facility had not had time to reviewed Resident 50's medication because he was newly admitted to facility. 2. Review of Resident 16's Medication Administration Record, dated September 2019, indicated Resident 16 was admitted to the facility with diagnoses that included hemiplegia and multiple severe chronic mental disorders. Resident 16's MAR also indicated she received Seroquel for hemiplegia. During an interview and concurrent record review on 10/24/19, at 3:47 p.m., Licensed Vocational Nurse (LVN) 1 stated reviewed Resident 16's MAR and stated Resident 16 received Seroquel for hemiplegia, unspecified affecting the left non-dominant side.

Based on observation, interview, and record review, the facility failed to implement their infection control policy and procedure when: 1. Resident 271 was not educated on infection prevention and proper handling of his urinary catheter drainage bag and it was sitting on the floor, and; 2. Infection Preventionist Designee/Director of Staff Development (IP) did not maintain a surveillance plan to identify, track, monitor, and report infections for the months of May 2019, June 2019, July, 2019, August 2019, and September 2019. This failure had the potential for facility Resident 271, Resident 32, and Resident 27 to suffer from facility acquired infections; and lack of surveillance had the potential for facility to be not aware of type and locations of infections occurring in the facility and measures needed to prevent similar infections from occurring in the future. Findings: 1. Review of Resident 271's History and Physical, dated 10/14/19, indicated Resident 271 was admitted to the facility with history of recurrent urinary tract infections. During an observation on 10/21/19, at 11:17 a.m., Resident 271's urinary catheter urinary drainage bag was sitting on the floor by the bedside, while Resident 271 was laying in the bed. Resident 271 stated, that when he could not hang the urinary catheter drainage bag on the bed, he would just leave it on the floor. During an interview on 10/21/19, at 11:24 a.m., Certified Nursing Assistant (CNA 1) picked up the urinary bag from the floor and hung it on the bed. CNA 1 stated Resident 271's urinary catheter drainage bag should not be on the floor. During an interview on 10/21/19, at 11:50 a.m., IP stated there were germs on the floor and Resident 271 could get a bladder infection. DSD also stated Resident 271 was not educated on infection prevention and proper handling of urinary catheter drainage bag yet. Review of facility's policy and procedure titled, Catheter - Care of, dated 1/1/12, indicated .II. Nursing Staff .D. Licensed Nurses will educate the resident or responsible party on the risks and benefits of catheter use 2. Review of the facility's infection control surveillance log indicated the IP last completed the log in April 2019. In an interview on 10/24/19, at 2:45 p.m., the IP could not provide infection control surveillance log documents for the months of May 2019, June 2019, July, 2019, August 2019, and September 2019. The IP stated she might have tossed the documents away. Review of the facility's policy and procedure titled, Infection Control, dated 1/1/12 indicated, .The facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections .II. Objectives; prevent, detect, investigate, and control infections in the facility Review of the facility's policy and procedure, titled Antibiotic Stewardship, dated 7/25/19 indicated, .The IP will be responsible for surveillance and (multi-drug resistant organism) tracking