Based on observation, interview, and record review, the facility failed to provide a resident with a communication board (a device that can help patients communicate with care providers and family using symbols, photos, or illustrations) for one of two sampled residents (Resident 3) whose primary and preferred language was not English. This deficient practice has the potential to prevent the resident from communicating with the staff and had the potential to delay receiving care/treatment the resident needed. Findings: During a review of Resident 3's Face Sheet (admission Record), the Face Sheet indicated the facility originally admitted Resident 3 on 1/25/2024 and readmitted the resident on 10/12/2024 with diagnoses that included unspecified dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) with agitation and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) with late onset. Resident 3's admission Record indicated primary language: Persian (foreign language). During review of Resident 3's Minimum Data Set (MDS- a resident assessment tool) dated 1/19/2025, the MDS indicated the resident usually made self-understood and usually had the ability to understand others. The MDS indicated Resident 3's preferred language is not English and needs an interpreter to communicate with a doctor or health care staff. The MDS indicated Resident 3's preferred language was Farsi (foreign language). The MDS indicated that Resident 3 required partial/moderate assistance with eating and required substantial/maximal assistance with oral hygiene, toileting hygiene, and dependent with personal hygiene. During a review of Resident 3's Care Plan (a document that summarizes a resident's needs, goals, and care/treatment) titled, Resident has Communication Impairment related to Foreign Language- Farsi speaking, edited 1/17/2025, the care plan indicated an intervention to offer alternative forms of communication such as: communication board. During a concurrent observation and interview on 2/27/2025 at 11:39 a.m., with Certified Nursing Assistant 2 (CNA 2), observed CNA 2 giving Resident 3 instructions in English. Observed Resident 3 speak in a foreign language. When asked what Resident 3 said, CNA 2 stated CNA 2 did not know. CNA 2 stated that Resident 3 does not speak English, Resident 3 speaks Farsi. When asked if there are staff on duty that speak Farsi, CNA 2 stated no one speaks Farsi. When asked how staff communicates with Resident 3, CNA 2 stated that she uses facial expressions and uses hand gestures to communicate with Resident 3. When asked if Resident 3 had a communication board, CNA 2 stated that Resident 3 has a communication board at Resident 3's bedside. Observed CNA 2 open Resident 3's bedside drawers and observed CNA 2 look around Resident 3's bedside. CNA 2 was unable to find/locate Resident 3's communicate board. CNA 2 stated that there should be communication boards at the nurses' station. During a concurrent observation and interview on 2/27/2025 at 11:41 a.m., with CNA 2, observed CNA 2 in the nurses' station looking for a Farsi communication board. CNA 2 stated she was unable to locate a Farsi communication board. During a concurrent observation and interview on 2/27/2025 at 11:42 a.m., with the Social Services Designee (SSD), the SSD stated that the social services department is in charge of communication boards for residents whose primary language is not English. Observed the SSD look through the facility's communication binder in the nurses' station. The SSD stated that the facility has ran out of Farsi communication boards. The SSD continued to state that the facility does not have a Farsi speaking employee working on the floor at this time. During an interview on 2/27/2025 at 3:09 p.m., with the Director of Nursing (DON), the DON stated that Resident 3 does not speak English and that Resident 3's primary language is Farsi. The DON stated that staff should use a communication board to communicate with Resident 3 to ensure that staff understands Resident 3's needs. The DON stated that a communication board is a tool in communicating with a resident if there is a language barrier. The DON stated that a communication board makes the communication easier between the resident and facility staff. During a review of the facility's policy and procedure titled, Interpreter Service, review date 10/2024, the policy indicated to provide communications for residents who do not speak English or are unable to communicate verbally. The resident's/patient's treatment plan shall include names of interpreters who can be called to assist with interpreting important information. The treatment plan may also include key words to assist staff in communicating with resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement their facility's policy on wheelchair use by failing to ensure staff locked residents' wheelchair brakes while residents were sitting on their wheelchair for two of three sampled residents (Resident 2 and Resident 3). This deficient practice had the potential to place the residents at increased risk of sustaining an injury. Findings: a. During a review of Resident 2's Face Sheet (admission Record), the Face Sheet indicated the facility originally admitted Resident 2 on 11/6/2023 and readmitted the resident on 7/14/2024 with diagnoses that included unspecified convulsion-seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness [the state of being awake and aware of one's surroundings), dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) with psychotic (a mental disorder characterized by a disconnection from reality) disturbance, Parkinson's disease (a movement disorder of the nervous system that worsens over time) with dyskinesia (uncontrolled, involuntary muscle movement) with fluctuations, muscle weakness, and need for assistance with personal care. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 11/12/2024, the MDS indicated Resident 2's cognitive (mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making was severely impaired. The MDS indicated under mobility devices: wheelchair. The MDS indicated Resident 2 was dependent on staff with eating, oral hygiene, toileting hygiene, and personal hygiene. During a review of Resident 2's Care Plan (a document that summarizes a resident's needs, goals, and care/treatment) for fall prevention, edited 2/12/2025, the care plan indicated Resident 2 is at high risk for fall/injury. The care plan indicated a goal that Resident 2 will be free of injury within safe confines of environment daily and interventions to maintain safe immediate environment and remove or identify safety hazards. During a concurrent observation and interview on 2/27/2025 at 11:31 a.m., with the MDS Nurse (MDSN) and Certified Nursing Assistant 1 (CNA 1), observed Resident 2 sitting on her wheelchair in the common area. The MDSN stated Resident 2's left wheelchair brake was unlocked. CNA 1 stated that when residents are sitting on the wheelchair, both wheelchair brakes should be locked so residents don't fall. b. During a review of Resident 3's Face Sheet, the Face Sheet indicated the facility originally admitted Resident 3 on 1/25/2024 and readmitted the resident on 10/12/2024 with diagnoses that included unspecified dementia with agitation and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) with late onset. During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3's cognitive skills for daily decision making was severely impaired. The MDS indicated under mobility devices: wheelchair. The MDS indicated that Resident 3 required partial/moderate assistance with eating and required substantial/maximal assistance with oral hygiene, toileting hygiene, and dependent with personal hygiene. During a review of Resident 3's Care Plan for fall prevention edited 2/20/2025, the care plan indicated Resident 3 is at risk for fall/injury related to dementia. The care plan indicated a goal that Resident 3 will be free of injury within safe confines of environment daily and interventions to maintain a safe immediate environment and remove or identify safety hazards. During a concurrent observation and interview on 2/27/2025 at 11:35 a.m., with the MDSN, observed Resident 3 sitting on her wheelchair in the common area. The MDSN stated Resident 3's left wheelchair brake was unlocked. During a concurrent observation and interview on 2/27/2025 at 11:38 a.m., with CNA 2, observed Resident 3 sitting on her wheelchair in the common area. CNA 2 stated Resident 3's left wheelchair brake was unlocked. CNA 2 stated that both wheelchair brakes should be locked for residents' safety. During an interview on 2/27/2025 at 2:20 p.m., with the Director of Staff Development (DSD), the DSD stated that when residents are on their wheelchairs, staff should lock both wheelchair brakes for safety. The DSD stated that it is ok to lock only one side of the wheelchair brakes if there are staff supervising residents. During an interview on 2/27/2024 at 3:07 p.m., with the Director of Nursing (DON), the DON stated that when residents are on their wheelchairs, wheelchair breaks should always be locked for their safety. During a review of the facility's policy and procedure titled, Wheelchair Use, review date 10/2024, the policy indicated that it is the policy of the facility to provide and utilize wheelchairs for residents, as appropriate, to assist with seating and locomotion as needed. Residents or staff should lock brakes when intended in remaining at the same location.

Based on observation, interview, and record review, the facility failed to ensure a medication cart was locked while the medication cart was left unattended for one of two sampled medication carts (Medication Cart A). This deficient practice had the potential to result in unauthorized personnel or residents accessing the medications stored in the unlocked medication cart. Findings: During an observation on 2/27/2025 at 11:24 a.m., observed Medication Cart A parked in the nurse's station, unlocked, and unattended. Observed residents and other facility staff walking by the unlocked medication cart. During a concurrent observation and interview on 2/27/2025 at 11:25 a.m., with the Minimum Data Set Nurse (MDSN), observed Medication Cart A parked in the nurse's station. The MDS Nurse confirmed the observation and stated that Medication Cart A was unlocked and unattended. During a concurrent observation and interview on 2/27/2025 at 11:30 a.m., with Licensed Vocational Nurse 1 (LVN 1), observed Medication Cart A parked in the nurse's station. LVN 1 stated that Medication Cart A was unlocked and belonged to LVN 2 who was on lunch. LVN 1 stated that the medication cart should always be locked for safety and so unauthorized staff and residents do not open the medication cart and access medications. During an interview on 2/27/2025 at 3:06 p.m., with the Director of Nursing (DON), the DON stated medication carts should always be kept locked when the nurses are away from the medication cart for safety. During a review of the facility's policy and procedure titled, Storage of Medications, updated date 1/2017, the policy indicated medications and biologicals are stored safely, securely and properly following manufacturers recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel. Pharmacy personnel or staff members lawfully authorized to administer medications. Medication rooms, cart, and medication supplies are locked or attended by persons with authorized access.

Based on interview and record review the facility failed to ensure the physician was notified of a resident's refusal of suprapubic catheter care for one of three sampled residents reviewed under the catheter care area. This deficient practice placed the resident at increased risk for infection. Cross reference F656 Findings: During a review of Resident 55's admission Record, the admission Record indicated the facility admitted the resident on 4/4/2023, with diagnoses including unspecified dementia (a progressive state of decline in mental abilities), retention of urine (a condition in which you are unable to empty all the urine from your bladder), and status post suprapubic catheter placement. During a review of Resident 55's Minimum Data Set (MDS -a resident assessment tool) dated 10/10/2024, the MDS indicated the resident`s cognitive skills (the brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated that Resident 55 was dependent on staff (helper does all of the effort) for showering/bathing and required substantial/maximum assistance (helper does more than half the effort) for toileting hygiene, oral hygiene, personal hygiene, and upper and lower body dressing. The MDS further indicated that Resident 55 had suprapubic catheter. During a review of Resident 55`s Physician order dated 9/17/2024, the order indicated to clean the suprapubic catheter with normal saline (a saltwater solution), pat dry, apply A&D ointment (a medication used as a moisturizer to treat or prevent dry, rough, and itchy skin), and leave it open to air two times a day. During a review of Resident 55`s Treatment Administration Record (TAR) for November 10 to December 2, 2024, the TAR indicated that the resident refused to receive treatment to his suprapubic catheter surrounding skin on 12/2/2024, 11/30/2024, 11/28/2024, 11/22/2024, 11/16/2024 and 11/13/2024 during the 3 p.m.-11p.m. shift, and on 11/10/2024, 11/15/2024, 11/16/2024, 11/17/2024 and 11/23/2024 during the 7 a.m.-3 p.m. shift. During a concurrent interview and record review on 12/3/2024 at 2:00 p.m., with the Director of Nursing (DON), Resident 55 `s TARs, nursing notes, and care plans were reviewed. The DON stated Resident 55 refused to receive treatment to his suprapubic catheter surrounding skin on 12/2/2024, 11/30/2024, 11/28/2024, 11/22/2024, 11/16/2024 and 11/13/2024 during the 3 p.m.-11p.m. shift and on 11/10/2024, 11/15/2024, 11/16/2024, 11/17/2024 and 11/23/2024 during the 7 a.m.-3 p.m. shift. The DON stated licensed staff were required to notify Resident 55`s physician of his refusal of treatment and care to his suprapubic catheter. The DON stated there is no documentation notifying Resident 55`s physician about his refusal of care. The DON stated the potential outcome of not informing a resident`s physician regarding his refusal of care and treatment is worsening of the resident`s condition due to lack of appropriate care During review of the facility`s Policy and Procedure (P&P) titled Indwelling Catheter Care, last revised 9/2024, the P&P indicated that a plan of care shall be developed and re-evaluated for the duration of the indwelling catheter use by nursing staff. The Plan of care should include indication for use, risk for infection and complications associated with use, and care plan for routine care and observation for signs and symptoms of complications such as infection. Resident response to treatment provided, physician communication regarding changes of condition should be documented in the medical record.

Based on observation, interview and record review, the facility failed to: 1. Develop a care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and the prevention of worsening a condition, and current treatments) addressing a resident's refusal to wear a mask while on contact/droplet precautions (steps that healthcare staff take to prevent the spread of germs when a patient has germs that can spread through touching and coughs and sneezes) for one (Resident 40) out of five sampled residents investigated during review of the infection control task. This deficient practice had the potential to delay the provision of necessary care and services to Resident 40. 2. Develop a care plan addressing the resident's refusal of care of his suprapubic indwelling catheter (a flexible plastic tube inserted into the bladder from a small cut in the stomach, that remains in place to provide continuous urinary drainage) and failed to implement a care plan intervention to monitor the resident`s urinary drainage bag for hematuria, checking the placement of the catheter and surrounding skin for signs of infection for one of three sampled residents reviewed under catheter care area. These deficient practices had the potential to result in the inadequate care and monitoring of Resident 55 and placed him at increased risk of infection. Cross reference F580 Findings: 1. During a review of Resident 40's admission Record, the admission Record indicated the facility originally admitted the resident on 5/1/2019 and readmitted the resident on 12/27/2023 with diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), hyperlipidemia (condition where there is too much fat in the blood), and spondylosis (age related arthritis [ abnormal wear on the cartilage and bones of vertebrae of the spine). During a review of Resident 40's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/07/2024, the MDS indicated the resident had severely impaired cognition (thought processes) and required moderate assistance from staff for most activities of daily living (ADLs - basic tasks that people do every day to survive and be well). During a review of Resident 40 Physician Order Report, the Physician Order Report indicated the following orders: 1. Contact/droplet isolation due to exposure to Respiratory Sinus Virus (RSV-common respiratory virus that infects the nose, throat, and lungs) from 11/20/2024 to 12/5/2024. 2. May use mask when going out of the room from 11/20/2024-12/5/2024. During a concurrent observation and interview on 11/18/2024 at 11:49 a.m. with Certified Nursing Assistant (CNA 1), Resident 40 was observed without a mask outside her room in the common area and surrounded by other residents. CNA 1 stated Resident 40 was refusing to wear a mask or to stay in her room. During a concurrent interview and record review on 12/4/2024 at 12:01 p.m., with the Infection preventionist (IP), the IP reviewed Resident 40's care plans (a document that outlines a patient's health information, conditions, treatments, care services, and goals). The IP was asked if Resident 40 had a care plan addressing the resident's refusal of following contact/droplet precautions and wearing a mask when outside the room. LVN 2 stated she could not find any. During an interview on 2/5/2024 at 2:19 p.m., with the Director of Nursing (DON), the DON stated that when a resident refuses to follow the physician order, there should be a care plan for non-compliance. The DON stated if care plans were not in place, then the staff would not be able to address the resident's needs. During a review of the facility's policy and procedure titled, Care Plan, last reviewed and revised on 1/22/2024, the policy indicated that an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, physical, mental, and psychosocial needs shall be developed for each resident. The comprehensive care plan includes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Assessments of residents are ongoing and care plans are reviewed and revised as information about the resident and the resident's condition change. 2. During a review of Resident 55's admission Record, the admission Record indicated the facility admitted the resident on 4/4/2023, with diagnoses including unspecified dementia (a progressive state of decline in mental abilities), retention of urine (a condition in which you are unable to empty all the urine from your bladder), and status post suprapubic catheter placement. During a review of Resident 55's Minimum Data Set (MDS -a resident assessment tool) dated 10/10/2024, the MDS indicated the resident`s cognitive skills (the brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated that Resident 55 was dependent on staff (helper does all of the effort) for showering/bathing and required substantial/maximum assistance (helper does more than half the effort) for toileting hygiene, oral hygiene, personal hygiene, and upper and lower body dressing. The MDS further indicated that Resident 55 had suprapubic catheter. During a review of Resident 55's Care Plan (CP-a document that outlines how a patient`s health care needs will be met) titled Alteration if Elimination: indwelling catheter related to neurogenic bladder and urinary retention, initiated on 11/10/2023, indicated a care plan goal that the resident will have a patent (open) indwelling catheter without sign and symptoms of infection. The care plan interventions were to empty the urinary drainage bag (a bag that collects urine from a catheter) every shift, offer fluids with meals, medication administrations, hydration passes, and bedside water, observe the urine output, observe for sign and symptoms of infection, monitor for hematuria (blood in the urine) in the urinary drainage bag, and check the placement of the catheter and surrounding skin for signs of infection during every shift. During a review of Resident 55`s Event Report dated 5/8/2024, the report indicated that the resident had redness surrounding his suprapubic catheter. During a review of Resident 55`s Physician order dated 9/17/2024, the order indicated to clean the suprapubic catheter with normal saline (a saltwater solution), pat dry, apply A&D ointment (a medication used as a moisturizer to treat or prevent dry, rough, and itchy skin), and leave it open to air two times a day. During a review of Resident 55`s Treatment Administration Record (TAR) for November 10 to December 2, 2024, the TAR indicated that the resident refused to receive treatment to his suprapubic catheter surrounding skin on 12/2/2024, 11/30/2024, 11/28/2024, 11/22/2024, 11/16/2024 and 11/13/2024 during the 3 p.m.-11p.m. shift, and on 11/10/2024, 11/15/2024, 11/16/2024, 11/17/2024 and 11/23/2024 during the 7 a.m.-3 p.m. shift. During a concurrent interview and record review on 12/3/2024 at 2:00 p.m., with the Director of Nursing (DON), Resident 55 `s TARs, nursing notes, and care plans were reviewed. The DON stated Resident 55 refused to receive treatment to his suprapubic catheter surrounding skin on 12/2/2024, 11/30/2024, 11/28/2024, 11/22/2024, 11/16/2024 and 11/13/2024 during the 3 p.m.-11p.m. shift and on 11/10/2024, 11/15/2024, 11/16/2024, 11/17/2024 and 11/23/2024 during the 7 a.m.-3 p.m. shift. The DON stated licensed staff were required to notify Resident 55`s physician of his refusal of treatment and care to his suprapubic catheter. The DON stated there is no documentation notifying Resident 55`s physician about his refusal of care. The DON stated residents` care plans are required to be reviewed and revised quarterly and as needed and reflect the current person-centered interventions and care that are currently being delivered to the residents. During a concurrent interview and record review on 12/3/2024 at 2:33 p.m., with the MDS Coordinator (MDSC), Resident 55`s TARs and care plans were reviewed. The MDSC stated that she is in charge of initiating and revising residents` care plans. The MDSC stated residents' care plans are required to have the current and active nursing interventions for the residents. The MDSC further stated Resident 55`s TAR did not indicate any documentation regarding his care plan interventions such as monitoring the resident`s urinary drainage bag for hematuria, checking the placement of the catheter and surrounding skin for signs of infection. The MDSC stated there is no evidence that licensed nurses implemented these interventions. The MDSC stated all the resident`s care plan interventions are required to be implemented and the documentation is required to be available in the resident`s medical record. The MDSC stated the potential outcome of not updating resident`s care plans and not implementing the care plan interventions is lack of care to the resident that can potentially lead to infection and complications for the resident. During review of the facility`s Policy and Procedure (P&P) titled Indwelling Catheter Care, last revised 9/2024, the P&P indicated that a plan of care shall be developed and re-evaluated for the duration of the indwelling catheter use by nursing staff. The Plan of care should include indication for use, risk for infection and complications associated with use, and care plan for routine care and observation for signs and symptoms of complications such as infection. Resident response to treatment provided, physician communication regarding changes of condition should be documented in the medical record. During a review of the facility`s Policy and Procedure (P&P) titled Care Plans, last reviewed 1/22/2024, the P&P indicated that each resident`s comprehensive care plan has been designed to reflect treatment goals and objectives in measurable outcomes, build on the resident`s strengths, incorporate identified problem areas and incorporate risk factors associated with identified problems. Goals and objectives are reviewed and /or revised when there has been a significant change in the resident`s condition, when the desired outcome has not been achieved and when the resident has been readmitted to the facility from a hospital/rehabilitation stay and at least quarterly. Documentation must be consistent with the resident`s care plan.

Based on interview and record review, the facility failed to revise a care plan addressing the removal of indwelling urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) for one (Resident 22) out of two sampled residents investigated during review of the catheter care area. This deficient practice had the potential to delay the provision of necessary care and services related to the resident's urinary catheter. Findings: During a review of Resident 22's admission Record, the admission Record indicated the facility originally admitted the resident on 1/25/2024 and readmitted the resident on 10/12/2024 with diagnoses including sepsis (a serious condition in which the body responds improperly to an infection where the infection-fighting processes turn on the body, causing the organs to work poorly), and metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood well). During a review of Resident 22's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 10/19/2024, the MDS indicated the resident had severely impaired cognition (thought processes) and required maximal assistance from staff for eating, oral hygiene, and upper body dressing. Further, the MDS indicated that Resident 22 was dependent on two or more helpers for toileting and personal hygiene, showering, and lower body dressing. During a review of Resident 22's Physician Order, dated 11/3/2024, the Physician Order indicated an order to discontinue the indwelling urinary catheter on 11/3/2024. During a concurrent observation and interview on 12/03/2024 at 2:34 p.m. in Resident 22 's room with Certified Nursing Assistant 3 (CNA 3), the surveyor observed CNA 3 wheeling Resident 22 out of the bathroom in a wheelchair. Surveyor did not observe any indwelling catheter attached to Resident 22. CNA 3 stated that Resident 22 used to have an indwelling catheter before, but it was discontinued. During a concurrent interview and record review on 12/03/2024 at 2:44 p.m., with Licensed Vocational Nurse 3 (LVN 3), reviewed Resident 22's care plans (a document that outlines a patient's health information, conditions, treatments, care services, and goals). LVN 3 stated Resident 22's care plan created on 10/14/2024, addressed the resident's risks of having an indwelling urinary catheter. LVN 3 stated that the indwelling catheter was discontinued 11/03/2024 and that the care plan should have been revised to ensure it is accurate and reflects Resident 22's current condition. During a concurrent interview and record review on 12/04/2024 at 9:26 a.m. with the Minimum Data Sheet Coordinator (MDSC), Resident 22's care plan for indwelling urinary catheter, dated 10/24/2024, was reviewed. The MDCS stated that the care plan was not revised when the medical device was removed. The MDCS stated that this deficient practice had the potential to delay the provision of necessary care and services to Resident 22. During an interview on 12/05/2024 at 2:19 p.m. with the Director of Nursing (DON), the DON stated that Resident 22's care plan for indwelling catheter had to be resolved after the catheter was removed to reflect Resident 22's assessment and current needs . During a review of the facility's policy and procedure titled, Care Plans, last reviewed on 1/22/2024, the policy indicated that an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychosocial needs shall be developed for each resident. The comprehensive care plan includes the services that are to be furnished to attain or maintain the resident's highest level of functioning. Care plans are revised as changes in the resident's condition dictate.

Based on observation, interview and record review, the facility failed to ensure a resident was provided a communication device with the language that the resident is able to understand for one of one sample resident (Resident 22) investigated under the communication care area. This deficient practice prevented the resident from communicating with the staff and had the potential to delay the appropriate care or treatment the resident needed. Findings: During a review of Resident 22's admission Record, the admission Record indicated the facility originally admitted the resident on 1/25/2024 and readmitted the resident on 10/12/2024 with diagnoses including sepsis (a serious condition in which the body responds improperly to an infection, where infection-fighting processes turn on the body, causing the organs to work poorly), metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood well). The admission Record indicated Resident 22's preferred language is Farsi. During a review of Resident 22's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 10/19/2024, the MDS indicated the resident had severely impaired cognition (thought processes) and required maximal assistance from staff for eating, oral hygiene, and upper body dressing. The MDS indicated that Resident 22 was dependent on two or more helpers for toileting and personal hygiene, showering, and lower body dressing. During a concurrent observation and interview on 12/03/2024 at 2:34 p.m. in Resident 22 's room with Certified Nursing Assistant 3 (CNA 3), observed CNA 3 wheeling Resident 22 out of the bathroom in a wheelchair. The surveyor did not observe any communication board (a tool that includes pictures that help residents communicate their healthcare and every-day needs to facility staff) in Resident 22's room or attached to the resident's wheelchair. CNA 3 stated that Resident 22 only speaks Persian, but CNA 3 never saw a communication board in the resident's room. During a concurrent interview and record review on 12/03/2024 at 3:43 p.m., with the Social Service Director (SSD), Resident 22's care plan (a document that outlines a patient's health information, conditions, treatments, care services, and goals) addressing the resident's language barrier, initiated on 2/14/2024 and revised 12/23/2024, was reviewed. The SSD stated that the care plan indicated that Resident 22 has a communication impairment (having difficulty understanding or expressing thoughts through speaking, writing or body language) because the resident speaks Farsi. The SSD stated that the interventions of the care plan indicated to provide Resident 22 with a communication board. The SSD stated that this deficient practice had the potential to leave Resident 22's needs unmet. During an interview on 11/5/2024 at 11:20 a.m. with the Director of Nursing (DON), the DON stated that the communication board had to be provided to Resident 22 according to the resident's care plan interventions. The DON stated if a communication board was not in place, then the staff would not be able to communicate with the resident effectively and address the resident's needs. During a review of the facility's undated policy of Interpreter services, last reviewed 10/2024, the policy indicated the facility shall have communication boards for residents, who are unable to communicate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide services that promote the prevention of pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) injury for one of three sampled residents (Resident 51) as evidenced by failing to monitor the functionality of the resident's low air loss mattress (LALM-mattress designed to treat and prevent pressure ulcers) to ensure the LALM was working properly. This deficient practice had the potential for Resident 51 to develop a new pressure injury. Findings: During a review of Resident 51's admission Record, the admission Record indicated the facility originally admitted the resident on 10/21/2021, and readmitted on [DATE], with diagnoses including unspecified dementia (a progressive state of decline in mental abilities), attention to gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and muscle weakness. During a review of Resident 51's Minimum Data Set (MDS -a resident assessment tool) dated 10/15/2024, the MDS indicated the resident`s cognitive skills (the brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated that Resident 51 was dependent on staff (helper does all of the effort) for eating, toileting hygiene, oral hygiene, personal hygiene, upper and lower body dressing, and showering/bathing. The MDS further indicated that Resident 51 was at risk for developing pressure ulcers and had pressure reducing device for bed. During a review of Resident 51's physician order dated 6/24/2024, the order indicated to apply a LALM for skin management. During a review of Resident 51's Care Plan (CP-a document that outlines how a patient`s health care needs will be met) for at risk for impaired skin integrity initiated on 1/3/2024, the CP indicated a care plan goal that the resident will have minimized risks for the development of skin breakdown. The care pan interventions were to utilize LALM and bilateral (both) heel protector for skin management, report any signs of skin breakdown, and to avoid shearing of skin while assisting the resident with positioning, transferring, and turning. During a concurrent observation, and interview on 12/4/2024 at 9:07 a.m., with Licensed Vocational Nurse 5 (LVN 5) inside Resident 51`s room, Resident 51 was observed lying on his bed with a LALM. LVN 5 stated that the LALM is powered on however, the display does not show any information. She (LVN 5) stated that normally the LALM is powered on and there is information displayed on the panel`s screen. She (LVN 5) stated that she does not remember the last time she observed Resident 51`s LALM display information on its panel. She (LVN 5) stated that she will call the company to report this issue. During an interview and record review on 12/5/2024 at 1:40 p.m., with LVN 5, Resident 51`s Treatment Administration Record (TAR), Medication Administration Record (MAR) and physician orders were reviewed. LVN 5 stated licensed staff are required to monitor a resident`s LALM once every shift and document on the resident`s MAR or TAR. LVN 5 stated she is unable to find any documentation regarding the monitoring of Resident 51`s LALM in his TAR or MAR. LVN 5 stated Resident 51`s physician order for LALM was not placed on the administrative section of the order. Therefore, the order was not transferred to Resident 51`s TAR or MAR as a task to be completed. She (LVN 5) stated this order was missed and it was never carried out. LVN 5 further stated she is unable to say for how long Resident 51`s LALM panel was off, or whether or not his LALM was functioning at the time of observation. LVN 5 stated the LALM company representative checked Resident 51`s LALM yesterday and replaced the machine. LVN 5 stated the potential outcome of not monitoring a resident`s LALM to make sure it is functioning is placing the resident at risk for development of pressure injuries or the worsening of their existing pressure injuries. During an interview on 12/5/2024 at 2:00 p.m., with the Director of Nursing (DON), the DON stated staff are required to monitor and check residents' LALM to ensure that it is functioning. The DON stated licensed staff are required to document their monitoring of LALM in the resident`s TAR. The DON stated Resident 51`s LALM panel was off, and staff did not notice that the unit was off. The DON stated there is no documentation regarding monitoring of Resident 51`s LALM in his TAR or MAR. The DON stated the potential outcome is the development of a skin breakdown and harm to the resident. During a review of the facility`s policy and procedure (P&P) titled Resident Pressure Redistribution Devices-Air Loss Mattress, reviewed 10/2022, the P&P indicated that the purpose of this policy is to ensure the effectiveness of air loss mattress use and cleaning. All residents utilizing an air loss mattress will be monitored appropriately to ensure pertinent and effective use and cleaning.

Based on interview, and record review, the facility failed to act upon a recommendation from the Pharmacy Consultant (PC -a healthcare specialist who provides expert advice on medications and pharmaceutical services, including patient safety) to clarify the behavior manifestation for the use of Seroquel (a psychoactive medication-any medication capable of affecting the mind, emotions, and behavior) for one of five sampled residents (Resident 64) reviewed for unnecessary medication. This deficient practice increased the risk of receiving medication that was not optimal for Resident 64's medical condition and increased the risk of adverse consequences (unwanted, uncomfortable, or dangerous effects that a drug may have) from the medication therapy. Findings: During a review of Resident 64's admission Record, the admission Record indicated the facility admitted the resident on 5/10/2024, with diagnoses including major depressive disorder a persistent feeling of sadness or a lack of interest in outside stimuli), dementia (a progressive state of decline in mental abilities), and psychotic disorders (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 64's Minimum Data Set (MDS - a resident assessment tool) dated 11/16/2024, the MDS indicated the resident`s cognitive skills (the brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated that Resident 64 did not exhibit potential indicators for psychosis such as hallucinations (a sight, sound, smell, taste, or touch that a person believes to be real but is not real) and delusions (having false or unrealistic beliefs). The MDS further indicated that Resident 64 was taking antipsychotic and antidepressant medications. During a review of Resident 64`s Physician Order dated 5/10/2024, the order indicated to administer Seroquel 25 mg by mouth at bedtime for psychotic disorder with delusions due to dementia manifested by sudden verbal agitation. During a review of Resident 64`s Physician Order dated 7/30/2024, the order indicated to administer Seroquel 25 mg by mouth at bedtime for psychotic disorder with delusions due to dementia manifested by sudden verbal agitation which may present a danger to self or others. During a review of the facility's Pharmacy Consultant (PC) Monthly Regimen Review (MRR- a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication), dated 9/17/2024, the MMR indicated that Resident 64 had been on Seroquel with target behavior of sudden verbal agitation. The review indicated to clarify what the resident said and how this presented a danger to self and others. During a review of Resident 64`s Psych Interdisciplinary Team meeting (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of their client) with PC form dated 11/18/2024, the IDT form indicated that the IDT team recommended a Gradual Dose Reduction (GDR- the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) for Seroquel to 12.5 mg at bedtime. The IDT form further indicated that the GDR recommendation will be sent to Resident 64`s primary care physician for review and order. During a review of Resident 64`s Physician Order dated 11/18/2024, the order indicated to administer Seroquel 12.5 mg by mouth at bedtime for psychotic disorder with delusions due to dementia manifested by sudden verbal agitation which may present a danger to self or others. During an interview on 12/5/2024 at 1:50 p.m., with LVN 5, LVN 5 stated that Resident 64`s Seroquel order did not indicate the specific behavior to monitor. The LVN 5 stated sudden verbal agitation is not an indication to administer Seroquel. She (LVN 5) stated Resident 64, who has dementia can have sudden verbal agitation when she is hungry, when she tries to make her needs known, or for any other reasons. She (LVN 5) stated the order for Resident 64`s Seroquel did not include a clear indication and the specific behavior to be monitored and requires clarification. She (LVN 5) stated the potential outcome of not having a clear indication and measurable target behavior (the specific, undesirable behavior that a medication is intended to reduce or manage) is inaccurate monitoring and exposure of the resident to side effects of the medication. During a concurrent interview and record review on 12/4/2024 at 3:50 p.m., with the facility`s Director of Nursing (DON), Resident 64`s physician orders and MRRs were reviewed. The DON stated Resident 64`s physician order for Seroquel did not include a specific measurable behavior to be monitored by a licensed staff member. The DON stated based on MRR dated 9/17/2024, the PC indicated that Resident 64 had been on Seroquel with target behavior of sudden verbal agitation. The PC further indicated to clarify what the resident said and how this presented a danger to self and others. However, the DON stated the facility failed to follow up on the PC recommendation to clarify this order. The DON stated the potential outcome of not following up on the PC recommendation to clarify the order is inaccurate monitoring and inability to measure efficacy of the medication for the resident. During a review of the facility's Policies & Procedures (P&P) titled, Psychotropic medication Assessment and Monitoring, last reviewed 10/2024, the P&P indicated that psychotropic drugs are used only when necessary and then at the lowest effective dose. The IDT team assesses and monitors the appropriateness, effectiveness and side effects associated with psychotropic medications for each resident. The PC reviews the appropriateness of the psychotropic medications order as part of each drug regimen. If at any time during the assessment for monitoring process, the psychotropic medication order is found to be inappropriate, the Director of Nursing is to be notified and the attending physician will be called for clarification. The behavior of residents receiving antipsychotic medication will be monitored by the Registered Nurses or LVN at appropriate intervals, as determined by the IDT using the behavior monitoring record. Record behavior, interventions and effectiveness of interventions taken in the behavior monitored. During a review of the facility's Policies & Procedures (P&P) titled, Consultant Pharmacist Reports, last reviewed 1/22/2024, the P&P indicated recommendations are acted upon and documented by the facility staff and or the prescriber. Physicians accepts and acts upon suggestion or rejects and provides an explanation for disagreeing. The Director of nursing or designated licensed nurse address and document recommendations that do not require a physician intervention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in accordance with accepted professional principles in one of (Second Floor, Medication Cart 2) four medication carts inspected when Resident 10's discontinued medication, amlodipine (a medication to lower blood pressure) was not removed from the medication cart and disposed of. This deficient practice had the potential for Resident 10 to receive this medication which could have lowered the blood pressure below normal limits causing dizziness, and loss of consciousness. Findings: During a review of Resident 10's Face Sheet, the Face Sheet indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included hypertensive heart disease (a group of heart problems that develop over time due to high blood pressure). During a review of Resident 10' s Minimum Data Set (MDS, a resident assessment tool), dated 10/14/2024, the MDS indicated Resident 10 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 10 needed setup help only (helper sets up or cleans up only) with eating and maximal assistance (helper does more than half the effort) with dressing. During a review of Resident 10's Physician's Orders, the physician's orders indicated an order for amlodipine tablet (a medication to lower blood pressure) 2.5 milligrams (mg, a metric unit of measurement for medications) at bedtime for hypertension (high blood pressure), dated 7/24/2024 and discontinued 10/04/2024. During a review of Resident 10's Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for the month of 10/2024, the MAR indicated that the last date Resident 10 received amlodipine was 10/04/2024. During a medication cart observation and concurrent record review on 12/04/2024 at 4:05 p.m. with Registered Nurse 4 (RN 4) observed Resident 10's medications inside the Second Floor, Medication Cart 2. Checked Resident 10's blister packs (also known as bubble pack, a card holding usually medicinal tablets or capsules that are individually packaged in a clear plastic case sealed to the card) with Resident 10's Physician's orders. There was a bubble pack for amlodipine but no corresponding physician order. Reviewed Resident 10's Physician's Orders with RN 4 with a discontinued order for amlodipine, dated 10/04/2024. RN 4 stated the medication should have been removed when it was discontinued 10/04/2024. RN 4 stated this was important so that the medication could not be accidentally given to Resident 10. During an interview with the Director of Nurses (DON) on 12/05/2024 at 8:14 a.m., the DON stated, when a medication is discontinued by a physician's order, it is to be removed immediately from the medication cart. The DON stated this is important to avoid a medication error of the medication accidentally being given to a resident. During a review of the facility's policy and procedure titled, Disposal of Medications and Medication-Related Supplies, last reviewed 1/22/2024, the policy indicated medications are removed from the medication cart or active supply immediately upon receipt of an order to discontinue to avoid inadvertent administration (unintentional medication administration).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure two (2) of five (5) sampled residents (Residents 61 and 64) were free from unnecessary use of psychotropic medications (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility policy and procedure by failing to ensure: 1. Resident 61 had a specific, measurable target behaviors (the specific, undesirable behavior that a medication is intended to reduce or manage) related to the use of Zoloft (medication to treat depression [a persistent feeling of sadness or a lack of interest in outside stimuli]). 2. Resident 64 had a specific, measurable target behaviors related to the use of Seroquel (medication used to treat mental illness). These deficient practices had the potential to place Resident 61 and Resident 64 at risk for significant adverse consequence (unwanted, uncomfortable, or dangerous effects that a drug may have) from the use of unnecessary psychotropic drug, which could result to impairment (being weakened) or decline (gradually become less) in the resident's mental, physical condition, functional, and psychosocial status. Findings: 1. During a review of Resident 61's admission Record, the admission Record indicated the facility admitted the resident on 9/1/2024, with diagnoses including major depressive disorder ( a persistent feeling of sadness or a lack of interest in outside stimuli), dementia (a progressive state of decline in mental abilities), and attention to gastrostomy (GT- a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 61's Minimum Data Set (MDS - a resident assessment tool) dated 9/7/2024, the MDS indicated the resident`s cognitive skills (the brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated that Resident 61 was rarely/never understood and was dependent to staff (helper does all of the effort) for eating, oral hygiene, toileting hygiene, showering/bathing and personal hygiene. The MDS further indicated that Resident 61 was taking antidepressant medication (medication used to treat depression). During a review of Resident 61`s physician History and Physical (H&P) dated 11/27/2024, the H&P indicated that the resident was non-verbal and unable to make his own needs known. During a review of Resident 61`s Physician Order dated 11/19/2024, the order indicated to administer Zoloft 25 milligrams (mg-a unit of measure of mass) via GT, once a day for depression manifested by verbalization of sadness. The order further indicated to monitor the resident`s behavior and verbalization of sadness and side effect of Zoloft during every shift. During a review of Resident 61`s Medication Administration Records (MAR), the MAR indicated that resident received Zoloft on 11/19/2024, and 11/26/2024 through 11/30/2024. During a concurrent observation and interview on 12/2/2024 at 10:26 a.m., at Resident 61`s bedside, the resident was observed laying on his bed with his eyes open. Resident 61`s Responsible Party (RP1) was present at his bedside. RP1 stated Resident 61 is not able to talk. During a concurrent interview and record review on 12/5/2024 at 11:00 a.m., with MDS Coordinator (MDSC), Resident 61`s physician orders and MDS were reviewed. The MDSC stated according to Resident 61`s MDS dated [DATE], the resident was not able to answer any questions and was not interviewable. The MDSC stated the reason the physician ordered Zoloft is due to Resident 61's verbalization of sadness, however, the resident is not able to verbalize his feelings as he is non-verbal. The MDSC stated Resident 61`s Zoloft's indication for use is incorrect, unclear, and requires clarification. The MDSC stated all psychotropic medications are required to have a specific and clear indication for use and measurable target behaviors so the licensed staff can monitor the frequency of the behavior. During an interview on 12/5/2024 at 1:46 p.m., with Licensed Vocational Nurse 5 (LVN 5), LVN 5 stated Resident 61 is nonverbal and unable to make his needs known. LVN 5 stated Resident 61`s Zoloft order did not indicate the specific behavior to be monitored. LVN 5 stated the potential outcome of not indicating the specific behavior to be monitored is inaccurate monitoring and inability to measure the effectiveness of the medication for the resident. 2. During a review of Resident 64's admission Record, the admission Record indicated the facility admitted the resident on 5/10/2024, with diagnoses including major depressive disorder, dementia, and psychotic disorders (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 64's Minimum Data Set, dated [DATE], the MDS indicated the resident`s cognitive skills (the brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated that Resident 64 did not exhibit potential indicators for psychosis such as hallucinations (a sight, sound, smell, taste, or touch that a person believes to be real but is not real) and delusions (having false or unrealistic beliefs). The MDS further indicated that Resident 64 was taking antipsychotic and antidepressant medications. During a review of Resident 64`s Physician Order dated 5/10/2024, the order indicated to administer Seroquel 25 mg by mouth at bedtime for psychotic disorder with delusions due to dementia manifested by sudden verbal agitation. During a review of Resident 64`s Physician Order dated 7/30/2024, the order indicated to administer Seroquel 25 mg by mouth at bedtime for psychotic disorder with delusions due to dementia manifested by sudden verbal agitation which may present a danger to self or others. During a review of the facility's Pharmacy Consultant (PC) Monthly Regimen Review (MRR), dated 9/17/2024, the MRR indicated that Resident 64 had been on Seroquel with target behavior of sudden verbal agitation. The review indicated to clarify what the resident said and how this presented a danger to self and others. During a review of Resident 64`s Psych Interdisciplinary Team meeting (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of their client) with PC form dated 11/18/2024, the IDT form indicated that the IDT team recommended a Gradual Dose Reduction (GDR- the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) for Seroquel to 12.5 mg at bedtime. The IDT form further indicated that the GDR recommendation will be sent to Resident 64`s primary care physician for review and order. During a review of Resident 64`s Physician Order dated 11/18/2024, the order indicated to administer Seroquel 12.5 mg by mouth at bedtime for psychotic disorder with delusions due to dementia manifested by sudden verbal agitation which may present a danger to self or others. During an interview on 12/5/2024 at 1:50 p.m., with LVN 5, LVN 5 stated that Resident 64`s Seroquel order did not indicate the specific behavior to monitor. The LVN 5 stated sudden verbal agitation is not an indication to administer Seroquel. She (LVN 5) stated Resident 64, who has dementia can have sudden verbal agitation when she is hungry, when she tries to make her needs known, or for any other reasons. She (LVN 5) stated the order for Resident 64`s Seroquel did not include a clear indication and the specific behavior to be monitored and requires clarification. She (LVN 5) stated the potential outcome of not having a clear indication and measurable target behavior is inaccurate monitoring and exposure of the resident to side effects of the medication. During a concurrent interview and record review on 12/4/2024 at 3:50 p.m., with the Director of Nursing (DON), Resident 64`s physician orders and MRRs were reviewed. The DON stated Resident 64`s physician order for Seroquel did not include a specific measurable behavior to be monitored by a licensed staff member. The DON stated the facility failed to follow up on PC recommendation dated 9/17/2024, to clarify this order. The DON stated the potential outcome of not indicating a specific measurable behavior to monitor is inaccurate monitoring and inability to measure efficacy of the medication for the resident. During a review of the facility's Policies & Procedures (P&P) titled, Psychotropic medication Assessment and Monitoring, last reviewed 10/2024, the P&P indicated that psychotropic drugs are used only when necessary and then at the lowest effective dose. The IDT team assesses and monitors the appropriateness, effectiveness and side effects associated with psychotropic medications for each resident. The PC reviews the appropriateness of the psychotropic medications order as part of each drug regimen. If at any time during the assessment for monitoring process, the psychotropic medication order is found to be inappropriate, the Director of Nursing is to be notified and the attending physician will be called for clarification. The behavior of residents receiving antipsychotic medication will be monitored by the Registered Nurses or LVN at appropriate intervals, as determined by the IDT using the behavior monitoring record. Record behavior, interventions and effectiveness of interventions taken in the behavior monitored.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a medication error rate below 5 percent (%) by having two medication errors out of 32 opportunities contributing to an overall error rate of 6.25 % for one of nine residents (Resident 61) observed during the Medication Administration facility task. These deficient practices resulted in the omission of medications which could have resulted in severe health complications. Findings: During a review of Resident 61's Face Sheet, the Face Sheet indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included diabetes mellitus (high blood sugar), BPH, Parkinson's disease, dysphagia (difficulty swallowing), and presence of a G-Tube (a plastic tube inserted into the stomach to infuse medications for one who has problems swallowing). During a review of Resident 61' s Minimum Data Set (MDS, a resident assessment tool), dated 9/07/2024, the MDS indicated Resident 61 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 61 was dependent (helper does all the effort) on staff for eating, dressing, and personal hygiene. During a review of Resident 61's Physician's Orders, the physician's orders indicated the following: - Terazosin capsule 2 milligrams (mg, a metric unit of measurement for medication dosage) by G-Tube, once daily for BPH, dated 11/25/2024. - Sinemet tablet 25-100 mg by G-Tube, three times a day at 8:30 a.m., 12:30 p.m., and 4:30 p.m., dated 11/26/2024. - Ipratropium-albuterol solution for nebulization (a medication to treat those with breathing problems given by a nebulizer, a device to administer medication in the form of a mist) 2.5 mg/3 milliliters (ml, a metric unit of measurement for medication dosage) for shortness of breathing or wheezing (a high-pitched sound made when breathing is restricted) by hand held nebulizer (HHN, or can be administered through a face mask if resident can not hold a nebulizer) every six hours, dated 11/25/2024. - Potassium chloride liquid 40 milliequivalents in 15 milliliters (mEq/ml, a metric unit of measurement for medication dosage) by G-tube for hypokalemia (low potassium, a mineral that is essential for proper body functioning), twice a day for two days, dated 12/03/2024. - Humalog insulin solution (a medication to decrease high blood sugar) 100 units/ ml (a unit of measure for insulin) per sliding scale: o If blood sugar is less than 70 milligrams per deciliter (mg/dL, a unit of measurement for blood sugar), call the physician. o If blood sugar is 71 to 150 mg/dL, give 0 units (a unit of measure for insulin). o If blood sugar is 151 to 200 mg/dL, give 1 unit. o If blood sugar is 201 to 250 mg/dL, give 2 units. o If blood sugar is 251 to 300 mg/dL, give 3 units. o If blood sugar is 301 to 350 mg/dL, give 4 units. o If blood sugar is 351 to 400 mg/dL, give 5 units. o If blood sugar is greater than (>) 400 mg/dL, give 6 units. o If blood sugar is greater than 400, call the physician. Subcutaneous (injected by needle into the fat under the skin) for diabetes mellitus every four hours, dated 12/03/2024. During a review of Resident 61's Care Plan for Parkinson's Disease, created on11/25/2024, the care plan indicated a goal that the resident's signs and symptoms in the neurological system will be identified and treated upon detection. The care plan indicated an intervention to follow medical regimen as ordered. During a review of Resident 61's Medication Administration Record (a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), covering the dates 12/01/2024 to 12/04/2024, the MAR indicated the following: - Sinemet tablet on 12/04/2024 at 8:30 a.m. was not given. - Terazosin capsule on 12/04/2024 at 8:30 a.m. was not given. During a review of Resident 61's Nursing Progress Notes, the nursing progress note, dated 12/04/2024 at 11:44 a.m., indicated RN 2 called Resident 61's physician, MD 1 for clarification of which medications to give and which medications to hold. The nursing progress note indicated Sinemet, terazosin, and finasteride medications were to be given. During a medication pass observation with RN 1 on 12/04/2024, observed RN 1 completed giving Resident 61's medications at 10:20 a.m. Confirmed with RN 1 the medications given were: potassium chloride liquid by G-Tube, ipratropium-albuterol breathing treatment, and fingerstick taken with insulin coverage given for fingerstick of 323 mg/dL. No other medications were given at that time. During a concurrent interview and record review with RN 2, on 12/04/2024 at 11:04 a.m., reviewed Resident 61's physician's orders which indicated orders to give finasteride at bedtime, Sinemet in the morning and afternoon, and terazosin in the morning. During an interview with RN 1 on 12/04/2024 at 11:15 a.m., RN 1 stated they had received instructions from the night RN supervisor that all medications were to be held except for potassium chloride, blood sugar checks with insulin sliding scale insulin administration if indicated and the ipratropium-albuterol breathing treatment. During a phone interview with Resident 61's physician, (MD 1) and RN 2 on the line, on 12/04/2024 at 11:25 a.m., MD 1 stated they wanted all medications for BPH and Parkinson's disease are to be given. MD 1 stated Resident 61's bowel needed to rest and wanted to give certain medications that were most necessary. During a concurrent phone interview and record review with RN 3 on 12/04/2024 at 11:55 a.m., with RN 2 and the Director of Nursing (DON) on the line, RN 3 stated MD 1 told him by phone to hold certain medications while giving others. RN 3 stated he printed out a list of Resident 61's medications and wrote on that sheet which medications MD 1 wanted to give and which ones MD 1 wanted to hold. RN 3 stated he (RN 3) told RN 2 where Resident 61's Physician Orders printout was, RN 2 retrieved Resident 61's Physician's Order printout which indicated the medications finasteride, Sinemet, and terazosin should be given. These medications were indicated to give and were indicated with the word Give indicated in cursive handwriting (a style of writing that has joined letters written with the help of loops made without lifting the writing instrument from the paper) next to the medication name. RN 3 indicated that the Resident 61 Physician's Orders printouts with the words Hold and Give indicated in cursive handwriting next to the medication names was the document he made notes on before entering the hold orders in the computer system. During a concurrent interview and record review with the DON on 12/05/2024 at 8:14 a.m., reviewed Resident 61's 12/2024 MAR which covered the dates 12/01/2024 to 12/04/2024. The DON confirmed that the following medications were not given but should have been given: - Sinemet tablet on 12/04/2024 at 8:30 a.m. - Terazosin capsule on 12/04/2024 at 8:30 a.m. The DON stated that she knew the medications were not given as indicated by the words: Not Administered: On Hold next to these medications on the indicated dates and times. The DON stated this was important so that Resident 61 does not experience adverse side effects from BPH such as urinary problems and adverse side effects such as tremors for Parkinson's disease. During a review of the facility's policy and procedure titled, Medication Administration, last reviewed 1/22/2024, indicated medications must be administered in a timely manner and in accordance with the attending physician's written or verbal orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from any significant medication errors for one of nine residents (Resident 61) investigated during the medication administration facility task by failing to: 1. Ensure Registered Nurse 1 (RN 1) administered the medications Sinemet (two medications combined into one medication to treat Parkinson's disease [(a nervous system disorder which leads to movement problems) and terazosin (a medication to treat benign prostatic hyperplasia (BPH, a non-cancerous condition that causes the prostate [a gland in the male reproductive system] to enlarge due to an overgrowth of cells), for one (Resident 61) of nine residents observed during the medication pass observation. 2. Ensure Licensed Vocational Nurse 4 (LVN 4) administered finasteride and Sinemet during the 3 p.m. to 11 p.m. shift on 12/03/2024 to Resident 61 These failures had the potential for Resident 61 to experience unwanted adverse effects such as tremors, and urination problems. Cross reference to F759. Findings: During a review of Resident 61's Face Sheet, the Face Sheet indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included diabetes mellitus (high blood sugar), BPH, Parkinson's disease, dysphagia (difficulty swallowing), and presence of a G-Tube (a plastic tube inserted into the stomach to infuse medications for one who has problems swallowing). During a review of Resident 61' s Minimum Data Set (MDS, a resident assessment tool), dated 9/07/2024, the MDS indicated Resident 61 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 61 was dependent (helper does all the effort) on staff for eating, dressing, and personal hygiene. During a review of Resident 61's Physician's Orders, the physician's orders indicated the following: - Terazosin capsule 2 milligrams (mg, a metric unit of measurement for medication dosage) by G-Tube, once daily for BPH, dated 11/25/2024. - Sinemet tablet 25-100 mg by G-Tube, three times a day at 8:30 a.m., 12:30 p.m., and 4:30 p.m., dated 11/26/2024. - Finasteride tablet 5 mg by G-Tube, once daily, dated 11/25/2024. - Ipratropium-albuterol solution for nebulization (a medication to treat those with breathing problems given by a nebulizer, a device to administer medication in the form of a mist) 2.5 mg/3 milliliters (ml, a metric unit of measurement for medication dosage) for shortness of breathing or wheezing (a high-pitched sound made when breathing is restricted) by hand held nebulizer (HHN, or can be administered through a face mask if resident can not hold a nebulizer) every six hours, dated 11/25/2024. - Potassium chloride liquid 40 milliequivalents in 15 milliliters (mEq/ml, a metric unit of measurement for medication dosage) by G-tube for hypokalemia (low potassium, a mineral that is essential for proper body functioning), twice a day for two days, dated 12/03/2024. - Humalog insulin solution (a medication to decrease high blood sugar) 100 units/ ml (a unit of measure for insulin) per sliding scale: o If blood sugar is less than 70 milligrams per deciliter (mg/dL, a unit of measurement for blood sugar), call the physician. o If blood sugar is 71 to 150 mg/dL, give 0 units (a unit of measure for insulin). o If blood sugar is 151 to 200 mg/dL, give 1 unit. o If blood sugar is 201 to 250 mg/dL, give 2 units. o If blood sugar is 251 to 300 mg/dL, give 3 units. o If blood sugar is 301 to 350 mg/dL, give 4 units. o If blood sugar is 351 to 400 mg/dL, give 5 units. o If blood sugar is greater than (>) 400 mg/dL, give 6 units. o If blood sugar is greater than 400, call the physician. Subcutaneous (injected by needle into the fat under the skin) for diabetes mellitus every four hours, dated 12/03/2024. During a review of Resident 61's Care Plan for Parkinson's Disease, created 11/25/2024, the care plan indicated a goal that the resident's signs and symptoms in the neurological system will be identified and treated upon detection. The care plan indicated an intervention to follow medical regimen as ordered. During a review of Resident 61's Care Plan for Altered Elimination Pattern, created 9/20/2024, the care plan indicated a goal that the resident will remain free of injury within the safe confines of his environment. The care plan indicated an intervention to give BPH medications as ordered. During a review of Resident 61's Medication Administration Record (a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 12/01/2024 to 12/04/2024, the MAR indicated the following: - Finasteride tablet on 12/03/2024 at 8:30 p.m. was not given. - Sinemet tablet on 12/03/2024 at 8:30 a.m., 12:30 p.m. and 4:30 p.m. and on 12/04/2024 at 8:30 a.m. was not given. - Terazosin capsule on 12/03/2024 at 8:30 a.m. and 12/04/2024 at 8:30 a.m. was not given. During a review of Resident 61's Nursing Progress Notes, the nursing progress note, dated 12/04/2024 at 11:44 a.m., indicated RN 2 called Resident 61's physician, MD 1 for clarification of which medications to give and which medications to hold. The nursing progress note indicated Sinemet, terazosin, and finasteride medications were to be given. During a medication pass observation with RN 1 on 12/04/2024, observed RN 1 completed giving Resident 61's medications at 10:20 a.m. Confirmed with RN 1 the medications given were: potassium chloride liquid by G-Tube, ipratropium-albuterol breathing treatment, and fingerstick taken with insulin coverage given for fingerstick of 323 mg/dL. No other medications were given at that time. During a concurrent interview and record review with RN 2, on 12/04/2024 at 11:04 a.m., reviewed Resident 61's physician's orders which indicated orders to give finasteride at bedtime, Sinemet in the morning and afternoon, and terazosin in the morning. During an interview with RN 1 on 12/04/2024 at 11:15 a.m., RN 1 stated they had received instructions from the night RN supervisor that all medications were to be held except for potassium chloride, blood sugar checks with insulin sliding scale insulin administration if indicated and the ipratropium-albuterol breathing treatment. During a phone interview with Resident 61's Physician, MD 1 and RN 2 on the line, on 12/04/2024 at 11:25 a.m., MD 1 stated MD 1 wanted all medications for BPH and Parkinson's disease to be given. MD 1 stated Resident 61's bowel needed to rest and wanted to give certain medications that were most necessary. During an interview with Licensed Vocational Nurse 4 (LVN 4) on 12/04/2024 at 11:37 a.m., she (LVN 4) stated she had received instructions from the night RN supervisor, RN 3, that all medications were to be held except for potassium chloride, blood sugar checks with insulin sliding scale insulin administration if indicated, and the ipratropium-albuterol breathing treatment. LVN 4 stated she only gave those medications on 12/03/2024. The medications not given were Sinemet and finasteride. During a concurrent phone interview and record review with RN 3 on 12/04/2024 at 11:55 a.m., with RN 2 and the Director of Nursing (DON) on the line, RN 3 stated MD 1 told him by phone to hold certain medications while giving others. RN 3 stated he printed out a list of Resident 61's medications and wrote on that sheet which medications MD 1 wanted to give and which ones MD 1 wanted to hold. RN 3 stated he (RN 3) told RN 2 where Resident 61's Physician Orders printout was, RN 2 retrieved Resident 61's Physician's Order printout which indicated the medications finasteride, Sinemet, and terazosin should be given. These medications were indicated to give and were indicated with the word Give indicated in cursive handwriting (a style of writing that has joined letters written with the help of loops made without lifting the writing instrument from the paper) next to the medication name. RN 3 indicated that the Resident 61 Physician's Orders printouts with the words Hold and Give indicated in cursive handwriting next to the medication names was the document he made notes on before entering the hold orders in the computer system During a concurrent interview and record review with the DON on 12/05/2024 at 8:14 a.m., reviewed Resident 61's 12/2024 MAR dated 12/01/2024 to 12/04/2024. The DON confirmed that the following medications were not given but should have been given: - Finasteride tablet on 12/03/2024 at 8:30 p.m. - Sinemet tablet on 12/03/2024 at 8:30 a.m., 12:30 p.m. and 4:30 p.m. and on 12/04/2024 at 8:30 a.m. - Terazosin capsule on 12/03/2024 at 8:30 a.m. and 12/04/2024 at 8:30 a.m. The DON stated that she knew the medications were not given as indicated by the words: Not Administered: On Hold next to these medications on the indicated dates and times. The DON stated it was important to give these medications so that Resident 61 does not experience adverse side effects from BPH such as urinary problems and adverse side effects such as tremors for Parkinson's disease. During a review of the facility's policy and procedure titled, Medication Administration, last reviewed 1/22/2024, indicated medications must be administered in a timely manner and in accordance with the attending physician's written or verbal orders.

Based on observation, interview, and record review, the facility failed to: 1. Store food in accordance with professional standards for food service safety by failing to: a. Label one container of oatmeal with a use by date label. b. Label one container of powdered sugar with a use by date label. c. Label one container of quinoa with a use by date label. d. Label one container of bulgur with a use by date label. e. Label one container of cream of wheat with a use by date label. f. Label one bag of lemon curd with a use by date label. g. Label one container of chicken with a use by date label. e. Label one container of ground beef with a use by date label. 2. Ensure the chlorine test strips used to check that the sanitizing solution was not expired. These deficient practices had the potential for residents in the facility to be at risk for food borne illness (illness caused by food contamination with bacteria, viruses, parasites, or toxins). Findings: 1. During a concurrent observation and interview on 12/2/24 at 8:00 a.m., with the Dietary Supervisor (DS), observed in the storage room one bin of oatmeal, one bin of powdered sugar, one bin of quinoa, one bin of bulgur, and one container of cream of wheat without a use by date label. During a concurrent observation and interview on 12/2/24 at 8:00 a.m., with the Dietary Supervisor (DS), observed in the walk-in refrigerator one container of lemon curd, one container of defrosting chicken, and one container ground beef without use by date labels. The DS stated there should have been a label with a use by date and if there was not, the residents could get sick from eating food that are past its use by due date. During a concurrent observation and interview on 12/04/2024 at 8:30 a.m., with Kitchen Supervisor (KS 1), observed KS 1 checking the concentration of the chlorine solution (solution used to sanitize the dishes) in the dish washer machine with a chlorine test strip (measures the concentration of free chlorine [chemical element that used to kill bacteria in water]). The surveyor observed that the test paper being used to test the sanitizing solution had an expiration date of 11/1/2024. KS 1 stated the testing equipment, such as test strips should not be expired to ensure adequate washing and sufficient concentration of sanitizing solution is present to effectively clean and sanitize dishware. During an interview on 12/5/24 at 3:30 PM, the Director of Nursing (DON), the DON stated food should have been labeled with use by date and should have always had a use by date label. The DON stated if the food was not labeled, the food could go bad, and the facility would want to prevent that. During a review of facility's policy and procedure (P&P) titled, Dietary Delivery and Storage safety, last reviewed on 1/22/2024, the policy indicated that delivered dietary items should be labeled and dated. During a review of facility's policy and procedure (P&P) titled, Dietary Delivery and Storage General Sanitation, last reviewed on 1/22/2024, the policy indicated: Sanitizing solution containers with Quaternary sanitizer must maintain sanitizer concentration to the manufacturer's recommendation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 68's admission Record, the admission Record indicated the facility admitted the resident on 7/1/2023 with diagnoses including Alzheimer's disease (a brain disorders the slowly destroys memory and thinking skills and eventually, the ability to carry out the simplest tasks), peripheral vascular disease (reduced circulation of blood to a body part due narrowed or blocked vessels), and diverticulosis (a condition where small pouches, called diverticula, form in the walls of the colon). During a review of Resident 68's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/7/2024, the MDS indicated that the resident had severely impaired cognition (a severely damaged mental abilities, including remembering things, making decisions, concentrating, or learning). The resident required set up/supervision assistance from staff for most activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 68's physician's orders, dated 11/20/2024, an order indicated to put the resident on contact and droplet precautions isolation for respiratory syncytial virus (RSV-is a common respiratory virus that infect the throat, lungs, and nose) from 11/20/2024 to 12/05/2024. During an observation on 12/4/2024 at 12:00 p.m., observed Resident 68's room had signage which indicated Resident 68 was on contact and droplet precaution. The signage also indicated instructions to don a gown, mask, gloves, and eye protection (goggles) when entering the resident's room. During an observation on 12/4/2024 at 12:01 p.m. in Resident 68's room, observed Housekeeper 1(HK 1) enter Resident 68's room. HK1 was observed wearing gloves, gown, and mask, but not wearing any eye protection. During a concurrent observation and interview on 12/4/2024 at 12:05 p.m. with Infection Prevention Nurse (IP), the IP confirmed the finding and stated she (IP) observed HK 1 cleaning inside Resident 68's room without wearing an eye protective equipment. The IP stated that according to the facility's policy regarding contact and droplet precautions, HK 1 should have donned eye protective equipment prior to performing the room cleaning. During an interview on 11/20/2024 at 11:20 a.m. with the Director of Nursing (DON), the DON stated that failure to wear eye protection when entering a room on contact /droplet isolation may lead to spread an infection among residents in the facility. During a review of the facility's policy and procedure titled, Guidelines for isolation Precautionslast reviewed on 1/22/2024, the policy indicated that : Contact precautions require staff don PPE-gloves, gown, and eye protection .Droplet precautions are used to reduce transmission of infectious agents from close respiratory or mucous membrane , i.e. less than three (3) feet . 3. During a review of Resident 72's admission Record, the admission Record indicated that the facility initially admitted Resident 72 on 1/18/2024 with diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), chronic heart failure (a long term condition in which a heart cannot pump blood well enough to meet the body needs), and dry eye syndrome (a condition that occurs when the lacrimal glands [ the tear glands responsible for producing tears] do not produce enough tears). During a review of Resident 72's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/24/2024, the document indicated that the resident had severely impaired cognition (a severely damaged mental abilities, including remembering things, making decisions, concentrating, or learning). The MDS further indicated that Resident 72 required moderate-to- maximal assistance for eating, dressing, toileting, personal hygiene, and shower transfer. The MDS indicated that Resident 72 had moderately impaired vision and was wearing glasses. During the review of Resident 72's Physician Order Report, dated 12/1/2024, the document indicated the following physician orders: Soothe XP drops (eye drops containing a light mineral oil and used to treat dry eye syndrome) 1-4.5% (%- unit of measurement of concentration) 1 drop in each eye at 8:30 a.m., 12:30 p.m., 4:30 p.m. dated 01/18/2024. During a medication administration observation on 12/4/2024 at 11:39 a.m. in Resident 72's room, the surveyor observed LVN 3 administering Soothe XP one (1) drop to both of Resident 72's eyes. LVN 3 washed his hands with soap and water and administered Soothe XP one (1) drop in Resident 72's right eye. Then, without washing his hands, proceeded to administer Soothe XP one (1) drop in Resident 72's left eye. During an interview on 12/4/2024 at 11:40 a.m., LVN 3 stated that he (LVN 3) did not know that he had to clean hands before treating each eye when administering eye drops. During an interview on 12/4/2024 at 12:05 p.m. with the Infection Preventionist (IP), the IP was not aware that licensed staff had to clean hands before treating each eye when administering eye drops. During an interview on 12/5/2024 at 11:20 a.m. with the Director of Nursing (DON), the DON stated that according to facility policy, during the administration of medication in both eyes of the resident the licensed staff has to clean hands before treatment of each eye. The DON stated that failure to properly perform hand hygiene during administration of eye drops for Resident 72 may lead to cross contamination of infection between the resident's left and right eyes. During a review of the facility policy named Installation of Eye Drops, last reviewed on 1/21/2024, the policy stated: should both eyes require instillation, wash and dry your hands thoroughly before treating each eye. During a review of the facility policy named Hand washing/Hand hygiene, last reviewed on 1/22/2024, the policy stated: This facility considers hand hygiene the primary means to prevent the spread of infection. Based on observation, interview, and record review, the facility failed to: 1. Observe infection control guidelines when Registered Nurse 1 (RN 1) was observed leaving a resident's room during a medication pass observation while still wearing an isolation gown for one (Resident 61) of 12 residents who were on enhanced barrier precautions (EBP-a method of using personal protective equipment [PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments] to reduce the spread of pathogens between residents in skilled nursing facilities). This deficient practice had the potential to increase the risk of spreading infection to other residents. 2. Ensure Housekeeper 1 (HK 1) used the eye protective personal equipment (PPE-goggles or face shields used to prevent or minimize exposure to respiratory droplets [a small droplet of saliva or mucus that is produced when someone exhales]) while cleaning inside the resident's room for one (Resident 68) out one resident sampled, who was on Contact/Droplet Precaution (Steps that healthcare staff take to reduce the spread of pathogens between residents in skilled nursing facilities). This deficient practice had the potential to increase the risk of spreading infection to other residents. 3. Implement its policy and procedure titled, Installation of Eye Drops (putting eye drops into residents' eyes) by failing to ensure Licensed Vocational Nurse 3 (LVN 3) washed and dried his hands thoroughly before treating each eye while administering eye drops to one (Resident 72) out of five residents investigated during review of the infection control task. This deficient practice had the potential to cause cross contamination (unintentional transfer of bacteria/germs or other contaminants from one surface to another) of infection (occurs when harmful microorganisms, such as bacteria or viruses enter the body and multiply) between Resident 72's eyes. Findings: 1. During a review of Resident 61's Face Sheet, the Face Sheet indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included diabetes mellitus (high blood sugar), BPH, Parkinson's disease, dysphagia (difficulty swallowing), and presence of a G-Tube (a plastic tube inserted into the stomach to infuse medications for one who has problems swallowing). During a review of Resident 61' s Minimum Data Set (MDS, a resident assessment tool), dated 9/07/2024, the MDS indicated Resident 61 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 61 was dependent (helper does all the effort) on staff for eating, dressing, and personal hygiene. During a review of Resident 61's Physician's Orders, the physician's orders indicated the following: - Humalog insulin solution (a medication to decrease high blood sugar) 100 units/ ml (a unit of measure for insulin) per sliding scale: o If blood sugar is less than 70 milligrams per deciliter (mg/dL, a unit of measurement for blood sugar), call the physician. o If blood sugar is 71 to 150 mg/dL, give 0 units (a unit of measure for insulin). o If blood sugar is 151 to 200 mg/dL, give 1 unit. o If blood sugar is 201 to 250 mg/dL, give 2 units. o If blood sugar is 251 to 300 mg/dL, give 3 units. o If blood sugar is 301 to 350 mg/dL, give 4 units. o If blood sugar is 351 to 400 mg/dL, give 5 units. o If blood sugar is greater than (>) 400 mg/dL, give 6 units. o If blood sugar is greater than 400, call the physician. Subcutaneous (injected by needle into the fat under the skin) for diabetes mellitus every four hours, dated 12/03/2024. During a medication pass observation with RN 1 on 12/04/2024 at 9:45 a.m., observed RN 1 taking a fingerstick (pricking the finger of a resident to obtain blood to measure how much glucose is in the blood) for Resident 61. RN 1 then removed her gloves and exited Resident 61's room while still wearing an isolation gown to get Resident 61's insulin from the medication cart. One of RN 1's gowned arms touched the medication cart. When asked why RN 1 was still wearing the isolation gown after exiting a resident's room on EBP precautions, RN 1 stated she should have removed the isolation gown before exiting the room. RN 1 removed the isolation gown. RN 1 stated it is important to follow EBP guidelines to prevent the spread of infection. During an interview with the Director of Nursing (DON) on 12/05/2024 at 8:14 a.m., the DON stated staff providing care for residents who are on EBP, the practice is to remove the isolation gown and gloves before leaving a resident's room. The DON stated RN 1 should have removed the gown before exiting Resident 61's room. The DON stated this was important to prevent the spread of infection. During a review of the facility's policy and procedure titled, Enhanced Barrier Precautions, revised 4/23/2024, the policy indicated EBP is used in conjunction with standard precautions (a set of infection control practices that are used to prevent the spread of disease in healthcare settings, such as hand washing) and expand the use of PPE during high-contact resident care activities. The policy indicated EBP are to be used for residents with indwelling medical devices, such as a G-Tube, even if the resident is not known to be infected or colonized with a multidrug-resistant organism (MDRO, bacteria that are resistant to three or more classes of antimicrobial drugs). The policy indicated the PPE: gloves and gown, are to be used in maintaining EBP.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the facility had arranged provisions of hospice (a type of medical care for residents who are in the last stages of life) services by failing to: 1. Ensure hospice staff signed the hospice Interdisciplinary Team Sign-in Sheet upon arriving to the facility for one of three sampled residents (Resident 1). 2. Ensure a hospice Interdisciplinary Team Sign in Sheet was placed in the chart for one of three sampled residents (Resident 3). 3. Ensure the hospice agency provided training programs in hospice care for facility staff per contractual agreement. This deficient practice has the potential to negatively affect Resident 1 and Resident 3's physical comfort, psychosocial (the state of mental, emotional, and social health of an individual) well-being, and has the potential to delay or have a lack of necessary care and services. Findings: 1. A review of Resident 1's Face Sheet indicated the facility originally admitted the resident on 12/2/2013 with diagnoses that included Alzheimer's disease (progressive disease that destroys memory and other important mental functions), dementia (group of thinking and social symptoms that interferes with daily functioning), psychotic disturbance (disconnection from reality), mood disturbance (disorder in which you experience long periods of extreme happiness, extreme sadness or both), anxiety (intense, excessive, and persistent worry and fear about everyday situations), and hypertensive and chronic kidney disease (high blood pressure caused by damaged kidney ) with heart failure (condition in which the heart doesn't pump blood as well as it should). A review of Resident 1's Minimum Data Set (MDS- an assessment and care screening tool), dated 3/30/2024, indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making was severely impaired. The MDS indicated Resident 1 was dependent (helper does all of the effort) with eating, oral hygiene, toileting, and personal hygiene. A review of Resident 1's Physician's Orders indicated an order to admit the resident to hospice care, dated 5/17/2024. During an interview and concurrent record review with the Director of Nursing (DON) on 5/29/2024 at 6:01 p.m., the DON stated when hospice staff arrive in the facility, hospice staff are to sign-in on the hospice sign-in sheet located in the residents' hospice binder. The DON stated that signing in in the hospice sign-in sheet ensures that hospice staff was physically in the facility to provide hospice care to the resident. During an interview and concurrent record review with the DON on 5/29/2024 at 6:19 p.m., the DON reviewed Resident 1's hospice admission orders and stated that Resident 1 was admitted under hospice care on 5/18/2024. The DON then reviewed Resident 1's hospice sign-in sheet titled Interdisciplinary Team Sign-in Sheet that was located inside Resident 1's hospice binder. The DON stated that there was no documented evidence that hospice staff was in the facility on 5/18/2024 when Resident 1 was admitted to hospice. 2. A review of Resident 3's Face Sheet indicated the facility admitted the resident on 3/1/2023 with diagnoses that included Alzheimer's disease, dementia, and chronic (constant) pain. A review of Resident 3's MDS dated [DATE], indicated Resident 3's cognition with skills required for daily decision making was severely impaired. The MDS indicated Resident 3 required setup or clean-up assistance (helper sets up or clean up; resident completes activity) with eating, oral hygiene and required substantial or maximal assistance with toileting and personal hygiene. A review of Resident 3's Physician's Orders indicated an order to admit the resident to hospice care, dated 4/23/2024. During an interview and concurrent record review with the DON on 5/29/2024 at 6:30 p.m., the DON reviewed Resident 3's hospice binder. The DON stated that there was no hospice sign-in sheet titled Interdisciplinary Team Sign-in Sheet in Resident 3's hospice binder. The DON further stated that there was no documented evidence that hospice staff was in the facility to provide hospice care to Resident 3 from 4/23/2024 to 5/8/2024. During an interview and concurrent record review with the Medical Records Team Leader (MRTM) on 5/29/2024 at 6:45 p.m., the MRTM reviewed Resident 3's hospice binder and stated she was unable to find the hospice sign-in sheet titled Interdisciplinary Team Sign-in Sheet that hospice staff is supposed to sign upon arrival to the facility. MRTM stated that MRTM was unaware that the hospice binder had to have a sign-in sheet for hospice staff. During an interview with the DON on 5/29/2024 at 6:50 p.m., the DON stated that it is the responsibility of the medical records department to ensure hospice sign-in sheets are in the hospice binder so that hospice staff can sign in. The DON stated that medical records should have conducted audits to ensure sign-in sheets are present and signed in all hospice binders. The DON stated that it is important to ensure hospice sign in sheets are signed when hospice staff are in the facility because it is used to validate and confirm hospice visits. A review of the facility's policy and procedure titled Hospice with a revision date of 10/11/2021 indicated that the facility is to facility hospice services for residents in accordance with state and federal law through contracted licensed vendors. 3. During an interview with Certified Nursing Assistant 1 (CNA 1) on 5/31/2024 at 8:40 a.m., CNA 1 stated that she (CNA 1) has cared for hospice residents in the facility. When asked if CNA 1 received any type of training from the hospice agency, CNA 1 stated that she has not received any trainings directly from the hospice agency. During an interview with Certified Nursing Assistant 2 (CNA 2) on 5/31/2024 at 9:35 a.m., CNA 2 stated that she (CNA 2) has cared for hospice residents in the facility. When asked if CNA 2 received any type of training from the hospice agency, CNA 2 stated that she has not received any trainings directly from the hospice agency. During an interview and concurrent record review with the DON on 5/31/2024 at 11:35 a.m., reviewed the hospice contract signed on 7/24/2017. DON stated that the contracted hospice agency does not provide any training programs to facility staff. The DON read the hospice contract signed on 7/24/2017. The DON stated that the DON was not aware of the Training Program aspect of the hospice contract. When asked what the importance of hospice training from the contracted hospice agency is, the DON stated that it is important for the contracted hospice agency to provide training programs to the facility staff so that the hospice agency and the facility staff can work collaboratively with the plan of care for each resident on hospice and provide quality care. A review of the facility's hospice contract titled Hospice and Facility Skilled Nurse Facility (SNF) Service Agreement, addendum date signed 7/24/2017, indicated under training programs: Hospice shall provide training programs in hospice care for facility staff involved in furnishing care to patients pursuant to this agreement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide dignity and respect when Registered Nurse 1 (RN 1) was observed wearing gloves and standing over two of four sampled residents (Resident 40 and 64) while assisting each resident with feeding. These deficient practices had the potential to affect residents' sense of self-worth and self-esteem. Findings: a. A review of Resident 40's Face Sheet (admission Record) indicated the facility readmitted the resident on 1/20/2020 with diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), history of falling, 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). A review of Resident 40's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 11/7/2023, indicated Resident 40 rarely made self-understood and rarely understood others. The MDS indicated Resident 40 required extensive assistance with activities of daily living (ADL- are activities related to personal care). A review of Resident 40's Care Plan (provides direction on the type of nursing care the individual/family/community may need) for Self-Care Deficits revised on 11/8/2023, indicated Resident 40 needed to be supervised and assisted with ADL's safely daily. b. A review of Resident 64's Face Sheet indicated the facility admitted the resident on 12/8/2022 with diagnoses that included Alzheimer`s disease, dementia (he loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), and chronic rhinitis (a reaction occurs that causes nasal congestion, runny nose, sneezing, and itching). A review of Resident 64's MDS dated [DATE], indicated Resident 64 rarely made self-understood and rarely understand others. The MDS indicated Resident 64 required extensive assistance with activities of daily living. A review of Resident 64's Care Plan for Self-Care Deficits revised on 10/2/2023, indicated Resident 64 needed to be supervised and assisted with ADL's safely daily. On 12/11/23 at 12:02 p.m., during a dining observation, observed Resident 40 and 64 seated in a four-seater table in the main dining room. At this time, observed Registered Nurse 1 (RN 1) standing between Resident 40 and 64 wearing disposable gloves and alternately feeding Residents 40 and 64. On 12/11/23 at 02:11 p.m., during an interview, RN 1 stated that she wore gloves because she does not want to touch Resident 40 and Resident 64's food. RN 1 stated that she was standing over the resident because she has frozen shoulder (a condition characterized by stiffness and pain in the shoulder joint). RN 1 was asked if she had some sort of work restrictions to which RN 1 denied. RN 1 stated that standing over the residents while feeding does not promote resident dignity. On 12/11/23 at 3:25 p.m., during an interview with the Director of Nursing (DON), the DON stated that when staff are assisting and feeding residents, staff have to sit beside the residents and not wear gloves. The DON stated that it is not dignified to be wearing gloves and standing over the resident when feeding them, and that residents and others may think that they are sick or are infectious. A review of the facility's policy titled, Dignity, last reviewed on 6/8/2023, indicated, The facility will promote care for residents in a manner and environment that maintains or enhances each resident`s dignity and respect in full recognition of his or her individuality .promoting resident independence and dignity in dining, such as avoidance of: staff standing over residents while assisting them to eat .

Based on interview and record review, the facility failed to ensure a copy of a resident's Advance Directive (a written statement of a person's wishes regarding medical treatment) was kept in the resident's chart and easily retrievable for one of three sampled residents (Resident 64) investigated for advance directive. This deficient practice has the potential to create confusion which could lead to conflict with the resident`s wishes regarding his/her health care. Findings: A review of Resident 64's Face Sheet (admission record) indicated the facility admitted the resident on 12/8/2022 with diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), dementia (he loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), and chronic rhinitis (a reaction occurs that causes nasal congestion, runny nose, sneezing, and itching). A review of Resident 64's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 9/14/2023, indicated Resident 64 rarely made self-understood and rarely understood others. The MDS indicated Resident 64 required extensive assistance with activities of daily living (ADL- are activities related to personal care. On 12/12/2023 8:09 a.m., during a concurrent interview and record review with Minimum Data Set Nurse 1 (MDSN 1), Resident 64's Advance Directive dated 3/15/2011 was reviewed. MDSN 1 stated that Resident 64's Advance Directive dated 3/15/2011 was not uploaded into the resident's electronic health record, and it was also not readily available inside Resident 64's physical chart. MDSN 1 stated that Advance Directives are resident's wishes for healthcare and should be in the active clinical record to reference in case of an emergency. A review of the facility's policy and procedure titled, Advance Directive, last reviewed on 6/8/2023, indicated that it is the policy of the facility to make sure a resident's advance directive is present in the resident's medical chart within 30 days of admission .

Based on interview and record review, the facility failed to monitor a resident's behaviors who was prescribed an antipsychotic medication (a medication used to treat psychosis [a mental disorder characterized by a disconnection from reality]) for one of five sampled residents (Resident 123) investigated for unnecessary medications. This deficient practice had the potential to result in adverse reaction (unwanted undesirable effects related to a medication) or impairment in the resident's mental or physical condition. Findings: A review of Resident 123's Face Sheet (admission record) indicated the facility admitted the resident on 11/29/2023 with diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), psychosis, depression (mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (intense, excessive, and persistent worry and fear about everyday situations). A review of Resident 123's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/5/2023, indicated Resident 123 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 123 was dependent (helper does all of the effort) with eating, toileting, dressing and personal hygiene. A review of Resident 123's physician's orders indicated the following: - Quetiapine tablet (an antipsychotic medication) 25 milligrams (mg, a unit of measure) by mouth twice a day, diagnosis: Alzheimer's dementia (loss of memory, language, problem-solving and other thinking abilities caused by Alzheimer's disease) with psychotic disorder manifested by physical aggression during nursing care, ordered 11/30/2023. - Quetiapine: Monitor side effects; please specify under notes what actual side effect occurred every shift, ordered 11/30/2023. A review of Resident 123's Medication Administration Record (MAR, a legal record of the drugs administered to a patient at a facility) indicated the following: - For the 11/2023 MAR, there was no documented evidence that behavior monitoring was done for quetiapine on 11/30/2023. - For the 12/2023 MAR, there was no documented evidence that behavior monitoring was done for quetiapine from 12/1/2023 to 12/13/2023. During a concurrent interview and record review on 12/13/2023 at 3:48 p.m., with Licensed Vocational Nurse 4 (LVN 4), reviewed Resident 123's MAR dated 12/2023. LVN 4 verified by stating that there was no behavior monitoring for Resident 123's quetiapine medication from 12/1/2023 to 12/13/2023. LVN 4 stated there should be behavior monitoring for Resident 123. LVN 4 stated it is important for behavior monitoring for quetiapine so the licensed nurses can assess if the medication was effective, and if it is not effective, the resident's physician could be notified to make any changes in dosage. During a concurrent interview and record review on 12/13/2023 at 4:41 p.m., with the Director of Nursing (DON), reviewed Resident 123's MAR dated 11/2023 and 12/2023. The DON verified by stating that there was no behavior monitoring for quetiapine from 11/30/2023 to 12/13/2023. The DON stated Resident 123's behaviors should be documented. The DON stated it was important to monitor Resident 123's behaviors to ensure Resident 123 did not receive an unnecessary medication and suffer adverse side effects. A review of the facility's policy and procedure titled, Psychotropic Medication Assessment and Monitoring, last reviewed 6/8/2023, indicated the behavior of residents receiving antipsychotic medication will be monitored by the Registered Nurse/Licensed Practical Nurse (also known as licensed vocational nurse [RN/LPN]) at appropriate intervals, as determined by the interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of the residents' care plan), using the behavior monitoring record when a new antipsychotic medication is started, dosage changed or during a drug holiday (a time interval when a medication is not being taken). The policy and procedure indicated to record behavior, interventions and effectiveness of interventions taken in the behavioral monitoring record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure liquids were prepared in a form designed to the meet the needs for one of two sampled residents (Resident 18) observed during the Dining Observation task by failing to ensure nectar thick liquids (a thickening agent is added to liquids for people with difficulty swallowing and at risk for aspiration [accidentally inhaling food or liquid through the vocal cords into the airway]) were prepared and served to the resident. This deficient practice had the potential to result in aspiration pneumonia (an infection of the lungs caused by inhaling saliva, food, or liquids) in Resident 18. Findings: A review of Resident 18's Face Sheet (admission record) indicated the facility admitted the resident on 10/3/2022 and readmitted the resident on 8/15/2023 with diagnoses that included Alzheimer's disease (a type of dementia [general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life] that affects memory, thinking and behavior) and dysphagia (difficulty swallowing). A review of Resident 18's Minimum Data Set (MDS - an assessment and screening too) dated 10/9/2023, indicated the resident usually had the ability to understand others and usually had the ability to make himself understood. A review of Resident 18's physician's orders indicated a dietary order for fortified (foods with nutrients added to them), nectar thick, mechanical soft (a type of texture-modified diet for people who have difficulty chewing and swallowing), dated 11/7/2023. During a concurrent dining observation and interview on 12/11/2023 at 12:18 p.m., observed Resident 18 sitting in Small Dining room [ROOM NUMBER] being assisted by Certified Nursing Assistant 1 (CNA 1). CNA 1 stated Resident 18 was served coffee and coca cola with lunch and was able to feed himself. Observed Resident 18 drinking coca cola and coffee that appeared thin liquid (un-thickened) in texture. CNA 1 stated Resident 18's liquids were not thickened. During a concurrent interview and record review on 12/11/2023 at 12:45 p.m., with CNA 1, reviewed Resident 18's Lunch Meal Ticket dated 12/11/2023. CNA 1 stated the ticket indicated Resident 18's liquids should have added thickener and they did not. CNA 1 stated she was responsible for adding the thickener and she did not add it, but she usually does and forgot it today. During an interview on 12/12/2023 at 3:49 p.m., with the Registered Dietician (RD) and Dietary Supervisor (DS), the DS stated there are packets of thickener at every dining station that should be added to liquids to thicken them. The RD stated it was important for Resident 18 to have nectar thick liquids because the resident could aspirate un-thickened liquids into his lungs resulting in choking. During a concurrent interview and record review on 12/12/2023 at 4:40 p.m., with the Director of Nursing (DON), reviewed the facility's policy titled, Thickened Liquids and Thickening Agents, last reviewed 6/8/2023. The DON stated when trays are delivered to the dining room, the licensed nurse checks the tray and communicates with the CNA regarding the consistency of the diets for residents. The DON stated the importance of providing the correct consistency of liquids is for safety of the residents at risk for choking and aspiration. The DON stated thin liquids pose a higher risk for aspiration and choking resulting in possible hospitalization of the resident. The DON stated the facility's policy was not followed because Resident 18 was not provided with nectar thick liquids. A review of the facility's policy and procedure titled, Thickened Liquids and Thickening Agents, last reviewed 6/8/2023, indicated the speech therapist or a person lawfully authorized to give such an assessment, will order one of the four consistencies of liquids available for patients who have swallowing difficulties. Instant food thickener, Hormel (American food processing company) Thick and Easy, packets are provided to nursing staff to add to other liquids (coffee, tea, and soft drinks). The staff is trained to follow the instructions on the thickening container.

Based on observation, interview, and record review the facility failed to: 1. Ensure licensed nurse staff completed reconciliation (a process that validates the controlled substance [medication with a high potential for abuse] amount at the end of a shift is the amount expected) of controlled medications for two of four medication carts (Medication Team 1 Cart and Medication Team 2 Cart) observed during medication storage. 2. Ensure a resident's Controlled Medication Count Sheet (a form that is signed at the time a licensed nurse gives a controlled medication to a resident, in order to account for each medication) was signed at the time a medication was given for one of one sampled resident (Resident 65). These deficient practices had the potential to result in inaccurate reconciliation of controlled medication and placed the facility at risk for the inability to readily identify loss and drug diversion (the illegal distribution of prescription drugs for unintended purposes) of controlled medications. Findings: 1.a. During a concurrent interview and record review on 12/11/2023 at 10:34 a.m., with Licensed Vocational Nurse 2 (LVN 2), reviewed Medication Team 2 Cart Floor Narcotic Release and Emergency Kit Release Form (this form is signed by the outgoing licensed nurse and incoming licensed nurse for each shift after they have checked the narcotic drug medication counts to ensure there is no discrepancy between what is on paper and what is in the medication cart), for 12/2023. LVN 2 stated the form indicated that narcotics must be checked when the medication cart key is passed to another nurse. LVN 2 stated the form is signed together by the incoming (on-coming) and outgoing (retiring) licensed nurses at every shift change to ensure all of the narcotic medications are accounted for and there are no discrepancies at the time of the handoff. LVN 2 stated the Floor Narcotic Release form indicated the following: - On 12/8/2023, the 3 p.m. to 11 p.m. shift was missing the retiring nurse's signature. LVN 2 stated she was the retiring nurse on 12/8/2023 and she did not sign because she forgot. - On 12/10/2023, the 3 p.m. to 11 p.m. shift was missing the retiring nurse's signature. LVN 2 stated both nurses should sign right away and did not. During a concurrent interview and record review on 12/11/2023 at 3:20 p.m., with the Director of Nursing (DON), reviewed the facility's policy and procedure titled, Medication Storage in The Facility: Controlled Substance Storage, last reviewed 6/8/2023. The DON stated the facility's policy indicated the release form should be signed by the on-coming and retiring nurse at every shift change. The DON stated it was important to sign the Floor Narcotic Release and Emergency Kit Release Form to verify that two nurses actually counted the narcotics inside the medication cart prior to the on-coming shift nurse assuming responsibility of the medication cart and are able to resolve any discrepancies. The DON stated completing the narcotic count is important to ensure that medications that are at risk for diversion are available for residents. A review of the facility's policy and procedure titled, Medication Storage in The Facility: Controlled Substance Storage, last reviewed 6/8/2023, indicated Medications included in the Drug Enforcement Administration classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations. Only authorized licensed nursing and pharmacy personnel have access to controlled substances. Schedule (II-V) medications (drugs and other substances that are considered controlled substances) and other medications subject to abuse or diversion are stored in a permanently affixed, locked compartment separate from all other medications. The medication nurse on duty maintains possession of the key to controlled substance storage areas. At each change of shift, or when a key is transferred, a physical inventory of all controlled substances is conducted by two licensed nurses and is documented. 1.b. During a concurrent interview and record review on 12/11/2023 at 11 a.m., with Licensed Vocational Nurse 1 (LVN 1), reviewed Medication Team 1 Cart Floor Narcotic Release and Emergency Kit Release Form for 12/2023. The Floor Narcotic Release Form indicated a blank space for the on-coming nurse's signature for 12/11/2023 at 7:00 a.m. LVN 1 stated he forgot to sign the sheet when he was counting medications with the retiring licensed nurse that morning. LVN 1 stated he should have signed the form. LVN 1 stated the importance of signing the form is to make sure there are no discrepancies with the controlled drugs in the medication cart. A review of the facility's policy and procedure titled, Medication Storage in The Facility: Controlled Substance Storage, last reviewed 6/8/2023, indicated Medications included in the Drug Enforcement Administration classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations. Only authorized licensed nursing and pharmacy personnel have access to controlled substances. Schedule (II-V) medications and other medications subject to abuse or diversion are stored in a permanently affixed, locked compartment separate from all other medications. The medication nurse on duty maintains possession of the key to controlled substance storage areas. At each change of shift, or when a key is transferred, a physical inventory of all controlled substances is conducted by two licensed nurses and is documented. 2. A review of Resident 63's Face Sheet (admission record) indicated the facility admitted the resident on 7/17/2023, with diagnoses that included anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations). A review of Resident 63's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/11/2023, indicated Resident 63 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 63 required two-person extensive assistance (resident involved in activity, staff provide weight-bearing assistance) with dressing and personal hygiene. A review of Resident 63's physician's orders, dated 8/16/2023, indicated an order for lorazepam (medication given to treat anxiety) tablet 0.5 milligrams (mg, a unit of measure) by mouth twice a day for generalized anxiety disorder manifested by hypersensitivity (excessive or abnormal sensitivity) to environment as evidenced by pushing away staff and objects near him. A review of Resident 63's Medication Administration Record (MAR, a legal record of the drugs administered to a patient at a facility) for 12/2023, indicated LVN 1 gave Resident 63 his lorazepam 0.5 mg on 12/11/2023 at 8:30 a.m. During a concurrent medication cart inspection and interview on 12/11/2023 at 11:03 a.m., with LVN 1, observed LVN 1 signing a document at the Medication Team 1 Cart. When LVN 1 was asked what he was signing, he stated he was signing Resident 63's Controlled Medication Count Sheet for lorazepam. LVN 1 stated he gave Resident 63 lorazepam 0.5 mg at 8 a.m. and stated he should have signed the form at the time the medication was administered but did not. LVN 1 stated it was important to sign this sheet once a controlled drug was given to a resident to keep track of the medication to ensure there is medication available to give to the resident. During a concurrent interview and record review on 12/14/2023 at 8 a.m., with the Director of Nursing (DON), reviewed the policy and procedure titled, Documentation - General, last reviewed 6/28/2023. The DON stated, even though there is not a specific time specified in the policy about signing a resident's Controlled Medication Count Sheet, it is to be signed at the time the controlled drug is given to a resident. The policy and procedure indicated entries must be timely - recorded within the required time period. The DON stated timely signatures are important to ensure that there is medication available to a resident and to avoid drug diversion by licensed nursing staff. A review of the facility's policy and procedure titled, Documentation - General, last reviewed 6/28/2023, indicated entries must be timely - recorded within the required time period.

Based on interview, and record review, the facility failed to ensure a blood pressure (the pressure of circulating blood against the walls of blood vessels) was checked prior to administering losartan (medication used to treat high blood pressure [the force of the blood pushing on the blood vessel walls is too high]) that had a hold (do not give) parameter to hold for systolic blood pressure (SBP, measures the force the heart exerts on the walls of the arteries each time it beats) less than (<) 110 mm Hg (millimeters of Mercury, a unit of measure for blood pressure) for one of five sampled residents (Resident 2). This deficient practice had the potential to result in hypotension (low blood pressure) which can result in confusion, dizziness, and fainting and require further treatment including hospitalization. Findings: A review of Resident 2's Face Sheet (admission record) indicated the facility admitted the resident on 6/30/2023, with diagnoses that included hypertensive heart disease (weakening the heart from chronic blood pressure elevation, making it harder to pump blood throughout the body). A review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/6/2023, indicated Resident 2 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 2 required set-up help (helper sets up or cleans up; resident completes the activity) with eating, oral hygiene, and personal hygiene. A review of Resident 2's physician's orders indicated an order for losartan tab, 25 milligrams (mg, a unit of measurement) by mouth at bedtime for hypertension (high blood pressure), hold for SBP < 110 mm Hg, ordered 11/13/2023. A review of Resident 2's Care Plan for Alteration in Cardiac (heart) status, initiated 11/13/2023, indicated a goal that there will be no signs or symptoms of hypertension daily for 90 days. The care plan indicated an intervention to take vital signs as ordered. The care plan indicated an order to hold the antihypertensive medication for SBP < 110. A review of Resident 2's Medication Administration Record (MAR, a legal record of the drugs administered to a patient at a facility) dated 11/2023 and 12/2023 indicated the following: - Losartan 25 mg was given 25 times from 11/15/2023 to 12/12/2023 with no blood pressure documented prior to the medication being administered. During a concurrent interview and record review on 12/13/2023 at 8:31 a.m., with Licensed Vocational Nurse 4 (LVN 4), reviewed Resident 2's MAR dated 11/2023 and 12/2023. LVN 4 stated there were no blood pressures documented prior to losartan being administered. When asked why there were no blood pressures indicated for Resident 2's losartan administration, LVN 4 stated there should be a blood pressure taken because there are parameters upon which to hold the medication. During a concurrent interview and record review on 12/13/2023 at 4:20 p.m., with the Director of Nursing (DON), reviewed Resident 2's MAR dated 11/2023 and 12/2023. The DON stated before giving an antihypertensive medication, the licensed nurse is to monitor a resident's blood pressure so that the blood pressure would not be too low to give the medication and, to hold the medication if below the parameter indicated in the physician's order. The DON stated by documenting the blood pressure, it would ensure the blood pressure was being taken and held if the SBP was below the ordered parameter. The DON stated this is important because an abnormally low blood pressure could cause dizziness and fainting in a resident, causing injury. The DON stated if there was no documentation of a blood pressure being taken, that indicates the blood pressure was not taken. During an interview on 12/14/2023 at 2:40 p.m., with LVN 4, LVN 4 stated she gives Resident 2 her medications from the 3 p.m. to 11 p.m. shift. LVN 4 stated she gave Resident 2 the 12/3/2023 losartan 25 mg dose at 8:30 p.m. LVN 4 stated she is sure she took a blood pressure and that the SBP was not less than 110 mm Hg but was not sure what the exact blood pressure was. LVN 4 stated there was not a place to document a blood pressure value in the computer when giving the medication. LVN 4 stated the licensed nurses should have added a place to put the blood pressure when they put the order into the computer or check the order if a physician placed the order into the computer himself. LVN 4 stated Resident 2 could have been at risk for headache, dizziness, and at risk for fall. A review of the facility's policy and procedure titled, Medication Administration, last reviewed 6/8/2023, indicated when administration of a drug is dependent upon vital signs, the vital signs shall be completed prior to the administration of medication and recorded in the medical record. A review of the facility's policy and procedure titled, Vital Signs, last reviewed 6/8/2023, indicated vital signs includes heart rate and blood pressure. The policy and procedure indicated the following: Vital signs shall be taken and recorded in accordance with the resident's condition, current treatment plan, and as prescribed by the attending physician. Staff taking vital signs should report those that are out of parameter to the charge nurse or supervisor promptly, so prescribed interventions may be implemented as per physician's order. The physician shall be notified promptly when the vital signs are out of range from the acceptable parameters provided or there are not orders to address the vital sign being out of the parameter. Vital signs shall be recorded in the medical record for each shift they are taken.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided with a psychiatry consult (a comprehensive evaluation of mental or emotional causes of distress) as ordered by the resident ' s physician on 5/14/2023. This deficient practice had the potential to negatively affect Resident 1 ' s psychosocial (relating to the interrelation of social factors and individual thought and behavior) well-being. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 3/6/2023 with diagnoses including Alzheimer ' s disease (a progressive disease that destroys memory and other important mental functions), anxiety disorder (a mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one ' s daily activities), osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time), and Vitamin D (a nutrient your body needs for building and maintaining healthy bones ) deficiency (your body is not getting enough vitamin D to stay healthy). A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 4/14/2023 indicated Resident 1 was able to understand others and was usually understood by others. The MDS further indicated that Resident 1 required limited assistance for activities of daily living (ADL - bed mobility, walking, dressing, toilet use, and personal hygiene). A review of Resident 1 ' s physician order dated 5/14/2023, indicated that the physician ordered a psychiatry consult. During a concurrent interview and record review on 7/19/2023, at 1:20 p.m., Licensed Vocational Nurse 1 (LVN 1) reviewed the progress notes for Resident 1 from 5/14/2023 to 6/3/2023. LVN 1 stated that she was unable to locate a psychiatrist consultation progress note indicating the psychiatric consult was provided for Resident 1 as ordered by the physician on 5/14/2023. During a concurrent interview and record review on 7/19/2023, at 4:25 p.m., the Director of Nursing (DON) reviewed Resident 1 ' s progress notes from 5/14/2023 to 6/3/2023. The DON stated that there was no documented evidence of a psychiatrist consultation progress note or supporting documents indicating that Resident 1 was seen by a psychiatrist (a medical doctor specializing in the diagnosis and treatment of mental illness) for the psychiatric consult ordered by the physician on 5/14/2023. A review of the facility policy and procedures titled, Psychosocial Assessment, last reviewed on 6/8/2023, indicated, To identify the specific maladaptive/dysfunctional factors that impacted the resident ' s psychosocial functioning. Services are rendered, either directly or by referrals, to minimize/eliminate the distress caused by those factors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report abnormal (outside of normal range) laboratory results to a resident's physician timely for one of three sampled residents (Resident 1). The facility received Resident 1 ' s abnormal laboratory results on 5/3/2023 and reported it to Resident 1 ' s physician five days later, on 5/8/2023. This deficient practice had the potential to cause a delay of obtaining appropriate medical treatment for Resident 1 which could have resulted in a negative impact to the resident ' s overall physical, mental, and psychosocial well-being. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 3/6/2023 with diagnoses including Alzheimer ' s disease (a progressive disease that destroys memory and other important mental functions), anxiety disorder (a mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities), osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time), and Vitamin D (a nutrient your body needs for building and maintaining healthy bones ) deficiency (your body is not getting enough vitamin D to stay healthy). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 4/14/2023 indicated Resident 1 was able to understand others and was usually understood by others. The MDS further indicated that Resident 1 required limited assistance from staff for activities of daily living (ADL – bed mobility, walking, dressing, toilet use, and personal hygiene). A review of Resident 1 ' s physician ' s orders indicated as follows: 1. On 5/3/2023, the physician ordered to check Resident 1 ' s laboratory tests including a complete blood count (CBC - a blood test that measures different parts and features on a person ' s blood) and 25-hydroxy Vitamin D test (a blood test that measures how much Vitamin D is in a person ' s body). A review of Resident 1 ' s laboratory results dated [DATE] indicated the following: 1. WBC at 12.5 thousand per cubic milliliter (K/uL - unit of measure). Normal range is 4 K/uL to 11 K/uL. 2. Vitamin D at 21.3 nanograms per millimeter (ng/mL - a unit of measurement). Normal range is 30 ng/mL to 100 ng/mL. A review of Resident 1 ' s Progress Note dated 5/8/2023 indicated the facility notified Resident 1 ' s NP regarding the Resident 1 ' s elevated WBC and low level of Vitamin D on 5/8/2023. During a concurrent interview and record review on 7/19/2023, at 1:09 p.m., Licensed Vocational Nurse 1 (LVN 1) reviewed Resident 1 ' s Lab results dated 5/3/2023 and Resident 1 ' s Progress Notes from 5/3/2023 through 5/8/2023. LVN 1 stated that the facility notified Resident 1 ' s NP of Resident 1 ' s abnormal WBC and Vitamin D lab values on 5/8/2023. LVN 1 stated that the licensed nursing staff should have report abnormal lab results to the resident ' s physician as soon as the facility receives the results so that the physicians are able to order necessary interventions. During a concurrent interview and record review on 7/19/2023, at 4:15 p.m., the Director of Nursing (DON) reviewed Resident 1 ' s Lab results dated 5/3/2023 and stated that the facility notified Resident 1 ' s NP on 5/8/2023. The DON stated that the facility should have reported Resident 1 ' s Lab results from 5/3/2023 to Resident 1 ' s physician upon receiving them from the laboratory for further directions. The DON stated that the facility having reported the results of Resident 1 ' s lab results five days after being first made aware of the results would be considered late reporting to the physician. The DON stated that abnormal lab results should be notified to the resident ' s physician promptly. A review of the facility ' s policy and procedure titled, Laboratory Result Reporting, with a revision date of 6/8/2023, indicated all lab results must be reported to assure all residents receive quality care and to maintain or attain the highest practicable level of functioning. All lab results will be checked upon receiving by the charge nurse against previous results and panic values. Immediate notification (as soon as possible) for WBC greater than (>) 12,000. The charge nurse will document this notification in the medical chart and will check off on Lab Log that the physician was notified. A review of the facility ' s policy and procedure titled, Change in Patient Condition, with a revision date of 6/8/2023, indicated, the facility shall promptly notify the patient, his or her attending physician, and representative of changes in the patient ' s medical/mental condition. The Nurse supervisor/charge nurse will notify the patient ' s attending physician or on-call physician when there has been: A need to alter the patient ' s medical treatment significantly Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the patient ' s physical/mental/emotional condition or status.

Based on interview and record review, the facility failed to ensure that Licensed Vocational Nurse 2 (LVN 2) evaluated and monitored one of two sampled residents (Resident 1) after being alerted by Certified Nursing Assistant 1 (CNA 1) of a newly identified skin discoloration on Resident 1 ' s right forearm on 5/31/2023. This deficient practice placed Resident 1 at risk for further skin break down and or infection due to not receiving care related to the newly identified skin discoloration. Findings: A review of Resident 1 ' s Face Sheet indicated the facility admitted the resident on 3/15/2020, with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) ,mood disturbance (feelings of distress, sadness or symptoms of depression, and anxiety), and psychosis (a mental disorder characterized by a disconnection from reality). A review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 3/7/2023 indicated Resident 1's cognitive (relating to the process of acquiring knowledge and understanding) was moderately impaired. The MDS indicated Resident 1 had clear speech, had the ability to make herself understood, and had the ability to understand others. The MDS indicated that Resident 1 required supervision with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. A review of Resident 1 ' s Skin Monitoring: Comprehensive Certified Nurse Assistant (CNA) Shower Review dated 5/31/2023 indicated old discoloration on Resident 1's right forearm. During an interview with CNA 1 on 6/13/2023 at 11:57 a.m., CNA 1 stated that on 5/31/2023, CNA 1 assisted Resident 1 with a shower. CNA 1 stated that during Resident 1 ' s shower, CNA 1 noticed Resident 1 had discoloration on the right forearm. CNA 1 stated that she reported the finding to Licensed Vocational Nurse 2 (LVN 2) and documented the findings on Resident 1 ' s Skin Monitoring: Comprehensive Certified Nurse Assistant (CNA) Shower Review . CNA 1 stated that when she was done documenting, she gave the document to LVN 2 and that LVN 2 signed the document. During an interview and concurrent record review with LVN 2 on 6/14/2023 at 10:15 a.m., Resident 1 ' s Skin Monitoring: Comprehensive CNA Shower dated 5/31/2023 was reviewed. LVN 2 stated that she was the assigned licensed nurse for Resident 1 on 5/31/2023. LVN 2 stated after reviewing Resident 1 ' s Skin Monitoring: Comprehensive CNA Shower Review, dated 5/31/2023, that she had signed the document. LVN 2 stated that by her signing the document, it meant that CNA 1 had reported the findings of Resident 1 ' s discoloration on the right forearm on 5/31/2023 to LVN 2. LVN 2 continued to state that when Certified Nursing Assistants (CNAs) report a new finding on a resident, it is the responsibility of the licensed nurses to check the resident to ensure the accuracy of the findings. LVN 2 further stated that she did not check on Resident 1 to confirm the right forearm discoloration because she was too busy. LVN 2 stated that she then forgot to check on Resident 1 ' s right forearm discoloration. LVN 2 stated that she should have checked Resident 1 ' s right forearm discoloration to confirm if the discoloration reported was a new or old finding. LVN 2 stated that if she had evaluated and monitored Resident 1, she could have taken the proper steps of documenting, reporting to the physician, informing the family, and creating a care plan related to Resident 1 ' s right forearm discoloration. A review of the facility ' s policy and procedure titled Wound and Skin Monitoring and Management, revised 7/2021, indicated that nursing staff is responsible for the prompt reporting of any skin related problems to the nurse in charge. Under Assessments: CNAs will complete body checks on resident ' s daily with care and on shower days and report findings to the charge nurse. The charge nurse/licensed nurse is responsible for evaluating and monitoring the resident ' s skin condition, response to treatment, and assess changes in skin integrity. New skin conditions will be communicated to the physician and IDT (Interdisciplinary Team- comprises professionals from various disciplines who work in collaboration to address) for plan of care treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement infection control practices by failing to ensure appropriate signages were placed outside resident rooms that were under isolation for two of three sampled residents. This deficient practice has the potential to spread infection and cross contamination among other residents. Findings: a. A review of Resident 1 ' s Face Sheet (a form providing information to the hospital admitting a patient) indicated the facility readmitted the resident on 6/12/2023 with diagnoses including encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition), Alzheimer ' s disease (a progressive disease that destroys memory and other important mental functions), dementia in other disease classified elsewhere, severe, without behavioral disturbance, psychotic (mental disorder characterized by a disconnection from reality) disturbance, mood disturbance, and anxiety (Intense, excessive, and persistent worry and fear about everyday situations). A review of Resident 1 ' s MDS (Minimum Date Set- an assessment and care screening tool), dated 4/20/2023, indicated Resident 1 ' s cognitive skills for daily decision-making is severely impaired. MDS indicates Resident 1 required extensive assistance with bed mobility, transfers, dressing, and was totally dependent with eating, toilet use, and personal hygiene. During a review of the Physician ' s Order for Resident 1 dated 6/13/2023 indicated Resident 1 contact precautions for Vancomycin-resistant Enterococcus(VRE- bacterial strains that are resistant to the antibiotic vancomycin)/Urinary tract infection (UTI- An infection in any part of the urinary system, the kidneys, bladder, or urethra). Special Instructions: On 5 days oral antibiotics until 6/18/2023. During an observation on 6/16/2023, at 10:14 a.m., outside Resident 1 ' s room, observed no signages outside Resident 1 ' s room indicating Resident 1 ' s room is an isolation room. During an observation and concurrent interview with Registered Nurse 1 (RN 1) on 6/16/2023, at 10:15 a.m., RN 1 observed the outside of Resident 1 ' s room and RN 1 confirmed that there were no signages observed outside Resident 1 ' s room. RN 1 confirmed that Resident 1 has a diagnosis of VRE of the urine and is on contact isolation (used when a patient has an infectious disease that may be spread by touching either the patient or other objects the patient has handled). RN 1 continued to state that there should be a sign outside the door of Resident 1 of the type of isolation that Resident 1 is in. RN 1 stated that signages are important and should be placed outside resident ' s door to inform staff and visitors of the precautions to take and the types of personal protective equipment when in contact with the resident. The facility policy and procedure titled Guidelines for Isolation Precautions, revision date 1/2022, indicated under contact precautions: Based on current literature, these are the recommendations regarding contact isolation for asymptomatic patients with VRE. Required personal protective equipment includes gloves and gown when providing care to the resident. b. A review of Resident 1 ' s Face Sheet indicated the facility readmitted to the facility on [DATE] with diagnoses that included acute respiratory distress disease Covid-19 (a potentially severe, primarily respiratory illness caused by a coronavirus and characterized by fever, coughing, and shortness of breath). A review of Resident 2 ' s MDS, dated [DATE], indicated Resident 2 ' s cognitive skills for daily decision-making is severely impaired. MDS indicated Resident 2 required limited assistance during bed mobility, transfer and required extensive assistance with eating, dressing, and toilet use. A review of Resident 2 ' s care plan titled, Communicable Illness/Infection related to Covid dated 6/15/2023, indicated Contact Precautions wear gown and gloves for all contact with residents and their environment; Droplet Precautions wear gown, gloves, and mask for all physical contact with residents and their environment. During an observation and concurrent interview with RN 1 on 6/16/2023, at 10:21 a.m., observed the outside of Resident 2 ' s room. RN 1 confirmed that there were no signages observed outside Resident 2 ' s room. RN 1 confirmed that Resident 2 is under droplet isolation (an infection with germs that can be spread to others by speaking, sneezing, or coughing) and contact isolation because of Resident 2 ' s Covid-19 diagnosis. The facility policy and procedure titled Covid-19 Facility Mitigation Plan, revision date 12/12/2022, indicated the purpose of this policy is to state our organization ' s understanding of how we ' ll manage and conduct actions under emergency conditions to mitigate the impact of a potential outbreak of covid-19 in the facility. Under signage: Signs are posted outside of resident rooms indicating appropriate transmission-based precautions and required PPE. The facility policy and procedure titled Guidelines for Isolation Precautions, revision date 1/2022, indicated under droplet precautions: Droplet precautions are used to reduce transmission of infectious agents from close respiratory or mucus membrane (the moist, inner lining of some organs and body cavities [such as the nose, mouth, lungs, and stomach]) contact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect resident ' s right to be free from sexual abuse (any sexual activity that occurs without consent [permission]) by Resident 2 for one of seven sampled residents (Resident 1). On 5/23/2023 at 5:00 p.m., Certified Nursing Assistant 1 (CNA 1) observed Resident 2 fondling (the act of molesting [touch in a sexual and improper way] someone sexually by touching or caressing) the right breast of Resident 1, who was dependent on staff for care, has severely impaired cognition (relating to the mental process involved in knowing, learning, and understanding things), and lacked the capacity to consent (give permission) to sexual activity. This deficient practice resulted in Resident 1 being subjected to a nonconsensual (when a resident does not agree or can not agree to participate in an act) sexual assault (the act in which one intentionally sexually touches another resident without that resident's consent) by Resident 2 while under the care of the facility. Based on the reasonable person concept, due to Resident 1 ' s severely impaired cognition and medical condition, an individual subjected to sexual assault has lifetime physical pain and psychological effects including feelings of hopelessness, helplessness, and humiliation. Findings: A review of Resident 1 ' s admission record indicated the facility originally admitted the resident on 3/20/2023, and then readmitted the resident on 4/13/2023 with diagnoses including Alzheimer (a brain disorder that slowly destroys memory and thinking skills) and dementia (impaired ability to remember, think, or make decisions). A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 3/26/2023 indicated Resident 1 had severely impaired cognition (ability to think and make decisions). The MDS also indicated Resident 1 required extensive two person assist with transfers, and one person assistance with all other Activities of Daily Living (ADLs- activities related to personal care) with the exception of eating which only required limited assistance. A review of Resident 1 ' s progress notes dated 5/23/2023 at 5:00 p.m. indicated that CNA 1 observed Resident 2 with his left hand on Resident 1 ' s right chest area. A review of Resident 2 ' s admission record indicated the facility originally admitted the resident on 8/20/2022 and readmitted the resident on 11/4/2022 with diagnoses including dementia, mood disturbance (feelings of distress, sadness or symptoms of depression [persistent feeling of sadness and loss of interest], and anxiety [a feeling of fear, dread, and uneasiness]), mood disorder (a mental health condition that primarily affects your emotional state), and alcoholic cirrhosis of the liver (liver damage caused by heavy use of alcohol). A review of Resident 2 ' s MDS dated [DATE] indicated Resident 2 had severely impaired cognition (ability to think and make decisions). The MDS also indicated Resident 2 required extensive one person assistance with dressing and personal hygiene; one person assistance with toilet use; and supervision with all other ADLs. A review of Resident 2 ' s progress notes dated 5/23/2023 at 5:00 p.m. indicated that CNA 1 observed Resident 2 with his left hand on Resident 1 ' s right chest area. The note further indicated that CNA 1 caught his (Resident 2) attention and he removed his hand quickly. During a concurrent observation and interview with CNA 1 on 5/24/2023 at 3:20 p.m., CNA 1 stated that on 5/23/2023 at approximately 5:00 p.m., she observed Resident 1 and Resident 2 in the facility common area. CNA 1 stated that she was closely behind both residents, approximately inches away as Resident 1 and Resident 2 were at the time sitting next to one another. CNA 1 stated that she then saw Resident 2 ' s left hand touching Resident 1 ' s right breast. Observed CNA 1 moving her hand in a circular motion mimicking Resident 2 ' s hand movement. CNA 1 stated that she immediately told Resident 2 to stop. CNA 1 stated that Resident 2 then began screaming at CNA 1 saying Are you stupid?. CNA 1 stated that she immediately reported the incident to the Charge Nurse (CN). CNA 1 stated that she knew she had to immediately report the incident because it was resident to resident abuse, and CNA 1 had previously received abuse training. CNA 1 stated that it was wrong that Resident 2 was touching Resident 1 ' s right breast because Resident 2 was touching a private part of Resident 1 ' s body. During an interview with Resident 2 on 5/24/2023 at 4:40 p.m., Resident 2 stated he does not remember the incident on 5/23/2023 where he touched Resident 1 ' s breast. During an attempted interview with Resident 1 on 5/24/2023 at 5:30 p.m., Resident 1 was unable to answer questions. During an interview with Resident 1 ' s Psychiatric (a branch of medicine that deals with mental, emotional, or behavioral disorders) Physician (MD 2) on 5/25/2023 at 12:23 p.m., MD 2 was asked if Resident 1 had the capacity to consent to sexual activity. MD 2 stated no, absolutely not. MD 2 stated that both Resident 1 and Resident 2 are demented (a severe mental illness where in a resident is unable to think or act clearly). During an interview with CNA 1 on 5/25/2023 at 12:58 p.m., CNA 1 was asked if the incident on 5/23/2023 where in Resident 2 placed his left hand on Resident 1 ' s right breast appeared accidental or intentional. CNA 1 stated that from what she saw, it looked like Resident 2 intentionally put his right hand on Resident 1 ' s left breast. CNA 1 stated that it appeared that Resident 2 wanted to put his hand on Resident 1 ' s breast. During an interview with the DON on 5/25/2023 at 1:55 p.m., DON was asked if the incident on 5/23/2023 wherein Resident 2 touched Resident 1 ' s breast was accidental or intentional, DON stated that it was not an accident. DON stated that on 5//23/2023, when Resident 2 touched Resident 1 ' s breast, that act was a deliberate action. During an interview with the ADM on 5/25/2023 at 4:21 p.m., ADM stated that she reported the incident that occurred on 5/23/2023 where in Resident 2 touched Resident 1 ' s breast to the SSA because she considered it sexual abuse. ADM stated that Resident 2 touching Resident 1 ' s breast was not appropriate. ADM stated that Resident 2 putting his hand on Resident 1 ' s breast on 5/23/2023 was not an accident because Resident 2 kept his hand on Resident 1 ' s breast. During an interview with the DON on 5/27/2023 at 2:10 p.m., DON stated she does not see why it was an issue that Resident 2 was touching Resident 1 ' s breast because there was no harm to Resident 1. DON was asked, as a woman with intact cognition, would the DON be affected if a man fondled her breast without consent, DON stated, it depends. A review of the facility ' s policy and procedure titled Abuse and Crime Prevention and Reporting last revised on 10/11/2022 indicated that the purpose of the facility ' s policy was to ensure that resident rights are protected from abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a patient-centered comprehensive care plan for one of two sampled residents (Resident 2) who was assessed as elopement risk (a resident who is incapable of adequately protecting himself, and who departs the facility unsupervised and undetected). This deficient practice could result in Resident 2 eloping from the facility. Findings: A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 8/22/2022 with diagnoses including unspecified dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment) with mood disturbance (feelings of distress, sadness, and anxiety [intense, excessive, and persistent worry and fear about everyday situations]). A review of Resident 2 ' s Minimum Data Set (MDS - standardized assessment and care-planning tool) dated 2/26/2023, indicated Resident 2 ' s cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision-making was severely impaired. Resident 2 required supervision with bed mobility, walking, transfers, and eating. On 5/22/2023 at 11:40 a.m., during an interview with Registered Nurse 1 (RN 1) and concurrent review of Resident 2 ' s Elopement Risk assessment dated [DATE], RN 1 stated Resident 2 was at risk for elopement and wandering (going about from place to place without any clear purpose). On 5/22/2023 at 12:49 p.m., during an interview with the MDS Nurse (MDSN) and concurrent review of Resident 2 ' s care plans, the MDSN stated care plans were developed based on the MDS assessment and any problems the resident may have. The MDSN stated there was no care plan developed for Resident 2 ' s elopement and wandering risks. The MDSN stated that care plans are important because interventions are created and documented to inform nursing staff on how to care for a resident or how to prevent an incident from occurring. A review of the facility provided policy and procedure titled Care plans, revised 4/2017, indicated an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident ' s medical, nursing, and psychological needs is developed for each resident. Each resident ' s comprehensive care plan has been designed to: a. incorporate identifies problem areas; b. incorporate risk factors associated with identified problems. Care plans are revised as changes in the resident ' s condition dictate. Under goals and objectives: Care plan goals and objectives are defined as the desired outcomes for a specific resident problem. Care plan goals and objectives are derived from information contained in the resident ' s comprehensive assessment and clinical documentation. Under using the care plan: Changes in the resident ' s condition must be reported to the MDS Assessment Coordinator so that a review of the resident ' s assessment and care plan can be made. A review of the facility provided policy and procedure titled Dementia Care, dated 8/2015, indicated under development of care plan: The interdisciplinary team will assure that the care plans are thorough with a well-defined problem statement that is specific in describing the behavior, approaches/interventions that are measurable, and goals for care to reach stated objectives. The care plan will outline the frequency, intensity, and duration of the behavior. Care plans will be approach specific and define the responsible team members to implement the approach/intervention as well as how they will monitor the approach/intervention for effectiveness on a regular basis.

Based on interview and record review, the facility failed to ensure one of 12 sampled residents (Resident 8) was provided with the necessary behavioral health care services in accordance with the comprehensive assessment and plan of care. Resident 8' s care plan for behavioral symptoms related to dementia (a group of thinking and social symptoms that interferes with daily functioning) with behavioral disturbances dated 3/16/2023 indicated that Resident 8 would be followed up by a psychiatrist if appropriate, the follow up was not done until 4/19/2023. This deficient practice had the potential to negatively affect the resident ' s psychosocial (the mental, emotional, social, and spiritual effects of a disease) well-being. Findings: A review of Resident 8' s admission Record indicated the facility admitted the resident on 12/05/2022 with diagnoses including Alzheimer ' s disease (a progressive disease that destroys memory and other important mental functions), dementia with psychotic disturbances, psychosis (a mental health problem that causes people to perceive or interpret things differently from those around them), mood disorder, and depression. A review of Resident 8' s Minimum Data Set (MDS-a standardized assessment and screening tool) dated 3/11/2023 indicated Resident 8' s cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) for daily decision making was severely impaired, and that the resident required limited to extensive assistance with activities of daily living (ADL, such as bed mobility, dressing, eating, toilet use, and personal hygiene). A record review of Resident 8' s care plan with the problem of behavioral symptoms related to dementia with behavioral disturbances initiated on 3/16/2023 indicated; history of episode of physical aggression sudden mood changes from calm to agitation, history of physical contact toward another resident manifested by (m/b) physical contact using backhand. One of approaches was to follow up with a psychiatrist if appropriate. A record review of Resident 8' s doctor ' s progress notes dated 4/5/2023 indicated, since admission, the resident was very combative, especially during shower and care, very difficult to be redirected by staff, very high risk of fall due to current mental status and combativeness. During a concurrent interview and record review on 4/19/2023 at 4:30 p.m., the Director of Nursing (DON) reviewed Resident 8' s care plan dated 3/16/2023 for the problem of behavioral symptoms related to dementia with behavioral disturbances and the doctor ' s progress notes dated 4/5/2023. The DON verified that the facility did not provide psychiatric or psychological services for Resident 8 since admission. When the DON was asked whether Resident 8 should be evaluated by the psychiatrist or a psychologist with behavioral issues and taking of psychotropic medications such as Depakote (to treat mood disorder m/b suddenly changing from calm to agitation), Seroquel (to treat physical aggression m/b striking out), and Ativan (to treat anxiety m/b feeling anxious and aggressive behavior towards other during care), the DON stated that Resident 8 needed to be evaluated by the psychiatrist due to the resident ' s ongoing behavioral issues with confusion and wandering episodes. A review of the facility ' s Policy and Procedures dated 2/2014, titled Behavioral symptom management: Assessment, intervention, and documentation indicated, To assure that each resident/patient receives an appropriate assessment of behavioral symptoms with appropriate interventions prior to and after starting psychotherapeutic medications . Consider referring resident/patient and/or resident ' s/patient ' s authorized representative to a support group for residents/patients with mental illness Identify additional resources if resident/patient does not respond to usual interventions and/or medications through the interdisciplinary team process, case managers etc.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident ' s right to be free from resident-to-resident physical abuse for one of four sampled residents (Resident 1).m on 3/11/2023, at 8:50 a.m., Resident 2 slapped Resident 1 on the neck area. This deficient placed Resident 1 at risk of injury and psychosocial outcome. Findings: A review of Resident 1 ' s admission Record, indicated the facility originally admitted the resident on 3/7/2022 with a readmission dated 8/2/2022. Resident 1 ' s diagnoses included dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 1 ' s Minimum Data Set (MDS- a standardized assessment and care-screening tool), dated 12/13/2022, indicated the resident usually could understand and be understood. A review of Resident 1 ' s Event Report dated 3/11/2023, timed at 8:55 a.m., indicated the resident was involved in a physical altercation with another resident and did not sustain any injury. A review of Resident 2 ' s admission Record, indicated the facility originally admitted the resident on 2/15/2021 with diagnoses included dementia. A review of Resident 2 ' s MDS, dated [DATE], indicated the resident usually had the ability to understand and be understood. During an interview on 3/13/2023 at 12:45 p.m., Certified Nursing Assistant 1 (CNA 1) stated that just after breakfast on 3/11/2023, she was standing about five to six feet away from where Resident 1 and Resident 2 were sitting, next to each other watching television in the common area. Resident 1 was seated on the right side of Resident 2. Resident 2 reached across from her left side of the body toward the right side where Resident 1 was sitting and slapped Resident 1 on her neck area between the chin and shoulder with an open palm one time. CNA 1 stated she ran over and immediately separated them. CNA 1 stated that it was a light slap but there was physical contact between the two residents. CNA 1 stated Resident 1 did not appear frightened or hurt and Resident 2 did not respond when and asked her why she hit Resident 1. During an interview on 3/13/2023 at 2:00 p.m., Licensed Vocational Nurse 1 (LVN 1) stated that on 3/11/2023, after breakfast, she was called over by other staff regarding a physical altercation between two residents. LVN 1 stated Resident 1 was immediately checked and did not have any redness or swelling in the area she was slapped. During a concurrent interview and record review on 3/23/23 at 3:30 p.m., the Director of Nursing (DON) verified that the facility ' s policy indicated the residents have the rights to be free from any form of abuse. A review of the facility ' s policy titled, Abuse and Crime Prevention and Reporting, dated 12/20/2016 and revised 10/11/2022, indicated it is the policy of the facility to ensure that the resident rights are protected from abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident ' s right to be free from abuse for one of three sampled residents (Resident 1). On 3/5/2023, during breakfast, Resident 2 threw cold coffee to Resident 1 splashing her on the shoulder area. This deficient practice resulted in Resident 1 being subjected to abuse from Resident 2. Findings: A review of Resident 1 ' s admission Record, indicated the facility admitted the resident on 9/1/2021 with diagnoses including dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 1 ' s Minimum Data Set (MDS- a standardized assessment and care-screening tool), dated 12/7/2022, indicated the resident had the ability to usually understand others and could be understood by others. A review of Resident 2 ' s admission Record, indicated the facility admitted the resident on 7/9/2022 with diagnoses including dementia. A review of Resident 2 ' s MDS dated [DATE], indicated the resident had the ability to usually understand others and could be understood by others. During an interview on 3/13/2023 at 2:45 p.m., the Certified Nursing Assistant 1 (CNA 1) stated that it was near the end of breakfast time on 3/5/2023 Resident 1 and Resident 2 were sitting across the table from each other. CNA 1 stated she saw Resident 2 throw a piece of bread toward Resident 1, but the bread did not hit Resident 1 and fell on the table. As another staff took the bread away from Resident 2, CNA 1 stated that she went behind Resident 1 to try to move Resident 1 away from the table area. CNA 1 stated that at this time Resident 2 grabbed a white foam cup near her and threw the contents inside the cup toward Resident 1. CNA 1 stated that the liquid content splashed on Resident 1 ' s shoulder as well as on CNA 1 ' s abdomen and leg areas. CNA 1 stated that the contents splashed on Resident 1 and CNA 1 was cold coffee. CNA 1 stated that Resident 1 just stated she ' s awful about resident 2. CNA 1 stated that Resident 2 threw the bread and splashed the coffee on purpose and that it was not by accident. During an interview on 3/13/2023 at 2:15 p.m., the Licensed Vocational Nurse 1 (LVN 1) stated she was assigned as the charge nurse on 3/5/2023. LVN 1 stated she heard a commotion in the dining area so she went over to make sure everything was okay. LVN 1 stated that she observed CNA 1 taking Resident 1 away from near the round table she was sitting by. LVN 1 stated that she did not see the incident take place where Resident 2 splashed Resident 1 and CNA 1 with the coffee, but that CNA 1 reported the incident to her. LVN 1 stated that Resident 1 denied any pain upon assessment. During a concurrent interview and record review on 3/23/2023 at 3:40 p.m., the Director of Nursing (DON) verified on the facility ' s policies and procedures that this incident violated the facility ' s policy to ensure that Resident 1 was free from abuse. The DON stated that by regulation Resident 1 was not free from abuse when she was splashed on the shoulder with the coffee. A review of the facility ' s policy titled, Abuse and Crime Prevention, dated 12/20/2016 and revised 10/11/2022, indicated it is the policy of the facility to ensure that the resident rights are protected from abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure one of five sampled residents (Resident 2) was free from physical abuse (causing injury, trauma, bodily harm or other physical suffering to another person by way of bodily contact) when Resident 3 used his hand to hit Resident 2's face on 2/9/2023. This deficient practice resulted in Resident 2 sustaining red discoloration to her face and had the potential for Resident 2 to be subjected to feeling fearful, withdraw from social activities, and experience sleep disturbance. Findings: A review of Resident 2 ' s admission Face Sheet indicated that the resident was a [AGE] year-old female admitted to the facility with a medical history of mental confusion. A review of Resident 2 ' s Minimum Data Set (MDS, a tool for resident assessment), dated 12/7/22, indicated Resident 2 ' s ability to think clearly and remember words was severely impaired. A review of Resident 2 ' s Event Report (a document that describes an event)dated 2/9/23, indicated that Resident 2 was status post (s/p- the resident ' s condition after an event)s/p physical contact being made to the right side of Resident 2 ' s face by another resident (Resident 3). The assessment further indicated that Resident 2 was noted with blanchable redness (when pressing on an area of the skin it causes the redness to temporarily be lost) sized at 10-centimeter (cm-unit of measurement) by five (5) cm . The form indicated that another resident used the back of his left hand to make physical contact to Resident 2 ' s right side of the face. A review of Resident 2 ' s Comprehensive Care Plan, dated 2/9/23, indicated the facility created a care plan for Resident 2 potentially experiencing distress related to the physical altercation with Resident 3. A review of Resident 3 ' s admission Face Sheet indicated that the resident was a [AGE] year-old male, admitted to the facility with a medical history of mental confusion and aggressive behavior. A review of Resident 3 ' s MDS, dated [DATE], indicates the cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) of Resident 3 was moderately impaired. A review of Resident 3 ' s Event Report, dated 2/9/23, indicated that Resident 3 used his left back of hand to make physical contact with another residents (Resident 2) right side of the face. During an interview on 2/17/23 at 6:00 PM, Administrator (ADM) stated that the physical altercation between Resident 3 and Resident 2 on 2/9/23 was witnessed by facility staff and resulted in Resident 2 having an area of reddened skin on the right side of her face. During an interview on 2/20/23 at 4:50 PM, ADM 1 stated that even though neither Resident 2 nor Resident 3 remembered the altercation on 2/9/23, the physical altercation was physical abuse. A review of the facility policy titled Section: I Operations Title: Abuse and Crime Prevention and Reporting dated 12/20/16, revised 10/11/22, indicated to ensure that resident rights are protected from abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all alleged violations involving abuse including injuries of unknown source were reported immediately, but no later than two hours after the allegation was made, to the State Survey Agency (SSA), the Ombudsman Program (residents' advocate group), and law enforcement as per its policies on abuse for four of eight sampled residents (Residents 1, 3, 4, and 5). The facility did not report when: 1. Resident 1 informed Certified Nursing Assistant 1 (CNA 1) that Resident 2 spat on her and pushed a table towards her. 2. CNA 2, Licensed Vocational Nurse 4 (LVN 4) and Registered Nurse 2 (RN 2) documented a grievance on 10/9/2022 about Family Member 1 (FM 1) yelling at Resident 3 and using profanity over the phone. 3. FM 2 emailed SS 1 on 10/26/2022 concerned about Resident 5 having black spot areas on the side of the head and questioning why staff did not know was hitting the resident. 4. FM 3 called LVN 3 on 5/17/2022 after Resident 4 told him she was hit by someone. These deficient practices resulted in no investigations conducted to rule out abuse and placed the residents at risk for further abuse. Findings: 1. A review of Resident 1 ' s admission Record (Face Sheet) indicated the facility admitted the resident on 11/28/2022 with diagnoses including Alzheimer ' s disease (a brain disease that affects memory, language and thinking skills). A review of Resident 1 ' s History and Physical dated 11/30/2022, indicated resident was able to make needs known and able to make simple medical decisions. A review of Resident 2 ' s MDS dated [DATE], indicated Resident 2's cognitive skills for daily decisions were moderately impaired (obvious difficulty with problem-solving, remembering names and details, and may withdraw socially as new situations and places are challenging). During an interview on 1/20/2023 at 10:44 a.m., CNA 1 stated Resident 1 informed her that Resident 2 (her roommate) spat on her and pushed a table towards her. CNA 1 stated she cannot remember when she was informed, and she did not report the allegation to anybody. CNA 1 stated she did not report the allegation because it did not happen in her shift. During an interview on 1/20/2023 at 1:41 p.m., the Director of Staff Development (DSD) stated CNA 1 should have reported to a supervisor Resident 1 ' s allegation of abuse. During an interview on 1/20/2023 at 2 p.m., Resident 1 stated Resident 2 spat on her face and yelled at her (unable to recall when) which made her mad. During an interview on 1/20/2023 at 2:39 p.m., ADM stated she was not informed of the allegation. 2. A review of Resident 3 ' s admission Record indicated the facility admitted the resident on 1/11/2023 with diagnoses including Alzheimer ' s disease. A review of Resident 3 ' s MDS, dated [DATE], indicated Resident 3 ' s cognitive skills for daily decisions were severely impaired. On 1/20/2023 at 3:49 p.m., a review of the Grievance Log dated 10/9/2022 indicated on 10/9/2022 at 6:15 p.m., CNA 2 heard FM 1 on the phone yelling and using profanity at Resident 3. CNA 2 reported the incident to LVN 4 who reported to RN 2. RN 2 reported to ADM who instructed RN 2 to fill out a Grievance Issues and Concerns form. On 1/20/2023 at 4:41 p.m., during an interview, ADM stated the incident sounded like an argument and not abuse. 3. A review of Resident 5 ' s admission Record indicated the facility admitted the resident on 7/3/2022 with diagnoses including Parkinson ' s disease (a progressive disorder of the nervous system that affects movement) and dementia (a group of thinking and social symptoms that interferes with daily functioning). A review of Resident 5 ' s MDS, dated [DATE], indicated Resident 5 ' s cognitive skills for daily decisions were severely impaired. On 1/23/2023 at 11:01 a.m., during an interview with SS1 and concurrent review of the Grievance Log, dated 10/26/2022 indicated FM 2 emailed reporting that for the second or third time he saw Resident 5 with black spots on the side of her head and no one knew who hit her. SS 1 stated ADM was informed. SS 1 stated she did not ask nursing and did not because she was hit and so she would not file a report of allegation of abuse. SS 1 stated she did not document FM 2 ' s allegation someone was hitting Resident 5. During an interview on 1/23/2023 at 11:31 a.m., ADM stated she did not read the full email from FM 2. 4. A review of Resident 4 ' s admission Record indicated the facility re-admitted the resident on 4/19/2019 with diagnoses including dementia. A review of Resident 4 ' s MDS dated [DATE], indicated Resident 4 ' s has moderately impaired cognition. A review of the Grievance Log dated 5/17/2022, indicated FM 3 called LVN 3 and told her that the resident told her Someone hit her. On 1/23/2023 at 4:52 p.m. during an interview with LVN 3 and concurrent review of the Grievance Log, dated 5/17/2022, LVN 3 stated she received a phone call from FM 3 about the resident telling him someone hit her. LVN 3 stated she immediately notified the RN 2. On 1/23/2023 at 4:46 p.m. during an interview, ADM confirmed FM 3 allegation was not reported to the SSA. A review of facility ' s policy and procedure titled, Abuse and Crime Prevention and Reporting dated 10/11/2022, indicated, It is the policy of this facility to implement steps to potentially prevent, report and investigate in accordance with local, state and /or federal laws and regulations, to the appropriate agency, any allegations of and /or suspected conditions of abuse. All employees and covered individuals of the facility who observed, reasonably suspect, or have knowledge of an incident of abuse are to report to his/her supervisor and / or Abuse Prevention Coordinator and may also separately report directly to the appropriate agencies without fear of retaliation /reprisal. When an allegation or reasonable suspicions occurs of alleged or known incident involves abuse or serious bodily injury, repot to police, CDPH (SSA) and Ombudsman immediately and not more than two hours.

Based on observation, interview, and record review, the facility failed to ensure a resident's dignity was preserved by not having a privacy cover over the urinary catheter (tube placed in the body to drain and collect urine from the bladder) drainage bag for one of one sampled resident (Resident 61). This deficient practice violated Resident 61's rights to dignity and privacy. Findings: A review of Resident 61's Face Sheet indicated the facility admitted the resident on 8/2/2022, with diagnoses including obstructive and reflux uropathy (condition in which the flow of urine is blocked and causes urine to flow backward), encounter for fitting and adjustment of urinary device (Foley catheter - thin, flexible tube inserted into the bladder to drain urine), and Alzheimer's disease (a progressive brain disorder that slowly destroys memory and thinking skills). A review of Resident 61's Minimum Data Set (MDS - an assessment and care screening tool), dated 11/9/2022, indicated the resident had the ability to make self-understood and had the ability to usually understand others. The MDS further indicated Resident 61 required extensive assistance with bed mobility, dressing, and personal hygiene and was totally dependent on staff with toilet use. A review of Resident 61's physician orders indicated the following order: Foley catheter French (Fr - unit of measure indicating the diameter of the catheter tube) #16/10 milliliter (ml - unit of measure) to drainage bag. Check every (q) shift, ordered on 11/3/2022. During an observation, on 12/19/2022 at 8:53 a.m., observed Resident 61 lying in his bed located next to the doorway. Observed urinary catheter drainage bag positioned and hanging on the right side of Resident 61's bed toward the door with no privacy cover and observable from the hallway. During a concurrent observation and interview, on 12/19/2022 at 9 a.m., Certified Nursing Assistant 2 (CNA 2) observed and verified Resident 61 did not have a privacy cover over his urinary catheter drainage bag. CNA 2 stated the resident should have been provided privacy by always covering the urinary catheter drainage bag so that the bag is not exposed to staff and other residents passing by the room. During an interview, on 12/22/2022 at 4:19 p.m., the Director of Nursing (DON) confirmed Resident 61's urinary catheter drainage bag should have been covered with a blue dignity bag. The DON stated the catheter drainage bag should have also been placed on the left side of the resident's bed facing away from the hallway as much as possible to prevent exposing Resident 61's urinary catheter to other residents and staff walking by. The DON stated the purpose of privacy covers is to maintain the resident's right to dignity and privacy. During an interview, on 12/23/2022 at 12:58 p.m., the DON checked and verified the facility does not have a policy and procedure that specifically addresses the need to have the urinary catheter bag covered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 79's Face Sheet indicated that the facility admitted the resident on 11/1/2022, with a diagnosis of diabetes mellitus (DM, a chronic condition that affects the way the body processes blood sugar [glucose]). A review of Resident 79's History and Physical, dated 11/4/2022, indicated that the resident had DM, with peripheral neuropathy (a nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness in different parts of the body), with fasting sugar blood glucose (FSBG, measures the amount of glucose in the blood when it should be at its lowest) three times a day with insulin coverage. A review of Resident 79's MDS, dated [DATE], indicated that the resident had the ability to make self-understood and understand others. The MDS also indicated that the resident had been receiving insulin injections. A review of Resident 79's Care Plan, dated 11/1/2022, indicated that the resident had alteration in endocrine system (consists of the glands that produce and release different types of hormones directly into the bloodstream) related to diabetes mellitus. The care plan indicated an intervention to observe for signs and symptoms of infection/changes to skin integrity. A review of Resident 79's Physician Order Report (current and active physician's orders for residents), dated 11/6/2022, indicated: -Blood sugar check (an easy way to measure the amount of glucose in the blood by making a small prick into your fingertip and collecting a blood sample into a specially designed test strip) for DM, three times a day (7:30 a.m., 12:30 p.m., and 4:30 p.m.). -Novolog U-100 insulin (insulin aspart u-100) (a fast-acting insulin that controls blood sugar around mealtimes) solution, 100 units/milliliter (units/ml, unit of measure per volume) per sliding scale (varies the dose of insulin based on blood glucose level). If Blood Sugar (BS) is less than 70, call Medical Doctor (MD). If BS is 71 to 250, give 0 units. If BS is 251 to 300, give 3 units. If BS is 301 to 350, give 5 units. If BS is 351 to 400, give 7 units. If BS is greater than 400, give 10 units. If BS is greater than 400, call MD. Subcutaneous, call MD for less than 70 more than 500 Three times a day before meals (7:30 a.m., 11:30 a.m., and 4:30 p.m.) A review of Resident 79's Administration History for Insulin (a report indicating the date, time, and what body part the insulin administered) from 11/19/2022 to 12/19/2022 indicated that on: 11/19/2022 at 4:40 p.m. - site: left lower quadrant of the abdomen (LLQ) 11/20/2022 at 7:30 a.m. - site: LLQ 11/24/2022 at 7:30 a.m. - site: right lower quadrant of the abdomen (RLQ) 11/25/2022 at 11:30 a.m. - site: RLQ 12/2/2022 at 4:30 p.m. - site: LLQ 12/3/2022 at 7:30 a.m. - site: LLQ 12/5/2022 at 11:30 a.m. - site: LLQ 12/6/2022 at 4:30 p.m. - site: LLQ 12/7/2022 at 11:30 a.m. - site: LLQ 12/8/2022 at 4:30 p.m. - site: LLQ 12/9/2022 at 11:30 a.m. - site: LLQ 12/12/2022 at 11:30 a.m. - site: LLQ 12/13/2022 at 11:30 a.m. - site: LLQ 12/16/2022 at 4:30 p.m. - site: LLQ 12/17/2022 at 11:30 a.m. - site: LLQ 12/18/2022 at 11:30 a.m. - site: LLQ 12/19/2022 at 11:30 a.m. - site: LLQ During an interview and record review of Resident 79's clinical record on 12/20/2022 at 10:40 a.m., LVN 2 stated that there were multiple times that the insulin injection site was not rotated as indicated on Resident 79's Administration History for Insulin. LVN 2 stated that repeated administration of insulin on the same site will cause bruising and can also cause bumps and tissue hardening that may result in decreased insulin absorption. During an interview on 12/21/2022 at 1:24 p.m., the DON stated that the site of insulin administration should be rotated due to potential adverse effects such as potency of the medication will be decreased due to tissue hardening of the area that is frequently accessed for administration. A review of the facility's recent policy and procedure titled, Preparing Insulin Injections, last reviewed on 10/28/2022, indicated that routine injections- site of injection should be rotated. A review of Manufacturer's Guideline (are paper handouts that come with many prescription medicines that addresses the issues that are specific to a particular drug and drug classes and contain Food and Drug Administration [FDA, responsible for protecting the public health by ensuring safety, efficacy, and security of human and veterinary drugs, biological products, and medical devices] -approved information that can help residents avoid serious adverse events) for Novolog (insulin aspart [rDNA origin-molecule inside cells that contains the genetic information responsible for the development and function of an organism] injection) solution for subcutaneous use, initial U.S. Approval: 2000, indicated that injection sites should be rotated within the same region to reduce the risk of lipodystrophy (a condition that is characterized by a complete or partial loss of and/or abnormal distribution of adipose[fat] tissue in certain areas of the body). Based on observation, interview, and record review, the facility failed to ensure professional standards were met for two of five sampled residents (Resident 21 and 79) by the licensed nurse by: 1. Failing to follow facility's policy and procedure in identifying Resident 21 prior to medication administration. This deficient practice had the potential to negatively affect the delivery of necessary care and services for Resident 21. 2. Failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin (a hormone that lowers the level of sugar in the blood) administration sites for Resident 79. This deficient practice had the potential to cause unnecessary tissue trauma and hardening of the area where frequent subcutaneous administration occurred that could lead to impaired absorption (a condition in which the body takes in another substance) of insulin. Findings: a. A review of Resident 21's Face Sheet indicated the facility admitted the resident on 11/6/2022, with diagnoses including dementia (a syndrome of memory disorders, personality changes, and impaired reasoning that interferes with daily functioning) and Alzheimer's disease (a brain disease that slowly destroys brain cells). A review of Resident 21's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/11/2022, indicated the resident's cognition (ability to think, understand, and reason) was severely impaired. The MDS indicated the resident required extensive assistance (resident involved in activity, staff provide weight-bearing support) with dressing, toilet use, and personal hygiene with physical assistance from the nursing staff. A review of Resident 21's Physician Orders indicated the following orders: - Systane eye drops, 1 drop on eye for dry eyes, dated 7/12/2022. - Omega-3 fish oil (supplement) 300 milligrams (mg, a unit of measure for weights) 1 capsule, oral, twice a day, for hyperlipidemia (abnormally elevated levels of any or all lipids or lipoproteins [fat] in the blood), dated 7/5/2022. - Tylenol (pain medication) 650 mg, oral, three times a day, dated 10/15/2022. - Vitamin D3 50 micrograms (mcg, a unit of measure for weights), oral, for vitamin D deficiency, dated 7/6/2022. - Symbicort 80/4.5 (a combination of a steroid and bronchodilator [relaxing the muscles in the lungs and widening the airways] medication) inhaler (breathed in) 2 puffs, inhalation for chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs), dated 7/5/2022. - Duloxetine (antidepressant medication) 60 mg delayed release, 1 capsule, delayed release, for depression (a mood disorder that involves a low mood and a loss of interest in activities) manifested by verbalization of sadness, dated 7/14/2022. - Losartan (medication used to lower blood pressure) 50 mg, oral, for hypertension (a condition in which the blood vessels have persistently raised pressure), dated 7/6/2022. During an observation on 12/21/2022 at 7:37 a.m., the Licensed Vocational Nurse 1 (LVN 1) prepared Resident 21's 8:30 a.m. scheduled medications. During a concurrent observation and interview on 12/21/2022, at 7:41 a.m., the LVN 1 confirmed a total of six medications and one fish oil (supplement) to be administered. LVN 1 crushed the tablets and mixed in the apple sauce and placed medications on a small medication tray. LVN 1 stated during medication administration his medication cart is parked in the nursing station and only brings the medications on a tray with him. During an observation on 12/21/2022 at 7:43 a.m., observed Resident 21 sitting in the common area. Observed LVN 1 called Resident 21 by first name and told the resident he will give the resident his medications. Observed LVN 1 administer the medications he prepared to the resident. During an interview on 12/21/2022 at 7:51 a.m., LVN 1 stated the facility does not use wrist band to identify residents. LVN 1 stated he assumed the resident was Resident 21 because the resident had a walker next to him labeled with Resident 21's name. LVN 1 stated he usually would ask the Certified Nursing Assistant (CNA), who is most familiar with the residents, to help identify the residents. LVN 1 stated if the resident is interviewable he would ask them to tell him their name and date of birth . LVN 1 stated he would also reference the photograph attached to the medical record as means of identifying a resident. LVN 1 stated he should have asked a CNA to verify the resident's identity since he did not have access to the resident's medical record while he was giving the resident his medications. LVN 1 stated the purpose of ensuring that medication is administered to the right resident is to prevent errors in medication administration. During an interview on 12/23/22 at 7:49 a.m., the Director of Nursing (DON) stated there are eight medication administration rights that includes the right patient, right medication, right time, right dose, right route, right position, right to refuse, and right to document. The DON stated during medication administration the facility's policy and procedure when identifying the right resident is to check the photo of the resident on the electronic medication administration record and compare next to the resident. The DON stated the second option would be for LVN 1 to call another facility staff to confirm the resident's identity, preferably a certified nursing assistant who is familiar of the resident. The DON stated if the LVN 1 failed to follow their facility's medication administration policy and procedure in identifying the right resident then it could result in administering the medications to the incorrect resident and may cause unwanted adverse effects. A review of the facility's policy and procedure titled, Medication Administration, reviewed and approved on 10/28/2022, indicated that residents are identified by at least two methods before medications are administered including checking identification band, checking the photograph attached to medical record, if necessary, verify resident identification with other facility personnel.

Based on observation, interview, and record review, the facility failed to ensure a resident who required assistance with nail trimming was provided care and services to maintain good personal hygiene for one of one sampled resident (Resident 10) investigated under activities of daily living (ADL, activities related to personal care). This deficient practice has the potential to result in a negative impact on the resident`s self- esteem due to an unkempt appearance. Findings: A review of Resident 10's Face Sheet indicated the facility admitted the resident on 4/3/2022, with diagnoses including Parkinson's disease (a progressive nervous system disorder that affects movement) and dementia (a syndrome of memory disorders, personality changes, and impaired reasoning that interferes with daily functioning). A review of Resident 10's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/9/2022, indicated the resident's cognition (ability to think, understand, and reason) was severely impaired. The MDS indicated the resident required extensive assistance (resident involved in activity, staff provide weight-bearing support) with personal hygiene with physical assistance from two or more persons. A review of Resident 10's Self-Care Deficits and Impaired Mobility Care Plan, last reviewed/revised 12/14/2022, indicated the resident with goals to maintain ADL ability and mobility included interventions of daily ADL care. During an observation on 12/20/2022 at 3:10 p.m., observed Resident 10 sitting on her wheelchair by the nursing station reading a magazine. Observed Resident 10's fingernails free edge with black debris deposits. During concurrent observation and interview on 12/21/2022 at 3:28 p.m., observed Resident 10 sitting in the wheelchair in the common area. CNA 1 confirmed black deposits underneath the free edge of the resident's fingernails. CNA 1 stated she will inform the charge nurse that the resident's fingernails need trimming. CNA 1 stated the resident's fingernails should be kept clean. During an interview on 12/23/22 at 8:13 a.m., the DON stated the Nursing Assistants are to provide nail care regularly by keeping the residents' fingernails clean and filed. The DON stated that nail care should be provided to the residents for infection control and to assist with residents' personal hygiene. A review of the facility's policy and procedure titled, Nail Care, reviewed and approved on 10/28/2022, indicated that it is the facility's policy to understand that importance of cleaning nails clean and trimmed. The procedure indicated nail care includes daily cleaning and regular trimming.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 68) had heel protectors on as ordered by the physician. This deficient practice placed the resident at risk for skin breakdown or further skin breakdown and development of pressure ulcers (a wound that occurs as a result of prolonged pressure on a specific area of the body). Findings: A review of Resident 68's Face Sheet (admission record) indicated the facility admitted the resident on 4/7/2021 with a readmission date of 4/20/2022 with diagnoses that included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), and chronic kidney disease (gradual loss of kidney function). A review of Resident 68's Minimum Data Set (MDS - an assessment and care screening tool) dated 10/27/2022 indicated the resident had the ability to make self-understood and had the ability to understand others. A review of Resident 68's physician orders indicated an order for heel protectors for blanchable redness both heels, ordered on 4/20/2022. A review of Resident 68's Braden Scale Assessment (a tool used to predict pressure ulcer risk) dated 10/26/2022, indicated the resident was at moderate risk for pressure ulcer development. A review of Resident 68's Care Plan in regards to risk for impaired skin integrity, initiated on 4/8/2021, indicated an intervention for heel protectors to both heels for skin maintenance. During an interview on 12/19/2022 at 3:01 p.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated Resident 68 will have heel protectors on when she is on her wheelchair and while in bed resident is on the low air loss mattress (LALM, a pressure-relieving mattress used to prevent and treat pressure ulcers). During an interview on 12/21/2022 at 10:56 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 68 will have heel protectors on when she is on her wheelchair and when in bed resident will have it off and be on the low air loss mattress. During an observation on 12/22/2022 at 2:15 p.m., observed Resident 68 sitting on her wheelchair with both feet on foot rest and did not have heel protectors on. During a concurrent observation and interview on 12/22/2022 at 2:17 p.m., with Certified Nursing Assistant 3 (CNA 3), observed and verified Resident 68 sitting on wheelchair and with feet resting on foot rest and did not have heel protectors on. CNA 3 stated she was not sure if Resident 68 has an order for heel protectors. CNA 3 stated Resident 68 had redness on her heels in the past and was using the heel protectors for that but does not have redness anymore. During a concurrent observation, interview, and record review on 12/22/2022 at 2:25 p.m., with LVN 2, reviewed Resident 68's physician orders. LVN 2 verified Resident 68 has a current active order for heel protectors. LVN 2 stated Resident 68 is to have it on when she is on her wheelchair. Observed and verified with LVN 2, Resident 68 sitting on her wheelchair with feet resting on foot rest and did not have heel protectors on. LVN 2 stated Resident 68 should have the heel protectors on. LVN 2 stated the importance for heel protectors is to prevent pressure to the area. LVN 2 stated too much pressure and the resident can have opening of the skin. LVN 2 stated heel protectors are used to prevent pressure ulcers. During an interview on 12/22/2022 at 4:11 p.m., with the Director of Nursing (DON), the DON stated Resident 68 should have heel protectors on when she is on her wheelchair. The DON stated the purpose of heel protectors is to relieve pressure and used for preventative measures. A review of the facility's policy and procedure titled, Wound and Skin Management, last reviewed on 10/28/2022, indicated, It is the policy of this facility that any resident/patient who enters the facility without pressure sores will have appropriate preventative measure taken to ensure that the resident/patient does not develop pressure ulcers unless the resident's/patient's clinical condition makes the development unavoidable .Interdisciplinary team (IDT), licensed nurses, and certified nursing assistants (CNAs) will assure the following preventative measures for residents/patients at risk for skin breakdown: provide pressure-redistribution device for chair if the resident/patient is confined to a chair .Provide other pressure relief devices such as pillows, foam wedges and soft splints to keep bony prominences from direct contact with one another or other unrelieved pressure as per residents plan of care and physicians orders.

Based on observation, interview, and record review, the facility licensed staff failed to label the intravenous (IV, into or within a vein) insertion site (areas where IV lines are placed) of the intravenous catheter (a device used to provide intravenous fluids, drugs, or blood transfusions) dressing per facility protocol to one out of four sampled residents (Resident 29) who had an ongoing intravenous fluids (especially formulated liquids injected into a vein) due to poor oral (by mouth) intake. This deficient practice had the potential to place Resident 29 for intravenous site insertion complications such as extravasation (the unintentional leakage of fluids or medications from the vein into the surrounding tissue), swelling, and infection in the insertion site. Findings: A review of Resident 29's Face Sheet indicated that the facility admitted the resident on 5/24/2022. The facility readmitted the resident on 10/31/2022, with diagnoses including atrial fibrillation with rapid ventricular response (an irregular heartbeat that occurs when the electrical signals in the atria [the two upper chambers of the heart] fire rapidly at the same time), pulmonary embolism (a sudden blockage of an artery [blood vessel] in the lung), and thrombosis of right femoral vein (a clot in the long vein in the thigh). A review of Resident 29's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/7/2022, indicated that the resident sometimes made self-understood and understand others. The MDS also indicated that the resident had malnutrition (a condition caused by not getting enough calories or the right amount of key nutrients, such as vitamins and minerals, that are needed for health) and had complaints of difficulty or pain with swallowing. The MDS further indicated that the resident while in the facility had parenteral (a form of nutrition that is delivered into a vein)/IV feeding. A review of Resident 29's Physician Order Report, dated 12/16/2022, indicated an order for 1 liter (L- a measure of volume for liquid) sodium chloride (also known as salt, is an essential compound our body uses to absorb and transport nutrients, maintain blood pressure, and maintain the right balance of fluid) 0.9 percent (%, a relative value indicating hundredth parts of any quantity) infuse intravenously (a method of putting fluids, including drugs, into the blood stream) at a continuous rate of 75 milliliters per hour (ml/hr, the desired rate of administration) until further order for poor oral intake. A review of Resident 29's Care Plan, dated 12/16/2022, indicated a goal of IV access will be maintained and free of serious local or systemic complications so that the resident can successfully complete prescribed therapy. The care plan indicated an intervention to rotate (changing the location of intravenous insertion) peripheral sites every 72 hours and when needed (PRN). During an observation on 12/19/2022, at 10:10 a.m., observed Resident 29 with an ongoing IV of 0.9% sodium chloride running at the rate of 75 ml/hr on the right hand. The IV dressing on the right hand did not have any label on it. During an observation and interview on 12/19/2022, at 10:40 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated that the IV site was not labeled. LVN 1 further stated that the IV should have been labeled with the date and the initials of the nurse who inserted the IV line. LVN 1 also stated that the dressing should be changed every 72 hours. LVN 1 stated that the purpose of labeling the IV site was to determine whether it was time to change the dressing of the line or rotate the insertion site to prevent infection and other complications of IV therapy. During an interview on 12/20/2022, at 9:57 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated that it was important to know when the IV site was started, and who was the person who inserted it. LVN 2 further stated that it was important to label the dressing in the insertion site to know it if it was time to change the IV; the IV site was only good for 72 hours; and they should check for irritation and infection at the site. During an interview on 12/21/2022, at 1:30 p.m., with the Director of Nursing (DON), the DON stated that the staff should have labeled the IV insertion dressing site with the date and initial of the nurse who inserted the IV to know when to change the dressing and when to change the IV catheter. The IV catheter was good for 72 hours per the DON. A review of the facility's recent policy and procedure titled Insertion of a Peripheral I.V. Device, last reviewed on 10/28/2022, indicated that it is the recommendation of this facility to establish infusion sites using aseptic technique (medical practices and procedures that help protect residents from dangerous germs). Peripheral infusion devices shall be removed routinely every 72 hours. Residents with limited peripheral venous access may be maintained at longer intervals with a physician's order. Label the dressing with the date and time the site was inserted, the gauge and length of the catheter inserted, and the initials of the inserting nurse.

Based on interview and record review, the facility failed to ensure one of five residents (Resident 11) reviewed for unnecessary medications, was free from unnecessary psychotropic medications (medications capable of affecting the mind, emotions, and behavior) by failing to ensure Resident 11's bupropion order (medication used to treat depression [(mood disorder that causes a persistent feeling of sadness and loss of interest]) had a behavior manifestation. This deficient practice had the potential to result in adverse reaction (any unexpected or dangerous reaction to a drug) or impairment in the resident's mental or physical condition. Findings: A review of Resident 11's Face Sheet (admission record) indicated the facility admitted the resident on 9/1/2021 with diagnoses that included unspecified dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), major depressive disorder, and hypertension (elevated blood pressure). A review of Resident 11's Minimum Data Set (MDS - an assessment and care screening tool) dated 12/7/2022 indicated the resident had the ability to make self-understood and had the ability to usually understand others. A review of Resident 11's physician orders indicated the following: - Bupropion extended release 150 milligram (mg- a unit of measure) by mouth once a day for diagnosis major depressive disorder, ordered on 12/5/2022. - Wellbutrin (brand name for bupropion) monitor verbalization of sadness and side effects, ordered on 9/1/2021. During a concurrent interview and record review on 12/21/2022 at 10:49 a.m., with Licensed Vocational Nurse 1 (LVN 1), reviewed Resident 11's physician orders. LVN 1 verified Resident 11's medication order for bupropion did not have a behavior manifestation. LVN 1 verified there is an order to monitor for verbalization of sadness that was ordered on 9/1/2021 but verified Resident 11's current order for bupropion ordered on 12/5/2022 did not include a behavior manifestation. LVN 1 stated order should reflect current behavior being monitored. During a concurrent interview and record review on 12/21/2022 at 3:40 p.m., with the Director of Nursing (DON), reviewed Resident 11's physician orders. The DON verified Resident 11 had an order for bupropion with no behavior manifestation. The DON stated the medication order should have a diagnosis and behavior manifestation. The DON stated the importance in having a behavior manifestation is to know what the medication indication is being used for. During a concurrent interview and record review, on 12/23/2022 at 12:34 p.m., a review of the facility's policy and procedure titled, Psychotropic Medication Assessment and Monitoring, last reviewed on 10/28/2022, indicated, A physician's order and an appropriate diagnosis is required for all psychotropic medications .Record behavior, interventions, and effectiveness of interventions taken in the behavior monitoring record. The DON verified the policy does not indicate medication order has to include behavior manifestation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d. A review of Resident 39's admission record indicated the resident was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including atrial fibrillation with rapid ventricular response (RVR) and hypertensive heart ( HTN [a condition in which the blood vessels have persistently raised pressure]). A review of the General Acute Care Hospital (GACH) Physician Discharge summary, dated [DATE], indicated a discharge diagnosis of new onset A. fib with RVR. A review of Resident 39's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 10/12/2022, indicated the resident was moderately impaired in cognition and required limited assistance with Activities of Daily Living (ADL). A review of Resident 39's care plan, dated 6/6/2022 and last revised on 12/12/2022, indicated Resident 39 had Alterations in Cardiac Status related to HTN, CKD, and hypercholesterolemia (a blood fat disorder in which the bad cholesterol is too high). The care plan did not indicate the new diagnosis of a. fib. During a concurrent interview and record review, on 12/22/22 at 1:01 p.m., with the Director of Nursing (DON), the DON stated Resident 39 was hospitalized from [DATE] through 10/13/2022 because of a. fib. The DON verified the care plan for Alterations in Cardiac Status related to HTN, CKD, and hypercholesterolemia failed to include the diagnosis of atrial fibrillation. During a subsequent interview on 12/23/22 at 10:41 a.m., the DON stated the importance of updating a care plan with the new diagnosis assist facility staff to assess residents appropriately based on concerns. A review of the facility's policy and procedure titled Care Plans, revised 6/2014, indicated Care plans are revised as changes in the resident's condition dictate., Goals and Objectives are reviewed and/or revised when there has been a significant change in the resident's condition, and when the resident has been readmitted to the facility from a hospital/rehabilitation stay. Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for four of four sampled residents (Resident 33, 29, 79, and 39) by: 1. Failing to ensure Resident 29 had a care plan that addressed the resident's use of Eliquis (apixaban) (anticoagulant, a substance that is used to prevent and treat blood clots in blood vessels and the heart). 2. Failing to ensure Resident 79 had a care plan that addressed the resident's use of Celexa (citalopram) (antidepressant, a substance that is used in the treatment of mood disorders). These deficient practices had the potential for residents taking unnecessary medications and licensed nurses to overlook the adverse (unwanted) side effects of anticoagulant and antidepressant medications. 3. Failing to develop a plan of care with measurable goals and objectives including person-centered interventions for Resident 33, who had orders of Restorative Nursing Assistant (RNA program, RNA provides specific treatments to residents to restore and/or maintain the strength, coordination, and skills to ambulate and perform functional activities of daily living [activities related to personal care]) for passive range of motion (PROM, an exercise provided by therapist or the RNAs who will have to do full range of motion [the amount of movement a person have at each joint] for the person without any help from the resident) for both lower extremities. This deficient practice placed Resident 33 at risk for not receiving services and treatment necessary to increase range of motion (ROM) and/or prevent further decrease in ROM. 4. Failing to ensure Resident 39 had a care plan that addressed the resident's diagnosis of atrial fibrillation with rapid ventricular response (a. fib [irregular and often very fast heartbeat that can lead to blood clots in the heart]) care plan. This deficient practice had the potential to delay in delivery of necessary care and services. Findings: a. A review of Resident 29's Face Sheet indicated that the facility admitted the resident on 5/24/2022 and readmitted the resident on 10/31/2022, with diagnoses including atrial fibrillation with rapid ventricular response (an irregular heartbeat that occurs when the electrical signals in the atria [the two upper chambers of the heart] fire rapidly at the same time), pulmonary embolism (a sudden blockage of an artery [blood vessel] in the lung), and thrombosis of right femoral vein (a clot in the long vein in the thigh). A review of Resident 29's History and Physical (H&P), dated 11/1/2022, indicated that the resident had bilateral deep vein thrombosis (DVT, occurs when a blood clot [thrombus] forms in one or more of the deep veins in the body, usually in the legs) and pulmonary embolism, improving on Eliquis. A review of Resident 29's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/7/2022, indicated that the resident sometimes made self-understood and understood others. The MDS also indicated that the resident was on an anticoagulant medication. A review of Resident 29's Physician Order Report, dated 11/1/2022, indicated an order for Eliquis (apixaban) tablet oral 5 milligrams (mg, a measure of weight) twice a day for DVT prophylaxis (PPX, an attempt to prevent disease). During a concurrent interview and record review on 12/19/2022, at 1:10 p.m., reviewed Resident 29's medical record with Licensed Vocational Nurse 1 (LVN 1). LVN 1 stated that there was no care plan developed for the use of Eliquis. LVN 1 stated that they should have created a care plan for Eliquis to help them monitor the resident's medication treatment progress. During an interview on 12/20/2022, at 9:54 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated that the purpose of the care plan was to outline the goals of treatments and interventions, so they can review and evaluate the resident's progress, and determine if the care plan goals were met or not met. During an interview on 12/21/2022, at 1:25 p.m., with the Director of Nursing (DON), the DON stated that Resident 29 should have a care plan for use of an anticoagulant so the staff will know the approaches needed to care for a resident receiving an anticoagulant medication. b. A review of Resident 79's Face Sheet indicated that the facility admitted the resident on 11/1/2022, with diagnoses including depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), mild cognitive impairment (problems with memory, language or judgment), and exposure to disaster, war and hostilities. A review of Resident 79's H&P, dated 11/4/2022, indicated that the resident had anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness) and was receiving Celexa 20 mg once daily. A review of Resident 79's MDS, dated [DATE], indicated that the resident had the ability to make self-understood and understand others. The MDS also indicated that the resident was receiving an antidepressant. A review of Resident 79's Physician Order Report, dated 11/2/2022, indicated an order for citalopram tablet 20 mg oral once a day for depression, monitor behavior for verbalization of sadness. During an interview and record review on 12/19/2022, at 1:08 p.m., reviewed Resident 79's medical record with LVN 1. LVN 1 stated that the resident did not have a care plan addressing use of citalopram. LVN 1 stated that they should have created a care plan to help them evaluate the appropriateness of the use of an antidepressant medication. During an interview on 12/21/2022, at 1:25 p.m., with the DON, the DON stated that they should have created a care plan addressing use of citalopram so the staff will know the approaches needed to care for a resident receiving an antidepressant medication. A review of the facility's recent policy and procedure titled Care Plans, last reviewed on 10/28/2022, indicated that an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The resident's comprehensive care plan is developed with seven (7) days of the completion of the resident's comprehensive assessment (MDS). c. A review of Resident 33's admission Record indicated the facility admitted the resident on 7/29/2022, with diagnoses of dementia (a syndrome of memory disorders, personality changes, and impaired reasoning that interferes with daily functioning) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 33's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/4/2022, indicated the resident's cognition (ability to think, understand, and reason) was severely impaired. The MDS indicated the resident required extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, transferring, and dressing with physical assistance from two or more nursing staffs. A review of Resident 33's Physician Order indicated an order dated 8/4/2022, to provide RNA for PROM to bilateral lower extremities (legs) every day three times a week as tolerated (Tuesday, Thursday, and Saturday). During a concurrent interview and record review of Resident 33's clinical record on 12/22/2022 at 8:40 a.m., the MDS Nurse (MDSN) confirmed Resident 33 did not have a care plan developed for range of motion. The MDS stated the range of motion care plan interventions would include the RNA program. The MDS Nurse stated she received the order for Resident 33 to be in the RNA program, but she missed creating the care plan. The MDS Nurse stated Resident 33's physical therapy evaluation indicated a recommendation for the resident to be in the RNA program with a physician's order. During an interview on 12/23/22 at 8:23 a.m., the Director of Nursing (DON) stated the purpose of developing a care plan is to identify the resident's concern, establish a smart goal, identify the approaches, and evaluate if the care plan is effective or not. The DON stated care plans should be resident-centered and specific to the resident. The DON stated care plans are developed within 14 days upon admission or as needed when concerns arise. A review of the facility's policy and procedure titled, Care Plans, reviewed and approved on 10/28/2022, indicated that the facility's care planning/interdisciplinary team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain . The resident's comprehensive care plan is developed within seven days of the completion of the resident's comprehensive assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure Certified Nursing Assistant 7 (CNA 7) maintained a current Cardiopulmonary Resuscitation (CPR -an emergency procedure involving repeated compression of an individual's chest, used to restart a person's heartbeat, and breathing after one or both have stopped.) certification for Healthcare Providers. This deficient practice placed the residents at risk for not receiving the necessary emergency care prior to the arrival of emergency medical services (EMS-a system that provides emergency medical care). Findings: During a review of CNA 7's employee file on [DATE], at 3:11 p.m., observed CNA 7 had a CPR card that expired on [DATE]. During an interview on [DATE], at 3:54 p.m., with the Director of Staff Development (DSD), the DSD stated that the facility does not require certified nursing assistants (CNAs) to have a CPR certificate. During an interview on [DATE], at 3:56 p.m., with the Human Resources Director (HRD) and the Administrator (ADM), the HRD stated that prior to Coronavirus Disease 2019 (COVID-19 -a highly contagious disease spread from person to person through droplets released when an infected person coughs, sneezes, or talks) they require all staff to be CPR certified. During COVID-19 pandemic (is an epidemic that spread over multiple countries and continents), they stopped requiring CNAs to have CPR certification due to limitation in spaces. The HRD stated that according to title 22 (the California Code of Regulations for community care facilities), all licensed nurses shall have training in cardiopulmonary resuscitation. The ADM stated that as a facility they decided not to require their CNAs to have CPR certification. The ADM stated that she spoke to their regional Human Resources (HR), and they are looking into to having CNAs have CPR certification again. During an interview on [DATE], at 8:07 a.m., with the Director of Nursing (DON), the DON stated that the licensed nurses are expected to perform CPR and maintain certification on the facility. During an interview on [DATE], at 8:20 a.m., with Registered Nurse 1 (RN 1), RN 1 stated that everyone including the CNAs are required to have CPR certification. During an interview on [DATE], at 8:37 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated that everyone should have CPR certification, including CNAs. During an interview on [DATE], at 8:40 a.m., with Certified Nursing Assistant 10 (CNA 10), CNA 10 stated that she has been working in the facility for five years. CNA 10 stated that when there is a resident in cardiopulmonary arrest, everyone is expected to perform CPR. CNA 10 stated that the facility mandated her to be CPR certified. During an interview on [DATE], at 8:45 a.m., with Certified Nursing Assistant 5 (CNA 5), CNA 5 stated that she has been working at the facility for three and a half months now and when she applied, the facility required her to have CPR Certification. A review of the facility's Job Description/Evaluation for Certified Nursing Assistant/Restorative Nurse Assistant, revised on 4/2013, indicated in the staff development functions, CNAs participates in and attends the following: fire/safety programs and First Aid/CPR . A review of the facility's recent policy and procedure titled Cardiopulmonary Resuscitation (CPR), revised on [DATE], indicated that staff, who are required per regulation or licensure, will maintain current CPR certification for healthcare providers through a CPR provider who evaluates proper technique through in-person demonstration of skills. CPR certification which includes an online knowledge component yet still requires in-person skills demonstrations to obtain certification or recertification is also acceptable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 9's Face Sheet indicated that the facility admitted the resident on 1/8/2021. The facility readmitted the resident on 4/18/2021, with diagnoses including abnormalities of gait (a manner of walking or moving on foot) and mobility, muscle weakness, and unsteadiness of the feet. A review of Resident 9's MDS, dated [DATE], indicated that the resident had the ability to make self-understood and understand others. The MDS indicated that the resident required extensive assistance on bed mobility, transfer, locomotion on unit, dressing, toilet use, and personal hygiene and required one to two persons' physical assist. The MDS further indicated that the resident had impairment on the lower extremities and used a walker (a walking aid that has four points of contact with the ground) and a wheelchair to move around. A review of Resident 9's Physician Order Report, dated 8/12/2021, indicated an order for: - RNA for ambulation using front wheel walker (FWW, a walker that has two wheels on the front legs and two straight legs on the back) every day five times per week as tolerated with 1 person assist and 1 person for wheelchair follow (Sunday, Tuesday, Wednesday, Friday, and Saturday) once a day. -RNA for active range of motion (AROM- how far a joint move without assistance) to both lower extremities everyday five times per week as tolerated (Sunday, Tuesday, Wednesday, Friday, and Saturday) once a day. A review of Resident 9's Care Plan, dated 10/19/2022, indicated a plan for at risk for unavoidable decline in mobility/activities of daily living (ADLs, tasks of everyday life). The care plan indicated an intervention to perform RNA therapy as tolerated. A review of Resident 9's Point of Care History for Restorative Nursing Record, indicated missing therapy documentation for the resident on 12/9/2022. During an interview on 12/20/2022 at 12:51 p.m., RNA 1 stated that she went home early that day because she was sick. RNA 1 stated that she did not do the RNA therapy of the resident on 12/9/2022. During an interview on 12/21/2022 at 1:23 p.m., the DON stated that RNA 1 went home on [DATE] because she was sick, they should have assigned somebody to do the RNA therapy to Resident 9 that day. The DON stated that there will be a potential for decline in function if they missed a therapy for the resident. During an interview on 12/22/2022 at 9:36 a.m., PT 1 stated that it was nice to have a consistency in therapy to achieve the goal of improving ROM. A review of the facility's recent policy and procedure titled, Restorative Nursing Program, last reviewed on 10/28/2022, indicated that the restorative aid carries out the program according to the written plan of care and documents daily. Written weekly summaries are completed for each resident by the RNA. Based on observation, interview, and record review, the facility failed to provide range of motion exercises per physician's orders for two of two sampled residents (Resident 33 and 9), by: 1. Failing to provide passive range of motion (PROM, an exercise provided by therapist or the RNAs who will have to do full range of motion [ROM, the extent or limit to which a part of the body can be moved around a joint or a fixed point] for the person without any help from the resident) exercises to Resident 33's both legs as ordered by the resident's physician. 2. Failing to document accurately the Weekly Evaluation by Nursing which reflects the resident's progress and response to treatment for Resident 33 from 10/24/2022 to 10/31/2022. 3. Failing to provide range of motion exercises to Resident 9, as ordered by the resident's physician, on 12/9/2022 when Restorative Nursing Assistant 1 (RNA 1) went home sick. These deficient practices had the potential to promote the development of contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) to the residents' extremities. Findings: a.1. A review of Resident 33's Face Sheet indicated the facility admitted the resident on 7/29/2022 with diagnoses of dementia (a syndrome of memory disorders, personality changes, and impaired reasoning that interferes with daily functioning) and major depressive depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 33's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/4/2022, indicated the resident's cognition (ability to think, understand, and reason) was severely impaired. The MDS indicated the resident required extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, transferring, and dressing with physical assistance from two or more nursing staff. A review of Resident 33's Physician Order, dated 8/4/2022, indicated an order to provide RNA for PROM to bilateral lower extremities (legs) every day three times a week as tolerated (Tuesday, Thursday, and Saturday) once a day. During a concurrent observation and interview on 12/22/2022 at 7:56 a.m., observed RNA 1 brought Resident 33 back to the resident's room to provide ROM exercises. RNA 1 stated she will keep the resident seated on her wheelchair while she provides PROM to resident's bilateral lower extremities. Observed RNA 1 removed the resident's bilateral footrests and the resident's footwear. RNA 1 proceeded to provide PROM exercises to the resident's right leg as follows: - Right knee bending - Right leg adduction (movement of a body part toward the body's midline) - Right leg extension (a straightening movement) - Right ankle extension - Right ankle flexion (bending) for one time (x1) held for five seconds - Right ankle rotation (movement in which a bone or a whole limb, pivots or revolves around a single point) in clockwise motion then counterclockwise motion. During an observation on 12/22/2022 at 8:05 a.m., RNA 1 continued PROM to Resident 33's left leg while the resident in a seated position, as follows: - Left knee bending - Left leg adduction - Left leg extension - Left ankle flexion x1 held for five seconds - Left ankle rotation in counterclockwise then clockwise During an interview on 12/22/2022 at 8:11 a.m., RNA 1 stated Resident 33's PROM exercises was completed for that day. RNA 1 stated she provided the PROM to both legs while the resident was in a seated position. RNA 1 stated she believed she provided all the exercises to the resident as ordered. RNA 1 also stated she has not received a recent in-service or education about range of motion. RNA 1 stated the last in-service she received has been more than 12 months ago. During a concurrent interview and record review of Resident 33's clinical record, on 12/22/2022 at 9:24 a.m., the Physical Therapist (PT 1 - PT is a rehabilitation profession that restores, maintains, and promotes optimal physical function) stated his responsibilities include providing physical therapy evaluation when referred by nursing or as ordered by the resident's physician. PT 1 stated based on the evaluation if the resident would benefit more in an RNA program or restorative exercises, he communicates it to the nursing staff and train the RNAs on what exercises to perform for the resident. PT 1 confirmed he signed the Therapy Communication Form (an RNA program referral completed by the physical therapist), dated 8/4/2022 and stated the RNA signs on the form indicating that the training program was reviewed and completed. During an observation and interview on 12/22/2022 at 9:34 a.m., PT 1 demonstrated ROM exercises to provide to Resident 33 including bending of the knees, adduction, and the ankle pumps (moving the ankle all the way up [pointing the toes towards the body] and all the way down [pointing the toes away from the body] without holding either position). PT 1 stated ankle pumps would include dorsiflexion (the movement that occurs at the ankle where the foot is lifted upwards) and plantar flexion (the movement of the foot in a downward motion away from the body). PT 1 stated it is important for the RNAs to perform all the ROM as tolerated by the resident. PT 1 stated he does not set the number of repetitions and as far as he knows, the RNA provides the treatment minutes. During a concurrent interview and record review on 12/22/2022 at 10:53 a.m., the Director of Staff Development (DSD) confirmed the following in-service attendance sheet with lesson plan on range of motion in-service dates 12/12/2022 and 12/13/2022; RNA 1 did not attend. The DSD stated the RNAs were expected to provide the PROM for bilateral lower extremities while the resident is in bed and not while seated in a chair or wheelchair. The DSD stated that would include hip rotation exercises unless instructed by physical therapist not to perform. The DSD stated the resident should be lying in bed when the RNA provides the exercises because this would provide the full range of motion on the resident's joint. The DSD stated bilateral lower extremities exercises for ROM should not be done while the resident is sitting in the chair. During a concurrent interview and record review on 12/22/2022 at 11:22 a.m., the DSD confirmed that RNA 1 last attended the range of motion in-service on 10/14/2021. During an interview on 12/23/2022 at 8:26 a.m., the Director of Nursing (DON) stated the nursing assistants (including RNAs) ensure they are competent to provide the quality of care the resident requires. A review of Resident 33's Point of Care History for Restorative Nursing Record (record of RNA therapy performed), reviewed from 10/28/2022 to 11/4/2022, indicated the RNA rendered PROM exercises to Resident 33 for 15 minutes on 10/29/2022, 11/1/2022, and 11/3/2022 During an interview on 12/23/2022 at 8:17 a.m., the DON stated her role in the RNA program includes attending the weekly RNA meetings for residents who are in the RNA program. The DON stated the weekly RNA meeting attendees include the RNA staff, MDS Nurse, DSD, and she occasionally joins in. The DON stated the purpose of the weekly RNA meetings is to discuss the resident's current health status including range of motion to prevent further decline or maintain current mobility, if feasible. During a concurrent interview and record review of Resident 33's Weekly Summary, dated 10/31/2022, on 12/23/2022 at 12:27 p.m., Registered Nurse 1 (RN 1) confirmed under section RNA: Weekly Evaluation by Nursing was left blank. RN 1 stated it should be filled out and should indicate Resident 33's RNA progress for that week. RN 1 stated the licensed nurse completing the documentation should refer to the Point Care History Report because it would include how many treatments the resident received and how the resident was tolerating and progressing with the current treatment orders and the resident's current goals. RN 1 stated for that respective week the licensed nurse will document how the resident is tolerating, if the resident is improving or declining in flexibility during ROMs exercises, and if there are any notes documented by the RNAs, the licensed nurse should review those as well. A review of the facility's policy and procedure titled, Restorative Nursing Program, reviewed and approved on 10/28/2022, indicated it is the facility's policy to assist each resident in achieving the highest level of self-care possible. The procedure indicated that the Charge Nurse completes the resident care plan entry and supervises its proper implementation. The Licensed nurse's weekly summary note reflects the resident's response to treatment and progress being made toward goal achievement. The procedure indicated that the restorative aid carries out the program according to the written plan of care and documents daily. Written weekly summaries are completed for each resident by the RNA.

Based on observation, interview, and record review, the facility failed to ensure licensed nurses and certified nursing assistants have the specific competencies (measurable pattern of knowledge, skills, abilities, behaviors in order to perform occupational functions successfully) and skills sets necessary to care for one of one sampled resident (Resident 33), by: 1. Failing to ensure competency of Minimum Data Set Nurse 1 (MDSN 1) in coding MDS Assessments, who coded (entered information) Resident 33's Minimum Data Set (MDS, a standardized assessment and care screening tool) assessment inaccurately. 2. Failing to ensure Restorative Nursing Assistant 1 (RNA 1) provided passive range of motion (PROM, an exercise provided by therapist or the RNAs who will have to do full range of motion [ROM, the extent or limit to which a part of the body can be moved around a joint or a fixed point] for the person without any help from the resident) to both legs as ordered by Resident 33's physician. 3. Failing to ensure RNA 1 maintained competency in providing exercises to residents participating in the RNA program (RNA provides specific treatments to residents to restore and/or maintain the strength, coordination, and skills to ambulate and perform functional activities of daily living [activities related to personal care]). These deficient practices had the potential to promote the development of contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) to the residents' extremities. Findings: a.1. A review of Resident 33's Face Sheet indicated the facility admitted the resident on 7/29/2022 with diagnoses of dementia (a syndrome of memory disorders, personality changes, and impaired reasoning that interferes with daily functioning) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 33's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/4/2022, indicated the resident's cognition (ability to think, understand, and reason) was severely impaired. The MDS indicated the resident required extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, transferring, and dressing with physical assistance from two or more nursing staffs. A review of Resident 33's Physician Order, dated 8/4/2022, indicated an order to provide RNA for PROM to bilateral lower extremities (legs) every day three times a week as tolerated (Tuesday, Thursday, and Saturday) once a day. A review of Resident 33's Point of Care History (POC history - RNA treatment record), reviewed from 10/28/2022 to 11/4/2022, indicated the RNA rendered PROM exercises to Resident 33 for 15 minutes on 10/29/2022, 11/1/2022, and 11/3/2022. During a concurrent interview and record review of Resident 33's MDS Assessment, dated 11/4/2022, on 12/23/2022 at 8:34 a.m., MDSN 1 stated she did not want to fill out the MDS section about the resident's Restorative Nursing Programs (RNA services received) without the supporting documentation and evidence that the resident's treatments were done. MDSN 1 confirmed she coded zero number of days PROM was performed in the last seven calendar days (of the look-back period [time frame for observation] between 10/29/2022 to 11/4/2022), to Resident 33. During a concurrent interview and record review on 12/23/2022 at 11:25 a.m., the DON stated the MDS should be coded accurately to reflect the resident's current condition in order for them to provide the necessary individualized care and services to the resident. The DON confirmed Resident 33's Point of Care history contained the RNA treatment record and during the 7-day look-back of the resident's Quarterly MDS, the resident received three PROM treatment exercises. The DON confirmed the MDS Nurse should have used the information gathered in the weekly evaluation by nursing, the POC history, and the physician orders when coding the resident's MDS section under restorative treatments. A review of MDSN 1's Job Description, dated 8/9/2022, indicated that the primary purpose of DSN 1's job position is to plan, conduct and coordinate the MDS's in accordance with current applicable federal, state, and local standards, guidelines, and regulations . to assure that the highest degree of quality resident care can be always maintained. A review of the Centers for Medicare & Medicaid Services, Long-Term care Facility Resident Assessment Instrument 3.0 User's Manual, updated 10/2019, indicated the steps for assessment: 1. Review the restorative nursing program (RNA provides specific treatments to residents to restore and/or maintain the strength, coordination, and skills to ambulate and perform functional activities of daily living [activities related to personal care]) notes and/or flow sheets in the medical record. 2. For the 7-day look-back period, enter the number of days on which the technique, training, or skill practice was performed for a total of at least 15 minutes during the 24-hour period. 3. The following criteria for restorative nursing programs must be met to code O0500 (section on Restorative Nursing Programs): - Measurable objective and interventions must be document in the care plan and in the medical record. - Evidence of periodic evaluation by the licensed nurse must be present in the resident's medical record. - A registered nurse or a licensed vocational nurse must supervise the activities in a restorative nursing program. a.2. During a concurrent observation and interview on 12/22/2022 at 7:56 a.m., observed RNA 1 brought Resident 33 back to the resident's room to provide ROM exercises. RNA 1 stated she will keep the resident seated on her wheelchair while she provides PROM to resident's bilateral lower extremities. Observed RNA 1 removed the resident's bilateral footrests and the resident's footwear. RNA 1 proceeded to provide PROM exercises to the resident's right leg as follows: - Right knee bending - Right leg adduction (movement of a body part toward the body's midline) - Right leg extension (a straightening movement) - Right ankle extension - Right ankle flexion (bending) for one time (x1) held for five seconds - Right ankle rotation (movement in which a bone or a whole limb, pivots or revolves around a single point) in clockwise motion then counterclockwise motion. During an observation on 12/22/2022 at 8:05 a.m., RNA 1 continued PROM to Resident 33's left leg while the resident in a seated position, as follows: - Left knee bending - Left leg adduction - Left leg extension - Left ankle flexion x1 held for five seconds - Left ankle rotation in counterclockwise then clockwise During an interview on 12/22/2022 at 8:11 a.m., RNA 1 stated Resident 33's PROM exercises was completed for that day. RNA 1 stated she provided the PROM to both legs while the resident was in a seated position. RNA 1 stated she believed she provided all the exercises to the resident as ordered. RNA 1 also stated she has not received a recent in-service or education about range of motion. RNA 1 stated the last in-service she received has been more than 12 months ago. During a concurrent interview and record review of Resident 33's clinical record, on 12/22/2022 at 9:24 a.m., the Physical Therapist (PT 1 - PT is a rehabilitation profession that restores, maintains, and promotes optimal physical function) stated his responsibilities include providing physical therapy evaluation when referred by nursing or as ordered by the resident's physician. PT 1 stated based on the evaluation if the resident would benefit more in an RNA program or restorative exercises, he communicates it to the nursing staff and train the RNAs on what exercises to perform for the resident. PT 1 confirmed he signed the Therapy Communication Form (an RNA program referral completed by the physical therapist), dated 8/4/2022 and stated the RNA signs on the form indicating that the training program was reviewed and completed. During an observation and and interview on 12/22/2022 at 9:34 a.m., PT 1 demonstrated ROM exercises to provide to Resident 33 including bending of the knees, adduction, and the ankle pumps (moving the ankle all the way up [pointing the toes towards the body] and all the way down [pointing the toes away from the body] without holding either position). PT 1 stated ankle pumps would include dorsiflexion (the movement that occurs at the ankle where the foot is lifted upwards towards the body) and plantar flexion (the movement of the foot in a downward motion away from the body). PT 1 stated it is important for the RNAs to perform all the ROM as tolerated by the resident. PT 1 stated he does not set the number of repetitions and as far as he knows, the RNA provides the treatment minutes. During a concurrent interview and record review on 12/22/2022 at 10:53 a.m., the Director of Staff Development (DSD) confirmed the following in-service attendance sheet with lesson plan on range of motion in-service dates 12/12/2022 and 12/13/2022; RNA 1 did not attend. The DSD stated the RNAs were expected to provide the PROM for bilateral lower extremities while the resident is in bed and not while seated in a chair or wheelchair. The DSD stated that would include hip rotation exercises unless instructed by physical therapist not to perform. The DSD stated the resident should be lying in bed when the RNA provides the exercises because this would provide the full range of motion on the resident's joint. The DSD stated bilateral lower extremities exercises for ROM should not be done while the resident is sitting in the chair. The DSD confirmed RNA 1 should have performed PROM for Resident 33 in bed to provide the full range of motion on the resident's legs. During a concurrent interview and record review on 12/22/2022 at 11:22 a.m., the DSD confirmed that RNA 1 last attended the range of motion in-service on 10/14/2021. During an interview on 12/23/2022 at 8:26 a.m., the Director of Nursing (DON) stated the nursing assistants (including RNAs) ensure they are competent to provide the quality of care the resident requires. A review of the facility's policy and procedure titled, Restorative Nursing Program, reviewed and approved on 10/28/2022, indicated it is the facility's policy to assist each resident in achieving the highest level of self-care possible. The procedure indicated that the restorative aid carries out the program according to the written plan of care and documents daily. Written weekly summaries are completed for each resident by the RNA.

Based on interview and record review, the facility failed to ensure blood pressure medications were held (not administered) per ordered parameters (limit or boundary) set by the physician for two of two sampled residents (Residents 7 and 68). This deficient practice had the potential to result in unintended complications related to the management of blood pressure such as hypotension (abnormally low blood pressure) for Resident 7 and Resident 68 that can lead to falls. Findings: a. A review of Resident 7's Face Sheet indicated the facility admitted the resident on 8/10/2022 with diagnoses that included chronic combined systolic and diastolic congestive heart failure (condition where the heart is not pumping enough blood out to the body due to inability to contract effectively with each heartbeat and inability to relax normally between beats), hyperlipidemia (abnormally high levels of fats in the blood), and cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body). A review of Resident 7's Minimum Data Set (MDS - an assessment and care screening tool), dated 11/17/2022, indicated the resident's cognitive (relating to thinking, reasoning, or remembering) skills for daily decision making was severely impaired. The MDS further indicated Resident 7 required extensive assistance from staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. A review of Resident 7's physician orders indicated the following: 1. Carvedilol (medication used to treat high blood pressure) tablet 6.25 milligrams (mg - unit of measure) 1 tablet oral (by mouth) twice a day. Special instructions: diagnosis: hypertension (elevated blood pressure). Hold for systolic blood pressure (SBP - the top number, measures the force your heart exerts on the walls of your arteries each time it beats) less than 140 or heart rate less than 55, ordered on 12/13/2022. 2. Valsartan (medication used to treat high blood pressure) tablet 40 mg oral once a day. Special instructions: Hold for SBP less than 140, ordered on 10/18/2022. During a concurrent interview and record review, on 12/22/2022 at 8:38 a.m., Licensed Vocational Nurse 3 (LVN 3) reviewed Resident 7's physician orders and verified the resident was on carvedilol and valsartan with ordered parameters to hold the blood pressure medications if SBP is less than 140. LVN 3 stated the licensed nurses check the blood pressure before administering blood pressure medications in the morning and explained they would hold the medication if the SBP is below the ordered parameters and document in the Medication Administration Record (MAR) that the medication was held with a rationale (underlying reason). LVN 3 explained that any medications that are held would show under administration history in the MAR that it was not administered along with a comment. LVN 3 reviewed Resident 7's MAR from December 2022 and confirmed the resident received carvedilol on 12/15/2022 at 8:30 a.m. for documented blood pressure of 132/69. LVN 3 further reviewed Resident 7's MAR and confirmed the resident received valsartan on the following dates: 1. 12/11/2022 at 8:30 a.m. for documented blood pressure of 133/68. 2. 12/12/2022 at 8:30 a.m. for documented blood pressure of 134/80. 3. 12/15/2022 at 8:30 a.m. for documented blood pressure of 132/69. LVN 4 stated the blood pressure medications should have been held on the specified dates since Resident 7's SBP was below 140 and verified the parameters were not followed as ordered by the physician. LVN 4 stated administering blood pressure medications when it should have been held has the potential to further drop Resident 7's blood pressure which can lead to the resident experiencing lightheadedness, headaches, and dizziness. During a concurrent interview and record review, on 12/22/2022 at 4:48 p.m., the Director of Nursing (DON) reviewed Resident 7's MAR for 12/2022 and verified carvedilol was given on 12/15/2022 and valsartan was given on 12/11/2022, 12/12/1022, and 12/15/2022 when it should have been held by the licensed nurse. The DON stated the physician placed a parameter for both blood pressure medications to hold if the SBP falls below 140 for a reason and confirmed the orders were not followed. The DON further stated the importance of administering blood pressure medications within ordered parameters to prevent adverse side effects such as hypotension, dizziness, and drowsiness which can potentially lead to falls with injuries. A review of the facility's policy and procedure titled, Range and Parameter Medication Orders, last reviewed on 10/28/2022, indicated the licensed nurse staff will follow the physician ordered parameters for medication. The policy and procedure indicated licensed nurse will obtain the required information such as blood pressure prior to administration and then follow the physician's order. b. A review of Resident 68's Face Sheet (admission record) indicated the facility admitted the resident on 4/7/2021 with a readmission date of 4/20/2022 with diagnoses that included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), and chronic kidney disease (gradual loss of kidney function). A review of Resident 68's Minimum Data Set (MDS - an assessment and care screening tool) dated 10/27/2022 indicated the resident had the ability to make self-understood and had the ability to understand others. A review of Resident 68's physician orders indicated an order for Norvasc (medication used to treat high blood pressure) 5 milligrams (mg- a unit of measure) hold for systolic blood pressure (SBP- the top number, measures the force your heart exerts on the walls of your arteries each time it beats) less than 110 or heart rate less than 60, ordered on 4/25/2022. During a concurrent interview and record review on 12/21/2022 at 10:56 a.m., with Licensed Vocational Nurse 1 (LVN 1), reviewed Resident 68's physician orders and Medication Administration Record (MAR). LVN 1 stated the procedure when giving blood pressure medications is to check the resident's blood pressure before giving the medication. LVN 1 stated to check the parameters for the medication and stated depending on the parameters and the resident's blood pressure and heart rate, will either give the medication or hold it. LVN 1 verified Resident 68's Norvasc order had hold parameters to hold for SBP less than 110 or heart rate less than 60. LVN 1 verified Resident 68's MAR for 12/2022 indicated on 12/7/2022, Resident 68 had a heart rate of 56 and was administered Norvasc. LVN 1 stated the medication should have been held because of the parameters. LVN 1 stated it is important to hold the medication because the resident's blood pressure or heart rate can drop too low and the resident can be unresponsive. During a concurrent interview and record review on 12/21/2022 at 3:33 p.m., with the Director of Nursing (DON), reviewed Resident 68's physician orders and MAR. The DON stated before giving blood pressure medication, the staff should check the resident's blood pressure and check the medication order for any parameters. The DON verified Resident 68's Norvasc order had hold parameters to hold for SBP less than 110 or heart rate less than 60. The DON verified Resident 68's MAR for 12/2022 indicated on 12/7/2022, Resident 68 had a heart rate of 56 and was administered Norvasc. The DON stated the medication should have been held because of the hold parameters and Resident 68's heart rate was less than 60. The DON stated the importance of holding the blood pressure medication is to avoid blood pressure or heart rate decreasing. The DON stated the medication is used to regulate blood pressure and heart rate and is important to avoid the side effect of heart rate decreasing. A review of the facility's policy and procedure titled, Range and Parameter Medication Orders, last reviewed on 10/28/2022, indicated, Medication order ranges and parameters will be followed when ordered by the physician or provider .Licensed Nurse staff will follow the physician order parameters for medication. The licensed nurse will obtain the required information, such as blood pressure, prior to the administration and then follow the physician's order.

c. A review of Resident 382's Face Sheet indicated the facility admitted the resident on 11/28/2022, with diagnoses that included dementia (an impaired ability to remember, think, or make decisions that interferes with doing everyday activities), irritable bowel syndrome (IBS [a disorder that affects the stomach and intestines with symptoms that include cramping, abdominal pain, bloating, gas, and diarrhea or constipation, or both]) and osteoporosis (disease in which bones become fragile and more likely to break). A review of Resident 382's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/4/2022, indicated the resident was cognitively (relating to thinking, reasoning, or remembering) intact and required limited assistance with one-person assistance for activities of daily living (ADLs-basic tasks that must be accomplished every day for an individual to thrive). During a concurrent interview and record review, on 12/21/2022 at 10:01 a.m., Licensed Vocational Nurse (LVN 3) verified the Physician's Order, dated 12/28/2022, indicated hydrocodone-acetaminophen tablet, Schedule II, 10/325 mg, every 6 hours, as needed for generalized pain. LVN 3 stated there were no parameters to indicate the pain level to administer hydrocodone-acetaminophen 10/325 mg. A review of Resident 382's care plan, dated 11/28/2022, indicated Resident 382 had Altered Comfort: Pain related to generalized pain, with the approach for pain management as ordered. During a concurrent interview and record review, on 12/21/2022 at 10:01 a.m., with LVN 3, Resident 382's Medication Administration Record (MAR) for the month of December 2022 indicated the following: 1. On 12/8/2022, hydrocodone-acetaminophen 10/325 milligrams (mg) was administered for resident's pain level of 5 out of 10 (pain scale) 2. On 12/9/2022, hydrocodone-acetaminophen 10/325 mg was administered for resident's pain level of 2 out of 10 (pain scale) 3. On 12/10/2022, hydrocodone-acetaminophen 10/325 mg was administered for resident's pain level of 1 out of 10 (pain scale) 4. On 12/11/2022, hydrocodone-acetaminophen 10/325 mg was administered for resident's pain level of 2 out of 10 (pain scale) 5. On 12/12/2022, hydrocodone-acetaminophen 10/325 mg was administered for resident's pain level of 7 out of 10 (pain scale) 6. On 12/13/ 2022, hydrocodone-acetaminophen 10/325 mg was administered for resident's pain level of 2 out of 10 (pain scale) 7. On 12/14/2022, hydrocodone-acetaminophen 10/325 mg was administered for resident's pain level of 2 out of 10 (pain scale) 8. On 12/15/2022, hydrocodone-acetaminophen 10/325 mg was administered for resident's pain level of 7 out of 10 (pain scale) 9. On 12/16/2022, hydrocodone-acetaminophen 10/325 mg was administered for resident's pain level of 2 out of 10 (pain scale) 10. On 12/18/2022, hydrocodone-acetaminophen 10/325 mg was administered for resident's pain level of 2 out of 10 (pain scale) 11. On 12/19/2022, hydrocodone-acetaminophen 10/325 mg was administered for resident's pain level of 0 out of 10 (pain scale) 12. On 12/20/2022, hydrocodone-acetaminophen 10/325 mg was administered for resident's pain level of 2 out of 10 (pain scale) During a concurrent interview and record review on 12/22/22 at 12:51 p.m., the Director of Nursing (DON) stated for a pain level of 2 out of 10, Tylenol (brand name of a pain medication) would be more appropriate with non-pharmacological interventions (NPI). The DON further stated hydrocodone-acetaminophen 10/325 mg was indicated for moderate to severe pain. A review of facility's policies and procedures titled Pain Management, revised in 2/2017, indicated it was the facility's policy to assess all residents/patients for pain on admission, each time vital signs are monitored, when pain indication was given and as indicated. The licensed nurse shall teach the resident/patient/surrogate regarding the facility pain scale. The facility policies and procedure indicated a pain severity scale of: 0 = no pain 1-3 = mild pain (nagging, annoying, interfering little with ADLs) 4-6 = moderate pain (interferes significantly with ADLs) 7-10 = severe pain (disabling, unable to perform ADLs) A review of facility's policies and procedures titled Range and Parameter Medication Orders, effective date 5/2017, indicated Medication orders are to be written to include drug name, dose and dosage form, strength, route of administration, dosage regimen (frequency) and parameters (when applicable). According to the Drug Enforcement Administration (DEA), a Schedule II/IIN Controlled Substances (2/2N): Substances in this schedule have a high potential for abuse which may lead to severe psychological or physical dependence. https://www.deadiversion.usdoj.gov/schedules/#define. d. A review of Resident 29's Face Sheet indicated that the facility admitted the resident on 5/24/2022. The facility readmitted the resident on 10/31/2022, with diagnoses including atrial fibrillation with rapid ventricular response (an irregular heartbeat that occurs when the electrical signals in the atria [the two upper chambers of the heart] fire rapidly at the same time), pulmonary embolism (a sudden blockage of an artery [blood vessel] in the lung), and thrombosis of right femoral vein (a clot in the long vein in the thigh). A review of Resident 29's History and Physical, dated 11/1/2022, indicated that the resident had bilateral deep vein thrombosis (DVT, occurs when a blood clot [thrombus] forms in one or more of the deep veins in the body, usually in the legs) and pulmonary emboli, improving on Eliquis (apixaban, an anticoagulant - a substance that is used to prevent and treat blood clots in blood vessels and the heart). A review of Resident 29's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/7/2022, indicated that the resident sometimes made self understood and sometimes had the ability to understand others. The MDS also indicated that the resident was on an anticoagulant medication. A review of Resident 29's Physician Order Report, dated 11/1/2022, indicated an order for Eliquis (apixaban) tablet oral 5 milligrams (mg, a measure of weight) twice a day for DVT prophylaxis (PPX, an attempt to prevent disease). During an interview and record review on 12/19/2022, at 1:10 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated that there was no monitoring for signs and symptoms of bleeding on the use of Eliquis to Resident 29 on the chart. LVN 1 further stated that they should monitor for the side effects of the anticoagulant (Eliquis) for patient safety. LVN 1 also stated that they should observe for signs and symptoms such as bleeding, bruising and report them to the medical doctor (MD). During an interview and record review on 12/20/2022, at 9:48 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated that there was no monitoring for signs and symptoms on the use of anticoagulant (Eliquis) on the chart of Resident 29. LVN 2 stated that they need to monitor for bleeding and bruising with residents on anticoagulants. LVN further stated that as a precaution they monitor for bleeding such as nosebleed, black stools. During an interview on 12/21/2022, at 1:26 p.m., with the Director of Nursing (DON), the DON stated that the staff should have monitored the side effects of Eliquis for safety because it could cause bleeding and bruising. A review of the facility's recent policy and procedure titled Anticoagulation (the process of hindering the clotting of blood) Policy, last reviewed on 10/28/2022, indicated that the purpose of the policy and procedure was to ensure residents/patients who are receiving anticoagulation will be monitored for signs and symptoms of bleeding, and if evident, the physician will be notified immediately. Based on interview and record review, the facility failed to ensure four of eight sampled residents (Resident 29, 32, 68, and 382) were free from unnecessary medications by: 1. Failing to include a time interval and pain scale (numerical scale used to measure pain with 0 being no pain and 10 being the worst pain) indication for the use of as needed (PRN) tramadol for Residents 32 and 68. 2. Failing to have pain parameters (a limits or rules) for the use of hydrocodone-acetaminophen (a Schedule II medication with a high potential for abuse which may lead to severe psychological or physical dependence) 10-325 milligrams (mg- a unit of measure) for Resident 382. 3. Failing to monitor for the side effects of anticoagulant (blood thinner) use such as bruising and bleeding for Resident 29. These deficient practices had the potential to result in the residents receiving unnecessary medications and placed the residents at risk for adverse side effects (undesired harmful effect resulting from a medication or other intervention). Findings: a. A review of Resident 32's Face Sheet indicated the facility admitted the resident on 1/24/2018 with a readmission date of 4/15/2019 with diagnoses that included dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), chronic kidney disease (gradual loss of kidney function), osteoarthritis (occurs when the cartilage that cushions the ends of bones in your joints gradually deteriorates) of knee. A review of Resident 32's Minimum Data Set (MDS - an assessment and care screening tool) dated 10/30/2022 indicated the resident had the ability to usually make self-understood and had the ability to usually understand others. A review of Resident 32's physician orders indicated the following: - Tramadol (medication used for moderate to severe pain) 25 milligrams (mg- a unit of measure) once a day as needed (PRN) for generalized pain, ordered on 11/15/2022 and discontinued on 12/21/2022. - Tramadol 25 mg twice a day as needed (PRN) for generalized pain, ordered on 12/21/2022. During a concurrent interview and record review on 12/22/2022 at 10:28 a.m., with Licensed Vocational Nurse 2 (LVN 2), reviewed Resident 32's physician orders. LVN 2 verified Resident 32 had an order for tramadol twice a day as needed with no time interval and no pain scale for the use of the medication. LVN 2 stated twice is day is like every 12 hours but stated the order did not specify a time interval. LVN 2 stated she would not know exactly when the next medication administration would be if the first medication administration was in the afternoon. LVN 2 stated there should be a time frame so there are no mistakes. LVN 2 stated Resident 32 was unable to rate her pain using a numeric pain scale and would rate the resident's pain on facial grimacing. During a concurrent interview and record review on 12/22/2022 at 12:33 p.m., with the Director of Nursing (DON), reviewed Resident 32's physician orders. The DON verified Resident 32's tramadol order indicated twice a day as needed with no time interval and no pain scale for the use of the medication. The DON stated the order should have a time frame and stated how would they know when the second dose is due and when they can give it since the medication is to be administered as needed. The DON stated tramadol is used for a pain level of moderate pain and stated according to the order, the resident can get tramadol for a pain level of two from pain scale. The DON stated when taking tramadol, staff need to watch out for fall precautions because the medication can cause drowsiness. The DON stated the order should have the name of the medication, dosage, route, and indication for use. The DON stated the order needed to be clarified with how often the medication can be given and with a time frame. The DON stated since tramadol is used for moderate to severe pain, there should be an order for a medication to be used for lesser pain. A review of the facility's policy and procedure titled, Pain Management, last reviewed on 10/28/2022, indicated, The licensed nurse shall administer PRN pain medication as ordered and document on the Medication Administration Record (MAR) the drug, time of administration, dose, pain scale rating and resident's/patient's response and subsequent pain scale to medication within one hour. The policy also that indicate that a pain severity of 4-6 is moderate pain. A review of facility's policy and procedure titled, Range and Parameter Medication Orders, last reviewed on 10/28/2022, indicated, Medication orders are to be written to include: drug name, dose and dosage form, strength, route of administration, dosage regimen (frequency) and parameters (when applicable). b. A review of Resident 68's Face Sheet indicated the facility admitted the resident on 4/7/2021 with a readmission date of 4/20/2022 with diagnoses that included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), and chronic kidney disease (gradual loss of kidney function). A review of Resident 68's Minimum Data Set (MDS - an assessment and care screening tool) dated 10/27/2022 indicated the resident had the ability to make self-understood and had the ability to understand others. A review of Resident 68's physician orders indicated an order for tramadol (medication used for moderate to severe pain) 25 milligrams (mg- a unit of measure) twice a day as needed (PRN) for generalized pain, ordered on 7/19/2022. During a concurrent interview and record review on 12/22/2022 at 10:28 a.m., with Licensed Vocational Nurse 2 (LVN 2), reviewed Resident 68's physician orders. LVN 2 verified Resident 68 had an order for tramadol twice a day as needed with no time interval and no pain scale for the use of the medication. LVN 2 stated twice is day is like every 12 hours but stated the order did not specify a time interval. LVN 2 stated she would not know exactly when the next medication administration would be if the first medication administration was in the afternoon. LVN 2 stated there should be a time frame so there are no mistakes. During a concurrent interview and record review on 12/22/2022 at 12:33 p.m., with the Director of Nursing (DON), reviewed Resident 68's physician orders. The DON verified Resident 68's tramadol order indicated twice a day as needed with no time interval and no pain scale for the use of the medication. The DON stated the order should have a time frame and stated how would they know when the second dose is due and when they can give it since the is to be administered as needed. The DON stated tramadol is used for a pain level of moderate pain and stated according to the order, the resident can get tramadol for a pain level of two from pain scale. The DON stated when taking tramadol, staff need to watch out for fall precautions because the medication can cause drowsiness. The DON stated the order should have the name of the medication, dosage, route, and indication for use. The DON stated the order needed to be clarified with how often the medication can be given and with a time frame. The DON stated since tramadol is used for moderate to severe pain, there should be an order for a medication to be used for lesser pain. A review of the facility's policy and procedure titled, Pain Management, last reviewed on 10/28/2022, indicated, The licensed nurse shall administer PRN pain medication as ordered and document on the Medication Administration Record (MAR) the drug, time of administration, dose, pain scale rating and resident's/patient's response and subsequent pain scale to medication within one hour. The policy also that indicate that a pain severity of 4-6 is moderate pain. A review of facility's policy and procedure titled, Range and Parameter Medication Orders, last reviewed on 10/28/2022, indicated, Medication orders are to be written to include: drug name, dose and dosage form, strength, route of administration, dosage regimen (frequency) and parameters (when applicable).

e. A review of Resident 79's Face Sheet indicated that the facility admitted the resident on 11/1/2022, with a diagnosis of vitamin B12 deficiency anemia (a condition in which the body does not have enough healthy red blood cells, due to lack of vitamin B12). A review of Resident 79's History and Physical, dated 11/4/2022, indicated that the resident had anemia (a condition in which the number of red blood cells is lower than normal) and was on B12 (a nutrient in the vitamin B complex that the body needs in small amounts to function and stay healthy). A review of Resident 79's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/7/2022, indicated that the resident had the ability to make self-understood and understand others. A review of Resident 79's Physician Order Report, dated 11/2/2022, indicated an order for iron (ferrous sulfate, a form of the mineral iron that is used to treat anemia caused by low amounts of iron in the blood) tablet 325 milligrams (mg, a unit of mass) give 1 tablet by mouth once a day every Monday, Wednesday, and Friday for anemia. During an observation, interview, and record review on 12/21/2022, at 9:13 a.m., with LVN 4, during the morning medication pass for Resident 79, observed a bottle of iron 325 mg tablet not labeled with open date. LVN 4 stated that the bottle of iron 325 mg tablet should be labeled with an open date to ensure medications are not expired and are safe for residents to take. During an interview on 12/21/2022, at 1:32 p.m., the DON stated that the staff should have labeled the over the counter (OTC, legally sold without prescription) iron 325 mg bottle with an open date to prevent administering expired medications. A review of the facility's recent policy and procedure titled Medication Labeling, last reviewed on 10/28/2022, indicated that the licensed nurse will date multi-dose medications (vials, containers) or medication related supplies when opened. Based on observation, interview, and record review, the facility failed to ensure safe handling and storage of medications and biologicals (drugs derived from natural sources) in two out of two medication carts (Med Cart 1 and Med Cart 2) and one out of two medication storage areas (Med Storage 1), by: 1. Failing to ensure a Biotech D3-5 (cholecalciferol, a vitamin) container with illegible expiration date was removed immediately from Medication Cart 1 (Med Cart 1). This deficient practice had the potential to place the residents at risk of receiving expired and ineffective medications. 2. Failing to discard two opened thickener powder packets from Med Cart 2, and failing to discard an opened yogurt in Med Cart 1. This deficient practice had the potential to contaminate medications stored inside the medication cart. 3. Failing to date glucose test strips (an absorbent strip that soaks up blood for checking of blood glucose [sugar] levels) of when they were opened for two of two sampled medication carts (Med Cart 1 and Med Cart 2). This deficient practice had the potential to place the residents at risk of inaccurate blood glucose readings. 4. Failing to ensure Medication Storage 1 (Med Storage 1) was kept clean and free of clutter. This deficient practice had the potential to contaminate medications stored inside the medication room. 5. Failing to replace intravenous (IV - through the vein) emergency kit (e-kit, a set of limited drugs furnished to a nursing facility by the providing pharmacy which may be required to meet the therapeutic needs of the residents which is not readily available in sufficient time to prevent the risk of harm) within 72 hours in Med Storage 1. This deficient practice had the potential to result in a delay of life-saving medicines to the residents in case of an emergency. 6. The licensed nurse failing to label drugs and biologicals with open dates for one of four sampled residents (Resident 79). This deficient practice had the potential for harm to the resident due to potential dispensing of expired (the day that a medicine becomes harmful or bad) drugs and biologicals. Findings: a. During a concurrent observation of Med Cart 1 and an interview with Licensed Vocational Nurse 1 (LVN 1), on 12/19/2022 at 10:53 a.m., LVN 1 confirmed the following stored inside the medication cart: - Biotech D3-5 (container of cholecalciferol, a vitamin) with illegible expiration date. - Non-fat greek yogurt, that was opened and used with no date and time of when it was opened. - Evencare G3 glucose test strips (small, plastic strips that help to test and measure blood glucose levels) with no date of when it was opened. LVN 1 stated the vial of test strips was good six months after opening or until the expiration date on the vial, whichever comes first. LVN 1 stated since it was not dated, he would throw it away and open a new vial of glucose test strips. During an interview on 12/19/2022 at 11:15 a.m., LVN 1 stated the importance of ensuring administering unexpired medications was to ensure the medications are effective and to prevent residents from experiencing any adverse effects (any unexpected or dangerous reaction to a drug) such as nausea, vomiting, and diarrhea. LVN 1 stated the opened date on the vial bottles should have a date on it to ensure the test strips have accurate reading. Upon further interview, LVN 1 stated the yogurt should have been labeled to indicate when it was provided. LVN 1 stated the yogurt was intended for the residents when he administers the residents' medications; he either uses apple sauce or yogurt depending on what the resident likes or prefers. LVN 1 stated he would keep the yogurt in his drawer until the end of his shift but since it was not labeled, he will throw it away. During an interview on 12/23/2022 at 7:59 a.m., the DON stated once the yogurt has been taken out of the refrigerator it should be dated and timed of when it was removed. The DON stated ideally the yogurt should be used immediately and disposed after opening. The DON stated the licensed should have a basin filled with ice placed on top of their medication carts when they are starting to pass medications. The DON stated if the yogurt and other dairy products are not maintained in appropriate temperatures, it could cause gastrointestinal issues among residents and contaminate the medications kept in the medication carts. During an interview on 12/23/2022 at 8:00 a.m., the DON stated all stored medications should have an expiration date and if there is none, the licensed nurses are expected to remove it from their medication cart immediately. During an interview on 12/23/2022 at 8:06 a.m., the DON stated the licensed nurses are expected to date the glucose test strips bottle and follow the manufacturer's manual. The DON stated the efficacy date of six months was indicated by the manufacturer's user guide, and if it was undated then it should be discarded because it may produce inaccurate blood sugar results. A review of the facility's policy and procedure titled, Storage of Medications, reviewed and approved on 10/28/2022, indicated that outdated, contaminated, or deteriorated medications . are immediately removed from stock, disposed according to procedures for medication. Medication storage areas are kept clean, well-lit, and free of clutter . A review of the facility's policy and procedure titled, Blood Glucose Monitoring, reviewed and approved on 10/28/2022, indicated the facility's procedure to maintain the blood glucose equipment according to the manufacturer's recommendation including dating all test strips . when opened and discarding. A review of Evencare G3 User Guide (task-oriented document), Blood Glucose Monitoring System, copyright dated 2016, indicated for vial test strips, record the date on the bottle when opening a new bottle of test strips. Discard any unused test strips six months after opening. b. During a concurrent observation of Med Cart 2 and an interview with Licensed Vocational Nurse 2 (LVN 2), on 12/19/2022 at 11:18 a.m., LVN 2 confirmed the following stored inside the medication cart: - Two opened packets of Hormel Thick & Easy Powder (brand of a thickener powder). LVN 2 stated she just used it for her residents that day. LVN 2 stated they should be thrown out and not stored inside the medication cart. - Evencare G3 glucose test strips with no date of when it was opened. LVN 2 confirmed the vial indicated to use the test strips within six months or until expiration date. LVN 2 stated she would keep the undated glucose test strips on her cart because it is not expired yet. During an interview on 12/23/2022 at 7:59 a.m., the DON stated the opened packets of thickener powders were for one-time use and once opened and used are to be discarded immediately. During an interview on 12/23/2022 at 8:06 a.m., the DON stated the licensed nurses are expected to date the glucose test strips bottle and follow the manufacturer's manual. The DON stated the efficacy date of six months was indicated by the manufacturer's user guide, and if it was undated then it should be discarded because it may produce inaccurate blood sugar results. A review of the facility's policy and procedure titled, Storage of Medications, reviewed and approved on 10/28/2022, indicated that outdated, contaminated, or deteriorated medications . are immediately removed from stock, disposed according to procedures for medication. medication storage areas are kept clean, well-lit, and free of clutter . A review of Evencare G3 User Guide (task-oriented document), Blood Glucose Monitoring System, copyright dated 2016, indicated for vial test strips, record the date on the bottle when opening a new bottle of test strips. Discard any unused test strips six months after opening. c. During a concurrent observation of Medication Storage 1 (Med Storage 1) and interview on 12/19/2022 at 11:28 a.m., LVN 2 confirmed the following multiple boxes sitting directly on the floor: 1. IV emergency kit (e-kit, remotely dispensed initial medications to residents who are in need of medications before the pharmacy can deliver their prescriptions) 2. Eight tube feeding formulas of Glucerna (brand of tube feeding formula) bottles 3. Twenty-four tube feeding formulas of Two Cal High Nitrogen (brand of tube feeding formula) in one carton. During an interview on 12/19/2022 at 11:35 a.m., LVN 2 stated they had a lot of supplies and were waiting on central supply staff to arrange the boxes. When asked if the boxes resting directly on the floor was a standard practice of the facility, especially tube feeding formulas and IV e-kits, LVN 2 failed to answer the question and proceeded to state that housekeeping was coming to organize the medication storage room. During an interview on 12/23/2022 at 8:07 a.m., the DON stated the medication storage rooms should be free of clutter; the boxes especially tube feeding formulas and medications should be off the floor. The DON stated they should have observed infection control practices to prevent contamination of the medications. A review of the facility's policy and procedure titled, Storage of Medications, reviewed and approved on 10/28/2022, indicated that outdated, contaminated, or deteriorated medications . are immediately removed from stock, disposed according to procedures for medication. Medication storage areas are kept clean, well-lit, and free of clutter . d. During a concurrent observation of Medication Storage 1 (Med Storage 1) and interview on 12/19/2022 at 11:28 a.m., LVN 2 confirmed the IV e-kit with filled date of 11/24/2022 was last opened and used on 12/16/2022 for Resident 29. A review of the Emergency Kit Pharmacy Log for Med Storage 1, indicated that on 12/16/2022 at 12:15 a.m., items used from IV e-kit were normal saline (NS, sterile water) 1 liter (a unit of measure for volume), primary IV tubing, IV starter kit, 1 NS 5 milliliter (ml, a unit of measure for volume) syringe. During an interview on 12/23/2022 at 8:09 a.m., the DON stated the licensed nurses are expected to call and follow-up with pharmacy to replace the e-kits including IV e-kits to ensure medications are readily available. The DON stated the e-kits are to be replaced within 72 hours once opened in case a resident or residents are needing the same medication. A review of the facility's policy and procedure titled, Emergency Pharmacy Service and Emergency Kits, reviewed and approved on 10/28/2022, indicated that if exchanging kits, opened kits are replaced with sealed kits within 72 hours of opening.

Based on observation, interview, and record review, the facility failed to: 1. Label food items stored in two out of two resident refrigerators (First Floor Resident Refrigerator and Second Floor Resident Refrigerator) with the residents' names and dates received per the facility's policy. 2. Label with an open date and time of the used and opened yogurt for one of one medication cart (Med Cart 1) by Licensed Vocational Nurse 1 (LVN 1). These deficient practices had the potential to result in harmful bacteria growth that could lead to foodborne illnesses (illness caused by the ingestion of contaminated food or beverages). Findings: a. During a concurrent observation and interview on 12/23/2022 at 11:22 a.m., with Registered Nurse 2 (RN 2), observed the following in the Second Floor resident refrigerator: - One opened cranberry juice bottle not labeled with a resident name or date received. - Two unopened cranberry juice bottles not labeled with a resident name or date received. - One slice of chocolate cake not labeled with a resident name or date received. - A plastic bag containing a jar with soup and container with chicken and rice not labeled with a resident name or date received. - A honey container not labeled with date received. RN 2 stated items should be labeled with name and date so the food items do not get served to a different resident. During a concurrent observation and interview on 12/23/2022 at 11:31 a.m., with RN 2, observed the following in the First Floor resident refrigerator: - One chocolate shake carton not labeled with a resident name or date received. - Two lemon ice cups in the freezer not labeled with a resident name or date received. RN 2 stated items should be labeled with name and date so the food items do not get served to a different resident. During an interview on 12/23/2022 at 12:36 p.m., with the Director of Nursing (DON), the DON stated items in the resident refrigerator should be labeled with the resident's name and date the item was received for infection control purposes and to make sure it is given to the right resident. A review of the facility's policy and procedure titled, Food From Outside Sources for Residents/Patients, last reviewed on 10/28/2022, indicated, If family and friends insist on bringing in foods, they are encouraged to bring food so residents/patients will immediately consume what has been brought in and discard any leftovers . Family and friends are encouraged to bring foods in single servings or in plastic containers with tight fitting lids that are labeled with resident/patient's name and date .Any food stored (in the designated resident refrigerator) that does not have the resident/patients name and the date it was brought will be discarded .All food stored will be discarded after 72 hours. b. During a medication cart observation on 12/19/2022 at 10:53 a.m., LVN 1 confirmed a yogurt with no date and time of when it was opened and used was stored inside the drawer of Med Cart 1. LVN 1 stated the yogurt came from the kitchen. During an interview on 12/19/2022 at 11:15 a.m., LVN 1 stated the yogurt should be dated to indicate when it was provided but he did not label it. LVN 1 stated the yogurt was intended for the residents when he administers the residents' medications. LVN 1 stated he would keep the yogurt inside his medication cart drawer until the end of his shift but since he did not label it, he will throw it away. During an interview on 12/22/2022 at 12:45 p.m., the Dietary Supervisor (DS) stated yogurt should be consumed within an hour after removed from the refrigerator and kept at room temperature. The DS stated if the yogurt has been opened and used no more than two hours, the facility staff should dispose it, and not serve it to the residents. A review of the facility's policy and procedure titled, Potentially Hazardous Foods, reviewed and approved on 10/28/2022, indicated that potentially hazardous foods include foods or animal origin that are raw, or heat treated (examples are eggs, milk, meat, and poultry). A review of the California Department of Education document titled, Temperature Controls of Potentially Hazardous Food: Cold Food, last reviewed 8/31/2022, indicated to hold cold foods at 41 degrees Fahrenheit (?, a unit of measure for temperature) or less and check the temperature every four hours. If the temperature of the food at four hours is greater than 41 degrees Fahrenheit, the food must be discarded. It is permissible to hold cold food without temperature controls for up to four hours if the following conditions are met including labelling the food upon receipt with the time it must be discarded.

Based on observation, interview, and record review, the facility failed to implement the facility's hospice (care designed to give supportive care in the final phase of a terminal illness and focus on comfort and quality of life) policy and procedure for one of two sampled residents (Resident 47). For Resident 47, the following documents were not available in the resident's medical record: 1. The monthly calendar for planned hospice visits, used to coordinate hospice care. 2. Nursing progress notes of hospice visits used to coordinate hospice care. 3. Certificate of Terminal Illness used to verify the need of hospice care and services. These deficient practices had the potential to delay coordination and delivery of hospice services. Findings: During an observation on 12/19/2022 at 9:23 a.m., observed Resident 47 sitting calmly with her hands covering her face while in the activities area. A review of the Face Sheet indicated the facility admitted Resident 47 on 07/26/2021 and admitted the resident on hospice care on 09/10/2022. A review Resident 47's Minimum Data Set (MDS, a standardized comprehensive assessment and care screening tool) dated 09/23/2022, indicated Resident 47 had long and short-term memory problems and required total assistance with activities of daily living (ADLs). In addition, the MDS indicated Resident 47 was receiving Hospice care. A review of Resident 47's hospice binder included the hospice contract and a check-in log for certified nursing assistant (CNA) visits. The hospice binder did not include the monthly calendar for planned hospice visits, nursing progress notes of hospice visits, and Certificate of Terminal Illness. During an interview on 12/22/2022 at 9:04 a.m., Registered Nurse 2 (RN 2), verified Resident 47's hospice binder and medical records did not include a monthly calendar for planned hospice visits, nursing progress notes for October and December, and the Certificate of Terminal Illness. During an interview on 12/22/2022 at 9:17 a.m., Medical Records Staff (MRS) confirmed there were no monthly calendar for the planned hospice visits, no Certificate of Terminal Illness, and no nursing progress notes for 10/2022 and 12/2022, in Resident 47's medical records. A review of the facility's Hospice policy and procedure, dated 12/11/2021, indicated to facilitate hospice services for residents in accordance with state and federal law through contracted licensed vendors. A review of the facility's Hospice Contract, dated 10/09/2022, indicated hospice care should be coordinated and communicated between the facility and the hospice agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** f. A review of Resident 9's Face Sheet indicated that the facility admitted the resident on 1/8/2021. The facility readmitted the resident on 4/18/2021, with diagnoses including chronic kidney disease (the kidneys are damaged and cannot filter blood the way they should) and personal history of Coronavirus Disease 2019 (COVID-19 -a highly contagious disease spread from person to person through droplets released when an infected person coughs, sneezes, or talks). A review of Resident 9's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 10/15/2022, indicated that that resident had the ability to make self-understood and understand others. A review of Resident 9's Care Plan, dated 10/19/2022, indicated that the resident was at risk for re-infection specific to pandemic (widespread occurrence of an infectious disease over multiple countries and continents) COVID-19 with a goal of limiting the spread/transmission of communicable disease. During an observation and interview on 12/19/2022, at 9:40 a.m., with Housekeeping Staff 1 (HSK 1), in Resident 9's room, observed HSK 1 picked up a box of tissues resting on the floor beside the resident's bed and was handed to the resident without wiping with an antiseptic wipe or discarding the contaminated tissue box and replacing with a new one. HSK 1 stated that she should have wiped the box of tissue that she picked up from the floor with an antiseptic wipe before handing it to the resident or better yet discarded the dirty box of tissue and gave a new one to the resident to prevent infection. During an interview on 12/21/2022, at 1:35 p.m., with the Director of Nursing (DON), the DON stated that HSK 1 should have thrown the box of tissue and gave a new one to the resident. The DON also stated that she could have also wiped the box with an antiseptic wipe before handing it to the resident to prevent infection. During an interview on 12/22/2022, at 1:37 p.m., with the Infection Preventionist (IP), the IP stated that HSK 1 should have not handed the box of tissue on the floor to the resident. The IP stated that HSK 1 should have changed the box. The IP further stated that the act of HSK 1 handing the contaminated tissue box had the potential to transfer an infection to the resident. g. A review of Resident 79's Face Sheet indicated that the facility admitted the resident on 11/1/2022 with diagnoses including personal history of COVID-19 and chronic kidney disease. A review of Resident 9's MDS, dated [DATE], indicated that resident had the ability to make self-understood and understand others. During an observation and interview on 12/21/2022, at 9:20 a.m., with Licensed Vocational Nurse 4 (LVN 4), during the medication pass observation, observed Resident 79 drop a pill on the floor and picked it up with her bare hands. LVN 4 stopped Resident 79 from taking the pill that fell on the floor and told Resident 79 that she would give her a new pill. LVN 4 allowed Resident 79 to continue taking her pills by herself without sanitizing or washing the resident's hands. LVN 4 stated that she should have not let Resident 79 take another pill because the resident touched the floor. LVN 4 stated that the incident had the potential for infection issue. During an interview on 12/21/2022, at 1:30 p.m., with the DON, the DON stated that should have offered to sanitize the hand or wash the hands of the resident due to potential for infection control issues. During an interview on 12/23/2022, at 1:35 p.m., with the IP, the IP stated that LVN 4 should have washed or used a sanitizer on the hand of the resident due to infection control. A review of the facility's recent policy and procedure about their Infection Control Program, last reviewed on 10/28/2022, indicated that facility is monitoring for adherence of use and cleaning/disinfection practices for medical equipment, supplies and devices. Strategies and interventions include: -Education of all staff and licensed independent providers regarding the disinfection of medical equipment -Devices and supplies policy and procedure -Observation of proper cleaning and disinfecting procedures of environment of care staff as well as nursing and Licensed Independent Providers (LIP) staff A review of the facility's policy and procedure titled Hand Hygiene/Handwashing, last reviewed on 10/28/2022, indicated that hands should be washed after touching patient surroundings. Based on observation, interview, and record review, the facility failed to implement its infection control policy and procedure by failing to: 1. Ensure Licensed Vocational Nurse 4 (LVN 4) performed hand hygiene prior to donning (putting on) gloves and entering Resident 61's room to handle the resident's urinary catheter (thin, flexible tube placed in the body to drain and collect urine from the bladder). 2. Ensure Resident 7's nasal cannula (thin, flexible tube containing two open prongs used to deliver oxygen) tubing was changed every seven days per facility policy for one of one sampled resident (Resident 7). 3. Ensure vital signs were taken daily for two of eight sampled residents (Residents 32 and 77). 4. Discard Resident 16's closed system tube feeding formula when the gastrostomy tubing (g-tube, a flexible tube inserted through the abdominal wall that directly delivers nutrition to the stomach) was resting directly on the floor and Licensed Vocational Nurse 1 (LVN 1) proceeded to reconnect and restart tube feeding for Resident 16. 5. Ensure the trash container being used for isolation gowns was placed inside the resident's room for one of one sampled resident (Resident 68) who was under contact isolation (used when a patient has an infectious disease that may be spread by touching either the patient or other objects the patient has handled). 6. Ensure Housekeeping Staff 1 (HSK 1) sanitized or discarded and replaced the box of tissue that fell on the floor before handing them to Resident 9. 7. Ensure Licensed Vocational Nurse 4 (LVN 4) sanitized or washed the contaminated hands of Resident 79 prior to self-administering medications. These deficient practices had the potential to transmit infectious microorganisms and placed the residents and staff at risk for infection. Findings: a. A review of Resident 61's Face Sheet indicated the facility admitted the resident on 8/2/2022 with diagnoses that included obstructive and reflux uropathy (condition in which the flow of urine is blocked and causes urine to flow backward), encounter for fitting and adjustment of urinary device (Foley catheter - thin, flexible tube inserted into the bladder to drain urine), and Alzheimer's disease (a progressive brain disorder that slowly destroys memory and thinking skills). A review of Resident 61's Minimum Data Set (MDS - an assessment and care screening tool), dated 11/9/2022, indicated the resident had the ability to make self understood and had the ability to usually understand others. The MDS further indicated Resident 61 required extensive assistance with bed mobility, dressing, and personal hygiene, and was totally dependent on staff with toilet use. During a concurrent observation and interview, on 12/20/2022 at 11:37 a.m., observed LVN 4 enter Resident 61's room and don gloves without performing hand hygiene. Observed LVN 4 pull down resident's blanket and proceed to handle the resident's urinary catheter. LVN 4 confirmed she did not perform hand hygiene prior to entering Resident 61's room and prior to donning her gloves. LVN 4 stated she should have performed hand hygiene by either washing her hands with soap and water for 60 seconds or by rubbing her hands until dry with an alcohol-based hand sanitizer (ABHS). LVN 4 stated the importance of hand hygiene was to prevent transferring bacteria to residents and thereby preventing infection. During an interview, on 12/22/2022 at 3:27 p.m., the Infection Preventionist (IP) stated all staff should be performing hand hygiene when entering and leaving a resident's room, before and after providing resident care, prior to donning and after doffing (taking off) gloves, and any time staff are administering medications or making contact with invasive devices such as urinary catheters. The IP stated LVN 4 should have performed hand hygiene first upon entering Resident 61's room and prior to donning her gloves with soap and water for at least 20 seconds or by using an ABHS and rubbing her hands until completely dissolved. The IP confirmed both opportunities for hand hygiene were missed. The IP further stated staff failing to perform hand hygiene can potentially result in spread of infection among residents within the facility. A review of the facility's policy and procedure titled, Hand Hygiene/Hand Washing, last reviewed and updated on 10/28/2022, indicated hands should be washed before touching a patient, before clean or aseptic (free from contamination caused by harmful microorganisms) procedure, after body fluid exposure or risk, after touching a patient, and after touching patient surroundings. b. A review of Resident 7's Face Sheet indicated the facility admitted the resident on 8/10/2022 with diagnoses that included chronic combined systolic and diastolic congestive heart failure (condition where the heart is not pumping enough blood out to the body due to inability to contract effectively with each heartbeat and inability to relax normally between beats), hyperlipidemia (abnormally high levels of fats in the blood), and cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body). A review of Resident 7's Minimum Data Set (MDS - an assessment and care screening tool), dated 11/17/2022, indicated the resident's cognitive (relating to thinking, reasoning, or remembering) skills for daily decision-making was severely impaired. The MDS further indicated Resident 7 required extensive assistance from staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. A review of Resident 7's physician orders indicated the following orders: - Oxygen via nasal cannula at 2 liters/minute as needed (PRN) for shortness of breath every shift, ordered on 10/28/2022. - Change oxygen tube and bag every Sunday. Special instruction: Label tube and bag, ordered on 11/20/2022. During an observation, on 12/19/2022 at 9:43 a.m., observed Resident 7 on 2 liters of oxygen via nasal cannula. Observed nasal cannula tubing labeled and dated 12/11. During a concurrent observation and interview, on 12/19/2022 at 9:47 a.m., Licensed Vocational Nurse 5 (LVN 5) observed and verified Resident 7's nasal cannula was labeled 12/11 and stated that the labeled date is when the nasal cannula was last changed. LVN 5 stated nasal cannula is changed once a week and confirmed it should have been changed by the night shift nurse on 12/18/2022. However, LVN 5 stated any licensed nurse who notices the nasal cannula is outdated can change the tubing. LVN 5 further stated nasal cannula should be changed weekly per facility policy to prevent infection. During a concurrent interview and record review, on 12/20/2022 at 5:32 p.m., the Infection Preventionist (IP) reviewed Resident 7's physician order to change the oxygen tube and bag every week on Sundays and verified Resident 7's nasal cannula should have been changed on 12/18/2022. The IP stated the nasal cannula should be changed weekly and as needed if the tubing becomes contaminated from touching the floor or any time it gets soiled. The IP stated the licensed nurses should be changing the nasal cannula for residents on oxygen therapy at least weekly and as needed when contaminated to minimize the resident's risk of getting an infection. A review of the facility's policy and procedure titled, Oxygen Therapy, last reviewed on 10/28/2022, indicated the oxygen cannula, mask, and tubing shall be dated and changed every seven days and as needed. c.1. A review of Resident 32's Face Sheet indicated the facility admitted the resident on 1/24/2018, and most recently readmitted the resident on 4/15/2019, with diagnoses that included Alzheimer's disease (a progressive brain disorder that slowly destroys memory and thinking skills) and personal history of Coronavirus disease-2019 [COVID-19, a highly contagious viral infection that can trigger respiratory tract infection]. A review of Resident 32's Minimum Data Set (MDS - an assessment and care screening tool), dated 10/30/2022, indicated the resident had the ability to make self usually understood and the ability to usually understood others. The MDS further indicated Resident 32 required limited assistance from staff with bed mobility, transfer, and dressing and required extensive assistance with toilet use and personal hygiene. A review of Resident 32's vital signs log taken from 11/22/2022 to 12/22/2022 indicated no vital signs were taken and recorded for the following dates: 11/27/2022, 11/28/2022, 11/29/2022, 12/4/2022, 12/6/2022, 12/7/2022, 12/8/2022, 12/9/2022, 12/11/2022, 12/13/2022, 12/14/2022, 12/16/2022, 12/18/2022, 12/19/2022, and 12/20/2022. c.2. A review of Resident 77's Face Sheet indicated the facility admitted the resident on 10/3/2022 with diagnoses that included Alzheimer's disease and personal history of COVID-19. A review of Resident 77's MDS, dated [DATE], indicated the resident's cognitive skills for daily decision making was moderately impaired. The MDS further indicated Resident 77 required one-person limited assistance from staff with bed mobility, transfer, dressing, toilet use, and personal hygiene. A review of Resident 77's vital signs log taken from 11/22/2022 to 12/22/2022 indicated no vital signs were taken and documented for the following dates: 12/18/2022, 12/19/2022, 12/20/2022, 12/21/2022, and 12/22/2022. During an interview, on 12/20/2022 at 10:53 a.m., Licensed Vocational Nurse 4 (LVN 4) stated vital signs are taken every four hours for residents that are symptomatic with COVID-19 symptoms or have tested positive for COVID-19. LVN 4 stated for residents that are asymptomatic, vital signs are not taken daily unless the resident is receiving blood pressure medications. LVN 4 explained that vital signs for asymptomatic residents are taken once a week which is documented in the weekly summary. During a concurrent interview and record review, on 12/22/2022 at 3:33 p.m., the Infection Preventionist (IP) stated vital signs are monitored for all residents at least once daily and more frequently every four hours for symptomatic and confirmed positive residents in accordance with its COVID-19 mitigation plan (MP- a plan to reduce loss of life and impact of COVID-19 in the facility) which the IP stated is part of the facility's infection control and prevention policies and procedures. The IP reviewed Resident 32's vital signs log and confirmed vital signs were not monitored and documented for the resident for 11/27/2022, 11/28/2022, 11/29/2022, 12/4/2022, 12/6/2022, 12/7/2022, 12/8/2022, 12/9/2022, 12/11/2022, 12/13/2022, 12/14/2022, 12/16/2022, 12/18/2022, 12/19/2022, and 12/20/2022. The IP also reviewed Resident 77's vital signs log and verified vital signs were not monitored and documented for 12/18/2022, 12/19/2022, 12/20/2022, 12/21/2022, and 12/22/2022. The IP confirmed a full set of vital signs that includes temperature, blood pressure, pulse, respiratory rate, and oxygen saturation (amount of oxygen circulating in the blood) should have been taken daily for all residents including residents who are not taking blood pressure medications to monitor for and detect any changes in the resident's conditions such as fever and low blood pressure. The IP explained the certified nursing assistants would report any abnormal vital signs to the charge nurse who would reassess the resident and recheck the resident's vital signs to confirm. The IP stated the licensed nurse, upon confirming the resident's change in condition, would then complete a Situation-Background-Assessment-Recommendation (SBAR - communication tool that helps provide essential, concise information between healthcare team members) and notify the physician. A review of the facility's COVID-19 facility mitigation plan, last reviewed on 10/28/2022, indicated all residents will be screened for symptoms of COVID-19 and have their vital signs monitored including oxygen saturation and temperature checks at least every 24 hours for the resident in the green zone (an area reserved for residents who do not have COVID-19) and twice a shift for symptomatic residents. e. A review of Resident 68's Face Sheet indicated the facility admitted the resident on 4/7/2021 with a readmission date of 4/20/2022 with diagnoses that included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), and chronic kidney disease (gradual loss of kidney function). A review of Resident 68's Minimum Data Set (MDS - an assessment and care screening tool) dated 10/27/2022 indicated the resident had the ability to make self-understood and had the ability to understand others. A review of Resident 68's physician orders indicated an order for contact isolation due to shingles (painful nerve root infection resulting in a skin rash), ordered on 12/12/2022. A review of Resident 68's Care Plan in regards to communicable illness/infection related to shingles, initiated on 12/12/2022, indicated an intervention that a dedicated trash hamper must be placed inside the resident's room. During an observation on 12/23/2022 at 8:28 a.m., observed a trash hamper being used for used isolation gowns outside Resident 68's room next to the resident's door. During an interview on 12/23/2022 at 8:41 a.m., with Registered Nurse 2 (RN 2), RN 2 stated they have a bin inside the resident's room and a bin outside the room. RN 2 stated the bin inside the room is for linen and the one outside the room is for the used isolation gowns. RN 2 stated staff doff (take off) outside the room. During a concurrent observation and interview on 12/23/2022 at 8:53 a.m., with the Infection Preventionist (IP), observed the trash hamper being used for used isolation gowns outside Resident 68's room. The IP stated the trash hamper should be inside the room. The IP stated the importance is so whatever infection that is inside the room does not spread outside to the hallway. A review of the facility's policy and procedure titled, Transmission-Based Precautions, last reviewed on 10/28/2022, indicated, Remove PPE and observe hand hygiene before leaving the resident/patient-care environment .Contact precautions: PPE are used for any room entry. [NAME] upon entry to the resident/patient's room. Remove before exiting the room. d. A review of Resident 16's Face Sheet indicated the facility admitted the resident on 11/9/2022 with diagnoses including dementia (a syndrome of memory disorders, personality changes, and impaired reasoning that interferes with daily functioning) and Alzheimer's disease (a brain disease that slowly destroys brain cells). A review of Resident 16's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/16/2022, indicated the resident's cognitive skills for decision making was severely impaired. The MDS indicated the resident was totally dependent (full staff performance every time during entire seven-day period) with eating and toilet use with physical assistance from nursing staff. A review of Resident 16's Physician Order, dated 11/9/2022, indicated an order for continuous g-tube feeding via enteral (way of delivering nutrition directly to the stomach through tube feeding) feeding pump: Jevity 1.5 (lactose-reduced with fiber) at 50 milliliters (mL, a unit of measure for volume) per hour (hr) for 20 hrs to provide 1000 ml-1500 kilocalories (kcal, a unit of measure for energy). During an observation on 12/22/2022 at 7:39 a.m., LVN 1 entered Resident 16's room and identified self as Resident 16's assigned LVN. LVN 1 performed hand hygiene using alcohol-based hand rub and put on gloves, then proceeded to disconnect Resident 16's tube feeding from the feeding pump and turned it off. Observed tube feeding tubing dropped to the floor. LVN 1 proceeded to administer Resident 16's medications. During a concurrent observation and interview on 12/22/2022 at 7:46 a.m., observed LVN 1 completed medication administration for Resident 16. Observed LVN 1 picked up the tube feeding tubing which was resting directly on the floor then proceeded to reconnect and restart Resident 16's tube feeding machine. LVN 1 confirmed the tube feeding tubing was on the floor because he didn't secure it properly on the machine but it was still okay to reuse and reconnect back to the resident to continue his tube feeding administration. LVN 1 stated he believed it was not an infection control issue because the tube feeding tubing had a cap in place on the tip, since it was closed. During an observation on 12/22/2022 at 7:47 a.m., observed LVN 1 successfully connected the tube feeding tubing to Resident 16 and turned on the tube feeding pump as ordered. During an interview on 12/23/2022 at 8:11 a.m., the Director of Nursing (DON) stated if a tube feeding tubing touched the floor it is considered contaminated and should be discarded right away to prevent the spread of infections to the resident. A review of the facility's policy and procedure titled, Enteral Feeding: Changing a Gastrostomy Tube, reviewed and approved on 10/28/2022, indicated the facility's procedure included the facility staff to maintain clean technique and isolation precautions as indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its antibiotic stewardship (set of commitments and actions designed to optimized treatment of infections while reducing the adverse events associated with antibiotic [medication used to treat bacterial infection] use) interventions by failing to conduct infection surveillance and complete the infection control reporting form once signs and symptoms of infection were identified and antibiotics were initiated for three of four sampled residents (Residents 7, 282, and 382). This deficient practice had the potential for Residents 7, 282, and 382 to develop antibiotic resistance from unnecessary or inappropriate antibiotic use. Findings: a. A review of Resident 7's Face Sheet indicated the facility admitted the resident on 8/10/2022 with diagnoses that included chronic combined systolic and diastolic congestive heart failure (condition where the heart is not pumping enough blood out to the body due to inability to contract effectively with each heartbeat and inability to relax normally between beats), hyperlipidemia (abnormally high levels of fats in the blood), and cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body). A review of Resident 7's Minimum Data Set (MDS - an assessment and care screening tool), dated 11/17/2022, indicated the resident's cognitive (relating to thinking, reasoning, or remembering) skills for daily decision making was severely impaired. The MDS further indicated Resident 7 required extensive assistance from staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. A review of Resident 7's physician orders indicated doxycycline monohydrate (antibiotic medication) capsule 100 milligrams (mg - unit of measure) oral (by mouth) twice a day for five days only. Diagnosis: left third fingernail paronychia (skin infection around the nails), ordered on 11/28/2022. b. A review of Resident 282's Face Sheet indicated the facility admitted the resident on 11/28/2022, and most recently readmitted the resident on 12/19/2022, with diagnoses that included Alzheimer's disease (a progressive brain disorder that slowly destroys memory and thinking skills) with late onset, chronic kidney disease (gradual loss of kidney [organ that filters the blood to removes wastes and excess fluid] function) stage three, and diabetes mellitus type two (chronic disease characterized by high levels of sugar in the blood). A review of Resident 282's MDS, dated [DATE], indicated the resident had the ability to make self sometimes understood and had the ability to sometimes understand others. The MDS further indicated Resident 282 required extensive assistance with bed mobility, transfer, dressing, and personal hygiene and was totally dependent on staff with toilet use. A review of Resident 282's physician orders indicated ampicillin (antibiotic medication) capsule 500 mg oral four times a day for five days until 12/24/2022. Diagnosis: urinary tract infection (infection in any part of the urinary system). c. A review of Resident 382's Face Sheet indicated the facility admitted the resident on 11/28/2022 with diagnoses that included blepharitis (inflammation of the eyelids) of right lower eyelid and Alzheimer's disease. A review of Resident 382's MDS, dated [DATE], indicated the resident had the ability to make self understood and had the ability to understand others. The MDS further indicated Resident 382 required limited assistance from staff with bed mobility, transfer, and toilet use and required extensive assistance with dressing and personal hygiene. A review of Resident 382's physician orders indicated Neomycin-Polymyxin B-Dexamethasone (medication used to treat bacterial eye infections) ophthalmic (eye) ointment 3.5 mg/10,000 units/1 mg per gram (g); 1 g three times a day to right eye. Diagnosis: unspecified blepharitis right lower eyelid, ordered 12/13/2022. During a concurrent interview and record review, on 12/21/2022 at 11:01 a.m., the Infection Preventionist (IP) stated the facility uses the Mcgeer's criteria (standard used for defining infections for surveillance purposes) to define infections and monitor antibiotic use. The IP explained the infection control reporting form (infection surveillance form) is completed by the licensed nurse once an order for an antibiotic is obtained from the physician and the forms are maintained in a separate binder. The IP stated he would then review the forms and the physician would be notified if the resident does not meet the criteria and allow the physician to decide to continue or discontinue the ordered antibiotic therapy. The IP reviewed Resident 382's chart and verified resident is receiving Neomycin-Polymyxin B-Dexamethasone ointment for right eyelid blepharitis. The IP reviewed the infection surveillance form binder and confirmed the form had not been completed for Resident 382. The IP further reviewed Residents 7 and 282's chart and verified that Resident 7 was receiving doxycycline for left third finger nail paronychia and Resident 282 was receiving ampicillin for diagnosis of UTI. The IP confirmed the forms were not completed for both Residents 7 and 282 upon reviewing the infection surveillance form binder. The IP stated the infection control surveillance form should have been completed by the assigned licensed nurse for Residents 7, 282, and 382 upon obtaining the order for antibiotic therapy from the physician to determine if the resident meets the Mcgeer's criteria for the suspected infection and whether antibiotics is appropriate for the resident. The IP stated he audits at least weekly and notifies the assigned nurse for any resident on antibiotics without a completed infection control reporting form. The IP stated he had been busy and admitted the surveillance forms had not been completed since September 2022. The IP stated the importance of conducting infection surveillance and completing the infection control reporting form to monitor residents for signs and symptoms that need to be promptly reported to the physician and to notify the physician if resident does not meet the Mcgeer's criteria for an infection to prevent unnecessary use of antibiotics that can lead to the resident developing antibiotic resistance. During a concurrent interview and record review, on 12/21/2022 at 3:01 p.m., the IP stated he does not maintain a separate infection surveillance log, other than Coronavirus disease-2019 [COVID-19, a highly contagious viral infection that can trigger respiratory tract infection] line list, to monitor and keep track of residents with signs and symptoms of infection. However, the IP explained he collects surveillance data from the licensed nurses, review the daily 24-hour log of patient conditions and nursing unit activities, and review the progress notes in the resident's chart for signs and symptoms of infection as part of infection surveillance. The IP confirmed an infection surveillance log should be maintained to keep track of all residents with any signs and symptoms of infection to readily identify clusters of infection and control spread of infection within the facility and for contact tracing purposes. The IP stated the importance of infection surveillance to prevent spread of infection which can lead to an outbreak if not monitored. The IP verified the facility's antibiotic stewardship and infection control and prevention policies and procedures did not specifically address the use of Mcgeer's criteria for infection surveillance and notification of the physician if resident does not meet the criteria and stated it should be included in the facility's policies. During an interview, on 12/23/2022 at 12:40 p.m., the Director of Nursing (DON) confirmed the licensed nurse is required to complete the infection control reporting form upon obtaining an order for antibiotics. The DON stated the licensed nurse should inform the physician if they identify the resident does not meet the Mcgeer's criteria for an infection as they are filling out the form and allow the physician to decide if the antibiotic therapy should be continued or stopped. The DON stated if the resident does not meet the criteria, the physician would need to document the reason in the resident's chart if they decide to move forward with the antibiotic therapy. The DON stated antibiotics should not be provided to residents that do not meet the criteria as much as possible to prevent unnecessary antibiotic use which can lead to multi-drug resistant organisms (MDRO - bacteria that has developed resistance to one or more classes of antibiotics). A review of the facility's policy and procedure titled, Antimicrobial Stewardship Policy and Procedure, last reviewed on 10/28/2022, indicated the IP will be responsible for infection surveillance and MDRO tracking and that the IP will collect and review physician specific orders (type of antibiotic orders and route of administration), clinical data, and whether a culture was obtained before the administration of an antibiotic.