**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 68 and Resident 31), were treated with dignity while eating. Resident 68, who had limited mobility, did not have a clothing protector, while having breakfast in bed. For Resident 31, Treatment Nurse 1 remained standing and did not position themselves at the resident's eye level while assisting with the lunch meal. This deficient practice resulted in Resident 68 having food and drink spillage on Resident 68 causing potential feelings of humiliation and embarrassment. For Resident 31, there was a potential feeling of disconnection and dominance or authority from the staff during the feeding process. Findings: a. During a review of Resident 68's admission Record (AR), the AR indicated Resident 68 was admitted to the facility on [DATE] with multiple diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infarction (a condition where blood flow to the brain is interrupted, causing brain tissue to die) affecting left non-dominant side and aphasia (a disorder that makes it difficult to speak). During a review of Resident 68's Alteration in Nutritional Status care plan dated 2/23/2023, the care plan interventions indicated to set up meal tray, assist and give verbal cues if needed, and up in chair to dining room at mealtime. During a review of Resident 68's History and Physical Examinations (H&P), dated 2/20/2025, the H&P indicated Resident 68 did not have the capacity to understand and make decisions. During a review of Resident 68's Minimum Data Set (MDS, a resident assessment tool), dated 3/25/2025, the MDS indicated Resident 68's cognitive skills (ability to think and process information) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated Resident 68 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating (the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident). During an observation on 6/10/2025 at 7:59 AM, Resident 68 was in bed having breakfast by herself. Resident 68 was using her right hand with no movement noted from her left hand. Resident 68 was drooling milk, had messy spills of food and drinks on Resident 68's chest, neck, gown, tray, bedside table and on Resident 68's maroon colored comforter, despite having a plate guard (a device used to prevent food from being pushed off the plate while eating to keep food contained on the plate and minimize spills or messes). Resident 68's plastic cup of milk was tipped over and milk spillage was on the tray. CNA 3 was observed feeding Resident 68's roommate while Resident 68 was eating breakfast. Resident 68 was within sight from the hallway. During a concurrent interview, CNA 3 stated CNA 3 was supposed to put something, a towel over Resident 68's chest to protect Resident 68. During an interview on 6/11/2025 at 9:45 AM, Registered Nurse (RN) 1 stated Resident 68 was able to feed herself and used a plate guard. RN 1 stated staff was supposed to put a towel over Resident 68's chest to protect Resident 68 from fluid or food dropping into Resident 68's gown. RN 1 stated a towel was also used for hygiene, wiping, and for dignity. b. During a review of Resident 31's AR, the AR indicated the facility admitted Resident 31 on 2/25/2021, and re-admitted the resident on 5/15/2024, with diagnoses including dementia (a progressive state of decline in mental abilities), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and severe protein-calorie malnutrition (a condition where the body lacks sufficient protein and calories, leading to a breakdown of body tissues, muscle wasting, and fluid retention). During a review of Resident 31's MDS dated [DATE], the MDS indicated Resident 44's cognition (the ability to think and process information) was moderately intact. The MDS indicated Resident 31 required substantial/maximal assistance (helper does more than half the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and dependent (helper does all of the effort) with mobility. During an observation on 6/9/2025 at 12:30 PM, Resident 31 was observed lying in bed with the head of the bed in a semi-recumbent (lying down with the upper body elevated at an angle, typically between 30 and 45 degrees) position. Treatment Nurse (TN) 1 was positioned standing at the bedside, leaning over Resident 31 while providing feeding assistance. TN 1 was observed hovering above the resident, holding the spoon at an elevated angle, and did not assume a seated position or align at eye level with Resident 31 during the feeding process. During an interview on 6/9/2025 at 1:47 PM, Resident 31 stated that she could tell when staff were standing over her during meals. Even though she could not see them, she could feel it by the way they talked and how quickly they gave her each bite. Resident 31 stated it made her feel rushed, like she had to hurry up. Resident 31 noted that this did not happen all the time, but it did occur on occasion. Resident 31 expressed that she preferred when staff sat next to her and took their time, as it made her feel more at ease and not hurried. During an interview on 6/10/2025 at 1:37 PM, Treatment Nurse 1 stated she should have sat next to Resident 31 while assisting with the lunch meal on 6/9/2025. LVN 1 acknowledged that she should have grabbed a chair and sat beside the resident while feeding her. LVN 1 stated that sitting at eye level promoted dignity and helped the resident feel more comfortable. LVN 1 expressed understanding that maintaining a calm and supportive approach during mealtime enhanced the resident's overall experience and promoted person-centered care. During an interview on 6/12/2025 at 12:29 PM, the Director of Nursing (DON) stated the facility's expectation was for staff to uphold resident dignity during all aspects of care, including meal assistance. The DON explained that sitting at eye level while assisting a resident with meals enhanced comfort and promoted dignity. The DON emphasized that residents were expected to feel respected and supported, and staff was trained to provide that level of care consistently. During a review of the facility's policy and procedure (P&P) titled, Dignity, dated 2/2021, the P&P indicated each resident shall be cared for in a manner that promoted and enhanced his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The P&P indicated the facility culture supported dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's facility stay. The policy indicated that when assisting with care, residents were supported in exercising their rights. For example, residents were provided with a dignified dining experience. During a review of the facility's P&P titled, Resident Rights, dated 2/2021, the P&P indicated employees shall treat all residents with kindness, respect, and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one sampled resident (Resident 2), was provided care in accordance with professional standards of practice by failing to conduct an Interdisciplinary Team (IDT - a group of healthcare professionals from various disciplines who collaborate, assess, coordinate, and manage each resident's comprehensive health care, including his or her medical, psychological, social, and functional needs) in accordance with the facility's policy and procedure (P&P) when Resident 2 had continuous episodes of hyperglycemia (high blood sugar). This deficient practice had the potential to result in Resident 2 developing serious health complications. Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including encounter for 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), type 2 diabetes mellitus (DM - adult onset disorder characterized by difficulty in blood sugar control and poor wound healing) without complications, unspecified dementia (a progressive state of decline in mental abilities), unspecified severity, without behavioral disturbance, psychotic (relating to or affected with a psychosis - a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) disturbance, mood disturbance, anxiety (intense, excessive, and persistent worry and fear about everyday situations, and sepsis (a life threatening blood infection), unspecified organism. During a review of Resident 2's History and Physical (H&P), dated 4/20/2025, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 4/24/2025, the MDS indicated Resident 2's cognitive status (memory, orientation, and judgement of the resident) was severely impaired. The MDS indicated Resident 2's primary reason for admission was due to medically complex conditions and the resident had a feeding tube (e.g., nasogastric or abdominal [PEG]). During a review of Resident 2's trend of blood glucose (sugar) levels, dated 5/4/2025 to 5/14/2025, the trend indicated Resident 2's blood glucose levels ranged anywhere from 306 mg/dL (milligrams per deciliter - a unit of measurement used to express the concentration in blood glucose testing) to 500 mg/dL. During a review of Resident 2's undated Hospital Tracking Portal (HTP), the HTP indicated Resident 2 was transferred to the GACH for abnormal blood sugar. During a review of Resident 2's Discharge Summary Report (DSR), dated, 5/14/2025, timed at 10:55 a.m., the DSR indicated Resident 2 was discharged to the GACH for uncontrolled hyperglycemia. During a review of Resident 2's Order Summary Report (OSR), active orders as of 5/31/2025, the OSR indicated an order on 5/14/2025 for puree texture, nectar/mildly thick consistency oral diet small portion for three meals per day and an order on 5/8/2025 for enteral feed (a method of providing nutrition directly into the gastrointestinal tract through a feeding tube) Glucerna 1.2 at 53 cubic centimeter (cc- a unit of volume) per hour for 20 hours. During a concurrent interview and record review on 6/12/2025 at 11:26 a.m., with Registered Nurse (RN) 3, Resident 2's medical records were reviewed. RN 3 stated the facility did not have any IDT documentation for Resident 2's hyperglycemia. RN 3 stated there was a Change of Condition (COD) on 5/14/2025 for Resident 2's hyperglycemia. During a concurrent interview and record review on 6/12/2025 at 11:59 a.m., with the Director of Nursing (DON), Resident 2's blood glucose levels for May 2025 and medical records were reviewed. The DON stated the DON could not find any documentation that an IDT was conducted to address Resident 2's hyperglycemia. The DON stated an IDT was conducted if there were any issues or trend (in general). The DON stated there should have been an IDT conducted for Resident 2's hyperglycemia, adding her blood sugar is consistently high, it's uncontrolled. The DON stated it was important to conduct an IDT to discuss the issues, problems and identify and create appropriate interventions and to see if the interventions were working and the progress of the patient. During a review of the facility's undated policy and procedure (P&P) titled, IDT Conference, the P&P indicated the care plans would be reviewed and revised by the IDT after each assessment, including both the comprehensive and quarterly review assessments, and/or if there were any significant changes. The P&P indicated the content of the IDT would include but were not limited to areas reviewed including diagnosis / health condition.

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 87) was free from a significant medication error. Facility staff opened a specially formulated (how the drug is prepared and put together to make it into a usable medicine that can be taken) antibiotic capsule which disrupted the time-release (when the medicine is designed to release small amounts of the drug into your body over a long period, rather than all at once) mechanism of the medication. This deficient practice resulted in Resident 87 receiving the medication in a manner that altered its intended pharmacokinetics (what your body does to a drug after you take it), potentially impacting its therapeutic effectiveness and increasing the risk of adverse effects. Findings: During a review of Resident 87's admission Record (AR), the AR indicated the facility admitted Resident 87 on 1/15/2025, with diagnoses including rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), and encephalopathy (a serious health problem that affects brain function or structure). During a review of Resident 87's Minimum Data Set (MDS - a resident assessment tool), dated 4/22/2025, the MDS indicated Resident 87's cognition (the ability to think and process information) was moderately impaired. The MDS indicated Resident 87 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with mobility. During a review of Resident 87's Order Summary Report (OSR), the OSR indicated to administer the following medications to Resident 87: a. Acetaminophen Oral Tablet 500 milligrams (mg-metric unit of measurement, used for medication dosage and/or amount) give 1 tablet by mouth one time a day for pain management due to rheumatoid arthritis. Start Date: 3/21/2025. b. Amlodipine Besylate Tablet 5 mg give 1 tablet by mouth one time a day for hypertension, hold if systolic blood pressure (SBP - the pressure in the arteries when the heart contracts and pumps blood throughout the body) less than 110. Start Date: 1/16/2025. c. Claritin Oral Tablet 10 mg (Loratadine) give 1 tablet by mouth one time a day for itchiness. Start Date: 3/18/2025. d. Colchicine Tablet 0.6 mg give 1 tablet by mouth one time a day every other day for gout. Start Date: 1/16/2025. e. Folic Acid Tablet 1 mg give 1 tablet by mouth one time a day for supplement. Start Date: 1/16/2025. f. Multiple Vitamins - Minerals Tablet give 1 tablet by mouth one time a day for supplement. Start Date: 1/16/2025. g. Ascorbic Acid Tablet 500 mg give 1 tablet by mouth two times a day for supplement. Start Date: 1/15/2025. h. Carvedilol Tablet 12.5 mg give 1 tablet by mouth two times a day for hypertension, hold if SBP less than 110 or heart rate (the number of times your heart beats in one minute) less than 60 and give with food. Start Date: 1/16/2025. i. Chlorhexidine Gluconate Solution 0.12 % give 30 ml (ml-metric unit used to measure capacity that's equal to one-thousandth of a liter) orally two times a day for good oral hygiene. Start Date: 6/11/2025. j. Cranberry Oral Tablet 450 mg (Vaccinium macrocarpon) give 1 tablet by mouth two times a day for urinary tract infection (UTI - an infection in the bladder/urinary tract) prophylaxis (measures designed to preserve health). Start Date: 6/8/2025. k. Macrobid Oral Capsule 100 mg (Nitrofurantoin Monohyd Macro) give 1 capsule by mouth two times a day for abnormal urinalysis (a simple examination of your pee to check for various health problems) for 5 days. Start Date: 6/7/2025. l. Gabapentin Capsule 300 mg give 1 capsule by mouth three times a day for neuropathic pain (nerve pain). Start Date: 3/17/2025. m. LiquaCel Oral Liquid (Amino Acids) give 30 ml by mouth three times a day for skin integrity. Start Date: 1/19/2025. During a review of Resident 87's Medication Administration Record (MAR,) the MAR indicated Resident 87 was administered Macrobid 100 mg oral capsule on 6/11/2025 at 9 AM. During an observation on 6/11/2025 at 8:30 AM, Licensed Vocational Nurse (LVN) 1 was observed opening a nitrofurantoin macrocrystals (Macrobid) 100 mg oral capsule, pouring the contents into a medication cup, and mixing with applesauce. During an interview on 6/11/2025 at 9:15 AM, LVN 1 stated that opening any capsule medication had to be verified or clarified with the pharmacist. LVN 1 stated that some capsules should not be opened, as doing so could alter how the medication worked, cause side effects, or reduce its effectiveness. LVN 1 stated that if there was any uncertainty, capsules were not to be opened from the pharmacy. Once verification had been received, the contents could be mixed with a small amount of applesauce if the resident had difficulty swallowing or preferred medications to be crushed. LVN 1 stated that opening Macrobid without proper verification could compromise the medication's safety and effectiveness. LVN 1 also stated that, particularly for antibiotics, proper delivery was important to ensure full treatment of infection and to prevent harm to the resident. During an interview on 6/12/2025 at 12:29 PM, the Director of Nursing (DON) stated it was important for nursing staff to have clarified with the pharmacist prior to opening any capsule medication, as altering the form of the medication could have affected its intended absorption, efficacy, and safety. The DON stated that this was especially important for capsule-form antibiotics, which were often time-released or specially formulated to deliver medication in a specific manner. The DON stated that failure to verify whether a capsule could be opened might have resulted in reduced effectiveness or unintended side effects. The DON further stated that if a resident preferred to take medications in crushed form, or had difficulty swallowing whole capsules, the physician should have been notified so that an alternative formulation - such as a liquid or tablet that was safe to crush - could have been ordered. The DON emphasized that ensuring the proper formulation helped maintain the integrity of the treatment plan and safeguarded the resident's health. During a review of the facility's Policy and Procedure (P&P) titled, Administering Medications dated 2001, the P&P indicated medications were administered in a safe and timely manner, and as prescribed. The P&P also indicated each nurses' station had a current Physician's Desk Reference (PDR) and/or other medication reference, as well as a copy of the surveyor guidance for F755-761 (Pharmacy Services) available. Manufacturer's instructions or user's manual related to any medication administration devices were kept with the devices or at the nurses' station. During a review of the facility's Job Description (LVN - Sub-Acute) dated 3/7/2024, the Job Description indicated the LVN administered medication and treatment following regulatory guidelines.

Based on observation, interview, and record review, the facility failed to maintain its infection prevention and control program for one of five sampled residents (Resident 59) by failing to wear appropriate personal protective equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) when handling soiled linens under Enhanced Barrier Precautions (EBP-extra measures, like wearing gowns and gloves, used during high-contact care activities with residents who are at a higher risk of having or spreading germs that are hard to treat, like multidrug-resistant organisms (MDROs). This deficient practice had the potential to transmit infectious microorganisms and increase the risk of infection for the residents. Findings: During a review of Resident 59's admission Record (AR), the AR indicated the facility admitted Resident 59 on 12/25/2021, with diagnoses including peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), and cellulitis (a skin infection that causes swelling and redness) of left lower limb. During a review of Resident 59's Minimum Data Set (MDS, a resident assessment tool), dated 3/28/2025, the MDS indicated Resident 59's cognition (the ability to think and process information) was severely impaired. The MDS indicated Resident 59 required partial/moderate assistance (helper does less than half the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and partial/moderate assistance with mobility). During an observation on 6/9/2025 at 10:19 AM, there was signage indicating EBP located outside of Resident 59's room. During an observation on 6/9/2025 at 10:25 AM, Certified Nursing Assistant (CNA) 1 was observed removing soiled linen from Resident 59's bed. CNA 1 exited the resident's room while visibly carrying the soiled linen in both hands and placed it directly into the soiled linen container located in the hallway outside the resident's room. CNA 1 was not wearing a gown at any point during the linen removal process nor while exiting the resident's room with the soiled linen. During an interview on 6/9/2025 at 10:39 AM, CNA 1 explained that EBP were implemented to help prevent the spread of germs, particularly drug-resistant organisms. CNA 1 stated that when a resident was on EBP, staff were expected to wear gloves and a gown when performing tasks such as providing personal care, cleaning the resident's environment, or handling soiled laundry. CNA 1 emphasized that staff should wear a gown during direct contact tasks, such as changing soiled linens, because germs could transfer onto clothing. CNA 1 added that following these precautions helped protect both residents and staff, and that failure to wear appropriate personal protective equipment could contribute to the spread of germs to other residents or environmental surfaces. During an interview on 6/12/2025 at 11:35 AM, the Infection Preventionist (IP) stated staff were expected to always follow EBP, particularly when handling soiled linens. The IP emphasized staff were required to wear gowns and appropriate PPE during such tasks to prevent the spread of infection. The IP stated that adhering to these precautions was essential to protect both residents and staff from potential exposure to harmful pathogens. During a record review of Resident 59's Order Summary Report, dated 6/12/2025, the order summary report indicated Resident 59 had an active order for EBP, with an order date of 6/27/2024. During a review of the facility's Policy and Procedure (P&P) titled, Enhanced Barrier Precautions dated 2001, the P&P indicated EBPs were utilized to prevent the spread of multi-drug organisms (MDROs) to residents. The P&P indicated: -EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown were applied prior to performing the high contact resident care activity (as opposed to before entering the room). -Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: b. Changing linens.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the low air loss mattress (LAL - pressure reducing mattress) was placed at the correct setting for two of two sampled residents (Resident 86 and Resident 32). This deficiency had the potential to place Resident 86 and 32 at increased risk of developing pressure injuries. Findings: A. During a review of Resident 86's admission Record (AR), the AR indicated Resident 86 was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including functional quadriplegia (complete immobility due to severe disability or frailty) and encephalopathy (disease or disorder of the brain, characterized. During a review of Resident 86's Minimum Data Set (MDS - a resident assessment tool) dated 3/26/2025, the MDS indicated Resident 86 had severely impaired cognition (ability to understand and process information) and was dependent (helper does all of the effort) on staff for toileting and rolling from left lying position to a right lying position. The MDS further indicated Resident 86 was at risk for developing pressure ulcers and had a pressure reducing device for the bed. During a review of Resident 86's Braden Scale for Predicting Pressure Sore Risk (BS), dated 3/26/2025, the BS indicated Resident 86 had a score of 8, very high risk. During a review of Resident 86's Order Summary Report (OSR) with active orders as of 6/12/2025, the Order Summary Report indicated a physician's order for low air loss mattress for wound care and management set at 160 every shift with order start date of 12/6/2024. During an interview on 6/11/2025 at 9:44 AM with Certified Nursing Assistant (CNA) 4, CNA 4 stated Resident 86 had a LAL, indicated for residents that either had pressure injuries or to prevent a resident from developing pressure injuries. During a concurrent observation and interview on 6/11/2025 at 9:58 AM with Licensed Vocational Nurse (LVN) 3 in Resident 86's room, Resident 86's LAL setting of 200 was observed. LVN 3 stated the current observed setting was incorrect and the mattress should be set at 160 based on Resident 86's weight. LVN 3 stated the mattress settings were checked every day during morning rounds and LVN 3 did not know why it was at the incorrect setting. LVN 3 stated the purpose of the LAL was to prevent pressure injuries. During an interview on 6/12/2025 at 1:11 PM with the Director of Nursing (DON), the DON stated the LAL mattress was for residents at high risk of developing pressure injuries and was used to prevent the development or worsening of pressure injuries. The DON stated if the LAL setting was incorrect, the resident could develop pressure injuries or current injuries could worsen. During a review of the facility's policy and procedure (P&P) titled, Pressure-Reducing Mattress, undated, the P&P indicated the purpose of the mattress was to prevent and/or minimize pressure on the skin, and to offer enhanced comfort when preferred by the resident. The P&P further indicated to adjust the LAL to desired firmness based on the resident's weight. B. During a review of Resident 32's AR, the AR indicated the facility admitted Resident 32 on 2/19/2021, and re-admitted the resident on 5/26/2025, with diagnoses including, chronic respiratory failure with hypoxia (when the lungs are unable to adequately transfer oxygen into the bloodstream, resulting in a chronically low level of oxygen in the blood and tissues), metabolic encephalopathy (a change in how your brain works due to an underlying condition), and pressure ulcer of sacral region Stage 4 (a severe, deep wound that has extended through the skin and into the muscle, tendon, or even bone located at the bottom of the spine and lies between the fifth segment of the lumbar spine [L5] and the coccyx [tailbone]) region). During a review of Resident 32's MDS dated [DATE], the MDS indicated Resident 32's cognition was severely impaired. The MDS indicated Resident 32 was dependent (helper does all of the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and was dependent with mobility. During a review of Resident 32's Weights and Vitals Summary, dated 6/2/2025, indicated Resident 32's weight was 107 lbs. During an observation on 6/9/2025 at 10:49 a.m., Resident 32 was noted lying on a Low Air Loss Mattress (LALM), the digital control panel on the LALM was visibly illuminated and displayed a weight setting of 400 lbs. During an interview on 6/10/2025 at 12:50 p.m., Treatment Nurse (TN) 2 stated the purpose of the LALM was to help prevent pressure ulcers by redistributing the resident's body weight and reduce pressure on high-risk areas of the body. TN 2 stated the mattress was designed to automatically adjust air pressure based on the resident's weight input to ensure proper therapeutic support. TN 2 stated that accurately setting the mattress to the resident's actual weight was essential and when set correctly, the system maintained optimal pressure to prevent excessive force on bony prominences and other vulnerable skin areas. TN 2 stated if the weight was set significantly higher or lower than the resident's true weight, the mattress did not function effectively, thereby increasing the risk of skin breakdown, and the development or worsening of pressure injuries. During a review of Resident 32's Order Summary Report, dated 6/12/2025, the Order Summary Report indicated Resident 32 had an active physician's order for a LALM for wound care and management (LALM set @ 80) every shift. The Order Summary Report indicated the start date of the LALM order was 6/10/2025. During an interview on 6/12/2025 at 12:29 p.m., the Director of Nursing (DON) stated it was important to maintain the correct settings on LALM to ensure optimal care, especially for residents at high risk of pressure ulcers or skin breakdown. The DON explained these mattresses were designed to redistribute pressure, minimize friction, and deliver continuous airflow to the skin - critical for immobile or frail residents. The DON stated that incorrect settings could compromise the mattress's effectiveness, potentially leading to discomfort or worsening of pressure-related injuries. During a review of the facility's policy and procedure (P&P) titled, Pressure-Reducing Mattresses, undated, the P&P indicated to follow the manufacturer's instruction and adjust LALM to a desired firmness based on the resident's weight and/or using the hand check method as described: slide one hand with the thumb facing up, between two LALM air tubes to feel the space between the bed frame and resident's buttocks. The space should not be too tight or too loose, with an acceptable range of approximately 1-1.5 inches. During a review of the manufacturer's operation manual titled, Proactive Medical Products, undated, the operation manual for the Protekt Aire 4000DX / 4600DX / and 5000DX the weight / pressure set up indicated users can adjust air mattress to a desired firmness according to patient's weight or the suggestion from a health care professional.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its antibiotic stewardship program (promotes the appropriate use of antibiotics) for two of five sampled residents (Resident 21 and Resident 87) to monitor the use of antibiotics for unnecessary or inappropriate use and ensure protocols were in place to reduce the risk of adverse events, including the development of antibiotic-resistant organisms. For Resident 87's swelling of the tooth and for Resident 21's vaginal discharge, the proper antibiotic screening forms were not used to accurately determine if the residents met the criteria of a true infection. These deficient practices had the potential for residents to develop antibiotic -resistant organisms, from unnecessary or inappropriate antibiotic use. Findings: a. During a review of Resident 21's admission Record (AR), the AR indicated Resident 21 was re-admitted to the facility on [DATE] with diagnoses including vascular dementia (loss of intellectual function) and generalized weakness. During a review of Resident 10's History and Physical (H&P), dated 10/27/2024, the H&P indicated Resident 21 did not have the capacity to understand and make decisions. During a review of Resident 21's Change in Condition (COC), dated 6/1/2025, the COC indicated the resident had a greenish vaginal discharge (bodily fluid produced by glands in the vagina and cervix), had no pain or discomfort, and a normal body temperature of 97.8 degrees. The COC indicated Resident 21's urine was yellow, had no foul odors, and no hematuria (blood in the urine). During a review of the Physician's Orders dated 6/1/2025, the order indicated Resident 21 was to receive Diflucan (an antibiotic) 100 milligrams (mg, unit of measurement) to be taken by mouth in the evenings for five days. During a review of Resident 21's Medication Administration Record (MAR), the MAR indicted Resident 21 was administered Diflucan 100 milligrams mg on 6/1 - 6/5/2025. During a review of Resident 21's Lab Results Report, for a urine culture (a laboratory test used to detect and identify bacteria or other microorganisms in a urine sample) / urine analysis with culture and sensitivity (a lab test used to identify bacteria or other microorganisms in a urine sample and determine which antibiotics are most effective in treating an infection caused by them) collected on 6/4/2025, indicated antibiotic therapy was not recommended without signs and symptoms of localizing to the urinary tract. During an interview with the Infection Control Nurse (ICN) on 6/11/2025 at 3:23 pm, the ICN stated the facility used the McGreer's criteria (a set of standardized definitions used for surveillance of infections in long-term care facilities) for infection surveillance based on the location of the possible infection. The ICN stated for Resident 21, the Surveillance Data Collection Form for other infections, (SDCF-[NAME], a McGreer's criteria infection analysis specified for certain areas of the body) was used. The ICN stated the McGreer's UTI surveillance form should have been used to screen Resident 21 to determine if antibiotics were needed because the resident had vaginal discharge potential to having a UTI. The ICN stated it was important to have the proper antibiotic (McGreer's) screening done to determine if antibiotic use was needed and to prevent the development of [NAME] drug resistant organism (MDRO, bacteria that are resistant to three or more classes of antimicrobial drugs). The ICN stated the ICN normally monitored every resident placed on an antibiotic to determine if the McGreer's criteria was met. The ICN stated, I missed it and did not have a chance to review for the month of June. b. During a review of Resident 87's AR, the AR indicated Resident 87 was admitted to the facility on [DATE] with diagnoses including neuralgia (intense, typically intermittent pain along the course of a nerve) and generalized weakness. During a review of the Physician's Orders dated 1/13/2025, it indicated Azithromycin (an antibiotic) 250 mg was to be given by mouth daily for four days, for a tooth infection. During a review of a Minimum Data Set (MDS, a resident assessment tool), dated 4/22/2025, indicated Resident 87 had moderate cognitive impairment, clear speech, usually understands and could be understood. The MDS indicated Resident 87 needed supervision (helper sets up and cleans up) with toilet needs, lower body dressing and sit to stand (ability to stand/sit from a chair). During an interview with the ICN on 6/11/2025, the ICN stated the nurse who completed the SDCF-[NAME] used the wrong antibiotic surveillance form. The ICN stated the correct antibiotic surveillance should be specified for skin / mucosal (__) because Resident 87 had an increased swelling of the tooth. The ICN stated it was important to complete the proper antibiotic screening forms to accurately determine if Resident 87 met the criteria of a true infection and qualified for the use of antibiotic. The ICN stated the ICN did not follow up and verify if the accurate antibiotic screening was done for Resident 87. During a review of Resident 87's MAR, the MAR indicted Resident 87 was administered Azithromycin on 6/12/2025. During a review of the facility's undated policy titled, Antimicrobial Stewardship Program, undated, indicated it was the policy of the facility to implement an Antimicrobial Stewardship program that would focus on coordinated interventions designed to improve and measure the appropriate use of antimicrobial agents by promoting the selection of optical antimicrobial drug regimen including dosing, duration of therapy and route of administration. The policy indicated the goal was to curb the emergence and spread of antimicrobial resurgent infection and the leadership team was to review and monitor antibiotic usage patterns on a regular basis. The policy indicated the IP was the designated person responsible for the implementation of the facility's infection Prevention and Control Program, collection, and review of the data. During a review of the facility's policy titled, Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes, revised 4/2023, it indicated antibiotic usage and outcome data would be collected and documented using a facility-approved antibiotic surveillance tracking form. The data would be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility - wide antibiotic stewardship.

Based on interview and record review, the facility failed, to maintain and implement its Infection Control Program to prevent the transmission of disease and infection for one of two sampled residents (Resident 1), by placing another resident's (unidentified) dentures in Resident 1's mouth. This failure had the potential to result in the spread of infection to Resident 1. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 9/5/2024 with diagnoses that included urinary tract infection (UTI, an infection in any part of the urinary system, including the kidneys, bladder, or urethra), dementia (a group of thinking and social symptoms that interferes with daily functioning), and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 10/28/2024, the MDS indicated Resident 1 was severely impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) from staff for bathing and toileting hygiene. The MDS indicated Resident 1 required Partial/moderate (helper does less than half the effort) from staff for eating, oral and personal hygiene, and dressing. During a telephone interview on 11/21/2024 at 2:15 p.m. with Resident 1's Niece (FM 1), FM 1 stated Resident 1 had intellectual disability (person who has limitations in mental functioning and skills). FM 1 stated Resident 1's sister (FM 2) was Resident 1's conservator (a court appointed person to act or make decisions for the resident). FM 1 stated Resident 1 was recently hospitalized , at a General Acute Care Hospital (GACH) before being transferred to the facility. FM 1 stated during Resident 1's stay at the facility, Resident 1's dentures were lost. FM 1 stated on 11/23/2024, FM 2 called FM 1 and informed FM 1 that someone (unidentified) had found the dentures at the facility. FM 1 stated FM 2 informed FM 1 the Dentist (DD) put the dentures in Resident 1's mouth and discovered the dentures did not belong to Resident 1. During a telephone interview on 11/21/2024 at 3:03 p.m. with FM 2, FM 2 stated on one occasion (FM 2 cannot remember exact date), FM 2 was visiting Resident 1 at the facility when the DD put some dentures in Resident 1's mouth. FM 2 stated the dentures were inside a denture cup and had been sitting in Resident 1's drawer next to Resident 1's bed. FM 2 stated the dentures and cup were not labeled with any one's name. FM 2 stated the dentures did not belong to Resident 1. During a telephone interview on 11/26/2024 at 8:50 a.m. with the DD, the DD stated the Social Services Director (SSD) informed DD the facility found Resident 1's missing dentures. The DD stated the missing dentures were stored at Resident 1's bedside. The DD stated the dentures at Resident 1's bedside was not labeled with an identifier. The DD stated based on the DD's experience, the DD did not think the dentures belonged to Resident 1. The DD stated the DD informed the SSD the dentures did not belong to Resident 1. During an interview on 11/26/2024 at 8:55 a.m. with the SSD, the SSD stated the unidentified dentures the DD tried in Resident 1's mouth had been left at Resident 1's bedside before the DD put them in Resident 1's mouth.The SSD stated no one came forward and informed the SSD they had found Resident 1's missing dentures. The SSD stated the unidentified dentures were in a denture box. The SSD stated the unidentified dentures and box were not labeled. The SSD stated the SSD threw the unidentified dentures away. During an interview on 11/26/2024 at 10:12 a.m. with the Infection Preventionist (IP), the IP stated residents' dentures (in general) needed to be stored in a denture container when not in use. The IP stated the denture contains must be labeled to identify whose dentures they were and to ensure the dentures did not end up in the wrong residents' (in general) mouth. The IP stated there was a risk of infection for residents (in general) if the residents (in general) use the wrong dentures. During a review of the facility's policy and procedure (P&P) titled, Dentures, Cleaning and Storing, revised March 2023, the P&P indicated, The purposes of this procedure are to cleanse and freshen the resident's mouth, to clean the resident's dentures, to prevent infections of the mouth . The P&P indicated, .Be sure the denture cup is properly labeled with the resident's name and room number . During a review of the facility's P&P titled, Policies and Practices - Infection Control, revised April 2023, the P&P indicated, This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. the P&P indicated, This facility's infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, nursing students, registry and the general public alike.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure resident-centered care plans (CP) related to risk of side effects of medication use for Depakote (medication used to control seizures, a sudden uncontrolled burst of electrical activity in the brain) and a CP related to Resident 2's allergies were developed for one of one sampled resident (Resident 2) in accordance with the facility's policy and procedure (P&P). This failure had the potential for Resident 2 to not receive the necessary care and services to achieve their optimal level of functioning. Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus (disease that occurs when a person's blood sugar is too high), generalized anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread and uneasiness) and bipolar disorder (serious mental illness that causes unusual shifts in mood). The AR indicated Resident 2's allergies were: iodine, penicillin, coconut, lemon, and shrimp. During a review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/8/2024, the MDS indicated Resident 2 had severely impaired cognition (the ability to make daily decisions). The MDS indicated Resident 2 was dependent (helper does all the effort to complete the activity) on staff for eating, toilet use, and personal hygiene. During a review of Resident 2's Order Summary Report (OSR), dated active as of 5/30/2024 indicated Resident 2 had a physician order for Depakote extended release 24-hour 500 mg (milligram, unit of measurement) tablet with order date 12/27/2023. During a concurrent interview and record review on 5/30/2024 at 11:40 AM with the Registered Nurse Supervisor (RNS), Resident 2's CP related to Depakote, dated 3/22/2023, was reviewed. The CP indicated interventions to monitor for cognitive impairment, tardive dyskinesia (TD - a drug induced movement disorder causing uncontrollable movements like lip-smacking), akathisia (inability to remain still), Parkinsonism Syndrome (a collection of movement symptoms that include slowness, stiffness, tremors, and balance issues) and orthostatic blood pressure (sudden drop in blood pressure upon standing from a sitting or lying down position). The RNS stated these interventions indicated in the CP should be in Resident 2's Medication Administration Record (MAR), the RNS did not find the interventions in the MAR (all monitoring is documented in the MAR). During a concurrent interview and record review on 5/30/2024 at 11:56 AM with the Director of Nursing (DON), Resident 2's CP related to Depakote, dated 3/22/2023, was reviewed. The DON stated the specific interventions indicated to monitor for cognitive impairment, TD, akathisia, Parkinsonism Syndrome and orthostatic blood pressure on the CP were not being implemented but they were also not needed and it would be removed from the CP. The DON further stated the DON had just called the Facility Consultant Pharmacist (FCP) and the FCP stated these side effects did not need to be monitored because Depakote was not an antipsychotic medication and [the medication] did not typically have these side effects. During a concurrent interview and record review on 5/30/2024 at 12 PM with the MDS Coordinator (MDSC), Resident 2's CP related to Depakote, dated 3/22/2023, was reviewed. The MDSC stated the interventions indicated in the CP were not centered toward Resident 2's care and they should be. During a review of Resident 2's Order Summary Report (OSR), dated active as of 5/30/2024, indicated Resident 2 had a physician order for Insulin Aspart injection (rapid-acting medication used to control blood sugar) solution 100 unit per milliliter (ml-unit of measurement) with order date 8/1/2023 and insulin glargine (long-acting medication used to control blood sugar) 100 unit/ml with order date 4/10/2024. During a concurrent interview and record review on 5/30/2024 at 12 PM with the MDSC, Resident 2's CP related to Resident 2's allergies, dated 3/22/2023, was reviewed. The CP indicated Resident 2's allergies were penicillin, iodine, shrimp, coconut, lemon, and insulin. The MDSC stated the facility failed to develop an individualized person-centered care plan for Resident 2 as evidenced by inaccurate allergies listed on the Resident 2's CP related to Resident 2's allergies, additionally, the interventions listed for Depakote that were not implemented. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated 3/2023, the P&P indicated the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The comprehensive, person-centered care plan reflects currently recognized standards of practice for problem areas and conditions. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide necessary care and services for one of one sampled resident (Resident 96) when Certified Nursing Assistant (CNA) 2 did not utilize a communication board when attempting to communicate with Resident 96 as indicated in the facility's Policy and Procedure (P&P) titled, Accommodation of Needs Related to Communication. This failure had the potential to result in unmet needs to Resident 96. Findings: During a review of Resident 96's admission Record (AR), the AR indicated Resident 96 was admitted to the facility on [DATE] with severe dementia (a group of conditions, decline in mental ability, that interfere with daily activities) with agitation, hypertension (high blood pressure), and dysphagia (difficulty swallowing foods or liquids). During a review of Resident 96's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/22/2024, the MDS indicated Resident 96 was severely impaired with cognitive skills (ability to make daily decisions). The MDS indicated Resident 96 required substantial/maximal assistance (helper does more than half the effort) from staff for toileting and dressing. During an interview on 5/28/2024 at 9:30 AM with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 96 sometimes yelled, and CNA 1 sat next to Resident 96 until Resident 96 was calm. CNA 1 stated Resident 96 spoke a different language but also English. CNA 1 stated Resident 96 was sometimes confused and did not speak English when he was confused. During an interview on 5/28/2024 at 10:26 AM with CNA 2, CNA 2 stated Resident 96 yelled often. CNA 2 stated Resident 96 did not speak English to CNA 2. CNA 2 stated CNA 2 did not understand what Resident 96 was trying to communicate to CNA 2 when she took care of Resident 96. CNA 2 stated CNA 2 did not use a communication board when providing care to Resident 96. CNA 2 stated CNA 2 did not think staff had a communication board available [to communicate with] Resident 96. CNA 2 stated a communication board would be helpful when trying to communicate with Resident 96. During a review of Resident 96's care plan titled Resident is at Risk for Having Needs Unmet Related to Difficulty in Communication Secondary to [being] Non-English Speaking ., dated 4/17/2024, the care plan's interventions indicated the use of a communication board when communicating with Resident 96. During a review of the facility's P&P titled, Accommodation of Needs Related to Communication, undated, the P&P indicated, The facility will take reasonable steps to ensure the staff will communicate with residents to accommodate the needs of residents. The P&P indicated a procedure included, Provide communication board with written translation as indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care and services, for one of three sampled residents (Resident 30), to reduce the risk of developing pressure ulcer-injuries [PU/PI, localized injury to the skin and or underlying tissue usually over a bony prominence as result of pressure or pressure in combination with shear (mechanical force that cause the skin to break off) and/or friction (movement of one surface of the skin against the other]) by failing to: follow the facility's Policy and Procedures (P&P), titled, Prevention of Pressure Injuries, Pressure Sore Management, and the, Certified Nursing Assistant [CNA] Job Description, for Resident 30, who was on a low air loss (LAL, a mattress designed to distribute body weight and prevent and treat pressure wounds) mattress and who was at high risk for developing PIs. This deficient practice had the potential to result in a physical decline and the development of PIs to Resident 30. Findings: During a review of Resident 30's admission Record (AR), the AR indicated Resident 30 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), hypertension (high blood pressure), aphasia (loss of ability to understand or express speech, caused by brain damage). During a review of Resident 30's Risk for developing pressure sore, bruising, and other types of skin breakdown Care Plan (CP), dated 3/16/2023, the CP indicated the goal for Resident 30 was to minimize the risk of skin breakdown/bruising/pressure sore daily. During a review of Resident 30's H&P, dated 5/30/2023, the H&P indicated Resident 30 did not have the capacity to understand and make decisions. During a review of Resident 30's quarterly Minimum Data Set (MDS, a standardized resident assessment care planning tool), dated 3/4/2024, the MDS indicated Resident 30 had severe impairment in cognitive skills for daily decision making. The MDS indicated Resident 30 was dependent (helper provided all the effort or the assistance of two or more helpers was required for the resident to complete the activity) for eating, oral hygiene, toileting hygiene, showering/bathing, and personal hygiene. The MDS indicated Resident 30 was dependent for rolling left to right. The MDS indicated Resident 30 did not have PU/PI. The MDS indicated Resident 30 had the following skin treatments: pressure reducing device for the chair, a pressure reducing device for the bed, nutrition or hydration intervention to manage skin problems, and applications of ointments/medication other than to feet. During a review of Resident 30's Wound Risk Assessment (WRA), dated 3/6/2024, the WRA indicated Resident 30's score was 17 (a score of 8 or greater is considered high risk for skin breakdown). During a review of Resident 30's Order Summary Report (OSR), active orders as of 5/28/2024, the OSR included a physician's order (PO), dated 3/2/2024, the PO indicated Resident 30 may have a LAL mattress for wound care and skin maintenance every shift. During an observation of Resident 30 on 5/28/2024 at 9:45 AM, Resident 30 was laying on a LAL mattress and had a sling (a device used with a mobility tool to assist with transfers of residents that have mobility challenges, allows a resident to be lifted and transferred with minimum physical effort) under Resident 30's back and a Vander-Lift (a mobility tool used to help lift and transfer patients safely) on the left side of Resident 30's bed. During a concurrent observation and interview on 5/28/2024 at 9:58 AM, with a certified nursing assistant 4 (CNA 4), CNA 4 stated the purpose of a LAL mattress was to prevent PIs. CNA 4 stated the facility staff taught CNA 4 that one sheet was acceptable when a resident used a LAL mattress. CNA 4 stated if there was more than one sheet, the LAL mattress would not work [to prevent] PIs. CNA 4 stated CNA 4 brought Resident 30 back to bed at 9:30 AM and was going to get Resident 30 up on the wheelchair at 10:30 AM. CNA 4 stated CNA 4 left the sling under Resident 30 because CNA 4 was going to get Resident 30 up again. CNA 4 stated if CNA 4 did not [plan] to get Resident 30 up, CNA 4 would not leave the sling under Resident 30. During an observation, Resident 30 had five layers of material between Resident 30 and the LAL mattress. The layers included: a flat sheet, chux (disposable pad that is highly absorbent and designed to protect beds, bedding, furniture, or other surfaces from incontinence [loss of bladder control] accidents or spills), cloth incontinence pad, adult diaper, and Vander-Lift sling. During a concurrent observation and interview with the Director of Nursing (DON) on 5/28/2024 at 10:08 AM, the DON stated CNA 4 should have removed the sling under Resident 30 after putting Resident 30 back to bed because Resident 30 was on a LAL mattress. The DON stated if the sling was [kept] under Resident 30, [this defeated] the purpose of the LAL mattress. The DON stated Resident 30 should only be [laying] on a flat sheet with an adult diaper or a flat sheet with a chux pad. The DON stated if the sling was left underneath Resident 30, Resident 30 could develop a PI. During a concurrent observation and interview with CNA 5 on 5/29/2024 at 9:34 AM, Resident 30 was laying on a LAL mattress, a flat sheet, was wearing pants, and wearing an adult diaper. CNA 5 stated Resident 30 was wearing pants, but Resident 30 should only be [laying] on a flat sheet and [wearing an] adult diaper when Resident 30 was [laying] on the LAL mattress. CNA 5 stated consistent pressure on Resident 30's buttocks could cause an opening, [put the resident at] risk of infection and development of PI. CNA 5 stated facility staff wanted to avoid and prevent those types of skin issues. During a review of the Vander-Lift II's (brand name) Operating Manual, dated 3/2007, the manual indicated [for the user] to back the lift away from the wheelchair, chair, etc. and remove the sling. During a review of the facility's Certified Nursing Assistant Job Description, dated 8/23/2011, the CNA Job Description indicated the CNA would utilize appropriate linens for specialized pressure-reducing beds. During a review of the facility's P&P, titled, Prevention of Pressure Injuries, revised on 3/2023, the P&P indicated to ensure that all residents will receive the proper care based on their assessments to reduce the risks for pressure injuries. During a review of the facility's P&P, titled, Pressure Sore Management, revised on 3/21/2024, the P&P indicated all available measures shall be taken to reduce skin breakdown and pressure sores.

Based on interviews and record review, the facility failed to ensure one of two sampled residents (Resident 41), who had limited range of motion (ROM, full movement potential of a joint), received the necessary rehabilitation services to maintain or prevent further decline in ROM by failing to follow up on the Occupational Therapist 2's (OT 2's, healthcare professional who involves the use of daily activities [occupations] to treat the physical, mental, and emotional ailments that impact a resident's ability perform daily tasks) recommendation to obtain an OT evaluation/treatment order on 5/30/2022. This failure had the potential to cause further decline in ROM with worsening contractures (deformity and joint stiffness) to both upper extremities (arms), which could lead to increased pain to Resident 41. Findings: During a review of Resident 41's admission Record (AR 1), AR 1 indicated the facility admitted Resident 41 on 9/29/2020 with multiple diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with daily activities), osteoarthritis (joint disease that worsens over time), and contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and tightness of the joints) of the right elbow and right hand. During a review of Resident 41's OT Discharge Summary (OTDS), dated 10/15/2020, the OTDS indicated Resident 41 was discharged from Skilled OT and was placed on a Restorative ROM Program (nursing-based rehabilitative care aimed at maintaining and/or improving self-involvement in ADLs) with passive ROM (PROM, movement of a joint through the ROM with no effort from the resident) to both upper extremities (BUE). The OTDS indicated the recommendation for the application of right hand and right elbow splints (rigid devices used to prevent and treat contractures) with Resident 41 tolerating 5 hours of wear time, for functional maintenance. During a review of Resident 41's Minimum Data Set (MDS 1, a standardized resident assessment and care-planning tool), dated 11/28/2020, the MDS 1 indicated Resident 41 had severely impaired cognitive skills (ability to obtain and process information) for daily decision-making. The MDS 1 indicated Resident 41 had impairment in both sides of the upper and lower extremities. The MDS 1 indicated Resident 41 was totally dependent on staff for all activities of daily living (ADL, term used in healthcare that refers to self-care activities). The MDS 1 indicated Resident 41 received Occupational Therapy (OT, profession aimed to increase or maintain a person's capability of participating in everyday life activities) from 10/1/2020 to 10/14/2020. During a review of Resident 41's Joint Mobility Screening (JMS 1), dated 1/11/2022, JMS 1 indicated Resident 41 had severe ROM loss (greater than 50%) on the right wrist, right hand/fingers, right elbow, and both shoulders. JMS 1 indicated Resident 41 had minimal ROM loss on the left wrist, left hand/fingers, and left elbow. During a review of Resident 41's JMS 2, dated 5/30/2022, JMS 2 indicated Resident 41 had a decline in the ROM of the left wrist, left hand/fingers, and left elbow from minimal ROM loss (less than 25%) to moderate ROM loss (26% - 50% loss). JMS 2 indicated OT 2 documented Resident 41 would benefit from skilled OT eval/tx [evaluation or treatment] for contracture management and would request OT eval order. During a review of Resident 41's MDS 2, dated 4/30/2024, MDS 2 indicated Resident 41 had severely impaired cognitive skills for daily decision-making. MDS 2 indicated Resident 41 was dependent on staff for all self-care activities. MDS 2 did not indicate Resident 1 received OT in the facility. During a review of Resident 41's Order Summary Report (OSR) for 5/2024, the OSR indicated the following active RNA physician orders for BUE: 1. Order Date: 11/10/2023 - PROM to BUE daily 7 times per week as tolerated. 2. Order Date: 11/10/2023 - Application of right-hand roll daily 7 times per week for 4-5 hours a day or as tolerated. During an interview on 5/30/2024 at 9:38 AM, OT 1 stated the JMS must be conducted upon a resident's (in general) admission, readmission, yearly, and if there were any changes in the resident's condition. OT 1 stated the goal was to maintain the current ROM, mobility, and function at the highest possible level. OT 1 stated if a decline in ROM was identified in the JMS, the resident (in general) could be evaluated by rehabilitation staff, and placed on rehabilitation therapy with new goals and care plans to improve or maintain the current ROM. During a concurrent interview and record review on 5/30/2024 at 2:09 PM with the Director of Rehabilitation (DOR), Resident 41's rehabilitation notes, physician orders, JMS, and care plans were reviewed. The DOR stated Resident 41 received OT in the facility on 10/1/2020-10/14/2020. The DOR stated Resident 41 had a decline in LUE ROM during the JMS on 5/30/2022, but there was no OT evaluation/treatment ordered and/or provided to Resident 41. During a concurrent interview and record review on 5/30/2024 at 4:16 PM, Registered Nurse 5 (RN 5) stated there was no documented evidence that nursing [staff] obtained a physician's order for OT evaluation or treatment regarding the change in Resident 41's LUE ROM on 5/30/2022. During an interview on 5/30/2024 at 4:22 PM, the Director of Nursing (DON) stated if the resident had a decline in ROM, was refusing and/or not tolerating the ordered splints, had an actual skin breakdown, and was having pain, the nursing staff must consult with the rehabilitation department to obtain recommendations and/or new interventions. The DON stated nursing staff would then call the primary care physician to obtain the new orders related to the resident's ROM or mobility. The DON stated the miscommunication between nursing staff and the rehabilitation team could result in further decline for the resident's ROM and worsening of contractures. During a review of the facility's policy and procedure (P&P 1), titled Occupational Therapy, dated 2/19/2021, P&P 1 indicated the following: 1. Occupational therapy goals include, but is not limited to, reduction of physical disability and contracture management. 2. The Occupational Therapist's must perform the application of purposeful, goal-oriented activity/activities in the evaluation, problem identification, and treatment of persons whose function is impaired by physical illness or aging process to achieve optimum functioning to prevent disability and to maintain health. During a review of the facility's policy and procedure (P&P 2), titled Joint Mobility Assessment (JMA), dated 3/21/2024, P&P 2 indicated the following: 1. The purpose of JMA was to determine the resident's ROM for all major joint and to implement plans of care to increase, maintain, or prevent deterioration of joint mobility. 2. All residents must be assessed for joint mobility limitations upon admission and at a minimum of every three months thereafter. 3. Resident care plans must be updated as necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based an observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 61) received proper respiratory (relating to breathing) care such as oxygen (02 [a colorless, odorless, tasteless gas essential for living]) therapy to meet Resident 61's needs and in accordance with the physician's order. This failure resulted in Resident 61 receiving 02 therapy at a lower level and had the potential to result in compromised respiratory status (the movement of air in and out of the lungs and exchange of carbon dioxide [a colorless, odorless gas] and 02 at the alveolar level [alveoli, the functional units of the lung with the overall task to warrant gas exchange, i.e., 02 supply and carbon dioxide removal from the body]) to Resident 61. Findings: During a review of Resident 61's admission Record (AR), the AR indicated Resident 61 was admitted to the facility on [DATE] with multiple diagnoses including respiratory failure, unspecified with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions), tracheostomy (a surgically created hole [stoma] in the windpipe [trachea] that provides an alternative airway for breathing) status and anoxic brain damage (when your brain loses oxygen supply). During a review of Resident 61's Care Plan (CP), titled, Respiratory Care, date initiated 3/1/2023, the CP indicated interventions that included Fi02: 2 LPM with humidifier via t-bar and monitor 02 saturation, titrate Fi02 to keep Sp02 greater than 92%. During a review of Resident 61's CP, titled, Resident is at risk for respiratory distress, date initiated 3/1/2023, the CP indicated, interventions included monitor oxygen saturation as needed/ordered, tritrate Fi02 to keep 02 greater than 92% and apply oxygen as needed/ordered, 2 LPM via t-bar. During a review of Resident 61's History and Physical (H&P), dated 8/26/2023, the H&P indicated, Resident 61 did not have the capacity to understand and make decisions. During a review of Resident 61's CP, titled, Oxygen date initiated 2/9/2024, the CP indicated, interventions included to check the rate of 02 flow every shift, monitoring of 02 saturation as ordered, oxygen therapy as ordered, and provided oxygen as ordered. During a review of Resident 61's Minimum Data Set (MDS, an assessment and screening tool), dated 5/14/2024, the MDS indicated, Resident 61's cognitive (ability to think and process information) skills were severely impaired (never/rarely made decisions). The MDS indicated, Resident 61 was receiving oxygen therapy and tracheostomy care. During a review of Resident 61's Order Summary Report (OSR), dated active as of 5/29/2024, the OSR indicated, a physician's order dated 8/8/2023 for the RT, [Respiratory Therapist] Fi02 (02 flow) [to follow]: 2 LPM (liters per minute) humidifier via T-bar (t-piece, a type of device used to deliver humidified oxygen to a tracheostomy tube) every 6 hours. The OSR indicated an order dated 8/7/2021 to titrate (adjust) the 02 to keep 02 saturation greater than 92% as needed. During a concurrent observation and interview on 5/28/2024 at 8:43 AM., with the Respiratory Therapist Supervisor (RTS), Resident 61 was asleep in bed with a t-piece connected to the oxygen humidifier concentrator and with the 02-flow rate below the 1-liter mark. The RTS stated, RTS adjusted the rate, it should be 2 liters, could titrate it [flow rate]. During an interview on 5/28/2024 at 1:11 PM with Registered Nurse (RN) 6, RN 6 stated, it was important for residents to have the correct 02 flow rate because residents might have distress, difficulty breathing. RN 6 stated, it was the RT or licensed nurse who checked for the correct 02 flow rate. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, date revised 10/2010, the P&P indicated, to adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. During a review of the facility's P&P titled, Physician Orders and Telephone Orders, dated 1/2004, the P&P indicated, physician's orders are in effect for 45 days from the date of the physician's signature unless otherwise specified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 49) was administered an eye drop medication properly in accordance with the facility's policy and procedure (P&P). This failure had the potential for Resident 49 to not receive the full benefits of the eye drop medication. Findings: During a review of Resident 49's admission Record (AR), the AR indicated, Resident 49 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including ventricular fibrillation (a life-threatening heart rhythm that results in a rapid, inadequate heartbeat), tracheostomy (a surgically created hole [stoma] in your windpipe [trachea] that provides an alternative airway for breathing) status, and gastrostomy (a surgical procedure used to insert a tube, often referred to as G-Tube [GT] through the belly that brings nutrition and/or medications directly to the stomach). During a review of Resident 49's Care Plan (CP) titled, Potential for alteration in visual function secondary to eye dryness, date initiated 4/21/2023, the CP indicated, one of the goals was for Resident 49's eye dryness will be relieved through appropriate interventions daily. The CP indicated one of the interventions was [administration of] Visine Dry Eye Relief Opthalmic Solution 1% instill 2 drops in both eyes three times a day. During a review of Resident 49's H&P, dated 11/28/2023, the H&P indicated, Resident 49 did not have the capacity to understand and make decisions. During a review of Resident 49's Minimum Data Set (MDS, an assessment and screening tool), dated 4/5/2024, the MDS indicated, Resident 49's vision was highly impaired (object identification in question, but eyes appear to follow objects) and Resident 49's cognitive (ability to think and process information) skills for daily decision making were severely impaired (never/rarely made decisions). During a review of Resident 49's Order Summary Report (OSR), dated active as of 5/29/2024, the OSR indicated a physician's order, dated 5/26/2024 for Visine Dry Eye Relief Ophthalmic (relating to the eyes) Solution 1%, instill 2 drops in both eyes three times a day for dry eye. During a review of Resident 49's Medication Administration Record (MAR), dated 5/2024, the MAR indicated, Resident 25 was administered Visine Dry Eye Relief Opthalmic Solution 2 drops in both eyes on 5/29/2024 at 9 AM. During a concurrent observation and interview on 5/29/24 at 9:17 AM. during the medication pass with Licensed Vocational Nurse (LVN) 7, LVN 7 administered 2 eye drops, one after the other, of Visine Dry Eye Relief Opthalmic Solution 1% in both of Resident 49's eyes. LVN 7 stated, LVN 7 did not know LVN 7 had to wait a few minutes in between eye drops and when administering multiple eye drops. During an interview on 5/30/24 at 11:21 AM. with the Director of Nursing (DON), the DON stated, for any eye drops, to wait 5 minutes between eye drop [application] even if the eye drop medication was for dry eyes. The DON stated, it was important to wait so the eye drop would be absorbed better, for optimal eye drop absorption, and for Resident 49 to get the full benefits of the eye drop medication. During a review of the facility's P&P titled, Specific Medication Administration Procedures: Eye Drop Administration, dated 4/2008, the P&P indicated, the purpose was to administer opthalmic solution into and around the eye in a safe and accurate manner. The P&P indicated, to wait at least five 5 minutes before applying additional medication to the eye.

Based on interviews and record review, the facility failed to ensure irregularities in the monthly Medication Regimen Review (MRR, thorough evaluation a resident's medication regimen) was identified for one of one sampled resident (Resident 11) who was on psychotropic medications (used to treat mental health disorders, alter neurotransmitters [transmit messages from neurons to muscles] in the brain). The facility's Consultant Pharmacist (FCP) failed to identify and report inadequate monitoring of duloxetine (psychotropic medication used to treat depression [a mental disorder with persistently depressed mood or loss of interest in activities that interferes with daily life] during the MRR done on 5/14/2024 to 5/15/2024. This failure had the potential to cause a decline Resident 11's physical and psychosocial well-being related to the administration of unnecessary psychotropic medications. Findings: During a review of Resident 11' s admission Record (AR), the AR indicated the facility admitted Resident 11 on 4/27/2024 with multiple diagnoses including Alzheimer's disease (progressive disease that destroys memory and other mental functions) and depression. During a review of Resident 11's History and Physical (H&P), dated 4/30/2024, the H&P indicated Resident 11 had worsening confusion and was very frail and weak. The H&P indicated Resident 11 did not have the capacity to understand and make decisions. During a review of Resident 11's Minimum Data Set (MDS, a standardized resident assessment and care-planning tool), dated 5/2/2024, the MDS indicated Resident 11 had severe impairment in cognition (ability to obtain and process information). During a review of Resident 11's Medication Administration Record (MAR) for 5/2024, the MAR indicated the following: 1. Order Date: 4/27/2024 - duloxetine hydrochloride (HCl) capsule delayed release particles 60 milligrams (mg, unit of measurement) give 1 capsule by mouth two times a day for depression as manifested by verbalization of feelings of poor self-worth/worthlessness. 2. Duloxetine HCl was administered to Resident 11 from 5/1/2024 through 5/15/2024. During a concurrent interview and record review on 5/29/2024 at 10:19 AM with Registered Nurse 4 (RN 4), Resident 11's AR 1, physician orders, MAR, nursing notes, and FCP's MRR for 5/2024 were reviewed. RN 4 stated there was no documented evidence [to show] duloxetine side effects for duloxetine were monitored 5/2024. RN 4 stated FCP reviewed Resident 11's medications, but FCP did not have any recommendations for the facility. During an interview on 5/30/2024 at 4:22 PM, the Director of Nursing (DON) stated monitoring the side effects of the psychotropic medications was important in preventing any adverse effects to the residents. During a telephone interview on 5/30/2024 at 4:44 PM, the FCP stated monitoring the side effects of psychotropic medications was important to ensure appropriate medication dose was ordered without any adverse effects to Resident 11. The FCP stated, I might have missed it. During a review of facility's P&P, titled Psychotherapeutic Medications, dated 3/21/2024, indicated the following: 1. The resident's response to psychotropic medication therapy must be evaluated to determine that the medications are appropriate, and resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy. 2. The licensed nurse must assess the resident and ensure side effects of psychotropic medications are monitored and documented on the medication sheets. 3. The pharmacist must complete monthly drug regimen review and give recommendations as indicated, and the facility would follow up with the recommendations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a snack to one of one sampled resident (Resident 48) in accordance with the facility's Policy and Procedure (P&P) titled, Frequency of Meals. This deficient practice had the potential for Resident 48 to be hungry and to negatively affect his feeling of well-being. Findings: During a review of Resident 48's admission Record (AR), the AR indicated Resident 48 was admitted to the facility on [DATE] with spinal stenosis (the spaces in the spine narrow and create pressure on the spinal cord and nerve roots), post laminectomy syndrome (a condition in which the patient continues to feel pain after undergoing a laminectomy [back surgery] or another form of back surgery), and type 2 diabetes mellitus (a chronic [long standing] condition that affects the way the body processes blood sugar). During a review of Resident 48's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/6/2024, the MDS indicated Resident 48 had no impairment with cognitive skills (ability to make daily decisions). The MDS indicated Resident 48 was dependent (helper does all the effort) on staff for toileting, showering, and dressing. During an interview on 5/28/2024 at 10:52 AM with Resident 48, Resident 48 stated Resident 48 got hungry at night and Resident 48 asked facility staff for a snack at night, but the facility staff did not provide Resident 48 with a snack. During an interview on 5/29/2024 at 7:19 AM with Registered Nurse (RN) 1, RN 1 stated facility staff took snacks from the snack carts and gave the snacks to residents (in general) whenever they requested snacks. RN 1 stated residents (in general) could have snacks during the afternoon and during the night shift. RN 1 stated sometimes we [the facility] ran out of snacks. RN 1 stated there was a time when RN 1 did not have a snack for Resident 48 when Resident 48 requested for a snack during the night shift. RN 1 stated RN 1 told Resident 48, Resident 48 had to wait until the kitchen provided breakfast in the morning to have a snack. During an interview on 5/29/2024 at 10:03 AM with the Dietary Supervisor (DS), the DS stated kitchen staff provided snack trays to the facility units and were distributed during the evening and night shifts. The DS stated nursing staff informed the DS, about a month ago, that there were not enough snacks available for residents during the night. During a review of Resident 96's care plan titled Resident has Alteration in Nutritional Status ., dated 5/1/2024, the care plan indicated to offer snacks to Resident 48. During a review of the facility's P&P titled, Frequency of Meals, revised July 2017, the P&P indicated, Nourishing snacks will be available for residents who need or desire additional food between meals.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were maintained in the kitchen as indicated in the facility's policy when one of one sampled Registered Dietician (RD 1) did not wear a beard cover, while working in the kitchen food preparation area. This deficient practices had the potential for the RD's beard/facial hair to fall into the residents food and contaminate the residents' food. Findings: During an observation in the facility kitchen, on 5/29/2024 from 11:49 AM to 12:44 PM, the Registered Dietician (RD), who had visible beard, was observed walking around the kitchen while the residents' lunch was being prepared. The RD walked from the cold drinks preparation area to the food assembly tray line that served food to the residents. The RD did not wear a beard cover. The RD wore a surgical mask. The RD's beard was uncovered from the mid of the RD's left and right cheeks to the RD's ear. The RD's goatee beard (a small, pointed beard) was protruding under the RD's chin, outside of the RD's surgical mask. During an interview with the Dietary Supervisor (DS), on 5/29/24 at 12:38 PM, The DS stated kitchen staff needed to covered his beard with a beard net/cover while they are working in the kitchen for sanitary purposes. During an interview with the Registered Dietician (RD), on 5/29/24 at 12:44 PM, The RD stated kitchen staff needed to wear a beard net if they had a beard due to facial hair could fall into the residents' food. A review of the facility policy titled, Sanitation and Infection Control, dated 3/21/24, food service employees will follow infection control policies to ensure the department operates under sanitary conditions at all times. The policy indicated beards and/or mustaches should be closely trimmed or must be covered at all times.

Based on observation, interview, and record review, the facility failed to follow infection prevention and control practices and implement interventions to prevent and control the spread of infections in the facility for one of five sampled residents (Resident 41) in accordance with the facility's policy and procedure (P&P) on Enhanced Standard Precautions (ESP, approach for preventing the transmission on Multidrug-Resistant Organisms [MDROs, germs resistant to many antibiotics] in skilled nursing facilities [SNFs]). This failure had the potential to result in the increased spread of infections throughout the facility. Findings: During a review of Resident 41's admission Record (AR 1), AR 1 indicated the facility admitted Resident 41 on 9/29/2020 with multiple diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with daily activities), type 2 diabetes mellitus (disorder causing elevated sugar level in the blood), and presence of gastrostomy (surgical opening into the stomach for the introduction of food). During a review of Resident 41's History and Physical (H&P), dated 4/29/2024, the H&P indicated Resident 41 did not have the capacity to understand and make decisions. During a review of Resident 41's Minimum Data Set (MDS, a standardized resident assessment and care-planning tool), dated 4/30/2024, the MDS indicated Resident 41 had severely impaired cognitive skills (ability to obtain and process information) for daily decision-making. The MDS indicated Resident 41 had impairment in both sides of the upper and lower extremities. The MDS indicated Resident 41 was dependent on staff for all self-care activities. The MDS indicated Resident 41 was frequently incontinent of urine and bowel (unintentional passing of urine or feces). The MDS indicated Resident 41 had a feeding tube (medical device used to deliver liquid nutrition formula directly into the digestive system). During an observation on 5/28/2024 at 1:36 PM, Certified Nursing Assistant 6 (CNA 6) was wearing gloves but no gown while CNA 6 changed Resident 41's adult brief in Resident 41's bed. During an interview on 5/28/2024 at 1:41 PM, CNA 6 stated Resident 41 was not on ESP. CNA 6 stated CNA 6 did not wear a gown, because Resident 41 was not on isolation [to stay away/kept away from others). CNA 6 stated ESP was implemented for residents with known infectious organisms and to prevent the transmission of infections. During an interview on 5/28/2024 at 1:51 PM, Registered Nurse 3 (RN 3) stated all residents must be placed on ESP due to the risk of infection transmission by bodily fluids and required the use of gown and gloves when providing resident care. During an interview on 5/30/2024 at 4:22 PM, the Director of Nursing (DON) stated ESPs must be implemented for high-risk residents who had indwelling medical devices (device inserted into the body) such as gastrostomy tube and/or wounds to prevent the transmission of MDROs. The DON stated all staff must wear gowns and gloves during high-contact care activities. During a review of the facility's policy and procedure (P&P), titled Enhanced Standard Precautions, dated 4/2023, the P&P indicated the following: 1. ESP must be used as an infection prevention and control intervention to reduce the spread of MDRO acquisitions. 2. ESP employ target gown and glove use during high-contact resident care activities when contact precautions do not otherwise apply. 3. Examples of high-contact resident care activities include dressing, providing hygiene, changing linens, changing briefs, or assisting with toileting. 4. ESP are indicated for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. 5. ESP remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C. During a review of Resident 25's AR, the AR indicated, Resident 25 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including tracheostomy (a surgically created hole [stoma] in your windpipe [trachea] that provides an alternative airway for breathing) status, gastrostomy (a surgical procedure used to insert a tube, often referred to as G-Tube [GT] through the belly that brings nutrition and/or medications directly to the stomach) status and cerebral palsy (a congenital disorder that affects movement, muscle tone, or posture). During a review of Resident 25's H&P, dated [DATE], the H&P indicated, Resident 25 did not have the capacity to understand and make decisions. During a review of Resident 25's MDS, dated [DATE], the MDS indicated, Resident 25's cognitive (ability to think and process information) skills for daily decision making was severely impaired (never/rarely made decisions). During a review of Resident 25's Care Plan [CP], titled, CPR (Cardiopulmonary Resuscitation, an emergency lifesaving procedure performed when the heart stops beating), date initiated [DATE], the CP indicated, interventions included to respect resident's and/or family's wishes. D. During a review of Resident 53's AR, the AR indicated, Resident 53 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including encounter for attention to tracheostomy, encounter for attention to gastrostomy and unspecified dementia. During a review of Resident 53's H&P, dated [DATE], the H&P indicated, Resident 53 did not have the capacity to understand and make decisions. During a review of Resident 53's MDS, dated [DATE], the MDS indicated, Resident 53's cognitive skills for daily decision making was severely impaired. During a review of Resident 53's CP, titled, Advance Directive initiated as follows, date initiated [DATE], the CP indicated, interventions included to respect resident's and/or family's wishes. During a review of Resident 53's undated (date left blank) Advance Directive Acknowledgement (ADA), the ADA indicated, the ADA form was not filled out (left blank) and had a physician's signature only. During a concurrent interview and record review on [DATE] at 1:11 PM with Registered Nurse (RN) 6, Resident 25's medical record was reviewed. RN 6 could not find an ADA form filed in Resident 25's chart. RN 6 stated, it was the responsibility of the admitting nurse and Social Service [staff] to inquire about the AD. RN 6 stated, according to the SSD (Social Services Director), there was no ADA on the chart for Resident 25. RN 6 stated, facility just started implementing the ADA earlier this year. Additionally, RN 6 stated for Resident 53, Resident 53's's husband was Resident 53's responsible party but was homeless and could not come to the facility to fill out the ADA form. RN 6 stated Resident 53 did not have an AD in Resident 53's chart and stated, it was important to have an AD so facility will know what to do with the patient, in case of emergency. During an interview on [DATE] at 1:41 PM with the SSD, the SSD stated, it was the admitting nurse who asked about [resident having an] AD upon admission and the SSD followed up. The SSD stated, the facility just implemented the ADA earlier this year. The SSD stated, Resident 25 was originally admitted 2014 and readmitted on [DATE] and the ADA form was just mailed to Resident 25's brother last week. The SSD stated, it was important to have an AD in Resident 25 and Resident 53's chart to let the facility know what the resident's last wishes and medical treatments were, if residents wanted to prolong their life, wanted CPR or to be DNR (Do Not Resuscitate). During a review of the facility's policy and procedure (P&P) titled, Advance Directives, revised 09/2022, the P&P indicated, the resident had the right to formulate an AD, including the right to accept or refuse medical or surgical treatment. The P&P indicated, the resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an AD if he or she chose to do so. The P&P indicated, information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record in a section of the record that is retrievable by any staff. B. During a review of Resident 30's AR, the AR indicated Resident 30 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), hypertension, aphasia (loss of ability to understand or express speech, caused by brain damage). During a review of Resident 30's H&P, dated [DATE], the H&P indicated Resident 30 did not have the capacity to understand and make decisions. During a review of Resident 30's quarterly MDS, dated [DATE], the MDS indicated Resident 30 had severe impairment in cognitive skills for daily decision making. The MDS indicated Resident 30 was dependent for eating, oral hygiene, toileting hygiene, showering/bathing, and personal hygiene. The MDS indicated Resident 30 was dependent for rolling left to right. During a review of Resident 30's physical chart (medical record), there was no ADA or AD found in Resident 30's chart. During a concurrent interview and record review on [DATE] at 12:47 PM with the SSD, the SSD stated Resident 30 had been at the facility since 2018. The SSD stated Resident 30 did not have an ADA or AD in Resident 30's chart. During a concurrent interview and record review on [DATE] at 2:32 PM, RN 2 stated the ADA should be in every resident (in general) chart so the facility staff was aware of the resident's wishes. RN 2 stated if the ADA was not in the chart, the facility staff would not be able to respect the resident's wishes. RN 2 stated Resident 30 did not have an ADA or AD in Resident's 30 chart. During a review of the facility's policy, titled, Advance Directives, revised on 9/2022, indicated the resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. Based on interviews and record review, the facility failed to ensure five of nine sampled residents (Residents 41,30, 25, and 53) and/or their legal representatives (RP) were informed and/or provided written information about Advance Directives (AD, legal document that provides instructions regarding medical care according to the resident's wishes and only goes into effect if the resident can no longer communicate their wishes). This failure had the potential to result in lack of knowledge regarding care and treatment decision making for Residents 41, 30, 25, and 53. Findings: A. During a review of Resident 41's admission Record (AR), the AR indicated the facility admitted Resident 41 on [DATE] with multiple diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with daily activities) and type 2 diabetes mellitus (disorder causing elevated sugar level in the blood). The AR indicated Resident 41 had Responsible Party 1 (RP 1) as the emergency contact. During a review of Resident 41's History and Physical (H&P), dated [DATE], the H&P indicated Resident 41 did not have the capacity to understand and make decisions. The H&P's portion indicating, Advanced Directive Executed, was left blank/unchecked. During a review of Resident 41's Minimum Data Set (MDS, a standardized resident assessment and care-planning tool), dated [DATE], the MDS indicated Resident 41 had severely impaired cognitive skills (ability to obtain and process information) for daily decision-making. During a concurrent interview and record review on [DATE] at 1:51 PM with Registered Nurse 3 (RN 3), Resident 41's medical records were reviewed. RN 3 stated RP 1 did not sign Resident 41's Advance Directive Acknowledgment [ADA, document that indicates residents and/or their legal RP were informed and/or provided written information about AD] form. RN 3 stated there was no documented evidence RP 1 was provided information regarding AD and written information on AD formulation. During an interview on [DATE] at 9:38 AM with the Social Services Director (SSD), the SSD stated the SSD offered AD information upon a resident's (in general) admission to the facility. The SSD stated if the H&P indicated a resident was unable to make decisions, the SSD offered the RP the AD information and/or written information on AD formulation and would have the resident and/or RP sign the Advance Directive Acknowledgment form. The SSD stated it was important to offer AD information upon admission to obtain the resident's wishes regarding his/her medical care if the resident's decision-making capacity was compromised. During a review of the facility's policy and procedure (P&P), titled Advance Directives, dated 9/2022, the P&P indicated the following: 1. Prior to or upon admission of a resident, the SSD must inquire if the resident had any written AD. 2. The resident and/or resident's RP must be provided with written information that is easily understood by the resident or RP concerning the resident's right to refuse or accept medical or surgical treatment and to formulate an AD if he/she chooses to do so. 3. Written information must include a description of the facility's policies to implement ADs and applicable state law.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure comprehensive assessments of the disease diagnoses, health conditions, and/or medications, were complete and accurate, for two of two sampled residents (Residents 27 & 20). This failure had the potential to result in a decline in the residents' physical and psychosocial well-being due to inaccurate or inconsistent plan of care. Findings: A. During a review of Resident 27's admission Record (AR), the AR indicated the facility admitted Resident 27 on 5/7/2021 with multiple diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with daily activities), Parkinsonism (brain conditions that cause slowed movements, stiffness, and tremors), and major depressive disorder (depression, mental disorder with persistently depressed mood or loss of interest in activities that interfere with daily life]). During a review of Resident 27's History and Physical (H&P), dated 7/6/2023, the H&P indicated Resident 27 did not have the capacity to understand and make decisions. During a review of Resident 27's physician order (PO), dated 7/14/2023, the PO indicated healthcare provider 1 (HCP 1) initially ordered Ativan (generic name lorazepam, medication to treat anxiety [excessive and persistent feelings of worry, fear, dread, and uneasiness that interfere with daily life]) 0.5 milligrams (mg, unit of measurement) 1 tab by mouth twice a day for generalized anxiety disorder (a mental health disorder characterized by feelings of fear, anxiety, or fear that are strong enough to interfere with daily activities) manifested by verbal outbursts screaming for help. During a review of Resident 27's Minimum Data Set (MDS, a standardized resident assessment and care-planning tool), dated 4/8/2024, the MDS indicated Resident 27 had moderate impairment in cognition (ability to obtain and process information). The MDS indicated Resident 27 required substantial/maximal assistance with most self-care activities and partial/moderate assistance with mobility. During a review of Resident 27's Order Summary Report (OSR) for 5/2024, the OSR indicated the following physician's order: 1. Order Date: 10/30/2023 - lorazepam tablet 1 mg by mouth two times a day for generalized anxiety disorder manifested by verbal outburst, screaming for help and tally by hashmarks. During a review of Resident 27's Medication Administration Record (MAR) for 5/2024, MAR indicated the following: 1. Lorazepam 1 mg 1 tablet was administered at 9 AM and at 5 PM from 5/1/2024 through 5/28/2024. 2. Resident 27 had 6 episodes of verbal outbursts/screaming for help on 5/1/2024 and 8 episodes on 5/4/2024. During a concurrent interview and record review on 5/29/2024 at 10:19 AM with Registered Nurse 4 (RN 4), Resident 27's AR, physician notes, physician orders, MDS, and MARs were reviewed. RN 4 stated Resident 27's AR, MDS, dated [DATE], and MDS, dated [DATE] did not indicate Resident 27 had generalized anxiety disorder. RN 4 stated it was important to ensure accurate comprehensive MDS assessment was done for [Resident 27] to ensure appropriate care was provided. B. During a review of Resident 20's admission Record (AR), the AR indicated the facility admitted Resident 20 on 2/6/2023 with multiple diagnoses including dementia. During a review of Resident 20's History and Physical (H&P), dated 2/9/2024, the H&P indicated Resident 20 did not have the capacity to understand and make decisions. During a review of Resident 20's MDS (MDS), dated [DATE], the MDS indicated Resident 20 had severe impairment in cognition. MDS 2 indicated Resident 20 required substantial/maximal assistance with most self-care activities and partial/moderate assistance with mobility. During a review of Resident 20's MARs from 3/2024 through 5/2024, the MARs indicated a physician's order, dated 2/27/2024, indicated to administer Ativan 0.5 mg by mouth every 8 hours as needed (PRN) for anxiety manifested by constant worrying about her health condition for 90 days. The MARs indicated the following: 1. On 3/3/2024 - Resident 20 received Ativan 0.5 mg by mouth four times. 2. On 3/4/2024 - Resident 20 received Ativan 0.5 mg by mouth four times. 3. On 3/5/2024 - Resident 20 received Ativan 0.5 mg by mouth four times. During a concurrent interview and record review on 5/29/2024 at 10:19 AM with RN 4, Resident 20's AR, MDS, physician orders, physician notes, MAR, and nursing notes were reviewed. RN 4 stated Resident 20's MDS, dated [DATE], and MDS, dated [DATE] did not indicate Resident 20 had anxiety. RN 4 stated Ativan 0.25 mg was initially ordered for Resident 20 on 9/2023 for anxiety. RN 4 stated Resident 20's MDS, dated [DATE], did not indicate Resident 20 was on any anti-anxiety medication. During an interview on 5/30/2024 at 4:22 PM, the Director of Nursing (DON) stated the MDS nurse must physically assess the residents (in general), interview the staff assigned to the residents, interview the family member/s of the residents, and review all the resident's medical records to complete an accurate MDS assessment and determine the correct plan of treatment for the resident. During a review of the facility's policy and procedure (P&P), titled Resident Assessment, dated 4/2014, the P&P indicated the following: 1. Sources of information to complete the MDS assessment include: review of the resident's record, observation of and communication with the resident, communication with the health provider, physician, and resident's family. 2. Once the MDS is completed, the Interdisciplinary Team (IDT) must develop the plan of care. 3. Care plans must be updated as the resident's condition or needs change by coordinating with the physician's orders as they are received, and/or with calls to the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. During a review of Resident 25's AR, the AR indicated, Resident 25 was originally admitted to the facility on [DATE] and last readmitted on [DATE] with multiple diagnoses including tracheostomy (a surgically created hole [stoma] in the windpipe [trachea] that provides an alternative airway for breathing) status, gastrostomy status, cerebral palsy (a congenital disorder that affects movement, muscle tone, or posture) and unspecified severe protein-calorie malnutrition (lack of sufficient nutrients in the body). During a review of Resident 25's CP titled, Resident is on GT feeding, date initiated 6/2/2023, the CP indicated, interventions included to monitor GT patency every shift. During a review of Resident 25's H&P, dated 2/3/2024, the H&P indicated, Resident 25 did not have the capacity to understand and make decisions. During a review of Resident 25's MDS, dated 5/20/2024, the MDS indicated, Resident 25's cognitive (ability to think and process information) skills for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated, Resident 25 had a feeding tube for nutritional approach. During a review of Resident 25's OSR, dated active as of 5/29/2024, the OSR indicated, an order dated 2/2/2024 for enteral feeding: Fibersourse (nutritionally complete tube feeding formula with fiber) HN 1.2 at 55cc (millimeters) per hour for 20 hours or until dose completed via pump to provide 1100 cc/1320 kcal (kilocalories, unit of heat energy) per day. The OSR indicated, an order dated 2/3/2024 to monitor GT patency every shift. During a review of Resident 25's Medication Administration Record (MAR), dated 5/2024, the MAR indicated, Resident 25 was receiving enteral feeding during the day, evening, and night shifts. C.During a review of Resident 252's AR, the AR indicated, Resident 252 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including cerebral infarction (also known as a stroke, refers to damage to tissues in the brain due to a loss of oxygen to the area), encounter for attention to gastrostomy and unspecified protein-calorie malnutrition. During a review of Resident 252's CP, titled, Resident is on GT feeding, date initiated 10/3/2023, the CP indicated, interventions included to check and maintain placement and patency of GT. During a review of Resident 252's MDS, dated 2/16/2024, the MDS indicated Resident 252's cognition was severely impaired. The MDS indicated, Resident 252 had a feeding tube for nutritional approach. During a review of Resident 252's H&P, dated 5/24/2024, the H&P indicated Resident 252 did not have the capacity to understand and make decisions. During a review of Resident 252's OSR, dated active as of 5/29/2024, the OSR indicated, a physician's order dated 5/23/2024 for enteral feeding: Jevity (calorically dense fiber-fortified therapeutic nutrition that provides complete balanced nutrition) 1.5 at 55 cc per hour for 20 hours via pump to provide 1100 CC/1320 kcal per day. The OSR indicated, an order dated 5/23/2024 to monitor GT patency every shift. During a review of Resident 252's MAR, dated 5/2024, the MAR indicated Resident 252 was receiving the enteral feeding during the day, evening, and night shifts. During an observation on 5/28/24 at 9:42 AM., Resident 25 was nonverbal and was sitting up on a wheelchair doing a coloring activity. Resident 25 was receiving Fibersource HN tube feeding via GT and the GT pump was beeping indicating Flow Error Clog in Line Downstream of Pump. During a concurrent observation and interview on 5/28/2024 at 10:15 AM., with LVN 6, Resident 25's GT pump continued to beep indicating Flow Error Clog in Line Downstream of Pump. LVN 6 stated, it was important to respond to the GT pump when the pump was beeping because if the GT was pump beeped, Resident 25 was not getting his feeding and that could result in weight loss, could result in clogging up the GT and cause more complications [to Resident 25]. During an observation and interview on 5/28/2024 at 10:22 AM., with Certified Nursing Assistant (CNA) 7, Resident 252 was awake in bed and receiving Jevity tube feeding via GT. The GT pump was beeping indicating Flow Error Clog in Line Downstream of Pump. Resident 252 stated, the GT pump had been beeping a long time. The HFEN (Health Facilities Evaluator Nurse) had to asked CNA 7 to get a licensed staff to check the GT pump. During a concurrent observation and interview on 5/28/2024 at 10:30 AM., with LVN 2, Resident 252's GT pump was beeping indicating Flow Error Clog in Line Downstream of Pump. LVN 2 stated, it was important to respond to the GT pump alarm to ensure Resident 252 was getting his feeding. LVN 2 stated [not responding to a GT alarm] could [result in] the GT getting clogged, complications, and could result in the replacement of the GT. During an observation on 5/28/2024 at 10:41 AM., Resident 252's GT pump was beeping. During an observation on 5/28/2024 at 11:10 AM., Resident 252's GT pump continued to beep, HFEN had to get an unidentified staff to check the GT pump. During a review of the facility's P&P titled, Enteral Tube Feeding via Continuous Pump, date revised November 2018, the P&P indicated, to ensure the equipment and devices are working properly by performing any calibrations or checks as instructed by the manufacturer or this facility. Based on observation, interview, and record review the facility failed to ensure appropriate treatment and services were provided for three of three sampled Residents (Resident 36, 25 and 252) by failing to ensure: A.Resident 36's head of bed (HOB) was elevated to at least 30 - 45 degrees while receiving g-tube (GT, gastrostomy tube; a type of tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) feedings as indicated in the facility's policy and procedure (P&P), titled, Enteral Feeding- Safety Precautions. B - C.Residents 25 and 252, who were receiving enteral feeding (nutrition taken through the mouth or through a tube that goes directly to the stomach or small intestine) received appropriate care and services by failing to respond timely to the GT pump that was continuously beeping (alarming). These failures had the potential to result in GT complications and harm to Residents 36, 25 and 252, additionally, there was a potential for aspiration (condition in which food, liquids, saliva, or vomit is breathed into the airways) pneumonia (infection that inflames the air sacs of the lungs) to Resident 36. Findings: A.During a review of Resident 36's admission Record (AR), the AR indicated Resident 36 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included gastrostomy placement (a surgical procedure used to insert a tube, often referred to as GT through the belly that brings nutrition and/or medications directly to the stomach) dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and gastro-esophageal reflux disease (GERD; digestive disorder that occurs when acidic stomach juices, or food and fluids back up from the stomach into the esophagus [muscular tube through which food passes from the throat to the stomach]). During a review of Resident 36's History and Physical (H&P), dated 1/4/2024, the H&P indicated, Resident 36 did not have the capacity to understand and make decisions. During a review of Resident 36's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 2/27/2024, the MDS indicated Resident 36 had severe impairment in cognitive (ability to understand and process information) skills for daily decision making. The MDS indicated Resident 36 had impairment on bilateral (both sides) upper extremities (shoulders, elbows, wrists, or hands) and bilateral lower extremities (hip, knee, ankle, foot). During a review of Resident 36's Order Summary Report (OSR), dated active as of 5/28/2024, the OSR included a physician's order (PO), dated 12/30/2024, that indicated to elevate the HOB 30 to 45 degrees at all times during GT feeding for aspiration precautions. Additionally, the ORS included a physician's order, dated 12/31/2023, that indicated to administer Glucerna 1.2 (calorically dense formula of low glycemic [presence of sugar in the blood] and slowly digestible carbohydrates designed to help minimize blood sugar) at 65 millimeters (ml, volume measurement) per hour for 20 hours to provide 1300 ml/1560 calories per day. During a review of Resident 36's GT feeding at risk for aspiration Care Plan (CP), dated 5/20/2024, the CP indicated to keep the HOB elevated. During an observation of Resident 36 in the Resident 36's room on 5/28/2024 at 10:19 AM, Resident 36 was receiving GT feeding at 55 cc and hour (cc/hr) and Resident 36's HOB was elevated at 20 -25 degrees. During an observation of Resident 36 and concurrent interview with Licensed Vocational Nurse 1 (LVN 1) on 5/28/2024 at 10:23 AM, LVN 1 suctioned (the act of sucking, removal of solids or fluid with air) Resident 36's mouth and stated Resident 36's HOB looked about 20 to 25 degrees. LVN 1 stated the resident's HOB should be at 30 degrees or higher to avoid aspiration. During an interview with the Assistant Director of Nursing (ADON), on 5/29/2024 at 10:43 AM, the ADON stated residents receiving GT feedings could not swallow and should have the HOBs [raised] greater than 30 to 40 degrees to prevent aspiration. During an observation and concurrent interview with Licensed Vocational Nurse 4 (LVN 4) on 5/29/2024 at 4:05 PM, LVN 4 stated residents who received GT feedings were placed on aspiration precautions because [those residents] usually did not have the capacity to swallow, and the HOB [for those residents] should be at least 30 degrees [raised] when the g-tube feeding was turned on. During an interview with the Director of Nursing (DON), on 5/30/2024 at 8:24 AM, the DON stated the HOB for residents who received GT feedings must be kept at least 30 degrees or higher to prevent aspiration from the feeding or from secretions (saliva). The DON stated the HOB should be greater than 30 degrees, so the residents do not aspirate. During a review of the facility's P&P, titled, Enteral Feeding- Safety Precautions, revised on 11/2018, indicated to elevate the head of bed (HOB) at least 30 degrees during tube feeding and at least 1 hour after feeding to prevent aspiration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C. During a review of Resident 96's AR, the AR indicated Resident 96 was admitted to the facility on [DATE] with severe dementia with agitation, hypertension (high blood pressure), and dysphagia (difficulty swallowing foods or liquids). During a review of Resident 96's MDS, dated 4/22/2024, the MDS indicated Resident 96 was severely impaired with cognitive skills. The MDS indicated Resident 96 required substantial/maximal assistance (helper does more than half the effort) from staff for toileting and dressing. The MDS indicated Resident 96 received psychotropic medications at the facility. During a concurrent interview and record review on 5/29/2024 at 3:22 PM with the DON, Resident 96's physician orders, dated 4/22/2024 and 5/23/2024 were reviewed. The physician orders both indicated Resident 96 had a medication order for Lorazepam 0.5 milligram (MG, a unit of measurement) give 1 tablet (tab) by mouth (PO) every 12 hours as needed (PRN) for anxiety manifested by (m/b) restlessness causing anger. The physician order dated 4/22/2024 indicated Resident 96's PRN order for Lorazepam was active for 30 days. The physician order dated 5/23/2024 indicated Resident 96's PRN order for Lorazepam was active for 30 days. The DON stated Resident 96's PRN order for Lorazepam needed to be written for 14 days. The DON sated the orders for Lorazepam were written for 30 days. The DON stated Resident 96's PRN order for Lorazepam was renewed on 5/23/2024. The DON stated Resident 96's PCP did not document in Resident 96's medical record the rational for extending Resident 96's PRN order for Lorazepam to 30 days. During a review of Resident 96's Order Summary Report dated 5/29/2024, the Order Summary Report indicated Resident 96 had a physician's order, dated 5/23/2024, for Lorazepam oral tablet 0.5 MG give 1 tab by mouth every 12 hours PRN for anxiety m/b restlessness causing anger. The medication order was started on 5/23/2023 and had an end date of 6/22/2024 (longer than 14 days). During a review of the facility's P&P titled, Psychotherapeutic Medications, updated 3/21/2024, the P&P indicated, antianxiety medications are psychotropic medications. The P&P indicated, The licensed nurse will assess resident to ensue: H.PRN psychotropic orders: 1. NO PRN antipsychotic unless the prescribe have evaluated resident and documented the rational/benefits; PRN antipsychotic will be limited to 14 days unless the primary care provider evaluate the rational and documents the rational for extension 2. PRN hypnotic order will be limited to 14 days unless the primary care provider evaluates and documents the rationale for extension 3. PRN antianxiety order will be limited to 14 days unless the primary care provider evaluates and documents the rationale for extension . Based on interviews and record review, the facility failed to ensure three of five sampled residents (Residents 11, 20, & 96) did not receive unnecessary psychotropic medications (medications used to treat mental health disorders that alter neurotransmitters [transmit messages from neurons to muscles] in the brain, affects brain activities associated with mental processes and behavior) by failing to: A. Monitor the side effects upon administration of Resident 11's duloxetine (psychotropic drug used to treat major depressive disorder [depression, mental disorder with persistently depressed mood or loss of interest in activities that interfere with daily life]. B. Provide a documented rationale for the continuation of Resident 20's as needed (PRN) Ativan (generic name lorazepam, psychotropic medication to treat anxiety [excessive and persistent feelings of worry, fear, dread, and uneasiness that interfere with daily life]) physician orders. C. Ensure Resident 96's order for PRN Lorazepam (psychotropic medication used for the treatment of anxiety), started on 4/22/2024, was limited to 14 days. The facility also failed to ensure Resident 96's primary care physician (PCP) documented the rational for extending the PRN order for Lorazepam on 5/23/2024 in accordance with the facility's policy and procedure (P&P) titled, Psychotherapeutic Medications, updated 3/21/2024. These failures had the potential to cause adverse effects (unwanted, uncomfortable, or dangerous effects that a resident may have due to a medication) to Residents 11, 20, and 96 related to the possible administration of unnecessary psychotropic medications. (Cross Reference with F636) Findings: A. During a review of Resident 11' s admission Record (AR), the AR indicated the facility admitted Resident 11 on 4/27/2024 with multiple diagnoses including Alzheimer's disease (progressive disease that destroys memory and other mental functions), depression, and anxiety disorder (a mental health disorder characterized by feelings of fear, anxiety, or fear that are strong enough to interfere with daily activities). During a review of Resident 11's History and Physical (H&P), dated 4/30/2024, the H&P indicated Resident 11 had worsening confusion and was very frail and weak. The H&P indicated Resident 11 did not have the capacity to understand and make decisions. During a review of Resident 11's Minimum Data Set (MDS, a standardized resident assessment and care-planning tool), dated 5/2/2024, the MDS indicated Resident 11 had severe impairment in cognition (ability to obtain and process information). During a review of Resident 11's Medication Administration Record (MAR) for 5/2024, the MAR indicated the following: 1. Order Date: 4/27/2024 - duloxetine hydrochloride (HCl) capsule delayed release particles 60 milligrams (mg, unit of measurement) give 1 capsule by mouth two times a day for depression as manifested by verbalization of feelings of poor self-worth/worthlessness. 2. Duloxetine HCl was administered to Resident 11 from 5/1/2024 through 5/15/2024. During a concurrent interview and record review on 5/29/2024 at 10:19 AM with Registered Nurse 4 (RN 4), Resident 11's physician orders, MAR, and nursing notes were reviewed. RN 4 stated there was no documented evidence to show side effects for duloxetine were monitored 5/2024. During an interview on 5/30/2024 at 4:22 PM, the Director of Nursing (DON) stated monitoring the side effects of the psychotropic medications was important in preventing any adverse effects to the residents. During a review of the National Library of Medicine's (NLM's) guidance, titled Duloxetine, dated 2024, the NLM's guidance indicated, but not limited to, the following potential side effects of duloxetine: nausea, vomiting, constipation, diarrhea, weight changes, heartburn, stomach pain, decreased appetite, dry mouth, increased urination, sweating, dizziness, headache, tiredness, drowsiness, muscle pain or cramps, sexual problems, and uncontrollable shaking of a part of the body, unusual bleeding or bruising, pain in the upper right part of the stomach, dark colored urine, fever, rash, hives, and difficulty breathing. https://medlineplus.gov/druginfo/meds/a604030.html#side-effects During a review of facility's P&P, titled Psychotherapeutic Medications, dated 3/21/2024, the P&P indicated the licensed nurse must assess the resident and ensure the side effects of psychotropic medications are monitored and documented on the medication sheets. B. During a review of Resident 20's AR, the AR indicated the facility admitted Resident 20 on 2/6/2023 with multiple diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with daily activities). During a review of Resident 20's H&P, dated 2/9/2024, the H&P indicated Resident 20 did not have the capacity to understand and make decisions. During a review of Resident 20's MDS, dated [DATE], the MDS indicated Resident 20 had severe impairment in cognition. During a review of Resident 20's MARs dated from 3/2024 through 5/2024, the MARs indicated the physician's order, dated 2/27/2024, to administer Ativan 0.5 mg by mouth every 8 hours PRN for anxiety for 90 days. During a concurrent interview and record review on 5/29/2024 at 10:19 AM with RN 4, Resident 20's admission record, MDS, physician orders, physician notes, MAR, and nursing notes were reviewed. RN 4 stated there was no documented rationale from the HCP, who prescribed the PRN Ativan beyond 14 days on 2/27/2024, to indicate the reason Ativan was ordered beyond 14 days. During an interview on 5/30/2024 at 12:58 PM, the facility's Consultant Pharmacist (FCP) stated it was important to limit the duration of PRN Ativan to 14 days because this would be the evaluation period to ensure the dosage was appropriate for the resident's (in general) diagnosis. The FCP stated if PRN Ativan was no longer needed, the HCP's order would automatically be discontinued after the 14 days. The FCP stated if PRN Ativan was still needed, the FCP stated the HCP had to review the resident's behavior manifestations and any side effects of the medication and document the rationale/s why the PRN Ativan had to be continued. The HCP would need to reorder and specify the duration of the PRN Ativan. During a review of facility's P&P, titled Psychotherapeutic Medications, dated 3/21/2024, indicated the following: 1. The resident's response to the psychotropic medication therapy must be evaluated to determine that the medications are appropriate, and resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy. 2. The PRN antianxiety order must be limited to 14 days unless the PCP evaluates and documents the rationale for extension.

Based on observation, interview and record review, the facility failed ensure three of four sampled glasses of milk/mocha mix were served at 40 degrees Fahrenheit (F, a unit used to measure temperature) or lower as indicated in the facility's policy. This deficient practice had the potential to compromise the residents' taste by serving unfresh or spoiled milk/mocha mix to the residents. Findings: During an observation with the Dietary Supervisor (DS) and Kitchen Aid 1 (KA 1), in the facility kitchen, on 5/29/2024 at 12:27 PM, several 8 ounces of glasses of milk were on the trays ready to be served with the residents' lunch. Three of the four glasses of milk were randomly selected and observed to have a temperature higher than 41F. The first glass measured at 42 F, the third glass measured at 44 F and the fourth glass measured at 51 F. During an interview with KA 1, on 5/29/2024 at 12:29 PM, KA 1 stated the milk temperature should be below 41 F because above 41F is the danger zone (the temperature range between 40F and 140F in which bacteria can grow rapidly) and the residents could get the sick from consuming those milk/mocha mix. During an interview with the DS on 5/29/2024 at 12:38 PM, the DS stated milk should be under 41 degrees F because if not, bacteria may grow or the milk/moca mix can be unfreshed or spoiled. A review of the facility's policy titled, Meal Service, updated on 3/21/2024, indicated food temperature will be taken to insure foods are at the proper serving temperature. The policy indicated cold beverages, desserts will be served no more than 40 degrees F.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to readmit one of one sampled resident (Resident 1) from the General Acute Care Hospital (GACH) after the resident was cleared by the GACH to return to the facility on 5/13/2024, according to the facility's Policy and Procedure (P&P). This deficient practice had the potential to result in the denial of Resident 1's rights to return to the facility. Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses that included hemiplegia (muscle weakness or partial paralysis on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following unspecified cerebrovascular (relating to the brain and its blood vessels) disease affecting left dominant side, respiratory failure (when the lungs can't get enough oxygen into the blood), and dysphagia (difficulty swallowing foods or liquids). During a review of Resident 1's Minimum Data Set (MDS, standardized assessment and care-screening tool), dated 2/16/2024, the MDS indicated the resident was severely impaired in cognitive skills (ability to make daily decisions). Resident 1 was dependent (helper does all the effort) on staff for dressing, personal hygiene, and toilet use. During a review of Resident 2's AR, the AR indicated Resident 2 was admitted to facility on 5/1/2024 with multiple diagnoses including spinal stenosis (the spaces in the spine narrow and create pressure on the spinal cord and nerve roots), post laminectomy (surgical procedure that removes a portion of a vertebra called the lamina, which is the roof of the spinal canal) syndrome (the patient continues to feel pain after undergoing a back surgery), and lack of coordination. During a review of Resident 2's MDS, dated 5/6/2024, the MDS indicated the resident had no impairment in cognitive skills (ability to make daily decisions). Resident 2 was dependent (helper does all the effort) on staff for dressing, personal hygiene, and toilet use. During an interview on 5/24/2024 at 9:04 AM with the administrator (ADM), the Adm stated Resident 1 was readmitted to room [ROOM NUMBER] of the facility on 5/23/2024. The ADM stated GACH tested Resident 1 for Candid Auris (C. Auris, a multidrug-resistant fungal infection) and that Resident 1 was positive (required an isolation room [separate infected residents from non-infected residents]). The ADM stated they would need to arrange an isolation room for Resident. The ADM stated the ADM made arrangements for Resident 1 to go to a different facility from the GACH. The ADM stated those arrangements eventually did not happen as the other facility could not accept Resident 1. The ADM stated the facility did have an empty room at the time the GACH was ready to send Resident 1 back to the facility but that the facility was concerned the C. Auris would spread in the facility. During a concurrent interview and record review on 5/24/2024 at 9:55 AM with the Admissions Coordinator (AC), the facility's Daily Census for 5/19/2024 and 5/25/23/2024 were reviewed. The Daily Census, dated 5/19/2024 indicated room A had an empty bed. The Daily Census, dated 5/23/2024 indicated Resident 2 was moved from Room B to Room A and that Resident 1 was admitted to Room B. The AC stated the facility moved Resident 2 to accommodate the readmission of Resident 1 to the facility. The AC stated Resident 1 was transferred to the GACH on 5/7/2024. The AC stated the Case Manager (CM) at the GACH notified AC on 5/13/2024 that Resident 1 was ready to be discharged from the GACH and would need to return to the facility. The AC stated the facility could not readmit Resident 1 to the facility because Resident 2 required an isolation room. The AC stated the facility could have accommodated the admission of Resident 1 on 5/19/2024 if the facility had made the same room changes that were done on 5/23/2024. During a telephone interview on 5/24/2024 at 10:01 AM with the CM, the CM stated Resident 1 had a discharge order from the GACH on 5/13/2024. The CM stated Resident 1 was stable and ready to return to the facility. The CM stated Resident 1 tested positive for C. Auris while at the GACH. The CM stated the AC told her that the facility did not have an isolation room for Resident 1. The CM stated the facility is required to take residents back even if the resident has an isolation need. The CM stated because the facility did not receive Resident 1 back Resident 1 overstayed at GACH for 10 days. During an interview on 5/24/2024 at 10:31 AM with the Infection Preventionist (IP), the IP stated Resident 1 was the fifth resident at the facility with C. Auris. During a review of the facility's P&P titled, readmission to the Facility, revised March 2017, the P&P indicated, Residents who have been discharged to the hospital or for therapeutic leave will be given priority in readmission to the facility. The P&P indicated, A Medicaid resident whose hospitalization or therapeutic leave exceeds the bed hold period allowed by the state will be readmitted to the facility upon the first availability of a bed in a semi-private room if the resident: a. Requires the services provided by the facility. b. Meets the admission criteria as outlined in facility policy. c. Was not discharged for any reason outlined in the transfer or discharge notice policy. d. Is eligible for Medicaid nursing facility services. During a review of the facility's P&P titled, Bed-Holds and Returns, revised October 2022, the P&P indicated, The requirement that residents be permitted to return to the facility following hospitalization or therapeutic leave applies to all residents regardless of payer source. Residents who seek to return to the facility within the bed-hold period defined in the state plan are allowed to return to their previous room, if available. Residents who seek to return to the facility after the state bed-hold period has expired (or when state law does not provide for bed-holds) are allowed to return to their previous room if available or immediately to the first available bed in a semi-private room provided that the resident: a. Still requires the services provided by the facility; and b. Is eligible for Medicare skilled nursing facility or Medicaid nursing facility services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow the repositioning (turning) schedule for one of two sampled residents (Resident 1). This failure had the potential for Resident 1 to be at risk for worsening skin condition and/or pressure injury (damage to an area of the skin caused by constant pressure on the area for a long time). Findings: During a review of Resident 1's admission Record (AR), the AR indicated, the facility admitted Resident 1 to the facility on [DATE] with diagnoses of acute respiratory failure (a condition in which the lungs were not able to release enough oxygen into the blood), dependence on ventilator (a machine to support or replace the breathing of a person who was ill or injured), type 2 diabetes mellitus (characterized by high levels of blood sugar in the blood) with foot ulcer (an open sore or wound), and pressure induced deep tissue damage (area of intact skin that looks purple or dark red due to damage to tissues under the skin) of right and left elbow, sacral region (area below the spine and above the tailbone), and right hip. During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/10/2023, the MDS indicated, Resident 1 had severely impaired (weakened) cognition (the act of knowing and understanding). The MDS indicated, Resident 1 was dependent (helper did all of the effort and the resident did none of the effort to complete the activity, or the assistance of two or more helpers was required for the resident to complete the activity) on staff for Resident 1 to roll left and right (the ability to roll from lying on back to left and right side and return to lying on back on the bed). The MDS indicated, Resident 1 was at risk of developing pressure ulcers or injuries. During a review of Resident 1's Care Plan (CP), initiated and revised on 2/9/2024, the CP indicated, Resident 1 was at risk for developing pressure ulcer and other types of skin breakdown. The CP indicated, for the staff to turn and position Resident 1 as needed when in bed or wheelchair. During a review of Resident 1's Order Summary Report (OSR) dated 2/14/2024, the OSR indicated, a physician's order dated 1/30/2024, for treatment on the sacrum (area below the spine and above the tailbone) every day for 30 days for ulceration of skin for skin maintenance. During a review of Resident 1's OSR dated 2/14/2024, the OSR indicated, a physician's order dated 1/31/2024, for treatment on the right dorsal (relating to the back) foot every day for 30 days for ulceration (a break in skin or open sore) of skin. During an observation on 2/14/2024 at 10:43 am, in Resident 1's room, Resident 1 was observed in bed with eyes closed and lying supine (lying on one's back, facing upward). Resident 1 was noted with pillows under the knees and Resident 1's heels were touching and resting directly on the mattress. Above Resident 1's bed was a repositioning schedule that indicated, at 10:00 am, Resident 1 was to be repositioned facing the door. The repositioning schedule indicated, at 12:00 pm, Resident 1 was to be repositioned facing the window. The repositioning schedule indicated, to float heels (a wound care term and intervention in which both heels are suspended in the air) of Resident 1. During a concurrent observation and interview on 2/14/2024 at 10:59 am with Registered Nurse (RN) 1, RN 1 stated Resident 1 was lying supine and was not facing the door. RN 1 stated Resident 1's heels were not floated. RN 1 stated Resident 1's heels needed to be floated. RN 1 stated it was important to follow Resident 1's repositioning schedule to help with circulation and to maintain skin integrity (the health of the skin) so Resident 1 would not get a pressure ulcer. During an interview on 2/14/2024 at 1:41 pm with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 was not able to lift Resident 1's own heels off the bed. CNA 1 stated CNA 1 usually followed the repositioning schedule. CNA 1 stated the only time Resident 1 could be positioned on Resident 1's back was during patient care. During an interview on 2/14/2024 at 2:41 pm with the Director of Nursing (DON), the DON stated Resident 1 needed to be positioned on Resident 1's left side or right side due to Resident 1's history of having a wound on the sacral area. The DON also stated Resident 1's heels needed to be offloaded (elevating the foot off the bed to help prevent and heal pressure ulcer) because if Resident 1's heels were not offloaded, it could lead to worsening of the pressure ulcer. During a review of the facility's policy and procedure (P&P) titled, Pressure Sore Management, undated, the P&P indicated, all available measures shall be taken to reduce skin breakdown and pressure sores. The resident was to be re-positioned as scheduled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of five sampled resident's (Resident 1) Actual Fall care plan (CP, provides direction on the type of nursing care an individual needs that includes goals of treatment, specific nursing interventions [actions, treatments, procedures, or activities designed to meet a goal], and an evaluation plan) interventions were revised to reflect the current status of Resident 1 in accordance with the facility's policy and procedures (P&P). This failure had the potential to result with implementation of inadequate interventions for Resident 1 and a decline in Resident 1's physical well-being. Findings: During a review of Resident 1's admission Record (AR), the AR indicated, Resident 1 was originally admitted to the facility on [DATE] to Room A (Rm A). Resident 1 had multiple diagnoses including repeated falls, abnormalities of gait (a manner of walking or moving on foot), mobility, dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), muscle weakness, and unsteadiness on feet. During a review of Resident 1's CP titled, Actual Fall, target date 12/5/22, the CP indicated the goal was to minimize risk of falls/injury and one of the interventions included, Place resident close to nursing station for close observation. During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 3/9/23, the MDS indicated, Resident 1's cognitive (ability to think and process information) status was severely impaired. The MDS indicated, Resident 1 required one-person physical assistance for locomotion on unit (how resident moved between locations in his/her room and adjacent corridor on same floor). During an observation on 6/14/23, at 7:00 a.m., in the resident care area, Resident 1's room, (Rm A), was located on the west side at the end of hallway, adjacent to the activities and dining area, on the opposite end of the nursing station. During an interview on 6/14/23, at 7:15 a.m., with Licensed Vocational Nurse (LVN 3), LVN 3 stated, after every fall incident, care plans were updated and interventions that were in place were reviewed for effectiveness, reevaluated, and updated for new interventions if needed and any changes to be made. LVN 3 stated, it was important to revise care plans to prevent future falls and optimize care. During a concurrent interview and record review on 6/14/23, at 8:50 a.m., with the Minimum Data Set Nurse (MDSN), Resident 1's CP titled, Actual Fall on 1/28/23, was reviewed. The CP indicated, the goal was to minimize risk of falls/injury and one of the interventions included Place resident close to nursing station for close observation. The MDSN stated, the MDSN was responsible for revising the care plan and I just missed it on that. The MDSN stated, Resident 1 was kept in Rm A since the room was suitable for her cuz she walks in the hallway, the nurses, activity always in that area. It [the intervention] should have been stated differently. During an interview on 6/14/23, at 11:03 a.m., with the MDSN, the MDSN stated, it was important for documentation to be accurate so it doesn't get confusing. During a concurrent interview and record review on 6/14/23, at 12:13 p.m., with the MDSN, the CP titled Actual Fall on 2/25/23 was reviewed. The CP indicated, the goal was to minimize risk of falls/injury through appropriate interventions and one of the interventions included Place resident close to nursing station for close observation. The MDSN stated, the intervention should have been worded, not to put close to nursing station cuz it [the intervention] was not suitable for her but keep resident in the same room [Rm A] where activity of the resident most of time happens, cuz always staff around. During a review of the facility's Daily Census (DC), dated 12/6/22, 1/29/22, 2/26/23 and 4/13/22, the DC indicated, Resident 1 was in Rm A. During a review of the facility's undated P&P titled, The Resident Care Plan, the P&P indicated, the care plan generally included Reassessment and change as needed to reflect current status. During a review of the facility's P&P titled, Charting and Documentation, revised 2017, the P&P indicated, Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, revised March 2023, the P&P indicated, Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on interview and record review, the facility failed to ensure one of three sampled Certified Nursing Assistants (CNA 1), received adequate training prior to be assigned to care for residents in the subacute unit (includes residents with an acute illness, injury, disease, or complex health problems requiring high level of care) in accordance with the facility's Sub-Acute Staff Education, Training and Evaluation policy and procedures. This deficient practice placed the residents in the subacute unit at risk of not receiving safe care. Findings: During an interview on 3/6/2023 at 3 pm CNA 1 stated, on 2/15/2023, she was assigned to care for eight subacute residents. CNA 1 stated, she did not receive enough training to care for the residents in the subacute care unit and did not feel capable of providing safe care to the residents with the limited training the facility provided to her. During an interview on 2/7/2023 at 2:26 pm, the Director of Staff Development (DSD) stated, newly hired certified nursing assistants are trained for two days in the classroom, two days in the skilled Nursing Facility (SNF- a rehabilitation center where hospital patients are transferred after leaving the hospital) Care Unit following a certified nurse assistant (CNA) preceptor (an experienced nurse), and two days in the sub-acute unit, following a CNA preceptor. During a concurrent record review and interview on 3/7/2023 at 3:15 pm, the DSD stated, the Respiratory Therapy Department goes over the form titled: The Key Competency Checklist, Respiratory Care- Emergency Preparedness Subacute staff (subacute competency check list), with the newly hired CNAs. A review of CNA 1's Key Competency Checklist, Respiratory Care- Emergency Preparedness Subacute staff, the form was not initialed or signed by CNA 1. The DSD stated, the form had not been completed for CNA 1. During an interview on 3/7/2023 at 3:28 pm, the Lead Respiratory Therapist (LRT) stated, that her department does the subacute competency check list for the newly hired CNAs, the first week of hire and before they go on the floor alone to take care of the residents. The LRT stated, she does the competency check list before the CNAs are assigned residents in the subacute. The LRT stated, the purpose of the subacute competency check list was to ensure the CNAs know how to loosen up the ventilator (a machine that helps you breathe or breaths for you) circuit (refers to the tubing that connects the ventilator to the patient) before they attempt to turn and reposition the residents to prevent accidental decannulation (removal of the tracheostomy [a hole that surgeons make through the front of the neck and into the windpipe] tube [a catheter that's inserted into the windpipe once the surgeon creates the hole]). The LRT stated, she likes the CNAs to demonstrate back to her the list of skills on the subacute competency list. I like to make sure they're safe. The LRT stated, when CNAs are on their own, they must recognize the signs and symptoms of respiratory distress. The LRT stated, she would not feel comfortable having a brand-new CNA (in general) work the subacute unit without passing the subacute competency skills demonstration. During an interview on 3/7/23 at 4:45 pm, the Administrator (ADM) stated, he thought it was by mistake that CNA 1 was assigned residents on 2/15/17. The ADM stated, the facility did not have a policy indicating the amount of training the CNAs are provided and the facility would work on developing a written plan to make sure there are no misunderstandings regarding the training to be provided. During an interview on 3/10/23 at 3:10 pm, the Director of Nurses stated, according to the LRT, the subacute competency check list should be done before the new hires are assigned residents on their own. During a concurrent record review and interview on 3/10/2023 at 3:24 pm, Registered Nurse 1 (RN 1) stated, the RNs do the staff assignment for the incoming shift. RN 1 stated, when the newly hired CNAs have completed the subacute competency check list, their names are added to the calendar and indicates they completed their training and are ready to be on their own. RN 1 stated, she would not feel comfortable having a CNA (in general) who did not complete the subacute competency skills check list, taking care of subacute residents because she would not know if they would be ready to safely care for those residents. RN 1 stated, the subacute competency check list should be completed before they are scheduled to work on their own. A review of the February 2023 schedule, RN 1 verified that CNA 1's name was written to start working on her own on 2/15/2023. During a concurrent interview and record review on 3/10/23 at 3:42 pm, the DSD stated, it was a mistake that CNA 1 was scheduled to work on her own on 2/15/2023. The DSD stated, CNA 1 was supposed to be on training on 2/15/2023. The DSD stated, her assistant and herself write the names of the newly hired staff on the calendar once they have completed their training and their competency skills check list for the SNF and the subacute unit. The competency check list was done during their orientation day and by the time they are scheduled on the floor on their own, it should be already completed. It was an honest mistake; she was not assigned to be on her own intentionally. Going forward we will be extra careful not to scheduled them on their own until they complete and sign the SNF, and subacute competency check list and they feel confident to work on their own. A review of the facility's policy and procedures titled, Sub-Acute Staff Education, Training and Evaluation Policy, revised 10/2018, indicated the sub-acute staff development program includes, but is not limited to, the following: 1. Initial skills competency of all sub-acute staff, both licensed and unlicensed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure three of 19 sampled residents (Resident 64, Resident 81, Resident 246) were provided a safe and sanitary environment by failing to store resident care equipment/supply properly in accordance with the facility policy. This failure could result in the spread of disease-causing organisms from residents to residents. Findings: a. A review of the admission Record indicated Resident 64 was originally admitted on [DATE] and readmitted last on 4/7/2020 with multiple diagnoses including chronic respiratory failure (a problem getting gases in and out of the blood), tracheostomy status (a tube inserted in the windpipe for breathing), multiple sclerosis (a potentially disabling disease of the brain and spinal cord), functional quadriplegia (complete inability to move due to severe disability or frailty) and type 2 diabetes mellitus (an adult onset characterized by high levels of sugar in the blood). A review of Resident 64's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/3/2021, indicated Resident 64 was severely impaired with cognitive skills (ability to think and reason) for daily decision making and was totally dependent with two or more person physical assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) and required two or more person physical assist with transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position) and had no indication for wheelchair use as a mobility devices. A review of Resident 64's specimen culture (a test involving taking a sample from your blood, urine, skin, or other part of your body to help find harmful bacteria in your body) report, dated 4/1/2020, timed @ 4:20 p.m., indicated Carbapenem-Resistant Enterobacteriaceae (CRE, strains of bacteria that are resistant to an antibiotic class carbapenem [used to treat severe infections]) was present in Resident 64's urine and MDRO (multidrug resistant organism, a germ that is resistant to many antibiotics) was present in Resident 64's sputum. During an observation on 12/13/2021, at 10:39 a.m., Resident 64 had a signage posted indicating Resident 64 was on transmission-based precautions (another term for isolation precautions, an added infection-control precautions in healthcare, in addition to standard precautions to help stop and/or prevent the spread of infectious agent or germs from one person to another) and a cart of personal protective equipment (PPE, equipment worn that will protect the user against health or safety risks at work) supply outside of room were observed. During a concurrent observation and interview on 12/13/2021, at 11:36 p.m., with Licensed Vocational Nurse 5 (LVN 5), in Resident 64's room, a wheelchair that had Resident 81's name on it was observed stored in the toilet room. LVN 5 stated, Resident 81 is a resident here in the facility but not occupying this room. The wheelchair should not be in Resident 64's toilet room. LVN 5 stated, Proper storage is important for infection control to prevent spread of germs of resident. A review of the facility's undated policy and procedure (P&P) titled, Equipment, indicated, Equipment will be cleaned, maintained, and replaced as needed. b. A review of the admission Record indicated Resident 246 was admitted on [DATE] with multiple diagnoses including essential hypertension (high blood pressure), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and history of falling. During a concurrent observation and interview on 12/13/2021, at 12:10 p.m., with Certified Nursing Assistant 4 (CNA 4), an empty urinal labeled with Resident 246's name was observed stored on the sink counter located inside the room across from the beds. CNA 4 stated, The urinal should be kept at bedside because this is the sink for handwashing, it should be a clean area and Resident 246 was independent. During an interview on 12/15/21, at 8:46 a.m., Infection Preventionist Nurse (IPN) stated, urinal should not be on the sink counter. IPN stated that was another infection control issue. IPN stated the urinal was considered contaminated with bodily fluid and and should have been placed on the side of the bedrail. IPN stated medical equipment should be stored in resident's own room to prevent cross contamination, for infection control. A review of the facility's undated P&P titled, Procedure: Giving and Removing Urinal, indicated to place cleaned urinal within reach of the resident. c. A review of the admission Record indicated Resident 81 was originally admitted on [DATE] and readmitted on [DATE] with multiple diagnoses including chronic respiratory failure (a problem getting gases in and out of the blood), tracheostomy status (a tube inserted in the windpipe for breathing), cerebrovascular disease (a stroke, damage to the brain from interruption of its blood supply) and epilepsy (a general term for conditions with recurring seizures). A review of Resident 81's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/10/2021, indicated Resident 81 was moderately impaired with cognitive skills (ability to think and reason) for daily decision making and required extensive assistance with two or more person physical assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) and required total dependence with two or more people with transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position) and indicated for walker and wheelchair for mobility devices. During a concurrent observation and interview on 12/13/2021, at 11:36 p.m., with Licensed Vocational Nurse 5 (LVN 5), in Resident 64's room, a wheelchair that had Resident 81's name on it was observed stored in the toilet room. LVN 5 stated, Resident 81 is a resident here in the facility but not occupying this room. The wheelchair should not be in Resident 64's toilet room. LVN 5 stated, Proper storage is important for infection control to prevent spread of germs of resident. A review of the facility's undated policy and procedure (P&P) titled, Equipment, indicated, Equipment will be cleaned, maintained, and replaced as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive, resident specific plan of care for two of 19 sampled residents (Residents 26 and 76). a. Resident 76 did not have a plan of care for contact isolation (is the state of being in a place or situation that is separate from others) for Clostridium difficile (C-diff a bacterium that causes an infection of the large intestine [colon]) as indicated in the physician's order and facility policy. b. Resident 26 did not have a plan of care for the use of Xarelto (a medication used as blood thinner). These deficient practices had the potential for the residents not to receive the care and services needed which could lead to a decline in their wellbeing or maintain their highest potentials. Findings: a. A review of Resident 76's admission Record indicated Resident 76 was admitted to the facility on [DATE]. Resident 76's diagnoses included enterocolitis (an inflammation that occurs in a person's digestive tract [gastrointestinal tract - is a long twisting tube that starts at the mouth and ends at the anus]) due to C - diff and hypertension (high blood pressure). A review of Resident 76's History and Physical (H&P) dated 11/9/2021, indicated Resident 76 did not have the capacity to understand and made medical decisions. A review of Resident 76's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 11/11/2021, indicated Resident 76's brief interview of mental status (BIMS, screening that aids in detecting cognitive impairment) score was 2 (a score of 0 - 7 represents severe impaired cognition [mental action or process of acquiring knowledge and understanding]). The MDS also indicated Resident 76 was totally dependent from staff for bed mobility, transfer, dressing, toilet use and personal hygiene. A review of Resident 76's Physician order, dated 11/23/2021, indicated to place Resident 76 on contact isolation precaution for C-diff. During a concurrent record review on 12/14/2021 at 2:28 pm, and an interview with Registered Nurse 1 (RN 1) stated, Resident 76 was on contact isolation precaution for C-diff and did not have a plan of care developed and implemented. RN 1 stated it was important to have developed and implemented a plan of care to be able to know what interventions to do for the particular resident. During an interview on 12/14/2021 at 3:47 pm, Director of Nursing (DON) stated it was important to develop and implement a plan of care for staff to be able to know how to take care the residents based on the nursing interventions. A review of the, Policy and Procedure (P&P) titled, The Resident Care Plan, dated 12//2016, indicated that the resident care plan shall be implemented for each resident on admission, and developed throughout the assessment process. It is the responsibility of the Licensed Nurse to ensure that the plan of care is initiated and evaluated. b. A review of Resident 26's admission Record, indicated, Resident 26 was originally admitted on [DATE] and readmitted last on 8/23/2021 with multiple diagnoses including dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), type 2 diabetes mellitus (an adult onset characterized by high levels of sugar in the blood) and other specified peripheral vascular diseases (a blood circulation disorder that causes the blood vessels outside of your heart and brain to narrow, block, or spasm). A review of Resident 26's MDS, dated [DATE], indicated, Resident 26 was severely impaired with cognitive skills (ability to think and reason) for daily decision making and was totally dependent with two persons physical assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) and transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position). A review of Resident 26's Physician Order Summary Report (OSR), dated 12/15/2021, indicated, Resident 26 had an order for Xarelto Tablet 10 mg (Rivaroxaban) Give 1 tablet via G-tube (gastrostomy tube, a feeding tube inserted through the belly that brings nutrition and/or medications directly to the stomach) one time a day for DVT PROHYLAXIS (measures taken to prevent deep vein thrombosis, the formation or presence of a thrombus or blood clot in the deep veins) and to monitor for discolored urine, black tarry stools, sudden severe headache, N&V (nausea & vomiting), diarrhea, muscle/joint pain, lethargy (sluggishness), bruising, sudden changes in mental status and/or vital signs, SOB (short of breath), bleeding in any orifice (an opening), abnormal lab. Document: 'N' if monitored and none of the above observed. Document 'Y' if monitored and any of the above observed, notify MD (physician) & document in nurses' progress notes every shift for Xarelto use. A review of Resident 26's Medication Administration Record (MAR), for November 2021, indicated, Resident 26 was administered Xarelto as ordered. During a concurrent interview and record review, on 12/15/2021, at 3:09 pm, with Registered Nurse (RN) 2, Resident 26's physician orders and care plans were reviewed. RN 2 stated, Resident 26 was on Xarelto and did not see any care plan for it. RN 2 stated, care plan specific to Xarelto is important to monitor the adverse reaction effects of Xarelto, if it's effective or not, the plan of care is based on the nursing interventions. A review of the facility's undated P&P titled, The Resident Care Plan, indicated, The resident care plan shall be implemented for each resident on admission and developed throughout the assessment process. One of the steps to providing an individualized nursing care plan and to promote continuity of resident care is to record the procedures directly ordered by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to refer one of 19 sampled residents (Resident 21) to an audiologist (a physician who evaluates hearing disorders) for the need of a hearing device (a device used to improve hearing). Resident 21 did not receive an Audiology consultation in accordance with the physician's order. This deficient practice had the potential to result in increased hearing loss, difficulty with communication and decline in Resident 21's quality of life. Findings: A review of Resident 21's admission Record, indicated Resident 21 was originally admitted on [DATE] and readmitted last on 2/22/2020 with multiple diagnoses including essential (primary) hypertension (high blood pressure), [NAME]-[NAME] syndrome (a rare, serious disorder of the skin and mucous membranes) and unspecified hearing loss, unspecified ear. A review of Resident 21's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/2/2021, indicated Resident 21 had no impairment with cognitive skills (ability to think and reason) for daily decision making and required limited assistance with one person physical assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) and extensive assistance with one person physical assist for transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position). A review of the facility's record of Optometry Visit, dated 11/29/21, indicated, Resident 21 was seen by the optometrist. A review of Resident 21's Optometric Consultation, record, dated 11/29/21, indicated, Resident 21 needed readers and liked to read her books. A review of Resident 21's Otolaryngology/ENT, record, dated 7/12/21, indicated Resident 21 had hearing loss. During a concurrent observation and interview on 12/13/2021, at 2:34 pm, with Resident 21, in her room, Resident 21 was observed sitting up in a wheelchair next to the window and gesturing she could not see well and could not hear well pointing to her right ear. Resident 21 was observed to have a pair of eyeglasses hanging around her neck. Resident 21 stated, no good, referring to her eyeglasses. A communication board instructions/objects, was observed posted across from the bed. During a concurrent observation and interview on 12/15/2021, at 10:18 am, with Certified ursing Assistant 5 (CNA 5), Resident 21 was observed sitting in a wheelchair by the door in her room gesturing could not see far and could not hear well. CNA 5 stated Resident 21 can't really see well but when she wants something, she's able to tell me what she needs. She has glasses, no hearing aids. During a concurrent interview and record review on 12/15/2021, at 12:37 pm, with Social Services Director (SSD 2), Resident 21's Order Summary Report (OSR) was reviewed. The OSR indicated orders included an Audiology consult prn (as needed) for hearing problems and Eye health and vision consult with follow up treatment as indicated. SSD 2 stated Resident 21 was seen by Optometrist (takes care of primary health care for the eye) on 11/29/2021 and her reader glasses were on back order. SSD 2 stated Resident 21 had hearing loss, had an order for an audio consult on 2/22/2020 and no documentation indicating an audio consult was done. SSD 2 stated,our audio person passed, facility is still looking for one. SSD 2 stated it was important for Resident 21 to have her audiology consult done to check for hearing cuz it's part of her living, affects her quality of life. She doesn't have hearing aids and the ENT (ear, nose, throat) doctor does not do the audio consult.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document specific indication for psychotropic (any medication capable of affecting the mind, emotions, and behavior) drug for one of five sampled residents (Residents 80) as indicated on the facility policy. This deficient practice had the potential to result in the use of unnecessary psychotropic drug, which may result in significant adverse (harmful) consequences to the residents. Findings: A review of Resident 80's admission Record indicated Resident 80 was admitted to the facility on [DATE]. Resident 80's diagnoses included schizophrenia ([serious mental disorder in which people interpret reality abnormally) and major depressive disorder (mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts). A review of Resident 80's Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 11/14/2021 indicated Resident 80's brief interview of mental status (BIMS, screening that aids in detecting cognitive impairment) score was 5 (a score of 0 - 7 represents severe impaired cognition [mental action or process of acquiring knowledge and understanding]). The MDS also indicated Resident 80 was totally dependent from staff for transfer, dressing, toilet use and personal hygiene. A review of Resident 80's Physician Order Sheet dated 12/2/2021, indicated to give Seroquel tablet 25 milligram (mg) (antipsychotic medication - drugs that are used to treat symptoms of psychosis such as delusions (for example, hearing voices), hallucinations, paranoia, or confused thoughts), one tablet was to be given by mouth at bedtime for agitation manifested by aggressiveness or hitting staff. During a concurrent record review on 12/15/2021 at 9:43 am and interview with Registered Nurse 2 (RN 2) stated, Resident 80 was on Seroquel tablet for agitation manifested by aggressiveness or hitting staff. RN 2 stated agitation was not a diagnosis or indication for Seroquel. During an interview on 12/15/2021 at 12:12 pm, Director of Nursing (DON) stated agitation was not a diagnosis or indication for residents receiving psychotropic medication. DON stated that staff were not supposed to give psychotropic medication for agitation. DON stated that based on facilities policy and procedure, agitation was not a specific diagnosis. A review of facility's policy and procedure titled Psychotherapeutic Medications dated 2/25/2021, indicated a specific diagnosis, and a specific behavior or thought process justifying the need for psychotherapeutic medications are to be identified in the resident's health record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to ensure the opened (in-use) Basaglar KwikPen insulin (Insulin Glargine - long-acting insulin- a hormone that works by lowering levels of sugar in the blood) was marked with the date opened as indicated in the facility policy. This deficient practice had the potential to result in the loss of efficacy of the Basaglar KwikPen insulin. Finding: A review of Resident 296's admission Record indicated Resident 296 was admitted to the facility on [DATE]. Resident 296's diagnoses included diabetes mellitus (a condition that affects the way the body processes blood sugar) and weakness. A review of Resident 296's History and Physical (H&P) dated 12/3/2021, indicated Resident 296 had the capacity to understand and made decisions. A review of Resident 296's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 12/7/2021, indicated Resident 296's brief interview of mental status (BIMS, screening that aids in detecting cognitive impairment) score was 14 (a score of 13 - 15 represents intact cognition [mental action or process of acquiring knowledge and understanding]). The MDS indicated Resident 296 needed limited assistance from staff for bed mobility, transfer, dressing, toilet use and personal hygiene. A review of Resident 296's Physician Order, dated 12/10/2021, indicated to inject Basaglar KwikPen 40 units subcutaneously (administering medication where a short needle is used to inject a medication into the tissue layer between the skin and the muscle) at bedtime for diabetes mellitus. During a medication cart observation on 12/15/2021, at 9:14 am, together with Licensed Vocational Nurse 1 (LVN 1), upon inspection one Basalgar KwikPen was opened but not dated as to when it was first used. During an interview on 12/15/2021 at 9:57 am, LVN 1 stated Resident 296's Basalgar KwikPen was not dated as to when was it opened. LVN 1 stated it was important to label the medications with an open date in order to know the medication was still effective. LVN 1 stated that based on the facility's policy, every medication should be labeled with open dates. During an interview on 12/15/2021 at 4:35 pm, the Director of Nursing (DON), stated based on the facility's policy medications should be labeled with date open. DON also stated that the efficacy and potency of the medication will be affected for Insulin will expire in 28 to 30 days based on the facility policy. A review of the facility's Policy and Procedure (P&P) titled, Medications with Special Expiration Dates, dated 6/2006, indicated each time a medication was opened, sign and date, then check expiration date each time medication is administered. P&P also indicated for insulin injection, once opened, it would expire in 30 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete and electronically transmit the Discharge Resident Assessment timely to Centers for Medicaid and Medicare (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system for three of three sampled residents (Residents 2, 3 and 4). This deficient practice had the potential to affect the facility's quality monitoring data at transition points, such as when residents enter or leave the nursing home. This also had the potential for residents not to be reassessed accurately and receive the necessary care if and when readmitted to the facility. Findings: a. A review of the admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included urinary tract infection ( presence of bacteria in the bladder, urethra, ureter and kidney) and the resident was discharged to home on 7/22/2021. A review of the Minimum Data Set (MDS) a resident assessment and care screening tool, dated 6/28/2021, indicated Resident 2 had moderate memory and cognitive (ability to reason). Resident 2 had no documented evidence the MDS was completed when the resident was discharged from the facility on 7/22/2021. b. A review of the admission Record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses that included benign neoplasm of the meninges (abnormal cell growth in the brain cells) and the resident was discharged to home on 9/9/2021. A review of the MDS, dated [DATE], indicated Resident 3 had no memory and cognitive impairment. Resident 3 had no documented evidence the MDS was completed when the resident was discharged from the facility on 9/9/2021. c. A review of the admission Record indicated Resident 4 was admitted to the facility on [DATE], with diagnoses that included partial traumatic amputation of the right breast (surgical removal of the right breast) and the resident was discharged to home on 8/30/2021. A review of the MDS, dated [DATE], indicated Resident 4 had no memory and cognitive (ability to reason). Resident 4 had no documented evidence the MDS was completed when the resident was discharged from the facility on 8/30/2021. During a concurrent record review of Residents 2, 3, and 4's clinical record and interview with MDS Nurse on 12/15/2021 at 10:43 am, the MDS Nurse stated Residents 2, 3 and 4 were discharged from the facility without an indication that the discharge assessment was completed and transmitted to the CMS data base. During an interview on 12/15/21 at 11:16 am, MDS Nurse stated while she was on leave from work from June 2021 to November 2021, another MDS Nurse was in charge of completing and transmitting the MDS to the CMS data base. MDS Nurse stated she does not know why the Discharge MDS assessment was not completed and transmitted for Residents 2, 3 and 4. MDS Nurse stated it was important to complete and transmit the MDS assessment to see if there was any improvement, change or decline in resident's condition so that the plan of care can be revised if needed. A review of the MDS Resident Assessment Instrument (RAI) user's manual, indicated that all Medicare and/or Medicaid-certified nursing homes and swing beds, or agents of those facilities, must transmit required MDS data records to CMS QIES ASAP system. Discharge MDS assessments are to be completed 14 calendar days after the discharge date and transmitted 14 days after MDS completion date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to ensure the Low Air Loss Mattress (LALM, a mattress that has small air holes in its top surface which continually blow out air causing the patient to float which reduces skin pressure at the mattress surface) were set at the correct setting for four of four sampled residents (Resident 65, 70, 84, and 85). a. Resident 65's LAL mattress pump was set to level four instead of the correct setting of level three. b. Resident 70's LAL mattress pump was set on a level of seven instead of the correct setting of level two. b. Resident 84's LAL mattress was set to firm instead of setting of three. c. Resident 85's LAL mattress was set to setting three instead of setting two. These deficient practices placed the residents at risk for developing pressure injuries (PI, injuries to the skin and underlying tissue resulting from prolonged pressure on the skin). Findings: a. A review of Resident 65's admission Record indicated Resident 65 was originally admitted on [DATE] and readmitted on [DATE] with multiple diagnoses including functional quadriplegia (complete inability to move due to severe disability or frailty); cerebral infarction (also known as a stroke refers to damage to tissues in the brain due to a loss of oxygen or blood flow to the area) and contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff). A review of Resident 65's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/31/2021, indicated Resident 65 was severely impaired with cognitive skills (ability to think and reason) for daily decision making and was totally dependent with two persons physical assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) and transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position) and was at risk of developing pressure ulcer/injuries requiring pressure reducing device for bed. A review of Resident 65's Physician Order Summary Report (OSR), dated 12/15/21, indicated for Resident 65 to have a LAL mattress for wound healing and skin maintenance. A review of Resident 65's Weights and Vitals Summary (WVS), from 6/1/21 to 12/31/21, indicated, Resident 65's latest weight was 143 pounds (lbs.) on 12/13/21, with weights ranging from 143-150 lbs. from 6/7/21 to 12/13/21. During an initial tour observation on 12/13/2021, at 3:24 pm, Resident 65 was observed lying on a LAL mattress on her back. The LAL mattress pump was observed to have a label 3, posted and the setting was on therapy mode and set on level 4, the light on. During a concurrent observation and interview on 12/13/21, at 3:48 p.m., with Licensed Vocational Nurse 9 (LVN 9), Resident 65's LAL mattress pump was observed to have a label 3 posted and the setting was on therapy mode and set on level 4, the light on. LVN 9 stated, the setting was the amount of pressure. During a concurrent interview and record review on 12/15/2021, at 8 am, with LVN 6, a copy of the undated DermaFloat LAL/TXCair (Low Air Loss) Model: Comfort Adjust Setting guidelines was reviewed. The guidelines indicated comfort setting based on weight with (8) LED light adjustment settings from soft to firm as follow: Firmest Setting=LED Light (8)=440 lbs (pounds) to 500 lbs LED Light (7)=375 lbs to 440 lbs LED Light (6)=315 lbs to 375 lbs LED Light (5)=250 lbs to 315 lbs LED Light (4)=185 lbs to 250 lbs LED Light (3)=125 lbs to 185 lbs LED Light (2)=60 lbs to 125 lbs Softest Setting=LED Light (1)=0 lbs to 60 lbs LVN 6 stated, LAL mattress is programmed to prevent any skin breakdown, it goes by weight, and stated the number posted on the pump indicate depending how much pressure it's gonna need, depending on the weight of the patient. LVN 6 stated the number went from 2 to 8 and the row of dots indicated the setting starting at number 2 for soft to number 8 for firm. LVN 6 stated the number label posted on the pump should correlate with the dot (light) that was on, set and if setting was not correct, it may cause skin breakdown. A review of the facility's undated P&P titled, Pressure-Reducing Mattress, indicated, the objective is To provide mattresses that will prevent and/or minimize pressure on the skin. b. A review of Resident 70's admission Record indicated Resident 70 was originally admitted on [DATE] and readmitted on [DATE] with multiple diagnoses including unspecified dementia without behavioral disturbance (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems); unspecified sequelae of unspecified cerebrovascular disease (a group of conditions, including stroke that affect blood flow and the blood vessels in the brain) and type 2 diabetes mellitus (an adult onset characterized by high levels of sugar in the blood). A review of Resident 70's MDS indicated Resident 70 was severely impaired with cognitive skills (ability to think and reason) for daily decision making and was totally dependent with one person physical assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) and required two+ persons physical assist with transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position) and is at risk of developing pressure ulcer/injuries requiring pressure reducing device for bed. A review of Resident 70's OSR indicated Resident 70 for a LAL mattress for wound care and management. A review of Resident 70's WVS, from 6/1/21 to 12/31/21, indicated, Resident 70's latest weight was 116 lbs. on 12/13/21, with weights ranging from 115-118 lbs. from 6/7/21 to 12/13/21. During an observation on 12/13/21, at 3:39 pm, Resident 70 was observed lying on a LAL mattress slightly on her right side. The LAL mattress pump was observed to have a label 2 posted and the setting was on therapy mode and set on level 7, the light on. During a concurrent observation and interview on 12/13/2021, at 3:48 pm, LVN 9 stated Resident 70's LAL mattress pump was observed to have a label 2 posted and the setting was on therapy mode and set on level 7, the light on. LVN 9 stated, the setting is the amount of pressure. During a concurrent interview and record review on 12/15/2021, at 8 am, with LVN 6, a copy of the undated DermaFloat LAL/TXCair (Low Air Loss) Model: Comfort Adjust Setting guidelines was reviewed. The guidelines indicated comfort setting based on weight with (8) LED light adjustment settings from soft to firm as follow: Firmest Setting=LED Light (8)=440 lbs (pounds) to 500 lbs LED Light (7)=375 lbs to 440 lbs LED Light (6)=315 lbs to 375 lbs LED Light (5)=250 lbs to 315 lbs LED Light (4)=185 lbs to 250 lbs LED Light (3)=125 lbs to 185 lbs LED Light (2)=60 lbs to 125 lbs Softest Setting=LED Light (1)=0 lbs to 60 lbs LVN 6 stated LAL mattress is programmed to prevent any skin breakdown, it goes by weight and the number posted on the pump indicate depending how much pressure it's gonna need, depending on the weight of the patient. LVN 6 stated, the number goes from 2 to 8 and the row of dots indicate the setting starting at number 2 for soft to number 8 for firm. LVN 6 stated, the number label posted on the pump should correlate with the dot (light) that's on, set and if setting is not correct, it may cause skin breakdown. A review of the facility's undated P&P titled, Pressure-Reducing Mattress, indicated, the objective is To provide mattresses that will prevent and/or minimize pressure on the skin. c. A review of Resident 84's admission Record indicated Resident 84 was admitted to the facility on [DATE]. Resident 84's diagnoses included chronic respiratory failure (a condition that develops over a long period of time in which the lungs have a problem getting gases, such as oxygen and carbon dioxide, in and out of the blood), quadriplegia (partial or complete paralysis of both the arms and legs that is usually due to injury or disease of the spinal cord in the region of the neck), pressure ulcer of left and right buttock (injuries to skin and underlying tissue resulting from prolonged pressure on the skin). A review of Resident 84's MDS dated [DATE], indicated cognitive (thinking and memory) skills for daily decision making was severely impaired. The MDS also indicated Resident 84 required total dependence from staff for bed mobility, dressing, toilet use, and personal hygiene. A review of Resident 84's Low Air Loss Mattress Care Plan, revised 11/24/2020, the care plan indicated the intervention was to ensure LAL mattress are inflated and recommended. A review of Resident 84's Order Summary Report, dated 12/14/2021, the order indicated a Low Air Loss Mattress for wound care and management was ordered on 2/1/2020. During a concurrent observation and interview on 12/13/2021 at 11:45 am LVN 5 in Resident 84's room, Resident 84's LALM setting was set to three. LVN 5 stated mattress should be set to three as indicated on machine but LALM machine was set to eight which was the most-firm setting. LVN 5 changed the LALM setting to three. LVN 5 stated the treatment nurse checks the machine for correct setting every day. During an interview on 12/13/2021 at 12:35 PM with LVN 6, LVN 6 stated she checked the LALM machine setting every morning. LVN 6 stated the machine setting could change when the resident was repositioned. LVN 6 stated when a resident was repositioned, she would follow up with the resident and check to make sure the LALM would set to the correct setting. LVN 6 stated she usually checked them every two hours. For Resident 84, the LALM setting was set to firm. LVN 6 stated this could result in Resident 84 developing a pressure injury. During an interview on 12/15/2021 at 8:08 am, LVN 6 stated the numbers on the LALM pump would indicate the setting on the machine according to the resident's weight. LVN 6 stated an incorrect LALM setting could make the mattress too firm leading to the resident at risk to sustain a fall and could cause the resident to have skin breakdown. A review of the Policy and Procedure (P&P), titled, Pressure-Reducing Mattresses, undated, P&P indicated the Objective: To provide mattresses that will prevent and/or minimize pressure on the skin. d. A review of Resident 85's admission Record indicated Resident 85 was admitted to the facility on [DATE]. Resident 85's diagnosis included orthopedic aftercare following surgical amputation (surgical removal of all or part of a limb or extremity such as an arm, leg, foot, hand, toe, or finger), abnormality of gait and mobility (gait is defined as a person's manner of walking). A review of Resident 85's History and Physical (H&P, the initial clinical evaluation and examination of the patient), dated 5/8/2021, the H&P indicated Resident 85 does not have the capacity to understand and make decisions. A review of Resident 85's MDS dated [DATE], indicated cognitive (thinking and memory) skills for daily decision making was severely impaired. The MDS indicated Resident 85 required total dependence from staff for bed mobility, dressing, toilet use, and personal hygiene. A review of Resident 85's Order Summary Report, dated 12/14/2021, the order indicated a Low Air Loss Mattress for wound healing and skin maintenance was ordered on 5/7/2021. During a concurrent observation and interview on 12/13/2021 at 3:43 pm, with LVN 8 in Resident 85's room, Resident 85's LALM was set to three but the LALM pump machine indicated the setting should be two. LVN 8 stated the LALM pump machine setting was not locked. LVN 8 stated she checked the setting every morning and the machine setting should not change even with repositioning of Resident 85. LVN 8 stated an incorrect setting could put Resident 85 at risk for a fall and for skin breakdown. A review of the Policy and Procedure (P&P), titled, Pressure-Reducing Mattresses, undated, P&P indicated the Objective: To provide mattresses that will prevent and/or minimize pressure on the skin. d. A review of Resident 65's admission Record indicated, Resident 65 was originally admitted on [DATE] and readmitted last on 2/2/2020 with multiple diagnoses including functional quadriplegia (complete inability to move due to severe disability or frailty); cerebral infarction (also known as a stroke refers to damage to tissues in the brain due to a loss of oxygen or blood flow to the area) and contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff). A review of Resident 65's MDS dated [DATE], indicated Resident 65 was severely impaired with cognitive skills (ability to think and reason) for daily decision making and was totally dependent with two+ persons physical assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) and transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position) and was at risk of developing pressure ulcer/injuries requiring pressure reducing device for bed. A review of Resident 65's Physician Order Summary Report (OSR), dated 12/15/21, indicated Resident 65 may have LAL mattress for wound healing and skin maintenance. A review of Resident 65's Weights and Vitals Summary (WVS), from 6/1/21 to 12/31/21, indicated, Resident 65's latest weight was 143 lbs. on 12/13/21, with weights ranging from 143-150 lbs. from 6/7/21 to 12/13/21. During an initial tour observation on 12/13/2021, at 3:24 pm, Resident 65 was observed lying on a LAL mattress on her back. The LAL mattress pump was observed to have a label 3 posted and the setting was on therapy mode and set on level 4, the light on. During a concurrent observation and interview on 12/13/21, at 3:48 pm, LVN 9, Resident 65's LAL mattress pump was observed to have a label 3 posted and the setting was on therapy mode and set on level 4, the light on. LVN 9 stated, the setting is the amount of pressure. During a concurrent interview and record review on 12/15/2021, at 8 am, with LVN 6, a copy of the undated DermaFloat LAL/TXCair (Low Air Loss) Model: Comfort Adjust Setting guidelines was reviewed. The guidelines indicated comfort setting based on weight with (8) LED light adjustment settings from soft to firm as follow: Firmest Setting=LED Light (8)=440 lbs (pounds) to 500 lbs LED Light (7)=375 lbs to 440 lbs LED Light (6)=315 lbs to 375 lbs LED Light (5)=250 lbs to 315 lbs LED Light (4)=185 lbs to 250 lbs LED Light (3)=125 lbs to 185 lbs LED Light (2)=60 lbs to 125 lbs Softest Setting=LED Light (1)=0 lbs to 60 lbs LVN 6 stated, LAL mattress is programmed to prevent any skin breakdown, it goes by weight and the number posted on the pump indicate depending how much pressure it's gonna need, depending on the weight of the patient. LVN 6 stated the number went from 2 to 8 and the row of dots indicated the setting starting at number 2 for soft to number 8 for firm. LVN 6 stated, the number label posted on the pump should correlate with the dot (light) that's on, set and if setting is not correct, it may cause skin breakdown. A review of the facility's undated P&P titled, Pressure-Reducing Mattress, indicated, the objective is To provide mattresses that will prevent and/or minimize pressure on the skin. b. A review of Resident 70's admission Record indicated Resident 70 was originally admitted on [DATE] and readmitted last on 6/18/2019 with multiple diagnoses including unspecified dementia without behavioral disturbance (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems); unspecified sequelae of unspecified cerebrovascular disease (a group of conditions, including stroke that affect blood flow and the blood vessels in the brain) and type 2 diabetes mellitus (an adult onset characterized by high levels of sugar in the blood). A review of Resident 70's MDS indicated Resident 70 was severely impaired with cognitive skills (ability to think and reason) for daily decision making and was totally dependent with one person physical assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) and required two+ persons physical assist with transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position) and is at risk of developing pressure ulcer/injuries requiring pressure reducing device for bed. A review of Resident 70's OSR, indicated, Resident 70 for a LAL mattress for wound care and management. A review of Resident 70's WVS, from 6/1/21 to 12/31/21, indicated, Resident 70's latest weight was 116 lbs. on 12/13/21, with weights ranging from 115-118 lbs. from 6/7/21 to 12/13/21. During an observation on 12/13/21, at 3:39 pm, Resident 70 was observed lying on a LAL mattress slightly on her right side. The LAL mattress pump was observed to have a label 2 posted and the setting was on therapy mode and set on level 7, the light on. During a concurrent observation and interview on 12/13/21, at 3:48 p.m., with LVN 9, Resident 70's LAL mattress pump was observed to have a label 2 posted and the setting was on therapy mode and set on level 7, the light on. LVN 9 stated the setting was the amount of pressure. During a concurrent interview and record review on 12/15/2021, at 8 am, with LVN 6, a copy of the undated DermaFloat LAL/TXCair (Low Air Loss) Model: Comfort Adjust Setting guidelines was reviewed. The guidelines indicated comfort setting based on weight with (8) LED light adjustment settings from soft to firm as follow: Firmest Setting=LED Light (8)=440 lbs (pounds) to 500 lbs LED Light (7)=375 lbs to 440 lbs LED Light (6)=315 lbs to 375 lbs LED Light (5)=250 lbs to 315 lbs LED Light (4)=185 lbs to 250 lbs LED Light (3)=125 lbs to 185 lbs LED Light (2)=60 lbs to 125 lbs Softest Setting=LED Light (1)=0 lbs to 60 lbs LVN 6 stated, LAL mattress is programmed to prevent any skin breakdown, it goes by weight and the number posted on the pump indicate depending how much pressure it's gonna need, depending on the weight of the patient. LVN 6 stated, the number goes from 2 to 8 and the row of dots indicate the setting starting at number 2 for soft to number 8 for firm. LVN 6 stated, the number label posted on the pump should correlate with the dot (light) that's on, set and if setting is not correct, it may cause skin breakdown. A review of the facility's undated P&P titled, Pressure-Reducing Mattress, indicated, the objective is To provide mattresses that will prevent and/or minimize pressure on the skin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide four of five sampled residents (Resident 5, 57, 65, and 74) with contractures (permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff, this prevents normal movement of a joint or other body part), the appropriate treatment and services to increase and/or prevent further decrease in range of motion (ROM, how far a person can move or stretch a part of the body, such as a joint or a muscle). a. For Resident 5, the facility did not provide ROM exercises, and did not apply splints (a firm material used for supporting and immobilizing a broken bone), to both of the resident's hands and right elbow. b. For Resident 57, the facility staff did not apply a hand splint to the resident's left hand. c. For Resident 74, the facility staff failed to apply left elbow splint. d. For Resident 65, the facility staff failed to provide ROM exercises. This failure had the potential for the residents to experience a decline in ROM and worsening of contractures. Findings: a. A review of Resident 5's admission Record indicated Resident 5 was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses including chronic respiratory failure (a condition that develops over a long period of time in which the lungs have a problem getting gases, such as oxygen and carbon dioxide, in and out of the blood), quadriplegia (partial or complete paralysis of both the arms and legs that is usually due to injury or disease of the spinal cord in the region of the neck), and contractures of the right and left elbow, and right and left hands. A review of the plan of care, titled Resident has self-care deficit: Bed Mobility . initiated on 11/21/2021 and revised on 11/21/2021 indicated Resident 5 was to receive Restorative Nursing Assistant (RNA, nursing aide program that helps residents maintain their function and joint mobility) services as ordered: Passive Range of Motion (PROM, amount of motion at a given joint when the joint is moved by an external force or by a therapist), exercises to both upper extremities every day seven times a week as tolerated; both hand splints and right elbow splint every day seven times a week, four to six hours or as tolerated. A review of Resident 5's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/26/2021, indicated the resident's cognitive (thinking and memory) skills for daily decision making was severely impaired. The MDS indicated Resident 5 required total dependence from staff for bed mobility, dressing, toilet use, and personal hygiene. During an interview on 12/15/2021 at 3:32 pm, the Director of Rehabilitation Department (DOR), stated contractures were very common in the resident population in Sub-Acute Unit which was the unit where Resident 5 resided. DOR stated it was almost impossible to prevent contractures in these types of residents. DOR stated the application of splints would lead to skin breakdown. DOR stated ROM exercises were the only thing that could be done. During an interview on 12/16/21 at 8:30 am, Restorative Nurse Assistant 1 (RNA 1) stated Resident 5 received ROM exercises to both arms and splints to both hands and a splint to the left elbow in the past, however, RNA 1 did not see the resident's name on the current list of residents to receive ROM exercises. During a concurrent interview and record review on 12/16/2021 at 10:46 am with Minimum Data Set Nurse 1 (MDS 1) stated Resident 5 received ROM exercises and hand and elbow splints from 4/24/2021 to 7/7/2021 according to the Point of Care Audit Report, dated 12/16/2021, but had not received ROM or splint placement from RNA since July 2021 to present. MDS 1 stated Resident 5 should have received ROM exercises and splint placement to help prevent contractures which could result in pain. During an interview on 12/16/2021 on 3:48 pm, Occupational Therapist (OT), stated doctor's order for splints were dropped from the orders list when a resident was re-admitted . OT stated when the residents were readmitted to the facility, he reassessed the resident and placed an order for RNA services for ROM automatically. OT stated an order for splints was not placed until the splints were found and then he would submit the order for splint placement. OT stated splint orders were based on the availability of the splints themselves. OT stated 30-day rehabilitation assessments should be conducted but sometimes they were not done due to a back-up of workload. OT stated Resident's 5 readmission screening may not have been done due to back up of workload. OT stated Resident 5 should have been receiving splints and ROM according to the resident's care plan. A review of the facility's Policy and Procedure (P&P), titled, Rehabilitation Services, undated, P&P indicated the Purpose: Skilled Rehabilitation Services shall be made available to residents in order to promote recovery, improve and maintain functional independence, and prevent any further decline. P&P further indicated Each resident is to be screened by the Rehab Team on admission, and as requested by nursing to determine resident's functional changes and potential for rehabilitation. The P&P further indicated the plan of care shall be reviewed at regular intervals, not to exceed 30 days, by the physician and therapist. Each thirty-day review shall be documented by the therapist in the resident's chart. b. A review of Resident 57's admission Record indicated Resident 57 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic respiratory failure (a condition that develops over a long period of time in which the lungs have a problem getting gases, such as oxygen and carbon dioxide, in and out of the blood), and quadriplegia (partial or complete paralysis of both the arms and legs that is usually due to injury or disease of the spinal cord in the region of the neck). A review of Resident 57's plan of care, titled Alteration in joint mobility as evidenced by limitations noted to bilateral (both) upper and lower extremities ., revised on 8/8/2021, indicated nursing staff should position Resident 57 to prevent further contractures with pillow or splints as needed. Bilateral hand splints every day seven times a week, four to six hours a day as tolerated. A review of Resident 57's MDS, dated [DATE], indicated the resident's cognitive (thinking and memory) skills for daily decision making was severely impaired. The MDS indicated Resident 57 required total dependence from staff for bed mobility, dressing, toilet use, and personal hygiene. A review of the physician order dated 12/13/2021 indicated Resident 57 was to receive RNA for Passive ROM exercises on both arms, followed by application of left hand splint and right hand roll every day six times a week for four to six hours a day or as tolerated. During an observation on 12/13/2021 at 2:37 pm, Resident 57 had contractures to both upper arms and hands and no splints present to both arms and hands. During an observation on 12/14/2021 at 9:16 am, Resident 57 did not have any splints in place to both arms and hands. During an observation on 12/15/2021 at 9:57 am, Resident 57 was not wearing a splint to left arm. During a concurrent observation and interview on 12/15/2021 at 1:43 pm, with Certified Nurse Assistant 3 (CNA 3) in Resident 57's room, Resident 57 did not have an elbow splint in place on his left arm. CNA 3 stated she floated from another unit and she was not familiar with the resident. CNA 3 stated she provided ROM services but she was assigned to CNA duties today. CNA 3 stated she had not provided ROM or placed a splint for Resident 57 today. During an interview on 12/15/2021 at 1:46 pm with Licensed Vocational Nurse 4 (LVN 4) stated there was no order for splints for Resident 57, then LVN 4 looked in the computer and saw there was an order for splints for Resident 57. c. A review of Resident 74's admission Record indicated Resident 74 was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE]. Resident 74's diagnoses included chronic respiratory failure (a condition that develops over a long period of time in which the lungs have a problem getting gases, such as oxygen and carbon dioxide, in and out of the blood), and quadriplegia (partial or complete paralysis of both the arms and legs that is usually due to injury or disease of the spinal cord in the region of the neck). A review of the physician order dated 10/16/2020 indicated Resident 74 was to receive RNA for Passive ROM exercises on both arms and both legs every day seven times a week as tolerated. A review of the plan of care, titled Resident has self-care deficits: Bed Mobility: ., revised on 5/21/2021, indicated RNA as ordered: apply left elbow splint every day seven times a week for four to six hours or as tolerated; passive ROM exercises seven times a week to both upper and lower extremities every day; apply left hand and right hand splints every day seven times a week for four to six hours or as tolerated. A review of Resident 74's MDS dated [DATE], indicated cognitive (thinking and memory) skills for daily decision making was severely impaired. The MDS indicated Resident 74 required total dependence from staff for bed mobility, dressing, toilet use, and personal hygiene. During an observation on 12/13/2021 at 9:56 am, Resident 74 was lying on his right side with a contracture to left arm with no presence of a splint in the room. During an interview on 12/14/2021 at 8:58 am, LVN 2 stated Resident 74 had an order for ROM exercises but not for splint placement. During an observation on 12/14/2021 at 11:25 am, Resident 74 had contractures noted to both arms and hands. No splints noted in Resident 74's room. c. A review of Resident 65's admission Record (AR), indicated, Resident 65 was originally admitted on [DATE] and readmitted last on 2/2/2020 with multiple diagnoses including functional quadriplegia (complete inability to move due to severe disability or frailty); cerebral infarction (also known as a stroke refers to damage to tissues in the brain due to a loss of oxygen or blood flow to the area) and contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff). A review of Resident 65's Restorative Nursing Weekly Summary, dated March 2020, indicated, Resident 65 refused ROM multiple times. A review of Resident 65's Multidisciplinary Progress Record, dated 5/14/21, indicated order for OT evaluation was discontinued due to Resident 65 not tolerating upper assessment for ROM and establish RNA ROM and possible splinting. A review of Resident 65's MDS, dated [DATE], indicated, Resident 65 was severely impaired with cognitive skills (ability to think and reason) for daily decision making and was totally dependent with two+ persons physical assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) and transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position) and was at risk of developing pressure ulcer/injuries requiring pressure reducing device for bed. During an observation on 12/13/21, at 3:24 p.m., in the room, Resident 65 lying in bed with both upper extremities contracted, both hands closed in a fist without a hand roll (a type of splint, a rigid or flexible device that maintains in position a displaced or movable part and/or used to prevent or treat contractures) or splint in place and no leg movements was observed. During a concurrent observation and interview on 12/13/2021, at 3:48 pm, with LVN 9, Resident 65 was observed lying in bed with both upper extremities contracted, hands closed in a fist without a hand roll or splint in place and no leg movements. LVN 9 stated that's her baseline, we just leave it like that cuz she's been like that. During a concurrent observation and interview on 12/15/2021, at 2:44 pm, with LVN 10, Resident 65 was observed lying in bed with both upper extremities contracted, hands closed in a fist, no splint or hand roll, no leg movements. LVN 10 stated Resident 65 did not have an RNA (Restorative Nurse Assistant, a nursing assistant who helps patients with providing rehabilitative exercises) order and not getting RNA treatment. LVN 10 stated Resident 65 should get RNA treatment to prevent breakdown cuz her fingers are digging into her palm, also RNA will work toward range of motion of her arms. During a concurrent interview and record review on 12/15/2021, at 3:43 pm, with Occupational Therapist (OT), Resident 65's Joint Mobility Screening (JMS), dated 2/2/2020 was reviewed. The JMS indicated, Resident 65 had minimal to severe loss of upper and lower extremity passive ROM and had a diagnosis/condition that put her at risk for contracture development and PT (physical therapy, care that aims to ease pain and help you function, move, and live better) and OT (occupational therapy, treatment for patients who have injuries, illnesses, or disabilities through the therapeutic use of everyday activities) skilled therapies were not recommended. OT stated Resident 65 was able to move fifty percent during the initial evaluation and order for splints were discontinued since Resident 65 did not tolerate on multiple evaluations even when medicated for pain. During a concurrent observation and interview on 12/16/2021, at 11:24 am, with Certified Nursing Assistant (CNA) 5, Resident 65 was observed calm in bed, appeared to be watching tv, both upper extremities contracted, hands closed in a fist without a hand roll or splint in place and no leg movements. CNA 5 stated, they're really contracted referring to resident's hands. Resident 65 started to cry when CNA 5 started to remove her sheet covers, stiff lower extremities with foot drop (difficulty lifting the front part of the foot) were observed. Resident 65 started having facial grimacing, turned red and got angry when CNA 5 attempted to move her lower extremities or open her hands. CNA 5 stated, she's always like that. During an interview on 12/16/2021, at 3 pm, with Resident 65's Physician (MD), MD stated, Resident 65 had been in the same condition for at least the last seven years and had no potential for recovery and whether Resident 65 got pain medication or not, Resident 65 did not tolerate therapy, she is the same and am not gonna give her the treatment if she is in pain. During an interview on 12/16/2021, at 3:58 pm, Administrator (ADM) stated Resident 65 had family visits and would be in a geri chair (a medical recliner chair to allow someone to get out of the confines of their bed and be able to sit comfortably in a variety of positions while being fully supported) outside or in the front lobby and did not grimace, in fact, she's happy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate assessment and interventions for two of two sampled residents (Resident 40 and 85) with indwelling urinary catheters (a flexible tube that is put through the urinary opening and into the bladder used to drain urine into a drainage bag, a small balloon filled with sterile water is placed inside the bladder to hold the catheter in place). This failure led to the presence of sediment (particles that may be indicative of an infection), in the urinary catheter which can lead to a Urinary Tract Infection (UTI, an infection in any part of the urinary system). Findings: a. A review of Resident 40's admission Record indicated Resident 40 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 40's diagnoses included chronic respiratory failure (a condition that develops over a long period of time in which the lungs have a problem getting gases, such as oxygen and carbon dioxide, in and out of the blood), and quadriplegia (partial or complete paralysis of both the arms and legs that is usually due to injury or disease of the spinal cord in the region of the neck), and UTI. A review of Resident 40's Care Plan titled Alteration in urinary elimination and at risk for UTI secondary to Foley Catheter, initiated on 3/26/2021 and revised on 4/17/2021 indicated the intervention to monitor urine for sediment, cloudiness, odor, blood, and amount of output. A review of Resident 40's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/28/2021, indicated cognitive (thinking and memory) skills for daily decision making was severely impaired. The MDS indicated Resident 40 required total dependence from staff for bed mobility, dressing, toilet use, and personal hygiene. During a concurrent observation and interview on 12/13/2021 at 12:55 pm, in Resident 40's room, the urinary catheter had sediment in the catheter tubing Licensed Vocational Nurse 7 (LVN 7) stated there were sediment in Resident 40's catheter tubing. LVN 7 stated this could be a sign of the presence of a UTI. LVN 7 stated some factors to prevent UTIs included good peri-care, good hydration, practicing good infection control such as hand washing and wearing gloves while providing care to the Resident 40. During an interview on 2/16/2021 at 1:36 pm, the facility's Infection Preventionist (IP, nurse who helps prevent and identify the spread of infectious agents like bacteria and viruses in a healthcare environment), stated the nurse should assess the catheter tubing for sediment and if found, report the findings to the doctor. The doctor may request for the urinary catheter to be flushed and order a urine specimen to be submitted for analysis. IP stated sediment in the urine may be a sign and symptom of a urinary tract infection. IP stated it was important to perform hand hygiene and wear gloves while providing catheter care to prevent the spread of infections. A review of the Policy and Procedure (P&P), titled, Foley Catheter Maintenance, undated, P&P indicated the objective is to maintain a closed drainage system; to prevent bacterial contamination; and to prevent backflow. It further indicated to wash hands before procedure. b. A review of Resident 85's admission Record indicated Resident 85 was admitted to the facility on [DATE]. Resident 85's diagnoses included orthopedic aftercare following surgical amputation (surgical removal of all or part of a limb or extremity such as an arm, leg, foot, hand, toe, or finger), abnormality of gait and mobility (gait is defined as a person's manner of walking), Urinary Tract Infection. A review of Resident 85's care plan titled Potential for unavoidable recurrent UTI related to: Advanced age/dementia, Catheter ., initiated on 5/7/2021 and revised on 5/18/2021 indicated the intervention to notify doctor if any signs and symptoms of UTI such as: complaints of pain, burning, increase in frequency and urgency during urination, increased temperature, change in urine character: color, cloudy, odor, amount, clarity, etc. A review of Resident 85's History and Physical (H&P, the initial clinical evaluation and examination of the patient), dated 5/8/2021, the H&P indicated Resident 85 did not have the capacity to understand and make decisions. A review of Resident 85's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/12/2021, indicated the residnet's cognitive (thinking and memory) skills for daily decision making was severely impaired. The MDS indicated Resident 85 required total dependence from staff for bed mobility, dressing, toilet use, and personal hygiene. During a concurrent observation inside Resident 85's room,and interview on 12/13/2021 at 3:43 pm, Licensed Vocational Nurse 8 (LVN 8) stated the resident's catheter tubing had sediment in the tubing. LVN 8 stated she flushed Resident 85's catheter every day. LVN 8 was unable to verbalize that sediments in the catheter tubing could indicate the presence of a UTI. LVN 8 stated that the next step would be to notify the doctor and wait for orders. LVN 8 verbalized the importance of hand hygiene to prevent the spread of infections. During an interview on 2/16/2021 at 1:36 pm with the facility's Infection Preventionist (IP, nurse who helps prevent and identify the spread of infectious agents like bacteria and viruses in a healthcare environment), stated the nurse should assess the catheter tubing for sediment and if found, report the findings to the doctor. The doctor may request for the urinary catheter to be flushed and order a urine specimen to be submitted for analysis. IP stated sediment in the urine may be a sign and symptom of a urinary tract infection. IP stated it was important to perform hand hygiene and wear gloves while providing catheter care to prevent the spread of infections. A review of the Policy and Procedure (P&P), titled, Foley Catheter Maintenance, undated, P&P indicated the objective was to maintain a closed drainage system; to prevent bacterial contamination; and to prevent backflow. It further indicated to wash hands before procedure.

Based on interview and record review the facility failed to ensure three of three staff (Licensed Vocational Nurse 2, 3, and 4) assigned to perform Range of Motion exercises (ROM, activity aimed at improving movement of a specific joint, a point where two bones make contact), apply splint (a supportive device that protects a broken bone or injury to help with pain and promote healing), and apply hand roll (a roll used for patients with contracted hands) placement to residents with limited ROM were trained, assessed and evaluated for adequate competency. This deficient practice had the potential to result for the residents not to received the appropriate ROM exercises, as ordered by the physician that could result in injury or decline in the residents's conditions. Cross reference to F688 Findings: During an interview on 12/15/2021 at 3 pm, the DSD stated Licensed Nurses performed the ROM, applied hand roll and splints if the Rehabilitation Nurse Assistant (RNA, nursing aide program that helps residents maintain their function and joint mobility) were not available to perform the task. DSD stated the skills to complete the task included the following: 1. Check physician order for the procedure to be performed. 2. Assess skin for skin integrity and skin breakdown. 3. Assess for pain during the procedure 4. Monitor decline in the patient then refer to the appropriate discipline and notify the physician. During an interview on 12/15/2021 at 3:15 pm, the DSD stated she provided training to the nursing staff on how to perform ROM and splint and hand roll placement but she did not evaluate or validate through return demonstration or skills competencies if the staff could perform the skills accurately. The DSD stated for LVNs 2, 3 and 4, there was no documented evidence LVNs 2, 3, and 4, were evaluated for skills and competencies after the training was provided. The DSD stated it was important to ensure the staff were evaluated to their competencies to do the ROM exercises and place splint or roll placement to ensure proper care was provided. A review of the facility's undated policy and procedure, titled Competency Assessment the facility would assess the employees upon hire and annually for skill competencies. A review of the Facility Assessment Tool, dated 12/13/2021, the facility would evaluate its residents population and identify the resources needed to provide the necessary person centered care and services the residents require. Facility resources needed to provide competent care for residents including staff training and education.

Based on observation, interview and record review, the facility failed to follow safe food storage and food handling practices in accordance with professional standards for food service safety and the facility's policy and procedure (P&P) by failing to: 1. Store dishware covered and/or inverted. 2. Discard old fresh produce food items stored in the kitchen's refrigerator. 3. Practice appropriate hand hygiene and glove use when necessary before handling food in the kitchen. 4. Store non-food items away from food items in the pantry. 5. Label opened/used food item stored on the shelf above the prep counter in the kitchen. These deficient practices could result in a risk for serious complications from food borne illness (illness caused by the ingestion of contaminated food or beverage) and/or affect the palatability of the meal to the residents. Findings: During a concurrent observation and interview on 12/13/2021, at 9:25 am, with Dietary Supervisor (DS), in the initial brief tour of the kitchen, the open dishware storage rack located by the entrance of the kitchen was observed to have three green colored pitcher like-looking containers stored uncovered and not inverted. DS stated those containers were for thickened liquids, and should be stored upside down or covered so dust doesn't get on it, doesn't get contaminated. DS could not provide a policy and procedure (P&P) on dishware storage. During a concurrent observation and interview on 12/13/2021, at 9:38 am, with DS, an undated container of fresh fruits of four oranges and five apples with three of the apples bruised in the walk-in kitchen refrigerator was observed. DS stated, don't serve, not good for the residents, they might get sick, don't know if they're fresh from the company. We serve fresh fruits and vegetables within 7-10 days of delivery. During a concurrent observation and interview on 12/13/2021, at 9:43 am, with DS, a container with a date label 11/29/2021, of green bell peppers with two of the bell peppers looking old and wrinkled in the walk-in kitchen refrigerator was observed. DS stated the green bell peppers should have been tossed away. During a concurrent observation and interview on 12/13/2021, at 9:45 am, with DS, Dietary [NAME] (DC 1), was observed opening the lid of the trash bin with bare hands, did not do hand hygiene, then proceeded to pick up a loaf of sliced bread from the kitchen counter. DC 1 stated with DS translating should wash hands to prevent contamination. DC 1 stated, they know that, especially with the COVID (a Coronavirus disease which is a mild to severe respiratory illness caused by a virus that spreads from person to person). They get too nervous. referring to the survey. During a concurrent observation and interview on 12/13/2021, at 9:54 am, with DS, a supply of unopened packages of apron and utility/kitchen gloves and three pairs of used?/loose utility/kitchen gloves stored on the second shelf of the rack of supply of food items in the Dry Goods Walk-in Pantry Room were observed. DS stated they shouldn't be there, it's cross contamination. During a concurrent observation and interview on 12/13/2021, at 9:59 am, with DS and DC 2, a used bottle of Kikkoman soy sauce without an open date label stored along with other dated used spices and sauces on the open top shelf above the prep counter in the kitchen was observed. DC 2 stated, should be labeled to prevent any illness or contamination, to make sure it's still good for the use time, put with open date to know the freshness of the spices, it could be bad for residents. DS added, if not dated, we don't know if old, it loses the flavor that's bad if it's not fresh. During an interview on 12/15/2021, at 8:46 am, with Infection Preventionist Nurse (IPN, nurse who helps prevent and identify the spread of infectious agents like bacteria and viruses in a healthcare environment), stated handwashing was still required every time staff touche something for infection prevention/control even if staff do not have direct contact with residents. A review of the facility's P&P titled, Produce Storage Guidelines, dated 2018, indicated, May use longer if no signs of spoilage are visible. The P&P, indicated, apples are stored 3 to 4 weeks in the refrigerator. [NAME] or red peppers are stored 7 to 10 days in the refrigerator. A review of the facility's P&P titled, Handwashing,, revised 2019, indicated, Before and after handling foods and After handling any waste and waste products were some of the indications listed for handwashing. A review of the facility's undated P&P titled, Hand Washing indicated, Hand Hygiene continues to be primary means of preventing transmission of infection. The P&P indicated, Before and after eating or handling food was one of the situations that require hand hygiene. A review of the facility's P&P titled, Storage of Canned and Dry Goods, revised 2019, indicated, Food and supplies will be stored properly and in a safe manner. No chemicals or cleaning products will be stored with food items.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d. A review of Resident 85's admission Record indicated Resident 85 was admitted to the facility on [DATE]. Resident 85's diagnosis included orthopedic aftercare following surgical amputation (surgical removal of all or part of a limb or extremity such as an arm, leg, foot, hand, toe, or finger), abnormality of gait and mobility (gait is defined as a person's manner of walking), Urinary Tract Infection. A review of Resident 85's History and Physical (H&P, the initial clinical evaluation and examination of the patient), dated 5/8/2021, the H&P indicated Resident 85 did not have the capacity to understand and make decisions. A review of Resident 85's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/12/2021, indicated cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 85 required total dependence from staff for bed mobility, dressing, toilet use, and personal hygiene. During a concurrent observation and interview on 12/13/2021 at 3:43 pm with Licensed Vocational Nurse 8 (LVN 8) in Resident 85's room, the catheter tubing had sediment (particles that may be indicative of an infection), in the line. LVN 8 touched the catheter tubing without performing hand hygiene or wearing gloves and only washed her hands when asked about touching the catheter tubing. LVN 8 stated the importance of hand hygiene and wearing gloves while touching the catheter tubing was to prevent the spread of infections. During an interview on 12/16/2021 at 1:36 pm with the IP stated it was important to perform hand hygiene and wear gloves while providing catheter care to prevent the spread of infections. A review of the Policy and Procedure (P&P), titled, Foley Catheter Maintenance, undated, P&P indicated the objective is to maintain a closed drainage system; to prevent bacterial contamination; and to prevent backflow. It further indicated to wash hands before procedure. A review of the Policy and Procedure (P&P), titled, Hand Washing, undated, P&P indicated hand washing must be performed as follows: before and after direct care of individual patients and in between performance of routine procedures such as handling catheters. b. A review of Resident 23's admission Record indicated Resident 23 was readmitted to the facility on [DATE]. Resident 23's diagnoses included hypoxemia (low concentration of oxygen in the blood) and endocarditis (inflammation of the endocardium [the thin, smooth membrane which lines the inside of the chambers of the heart]. A review of Resident 23's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 9/6/2021, indicated Resident 23's brief interview of mental status (BIMS, screening that aids in detecting cognitive impairment) score was 14 (a score of 13-15 represents intact cognition [mental action or process of acquiring knowledge and understanding]). The MDS indicated Resident 23 required extensive assistance for bed mobility, transfer, dressing, eating, toilet use and personal hygiene. A review of Resident 23's Physician Order, dated 11/24/2021, indicated to administer oxygen (O2) at two (2) liters per minute (l/min) via nasal cannula) for O2 saturation less than 90% for shortness of breath (SOB - difficulty breathing). A review of Resident 23's Oxygen Care Plan dated 12/13/2021, indicated Resident 23 was receiving oxygen therapy and the nursing interventions were to change oxygen tubing weekly or as needed. During a concurrent observation and interview on 12/13/2021 at 11:41 am, together with Registered Nurse 1 (RN 1) observed Resident 23's O2 tube was undated. RN 1 stated it should be labeled with the date and initial in the tubing. RN stated O2 tubing must be labeled to know when was the last time was changed for infection control purposes. During an interview on 12/14/2021 at 3:43 pm, Director of Nursing (DON) stated that O2 tubing should have a date label. DON stated it was important to have a date labelled in the tubing for the staff to know when the tubing was changed to prevent the spread of infection and it was also indicated in the policy. A review of the undated Policy and Procedure (P&P) titled, Oxygen Administration, indicated the oxygen tubing should be changed weekly and as needed including cannula. P&P also indicated the date, time, and initials should be noted on oxygen equipment when it is initially used and when changed. c. During an observation on 12/13/21 at 10:55 am, observed CNA 1 used the IPAD in the hallway and left without disinfecting after used. During an interview on 12/13/21 at 10:57 am, CNA 1 stated she was done using the machine and did not disinfect it after use. CNA 1 stated she was supposed to disinfect it after used by using the disinfectant wipes. CNA 1 stated it was important to disinfect the machine before and after use to prevent the spread of infection. During an interview on 12/14/21 at 3:36 pm, the Director of Nursing (DON), stated staff should supposed to disinfect any equipment before and after use to prevent the spread of infection. DON also stated it was stated in the facility policy that they have to follow infection control. During an observation on 12/16/21 at 10:32 am, observed CNA 2 used the IPAD in the hallway and left without disinfecting after used. During an interview on 12/16/21 at 10:35 am, CNA 2 stated she did not disinfect the IPAD after use. CNA 2 stated, she should supposed to disinfect the IPAD or any computer device before and after use as what was stated in the reminder on top of the device. CNA 2 added it was important to disinfect the machine every after use for infection control. A review of the Policy and Procedure (P&P) titled, Environmental Services Cleaning and Disinfection, dated 1/14/2021 indicated to disinfect surface before and after use such as the computer devices. Based on observation, interview, and record review, the facility failed to follow infection control practices as indicated in the facility's policy and procedure by failing to: a. Perform surveillance (closed observation) and monitoring (observe and check the progress or quality of work over a period of time to keep under systematic review), of the staff's non-compliance or compliance with proper hand washing, donning (put on), doffing (remove) personal protective equipment (PPE) such as the gown, goggles, gloves and face mask and other infection control practices to identify the possible cause(s) of the residents facility's acquired infections (an infection that was not present prior to the admission to the facility) from September 2021 to November 2021 such as: 1. Urinary tract infection (infection in the bladder, ureter, urethra and kidney). 2. cellulitis (skin infection) 3. Pneumonia (severe infection in the lungs) b. Ensure Resident 23's resident's nasal cannula tubing (a device used to deliver oxygen to a resident) was labeled as indicated on the facility policy and plan of care. c. Ensure Certified Nurse Assistant 1 (CNA 1) and CNA 2 disinfected mounted IPAD (computer device used to document residents medical records) outside the resident's room. d. For resident 85, the staff failed to perform hand hygiene when handling the urinary catheter tubing. These deficient practices had the potential to result in the wide spread infection in the facility and the decline in the well being of the residents. Findings: a. During an interview and concurrent record review with the Infection Control Prevention Nurse (IPN-the person in charge of monitoring the infection control practices in the facility) on 12/13/21 2:50 pm stated from September to November 2021 the facility identified the following facility acquired infection that indicated below: a. September 2021 Number of Residents with Urinary Tract infection-2 Number of Residents with cellulitis -4 b. October 2021 Number of Residents with Pneumonia- 1 c. November 2021 Number of Residents with Pneumonia- 2 Number of Residents with Urinary Tract infection-2 Number of Residents with cellulitis -4 In a concurrent interview the IPN stated, she and the infection control committee did not perform a surveillance and monitoring (during the day, evening and night shifts) of the staff compliance with the infection control practices or investigate to determine the possible causes of the infections that was identified. During an interview with the Director of Nursing (DON) on 12/16/2021 at 12:41 pm, stated it was important to perform a random monitoring and surveillance of the infections control practices in the facility to prevent the spread of infection and prevent an infection outbreak. A review of the the facility's undated policy and procedure, titled Infection Control, indicated the facility would maintain an infection control program designed to provide safe, sanitary and comfortable environment to prevent the development and transmission of disease and infection by performing surveillance and monitoring residents and healthcare personnel for acquisition of infection and or colonization and investigate to identify and analyze infection problems or trends.