**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the foley catheter (a flexible tube that drains urine from the bladder into a collection bag outside of the body) was covered with a dignity bag (a bag that covers and holds a foley catheter drainage bag to keep it out of sight) for one of 18 residents (Resident 225). This deficient practice had the potential to result in Resident 225 having decreased feelings of self-worth and/or self-esteem. Findings: During a review of Resident 225's admission Record, the admission record indicated resident 225 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (progressive neurological disease characterized by a fixed inexpressive face, tremor at rest, slowing of voluntary movements), muscle wasting (deterioration of muscle tissue) and atrophy (deterioration of a part of the body) and polyneuropathy (damage to multiple nerves outside of the brain and central nervous system). During a review of Resident 225's Minimum Data Set (MDS- a federally mandated assessment tool), dated 10/15/2024, the MDS indicated Resident 225 had moderately impaired cognitive skills (ability to understand and make decisions) for daily decision making. Resident 225 required substantial/maximal assistance (helper does more than half the effort needed to complete the activity) with eating, oral and personal hygiene, and dependent (helper does all effort needed to complete activity) with toileting. During a review of Resident 225's Initial History & Physical (H&P), dated 10/12/2024, the H&P indicated Resident 225 has the capacity to understand and make decisions. During a review of Resident 225's Order Summary Report, dated 10/17/2024, the Order Summary Report indicated foley catheter 18 French (F- a measurement of the foley catheter's diameter) for benign prostatic hyperplasia (BPH - age-associated prostate gland enlargement that can cause urination difficulty). During on observation on 10/15/2024 at 10:12 AM at Resident 225's bedside, Resident 225's urinary catheter bag was observed uncovered without a dignity bag. During an interview on 10/17/2024 at 9:07 AM with Treatment Nurse 1 (TN1), TN1 stated facility policy is to have a dignity bag on every foley catheter bag. During an interview on 10/17/2024 at 10:11 AM with Director of Nursing (DON), the DON stated the dignity bags are to be used according to the facility policy and are important because they keep the dignity and privacy for Resident 225. The DON stated the dignity bags are a way to maintain Resident 225's self-esteem in a positive way and not having it could cause his self esteem to be low if he or other residents were to see the urinary catheter bag without a dignity bag to cover. During a review of the facility's Policy and Procedure (P&P) titled, Dignity, revised February 2021, the P&P indicated each resident will be cared for in a manner that promotes and enhances their sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem, residents are always treated with dignity and respect. The P&P also stated demeaning practices and standards of care that compromise dignity are prohibited and staff are expected to promote dignity and assist residents with keeping the urinary catheter bag covered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accommodate the needs of one (1) of three (3) sampled residents (Resident 63) by failing to provide a pad call light (a device for residents who have difficulty using a call light cord). This failure had the potential for Resident 63's needs to not be met, resulting in a lowered quality of care and quality of life. Findings: During a review of Resident 63's admission Record, the admission Record indicated Resident 63 was admitted to the facility on [DATE] with diagnoses that included left hand contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff), pain in right shoulder, weakness (lack of strength), and major depressive disorder (MDD - a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). During a review of Resident 63's Minimum Data Set (MDS- a federally mandated assessment tool), dated 9/2/2024, the MDS indicated Resident with clear speech, usually having the ability to express her ideas and wants when prompted or given time and moderately impaired cognitive skills (ability to understand and make decisions) with daily decision making. The MDS indicated Resident 63 had a functional limitation in range of motion (ROM- the distance and direction a joint or muscle can move) that interfered with daily functions to both left and right upper extremities (shoulder, elbow, wrist, hand). The MDS also indicated Resident 63 dependent (helper does all the effort needed to complete the activity) with toileting, bathing, upper and lower body dressing, personal hygiene and rolling left and right and substantial/maximal assistance (helper does more than half the effort needed to complete the activity by lifting, holding, or supporting the trunk or limbs) with eating (the ability to use the utensils to bring food/liquids to the mouth and swallow) and oral hygiene (the ability to use items to clean teeth). During a review of Resident 63's Initial History & Physical (H&P), dated 4/21/2024, the H&P indicated Resident 63 has deformity (condition when a part of the body is not developed in the normal way or with the normal shape) to the extremities. During a concurrent observation in Resident 63's room and interview on 10/15/2024 at 8:45 AM with Resident 63, Resident 63 was observed with a call cord (a string that allows residents in healthcare settings to remotely call for help from a nurse or other medical staff) attached to a silver clip, clipped to the bedsheet on the left side of Resident 63's head. Resident 63 stated she was not aware of a cord she could use to call for assistance and stated she normally will wait for staff to come into her room to ask for assistance. During a concurrent observation in Resident 63's room and interview on 10/15/2024 at 8:55 AM with Resident 63, Resident 63 was informed of the cord on the left side of her head and attempted to reach and pull the call cord but was unable to see and reach it. Resident 63 stated she cannot see the clip and is unable to reach it. Resident 63 stated, I'd love to be able to have a button to push for when I need help just to make sure I get to the bathroom and back safely. During an interview on 10/15/204 9:08 AM with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 63 has restricted movement in her arms and Resident 63 does not use the call cord for assistance but will verbally call for assistance. CNA 1 stated Resident 63 should have a call button for the contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) of her hands, not her current call cord. During an interview on 10/17/2024 at 3:52 PM with CNA 2, CNA 2 stated Resident 63 has limited mobility in both her hands, and when Resident 63 needs assistance from staff she will yell or let staff know during rounding. CNA 2 also stated he has not seen Resident 63 use her call cord due to the limitation of her hand movement and the pulling, I believe there is not enough energy in her hands to pull it. During an interview on 10/18/2024 at 9:16 AM with Registered Nurse 3 (RN3), RN 3 stated Resident 63 has limitation with her upper extremities due to her left and right-hand contractures in her fingers. RN 3 stated Resident 63 cannot use the call cord [due to her hand contractures] so staff round every two hours to check if any assistance was needed. RN 3 stated if resident needs assistance between the rounds or has an emergency, she will yell for assistance. During a concurrent observation in Resident 63's room and interview on 10/18/2024 at 9:22 AM with RN 3, Resident 63 was observed trying to pull the call cord to see if accessible with Resident 63's contractures. Resident 63 was observed unable to grasp the call cord in her hand. Resident 63 stated I guess I can't get to it. RN 3 stated Resident 63 was unable to use her call cord. RN 3 stated if Resident 63 needed help at this time It would be impossible to call for help using her string [call cord]. RN 3 stated Resident 63 has not been evaluated for a different type of call light device like the pad call light (a device for residents who have difficulty using a call light cord) and could benefit from the padded call light. RN 3 also stated it was important for Resident 63 to have a call light that accommodates her limitations to ensure her needs were met including during emergencies. RN 3 stated if Resident 63 does not have an accessible call light, she may fall and/or be neglected. During a review of the facility's Policy and Procedure (P&P) titled, Accommodation of Needs, revised March 2021, the P&P indicated the facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity, and well-being. The P&P also indicated the resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis. During a review of the undated P&P titled,Call Lights, indicated the purpose is to assure that residents receive prompt service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the care plan (a document that outlines the facility's plan to provide personalized care to a resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs) interventions for one (1) of 18 residents (Resident 3), were applicable and resident-centered. This failure had the potential for Resident 3 to receive inappropriate and/or inadequate services which could harm the resident. Findings: During a review of Resident 3's admission Record, the admission record indicated Resident 3 was readmitted to the facility on [DATE] with diagnoses that included chronic kidney disease (CKD - longstanding disease of the kidneys leading to renal failure), retention of urine (inability to completely empty the bladder), dementia (a condition characterized by progressive or persistent loss of intellectual functioning) and gross hematuria (a condition where blood is visibly present in the urine). During a review of Resident 3's Minimum Data Set (MDS- a federally mandated assessment tool), dated 7/19/2024, the MDS indicated Resident 3 had severely impaired cognitive skills (ability to understand and make decisions) for daily decision making. The MDS also indicated Resident 3 was dependent (helper does all effort needed to complete activity) with toileting, bathing, and lower body dressing and substantial/maximal assistance (helper does more than half the effort needed to complete the activity) with oral and personal hygiene. During a concurrent interview and review on 10/17/2024 at 8:38 AM with Registered Nurse 1 (RN1), Resident 3's Indwelling Foley Catheter, care plan, dated 9/13/2024 was reviewed. The care plan indicated to provide adequate fluid via percutaneous endoscopic gastrostomy tube (PEG- a feeding tube that is surgically inserted through the abdominal wall and into the stomach to allow access for food, fluids, and medications) as ordered. RN 1 stated this intervention was not appropriate because Resident 3 does not have a PEG tube and eats foods and liquids by mouth only. RN 1 stated this intervention should have not been included in the care plan. During a concurrent interview and review on 10/17/2024 at 9:43 AM with RN 1, Resident 3's Hematuria on Foley Catheter, care plan, dated 9/1/2024 and Order Summary Report, dated 10/17/2024, were reviewed. The care plan indicated cranberry as ordered for urinary tract infection (UTI) prophylaxis. Registered Nurse 1 (RN 1) stated the summary report failed to indicate any order for cranberry. RN 1 stated Resident 3 has never had an order for cranberry and the intervention was not implemented. RN 1 stated a resident's care plan needs to be applicable to the resident's current needs. RN 1 stated it was important to make sure the care plan was applicable to the resident to ensure the interventions will be effective or beneficial to the resident. A review of the facility's Policy and Procedure titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, the P&P indicated: 1. A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 2. Care plan interventions are chosen only after data gathering. proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the licensed nursing staff failed to meet professional standards of quality for assessing one (1) of five sampled residents (Resident 72) by failing to ensure Resident 72 was assessed and evaluated by Medical Doctor (MD) before adding a new diagnosis of schizophrenia (a mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others ) according to accepted standards of clinical practice. This deficient practice had the potential to result in provision of unnecessary care for Resident 72. Findings: During a review of Resident 72's admission Record, the admission record indicated Resident 72 was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), major depressive disorder (MDD- a mood disorder that causes a persistent feeling of sadness and loss of interest), and Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills and eventually the ability to carry out the simplest tasks). During a review of Resident 72's History and Physical (H&P), dated 10/21/2023, the H&P indicated Resident 72 did not have the capacity to understand and make decisions. During a review of Resident 72's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 10/24/2023, the MDS indicated Resident 72 was assessed having moderately impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. Resident 72 required partial/moderate assistance (helper does less than half the effort) with oral hygiene, toileting hygiene, shower/bathe self, and toilet transfer. Resident 72 required supervision or touching assistance with eating. Resident 72 did not have a diagnosis of schizophrenia. During a review of Resident 72's Order Summary Report, dated 2/29/2024, the Order Summary Report indicated a physician order, with a start date of 10/23/2023 for Seroquel Oral Tablet give 25 milligrams (mg- unit of measurement) by mouth (po) two times a day (bid) for dementia with behavioral disturbances manifested by (m/b) being aggressive towards other people which impedes own self health and performing activities of daily living (ADLs). During a review of Resident 72's Physician Order, dated 3/7/2024, the Physician's Order indicated an order to continue Seroquel oral tab (Quetiapine Fumarate) give 25 mg by mouth every (q) twelve hours for schizophrenia m/b being aggressive towards other people which impedes own self health and performing ADLs. During a review of Resident 72's Psychiatric Follow Up Note, signed by the Certified Nurse Practitioner 1 (CNP 1), dated, 3/7/2024, the Psychiatric Follow Up Note indicated that Resident 72's case was reviewed and discussed with Interdisciplinary Team (IDT- a group of healthcare professionals who work together to help residents receive the care they need). Resident 72 was presently stable without any new symptoms and no need for any medication adjustment at this time. Resident 72's Mental Status Examination on the Psychiatric Follow Up Note did not indicate any paranoid interactions, delusions (an unshakable belief in something untrue), or hallucinations (an experience in which you see, hear, feel, or smell something that does not exist). The Psychiatric Follow Up Note assessment indicated Resident 72's psychiatric condition was generally unchanged and Resident 72's weaknesses were impaired insight and judgment, inability to function in less structured setting, and significantly impaired coping skills. The Psychiatric Follow Up Note indicated Resident 72's diagnosis was Major Depressive Disorder (MDD, mental condition that can cause a persistent low mood and loss of interest in activities that were once enjoyable. During an observation of Resident 72 on 10/15/2024, at 9:08 AM, Resident 72 was sitting in bed eating breakfast. Resident 72 was quiet and folded tissues while chewing her food. During a concurrent interview and record review with Registered Nurse 2 (RN 2) on 10/17/2024, at 12 PM, Resident 72's admission Record and H&P were reviewed. RN 2 stated the admission Record and H&P did not indicate Resident had a diagnosis of schizophrenia. RN 2 stated CNP 1 added the schizophrenia diagnosis on 3/7/2024. RN 2 stated she did not know why CNP 1 diagnosed Resident 72 with schizophrenia. During an interview with CNP 1 on 10/17/2024, at 3:18 PM, the CNP 1 stated Resident 72 was diagnosed with Alzheimer's Disease on admission. The CNP 1 stated he diagnosed Resident 72 with schizophrenia on 3/7/2024 because Resident 72 had delusions and disorganized thoughts based on his evaluation and reports from the facility staff. The CNP 1 stated the delusions could be from Alzheimer's Disease but Resident 72 was misdiagnosed. The CNP 1 stated he did not document Resident 72's delusions on the Psychiatric Follow Up Note but he will write a late entry psychiatry note on 10/17/2024. During an observation of Resident 72 on 10/17/2024, Resident 72 was observed sitting on her wheelchair in the Activity Room. Resident 72 did not have any outbursts or demonstrated aggressive behavior towards other residents in the Activity Room. During an interview with the Director of Nursing (DON), on 10/18/2024, at 4:55 PM, the DON stated there was no documentation that CNP 1 spoke to Resident 72's family to confirm her mental history or schizophrenia diagnosis. The DON stated schizophrenia develops at a younger age. The DON stated there was no indication from Resident 72's admission records and H&P that Resident 72 was diagnosed with schizophrenia. The DON stated Resident 72's family never mentioned to facility staff that Resident 72 had schizophrenia. The DON stated CNP 1 should have assessed Resident 72 according to standard practice. During a review of the American Psychiatric Association's website, reviewed on 3/2024, titled, What is Schizophrenia, the website indicated the following: Schizophrenia is a chronic brain disorder that affects less than one percent of the U.S. population. When schizophrenia is active, symptoms can include delusions (when a person has strong beliefs that are not true and may seem irrational to others), hallucinations (when a person sees, hears, smells, tastes or feels things that are not actually there), disorganized speech, trouble with thinking and lack of motivation. When the disease is active, it can be characterized by episodes in which the person is unable to distinguish between real and unreal experiences. As with any illness, duration and frequency of symptoms can vary; however, in persons with schizophrenia, the incidence of severe psychotic symptoms often decreases as the person becomes older. Symptoms of schizophrenia usually first appear in early adulthood and must persist for at least six months for a diagnosis to be made. Men often experience initial symptoms in their late teens or early 20s while women tend to show first signs of the illness in their 20s and early 30s. More subtle signs may be present earlier, including troubled relationships, poor school performance and reduced motivation. Before a diagnosis can be made, however, a psychiatrist should conduct a thorough medical examination to rule out substance misuse or other neurological or medical illnesses whose symptoms may mimic schizophrenia. https://www.psychiatry.org/patients-families/schizophrenia/what-is-schizophrenia

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one (1) of 18 sampled residents (Resident 2) with limitations in mobility was provided assistance while eating as indicated in the care plan and facility policy. This deficient practice had the potential for decline and not to maximize Resident 2's functional ability to perform activities of daily living (ADL), which can affect the resident's physical and mental wellbeing. This failure also had the potential not to meet Resident 2's nutritional needs which could lead to malnutrition (a condition that occurs when a person's body doesn't get the right amount of nutrients it needs to function properly) and hospitalization. Findings: During a review of Resident 2's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included reduced mobility and Parkinson's disease (a progressive disease of the nervous system marked by rhythmic movement in one or more parts of the body, inability of the muscles to relax normally, and slow, non-precise movement affecting middle aged and elderly people). During a review of Resident 2's Care Plan initiated on 9/26/2024, the Care Plan indicated a problem with Resident 2's right hand contracture and an approach plan to assist Resident 2 in attending to activities of daily living (ADL, basic tasks that people need to do to live independently). During a review of Resident 2's History and Physical (H&P), dated 9/27/2024, the H&P indicated Resident 2 does not have the capacity to understand and make decisions. During a review of Resident 2's Occupational Therapy Daily notes with a service date of 10/3/2024, the Occupational Therapy Daily notes indicated Resident 2 preferred assistance when presented with plate guard (a dining aid that fits around the rim of a plate to help prevent food from falling off and to make it easier to eat with one hand) option to maximize independence in self-feeding. During a review of Resident 2's Minimum Data Set (MDS- a federally mandated assessment tool), dated 10/4/2024, the MDS indicated Resident 2 had moderately impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 2 was dependent (helper does all the effort) with toileting hygiene, shower, lower body dressing, and putting on/taking off footwear. The MDS further indicated Resident 2 required substantial assistance (helper does more than half the effort) with oral hygiene, upper body dressing, and personal hygiene and required partial/moderate assistance (Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with eating. The MDS also indicated Resident 2 had a functional limitation in range of motion (ROM- how far one can move or stretch a part of the body, such as a joint or a muscle) that interfered with daily functions that involved impairment on 1 side of Resident 2's upper extremity (shoulder, elbow, wrist, and hand). During a dining observation on 10/15/2024 at 12:26 PM, Resident 2 was observed with contracted (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) left hand and was only able to use his right hand while trying to get food from his plate onto the spoon. Resident 2 was also observed spilling some of the food from his plate to his clothes and onto the floor. There were no staff providing assistance to Resident 2. During another dining observation on 10/17/2024 at 12:20 PM, Resident 2 was observed eating at the dining room area using his right hand to spoon food from his plate. A plate guard recommended by occupational therapy (OT) was not observed being used by Resident 2. Resident 2 was observed with food particles on the front of the residents' clothes. There were no staff providing assistance to Resident 2 while eating. During an interview on 10/17/2024 at 4:09 PM, Registered Nurse 3 (RN 3) stated if Resident 2 refused the plate guard, the staff should have assisted the resident with eating to ensure Resident 2's nutritional needs were met. During an interview on 10/18/2024 at 9:15 AM, Resident 2 stated he prefers to be assisted by staff as opposed to using the plate guard when eating. Resident 2 stated it made him upset when food gets all over his clothes and floor when eating and stated, I could do better than that. Resident 2 further stated that he does need help with eating. During an interview with the Director of Nursing (DON) on 10/18/2024 at 9:22 AM, the DON stated Resident 2 does tend to spill food and stated staff should be assisting the resident since Resident 2 only had 1 hand to use and to accommodate his needs and adequate food intake provided. During a review of the facility's Policy and Procedure (P&P) titled, Activities of Daily Living, revised March 2018, indicated that residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. The policy also indicated that appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with dining. During a review of the facility's P&P titled, Accommodation of Needs, revised March 2021, indicated that the facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity, and well-being. The policy also indicated that the resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide the necessary treatment and services for one of one sampled residents (Resident 24) by failing to ensure Resident 24 received treatment for right heel (ankle) stage 3 (full-thickness loss of skin, dead and black tissue may be visible) pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) from 10/1/2024 to 10/7/2024 as indicated in Resident 24's wound treatment plan. This deficiency had the potential for Resident 24's right heel stage 3 pressure injury to worsen and had the potential to develop an infection. Findings: During a review of Resident 24's admission Record, the admission Record indicated Resident 24 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), unspecified protein-calorie malnutrition (inadequate intake of food that leads to changes in the body), and hyperlipidemia (a condition in which there are high levels of fat particles in the blood). During a review of Resident 24's History and Physical Examination (H&P), dated, 9/25/2024, the H&P indicated Resident 24 did not have the capacity to understand and make decisions. During a review of Resident 24's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 9/4/2024, the MDS indicated Resident 24 was assessed having severely impaired cognitive skills for daily decision making. Resident 24 required substantial/maximal assistance (helper does more than half the effort) with oral/personal hygiene, upper/lower body dressing, putting on/taking off footwear, and sit to lying. Resident 24 was dependent with toileting hygiene, shower/bathe self, and sit to stand. Resident 24 had one or more unhealed pressure ulcers/injuries. During a review of Resident 24's Order Summary Report, dated 10/18/2024, the Order Summary report indicated an order with a start date of 10/1/2024, for the resident's treatment on right heel stage 3 pressure injury (full-thickness loss of skin, dead and black tissue may be visible), cleanse with normal saline (NS-a saltwater solution), pat dry, apply collagen powder (a powder used to absorb wound drainage), cover with dry dressing (a wound dressing that absorbs but does not retain moisture), wrap with Kerlix roll (a bandage made of 100% woven gauze that's used to protect wound areas) every day shift for 30 days. During a concurrent interview and record review on 10/18/2024, at 9:30 AM, with Registered Nurse 2 (RN 2), Resident 24's Wound Care Physician (WCP) Progress Note, dated 10/1/2024 was reviewed. RN 2 stated WCP comes to the facility to assess and treat Resident 24's right heel pressure injury every Tuesday. RN 2 stated Resident 24's treatment plan from the WCP Progress Note, dated 10/1/2024, indicated to cleanse with wound cleanser, pat dry with gauze pad, apply collagen to the size of the wound bed, cover with calcium alginate (a highly absorbent wound dressing that is a combination of alginic acid and calcium ions, ideal for wounds with moderate to heavy drainage) and bordered gauze dressing, wrap with rolled gauze and secure with tape. RN 2 also stated, the WCP progress note indicated dressing change frequency: every 3 days and as needed (PRN) for loss of integrity/soiling. RN 2 stated the treatment plan did not match what was in the physician's order dated 10/1/2024. During a concurrent interview and record review on 10/18/2024 at 9:56 AM, with Treatment Nurse 1 (TN 1), Resident 24's WCP Preliminary Wound Report, dated 10/2/2024 was reviewed. TN 1 stated she followed the Preliminary Wound Report which indicated under post debridement (removal of damaged tissue or foreign objects from a wound)/procedure to irrigate/cleanse with NS, pat dry, apply collagen, cover/wrap with border gauze daily. TN 1 stated she did not read or follow the treatment plan on the WCP Progress Note after it was sent to the facility. TN 1 stated it was important to follow the treatment plan on the WCP Progress Note to prevent infection and prevent the wound from getting worse. TN 1 stated she did not follow the treatment plan from 10/1/2024 to 10/7/2024. During an interview with the Director of Nursing (DON), on 10/18/2024 at 4:47 PM, the DON stated TN 1 should have confirmed that the treatment plan on the WCP was correct before filing and implementing. The DON stated Resident 24's WCP treatment plan should have been followed to provide proper wound treatment and promote wound healing. During a review of the facility's policy and procedure (P&P), titled, Pressure Ulcers/Skin Breakdown- Clinical Protocol, revised on 4/2018, the P&P indicated, The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.) and application of topical agents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the head of bed (HOB) was elevated at 30 degrees angle for one (1) of 1 sampled Resident (Resident 28) while receiving gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) tube (GT) feeding in accordance with the facility's policy. This failure has the potential for Resident 28 to aspirate (feeding could enter the windpipe and lungs) which could lead to lung problem such as pneumonia (an infection/inflammation of the lungs). Findings: During a review of Resident 28's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing). During a review of Resident 28's Care Plan, initiated on 4/9/2024, the Care Plan indicated, to administer tube feeding as ordered and to always elevate the HOB during GT feeding. During a review of Resident 28's History and Physical (H&P), dated 8/28/2024, the H&P indicated Resident 28 does not have the capacity to understand and make decisions. During a review of Resident 28's Minimum Data Set (MDS- a federally mandated assessment tool), dated 10/7/2024, the MDS indicated Resident 28 had severe cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 28 was dependent (helper does all the effort) oral, personal and toileting hygiene, shower, upper and lower body dressing, and putting on/taking off footwear. The MDS further indicated Resident 28 had a feeding tube. During a concurrent observation in Resident 28's room and interview with LVN 1 on 10/18/2024 at 8:49 AM, Resident 28 was observed receiving gastrostomy tube (GT - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) feeding of Glucerna (tube feeding formula) at 55 cubic centimeters (cc - units of volume on liquids) per hour with the HOB less than 30 degrees elevation. LVN 1 stated Resident 28's HOB should be at least 30 to 45 degrees to prevent aspiration which can cause pneumonia if resident vomits and end up in the resident's lungs. During an interview on 10/18/2024 at 8:51 AM, the Director of Nursing (DON) stated Resident 28's HOB should be elevated to at least 30 degrees when receiving tube feeding to prevent aspiration due to possible food back up. During a review of Resident 28's Order Summary, recapitulated 10/18/2024, indicated an order on 8/28/2023 for enteral feeding (a method of delivering nutrition directly to the stomach) and to elevate HOB 30 to 45 degrees at all times during feeding. During a review of the facility's Policy and Procedure titled, Enteral Feedings - Safety Precautions, revised November 2018, the P&P indicated to ensure the safe administration of enteral nutrition and to prevent aspiration, the HOB must be elevated at least 30 degrees during tube feeding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide trauma-informed care (an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of traumas) for one (1) of three (3) sampled residents (Resident 35) who was diagnosed with post-traumatic stress disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) in accordance with the facility's policy. This deficient practice had the potential for Resident 35 to experience re-traumatization, (unintentionally causing harm through practices, policies, and/or activities that are insensitive to the needs of the residents) that could lead to severe psychosocial harm and negatively affecting Resident 23's quality of life. Findings: During a review of Resident 35's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included post traumatic PTSD and anxiety disorder (a mental health disorder characterized by feeling of worry, or fear that are strong enough to interfere with one's daily activities). During a review of Resident 35's History and Physical (H&P), dated 7/6/2024, the H&P indicated Resident 35 had the capacity to understand and make decisions. During a review of Resident 35's Minimum Data Set (MDS, a federally mandated assessment tool), dated 10/7/2024, the MDS indicated Resident 35 had an intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 35 required partial assistance (helper does less than half the effort) shower, upper body dressing, and putting on/taking off footwear. The MDS further indicated Resident 35 required supervision (helper provides verbal cues) with oral and personal hygiene, toileting, and lower body dressing and required setup assistance (helper sets up; resident completes activity) with eating. During a review of Resident 35's MDS, dated [DATE], the MDS indicated Resident 35 had an active diagnosis of PTSD. During an interview on 10/17/2024 at 12:44 PM, Resident 35 stated that his PTSD triggers is seeing a gun. Resident 35 also stated he was robbed before with a person whose face was covered and seeing violence involving guns on television (TV) triggers his PTSD. Resident 35 further stated he just lays down in bed, turns his head away from the TV, tries to relax, and avoid watching when he sees violence involving guns on TV. Resident 35 also stated he had mentioned his PTSD triggers to the staff (unable to recall who). During an interview on 10/17/2024 at 12:56 PM, Certified Nursing Assistant 4 (CNA 4) stated he was unaware that Resident 35 had a diagnosis of PTSD. CNA 4 also stated it was important to know Resident 35's trigger to help avoid reminding the resident of the past incident that caused the PTSD. During an interview on 10/17/2024 at 1:02 PM, Licensed Vocational Nurse 1 (LVN 1) was unaware of Resident 35's PTSD diagnosis. LVN 1 stated it was important to know Resident 35's diagnosis of PTSD to avoid triggers which could cause extreme anxiety (a feeling of fear, dread, and uneasiness that may occur as a reaction to stress) and to prevent Resident 35 from reliving the incident that happened in the past that caused the PTSD. During an interview on 10/17/2024 at 3:12 PM, the Social Services Director (SSD) stated and confirmed Resident 35 did not have a care plan for trauma informed care. The SSD also stated Resident 35 was assessed during initial admission but should have been reassessed for trauma informed care upon readmission so the facility would know what the resident's PTSD triggers were. The SSD further stated it was important to identify Resident 35's PTSD triggers to be able to know what type of approach the staff should provide to the resident to help prevent triggers. During a review of the facility's Policy and Procedure (P&P) titled, Trauma Informed Care and Culturally Competent Care, revised August 2022, the P&P indicated its purpose was to guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice. The policy also indicated that they are used to address the needs of the trauma survivors my minimizing triggers and/or re-traumatization. The policy further indicated to utilize initial screening to identify the need for further assessment and care and to recognize that trust is earned over time and that individuals may not disclose information until a relationship has been established.

Based on interview and record review, the facility failed to ensure Registry (a placement service that provides staff on a temporary or day-to day basis in a facility) Certified Nursing Assistant 1 (RCNA 1) had the competency (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) in skill sets necessary before providing care to residents in the facility. RCNA 1 worked in the facility on 10/17/2024. This deficient practice had the potential for residents to not receive appropriate nursing services and had the potential to place residents at risk for injury or harm. Findings: During an interview with the Director of Staff Development (DSD), on 10/18/2024, at 12:30 PM, DSD stated the facility uses a registry when there is not enough staff to work in the facility. The DSD stated RCNA 1 was from a registry and worked during the 7AM to 3PM shift on 10/17/2024. The DSD stated she did not check and did not ask for a copy of RCNA 1's competency skills check and RCNA 1's certificate verification (the process of confirming that a certified nursing assistance has a valid certification and is legally qualified to practice). The DSD stated the registry informed her only over the phone regarding RCNA 1's competency but did not know which competency skills and in-services RCNA 1 has completed. The DSD stated she did not have a copy of RCNA1's competency skills before RCNA 1 began working in the facility on 10/17/2024. The DSD stated it was important to know the CNA's competency skills, certifications, and in-service trainings that staff have completed to ensure they can take care for the resident's needs, to protect and for the safety of the residents. The DSD stated it was the DSD and the Director of Nursing's (DON) responsibility to make sure facility staff had the competency skills completed before providing resident care in the facility. During an interview with the DON on 10/18/2024, at 5:07 PM, the DON stated it was important for the facility to know which skill sets the staff was competent to ensure the staff is able to provide proper care for the residents and for the residents' safety. The DON stated the facility did not have any documentation or information of RCNA 1's competency skill sets before. During a review of the facility's policy and procedure (P&P), titled, Competency and Training- All Staff, dated 9/12/2019, the P&P indicated the Facility will develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles. The P&P indicated competency Based Education and Training is defined as measurable pattern of knowledge, skills, abilities, behaviors, communication abilities to perform specific tasks and assignments with success. The P&P further indicated that a continuing competency-based education program is conducted for all staff at the facility to promote and measure specific competencies and skill sets necessary to provided related services to meet Resident needs, safety of the resident while considering the Resident's choice, rights, physical, mental, and psychosocial well-being based on the facility assessment. The P&P's definition of staff included employees, consultants, contractors, volunteers, caregivers who provide care and services to residents on behalf of the facility, and students in the facility's nurse aide training programs of from affiliated academic institutions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident 68) was free from unnecessary use of psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility policy and procedure by failing to have a clinical justification for the use of Risperdal (medication used to treat schizophrenia [a serious mental illness that affects a person's ability to think, feel, and behave], bipolar disorder [sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs], and autism spectrum disorder [ASD - a complex developmental condition that affects how people interact, communicate, and behave]) without a clinical justification for use. This deficient practice had the potential to place Resident 68 at risk for significant adverse (harmful) consequences from the use of unnecessary psychotropic drug, which could result to impairment or decline in the residents' mental, physical condition, functional, and psychosocial status. Findings: During a review of Resident 68's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (a progressive state of decline in mental abilities). During a record review of Resident 68's Discharge Medication Order from General Acute Care 1 (GACH 1), dated 2/6/2024, the discharge order medication included a new prescription of Risperdal 0.5 milligrams (mg - metric unit of measurement, used for medication dosage and/or amount) twice a day as directed for 30 days. During a review of Resident 68's H & P dated 2/7/2024, the H&P indicated that Resident 68 did not have the capacity to understand and make decisions. During a review of Resident 68's Minimum Data Set (MDS- a federally mandated assessment tool), MDS dated [DATE], the MDS did not indicate Resident 68 had a diagnosis of Schizophrenia. During a review of Resident 68's MDS, dated [DATE], the MDS indicated Resident 68 had moderately impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 68 required supervision (helper provides verbal cues) with toileting, shower, lower body dressing, and putting on/taking off footwear. The MDS further indicated Resident 68 required setup assistance (helper sets up; resident completes activity) with eating, oral hygiene and personal hygiene and upper body dressing. Resident 68 had little interest or pleasure in doing things and feeling down, depressed, or hopeless for two (2) to six (6) days in the last 2 weeks. The MDS also indicated Resident 68 sometimes feel lonely or isolated from those around him. The MDS further indicated Resident 68 had other behavioral symptoms not directed towards others which occurred 1 to three (3) days over the last 2 weeks. During a review of Resident 68's Order Summary, recapitulated 10/18/2024, the order summary included an order for Risperdal 0.5 mg two times a day on 2/6/2024 for schizophrenia bipolar type manifested by fluctuation of mood from being pleasant, calm, and sweet to being cranky and having sudden outburst of anger towards people around him. During a concurrent interview and review on 10/18/2024 at 11:49 AM, the Director of Nursing (DON) stated that she had reviewed all of Resident 68's records but was unable to find any evidence to support the resident's diagnosis of schizophrenia. The DON stated Resident 68 was given Risperdal without a diagnosis of Schizophrenia. The DON stated Resident 68 received an unnecessary medication and Resident 68 could develop potential adverse reactions. During a concurrent interview and review on 10/18/2024 at 12:15 PM, Registered Nurse 3 (RN 3) stated Resident 68 was readmitted from GACH 1 with discharge order for a new prescription of Risperdal 0.5 mg twice a day for 30 days without any indication of diagnosis. RN 3 also stated the process was to call the primary physician (MD) as soon as the resident is admitted to the facility and inform MD of all the medications the resident was receiving. RN 3 confirmed that she transcribed Resident 68's GACH transfer order of Risperdal on 2/6/24 and indicated the antipsychotic medication was for Schizophrenia. During a concurrent interview and review on 10/18/2024 at 1:27 PM, the DON stated Resident 68's initial Psychiatric Evaluation dated, 2/8/2024 did not indicate the resident had Schizophrenia and did not include Risperdal under the current medication. The DON stated Risperdal was not listed under Resident 68's current medications during the subsequent psychiatric evaluations dated, 5/15/2024, 6/14/2024, 8/17/2024, and 9/13/2024. During a concurrent review of Resident 68's H & P, dated 2/7/2024 and interview on 10/18/2024 at 2:23 PM with the DON, the DON stated a diagnosis of Paranoid Schizophrenia from the primary physician. During an interview on 10/18/2024 at 4:11 PM, RN 3 stated Resident 68's Risperdal would be considered unnecessary since the resident did not have Schizophrenia diagnosis. During a review of the facility's Policy and Procedure titled, Antipsychotic Medications, revised July 2022, the Policy and Procedure indicated that residents will not receive medications that are not clinically indicated to treat a specific condition. The policy also indicated that residents who are transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow the resident personal food choices for one of eighteen (18) sampled residents (Resident 68) in accordance with the care plan and facility policy by failing to: 1. Follow Resident 68's food preference for Mexican food on 11/20/2023 and 5/10/2024. 2. Provide Resident 68 requested tacos on 1/25/2024, 1/30/2024 and 2/8/2024. 3. Provide Resident 68 requested beef soup on 1/26/2024. This deficient practice failed to accommodate Resident 68's food preference which had the potential to result in weight loss and affect the resident's psychological, physical, and emotional well-being. Findings: During a review of Resident 68's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), metabolic encephalopathy (ME, occurs when problems with your metabolism cause brain dysfunction), and dementia (a progressive state of decline in mental abilities). During a review of Resident 68's History and Physical (H&P), dated 2/7/2024, the H&P indicated Resident 68 does not have the capacity to understand and make decisions. During a review of Resident 68's Minimum Data Set (MDS, a federally mandated assessment tool), dated 10/7/2024, the MDS indicated Resident 68 had severe cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 68 required supervision (helper provides verbal cues) with toileting, shower, lower body dressing, and putting on/taking off footwear. The MDS further indicated Resident 68 required setup assistance (helper sets up; resident completes activity) with eating, oral hygiene and personal hygiene and upper body dressing. During a review of Resident 68's Order Summary Report, dated 2/28/2024, the Order Summary Report, indicated no added salt diet (NAS), mechanical soft texture, regular consistency, ice cream lunch and dinner, and High Protein Nourishment (HPN) 4 ounces (oz) for lunch and dinner. During a review of Resident 68's Nutritional Care Plan, dated 2/6/2024, the Nutritional Care Plan interventions indicated: Mechanical Soft, No added salt diet Monitor amount of food intake every meal Honor Resident's reasonable food preference. Offer substitute. Discuss with Resident personal goals for weight, weight history nutritional status and food preferences. During a record review of Resident 68's Food Preference Record, dated 11/20/2023, the Food Preference Record indicated Resident 68 special preferences were Mexican food, Jello, pudding, and sweets. During a record review of Resident 68's Nutritional Assessment Form, dated 11/24/2023, the Nutritional Assessment Form indicated, Resident 68 food preferences were Mexican food, and pudding. During a record review of Resident 68's Speech/Language Pathology Daily Note indicated: 1. On 1/25/2024, Resident 68 communicated he wanted, tacos. 2. On 1/26/2024, Resident 68 communicated he wanted, beef soup. 3. On 1/30/2024, Resident 68 continued to stated that he wants, tacos. 4. On 2/8/2024, Resident 68 communicated he wanted, tacos. During a record review of Resident 68's Dietary Progress Notes, dated 5/10/2024, the Dietary Progress Notes indicated, Resident 68 likes Mexican Food (enchilada), Jello and Pudding. During a record review of Resident 68's Food Preference Record dated 8/8/2024, the Food Preference Record indicated, Resident 68 special preferences were Mexican Food, enchiladas, and pudding. During a record review of Resident 68's Daily Meal Eating Log and Weekly Menu for the month of 9/2024, Eating Log indicated Resident 68 refused lunch and dinner meals on the following dates: 9/2/2024, 9/3/2024, 9/8/2024, 9/14/2024, 9/15/2024, 9/18/2024, 9/20/2024, 9/21/2024, 9/22/2024, 9/23/2024, 9/24/2024, 9/25/2024, 9/29/2024 and 9/30/2024. There were no Mexican food included in the following dates in the facility's September weekly menu. During a concurrent observation and interview with Resident 68 on 10/16/2024 at 11:13 AM, Resident 68 was observed with no upper and lower dentures. Resident 68 stated he does not look at the food because he does not have dentures. Resident 68 has no teeth to chew the food. Resident 68 stated he likes to eat beans, but he cannot chew it. Resident 68 stated he felt sad because he cannot eat solid food. During concurrent observation and interview with the Dietary Service Supervisor (DSS) on 10/17/2024 at 12:52 PM, Resident 68's food ticket indicated Mechanical Soft, No Added Salt. DSS was not aware of Resident 68's food preference and stated, Resident 68 did not and should have Mexican food listed as food preference on his meal ticket. During a concurrent interview with the Director of Nursing (DON) and review of Resident 68's dietary progress notes on 10/17/2024 at 3:33 PM, the DON stated, There was no documentation from the DSS that Resident (Resident 68)'s food preference was being offered. During a concurrent record review of Resident 68's Food Preference Record, dated 8/8/2024, and interview with the DSS on 10/17/2024 at 3:38 PM, DSS stated, Resident 68's food preference will not always be served because it was just what he likes but not what he wants. During an interview with the DSS on 10/17/2024 at 3:44 PM, DSS stated, Cinco de mayo is the only day we serve tacos to the residents. We serve residents with Mexican food, only during the days that we have it on the Menu. During a concurrent interview with DON and record review of Resident 68's nurses' progress notes on 10/17/2024 at 4PM, the DON stated, There were no documentation that nursing and dietary staff offered tacos to Resident (Resident 68) on the dates that he requested it. The DON stated, If Resident (Resident 68) will not receive his meal preference, he will continue to refuse his meals and there is a possibility that the resident will start losing weight. During a review of the facility's policy and procedure (P&P) titled, Accommodation of Needs revised on 03/2021, the P&P indicated the resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would been endangered. During a review of the facility's undated P&P titled, Food Preferences indicated Resident's food preferences will be adhered to within reason. Substitutes for all foods disliked will be given from the appropriate food group. P&P also indicated updating of food preferences will be done as the Resident's needs change and/or during the quarterly review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to offer the pneumococcal vaccine (a medical injection that protects against the bacteria Streptococcus pneumoniae) for one of five sampled residents (Resident 2) upon readmission on [DATE] as indicated in the facility's policy. This failure placed Resident 2 at a higher risk of acquiring preventable infections such as pneumonia (PNA- an infection in your lungs), bacteremia (infection of the blood), or meningitis (infection of the tissue covering the brain and spinal cord) and increased the risk of transmission to other residents in the facility. Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included ventricular tachycardia (a condition in which the lower chambers of the heart [ventricles] beat too fast), Parkinson's Disease (progressive neurological disease characterized by a fixed inexpressive face, tremor at rest, slowing of voluntary movements), and major depressive disorder (MDD - a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). During a review of Resident 2's Minimum Data Set (MDS- a federally mandated assessment tool) dated 10/4/2024, the MDS indicated Resident 2 with moderately impaired cognitive skills (ability to understand and make decisions) for daily decision making. The MDS also indicated Resident 2 was dependent (helper does all the effort needed to complete the activity) with toileting, bathing, and lower body dressing and substantial/maximal assistance (helper does more than half the effort needed to complete the activity) with oral and personal hygiene. During a review of Resident 2's Immunization Record, the Immunization Record indicated Resident 2 refused the pneumococcal vaccine on 4/14/2022. The record did not indicate any pneumococcal vaccination administration or declinations from Resident 2 upon facility admission on [DATE]. During an interview on 10/18/2024 at 12:42 PM with Director of Nursing (DON), the DON stated per facility protocol, staff are supposed to offer the pneumococcal vaccine during all admission and readmissions. The DON stated staff are supposed to check if vaccine was indicated and should offer to the resident, then document administration or declination and education provided in the resident's medical record. During a concurrent interview and record review of Resident 2's medical chart on 10/18/2024 at 12:57 PM with Infection Preventionist Nurse (IPN), IPN stated the chart indicated Resident 2 declined the pneumococcal vaccination when offered on 4/14/2022. The IPN stated there was no documentation to indicate any education and offering of the pneumococcal vaccine to Resident 2 during Resident 2's admission on [DATE]. IPN stated the facility did not offer Resident 2 the pneumococcal vaccine during current admission on [DATE]. IPN stated the facility should have offered Resident 2 the pneumococcal vaccine once admitted to the facility. IPN stated it was important to offer the vaccinations to the residents to prevent the resident from developing illnesses like PNA because PNA is very common in the elderly population. IPN stated the risks for residents, if not reoffered the pneumococcal vaccine is potentially getting a preventable illness. During an interview on 10/18/2024 at 4:47 PM with Resident 2, Resident 2 stated he cannot recall being offered the pneumococcal vaccine by the facility during current admission, and that he would be interested in getting the pneumococcal vaccine because he has had PNA twice in the past. During a review of the Centers for Disease Control and Prevention, Vaccine Information Statement: Pneumococcal Conjugate Vaccine: What You Need to Know, revised 5/12/2023, the statement indicated the pneumococcal conjugate vaccine can prevent pneumococcal disease, which refers to any illness cause by the pneumococcal bacteria including PNA, meningitis and bacteremia. The statement also indicated adults 65 years or older are at higher risk to get pneumococcal disease, which can result in long-term problems like brain damage or hearing loss or meningitis, bacteremia or PNA which can be fatal (cause death). During a review of the facility's Policy and Procedure (P&P) titled, Pneumococcal Vaccine, revised 10/2019, the P&P indicated all residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. The P&P also indicated prior to, upon admission, or within five (5) working days, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, offered the vaccine series within 30 days of admission to the facility. The P&P indicated if a resident refuses, appropriate entries will be documented in the resident's medical record and if administered, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's medical record.

Based on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with its policy and procedure by failing to: 1. Properly store frozen food items in the kitchen freezer. 2. Properly store and label dry pasta in sealed containers. 3. Ensure there were no expired foods in the kitchen. These deficient practices had the potential to result in food borne illness (any sickness that is caused by the consumption of foods or beverages that are contaminated with certain infectious or noninfectious agents) in a population of 67 residents consuming food by mouth. Findings: 1. During a concurrent observation in the facility kitchen with [NAME] 1 on 10/15/2024 at 8:02 AM, a box of sliced bacon and a box of frozen meat were observed in the freezer. Both boxes were observed opened, with the top box flaps folded and the contained meats were not in an airtight moisture resistant wrapper. During an interview on 10/16/2024 at 8:50 AM with Dietary Service Supervisor (DSS), DSS stated the kitchen staff do not remove frozen meats from the original box to store in a sealed bag for the freezer, instead the kitchen staff only need to close [fold] the flaps of the original box because sealed storage is not necessary for the frozen meats. During a review of the facility's Policy and Procedure (P&P) titled Procedure for Freezer Storage, dated 2023, indicated facility is to store frozen foods in an airtight moisture-resistant wrapper such as a plastic bag or freezer paper to prevent freezer burn. 2. During a concurrent observation in the kitchen's dry storage room and interview with [NAME] 1 on 10/15/2024 at 8:10 AM, a ripped clear bag of dry twisted pasta noodles and a bag of unlabeled and undated dry egg noodles were observed. [NAME] 1 stated the bag of twisted pasta was opened and not sealed because of the rip in the bag and should have been placed in a Ziploc bag to be sealed properly. [NAME] 1 also stated the bag of egg noodles should have been labeled and dated with an open and use by date. During a review of the facility's P&P titled, Storage of Food and Supplies, Procedures for Dry Storage, dated 2023, the P&P indicated: 1. Food and supplies will be stored properly and in a safe manner. 2. Dry bulk foods should be stored in seamless metal or plastic containers with tight covers, or in bins which are easily sanitized. 3. Dry food items which have been opened such as pudding, gelatin, biscuit mix, pancake mix, dry cereal, spices, coffee, noodles, etc., will be tightly closed, labeled, and dated. 4. Liquid foods such as syrup oils, vinegar, honey, corn syrup, Worcestershire sauce, and molasses which have been opened will be closed, labeled, and dated. 3. During a concurrent observation in the kitchen and interview with [NAME] 1 on 10/15/2024 at 8:18 AM, the following expired items were observed: a. Bottle of Worchester sauce labeled with an expiration date of 8/15/2024. b. Container of peanut butter labeled with an expiration date of 8/27/2024. c. Baking Soda labeled with an expiration date of 1/30/2024. d. Package of Seasoning (Red shade) labeled with unreadable expiration date. Cook 1 stated the food items that have already expired should have been discarded. [NAME] 1 stated the peanut butter was only good for 30 days after it has been opened so it should have been discarded. [NAME] 1 stated he was unable to identify the expiration date of the seasoning so it should have been discarded and replaced. During an interview on 10/16/2024 at 8:50 AM with Dietary Service Supervisor (DSS), DSS stated once any food items were opened, there should be a label with the date the item was opened and a use by date. DSS also stated the use by date indicates the date the item expires and needs to be discarded. During a review of the facility's P&P titled, Labeled and Dating Foods, dated 2023, the P&P indicated all food items in the storeroom, refrigerator, and freezer need to be labeled and dated. The P&P also indicated opened food items need to be used by the date that follows storage guidelines. During an interview on 10/17/2024 at 12:21 PM with DSS, DSS stated it is important to follow the facility protocol with the storage of frozen to prevent freezer burn, which would damage the food. DSS stated it is important to store opened dry foods in a tight closed manner to prevent contamination. DSS stated it is important to label all foods because if food is mislabeled, not labeled, or expired, the food can be given to the residents, and they can experience illnesses.

Based on observation, interview and record review, the facility failed to ensure two (2) of 2 garbage container (dumpster) lids remained closed and were not overflowing with trash in accordance with the facility's policy. This failure had the potential to result in the attraction and spread of vermin (animals that are believed to be harmful, or that carry diseases, e.g. rodent's parasitic worms or insects) that could potentially enter the facility and spread diseases to the residents. Findings: During a concurrent observation and interview on 10/16/2024 at 8:32 AM, with Maintenance Supervisor (MS) and Maintenance Assistant (MA), in the facility's parking lot dumpster area, two dumpsters were observed with trash overflowing out of the sides and top of both dumpsters, with the dumpster lids opened due to overflowing trash. MA stated, The trash is overflowing, and the dumpster lids are not closed. Facility may need bigger trashcans. MS stated per facility policy, the dumpster lids should not be open and are to stay closed to make sure rodents, flies and insects [pests] do not go to dumpsters and possibly the facility. MS stated if pests entered the facility, that would be a danger to the everyone, including residents and staff. During a review of the facility's Policy and Procedure (P&P) titled, Exterior Maintenance: Grounds, Sidewalks, Patios, and Parking Lots, dated 1/1/2018, the P&P indicated facility is to make sure garbage and trash containers are maintained in a clean and pest free condition. Trash must be packed down, boxes folded, and container lids must stay closed when not in use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement enhanced barrier precautions (EBP - an infection control practice that involves wearing gloves and gowns during high-contact patient care activities to reduce the spread of multidrug-resistant organisms [MDROs- microorganisms that are resistant to multiple classes of antibiotics and antifungals]) for 11 of 11 sampled residents on EBP (Residents 27, 3, 7, 21, 23, 42, 69, 225, 28, 1, and 24) as indicated in the facility policy, by failing to ensure: 1. Licensed Vocational Nurse 3 (LVN 3) wore indicated personal protective equipment (PPE- protective clothing or equipment designed to protect the body from injury or infection) of a gown while administering medications through Resident 27's gastrostomy tube (GT - a tube that is surgically inserted into the resident's stomach to allow access for food, fluids, and medications) on 10/18/2024. Facility also failed to implement signage posted and PPE cart at the resident's door per policy. 2. - 8. Facility implemented posted signage in the door or wall outside the rooms of Residents 3, 7, 21, 23, 42, 69 and 225, that indicated EBP, and specific PPE required. The facility also failed to ensure PPE is available outside Residents 3, 7, 21, 23, 42, 69 and 225 room per policy. 9. Certified Nurse Assistant 3 (CNA 3) wore a gown while providing diaper change for Resident 28 on 10/18/2024. Facility also failed to implement posted signage and have available PPE for Resident 28's room. 10. Ensure LVN 2 observed infection control measures for Resident 1 by not donning (wear) a gown before administering medications for Resident 1 who had a GT. 11. Ensure Treatment Nurse 1 (TN 1) observed infection control measures for Resident 24 by not donning a gown before providing wound care. TN 2 also failed to ensure the wound bandage scissor was disinfected with the appropriate disinfectant solution before returning it to the treatment cart after providing wound treatment to Resident 24. These deficient practices placed the residents at a higher risk for cross-contamination and increased spread of infection in the facility. Findings: 1. During a review of Resident 27's admission Record, the admission Record indicated Resident 27 was readmitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing), dementia (a condition characterized by progressive or persistent loss of intellectual functioning), and heart failure (a chronic condition in which the heart does not provide adequate blood flow to meet the body's needs). During a review of Resident 27's Minimum Data Set (MDS- a federally mandated assessment tool), dated 8/5/2024, the MDS indicated Resident 27 was severely impaired with cognitive (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 27 was partial/moderate assistance (helper does less than half the effort needed to complete the activity) with oral and personal hygiene, and substantial/maximal assistance (helper does more than half the effort needed to complete the activity) with toileting. The MDS also indicated Resident 27 had a feeding tube (nasogastric or abdominal) while a resident in the facility. During a review of Resident 27's Initial History and Physical (H&P), dated 4/30/2024, the H&P indicated Resident 27 does not have the capacity to understand and make decisions and had an abdominal GT in place. During a concurrent observation and interview on 10/18/2024 at 10:16 AM with LVN 3, at Resident 27's bedside, LVN 3 was observed checking the GT placement, flushing the GT with water, and administering medications into the GT without a gown. LVN 3 stated she only needs to perform hand hygiene and apply gloves while caring for Resident 27's GT and medication administration. LVN 3 also stated EBP is only utilized for residents with foley catheter (a medical device that drains urine from the bladder) or GT when the resident has a current infection. During an observation and interview on 10/18/2024 AT 11:10 AM with IPN outside of Resident 27's room was observed with no EBP signage and PPE [NAME] outside the doorway. IPN stated per policy, it should be an EBP sign and PPE cart outside of Resident 27's room. 2. During a review of Resident 3's admission Record, the admission record indicated Resident 3 was readmitted to the facility on [DATE] with diagnoses that included chronic kidney disease (CKD - longstanding disease of the kidneys leading to renal failure), dementia and urinary retention (inability to completely empty the bladder). During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 was severely impaired with cognitive skills for daily decision making. Resident 3 was dependent (helper does all effort needed to complete activity) for toileting, bathing, and lower body dressing. The MDS also indicated Resident 3 had an indwelling catheter (Foley catheter). 3. During a review of Resident 7's admission Record, the admission record indicated Resident 7 was readmitted to the facility on [DATE] with diagnoses that included dysphagia, heart failure and chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe). During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7 was severely impaired with cognitive skills for daily decision making. Resident 7 was dependent with oral and personal hygiene, toileting, and dressing. The MDS also indicated Resident 7 with an indwelling catheter and a feeding tube. During a review of Resident 7's H&P, dated 9/15/2024, the H&P indicated Resident 7 does not have the capacity to understand and make decisions and had an abdominal GT. 4. During a review of Resident 21's admission Record, the admission record indicated Resident 21 was readmitted to the facility on [DATE] with diagnoses that included gastro esophageal reflux disease (GERD - chronic digestive disease where the contents of the stomach refluxes and irritates the esophagus), adult failure to thrive (AFTT - a condition that describes a gradual decline in a person's physical and mental health) and dementia. During a review of Resident 21's MDS, dated [DATE], the MDS indicated Resident 21 was moderately impaired with cognitive skills for daily decision making. Resident 21 was dependent with toileting and bathing and partial/moderate assistance with oral and personal hygiene. The MDS also indicated Resident 21 had a feeding tube. During a review of Resident 21's H&P, dated 9/30/2024, the H&P indicated Resident 21 does not have the capacity to understand and make decisions and had an abdominal GT in place. 5. During a review of Resident 23's admission Record, the admission record indicated Resident 23 was readmitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), AFTT, and type 2 diabetes mellitus (DM2 - a chronic metabolic disease that occurs when the body doesn't produce enough insulin or cannot use it properly). During a review of Resident 23's MDS, dated [DATE], the MDS indicated Resident 23 was severely impaired with cognitive skills for daily decision making. Resident 23 was dependent with toileting and bathing. The MDS also indicated Resident 23 had a feeding tube. During a review of Resident 23's H&P, dated 8/6/2024, the H&P indicated Resident 23 does not have the capacity to understand and make decisions and had an abdominal GT. 6. During a review of Resident 42's admission Record, the admission record indicated Resident 42 was readmitted to the facility on [DATE] with diagnoses that included dysphagia, DM2, and dementia. During a review of Resident 42's MDS, dated [DATE], the MDS indicated Resident 42 was severely impaired with cognitive skills for daily decision making. Resident 42 was dependent with toileting, lower body dressing and bathing and substantial/maximal assistance with oral and personal hygiene. The MDS also indicated Resident 42 had a feeding tube. During a review of Resident 42's H&P, dated 6/6/2024, the H&P indicated Resident 42 does not have the capacity to understand and make decisions. 7. During a review of Resident 69's admission Record, the admission record indicated Resident 69 was readmitted to the facility on [DATE] with diagnoses that included urinary tract infection (UTI- an infection in any part of the urinary system), obstructive uropathy (occurs when urine cannot drain or flows backwards through a ureter [a tube that carries urine from the kidneys to the bladder]) and anemia (a condition in which the blood doesn't have enough healthy red blood cells and hemoglobin to carry oxygen all through the body). During a review of Resident 69's MDS, dated [DATE], the MDS indicated Resident 69 was severely impaired with cognitive skills for daily decision making. Resident 69 required substantial/maximal assistance with eating and oral hygiene and dependent with toileting, bathing, and lower body dressing. The MDS also indicated Resident 69 with an indwelling catheter. During a review of Resident 69's H&P, dated 9/25/2024, the H&P indicated Resident 69 had a fluctuating (changing) capacity to understand and make decisions. 8. During a review of Resident 225's admission Record, the admission record indicated resident 225 was admitted to the facility on [DATE] with diagnoses that included muscle wasting (deterioration of muscle tissue), chronic kidney disease (CKD - longstanding disease of the kidneys leading to renal failure) and atrophy (deterioration of a part of the body). During a review of Resident 225's MDS, dated [DATE], the MDS indicated Resident 225 was moderately impaired with cognitive skills for daily decision making. Resident 225 required substantial/maximal assistance with eating, oral and personal hygiene and dependent with toileting. The MDS also indicated Resident 225 had an indwelling catheter. During a review of Resident 225's H&P, dated 10/12/2024, the H&P indicated Resident 225 has the capacity to understand and make decisions. During an observation on 10/16/2024 at 8:30 AM, there were no facility rooms observed to have EBP signage on the door or walls. There were also no PPE carts outside the rooms. During an interview on 10/16/2024 at 8:59 AM with IPN, IPN stated there were no rooms with EBP in the facility. IPN stated EBP was not implemented because the EBP only needed to be implemented with residents who have wounds, GTs, and indwelling catheters in addition to an MDRO. During an interview on 10/18/2024 at 10:56 AM with IPN, IPN stated per the facility policy, EBP should have been implemented and followed throughout the facility for residents with wounds, indwelling catheters and/or feeding tubes regardless of their MDRO status or history to prevent the spread of infections within the facility to everyone [residents, staff, and visitors]. During a review of the facility's Policy and Procedure (P&P) titled, Enhanced Barrier Precautions, dated 8/2022, the P&P indicated: a. EBPs are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. b. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. c. Gloves and gown are applied prior to performing the high contact care activity. d. Examples of high contact resident care activities requiring the use of gown and gloves for EBPs include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, device care or use (urinary catheter, feeding tube, etc.) and wound care. e. EBPs are indicated for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. f. Signs are posted in the door or wall outside the resident's room indicating the type of precautions and PPE required. g. PPE is available outside of the resident rooms. 10. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included bladder-neck obstruction (a condition that occurs when the bladder neck doesn't open properly, which can slow or stop urine flow), encounter for attention to gastrostomy, and hyperlipidemia (a condition in which there are high levels of fat particles in the blood). During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1 was assessed having severely impaired cognitive skills for daily decision making. Resident 1 was dependent with oral/toileting hygiene, upper/lower body dressing, sit to lying, and toilet transfer. Resident 1 had a feeding tube. During a review of Resident 1's Physician Order, dated 8/22/2024, Resident 1 had an enteral (Gtube) feed order to check tube placement every shift. During an observation of Resident 1's medication administration on 10/17/2024, at 8:26 AM, LVN 2 disconnected Resident 1's Gtube feeding and administered Resident 1's medications thru the Gtube. LVN 2 did not wear a gown prior to Resident 1's medication administration. 11. During a review of Resident 24's admission Record, the admission Record indicated Resident 24 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), unspecified protein-calorie malnutrition (inadequate intake of food that leads to changes in the body), and hyperlipidemia (a condition in which there are high levels of fat particles in the blood). During a review of Resident 24's H&P, dated, 9/25/2024, the H&P indicated Resident 24 did not have the capacity to understand and make decisions. During a review of Resident 24's MDS, dated [DATE], the MDS indicated Resident 24 was assessed having severely impaired cognitive skills for daily decision making. Resident 24 required substantial/maximal assistance with oral/personal hygiene, upper/lower body dressing, putting on/taking off footwear, and sit to lying. Resident 24 was dependent with toileting hygiene, shower/bathe self, and sit to stand. Resident 24 had one or more unhealed pressure ulcers/injuries. During a review of Resident 24's Order Summary Report, dated 10/18/2024, the Order Summary report indicated a physician order, with a start date of 10/1/2024, for treatment on right heel stage 3 pressure injury (full-thickness loss of skin, dead and black tissue may be visible), cleanse with normal saline (NS-a saltwater solution), pat dry, apply collagen powder (a powder used to absorb wound drainage), cover with dry dressing, wrap with Kerlix roll every day shift for 30 days. During an observation of Resident 24's wound treatment on 10/18/2024, at 9AM, TN 1 cut Resident 24's old wound dressing with bandage scissors and provided wound care to Resident 24. TN 2 was observed not wearing a gown while providing wound treatment. TN 1 did not clean the bandage scissor with sanitizing wipes before placing it back in the treatment cart. During an interview with TN 1 on 10/18/2024, at 9:09 AM, TN 1 stated she only needed to wash her hands and wear gloves before providing wound treatment to Resident 24. TN 1 stated a gown was only worn for wound treatment if a resident was in isolation (process of separating sick residents with contagious disease from residents who are not sick). TN 1 stated she washed the bandage scissors with soap and water before placing it back in the treatment cart. TN 1 stated she did not follow the facility's policy to clean and disinfect the bandage scissor with a disinfectant wipe before placing it back in the treatment cart. During an interview with the Infection Preventionist Nurse (IPN), on 10/18/2024, at 11:54 AM, the IPN stated drainage from wounds can get on bandage scissors during wound dressing change. The IPN stated bandage scissors should be cleaned and disinfected with disinfectant wipe and not soap and water. The IPN stated disinfectant wipes have the proper chemicals to kill and remove microorganisms that cause infection. The IPN stated infection can get transferred from one resident to another if a bandage scissor was not cleaned and disinfected properly before placing it back in the treatment cart. During a review of the facility's P&P titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised on 9/2022, the P&P indicated the following: 1. Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. 2. Non-critical items are those that come in contact with intact skin but not mucous membranes. 3. Non-critical items require cleaning followed by either low- or intermediate-level disinfection following manufacturers' instructions. Disinfection is performed with an EPA-registered disinfectant labeled for use in healthcare settings. All applicable label instructions on EPA-registered disinfectant products are followed (e.g., use-dilution, shelf life, storage, material compatibility, safe use, and disposal). a. Low-level disinfection is defined as the destruction of all vegetative bacteria (except tubercle bacilli) and most viruses, some fungi, but not bacterial spores. Examples of low-level disinfectants include EPA- registered hospital disinfectants with an HBV and HIV label claim. Low-level disinfection is generally appropriate for most non-critical equipment. b. Intermediate-level disinfection is traditionally defined as destruction of all vegetative bacteria, including tubercle bacilli, lipid and some nonlipid viruses, and fungi, but not bacterial spores. EPA-registered hospital disinfectants with a tuberculocidal claim are intermediate-level disinfectants. Intermediate-level disinfection is considered for non-critical equipment that is visibly contaminated with blood. However, a low-level disinfectant with a label claim against HBV and HIV may also be used. 4. Intermediate and low-level disinfectants for non-critical items include: a. Ethyl or isopropyl alcohol; b. Sodium hypochlorite (5.25-6.15% diluted 1:500 or per manufacturer's instructions); c. Phenolic germicidal detergents; d. Iodophor germicidal detergents; and e. Quaternary ammonium germicidal detergents (low-level disinfection only). 9. During a review of Resident 28's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing). During a review of Resident 28's History and Physical (H&P), dated 8/28/2024, the H&P indicated Resident 28 does not have the capacity to understand and make decisions. During a review of Resident 28's Minimum Data Set (MDS- a federally mandated assessment tool), dated 10/7/2024, the MDS indicated Resident 28 had severe cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 28 was dependent (helper does all the effort) with oral, personal and toileting hygiene, shower, upper and lower body dressing, and putting on/taking off footwear. During an observation on 10/18/2024 at 8:49 AM, Resident 28 was receiving gastrostomy tube (GT - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) feeding of Glucerna (tube feeding formula) at 55 cubic centimeters (cc - units of volume on liquids) per hour. During a concurrent observation and interview with Certified Nursing Assistant 3 (CNA 3) on 10/18/2024 at 9:11 AM, there was no isolation cart for Personal Protective Equipment (PPE - Personal Protective Equipment (PPE - is a specialized clothing or equipment worn by an employee for protection against infectious materials, such as gowns, gloves, masks, and goggles) and no signage to indicate Enhanced Barrier Precaution (EBP - an infection control intervention designed to reduce transmission of resistant organism by using PPE's during high contact resident care activities) was needed outside Resident 28's room. CNA 3 stated she cleaned and changed Resident 28's diaper using gloves and did not wore any gowns. During an interview on 10/18/2024 at 9:14 AM, Licensed Vocational Nurse 1 (LVN 1) stated he only wears a mask and gloves when giving medications via GT to Resident 28. LVN 1 also stated he believed an isolation gown was not required when providing care to Resident 28. During an interview on 10/18/2024 at 10:16 AM, CNA 3 stated she should have worn an isolation gown when providing care to Resident 28 to protect the resident from getting infections from the staff and prevent the resident prevent the resident from getting sick. During an interview on 10/18/2024 at 10:22 AM, LVN 1 stated the staff should use EBP for residents that had open wounds, indwelling catheter (a flexible tube that passes through the urethra [a tube through which the urine leaves the body] and into the bladder to drain urine) and GT to prevent transmission of any infections to the resident. LVN 1 also stated EBP should be used to prevent facility acquired infections that could be transmitted from one resident to another. During an interview on 10/18/2024 at 10:39 AM, the Director of Nursing (DON) stated the staff should use PPE when providing care to residents with open wounds, GT, and indwelling catheters to prevent transmission of infections to other residents. The DON also stated the facility should have a small cart for PPEs and signage posted outside the rooms for all residents that required EBP's. During an interview on 10/18/2024 at 10:47 AM, the Infection Prevention Nurse (IPN) stated the facility only uses EBP for residents with indwelling catheters, GT, and those with wounds that had multidrug - resistant organism (MDRO, bacteria that resist treatment with more than one antibiotic) to prevent the spread of infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to promote dignity and respect for one of 23 sampled residents (Resident 24). The facility staff was observed standing above Resident 24's eye level while assisting the resident during mealtime. This deficient practice had the potential to affect Resident 24's self-esteem and self-worth and violates Resident 24's right to be treated with dignity. Findings: A review of Resident 24's admission Record indicated Resident 24 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and dementia (a brain disorder that results in memory loss, poor judgment, and confusion). A review of Resident 24's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 10/1/2023, indicated Resident 24 had moderately impaired cognition (thought process and ability to reason or make decisions) for daily decision making and required supervision or touching assistance (helper provides assistance as resident completes activity, assistance may be provided throughout the activity or intermittently) with eating and oral hygiene. The MDS also indicated, Resident 24 required partial/moderate assistance (helper does less than half the effort) with toileting hygiene, upper/lower body dressing and personal hygiene and substantial/maximal assistance (helper does more than half the effort) with shower/bathe self and putting on/taking off footwear. During a concurrent observation in Resident 24's room and interview with Restorative Nursing Assistant 1 (RNA 1) on 10/30/2023, at 8:23 AM, Resident 24 was observed eating in bed with the head-of-bed elevated (resident in a sitting position). RNA 1 stood on the left side of the bed and above Resident 24's eye level while feeding the resident breakfast. RNA 1 stated he should be sitting down and maintain eye level with Resident 24 while assisting with feeding. During an interview with Certified Nursing Assistant (CNA 1) on 11/2/2023, at 8:57 AM, CNA 1 stated staff need to maintain eye level and talk to the residents and tell them what food they are giving when providing assistance with feeding. CNA 1 stated staff need to sit down and be at an eye level with the residents to establish rapport and to show respect. A review of the facility's policy and procedure (P&P) titled, Dignity, revised on 02/2021, the P&P indicated, .residents are provided with a dignified dining experience. A review of the facility's P&P titled, Assistance with Meals, revised on 3/2022, the P&P indicated, Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity .not standing over residents while assisting them with meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the call light device (a device used by a resident to signal his or her need for assistance) was within reach for one of 23 sampled residents (Resident 69) who had a history of cerebrovascular accident (CVA, stroke- loss of blood flow to a part of the brain) and left sided weakness. This deficient practice had the potential to negatively impact the psychosocial well-being of Resident 23 and result in delayed provision of care and services. Findings: A review of Resident 69's admission Record indicated Resident 69 was admitted on [DATE] with diagnoses that included occlusion and stenosis of right carotid artery (condition that happens when the large artery on either side of the neck becomes blocked), dementia (a brain disorder that results in memory loss, poor judgment, and confusion), and essential hypertension (high blood pressure). A review of Resident 69's Care Plan titled, Falls Care Plan, dated 9/15/2023, indicated Resident 69 was at risk for falls due to the following reasons: poor safety awareness, impaired mobility, and impaired visual function. The Care Plan indicated Resident 69 had a fall risk assessment of 11 and staff interventions included were to keep environment free of hazards, clutter free, call and light within reach. A review of Resident 69's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 09/19/2023, indicated Resident 69 had moderately impaired cognition (thought process and ability to reason or make decisions) for daily decision making and required extensive assistance (resident involved in activity, staff provide weight-bearing support) with one-persons physical assistance with bed mobility, transfer, locomotion (movement or the ability to move from one place to another) on/off unit, dressing, eating, toilet use, and personal hygiene. The MDS indicated Resident 69 had an impairment on one side (did not indicate which side) of the upper extremity. A review of Resident 69's Initial History and Physical, dated 09/16/2023, indicated Resident 69 had a history of CVA with left-sided hemiplegia (paralysis of one side of the body). During a concurrent observation in Resident 69's room and interview with Resident 69 on 10/31/2023, at 12:43 PM, Resident 69 was sitting on his bed eating his lunch. Resident 69's call light string was clipped to the bed sheet above Resident 69's left shoulder. Resident 69 stated he needed a straw but unable to ask for assistance because he could not reach his call light. Resident 69 able to move his right arm towards the left side of his body but could not grab the string above his left shoulder. During a concurrent observation in Resident 69's room and interview with Certified Nursing Assistant 2 (CNA 2), on 10/31/2023, at 12:50 PM, CNA 2 stated Resident 69's call light was clipped on the left side of the bed. CNA 2 stated, it is important for Resident 69 to be able to reach his call light so he can call for help especially during an emergency. CNA 2 stated it is important to ask Resident 69 where he prefers his call light to be placed because he is unable to move his left arm. During an interview with CNA 4, on 11/02/2023 at 10:23 AM, CNA 4 stated, the call light needs to always be within the resident's reach to be able to call for assistance. During a review of the facility's policy and procedure (P&P) titled, Accommodation of Needs, revised on 03/2021, the policy statement indicated, .facility's environment and staff behaviors are directed toward assisting the Resident in maintaining and/or achieving safe independent functioning, dignity, and well-being. The P&P also indicated, The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis. During a review of the facility's policy and procedure titled, Answering the Call Light, revised on 09/2022, the P&P indicated, Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide quarterly statement of funds per policy and procedure for one of one sampled resident (Resident 3). This deficient practice had the potential to result in Resident 3 being worried about how much money was in his account and potential for misappropriation of funds. Findings: A review of Resident 3's admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Parkinson's disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), and contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of the right elbow and right hand. A review of Resident 3's Minimum Data Set (MDS - a standardized assessment and care planning tool), dated 10/5/2023, indicated Resident 3 had moderate cognitive (mental action or process of acquiring knowledge and understanding) impairment for daily decision making. The MDS indicated Resident 3 required substantial/maximal assistance (helper does more than half the effort) for showering, lower body dressing, sit to lying position and lying to sitting on the bed. The MDS also indicated Resident 3 required partial/moderate assistance (helper does less than half the effort) for oral hygiene, upper body dressing, and personal hygiene (practices conducive to maintaining health and preventing disease, especially through cleanliness). During an interview on 10/23/2023 at 2:25 PM, Resident 3 stated he had never received a statement since he has been in the facility. Resident 3 stated he was not aware how much money he had in his account. During an interview on 11/1/2023 at 8:49 AM with the Social Service Director (SSD), the SSD stated residents were able receive their statements anytime when they made a request. SSD stated once a resident requested their bank statement, the business office would give the resident a copy. The SSD stated residents who were alert and oriented would only receive a copy of their bank statement when they requested to know how much money was in their account. During an interview on 11/1/2023 at 9:03 AM with the Business Office Assistant (BOA), the BOA stated when residents asked how much money was in their account, then business office would provide the resident with a copy of their statement. The BOA stated residents were only to receive statements upon request. The BOA stated no quarterly statements were provided to the residents or their responsible party. During a following interview on 11/1/2023 at 9:43 AM with the BOA, the BOA stated it was important to keep Resident 3 updated about his statements since Resident 3 was worried about how much he has in his account. The BOA also stated Resident 3 was also concerned if he had enough money in his account. A concurrent review of the facility's policy with the BOA indicated residents are provided quarterly statements. A review of the facility's policy and procedure titled, Deposit of Residents' Personal Funds, revised 3/2021, indicated the resident is provided a confidential quarterly statement of funds on deposit with the facility, including activity since the previous statement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents' medical records were updated to show documentation that advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed and written information were provided to the residents and/or resident representatives for two (2) of nine (9) sampled residents (Resident 23 and 30). This deficient practice violated the residents' and/or the representatives' right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding health care. Findings: 1. A review of Resident 23's admission Record indicated Resident 23 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of dementia (progressive brain disorder that slowly destroys memory and thinking skills), schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves), anxiety disorder (persistent and excessive worry that interferes with daily activities), and chronic obstructive pulmonary disease (COPD- disease that causes obstructed airflow from the lungs). A review of Resident 23's Minimum Data Set (MDS - a standardized assessment and care planning tool), dated 9/21/2023, indicated Resident 23 had severe cognitive (mental action or process of acquiring knowledge and understanding) impairment for daily decision making. The MDS indicated Resident 23 required extensive assistance (resident involved in activity, staff provide weight-bearing support) for bed for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed), transfers (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position), locomotion on unit (how resident moves between location in his/her room) and off unit (how resident moves to and returns from areas such as activities, treatment, or dining), dressing, eating, and personal hygiene (practices conducive to maintaining health and preventing disease, especially through cleanliness). A record review on 10/30/2023 at 11:29 AM of Resident 23's medical chart, there was no Advanced Directive Acknowledgement Form (indicated if the resident chose to execute an Advance Directive or not execute an Advanced Directive signed by either the resident or resident representative and witness by the facility staff). 2. A review of Resident 30's admission Record indicated Resident 30 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of dementia (progressive brain disorder that slowly destroys memory and thinking skills), paranoid schizophrenia (characterized by predominately positive symptoms of schizophrenia including delusions and hallucinations), and bipolar disorder (mental disorder characterized by episodes of mania and depression). A review of Resident 30's MDS dated [DATE], indicated Resident 30 had severe cognitive impairment for daily decision making. The MDS indicated Resident 30 required total dependence (full staff performance) for transfers, locomotion on and off unit, eating, toilet use, and bathing. The MDS also indicated Resident 30 required extensive assistance for bed mobility, dressing, and personal hygiene. During a record review on 10/31/23 at 9:30 AM of Resident 30's chart, there was no Advanced Directive Acknowledgement Form. During an interview on 10/31/2023 at 2:45 PM with the Social Service Director (SSD), the SSD stated the advanced directive was not done for Resident 23 or Resident 30 since they do not have the capacity to understand. The SSD stated the responsible party was not notified, therefore they did not sign the advance directive. The SSD stated Residents 23 and 30 do not have an Advanced Directive Acknowledgement Form. The SSD stated only the resident can sign for the advanced directive if they are able to comprehend. The SSD stated the advanced directives are not done if the residents are not able to comprehend. During a concurrent record review of the facility's advanced directives policy and procedure and interview on 11/1/2023 at 10:14 AM with the Director of Nursing (DON), the DON stated the facility offers all residents an advanced directive. The DON stated if the resident was not capable of understanding, the facility would contact the resident's responsible party and offer the advance directive to the responsible party. The DON stated the social service worker should had offered the advanced directive to the resident or responsible party upon admission. The DON stated if the resident did not have the capacity and did not have a responsible party to sign the advanced directive, the Bioethics Team (which consisted of the Interdisciplinary Team, group of healthcare professionals from diverse fields who work in a coordinated manner toward a common goal for the resident) would make the decision for the patient and sign the Advance Directive Acknowledgement Form. The DON stated the advance directive should be offered to each resident in the facility. The DON stated it was the physician's order to have an advance directive be done for each resident. The DON stated the importance of having an advanced directive was to know the resident's wishes for their code status (the type of resuscitation procedures [if any] you would like the health care team to conduct if a person's heart stopped beating and/or the person stopped breathing) and treatment. The DON stated the facility's advanced directives policy and procedure indicated the resident or resident representative are given the option to accept or decline the advanced directives and the advanced directive refusal or acceptance will be placed in the resident's medical record. A review of the facility's policy and procedure titled, Advance Directives, revised September 2022, indicated if the resident or representative indicates that he or she has not established advanced directives, the facility staff will offer assistance in establishing advance directives. The resident or representative is given the option to accept or decline assistance, and care will not be contingent on either decision. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance. The information about whether or not the resident has executed an advance directive is displayed prominently in the medical record in a section of the record that is retrievable by any staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the State Long Term Care Ombudsman (public advocate) of the resident's transfer from the facility to the General Acute Care Hospital (GACH) for one (1) of 1 sampled resident (Resident 30). This deficient practice had the potential to result in the State Long Term Care Ombudsman not being aware of the resident's transfer and condition and inappropriate resident discharge or transfer. Findings: A review of Resident 30's admission Record indicated Resident 30 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of dementia (progressive brain disorder that slowly destroys memory and thinking skills), paranoid schizophrenia (characterized by predominately positive symptoms of schizophrenia including delusions and hallucinations), and bipolar disorder (mental disorder characterized by episodes of mania and depression). A review of Resident 30's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 9/13/2023, indicated Resident 30 had severe cognitive (mental action or process of acquiring knowledge and understanding) impairment for daily decision making. The MDS indicated Resident 30 required total dependence (full staff performance) for transfers (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position), locomotion on unit (how resident moves between location in his/her room) and off unit (how resident moves to and returns from areas such as activities, treatment, or dining), eating toilet use, and bathing. The MDS also indicated Resident 30 required extensive assistance (resident involved in activity, staff provide weight-bearing support) for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed), dressing and personal hygiene (practices conducive to maintaining health and preventing disease, especially through cleanliness). A review of Resident 30's Licensed Personnel Weekly Progress Notes, dated 6/30/2023, timed at 5:30 AM, indicated Resident 30 was noted to have congested breathing with an oxygen saturation (SpO2, measures how much oxygen is carried by the hemoglobin [Hgb- a protein in red blood cells that carries oxygen to the body's organs and tissues and transports carbon dioxide from your organs and tissues back to the lungs] in the blood or how well a person is breathing) of 88% in room air. 911 (a phone number used to contact the emergency services) was called and paramedics arrived, and Resident 30 was transferred to GACH. During a concurrent record review of Resident 30's records and interview with the Director of Nursing (DON) on 11/2/2023 at 3:34 PM, the DON stated when residents are transferred to the hospital, nurses need to notify the doctor, family, and fax the transfer/discharge form to the Ombudsman. The DON stated Resident 30's records did not indicate the Ombudsman was notified of Resident 30's transfer to GACH. The DON stated the Ombudsman should be notified of Resident 30's transfer to the hospital on the day of the resident's transfer. The DON stated the purpose of notifying the Ombudsman was to ensure Resident 30 had an appropriate transfer to GACH. A review of the facility's policy and procedure titled, Transfer or Discharge Notice, revised 3/2021, indicated a copy of the transfer or discharge notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop an individualized baseline care plan with 48 hours of admission to meet the immediate needs that included interventions for safety and preferences for one of 23 sampled residents (Resident 69) who had left-sided hemiplegia (paralysis of one side of the body). This deficient practice had the potential to negatively affect the well-being and the delivery of necessary care and services for Resident 69. Findings: A review of Resident 69's admission Record indicated Resident 69 was admitted to the facility on [DATE] with diagnoses that included occlusion and stenosis of the right carotid artery (condition that happens when the large artery on either side of the neck becomes blocked), dementia (a brain disorder that results in memory loss, poor judgment, and confusion), and essential hypertension (high blood pressure). A review of Resident 69's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 09/19/2023, indicated Resident 69 had moderately impaired cognition (thought process and ability to reason or make decisions) for daily decision making and required extensive assistance (resident involved in activity, staff provide weight-bearing support) with one-person physical assistance with bed mobility, transfer, locomotion (movement or the ability to move from one place to another) on/off unit, dressing, eating, toilet use, and personal hygiene. The MDS indicated Resident 69 had an impairment on one side of the upper extremity. A review of Resident 69's Initial History and Physical (H&P), dated 09/16/2023, indicated Resident 69 had a history of CVA (stroke- a loss of blood flow to part of the brain) with left-sided hemiplegia (paralysis of one side of the body). The H&P indicated Resident 69 had the capacity to understand and make decisions. During a concurrent observation and interview in Resident 69's room with Resident 69 on 10/30/2023, at 9:27 PM, Resident 69 was observed sitting in bed with the head of the bed elevated. Resident 69 stated using his right hand to feed himself due to left-sided weakness. During a concurrent interview and record review on 11/02/2023, at 10:58 AM, with Minimum Date Set Nurse (MDSN), Resident 69's Baseline Care Plan Summary, dated 09/15/2023 was reviewed. MDSN stated Resident 69 did not have a baseline care plan for left-sided weakness. MDSN stated a baseline care plan for Resident 69's left-sided weakness was important so staff could be guided on delivering care to Resident 69. MDSN stated the admitting nurse was responsible for initiating the baseline care plan. During a concurrent interview and record review on 11/02/2023, at 5:22 PM, with Registered Nurse (RN 1), Resident 69's Baseline Care Plan Summary, dated 9/15/2023 was reviewed. RN 1 confirmed that Resident 69's did not have a baseline care plan for left-sided weakness. RN 1 stated it is the responsibility of the admitting nurse to develop a baseline care plan after admission. RN 1 stated it was important for Resident 69 to have a baseline care plan for left-sided weakness so the staff were aware and could appropriately care for Resident 69. During a review of the facility's policy and procedure (P&P) titled, Care Plans-Baseline, revised on March 2022, the P&P indicated, The baseline plan of care to meet the resident's immediate health and safety needs is developed for each Resident within forty-eight (48) hours of admission. The policy also indicated, The baseline care plan included instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the Resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a comprehensive and resident-centered care plan for two of 23 sampled residents (Residents 45 and 69) as indicated on the facility policy and procedure. 1. Resident 45's Care Plan did not indicate complete interventions to prevent falls. 2. Resident 69 did not have a care plan for left-sided hemiplegia (paralysis of one side of the body. These deficient practices had the potential for Resident 45 and Resident 69 to not be appropriately cared for by facility staff in providing resident-centered care and services. Findings: 1. A review of Resident 45's admission Record indicated Resident 45 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included pneumonia (an infection that affects one or both lungs), unspecified dementia (a brain disorder that results in memory loss, poor judgment, and confusion), and schizophrenia (a mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others). A review of Resident 45's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 8/23/2023, indicated Resident 45 had severely impaired cognition (thought process and ability to reason or make decisions) for daily decision making. The MDS indicated Resident 45 had total dependence (full staff performance every time) with one-person physical assist for eating and toilet use and required extensive assistance (resident involved in activity, staff provide weight-bearing support) with one-person physical assist for bed mobility, transfer, locomotion (movement or the ability to move from one place to another) on/off unit, dressing, and personal hygiene. A review of Resident 45's Fall Risk Assessment, updated on 8/23/23, indicated Resident 45 was at high risk for falls. During an observation in Resident 45's room, on 10/31/2023, at 12:09 PM, Resident 45 was observed lying down horizontally on his bed with the curtains closed. Resident 45's head was to the left side of the bed while both legs were to the right side of the bed. Only Resident 45's back was on the bed. Resident 45 was mumbling words and moving his arms around. Registered Nurse (RN 2) entered the room with two unnamed staff and positioned Resident 45 to a safer position on the bed. During an observation in Resident 45's room, on 10/31/2023, at 12:18 PM, Resident 45 was observed lying down diagonally on his bed with his head partially to the left side of the bed while both feet were to the right side of the bed. RN 2 entered into Resident 45's room and repositioned Resident 45 back to the center of the bed with Resident 45's head of bed (HOB) elevated. During an interview with Certified Nursing Assistant (CNA 1), on 11/2/2023, at 9:03 AM, CNA 1 stated Resident 45 moves a lot in bed. CNA 1 stated Resident 45 was monitored by staff to ensure he would not fall off the bed. CNA 1 stated Resident 45's bed was in low position with bilateral floormats to protect Resident 45 from falls. CNA 1 stated Resident 45 was a fall risk and was on the Falling Apple Program (a program to reduce the incident of falls, resident injuries related to falls, and improve quality of care for the residents in the facility). CNA 1 stated Resident 45 often required redirection and repositioning in bed. During a concurrent interview and record review on 11/02/2023, at 5:22 PM, with RN 1, Resident 45's care plan titled, Falls Care Plan, dated 5/31/2023 was reviewed. RN 1 stated Resident 45 frequently attempts to get out of the bed without assistance. RN 1 stated Resident 45 bed was kept in low position, with bilateral floormats present, and required frequent visual checks to for prevention. RN 1 stated a visual check was done on Resident 45 every now and then but could not state the frequency of the visual checks. RN 1 stated Resident 45 had a history of falls and was placed on the Falling Apple Program. RN 1 confirmed Resident 45's care plan did not indicate that Resident 45 was in the Falling Apple Program. RN 1 verified the care plan interventions did not include having the bed in a low position, having floor mats on both sides of the bed, and how often the visual checks should be done. RN 1 confirmed the care plan interventions were incomplete. RN 1 stated it was important for Resident 45's care plan to be resident-centered and comprehensive so the staff would know how to care for Resident 45 to prevent falls incidents. 2. A review of Resident 69's admission Record indicated Resident 69 was admitted on [DATE] with diagnoses that included occlusion and stenosis of the right carotid artery (condition that happens when the large artery on either side of the neck becomes blocked), dementia (a brain disorder that results in memory loss, poor judgment, and confusion), and essential hypertension (high blood pressure). A review of Resident 69's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 9/19/2023, indicated Resident 69 had moderately impaired cognition (thought process and ability to reason or make decisions) for daily decision making and required extensive assistance (resident involved in activity, staff provide weight-bearing support) with one-persons physical assistance with bed mobility, transfer, locomotion (movement or the ability to move from one place to another) on/off unit, dressing, eating, toilet use, and personal hygiene. The MDS indicated Resident 69 had an impairment on one side of the upper extremity. A review of Resident 69's Initial History and Physical (H&P), dated 9/16/2023, indicated Resident 69 had a history of CVA (stroke- a loss of blood flow to part of the brain) with left-sided hemiplegia (paralysis of one side of the body). The H&P indicated Resident 69 had the capacity to understand and make decisions. A review of Resident 69's Physical Therapy Certification, dated 9/18/2023, indicated Resident 69 had a history of CVA resulting in left sided weakness. The Physical Therapy Certification also indicated that Resident 69 requires cuing to promote safety during functional tasks. Noted to have right upper extremity tremor, weakness overall in LLE > RLE (left lower extremity greater than right lower extremity) and reported fear of falling. During a concurrent observation and interview in Resident 69's room with Resident 69 on 10/30/2023 at 9:27 PM, Resident 69 was observed sitting in bed with the head of the bed elevated. Resident 69 stated using his right hand to feed himself since he has left-sided weakness. During a concurrent interview and record review on 11/02/2023, at 10:58 AM, with Minimum Data Set Nurse (MDSN), Resident 69's care plan titled, CAA 5B ADLS/Functional Mobility, dated 9/15/2023 was reviewed. MDSN stated Resident 69 was admitted with left sided weakness. MDSN stated the care plan did not address Resident 69's left-sided weakness. MDSN stated it is important for Resident 69 to have a specific care plan addressing his weakness to guide the staff on how to deliver the specific care that Resident 69 needs. MDSN stated when care plans were not resident-specific, care for the residents could be ineffective. During a concurrent interview and record review on 11/2/2023, at 5:22 PM, with RN 1, Resident 69's care plan titled, ADLS/Functional Mobility, dated 9/15/2023 was reviewed. RN 1 confirmed the care plan did not address Resident 69's left sided weakness and decreased range of motion. RN 1 stated it was important for Resident 69 to have a care plan for left-sided weakness so staff were informed on how to assist Resident 69's specific needs. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised on March 2022, the P&P indicated, The interdisciplinary team (IDT-a coordinated group of experts from different fields), in conjunction with the Resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The P&P also indicated, The comprehensive, person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and . builds on the resident's strengths; and reflects currently recognized standards of practice for problem areas and conditions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a functioning television remote control for one of 23 sampled residents (Resident 64) to support her choice of activity based on the comprehensive assessment. This deficient practice resulted in Resident 64 not able to watch television from 10/27/2023 to10/30/2023, which is a part of her preferred activity and had the potential to affect Resident 64's sense of self-worth and psychosocial well-being and meaningfulness. Findings: A review of Resident 64's admission Record indicated Resident 64 was admitted on [DATE] with diagnoses that included schizoaffective disorder (a mental illness that can affect the thought, mood, and behavior), osteoarthritis (a disease in which the tissues in the joint breakdown over time), and muscle weakness. A review of Resident 64's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 02/15/2023, indicated Resident 64 had moderately impaired cognition (thought process and ability to reason or make decisions) for daily decision making and required limited assistance (resident highly involved in activity, staff provide guided maneuvering of limbs or other non-weight bearing assistance) with one-person physical assistance with bed mobility, transfer, walk in room/corridor, locomotion (movement or the ability to move from one place to another) on/off unit, dressing, toilet use, and personal hygiene. The MDS also indicated it is very important for Resident 64 to keep up with the news. A review of Resident 64's Activity Assessment, dated 02/15/2023, indicated that while in the facility Resident 64 preferred to watch the news, musical shows, sports, and entertainment by watching television. A review of Resident 64's Activity Progress Note, dated 08/09/2023, indicated Resident 64's current activity preferences included TV (television)/movies. A review of Resident 64's Care Plan titled, Resident Care Plan-Accommodation of Needs dated 02/15/2023, indicated Accommodation of Needs Plan: Resident Prefers to stay in room and watch television. The care plan intervention included to incorporate preferences to daily care and schedule of Resident while in the facility. A review of Resident 64's Activity Care Plan, dated 02/15/2023, indicated that Resident expresses a preference to engage in her stated self-directed activities of: watching television, listen to music, read/scan magazines, etc. daily. During a concurrent observation in Resident 64's room and interview with Resident 64 on 10/30/2023, at 10:51 AM, Resident 64 was observed lying in bed with the televisions turned off and stated she was not watching television for four days because her television remote control broke on 10/27/2023. Resident 64 stated she asked Maintenance 2 for a new remote control on 10/27/2023 but he has not given her the new one yet. Resident 64 stated it is easy to watch television with the remote control because she can change the channel and adjust the volume herself. Resident 64 stated she likes to watch reality tv shows and the news. During an interview with Maintenance 2, on 10/30/2023 at 10:57 AM, Maintenance 2 stated Resident 64 informed him on 10/27/2023 that the television remote control in the resident's room was not working. Maintenance 2 stated he tried three different universal remotes for Resident 64 on 10/27/2023 but none of them were compatible with her television. Maintenance 2 stated Maintenance Supervisor (Maintenance 1) was notified about the remote control on 10/27/2023 and was told that a new one needed to be ordered. Maintenance 2 stated if Resident 64 wants to watch television she cannot turn on the TV by herself and would need to ask the staff to turn it on for her. During a concurrent observation in Resident 64's room and interview with Certified Nursing Assistant 7 (CNA 7), on 10/30/2023, at 12:01 PM, CNA 7 demonstrated she was able to turn on the television manually but could not find the channel or volume buttons. CNA 7 stated it would be difficult to change the channel or adjust the volume without the remote control. CNA 7 stated it is important for Resident 64 to be able to watch television when she wants. CNA 7 stated the facility is Resident 64's home so she should have access to her television anytime. A record review of the facility's policy and procedure (P&P) titled Accommodation of Needs, revised on 03/2021, the P&P indicated, The resident individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement treatment for the prevention of pressure ulcer/injury (painful wound caused as a result of pressure or friction) by failing to ensure that the low air loss mattress (LAL, mattress used for residents who are at risk for developing sores or already have pressure sores designed to circulate a constant flow of air for the management of pressure sores) was on the correct settings for one of one sampled resident (Resident 3) in accordance with the facility's policy. This deficient practice had the potential to place the Resident 3 at risk for skin integrity complications and pressure injury. Findings: A review of Resident 3's admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of open wound of scrotum (the external sac of skin that encloses the testes [male reproductive gland that produces sperm]) and testes, Parkinson's disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), and contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of the right elbow and right hand. A review of Resident 3's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 10/5/2023, indicated Resident 3 had moderate cognitive (mental action or process of acquiring knowledge and understanding) impairment for daily decision making. The MDS indicated Resident 3 was at risk for developing pressure ulcers/injuries. The MDS indicated Resident 3 required substantial/maximal assistance (helper does more than half the effort) for showering, lower body dressing, sit to lying position and lying to sitting on the bed. The MDS also indicated Resident 3 required partial/moderate assistance (helper does less than half the effort) for oral hygiene, upper body dressing, and personal hygiene (practices conducive to maintaining health and preventing disease, especially through cleanliness). A review of Resident 3's Braden Scale (scale used for predicting pressure sore risk), dated 10/5/2023, indicated Resident 3 was at high risk for pressure sores. A review of Resident 3's care plan titled, Pressure Injury, dated 10/26/2023, indicated to maintain the LAL mattress for wound management. A record review of the Preliminary Wound Report by the physician assistant, certified (PA-C) dated 10/26/2023, indicated Resident 3 had a Stage 2 pressure ulcer on the left ischium with light exudate (the fluid that is secreted from a wound during the healing process), mild erythema (reddening of the skin due to inflammation), and no odor. During an observation in Resident 3's room on 10/30/2023 at 4:11 PM, Resident 3 was lying on his back with the head of bed elevated, drinking water with the assistance of a nurse. Resident 3's LAL mattress setting was set at 350 lbs. During a concurrent observation in Resident 3's room and interview on 10/30/2023 at 4:13 PM with Registered Nurse 2 (RN 2), RN 2 stated the treatment nurse, charge nurses, and RN supervisors were in charge of monitoring the LAL mattress settings. RN 2 stated nurses check the LAL mattress setting every shift. RN 2 stated the setting should be based on the resident's weight. RN 2 verified Resident 3's LAL mattress setting was set at 350 lbs., which had too much pressure for the resident. During a concurrent observation, record review of Resident 3's weight, and interview on 10/30/2023 at 4:20 PM with the treatment nurse (Licensed Vocational Nurse 4), LVN 4 stated she oversaw the LAL mattress settings for residents. LVN 4 verified Resident 3 was laying on the bed with LAL mattress setting set at 350 lbs. A record review of Resident 3's current weight indicated Resident 3 weighed 219 lbs. LVN 4 stated the LAL mattress should be set at the weight of the patient which was 219 lbs. LVN 4 stated the LAL mattress setting at 350 lbs. was too hard and could create more pressure on the skin which could lead to skin breakdown. LVN 4 stated Resident 3 had a stage 2 pressure injury (partial thickness of loss of dermis presenting as a shallow open ulcer with red or pink wound bed, without slough or bruising) on the left ischium (forms the lower and posterior of the three principal bones composing either half of the pelvis). A review of the facility's policy and procedure titled, Policy and Procedure of Low Air Loss Mattress, revised 2023, indicated the LAL mattress setting will be adjusted according to the resident's weight.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain a safe environment for one (1) of six (6) sampled residents (Resident 57), a fall risk resident, when Resident 57's bed was observed not in the lowest position. Resident 57 did not have a fall risk signage inside the room per facility policies and procedures. This deficient practice had the potential for Resident 57 to sustain an injury in an event of a fall. Findings: A review of Resident 57's admission Record indicated, the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of muscle weakness, dementia (a loss of thinking, remembering, and reasoning skills), and schizophrenia (a mental disorder involving a disconnection from reality). A review of Resident 57's Fall Risk Assessment, dated 10/8/2023, indicated a score of 14. A total score above 10 on the Fall Risk Assessment indicated high risk for falls. A review of Resident 57's Falls Care Plan, dated 10/8/2023, indicated Resident 57 was at risk for falls due to poor safety awareness and impaired mobility. Fall Care Plan indicated an intervention to maintain a safe environment at all times. A review of Resident 57's Quarterly Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 10/12/2023, indicated the resident was dependent (helper does all the effort) with eating, oral hygiene, toileting, bathing self, and dressing. Resident 57 was dependent for rolling left to right, sit to lying, lying to sitting on the side of the bed, sit to stand, and with chair/bed-to-chair transfer. During an observation on 10/30/2023 at 8:38 AM, Resident 57's bed was not in the lowest position. Resident 57's was in the bed, which measured 21 inches off the floor. During a concurrent observation in Resident 57's room and interview with Certified Nurse Assistant 5 (CNA 5) on 10/30/2023 at 9:19 AM, CNA 5 stated that Resident 57's bed was not and should be in the lowest position. CNA 5 stated that if the bed was not in the lowest position, the resident can fall. During an interview with Licensed Vocational Nurse 2 (LVN 2) on 10/31/2023 at 10:07 AM, LVN 2 stated that the bed should be in the lowest position for residents at risk for falls. LVN 2 stated that residents can have injuries if fall precautions were not followed. During an interview with CNA 3 on 11/1/2023 at 11:10 AM, CNA 3 stated that resident's bed should be in the lowest position to prevent falls. CNA 3 stated if a resident falls, the resident can have trauma. During a concurrent observation in Resident 57's room and interview on 11/2/2023 at 12:28 PM, with LVN 2, observed Resident 57 without any visual identifiers or signage in the room to indicate that Resident 57 was high risk for falls. LVN 2 confirmed Resident 57 does not have any identifiers to indicate high risk for falls. During an interview with the Director of Nursing (DON) on 11/2/2023 at 12:52 PM, DON stated the bed should be in the low position for high fall risk residents. The DON added if the bed is not in the lowest position, the resident can fall and have an injury. The DON also stated the facility should have an identifier for residents who are high risk for falls. A review of the facility's policy dated 11/8/2010, titled Fall Prevention Program indicated It is the policy of this facility to identify residents at risk for falls and to implement a fall prevention approach to reduce the risk of falls and possible injury. The goal of the Fall Prevention Program is to reduce incidence of falls, resident injuries related to falls, and improve quality of care for the residents. This facility will attempt to properly identify, evaluate, and monitor residents who are at risk for falls. The falls prevention approaches will be evaluated by the Quality Improvement Committee to determine the effectiveness of the approaches. With the recommendations of the committee, changes will be implemented to reduce falls risk in the facility. A visual identifier will be used to identify residents on the fall prevention program. This identifier will be placed on the head of the resident's bed, and inside of the resident's closet door. If possible, an identifier will be placed on the resident's assistive device (i.e., wheelchair, walker, etc. ). A review of the facility's revised policy dated March 2018, titled Fall Risk Assessment indicated The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. The staff will seek to identify environmental factors that may contribute to falling, such as lighting and room layout. The staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident with a gastrostomy tube (GT, a tube that is passed through the abdominal wall to the stomach used to provide nutrition) received tube feeding as indicated on the physician's order for one (1) of five (5) sampled residents (Resident 23). This deficient practice had the potential to result in Resident 23 to not receive the volume of tube feeding formula ordered, which can lead to weight loss, malnutrition (lack of sufficient nutrients in the body), and death. Findings: A review of Resident 23's admission Record indicated Resident 23 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of failure to thrive (state of decline that may include weight loss, decreased appetite, poor nutrition, and inactivity), dementia (progressive brain disorder that slowly destroys memory and thinking skills), schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves), anxiety disorder (persistent and excessive worry that interferes with daily activities), and chronic obstructive pulmonary disease (COPD- disease that causes obstructed airflow from the lungs). A review of Resident 23's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 9/21/2023, indicated Resident 23 had severe cognitive (mental action or process of acquiring knowledge and understanding) impairment for daily decision making. The MDS indicated Resident 23 required extensive assistance (resident involved in activity, staff provide weight-bearing support) for bed for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed), transfers (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position), locomotion on unit (how resident moves between location in his/her room) and off unit (how resident moves to and returns from areas such as activities, treatment, or dining), dressing, eating, and personal hygiene (practices conducive to maintaining health and preventing disease, especially through cleanliness). A review of Resident 23's Order Summary Report dated, 10/31/2023, indicated enteral feed (also known as tube feeding, is a way of delivering nutrition directly to your stomach) order of Glucerna (a specialized nutrition with fiber providing complete nutrition) 1.5 at 75 milliliter (ml, units of measurement) every hour for 12 hours via enteral pump, start at 6 PM and off at 6 AM, with order date of 9/18/2023. A review of Resident 23's Care Plan titled, Altered Nutrition, on Percutaneous Endoscopic Gastrostomy (PEG, a procedure to place a feeding tube) Tube Feeding, indicated staff interventions included were to provide Glucerna 1.5 at 75 ml every hour for 12 hours via enteral pump, start at 6 PM and off at 6 AM or until total volume is completed, as ordered. During an observation in Resident 23's room on 11/1/2023 at 7:07 PM, there was no tube feeding of Glucerna 1.5 infusing on the tube feeding pump (machine for feeding tubes to deliver nutrition to patients who cannot obtain such by swallowing). During a concurrent observation in Resident 23's room and interview with Licensed Vocational Nurse 2 (LVN 2) on 11/1/2023 at 7:16 PM, LVN 2 stated that she forgot to start the tube feeding for Resident 23 at 6 PM, LVN 2 stated, Starting tube feeding per physician's order was important to prevent change of condition such as dropped blood sugar, blood pressure drop, and resident might become weak. During an interview on 11/2/2023 at 9AM with the Director of Nursing (DON), the DON verified that Resident 23's tube feeding was started late at 7:45 PM on 11/1/2023, as documented on MAR. The DON stated not providing the ordered amount of formula can lead to weight loss and harm to the resident. A review of facility's policy and procedure titled, Assistance with Meals, revised in March 2022, indicated that Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. It also indicated that Nursing staff will provide feedings to tube-fed residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a coordination of care between facility and hospice (care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure) staff for one of one sampled resident (Resident 54) in accordance with the facility's hospice policy and hospice agreement by failing to ensure: a. a hospice comprehensive assessment to include a documented evidence of hospice staff notes visits on 10/25/2023, and 10/28/2023. b. hospice care plan was revised This deficient practice had the potential for Resident 54 not to receive the hospice care and services necessary to promote comfort and quality of life. Findings: A review of Resident 54's admission Record indicated Resident 54 was admitted to the facility on [DATE]. Resident 54's diagnoses included diabetes mellitus (high blood sugar), dysphagia (difficulty swallowing), and senile degeneration of bran (mental decline). A review of Resident 54's Minimum Data Set (MDS, a comprehensive assessment and care-screening tool), dated 9/15/2023, indicated Resident 54 was severely impaired with cognitive skills [ability to think, understand, and reason]) for daily decision making. The MDS indicated Resident 54 required one-person extensive assistance for bed mobility, transfer, locomotion on and off unit, dressing, toilet use and personal hygiene. A review of Resident 54's hospice care plan, dated 12/5/2022, indicated staff approach plans were for hospice staff to render care during their visits, hospice licensed nurse visit (but frequency was not indicated), social service and chaplain visits as needed. A review of Resident 54's hospice binder indicated the following: a. Hospice integrated plan of care dated 3/27/2023 that indicated hospice nurse frequency of visit of once a week, hospice aide visit frequency of twice a week, hospice social worker frequency of twice a month, and hospice chaplain frequency of twice a month. b. Hospice staff sign-in sheet for the month of October 2023 indicated hospice staff visit on 10/3/2023, 10/4/2023, 10/10/2023, 10/13/2023, 10/17/2023, 10/18/2023, 10/23/2023, 10/25/2023, and 10/28/2023. During a concurrent record review of Resident 54's hospice binder and interview with Director of Nursing (DON) on 11/1/2023 at 4:25 PM, DON stated resident on hospice has a hospice binder, which contains all the Resident's hospice records. The DON stated having a hospice binder was important for the facility staff because it was where they check hospice nurses' visits and documentation. The DON stated the hospice staff communicates with the facility staff and would document resident visit under communication update. The DON added hospice aide visit should be documented on Certified Home Health Aide (CHHA) communication sheet. The DON stated that hospice sign in sheet only indicated hospice staff visits on 10/3/2023, 10/4/2023, 10/10/2023, 10/13/2023, 10/17/2023, 10/18/2023, 10/23/2023, 10/25/2023, and 10/28/2023. The DON stated, there was no other documentation of the hospice nurses' visit besides the date, time, name, and discipline. The DON verified that there was no hospice staff communication documentation for the date of 10/25/2023, and 10/28/2023. The DON also stated that there was no documentation of Hospice aide visits on the CHHA communication sheet for the month of October 2023. The DON stated that hospice staff should communicate with the facility staff when they plan to visit or have visited a resident. During a concurrent record review of Resident 54's hospice binder and interview with Registered Nurse 3 (RN 3) on 11/1/2023 at 6:45 PM, RN 3 stated that the hospice communication update has documentation of hospice staff visit on 10/3/2023 (hospice chaplain), 10/4/2023 (hospice RN), 10/10/2023 (hospice social worker), 10/13/2023 (hospice LVN), 10/17/2023 (hospice chaplain), 10/23/2023 (hospice social worker). RN 3 stated that the last documentation on the CHHA communication sheet was on 9/25/2023. RN 3 stated that hospice staff communication was important so facility would know what hospice staff did during their visit. RN 3 stated that Resident 54's hospice care plan was not and should be revised to indicate hospice staff visits. RN 3 added that the care plan did not indicate hospice Doctor, hospice registered nurse and hospice aide visit. The hospice licensed nurse frequency of visit was left blank. A review of hospice agreement dated July 2022, indicated delineation of nursing and aid services as follows: Hospice RN responsibilities: Assignment and supervision of Hospice Health Aides Collaboration with Facility Staff in delivery and updating plan of care Communication and coordination of patient care services of Facility Staff and Hospice Interdisciplinary team Hospice Health Aide responsibilities: Provision of scheduled visits as indicated on plan of care to supplement the care provided by facility Health Aide. Completion of assignment as indicated by Hospice RN and the provision of a copy of the completed assignment form to facility. A review of facility's policy and procedure titled Hospice Program, with revised date of July 2017, indicated the facility to coordinate care provided to the resident and the hospice staff. Facility is responsible for the following: Collaborating with hospice representatives and coordinating facility staff participation in the hospice care planning process for a resident receiving these services Obtaining the most recent hospice plan of care specific to each resident Ensuring that facility staff provides orientation on the policies and procedures of the facility including the resident rights, appropriate forms and record keeping requirements, to hospice staff furnishing care to the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain infection control measures for three (3) of three (3) sampled residents (Residents 16, 41 and 45), when: 1. Cleaning of the manual blood pressure monitor (an instrument for measuring blood pressure), was not done prior to use for Resident 16. 2. Cleaning of the blood pressure cuff (attached to the manual blood pressure monitor) was not done between each use for Residents 41 and 45. 3. Purified water was not used to flush the gastrostomy tube (g-tube, a tube inserted through the belly that brings nutrition directly to the stomach), per policy, for Resident 45. These deficient practices had the potential to spread infection through pathogens (organisms or agents that can produce disease) to Residents 16, 41, and 45 by using an unclean blood pressure cuff, and using unfiltered water in Resident 45's g-tube. Findings: 1. A review of Resident 16's admission Record indicated, Resident 16 was admitted to the facility 4/7/2023 and readmitted [DATE], with diagnoses of urinary tract infection (UTI, an infection in the kidney, ureter, or bladder), hypertensive chronic kidney disease (high blood pressure that causes kidney damage), hyperlipidemia (high levels of fat in the blood). During observation on 10/31/2023 at 8:12 AM, Licensed Vocational Nurse 1 (LVN 1) was observed removing the manual blood pressure machine from the nurse's station, and not cleaning the manual blood pressure machine and cuff before and after use on Resident 16. During an interview on 10/31/2023 at 10:28 AM with LVN 1, LVN 1 stated the blood pressure cuff needs to be cleaned before and after use on residents, per facility policy. LVN 1 stated she should clean medical equipment before and after it is used on residents to prevent infection. During an interview on 11/2/2023 at 5:01 PM with Infection Prevention Nurse (IPN), IPN stated medical equipment used on resident's is cleaned before and after each use. IPN stated that if the equipment is not cleaned, it can transport bacteria to the resident and cause infection. 2. A review of Resident 41's admission Record indicated, Resident 41 was admitted to the facility 7/25/2017 and readmitted [DATE], with diagnoses of urinary tract infection, hypertensive heart disease (high blood pressure), and hyperlipidemia. During an observation on 10/31/2023 at 8:37 AM, LVN 1 was observed not cleaning the blood pressure cuff used on Resident 16, before use on Resident 41. A review of Resident 45's admission Record indicated, Resident 45 was admitted to the facility 4/28/2022 and readmitted [DATE], with diagnoses of pneumonia (lung inflammation caused by bacterial or viral infection), urinary tract infection, and dysphagia (impairment or difficulty swallowing). During an observation on 10/31/2023 at 9:12 AM, LVN 1 was observed not cleaning the blood pressure cuff used on Resident 41, before use on Resident 45. LVN 1 did not clean the blood pressure cuff after use on Resident 45. 3. During an interview on 10/31/2023 at 9:44 AM with LVN 1, LVN 1 stated she prepared Resident 45's water for the g-tube from the bathroom sink. LVN 1 stated she filled 2 small clear plastic cups with water, one with cold water and one with warm water, from Resident 45's bathroom sink tap. LVN 1 stated she mixes hot and cold water together, so the g-tube water is not too cold for Resident 45's stomach During an observation on 10/31/2023 at 10:06 AM, observed LVN 1 administer Glucerna feeding and g-tube medications to Resident 45. After administering the Glucerna feeding in Resident 45's g-tube, LVN 1 prepared 30ml of tap water as a g-tube flush. During an interview on 11/1/2023 at 12:19 PM with Infection Prevention Nurse (IPN), IPN stated the kitchen will provide water for medication carts and this water can be used for flushing g-tubes and during g-tube medication administration. IPN stated if the g-tube water is too cold, the staff should ask for warm water from the kitchen. IPN stated it is not common practice anywhere to get g-tube water from the bathroom sink. IPN stated if sink water is used, it can cause injury and harm to the resident. During an interview on 11/01/2023 at 3:02 PM with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated that water for g-tubes is from a filtered tap in the kitchen. During an interview on 11/1/2023 at 3:13 PM with LVN 1, LVN 1 stated if the pipes from the bathroom sink are not in good condition, the water used can give residents diarrhea, stomach upset, infection and require hospitalization. During a concurrent observation and interview on 11/1/2023 at 4:31 PM with Dietary Services Supervisor (DSS) in the kitchen, DSS stated that the water for g-tubes comes from the juice machine located in the kitchen. Observed one Nutri Juice machine with a controller attachment and button labeled water. DSS stated the filter attached to the juice machine was last changed 9/25/2023. Observed DSS press the water button and clear water was dispensed from the juice machine into a clear cup. A review of the facility's revised policy dated November 2018, titled Administering Medications through an Enteral Tube, indicated, Purpose: The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube. General Guidelines: Follow the medication administration guidelines in the policy entitled Administering Medications. Use warm, purified water for diluting medications and for flushing. A review of the facility's revised policy dated May 15, 2022, titled Cleaning and Disinfection of Resident-Care Equipment, indicated, Purpose: To ensure that the cleaning and disinfection of resident care equipment is in accordance with CDC and OSHA guidelines. Policy: Resident-care equipment, including reusable items and durable medical equipment is cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Blood borne Pathogens Standard. Reusable resident care equipment is decontaminated and/or sterilized between residents, according to manufacturer's instructions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 36's admission Record, indicated Resident 36 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of COPD, morbid obesity (abnormal or excessive fat accumulation), and diabetes mellitus type 2 (high blood sugar). A review of Resident 36's Quarterly Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 10/9/2023, indicated the resident had an active diagnosis of COPD with acute exacerbation. A review of Resident 36's COPD care plan, dated 7/4/2023, indicated the care plan was not revised according to the re-evaluation date on the care plan. A review of Resident 36's care plan on 11/2/2023 at 10:03 AM, indicated Resident 36's quarterly COPD care plan's re-evaluation date listed as 10/2023. During a concurrent interview and record review on 11/2/2023 at 10:10 AM with Director of Nursing (DON), the DON stated the COPD care plan for Resident 36 was not and should have been revised during the quarterly interdisciplinary team (IDT) meeting in 10/2023. During a concurrent interview and record review on 11/2/2023 at 10:32 AM with the Minimum Data Set Nurse (MDSN), MDSN stated Resident 36's COPD care plan should have been reviewed during the quarterly IDT meeting. MDSN stated the last IDT meeting for Resident 36 was on 10/9/2023. MDSN stated that if the care plan is not updated, the resident will be at risk for decline in well-being. A review of the facility's revised policy titled, Care Plans, Comprehensive Person-Centered, dated March 2018, indicated: The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment Based on interview and record review the facility failed to review and revise the care plans for three (3) of 3 sampled residents (Residents 18, 36, and 40), in accordance with the facility policy by failing to: 1. Update Resident 18's care plan on gastrostomy tube (G-Tube, a flexible tube surgically inserted through the wall of the abdomen directly into the stomach for feeding, fluid, and medication administration) in accordance with the resident's physician order. This deficient practice had the potential for Resident 18 to not receive the correct amount of G-Tube feeding and had the potential to negatively affect Resident 18's physical well-being. 2. Revise Resident 36's care plan for chronic obstructive pulmonary disease (COPD- chronic inflammatory lung disease that causes obstructed airflow from the lungs). This deficient practice had the potential for Resident 36 not to receive the interventions to prevent respiratory distress (a serious lung condition that causes low blood oxygen) and respiratory failure (a life-threatening condition in which the lungs are unable to provide enough oxygen), which may lead to death. 3. Update Resident 40's care plan when the order of Physical Therapy (PT, treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather than by drugs or surgery) and Occupational Therapy (OT, a form of therapy for those recuperating from physical or mental illness that encourages rehabilitation through the performance of activities required in daily life) was discontinued on 8/31/2023. This deficient practice had the potential for Resident 40 to not receive appropriate care treatment and/or services for residents' specific needs. Findings: 1. A review of Resident 18's admission Record indicated Resident 18 was initially admitted on [DATE] and was readmitted on [DATE] with diagnoses that included moderate protein-calorie malnutrition (inadequate intake of food that leads to changes in the body), dementia (a brain disorder that results in memory loss, poor judgment and confusion), and schizoaffective disorder (a mental health problem where a person experiences loss of contact with reality as well as mood symptoms). A review of Resident 18's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 9/26/2023, indicated Resident 18 had severely impaired cognition (thought process and ability to reason or make decisions) for daily decision making and had total dependence (full staff performance every time) with two person physical assistance with transfer and one-person physical assistance for locomotion (movement or the ability to mover from one place to another) on unit, eating, and toilet use. Resident 18 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with one-person physical assist with bed mobility, dressing, and personal hygiene (practices conducive to maintaining health and preventing disease, especially through cleanliness). During an observation on 10/30/2023, at 9:08 AM, in Resident 18's room, Resident 18 completed her daily enteral feeding (a way of delivering nutrition directly to the stomach or small intestines) of Jevity (a fiber enriched formula that provides a complete and balanced nutrition for long-term of short-term tube feeding) 1.5 at a rate of 60 milliliters ([ml] unit of measurement)/hour and received a total volume of 1200 ml. During a concurrent record review of Resident 18's Order Summary Report and interview on 11/2/2023, at 4:58 PM, Registered Nurse (RN 1) verified Resident 18's enteral feed order, ordered on 10/6/2023 was Jevity 1.5 at 60 ml/ hour for 20 hours, via enteral pump (to provide 1200ml/1800 Kcal [kilocalorie- 1 kcal equals 1000 calories]) start at 1 PM and off at 9AM or until total volume is completed every day shift. During a concurrent record review of Resident 18's care plan, titled, Feeding Tube/Dysphagia Care Plan and interview on 11/2/2023, at 5:10 PM, with Registered Nurse (RN 1), RN 1 stated Resident 18's care plan indicated to provide Jevity 1.5 at 50 ml/hr, via enteral pump (to provide 1000ml/1500 Kcal) start at 1PM and off at 9AM or until total volume is completed. RN 1 confirmed the care plan was not updated after the order was discontinued. RN 1 stated it was important for the care plan to be updated with the right enteral feed order to avoid confusion or mistakes, which can lead to weight loss. RN 1 stated it was the responsibility of all the licensed nurses who received the new order to update the care plan. A review of the facility's policy and procedure (P&P) titled, Care Plan, Comprehensive Person-Centered, revised on March 2022, indicated, Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. 3. A review of Resident 40's admission Record indicated Resident 40 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses included major depressive disorder (MDD, a mood disorder that causes a persistent feeling of sadness and loss of interest in daily activity), osteoarthritis (disease that causes joint pain and reduces joint mobility and function), and history of falling. A review of Resident 40's MDS dated [DATE], indicated Resident 40 had intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 40 required partial/moderate assistance (helper does less than half the effort) for toileting hygiene and shower. The MDS also indicated Resident 40 required supervision or touching assistance (helper provides verbal cues) for eating, oral hygiene, lower body dressing, putting on/taking off footwear and personal hygiene (practices conducive to maintaining health and preventing disease, especially through cleanliness). A review of Resident 40's care plan titled, Risk for Falls, dated 8/2/2023, staff interventions included PT and OT as ordered. A review of Resident 40's care plan titled, Self-care Deficit, dated 8/2/2023, staff interventions included PT and OT as ordered. A review of Resident 40's order summary report dated 11/1/2023, did not indicate an order of PT and OT. During an interview on 10/30/2023 at 4 PM with Resident 40, he stated that he is no longer receiving PT and OT. During a concurrent record review of Resident 40's care plans and interview with MDS nurse (MDSN) on 11/2/2023 at 10:15 AM, MDSN stated that Resident 40 is no longer receiving physical therapy and occupational therapy since 8/31/2023. MDSN verified that care plans titled, Risk for Falls, and Self-care Deficit have staff interventions indicating PT and OT as ordered. During a follow up interview with MDSN nurse on 11/2/2023 at 10:40 AM, MDSN stated that Resident 40's care plans were not revised timely. MDSN stated, the licensed nurse who received the order to discontinue the PT and OT should had revised the care plans to avoid confusion. MDSN stated that care plans reflect the care that was being provided to the Resident. MDSN nurse stated that it was important to revise residents care plans in accordance to the present need of the residents to ensure specific interventions and type of care were provided to the resident. A review of the facility's policy and procedure titled, Comprehensive Person-Centered Care Plans, revised March 2022, indicated assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. A review of Resident 45's admission Record indicated Resident 45 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included pneumonia (an infection that affects one or both lungs), unspecified dementia (a brain disorder that results in memory loss, poor judgment, and confusion), and schizophrenia (a mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others). A review of Resident 45's care plan titled, Dehydration Care Plan, dated 5/31/2023, indicated staff interventions were to keep fluids within reach and offer as tolerated unless contraindicated. A review of Resident 45's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 8/23/2023, indicated Resident 45 had severely impaired cognition (thought process and ability to reason or make decisions) for daily decision making. The MDS indicated Resident 45 had total dependence (full staff performance every time) with one-person physical assist for eating and toilet use and required extensive assistance (resident involved in activity, staff provide weight-bearing support) with one-person physical assist for bed mobility, transfer, locomotion (movement or the ability to move from one place to another) on/off unit, dressing, and personal hygiene. A review of Resident 45's Order Summary Report, dated 10/31/2023, indicated a physician order, with a start date of 10/13/2023, to administer Glucerna 1.5 Tetra pack (a type of plasticized carton for milk, juice, and other drinks) 237 ml/ 356 calories (a unit of measurement for the energy value of food) via bolus (the administration of an amount of medication, drug or fluid within a specific time) feeding at 9:00 AM and 1:00 PM with 200 ml water flushing every bolus two times a day for nutritional supplement. During an observation in Resident 45's room on 10/30/2023 at 2:36 PM, Resident 45 did not have a pitcher of water at the bedside. Resident 45 was awake in bed and asking for water. Resident 45's lips appeared dry and slightly peeling. During an observation of Resident 45's G-tube bolus feeding administration in Resident 45's room on 10/31/2023, at 10:06 AM, Licensed Vocational Nurse (LVN 1) administered Glucerna 1.5 Tetra pack 237 ml/356 cal via G-tube. LVN 1 flushed the G-tube with 30 ml of water before Glucerna administration. LVN 1 flushed the G-tube with 30 ml after receiving Glucerna administration then proceeded to administer Resident 45's medication. During an interview on with LVN 1 on 11/1/2023 at 3:13 PM, LVN 1 stated she did not flush Resident 45's G-Tube with 200 ml of water after administering Glucerna. LVN 1 stated Resident 45 has an order for 200 ml water bolus to keep him hydrated. LVN 1 stated she should have given Resident 45 200 ml instead of 30 ml water after receiving Glucerna. LVN stated it was important for Resident 45 to get the water bolus to prevent him from getting dehydrated (having lost a large among of water from the body). A record review of the facility's policy and procedure titled, Hydration- Clinical Protocol, revised on 9/2023, indicated, The staff will provide supportive measures such as supplemental fluids and adjusting environmental temperature, where indicated. A record review of the undated facility's policy and procedure titled, Water Pitchers, indicated nursing care and duties include placing pitchers or cups at residents' bedsides and refilling pitchers as needed. Based on observation, interview, and record review, the facility failed to ensure four (3) of five (5) Residents (Resident 3, 5, and 45) were hydrated as indicated on the facility policy. a. Resident 3 was not provided a water pitcher b. Resident 5 was not provided a water pitcher c. Resident 45 was not given 200 milliliters ([ml] unit of measurement) of water, as ordered, after administration of Glucerna (a nutritional supplement meal replacement designed for residents with diabetes [a condition whereby the body is not able to regulate blood levels of sugar]) via gastrostomy tube (G-tube, surgical procedure wherein a tube is inserted through the abdomen wall and into the stomach used for nutrition and medication administration) on 10/31/23. This deficient practice had the potential to place the residents at risk for dehydration (harmful reduction in the amount of water or fluids in the body). Findings: a. A review of Resident 3's admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Parkinson's disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), and contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of the right elbow and right hand. A review of Resident 3's care plan titled, Dehydration Care Plan, dated 4/6/2023, indicated staff interventions were to keep fluids within reach and offer as tolerated unless contraindicated. A review of Resident 3's Minimum Data Set (MDS - a standardized assessment and care planning tool), dated 10/5/2023, indicated Resident 3 had moderate cognitive (mental action or process of acquiring knowledge and understanding) impairment for daily decision making. The MDS indicated Resident 3 required supervision or touching assistance for eating, partial/moderate assistance for oral hygiene and personal hygiene (practices conducive to maintaining health and preventing disease, especially through cleanliness). During an observation on 10/30/2023 at 9:37 AM, Resident 3 was out of bed with no water pitcher at bedside. During an observation on 10/30/2023 at 11:30 AM, Resident 3 did not have a water of pitcher at bedside. During an observation on 10/30/2023 at 2:31 PM, Resident 3 was sitting up in bed with a notebook, papers, and a pencil. Resident 3 did not have a water pitcher on his bedside. During a concurrent observation and interview on 10/30/2023 at 2:47 PM with Certified Nursing Assistant 7 (CNA 7), CNA 7 stated Resident 3 did not have a water pitcher at beside. CNA 7 stated Resident 3 was supposed to have a water pitcher at bedside in case he wants to drink water. b. A review of Resident 5's admission Record indicated Resident 5 was initially admitted to the facility of 6/1/2017 and readmitted on [DATE], with diagnoses of chronic kidney disease (gradual loss of kidney damage where kidneys cannot filter the blood the way they should), schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves), and dementia (progressive brain disorder that slowly destroys memory and thinking skills). A review of Resident 5's care plan titled, Dehydration Care Plan, dated 6/2/2023, indicated staff interventions were to keep liquids within reach and offer as tolerated unless contraindicated. A review of Resident 5's MDS dated [DATE], indicated Resident 5 had severe cognitive impairment for daily decision making. The MDS indicated Resident 5 required limited assistance with bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed), transfers (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position), locomotion on unit (how resident moves between location in his/her room), and personal hygiene. The MDS also indicated Resident 5 required extensive assistance (resident involved in activity, staff provide weight-bearing support) for dressing, toilet use, and bathing. During an observation on 10/30/2023 at 9:34 AM, Resident 5 was sleeping in bed with no water pitcher at bedside. During an observation on 10/30/2023 at 11:42 AM, Resident 5 did not have a pitcher of water at his bedside. During a concurrent observation and interview on 10/30/2023 at 2:58 PM with CNA 3, CNA 3 stated Resident 5 does not have a water pitcher at beside. CNA 3 stated water pitchers should be kept at beside so if the resident gets thirsty, they can drink water to prevent from getting dehydrated. CNA 3 stated Resident 5 walks around a lot and he should have a pitcher of water at the bedside. During an interview on 11/1/2023 at 1:01 PM with the Dietary Supervisor (DS), the DS stated all residents except for gastrostomy tube (G-Tube - a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration), on fluid restriction, or nectar diet should have a pitcher of water at the bedside. The DS stated water at the bedside is needed for hydration if the residents were thirsty, they can drink the water. The DS stated residents can get dehydrated or exhausted walking around the facility without having a water pitcher at their bedside when they return to their room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure they do not have a medication error rate of five percent (%) or greater as evidenced by the identification of eleven (11) medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturers specifications (not recommendations) regarding the preparation and administration of the medication or biological; accepted professional standards and principles which apply to professionals providing services) out of 25 opportunities (observed administered medications) for error and yielded a facility medication error rate of 44 percent for five out of 23 sampled residents (Residents 9, 16, 41, 45, and 48) observed during medication administration (med pass). Licensed Vocational Nurse (LVN 1) failed to administer: 1. Metoprolol (a medication that lowers your blood pressure and heart rate) twice daily for Resident 9 as indicated in the Physician's order. 2. Medications within 60 minutes of scheduled time of 7AM for Residents 16, 41, and 48 as indicated on the facility policy and procedure. 3. Medications within 60 minutes of scheduled time of 9AM for Resident 45 as indicated on the facility policy and procedure. These deficient practices had the potential to result in harm to Residents 9, 16, 41, 45, and 48 by not administering medications as prescribed by the physician in order to meet their individual medication needs. Findings: 1. A review of Resident 9's admission Record indicated Resident 9 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included sepsis (infection of the blood) of unspecified organism, type 2 diabetes mellitus (a disease that occurs when your blood sugar is too high), and hypertension (high blood pressure). A review of Resident 9's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 10/10/2023, indicated Resident 9 had moderately impaired cognition (thought process and ability to reason or make decisions) for daily decision making and required partial/moderate assistance (helper does less than half the effort) with shower/bathing self and supervision with oral hygiene, toileting hygiene, upper/lower body dressing, personal hygiene, and putting on/taking off footwear. A review of Resident 9's Order Summary Report, dated 9/29/2023, indicated a physician's order to administer Metoprolol Tartrate 50 milligrams (mg- unit of measurement of mass) by mouth two times a day for hypertension. During an observation of the medication administration for Resident 9 on 10/31/2023, at 7:44 AM, LVN 1 administered Pioglitazone (a medication used to treat high blood sugar levels caused by type 2 diabetes) 30 mg 1 tablet by mouth and Metformin (a medication used to treat high blood sugar levels caused by type 2 diabetes) 1000 mg 1 tablet by mouth to Resident 9. During a record review of Resident 9's Medication Administration Record (MAR) from 10/1/2023-10/31/2023, the MAR indicated Resident 9 was scheduled to receive three medications at 7 AM: 1. Pioglitazone 30 mg 2. Metformin 1000 mg 3. Metoprolol Tartrate 50 mg During an interview with LVN 1 on 10/31/2023, at 2:50 PM, LVN 1 confirmed she did not administer Metoprolol at 7AM as scheduled. LVN stated she administered Metoprolol to Resident 9 at around 10:30 AM. LVN 1 stated she did not notice the Metoprolol 50 mg bubble pack (medication container) when she administered the 7AM medications. 2.a. A review of Resident 48's admission Record indicated Resident 48 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included cellulitis (a deep infection of the skin caused by bacteria) of the right lower limb, type 2 diabetes mellitus, and heart failure. A review of Resident 48's MDS, dated [DATE], indicated Resident 48 had intact memory and cognition for daily decision making and required extensive assistance (resident involved in activity, staff provide weight-bearing support) with one-persons physical assistance with bed mobility, transfer, walk in room/corridor, locomotion (movement or the ability to move from one place to another) on/off unit, dressing, toilet use, and personal hygiene. Resident required supervision with setup help for eating. A review of Resident 48's Order Summary Report, dated 9/29/2023, indicated a physician's order to administer Metformin 850 mg by mouth two times a day for type 2 diabetes mellitus. A record review of Resident 48's MAR from 10/1/2023-10/31/2023, the MAR indicated Resident 48 was scheduled to received Metformin 850 mg at 7AM. During an observation of the medication administration for Resident 48 on 10/31/2023, at 8:04 AM, LVN 1 administered Metformin 850 mg 1 tablet by mouth. 2.b. A review of Resident 16's admission Record indicated Resident 16 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included thrombocytopenia (a condition that occurs when the platelet [a fragment in the blood that prevents or stops bleeding] count in the body is too low), type 2 diabetes, and bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). A review of Resident 16's MDS, dated [DATE], indicated Resident 16 had intact memory and cognition for daily decision making and required partial/moderate (helper does less than half the effort) assistance with showers and taking off footwear. Resident 16 also required supervision or touching assistance with toilet transfer, shower transfer, personal hygiene, toileting hygiene, and oral hygiene. A review of Resident 16's Order Summary Report, dated 9/29/2023, indicated a physician's order to administer Carvedilol (a medication that slows down the heart rate making it easier for the heart to pump blood around the body) 25 mg by mouth two times a day and Metformin 1000 mg by mouth two times a day. A review of Resident 16's MAR from 10/1/2023-10/31/2023, indicated Resident 16 was scheduled to received Carvedilol 25 mg and Metformin 1000 mg at 7AM. During an observation of the medication administration for Resident 16 on 10/31/2023, at 8:11 AM, LVN 1 administered Carvedilol 25 mg 1 tablet by mouth and Metformin 1000 mg 1 tablet by mouth to Resident 16. 2.c. A review of Resident 41's admission Record indicated Resident 41 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included unspecified dementia (a brain disorder that results in memory loss, poor judgment and confusion), major depressive disorder (a mental health disorder characterized by persistently depressed mood or low interest in activities), and hypertensive heart disease. A review of Resident 41's MDS, dated [DATE], indicated Resident 41 had severely impaired cognition for daily decision making and required extensive assistance with one-persons physical assistance with dressing, toilet use, and personal hygiene and required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) with one-person physical assistance with bed mobility, transfer, walk in room/corridor, and locomotion on/off unit. A review of Resident 41's Order Summary Report, dated 9/29/2023, indicated a physician's order to administer Carvedilol 3.125 mg by mouth two times a day for hypertension. A review of Resident 41's MAR from 10/1/2023-10/31/2023, indicated Resident 41 was scheduled to received Carvedilol 3.125 mg at 7AM. During an observation of the medication administration for Resident 41 on 10/31/2023, at 8:37 AM, LVN 1 administered Carvedilol 3.125 mg 1 tablet by mouth to Resident 41. 2.d. A review of Resident 45's admission Record indicated Resident 45 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included pneumonia (an infection that affects one or both lungs), unspecified dementia, and schizophrenia (a mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others). A review of Resident 45's MDS dated [DATE], indicated Resident 45 had severely impaired cognition for daily decision making. The MDS indicated Resident 45 had total dependence (full staff performance every time) with one-person physical assist for eating and toilet use and required extensive assistance with one-person physical assist for bed mobility, transfer, locomotion on/off unit, dressing, and personal hygiene. A review of Resident 45's Order Summary Report, dated 9/29/2023, indicated a physician's order to administer the following medications: 1. Amlodipine (a medication to treat high blood pressure) 10 mg via PEG-Tube (a flexible tube surgically inserted through the wall of the abdomen directly into the stomach for feeding, fluid, and medication administration) one time a day 2. Citalopram (a medication used to treat depression) 10 mg via PEG-Tube one time a day 3. Eliquis (a medication used to prevent blood clots in the vein) 5 mg via PEG-Tube two times a day for atrial fibrillation (irregular heartbeat) 4. Namenda (a medication used to treat dementia) 5 mg via PEG-Tube two times a day 5. Quetiapine Fumarate (a medication used to treat different kinds of mental health conditions including schizophrenia) 25 mg via PEG-Tube every 12 hours 6. Ferrous Sulfate (a medication used to treat anemia [a lack of red blood cells caused by having too little iron in the body) 300 mg give 7.5 milliliters (ml- unit of measurement) via PEG-Tube two times a day every other day During an observation of the medication administration for Resident 45 on 10/31/2023, at 10:12 AM, LVN 1 administered the following medications via Resident 45's PEG-Tube: 1. Ferrous Sulfate 300 mg 7.5 milliliters 2. Citalopram 10 mg 3. Amlodipine 10 mg 4. Namenda 5 mg 5. Eliquis 5 mg 6. Quetiapine Fumarate 25 mg During a record review of Resident 45's Medication Administration Record (MAR) from 10/1/2023-10/31/2023, the MAR indicated Resident 45 was scheduled to receive the following medications at 9:00 AM: 1. Amlodipine 10 mg 2. Citalopram 10 mg 3. Eliquis 5 mg 4. Ferrous Sulfate 330 mg 5. Namenda 5 mg 6. Quetiapine 25 mg During an interview with LVN 1 on 10/31/2023, at 10:28 AM, LVN 1 confirmed the medications administered for Residents 16, 41, and 48 were medications scheduled for 7AM. LVN 1 confirmed the medications administered to Resident 45 were scheduled for 9AM. LVN 1 stated medication administration started late because she assisted with feeding the residents their breakfast. LVN 1 stated she needs to manage her time better and will speak to the Director of Nursing (DON). LVN 1 stated, It is important for residents to get their medications on time for their health. LVN 1 added if medications were not administered on time, it can affect the blood pressure or blood sugar of the residents which can cause a change in the residents condition. During an interview with the DON on 10/31/2023 at 3:02 PM, the DON stated LVN 1 should have asked for help when she started falling behind with medication administration. The DON stated residents can have a change in condition if medications were not given on time. During an interview with Registered Nurse (RN 1) on 11/02/2023, at 5:48 PM, RN 1 stated it was the responsibility of the LVN administering medications to administer the medications on time. RN 1 stated the acceptable time to give medications was one (1) hour before or one hour after the scheduled time. RN 1 stated if the LVN administering the medications should ask for assistance if running behind schedule. RN 1 stated residents who need medications for blood pressure, blood sugar, or seizures (abnormal electrical activity in the brain that happens quickly) can have medication complications if medications were received late. A record review of the facility's policy and procedure (P&P) titled, Administering Medications, revised on April 2019, indicated Medications are administered in accordance with prescriber orders, including any required time frame. The P&P also indicated, Medications are administered within 1 hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors by failing to administer 10 medications on 10/31/2023 according to the physician's order for five (5) of 11 residents observed for medication administration (Residents 9, 16, 41, 45, and 48). 1. Late administration of Metoprolol Tartrate (a medication used to treat high blood pressure) 50 milligrams (mg-a unit of measure for mass) for Resident 9. 2. Late administration of Metformin (a medication used to treat high blood sugar levels caused by type 2 diabetes) 850 mg for Resident 48. 3. Late administration of Carvedilol (a medication that slows down the heart rate making it easier for the heart to pump blood around the body) 25 mg and Metformin 1000 mg for Resident 16. 4. Late administration of Carvedilol 3.125 mg for Resident 41. 5. Late administration of Citalopram (a medication used to treat depression) 10 mg, Amlodipine (a medication used to treat high blood pressure) 10 mg, Namenda (a medication used to treat dementia) 5 mg, Eliquis (a medication used to treat blood clots in the vein), and Quetiapine Fumarate (a medication used to treat different kinds of mental health conditions including schizophrenia) 25 mg for Resident 45. The deficient practice of failing to administer the medications in accordance with the physician's orders increased the risk for Residents 9, 16, 41, 45, and 48 to may have experienced serious medical complications such as a psychiatric emergency, stroke or complications related to poor blood sugar or blood pressure control possibly resulting in hospitalization or death. Crossed reference F759 Findings: 1. A review of Resident 9's admission Record indicated Resident 9 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included sepsis (infection of the blood) of unspecified organism, type 2 diabetes mellitus (a disease that occurs when your blood sugar is too high), and hypertension (high blood pressure). A review of Resident 9's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 10/10/2023, indicated Resident 9 had moderately impaired cognition (thought process and ability to reason or make decisions) for daily decision making and required partial/moderate assistance (helper does less than half the effort) with shower/bathing self and supervision with oral hygiene, toileting hygiene, upper/lower body dressing, personal hygiene, and putting on/taking off footwear. A review of Resident 9's Order Summary Report, dated 9/29/2023, indicated a physician's order to administer Metoprolol Tartrate 50 milligrams (mg- unit of measurement of mass) by mouth two times a day for hypertension. During an observation of the medication administration for Resident 9 on 10/31/2023, at 7:44 AM, LVN 1 administered Pioglitazone (a medication used to treat high blood sugar levels caused by type 2 diabetes) 30 mg 1 tablet by mouth and Metformin 1000 mg 1 tablet by mouth to Resident 9. During a record review of Resident 9's Medication Administration Record (MAR) from 10/1/2023-10/31/2023, the MAR indicated Resident 9 was scheduled to receive three medications at 7 AM: 1. Pioglitazone 30 mg 2. Metformin 1000 mg 3. Metoprolol Tartrate 50 mg During an interview with LVN 1 on 10/31/2023, at 2:50 PM, LVN 1 confirmed she did not administer Metoprolol at 7 AM as scheduled. LVN stated she administered Metoprolol to Resident 9 at around 10:30 AM. LVN 1 stated she did not notice the Metoprolol 50 mg bubble pack (medication container) when she administered the 7 AM medications. 2. A review of Resident 48's admission Record indicated Resident 48 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included cellulitis (a deep infection of the skin caused by bacteria) of the right lower limb, type 2 diabetes mellitus, and heart failure. A review of Resident 48's MDS, dated [DATE], indicated Resident 48 had intact memory and cognition for daily decision making and required extensive assistance (resident involved in activity, staff provide weight-bearing support) with one-persons physical assistance with bed mobility, transfer, walk in room/corridor, locomotion (movement or the ability to move from one place to another) on/off unit, dressing, toilet use, and personal hygiene. Resident required supervision with setup help for eating. A review of Resident 48's Order Summary Report, dated 9/29/2023, indicated a physician's order to administer Metformin 850 mg by mouth two times a day for type 2 diabetes mellitus. A record review of Resident 48's MAR from 10/1/2023-10/31/2023, the MAR indicated Resident 48 was scheduled to received Metformin 850 mg at 7 AM. 3. A review of Resident 16's admission Record indicated Resident 16 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included thrombocytopenia (a condition that occurs when the platelet [a fragment in the blood that prevents or stops bleeding] count in the body is too low), type 2 diabetes, and bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). A review of Resident 16's MDS, dated [DATE], indicated Resident 16 had intact memory and cognition for daily decision making and required partial/moderate (helper does less than half the effort) assistance with showers and taking off footwear. Resident 16 also required supervision or touching assistance with toilet transfer, shower transfer, personal hygiene, toileting hygiene, and oral hygiene. A review of Resident 16's Order Summary Report, dated 9/29/2023, indicated a physician's order to administer Carvedilol 25 mg by mouth two times a day and Metformin 1000 mg by mouth two times a day. A review of Resident 16's MAR from 10/1/2023-10/31/2023, indicated Resident 16 was scheduled to received Carvedilol 25 mg and Metformin 1000 mg at 7 AM. During an observation of the medication administration for Resident 16 on 10/31/2023, at 8:11 AM, LVN 1 administered Carvedilol 25 mg 1 tablet by mouth and Metformin 1000 mg 1 tablet by mouth to Resident 16. 4. A review of Resident 41's admission Record indicated Resident 41 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included unspecified dementia (a brain disorder that results in memory loss, poor judgment and confusion), major depressive disorder (a mental health disorder characterized by persistently depressed mood or low interest in activities), and hypertensive heart disease. A review of Resident 41's MDS, dated [DATE], indicated Resident 41 had severely impaired cognition for daily decision making and required extensive assistance with one-persons physical assistance with dressing, toilet use, and personal hygiene and required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) with one-person physical assistance with bed mobility, transfer, walk in room/corridor, and locomotion on/off unit. A review of Resident 41's Order Summary Report, dated 9/29/2023, indicated a physician's order to administer Carvedilol 3.125 mg by mouth two times a day for hypertension. A review of Resident 41's MAR from 10/1/2023-10/31/2023, indicated Resident 41 was scheduled to received Carvedilol 3.125 mg at 7 AM. During an observation of the medication administration for Resident 48 on 10/31/2023, at 8:04 AM, LVN 1 administered Metformin 850 mg 1 tablet by mouth. During an observation of the medication administration for Resident 41 on 10/31/2023, at 8:37 AM, LVN 1 administered Carvedilol 3.125 mg 1 tablet by mouth to Resident 41. 5. A review of Resident 45's admission Record indicated Resident 45 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included pneumonia (an infection that affects one or both lungs), unspecified dementia, and schizophrenia (a mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others). A review of Resident 45's MDS, dated [DATE], indicated Resident 45 had severely impaired cognition for daily decision making. The MDS indicated Resident 45 had total dependence (full staff performance every time) with one-person physical assist for eating and toilet use and required extensive assistance with one-person physical assist for bed mobility, transfer, locomotion on/off unit, dressing, and personal hygiene. A review of Resident 45's Order Summary Report, dated 9/29/2023, indicated a physician's order to administer the following medications: 1. Amlodipine 10 mg via PEG-Tube (a flexible tube surgically inserted through the wall of the abdomen directly into the stomach for feeding, fluid, and medication administration) one time a day. 2. Citalopram 10 mg via PEG-Tube one time a day. 3. Eliquis 5 mg via PEG-Tube two times a day for atrial fibrillation (irregular heartbeat) 4. Namenda 5 mg via PEG-Tube two times a day. 5. Quetiapine Fumarate 25 mg via PEG-Tube every 12 hours. 6. Ferrous Sulfate (a medication used to treat anemia [a lack of red blood cells caused by having too little iron in the body) 300 mg give 7.5 milliliters (ml- unit of measurement) via PEG-Tube two times a day every other day. During an observation of the medication administration for Resident 45 on 10/31/2023, at 10:12 AM, LVN 1 administered the following medications via Resident 45's PEG-Tube: 1. Ferrous Sulfate 300 mg 7.5 milliliters 2. Citalopram 10 mg 3. Amlodipine 10 mg 4. Namenda 5 mg 5. Eliquis 5 mg 6. Quetiapine Fumarate 25 mg During a record review of Resident 45's Medication Administration Record (MAR) from 10/1/2023-10/31/2023, the MAR indicated Resident 45 was scheduled to receive the following medications at 9:00 AM 1. Amlodipine 10 mg 2. Citalopram 10 mg 3. Eliquis 5 mg 4. Ferrous Sulfate 330 mg 5. Namenda 5 mg 6. Quetiapine 25 mg During an interview with LVN 1 on 10/31/2023, at 10:28 AM, LVN 1 confirmed the medications administered for Residents 16, 41, and 48 were medications scheduled for 7 AM. LVN 1 confirmed the medications administered to Resident 45 were scheduled for 9 AM. LVN 1 stated medication administration started late because she assisted with feeding the residents their breakfast. LVN 1 stated she needs to manage her time better and will speak to the Director of Nursing (DON). LVN 1 stated, It is important for residents to get their medications on time for their health. LVN 1 added if medications were not administered on time, it can affect the blood pressure or blood sugar of the residents which can cause a change in the residents' condition. During an interview with the DON on 10/31/2023 at 3:02 PM, the DON stated LVN 1 should have asked for help when she started falling behind with medication administration. The DON stated residents can have a change in condition if medications were not given on time. During an interview with Registered Nurse (RN 1) on 11/02/2023, at 5:48 PM, RN 1 stated it was the responsibility of the LVN administering medications to administer the medications on time. RN 1 stated the acceptable time to give medications was one (1) hour before or one hour after the scheduled time. RN 1 stated if the LVN administering the medications should ask for assistance if running behind schedule. RN 1 stated residents who need medications for blood pressure, blood sugar, or seizures (abnormal electrical activity in the brain that happens quickly) can have medication complications if medications were received late. A record review of the facility's policy and procedure (P&P) titled, Administering Medications, revised on April 2019, indicated Medications are administered in accordance with prescriber orders, including any required time frame. The P&P also indicated, Medications are administered within 1 hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Based on observation, interview, and record review, the facility failed to store and dispose medication for one of one medication storage room in accordance with the facility's policy and procedure. There were four (4) medications observed stored in the medication storage room with past the expiration date. In addition, there were 4 bottles of medications/ supplements that were stored in the Director of Nursing's (DON) office. These deficient practices had the potential to cause inaccurate test results when expired blood sugar strips are used, medication error (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturers specifications [not recommendations] regarding the preparation and administration of the medication or biological; accepted professional standards and principles which apply to professionals providing services), and for residents to be exposed to adverse side effects ( unwanted undesirable effects that are possibly related to a drug) of using expired supplies such as signs of an allergic reaction, like rash, itching, severe dizziness and trouble breathing in the event that it was used. Findings: During a concurrent observation in the medication room, and interview with Registered Nurse 2 (RN 2) on 10/31/2023 at 2:30 PM, RN 2 stated storing expired medications and supplies increase the risk to be mistakenly used and can cause possible harm to the residents. RN 2 stated, expired medications and supplies should not be kept in the medication room. RN 2 stated the following expired medications were stored in medication room: a. One (1) bottle of blood sugar strip (strips used with glucose meters to read your blood sugar levels) with expiration date of 4/13/2023 b. One (1) bottle of blood sugar strip with expiration date of 7/5/2023. During a concurrent observation in the medication room and interview with Director of Nursing (DON) on 10/31/2023 at 2:40 PM, the DON stated, expired blood sugar check supplies might not be beneficial and could cause harm to the residents. During a concurrent observation in the DON's office and interview with DON on 11/2/2023 at 11 AM, the DON stated, only discontinued and expired narcotic (a controlled substance, a drug or chemical whose manufacture, possession, or use is regulated by a government) medications are kept in her office. The DON stated, there is a designated locked cabinet in her office for these expired and discontinued narcotic medications. The DON stated that expired and discontinued medications and house supplies such as vitamins and stool softeners that are not narcotics are being disposed in the designated disposable bin that is located inside the medication storage room. The DON stated the following were in DON's office: a. 1 bottle of stool softener with expiration date of 7/2023 b. 1 bottle of vitamins with expiration date of 10/2023 c. 2 bottles of acetaminophen (used to treat minor aches and pains) d. 2 bottles of zinc (mineral that is essential for many of the body's normal functions and systems) e. 2 bottles of Magnesium chloride (mineral supplement used to increase your intake of magnesium) During the same interview on 11/2/2023 at 11 AM, the DON stated, she was not aware that these 8 bottles of medications are in her office. The DON stated, these items should not be in the DON's office and should be in the medication room, and the expired stool softener and vitamins should have been disposed already. A review of the facility's policy and procedure (P&P) titled, Discarding and Destroying Medications revised 04/2019, indicated policy that medications will be disposed of in accordance with federal, state, and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste, and controlled substances. Both controlled and non-controlled substances may be disposed of in the collection receptacle. A review of the facility's policy and procedure (P&P) titled, Storage of Medication, revised 11/2020, indicated policy that the facility stores all drugs and biologicals in a safe, secure, and orderly manner. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow the diet menu instructions when serving lunch for two of four sampled residents. (Residents 45 and 61). This had the potential for the residents not to receive the required amount of nutrition as indicated on the therapeutic diet (a meal plan that controls the intake of certain foods or nutrients in the treatment or management of certain diseases, illnesses, or medical conditions) menu, which could lead to weight loss or gain. Findings: a. A review of Resident 45's admission Record indicated Resident 45 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of dysphagia (difficulty swallowing), Gastro-Esophageal Reflux Disease (GERD - a digestive disease in which stomach acid or contents irritates the food pipe lining), and Type 2 Diabetes Mellitus (a disorder in which the body does not produce enough or respond normally to insulin [a hormone released from the pancreas that controls the amount of glucose in the blood], causing blood sugar [glucose] levels to be abnormally high), and encounter for attention to gastrostomy tube (G-Tube - a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration). A review of Resident 45's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 8/23/2023, indicated Resident 45 had severe cognitive (mental action or process of acquiring knowledge and understanding) impairment for daily decision making. The MDS indicated Resident 45 required extensive assistance (resident involved in activity, staff provide weight-bearing support) for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed), transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position), locomotion on unit (how resident moves between location in his/her room) and off unit (how resident moves to and returns from areas such as activities, treatment, or dining), dressing, eating, and personal hygiene (practices conducive to maintaining health and preventing disease, especially through cleanliness). A review of Resident 45's Physician's Order Summary Report for the month of October 2023, indicated Resident 45's diet order was for no added salt (NAS - food is seasoned as regular food), consistent (or controlled) carbohydrate (one of several substances such as sugar or starch that provide the body with energy) diet (CCHO - a restrictive diet that involves eating the same numbers of carbohydrate daily) pureed (a food item that has been blended, mixed, or processed into a smooth and uniform texture) texture small portion for breakfast and lunch only. b. A review of Resident 61's admission Record indicated Resident 61 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of dysphagia, Type 2 Diabetes Mellitus, and encounter for attention to gastrostomy tube. A review of Resident 61's MDS dated [DATE], indicated Resident 61 had severe cognitive impairment for daily decision making. The MDS indicated Resident 61 required extensive assistance for bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing. The MDS also indicated Resident 61 required total dependence (full staff performance) for eating. A review of Resident 61's Physician's Order Summary Report for the month of October 2023, indicated Resident 61's diet order was NAS, CCHO diet pureed texture of two meals per day (lunch and dinner) with small portion. A review of the cook's spreadsheet fall menu, dated 11/1/2023, indicated pureed beef cubes with mushroom for small portion required scope #8 (1/2 cup). It also indicated pureed egg noodles for small portion required scoop #16. During a lunch tray observation on 11/1/2023 at 12:07 PM, the Dietary [NAME] (Cook 1) used one scoop of pureed beef cubes with mushrooms using the blue # 16 scoop (1/4 cup) instead of the gray # 8 scoop for Residents 45 and 61 per the cook's spreadsheet menu. [NAME] 1 used one scoop of the gray #8 instead of the blue # 16 scoop for the pureed egg noodles for small portions to Resident 45 and 61. During an interview on 11/1/2023 at 12:21 PM, [NAME] 1 stated that he thought the menu small portion size for the pureed beef cubes with mushrooms was scoop # 16. [NAME] 1 stated for the pureed egg noodles he used scoop # 8. During an interview on 11/1/2023 at 12:47 PM with the Dietary Supervisor (DS), the DS stated for small portion size Residents 45 and 61 were supposed to receive scoop #8, instead they received scoop # 16 for the pureed beef cubes with mushrooms. The DS stated the pureed egg noodles small portion were given with scoop # 8 and [NAME] 1 was supposed to serve the portion with scoop # 16. The DS stated the correct scoop should be used to follow menu portions and ensure all residents receive their adequate nutritional needs. The DS stated different portions could cause residents to either lose weight or gain weight. A review of the facility's policy and procedure titled, Portion Sizes, dated 2023, indicated the small and large portion servings will be served as printed on the cook's spreadsheets for every meal.

Based on observation, interview, and record review, the facility failed to label foods in the kitchen with item names, open date, and expiration date and discard expired food as indicated on the facility policy. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization. Findings: During a concurrent observation in the kitchen and interview with [NAME] 1 on 10/30/2023 at 8:26 AM, [NAME] 1 stated all food items were supposed to be labeled with item name and dated with the open and used by date. In Freezer 1 were the following: a. Ham dated 10/22/2023. The date did not indicate if it was received on this date or needed to be used by this date. b. A piece of turkey was dated 9/7/2023. The date did not indicate if it was received on this date or needed to be used by this date. c. An unidentified meat dated received on 10/24/2023 was not labelled with item name and a use by date. d. Two packs of chicken were not labeled with item name and did not have a receive date or use by date. Cook 1 stated the ham and turkey were not labelled with an expiration date. [NAME] 1 verified all above food items were incompletely labeled since they were either missing the item name or used by date. During a concurrent observation in the kitchen and interview with [NAME] 1 on 10/30/2023 at 8:28 AM, in Freezer 2 were the following: a. Two bags of patties were not labeled with item name and was not dated. b. One bag of kielbasas was not labelled with item name or dated. In Freezer 3 were 13 small Styrofoam containers which were not labelled with food item name. [NAME] 1 stated the two packs of sausage patties were not labelled with the item name and was not dated. [NAME] 1 stated the bag of kielbasas was not labelled with item name and dated. [NAME] 1 stated the small containers had ice cream and they were supposed to be labeled with the item name but were not labelled. During a concurrent observation in the kitchen and interview with the Dietary Supervisor (DS) on 10/30/2023 at 8:41 AM, in the walk-in refrigerator were the following: a. Three cups of rice pudding with an expiration date of 10/20/2023. b. One gallon of opened tartar sauce had a used by date of 10/2/2023. c. An opened bottle of purified drinking water did not have a receive and use by date. d. 11 pasteurized eggs were not labeled with item name and was not dated with a receive and use by date. e. Three packs of ground meat were not labeled with item name and use by date. f. Two bags of chicken were not labeled with item name and use by date. g. Three packs of meat were not labelled with item name and use by date. h. Five packs of leafy greens, one bag of tomatoes, three bags of onions, one bag of celery, and three heads of cabbage were not dated with receive date. The DS stated the three packs of ground beef, chicken and pork were supposed to be labelled with item name and used by date. The DS stated food items were supposed to be monitored by kitchen staff and expired items were supposed to be discarded. The DS also stated food items needed to be labeled with item name and received by and used by date. During an observation with the DS on 10/30/2023 at 8:58 AM, in the Storage Room were the following: a. One large round container of labelled brown rice without a label indicating received or used by date. b. One large ground container of labelled flour without a label indicating received or used by date. c. One large round container of labelled thickener did without a received or used by date. d. Two bags of potatoes and four bunches of bananas were not labeled with received date. During an observation with the DS on 10/30/2023 at 8:59 AM in the kitchen, a container of ground mustard seasoning 1 pound (lb.), poultry seasoning 12 ounce (oz), ground sage seasoning 12 oz, one gallon of sesame oil, low sodium beef flavored soup base 1 lb. were expired. The DS stated these items were all expired and needed to be thrown away. During an interview with the DS on 10/31/2023 at 2:01 PM, DS stated food items needed to be labeled to make sure the facility gave the right products to the residents. The DS stated items needed to be labeled by received and used by date so expired foods were not given to the residents. A review of the facility's policy and procedure titled, Labeling and Dating of Foods, dated 2023, indicated all food items in the storeroom, refrigerator, and freezer need to be labeled and dated. Newly opened food items needed to be labeled with an open date and used by date. The policy also indicated produce is to be dated with received date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure one of four sampled Residents (Residents 6) was treated with respect and dignity by failing to keep the resident's clothing dry, free from food stains and accumulated food particles. The deficient practice had the potential to negatively affect Resident 6 's sense of self-esteem/ emotional well-being. Findings: A review of the admission Record indicated Resident 6 was admitted to the facility on [DATE]. Resident 6's diagnoses included contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of the right elbow and right hand, lack of coordination (the ability to use different parts of the body together smoothly and efficiently), and Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves.) A review of Resident 6's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 10/07/22, indicated the resident usually made self-understood and understood others. Resident 6 had moderate impairment in cognitive skills (the ability of an individual to perform the various mental activities most closely associated with learning and problem-solving.) for daily decision making. The MDS indicated Resident 6 needed supervision (staff oversight, encouragement or cueing provided) with eating. Resident 6 needed extensive assistance (resident involved in activity, staff provided weight-bearing support) from staff with dressing, personal hygiene, and total dependence with transfer and toilet use. During a concurrent meal observation and interview on 11/02/22 at 12:40 PM, Resident 6 was observed sitting in a wheelchair in the hallway. Resident 6 was observed having a white towel covering below his chest. Resident 6 was wearing a shirt that was wet and had food stains and accumulated food particles. Certified Assistant Nurse 1 (CNA1) stated Resident 6's shirt was wet and soiled. During a concurrent observation and interview with the Registered Nurse (RN 2) on 11/02/22 at 12:45 PM, RN 2 stated Resident 6 needed to be changed right away as his shirt was very soiled. RN 2 also stated Resident 6's dignified dining experience was not granted. RN 2 further stated she would find a CNA and ensure Resident 6 would be changed. A review of License Nurse Weekly Summary, dated 11/03/22, indicated Resident 6 needed supervision with eating. A review of facility's policy and procedure titled, Dignity, revised February 2021, indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The policy also indicated that when assisting with care, residents are supported in exercising their rights. For example, residents are provided with a dignified dining experience.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the call light (a device used by a resident to signal his or her need for assistance from staff) was within reach and a call light that was appropriate for to use for one of 19 sampled resident (Resident 42). Resident 42's call light cord was on the floor, out of reach of the resident. Resident 42 also did not have the ability to pull the call light cord even when it was within reach. This deficient practice had the potential for the delay in meeting residents' needs to get assistance. Findings: A review of Resident 42's Face Sheet (a record of admission) indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood), and schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms). A review of Resident 42's Minimum Data Set (MDS, standardized assessment and care planning tool), dated 7/21/22, indicated the resident was severely impaired in cognitive skills (ability to make daily decisions) and was totally dependent on staff for transferring, dressing, personal hygiene, and toileting. During an observation and interview, on 11/1/22 at 9:16 AM, the Infection Preventionist (IP) verified Resident 42's call light cord was on the floor. IP stated if the resident could not activate the call light, then there was a potential his needs would not be met timely and there was also a risk that staff would not be able to respond to any possible medical emergency. IP also stated Resident 42 was not able to activate the call light system by pulling the call light cord when it was placed on his gown over his right chest. IP stated the resident could not activate the call light system and needed a different type of call light since he was too weak to pull the cord. During an interview, on 11/01/22 at 9:22 AM, Resident 42 stated he would yell for help because he could not pull the call light cord to get help from the facility staff. During an interview, on 11/1/22 at 11:07 AM, Resident 42's Responsible Party 1 (RP 1) stated when she would come to visit Resident 42, she would sometimes here him calling out for help. RP 1 stated Resident 42 could not use the call light cord he had right now. RP 1 stated that he used to have a push button at the bedside, but that it has been missing for months. A review of the facility's policy and procedure (P&P) titled, Accommodation of Needs, revised 3/2021, indicated the resident's individual needs and preferences were accommodated to the extent possible. The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, were evaluated upon admission and reviewed on an ongoing basis. A review of the facility's P&P titled, Answering the Call Light, revised 3/2021, indicated the facility would upon admission and periodically as needed, explain and demonstrate use of the call light to the resident. The facility would ask the resident to conduct a return the demonstration.

Based on observation, interview, and record review, the facility failed to ensure the most recent State and Federal inspection results were posted in a manner that was clear and visible for the residents and their families, including for five of five residents who attended the resident group meeting. This deficient practice had the potential to prevent the residents' right to view inspection results. Findings: During a resident group meeting on 11/02/22 at 10:13 AM, five of five alert, verbal, and oriented residents stated that they did not know where to find the latest State and Federal inspection results for the facility. During an observation in the south nursing station on 11/02/22 at 10:42 AM, a binder was placed in a container mounted to the wall. There was an advertisement covering the container's label. During a concurrent interview on 11/02/22 at 10:42 AM, the Director of Nursing (DON) stated an advertisement covered the signage of the binder, which contained the inspection results. The DON stated the residents' had the right to know where the survey binder was located. A review of the facility's policy and procedure titled, Resident Rights, revised 2/2021, indicated that federal and state laws guaranteed certain basic rights to all residents of the facility. These rights included the residents' right to know where to examine survey results.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide eating assistance to one of four sampled residents (Resident 6) who was observed using nondominant hand (left hand) to eat. This deficient practice had the potential for decline in the Resident's ability to perform activities of daily living (ADL) specifically with eating. This also resulted in the resident not being able to pick up all his food on the plate and was observed with food on his shirt, which placed the resident at risk for weight loss. Findings: A review of the admission Record indicated Resident 6 was admitted to the facility on [DATE]. Resident 6's diagnoses included contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of the right elbow and right hand, lack of coordination (the ability to use different parts of the body together smoothly and efficiently), and Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves.) A review of Resident 6's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 10/07/22, indicated the resident usually made himself-understood and understand others. Resident 6 had moderate impairment in cognitive skills (the ability of an individual to perform the various mental activities most closely associated with learning and problem-solving.) for daily decision making. The MDS indicated Resident 6 needed supervision (staff provided cueing, oversight, or encouragement) with eating and needed extensive assistance (while resident performed part of activities, staff provided weight-bearing support) from staff with dressing, personal hygiene, and total dependence with transfer and toilet use. During a concurrent meal observation and interview on 11/02/22 at 12:40 PM to 12:43 PM, Resident 6 was observed sitting in a wheelchair in the hallway. Resident 6 was observed having a white towel covering below his chest. Resident 6 was wearing a wet shirt and had food stains on it. Food particles accumulation was observed all over Resident 6's chest area. Resident 6 stated, I am outside the room. I cannot use the call light. No one comes to feed me, I feel I have no other option but eat by myself. Resident 6 told Certified Nurse Assistant 1 (CNA1) that he needed help with eating. CNA1 confirmed Resident 6 was having difficulty picking up food using his left hand. During a concurrent interview with the Registered Nurse (RN 2) on 11/02/22 at 12:45 PM, RN 2 validated and confirmed Resident 6 was not able to pick up salad on his plate using his left hand, which was the resident's nondominant hand. RN 2 stated Resident 6 has contractures on his right hand. RN 2 stated Resident 6 needed help with eating or he would not consume all his food. RN2 stated, It would put him at risk for weight loss. A review of Resident 6's care plan titled, ADLs/Functional Mobility, revised and updated on 04/08/22, included staff interventions were to encourage Resident to participate in activities such as feeding, toileting and bathing. A review of License Nurse Weekly Summary, dated 11/03/22, indicated Resident 6 needed supervision with eating. A review of the facility's policy and procedure titled, Assistance with Meals revised March 2022, stipulated outlines that a. Facility staff will serve resident trays and will help residents who require assistance with eating. b. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity. A review of the facility's policy and procedure titled, Supporting Activities of ADLs, revised March 2018, indicated that residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on observation, interview, and record review, the facility failed to thoroughly clean the lint trap from the facility's dryer machine. This deficient practice placed the facility and residents at risk for fire hazards. Findings: During an observation and interview on 11/01/22 at 10:42 AM, the facility's laundry room had one washer and one dryer. Laundry Supervisor (LS) opened the dryer's front compartment to check the lint trap and found colored lint on the bottom surface of the compartment. LS stated the laundry staff last cleaned the lint trap at 6 AM. LS stated the lint trap was supposed to be cleaned every two hours. LS stated no one removed the dryer lint at 8 AM and 10 AM. LS proceeded to remove the lint from the front compartment's bottom surface and from the lint screen. LS stated he did not know how and had never removed the dryer's lint screen before. LS called the Maintenance Assistant (MA) for assistance. During an observation and interview on 11/01/22 at 10:49 AM, MA came into the laundry room and removed the dryer's lint screen. MA and LS observed a layer of lint around an internal compartment located between the lint screen and the dryer's lint vent. LS stated the lint present in this internal compartment was a fire hazard. A review of the facility's policy and procedure titled, Interior Maintenance Laundry Room/ Water Temperature, effective 1/1/1999, indicated maintenance of the clothes dryer included to check that the laundry personnel were cleaning filters every two hours, vacuum areas around filters, and to make sure equipment was free of lint.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure proper care and treatment for gastrostomy tube (G-tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach) was provided for one of three sampled residents (Resident 35). Resident 35's head of bed (HOB) was not elevated to an angle of 30 to 45 degrees while the resident was receiving G-tube feeding (a liquid food mixture provided through the G-tube). This deficient practice had the potential for the resident to acquire aspiration (when something you swallow enters your lungs) pneumonia (infection that inflames air sacs in one or both lungs) and/or choke. Finding: A review of Resident 35's Face Sheet (a record of admission) indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included urinary tract infection (UTI, an infection in any part of the urinary system, including the kidneys, bladder, or urethra), dementia (a group of thinking and social symptoms that interferes with daily functioning), and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A review of Resident 35's Minimum Data Set (MDS, standardized assessment and care planning tool), dated 10/4/22, indicated the resident was severely impaired in cognitive skills (ability to make daily decisions) and was totally dependent on staff for transferring, dressing, personal hygiene, and toileting. A review of Resident 35's monthly Oder Summary Report for October 2022, indicated to elevate the HOB 30 to 45 degrees during G-tube feeding. During an observation and interview on 11/2/22 at 3:19 PM, a Licensed Vocational Nurse 2 (LVN 2) stated Resident 35 was receiving G-tube feeding and the HOB was elevated to 20 degrees. LVN 2 stated she normally estimated the proper angle of the HOB while the resident was receiving G- tube feeding by raising the HOB to a distance halfway between flat and 90 degrees. During an observation and interview on 11/2/22 at 3:22 PM, the Director of Staff Development (DSD) stated Resident 35 was receiving G-tube feeding and the HOB was raised to 20 degrees. DSD stated Resident 35's HOB should be raised to 30 to 45 degrees while the resident was receiving G-tube feeding. DSD stated the resident was at risk for aspiration if the HOB was too low. A review of the facility's policy and procedure titled, Enteral Feedings - Safety Precautions, revised 11/2018, indicated staff were to elevate the HOB to at least 30 degrees during tube feeding and at least one hour after feeding.

Based on observation, interview, and record review, the facility failed to ensure the kitchen was maintained in a sanitary manner. The facility failed to label and secure an open container of uncooked bacon and label prepared food in the refrigerator. These deficient practices had the potential to promote food-borne illnesses. Findings: During an observation and interview in the kitchen, on 11/01/22 at 8:34 AM, the Dietary Supervisor (DS) stated there were seven of eight pitchers of juice in the walk-in refrigerator not labeled with a date (when it was prepared). DS stated the pitchers should have been dated to know when the facility staff prepared them. The walk-in refrigerator also had an opened box containing an opened plastic bag of uncooked bacon not labeled when it was opened. DS stated the uncooked bacon should be in a closed container and should have been labeled with an open date and best-by (use by) date, which was usually five days after opening. DS stated it was important for the uncooked bacon container to be sealed and dated to prevent bacteria from growing and prevent food-borne illnesses. A review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage, revised 10/2017, indicated foods shall be received and stored in a manner that complied with safe food handling practices. The P&P indicated all foods stored in the refrigerator or freezer would be covered, labeled, and dated with a use by date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that information contained in the Physician Orders for Life Sustaining Treatment (POLST) form for three of four sampled residents (Residents 61, 15, and 49) was accurate. 1. Resident 61's Physician Orders did not indicate the resident's code status (the type of emergency treatment a person would or would not receive if their heart or breathing were to stop) as Do Not Resuscitate [DNR, health care providers not to do cardiopulmonary resuscitation (CPR, a medical technique for reviving someone whose heart has stopped beating by pressing on their chest and breathing into their mouth)] as indicated on her POLST. 2 and 3. Resident 15 and Resident 49 did not have a POLST and the facility did not provide the resident with advanced directive (legal documents that allow you to spell out your decisions about end-of-life care ahead of time) information. These deficient practices had the potential for the residents to receive unnecessary care and/or treatment services against the residents' wishes. Findings: 1. A review of Resident 61's Face Sheet (a record of admission) indicated the resident was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), osteoarthritis (A type of arthritis [swelling and tenderness of joints] that occurs when flexible tissue at the ends of bones wears down), and unsteadiness of feet. A review of Resident 61's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated [DATE], indicated the resident was moderately impaired in cognitive skills (ability to make daily decisions) and required limited assistance from staff for transferring, dressing, and toileting. A review of Resident 61's POLST, dated [DATE], indicated the resident's code status was DNR. Resident 61's responsible party and physician signed the POLST. A review of Resident 61's monthly Oder Summary Report for [DATE], did not indicate a code status as ordered. During an interview and record review, on [DATE] at 1:47 PM, the Director of Nursing (DON) confirmed Resident 61's monthly Order Summary Report for [DATE] was missing an order for the resident's code status. DON stated Resident 61 would be considered a full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive) since the resident's physician did not write an order to follow the code status of DNR as indicated on the resident's POLST. DON stated because there was no order for DNR, then there was a potential to not honor the resident's wishes and/or provide medical interventions the resident did not want. 2. A review of Resident 15's Face Sheet indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included major depression (a group of conditions associated with the elevation or lowering of a person's mood), bipolar disorder (a disorder associated with episodes of mood swings that include emotional highs and low), and spondylosis (a general term for age-related wear and tear of the spine). A review of Resident 15's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated [DATE], indicated the resident was usually made self-understood and understood others and had moderate impairment in cognitive skills. The MDS indicated the resident needed extensive assistance with bed mobility, transfer, locomotion, dressing, toilet use and personal hygiene. A review of Resident 15's monthly Order Summary Report for [DATE], indicated a code status to attempt resuscitation/CPR, provide full treatment, and long-term artificial nutrition including feeding tubes. During an interview and record review on [DATE] at 2:15 PM, the Social Service Director (SSD) confirmed Resident 15 did not have POLST or Advance Directive documents in the medical record. SSD stated Resident 15's Advance Directive Acknowledgment and Advanced Healthcare Directive Preferred Intensity of Care Documentation were missing signatures from the resident's physician and the resident's legally recognized decision-maker. 3. A review of Resident 49's Face Sheet indicated the resident was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), dementia (decline in mental ability severe enough to interfere with daily life), and hypertension (elevated blood pressure). A review of Resident 49's Initial History and Physical, dated [DATE], indicated the resident did not have the capacity to understand or make decisions. A review of Resident 49's MDS, dated [DATE], indicated the resident usually made self-understood and understood others and had moderate impairment in cognitive skills. The MDS indicated the resident required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) from staff with transferring, toileting, and personal hygiene. A review of Resident 49's monthly Order Summary Report for [DATE], indicated a code status to attempt resuscitation/CPR and provide full treatment. During an interview and record review, on [DATE] at 2:27 PM, the SSD stated she did not provide Resident 49 and/or the responsible party written information on how to formulate an advance directive. A review of the facility's policy and procedure titled, Physician Orders for Life Sustaining Treatment (POLST), revised [DATE], indicated the order to Follow POLST instructions will be added to the resident's admitting orders, when there is a completed POLST in the chart, for the attending physician to review. The physician will complete the review process by signing an order in the chart stating, Follow POLST instructions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure four of eight sampled residents (Resident 42, 18, 5, and 50) received appropriate treatment and services to prevent further decline in range of motion ([ROM], full movement potential of a joint) and mobility. 1. For Resident 42, the facility did not provide intervention to both legs with identified ROM limitations after discharge from Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) on 3/16/22 (more than seven months). 2. For Resident 18, the facility did not perform a quarterly joint mobility assessment in accordance with the facility's policy to monitor the resident's ROM in both arms and both legs. The facility did not provide intervention to both arms and both legs with identified ROM limitations since readmission to the facility on 8/10/22 (three months). 3. For Resident 5, the facility did not provide intervention to maintain the resident's ambulation (walking) distance of 200 feet after discharge from PT on 1/06/22. The facility did not provide arm weights for both arm exercises in accordance with the Occupational Therapy (OT, profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) recommendation and physician's order. 4. For Resident 50, the facility did not provide intervention to maintain the resident's ambulation distance of 250 feet after discharge from PT on 8/16/21. These deficient practices had the potential for Resident 42, 18, 5, and 50 to experience a decline in mobility, including a decline in ROM, development of contractures (chronic loss of joint motion associated with deformity and joint stiffness), decline in strength, and decreased endurance for walking. Findings: 1. A review of Resident 42's admission Record indicated the facility originally admitted Resident 42 on 4/27/18 and re-admitted on [DATE]. Resident 42's diagnoses included but was not limited to dementia (decline in mental ability severe enough to interfere with daily life), squamous cell carcinoma of the skin (skin cancer), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning), and contractures of the left shoulder, left elbow, left wrist, left hand, right hand, left knee, left ankle, and right ankle. A review of the minimum data set (MDS, a comprehensive assessment used as a care planning tool), dated 10/21/22, indicated Resident 42 was usually understood, usually understood others, and had severe impairments for cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 42 required total dependence for bed mobility, transfers between surfaces, eating, dressing, and bathing. The MDS indicated Resident 42 had functional limitations in ROM to both arms and both legs. A review of the PT Certification (Evaluation), dated 3/03/22, indicated Resident 42 required skilled PT treatment services to improve ROM to both legs and to prevent further development of joint contractures. The PT Certification also indicated skilled intervention for Resident 42 was needed to establish an appropriate Restorative Nursing Aide (RNA, nursing aide program that helps residents to maintain their function and joint mobility) program. A review of the PT Discharge summary, dated [DATE], indicated PT services were discontinued due to Resident 42's positive Coronavirus-19 (COVID-19, a highly contagious virus that can affect lungs and airways) result. The PT Discharge Summary indicated Resident 42's goal to establish an appropriate RNA program for ROM exercises to both legs was initiated. A review of the facility's Order Listing Report for residents receiving active RNA services, dated 11/01/22, did not include Resident 42. A review of Resident 42's physician's orders for 11/2022 did not include RNA services. During an observation and interview on 11/01/22 at 11:55 AM in the resident's room, Resident 42 was lying upright with the head-of-bed elevated. Resident 42 had pillows placed below both legs. Resident 42 lifted the right leg upward but was unable to lift the left leg. During an observation and interview on 11/02/22 at 8:25 AM in the resident's room, Resident 42 was lying upright in bed. Resident 42's right leg was crossed over the left leg and both ankles were positioned in plantarflexion (ankle bent away from body). During an interview on 11/03/22 at 2:09 PM, Restorative Nursing Aide 1 (RNA 1) stated Resident 42 did not have an RNA program to receive ROM to both legs. During an interview and record review on 11/03/22 at 2:46 PM in the therapy room, Rehabilitation Coordinator (RC) and Physical Therapist 1 (PT 1) stated RNA services were important for residents to maintain mobility and prevent contractures from progressing. RC and PT 1 reviewed Resident 42's PT Discharge summary, dated [DATE], and stated Resident 42's RNA ROM program was initiated but was not completed. RC stated Resident 42 did not have any physician's orders to receive RNA services for ROM to both legs. RC and PT 1 stated Resident 42 did not receive any intervention and ROM to both legs after PT services were discontinued on 3/16/22. During an interview on 11/03/22 at 4:14 PM, the Director of Nursing (DON) stated Resident 42 was at-risk for developing stiffness and contractures without ROM exercises to both legs. DON stated the facility was unaware Resident 42 was not receiving ROM to both legs for more than seven months. During an observation on 11/03/22 at 4:26 PM in the resident's room, PT 1 performed a brief assessment of Resident 42's legs. Resident 42 stated to PT 1 that he would like to receive exercises to both legs. A review of the facility's policy titled, Resident Mobility and Range of Motion, revised 1/2017, indicated Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. 2. A review of Resident 18 admission Record indicated the facility originally admitted Resident 18 on 8/15/15 and re-admitted on [DATE]. Resident 18's diagnoses included but was not limited to epilepsy (abnormal electrical activity in the brain marked by sudden, recurrent episodes of loss of consciousness or uncontrolled body shaking), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning), and functional quadriplegia (paralysis from the neck down, including the arms, trunk, and legs). A review of Resident 18's minimum data set (MDS, a comprehensive assessment used as a care planning tool), dated 9/23/22, indicated Resident 18 was usually understood, usually understood others, and had severe impairments for cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 18 required total dependence for bed mobility, transfers between surfaces, eating, dressing, and bathing. The MDS indicated Resident 18 had functional limitations in range of motion (ROM) to both arms and both legs. A review of Resident 18's Joint Mobility Assessment (JMA, brief assessment of a resident's range of motion in both arms and both legs), dated 3/24/22 and 6/24/22, indicated Resident 18 had the following: - minimal (25-50% of the normal measurement) loss of motion in both shoulders, - moderate (50-75% of the normal measurement) loss of motion in the left hand - severe (75-100% of the normal measurement) loss of motion in both hips, knees, and ankles. There were no other JMAs found in Resident 18's clinical record. A review of the facility's Order Listing Report for residents receiving active Restorative Nursing Aide (RNA, nursing aide program that helps residents to maintain their function and joint mobility) services, dated 11/01/22, did not include Resident 18. A review of Resident 18's physician's orders for 11/2022 did not include RNA services. During an observation and interview on 11/02/22 at 9:09 AM in the resident's room, Resident 18 was lying in bed and lifted both arms at the shoulder joints, bent both elbows, bent both wrists, and had more movement in the right hand than the left hand. Resident 18 slightly bent and extended both knees. Resident 18 was unable to lift the either leg from the hip joint and unable to bend both ankles. During an interview on 11/03/22 at 2:09 PM, Restorative Nursing Aide 1 (RNA 1) stated Resident 18 used to receive RNA services for active assistive range of motion (AAROM, use of muscles surrounding the joint to perform the exercise but requires some help from a person or equipment) to both arms, passive range of motion (PROM, movement of a joint through the ROM with no effort from patient) to the left hand, and PROM to both legs in 8/2022. RNA 1 stated RNA 1 went on vacation from 8/2022 to 10/2022. RNA 1 stated Resident 18 was no longer receiving RNA services upon RNA 1's return to the facility in 10/2022. A review of the facility's undated policy titled, Joint Mobility Assessment, indicated It is the policy of this facility that all residents will be assessed for joint mobility limitations upon admission and at a minimum of every three months thereafter. During an interview and record review on 11/03/22 at 2:46 PM in the therapy room, Rehabilitation Coordinator (RC) and Physical Therapist 1 (PT 1) stated RNA services were important for residents to maintain mobility and prevent contractures from progressing. RC stated the purpose of the JMA was to assess all residents for ROM in the facility every three months and determine if there needs to be any changes in the care plan. RC and PT 1 reviewed Resident 18's clinical record. The RC stated Resident 18 did not receive but should have received a quarterly JMA in 9/2022. RC stated Resident 18 did not have any physician's orders in the clinical record to receive RNA services for ROM to both arms and both legs. The RC stated Resident 18 had not received any RNA services since re-admission to the facility on 8/10/22 (three months). During an interview on 11/03/22, at 4:14 PM, the Director of Nursing (DON) stated Resident 18 was at-risk for developing contractures without ROM exercises to both arms and both legs. The DON stated the facility was unaware Resident 18 was not receiving ROM to both arms and legs for three months. A review of the facility's policy titled, Resident Mobility and Range of Motion, revised 1/2017, indicated Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. 3. A review of Resident 5's admission Record indicated the facility originally admitted Resident 5 on 6/16/19 and re-admitted on [DATE]. Resident 5's diagnoses included but was not limited to Parkinson's disease (a progressive disease of the nervous system resulting impaired movement) and difficulty walking. A review of Resident 5's minimum data set (MDS, a comprehensive assessment used as a care planning tool), dated 9/02/22, indicated Resident 5 was usually understood, usually understood others, and was moderately impaired for cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 5 required limited assistance with one person's physical assistance for bed mobility, transfers between surfaces, and walking. The MDS indicated Resident 5 did not have any functional limitations in both arms and both legs. A review of Resident 5's Occupational Therapy (OT) Discharge summary, dated [DATE], indicated the Restorative Nursing Aide (RNA, nursing aide program that helps residents to maintain their function and joint mobility) training was completed for active range of motion (AROM, performance of ROM of a joint without any assistance or effort of another person) to both arms with added resistance of two-pound (2 lb.) free weights. A review of Resident 5's Physical Therapy (PT) Discharge summary, dated [DATE], indicated Resident 5 walked 200 feet using a front wheeled walker (FWW, an assistive device with two front wheels used for stability when walking). The PT Discharge Summary indicated for Resident 5 to be discharged to the RNA program for ambulation. A review of Resident 5's physician's order, dated 1/05/22, indicated the following: - RNA program for AROM to LUE (left arm) with 1-2 lb. free weights every day (QD) five times per week (5x/week) as tolerated. - RNA program for AROM to RUE (right arm) with 1-2 lb. free weights QD 5x/week as tolerated. - RNA QD 5x/week for ambulation with FWW as tolerated. During an observation on 11/03/22 at 8:40 AM, Resident 5 was seated in a wheelchair prior to working with Restorative Nursing Aide 1 (RNA 1) and RNA 2. RNA 2 walked with Resident 5, who walked with a FWW. RNA 1 pushed the wheelchair behind Resident 5. Resident 5 walked approximately 35 using the FWW prior to sitting in the wheelchair to rest. Resident 5 then walked 15 feet using the FWW prior to sitting in the wheelchair to rest. Resident 5 walked another 25 feet using the FWW prior to sitting in the wheelchair. Resident 5 walked a total of approximately 75 feet. During an observation and interview on 11/03/22 at 8:46 AM, RNA 1 stated Resident 5 felt tired today. RNA 2 brought Resident 5 into the therapy room. Rehabilitation Coordinator (RC) was present in the room during Resident 5's RNA session. RNA 2 demonstrated shoulder abduction (movement at the shoulder joint to lift the arm away from the body) to Resident 5. Resident 5 performed AROM exercises for shoulder abduction prior to feeling tired. During a follow-up interview on 11/03/22 at 9:00 AM, RNA 2 stated Resident 5's RNA program included walking and shoulder AROM. RNA 2 stated Resident 5 did not use weights when performing shoulder AROM. During an interview and record review on 11/03/22 at 2:46 PM in the therapy room, RC, Occupational Therapist 1 (OT 1), Physical Therapist 1 (PT 1), and Physical Therapist Assistant (PT 2) reviewed Resident 5's clinical record. OT 1 reviewed Resident 5's OT Discharge summary, dated [DATE], and the physician's order for RNA, dated 1/05/22, which included AROM to both arms using 1-2 lb. weights. OT 1 stated it was important to use weights with AROM to maintain Resident 5's mobility and arm strength. RC confirmed RNA 2 did not provide Resident 5 with weights to perform arm AROM as indicated in both the OT discharge recommendations and physician's order. During an interview and record review on 11/03/22 at 2:46 PM in the therapy room, PT 1 reviewed Resident 5's PT Discharge summary, dated [DATE], which indicated Resident 5 walked 200 feet with a FWW. PT 1 reviewed Resident 5's physician's order, dated 1/5/22, for ambulation with a FWW. PT 1 stated Resident 5's physician's order did not include but should include a distance for ambulation to maintain the ability to walk 200 feet. PT 1 and PT 2 stated they were not notified that Resident 5 only walked 75 feet with three rest breaks. A review of the facility's policy titled, Resident Mobility and Range of Motion, revised 1/2017, indicated Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. 4.A review of Resident 50's admission Record indicated the facility originally admitted Resident 50 on 4/06/20 and re-admitted on [DATE]. Resident 50's diagnoses included but was not limited to polyneuropathy (damage to multiple nerves located outside of the brain and spinal cord), muscle weakness, and difficulty walking. A review of Resident 50's minimum data set (MDS, a comprehensive assessment used as a care planning tool), dated 10/07/22, indicated Resident 50 clearly understood, clearly understood others, and was moderately impaired for cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 50 required limited assistance with one person's physical assistance for bed mobility, transfers between surfaces, and walking. The MDS indicated Resident 50 did not have any functional limitations in both arms and both legs. A review of the Physical Therapy (PT) Discharge summary, dated [DATE], indicated Resident 50 walked 250 feet using a front wheeled walker (FWW, an assistive device with two front wheels used for stability when walking). The PT Discharge Summary indicated for Resident 50 to be discharged to the RNA program for ambulation. A review of Resident 50's physician's order, dated 8/16/21, indicated RNA for ambulation with FWW five times per week or as tolerated. During an observation and interview on 11/03/22 at 8:26 AM, Resident 50 was seated in a wheelchair prior to working with Restorative Nursing Aide 1 (RNA 1) and RNA 2. Resident 50 used a FWW to walk down the facility's four hallways, requiring three rest breaks. RNA 1 stated each hallway was 50 feet and confirmed Resident 50 walked 200 feet. During an interview and record review on 11/03/22 at 2:46 PM in the therapy room, Rehabilitation Coordinator (RC) and Physical Therapist 1 (PT 1) stated RNA services were important for residents to maintain mobility and prevent contractures from progressing. RC and PT 1 reviewed Resident 50's PT Discharge summary, dated [DATE], and physician's order for RNA, dated 8/16/21. PT 1 stated Resident 50's physician's order did not include but should include a distance for ambulation to maintain the ability to walk 250 feet. A review of the facility's policy titled, Resident Mobility and Range of Motion, revised 1/2017, indicated Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable.

Based on interview and record review, the facility failed to ensure the change of shift narcotics reconciliation records were properly completed for one (1) of two (2) medication carts (North Station cart) inspecyted. This deficient practice had the potential for the diversion (illegal distribution or abuse of prescription drugs or their use for unintended purposes) of controlled substance medications. Findings: On 11/3/22 at 3:48 PM, a review of the facility's change of shift narcotics reconciliation records for North Station cart titled, Controlled Drug Inventory Sheet for the month of March to October 2022, indicated on the following dates missing licensed nurse's initials: 1. outgoing (going off duty-leaving the shift) licensed nurse on 3/1/22 who worked the 7 AM to 3 PM (day) shift. 2. outgoing licensed nurse on 3/24/22 who worked the 11 PM to 7 AM (night) shift. 3. outgoing licensed nurse on 5/9/22 who worked the day shift. 4. outgoing licensed nurse on 6/25/22 who worked the day shift. 5. outgoing licensed nurse on 7/25/22 who worked the day shift. 6. outgoing licensed nurse on 8/9/22 who worked the night shift. 7. outgoing licensed nurse on 8/9/22 who worked the day shift. 8. outgoing licensed nurse on 9/5/22 and 9/26/22 who worked the day shift. During an interview, on 11/3/22 at 4 PM, Registered Nurse 1 (RN 1) stated incoming (starting the shift) and outgoing licensed nurses count the controlled medications (together). RN 1 stated the licensed nurses should initial after they counted the controlled medications to verify that the count was accurate. RN 1 stated that was very important to initial (the log) to show the controlled drugs were counted and reconciled at the start and end of the shifts. RN 1 stated it was also very important to initial on the Controlled Drug Inventory Sheet to know who conducted the count and prevent the loss of the controlled drugs. During an interview and record review, on 11/3/22 at 4:04 PM. The Director of Nursing (DON) stated there were missing initials of the outgoing licensed nurses on the following dates: 3/1/22, 3/24/22, 5/9/22, 6/25/22, 7/5/22, 8/9/22, 9/5/22, and 9/26/22. DON stated the facility required two licensed staff to initial and document accurately on the log to ensure the count of controlled medications was done and there were no missing medications. DON stated if the initial was not being recorded that meant that the task was not done. A review of the facility's undated policy and procedure titled, Medications-Narcotics, indicated that narcotics must be counted at the beginning and end of every shift by the licensed nurse ending the shift and licensed nurse beginning the shift. Both nurses must date and sign the count log that was in the cart's narcotic book.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement appropriate infection control practices. 1. For one of 19 sampled residents (Resident 38), the facility failed to label the resident's intravenous (IV, a method of administering fluids and/or medications via the vein) tubing and IV site with a date of when it was placed and/or changed. 2. The facility failed to handle clean and soiled laundry in a sanitary manner to prevent the spread of infection. 3. The laundry staff failed to wear a face mask while working in the facility to prevent the spread of droplet or airborne illness, including but not limited to Coronavirus-19 (COVID-19, a new infectious viral disease that can cause respiratory illness) while working in the laundry room. These deficient practices had the potential to cause and spread infection throughout the facility. Findings: 1. A review of Resident 38's admission Record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis that included hypertension (high blood pressure) and muscle weakness. A review of Resident 38's Minimum Data Set (MDS, a comprehensive standardized assessment and care-screening tool), dated 9/16/22, indicated the resident had severe impairment in cognitive skills (ability to think and reason) and required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) from staff for bed mobility, transfers, and personal hygiene. A review of Resident 38's physician order, dated 10/29/22 indicated the following orders: a Meropenem (antibiotic medication used to treat infections caused by bacteria) 500 milligram (mg, a unit of measurement) every 12 hours for three day. b.Restart IV every 96 hours and PRN (as needed) complications. Change dressing with site change and PRN. On 11/1/22 at 10:26 AM, during an initial tour observation and interview, the Director of Nursing (DON) stated Resident 38's IV dressing and IV tubing were not labeled/dated. DON stated Resident 38's IV was at risk for infection if it was not labeled or dated since the staff would not know when the IV was inserted. On 11/2/22 at 8:53 AM, during an interview, a Licensed Vocational Nurse 1 (LVN 1) stated he assessed Resident 38's IV site daily but did not pay attention if the labels were there. LVN 1 stated that it was the licensed nurse's responsibility to assess the IV site, label the IV insertion site, and IV tubing for early detection of infection. A review of the facility's policy and procedure (P&P) titled, Administering Set/Tubing Changes, revised on 2/2010, indicated the importance for the aseptic administration set changes to prevent infections associated with contaminated IV therapy equipment. The P&P indicated to label tubing with date, time, and initials to know when tubing should be discontinued or changed. 2. During an observation and interview with the Laundry Supervisor (LS), on 11/01/22 at 10:49 AM, the laundry room had two trash bags with visibly soiled rags placed on the ground of the laundry room. Both trash bags were opened and not sealed. Two reusable gowns were hanging on a door hook located on the soiled side of the laundry room. LS stated soiled rags should be in sealed bags and not on the floor. LS initially stated the gowns hanging on the soiled side of the laundry room were clean. LS stated clean clothes should be covered. LS then stated the gowns hanging on the soiled side of the laundry were no longer clean if they were not covered. A review of the facility's policy and procedure (P&P) titled, Departmental (Environmental Services) - Laundry and Linen, revised 1/2014, indicated bagging and handling soiled linen included placing any linen saturated with blood or body fluids into a leak-resistant bag before placing it into the hamper. The P&P indicated clean linen would remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures design to protect it from environmental contamination, such as covering clean linen carts. 3. During an observation and interview, on 11/01/22 at 10:42 AM, LS was not wearing a face mask while hanging clean clothes on the clean side of the laundry room. LS stated a face mask was only needed in the soiled laundry area. During an interview, on 11/01/22 at 11:08 AM, the Infection Prevention Nurse (IPN) stated that all staff should be wearing a surgical face mask while in the building. IPN stated the face masks were supposed to prevent any airborne particles, especially COVID-19, from spreading. A review of the facility's COVID-19 Mitigation Plan, dated 4/13/22, indicated all facility personnel would be wearing a surgical mask/face mask while in the facility.