**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility to ensure the primary care provider (PCP) was notified for one of seven residents ' (Resident 1), when: 1. Resident 1 had missed doses of Macrobid oral capsule (a type of antibiotic) to treat Urinary Tract Infection ([UTI], an infection in the bladder/urinary tract) on 3/11/2025, 3/13/2025, and 3/15/2025. 2. Resident 1 refused the suprapubic catheter (a thin, flexible tube inserted directly into the bladder through a small incision in the lower abdomen above the pubic bone) changed as ordered by the PCP. These failures had the potential to cause unresolved UTI and can lead complications such as sepsis (a life-threatening infection), hospitalization, and death. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of pneumonitis (inflammation of lung tissue, usually caused by a virus) and acute (sudden) pulmonary edema (excess accumulation of fluid in the lungs, causing shortness of breath, difficulty breathing). During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 1/16/2025, the MDS indicated Resident 1 had moderate cognitive (the ability to think and reason) impairment. The MDS indicated Resident 1 was dependent (helper does all the effort) for Activities of Daily Living (ADLs) such as rolling left to right and transferring from chair/bed-to-chair. 1. During a review of Resident 1 ' s Medication Administration Record (MAR) for March 2025, the MAR indicated Resident 1 had an order of Macrobid Oral Capsule 100 mg, one (1) capsule by mouth two times a day for seven (7) days for UTI. The MAR indicated Resident 1 had missed dosage of Macrobid on 3/11/2025, 3/13/2025, and 3/15/2025. During a review of Resident 1 ' s nursing progress notes, the progress notes did not indicate that Resident 1 ' s PCP was notified that Resident 1 ' s Macrobid evening doses were missed on 3/11/2025, 3/13/2025, and 3/15/2025. During an interview on 3/26/2025 at 1:55 p.m. with Licensed Vocational Nurse (LVN) 5, LVN 5 stated Resident 1 did not receive the evening doses of Macrobid on 3/11/2025 and 3/13/2025 because Resident 1 was at dialysis. LVN 5 stated Resident 1 ' s PCP was not informed of the missed doses because they were busy. LVN 5 stated because of the missed antibiotic doses, Resident 1 ' s UTI would become severe. LVN 5 stated that if a resident was not available during medication pass, the medication should be offered when the resident return. During an interview on 3/26/2025 at 2:22 p.m. with LVN 3, LVN 3 stated that if a resident missed a medication, it should be documented in the resident ' s clinical record. LVN 3 stated the PCP should also be notified if a resident missed a medication dose. LVN 3 Resident 1 ' s PCP was not notified on 3/15/2025 when the resident missed the 3/15/2025 Macrobid dose, because LVN 3 did not think they had to notify the PCP. LVN 3 stated if a resident missed an antibiotic dose, the effectiveness of the antibiotic would not be as strong. During a concurrent interview and record review on 3/26/2025 at 3:53 p.m. with the Director of Nursing (DON), Resident 1 ' s 3/2025 MAR was reviewed. The DON stated, If a resident had an order for antibiotics and was unavailable, staff should give the antibiotic when the resident return and clarify with the doctor for any additional orders for the missed dose. During a review of the facility ' s P&P titled, Administering Medications, dated 3/2023, the P&P indicated if a resident is not available to receive the medication on the pass, the MAR may be flagged and the nurse should return to the missed resident to administer the medication after the medication pass. 2. During a review of Resident 1 ' s physician order dated 1/15/2025, the physician ' s order indicated Suprapubic catheter change by Skilled Nursing Facility (SNF) wound care in facility every month and as needed (PRN). During a review of Resident 1 ' s wound physician progress notes dated 2/25/2025, the progress notes indicated Resident 1 refused suprapubic catheter change. During a review of Resident 1 ' s nursing progress notes dated 2/25/2025, the progress notes did not indicate Resident 1 ' s PCP was notified of the resident ' s refusal to have the suprapubic catheter changed. During an interview on 4/1/2025 at 12:43 p.m. with Registered Nurse (RN) 1, RN 1 stated the PCP should have been notified of Resident 1 ' s refusal to have the suprapubic catheter changed and obtain additional orders for monitoring signs and symptoms of infection. During a concurrent interview and record review on 4/1/2025 at 3:28 p.m. with RN 2, the facility ' s P&P titled, Change in a Resident ' s Condition or Status, dated 3/2023 was reviewed. RN 2 stated the facility did not follow the P&P which indicated, any refusal of treatment should be reported to the PCP. RN 2 stated the PCP should have been notified when Resident 1 refused to have the suprapubic catheter changed and so the staff can obtain additional monitoring orders. During a review of facility ' s P&P titled, Change In A Resident ' s Condition or Status, dated 3/2023, the P&P indicated the nurse should notify the resident ' s attending physician or physician on call, when the resident refused treatment or medications two (2) or more consecutive times. The P&P indicated the nurse should record in the resident ' s medical records information related to changes in the resident ' s medical condition or status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure, three of seven sampled residents (Residents 1, 6, and 7), received oxygen as per physician's orders and oxygen saturations ([O2 sat], a measurement of how much oxygen the blood is carrying as a percentage, normal range is 95-100%) were checked accurately. These failures had the potential to not identify Residents 1, 6, and 7's oxygenation status and placed the residents at risk for complications related to poor oxygenation (the process of supplying blood or tissues with oxygen) such as respiratory distress (a condition where breathing is labored and inadequate), hospitalization and death. Findings: 1). During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of pneumonitis (inflammation of lung tissue, usually caused by a virus) and acute (sudden) pulmonary edema (excess accumulation of fluid in the lungs, causing shortness of breath, difficulty breathing). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 1/16/2025, the MDS indicated Resident 1 had moderate (average) cognitive (the ability to think and reason) impairment. The MDS indicated Resident 1 was dependent (helper does all of the effort) for Activities of Daily Living (ADLs) such as rolling left to right and transferring from chair/bed-to-chair. During a review of Resident 1's Order Summary Report (a list of current doctor's orders), the Order Summary Report indicated to administer oxygen (O2) at three (3) liters (L) per minute (PM) via nasal cannula ([NC] a small plastic tube applied into the resident's nostrils for providing supplemental oxygen) and may titrate (adjust) up to five (5) L/min for O2 saturation (sat, amount of oxygen in the system (normal is 90-100%)) less than 89% every shift. During a review of Resident 1's O2 Sat Summary, the summary indicated Resident 1's O2 sats were assessed at room air (without oxygen use). 2). During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of chronic (persisting for a long time) respiratory failure (a medical condition where the lungs are unable to exchange gases, leading to insufficient oxygen in the blood) with hypercapnia (excessive carbon dioxide). During a review of Resident 6's MDS dated [DATE], the MDS indicated Resident 6 had moderate cognitive impairment. The MDS indicated Resident 6 was dependent to perform ADLs such as toileting hygiene and lower body dressing. During a review of Resident 6's Order Summary Report, the Order Summary Report indicated, Resident 6 had orders for continuous O2 at 2 LPM via NC and may titrate up to 5 LPM for O2 sat less than 92% every shift for Chronic Obstructive Pulmonary Disease ([COPD], a chronic lung disease causing difficulty in breathing). During a review of Resident 6's O2 Sats Summary, the O2 Sats Summary indicated Resident 6's O2 sats were assessed at room air. During a concurrent interview and record review on 3/28/2025 at 12:22 p.m. with Licensed Vocational Nurse (LVN) 7, Resident 6's oxygen orders and O2 sats were reviewed. LVN 7 stated Resident 6's O2 sats should have checked while receiving oxygen via NC and not on room air. During a concurrent observation and interview on 3/28/2025 at 12:29 p.m. with LVN 7 of Resident 6's bedside oxygen tank, LVN 7 stated Resident 6's oxygen tank was at 1 liter. LVN 7 stated Resident 6's oxygen should have been set at 2 liters. LVN 7 stated residents with oxygen orders should be assessed at the beginning of the shift to ensure that their oxygen is on and calibrated correctly. LVN 7 stated Resident 6's O2 sat needed to be accurate to assess how well the resident is tolerating oxygen along if resident is experiencing respiratory distress. 3). During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was originally admitted to the facility on [DATE] with diagnoses of chronic (persisting for a long time) respiratory failure (a medical condition where the lungs are unable to exchange gases, leading to insufficient oxygen in the blood) with hypercapnia (excessive carbon dioxide). During a review of Resident 7's MDS dated [DATE], the MDS indicated Resident 7 was cognitively intact. The MDS indicated Resident 7 required partial/moderate assistance (helper does less than half the effort) for ADLs such as oral and personal hygiene. During a review of Resident 7's Order Summary Report, the Order Summary Report indicated, Resident 7 had orders for O2 at 2 LPM via NC and may titrate up to 5 LPM for O2 sat less than 92% every shift for interstitial lung disease (a group of conditions that cause inflammation and scarring of the space between the air sacs and blood vessels of the lungs) continuously. During a review of Resident 7's O2 Sats Summary, the summary indicated Resident 7's O2 sats were assessed at room air. During a concurrent interview and record review on 3/28/2025 at 12:37 p.m. with LVN 7, Resident 7's oxygen orders and O2 sat were reviewed. LVN 7 stated he had not taken Resident 7's O2 sat on the morning of 3/28/2025. During a concurrent observation and interview on 3/28/2025 at 12:42 p.m. with LVN 7, Resident 7's oxygen tank was observed. LVN 7 stated Resident 7's oxygen was set at 2.5 liters. LVN 7 stated if O2 sat was not assessed, Resident 7 may not receive adequate oxygenation. During a concurrent interview and record review on 3/28/2025 at 1:45 p.m. with Director of Nursing (DON), Residents 1, 6, and 7's oxygen orders and O2 sats were reviewed. The DON stated, staff should check residents' oxygen order were implemented correctly and residents' O2 sats were checked with vitals. The DON stated if a resident had an order of oxygen, the documentation should reflect the amount in percentage according to the doctor's order, to ensure monitoring that residents receivedproper oxygenation or to identify any changes. During a concurrent interview and record review on 3/28/2025 at 2:19 p.m. with the DON, a photo of Resident 6 and Resident 7's oxygen tanks were reviewed. The DON stated Resident 6 and Resident 7's oxygen tanks were not accurately set according to physician's order. The DON stated if residents did not receive the ordered amount of O2 and O2 sats were not properly assessed, it could lead to a change of condition and symptoms such as shortness of breath. During a concurrent interview and record review with DON on 3/28/2025 at 2:37 p.m., the facility's policy and procedure (P&P) titled, Oxygen Administration, undated, was reviewed. The DON stated, the P&P indicated oxygen should be administered per physician's orders, document the resident's response to oxygen use. The DON stated, in order to determine if a resident needed to have their oxygen titrated, the O2 sat should have been checked with the residents' O2 orders. The P&P also indicated to check the O2 sat to ensure that oxygen use is effective. The DON stated when the residents' O2 sats were checked at room air, the facility did not follow their policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to remove the identifiable health information (any information that could be used to identify the individual, such as the full name, date of birth , etc.) on the gastrostomy tube (GT, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach, for people with swallowing problems) feeding bottle before disposing in the trash can for one of eight sampled residents (Resident 23). This deficient practice had the potential to result in unauthorized disclosure of Resident 23's personal information to unauthorized users. Findings: During an observation on 1/6/2025 at 10:36 a.m., in Resident 23's room, Resident 23's GT feeding bottle with the resident's name was observed in the trash can. During an observation on 1/7/2025 at 8:50 a.m., in Resident 23's room, Resident 23's GT feeding bottle with the resident's name was observed in the trash can. During a review of Resident 23's admission Record, dated 1/8/2025, the admission record indicated Resident 23 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 23's diagnoses included pneumonia (an infection/inflammation in the lungs), sepsis (a life-threatening blood infection), seizure (a sudden, uncontrolled electrical disturbance in the brain which could cause uncontrolled jerking, blank stares, and loss of consciousness), and major depressive disorder (a mood disorder that caused a persistent feeling of sadness and loss of interest). During a review of Resident 23's History and Physical (H&P), dated 12/23/2024, the H&P indicated Resident 23 did not have the capacity to make decisions. During a review of Resident 23's Minimum Data Set (MDS - a resident assessment tool), dated 8/15/2024, the MDS indicated Resident 23's cognitive (the ability to think and process information) skill for daily decision making was severely impaired. The MDS indicated Resident 23 was dependent (helper did all the effort) with oral hygiene, toileting hygiene, shower/ bathe self, and personal hygiene. During a review of Resident 23's Order Summary Report, as of 1/8/2025, the report indicated an order dated 12/22/2024, GT Jevity 1.2 (a high-protein, fiber-fortified nutritional formula that could be used for tube feeding) rate 65 cubic centimeter (cc, a unit of volume) per hour for 20 hours. During a concurrent interview and review of a picture of Resident 23's GT feeding bottle on 1/7/2025 at 12:14 p.m. with Licensed Vocational Nurse (LVN) 1, the picture dated 1/6/2025 at 10:41 a.m. was reviewed. The picture indicated a GT feeding bottle with Resident 23's name disposed of in the trash can in the resident's room. LVN 1 stated the used GT bottle with Resident 23's name should not be in the trash can in the resident's room. LVN 1 stated staff should blacken out Resident 23's name using a sharpie or remove the label before disposing in the trash can because of the Health Insurance Portability and Accountability Act (HIPPA, a United States legislation that provided data privacy and security provisions for safeguarding medical information). LVN 1 stated it was for protecting the resident's privacy and confidentiality. LVN 1 stated the nurses were responsible with ensuring the resident's privacy and confidentiality and there was a risk that information was exposed without the resident's consent. During an interview on 1/8/2025 at 3:49 p.m. with the Director of Staff Development (DSD), the DSD stated nurses needed to make sure there was no resident's information on the GT bottle before disposing in the trash can. The DSD stated the resident's information should be peeled off or use a marker should be used to blacken out the resident's information before disposal for the resident's privacy. The DSD stated the potential risk was that the resident's privacy would be seen by unauthorized personnel, and all staff were responsible to ensure the resident's information was protected. During a review of the facility's Policy and Procedure (P&P) titled Enteral feeding, revised in 3/2023, the P&P indicated When disposing of enteral feeding formula bottle/bag/tubing/syringe, the licensed nurse must ensure the resident's personal information is de-identified. This includes removing or obscuring the resident's name and room number before disposal to maintain privacy and confidentiality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a plan of care for a resident that exhibited a behavior of teeth grinding for one out of six sampled residents (Resident 4). This deficient practice had the potential to delay the care or treatment of Resident 4's teeth grinding behavior. Findings: During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Resident 4's diagnoses included gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), cognitive (mental action or process of acquiring knowledge and understanding) communication deficit, dementia (a progressive state of decline in mental abilities), and adult failure to thrive (a progressive decline in an individual's ability to care for themselves due to multiple contributing factors). During a review of Resident 4's Minimum Data Set ([MDS], a resident assessment tool), dated 11/12/2024, the MDS indicated Resident 4's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 4 was entirely dependent on staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a concurrent record review, on 1/7/2024, at 9:44 a.m., with the Infection Prevention Nurse (IPN), all of Resident 4's care plans, dated in 2024 to 2025, were reviewed. There were no care plans addressing Resident 4's behavior of teeth grinding. During an interview, on 1/7/2025, at 9:50 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated that LVN 2 had known Resident 4 to grind her teeth in the morning time. LVN 2 stated that she noticed Resident 2 started grinding her teeth around Christmas time. LVN 2 stated that it was a behavior that should have been care planned to ensure the Resident 2's care was rendered appropriately. During an interview, on 1/8/2025, at 4:04 p.m., with the Director of Nursing (DON), the DON stated Resident 4 exhibited a change of condition and Resident 4's behavior of teeth grinding should have been care planned. During a review of the facility's Policy and Procedure (P&P), titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observation, interview, and record review, the facility failed to provide necessary respiratory care and services that were in accordance with the facility's policy for one of eight sampled residents (Resident 239), when the facility did not display No Smoking/ Oxygen in Use signs on the outside of the door of the resident room or in the room where an oxygen concentrator (a medical device that provides oxygen-enriched air to help people breathe) was at the bedside. This deficient practice had the potential to cause fire hazards to all residents, families, visitors, staff, and residents' properties, and result in serious harm and injury. Findings: During an observation on 1/6/2025 at 9:48 a.m., outside of Resident 239's room, there was no No Smoking/ Oxygen in Use sign on the entrance room door. Resident 239 was observed lying on the bed with an oxygen concentrator (a medical device that provides oxygen-enriched air to help people breathe) at the bedside. There was no No Smoking/ Oxygen in Use sign observed in the room. During an observation on 1/7/2025 at 8:32 a.m., outside of Resident 239's room, there was no No Smoking/ Oxygen in Use sign on the entrance room door. Resident 239 was observed lying on the bed with an oxygen concentrator observed at the bedside. There was no No Smoking/ Oxygen in Use sign observed in the room. During a review of Resident 239's admission Record, the admission record indicated Resident 239 was admitted to facility on 12/18/2024. Resident 239's diagnoses included cirrhosis of the liver (conditions that stopped the liver from working or prevent it from functioning well), generalized muscle weakness, dysphagia (difficulty swallowing), and depression (a constant feeling of sadness and loss of interest). During a review of Resident 239's History and Physical (H&P) dated 12/30/2024, the H&P indicated Resident 239 did not have the capacity to understand and make decisions. During a review of Resident 239's Minimum Data Set (MDS, a resident assessment tool), dated 12/29/2024, the MDS indicated Resident 239's cognitive (the ability to think and process information) skills for daily decision making was severely impaired. The MDS indicated Resident 239 required supervision in eating, partial assistance (helper did less than half the effort) with oral hygiene and personal hygiene, and was dependent (helper did all the effort, resident did none of the effort to complete the activity) for toileting hygiene and showering/ bathing. The MDS indicated Resident 239 used a cane/crutch for mobility. During a review of Resident 239's care plan titled Oxygen, initiated on 12/29/2024, the care plan indicated the goal was for Resident 239 to be free of adverse effects (a harmful or abnormal result) related to use of oxygen daily. During a review of Resident 239's Order Summary report, as of 1/8/2025, the summary indicated an order, dated 12/29/2024, to administer oxygen 2-5 liter (L, a unit for measuring the volume of a liquid) per minute for oxygen saturation (a measure of how much oxygen was in blood) less than 90 percent (%) or respiratory comfort as needed. During a concurrent observation and interview on 1/7/2025 at 11:57 p.m. with Licensed Vocational Nurse (LVN) 1, outside Resident 239's room, there was no No Smoking/ Oxygen in Use sign on the room entrance door. Resident 239 was observed lying on the bed with an oxygen concentrator at the bedside. There was no No Smoking/ Oxygen in Use sign observed in the room. LVN 1 stated there should be a No Smoking/ Oxygen in Use sign outside the door when the oxygen concentrator was at the bedside. LVN 1 stated the purpose of a No Smoking/ Oxygen in Use sign was to make sure everyone was aware there was oxygen in the room, and to make sure there was no one smoking. LVN 1 stated it was not safe without the sign and the potential risk was explosion. LVN 1 stated this affected all residents and put the resident at risk for injury. LVN 1 stated it could possibly cause a fire hazard, and the building could become damaged. LVN 1 stated all staff were responsible with ensuring there was a No Smoking/ Oxygen in Use sign outside the resident's door. During a concurrent observation and interview on 1/8/2025 at 3:49 p.m. with the Director of Staff Development (DSD), the DSD stated for safety precautions there should be a No Smoking/ Oxygen in Use sign outside the door if there was an oxygen concentrator at the resident's bedside. The DSD stated whoever installed the oxygen concentrator was responsible in making sure the sign was up. The DSD stated everyone needed to pay attention to ensure there was a No Smoking/ Oxygen in Use sign during room rounds. The DSD stated the purpose of the No Smoking/ Oxygen in Use sign was to alert people during an emergency. During a review of facility policy and procedure (P&P) titled, Oxygen Administration, revised on 10/2010, the P&P indicated No Smoking/ Oxygen in Use sign was necessary for oxygen administration. The P&P indicated staff needed to place an Oxygen in Use sign on the outside of the room entrance door and in a designated place on or over the resident's bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater, as evidenced by the identification of 6 medication errors out of 28 opportunities for error, to yield a cumulative error rate of 21.43% for one of two of sampled residents (Residents 43). Licensed Vocational Nurse (LVN) 1 administered six oral medications to Resident 43 at one time. Resident 43 had a diagnosis of dysphagia (difficulty swallowing). This deficient practice resulted in Resident 43 not being able to swallow her medications and had the potential to cause aspiration (when a fluid or solid accidentally enters the windpipe and lungs) or a choking hazard for Resident 43. Findings: During a review of Resident 43's admission Record, dated 1/8/2025, the admission record indicated Resident 43 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission record indicated Resident 43 had the following diagnoses which included dysphagia (difficulty swallowing), dementia (a progressive state of decline in mental abilities), and encephalopathy (decreased brain function). During a review of Resident 43's Minimum Data Set (MDS - a resident assessment tool), dated 12/4/2024, the MDS indicated Resident 43's cognition (the ability to think, remember and reason) was severely impaired. The MDS indicated Resident 43 required supervision (helper provides verbal cues and/or touching/steadying as resident completes activity) with eating and maximal assistance (helper does more than half the effort) for oral hygiene, toileting, bathing, and personal hygiene. During a review of Resident 43's History and Physical (H&P), dated 7/22/2024, the H&P indicated Resident 43 did not have the capacity to understand and make decisions. During a review of Resident 43's care plan titled, Patient presents with oral and pharyngeal (throat area) deficits affecting safe and effective swallow, initiated on 7/22/2024 and revised on 1/8/2025, the care plan indicated Resident 43's goal would be to consume a puree (foods that have soft, pudding-like consistency) diet and thin liquids with safe and effective swallowing while maintaining nutritional needs. The care plan interventions included speech therapy, sit resident up right for all oral intake, give smaller bites and sips, double swallows, and chin tuck (moving the chin towards the chest). During a review of Resident 43's Order Summary Report, dated 1/8/2024, the order summary report indicated an active order started on 7/20/2024 May crush medications and mix with applesauce or food. During a review of Resident 43's Order Summary Report, dated 1/8/2024, the order summary report indicated an active order started on 7/20/2024 for Acetaminophen (Tylenol - a medication used to relieve minor aches and pains) 325 milligrams (mg - metric unit of measurement, used for medication dosage and/or amount) oral tablet. Give two tablets by mouth every four hours as needed for mild pain. During a review of Resident 43's Order Summary Report, dated 1/8/2024, the order summary report indicated an active order started on 7/20/2024 for Apixaban (a medication used to prevent blood clots) 5 milligrams (mg, unit of measurement) oral tablet. Give one tablet by mouth two times a day for atrial fibrillation (abnormal heartbeat). During a review of Resident 43's Order Summary Report, dated 1/8/2024, the order summary report indicated an active order started on 7/21/2024 for Aspirin (a medication used to reduce the formation of blood clots), 81 mg oral tablet. Give one tablet by mouth one time a day. During a review of Resident 43's Order Summary Report, dated 1/8/2024, the order summary report indicated an active order started on 7/21/2024 for Losartan Potassium (a medication used to treat high blood pressure) 25 mg oral tablet. Give one tablet by mouth one time a day. During a review of Resident 43's Order Summary Report, dated 1/8/2024, the order summary report indicated an active order started on 7/21/2024 for Namenda (Memantine - a medication used to treat dementia) 5 mg oral tablet. Give one tablet by mouth two times a day. During a review of Resident 43's Order Summary Report, dated 1/8/2024, the order summary report indicated Resident 43 had an active order started on 12/24/2024 for a Renal (related to kidneys) 80 gram (g, unit of measurement), NAS (no added salt) mechanical soft texture, (soft, easily chewable foods that are either pureed, mashed, finely chopped, or ground, designed for individuals who have difficulty swallowing or chewing due to medical conditions like dental issues or swallowing disorders) diet, thin consistency. During a review of Resident 43's Order Summary Report, dated 1/8/2024, the order summary report indicated an active order started on 1/7/2025 for Oyster Shell (a calcium supplement) 500 mg oral tablet. Give one tablet by mouth two times a day. During a medication pass observation on 1/8/2025 at 8:40 a.m., with LVN 1, observed LVN 1 enter Resident 43's room with a medicine cup filled with oral medications. LVN 1 scooped a spoonful of the oral medications from the medicine cup and placed it in front of Resident 43's mouth. LVN 1 stated, It's time to take your medicine, [NAME]. Resident 43 opened her mouth and took the medication from the spoon. LVN 1 offered Resident 43 a sip of water and scooped another spoonful of oral medications from the medicine cup. LVN 1 fed the medication from the spoon to Resident 43 and gave her another sip of water. Resident 43 was squirming in her bed and stated that she needed to go to the restroom. LVN 1 stated, [NAME]! You have to take your medicine. LVN 1 then asked Resident 43 to open her mouth. Resident 43 still had five whole pills on her tongue. LVN 1 stated, Swallow the pills [NAME]! You have to swallow the pills. LVN 1 gave Resident 43 more water and asked Resident 43 to stick out her tongue. The pills were still on the resident 43's tongue. LVN 1 stated again, You have to swallow the pills [NAME]. Swallow [NAME]! LVN 1 continued to give Resident 43 more sips of water to drink and check her tongue. The pills remained on Resident 43's tongue. LVN 1 left the room and went to the med cart to get another cup of water. Resident 43 then stated that she had to use the restroom. LVN 1 stated, I will take you to the restroom as soon as you finish taking your medications. LVN 1 continued to give Resident 1 sips of water and prompted the resident to swallow the pills. After Resident 43 finished a second cup of water, LVN 1 asked Resident 43 to stick out her tongue. The medication was still observed on Resident 43's tongue. Some of the medication had started to dissolve on Resident 43's tongue but had not been swallowed. LVN 1 stated, You have to swallow the medication [NAME]. Resident 43 stated, I did! Resident 43 continued to move around uncomfortably in her bed and stated that she needed to use the restroom again. LVN 1 asked Resident 43 to stick out her tongue again. The pills were still observed on Resident 43's tongue. LVN 1 proceeded to use her gloved hand and scrape the medication from Resident 43's tongue, the back of her throat and sides of her cheeks and placed them back into a medicine cup. LVN 1 then assisted Resident 43 to the restroom. During a concurrent interview and record review on 1/8/2025 at 9:15 a.m., with LVN 1, Resident 43's Medication Administration Record (MAR) for January 2025 and Diagnosis Report was reviewed. LVN 1 stated Resident 43 did get her Aspirin, Apixaban, Losartan, Namenda, and Oyster Shell tablets because she was unable to take them. LVN 1 stated, she also attempted to give Resident 43 Tylenol for pain to her buttocks area. LVN 1 stated she had not known Resident 43 to have difficulty swallowing her medications. LVN 1 reviewed Resident 43's Diagnosis Report. LVN 1 stated, the resident has dysphagia. LVN 1 stated since Resident 43 has a history of dysphagia, she should have given her one medication at a time and given her time to swallow each pill before giving another one. LVN 1 stated Resident 43 could have choked or aspirated because she (LVN 1) gave her (Resident 43) several medications at one time. During an interview on 1/8/2025 at 2:10 p.m., with the facility's Speech Language Pathologist (ST), the ST stated an evaluation was done on Resident 43 and a treatment diagnosis for dysphagia was made. The ST stated she checked Resident 43 during mealtimes to see if there were any deficits in cognition, communication, or swallowing. The ST stated based on her evaluation of Resident 43 she would not recommend giving several medications at one time. The ST stated Resident 43 was at risk of choking or not being able to pass the medications and choking was a life-threatening event. The ST stated it would have been safer for Resident 43 to take one pill at a time. The ST stated if Resident 43 was unable to swallow the first pill, the nurse could have crushed the remaining pills and administered the pills in applesauce. During an interview on 1/9/2025 at 11:12 a.m., with the Director of Nursing (DON), the DON stated the best practice for administering medications to Resident 43 was to assess Resident 43 before giving her the medications. The DON stated Resident 43 had dysphasia and dementia and this could cause behavioral problems that could prevent Resident 43 from swallowing the medication. The DON stated if Resident 43 was not cooperating at the time of the med pass, the nurse (LVN 1) should have come back later when it was safe to give the medication. The DON stated the nurse should have given one medication at a time and waited for Resident 43 to swallow the medication properly before giving more medications. The DON stated the nurse should have also instructed Resident 43 on how to take the medication properly. The DON stated she (DON) did not recommend giving Resident 43 multiple medications at one time because Resident 43 could pocket the medicine, the medication could have gotten stuck in her throat or Resident 43 could have choked. The DON stated she would have to reeducate LVN 1 on how to administer medication to residents like Resident 43 who have dementia because these residents can be unpredictable. During review of the facility's Policy and Procedure (P&P) titled, Administering Medications, revised March 2023, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed. During a review of the facility's Job Description for LVNs, revised 3/7/2024, the LVN job description indicated the LVN assists in providing a clean, safe, dignified, happy and healthy environment for residents by performing the duties as described below: 1. Medication Pass: a. Prepares and passes medications as indicated. Administer medications according to policy and procedure and observe and document patient's response to pertinent medications. b. Prepares and administers treatment as indicated. Performs resident treatments in accordance with physician orders and evaluates and documents the resident's response to the treatment. c. Administers medication and treatment following regulatory guidelines. d. Provides resident teaching regarding medication as required. 2. Nursing Care: a. Maintains awareness of comfort and safety needs of patient. 3. Competencies: a. Exhibit sound an accurate judgment; makes timely decisions. b. Observe safety and security procedures, reports potentially unsafe conditions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of two sampled resident (Resident 43) was assessed for swallowing ability prior to administering oral medications. This deficient practice resulted in Resident 43 not being able to swallow her medications and had the potential to cause aspiration (when a fluid or solid accidentally enters the windpipe and lungs) or a choking hazard. Findings: During a review of Resident 43's admission Record, dated 1/8/2025, the admission record indicated Resident 43 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission record indicated Resident 43 had the following diagnoses which included dysphagia (difficulty swallowing), dementia (a progressive state of decline in mental abilities), and encephalopathy (decreased brain function). During a review of Resident 43's Minimum Data Set (MDS - a resident assessment tool), dated 12/4/2024, the MDS indicated Resident 43's cognition (the ability to think, remember and reason) was severely impaired. The MDS indicated Resident 43 required supervision (helper provides verbal cues and/or touching/steadying as resident completes activity) with eating and maximal assistance (helper does more than half the effort) with oral hygiene, toileting, bathing, and personal hygiene. During a review of Resident 43's History and Physical (H&P), dated 7/22/2024, the H&P indicated Resident 43 did not have the capacity to understand and make decisions. During a review of Resident 43's care plan titled, Patient presents with oral and pharyngeal (throat area) deficits affecting safe and effective swallow, initiated on 7/22/2024 and revised on 1/8/2025, the care plan indicated Resident 43's goal would be to consume a puree (foods that have soft, pudding-like consistency) diet and thin liquids with safe and effective swallow maintaining nutritional needs. The care plan interventions included speech therapy, to sit Resident 43 up right for all oral intake, give smaller bites and sips, double swallows, and chin tuck (moving the chin close to the chest). During a review of Resident 43's Order Summary Report, dated 1/8/2024, the order summary report indicated an active order started on 7/20/2024 May crush medications and mix with applesauce or food. During a review of Resident 43's Order Summary Report, dated 1/8/2024, the order summary report indicated an active order started on 7/20/2024 for Acetaminophen (Tylenol - a medication used to relieve minor aches and pains) 325 milligrams (mg - metric unit of measurement, used for medication dosage and/or amount) oral tablet. Give two tablets by mouth every four hours as needed for mild pain. During a review of Resident 43's Order Summary Report, dated 1/8/2024, the order summary report indicated an active order started on 7/20/2024 for Apixaban (a medication used to prevent blood clots), 5 mg oral tablet. Give one tablet by mouth two times a day for atrial fibrillation (abnormal heartbeat). During a review of Resident 43's Order Summary Report, dated 1/8/2024, the order summary report indicated an active order started on 7/21/2024 for Aspirin (a medication used to reduce the formation of blood clots), 81 mg oral tablet. Give one tablet by mouth one time a day. During a review of Resident 43's Order Summary Report, dated 1/8/2024, the order summary report indicated an active order started on 7/21/2024 for Losartan Potassium (a medication used to treat high blood pressure) 25 mg oral tablet. Give one tablet by mouth one time a day. During a review of Resident 43's Order Summary Report, dated 1/8/2024, the order summary report indicated an active order started on 7/21/2024 for Namenda (Memantine - a medication used to treat dementia) 5 mg oral tablet. Give one tablet by mouth two times a day. During a review of Resident 43's Order Summary Report, dated 1/8/2024, the order summary report indicated Resident 43 had an active order started on 12/24/2024 for a Renal (related to kidneys) 80 gram (g, unit of measurement), no added salt (NAS) mechanical soft texture, (soft, easily chewable foods that are either pureed, mashed, finely chopped, or ground, designed for individuals who have difficulty swallowing or chewing due to medical conditions like dental issues or swallowing disorders) diet, thin consistency. During a review of Resident 43's Order Summary Report, dated 1/8/2024, the order summary report indicated an active order started on 1/7/2025 for Oyster Shell (a calcium supplement) 500 mg oral tablet. Give one tablet by mouth two times a day. During a medication pass observation on 1/8/2025 at 8:40 a.m., with Licensed Vocational Nurse (LVN 1), observed LVN 1 enter Resident 43's room with a medicine cup filled with oral medications. LVN 1 scooped a spoonful of the oral medications from the medicine cup and placed it in front of Resident 43's mouth. LVN 1 stated, It's time to take your medicine, [NAME]. Resident 43 opened her mouth and took the medication from the spoon. LVN 1 offered Resident 43 a sip of water and scooped another spoonful of oral medications from the medicine cup. LVN 1 fed the medication from the spoon to Resident 43 and gave her another sip of water. Resident 43 was squirming in her bed and stated that she needed to go to the restroom. LVN 1 stated, [NAME]! You have to take your medicine. LVN 1 then asked Resident 43 to open her mouth. Resident 43 still had five whole pills on her tongue. LVN 1 stated, Swallow the pills [NAME]! You have to swallow the pills. LVN 1 gave Resident 43 more water and asked Resident 43 to stick out her tongue. The pills were still observed on Resident 43's tongue. LVN 1 stated again, You have to swallow the pills [NAME]. Swallow [NAME]! LVN 1 continued to give Resident 43 more sips of water to drink and check her tongue. The pills remained on Resident 43's tongue. LVN 1 left the room and went to the med cart to get another cup of water. Resident 43 stated again that she had to use the restroom. LVN 1 stated, I will take you to the restroom as soon as you finish taking your medications. LVN 1 continued to give Resident 43 sips of water and told the resident to swallow the pills. After Resident 43 finished a second cup of water, LVN 1 asked Resident 43 to stick out her tongue. The medication was still on the resident's tongue. Some of the medication started to dissolve on Resident 43's tongue but had not been swallowed. LVN 1 stated, You have to swallow the medication [NAME]. Resident 43 stated, I did! Resident 43 continued to move around uncomfortably in her bed and stated that she needed to use the restroom again. LVN 1 asked Resident 43 to stick out her tongue again. The pills were still on Resident 43's tongue. LVN 1 proceeded to use her gloved hand and scrape the medication from Resident 43's tongue, the back of her throat and sides of her cheeks and placed them back into a medicine cup. LVN 1 then assisted Resident 43 to the restroom. During a concurrent interview and record review on 1/8/2025 at 9:15 a.m., with LVN 1, Resident 43's Medication Administration Record (MAR) for the month of January 2025 and Diagnosis Report was reviewed. LVN 1 stated Resident 43 did get her Aspirin, Apixaban, Losartan, Namenda, and Oyster Shell tablets because she was unable to take them. LVN 1 stated, she also attempted to give Resident 43 Tylenol for pain to her buttocks area. LVN 1 stated she had not known Resident 43 to have difficulty swallowing her medications. LVN 1 reviewed Resident 43's Diagnosis Report. LVN 1 stated, the resident has dysphagia. LVN 1 stated since Resident 43 has a history of dysphagia, she should have given her one medication at a time and given her time to swallow each pill before giving her another one. LVN 1 stated Resident 43 could have choked or aspirated because she gave her several medications at one time. During an interview on 1/8/2025 at 2:10 p.m., with the facility's Speech Language Pathologist (ST), the ST stated an evaluation was done on Resident 43 and a treatment diagnosis for dysphagia was made. The ST stated she checked Resident 43 during mealtimes to see if there were any deficits in cognition, communication, or swallowing. The ST stated based on her evaluation of Resident 43 she would not recommend giving several medications at one time. The ST stated Resident 43 was at risk of choking or not being able to pass the medications and choking is a life-threatening event. The ST stated it would have been safer for Resident 43 to take one pill at a time. The ST stated if Resident 43 was unable to swallow the first pill, the nurse could have crushed the remaining pills and administered the pills in applesauce. During an interview on 1/9/2025 at 11:12 a.m., with the Director of Nursing (DON), the DON stated the best practice for administering medications to Resident 43 was to assess Resident 43 before giving her the medications. The DON stated Resident 43 had dysphasia and dementia and this could cause behavioral problems that could prevent Resident 43 from swallowing the medication. The DON stated if Resident 43 was not cooperating at the time of the med pass, the nurse (LVN 1) should have come back later when it was safe to give the medication. The DON stated the nurse should have given one medication at a time and waited for Resident 43 to swallow the medication properly before giving more medications. The DON stated the nurse should have also instructed Resident 43 on how to take the medication properly. The DON stated she (DON) did not recommend giving Resident 43 multiple medications at one time because Resident 43 could pocket the medicine, the medication could have gotten stuck in her throat or Resident 43 could have choked. During review of the facility's Policy and Procedure (P&P) titled, Administering Medications, revised March 2023, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed. During a review of the facility's Job Description for LVNs, revised 3/7/2024, the LVN job description indicated the LVN assists in providing a clean, safe, dignified, happy and healthy environment for residents by performing the duties as described below: 1. Medication Pass: a. Prepares and passes medications as indicated. Administer medications according to policy and procedure and observe and document patient's response to pertinent medications. b. Prepares and administers treatment as indicated. Performs resident treatments in accordance with physician orders and evaluates and documents the resident's response to the treatment. c. Administers medication and treatment following regulatory guidelines. oProvides resident teaching regarding medication as required. 2. Nursing Care: a. Monitors condition changes and properly documents and follows-up if necessary. b. Maintains awareness of comfort and safety needs of patient. 3. Competencies: a. Exhibit sound an accurate judgment; makes timely decisions. b. Observe safety and security procedures, reports potentially unsafe conditions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to honor the food preferences and offer an alternative menu for one of eight sampled residents (Resident 75). This deficient practice had the potential to impact Resident 75's nutritional status and quality of life and result in food dissatisfaction leading to insufficient food intake. Findings: During a review of Resident 75's admission Record, dated 1/8/2025, the admission record indicated Resident 75 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission record indicated Resident 75 had the following diagnoses which included dysphagia (difficulty swallowing), anemia (a condition where the body does not have enough healthy red blood cells), diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN- high blood pressure), hyperlipidemia (an abnormally high amount of fat in the blood). During a review of Resident 75's Minimum Data Set (MDS - a resident assessment tool), dated 12/4/2024, the MDS indicated Resident 75 was cognitively intact (the ability to think, remember and reason). The MDS indicated Resident 75 required supervision (helper provides verbal cues and/or touching/steadying as resident completes activity). The MDS indicated Resident 75 required maximal assistance (helper does more than half the effort) for oral hygiene, toileting, bathing, and personal hygiene. During a review of Resident 75's History and Physical (H&P), dated 8/29/2024, the H&P indicated Resident 75 had the capacity to understand and make decisions. During a review of Resident 75's care plan titled, Resident has alteration in nutritional status, initiated on 7/2/2024 and revised on 9/2/2024, the care plan indicated Resident 75's alteration in nutritional status was related to a mechanically altered and therapeutic diet. The care plan interventions included diet as ordered, adhere to food preferences, offer substitute for any meals refused or poor intakes, and respect Resident 75's right to refuse. During a review of Resident 75's Order Summary Report, dated 1/8/2024, the order summary report indicated an active order on 8/28/2024 for a controlled carbohydrates (CCHO, receiving the same amount of carbohydrates a day) no added salt (NAS) diet, dysphagia mechanical soft texture (a specially prepared diet with soft, easily chewed foods for people who have difficulty swallowing), thin consistency. During an interview on 1/6/2025 at 11:08 a.m. with Resident 75, Resident 75 stated she did not like the food at the facility. Resident 75 stated she only ate the fruit and drank the milk. Resident 75 stated the nurses would occasionally offer her an alternative but not for all meals that she did not like. Resident 75 stated she felt like she was getting skinny because she was not eating enough. During a review of the lunch menu on 1/7/2025, the lunch menu indicated Pork with pear sauce, polenta (a paste or dough made from cornmeal), seasoned broccoli, fresh green salad with dressing, and cranberry crunch bar. During an observation on 1/7/2025 at 1 p.m., in Resident 75's room, observed Resident 75 sitting at her bedside eating lunch. Resident 75 had eaten less than 25 percent (%) of her lunch. Resident 75 pointed to the left-over items on her tray and stated, I don't like this! Resident 75 then pointed to her milk, which was untouched and shook her head. During a concurrent observation and interview on 1/7/2025 at 1:10 p.m. with Certified Nursing Assistant (CNA) 1 and Resident 75, Resident 75's lunch tray was observed. Resident 75 informed CNA 1 she did not like her lunch or the milk. CNA 1 pointed to each item remaining on Resident 75's tray and asked if Resident 75 if she wanted any of the items left on the tray. Resident 75 grimaced (facial expression showing dislike) and said the resident did not want to eat any of the remaining items. CNA 1 stated Resident 75 had only eaten about 5% of her meal. CNA 1 stated when a resident did not like their meal or if they had eaten very little of their meal the CNAs were supposed to offer the resident something else to eat and inform the charge nurse. CNA 1 stated she could also offer residents an alternative menu if it was approved by the charge nurse. Resident 75 stated the nurses did not offer Resident 75 anything else to eat nor did they offer an alternative menu. CNA 1 admitted she had not offered Resident 75 something else to eat or an alternative menu. CNA 1 stated if Resident 75 did not like her meal, she may not get enough nutrition and could lose weight. CNA 1 stated she would report to the charge nurse and would make sure to get Resident 75 something else she preferred to eat for lunch. During a concurrent observation and interview on 1/8/2025 at 7:53 a.m., with Resident 75, observed Resident 75 sitting in bed with her breakfast tray. Resident 75 had only eaten a small bowl of yogurt and half a cup of milk. Resident 75 frowned at her food and stated she did not like her breakfast. Resident 75 pointed to her juice and shook her head and stated she did not like the way the juice tasted. Resident 75 stated she was not offered any alternatives for breakfast. During an interview on 1/8/2025 at 12:02 p.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated per the facility's policy if resident a did not like their meal or ate less than 50%, the CNA must communicate this to the charge nurse. LVN 3 stated she would then visit the resident to find out if the resident would prefer something else to eat. LVN 3 stated she was not informed Resident 75 did not like her breakfast. During an interview on 1/8/2025 at 4:05 p.m., with the facility's Registered Dietician (RD), the RD stated the kitchen was available for the residents if they did not like their meals. The RD stated there was an alternate menu available to the residents and the residents were more than welcome to request something on the alternative menu list. The RD stated nursing should offer an alternate meal if residents did not like their meals. The RD stated Resident 75's food preferences were important and could be detrimental to the resident's health. The RD stated the facility was Resident 75's home and the resident should be happy with her meals. The RD stated not honoring Resident 75's food preferences could potentially cause weight loss. During an interview on 1/9/2025 at 12:46 p.m. with the Dietary Supervisor (DSS), the DSS stated Resident 75 was on a dysphagia mechanically soft diet. The DSS stated Resident 75 preferred hot cereal, soups, and quesadillas. The DSS stated there was a diet substitute for every meal and Resident 75 should be offered a substitute for every meal if she did not like her food. The DSS stated a diet communication slip should have been sent to the kitchen from the nurses to request a substitute. The DSS stated if she was aware Resident 75 was disliking her food, she would have met with the resident to go over her food preferences, likes and dislikes. The DSS stated she wanted to make sure the residents were enjoying their foods. The DSS stated if Resident 75 was not enjoying her meals it could lead to weight variances overtime. During a review of the facility's policy and procedure (P&P) titled, Food Substitution, revised 2019, the P&P indicated, Residents who do not like the menu item will be given an alternate food of similar nutritive value. The P&P indicated menu alternates would be planned and available for all meals. During a review of the facility's P&P titled, Dignity, revised February 2021, the P&P indicated, The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. The P&P indicated individual needs and preferences of the resident were identified through the assessment process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed ensure proper infection control practices were implemented for two of six sampled residents (Resident 189 and Resident 23) when the facility failed to perform the following: 1. Ensure Resident 189, who had a fever and a productive cough, was placed on isolation precautions (methods used to prevent the spread of germs and infections in healthcare and residential settings), as indicated in the facility's policy. 2. Ensure Resident 23's nasal cannula (NC, a plastic medical device to provide additional oxygen to a person directly into the nostrils) was not touching the floor on 1/6/2025 and 1/7/2025. These deficient practices had the potential to spread infection to other residents and staff within the facility and had the potential to place Resident 23 at risk for an upper airway respiratory infection (infection affecting the sinuses and throat). Findings: 1. During a review of Resident 189's admission Record, the admission Record indicated Resident 189 was originally admitted to the facility on [DATE]. Resident 189's diagnoses included displaced fracture (broken bone) of the epicondyle (part of the upper arm bone) of the right humerus (upper arm bone), Parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and muscle weakness. During a review of Resident 189's History and Physical (H&P), dated 1/5/2025, the H&P indicated Resident 189 was able to make medical decisions, and suffered a fall resulting in a right shoulder dislocation. During a review of Resident 189's care plan titled, Urinary Catheter (a hollow tube inserted into the bladder to drain or collect urine) Care Plan, initiated 6/4/2024, the Care Plan indicated the facility was to monitor Resident 259's urine for color, sediments (matter that settles at the bottom of a liquid), amount, and hematuria (blood in the urine), and order laboratory tests, if indicated. During a review of Resident 189's Situation, Background, Assessment, Recommendation (SBAR -a communication tool used by healthcare workers when there is a change of condition among the residents), dated 1/2/2025, the SBAR indicated Resident 189 exhibited a productive cough (cough that produces mucus or phlegm [thick substance secreted by the mucous membranes)] with light green phlegm and a low-grade fever (body temperature slightly above normal). The SBAR indicated Resident 189 had a temperature of 100.1 Fahrenheit (F, unit of temperature, normal range 97 to 99 degrees F). During a review of Resident 189's Order Summary Report, dated 1/8/2025, the summary report indicated Resident 189 did not have orders for any type of isolation precautions. The summary report also indicated to test Resident 189 for the presence of COVID (a contagious disease caused by the coronavirus), influenza (a highly contagious respiratory infection caused by a virus), or respiratory syncytial virus (RSV- s a contagious virus that infects the respiratory tract) and to perform a sputum culture for his cough (a laboratory test that analyzes a sample of sputum, or phlegm, to identify bacteria or other germs that may be causing a respiratory infection). During a review of all of Resident 189's lab results, dated in 1/2025, there were no results indicating the COVID, influenza, or the RSV exams were performed. During an observation on 1/6/2025, at 12:34 p.m., and 1/7/2025, at 9:00 a.m., Resident 189 was observed not on contact or droplet isolation (type of isolation for residents suspected to be infected with pathogens transmitted by respiratory droplet). During an interview, on 1/7/2025, at 9:44 a.m., with the Infection Prevention Nurse (IPN), the IPN stated Resident 189's results were pending, and Resident 189 should have been placed on contact isolation to minimize the spread of infection to other residents and staff. During a review of the facility's Policy and Procedure (P&P), titled, COVID-19, dated 8/26/2024, the P&P indicated to immediately isolate symptomatic (showing signs of) residents in place and to initiate COVID-19 transmission-based precautions while pending testing results. 2. During an observation on 1/6/2025 at 10:40 a.m., in Resident 23's room, Resident 23 was observed receiving oxygen via NC. The NC was observed touching the floor. During an observation on 1/7/2025 at 8:48 a.m., in Resident 23's room, Resident 23 was observed receiving oxygen via NC. The NC was observed touching the floor. During a review of Resident 23's admission Record, dated 1/8/2025, the admission record indicated Resident 23 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 23's diagnoses included pneumonia (an infection/inflammation in the lungs), sepsis (a life-threatening blood infection), seizure (a sudden, uncontrolled electrical disturbance in the brain which could cause uncontrolled jerking, blank stares, and loss of consciousness), and major depressive disorder (a mood disorder that caused a persistent feeling of sadness and loss of interest). During a review of Resident 23's H&P, dated 12/23/2024, the H&P indicated Resident 23 did not have the capacity to make decisions. During a review of Resident 23's MDS, dated [DATE], the MDS indicated Resident 23's cognition was severely impaired. The MDS indicated Resident 23 was dependent (helper did all the effort) with oral hygiene, toileting hygiene, shower/ bathe self, and personal hygiene. During a review of Resident 23's Oder Summary Report, dated 1/8/2025, the report indicated an order, dated 12/22/2024, to administer oxygen at 2 liters (a unit for measuring the volume of a liquid or a gas) per minute (L/min) via NC. During a concurrent observation and interview on 1/7/2025 at 12:04 p.m. with Licensed Vocational Nurse (LVN) 1, in Resident 23's room, Resident 23 was observed receiving oxygen via NC. The NC was touching the floor. LVN 1 stated the NC should not be touching the floor because it put Resident 23 at risk for infection. LVN 1 stated the bacteria could move up to the NC tube, and the resident might develop a respiratory infection. LVN 1 stated everyone who took care of the resident should ensure the NC was not touching the floor. During an interview on 1/8/2025 at 11:57 a.m. with the IPN, the IPN stated the NC was not supposed to be touching the floor because it was the source of bacteria. The IPN stated Resident 23 could develop a respiratory infection, such as pneumonia. The IPN stated Resident 23 might experience coughing, fever, increased confusion, and shortness of breath. The IPN stated all staff were responsible to ensure the NC was not touching the floor. During a review of the facility's P&P titled, Oxygen administration, undated, the P&P indicated oxygen tubing should be used in a manner that prevents it from touching the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff were sitting at eye-level while providing feeding assistance to one of five sampled residents (Resident 10). This failure had the potential to result in affecting Resident 10's self-esteem and self-worth. Findings: During a review of Resident 10's admission Record (Face Sheet), the admission Record indicated Resident 10 was initially admitted to the facility on [DATE] and was readmitted to the facility on [DATE], with diagnoses that included but not limited to type 2 diabetes mellitus (condition that results in too much sugar circulating in the blood), dementia (a condition characterized by progressive or persistent loss of intellectual functioning), and metabolic encephalopathy (problem in the brain caused by chemical imbalances in the blood). During a review of Resident 10's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 10/19/2023, the MDS indicated Resident 10 was able to sometimes understand and sometimes be understood by others. The MDS indicated Resident 10's cognition (process of thinking) was severely impaired. The MDS indicated Resident 10 was dependent in eating. The MDS indicated Resident 10 had a feeding tube (a flexible plastic tube placed into the stomach to assist in nutrition). The MDS indicated Resident 10 was receiving a mechanically altered diet (required change in texture in food or liquids due to difficulty chewing or swallowing). During a review of Resident 10's History and Physical (H&P), dated 3/13/2023, the H&P indicated Resident 10 did not have the capacity to understand and make decisions. During a review of Resident 10's Order Summary Report, dated 1/7/2024, the Order Summary Report indicated a Consistent Carbohydrate, No Added Salt Diet (diet that consists of the same about of carbohydrates [sugars] and no additional added salt), liquidized texture (foods that are smooth, moist, and lump-free and is moderately thick in consistency), small portions. During a concurrent observation and interview on 1/8/2024 at 12:50 p.m. with the Infection Preventionist Nurse (IPN) in Resident 10's room, the IPN was observed standing on the right side of Resident 10's bed while providing feeding assistance. The IPN stated she was standing and was supposed to be sitting at eye-level with Resident 10 while assisting with feeding. The IPN stated sitting at eye-level showed respect and dignity to the resident. During an interview on 1/11/2024 at 10:20 a.m., with the Director of Nursing (DON), the DON stated the staff were expected to sit next to the resident, at eye-level, when assisting with feeding. The DON stated sitting next to the resident provided the staff an optimal angle to assess the resident for choking and to provide dignity to the resident while they were being assisted. The DON stated the staff who provide feeding assistance were supposed to sit with the residents and talk with them as a sign of respect. During a review of the facility's policy and procedure (P&P) titled, Dignity, undated, the P&P indicated, When assisting with care, residents are supported in exercising their rights. For example, residents are . provided with a dignified dining experience. During a review of the facility's P&P titled, Feeding Residents, undated, the P&P indicated, Staff should be sitting down and within eye level of resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide information and education regarding an Advance Directive (a written instruction, such as a living will or durable power of attorney for healthcare, recognized under State law, relating to the provision of healthcare when the individual is incapacitated) to one of six sampled residents' (Resident 7) Responsible Party (RP). This failure had the potential to result in Resident 7's preferences for care in an emergency, or in the event she became incapacitated (unable to participate in a meaningful way in medical decisions) or unable to make medical decisions, would not be identified and/or carried out by the facility staff. Findings: During a review of Resident 7's admission Record (Face Sheet), the admission Record indicated Resident 7 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included but not limited to epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), dementia (a condition characterized by progressive or persistent loss of intellectual functioning), and major depressive disorder (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 7's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 11/7/2023, the MDS indicated Resident 7 was able to understand and be understood by others. The MDS indicated Resident 7's cognition (process of thinking) was severely impaired. During a review of Resident 7's History and Physical (H&P), dated 7/5/2018, the H&P indicated Resident 7 did not have the capacity to understand and make decisions. During a review of Resident 7's Advance Directive Acknowledgement, dated 9/13/2018, the Acknowledgement indicated Resident 7 had not executed an Advance Directive and that Resident 7 was not capable of making preferred intensity of care decisions at the time. The Advance Directive Acknowledgment indicated Resident 7 had initialed and signed the form. During a review of Resident 7's H&P, dated 1/18/2023, the H&P indicated Resident 7 had the capacity to understand and make decisions. During an interview on 1/10/2024 at 3:21 p.m., with the Social Services Director (SSD), the SSD stated she was responsible for providing information regarding Advance Directives to the residents and/or their family. The SSD stated she would review the resident's H&P to determine if the resident was capable of understanding and deciding whether they would like to execute an Advance Directive. The SSD stated Resident 7 was not capable of making medical decisions at the time the previous SSD provided the Advance Directive information and Resident 7's family should have been the ones consulted. The SSD stated the Advance Directive was not reviewed with the appropriate person and there was no indication that it was reviewed with Resident 7's RP. The SSD stated a new Acknowledgement form should have been formulated because the previous was not valid. The SSD stated the purpose of informing the resident and their family about an Advance Directive was to give them the opportunity to have in writing their medical wishes for the resident. During an interview on 1/11/2024 at 11:09 a.m., with the Administrator (ADM), the ADM stated a resident whose H&P indicated they did not have the capacity to understand and make decisions should not be provided any information regarding executing an Advance Directive and the information should be provided to the resident's RP. The ADM stated at the time the Advance Directive Acknowledgement form was completed, Resident 7 did not have the capacity, therefore, a new Acknowledgement form should have been reviewed with Resident 7's RP anytime from 2018 until present day. The ADM stated Resident 7's RP was not given the opportunity to have in writing their life sustaining decisions for Resident 7. During a review of the facility's policy and procedure (P&P) titled, Lack of Capacity- When Medical Intervention(s) Require Informed Consent, undated, the P&P indicated, As soon as reasonably possible during the admission process, an inquiry should be directive to the adult resident or, if the patient is incapacitated, to the patients surrogate decision maker as to whether or not the patient has completed an advance directive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC, notice indicating when Medicare [federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] covered services are ending) to the resident's Responsible Party (RP) two days before their Medicare covered services ended for one of three sampled residents (Resident 27). This failure had the potential to result in Resident 27's RP not having ample time to exercise their right to file an appeal. Findings: During a review of Resident 27's admission Record (Face Sheet), the admission Record indicated Resident 27 was admitted to the facility on [DATE] with diagnoses included but not limited to dementia (a condition characterized by progressive or persistent loss of intellectual functioning), type 2 diabetes mellitus (condition that results in too much sugar circulating in the blood), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest in life). During a review of Resident 27's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 10/19/2023, the MDS indicated Resident 27 was able to understand and be understood by others. The MDS indicated Resident 27 cognition (process of thinking) was moderately impaired. During a review of Resident 27's History and Physical (H&P), dated, 7/18/2023, the H&P indicated Resident 27 was able to make decisions for activities of daily living. During a review of Resident 27's NOMNC, undated, the NOMNC indicated Resident 27's coverage for his current skilled nursing services ended on 8/24/2023. During a review of Resident 27's Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN), undated, the SNFABN indicated Resident 27 and their RP were notified on 8/23/2023 that Resident 27's coverage was ending. During an interview on 1/9/2024 at 11:11 a.m., with the Business Office Manager (BOM), the BOM stated Resident 27's last date of Medicare Part A coverage was 8/24/2023 and the NOMNC should have been provided to Resident 27 and their RP no later than 8/22/2023. The BOM stated Resident 27 and their RP were notified on 8/23/2023, which meant they were notified late. The BOM stated the purpose of notifying the resident and/or the RP two days prior to their last coverage date was to ensure they were given enough notice and time to send a request to appeal. During an interview on 1/9/2024 at 1:40 p.m., with the Administrator (ADM), the ADM stated the resident and/or their RP should be provided the NOMNC no later than two days prior to their last coverage date to give sufficient time to appeal and to decide whether the resident will remain in the facility. During a review of the facility document titled, Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, undated, the document indicated, The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement an individualized care plan with measurable objectives, timeframes, and interventions to improve, prevent and/or limit a decline in joint (where two bones meet) range of motion (ROM, full movement potential of a joint) for one of seven sampled residents (Resident 27) who was identified as having a decline in ROM to both arms. This deficient practice had the potential to negatively affect the delivery of necessary care and services for Resident 27 and lead to contracture (loss of motion of a joint associated with stiffness and joint deformity) development and a decline in overall physical functioning such as the ability to move, eat and dress. Findings: During a review of Resident 27's admission Record, the admission Record indicated the facility admitted Resident 27 on 7/17/2023 with diagnoses including osteoarthritis (loss of protective cartilage that cushions the ends of your bones), muscle weakness, and neuropathy (nerve damage). During a review of Resident 27's Minimum Data Set (MDS, an assessment and care-screening tool), dated 7/21/2023, the MDS indicated Resident 27 had moderate cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 27 required extensive assistance for bed mobility and eating and total assistance for transfers (moving from one surface to another), locomotion (ability to move from one place to another) on and off the unit, dressing, personal hygiene, and toilet use. The MDS indicated Resident 27 had no functional limitations in ROM in both arms (shoulder, elbow, wrist, hand) and both legs (hip, knee, ankle, foot). During a review of Resident 27's MDS, dated [DATE], the MDS indicated Resident 27 required substantial/maximal assistance for eating, oral hygiene, toilet hygiene, and bathing and total assistance in dressing and personal hygiene. The MDS indicated Resident 27 had functional ROM limitations in both arms (shoulder, elbow, wrist, hand) and both legs (hip, knee, ankle, foot). During a review of Resident 27's care plans, the care plans did not indicate a care plan addressing the resident's decline in ROM of both arms. During a concurrent observation and interview with Resident 27 on 1/9/2024 at 9:52 a.m., in Resident 27's room, Resident 27 was observed lying in bed with blankets covering the entire body. Resident 27 stated she had pain all over her body and requested pain medication. Resident 27 stated she has had more pain on the left side of the body for years and stated it was hard to move the left wrist and left shoulder. Resident 27 was unable to bring both arms overhead and was unable to make a full fist with both hands. Resident 27 stated she wished staff would assist with ROM exercises to both arms because they were painful and hard to move on her own. During a concurrent observation and interview with Resident 27 on 1/9/2023 at 2:20 p.m., in Resident 27's room, Resident 27 was observed lying in bed with blankets covering the body. Resident 27 stated she felt much better because she was in less pain and removed the blanket from the upper half of the body using both arms. Resident 27 moved both arms to shoulder level and bent and straightened both elbows. Resident 27 was able to make 90 (percent) % of a full fist with both hands, bent the left wrist downwards, and had difficulty moving the left wrist upwards due to pain. Resident 27 stated she was able to feed herself and wash her face once nursing assisted with set-up. During a concurrent interview and record review on 1/10/2024 at 2:08 p.m., with the Minimum Data Set Nurse (MDSN), Resident 27's MDS (dated 7/21/2023 and 10/19/2023), physician's orders, and care plan were reviewed. The MDSN stated the MDS was a comprehensive (inclusive, including everything necessary) assessment of a resident used to create individualized care plans. The MDSN confirmed Resident 27 had a decline in ROM to both arms and both legs according to the MDS. The MDSN stated Resident 27 was unable to demonstrate she was able to perform her activities of daily living (ADLs, basic activities such as eating, dressing, and toileting) using her arms during the MDS assessment on 10/19/2023 primarily because she was uncooperative. The MDSN stated an Interdisciplinary Team (IDT) meeting should have been initiated to ensure interventions were developed and implemented to address the limitations once the decline in ROM of Resident 27's arms and legs were identified but was not done. The MDSN stated Resident 27 should have been on therapy or RNA services to address the decline in ROM of both arms identified in the MDS but was not. The MDSN confirmed RNA services were ordered for PROM of both legs but was not ordered for the arms. The MDSN confirmed there were no interventions in place to address the change in ROM or prevent a further decline in ROM of Resident 27's arms. The MSDN stated Resident 27 was at risk for contractures because she did not get out of bed, required assistance with ADLs, and needed a lot of encouragement to participate in everyday activities. During a concurrent interview and record review on 1/10/2024 at 2:47 p.m., with the Director of Rehabilitation (DOR) who was an Occupational Therapist (OT), Resident 27's OT notes, Rehabilitation screens, joint mobility screen, and physician's orders were reviewed. The DOR stated she was unaware nursing identified Resident 27 as having a decline in arm ROM in the MDS. The DOR stated the decline in Resident 27's arm ROM should have been communicated to the rehab department in an IDT meeting but was not. The DOR stated Resident 27 was at high risk for contracture development and a functional decline because Resident 27 had a diagnosis of osteoarthritis, required assistance with mobility and ADLs, and required encouragement to move on her own. During a concurrent interview and record review on 1/11/2024 at 2:38 p.m., with the Director of Nursing (DON), Resident 27's IDT notes, MDS assessments, care plan, and physician's orders were reviewed. The DON confirmed Resident 27's had a decline in both arm ROM according to the MDS assessments. The DON confirmed Resident 27 did not have a care plan, interventions, and any services in place to address the decline in Resident 27's arm ROM. The DON stated residents with ROM impairments should be on therapy or RNA services to prevent a decline in function. The DON stated an IDT meeting should have been done, a care plan should have been created, and interventions should have been implemented once Resident 27's arm ROM decline was identified on the MDS but was not. The DON stated Resident 27 was at risk for contracture development and a functional decline because there were no interventions in place improve or prevent a decline in Resident 17's arm ROM. During a review of the facility's undated policy and procedure (P&P) titled, The Resident Care Plan, the P&P indicated the objective of comprehensive care plans was to provide individualized nursing care and to promote continuity of resident care. The P&P indicated the care plan was comprehensive in nature and generally included: identification of medical, nursing, and psychosocial needs, measurable goals, staff approaches to meet the goals, the discipline, or staff responsible for the interventions, and re-assessment and change as needed to reflect the resident's current status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise the resident-centered care plan (document that helps nurses and other team care members organize aspect of resident care) for one of six sampled residents (Resident 74) who had a change in her ability to carry out her activities of daily living (ADLs, term used to collectively describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility). This failure had the potential to result in Resident 74's needs not be met due to the staff being unaware of the required assistance needed. Findings: During a review of Resident 74's admission Record (Face Sheet), the admission Record indicated Resident 74 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses included but not limited to type 2 diabetes mellitus (condition that results in too much sugar circulating in the blood), heart failure (a chronic condition in which the heart does not provide adequate blood flow to meet the body's needs), and chronic obstructive pulmonary disease (COPD, a lung disease characterized by long-term poor airflow). During a review of Resident 74's History and Physical (H&P), dated 4/24/2023, the H&P indicated Resident 74 had the capacity to understand and make decisions. During a review of Resident 74's Minimum Data Set (MDS, comprehensive resident assessment and care screening tool), dated 12/14/2023, the MDS indicated Resident 74 was able to understand and be understood by others. The MDS indicated Resident 74's cognition was intact (ability to think and reason). The MDS indicated Resident 74 required moderate assistance with bed mobility, maximal assistance with toileting, bathing, and dressing, and required setup or clean-up assistance with personal hygiene. The MDS indicated Resident 74 had a fall with a major injury. During a review of Resident 74's Care Plan, revised 4/5/2022, the Care Plan indicated Resident 74 had self-care deficits with bed mobility that required extensive one-person assist, dressing that required total one-person assist, toileting that required total one-person assist, personal hygiene that required extensive one-person assist, and bathing that required total one-personal assist. During an interview on 1/10/2024 at 12:16 p.m., with the MDS Nurse (MDSN), the MDSN stated she was responsible for developing residents' care plans based on their MDS and to revise care plans if there were any changes in the residents' condition. The MDSN stated based on Resident 74's most current MDS on 12/14/2023 the resident's care plan on self-care deficits with bed mobility, dressing, toileting, personal hygiene, and bathing should have been revised to correctly portray her current status. The MDSN stated the residents' care plans was a communication tool with the staff and without an updated care plan for Resident 74, she potentially would not receive the proper care the required. During an interview on 1/11/2024 at 10:24 a.m., with the Director of Nursing (DON), the DON stated the purpose of care plans was to direct the staff on how to care for the resident based on their needs and goals. The DON stated care plans were revised if a resident had a change in condition, the interventions were no longer appropriate, or new interventions needed to be added according to the needs of the resident. The DON stated Resident 74 had changes in her ability to carry out her ADLs and her care plan should have been updated to reflect those changes to ensure Resident 74 received the proper care. During a review of the facility's policy and procedure (P&P) titled, Resident Assessment, undated, the P&P indicated, Care plans shall be updated more often, as the resident's condition or needs change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Registered Nurse (RN) 3 received report (oral communication between care providers to describe that status of the resident) for one of three sampled residents (Resident 74) who was readmitted to the facility from the general acute care hospital (GACH). This failure resulted in the nursing staff and physician being unaware of Resident 74's computed tomography (CT, imaging that helps detect internal injuries and diseases) scan results that showed a compression fracture (type of broken bone that can cause the vertebra [bone in the spine] to collapse) of the second lumbar vertebrae (L2, bone in the lower end of the spinal column). Findings: During a review of Resident 74's admission Record (Face Sheet), the admission Record indicated Resident 74 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (condition that results in too much sugar circulating in the blood), heart failure (a chronic condition in which the heart does not provide adequate blood flow to meet the body's needs), and chronic obstructive pulmonary disease (COPD, a lung disease characterized by long-term poor airflow). During a review of Resident 74's History and Physical (H&P), dated 4/24/2023, the H&P indicated Resident 74 had the capacity to understand and make decisions. During a review of Resident 74's Minimum Data Set (MDS, a standardized resident asssessment and care screening tool) dated 12/14/2023, the MDS indicated Resident 74 was able to understand and be understood by others. The MDS indicated Resident 82's cognition was intact (ability to think and reason). The MDS indicated Resident 74 required moderate assistance with bed mobility, maximal assistance with toileting, bathing, and dressing, and required setup or clean-up assistance with personal hygiene. The MDS indicated Resident 74 had a fall with a major injury. During a review of Resident 74's Change of Condition (COC), dated 11/6/2023, the COC indicated Resident 74 returned to her room from the shower room and was being assisted to bed by the certified nursing assistant (CNA). The COC indicated Resident 74 stood up to transfer to the bed, was unable to reach for the bed handles, and fell and landed on her back. The COC indicated Physician 2 was informed and orders for X-ray (imaging that creases pictures of the inside of the body) of the hip, spine, head, leg, and pelvis were received. The COC indicated Resident 74 complained of lower back and left hip pain. During a review of Resident 74's Radiology Results Report, dated 11/6/2023, the Radiology Results Report indicated the X-ray result of the lumbar spine indicated a compression deformity at the L2 level, age indeterminate (not exactly known). During a review of Resident 74's Progress Notes, dated 11/6/2023 and timed at 1:48 p.m., the Progress Note indicated Physician 2 was informed of Resident 74's X-ray results and Physician 2 ordered a CT scan of the head and lumbar. During a review of Resident 74's COC, dated 11/28/2023, the COC indicated Resident 74 complained of lower back pain and another lumbar X-ray was done with result of a compression deformity at the L2 level, age determinate. The COC indicated Physician 2 was notified that Resident 74 had not received the CT scan of the head and lumbar due to insurance. The COC indicated Physician 2 ordered for Resident 74's transfer to the GACH for CT scan of the head and lumbar. During a review of Resident 74's GACH Radiology Report, dated 11/28/2023, the Radiology Report indicated the report was faxed to the facility on [DATE]. The Radiology Report indicated the CT scan result of the lumbar indicated an acute compression fracture of L2. During a review of Resident 74's (Re)admission Assessment, dated 11/28/2023, the admission Assessment indicated Resident 74 was transferred to the GACH for a CT scan of the head and lumbar and was readmitted to the facility. The admission Assessment had no indication of report from the GACH being provided to the admitting nurse from the facility and of the results of the CT scan. During a review of Resident 74's COC, dated 12/12/2023, the COC indicated the lumbar CT scan results were received from the GACH and Physician 2 was notified of the results. The COC indicated Physician 2 ordered for Resident 74 to see a neurosurgeon in one to six weeks for evaluation. During an interview on 1/10/2024 at 8:59 a.m., with Registered Nurse (RN) 2, RN 2 stated she and the other nurses were unaware of Resident 74's compression fracture until the facility received the results from the GACH. RN 2 stated Resident 74 was transferred to the GACH on her shift and was readmitted to the facility the following shift. RN 2 stated she had not received any report regarding Resident 74 while the resident was at the GACH. During an interview on 1/10/2024 at 3:46 p.m., with RN 3, RN 3 stated Resident 74 was transferred to the GACH on 11/28/2023 for a CT scan and was readmitted to the facility that same night. RN 3 stated the case manager from the GACH called her to inform her that Resident 74 would be returning to the facility, and someone would give her report. RN 3 stated normally when a resident was readmitted to the facility from the GACH, she would receive report prior to the resident's arrival. RN 3 stated she had not received report and Resident 74 was brought back to the facility. RN 3 stated she was curious what the CT scan results were, but she did not follow up with the GACH. RN 3 stated she could have called the GACH and spoken to the physician. RN 3 stated receiving report when a resident was admitted to the facility from the GACH was important in order to receive all the information that transpired at the GACH to care for the resident and collaborate with the physician. During an interview on 1/11/2024 at 10:28 a.m., with the Director of Nursing (DON), the DON stated the admitting nurse should receive report from the nurse at the GACH, especially if there were any abnormal results. The DON stated receiving report when a resident was admitted was important to know how to take care of the resident, if any precautions needed to be taken, to coordinate with other departments, in order to form a plan to care for the resident properly. During a review of the facility's policy and procedure (P&P) titled, Out-of-Facility Therapeutic Visit, undated, the P&P indicated, The facility will follow up on the recommendation from the out-of-facility therapeutic visit, if any.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff provided the necessary care and services to two sampled residents (Resident 85 and 35) when: 1. Certified Nursing Assistant (CNA) 2 failed to report Resident 85's change in condition to a licensed nurse. 2. CNA 2 failed to properly reposition Resident 85 in bed. 3. Staff did not reposition Resident 35 and Resident 85 every 2 hours. These deficient practices had the potential for Resident 85's health changes to become compromised and go unnoticed, and had the potential to result in skin breakdown or compromised skin integrity for Resident 35 and Resident 83. Findings: 1. During a review of Resident 85's admission Record, the admission record indicated Resident 85 was originally admitted to the facility on [DATE] with diagnoses including dysarthria (weakness in muscles used for speech, which often causes slowed or slurred speech) and dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). During a review of Resident 85's H&P dated 6/13/2023, the H&P indicated Resident 85 did not have the capacity to understand and make decisions. The H&P indicated Resident 85 had a diagnosis of chronic obstructive pulmonary disease ([COPD] group of chronic lung diseases that block airflow and make it harder to breathe air out of the lungs). During a review of Resident 85's MDS, dated [DATE], the MDS indicated Resident 85's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 85 was dependent on staff for all ADLs. The MDS indicated Resident 85 had a diagnosis of hemiplegia (a condition caused by a brain injury, that results in a varying degree of weakness, stiffness, and lack of control in one side of the body). During a review of Resident 85's Care Plan for Skin, dated 5/16/2023, the care plan indicated Resident 85 was at risk for developing pressure ulcers and other skin breakdown related due to fragile skin, hemiplegia, and immobility. The Care Plan indicated Resident 85's goal was to minimize the risk of skin breakdown and pressure ulcer daily. The staff's interventions indicated to turn and position Resident 85 as needed when in bed or wheelchair. During a review of Resident 85's Care Plan for Respiratory System, dated 5/16/2023, the care plan indicated Resident 85 was at risk for respiratory distress related to COPD. The care plan indicated Resident 85's goal was to not have unrecognized signs and symptoms of respiratory distress. The staff's interventions indicated to assess Resident 85 for shortness of breath, wheezing, coughing, weakness and to notify the physician promptly. During an observation on 1/8/2024 at 10:19 a.m., in Resident 85's room, Resident 85 was observed lying on his left side facing the wall. During an observation 1/8/2024 at 12:44 p.m., in Resident 85's room, Resident 85 was observed lying on his left side facing the wall. During an observation on 1/9/2024 at 1:00 p.m., in Resident 85's room, Resident 85 was observed lying on his left side facing the wall with no pillows between his legs. During an observation on 1/9/2024 at 3:28 p.m., in Resident 85's room, Resident 85 was observed lying on his left side facing the wall. During an observation on 1/10/2024 at 7:44 a.m., in Resident 85's room, CNA 2 was observed at the resident's bedside during breakfast. Resident 85 was making grunting noises when breathing. During an observation on 1/10/2024 at 8:00 a.m., in Resident 85's room, Resident 85 was observed lying on his back, his bilateral (both) lower extremities (BLE) were contracted (a fixed tightening or shorten of muscle, tendons, ligaments, or skin) and tucked underneath him with no pillow between the legs. Resident 85 was making loud grunting noises when breathing. During an interview on 1/10/2024 at 8:14 a.m. with the Infection Preventionist Nurse (IPN), in Resident 85's room, the IPN stated Resident 85 should not have his legs in that position because it was uncomfortable and would create more of a contracture to the legs or it would cause a fracture (break in the bone) to the legs. During an observation on 1/10/2024 at 8:20 a.m., in Resident 85's room, the IPN and CNA 2 attempted to reposition Resident 85. Resident 85 could not straighten out his legs. CNA 2 kept pulling on Resident 85's legs and placed a pillow under the resident's legs. During an interview on 1/10/2024 at 8:29 a.m. with CNA 2, in Resident 85's room, CNA 2 stated she positioned Resident 85 on his back with the resident's BLE tucked under him. CNA 2 stated that positioning provided comfort to Resident 85. CNA 2 stated it was acceptable to place Resident 85 in that position without any support for his BLE because it did not cause any pain or discomfort. CNA 2 stated Resident 85 made beathing noises when she was with him. During a concurrent observation and interview on 1/10/2024 at 8:40 a.m. with the IPN, in Resident 85's room, Resident 85 was grunting loudly and struggling to breath. The IPN stated she needed to check Resident 85's oxygen saturation (percentage of oxygen circulating in the blood). The IPN stated Resident 85's oxygen saturation was 91 percent (%) (Normal Reference Range, 95% to 100%) and that she would administer oxygen to Resident 85. The IPN stated CNA 2 should have realized that Resident 85 was having trouble breathing and she should have notified a nurse. The IPN stated CNAs received in-service training to look out for any changes in residents and to notify a licensed nurse. During an interview on 1/10/2024 at 10:15 a.m. with Licensed Vocational Nurse (LVN) 2, in Resident 85's room, LVN 2 stated Resident 85 should be repositioned every 2 hours because the resident was bed bound. LVN 2 stated Resident 85 must be repositioned every 2 hours because the resident developed redness on his buttocks. LVN 2 stated Resident 85 would benefit from frequent position changes to relieve skin pressure and promote circulation. During an interview on 1/11/2024 at 8:25 a.m. with LVN 5, LVN 5 stated residents that were bed bound must be repositioned every 2 hours or as needed. LVN 5 stated residents were repositioned to prevent pressure on their skin. LVN 5 stated if residents were not repositioned it would increase the risk of skin breakdown/wounds. During an interview on 1/11/2024 at 11:02 a.m. with the DSD, the DSD stated CNAs were trained on what to look out for in residents when there was a change of condition. The DSD stated CNAs were instructed to observe residents for facial grimaces, body language, or anything out of the normal and report it to a nurse. The DSD stated CNA 2 should have reported Resident 85 was making loud noises when breathing. During an interview on 1/11/2024 at 12:29 p.m. with the Director of Nursing (DON), the DON stated CNAs were trained to observe residents and trained to notify any change of conditions to the charge nurse. The DON stated CNA 2 should have notified a licensed nurse that Resident 85's breathing was not normal. 2. During a review of Resident 35's admission Record, the admission record indicated Resident 35 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including heart failure (progressive heart disease that affects pumping action of the heart muscles) and peripheral vascular disease ([PVD] a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). During a review of Resident 35's History and Physical (H&P) dated 7/14/2023, the H&P indicated Resident 35 did not have the capacity to understand and make decisions. The H&P indicated Resident 35 had a diagnosis of quadriplegia (paralysis [inability to move] that affects all the limbs and body from the neck down). During a review of Resident 35's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/6/2023, the MDS indicated Resident 35's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired. The MDS indicated Resident 35's speech was unclear. The MDS indicated Resident 35 was dependent on staff for all activities of daily living (ADLs, self-care activities performed daily such as dressing, personal hygiene, grooming, and toilet use). The MDS indicated Resident 35 was at risk for a pressure ulcer/injury (injury to the skin and underlying tissue due to prolonged pressure). During a review of Resident 35's Care Plan for Skin, dated 8/30/2019, the care plan indicated Resident 35 was at risk for developing skin breakdown due to fragile skin, immobility, and history of skin alteration. The Care Plan indicated Resident 35's goal was to minimize the risk of skin breakdown/ bruising/pressure ulcer daily. The staff's interventions indicated to turn and position Resident 35 as needed when in bed or wheelchair. During an observation on 1/8/2024 at 12:19 p.m., in Resident 35's room, Resident 35 was observed lying on his left side facing the door. During an observation on 1/8/2024 at 2:56 p.m., in Resident 35's room, Resident 35 was lying observed on his left side facing the door. During an observation on 1/9/2024 at 9:36 a.m., in Resident 35's room, Resident 35 was observed lying on his left side facing the door. During an observation on 1/9/2024 at 1:52 p.m., in Resident 35's room, Resident 35 was observed lying on his left side facing the door. During an observation on 1/9/2024 at 3:21 p.m., in Resident 35's room, Resident 35 was observed lying on his left side facing the door. During an interview on 1/11/2024 at 10:48 a.m. with the Director of Staff Development (DSD), the DSD stated residents that had contractions, were weak and bedridden must get repositioned every 2 hours. The DSD stated residents were repositioned to prevent skin breakdown. The DSD stated CNAs received in-service training on repositioning residents and the CNAs should know that residents were to be repositioned every 2 hours. During an interview on 1/11/2024 at 12:17 p.m. with the DON, the DON stated bedridden resident should be repositioned every 2 hours and as needed. The DON stated CNAs have been told to reposition residents continuously throughout the day to prevent skin breakdown. The DON stated she expected all CNAs to assist all bedridden residents with repositioning at least every 2 hours to relieve skin pressure. The DON stated if residents did not get repositioned, they would be prone to skin breakdown and pain due to discomfort. During a review of the facility's policy and procedure (P&P) titled, Positioning/repositioning Residents, undated, the P&P indicated a pillow must be placed under the resident's upper arm to support it. The P&P indicated the upper leg must be bent, pillows must be placed under the thigh, calf, and foot for support. During a review of the facility's P&P titled, Change of Condition, undated, the P&P indicated its purpose was to ensure proper assessment and follow-through for any resident with a change condition. The P&P indicated a change of condition was a sudden or marked difference in residents: Vital signs (Temperature, pulse, heart rate, irregular pulse, shortness of breath). The P&P indicated all changes of condition in a resident shall be handled promptly.

Based on observation, interview, and record review, the facility failed to ensure precautions were maintained to prevent the development of pressure ulcers (PU, an injury that breaks down the skin and underlying tissue, caused when an area of skin is placed under prolonged pressure) for one of five sampled residents (Resident 73) by failing to: 1. Ensure Resident 73's weight was accurately set on the low air loss mattress (LALM, a mattress designed to distribute body weight over a broad surface area to help prevent skin breakdown). These failures had the potential to result in the development of skin breakdown and/or pressure ulcers which could result in complications associated with impaired skin integrity for Residents 73. Findings: During a review of Resident 73's admission record, the record indicated the facility originally admitted Resident 73 on 7/29/2022 and re-admitted Resident 73 on 10/14/2023. Resident 73's admitting diagnoses included abnormal posture, generalized muscle weakness, and lack of coordination. During a review of Resident 73's progress note by Registered Nurse (RN) 1, dated 9/28/2023, the progress note indicated New orders for low air loss mattress [LALM] for wound [management] and prevention per [Medical Doctor] noted and carried out. During a review of Resident 73's medical record titled Wound Risk Assessment, dated 10/14/2023, the record indicated Resident 73 was at high risk for skin breakdown based on her medical conditions, and indicated Resident 73 was willing to participate in the plan of care for wound management. During a review of Resident 73's History and Physical (H&P), dated 11/2/2023, the H&P indicated Resident 73 did not have the capacity to understand and make decisions. During a review of Resident 73's Minimum Data Set (MDS, a standardized assessment and care screening/planning tool), dated 12/26/2023, the MDS indicated Resident 73 experienced cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 73 required partial to moderate assistance from staff when rolling from her back to a side-lying position in bed and was fully dependent on staff assistance to transition from a sitting position to a lying position, and a lying position to a sitting position. The MDS further indicated Resident 73 was at risk for developing PUs. During a review of Resident 73's care plans, the care plans indicated Resident 73 was at risk for developing PUs, and goals of care included reducing Resident 73's risk of experiencing skin breakdown/PUs through appropriate interventions. Staff's interventions indicated to ensure skin treatments and management as ordered. During an observation, on 1/8/2023 at 10:34 a.m., at Resident 73's bedside, Resident 73 was observed lying on a Proactive brand Protekt Aire 4000DX/5000DX Low air loss mattress (LALM). The weight settings on the pump that inflated the LALM indicated the LALM was set for a resident that weighed 280 pounds (lbs., a unit of measuring weight). During an observation, on 1/10/2023 at 9:16 a.m., at Resident 73's bedside, Resident 73 was observed lying on a Proactive brand Protekt Aire 4000DX/5000DX LALM. The weight settings on the pump that inflated the LALM indicated the LALM was set for a resident that weighed 280 lbs. During a concurrent interview and record review, on 1/10/24 at 9:42 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 reviewed Resident 73's monthly weight measurements for 1/2024. LVN 1 stated Resident 73's records indicated Resident 73 weighed 141.0 lbs. on 1/2/2024. LVN 1 stated she was responsible for adjusting the LALM settings. LVN 1 stated resident 73's LALM settings had not been changed within the last few months. During a concurrent observation and interview, on 1/10/2024 at 9:49 a.m., at Resident 73's bedside, with Licensed Vocational Nurse (LVN) 1, LVN 1 observed the LALM Resident 73 was lying on. LVN 1 stated Resident 73's LALM was set for a resident that weighed 280 lbs. LVN 1 stated the settings for Resident 73's LALM were not correct. LVN 1 stated it was important to ensure the weight settings were correct to ensure the pressure to Resident 73's skin was offloaded effectively. LVN 1 stated that incorrect settings increased risk for the resident to develop a PU. During an interview on 1/11/2024 at 1:09 p.m., with the Director of Nursing (DON), the DON stated the air in the LALM was used to relieve pressure on the skin. The DON stated LALMs were used for PU prevention in residents who were at high risk for developing PUs. The DON stated it was important to ensure the weight settings were correct to ensure accurate pressure in the mattress and stated facility staff were supposed to use and operate the mattress according to the manufacturer's guidelines. During a review of the facility policy and procedure (P&P) titled, Pressure Sore Management, undated, the P&P indicated all available measures shall be taken to reduce skin breakdown and pressure [ulcers] and that individual care plans for management of skin condition would be developed as indicated. During a review of the facility document titled, Proactive Medical Products Operation Manual for Protekt Aire 4000DX/5000DX, undated, the document indicated facility staff were supposed to press the up/down buttons on panel to adjust the weight/pressure level to the patient's specific requirements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure fall precautions were maintained for two of five sampled residents (Resident 22 and Resident 73) when the following occurred: 1. Resident 22 did not have fall mats placed at her bedside, and call light was not within her reach. 2. Resident 73 did not have a fall mat placed at her bedside. These failures had the potential to cause avoidable harm to Resident 22 and Resident 73 related to repeat falls and the potential injuries related to sustaining a fall. Findings: 1. During a review of Resident 22's admission Record, the admission record indicated the facility originally admitted Resident 22 on 12/5/2015 and re-admitted Resident 22 on 8/13/2021. Resident 22's admitting diagnoses included osteoarthritis (wearing down of the protective tissue at the ends of bones that occurs gradually and worsens over time), unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), aphakia in both eyes (not having a lens inside the eye, causing lack of focus and blurry vision), difficulty walking, and generalized muscle weakness. During a review of Resident 22's History and Physical (H&P), dated 8/30/2023, the H&P indicated Resident 22 did not have the capacity to understand and make decisions. During a review of Resident 22's Minimum Data Set (MDS, a standardized assessment and care screening/planning tool), dated 12/14/2023, the MDS indicated Resident 22 experienced severe cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 22 also exhibited inattention and disorganized thinking. The MDS indicated Resident 22 required partial to moderate assistance from staff when rolling in bed from her back to a side-lying position, transitioning from a sitting position to lying position and vice versa, and transferring between surfaces (chair to bed and vice versa, on and off the toilet, and in and out of the shower). During a review of Resident 22's medical records, the records indicated Resident 22 sustained two falls in the facility on 10/26/2021 and 2/26/2022. During a review of Resident 22's medical record titled, Fall Risk Assessment, dated 12/14/2023, the record indicated Resident 22 was high risk for falls. The record indicated staff were required to develop a care plan to reduce falls and injuries. During a review of Resident 22's care plans regarding falls, the care plans indicated Resident 22 was at risk for falls and injury. The goals of care included a reduction of the risk for falls and injury daily. Staff's interventions indicated to place floor mats at the bedside and keep the call light within easy reach. During a review of Resident 22's physician orders, dated 5/26/2023, the orders indicated staff were to place floor mats at Resident 22's bedside to decrease potential injury. During an observation on 1/8/2024 at 11:22 a.m., at Resident 22's bedside, Resident 22 was observed lying at the foot-end of her bed, with a gap of two (2) feet between her head and the headboard. Resident 22's legs were dangling at the right edge of the bed. Resident 22's call light was at the head of the bed and not within reach. No fall mats observed to either side of the bed. During an observation on 1/11/2024 at 10:45 a.m., at Resident 22's bedside, Resident 22 was observed lying in bed. Call light was not observed in Resident 22's bed or placed near Resident 22. During a concurrent observation and interview, on 1/11/2024 at 10:53 a.m., at Resident 22's bedside, with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 22 had a history of falls and was high risk for repeat falls. LVN 2 stated Resident 22 tended to get out of bed without assistance and required fall mats for injury prevention. LVN 2 stated Resident 22's call light was on the floor behind Resident 22's bed, and out of Resident 22's reach. 2. During a review of Resident 73's admission Record, the record indicated the facility originally admitted Resident 73 on 7/29/2022 and re-admitted Resident 73 on 10/14/2023. Resident 73's admitting diagnoses included left knee osteoarthritis, abnormal posture, generalized muscle weakness, and lack of coordination. During a review of Resident 73's H&P, dated 11/2/2023, the H&P indicated Resident 73 did not have the capacity to understand and make decisions. During a review of Resident 73's MDS, dated [DATE], the MDS indicated Resident 73 experienced cognitive impairment. The MDS indicated Resident 73 required partial to moderate assistance from staff when rolling from her back to a side-lying position in bed and was fully dependent on staff assistance to transition from a sitting position to lying position, and a lying position to a sitting position. The MDS further indicated Resident 73 required substantial to maximal assistance with performing hygiene activities, getting dressed, and bathing. During a review of Resident 73's medical records, the records indicated Resident 73 sustained a fall on 9/15/2023. Resident 73's radiology report, dated 9/15/2023, indicated Resident 73 sustained a proximal right humerus fracture (broken arm bone) and swelling of the soft tissue (muscles, fat, blood vessels, nerves, tendons, and tissues that surround the bones and joints). The records further indicated Resident 73 was hospitalized from [DATE] to 9/22/2023. During a review of Resident 73's medical record titled, Fall Risk Assessment, dated 9/15/2023, the record indicated Resident 73 sustained a change of condition and was high risk for falls. The record indicated staff were required to develop a care plan to reduce falls and injuries. During a review of Resident 73's care plans regarding falls, the care plans indicated Resident 73 was at risk for falls and injury. The goals of care included a reduction of the risk for falls and injury daily. During a review of Resident 73's physician orders, dated 10/14/2023, the orders indicated staff were supposed to keep Resident 73's bed in a low position with a floor mat at the bedside to decrease potential injury. During a concurrent observation and interview, on 1/8/2024 at 10:32 a.m., with Resident 73 at Resident 73's bedside, Resident 73 observed with a sling to her right arm. Resident 73 stated she had sustained a fall in the facility. Resident 73 stated that following the fall, staff placed a fall mat at her bedside, and could not state when the mat was removed. Resident 73 stated it had been gone a while. No fall mat observed at Resident 73's bedside. During an interview on 1/10/2024 at 11:01 a.m., with LVN 3, LVN 3 stated fall mats were for prevention of injury related to falls. LVN 3 stated that if a resident has orders for fall mats, and they are indicated in the care plan, and the floor mats should be at the resident's bedside. LVN 3 stated the facility had enough floor mats to ensure that all residents who require them have them available. LVN 3 stated not having fall mats at the bedside could increase the potential for injury if a resident sustained a fall. LVN 3 stated a resident could fall and sustain a broken bone. During an interview on 1/11/2024 at 1:13 p.m., with the Director of Nursing (DON), the DON stated fall precautions and interventions should be implemented when assessments indicate the resident is at risk for falls. The DON stated the purpose of fall mats was to reduce injury if a resident were to fall. The DON also stated the purpose of a call light was to allow residents to call for help when needed, and stated the call light should always be within the resident's reach. The DON stated the call light should not be on the floor behind the resident's bed. The DON stated that failure to implement the fall prevention interventions on a resident's care plan, or as ordered, increased the risk for residents to sustain falls and injury. During a review of the facility's policy and procedure (P&P) titled, Promoting Safety, Reducing Falls, undated, the P&P indicated major risk factors for falls included a history of falls, and intrinsic factors such as the age of a resident, vision losses, and medical conditions such as neurological deficits, and gait and balance disturbances. The P&P further indicated that staff were supposed to keep call-lights within easy reach of residents. During a review of the facility's P&P titled, The Resident Care Plan, undated, the P&P indicated the nursing care plan acts as a communication instrument between nurses and other disciplines. The P&P further indicated the resident care plan shall be implemented for each resident and it is the responsibility of the Licensed Nurse to ensure that the plan of care is initiated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure the resident's nasal cannula (device used to deliver supplemental oxygen or increased airflow through the nose) and the oxygen concentrator humidifier bottle (medical devise that increases the humidity in the nostrils while using supplemental oxygen) were labeled with the date, time, and initials of the nurse when initially used for Resident 10 and Resident 51. This deficient practice had the potential to cause a negative respiratory outcome and increased the risk for Resident 10 and Resident 51 to acquire a respiratory infection. Findings: 1. During a review of Resident 10's admission Record (Face Sheet), the admission Record indicated Resident 10 was initially admitted to the facility on [DATE] and was readmitted to the facility on [DATE], with diagnoses that included but not limited to type 2 diabetes mellitus (condition that results in too much sugar circulating in the blood), dementia (a condition characterized by progressive or persistent loss of intellectual functioning), and metabolic encephalopathy (problem in the brain caused by chemical imbalances in the blood). During a review of Resident 10's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 10/19/2023, the MDS indicated Resident 10 was able to sometimes understand and sometimes be understood by others. The MDS indicated Resident 10's cognition (process of thinking) was severely impaired. During a review of Resident 10's History and Physical (H&P), dated 3/13/2023, the H&P indicated Resident 10 did not have the capacity to understand and make decisions. During a review of Resident 10's Order Summary Report, dated 1/7/2024, the Order Summary Report indicated to administer oxygen at two (2) liters (unit of measurement) per minute (L/min) via nasal cannula, may titrate (change rate) up to five L/min for oxygen saturation (amount of oxygen circulating in the blood, normal value 95% to 100%) less than 95%. The Order Summary Report indicated to change the humidifier and nasal cannula every Sunday during the night shift. During an observation on 1/8/2024 at 9:15 a.m., in Resident 10's room, Resident 10 was receiving 2 L/min of oxygen. Resident 10's oxygen concentrator humidifier bottle was dated, 1/8/2024, and the nasal cannula tubing did not have a label. During an observation on 1/9/2024 at 1:55 p.m., in Resident 10's room, Resident 10 was receiving 2 L/min of oxygen. Resident 10's oxygen concentrator humidifier bottle was dated, 1/8/2024, and the nasal cannula tubing did not have a label. During an observation on 1/11/2024 at 7:43 a.m., in Resident 10's room, Resident 10 was receiving 2 L/min of oxygen. Resident 10's oxygen concentrator humidifier bottle was dated, 1/8/2024, and the nasal cannula tubing was dated, 1/10/2024. During an interview on 1/11/2024 at 7:51 a.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated the nurses had to label the nasal cannula and humidifier bottle with the date and time it was opened. LVN 3 stated the nasal cannula and humidifier bottles were to be changed every week or as needed. LVN 3 stated dating these items ensured that they would not be used past the date because using the nasal cannula and humidifier bottle longer than ordered could be an infection control issue. LVN 3 stated if the nasal cannula and humidifier bottle were not dated, the staff would be unsure when they were opened and should be thrown away. LVN 3 stated there was a potential for the nasal cannula and humidifier bottle to be used longer than intended if they were not dated and that could lead to infection from growth of bacteria that could enter through the nose and into the body. During an interview on 1/11/2024 at 9:48 a.m., with the Infection Preventionist Nurse (IPN), the IPN stated the nasal cannulas and humidifier bottles were changed weekly but could be changed more frequently. The IPN stated the labels on the nasal cannula and humidifier bottle would notify the nurses if they were old and if they needed to be changed. The IPN stated germs and bacteria could develop in the tubing over time and if those germs and bacteria were to be administered to the resident, they could become sick. During a concurrent interview and record review on 1/11/2024 at 12:02 p.m., with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Oxygen Administration, undated, was reviewed. The P&P indicated, The date, time, and initials should be noted on oxygen equipment when it is initially used and when changed. The DON stated the nasal cannula, humidifier bottle, and any other oxygen equipment used for the residents must be labeled with the date, time, and initials when initially opened and changed. The DON stated if the equipment were not labeled correctly, the nurse must remove them and change with a brand-new set. The DON stated without the label, the equipment could be used for an unknown duration of time and organisms could develop inside. The DON stated oxygen was administered directly into the residents' nose and when they inhale, they could potentially inhale harmful organisms that could make them sick. 2. During a review of Resident 51's admission Record, the admission record indicated Resident 51 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included pneumonia (lung inflammation caused by bacterial or viral infection, in which the air sacs fill with pus and may become solid) and pulmonary hypertension (a condition that affects the blood vessels in the lungs which develops when the blood pressure in your lungs is higher than normal). During a review of Resident 51's Order Summary report, dated 8/27/2023, the Order Summary Report indicated Resident 51 had an order for oxygen therapy at 2 L/min via nasal cannula. During a review of Resident 51's H&P dated 8/28/2023, H&P indicated Resident 51 had the capacity to understand and make decisions. During a review of Resident 51's MDS, dated [DATE], the MDS indicated Resident 51's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 51 required substantial assistance (staff does more than half the effort) for personal hygiene and toileting hygiene and required set up assistance for eating. During an observation on 1/8/2024 at 11:18 a.m., in Resident 51's room, Resident 51's nasal cannula was not labeled with the date and time it was opened and did not have the initials of nurse that set up the oxygen administration. During an observation on 1/9/2024 at 8:08 a.m., in Resident 51's room, Resident 51's nasal cannula was not labeled with the date and time it was opened and did not have the initials of nurse that set up the oxygen administration. During an observation on 1/10/2024 at 7:46 a.m., in Resident 51's room, the Resident 51's nasal cannula was not labeled with the date and time it was opened and did not have the initials of nurse that set up the oxygen administration. During an observation on 1/11/2024 at 2:56 p.m., in Resident 51's room, Resident 51's nasal cannula was not labeled with the date and time it was opened and did not have the initials of nurse that set up the oxygen administration. During an interview on 1/10/2024 at 10:15 a.m. with LVN 2, LVN 2 stated oxygen equipment must be dated when it was opened. LVN 2 stated oxygen equipment was dated to prevent infections. During an interview on 1/11/2024 at 11 a.m. with the Director of Staff Development (DSD), the DSD stated nasal cannulas should be changed weekly. The DSD stated the nasal cannula must be labeled with the date and the nurses' initials. The DSD stated it was important to date the nasal cannulas to know how old the nasal cannula was and served as an infection control measure. During an interview on 1/11/2024 at 12:03 p.m. with the DON, the DON stated the nasal cannula should be changed every 7 days. The DON stated the nasal cannula must be labeled with the date and the time the nasal cannula was opened and with the initials of the nurse that set up the oxygen administration. The DON stated if a nurse noticed an undated nasal cannula, the nurse must get rid of it and place a new one because there was no way of knowing how old the nasal cannula was. The DON stated it was important to date the nasal cannula to prevent using an old nasal cannula because it had the potential to cause an infection because it went directly into the resident's nose. During a review of facility's P&P titled, Oxygen Administration, undated, the P&P indicated the date, time and initials should be noted on oxygen equipment when it is initially used and when changed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident who received dialysis (the process of removing waste products and excess fluid from the body using a machine when the kidneys are not able to do so) treatment was assessed before and after dialysis treatment and the assessment was documented in the Dialysis Communication Records for one of one sampled resident (Resident 81). This deficient practice had the potential for unidentified complications after dialysis treatment such as swelling, pain, bleeding, and bruising. Findings: During a review of Resident 81's admission Record, the admission record indicated Resident 81 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including dependence on renal dialysis and end stage of renal disease (ESRD, a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). During a review of Resident 81's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 10/25/2023, the MDS indicated Resident 81's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact. The MDS indicated Resident 81 required assistance with setup or cleanup for eating, and required supervision or touching assistance for oral hygiene, toileting hygiene and personal hygiene. The MDS indicated Resident 81 had a diagnosis of diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine). During a review of Resident 81's History and Physical (H&P) dated 12/15/2023, the H&P indicated Resident 81 was not able to make his own decisions but was able to make needs known. During a review of Resident 81's Order Summary Report dated 12/15/2023, the order summary report indicated to monitor Resident 81's dialysis access site (right upper chest) for pain, itching, bleeding, and swelling on every shift. During a review of Resident 81's Dialysis Communication Records, for the months of December 2023 and January 2024, indicated the pre-dialysis assessment and post dialysis assessment were inaccurately performed or were not performed, under the following sections on the following dates: On 12/18/2023 - The pre dialysis assessment and post dialysis assessment indicated Resident 81's graft (access) site location was on the right forearm. The record indicated Resident 81 did not have a central line and indicated Resident 81's access site was not checked for bleeding. On 12/20/2023 - The pre dialysis assessment and post dialysis assessment indicated Resident 81's graft site location was on the right forearm. The record indicated Resident 81's access site was not checked for bleeding. On 12/22/2023 - The pre dialysis assessment and post dialysis assessment indicated Resident 81's graft site location was on the right forearm. The record indicated Resident 81 did not have a central line. On 12/27/2023 - The pre dialysis assessment indicated Resident 81's graft site was on the right arm. On 12/29/2023 - The pre dialysis assessment indicated Resident 81 did not have a central line. The post dialysis assessment indicated the central line section was not addressed. On 1/3/2024 - The record indicated Resident 81's access site was not checked for bleeding pre and post dialysis treatment. On 1/5/2024 - The pre dialysis assessment and post dialysis assessment indicated Resident 81's access site was not assessed. The record indicated Resident 81's access site was not checked for bleeding post dialysis treatment. On 1/10/2024 - The pre dialysis assessment and post dialysis assessment indicated Resident 81's access site location was on the right forearm. In the pre dialysis assessment and post dialysis assessment the access site was not assessed. The record indicated Resident 81's access site was not checked for bleeding pre and post dialysis treatment. During an interview on 1/8/2024 at 2:33 p.m. with Resident 81, in Resident 81's room, the Resident 81 stated he received dialysis treatment through his right perma catheter (a flexible tube placed into the blood vessel in your neck or upper chest and is threaded to the right side of the heart). Resident 81 stated he used to get dialysis treatment to his right arm but it was not working. Resident 81 stated he had to keep reminding the nurses that his dialysis treatment was done through his chest and not his arm. During an interview on 1/11/2024 at 4:02 p.m. with Director of Nursing (DON), the DON stated she expected nursing staff to assess residents before they leave for dialysis treatment. The DON stated she expected nurses to take the residents vital signs, and assess the dialysis access site for bleeding, redness and pain before the residents leave to dialysis treatment. The DON stated she expected nurses to assess the residents when they returned from dialysis treatment. The DON stated nurses must assess the resident's cognitive status, assess the access site for bleeding, redness, and pain, and check for a bruit (an audible vascular sound associated with turbulent blood flow) and thrill (an abnormal vibration that is felt on the skin overlying a loud cardiac murmur or an arteriovenous fistula) if applicable. The DON stated she expected nurses to completely fill out the dialysis communication record. The DON stated assessing residents pre and post dialysis was a preventive measure and it must be done. During a review of the facility's policy and procedure (P&P) titled, Care of Resident Receiving Renal Dialysis, undated, the P&P indicated a Dialysis Communication record must be completed during dialysis days. The P&P indicated to send the form with the resident to dialysis and complete the post dialysis section when the resident returns from dialysis. The P&P indicated a complete pre-dialysis assessment includes cognitive status, vital signs, access site (central line, shunt, graft site), document presence or absence of bruit and/or thrill, bleeding at site, and breathing patterns/breathing sounds.

Based on observation, interview, and record review, the facility failed to perform a competency assessment for Licensed Vocational Nurse (LVN) 4 upon hire as per the facility's policy and procedure (P&P), which resulted in LVN 4 failing to competently administer medications and supplements as ordered by the physician for three out of five sampled residents (Resident 81, 74, and 7), including one significant medication administration error, during the medication administration observations. This deficient practice had the potential to place Resident 81, 74, and 7, and other residents at risk for harm related to improper administration of medication, and delays in provision of care related to missed administrations of ordered medications and supplements. Cross Reference: F-tag 726, F-tag 760, and F-tag 684 Findings: 1. During a review of Resident 81's admission Record, the record indicated the facility originally admitted Resident 81 on 7/29/2022 and re-admitted Resident 81 on 12/15/2023. Resident 81's admitting diagnoses included end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis), dependence on renal dialysis (a treatment for people whose kidneys are failing), type 2 diabetes mellitus (DM, a chronic condition that affects the way the body processes blood sugar), and hyperlipidemia (a condition in which there are high levels of fat particles in the blood, creating risk of heart attack and stroke). During a review of Resident 81's History and Physical (H&P), dated 12/15/2023, the H&P indicated Resident 81 did not have the capacity to make his own decisions. During a review of Resident 81's Physician Orders, dated 12/15/2023, the orders indicated staff were to administer a total of seven (7) medications and four (4) supplements at 9:00 a.m. on 1/9/2024. During an interview on 1/9/2024 at 8:20 a.m., with Licensed Vocational Nurse (LVN) 4, LVN 4 stated she was preparing to administer medications for Resident 81 and had not administered any medications yet. During a concurrent observation and interview on 1/9/2024 at 8:34 a.m., outside of Resident 81's room, LVN 4 confirmed a total of three (3) medications were being administered to Resident 81. LVN 4 did not prepare any supplements for administration. LVN 4 then entered Resident 81's room and Resident 81 took all three (3) medications with water. The three medications administered were Labetalol HCl (used to treat high blood pressure), Amlodipine besylate (used to treat high blood pressure), and hydralazine HCl (used to treat high blood pressure). LVN 4 did not offer or administer any further medications or supplements to Resident 81. During a concurrent observation and interview on 1/9/2024 at 8:41 a.m., outside of Resident 81's room, with LVN 4, LVN 4 prepared one (1) injection of Lantus (insulin glargine, a medication for controlling blood sugar levels) for Resident 81 and confirmed a total of one (1) medication was to be administered. LVN 4 did not prepare any supplements for administration. LVN 4 then entered Resident 81's room and Resident 81 refused the insulin glargine administration. LVN 4 exited the room with the one (1) unadministered medication and returned the medication to the medication cart. LVN 4 did not offer or administer any further medications or supplements to Resident 81. During a review of Resident 81's Medication Administration Record (MAR), for the month of January 2024, the MAR indicated LVN 4 documented she had administered six (6) medications and four (4) supplements scheduled for the 9 a.m. administration. There were four (4) medications and four (4) supplements documented as administered by LVN 4 that were not observed as administered. Hydralazine HCl was administered at 8:34 a.m. by LVN 4 was not documented on the MAR. The MAR further indicated the Hydralazine HCl was supposed to be given at 6 a.m. During a concurrent interview and record review on 1/10/2024 at 10:30 a.m., with LVN 5, Resident 81's progress notes and MAR for the month of January 2024 was reviewed. LVN 5 stated there was no documentation of Hydralazine HCl administration on 1/9/2024 at 8:34 a.m. by LVN 4 on Resident 81's MAR or in Resident 81's progress notes. LVN 5 stated Resident 81 received another dose of Hydralazine HCl on 1/9/24 at 2 p.m. LVN 5 stated that if multiple doses of a blood pressure medication were administered too close together, there was potential for the resident to experience hypotension (low blood pressure) and potential changes in their level of consciousness (a medical term used to describe how awake, alert, and aware someone is). LVN 5 stated nursing staff were to call the doctor and document if they were administering a medication outside of the scheduled administration time. During an interview on 1/10/2024 at 3:35 p.m. with the Director of Nursing (DON), the DON stated medications were required to be administered as ordered by the physician. The DON stated staff have one hour before and one hour after the scheduled administration time to administer the medication. The DON stated if a medication is administered outside of the permitted timeframe, the physician needs to be contacted to ensure that it is safe to proceed with the next scheduled dose. The DON also stated the administration should be documented on the progress note. 2. During a review of Resident 74's admission Record, the admission record indicated the facility originally admitted Resident 74 on 3/24/2022 and re-admitted Resident 74 on 4/8/2022. Resident 74's admitting diagnoses included type 2 diabetes mellitus, stage 3 chronic kidney disease (mild to moderate damage of the kidneys, making them less able to filter waste and fluid out of the blood), and a compression fracture (broken bone) of the lumbar vertebra (spinal bone in the lower back), and anemia (low red blood cell count). During a review of Resident 74's H&P, dated 4/25/2023, the H&P indicated Resident 74 had the capacity to understand and make decisions. During a review of Resident 74's current Physician Orders, the orders indicated staff were to administer a total of nine (9) medications and one supplement at 9 a.m. on 1/9/2024. During an interview on 1/9/2024 at 8:59 a.m., with LVN 4, LVN 4 stated she was preparing to administer medications for Resident 74. During a concurrent observation and interview on 1/9/2024 at 9:02 a.m., inside Resident 74's room, LVN 4 checked Resident 74's blood sugar. LVN 4 stated Resident 74's blood sugar was 110. No medications or supplements were administered. During a concurrent observation and interview on 1/9/2024 at 9:04 a.m., outside of Resident 74's room, LVN 4 stated a total of two (2) medications were being administered to Resident 74 and restated that Resident 74's blood sugar was 110. LVN 4 did not prepare any supplements for administration. LVN 4 then entered Resident 74's room and Resident 74 took one medication with water while LVN 4 administered Lantus into Resident 74's left lower abdomen by injection. LVN 4 did not offer or administer any further medications or supplements to Resident 74. During a review of Resident 74's Medication Administration Record (MAR), for the month of January 2024, the MAR indicated LVN 4 documented she administered nine (9) medications and one supplement scheduled for the 9 a.m. administration. There were seven (7) medications and one supplement documented as administered by LVN 4 that were not observed as administered. The MAR further indicated the Lantus was not supposed to be administered if Resident 74's blood sugar was less than 120, and further indicated LVN 4 documented a blood sugar of 110 and administered the Lantus. During a concurrent interview and record review, on 1/09/2024 at 9:33 a.m., with LVN 4, Resident 74's MAR and physician orders were reviewed. LVN 4 stated the physician order was to not administer the Lantus injection if Resident 74's blood sugar was less than 120. LVN 4 stated she misread the physician order. LVN 4 stated the blood glucose was 110 and the Lantus was administered. LVN 4 stated administration of Lantus put Resident 74 at risk for hypoglycemia and could cause harm to the resident. During a review of Resident 74's care plan dated 1/9/2024, the care plan indicated Resident 74 was at risk for an adverse reaction or change in condition due to the incorrect Lantus administration. 3. During a review of Resident 7's admission Record, the record indicated the facility originally admitted Resident 7 on 9/24/2014 and re-admitted Resident 7 on 7/7/2019. Resident 7's admitting diagnoses included spinal stenosis (narrowing of the spinal canal that can put pressure on the spinal cord and the nerves within the spine), right shoulder contracture (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), and cognitive communication deficit. During a review of Resident 7's H&P, dated 11/24/2021, the H&P indicated Resident 7 did not have the capacity to understand and make decisions. During a review of Resident 7's current Physician Orders, the orders indicated staff were to administer a total of eleven (11) medications and two supplements at 9 a.m. on 1/9/2024. During an interview on 1/9/2024 at 9:14 a.m., with LVN 4, outside of Resident 7's room, LVN 4 stated she was preparing to administer medications for Resident 7. During a concurrent observation and interview on 1/9/2024 at 9:21 a.m., outside of Resident 7's room, LVN 4 stated a total of seven (7) medications were being administered to Resident 7. LVN 4 did not prepare any supplements for administration. LVN 4 then entered Resident 7's room and Resident 7 took six (6) medications with water, and LVN 4 administered one (1) medication to Resident 7's eyes. LVN 4 did not offer or administer any further medications or supplements to Resident 7. During a review of Resident 7's MAR, for the month of January 2024, the MAR indicated a total of eleven (11) medications and two supplements were scheduled for 9 a.m. administration. The MAR indicated LVN 4 documented she had administered eleven (11) medications and two supplements scheduled for 9 a.m. administration. There were four (4) medications and two supplements documented on the MAR as administered by LVN 4 that were not observed as administered. During a concurrent interview and record review on 1/11/2024 at 3:54 p.m., with the DON, LVN 4's employee file was reviewed. The DON stated the facility policy was to ensure that a competency assessment was completed for licensed nurses upon hire, stating the facility practice was to have an experienced licensed nurse follow and observe the new licensed nursing staff to assess competency. The DON stated a competency assessment was not completed for LVN 4, and stated there was no documentation in her employee file to indicate an assessment had been done. The DON stated it was not safe for LVN 4 to administer medication to facility residents without the required competencies, and stated it was not correct nursing practice for LVN 4 to document medications or supplements as administered if they were not administered. During a review of the facility's undated, policy and procedure (P&P) titled, Competency Assessment, the P&P indicated Employees will be assessed for competency upon hire and annually. During a review of the facility document, titled Job Description, Job Title: Licensed Vocational Nurse (LVN), dated 8/2011, the document indicated essential duties and responsibilities included: a. Preparing and passing medication as indicated and administering medications according to policy and procedure. b. Contacting the attending physician for required orders as needed. c. Ensuring medications are documented in a timely fashion and in accordance with company policies and procedures. d. Assuring that documentation is accurate. During a review of the facility P&P titled, Medication Administration - General Guidelines, dated 10/2017, the P&P indicated: a. Medications are administered in accordance with written orders of the attending physician. b. Medications are administered within 60 minutes of the scheduled time (1 hour before and 1 hour after). c. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility. d. The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 74) was free of significant medication errors by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 4 did not administer 10 units (a unit of measurement for insulin) of Lantus (insulin glargine, a medication used to control blood sugar levels) when resident 74's blood sugar was outside of the holding parameters (specific instructions for when and when not to administer a medication based on measurable values). 2. Ensure Licensed staff did not document administration of thirty-seven (37) of Lidocaine 5% patches (medicated patch applied to the skin for pain management) for Resident 74, when only fourteen (14) patches had been dispensed to the facility. These deficient practices had the potential to result in avoidable harm from pain related to non-administered pain medication, and low blood sugar related to insulin being administered outside of the ordered parameters. Cross Reference: F-tag 726, F-tag 759, and F-tag 684 Findings: During a review of Resident 74's admission Record, the admission record indicated the facility originally admitted Resident 74 on 3/24/2022 and re-admitted Resident 74 on 4/8/2022. Resident 74's admitting diagnoses included type 2 diabetes mellitus, stage 3 chronic kidney disease (mild to moderate damage of the kidneys, making them less able to filter waste and fluid out of the blood), and a compression fracture (broken bone) of the lumbar vertebra (spinal bone in the lower back), and anemia (low red blood cell count). During a review of Resident 74's History and Physical (H&P), dated 4/25/2023, the H&P indicated Resident 74 had the capacity to understand and make decisions. During a review of Resident 74's active Physician Orders, the orders indicated staff were to administer 10 units of Lantus subcutaneously (injected beneath the skin) once a day for DM, with orders to not administer the medication if Resident 74's blood sugar was less than 120. The orders also indicated staff were to apply a Lidocaine 5% patch to Resident 74's right lower back, once a day, for pain management, starting on 11/25/2023. During a concurrent observation and interview on 1/9/2024 at 9:02 a.m., inside Resident 74's room, LVN 4 checked Resident 74's blood sugar. LVN 4 stated Resident 74's blood sugar was 110. During a concurrent observation and interview on 1/9/2024 at 9:04 a.m., outside of Resident 74's room, LVN 4 prepared Resident 74's Lantus injection for administration and restated that Resident 74's blood sugar was 110. LVN 4 then entered Resident 74's room and injected the 10 units of Lantus into Resident 74's left lower abdomen. LVN 4 did not apply a Lidocaine 5% patch to Resident 74's right lower back. During a concurrent interview and record review, on 1/09/2024 at 9:33 a.m., with LVN 4, Resident 74's Medication Administration Record (MAR) and physician orders were reviewed. LVN 4 stated the physician order was to not administer the Lantus injection if Resident 74's blood sugar was less than 120. LVN 4 stated she misread the physician order. LVN 4 stated Resident 74's blood sugar level was 110 and the Lantus was administered. LVN 4 stated the administration of Lantus put Resident 74 at risk for hypoglycemia and could cause harm to the resident. During a review of Resident 74's MAR, for the month of November 2023, the MAR indicated licensed facility staff documented Resident 74's Lidocaine 5% patch as administered on 11/25/2023, 11/26/2023, 11/27/2023, 11/28/2023, 11/29/2023, and 11/20/2023. The MAR indicated a total of six administrations of Resident 74's Lidocaine 5% patch for the month of 11/2023. During a review of Resident 74's MAR, for the month of December 2023, the MAR indicated licensed facility staff documented Resident 74's Lidocaine 5% patch as administered on: 12/1/2023, 12/2/2023, 12/3/2023, 12/4/2023, 12/5/2023, 12/6/2023, 12/7/2023, 12/8/2023, 12/9/2023, 12/10/2023, 12/11/2023, 12/12/2023, 12/13/2023, 12/14/2023, 12/17/2023, 12/20/2023, 12/21/2023, 12/22/2023, 12/23/2023, 12/24/2023, 12/26/2023, 12/27/2023, 12/28/2023, and 12/31/2023. The MAR indicated a total of 24 administrations of Resident 74's Lidocaine 5% patch for the month of 12/2023. During a review of Resident 74's MAR, for the month of January 2024, the MAR indicated LVN 4 documented Resident 74's Lidocaine 5% patch as administered on 1/9/2024. Further review of the MAR indicated other licensed facility staff documented the Lidocaine 5% patch as administered on: 1/1/2024, 1/2/2024, 1/3/2024, 1/4/2024, 1/5/2024, and 1/7/2024. The MAR indicated a total of 7 administrations of Resident 74's Lidocaine 5% patch for the month of 1/2024. During a concurrent observation and interview, on 1/9/2024 at 1 p.m., at Resident 74's bedside, Resident 74 rolled into a left-facing position in her bed. No Lidocaine 5% patch was observed on Resident 74's right lower back or displaced in Resident 74's bed linens. Resident 74 stated she did not receive the Lidocaine 5% patch that day and stated the patch had not been offered to her. During a concurrent observation and interview on 1/9/2024 at 1:08 p.m., with LVN 5, LVN 5 opened the medication cart and removed the current inventory of Resident 74's Lidocaine 5% patches. LVN 5 stated the label affixed to the bag containing Resident 74's inventory of Lidocaine 5% patches was dated 11/24/2023 and indicated a total of 14 patches had been dispensed. LVN 5 stated there were two patches remaining in Resident 74's inventory. LVN 5 stated no additional patches had been requested or dispensed from the pharmacy. During an interview on 1/9/2024 at 1:44 p.m., with the facility's contracted pharmacy, the pharmacy staff stated a total of 14 Lidocaine 5% patches had been dispensed to the facility on [DATE] for Resident 74. Pharmacy staff stated no refills had been requested or delivered. The pharmacy staff stated that when a medication is dispensed to the facility, the staff receiving the medication sign a receipt to confirm the medication was received. During a review of a document titled, Manifest: [Facility Name], dated 11/25/2023, the document indicated LVN 6 signed the document on 11/25/2023 at 4:14 a.m., confirming receipt of 14 Lidocaine 5% patches for Resident 74. During a concurrent record review and interview on 1/11/2024 at 3:35 p.m., with the Director of Nursing (DON), Resident 74's physician orders, MARs for November 2023, December 2023, January 2024, and the Lidocaine 5% patch delivery records from the contracted pharmacy were reviewed. The DON stated medications were supposed to be administered as ordered by the physician. The DON stated that not following physician orders for Lantus administration could cause an alteration in Resident 74's blood sugar, and a potentially harmful change in condition. The DON further stated only 14 Lidocaine 5% patches had been delivered to the facility, and stated there were not enough patches delivered to account for the 37 administrations documented from 11/25/2023 to 1/9/2024. The DON stated the medications had not been administered as ordered and stated that a resident's pain could go unaddressed if they did not receive their pain medication as ordered. During a review of the facility's policy and procedure (P&P) titled, Medication Administration - General Guidelines, dated 10/2017, indicated: a. Medications are administered in accordance with written orders of the attending physician. b. The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain the results for one of two sampled residents (Resident 74) computed tomography (CT, imaging that helps detect internal injuries and diseases) scan in a timely manner when Resident 74 was readmitted to the facility from the general acute care hospital (GACH). This failure resulted in Resident 74's physician being notified two weeks after the CT scan was completed with results that indicated a compression fracture (type of broken bone that can cause the vertebra [bone in the spine] to collapse) of the second lumbar vertebrae (L2, bone in the lower end of the spinal column). Findings: During a review of Resident 74's admission Record (Face Sheet), the admission Record indicated Resident 74 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (condition that results in too much sugar circulating in the blood), heart failure (a chronic condition in which the heart does not provide adequate blood flow to meet the body's needs), and chronic obstructive pulmonary disease (COPD, a lung disease characterized by long-term poor airflow). During a review of Resident 74's History and Physical (H&P), dated 4/24/2023, the H&P indicated Resident 74 had the capacity to understand and make decisions. During a review of Resident 74's Minimum Data Set (MDS, a comprehensive resident assessment and care screening tool,) dated 12/14/2023, the MDS indicated Resident 74 was able to understand and be understood by others. The MDS indicated Resident 74's cognition was intact (ability to think and reason). The MDS indicated Resident 74 required moderate assistance with bed mobility, maximal assistance with toileting, bathing, and dressing, and required setup or clean-up assistance with personal hygiene. The MDS indicated Resident 74 had a fall with a major injury. During a review of Resident 74's Change of Condition (COC), dated 11/6/2023, the COC indicated on 11/6/2023, Resident 74 returned to her room from the shower room and was being assisted to bed by the certified nursing assistant (CNA). The COC indicated Resident 74 stood up to transfer to the bed, was unable to reach for the bed handles, and fell and landed on her back. The COC indicated Physician 2 was informed and gave orders for an X-ray (imaging that creases pictures of the inside of the body) of the hip, spine, head, leg, and pelvis. The COC indicated Resident 74 complained of lower back and left hip pain. During a review of Resident 74's Radiology Results Report, dated 11/6/2023, the Radiology Results Report indicated the lumbar spine X-ray indicated a result of a compression deformity at the L2 level, age indeterminate (not exactly known). During a review of Resident 74's Progress Notes, dated 11/6/2023 and timed at 1:48 p.m., the Progress Note indicated Physician 2 was informed of Resident 74's X-ray results and Physician 2 ordered a CT scan of the head and lumbar. During a review of Resident 74's COC, dated 11/28/2023, the COC indicated Resident 74 complained of lower back pain and another lumbar X-ray was done which indicated a result of a compression deformity at the L2 level, age determinate. The COC indicated Physician 2 was notified that Resident 74 had not received the CT scan of the head and lumbar due to insurance. The COC indicated Physician 2 ordered for Resident 74's transfer to the GACH for CT scan of the head and lumbar. During a review of Resident 74's GACH Radiology Report, dated 11/28/2023, the Radiology Report indicated the report was faxed to the facility on [DATE]. The Radiology Report indicated the lumbar CT scan result indicated an acute compression fracture of L2. During a review of Resident 74's admission Assessment, dated 11/28/2023, the admission Assessment indicated Resident 74 was transferred to the GACH for a CT scan of the head and lumbar and was readmitted to the facility. The admission Assessment had no indication of the report provided to the admitting nurse and of the results of the CT scan. During a review of Resident 74's COC, dated 12/12/2023, the COC indicated the lumbar CT scan results were received from the GACH and Physician 2 was notified of the results. The COC indicated Physician 2 ordered for Resident 74 to see a neurosurgeon in one to six weeks for evaluation. During an interview on 1/10/2024 at 8:59 a.m., with Registered Nurse (RN) 2, RN 2 stated Resident 74 was transferred to the GACH on her shift and was readmitted to the facility the following shift. RN 2 stated she and the other nurses were unaware of Resident 74's compression fracture until the facility received the results from the GACH two weeks later. RN 2 stated when Resident 74 was brought back to the facility, the GACH did not send any paperwork with the resident regarding the CT scan results. RN 2 stated the facility's medical personnel followed up with the GACH in obtaining the CT scan results. During an interview on 1/10/2024 at 11:55 a.m., with the Medical Record Director (MRD), the MRD stated he requested Resident 74's CT scan results on 12/4/2023 but did not receive them until 12/12/2023. During an interview on 1/10/2024 at 1:10 p.m., with Physician 3, Physician 3 stated she expected to be notified of abnormal results of any kind promptly to develop a plan of care based on those results. During an interview on 1/10/2024 at 3:46 p.m., with RN 3, RN 3 stated Resident 74 was transferred to the hospital on [DATE] for a CT scan and was readmitted to the facility that same night. RN 3 stated normally when a resident was readmitted to the facility from the hospital, she would receive report prior to the residents' arrival. RN 3 stated she had not received report and Resident 74 was brought back to the facility. RN 3 stated she was curious what the CT scan results were, but she did not follow up with the GACH. RN 3 stated she could have called the GACH and spoken to the physician. RN 3 stated she should have obtained the CT scan results and informed the physician so Resident 74 could receive the proper care. During an interview on 1/11/2024 at 10:36 a.m., with the Director of Nursing (DON), the DON stated the admitting nurse should have received the results of the CT scan, however, all the nurses had the responsibility to follow-up on diagnostic tests for the residents. The DON stated obtaining the results and notifying the physician was important to provide the appropriate care for the resident. During a review of the facility's Registered Nurse (RN) Job Description, dated 1/27/2022, the Job Description indicated, Essential duties and responsibilities include . Makes actual patient rounds, assessing and observing the following at least three times per day: Monitoring lab and x-ray values related to patient's condition. During a review of the facility's policy and procedure (P&P) titled, Change of Condition, revised 1/24/2017, the P&P indicated, A change of condition is a sudden or marked different in resident's . lab or x-ray results . All changes of condition in a resident shall be handled promptly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure three of three sampled residents (Resident 41, 74, and 82) understood the Arbitration Agreement (an agreement between the facility and the resident where they would resolve any disputes through a neutral person rather than going to court) when entering a binding contract by failing to: 1. Present the Arbitration Agreement in a language Resident 82 understood. 2. Ensure Resident 82, Resident 41's Family Member (FM) 1, and Resident 74's Family Member (FM) 2 understood that signing the Arbitration Agreement was not necessary as a condition of admission to the facility. These failures resulted in Resident 82 not understanding in the language he understood and Residents 41, 74, and 82 entering the binding agreement as a pretense that it was mandatory. Findings: a. During a review of Resident 82's admission Record (Face Sheet), the admission Record indicated Resident 82 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses included but not limited to type 2 diabetes mellitus (condition that results in too much sugar circulating in the blood), hypertensive heart disease (heart conditions caused by complications of high blood pressure), 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 82's Minimum Data Set (MDS, a standardized resident assessment care screening tool), dated 11/17/2023, the MDS indicated Resident 82 was able to understand and be understood by others. The MDS indicated Resident 82's cognition (process of thinking) was intact. During a review of Resident 82's Facility Arbitration Agreement, undated, the Facility Arbitration Agreement indicated Resident 82 signed and entered into the binding agreement. b. During a review of Resident 41's admission Record (Face Sheet), the admission Record indicated Resident 41 was admitted to the facility on [DATE] with diagnoses that included but not limited to type 2 diabetes mellitus, end stage renal disease (a stage where the kidneys can no longer support the body's needs for waste removal and fluid balance), and atrial fibrillation (an irregular, often rapid heart rate that can cause poor blood flow, leading to blood clots, stroke, or heart failure). During a review of Resident 41's MDS, dated [DATE], the MDS indicated Resident 41 was able to understand and be understood by others. The MDS indicated Resident 41's cognition was moderately impaired. During a review of Resident 41's History and Physical (H&P), dated 11/8/2023, the H&P indicated Resident 41 had the capacity to understand and make decisions. During a review of Resident 41's Facility Arbitration Agreement, dated 11/28/2023, the Facility Arbitration Agreement indicated FM 1 signed and entered the binding agreement on behalf of Resident 41. c. During a review of Resident 74's admission Record (Face Sheet), the admission Record indicated Resident 74 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses included but not limited to type 2 diabetes mellitus, heart failure, and chronic obstructive pulmonary disease (COPD, a lung disease characterized by long-term poor airflow). During a review of Resident 74's MDS, dated [DATE], the MDS indicated Resident 74 was able to understand and be understood by others. The MDS indicated Resident 82's cognition was intact. During a review of Resident 74's H&P, dated 4/24/2023, the H&P indicated Resident 74 had the capacity to understand and make decisions. During a review of Resident 74's Facility Arbitration Agreement, dated 4/11/2022, the Facility Arbitration Agreement indicated FM 2 signed and entered the binding agreement on behalf of Resident 74. During an interview on 1/9/2024 at 10:35 a.m., with Resident 82, Resident 82 stated he spoke primarily Spanish and could understand very little English. Resident 82 stated, When signing important forms, I would like it in Spanish. Resident 82 stated he remembered signing the form; however, he was not told signing was voluntary and he thought he had to sign to continue living at the facility. During an interview on 1/9/2024 at 10:44 a.m., with FM 1, FM 1 stated she understood the binding arbitration agreement, however, when she came to the facility to sign Resident 41's paperwork, she was not told that entering the binding arbitration agreement was not necessary and she felt that she had to sign the agreement for Resident 41 to be admitted to the facility. During an interview on 1/9/2024 at 10:54 a.m., with FM 2, FM 2 stated when he came to the facility to sign paperwork for Resident 74, the staff member who assisted him had given him everything he had to sign. FM 2 stated, They gave me all the paperwork they needed in my mom's record, and I had to sign them. I did not know I did not need to sign the agreement. During an interview on 1/9/2024 at 1:20 p.m., with the Business Office Manager (BOM), the BOM stated when a resident was admitted to the facility, the admission packet was reviewed with the resident and/or their family members. The BOM stated the Arbitration Agreement was available in many languages, including Spanish. The BOM stated Resident 82 was spoke primarily Spanish and should have been provided the Arbitration Agreement in Spanish for him to understand the form and decide if he wanted to enter the binding agreement. The BOM stated the Arbitration Agreement was not mandatory and it was an issue if the residents and family members were under the impression that it was. The BOM stated the Arbitration Agreement was not properly explained. The BOM stated the residents, and their family members had the right to be aware that entering a binding arbitration was not mandatory because if they did not agree with the terms, they would not have to enter it. During an interview on 1/9/2024 at 1:44 p.m., with the Administrator (ADM), the ADM stated the Arbitration Agreement should always be presented to the resident and their family members in the language they understood. The ADM stated Resident 82 should have been presented with the Spanish version of the Arbitration Agreement so he could understand and comprehend the information. The ADM stated the Arbitration Agreement was not mandatory and it was an issue if those who entered into the binding agreement were under the impression that it was mandatory for admission into the facility. The ADM stated everyone should be able to make an informed decision and to understand their options.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement effective infection prevention measures for three of seven sampled residents (Resident 2, 10, and 46) when the facility failed to: 1. Post signage in and around Resident 2's room to ensure staff providing direct resident care activities were aware of Resident 2's Enhanced Standard Precautions (ESP, infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug resistant organisms). 2. Ensure the Treatment Nurse (TN) performed hand hygiene (a way of cleaning one's hands that substantially reduces the potential germs on the hands) throughout Resident 46's wound treatment. 3. Ensure Resident 10's enteral hydration (water provided through a feeding tube [a flexible plastic tube placed into the stomach to assist in nutrition and hydration) administration kit (tubing system that delivers the water into the body) was changed within 24 hours. These failures had the potential to result in the transmit of infectious microorganisms and increase the risk of infection. Findings: 1. During a review of Resident 2's admission Record, the admission Record indicated the facility initially admitted Resident 2 on 12/14/2017 and re-admitted the resident on 5/17/2019 with diagnoses including cerebral palsy (group of disorders that affect a person's ability to move and maintain balance and posture) and contractures (loss of motion of a joint associated with stiffness and joint deformity). During an observation on 1/10/2024 at 10:19 a.m., in the resident's room, Resident 2 was observed lying in bed. No signage indicating Resident 2 was on ESP was observed above the bed, in the room, on the door, or outside of the room. A pole holding a gastrostomy tube (G-tube, tube inserted through the abdomen that brings nutrition directly to the stomach) machine was observed to the right of Resident 2's bed. A container with drawers containing yellow isolation gowns (protective apparel used to prevent the transfer of microorganisms and body fluids from one person to another) was in the corner of the room against the wall in front of Resident 2's bed. During an interview on 1/10/2023 at 10:40 p.m., Restorative Nursing Aide (RNA) 1 stated she just finished performing exercises to Resident 2's both legs and both arms and applying a splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) to the left hand. RNA 1 stated she did not know what type of precautions Resident 2 was on because there was no signage in or around the room to indicate the precaution type. RNA 1 stated she thought Resident 2 might be on ESP precautions because Resident 2 had a G-tube but was unsure. During an interview on 1/10/2023 at 11:08 a.m., Certified Nursing Assistant (CNA) 1 stated he was unsure what type of precautions Resident 2 was on because there was no signage in or around the room to indicate the precaution type. CNA 1 stated he thought Resident 2 might be on ESP precautions or on droplet precautions (procedures to reduce risk of spread of infections transmitted by respiratory droplets generated by coughing, sneezing, talking) but was unsure. CNA 1 stated he only knew Resident 2 required an isolation gown and gloves for direct resident care activities because he had worked with him several times in the past. CNA 1 stated there was a potential for spreading infection if staff providing direct resident care activities to Resident 2 were not aware he was on precautions. During an interview on 1/10/2024 at 12:32 p.m., the Infection Preventionist Nurse (IPN) confirmed Resident 2 was on ESP precautions but did not have any signage in or around the room to ensure staff providing direct care activities were aware of his precautions. The IPN stated all staff providing any direct care activities to Resident 2 must wear an isolation gown and gloves. The IPN stated ESP precautions were important because it protected the residents from bacteria or viruses that may cause infections (a condition in which bacteria or viruses that care disease enter the body). The IPN stated all residents on ESP precautions should have signage with a number 6 over the resident's bed and signage indicating Enhanced Standard Precautions above the personal protective equipment (PPE, equipment worn to minimize exposure to hazards that can cause serious injuries and illnesses) container in the room to ensure staff knew what type of precautions the residents were on and what type of PPE to wear. The IPN stated staff may forget or may not know a resident was on ESP precautions if there was no precaution signage in or around the room which could potentially lead to the spread of infection. During a review of the facility's undated Policy and Procedure (P&P), titled Infection Control, the P&P indicated the facility had established and will maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. 2. During a review of Resident 46's admission Record (Face Sheet), the admission Record indicated Resident 46 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included but not limited to type 2 diabetes mellitus (condition that results in too much sugar circulating in the blood), stage 4 pressure ulcer (full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) of sacral region (area at the end of the spine), and major depressive disorder (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 46's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 12/8/2023, the MDS indicated Resident 46 was able to understand and be understood by others. The MDS indicated Resident 46's cognition (process of thinking) was intact. The MDS indicated Resident 46 required supervision when rolling left to right on the bed. The MDS indicated Resident 46 had a colostomy (an operation that redirects the colon [large intestine] to a new opening, called a stoma, on the abdomen for the expulsion of stool). The MDS indicated Resident 46 had a Stage IV (4) pressure ulcer (injury to skin and underlying tissue due to prolonged pressure) that was present upon admission. During a review of Resident 46's History and Physical (H&P), dated 9/10/2023, the H&P indicated Resident 46 had the capacity to understand and make decisions. During a review of Resident 46's Order Summary Report, dated 1/9/2024, the Order Summary Report indicated the following daily wound care orders: a. Left posterior (back side) thigh excoriation (skin damage from injury such as scratching or picking at the skin), cleanse with normal saline (NS, solution made of salt and water to cleanse wounds), pat dry, apply Calazime cream (a skin protectant), and cover with bordered gauze. b. Right posterior thigh excoriation, cleanse with NS, pat dry, apply Calazime cream, and cover with bordered gauze. c. Stage IV sacrococcyx (at the area of the tailbone) pressure injury, cleanse with NS, pat dry, apply collagen powder (contains essential building blocks of the skin that assists with wound healing), and cover with bordered foam dressing. d. Colostomy site, cleanse with NS, pat dry, apply colostomy bag (bag that covers the stoma to collect stool). During an observation on 1/9/2024 at 9:02 a.m., with the TN, in Resident 46's room, the TN explained that she would be doing Resident 46's wound treatment. Resident 46 stated she did not have any pain and consented for the TN to continue with the wound treatment. The TN prepared her supplies, performed hand hygiene, and applied new gloves. The TN removed the dressing on Resident 46's left thigh, removed her gloves, and applied new gloves. The TN cleansed the area of the left thigh with NS, patted dry, removed her gloves, and applied new gloves. The TN applied Calazime cream, covered with bordered gauze, removed her gloves, and applied new gloves. The TN removed the dressing on Resident 46's right thigh, removed her gloves, applied new gloves. The TN cleansed the area of the right thigh with NS, patted dry, removed her gloves, and applied new gloves. The TN applied Calazime cream, covered with bordered gauze, removed her gloves, and applied new gloves. The TN removed the dressing on Resident 46's sacrococcyx area, removed her gloves, and applied new gloves. The TN cleansed the area with NS, patted dry, removed her gloves, and applied new gloves. The TN applied collagen powder to the area, removed her gloves, and applied new gloves. The TN covered the area with the padded dressing, removed her gloves, and stated, I was supposed to wash my hands. The TN walked to the sink to perform hand hygiene. During an interview on 1/9/2024 at 9:24 a.m., with the TN, the TN stated she was supposed to perform hand hygiene throughout the wound treatment any time she removed her gloves, removed an old dressing, and moved to a new wound area. The TN stated hand hygiene was done to prevent contamination of other wounds and prevent infection. During an interview on 1/11/2024 at 10:39 a.m., with the Director of Nursing (DON), the DON stated hand hygiene was the number one way to control the spread of infection. The DON stated throughout a wound treatment, the nurse had to perform hand hygiene after removing a dirty dressing, after providing the treatment, before proceeding to the next wound site, and after the conclusion of the treatment. The DON stated there was a potential for cross contamination and infection if hand hygiene was not performed during a wound treatment. During a review of the facility's policy and procedure (P&P) titled, Hand Washing, undated, the P&P indicated, Hand washing must also be performed as follows . in between performance of routine procedures (i.e. [that is] handling urinals, bedpans, catheters, changing dressings, collecting specimens, etc. [et cetera, and other similar things]. During a review of the facility's P&P titled, Infection Control, undated, the P&P indicated, Some situations that require hand hygiene, include . before and after changing a dressing. 3. During a review of Resident 10's admission Record (Face Sheet), the admission Record indicated Resident 10 was initially admitted to the facility on [DATE] and was readmitted to the facility on [DATE], with diagnoses included but not limited to type 2 diabetes mellitus dementia (a condition characterized by progressive or persistent loss of intellectual functioning), and metabolic encephalopathy (problem in the brain caused by chemical imbalances in the blood). During a review of Resident 10's MDS, dated [DATE], the MDS indicated Resident 10 was able to sometimes understand and sometimes be understood by others. The MDS indicated Resident 10's cognition severely impaired. The MDS indicated Resident 10 was dependent in eating. The MDS indicated Resident 10 had a feeding tube (a flexible plastic tube placed into the stomach to assist in nutrition). The MDS indicated Resident 10 was on a mechanically altered diet (required change in texture in food or liquids due to difficulty chewing or swallowing). During a review of Resident 10's H&P, dated 3/13/2023, the H&P indicated Resident 10 did not have the capacity to understand and make decisions. During a review of Resident 10's Order Summary Report, dated 1/7/2024, the Order Summary Report indicated to administer Jevity 1.5 (type of enteral feeding [a special liquid food mixture containing protein, carbohydrates, fats, vitamins, and minerals]) at 45 milliliters per hour (mL/hr, a unit of measurement) for 12 hours. The Order Summary Report indicated for continuous water flush through the enteral tube with 35 mL/hr for 20 hours. During an observation on 1/8/2024 at 9:15 a.m., in Resident 10's room, Resident 10's enteral hydration administration bag was dated 1/4/2024. During an interview on 1/10/2024 at 2:53 p.m., with Licensed Vocational Nurse (LVN) 5, LVN 5 stated the enteral hydration administration kit was supposed to be changed every 24 hours. LVN 5 stated the hydration tubing was connected to the resident and if the administration kit was hung for over 24 hours, bacteria could grow inside and be transmitted to the resident. LVN 5 stated if the hydration administration kit was dated 1/4/2024, it was hung for four days, which could mean the nurses were opening the bag and refilling the water instead of changing it. LVN 5 stated that was an issue because there would be a higher chance of contamination every time the administration kit would be opened to the air. During an interview on 1/10/2024 at 2:47 p.m., with the Infection Preventionist Nurse (IPN), the IPN stated the enteral hydration administration kit was supposed to be changed every 24 hours to prevent infection in the resident. The IPN stated after the administration kit was initially opened and the water poured in, once the water was depleted, the whole system had to be changed. The IPN stated using the same administration kit for four days was an issue because that meant the system was opened multiple times and was exposed to the environment. The IPN stated the potential for contamination increased every time the kit was opened and every day it was not changed. During an interview on 1/11/2024 at 10:45 a.m., with the DON, the DON stated the administration kit was supposed to be changed every 24 hours. The DON stated the administration kit should not have been hung for four days because the whole kit should have been changed when it was empty or when the 24 hours has elapsed, whichever came first. The DON stated cross contamination could have occurred, which had the potential to make the resident sick. During a review of the manufacturer's guideline for the AMSINO AMSure Enteral Administration Kit, the guideline indicated Discard administration set and transition connector when delivery is complete within a maximum of 24 hours . Do not re-use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a call light that was maintained in proper working condition and without a frayed cord with inner wires exposed for one out of 24 sampled residents (Resident 69). This deficient practice resulted in Resident 69 using an unsafe call light and the potential to not have needs met. Findings: During a review of Resident 69's admission Record, the admission record indicated Resident 69 was originally admitted to the facility on [DATE] with diagnoses including chronic kidney disease (CKD, gradual loss of kidney function) and benign prostatic hyperplasia (BPH, enlarged prostate gland). During a review of Resident 69's History and Physical (H&P) dated 6/28/2023, the H&P indicated Resident 69 had the capacity to understand and make decisions. During a review of Resident 69's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 10/3/2023, the MDS indicated Resident 69's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired. The MDS indicated Resident 69 required supervision for activities of daily living (ADLs, daily self-care activities such as grooming, personal hygiene, dressing, and toileting). During an interview on 1/8/2024 at 11:18 a.m., in Resident 69's room, Resident 69 stated his call light cord was frayed and he was afraid to use it because he thought it would catch on fire. Resident 69 stated it was not safe to have him use the call light because the inner cables were exposed. Resident 69 stated had notified staff about the frayed cord and staff told him it was ok because the call light still worked. Resident 69 stated staff did not want to help him because they said the call light still worked but the call light sometimes did not work. Resident 69 stated he wanted the call light replaced because it was unsafe and because the call light did not work all the time. During an observation on 1/9/2024 at 9:06 a.m. in Resident 69's room, Resident 69's call light cord was observed frayed and attached to the resident's bed. During an observation on 1/10/2024 at 2:32 p.m. in Resident 69's room, Resident 69's call light cord was observed frayed and attached to the resident's bed. During an interview on 1/11/2023 at 10:14 a.m. with the Maintenance Supervisor (MS), the MS stated he did resident room rounds every day. The MS stated he checked residents call lights every day because that was part of his job. The MS stated that he was not aware that Resident 69's call light cord was frayed. The MS stated nurses report items to be repaired in the maintenance logbook and he did not see that Resident 69's call light needed to be replaced. The MS stated it was important to have all residents with a call light in a good condition. During a concurrent observation and interview on 1/11/2024 at 11:38 a.m. with the MS and Resident 69, in Resident 69's room, Resident 69's call light cord was frayed. The MS stated he had checked on Resident 69's call light every day that week and did not see the frayed cord and he had checked that the call light worked. Resident 69 stated the call light did not work all the time and there were times where it did not work. The MS stated he did not know it was not working. During a review of the facility's policy and procedure (P&P) titled, Resident and Medical equipment Check, undated, the P&P indicated the purpose of the policy was to have staff make routine resident and environment checks to help maintain resident safety and well-being. The P&P indicated the maintenance department will check medical equipment such as call lights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure quality of care was provided for two of 23 sampled residents (Resident 74 and 297) when the following occurred: 1. Licensed staff failed to complete a 72-hour neurological check (a physical examination to identify signs of disorders affecting your brain, spinal cord and nerves) as ordered by the physician and as indicated within the facility's policy after Resident 297, who was admitted to the facility with a history of a fall which resulted in a subdural hemorrhage (bleeding in the area between the brain and the skull), had another fall (in the facility) with head trauma (physical injury). 2. Licensed staff documented thirty-seven (37) administrations of Lidocaine 5% patch (medicated patch applied to the skin for pain management) for Resident 74, when only fourteen (14) patches had been dispensed to the facility. These deficient practices had the potential to result in a missed assessment that could have led to an undetected, repeated subdural hemorrhage, which could have resulted in severe neurological (brain) impairment or death for Resident 297, and created the potential for Resident 74 to experience avoidable harm from pain related to non-administered pain medication. Cross Reference: F-tag 726, F-tag 759, and F-tag 760 Findings: 1. During a review of Resident 297's admission Record, the admission Record indicated Resident 297 was admitted to the facility on [DATE] with diagnoses that included traumatic subdural hemorrhage, malignant neoplasms (cancerous growths) of the lung, and history of falling. During a review of Resident 297's History and Physical (H&P), dated 1/3/2024, the H&P indicated Resident 297 had the capacity to understand and make decisions. During a review of Resident 297's care plan titled, Actual Fall, initiated 1/7/2024, the care plan indicated Resident 297 had an actual fall related to balance deficit (difficulty), decreased strength and endurance (the body's physical capability to sustain an exercise for an extended period), history of falls, and unsteady gait (ability to walk). The staff's interventions were to conduct a neurological assessment for 72 hours. During a review of Resident 297's Change of Condition (COC) Form, dated 1/7/2024, the COC form indicated Resident 297 had an unwitnessed fall and staff found Resident 297 lying on his back. The note indicated Resident 297 stated that he tried to get up to use the restroom . slipped, and fell to the floor, hitting the posterior of his head. During a review of Resident 297's Order Summary, dated 1/9/2024, the Order Summary had indicated the facility was to perform a neurological check for 72 hours for an unwitnessed fall from 1/7/2024 to 1/10/2024. During a concurrent review and interview, on 1/8/2024, at 3:58 p.m., with Licensed Vocational Nurse (LVN) 7, the 72 Hours Neuro- Check List, dated 1/7/2024 to 1/8/2024 was reviewed. LVN 7 verified the neurological check list indicated the section where Resident 297's vital signs and neurological function (blood pressure, temperature, pulse, respiratory rate, level of consciousness, the left and right pupils, left and right-hand grips) were to be documented had been left blank for the hours of 12:30 a.m., 4:30 a.m., 8:30 a.m., and 12:30 p.m. on 1/8/2024. LVN 7 stated the form was incomplete, and it should have been completed to indicate and ensure Resident 297's neurological function was intact. LVN 7 stated the importance of completing the form and documenting in real time was to ensure no assessments were missed and that Resident 297 did not experience signs of an internal brain bleed. During a concurrent review and interview, on 1/8/2024, at 4:10 p.m., with the Infection Prevention Nurse (IPN), the 72 Hours Neuro- Check List, dated 1/7/2024 to 1/8/2024 was reviewed. The IPN verified the neurological check list indicated the section where Resident 297's vital signs and neurological function were to be documented was left blank for the hours of 12:30 a.m., 4:30 a.m., 8:30 a.m., and 12:30 p.m. on 1/8/2024. The IPN stated the form should have been completed and that if vitals were not taken, there would be a possibility the nurses would have missed an important change in Resident 297's condition, or a neurological assessment that could have indicated an internal brain bleed. During a concurrent review and interview, on 1/11/2024, at 1:47 p.m., with the Director of Nursing (DON), the 72 Hours Neuro- Check List, dated 1/7/2024 to 1/8/2024, was reviewed. The DON verified the neurological check list indicated the section where Resident 297's vital signs and neurological function were to be documented was left blank for the hours of 12:30 a.m., 4:30 a.m., 8:30 a.m., and 12:30 p.m. on 1/8/2024. The DON stated the sheet had not been complete and should have been complete so that the nurses can properly assess the resident. The DON stated that there was a potential for the nurses to have missed an assessment, like a spike in the resident's blood pressure, unrelieved pain, and signs of a hemorrhage. During a review of the facility's policy and procedure (P&P) titled, Incidents and Accidents (undated), the P&P indicated the facility was to ensure vital signs are taken with neurocheck[s] on any head injury for 72 hours (use of Neurocheck form). 2. During a review of Resident 74's admission Record, the record indicated the facility originally admitted Resident 74 on 3/24/2022 and re-admitted Resident 74 on 4/8/2022. Resident 74's admitting diagnoses included type 2 diabetes mellitus, stage 3 chronic kidney disease (mild to moderate damage of the kidneys, making them less able to filter waste and fluid out of the blood), and a compression fracture (broken bone) of the lumbar vertebra (spinal bone in the lower back), and anemia (low red blood cell count). During a review of Resident 74's H&P, dated 4/25/2023, the H&P indicated Resident 74 had the capacity to understand and make decisions. During a review of Resident 74's active physician orders, the orders indicated staff were supposed to administer a Lidocaine 5% patch to Resident 74's right lower back, once a day, for pain management, starting on 11/25/2023. During a review of Resident 74's care plans, the care plans indicated Resident 74 had a recent fracture. The goals of the care indicated Resident 74's pain would be managed and kept within a tolerable level. The staff's interventions indicated to administer pain medication as ordered by the physician. During a concurrent observation and interview on 1/9/2024 at 9:04 a.m., LVN 4 administered two medications to Resident 74. LVN 4 did not apply a Lidocaine 5% patch to Resident 74's right lower back. During a review of Resident 74's MAR, for the month of November 2023, the MAR indicated licensed staff documented Resident 74's Lidocaine 5% patch as administered on: 11/25/2023, 11/26/2023, 11/27/2023, 11/28/2023, 11/29/2023, and 11/20/2023. The MAR indicated a total of six administrations of Resident 74's Lidocaine 5% patch for the month of 11/2023, by five different licensed nursing staff. During a review of Resident 74's MAR, for the month of December 2023, the MAR indicated licensed staff documented Resident 74's Lidocaine 5% patch as administered on: 12/1/2023, 12/2/2023, 12/3/2023, 12/4/2023, 12/5/2023, 12/6/2023, 12/7/2023, 12/8/2023, 12/9/2023, 12/10/2023, 12/11/2023, 12/12/2023, 12/13/2023, 12/14/2023, 12/17/2023, 12/20/2023, 12/21/2023, 12/22/2023, 12/23/2023, 12/24/2023, 12/26/2023, 12/27/2023, 12/28/2023, and 12/31/2023. The MAR indicated a total of 24 administrations of Resident 74's Lidocaine 5% patch for the month of 12/2023, by seven different licensed nursing staff. During a review of Resident 74's Medication Administration Record (MAR), for the month of January 2024, the MAR indicated LVN 4 documented Resident 74's Lidocaine 5% patch as administered on 1/9/2024. Further review of the MAR indicated other licensed staff documented the Lidocaine 5% patch as administered on: 1/1/2024, 1/2/2024, 1/3/2024, 1/4/2024, 1/5/2024, and 1/7/2024. The MAR indicated a total of 7 administrations of Resident 74's Lidocaine 5% patch for the month of 1/2024, by five different licensed nursing staff. During a concurrent observation and interview, on 1/9/2024 at 1:00 p.m., at Resident 74's bedside, Resident 74 rolled into a left-facing position in her bed. No Lidocaine 5% patch was observed to Resident 74's right lower back or displaced in Resident 74's bed linens. Resident 74 stated she did not receive the Lidocaine 5% patch that day and stated the patch had not been offered to her. During a concurrent observation and interview on 1/9/2024 at 1:08 p.m., with LVN 5, LVN 5 opened the medication cart and removed the current inventory of Resident 74's Lidocaine 5% patches. LVN 5 stated the label affixed to the bag containing Resident 74's inventory of Lidocaine 5% patches was dated 11/24/2023 and indicated a total of 14 patches had been dispensed. LVN 5 stated there were two patches remaining in Resident 74's inventory. LVN 5 stated no additional patches had been requested or dispensed from the pharmacy. During an interview on 1/9/2024 at 1:44 p.m., with facility's contracted pharmacy, the pharmacy staff stated a total of 14 Lidocaine 5% patches had been dispensed to the facility on [DATE] for Resident 74. Pharmacy staff stated no refills had been requested or delivered. The pharmacy staff stated that when a medication was dispensed to the facility, the staff receiving the medication sign a receipt to confirm the medication was received. During a review of a document titled, Manifest: [Facility Name], dated 11/25/2023, the document indicated LVN 6 signed the document on 11/25/2023 at 4:14 a.m., confirming receipt of 14 Lidocaine 5% patches for Resident 74. During a concurrent record review and interview on 1/11/2024 at 3:35 p.m., with the Director of Nursing (DON), Resident 74's physician orders, MARs for 11/2023, 12/2023, 1/2024, and the Lidocaine 5% patch delivery records from the contracted pharmacy were reviewed. The DON stated medications were supposed to be administered as ordered by the physician. The DON stated only 14 Lidocaine 5% patches had been delivered to the facility, and stated there were not enough patches delivered to account for the 37 administrations documented from 11/25/2023 to 1/9/2024. The DON stated the medications had not been administered as ordered and stated that a resident's pain could go unaddressed if they did not receive their pain medication as ordered. During a review of the facility's P&P titled, Medication Administration - General Guidelines, dated 10/2017, the P&P indicated: a. Medications are administered in accordance with written orders of the attending physician. b. The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatments and services to two of seven sampled residents (Residents 27 and 82) to prevent and/or limit a decline in joint (where two bones meet) range of motion (ROM, full movement potential of a joint) and mobility (ability to move) when the facility failed to: 1. Provide ROM services for Resident 27 to improve or prevent a decline in both of Resident 27's arms. 2. Provide Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and mobility) ambulation (walking) exercise five times a week as ordered for Resident 82. These deficient practices had the potential to cause residents to have a decline in mobility (ability to move), lead to contractures (loss of motion of a joint), and have a decline in physical functioning such as the ability to eat, dress, and walk. Findings: 1. During a review of Resident 27's admission Record, the admission Record indicated the facility admitted Resident 27 on 7/17/2023 with diagnoses including osteoarthritis (loss of protective cartilage that cushions the ends of your bones), muscle weakness, and neuropathy (nerve damage). During a review of Resident 27's Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) admission Rehabilitation Screening, dated 7/18//2023, the OT admission rehabilitation screening indicated Resident 27 had functional ROM limitations (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both arms (shoulder, elbow, wrist, hand). During a review of Resident 27's OT Joint Mobility Screening, dated 7/18/2023, the OT joint mobility screening indicated Resident 27 had full ROM in both wrists, both hands, both elbows, and severe (>50% loss) ROM limitations in both shoulders and recommended Resident 27 be evaluated by OT. During a review of Resident 27's OT Evaluations and Plan of Treatment, dated 7/18/2023, the OT evaluations and plan of treatment indicated Resident 27 had ROM impairments (state of being weakened or damaged) in both shoulders and had decreased strength in both shoulders, both elbows, both wrists, and both hands. During a review of Resident 27's Minimum Data Set (MDS, an assessment and care-screening tool), dated 7/21/2023, the MDS indicated Resident 27 had moderate cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 27 required extensive assistance for bed mobility and eating and total assistance for transfers (moving from one surface to another), locomotion (ability to move from one place to another) on and off the unit, dressing, personal hygiene, and toilet use. The MDS indicated Resident 27 had no functional limitations in ROM in both arms (shoulder, elbow, wrist, hand) and both legs (hip, knee, ankle, foot). During a review of Resident 27's OT Discharge summary, dated [DATE], the OT discharge summary indicated Resident 27 was discharged per case manager with no recommendation for RNA services because Resident 27 was able to move both arms actively and independently. During a review of Resident 27's Order Summary Report, the order summary report indicated for RNA to perform passive ROM exercises (PROM, movement at a given joint with full assistance from another person) to Resident 27's both legs. During a review of Resident 27's MDS, dated [DATE], the MDS indicated Resident 27 required substantial/maximal assistance for eating, oral hygiene, toilet hygiene, and bathing and total assistance in dressing and personal hygiene. The MDS indicated Resident 27 had functional ROM limitations in both arms (shoulder, elbow, wrist, hand) and both legs (hip, knee, ankle, foot). During a review of Resident 27's OT Rehabilitation Screen, dated 10/20/2023, the OT rehabilitation screen indicated OT recommended an RNA program to prevent a decline in function. During a review of Resident 27's Order Summary Report, the order summary report did not include an RNA order for ROM to Resident 27's arms. During a concurrent observation and interview with Resident 27 on 1/9/2024 at 9:52 a.m., in Resident 27's room, Resident 27 was observed lying in bed with blankets covering the entire body. Resident 27 stated she had pain all over her body and requested pain medication. Resident 27 stated she has had more pain on the left side of the body for years and stated it was hard to move the left wrist and left shoulder. Resident 27 was unable to bring both arms overhead and was unable to make a full fist with both hands. Resident 27 stated she wished staff would assist with ROM exercises to both arms because they were painful and hard to move on her own. During a concurrent observation and interview on 1/9/2023 at 2:20 p.m., in Resident 27's room, Resident 27 was observed lying in bed with blankets covering the body. Resident 27 stated she felt much better because she was in less pain and removed the blanket from the upper half of the body using both arms. Resident 27 moved both arms to shoulder level and bent and straightened both elbows. Resident 27 was able to make 90% of a full fist with both hands, bent the left wrist downwards, and had difficulty moving left wrist upwards due to pain. Resident 27 stated she was able to feed herself and wash her face once nursing assisted with set-up. During an interview on 1/10/2024 at 10:02 a.m., Restorative Nursing Aide 1 (RNA 1) stated she provided PROM exercises to Resident 27's legs and did not provide ROM exercises to the arms. RNA 1 stated Resident 27 frequently asked RNA to assist with arm exercises, but RNA 1 was unable to because the RNA order indicated to provide exercises to both legs only. RNA 1 stated she informed the Director of Rehabilitation (DOR) and the Director of Nursing (DON) in a weekly meeting about Resident 27's request for arm exercises, but the DOR stated Resident 27 did not need assistance with arm exercises. During a follow up interview on 1/10/2024 at 2:45 p.m., RNA 1 stated she felt Resident 27 could benefit from RNA services for arm exercises because Resident 27 frequently requested assistance with arm exercises and had the potential to do more for herself if her arms were stronger and moved better. During a concurrent interview and record review on 1/10/2024 at 2:08 p.m., with the MDS Nurse (MDSN), Resident 27's MDS (dated 7/21/2023 and 10/19/2023), physician's orders, and care plan were reviewed. The MDSN confirmed Resident 27 had a decline in ROM to both arms and both legs according to the MDS. The MDSN stated Resident 27 was unable to demonstrate she was able to perform her activities of daily living (ADLs, basic activities such as eating, dressing, and toileting) using her arms during the MDS assessment on 10/19/2023 primarily because she was uncooperative. The MDSN stated an Interdisciplinary Team (IDT, group of different disciplines working together for a common goal of a resident) meeting should have been initiated to ensure interventions were developed and implemented to address the limitations once the decline in ROM of Resident 27's arms and legs were identified but was not done. The MDSN stated Resident 27 should have been on therapy or RNA services to address the decline in ROM of both arms identified in the MDS but was not. The MDSN confirmed RNA services were ordered for PROM of both legs but was not ordered for the arms. The MDSN confirmed there were no interventions in place to address the change in ROM or prevent a further decline in ROM of Resident 27's arms. The MSDN stated Resident 27 was at risk for contractures because she did not get out of bed, required assistance with ADLs, and needed a lot of encouragement to participate in everyday activities. During a concurrent interview and record review on 1/10/2024 at 2:47 p.m., with the Director of Rehabilitation (DOR) who was an Occupational Therapist (OT), Resident 27's OT notes, Rehabilitation screens, joint mobility screen, and physician's orders were reviewed. The DOR stated she did not write an RNA order for arm exercises because Resident 27 was able to use both arms for ADLs during the Rehabilitation Screening but required a lot of encouragement due to guarded and self-limiting behavior. The DOR stated nursing and RNA reported Resident 27 had been increasingly asking for assistance for care that required the use of the arms but felt that issue was more related to Resident 27's behavior rather than physical abilities. The DOR stated she was unaware nursing identified Resident 27 as having a decline in arm ROM in the MDS. The DOR stated the decline in Resident 27's arm ROM should have been communicated to the rehab department in an IDT meeting but was not. The DOR stated RNA arm exercises should have been ordered when nursing staff identified the functional decline in the MDS, at the time of the Rehabilitation Screening since Resident 27 required encouragement to use both arms for ADLs, and when Resident 27 requested arm exercises from RNA, but was not. The DOR stated Resident 27 was at high risk for contracture development and a functional decline because Resident 27 had a diagnosis of osteoarthritis, required assistance with mobility and ADLs, and required encouragement to move on her own. During a concurrent interview and record review on 1/11/2024 at 2:38 p.m., with the Director of Nursing (DON), Resident 27's IDT notes, MDS assessments, care plan, and physician's orders were reviewed. The DON confirmed Resident 27's had a decline in both arm ROM according to the MDS assessments. The DON confirmed Resident 27 did not have a care plan, interventions, and any services in place to address the decline in Resident 27's arm ROM. The DON stated residents with ROM impairments should be on therapy or RNA services to prevent a decline in function. The DON stated an IDT meeting should have been done, a care plan should have been created, and interventions should have been implemented once Resident 27's arm ROM decline was identified on the MDS but was not. The DON stated Resident 27 was at risk for contracture development and a functional decline because there were no interventions in place improve or prevent a decline in Resident 17's arm ROM. 2. During a concurrent observation and interview on 1/11/2024 at 2:05 p.m., in Resident 82's room, Resident 82 was observed sitting at the edge of the bed wearing a right leg prosthesis (artificial device used to replace a missing or impaired part of the body). A cane (mobility device used for walking) and wheelchair were observed next to the bed. Resident 82 stated he needed help putting on and taking off the right leg prosthesis, was able to walk short distances with a cane, and used a wheelchair for mobility when he got tired from walking. During a review of Resident 82's admission Record, the admission Record indicated the facility initially admitted Resident 82 on 5/2/2023 and re-admitted the resident on 6/12/2023 with diagnoses including peripheral vascular disease (reduced circulation of blood to a body part due to a narrowed or blocked blood vessel) and acquired absence of the right leg below the knee (amputation of the leg below the level of the knee). During a review of Resident 82's MDS dated [DATE], the MDS indicated Resident 82 was cognitively intact. The MDS indicated Resident 82 required supervision or touching assistance for eating, dressing, oral hygiene, toileting hygiene, bathing, rolling, and transfers and partial/moderate assistance for walking ten feet. The MDS indicated Resident 82 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) on one leg (hip, knee, ankle, foot). During a review of Resident 82's Order Summary Report, the order summary report indicated for RNA to perform walking exercises with Resident 82 on an even surface using crutches (mobility device used to provide support while walking), five times a week. During a review of Resident 82's RNA flowsheets for December 2023, the RNA flowsheets indicated for the RNA to perform walking exercises with Resident 82 on an even surface using crutches, five times a week. The squares on the RNA flowsheet were blank on the following days: 12/8/2023, 12/11/2023, 12/14/2023, 12/18/2023, and 12/21/2023. During a concurrent interview and record review on 1/11/2024 at 9:26 a.m., with the Director of Staff Development (DSD), Resident 82's RNA December 2023 flowsheets and physician's orders were reviewed. The DSD confirmed Resident 82 had physician orders for RNA to provide RNA services five times a week. The DSD stated a blank square on the RNA flowsheet grid indicated the resident was not seen for RNA treatment that day. The DSD confirmed Resident 82 missed five days of scheduled RNA services for the month of December. The DSD stated Residents 82 did not receive RNA treatments as ordered by the physician. The DSD stated it was important for RNA to provide services as prescribed by the physician because missed treatments could place residents at risk for a functional decline. During an interview on 1/11/2024 at 2:28 p.m., with the Director of Nursing (DON), the DON stated the purpose of the RNA program was to maintain a resident's current level of function. The DON stated missed RNA treatments could potentially cause a resident to experience a decline in overall function, mobility, and ADLs. During a review of the facility's undated Policy and Procedure (P&/P), titled Restorative Nursing Program, the P&P indicated the purpose of the RNA program was to maintain the resident's functional abilities and to reduce further declines. The P&P indicated each resident would be given care to reduce the risk of pressure sore (injuries to the skin and underlying tissue resulting from prolonged pressure on the skin) formations, contractures, deformities (disfigured), and a decline in functional activities that include ROM exercises, strengthening, and ambulation activities. During a review of the facility's undated P&P, titled Joint Mobility Contracture Management Program, the P&P indicated the purpose of the facility's Contracture Management Program was to reduce contractures in the arms and legs and to promote function and skin integrity. The P&P indicated all resident's ROM was to be assessed and reviewed quarterly by the nursing staff. Any ROM changes or concerns were to be noted, therapy interventions for a ROM program would be recommended, appropriate physician's orders would be obtained by nursing, a care plan would be developed, and the recommended ROM program would be implemented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy and procedure (P&P) for medication administration for six out of 10 sampled residents (Resident 28, 35, 51, 68, 81, 82) when: 1. Licensed Vocational Nurse (LVN) 4 did not administer the routine 9:00 a.m. dose of medication to Resident 28, 35, 68, 81, and 82 on [DATE]. 2. Resident 28, 35, and 81 was administered Tenormin, Diltiazem, Amlodipine, Labetalol, and Hydralazine (medications used to treat high blood pressure) despite meeting the hold parameters (when a medication is not administered based on a specific condition) for having a heart rate lower than 60. 3. Resident 51 was administered Midodrine (medication used to treat low blood pressure) despite meeting the hold parameters for having a systolic blood pressure (SBP, the maximum blood pressure during contraction of the ventricles [the two lower chambers of the heart responsible for pumping blood out of the heart]) more than 110. These deficient practices caused Resident's 28, 35, 68, 81, and 82 to have an interruption with their medication therapy, and exposed Resident's 28, 35, 51, and 81 to a potential adverse effect to their medications. Findings: 1. During a review of Resident 28's admission Record, the admission record indicated Resident 28 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included heart failure (progressive heart disease that affects pumping action of the heart muscles) and kidney failure (occurs when kidneys become unable to filter waste products from the blood, kidneys lose their filtering ability). During a review of Resident 28's History and Physical (H&P) dated [DATE], the H&P indicated Resident 28 did not have the capacity to understand and make decisions. The H&P indicated Resident 28 had a diagnosis of Non-ST-elevation myocardial infarction ([NSTEMI] is a type of heart attack that usually happens when your heart's need for oxygen can't be met). During a review of Resident 28's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated [DATE], the MDS indicated Resident 28's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired. The MDS indicated Resident 28 required substantial/maximal assistance from staff for all activities of daily living (ADLs, activities performed daily such as personal hygiene, grooming, dressing, and toileting). During a review of Resident 28's Order Summary Report, the order summary report indicated Resident 28 was to receive: 1. Aspirin 81 milligrams (mg, unit of measurement), by mouth, one time a day, for cerebral vascular disease ([CVA] an interruption in the flow of blood to cells in the brain, when cells in the brain are deprived of oxygen, they die) prophylaxis (to prevent). 2. Colace 100 mg, by mouth, one time a day, for stool softener. 3. Hydroxychloroquine sulfate 200 mg, by mouth, 2 times a day, for rheumatoid arthritis (body's immune system attacks its own tissue, affects joint linings, causing painful swelling). 4. Lasix tablet 20 mg, 1 tablet a day, by mouth, for congestive heart failure (CHF, chronic condition in which the heart doesn't pump blood as well as it should). 5. Tenormin 50 mg, give 1 tablet, by mouth, one time a day, for high blood pressure, hold medication if SBP was less than 110, and to hold if heart rate was less than 60. 6. Uloric 80 mg, by mouth, one time a day, for gout (form of arthritis characterized by severe pain, redness, and tenderness in joints). 7. Cranberry 2 capsules 425 mg, by mouth, two times a day, for urinary tract infection (UTI, infection of the bladder) prophylaxis. 8. Potassium chloride 10 Milliequivalent per liter (MEQ) by mouth, one time a day, for supplement. 9. [NAME]-vita tablet, by mouth, one time a day, for renal (kidney) supplement. During a review of Resident 28's Medication Administration Record (MAR), for the month of [DATE], the MAR indicated on [DATE], Resident 28 received Tenormin however the resident's heart rate was 58. During a review of Resident 28's MAR, for the month of [DATE], the MAR indicated on [DATE], Resident 28 did not receive his 9:00 a.m. dose of Aspirin 81 mg, Colace 100 mg, Lasix 20 mg, potassium chloride 10 MEQ, Rena Vite tablet, Tenormin 50 mg, uloric 80 mg, cranberry capsule 425 mg and hydroxychloroquine sulfate 200 mg. 2. During a review of Resident 35's admission Record, the admission record indicated Resident 35 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included of heart failure and peripheral vascular disease ([PVD] a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). During a review of Resident 35's H&P dated [DATE], the H&P indicated Resident 35 did not have the capacity to understand and make decisions. During a review of Resident 35's MDS, dated [DATE], the MDS indicated Resident 35's cognitive skills daily decision making was severely impaired. The MDS indicated Resident 35 was dependent on staff for all ADLs. The MDS indicated Resident 35's speech was unclear. The MDs indicated Resident 35 had a diagnosis of PVD. During a review of Resident 35's Order Summary Report, the order summary report indicated Resident 35 was to receive: 1. Aspirin 81 oral tablet chewable, give 1 tablet, via G-tube, one time a day, for CVA prophylaxis. 2. Cholecalciferol 25 micrograms (mcg, unit of measurement), give via gastrostomy tube (G-tube, tube surgically inserted into the stomach for nutrition, hydration, and medications), in the morning, for supplement. 3. Colace 100 mg, via G-tube, for stool softener. 4. Cranberry tablet 450 mg, give 1 tablet, via G-tube, for UTI prophylaxis. 5. Cyanocobalamin tablet 10000 mcg, 1 time a day, for supplement. 6. Multivitamins with mineral, 1 tablet, via G-tube, one time a day, for supplement. 7. Vitamin C tablet 500 mg, give 1 tablet, via G-tube, one time a day, for supplement. 8. Apixaban tablet 2.5 mg, give one tablet, via G-tube, two times a day, for PVD. 9. Diltiazem 30 mg, one tablet, via G-tube, every 8 hours, for high blood pressure, hold if SBP was less than 105 and hold if heart rate was less than 65. During a review of Resident 35's MAR, for the month of [DATE], the MAR indicated on [DATE], Resident 35 did not receive his 9:00 a.m. dose of Aspirin 81 mg, Colace 100 mg, cholecalciferol 25 mcg, cranberry 450 mg, cyanocobalamin 1000 mcg, multivitamin, vitamin C 500 mg, and Apixaban 2.5 mg. During a review of Resident 35's MAR, for the month of [DATE], the MAR indicated Resident 35's heart rate was the following on the following dates and times: On [DATE] at 2 p.m., Resident 35's heart rate was 62. On [DATE] at 2 p.m., Resident 35's heart rate was 63. On [DATE] at 10 p.m., Resident 35's heart rate was 60. On [DATE] at 10 p.m., Resident 35's heart rate was 63. According to the MAR, Resident 35's heart rate met the hold parameters however Diltiazem was given. 3. During a review of Resident 51's admission Record, the admission record indicated Resident 51 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included pneumonia (lung inflammation caused by bacterial or viral infection, in which the air sacs fill with pus and may become solid) and pulmonary hypertension (a condition that affects the blood vessels in the lungs which develops when the blood pressure in your lungs is higher than normal). During a review of Resident 51's H&P dated [DATE], H&P indicated Resident 51 had the capacity to understand and make decisions. The H&P indicated Resident 51 had a diagnosis of rheumatoid arthritis (body's immune system attacks its own tissue, affects joint linings, causing painful swelling). During a review of Resident 51's MDS, dated [DATE], the MDS indicated Resident 51's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 51 required substantial assistance with personal hygiene and toileting hygiene and required set up assistance for eating. The MDS indicated Resident 51 had a diagnosis of coronary artery disease (CAD, artery disease that is caused by plaque buildup in the wall of the arteries that supply blood to the heart, causes coronary arteries to narrow, limiting blood flow to the heart). During a review of Resident 51's Order Summary report, dated [DATE], the Order Summary Report indicated to administer Midodrine 10 mg, give 1 tablet, by mouth, two times a day for low blood pressure, hold if SBP more than 110. During a review of Resident 51's MAR, for the month of [DATE], the MAR indicated the following: On [DATE] at 5:00 p.m., Resident 51's SBP was 137. On [DATE] at 9:00 a.m., Resident 51's SBP was 116. On [DATE] at 9:00 a.m., Resident 51's SBP was 115. The MAR indicated Resident 51's SBP met the hold parameters however Midodrine was administered. During a concurrent interview and record review on [DATE] at 2:21 p.m. with the MDS Nurse (MDSN), Resident 51's MAR, for the month of [DATE] was reviewed. The MAR indicated on [DATE], for the 9:00 a.m. administration time, Resident 51's SBP was 116. Resident 51's SBP met the hold parameters however Midodrine was administered. The MDSN stated she should not have administered Midodrine medication to Resident 51 because the resident's SBP was higher than 110. The MDSN stated she did not know why she gave the medication to Resident 51. The MDSN stated it was important to follow the medication parameters to prevent a negative outcome for residents. 4. During a review of Resident 68's admission Record, the admission record indicated Resident 68 was originally admitted to the facility on [DATE] with diagnoses that included cardiomyopathy (acquired or hereditary disease of heart muscle, this condition makes it hard for the heart to deliver blood to the body and can lead to heart failure) and atherosclerosis of aorta (a material called plaque [fat and calcium] built up in the inside wall of a large blood vessel [aorta]). During a review of Resident 68's H&P dated [DATE], the H&P indicated Resident 68 did not have the capacity to understand and make decisions. The H&P indicated Resident 68 had a diagnosis of hypertension (high blood pressure). During a review of Resident 68's MDS, dated [DATE], the MDS indicated Resident 68's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 68 required substantial assistance for all ADLS. The MDS indicated Resident 68 had a diagnosis of dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). During a review of Resident 68's Order Summary Report, the order summary report indicated Resident 68 was to receive: 1. Aspirin 81 mg, give 1 tablet by mouth, one time a day. 2. Benazepril tablet 20 mg, give 1 tablet by mouth, one time a day, for high blood pressure. 3. Colace 100 mg, by mouth, one time a day. 4. Lactulose solution 20 gram (gm, unit of measurement) per (/) 30 milliliters (ml, unit of measurement), by mouth, one time a day, for elevated ammonia level (waste product normally processed in the liver and removed through the urine). 5. Multivitamin with mineral 1 tablet, by mouth, one time a day, for supplement. 6. Vitamin B12 oral tablet 500 mcg, give 1 tablet by mouth, one time a day, for supplement. 7. Vitamin D3 25 mcg, give 2 tablets by mouth, one time a day, for low vitamin D level. 8. Carvedilol 12.5 mg, give 1 tablet by mouth, 2 times a day, for high blood pressure. 9. Cranberry tablet 450 mg, give 2 tablets by mouth, two times a day. 10. Namenda 10 mg tablet, give 1 tablet by mouth, two times a day, for dementia. During a review of Resident 68's MAR, for the month of [DATE], the MAR indicated on [DATE] Resident 68 did not receive his 9:00 a.m. dose of Aspirin 81 mg, Benazepril 20 mg, Colace 100 mg, lactulose solution 20 gm/ml, multivitamin with mineral, Vitamin B12 500 mcg, Vitamin D3 25 mcg, Carvedilol 12.5 mg, cranberry 10 mg, and Namenda 10 mg. 5. During a review of Resident 81's admission Record, the admission record indicated Resident 81 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included dependence on renal dialysis (the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood) and end stage of renal disease (ESRD, a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). During a review of Resident 81's MDS, dated [DATE], the MDS indicated Resident 81's cognitive skills for daily decision making was intact. The MDS indicated Resident 81 required assistance with setup or cleanup for eating, and supervision or touching assistance for oral hygiene, toileting hygiene and personal hygiene. The MDS indicated Resident 81 had a diagnosis of diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine). During a review of Resident 81's H&P dated [DATE], H&P indicated Resident 81 was not able to make his own decisions however was able to make needs known. The H&P indicated Resident 81 had a history of benign prostatic hyperplasia (BPH, a condition in men in which the prostate gland is enlarged). During a review of Resident 81's Order Summary Report, the order summary report indicated Resident 81 was to receive: 1. Amlodipine besylate tablet 10 mg, give 1 tablet, by mouth, one time a day, for high blood pressure, hold if SBP is less than 110 and heart rate is less than 60. 2. Hydralazine tablet 25 mg, give 1 tablet, by mouth, every 8 hours, for high blood pressure, hold medication if SBP less than 110 and if heart rate less 60. 3. Labetalol tablet 200 mg, give 1 tablet by mouth, every 12 hours, for high blood pressure, hold if SBP less than 110 and heart rate less than 60. During a review of Resident 81's MAR, for the month of [DATE], the MAR indicated the following: On [DATE] at 2:00 p.m., Resident 81's heart rate was 57, however Amlodipine administered. On [DATE] at 9:00 a.m., Resident 81's heart rate was 57, however Labetalol was administered. On [DATE] at 2:00 p.m., Resident 81's heart rate was 57, however Hydralazine was administered. 6. During a review of Resident 82's admission Record, the admission record indicated Resident 82 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnosis that included heart failure (progressive heart disease that affects pumping action of the heart muscles) and nonrheumatic aortic valve stenosis (a thickening and narrowing of the valve between the heart's main pumping chamber and the aorta, creates a smaller opening for blood to pass through and reduces or blocks blood flow from the heart to the rest of the body). During a review of Resident 82's H&P dated [DATE], the H&P indicated Resident 82 was able to give appropriate consent based on adequate decision-making capacity. The H&P indicated Resident 82 had a history of kidney transplant (a surgery to placing a healthy kidney from a living or deceased donor into a person whose kidneys no longer function). During a review of Resident 82's MDS, dated [DATE], the MDS indicated Resident 82's cognitive skills for daily decision making was intact. The MDS indicated Resident 82 required supervision for all ADLs. The MDS indicated Resident 82 had a diagnosis of diabetes mellitus. During a review of Resident 82's Order Summary Report, the order summary report indicated Resident 82 was to receive: 1. Cinacalcet oral tablet 30 mg, give 1 tablet, by mouth, in the morning for chronic kidney disease (CKD, gradual loss of kidney function. Kidneys are unable to filter wastes and excess fluids from blood). 2. Furosemide oral tablet 40 mg, give 1 tablet, by mouth, one time a day, for high blood pressure, hold if SBP less than 110 and if heart rate less than 60. 3. Lisinopril oral tablet 10 mg, give 1 tablet, by mouth, one time a day, for high blood pressure, hold if SBP less than 110 and if heart rate less than 60. 4. Prednisone oral tablet 5 mg, give 1 tablet, by mouth, one time a day, for renal transplant. 5. Valacyclovir oral tablet 50 mg, give 1000 mg by mouth, one time a day, for warts. 6. Colace give 100 mg, by mouth, two times a day. 7. Prograf oral capsule 0.5 mg, give 1 capsule, by mouth, every 12 hours, for renal transplant. 8. Ketorolac tromethamine ophthalmic solution 4%, instill 1 drop in left eye, four times a day, for status post (S/P) cataract (a clouding of the lens of the eye) surgery. 9. Ofloxacin ophthalmic solution 0.3 %, instill 1 drop in left eye, four times a day, for status post (S/P) cataract surgery. 10. Prednisolone acetate ophthalmic suspension 1 %, instill 1 drop in left eye, four times a day, for S/P cataract surgery. During a review of Resident 82's MAR, for the month of [DATE], the MAR indicated the following: On [DATE] at 9:00 a.m., Resident 82's SBP was 104. The MAR indicated Resident 82's SBP met the hold parameters however Furosemide and Lisinopril were administered. The MAR indicated on [DATE], Resident 82 did not receive his 9:00 a.m. dose of Cinacalcet 30 mg, Colace 100 mg, Furosemide 40 mg, Lisinopril 10 mg, Ketorolac tromethamine 4%, Ofloxacin 0.3 %, Prednisone 5 mg, Prednisolone acetate 1 %, Prograf oral capsule 0.5 mg, and Valacyclovir 50 mg. During an interview on [DATE] at 8:25 a.m. with Licensed Vocational Nurse (LVN) 5, LVN 5 stated on [DATE] she took over LVN 4's assignment when LVN 4 went home for the day. LVN 5 stated LVN 4 did not give her report before leaving. LVN 5 stated she did not remember what time she took over LVN 4's assignment but administered the resident's lunch time medications. LVN 5 stated LVN 4 did not inform LVN 5 the resident's 9:00 a.m. meds were not administered. LVN 5 stated medications that have hold parameters must be held if the resident met the parameters. LVN 5 stated if medication was administered it could cause a resident to have a negative response to medication. During an interview on [DATE] at 3:45 p.m. with the Director of Nursing (DON), the DON stated she expected the licensed nurses to pass all resident medications at their assigned times. The DON stated if the MAR was blank, it meant the medication was not given. The DON stated that if a medication was not given, the nurse must document the reason why it was not given. The DON stated it was not acceptable to leave the MAR blank. The DON stated if a resident's heart rate or blood pressure met the hold parameters the medication should not be administered to the resident. The DON stated that if the medication was administered to the resident, it could cause the resident harm instead of helping them. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, dated 10/2017, the P&P indicated the individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administrating the medications reviews the MAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medication report off-duty without first recording the administration of any medications. The P&P indicated medications are administered in accordance with written orders of the attending physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure their medication error rate was less than five (5) percent (%) when Licensed Vocational Nurse (LVN) 4 failed to competently administer medications to three (3) of five (5) randomly selected residents (Residents 81, 74, and 7) during the medication administration observation. The outcome was 16 medication errors out of thirty opportunities for errors, which resulted in a Medication Administration Error Rate of fifty-three (53) percent, based on the following: 1. Resident 81 did not receive four (4) ordered medications that were documented as administered, and Resident 81 received one (1) medication more than one hour after the permitted administration time. 2. Resident 74 did not receive seven (7) ordered medications that were documented as administered, and Resident 74 received one (1) medication outside of the ordered holding parameters (specific instructions for when and when not to administer a medication based on measurable values). 3. Resident 7 did not receive four (4) ordered medications that were documented as administered. These deficient practices created the potential for residents to experience harm from pain related to non-administered pain medication, low blood pressure related to blood pressure medication being administered outside of the schedule time and too close to the next scheduled dose, and low blood sugar related to insulin administered outside of the ordered parameters. The deficient practice also created the potential for interruptions in health maintenance and improvement related to missed administrations of necessary medications. Cross Reference: F-tag 726, F-tag 760, and F-tag 684 Findings: 1. During a review of Resident 81's admission Record, the admission record indicated the facility originally admitted Resident 81 on 7/29/2022 and re-admitted Resident 81 on 12/15/2023. Resident 81's admitting diagnoses included end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis), dependence on renal dialysis (a treatment for people whose kidneys are failing), type 2 diabetes mellitus (DM, a chronic condition that affects the way the body processes blood sugar), and hyperlipidemia (a condition in which there are high levels of fat particles in the blood, creating risk of heart attack and stroke). During a review of Resident 81's History and Physical (H&P), dated 12/15/2023, the H&P indicated Resident 81 did not have the capacity to make his own decisions. During a review of Resident 81's Physician Orders, dated 12/15/2023, the orders indicated staff were supposed to administer medications a total of seven (7) medications at 9 a.m. on 1/9/2024. The medications were as follows: 1. Aspirin 81 milligram (mg, a unit of dose measurement) tablet, by mouth, once a day, for stroke prevention. 2. Polyethylene glycol 3350, one packet, by mouth, one time a day, for bowel (intestine) management. 3. Nephro-vite tablet, once a day, for supplement. 4. Docusate sodium 100 mg, by mouth, once a day, for stool softener. 5. Labetalol 200 mg, by mouth, every 12 hours, for high blood pressure. 6. Amlodipine besylate 10 mg, by mouth, once a day, for high blood pressure. 7. Insulin glargine 15 units subcutaneously (under the skin), every 12 hours, for DM. During an interview on 1/9/2024 at 8:20 a.m., with LVN 4, LVN 4 stated she was preparing to administer medications for Resident 81 and had not administered any medications yet. During an observation on 1/9/2024 at 8:24 a.m., inside Resident 81's room, LVN 4 checked Resident 81's heart rate and blood pressure. No medications were administered. During a concurrent observation and interview on 1/9/2024 at 8:34 a.m., outside of Resident 81's room, LVN 4 prepared a total of three (3) medications for Resident 81. After dispensing the medications, LVN 4 confirmed a total of three (3) medications were being administered to Resident 81. LVN 4 then entered Resident 81's room and Resident 81 took all three (3) medications with water. The three medications administered were abetalol HCl, amlodipine besylate, and hydralazine HCl (medication to treat high blood pressure). No further medications were administered. During an observation on 1/9/2024 at 8:36 a.m., at Resident 81's bedside, LVN 4 checked Resident 81's blood sugar then exited the room. No medications were administered. During a concurrent observation and interview on 1/9/2024 at 8:41 a.m., outside of Resident 81's room, with LVN 4, LVN 4 prepared one (1) injection of insulin glargine for Resident 81 and confirmed a total of one (1) medication was to be administered. LVN 4 then entered Resident 81's room and Resident 81 refused the insulin glargine administration. LVN 4 exited the room with the one (1) unadministered medication and returned the medication to the medication cart. No further medications were offered to or administered to Resident 81. During a review of Resident 81's Medication Administration Record (MAR), for the month of January 2024, the MAR indicated a total of seven (7) medications were scheduled for 9 a.m. administration. The MAR indicated LVN 4 documented she had administered six (6) scheduled 9 a.m. medications, and one (1) refusal of the insulin glargine. The MAR further indicated Resident 81's hydralazine HCl was scheduled for administration at 6 a.m., 2 p.m., and 10 p.m. The hydralazine HCl administered at 8:34 a.m. by LVN 4 was not documented on the MAR. There were four (4) medications documented as administered by LVN 4 on the MAR that were not observed as administered. During a review of document titled, Medication [Administration] Audit Report, dated 1/9/2024, the document indicated Resident 81 had a total of seven (7) medications scheduled for administration at 9 a.m. The document indicated LVN 4 documented she administered a total of seven (7) medications to Resident 81 between 8:22 a.m. and 8:43 a.m. The hydralazine HCl administered at 8:34 a.m. by LVN 4 was not documented. 2. During a review of Resident 74's admission Record, the record indicated the facility originally admitted Resident 74 on 3/24/2022 and re-admitted Resident 74 on 4/8/2022. Resident 74's admitting diagnoses included type 2 diabetes mellitus, stage 3 chronic kidney disease (mild to moderate damage of the kidneys, making them less able to filter waste and fluid out of the blood), and a compression fracture (broken bone) of the lumbar vertebra (spinal bone in the lower back), and anemia (low red blood cell count). During a review of Resident 74's H&P, dated 4/25/2023, the H&P indicated Resident 74 had the capacity to understand and make decisions. During a review of Resident 74's current physician orders, the orders indicated staff were supposed to administer a total of nine (9) medications at 9 a.m. on 1/9/2024. The medications were as follows: 1. Ferrous sulfate 325 mg tablet, twice a day, for anemia. 2. Cholecalciferol (Vitamin D3) 1000 unit, once a day, for supplement. 3. Multivitamin, once a day, for supplement. 4. Vitamin C 500 mg tablet. 5. [NAME]-Vite (vitamin), one a day, for renal integrity. 6. Eliquis (apixaban) 5 mg, by mouth, once a day, for atrial fibrillation (abnormal heartbeat). 7. Magnesium-oxide 400 mg tablet, twice a day, for supplement. 8. Insulin glargine (Lantus) 10 units subcutaneously, once a day, for DM, with orders to not administer if Resident 74's blood sugar was less than 120. 9. Lidocaine 5% patch, applied above right pelvis and low back, once a day, for pain management. During an interview on 1/9/2024 at 8:59 a.m., with LVN 4, LVN 4 stated she was preparing to administer medications for Resident 74. During a concurrent observation and interview on 1/9/2024 at 9:02 a.m., inside Resident 74's room, LVN 4 checked Resident 74's blood sugar. LVN 4 stated Resident 74's blood sugar was 110. No medications were administered. During a concurrent observation and interview on 1/9/2024 at 9:04 a.m., outside of Resident 74's room, LVN 4 prepared a total of two (2) medications for Resident 74. After preparing the medications, LVN 4 confirmed a total of two (2) medications were being administered to Resident 74 (Eliquis and Lantus) and restated that Resident 74's blood sugar was 110. LVN 4 then entered Resident 74's room and Resident 74 took the Eliquis with water while LVN 4 injected 10 units of Lantus into Resident 74's left lower abdomen. No further medications were offered to or administered to Resident 74, and LVN began preparing medications for the next resident at 9:14 a.m. During a review of Resident 74's MAR, for the month of January 2024, the MAR indicated a total of nine (9) medications were scheduled for 9 a.m. administration. The MAR indicated LVN 4 documented she had administered nine (9) scheduled 9 a.m. medications. There were seven (7) medications documented as administered by LVN 4 on the MAR that were not observed as administered. The MAR also indicated LVN 4 documented a blood sugar of 110 and documented that the Lantus had been administered despite the order to not administer the medication if the blood sugar was less than 120. During a review of a document titled, Medication [Administration] Audit Report, dated 1/9/2024, the document indicated Resident 74 had a total of nine (9) medications scheduled for administration at 9 a.m. The document indicated LVN 4 documented she administered a total of nine (9) medications to Resident 74 between 8:58 a.m. and 9:12 a.m. During a concurrent interview and record review, on 1/09/2024 at 9:33 a.m., with LVN 4, Resident 74's MAR and physician orders were reviewed. LVN 4 stated the physician order was to not administer the Lantus injection if Resident 74's blood sugar was less than 120. LVN 4 stated she misread the physician order. LVN 4 stated the blood glucose was 110 and the Lantus was administered. LVN 4 stated administration of Lantus put Resident 74 at risk for hypoglycemia and could cause harm to the resident. 3. During a review of Resident 7's admission Record, the record indicated the facility originally admitted Resident 7 on 9/24/2014 and re-admitted Resident 7 on 7/7/2019. Resident 7's admitting diagnoses included spinal stenosis (narrowing of the spinal canal that can put pressure on the spinal cord and the nerves within the spine), right shoulder contracture (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), and cognitive communication deficit. During a review of Resident 7's H&P, dated 11/24/2021, the H&P indicated Resident 7 did not have the capacity to understand and make decisions. During a review of Resident 7's current physician orders, the orders indicated staff were to administer a total of eleven (11) medications at 9 a.m. on 1/9/2024. The medications were as follows: 1. Multivitamin with minerals, one tablet, once a day, for supplement. 2. Lidocaine-Prilocaine external cream 2.5%, applied to right shoulder, twice a day, for pain management. 3. Cholecalciferol (Vitamin D3) two 1000-unit tablets, once a day, for low vitamin D levels. 4. Potassium chloride 50 milliequivalents (mEq, a unit of dose measurement), in the morning, for supplement secondary to furosemide (medication that makes you urinate) use. 5. Docusate sodium 100 mg, in the morning, for stool softener. 6. Furosemide 40 mg tablet, in the morning, for extremity edema (swelling). 7. Sodium chloride solution 5% instillation of one drop to the right eye, twice a day, for corneal edema (swelling of the outermost layer of the eye). 8. Gabapentin 100 mg capsule, twice a day, for pain management. 9. Artificial tears instillation of one drop to both eyes, four times, a day for dry eyes. 10. Divalproex sodium 500 mg, twice a day, for seizure (a sudden, uncontrolled burst of electrical activity in the brain that can cause changes in behavior, movements) disorder. 11. Levetiracetam 750 mg, twice a day, for seizure disorder. During an interview on 1/9/2024 at 9:14 a.m., with LVN 4, outside of Resident 7's room, LVN 4 stated she was preparing to administer medications for Resident 7. During a concurrent observation and interview on 1/9/2024 at 9:21 a.m., outside of Resident 7's room, LVN 4 prepared a total of six (6) medications for Resident 7. After preparing the medications, LVN 4 confirmed a total of 6 (6) medications were being administered to Resident 7. LVN 4 then entered Resident 7's room and Resident 7 took 5 medications with water, and LVN 4 administered one (1) medication (artificial tears) to both of Resident 7's eyes. No further medications were offered to or administered to Resident 7. During a review of Resident 7's MAR, for the month of January 2024, the MAR indicated a total of eleven (11) medications were scheduled for 9 a.m. administration. The MAR indicated LVN 4 documented she had administered eleven (11) scheduled 9 a.m. medications. There were four (4) medications documented as administered by LVN 4 on the MAR that were not observed as administered. During a review of a document titled, Medication [Administration] Audit Report, dated 1/9/2024, the document indicated Resident 7 had a total of eleven (11) medications scheduled for administration at 9 a.m. The document indicated LVN 4 documented she administered a total of eleven (11) medications to Resident 7 between 9:15 a.m. and 9:20 a.m. During an interview on 1/11/2024 at 3:35 p.m., with the Director of Nursing (DON), the DON stated medications are to be administered as ordered by the physician. The DON stated staff have one hour before and one hour after the scheduled administration time to administer medications. The DON stated medication administered outside of the scheduled time required prior physician notification to ensure it was safe, and stated there should be documentation in the resident's medical record to indicate when the medication was administered. The DON also stated documentation of medication administration is supposed to be done immediately at time of administration and should be accurate. During a review of the facility's policy and procedure (P&P) titled, Medication Administration - General Guidelines, dated 10/2017, indicated: a. Medications are administered in accordance with written orders of the attending physician. b. Medications are administered within 60 minutes of the scheduled time (1 hour before and 1 hour after). c. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility. d. The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given.

Based on observation, interview, and record review, the facility failed to maintain and calibrate (process that ensures the reading and functionality of a device is accurate and in full working order) the ultrasound/electrotherapy modality machine (medical device that includes both ultrasound, a method to produce high-frequency sound waves that can travel deep into tissue and create therapeutic heat and electrotherapy, a method that sends electrical pulses through the skin) for resident use in the rehabilitation department. This deficient practice had the potential to cause injury to any resident who used this equipment as part of their therapy treatment. Findings: During a concurrent observation and interview on 1/10/2024 at 1:41 p.m., in the rehab gym, the Director of Rehabilitation (DOR) stated the rehab department had one electrical modality machine that provided both ultrasound and electrotherapy treatment. A sticker on the ultrasound/electrotherapy machine indicated the device was last inspected in 6/2022 and was due for reinspection in 6/2023. The DOR stated the ultrasound/electrotherapy machine was supposed to be calibrated yearly and was overdue. During a concurrent observation and interview on 1/11/2024 at 11:00 a.m., in the rehab gym, the Maintenance Director (MD) examined the ultrasound/electrotherapy machine and confirmed the device was due for inspection and calibration on 6/2023. The MD stated the ultrasound/electrotherapy machine should have been calibrated yearly and was overdue. The DOR stated an outside company calibrated the machine and was not sure why it was not done timely. The MD stated it was important the device was maintained and calibrated according to manufacturer's guidelines and recommendations to ensure the device worked properly and did not cause harm to the residents. During a follow up interview on 1/11/2024 at 11:20 a.m., the DOR stated the purpose of calibrating and maintaining equipment routinely and according to manufacturer's recommendations was to ensure the device was safe for resident use and working properly. During a review of the manufacturer's user's manual (revised 9/2008) for the Dynatron Solaris 700 Series ultrasound/electrotherapy machine, the user's manual indicated the calibration process must be performed by a qualified technician using the proper equipment with recommended calibration every six to twelve months. The user's manual further indicated the soundheads (part of the machine that converts energy from one for to another) of the ultrasound device must be calibrated with the device every six months to a year to ensure proper operation and accuracy of the device. During a review of the facility's undated policy and procedure (P&P) titled, Rehabilitation Services, the P&P indicated equipment would be safe and adequate for resident needs and electrical equipment would be calibrated annually.

Based on observation, interview, and record review, the kitchen staff failed to wash their hands prior to becoming in contact with food, failed to check food temperatures, and failed to store food under sanitary conditions when the following occurred: 1. The Dietary Supervisor (DS) did not wash their hands before checking food temperatures. 2. The refrigerator stored food without a use by date. 3. The refrigerator stored food that was spoiled. 4. The freezer stored food without the date that it was placed in the freezer and did not have a use by date. 5. Food temperatures were not checked prior to serving food to residents. These deficient practices had the potential to result in the transmission of infectious agents that could lead to food borne illnesses in vulnerable residents. Findings: During a concurrent initial kitchen tour observation and interview on 1/8/2024 at 8:55 a.m. with [NAME] 1, in the dry storage room, [NAME] 1 stated items placed in the storage room were dated with the received date (date item was placed on the shelf), the date the item was opened, and a use by date (date item must be removed or the expiration date). During an observation on 1/8/2024 at 9:05 a.m. in the dry storage room, there was an open container of browning and seasoning sauce with no use by date. Observed graham cracker crumbs, buttermilk boxes, cheesecake mix, gelatin powder mix and apple sauces with no received date. Observed an open jar of peanut butter and an open bag of cornflakes without a received date, opened date, or use by date. During an interview on 1/8/2023 on 9:02 a.m. with the Dietary Supervisor (DS), in the dry storage food, the DS stated that all items needed to be labeled with the received date, open date, and use by date. The DS stated these items needed to be labeled with these dates to help staff know which items were older, which items needed to be used next, and when the item could no longer be used. During an observation on 1/8/2024 at 9:29 a.m. in the walk-in refrigerator, observed an open bag of sliced carrots with no use by date. Observed open and unopened bags of green grapes that contained spoiled grapes. Observed an undated bag of green peppers. During an observation on 1/8/2023 at 9:41 a.m. at the kitchen's freezer, observed multiple bags of frozen mixed vegetables and multiple bags of frozen broccoli, multiple bags of frozen zucchini, a package of hamburger patties, a bag of bacon, a bag of sausage links, and a bag of waffles with no date indicating when those items were put in freezer. The items were not labeled with a use by date or expiration date. Observed turkey sausages saran wrapped and labeled with the date of 1/5/2024, unable to identify what that date was for. During an interview on 1/10/2024 at 11:35 a.m. with the DS, in the kitchen, the DS stated once an item has been opened, it must be dated with the open date and a use by date. During an interview on 11/10/2024 at 11:40 a.m. with the DS, in the walk-in refrigerator, the DS stated the green grapes were spoiled and should not be in the refrigerator. The DS stated it was important not to keep spoiled food in the refrigerator to prevent staff from serving them to residents. During a concurrent observation and interview on 1/10/2024 at 11:48 a.m. with the DS, in the kitchen, the freezer had food items with no dates. The DS stated all food in the freezer must be labeled with the date it was put in the freezer. The DS stated the opened food in the freezer did not have a use by date and stated the items should have been dated. The DS stated there was no way of knowing if the bag of frozen burritos and a frozen bag of raviolis were still good to be served to residents because it did not have an open date and a use by date. The DS stated it was important to accurately date all food items to make sure the facility served unexpired and safe food to the residents. During an observation on 1/10/2024 at 12:15 p.m. in the kitchen, observed the DS removing potentially expired food from the freezer. The DS then went and began checking the temperatures of food that was currently being plated and served to the residents for lunch. The DS did not their wash hands before checking food temperatures. Observed the DS log temperatures on the temperature log form. Observed kitchen staff serving lunch plates for residents and delivering to the floor without first checking food temperatures. During an interview on 1/10/2024 at 12:29 p.m. with the DS, in the kitchen, the DS stated he should have washed his hands before becoming in contact with the resident's food. The DS stated he should have washed his hands before touching the food to prevent food contamination. The DS stated food temperatures were checked by the cook or himself only before plating food. During a review of the facility's policy and procedure (P&P) titled, Refrigerator/Freezer Storage, dated 2019, the P&P indicated leftover food or unused portions of packaged foods should be covered, dated, and labeled to ensure they will be used first. The P&P indicated food items should have the following appropriate dates: Delivery date- upon receipt, Open date- opened containers, and thaw date - any frozen items. During a review of the facility's P&P titled, Daily Food Temperature Control, dated 2019, the P&P indicated the temperature of all hot and cold food shall be taken prior to every meal service and recorded on the temperature log.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure medication was not left at the bedside and that medication was administered under the supervision of a licensed nurse for one of five sampled residents (Resident 2). This deficient practice had the potential to cause medication error and harm to Resident 2. Findings During a review of Resident 2's Face Sheet (admission Record), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including diabetes (a group of diseases that result in too much sugar in the blood), dysphagia (difficulty swallowing foods or liquids), and muscle weakness (lack of muscle strength). During a review of Resident 2's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 4/11/2023, the MDS indicated Resident 2 was able to understand and be understood by others. The MDS indicated Resident 2 required supervision while eating, limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) for personal hygiene, was totally dependent on staff for transferring, and required extensive assistance (resident involved in activity, staff provide weight-bearing support for other aspects of activities of daily living (ADLs) such as dressing, bed mobility, and toilet use. During a concurrent observation and interview on 5/22/2023 at 5:12 p.m. with Resident 2, in Resident 2's room, three medications in a medicine cup was observed on Resident 2's bedside table and Resident 2 took the medications without a licensed nurse supervision. Resident 2 stated she was not sure what the medications were and that nurses would sometimes leave her medication at the bedside table for her to take on her own. During a review of Resident 2's Medication Administration Record (MAR), dated 5/23/2023, the MAR indicated Resident received Gabapentin 400 mg capsule, Oyster Calcium 500 mg tablet, and Metamucil 400 mg capsule during the 5 p.m. medication pass. During an interview with Licensed Vocational Nurse (LVN 1) on 5/22/2023 at 5:22 p.m., LVN 1 stated she gave medication to Resident 2 and that the resident was able to take the medication herself. During an interview and concurrent record review with LVN 2 on 5/22/2023 at 6 p.m., Resident 2's physician orders were reviewed. LVN 2 stated Resident 2 did not have an order to self-administer medications. LVN 2 also stated if a nurse left the resident's room before the resident took the medication, the resident might not take the medication or take the medication too late which could cause harm to the resident. During a review of the facility's Policy and Procedure (P&P) titled, Policy & Procedure: Med Pass, undated, the P&P indicated to prepare, administer, and chart the medication correctly. The P&P also indicated medications should not be left at the bedside for residents unless ordered by the MD and always observe resident taking medication, even when the medication may be administered independently.

Based on interview and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections by preventing and managing the potential spread of COVID-19 (a highly contagious respiratory infection caused by a virus that can easily spread from person to person) by failing to ensure three of six staff (Licensed Vocational Nurse [LVN] 2, LVN 3, and Certified Nurse Assistant [CNA] 2) were screened for symptoms of COVID-19 infection, close contact exposure, or recent travel to a state or country prior to entrance to the facility. This deficient practice had the potential to result in the spread of COVID-19 in the facility and cause harm to residents' health and well-being. Findings: During a record review of facility ' s Daily Staffing log (staffing log), dated 1/19/2023, staffing log indicated Licensed Vocational Nurse (LVN) 2 and Certified Nurse Assistant (CNA) 2 both worked from 1/18/2023 11:00 p.m. to 1/19/2023 7:00 a.m. The log also indicated LVN 3 worked on 1/19/2023 at 7:00 a.m. to 3:00 p.m. shift. During a review of the facility document titled, Employee Screening for Covid-19 (screening log), dated 1/19/2023, screening log indicated LVN 2, LVN 3, and CNA 2 were not listed screened prior to start of their shifts on 1/18/2023 to 1/19/2023. During a concurrent interview and record review of Employee Screening for Covid-19, dated 1/19/2023, with the screener on 1/19/2023 at 11:00 a.m., the screener was unable to provide document that indicated LVN2, LVN3 and CNA 2 were screened on 1/18/2023 to 1/19/2023. The screener stated LVN 2 and CNA 2 were not screened before and after their shifts on 1/18/2023 from 11:00 p.m. to 1/19/2023 7:00 a.m., and LVN 3 was not screened prior to starting her shift on 1/19/2023 at 7:00 a.m. During an interview with the infection preventionist (IP) on 1/19/2023 at 12:00 p.m., IP stated all employees should have self-screened prior to entry to the facility according to their policy to prevent the spread of infection. During a review of facility ' s policy and procedure (P&P) titled, Covid-19 Policy, dated 12//20/2022, P&P indicated the facility screens and documents every individual entering the facility, including staff and visitors, for covid-19 symptoms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to assess for eligibility and failed to ensure residents were offered the pneumococcal vaccination (vaccine to help prevent one from getting pneumonia [infection of the lungs]) for two of five sampled residents (Residents 5 and 9). This deficient practice placed Residents 5 and 9 at risk of acquiring pneumonia. Findings: a. During a review of Resident 5's admission Record, the admission record indicated Resident 5 was admitted to the facility on [DATE] with diagnoses that included Covid-19 (highly contagious respiratory infection), diabetes (body cannot regulate glucose [blood sugar] normally, dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), anemia (a condition in which the blood does not have enough healthy red blood cells), and hypertension (a condition in which the force of the blood against the artery walls is too high). During a review of Resident 5's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 12/20/2022, the MDS indicated Resident 5 was sometimes able to be understood or sometimes understood others. The MDS indicated Resident 5 required extensive limited assistance with eating, extensive assistance from one person assistance with bed mobility, dressing, personal hygiene, and toilet use. During a record review of Resident 5's Immunization Report, the report indicated the pneumococcal vaccine was not administered or offered to Resident 5. b. During a review of Resident 9's admission Record, the admission record indicated Resident 9 was admitted to the facility on [DATE] with diagnoses that included anemia, injury of the head, hypertension, and osteoarthritis (wear and tear of joints causing pain). During a review of Resident 9's MDS dated [DATE], the MDS indicated Resident 9's cognitive (the ability to understand or to be understood by others) skills for daily decisions making was intact. MDS indicated the resident needed supervision with eating, and needed extensive assistance on staff with dressing, bed mobility, toilet use, and personal hygiene. During a record review of Resident 9's Immunization Report, the report indicated the pneumococcal vaccine was not administered or offered to Resident 9. During an interview with the Infection Preventionist (IP) on 1/27/2023 on 2:54 p.m., the IP stated Resident 5 and Resident 9 were not screened for pneumococcal vaccination. IP stated that Resident 5 and Resident 9 should have been screened for pneumococcal vaccine to prevent pneumonia and will make sure they were screened for pneumococcal vaccine eligibility. During a record review of the facility's policy and procedure (P&P) titled, Pneumococcal Vaccine, dated 7/18/2022, the P&P indicated all residents were offered pneumococcal vaccines to ensure all residents were up to date with pneumococcal vaccination based on Centers for Disease Control guidance. The P&P indicated the pneumococcal vaccines orders will be obtained from all attending physicians on admission and as needed for all residents unless contraindicated. P&P indicated before offering the pneumococcal immunization, each resident and or the resident's legal representative will receive education regarding the benefits and potential side effects of the immunization. P&P indicated the medical record of the resident will include documentation that indicates: a. The resident or resident's legal representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and b. The resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindications or refusal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b) During a review of the admission record (Face Sheet), the face sheet indicated Resident 50 was admitted to the facility on [DATE]. Resident 50's diagnoses included weakness, tremors, and major depressive disorder (mental health disorder with episodes of sadness, tiredness, irritability and sleep disorder). During an observation on 6/3/2021 at 8:50 a.m., a computer in the Activities Office, was observed unattended and with the computer screen displaying Resident 50's electronic medical record. During an interview on 6/3/2021 at 9:01 a.m., the Activities Director (Act. Dir) acknowledged she had left her office with Resident 50's medical record on the computer screen open and was aware it violated Resident 50's right to privacy. During a review of facility policy and procedures (P/P) titled, Resident Rights, revised 4/2018, the P/P indicated the resident had the right to personal privacy and confidentiality of his/her personal and clinical records. Based on observation, interview and record review, the facility failed to protect a resident's medical information and provide privacy during morning care for two of two sampled residents (Residents 50 and 67) by failing to: a) Provide privacy to Resident 67 during a bed bath and having the privacy curtain open and the resident being cold and exposed to passersby. b) Leave Resident 50's medical record open on the computer screen and unattended for an extended amount of time. These deficient practices resulted in Resident 50's personal information exposed to other staff members and residents and had the potential to violate other resident's right to privacy of medical information. Resident 67 feeling uncomfortable due to body exposure and cold during a bed bath. Findings: a) During a review of Resident 67's admission Record (Face sheet), the Face Sheet indicated Resident 67 was admitted to the facility on [DATE]. Resident 67's diagnosis including history of falling, localized edema (swelling caused by excess fluid trapped in the body's tissues), and constipation (condition in which there is difficulty in emptying the bowels, usually associated with hardened feces). During a review of Resident 67's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 7/29/2020, the MDS indicated Resident 67 had cognitive (ability to make decisions, understand, learn) impairment for daily decision making. The MDS assessment indicated Resident 67 required extensive assistance for activities of daily living ([ADL]) bed mobility, transfer, dressing, eating, toilet, and personal hygiene. During a review of Resident 67's Care Plan titled, Activities of Daily Living, dated 4/12/2021, the care plan indicated Resident 67 require assistance with ADLs due to limitation in mobility, history of falls and weakness. The staffs' intervention indicated Resident 67 would be dressed appropriately, provide good perineal care every shift and when necessary and staff would maintain resident's privacy and respect their rights. During an observation on 6/02/2021 at 9:00 a.m., Certified Nurse Assistance 3 (CNA 3) was observed performing morning care bed bath to Resident 67 with the resident's room door widely open and the privacy curtain partially opened. Resident 67 was hear telling CNA 3 in two separate occasions not being comfortable with the curtain been open and asked CNA 3 to close the curtain to provide privacy. Resident 67 was observed exposed from the chest and arms and was noted shivering. Resident 67 also, requested to be covered because he was cold, but CNA 3 stated she would be done soon. During a concurrent observation of Resident 67's bed bath and interview on 6/2/2021 at 9:09 a.m., CNA 3 was observed using a wet white towel to clean Resident 67 perineal area front and back, and continued to use the same towel to clean Resident 67's chest. CNA 3 stated she used only one towel to clean the resident because the resident was not soiled. CNA 3 stated she did not cover the resident during the bed bath because the water was hot, and she was going to be done with the bed bath soon. CNA 3 stated the privacy curtain was used to provide privacy to the residents during care, but she forgot to close the curtain when she was providing care for Resident 67. During an interview on 6/4/2021 at 11:15 p.m., the Director of Staff Development (DSD) stated she had done in-service on peri care once for the year of 2021 and always reminds staff to announce what they are doing to the resident, provide privacy, dignity and respect. DSD stated she always reminds staff to expose the area they are cleaning and cover the rest of the body and be responsive towards resident's concern. During an interview on 6/4/2021 at 11:14 a.m., the Director of Nursing ( DON ) stated when staff was providing care to residents and the residents complained of feeling cold, the staff was responsible to stop care, check the water temperature, get a blanket and cover the residents before continuing with the care and ask the residents if they preferred to be covered or to have the water changed. During a review of facility's undated P/P, the P/P indicated residents should be examined and treated in a manner that maintains the privacy of their bodies. A closed door or drawn curtain shields the resident from passersby. The P/P indicated privacy of a Resident's body shall be maintained during toileting, bathing, and other activities of personal hygiene, except when staff assistance is needed for the resident's safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Registered Dietitian ([RD] health professional with special training in the use of diet and nutrition to keep the body healthy) recommendation were carried, re-evaluate nutrition interventions and implement weekly weight monitoring for one of seven sampled residents (Resident 29). These failures had the potential to negatively impact Resident 29 nutrition status and result in unplanned weight loss. Findings: During a review of Resident 29's admission record (Face sheet), the Face Sheet indicated Resident 29 was admitted to the facility on [DATE]. Resident 29's diagnosis included dysphagia (difficulty or discomfort in swallowing), anemia (condition marked by a deficiency of red blood cells or of hemoglobin in the blood, resulting in pallor and weariness) and hypertension (high blood pressure). During a review of Resident 29's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 4/2/2021, the MDS indicated Resident 29 was severely impaired of cognition (taught process). The MDS indicated Resident 29 required extensive assist of one-person physical assist to eat. The MDS indicated Resident 29 had a swallowing disorder, cough or choking during meals or when swallowing medications. During a review of Resident 29's physician orders, dated 2/10/2021, the orders indicated for Resident 29 to have a no added salt puree texture diet, large portion and thick liquids. During a review of Resident 29's electronic weight log, in the presence of the RD, on 6/3/2021 at 8:25 a.m., Resident 29's had a 3.5 percent (%) weight loss of 6 pounds ([lbs.] units of measurement) in one month from 4/2021 thru 5/2021, a 6.8 % weight loss of 12 lbs. in 3 months from 2/2021 thru 5/2021 and a 21% severe weight loss of 44 lbs. in 6 months from 11/2020 to 5/2021. The RD stated she made recommendations for appetite stimulants on 5/13/2021 if medical doctor (MD) agreed with it, but she was unable to find an order for the appetite stimulant in the physician's order. During an interview on 6/3/21 at 8:27 a.m., the RD stated Resident 29 was on a high protein nourishment ([HPN] diet in which 20% or more of the total daily calories comes from protein) diet for two months but RD did not resume the diet on 4/2021 because Resident 29 appetite was poor. RD also stated Resident 29's poor intake was due to dislike of puree food texture. During a concurrent review of Resident 29's RD recommendations and interview on 6/3/2021 at 8:30 a.m., the Director of Nursing (DON) stated she was not able to find an order for Resident 29's appetite stimulant recommended by the RD. the DON stated there was no nursing notes documentation on whether the recommendation was relayed to Resident 29's primary physician. During an interview on 6/3/21 at 8:45 a.m., the DON stated the Interdisciplinary Team ([IDT] members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) weight variance meeting was conducted on 5/8/2021 regarding Resident 29's nutrition. The DON stated no weekly weights were recommended for monitoring because the concern was Resident 29's dislike of puree foods. During an interview on 6/3/2021 at 10:32 a.m., the RD stated the policy for weekly weights and monitoring was for nursing. The RD stated she usually did not make weekly weight recommendations because she thought weekly weights would be automatically initiated for residents with significant weight loss by the nursing staff. During an interview with the DON on 6/3/2021 at 10:35 a.m., DON stated she agreed Resident 29 could have benefit from weekly weight for closer monitoring of the weight change. During an interview on 6/3/21 at 1:25 p.m., Registered Nurse 1 (RN 1) stated when she talked to Resident 29's primary physician about the RD's recommendations, she should had written a note under the nursing progress notes indicating the recommendations had be relayed to the primary physician within 3 days regardless if the primary physician agreed or disagreed with the recommendations. RN 1 stated she received and carried out the RD's recommendations on 5/13/2021, but she did not call Resident 29's primary physician for the appetite stimulant on 5/13/21 because she forgot. During a review of facility's policy and procedure (P/P), titled Consultant Dietitian Recommendation Completion, dated 2019, the P/P indicated it was the policy of the facility to complete Consultant Registered Dietitian Recommendations within 72 hours. The P/P indicated the staff would notify the physician of any recommendations within 72 hours and nurses would document in the progress notes of the recommendations relayed to the physician. During a review of the facility's undated policy and procedure (P/P), titled Weight Change, the P/P indicated to implement weekly weight for residents with significant weight changes and the method to review include .2. Weekly weights. 3. Dietary supplements .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a 35 degree safe gastrostomy tube ([g-tube] creation of an artificial external opening into the stomach for nutritional support) feeding position for one (1) of one (1) sampled residents (Resident 54). This deficient practice had the potential to cause aspiration (when food, liquid, or any other material enters the airway or lungs by accident) pneumonia (infection that inflames the air sacs in one or both lungs with fluid or pus [purulent material], causing cough with phlegm or pus, fever, chills, and difficulty breathing), and impede progress to wellness. Findings: During a concurrent observation and interview, on 6/3/2021 at 3:00 p.m. in the presence of Licensed Vocational Nurse 4 (LVN 4), Resident 54 was observed lying in bed with the head of the bed at a 20 degree angle receiving a gastrostomy tube feeding of Jevity (fiber-fortified tube-feeding formula; for supplemental or sole-source nutrition) infusing at 60 milliliters ([cc] units of measurement) per hour. LVN 4 was observed raising Resident 54's head of the bed to a 30-degree angle and stated the feeding could go into Resident 54's lungs. During a review of Resident 54 admission record (Face Sheet), the Face Sheet indicated Resident 54 was admitted on [DATE] with diagnosis of gastrostomy, hypertension (high blood pressure), and seizures (burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements). During a review of Resident 54's Minimum Data Set (MDS- an assessment and care planning tool,) dated 3/19/2021, the MDS indicated Resident 54 had no speech, rarely/never understood ideas, wants, and rarely/never comprehended others. The MDS further assessed Resident 54 as total dependence on full staff for dressing, eating, and personal hygiene. During a review of Resident 54's physician orders, dated 12/22/2020, the orders indicated enteral (nutrition taken through the mouth or through a tube that goes directly to the stomach or small intestine) aspiration precaution: elevate head of bed at 30-45 degrees at all times during gastrostomy feeding. During a review of Resident 54's care plan titled, G-Tube Feeding, dated 12/4/2020, the care plan indicated Resident 54 was on specify feeding, and was at risk for aspiration, dehydration, and weight loss. The staffs' interventions included to keep the head of bed elevated, assess tolerance to feeding, and check and maintain placement and patency of g-tube. During a review of the facility's undated policy and procedure (P/P) titled, HOB (head of bed) Positioning During Enteral Feeding, the P/P indicated the facility would maintain the HOB elevated at least 35 degrees during enteral feeding administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the attending physician responded to a recommendation made by the consultant pharmacist (CP) on 2/2021 for one of one sampled resident (Resident 44). This deficient practice had the potential to increase the risk of Resident 44's medication therapy not being at an optimal and therapeutic level. Findings: During a review of Resident 44's medical record (Face Sheet(, the Face Sheet indicated Resident 44 was admitted to the facility on [DATE] with diagnoses that included dementia (a brain disease with a group of symptoms that affect memory, thinking and interfere with daily life without behavioral disturbance, hypertension (high blood pressure) and schizophrenia (a long-term mental disorder involving a breakdown in the connection between thought, emotion, and behavior). During a review of Resident 44's Minimum Data Set (MDS- a standardized assessment and care planning tool) dated 1/21/2021, the MDS indicated Resident 44 was cognitively (ability to make decisions of daily living) intact, and required minimal assistance with activities of daily living such as getting dressed, eating, toileting and personal hygiene. Further review of the MDS indicated Resident 44 had not presented any behavioral symptoms such as hallucinations (seeing, hearing, or feeling something that does not exist outside of one's min.) or delusions (a strong belief or judgment that is not grounded in reality). During a review of Resident 44's physician orders indicated an order on 1/14/2021 for Olanzapine Tablet (a medication used to treat hallucinations and delusions) 2.5 milligrams ([mg] units of measurement) by mouth at bedtime for schizophrenia manifested by inability to process internal stimuli causing anger or stress. During a review of Resident 44's physician orders dat3ed 1/21/2021, the orders indicated to monitor Resident 44's episodes of behaviors of inability to process internal stimuli causing anger or stress by hashmarks every shift for the use of olanzapine. During a review of Resident 44's medication administration record (MAR), dated 1/21/2021, the MAR indicated Resident 44 had taken this medication daily since admission, on 1/21/21 until present. During a review of Resident 44's Psychotropic Summary Tally Sheet, the tally sheet indicated Resident 44 had no behaviors starting 1/14/2021 through 5/31/2021. During a review of a pharmacist's monthly medication regimen review (MRR) for Resident 44 for the month of 2/2021 indicated a recommendation, your patient has a dementia disorder and takes olanzapine. The FDA (federal food and drug administration; a governmental agency responsible for protecting and promoting health through supervision of items such as food, tobacco, and prescription medications), warns that antipsychotics (olanzapine) are associated with an increased risk of mortality in elderly individuals with dementia disorders. During a concurrent interview and record review, on 6/4/21 at 1:44 p.m. Registered Nurse 2 (RN 2) stated the physician was responsible for reviewing Resident 44's medications and determining if Olanzapine for Resident 44 should be continued or discontinued. RN 2 acknowledged the pharmacists' recommendations had not been addressed, and the olanzapine was not discontinued, or the dosage adjusted. RN 2 stated there should be documentation Resident 44's physician agreed or disagreed with the pharmacist's recommendation and if medications should be continued, adjusted, or discontinued. During a review of the facility policy and procedures (P/P) titled, Consultant Pharmacist Reports, dated 3/2020, the P/P indicated the consultant pharmacist performed a comprehensive MRR at least once a month, evaluating the resident's response to medication therapy to determine if the resident maintained the highest level of functioning and prevent or minimized adverse consequences related to medication therapy. Recommendations were acted upon and documented by the facility staff and or the prescriber. The P/P indicated the Physician accepted and acted upon suggestion or rejection and provided an explanation for disagreement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide food preferences for one of six sampled residents (Resident 44). This deficient practice had the potential to result in decreased meal satisfaction and decreased overall caloric intake. Findings: During a review of Resident 44's admission Record (Face Sheet), the face sheet indicated Resident 44 was admitted to the facility on [DATE]. Resident 44's diagnosis included difficulty walking, hypertension (high blood pressure), and depression (constant feeling of sadness and loss of interest, which stops you doing your normal activities). During a review of Resident 44's Minimum Data Set (MDS), a resident assessment and care screening planning tool, dated 1/212021, the MDS indicated Resident 44 was intact of cognitive skill and was able to understand and understood others. The MDS indicated Resident 44 required supervision and set up for eating only. During a concurrent observation and interview on 6/2/21 at 1:00 p.m., Resident 44 stated hey had asked multiple times no to have fried eggs and peas on his tray. Resident 44's lunch tray was observed with peas and with a diet card indicating Resident 44 was not to have peas. Resident 44 stated he had spoken to management in several occasions regarding his food preferences, but no changes had been made. During an interview on 6/3/21 at 9:00 a.m., Dietary Services Supervisor (DSS) stated not having receive a preference diet notice from Resident 44. DSS stated residents fill out a Diet Order Form regarding their food preferences and place it on a card box. During an interview on 6/2/21 at 9:10 a.m., Licensed Vocational Nurse 1 (LVN 1) stated when a resident had a food preference, the nurse either calls the kitchen to let them know or a Diet Order Form is completed. During a record review of the resident's chart, the RD Nutritional Assessment Screening dated 1/18/2021 indicated Resident 44's dislikes were pork, liver, beets, and peas. During a review of the undated facility's policy and procedure (P/P) titled, Diet Orders, revised in 2019, the P/P indicated, the resident's name, diet order, food likes and dislikes, and allergies were noted on the resident's Profile Card and tray card for staff reference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide advance directives to three (3) of three (3) sampled resident (Residents 17, 50, and 59) This deficient practice had the potential to result in unclear guidance to health providers regarding the resident's medical wishes in the event of the resident becoming unresponsive. Findings: a) During a review of Resident 17's admission Record (Face Sheet), the face sheet indicated Resident 17 was re-admitted to the facility on /29/2021. Resident 17's diagnosis included dysphagia (difficulty swallowing). During a review of Resident 17's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 4/3/2021 indicated Resident 17 had cognitive (ability to make decisions of daily living) impairment. The MDS indicated Resident 17 was total dependent of a-staff assist for activities of daily living such as bed mobility, transfer, walk in room, walk in corridor, dressing, toilet use, and personal hygiene. During a review of Resident 17's History and Physical (H/P) dated 6/2/2021, the H/P indicated Resident 17 did not have the capacity to understand and make decisions. b) During a review of Resident 59's face sheet, the face sheet indicated Resident 59 was admitted to the facility on [DATE]. Resident 59's diagnosis included Parkinson's disease (brain disorder that causes shaking, stiffness, and difficulty with walking, balance, and coordination) and difficulty walking. During a review of Resident 59's MDS, dated [DATE] indicated Resident 59 had cognitive impairment. The MDS indicated Resident 59 was total dependent in activities of daily living such as bed mobility, transfer, walk in room, walk in corridor, dressing, toilet use, and personal hygiene. During a review of Resident 59's H/P, dated 1/26/2020, indicated Resident 59 had the capacity to understand and make decisions. c) During a review of Resident 50's face sheet indicated Resident 50 was admitted to the facility on [DATE]. Resident 50's diagnosis included multiple sclerosis (disease of the brain and spinal cord) and generalized weakness. During a review of Resident 50's H/P, dated 3/26/2021, the H/P indicated Resident 50 had the capacity to understand and make decisions. During a concurrent interview and review of Residents 17, 50 and 59's Advance Directives, on 6/2/2021 at 11:57 a.m., the Social Service Director (DSS) stated and confirmed there was no Advance Directives on file for Residents 17, 50 and 59. The SSD stated she did not make an attempt to provide the residents with an Advance Directive or with a conservator for the residents requiring representation. During an interview on 6/4/2021 at 11:04 a.m., the Director of Nursing (DON) stated upon admission of the residents, the SSD, Minimum Data Set Director, Activity Coordinator and DON met and discuss care plans, care, immunizations, and advance directives. The [NAME] stated Advance Directives were obtained in case of emergency to direct the staff on the care of the resident. During a review of the facility's undated Policy and Procedure (P/P) titled Advance Directive-Acknowledgement, indicated an advance directive acknowledgement will be provided to residents and/or responsible parties upon admission. They will be informed on the availability of options of medical care providers advance directive regarding the residents' health care decisions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to accurately check the blood sugar (BS) for one of one sampled resident (Resident 45) and use test strips per manufacturers recommendations. This deficient practice resulted in a staff placing a few test strips in a medication cup (open to air) and taking it from one resident's room to another room and had the potential for inaccurate blood sugar results and monitoring of Resident 45's diabetes (irregular blood sugar levels). Findings: During a review of Resident 45's admission Record (Face Sheet), the face sheet indicated Resident 45 was admitted to the facility on [DATE]. Resident 45's diagnoses included diabetes mellitus, hypertension (high blood pressure) and anemia (low blood count). During a review of Resident 45's Minimum Data Set (MDS- a standardized assessment and care planning tool), dated 4/21/2021, the MDS indicated Resident 45 was cognitively (ability to make decisions of daily living) intact, and required physical assistance for activities of daily living such as getting dressed, toileting, eating and personal hygiene. During an observation on 6/2/2021 at 11:32 a.m., licensed vocational nurse (LVN) 1 was observed cleaning Resident 45's finger with an alcohol swab, and immediately pricked the finger and checked the blood sugar. During an interview on 6/3/2021 at 2:38 p.m. LVN 1 acknowledged it was important to wait for the alcohol to dry on Resident 45's finger before pricking it. LVN 1 stated the alcohol could affect the outcome of the blood sugar check with the blood sugar resulting higher than it is. During a review of the National Health Institute (NIH: a governmental agency responsible for biomedical and public health research.), the steps for measuring blood glucose (blood sugar): wash hands and put on gloves, choose the site for the blood sample, use an alcohol swab to clean the site and let the alcohol dry, use the lancet to draw blood. How to measure blood glucose (nih.gov) During an observation on 6/2/2021 at 11:32 a.m., LVN 1 took several blood sugar test strips from an airtight container and placed them in a medicine cup. LVN 1 used a strip (from the medicine cup) for Resident 43 and continued to the next resident's room with the same open container of test strips. During an interview on 6/3/21 at 2:38 p.m. LVN 1 acknowledged the test trips should be kept in an airtight container until they are ready for use. Transporting them in an open container from room to room is a potential risk for moisture damage or infectious agents. According to The Federal Food and Drug Administration (a governmental agency responsible for protecting and promoting health through supervision of items such as food, tobacco, and prescription medications), Blood sugar testing strips should be kept in a closed container to give accurate results. How to Safely Use Glucose Meters and Test Strips for Diabetes. During an interview on 6/3/21 at 9:02 a.m., Infection Preventionist Nurse (IP) acknowledged that blood sugar test strips should not be taken from resident's room to resident's room in an open container due to risk of infection, and contamination. During a review of the facility's undated policy titled, Infection Control, indicated the facility had established and would maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure three of three multi-dose insulin (a hormone substitute used to treat irregular blood sugar levels) vials were labeled and properly disposed for three of three sampled residents (Residents 14, 21, and 45). This deficient practice had the potential for Residents 14, 21 and 45 to not received their therapeutic insulin dose and for their health to decline due to receiving expired insulin. Findings: During a review of Resident 14's admission Record (Face Sheet), the Face Sheet indicated Resident 14 was readmitted to the facility on [DATE]. Resident 14's diagnoses included Type 2 Diabetes Mellitus (DM II: irregular blood sugar [BS]levels). During a review of Resident 14's physician orders dated [DATE], the orders indicated and order for Insulin Regular inject subcutaneously (injected into tissue directly under the skin) before meals and at bedtime for diabetes mellitus, per sliding scale: If BS is 60-150 = 0 units If BS is 151-200 = 0 units If BS is 201-250 = 3 units If BS is 251-300 = 4 Units If BS is 301-350 = 6 units If BS is 351-400 = 9 units If 401and higher = 12 units During a review of Resident 21's Face Sheet, the Face Sheet indicated Resident 21 was readmitted to the facility on [DATE]. Resident 21's diagnoses included DM II. During a review of Resident 21's physician's order dated [DATE], the orders indicated to administer Insulin Regular inject before meals and at bedtime for diabetes mellitus, per sliding scale: If BS is 60-150 = 0 units If BS is 151-200 = 0 units If BS is 201-250 = 3 units If BS is 251-300 = 4 Units If BS is 301-350 = 6 units If BS is 351-400 = 9 units If 401and higher = 12 units During a review of Resident 45's Face Sheet, the Face Sheet indicated Resident 45 was admitted to the facility on [DATE] with diagnoses that included DM II. During a review of Resident 45's physicians order dated [DATE], the orders indicated to administer Insulin Regular inject before meals and at bedtime for diabetes mellitus, per sliding scale: If BS is 60-150 = 0 units If BS is 151-200 = 0 units If BS is 201-250 = 3 units If BS is 251-300 = 4 Units If BS is 301-350 = 6 units If BS is 351-400 = 9 units If 401and higher = 12 units During an observation of a medication cart for rooms 10-19 and interview on [DATE] at 2:45 p.m., Licensed Vocational Nurse 1 (LVN 1) acknowledged a vial of Humulin (a type of insulin) for Resident 14 was dated opened on [DATE] and should have been discarded after 28 days. A vial of Humulin for Resident 21 was dated opened on [DATE] and should have been discarded after 28 days, and a vial of Humulin for Resident 45 was dated [DATE] and should have been discarded after 28 days. LVN 1 stated administering the medication after the expiration date had the potential to be ineffective in treating a high blood sugar levels for all three residents which could lead to severe complications. During a review of the facility policy and Procedures (P/P) titled, Guide for Special Handling of Medications, revised 1/2013, the P/P indicated Insulin products storage requirements indicated to store the opened vials at room temperature or in the refrigerator and to discard 28 days after opening or removing from refrigeration.

Based on observation, interview, and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills as followed: 1. Diet Aide 1 (DA 1) did not know how to utilize the sanitizing test strip instruction and no documented in-service of DA 1 trained on the new test strip instruction after it was changed. 2. [NAME] 1 prepared liquified puree foods (adding more liquids to pureed food to a drinkable consistency) in bulk and did not follow diet manual instruction to ensure adequate portion in each liquified puree diets was served to the residents. 3. DA 2 stored personal food in the walk-in refrigerator and did not know the facility policy regarding personal belonging. These failures had the potential to result in ineffective sanitizer concentration testing, inadequate nutrition and aspiration (occurs when food, saliva, liquids, or vomit is breathed into the lungs or airways leading to the lungs, instead of being swallowed into the esophagus and stomach) for residents requiring liquified pureed diets, and potential cross contamination of foods in the walk-in refrigerator. Findings: a) During an observation on 6/2/2021 at 8:47 a.m., DA 1 demonstrated how to check quaternary ammonium (QUAT - a type of sanitizing solution) sanitizer concentration inside the red bucket. DA 1 dipped the test strip in the bucket for about 10 seconds and the concentration registered on the strip showed 100 parts per million ([ppm] unit of chemical concentration measurement). DA 1 stated it should be between 200-400 ppm. During an observation on 6/2/2021 at 8:49 a.m., dietary service supervisor (DSS) refilled the QUAT sanitizer directly from the chemical pump and re-tested the concentration with the test strip, the strip still showed 100 ppm. DSS read the sanitizer test strip bottle and stated test strip should be inside the sanitizer for 90 seconds before reading. DSS stated their test strip instruction was 10 seconds in the past, but the newer strip required 90 seconds testing time and she had forgotten about the new information. During an interview on 6/2/2021 at 2:20 p.m., the RD stated she did a verbal in-service regarding the new sanitizer test strip and posted a written instruction on the wall. The RD stated DA 1 was likely not present during the verbal in-service. The RD stated no formal written in-service with all kitchen staff was conducted to assess their understanding and knowledge. b) During an observation on 6/2/2021 at 11:47 a.m., [NAME] 1 was observed making liquefied pureed turkey using two 4-ounce (oz - unit of measurement) scoops of pureed turkey and added four 4-oz scoops of broth into a blender, blended and served the liquefied puree turkey using the same 4 oz scoop. [NAME] 1 also, made liquefied pureed vegetables by using two 3-oz scoop, then added broth into a blender to blend the pureed food and served 3-oz scoop portion out the liquefied pureed vegetable utilizing the same scoop. During an interview on 6/2/2021 at 2:28 p.m., the RD stated she had not conducted an in-service regarding liquefied pureed diet preparation. The RD stated when the liquefied puree was prepared in bulks, the pureed was thin down with broth and then use the same serving scoop. The RD stated the actual food portion served would be less than the regular pureed food. During a review of facility's diet manual on Liquefied Puree Diet, dated 2020, the manual indicated the regular servings for a pureed diet were to be served and then thinned to a drinkable consistency using appropriate fluids to ensure proper nutrition. c) During an observation on 6/2/2021 at 12:03p.m., DA 2 was observed entering the kitchen and placing a plastic bag inside the walk-in refrigerator. During an interview on 6/2/2021 at 12:04 p.m., the DA 2 stated the plastic bag was contained her personal food. The DA 2 stated she usually kept her food in the walk-in refrigerator since she had not been aware personal food should not be placed with the food in the walk-in refrigerator. During an interview on 6/2/2021 at 12:07p.m., the RD stated the staff should not be storing their personal food in the facility's walk-in refrigerator. During a review of facility's untitled policy related personal belongings, dated 2019, indicated employee's personal belongings (i.e. clothing, food, cellphone, etc.) should be stored in a separate area away from food or items used in food service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review, the facility fail to follow the recommended dietary order for Carbohydrate diets ([CCHO] diet with controlled amount of carbohydrates to help prevent the blood sugar from escalating) plain ice cream and substituting it with sherbet (frozen dessert made from sugar-sweetened water with flavoring) for nine (9) of 41 residents (Resident 39, 276, 279, 527, 277, 45, 526, 2 and 16). This deficient practice had the potential for Residents 39, 276, 279, 527, 277, 45, 526, 2 and 16 to not received their therapeutic carbohydrate intake and to increase their blood sugar levels. Findings: During an observation of meal tray distribution, on 6/2/2021 at 12:30 p.m., 9 out of 41 CCHO food trays were observed with sherbet instead of the recommended plain ice cream. a) During a review of Resident 39's admission Record (Face Sheet), the Face Sheet indicated Resident 39 was admitted to the facility on [DATE]. Resident 39's diagnosis included diabetes (disease in which the organ does not produce insulin or not enough insulin to break down sugars in the body). During a review of Resident 39's Minimum Data Set (MDS), a resident assessment and care screening planning tool, dated 4/16/2021, the MDS indicated Resident 39 was moderately impaired of cognition (thought process). b) During a record review of Resident 276's Face Sheet indicated Resident 276 was admitted on [DATE]. Resident 276's diagnoses include metabolic encephalopathy, (a neurological disorder that decreases brain function caused by diseases that impact the metabolism) and diabetes. c) During a record review of Resident 279's Face Sheet indicated Resident 279 was admitted on [DATE]. Resident 279's diagnosis included diabetes. During a record review of Resident 279's MDS, dated [DATE], the MDS indicated Resident 279 was able to understand and understood others. d) During a review of Resident 527's Face Sheet, the face sheet indicated Resident 527 was admitted on [DATE] with a diagnosis of diabetes. During a record review of Resident 527's MDS, dated [DATE], the MDS indicated Resident 527's was able to understand and understood others. e) During a review of Resident 277's Face Sheet, the Face Sheet indicated Resident 277 was admitted to the facility on [DATE]. Resident 277's diagnoses include diabetes. f) During a review of Resident 45's the Face Sheet indicated Resident 45 was admitted to the facility on [DATE]. Resident 45's diagnoses included diabetes. During a review of Resident 45's MDS, dated [DATE], the MDS indicated Resident 45 was able to make himself understood and understood others. During an interview on 6/3/2021 at 4:22 p.m., Resident 45 stated he was concern regarding his blood sugars because he was diabetic. g) During a review of Resident 526's Face Sheet, the face sheet indicated Resident 526 was admitted to the facility on [DATE]. Resident 526 diagnoses included diabetes. During an interview on 6/3/2021 at 4:30 p.m., Resident 526 stated the problem with getting something too sweet was he had diabetes. h) During a review of Resident 2's Face Sheet, the Face Sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses include diabetes. i) During a review of Resident 16's Face Sheet, the Face Sheet indicated Resident 16 was admitted to the facility on [DATE]. Resident 16's diagnosis included diabetes, dementia (a decline in mental function and cognition), and aphasia (an inability to speak or express oneself). During an interview on 6/2/2021 at 12:40 p.m., the Dietary Services Supervisor (DSS) stated the CCHO diets for all nine residents should not have sherbet and instead served plain ice cream based on the resident's diet orders. During a review of facility's document tiled, Controlled Carbohydrate Diet (CCHO), dated 2020, the document indicated a controlled carbohydrate diet was a meal plan without specific calorie levels for diabetic residents, but instead of counting calories, the carbohydrates were evenly systematically and consistently distributed through three meals and snacks in an effort to maintain a stable blood sugar level throughout the day. During a review of the facility's Spring Cycle Menus dated 6/2/2021, the menu indicated for the CCHO diet Plain Ice Cream be provided and did not indicate to substitute with sherbet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b) During an observation in Resident 29's room on 6/02/2021 at 1:27 p.m., a tissue box fell from Resident 29's side table and CNA 4 was observed picking up the tissue box and placing it back on Resident 29's side table next to the food tray. During an interview with CNA 4 on 6/02/2021 at 2:28 p.m., CNA 4 stated she picked up the tissue box after it fell on the floor and placed it back on Resident 29's side table. CNA 4 stated she should have not placed the contaminated tissue box back on resident's table because it could be a source of infection for the resident. During an interview with Infection Preventionist (IP) on 6/04/2021 at 9:17 a.m., IP Nurse stated CNA 4 should have thrown the tissue box if it fell on the floor and replaced it with a new tissue box. IP nurse stated the floor was dirty and the resident may get infection or transfer the dirt from the dirty tissue box to resident's table and to the resident. During a review of the facility's undated P/P titled, Infection Control, indicated the facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Based on observation, interview, and record review, the facility failed to follow appropriate infection control procedures as follow: 1. Certified Nurse Assistant 5 (CNA 5) provide hand hygiene to one of one sampled resident (Resident 41) before serving lunch meal tray. 2. Ensure CNA 4 placed a contaminated tissue box that fell on the floor back to Resident's 29 side table that has Resident 29's food tray. These deficient practices had the potential for cross contamination (unintentional transfer of bacteria/germs or other contaminants from one surface to another) and spread of infection. Findings: a) During an observation, on 6/2/2021 at 12:22 p.m., Resident 41 was observed using her hands to turn the wheelchair wheels and CNA 5 was observed giving a lunch tray to Resident 41 and failed to offer or provide hand hygiene before Resident 41 started eating her lunch using a fork and her right hand fingers to eat. During a review of Resident 41's admission Record (Face Sheet), the Face Sheet indicated Resident 41 was admitted to the facility on [DATE]. Resident 41's diagnosis included difficulty walking, type 2 diabetes mellitus (impairment in the way the body regulates and uses sugar [glucose] as a fuel) with diabetic nephropathy (nerve damage caused by long-term high blood sugar levels), and muscle weakness. During a review of Resident 41's Minimum Data Set (MDS- an assessment and care planning tool), dated 5/11/2021, the MDS indicated Resident 41 had clear speech, and was able to understand and understood others. The MDS indicated Resident 41 required extensive assistance of one-person assist and was dependent of a wheelchair for mobility. During an interview on 6/2/2021 at 3:15 p.m., CNA 5 stated being aware she fail to provide handwashing to Resident 41 prior to providing her with the food tray and was aware it could lead to an increase risk for infection. During a review of the facility's undated policy and procedure (P/P), titled Hand Washing, indicated hand washing must be performed before and after eating. The policy indicated hand hygiene continued to be the primary means of preventing transmission of infection.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and hand hygiene practice in the kitchen when: 1. Ice machine ice deflector (inner plastic cover in the ice storage bin) and internal compartment were dirty. 2. Not all foods were dated when received and opened, and not all foods were labeled to indicate content. 3. Resident food trays were not air dried completely before stacking. 4. Visible dust build up on the vent above the steam table and the dishwashing area. 5. Egg salad made on 6/2/2021 in the walk-in refrigerator was not monitored for safe cool down process (hot food cooled down within a certain time frame to prevent harmful bacterial growth). 6. Two diet aides (DA 1 and DA 2) did not follow hand washing procedure to prevent recontamination (become dirty again) when washing hands. 7. Lack of temperature monitoring for resident's food refrigerators in both nursing stations (East and [NAME] station) to ensure refrigerators were functioning and maintaining within temperature of 41-degree Fahrenheit (unit of measurement) or below. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 77 out of 82 medically compromised residents who received food and ice from the kitchen, and those who store and consume personal foods from the nursing station food refrigerator. Findings: 1) During an observation on 6/2/2021 at 8:17 a.m., in presence of the Dietary Service Supervisor (DSS), rusty brown color residues were observed and removed on the ice deflector in the lower ice machine bin. The DSS stated and agreed the ice deflector was dirty, and stated it was the responsibility of the maintenance department for cleaning the lower bin and upper internal compartment of the ice machine monthly. During a review of the ice machine cleaning log posted by the ice machine, the log indicated last cleaning of the ice machine by the maintenance department was conducted on 3/2021. During an interview on 6/2/2021 at 9:14 a.m., the Maintenance Supervisor (MS) stated he cleaned the ice machine internal compartments and ice bin every month. The MS stated he last cleaned the ice machine on 5/2021, but he forgot to sign off on the cleaning log for the months of 4/2021 and 5/2021. During a concurrent observation and interview on 6/2/2021 at 9:15 a.m., the MS stated he could see the brown color residues being wiped off from the ice deflector when it was wiped down with a white paper towel. During a concurrent observation and interviews on 6/2/2021 at 9:18 a.m., in the presence of the DSS, the MS was observed removing the cover from the upper compartment of the ice machine and stated the inside of the water curtain (inner plastic cover of the upper compartment) had brown and greyish color residues build up. The MS stated there were brown and pink colored residues on the plastic section of the water distribution tube (area that runs water to form ice). Both the MS and DSS stated they were aware the ice machine was dirty and not safe to use until it was thoroughly cleaned and sanitized. During a review of facility's policy and procedure (P/P) titled Ice machine cleaning, dated 2019, the P/P indicated the ice machine (bin) would be cleaned and sanitized once a month and Maintenance staff would clean and sanitize the motor (evaporator) every 3 to 6 months, depending on manufacture's recommendation. The P/P indicated the assigned staff in cleaning the ice machine would record date of cleaning. 2) During a concurrent observation and interview on 6/2/2021 at 8:21 a.m., the DSS stated there were two-gallon vanilla ice cream in the freezer without a received date. The DSS stated the staff should have dated the ice cream when received and dated again when it was opened. During an observation of the walk-in refrigerator on 6/2/2021 at 8:28 a.m., there was one container labeled as thickener, but it did not have a date on the container. During an observation on 6/2/2021 at 8:35 a.m., there was one undated bulk container labeled as dry pancake mix. During a concurrent observation and interview on 6/2/21 at 8:44 a.m., the DSS stated there was one bowl with unknown content inside the walk-in refrigerator dated 6/2/21. The DSS stated the staff should have labeled the container indicating the food inside the container. During a review of facility's P/P titled, Refrigerator and Freezer Storage, dated 2019, the P/P indicated all items should be properly covered, dated, and labeled. The P/P indicated food items should have delivery date- upon receipt, open date - opened containers. 3) During an observation in the kitchen on 6/2/2021 at 8:24 a.m., a stack of resident's food trays stored under the food preparation counter were observed with water droplets in between each tray. During an interview on 6/2/2021 in the presence of the DSS, the dishwasher (DW 1) stated trays should be air dried after washing. During a review of facility's P/P titled Dishwashing Procedures-Dish machine, dated 2019, indicated dishes and utensils would be air dried before storage. 4) During a concurrent observation and interview on 6/2/21 at 8:37a.m., the DSS stated there was visible black dust build up on the vent above the steam table and build up on the ceiling by the vent. The DSS stated she saw the dust and agreed it was dirty and it should be cleaned again. During a concurrent observation and interview on 6/2/21 at 9:01 a. m., the DSS stated there was visible black dust build up on the vent above the dishwasher. During a review of facility's P/P titled Cleaning Schedule, dated 2019, indicated the dietary staff would maintain a clean and sanitary kitchen through compliance with a written cleaning schedule. The P/P indicated all areas and equipment in the kitchen would be cleaned and sanitized on a daily or weekly basis. 5) During a concurrent observation and interview on 6/2/2021 at 8:45 a.m., the DSS observed one container labeled as egg salad dated 6/2/2021 in the walk-in refrigerator. The DSS stated the cool down log was not available because it was not monitored on the cool down log this morning. The DSS stated it should have been monitored for safe cooling procedure. During a review of facility's P/P titled, Safe Cooling Method, dated 2019, indicated all cooked food not prepared for immediate use will be cooled properly to keep bacteria from developing. The P/P indicated a cooling log would be maintained to ensure standards were met. 6) During a concurrent observation an interview on 6/2/2021 at 9:10 a.m., the DA 1 was observed washing her hands and turned off the faucet with washed hands and not with a paper towel. The DA 1 stated the correct hand washing procedure was to use a paper towel to turn off the faucet, but she forgot when she was washing her hands to use one. During an observation on 6/2/2021 at 12:01 p.m., DA 2 was observed washing her hands and turned off the faucet with washed hands and not with a paper towel. During an interview on 6/2/2021 at 12:05 p.m. the DA 2 stated she should have used paper towel to turn off the faucet and not with washed hands. During a review of facility's P/P titled Hand Washing, dated 2019, indicated to protect clean hands by turning faucets off with paper towels. 7) During a concurrent observation of the East station medication room (Residents refrigerator) and interview on 6/2/2021 at 10:10 a.m., Licensed Vocational Nurse 1 (LVN 1) stated there was no thermometer inside to ensure proper temperatures. LVN 1 stated she could not find a thermometer inside and she did not check or record temperature today. LVN 1 stated it was night shift nurse's responsibility to check temperatures. During an interview on 6/2/2021 at 10:14 a.m., LVN 1 stated and confirmed there was no log and stated they only had one temperature log which was for medication refrigerator and not for the food refrigerator. During a concurrent observation of [NAME] Station Medication room and interview on 6/2/2021 at 10:19 a.m., LVN 2 stated there was a thermometer in the food refrigerator but LVN 2 also confirmed and stated the only temperature log they had was for the medication refrigerator. LVN 2 stated she checked food refrigerator temperature this morning, but she did not write it down because they did not have a log. During an interview on 6/2/2021 at 10:24 a.m., the Infection Preventionist (IP) nurse stated they should have a monitoring system for food refrigerator temperatures to ensure food safety and infection control. During a review of facility's undated P/P titled Refrigerator Use, the P/P indicated refrigerator temperatures must be kept at 41 degrees Fahrenheit or less and a thermometer would be kept inside the refrigerator to monitor temperatures.