**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the baseline care plan for one of three sampled residents (Resident 1) was initiated upon admission. * The facility failed to ensure Resident 1's baseline care plan included the necessary information to properly care for the resident with ileostomy (a surgery that lets stool pass from your body without going through your colon or anus) and the necessary nutritional interventions to maintain or prevent weight loss of the resident. This failure had the potential for Resident 1 to not receive the necessary resident-centered care.Findings: Review of the facility's P&P titled admission of a Resident revised on 8/23/23, showed the admission process is intended to obtain all possible information regarding the resident for the development of the comprehensive plan of care, and to assist the resident in becoming comfortable in the facility. The residents are admitted to the facility under orders of the attending physician. Upon admission, the designated facility staff will obtain information and perform assessments as per their respective departments and as per facility protocol. The information gathered will be placed into the resident's medical record via the facility's means of recordkeeping. A baseline care plan will be developed within 48 hours of a resident's admission. Closed medical record review for Resident 1 was initiated on 7/22/25. Resident was admitted to the facility on [DATE], and was discharged on 7/14/25. Review of Resident 1's H&P examination dated 7/9/25, showed resident had the capacity to understand and make decisions. Review of Resident 1's After Visit Summary from the acute care hospital printed on 7/8/25, included an ostomy care discharge instructions. The discharge instruction showed to drink at least 2 liters of fluid (around 8-10 glasses or 64 oz.) per day to prevent dehydration. Half of this (1 liter) should be water, and the other half (1 liter) should be an electrolyte solution like Gatorade, Vitamin Water, Powerade etc., and to notify the colorectal clinic if the daily output is greater than 1,500 ml or if you begin to experience dry mouth/tongue, dizziness, weakness decreased urine output, cramps in abdomen and/or leg or confusion which may be symptoms of dehydration. Additionally, the discharge instruction form included a chart titled Ostomy Intake/Output Daily Measurement with an example of the documentation. The instruction included to bring the chart to the follow up clinic visit. Review of Resident 1's plan of care failed to show a baseline care plan problem to address the resident's ileostomy care and monitoring. On 7/23/25 at 0953 hours, an interview and concurrent closed medical record review was conducted with LVN 1. LVN 1 verified Resident 1's After Visit Summary showed for an ostomy care section to drink at least 2 liters of fluid per day to prevent dehydration, half of this (1 liter) should be water, and the other half (1 liter) should be an electrolyte solution and, to record fluid intake and ileostomy output daily. LVN 1 verified the resident's intake and output was not monitored. On 7/23/25 at 1026 hours, an interview was conducted with the DON. The DON verified a baseline care plan was not initiated for Resident 1 for the ileostomy care and monitoring of the intake and output. The DON stated the baseline care plan should have been initiated for the resident within 48 hours of admission. Cross reference to F684.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the care plan was developed for one of three sampled residents (Resident 1) who had a change in condition. * The facility failed to develop a care plan when Resident 1 had nausea, vomiting, poor meal intake, and weight loss. This failure had the potential for Resident 1 to not receive the necessary care and services.Findings: Review facility's P&P titled Resident Change of Condition revised on 5/22/24, showed it is the policy of this facility that all changes in resident condition will be communicated to the physician. The nurse in charge is responsible for the notification of the physician prior to end of the assigned shift when a change in a resident's condition is noted. To document the resident change of condition and response in Nursing Progress Notes, on Twenty-Four Hour Report and update resident care plan as indicated. Closed medical record review for Resident 1 was initiated on 7/22/25. Resident was admitted to the facility on [DATE], and was discharged on 7/14/25. Review of Resident 1's H&P examination dated 7/9/25, showed the resident had the capacity to understand and make decisions. Review of Resident 1's System Note dated 7/11/25 at 1336 hours, showed the resident had a change in condition wherein resident complained of nausea. Review of Resident 1's Weights and Vitals Summary showed Resident 1's weights for the following dates:- dated 7/9/25, the resident weighed 197 pounds;- dated 7/12/25, the resident weighed 180 pounds; and- dated 7/13/25, the resident weighed 180 pounds. Further review of Resident 1's plan of care failed to show a care plan problem to address the resident had nausea and weight loss. On 7/23/25 at 0953 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 verified Resident 1's Weights and Vitals Summary showed a weight loss of 17 pounds in four days. LVN 1 verified Resident 1's plan of care was not initiated for the resident's poor appetite and weight loss. On 7/23/25 at 1026 hours, an interview and concurrent closed medical record review was conducted with the DON. The DON verified a care plan was not initiated for Resident 1's nausea and weight loss. On 7/24/25 at 0954 hours, an interview and concurrent record review was conducted with the RD. The RD stated resident was at risk for weight loss. The RD verified there was no plan of care initiated for the resident to address resident's poor intake and weight loss. The RD further stated she did not initiate a care plan problem until MDS was completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of three sampled residents (Resident 1) attained and maintained the highest practicable physical well-being. The facility failed to to notify Resident 1's physician regarding the discharge instructions from the acute care hospital to provide specific fluid amount and type to the resident, and to monitor the resident's intake and output. In addition, the facility failed to notify the physician regarding the resident's weight loss of 17 pounds timely. This failure posed the risk for Resident 1 to not receive the necessary care and services timely to maintain the resident's highest physical well-being.Findings: a. Review of the facility's P&P titled admission of a Resident revised on 8/23/23, showed the admission process is intended to obtain all the possible information regarding the resident for the development of the comprehensive plan of care, and to assist the resident in becoming comfortable in the facility. Residents are admitted to the facility under orders of the attending physician. Upon admission, the designated facility staff will obtain information and perform assessments as per their respective departments and as per facility protocol. The information gathered will be placed into the resident's medical record via the facility's means of recordkeeping. Review of the facility's P&P titled admission Orders revised on 8/13/23, showed a physician's order is necessary for an individual to be admitted to a facility. A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide written and/or verbal orders for the residents' immediate care and needs. The written and/or verbal orders should include at a minimum: a. Dietary; b. Medication orders if indicated; and c. Routine care orders. The orders should allow facility staff to provide essential care to the residents consistent with the resident's mental and physical status on admission. The orders should provide information to maintain or improve the resident's functional abilities until staff can conduct a comprehensive assessment and develop an interdisciplinary care plan. Closed medical record review for Resident 1 was initiated on 7/22/25. Resident 1 was admitted to the facility on [DATE], and discharged on 7/14/25. Review of Resident 1's After Visit Summary discharge instructions dated 6/24 to 7/8/25, showed to provide the resident at least two liters of fluid (one liter should be water and the other one liter should be an electrolyte solution), and to record how much fluid the resident was drinking and the resident's output from the ostomy everyday. Review of Resident 1's Order Summary Report showed a physician's order dated 7/8/25, to monitor the ileostomy output every shift. However, there was no physician's order to monitor the resident's intake. Further review of Resident 1's medical record failed to show if the Attending Physician was notified regarding Resident 1's discharge instructions from the acute care hospital to monitor the resident's intake and output and provide at least two liters of fluid (one liter should be water and the other one liter should be an electrolyte solution). Review of Resident 1's H&P examination dated 7/9/25, showed the resident had the capacity to understand and make decisions. Review of Resident 1's progress notes dated 7/9/25 at 1050 hours, showed Family Member 1 complained to LVN 2 that the facility was not monitoring the resident's intake and output per the acute care hospital's discharge instructions. On 7/22/25 at 1215 hours, a telephone interview was conducted with Family Member 1. Family Member 1 stated the facility refused to monitor the resident's intake and output and provide the fluids as directed in the resident's acute care hospital discharge instructions. Family Member 1 further stated the nurse staff had told her the facility knew how to assess the resident's bowel movement without having to monitor the intake and output. b. Review facility's P&P titled Weight Variance Monitoring revised on 11/17/23, showed unusual or significant weight variance includes the following: a. 3% +/- in one week; b. 5% in 30 days; c. 7.5% in 90 days; and d. 10% in 180 days. Unusual or significant weight losses or gains will be reported by nursing to the physician. When weight loss or gain has been identified as a problem, an entry will be included in the Resident Care Plan and reported to the Providers. Review facility's P&P titled Resident Change of Condition revised on 5/22/24, showed it is the policy of this facility that all changes in resident condition will be communicated to the physician. Routine medical change are all symptoms, and unusual signs will be communicated to the physician promptly. Routine changes are a minor change in physical and mental behavior, abnormal laboratory and x-ray results that are not life-threatening and weight loss or gain. The nurse in charge is responsible for notification of physician prior to end of assigned shift when a change in a resident's condition is noted. If unable to reach a physician, all call to physicians or exchanges requesting callbacks will be documented on the Nursing Progress Note. If the physician has not returned the call by the end of the shift, the on-coming nurse will be notified for follow-up. If unable to contact attending physician or alternate timely, notify the Medical Director for response and follow-up to change in resident status. Document resident change of condition and response in Nursing Progress Notes, on Twenty-Four Hour Report and update resident care plan as indicated. All attempts to reach the physician and responsible party will be documented in the Nursing Progress Notes. Documentation will include time and response. Review of Resident 1's Weights and Vitals Summary showed the following weight for Resident 1: - on 7/9/25, Resident 1 weighed 197 pounds;- on 7/12/25, Resident 1 weighed 180 pounds; and - on 7/13/25, Resident 1 weighed 180 pounds. Review of Resident 1's SNF Documentation Survey Report for nutrition (amount eaten) showed the following:- on 7/8/25, for dinner the resident consumed 0-25% of the meal;- on 7/9/25, for breakfast, lunch, and dinner, the resident consumed 0-25% of the meal and resident refused the supplements offered when the resident ate less than 50% for all the meals; - on 7/10/25, for breakfast the resident consumed 26-50% of the meal and for lunch and dinner, the resident consumed 0-25% of the meal. In addition, the resident refused the supplements offered when the resident ate less than 50% for all the meals; - on 7/11/25, for breakfast and dinner the resident consumed 26-50% of the meal and refused lunch. In addition, the resident refused the supplements offered when the resident ate less than 50% for breakfast and lunch but for dinner, the documentation if the supplement was offered showed NA;- on 7/12/25, for breakfast the resident consumed 26-50% of the meal and 0-25% for dinner, but refused lunch; and- on 7/13/25, for lunch and dinner the resident consumed 0-25% of the meal and refused the supplements offered when the resident ate less than 50% for all the meals. Review of Resident 1's SNF Documentation Survey Report for the bedtime snack showed the following:- on 7/9, 7/11, and 7/13/25, the documentation showed NA; and- on7/14 and 7/15/25, the resident refused the snack provided. Review of Resident 1's plan of care failed to show a care plan problem addressing the resident's poor meal intake and weight loss of 17 pounds in four days. Further review of Resident 1's closed medical record failed to show the physician was notified regarding the resident's 17 pounds weight loss on 7/12/25 or on 7/13/25, after being reweighed. In addition, there was no documentation to show the physician was notified regarding Resident 1's poor meal intake. On 7/23/25 at 0953 hours, an interview and concurrent closed medical record review was conducted with LVN 1. LVN 1 verified Resident 1's After Visit Summary discharge instructions dated 6/24/25 to 7/8/25, showed in the ostomy care section to drink at least two liters of fluid per day to prevent dehydration (one liter should be water, and the other one liter should be an electrolyte solution) and to record how much fluid the resident was drinking and the resident's output from the ostomy everyday. LVN 1 verified the physician was not notified of the resident's discharge instructions. LVN 1 verified Resident 1's Weights and Vitals Summary showed a weight loss of 17 pounds in four days from 7/9 to 7/12/25. LVN 1 verified the resident's medical record failed to show the resident's physician was notified of the weight loss and/or the resident's poor meal intake. LVN 1 stated the physician should have been notified of the resident's significant weight loss. LVN 1 verified Resident 1's plan of care was not initiated to address the resident's poor appetite and weight loss. On 7/23/25 at 1026 hours, an interview was conducted with the DON. The DON verified Resident 1's discharge instructions from the acute care hospital were not relayed to the Attending Physician. The DON stated the physician's orders for the discharge instructions should have been ordered in the facility for the resident's continuity of care. The DON further stated there was too much discharge paperwork, and the licensed nurse usually focused on the resident's discharge medication list to prevent a medication error. The DON further stated the licensed nurse should have notified the physician regarding the resident's significant weight loss prior to the end of shift when the resident was weighed on 7/12/25, and/or reweighed on 7/13/25. On 7/23/25 at 1205 hours, an interview was conducted with the Attending Physician. The Attending Physician stated she usually followed the acute care hospital's discharge instruction per the facility's protocol. The Attending Physician stated she was not aware of the resident's discharge instructions regarding the fluid intake. The Attending Physician stated she could have given an order to provide one liter of fluid from an electrolyte source and one liter from water. The Attending Physician further stated she told the licensed nurse to monitor the resident's intake and output as per the facility's protocol. The Attending Physician stated she was not informed of the resident's weight loss. On 7/24/25 at 1630 hours, a follow up interview was conducted with the DON. The DON was informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 18 final sampled residents (Resident 43) reviewed for side rail use and unnecessary medication was provided the right to self-determination regarding the use of psychotropic medication (medications affecting brain activity) and side rails. * The facility failed to obtain the informed consent for side rail from Resident 43's responsible party when Resident 43 was deemed to not have the capacity to make medical decisions. In addition, the facility failed to ensure the informed consent was obtained from the responsible party and signed by the physician before administering alprazolam (antianxiety) medication for Resident 43. These failures posed the risk of Resident 43 and his responsible party not being informed not understanding risks and benefits of the treatments and medications. Findings: Review of the facility's P&P titled Informed Consent revised 3/1/24, showed the following: - The facility shall ensure the resident's rights are not violated and copy of these rights and pertinent policies are made available to the resident and to any representative of the resident. These rights, under this section, are the right to: (1) Receive in advance all information that is material to a decision to accept or refuse treatment; (2) Consent to or to refuse any psychotherapeutic drugs; and (3) participate in care planning; - Physician's orders related to the use of psychotherapeutic drugs shall not be initiated until informed consent is obtained from the physician or his/ her agent. - The disclosure of material information and obtaining informed consent is the responsibility of the physician, however, it can be coordinated with other care professionals. The material information is provided to the resident or surrogate so they can make an informed choice and then consent to the psychotherapeutic drugs; - Informed consent is the voluntary agreement of a patient or a representative of an incapacitated resident to accept treatment or procedure after receiving the material information. Review of the facility's P&P titled Use of Psychotropic Drugs revised date 11/13/23, showed the residents and/or representatives shall be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments/ non-pharmacological interventions. Review of the facility's P&P titled Bed Rails revised 4/2/18, showed to review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. On 9/10/24 at 0904 hours, 9/11/24 at 0941 and 1326 hours, 9/12/24 at 0801, 1008, 1358, and 1550 hours, and 9/13/24 at 1532 hours, Resident 43 was observed in bed with bilateral ¼ side rails elevated. Medical record review for Resident 43 was initiated on 9/10/24. Resident 43 was admitted to the facility on [DATE]. Review of Resident 43's Initial H&P examination showed Resident 43 did not have the capacity to understand and make decisions. Review of Resident 43's Order Summary Report showed the following physician's orders dated: -8/9/24, for bilateral ¼ bed rails in place to assist with bed mobility; and -9/6/24, to administer alprazolam 0.5 mg one tablet by mouth every 12 hours as needed for anxiety manifested by verbalization of feeling anxious for 14 days. Review of Resident 43's Bed Rails Assessment and Consent dated 8/9/24, under the Consent section, showed the bed rail risk and discussed were discussed, and the consent was received from Resident 43. Further review of Resident 43's medical record did not show documented evidence the informed consent related to the use of alprazolam medication was obtained. On 9/12/24 at 0935 hours, an interview and concurrent medical record review for Resident 43 was conducted with RN 1. RN 1 verified the above findings. When asked about the informed consent for bed rail use, RN 1 verified the consent for bed rail use showed the consent was obtained from Resident 43 who did not have the capacity. When asked about the informed consent for the use of alprazolam medication, RN 1 stated all informed consents for psychotropic medications were uploaded in the resident's electronic medical record. RN 1 was not able to find any consent for the alprazolam medications in Resident 43's electronic medical record. RN 1 was unable to find documentation in Resident 43's medical record to show an informed consent was obtained from Resident 43's representative related to the use of bed rails and alprazolam medication. After requesting for a copy of informed consent for the alprazolam medication, the facility showed a copy of the Physician Order and Informed Consent Verification Sheet for Psychotropic Drugs, Physical Restraint Use and Prolonged Use of a Device form. However, the consent form showed the physician signed the consent on 9/12/24, for the use of alprazolam medication. On 9/13/24 at 1438 hours, a concurrent interview and medical record review for Resident 43 was conducted with the DON. The DON verified the above findings. When asked about the informed consent for bed rail use, the DON stated the consent should have been obtained from the resident's representative since Resident 43 did not have the capacity. When asked about the informed consent for the alprazolam medication use, the DON stated the informed consent could be found in the resident's electronic medical record. The DON verified the informed consent for alprazolam medication was signed by the physician only on 9/12/24, and was only uploaded in Resident 43's electronic medical records on 9/12/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Medical record reviewed for Resident 37 was initiated on [DATE]. Resident 37 was admitted to the facility on [DATE]. Review of Resident 37's H&P examination dated [DATE], showed Resident 37 had the capacity to understand and make decisions. Review of Resident 37's Advanced Directive Acknowledgement form dated [DATE], showed Resident 37 had executed an advanced directive. Further review of Resident 37's medical record did not show a copy of the resident's advanced directive or documentation to show the facility had obtained a copy of the advanced directive. 5. Medical record review for Resident 669 was initiated on [DATE]. Resident 669 was readmitted to the facility on [DATE]. Review of Resident 669's H&P examination dated [DATE], showed Resident 669 had the capacity to understand and make decisions. Review of Resident 669's Advanced Directive Acknowledgement form dated [DATE], showed Resident 669 had executed an advanced directive. Further review of Resident 669's medical record did not show a copy of the resident's advanced directive or documentation to show the facility had obtained a copy of the advanced directive. On [DATE] at 1236 hours, a concurrent interview and medical record review was conducted with the SSD and Social Service Designee for Residents 37 and 669. The SSD and Social Service Designee verified the above findings. On [DATE] at 1242 hours, a follow-up interview was conducted with the SSD and Social Service Designee. The SSD and Social Services Designee stated the facility should request and obtain the copy of the advanced directive if the resident had one prior to admission. 6. Medical record review for Resident 44 was initiated on [DATE]. Resident 44 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 44's H&P examination dated [DATE], showed Resident 44 did not have the capacity to understand and make decisions. Review of Resident 44's Advanced Directive Acknowledgment dated [DATE], showed the resident has executed an advance directive and to provide the facility with a copy. Review of Resident 44's POLST dated [DATE], showed Section D Information and Signatures was incomplete. Section D of the POLST showed no documented evidence if the resident had or had not executed an advance directive; and there was no documented evidence of the physician/NP/PA name and date signed. On [DATE] at 1537 hours, a concurrent interview and medical record review was conducted with the SSD. The SSD verified Resident 44's POLST was incomplete and the facility did not have an advance directive in the resident's medical record. The SSD further verified Resident 44 did not have documented evidence the facility had obtained a copy of the resident's advance directive. The SSD stated the POLST should be completed and the facility should have followed up for a copy of Resident 44's advance directive to ensure the resident's wishes were maintained. [DATE] at 1619 hours, an interview was conducted with the DON. The DON acknowledged the above findings. Based on interview, medical record review, and facility P&P review, the facility failed to obtain and maintain a copy of the advance directives (a legal document stating a person's wishes about receiving medical care if the person is no longer able to make medical decisions) for six of 18 final sampled residents (Residents 8, 37, 43, 44, 320, and 669). * The facility failed to obtain a copy of advance directives for Residents 8, 37, 43, and 669. * The facility failed to obtain a copy of advance directives for Residents 44 and 320. In addition, the facility failed to ensure the POLSTs for Residents 44 and 320 were completed. These failures had the potential for the residents' decisions regarding their healthcare and treatment options to not be honored. Findings: Review of the facility's P&P titled Advanced Directives revised date [DATE], showed in part, the facility will verify and/or modify the presence of advance directives or the resident's wishes with regard to CPR upon admission .each resident will receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. The facility complies with Federal and State laws and court decisions on Advanced Directives. We do not condition the provision of care or otherwise discriminate against anyone based on their health care preferences whether or not they have executed an AD. The resident has the right to request, accept, refuse, and/or discontinue medical treatment, accept, or refuse surgical treatment, to participate in or refuse to participate in experimental research, and to formulate an advanced directive. 1. Medical record review for Resident 43 was initiated on [DATE]. Resident 43 was admitted to the facility on [DATE]. Review of Resident 43's Advanced Directive Acknowledgment dated [DATE], showed Resident 43 had executed an advance directive and to provide the facility a copy of the advance directive. Further review of Resident 43's medical record failed to show a copy of Resident 43's advance directive was obtained, or an attempt was made to obtain Resident 43's advance directive. 2. Medical record review for Resident 8 was initiated on [DATE]. Resident 8 was readmitted to the facility on [DATE]. Review of Resident 8's Advanced Directive Acknowledgment dated [DATE], showed Resident 8 had executed an advance directive and to provide the facility a copy of the advance directive. Further review of Resident 8's medical record failed to show a copy of Resident 8's advance directive was obtained, or an attempt was made to obtain Resident 8's advance directive. 3. Medical record review for Resident 320 was initiated on [DATE]. Resident 320 was admitted to the facility on [DATE]. Review of Resident 320's Advanced Directive Acknowledgment dated [DATE], showed Resident 320 had executed an advance directive and to provide the facility a copy of the advance directive. Review of Resident 320's POLST dated [DATE], showed Section D Information and signatures section to show whether Resident 320 had an advance directive or not were left blank. Further review of Resident 320's medical record failed to show a copy of Resident 320's advance directive was obtained, or an attempt was made to obtain Resident 320's advance directive. On [DATE] at 0839 hours, an interview and concurrent medical record review for Residents 8, 43, and 320 was conducted with RN 1. RN 1 verified the above findings. RN 1 stated upon admission to the facility, the resident who had capacity or for the resident who had no capacity, a resident representative was asked to fill out the CPR and DNR form. RN 1 stated the resident or the resident representative could also fill out the POLST form under Sections A, B, and C; while Section D regarding advance directives would be filled out by the social services department. RN 1 stated the newly admitted residents were also asked regarding the existence of advance directives, and if the resident had executed an advance directive, the social services would follow up to obtain a copy of the advance directive. On [DATE] at 0916 hours, a concurrent interview and medical record review for Residents 8, 43, and 320 was conducted with the Social Services Designee. The Social Services Designee verified the above findings. The Social Services Designee stated Residents 8, 43, and 320 had executed an advance directive, but he did not follow up to obtain copies of their advance directives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review and facility document review, the facility failed to provide an individualized and ongoing activity program to meet the needs and interests of one of one final sampled resident reviewed for activities (Resident 43). * The facility failed to provide activities for Resident 43 to meet the resident's identified interests. The facility only provided activity program to Resident 43 on 8/8, 8/9, and 8/18/24 since his admission on [DATE]. This failure had the potential for the resident to experience feelings of social isolation and frustration. Findings: On 9/10/24 at 0904 hours, during the initial tour of the facility, Resident 43 was observed in bed, awake, and staring at the ceiling. The TV was turned off, and there was no other in-room sensory stimulation observed. On 9/11/24 at 0941 and 1326 hours, and 9/12/24 at 0801, and 1008 hours, Resident 43 was observed in bed and awake. The TV was turned off, and there was no other in-room sensory stimulation observed. Medical record review for Resident 43 was initiated on 9/10/24. Resident 43 was admitted to the facility on [DATE]. Review of Resident 43's MDS dated [DATE], showed Resident 43 had a severe cognitive impairment. Review of Resident 43's Activities - Initial Review dated 8/9/24, showed Resident 43 wished to participate in group activities and independent activities, watching TV and visitations. Review of Resident 43's plan of care showed a care plan problem dated 8/9/24, to address the resident's preference with independent activities. The interventions included to encourage independent or self-directed activity pursuits such as visitations and watching TV. Review of Resident 43's Progress Notes dated 8/9/24, under the Activity Participation Note, showed Resident 43 loved planting orchids, going fishing, camping and music-related activities. On 9/12/24 at 0802 hours, an interview for Resident 43 was conducted with CNA 1. When asked about Resident 43's activities, CNA 1 stated Resident 43 went to the activities only once, but Resident 43 went to therapy instead. On 9/13/24 at 1502 hours, a concurrent interview and medical record review for Resident 43 was conducted with the Director of Activities. When asked about activities assessment, the Director of Activities, her assistant went to the resident's room to interview the resident and completed the resident's activities assessment upon admission. The Director of Activities stated independent activities were provided usually for alert and oriented residents who liked to do their own activities and not interested in group activities; while room visits were provided to those residents who did not go out of their rooms where the activity staff provided daily activities such as providing copies of the Daily Chronicles. When asked about Resident 43's activities, the Director of Activities stated the resident was a short-term resident and was in the facility mainly for therapy. When asked what activities were provided for Resident 43, the Director of Activities stated the resident liked to be in the room and enjoyed reading the Daily Chronicles. When asked for the documentation of the resident activities, the Director of Activities stated they documented in the progress notes, but there were no daily note and use the calendar in the resident's electronic medical record. Review of Resident 43's Event Calendar Report for August and September 2024 showed Resident 43 attended exercise activity on 8/8/24, bingo on 8/9/24, and music therapy on 8/18/24. The report also showed Resident 43 was invited for an initial on 8/9/24, sing along activity on 8/16/24, birthday party on 9/4/24, dermatologist appointment on 9/6/24, and music therapy on 9/14/24. There were no other activities provided for Resident 43. The Director of Activities verified Resident 43 only attended activities on 8/8, 8/9, and 8/18/24, as per the activity calendar. The Director of Activities stated they provided the Daily Chronicles and turned the TV on for the resident, but they did not document those daily activities provided to the resident. The Director of Activities verified there were no documented evidence to show Resident 43 was provided activities to meet his identified interests, other than the activities he attended on 8/8, 8/9, and 8/18/24. On 9/13/24 at 1532 hours, an observation for Resident 43 and concurrent interview was conducted with the Director of Activities. Resident 43 was observed in bed and asleep. When asked about the Daily Chronicles, the Activities Director showed the Daily Chronicles dated 9/12/24, in a bin on top of Resident 43's nightstand, and out of resident's reach, and the Daily Chronicles dated 9/13/24, was observed folded and inside the trash can.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's P&P titled Notification of Changes revised 11/29/23, showed the facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requirement such notification. Circumstances requiring notification include a significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include life threatening conditions or clinical complications. Review of the facility's P&P titled Weight Variance Monitoring revised on 11/17/23, showed unusual or significant weight variance includes, but is not limited to, weight loss of plus or minus 3% in a week. Unusual or significant weight loss will be reported by nursing to the physician. Medical record review for Resident 37 was initiated on 9/10/24. Resident 37 was admitted to the facility on [DATE]. Review of Resident 37's Order Summary Report showed a physician's order dated 8/29/24, to weigh the resident every day shift and notify the physician if the resident's weight changed greater than or equal to three lbs for CHF. Review of Resident 37's Weight and Vitals Summary dated 9/13/24, showed the following weights: - on 9/3/24, a weight of 197 lbs - on 9/4/24, a weight of 194 lbs (weight loss of three lbs) - on 9/7/24, a weight of 197 lbs (weight gain of three lbs) - on 9/8/24, a weight of 194 lbs (weight loss of three lbs) Further review of Resident 37's medical record did not show documentation the physician was notified for Resident 37's three lbs weight loss on 9/4 and 9/8/24. On 9/13/24 at 1548 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified Resident 37's medical record showed the resident lost three lbs in a day on 9/4/24, and again on 9/8/24. The DON verified Resident 37's physician's order dated 8/29/24, showed to notify the physician if Resident 37's weight changed greater than or equal to three lbs daily. However, the physician was not contacted regarding the weight changes for Resident 37 on these dates. Based on observation, interview, medical record review and facility P&P review, the facility failed to provide services to attain or maintain the highest practicable well-being for two of 18 final sampled residents (Residents 37 and 52) and one nonsampled resident (Resident 621). * LVN 3 failed to follow the physician's order to give furosemide (medication to treat fluid retention) 30 minutes before spironolactone-hydrochlorothiazide (medication to treat high blood pressure and fluid retention) to Resident 621. * Resident 37's physician's order was not followed when the physician was not notified of Resident 37's weight changes. * The licensed nurse failed to document the resident's BP when administered the as needed BP medication to evaluate the effectiveness of medication. These failures had the potential to compromise the health and safety of these residents. Findings: Review of the facility's P&P titled Medication Administration revised 2/13/17, showed the nurse shall read and follow precautionary or additional instructions available on the prescription label (i.e., Shake Well, Give on an Empty Stomach). 1. During a medication administration observation on 9/11/24 at 0801 hours with LVN 3, LVN 3 was observed administering one tablet of furosemide 20 mg and one tablet of spironolactone-hydrochlorothiazide 25-25 mg to Resident 621. Medical record review was initiated for Resident 621 on 9/11/24. Resident 621 was admitted to the facility on [DATE]. Review of Resident 621's Order Summary Report dated 8/10/22, showed the following: - an order dated 9/2/24, to administer furosemide tablet 20 mg one tablet by mouth one time a day for bilateral lower extremity swelling, give 30 minutes before spironolactone-hydrochlorothiazide medication. - an order dated 9/2/24, to administer spironolactone-hydrochlorothiazide oral tablet 25-25 mg one tablet by mouth one time a day for bilateral lower extremity swelling. On 9/11/24 at 0820 hours, a concurrent interview and medical record review for Resident 621 was conducted with LVN 3. The instruction on the prescription label and the physician's order for Resident 621's furosemide medication was reviewed. LVN 3 verified she gave the furosemide 20 mg tablet and spironolactone-hydrochlorothiazide 25-25 mg tablet at the same time. LVN 3 stated she should have followed the instruction to give furosemide medication 30 minutes before spironolactone-hydrochlorothiazide medication. On 9/13/24 at 1517 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 3. Medical record review for Resident 52 was initiated on 9/11/24. Resident 52 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 52' H&P examination dated 3/26/24 showed Resident 52 had the capacity to understand and make decisions. Review of Resident 52's Order Summary Report for September 2024 showed a physician order dated 9/9/24, to administer clonidine hydrochloride (a medication used to treat high blood pressure) 0.1 mg one tablet by mouth every eight hours as needed for hypertension if systolic blood pressure greater than 160 mmHg. Review of Resident 52's MAR for September 2024 showed clonidine hydrochloride 0.1 mg one tablet was given on 9/11/24 at 0541 hours, to Resident 52 and was documented effective; however, the documentation failed to show the BP readings documented to show why the medication was given and effective. Review of Resident 52's progress notes on 9/10/24, failed to show the resident's response to the clonidine hydrochloride 0.1 mg given on 9/10/24 at 0541 hours. On 9/12/24 at 1536 hours, an interview and concurrent record review was conducted with the IP. The IP stated the licensed nurse should have followed up by checking Resident 52's BP. On 9/13/24 at 1533 hours, an interview with the DON was conducted. The DON was informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure accurate reconciliation and disposal of medications. * The facility failed to ensure the removed controlled medications for Resident 31 was documented in the controlled drug record. * The facility failed to ensure the discontinued controlled medication for Resident 670 was removed from the current medication supply in Medication Cart B. These failures had the potential for drug diversion of the controlled medications, and potential for medication errors. Findings: According to Taylor's Fundamentals of Nursing, Seventh Edition, under Handling Controlled Substances Safely, a record must be kept for each narcotic that is administered. Healthcare agencies provide forms for keeping such records, and these forms are kept with the narcotics. Although the forms differ, the following information usually is required: name of the resident receiving the narcotic, amount of the narcotic used, hour the narcotic was given, name of the physician who prescribed the narcotic, and name of the nurse who administered the narcotic. The nurse has a secure identification code that provides access into the system, identifies the resident by name or identification number, and verifies the count for each drug as it is removed. Review of the facility's P&P titled Medication Storage dated 11/29/23, showed for unused medications: the pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with the destruction of unused drugs policy. On 9/11/24 at 1115 hours, a concurrent inspection of Medication Cart B, interview, and medical record review was conducted with LVN 3. Upon inspection of Medication Cart B, the following was observed: a. A bubble pack of morphine (narcotic analgesic) 60 mg for Resident 31 was observed with 10 tablets. Review of Resident 31's Antibiotic or Controlled Drug Record for the morphine medication showed one tablet of morphine medication was removed on 9/10/24 at 0900 hours, and the last count was 11 tablets of morphine medication. b. A bubble pack of oxycodone/ acetaminophen (narcotic analgesic) 10- 325 mg medication for Resident 31 was observed with 103 tablets. Review of Resident 31's Antibiotic or Controlled Drug Record for the oxycodone/ acetaminophen medication showed one tablet of oxycodone/acetaminophen medication was removed on 9/11/24 at 0600 hours, and the last count was 104 tablets of oxycodone/acetaminophen medication. Medical record review for Resident 31 was initiated on 9/10/24. Resident 31 was readmitted to the facility on [DATE]. Review of Resident 31's Order Summary Report dated 8/28/24, showed the following physician's orders dated 11/28/23: - To administer morphine sulfate extended release 60 mg one tablet by mouth two times a day for pain management; and - To administer Percocet (brand name for oxycodone/acetaminophen) 10-325 mg one tablet by mouth six times a day for pain management. Review of Resident 31's MAR for Resident 31 showed the resident was administered the morphine medication on 9/11/24 at 0900 hours, and Percocet medication on 9/11/24 at 1000 hours. c. A bubble pack of hydrocodone/acetaminophen (narcotic analgesic) 5-325 mg medication with four tablets for Resident 670 was observed inside the narcotic medications drawer with the current supply of medications of other residents. Medical record review for Resident 670 was initiated on 9/10/24. Resident 670 was readmitted to the facility 9/5/24. Review of Resident 670's list of medications showed the hydrocodone-acetaminophen 5-325 mg medication was discontinued on 9/8/24. LVN 3 verified the above findings. When asked about Resident 31's morphine and oxycodone/acetaminophen medications, LVN 3 stated she administered the morphine and oxycodone/acetaminophen medications to Resident 31. LVN 3 stated she did not sign the controlled drug record after removing the medications from the bubble pack, nor the MAR after administering the medications, but she usually signed the controlled drug record and MAR towards the middle of her shift. When asked about Resident 670's hydrocodone medication, LVN 3 stated the medication was already discontinued and should not be in the medication cart. On 9/13/24 at 1338 hours, an interview was conducted with the DON. When asked about documentation on the controlled drug record and MAR, the DON stated the nurses should sign the controlled drug record as soon as they removed the controlled medication from the bubble pack, then administered the medication to the resident. After administering the medication, the nurses should sign the MAR. When asked about the discontinued medication, the DON stated the medication should be removed by the nurses at the end of their shift, and the medication should be brought to the DON. If the medication was discontinued on a weekend, the nurses should have removed the discontinued medication from the medication cart on the following weekday.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure two of two final sampled residents (Residents 2 and 56) reviewed for unnecessary medications were free from unnecessary drugs. * The facility failed to ensure Resident 2's losartan potassium (medication used to lower high blood pressure) was administered as per the physician's ordered parameter. * The facility failed to ensure Resident 56's midodrine hydrochloride (medication used to treat low blood pressure) was administered as per the physician's ordered parameter. These failures had the potential for Residents 2 and 56 to receive unnecessary medications and develop significant side effects arising from errors in administration. Findings: 1. Medical record review for Resident 2 was initiated on 9/11/24. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's Order Summary Report as of 9/11/24, showed an order dated 6/27/24 to administer losartan potassium 25 mg one tablet by mouth at bedtime for hypertension, hold if SBP less than 120 mmHg. Review of Resident 2's MAR showed losartan potassium 25 mg was administered with the following dates and blood pressure readings: - On 6/28/24, BP of 111/58 mmHg. - On 7/12/24, BP of 112/57 mmHg. - On 7/18/24, BP of 110/61 mmHg. - On 7/24/24, BP of 110/64 mmHg. - On 9/2/24, BP of 114/74 mmHg - On 9/3/24, BP of 117/77 mmHg. - On 9/5/24, BP of 118/62 mmHg. - On 9/7/24, BP of 112/59 mmHg. - On 9/8/24, BP of 116/63 mmHg. - On 9/10/24, BP of 111/68 mmHg. On 9/12/24 at 1532 hours, a concurrent interview and medical record review was conducted with the IP. The IP verified losartan potassium 25 mg was administered to Resident 2 when SBP was less than 120 mmHg. On 9/13/24 at 1529 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 2. Record review for Resident 56 was initiated on 9/11/24. Resident 56 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 56's Order Summary Report as of 9/11/24, showed a physician order dated 8/22/24, to administer midodrine hydrochloride 5 mg one tablet by mouth one time a day for hypotension, hold if SBP greater than 110 mmHg. Review of Resident 56's MAR for September 2024 showed midodrine hydrochloride 5 mg was documented administered with the following dates and blood pressure readings: - On 9/3/24, BP of 113/27 mmHg - On 9/6/24, BP of 132/79 mmHg. - On 9/9/24, BP of 112/65 mmHg. - On 9/11/24, BP of 112/63 mmHg. On 9/13/24 at 0834 hours, a concurrent interview and medical record review was conducted with LVN 6. LVN 6 verified midodrine hydrochloride 5 mg was administered to Resident 56 when SBP was greater than 110 mmHg. On 9/13/24 at 1532 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of five final sampled residents reviewed for unnecessary medication (Resident 43) was free from unnecessary psychotropic drugs. * The facility failed to ensure the side effects were monitored for Resident 43 related to the use of alprazolam (antianxiety medication). This failure posed the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Use of Psychotropic Drugs revised date 11/13/23, showed the resident's response to the medication(s), including progress towards goals and presence/absence of adverse consequences, shall be documented in the resident's medical record. Medical record review for Resident 43 was initiated on 9/10/24. Resident 43 was admitted to the facility on [DATE]. Review of Resident 43's Initial H&P evaluation dated 8/8/24, showed Resident 43 had no capacity to understand and make decisions. Review of Resident 43's Order Summary Report dated 9/12/24, showed a physician's order dated 9/6/24, to administer alprazolam 0.5 mg one tablet by mouth every 12 hours as needed for anxiety manifested by verbalization of feeling anxious for 14 days. Review of Resident 43's MAR for September 2024 showed Resident 43 was administered the alprazolam medication on 9/11/24 at 1836 hours. Review of Resident 43's plan of care showed a care plan problem to address the resident's anxiety manifested by verbalization of feeling anxious. The interventions included to monitor behaviors and monitor side effects every shift. Further review of Resident 43's medical record did not show documented evidence for the monitoring of the side effects related to the use of alprazolam medication. On 9/12/24 at 0835 hours, an interview and concurrent medical record review for Resident 43 was conducted with RN 1. RN 1 verified the above findings. When asked about the monitoring for Resident 43's behavior related to the use of alprazolam medication, RN 1 stated the monitoring of behavior was conducted when the resident received the medication, which meant when the resident verbalized feeling anxious, he received the medication. When asked about monitoring the side effects for Resident 43 related to the use of alprazolam medication, RN 1 verified there was no documented evidence the side effects were monitored for Resident 43 related to the use of alprazolam medication.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage, labeling, and disposal of medications. * The facility failed to ensure the orally administered medications were stored separate from externally used medications. * The facility failed to ensure disinfectant wipes were stored separately from medications and treatment supplies. * The facility failed to ensure the medication bottle was kept clean and free of sticky residue. These failure posed the risk for cross-contamination of the medications. Findings: Review of the facility's P&P titled Medication Storage dated 11/29/23, showed the following: -It is the policy of the facility to ensure all medications housed on our premises will be stored in the pharmacy and/ or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. -External products: disinfectants and drugs for external drugs for external use are stored separately from internal and injectable medications; and -Internal products: medications to be administered by mouth are stored separately from other formulations (i.e. eye drops, ear drops, injectables). 1. On 9/11/24 at 0808 hours, an inspection of Medication Room A and concurrent interview was conducted with RN 1. The following was observed: - Two boxes of Fever All suppositories were stored with three boxes of oral loperamide (antidiarrheal) tablets. - One bottle of DHEA (dehydroepiandrosterone, a hormone the body produces in the adrenal gland) mood and stress tablets was stored with three boxes of eye drops. - One bottle of nasal moisturizing spray was stored with three boxes of earwax removal drops. RN 1 verified the above findings. 2. On 9/11/24 at 0852 hours, an inspection of Medication Cart A, and concurrent interview was conducted with LVN 2. A bottle of Spectrum hand sanitizing wipes (fragrance-free wipes with 70% alcohol used to clean and sanitize hands) was stored with a bottle of ammonia lactate lotion (alpha-hydroxy acids used to treat dry skin), a box of Optifoam Gentle EX (wound dressing used to help absorb shear force and manage moisture) and a box of tubular elastic retainer net dressing (used as a secondary dressing and to keep bandages and medical devices in place). LVN 2 verified the above findings. 3. On 9/11/24 at 1115 hours, an inspection of Medication Cart B and concurrent interview was conducted with LVN 3. A container of Micro-Kill Two germicidal disinfectant wipes (ready to use wipes with a quaternary-based alcohol solution used to clean and disinfect hard and nonporous surfaces) was stored with box of NexTemp thermometer strips (single use thermometers used to check temperature by placing the thermometer strip under the tongue) and a bag of spill kit (a bag containing a set of materials used to safely clean up and dispose biohazardous spills). LVN 3 verified the above findings. 4. On 9/11/24 at 1249 hours, an inspection of Medication Cart C and concurrent interview was conducted with LVN 1. A bottle of potassium chloride (supplement) was observed with orange sticky residue around the neck of the bottle. LVN 1 verified the above findings. On 9/13/24 at 1338 hours, an interview was conducted with the DON. When asked about the medication storage, the DON stated orally administered medications should be stored separately from the external medications, and eyedrops should be stored separately. The DON stated they focused more on the medication storage in the medication carts and medication refrigerator. The DON also stated the nurses should wipe the medication bottle to prevent sticky residue on the medication bottle.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the pureed recipes were followed for three of 77 residents who received pureed food from the kitchen. * The facility failed to ensure the puree recipes for biscuit and rice were followed. This failure had a potential for not providing nutritional meals to meet the residents' needs. Findings: Review of the facility's census on 9/10/24, showed there were 77 residents at the facility. The facility document titled Diet Type Report for September 2024 showed the kitchen provided the diets to 75 residents in the facility. Further review of the Diet Type Report showed three of 75 residents receiving food prepared from the kitchen were on pureed diet. Review of the facility's P&P titled Meal/Tray Assembly Procedures revised 1/2024 showed meal service is prompt and accurate to ensure temperatures and nutrient content of food is preserved. Procedures showed to ensure current diet spreadsheet is available and followed at each meal period, checks meals for accuracy, and tastes the food (all diets) to evaluate flavor and consistency. If the product is unacceptable, corrective action is taken. Review of the facility's pureed recipe titled P. Biscuit/Biscuit Mix, undated, showed to blend bread in food processor until smooth, heat vegetable stock, gradually add stock in a thin stream to bread, and blend until thoroughly combined with no lumps or bits. Review of the pureed recipe titled P. [NAME] Pilaf w/Veg Base, undated, showed to blend pasta in a food processor until smooth, gradually add vegetable broth in a thin stream to pasta and blend until thoroughly combined, no lumps or bits. On 9/11/24 at 1123 hours, a concurrent observation and interview with [NAME] 2 was conducted during the puree preparation for pureed biscuits and pureed rice. For the puree of biscuits, [NAME] 2 was observed gradually adding a total of 34 oz of hot water to the blended biscuits. For the puree of rice, [NAME] 2 was observed adding eight oz of hot water. [NAME] 2 verified he did not follow a recipe during the puree preparation. On 9/13/24 at 1346 hours, an interview was conducted with the RD, DSS, and Executive Chef. The RD, DSS, and Executive Chef acknowledged the findings. 09/13/24 at 1619 hours, an interview was conducted with the DON. The DON acknowledged the above findings and stated the recipes should be followed as per the instructions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure four of 75 residents (Residents 17, 26, 39, and 65) who received food from the kitchen were palatable. * The facility failed to ensure Residents 17, 26, 39, and 65 received palatable green beans during dining observation. This failure had a potential for the residents not consuming the food and may experience weight loss. Findings: Review of the facility's P&P titled Modified Texture Foods revised 1/2024 showed a standardized process for modified texture foods to meet community-approved diet guidelines and to assure palatability, flavor, texture, and nutritional value. Review of the facility's recipe titled [NAME] Beans Seasoned (Seasoned [NAME] Beans), undated, showed to steam vegetables until tender. Review of the International Dysphagia Diet Standardization Initiative (IDDSI) dated 7/2019, showed easy to chew texture is described as normal, everyday foods of soft/tender textures that are developmentally and age appropriate. 1. Medical record review for Resident 17 was initiated on 9/10/24. Resident 17 was admitted to the facility on [DATE], and readmitted back to the facility on [DATE]. Review of Resident 17's H&P examination dated 3/21/24, showed Resident 17 had the capacity to understand and make decisions. Review of Resident 17's Order Summary Report dated September 2024, showed a physician's order dated 1/26/24, for Regular Diet 7 Easy To Chew Texture, 0 Thin Liquid Consistency. On 9/10/24 at 1231 hours, a concurrent observation and interview with Resident 17 was conducted in the dining room. Resident 17 stated the green beans were tough and they shouldn't be tough. 2. Medical record review for Resident 26 was initiated on 9/10/24. Resident 26 was admitted to the facility on [DATE], and readmitted back to the facility on 5/2/22. Review of Resident 26's H&P examination dated 5/1/24, showed Resident 26 did not have capacity to understand and make decisions. Review of Resident 26's Order Summary Report dated September 2024 showed a physician's order dated 8/15/23, for No Restriction Diet 7 Easy To Chew Texture, 0 Thin Liquid Consistency, Small Portions. On 9/10/24 at 1237 hours, a concurrent observation and interview with Resident 26 was conducted in the dining room. Resident 26 stated the green beans were tough. 3. Medical record review for Resident 39 was initiated on 9/10/24. Resident 39 was admitted to the facility on [DATE]. Review of Resident 39's H&P examination dated 10/30/23, showed Resident 39 had fluctuating capacity to understand and make decisions. Review of Resident 39's Order Summary Report dated September 2024 showed a physician's order dated 9/3/24, for NAS (No Added Salt) Diet 7 Regular Texture, 0 Thin Liquid Consistency, for No Fish - Small Portion. On 9/10/24 at 1240 hours, a concurrent observation and interview with Resident 39 was conducted in the dining room. Resident 39 stated the green beans were tough to cut and not easy to chew on, it shouldn't be tough. On 9/10/24 at 1315 hours, a concurrent observation and interview with LVN 5 and the RD was conducted in the dining room. LVN 5 and the RD cut the green beans and verified findings. LVN 5 stated the green beans can be a bit tougher and the RD stated the residents' diets will be re-evaluated for kitchen to cut up their vegetables. 09/13/24 at 1619 hours, an interview was conducted with the DON. The DON acknowledged the above findings for Residents 17, 26, and 39. 4. On 9/10/24 at 1245 hours, during a dining observation, Resident 65 was observed in her room with a lunch tray in front of the resident. The lunch tray included a serving of green beans. Resident 65 stated the green beans were tough. Resident 65 stated she did not want any alternative menu but would not eat the green beans. Review of Resident 65's S/S 2024 Main/Week 2 meal card dated 9/10/24, showed four ounces of seasoned green beans was included in the lunch menu. On 9/10/24 at 1314 hours, a concurrent observation for Resident 65 and interview was conducted with the RD. The RD verified the above findings. Resident 65 stated the green beans were tough and not well-prepared. The RD stated she would check the green beans and why the residents complained about it. Medical record review for Resident 10 was initiated on 9/10/24. Resident 65 was admitted to the facility on [DATE]. Review of Resident 65's Order Summary Report showed a physician's order dated 8/7/24, for a regular diet, regular consistency and thin liquid consistency.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the facility's P&P titled Use of Food Brought Into the Facility was updated to address the use and storage of foods brought to the residents by the family or visitors. In addition, the facility failed to ensure the visitors were educated on safe food handling of outside food. These failures had the potential to cause foodborne illnesses to the medically vulnerable resident population who consume food brought from outside sources. Findings: 1. Review of the CMS S&C-09-39 dated 5/29/09, showed the residents have the right to choose to accept food from visitors, family, friends, or other guests according to their rights to make choices. Review of the State regulations dated 2/3/23, showed the facility must have a policy regarding use and storage of foods brought to the residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. Review of the facility's P&P titled Use of Food Brought Into the Facility revised 7/2023 showed it is the right of the residents of this facility to have food brought in by family or other visitors, however, the food must be handled in a way to ensure the safety of the resident. The P&P further showed all food items that are already prepared by the family or visitor brought in must be for immediate consumption. On 9/10/24 at 0940 hours, an interview with the RD was conducted. The RD stated the facility did not have a resident refrigerator. The RD further stated the food brought from outside were for immediate consumption. 09/13/24 at 1619 hours, an interview was conducted with the DON. The DON acknowledged the above findings and stated the facility did not have a refrigerator designated for the residents. 2. Review of the CMS S&C-09-39 dated 5/29/09, showed the residents have the right to choose to accept food from visitors, family, friends, or other guests according to their rights to make choices. The CMS guideline further shows the facility has the responsibility under the food safety regulation to help visitors to understand safe food handling practices such as not holding or transporting foods containing perishable ingredients at temperatures above 41 degrees Fahrenheit. Further Review of the facility's P&P titled Use of Food Brought Into the Facility revised 7/2023 showed no documented evidence of safe food handling instructions provided to the visitors or family bringing food from outside. On 9/12/24 at 1015 hours, an interview was conducted with the RD. When asked if the RD provided the visitors information on safe food handling including proper hand hygiene, the RD verified she did not. The RD stated the visitors were informed that the food brought from outside sources would be for the residents' immediate consumption; however, the RD stated the visitors were not educated on the safe food handling. On 9/13/24 at 1619 hours, an interview was conducted with the DON. The DON acknowledged the above findings and stated the facility did not provide the visitors education on safe handling of foods brought from outside.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitary requirements were met in the kitchen. * The facility failed to ensure the ice machine was properly cleaned. * The facility failed to ensure the ice scoopers were properly stored. * The facility failed to ensure the food items were discarded on or before the best by date. * The facility failed to ensure the food preparation utensils and equipment were in good, sanitary, and cleanable working conditions. * The facility failed to ensure the kitchen staff wore hair and beard restraint. * The facility failed to ensure the blender was free of water prior to use. * The facility failed to ensure the water liners were covered during transportation in the hallway. * The facility failed to ensure the kitchen staff performed hand hygiene. These failures had the potential to cause foodborne illnesses to the medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the facility document titled Diet Type Report for September 2024 showed 75 of 77 residents in the facility received food prepared by the facility's kitchen. 1. According to the USDA Food Code 2022, Section 4-601.11, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils: (A). Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B). The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C). Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. On 9/11/24 at 0945 hours, a concurrent observation and interview was conducted with Dishwasher 3. Dishwasher 3 stated the facility assigned him to clean inside and outside of the ice machines. There were white residue noted on the right and left sides of Ice Machine 1 and white residue with hardened white crust to the right side of Ice Machine 2. Dishwasher 3 verified findings. Dishwasher 3 stated the ice machines should be cleaned. 2. Review of the facility's P&P titled Ice Handling revised 1/2024 showed to use a scoop to remove ice from the storage bin into the receptacle used for service. A scoop should be designated for removing ice from the bin and should not be used for other purposes. Store the scoop in a self-draining container, in an area protected from contamination. On 9/11/24 at 0927 hours, a concurrent observation and interview was conducted with the RD. Two ice scoopers in a metal holder attached outside of Ice Machine 1 and Ice Machine 2 were observed not covered and protected from contamination as per the facility's P&P. The RD verified the observation. 3. According to the USDA Food Code 2022, Manufacturer's use-by dates, manufacturers assign a date to products for various reasons, and spoilage may or may not occur before pathogen growth renders the product unsafe. The manufacturer's use-by date is its recommendation for using the product while its quality is at its best. Although it is a guide for quality, it could be based on food safety reasons. It is recommended that food establishments consider the manufacturer's information as good guidance to follow to maintain the quality (taste, smell, and appearance) and salability of the product. If the product becomes inferior quality-wise due to time in storage, it is possible that safety concerns are not far behind. On 9/10/24 at 0750 hours, during the initial tour of the kitchen, the following was observed: - Ten boiled eggs with the best by date of 9/9/24 - Two bags of Hoagie breads with the best by date of 9/6/24 - One bag of fries with the best by date of 9/9/24 - Four one-gallons of fat free milk, two gallons with the best by dated of 8/22/24 and another two gallons with the best by dated of 8/24/24. The DSS and Chef 1 verified the above findings. Chef 1 stated the food products should be used prior to the best by date to ensure the items were not served expired. 4. According to the USDA Food Code 2022, Section 4-601.11, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils: (A). Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B). The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C). Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the USDA Food Code 2022 4-501.12, Cutting Surfaces, cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces. Review of the facility's P&P titled Food Handling guidelines (HACC) revised 1/2024, showed to use clean sanitized equipment and food contact surfaces (e.g., knives, skinks, utensils, table surfaces, slicers, multipurpose cutting boards, bowels, etc.) for each task. Review of the facility's P&P titled Cutting Boards revised 1/2024 showed to replace all cutting boards with grooves and pits 1/8-inch or deeper that cannot be cleaned and sanitized using routine cleaning and sanitizing procedures. On 9/10/24 at 0750 hours, during the initial tour of the kitchen, the following utensils and equipment were observed not in good, sanitary, and cleanable working conditions: - five red, three yellow, three white, two blue, two tan, two green, and one black cutting boards were heavily marred. - four rubber spatulas heavily were worn out with dark brown discoloration. - five small, four medium, and two large frying pans were heavily scratched and worn out. - three measuring cups with brown residue. - two scoopers with brown discoloration. - one peeler with brown crusted residue. - one hot tray transportation warmer with brown streak residue inside equipment. The above findings were verified with the RD, DSS, and Chef 1. The DSS stated the items in the kitchen should be cleaned. 5. Review of the facility's P&P titled Dress Guidelines for Food Service Management and Clinical Nutrition Staff revised 1/2022 showed dress for food service management and clinical nutrition staff must be professional in appearance and function to portray a positive image of the department. The P&P further showed hair restraints are worn by all when in the kitchen. This includes department associates, associates from other facility departments and guest, such as vendors. On 9/10/24 at 0819 hours, a concurrent observation and interview was conducted with Server 1 and DSS. Server 1 was observed in the kitchen without a hair restraint. The DSS verified the findings and stated hair restraints were necessary to ensure hair would not get into the residents' food. On 9/10/24 at 0932 hours, a concurrent observation and interview was conducted with Dishwasher 2 and Chef 1. Dishwasher 2 was observed with facial hair wearing a face mask with facial hair exposed. Dishwasher 2 stated he did not wear beard restraints; however, stated he should to ensure hair would not fall into the food. Chef 1 was also observed with facial hair with no beard restraint. Chef 1 verified observation and stated he would be shaving his beard and order beard restraints. 6. On 9/11/24 at 1123 hours, a concurrent observation and interview was conducted with [NAME] 2. During the puree food preparation observation for cauliflower, water was observed inside the blender. [NAME] 2 verified findings and stated the blender should be dried. 09/13/24 at 1619 hours, an interview was conducted with the DON. The DON acknowledged the above findings and stated the blender should not have water since water can harbor and grow organisms. 7. On 9/13/24 at 0945 hours, a concurrent observation and interview was conducted with CNA 7. CNA 7 was observed transporting water liners for the water pitchers without a cover in the hallway across from Nursing Station 5. When asked what the facility's protocol was when transporting water liners in the hallway, CNA 7 stated they should be covered. On 9/13/24 at 1005 hours, an interview was conducted with the DON. The DON acknowledged above findings. 8. According to the USDA Food Code 2022 2-301.14, When to Wash, food employees shall clean their hands and exposed portions of their arms after engaging in other activities that contaminate the hands. In addition, according to the USDA Food Code 2022 2-301.11, Clean Condition, the hands are particularly important in transmitting foodborne pathogens. Food employees with dirty hands and/or fingernails may contaminate the food being prepared. Therefore, any activity which may contaminate the hands must be followed by thorough handwashing in accordance with the procedures outlined in the Code. Review of the facility's P&P titled Hand Hygiene revised 1/2024 showed in the Food and Nutrition Services Department: all associates associated with the handling of food shall wash hands. Hands are washed with soap and water in the following times including: - Before each shift. - Before handling food or clean utensils/dishes/equipment -After taking a break/when returning to kitchen On 9/11/24 at 1111 hours, a concurrent observation and interview was conducted with [NAME] 1. [NAME] 1 was observed entering the kitchen without performing hand hygiene. When asked if hand hygiene was performed upon entering the kitchen, [NAME] 1 stated he did not. [NAME] 1 stated hand hygiene prevents illness and cross contamination. [NAME] 1 further stated he should have performed hand hygiene. On 9/11/24 at 1134 hours, a concurrent observation and interview was conducted with [NAME] 2. During pureed food preparation observations, [NAME] 2 was observed removing the used kitchen equipment and utensils from the sink to the three-compartment sink for washing. Further observation showed [NAME] 2 returned without changing out gloves and performing hand hygiene. [NAME] 2 then started crumbing the biscuits to prepare the puree biscuit. When asked if change of gloves and hand hygiene were performed prior to crumbing the biscuits, [NAME] 2 stated he did not. [NAME] 2 further stated he should have performed hand hygiene and changed his gloves to present cross contamination. 09/13/24 at 1619 hours, an interview was conducted with the DON. The DON acknowledged the above findings and stated the kitchen staff were expected to perform hand hygiene upon entering the kitchen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to establish and maintain the infection control program and practices designed to help prevent the development and transmission of diseases and infections as evidenced by: * The facility failed to ensure the contact and droplet precautions were practiced for Resident 569. * The facility failed to ensure the infection control was maintained in the laundry room. * The facility failed to show consistent and accurate documentation of its testing protocols for Legionella and other opportunistic pathogens in building water systems. These failures had the potential risk for transmission of communicable diseases or organisms to residents in the facility. Findings: 1. Review of the facility's P&P titled Transmission Based Precautions revised 10/31/22, showed the Definitions section includes the following: - Contact precautions refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment; and - Droplet precautions refer to actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Under the section Policy Explanation and Compliance Guidelines: - Visitors coining to visit a resident who is on transmission-based precautions (isolation precautions) or quarantine, will be informed by the facility of the potential risk of visiting and precautions necessary when visiting the resident. Review of the facility's P&P titled Isolation Precautions revised 5/31/22, showed the following: - The facility will use standard approaches, as defined by the CDC (Center for Disease Control and Prevention), for transmission-based precautions: airborne, contact, and droplet precautions. The category of transmission-based precautions will determine the type of PPE (personal protective equipment) to be used; and - Information regarding the particular type of precaution to be utilized will be communicated through verbal reports, written in-house communications forms, and signage. Review of the facility's P&P titled Personal Protective Equipment revised 5/31/22, showed the following: - Wear gloves when direct contact with blood, body fluids, mucous membranes, non-intact skin, or potentially contaminated surfaces or equipment is anticipated; - Gowns should fully cover torso from neck to knees, arms to end of wrist, and wrap around the back. Fasten in back at neck and waist; and - Wear goggles or face shield as added face/eye protection. Personal eyeglasses are not a substitute for goggles. Review of the facility's P&P titled Shingles revised 5/23/23, showed for the residents that exhibit signs and symptoms of shingles, to apply contact and droplet precautions. On 9/10/24 at 1049 hours, during a concurrent initial tour observation of the facility and interview with CNA 6, a contact and droplet precautions signage was observed posted outside the room on top of the three-tier PPE drawer of Resident 569. The signage showed anyone entering the room must follow the following precautions- hand hygiene before and after entering/exiting the room, eye protection (goggles/face shield), face mask, gloves, and gown. CNA 6 stated Resident 569 had shingles. Medical record review for Resident 569 was initiated on 9/10/24. Resident 569 was admitted to the facility on [DATE]. Review of Resident 569's H&P examination dated 9/4/24, showed Resident 569 had the capacity to understand and make decisions. Review of Resident 569's Order Summary Report dated September 2024 showed a physician's order dated 9/6/24, for contact droplet precautions every shift for shingles. On 9/10/24 at 1242 hours, LVN 7 was observed standing outside Resident 569's room and talking to Family Member 1. Family Member 1 was observed wearing a personal eyeglass, an untied yellow disposable gown which was falling off from her shoulders down to half of her upper body, and mask, without gloves and eye goggles or face shield. Family Member 1 was observed standing beside the bed of the resident and touching the resident and the bed. Family Member 1 was further observed talking to Resident 569. When Family Member 1 was asked to be interviewed, LVN 7 instructed Family Member 1 to tie her gown, wear gloves, and to remove the PPEs before leaving the room and sanitize her hands. On 9/10/24 at 1250 hours, an interview was conducted with Family Member 1. Family Member 1 stated she was aware Resident 569 had shingles and had been visiting the resident almost everyday, but no one had instructed her on what to do prior to entering the room. Family Member 1 stated she did not notice the signage for contact and droplet precautions outside the room. Family Member 1 further stated she was just told by LVN 7 to read the sign by the door. On 9/10/24 at 1315 hours, LVN 7 stated Resident 569 was on contact and droplet precautions because of shingles. LVN 7 stated Family Member 1 was already inside the room when she saw her. LVN 7 further stated the visitors of resident on isolation precaution should be taught or reminded of the precautions to observe before entering the room to prevent spread of infection. On 9/11/24 at 1113 hours, a concurrent interview and medical record review was conducted with the IP. The IP stated he would call the family of the resident and provide information regarding the infection and precautions to observe when visiting the resident, and the staff could also provide information to the resident and family members. The IP stated the visitor's personal eyeglass was not considered as a substitute for the eye protectors or goggles. The IP further stated the facility should provide all needed PPE to be used for the residents on isolation precaution. The IP was informed and acknowledged the above findings. 2. Review of the facility's document titled Employee Handbook dated 2020 showed each department has lockers that can be used by employees to store personal belongings while an employee is on duty. On 9/12/24 at 0927 hours, a concurrent observation of the laundry room and interview was conducted with Laundry Aide 1. The cellphone and body lotion were observed in the clean folding area. Laundry Aide 1 verified the findings. Laundry Aide 1 stated both cellphone ad body lotion were hers. On 9/12/24 at 1119 hours, an interview was conducted with the Housekeeping Manager. The Housekeeping Manager stated the laundry area's clean folding area should be free of any employee's personal belongings to prevent spread of infection and contamination of linens. 3. According to the CMS QSO 17-30 titled Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaire's Disease dated 6/2/17, the facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. These facilities must have water management plans and documentation that, at a minimum, ensure each facility specifies testing protocols and acceptable ranges for control measures and documents the results of testing and corrective actions when control limits are not maintained. Review of the facility's Water Management Program revised on 10/01/21, showed a risk assessment will be conducted by the water management team annually to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water systems. On 9/12/24 at 1515 hours, a concurrent interview and facility document review was conducted with the Director of Facilities. Review of the facility's Water System Infection Control Risk Assessment failed to show a recent documentation of its testing protocols for Legionella and other opportunistic pathogens in the building water systems. The risk assessment was last completed on 10/15/18. The Director of Facilities verified this finding and stated the testing was conducted by an outside company. On 9/13/24 at 1545 hours, an interview was conducted with the Administrator. The Administrator acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the essential kitchen equipment were in safe operating condition. * The facility failed to ensure two of two ice machines were properly cleaned as per the ice machine cleaning instruction. This failure had the potential for ice served from the kitchen to be unsanitary. Findings: Review of the facility document titled Hoshizaki Instruction Manual revised 11/2018 showed Hoshizaki provides this manual primarily to assist qualified service technicians in the installation, maintenance, and service of the appliance. Further review of the facility document showed the cleaning and sanitizing instructions in the manual included the following: - Cleaning solution: dilute 9.6 fl. oz. (0.29 L) of Hoshizaki Scale Away with 1.6 gal (6.0 L) of warm water. This is a minimum amount. Make more solution if necessary. - Sanitizing solution: dilute 2.5 fl. oz. (75 ml or 5 tbs) of 5.25% sodium hypochlorite solution (chorine bleach) with 5 gallons (19 L) of warm water. This is a minimum amount. Make more solution if necessary. Review of the facility document titled Service/Project Report by Ram Air Engineering dated 5/2/24, showed the ice machines are cleaned with nickel safe food grade cleaner, brushed, and rinsed. The document further showed sanitizing solution is processed through the system, rinsed and restored all components after rinsing. Review of the document showed no documented evidence of the sanitizing solution used to clean the ice machines. On 9/11/24 at 0927 hours, a concurrent observation and interview was conducted with the Maintenance Staff. Ice Machines 1 and 2 were noted with white and brown residue and gray particles inside the ice machines. The Maintenance Staff stated the facility used an outside company called Ram to service and clean both ice machines every six months. The Maintenance Staff verified observations and stated the ice machines should be cleaned to ensure the ice would not get contaminated. On 9/13/24 at 1346 hours, a concurrent facility document review and interview was conducted with the RD, DSS, and Chef 1. The RD stated the facility contacted Ram to verify the solutions used when cleaning the ice machines which included the following: - Nu-Calgon IMS-III Sanitizing Concentrate - Nu-Calgon Nickel-Safe Ice Machine Cleaner The RD verified the Nu-Calgon IMS-III Sanitizing Concentrate's active ingredients did not include 5.25% sodium hypochlorite solution (chorine bleach) as per the Hoshizaki Instruction Manual. 09/13/24 at 1619 hours, an interview was conducted with the DON. The DON acknowledged the above findings and stated the current instructions from the Hoshizaki Instruction Manual revised 11/2018 should be followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 15. On 9/10/24 at 0911 hours, a concurrent observation and interview was conducted with Resident 37. Resident 37 was observed sitting in his wheelchair next his bed, with bilateral side rails elevated. Resident 37 stated he used the side rails to help turning himself in bed and getting out of bed. On 09/11/24 at 0806 hours, a concurrent observation and interview was conducted with Resident 37. Resident 37 stated the bilateral side rails were elevated all the time. Medical record review for Resident 37 was initiated on 9/10/24. Resident 37 was admitted to the facility on [DATE]. Review of Resident 37's H&P examination dated 7/28/24, showed Resident 37 had the capacity to understand and make decisions. Review of Resident 37's Bed Rail Assessment and Consent dated 7/26/24, showed the resident and the resident's representative requested the use of the side rails for mobility and transfer assistance and the resident's representative gave consent for the use of the side rails. However, the Bed Rail Assessment and Consent did not show Resident 37 was assessed for the risk of entrapment from the side rails use prior to installation. Review of the facility's Bed Maintenance and Inspection log dated 7/2/24, showed the beds for Room F had no gaps. However, the log did not show which entrapment zones were measured. In addition, the log did not have a resident identifier to show which residents were associated with that room number. 16. On 9/10/24 at 1152 hours, a concurrent observation and interview was conducted with Resident 669. Resident 669 was observed lying in bed with bilateral side rails elevated. Resident 669 stated he used the bilateral siderails to change his position in bed and get out of bed. Medical record review for Resident 669 was initiated on 9/10/24. Resident 669 was readmitted to the facility on [DATE]. Review of Resident 669's H&P examination dated 9/4/24, showed Resident 669 had the capacity to understand and make decisions. Review of Resident 669's Bed Rail Assessment and Consent dated 9/2/24, showed the resident requested the use of bed rails for mobility and transfer assistance and the resident's representative gave consent for the use of the side rails. However, the Bed Rail Assessment and Consent did not show Resident 669 was assessed for the risk of entrapment from the side rails use prior to installation. Review of Resident 669's Order Summary Report showed a physician's order dated 9/1/24, for bilateral ¼ bed rails in place to assist with bed mobility. Review of the Bed Maintenance and Inspection log dated 7/2/24, showed for Room G, Bed A had no gaps. However, the log did not show which entrapment zones were measured. In addition, the log did not have a resident identifier to show which residents were associated with that room number. On 9/12/24 at 1429 hours, an interview was conducted with the Director of Facilities. The Director of Facilities acknowledged and verified the above findings for Residents 37 and 669. On 9/13/24 at 1545 an interview was conducted with the DON. The DON acknowledged and verified the above findings. 12. On 9/12/24 at 0854 hours, Resident 1 was observed sitting in a wheelchair inside her room. The bed was observed with the bilateral ¼ side rails elevated. Resident 1 stated she used the ¼ side rails for turning and to get in the bed. Medical record review for Resident 1 was initiated on 9/10/24. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's MDS dated [DATE], showed Resident 1's cognition was intact. Review of Resident 1 s Order Summary Report showed a physician's order dated 7/30/24, for bilateral 1/4 side rails in place to assist with bed mobility every shift. Further review of Resident 1's medical record failed to show documented evidence of any measurements related to the bed rail entrapment zones. On 9/12/24 at 0925 hours, a concurrent observation and interview was conducted with CNA 1. CNA 1 verified Resident 1's bilateral ¼ side rails were elevated. CNA stated Resident 1 was using the side rails for mobility. On 9/12/24 at 1430 hours, an interview and concurrent record review for Resident 1 was conducted with the Director of Facilities. The Director of Facilities stated he performed bed inspection on resident's discharge and quarterly. The Director of Facilities stated he used LifeLoop (connects senior living residents, staff, and family members with its inclusive software) digital work order program anytime when he got a work order. The Director of Facilities stated the maintenance used the Bionix (bed entrapment measurement tool) bed system measuring device on an empty bed. The Director of Facilities showed the Bed Maintenance and Inspection form dated 7/2/24, included the room, date, and no gaps comment for Resident 1's bed. However, the Director of Facilities was not able to present a form with measurement of the entrapment zones. The Director of Facilities acknowledged he was not familiar with the entrapment zones. On 9/12/24 at 1610 hours, a concurrent interview and facility document review for Resident 1 was conducted with the Director of Facilities. The Director of Facilities showed a copy of the LifeLoop work order to install or remove side rails. The Director of Facilities verified the copy of the LifeLoop work order did not show the entrapment assessment for Resident 1. On 9/13/24 at 1517 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 13. On 9/10/24 at 0944 hours, Resident 27 was observed lying in bed and watching TV inside her room. The bed was observed with the bilateral ¼ side rails elevated. Resident 27 stated she used the ¼ side rails for turning in the bed. Medical record review for Resident 27 was initiated on 9/10/24. Resident 27 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 27's MDS dated [DATE], showed Resident 27's cognition was intact. Review of Resident 27's Order Summary Report showed a physician's order dated 7/23/24, for bilateral 1/4 side rails in place to assist with bed mobility every shift. Further review of Resident 27's medical record failed to show documented evidence of any measurements related to the bed rail entrapment zones. On 9/12/24 at 1013 hours, a concurrent observation and interview was conducted with CNA 4. CNA 4 verified Resident 27's bilateral ¼ side rails were elevated. CNA 4 stated Resident 27 requested for side rails and was using the side rails for turning. On 9/12/24 at 1430 hours, a concurrent interview and facility document review for Resident 27 was conducted with the Director of Facilities. The Director of Facilities stated he performed bed inspection on the resident's discharge and quarterly. The Director of Facilities stated he used LifeLoop (connects senior living residents, staff, and family members with its inclusive software) digital work order program anytime when he got a work order. The Director of Facilities stated the maintenance staff used the Bionix (bed entrapment measurement tool) bed system measuring device on an empty bed. The Director of Facilities showed the Bed Maintenance and Inspection form dated 7/2/24, included the room, date, and no side rail comment for Resident 27's bed. The Director of Facilities was not able to present a form with measurement of the entrapment zones. The Director of Facilities acknowledged he was not familiar with the entrapment zones. On 9/12/24 at 1610 hours, a concurrent interview and facility document review for Resident 27 was conducted with the Director of Facilities. The Director of Facilities showed a copy of the LifeLoop work order to install or remove side rails. The Director of Facilities verified the copy of the LifeLoop work order did not show the entrapment assessment for Resident 27. On 9/13/24 at 1517 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 14. On 9/12/24 at 0949 hours, Resident 620 was observed lying in bed inside her room. The bed was observed with the bilateral ¼ side rails elevated. Resident 620 stated she used the ¼ side rails for turning and getting up. Medical record review for Resident 620 was initiated on 9/10/24. Resident 620 was admitted to the facility on [DATE]. Review of Resident 620's MDS dated [DATE], showed Resident 620's cognition was intact. Review of Resident 620's Order Summary Report showed a physician's order dated 8/26/24, for bilateral 1/4 side rails in place to assist with bed mobility every shift. Further review of Resident 620's medical record failed to show documented evidence of any measurements related to the bed rail entrapment zones. On 9/12/24 at 1002 hours, a concurrent observation and interview was conducted with CNA 4. CNA 4 verified Resident 620's bilateral ¼ side rails were elevated. CNA 4 stated Resident 620 requested the side rails because she was afraid to fall and was using the side rails for turning. On 9/12/24 at 1430 hours, a concurrent interview and facility document review for Resident 620 was conducted with the Director of Facilities. The Director of Facilities stated he performed bed inspection on resident's discharge and quarterly. The Director of Facilities stated he used LifeLoop (connects senior living residents, staff, and family members with its inclusive software) digital work order program anytime when he got a work order. The Director of Facilities stated the maintenance staff used the Bionix (bed entrapment measurement tool) bed system measuring device on an empty bed. The Director of Facilities showed the Bed Maintenance and Inspection form dated 7/2/24, included the room, date, and no gaps comment for Resident 620's bed. However, the Director of Facilities was not able to present a form with measurement of the entrapment zones. The Director of Facilities acknowledged he was not familiar with the entrapment zones. On 9/12/24 at 1610 hours, a concurrent interview and facility document review for Resident 620 was conducted with the Director of Facilities. The Director of Facilities showed a copy of the LifeLoop work order to install or remove side rails. The Director of Facilities verified the copy of the LifeLoop work order did not show the entrapment assessment for Resident 620. On 9/13/24 at 1517 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.5. On 9/10/24 at 0835 hours, during the initial tour of the facility, Resident 4 was observed awake sitting in the wheelchair. Resident 4's bed was observed with bilateral ¼ bed rails elevated. Resident 4 did not speak English. On 9/12/24 at 0826 hours, Resident 4 was observed sitting in the wheelchair and having breakfast. Resident 4's bed was observed with bilateral ¼ bed rails elevated. Medical record review for Resident 4 was initiated on 9/12/24. Resident 4 was readmitted to the facility on [DATE]. Review of Resident 4's H&P examination dated 11/14/23, showed Resident 4 had the capacity to understand and make decisions. Review of Resident 4's Order Summary Report dated September 2024 showed a physician's order dated 11/8/23, for bilateral ¼ bed rails in place to assist with bed mobility. Review of Resident 4's plan of care showed a care plan problem dated 12/16/23, addressing the use of the bilateral ¼ bed rails for bed mobility. The interventions/tasks included the facility to perform quarterly and prn (as needed) safety checks of bed rails by maintenance. Review of Resident 4's Bed Rail Assessment and Consent dated 8/13/24, showed the resident had the right and left ¼ length rails for mobility and transferring assistance, and the potential for significant risk for injury and potential hazard for getting caught between rails or bed rails and mattress were discussed. On 9/12/24 at 0930 hours, an interview was conducted with CNA 6. CNA 6 verified Resident 4's used of the bilateral ¼ bed rails. CNA 6 stated Resident 4 had been using the bed rails for assistance with bed mobility, turning, and getting out of bed. On 9/12/24 at 0940 hours, a concurrent interview and facility document review for Resident 4 was conducted with LVN 8. LVN 8 verified Resident 4 used the bilateral ¼ bed rails. When asked about the entrapment assessment, LVN 8 stated the entrapment assessment was not included in the bed rail assessment the nurses had to complete, but they would call the maintenance department to install the bed rails. 6. On 9/12/24 at 1145 hours, Resident 16 was observed awake and lying in the bed. Resident 16's bed was observed with bilateral ¼ bed rails elevated. Resident 16 stated the bed rails helped her with turning and she grabbed on it when they cleaned her or if she would get out of bed. Medical record review for Resident 16 was initiated on 9/12/24. Resident 16 was admitted to the facility on [DATE]. Review of Resident 16's H&P examination dated 10/25/23, showed Resident 16 had the capacity to understand and make decisions. Review of Resident 16's Order Summary Report dated September 2024 showed a physician's order dated 10/24/23, for bilateral ¼ bed rails in place to assist with bed mobility. Review of Resident 16's plan of care showed a care plan problem dated 1/15/24, addressing the use of the bilateral ¼ bed rails for bed mobility. The interventions/tasks included the facility to perform quarterly and prn safety checks of bed rails by maintenance. Review of Resident 16's Bed Rail Assessment and Consent dated 7/29/24, showed the resident had right and left ¼ length rails for mobility and transferring assistance, and potential for significant risk for injury and potential hazard for getting caught between rails or bed rails and mattress were discussed. On 9/12/24 at 1210 hours, an interview was conducted with CNA 7. CNA 7 verified Resident 16's use of the bilateral ¼ bed rails. CNA 7 stated Resident 16 had been using the bed rails for assistance with turning and getting out of bed. On 9/12/24 at 1220 hours, a concurrent interview and facility document review for Resident 16 was conducted with LVN 8. LVN 8 verified Resident 16 used the bilateral ¼ bed rails. When asked about the entrapment assessment, LVN 8 stated the entrapment assessment was not included in the bed rail assessment that the nurses had to complete, but they would call the maintenance department to install the bed rails. 7. On 9/12/24 at 0822 hours, Resident 56 was observed sleeping in the bed. Resident 56's bed was observed with bilateral ¼ bed rails elevated. Medical record review for Resident 56 was initiated on 9/12/24. Resident 56 was readmitted to the facility on [DATE]. Review of Resident 56's H&P examination dated 6/13/24, showed Resident 16 did not have the capacity to understand and make decisions. Review of Resident 56's Order Summary Report dated September 2024, showed a physician's order dated 6/12/24, for bilateral ¼ bed rails in place to assist with bed mobility every shift. Review of Resident 56's plan of care showed a care plan problem dated 6/12/24, addressing the use of the bilateral ¼ bed rails for bed mobility. The interventions/tasks included the facility to perform quarterly and prn safety checks of bed rails by maintenance. Review of Resident 56's Bed Rail Assessment and Consent dated 7/15/24, showed the resident had the right and left ¼ length rails for mobility and transferring assistance, and the potential for significant risk for injury and potential hazard for getting caught between rails or bed rails and mattress were discussed to the resident's family member. On 9/12/24 at 0822 hours, an interview was conducted with CNA 7. CNA 7 verified Resident 56's use of the bilateral ¼ bed rails. CNA 7 stated Resident 56 felt safe holding on to the bed rails while being turned. On 9/12/24 at 0940 hours, a concurrent interview and facility document review for Resident 56 was conducted with LVN 8. LVN 8 verified Resident 56 used the bilateral ¼ bed rails. LVN 8 stated the entrapment assessment was not included in the bed rail assessment the nurses had to complete, but they would call the maintenance department to install the bed rails. 8. On 9/10/24 at 1049 hours, during the initial tour of the facility, Resident 569 was observed awake lying in the bed. Resident 569's bed was observed with bilateral ¼ bed rails elevated. Medical record review for Resident 569 was initiated on 9/10/24. Resident 569 was admitted to the facility on [DATE]. Review of Resident 569's H&P examination dated 9/4/24, showed Resident 569 had the capacity to understand and make decisions. Review of Resident 569's Order Summary Report dated September 2024, showed a physician's order dated 9/4/24, for bilateral ¼ bed rails in place to assist with bed mobility. Review of Resident 569's plan of care showed a care plan problem dated 9/4/24, addressing the use of the bilateral ¼ bed rails for bed mobility. The interventions/tasks included the facility to perform quarterly and prn safety checks of bed rails by maintenance. Review of Resident 569's Bed Rail Assessment and Consent dated 9/4/24, showed the resident had the right and left ¼ length rails for mobility and transferring assistance, and the potential for significant risk for injury and potential hazard for getting caught between rails or bed rails and mattress were discussed. On 9/10/24 at 1115 hours, an interview was conducted with CNA 6. CNA 6 verified Resident 569's use of the bilateral ¼ bed rails since admission to the facility. CNA 6 stated Resident 569 had been using the bed rails for assistance with turning. On 9/10/24 at 1315 hours, a concurrent interview and facility document review for Resident 569 was conducted with LVN 7. LVN 7 verified Resident 569 used the bilateral ¼ bed rails. LVN 7 stated the nurses had to complete the bed rail assessment, but the entrapment assessment was not performed. LVN 7 stated the maintenance staff would install the bed rails and check the bed. On 9/12/24 at 1429 hours, an interview and concurrent facility document review for Residents 4, 16, 56, and 569 was conducted with the Director of Facilities. When asked about bed inspection, the Director of Facilities stated the bed inspection was performed when the resident was discharged , and the bed rails were also removed at the same time. The Director of Facilities further stated they performed a quarterly maintenance bed inspection for all the beds but they did not do the bed inspection during admission of the resident. Review of the facility document titled Bed Maintenance and Inspection dated 7/2/24, showed the following: - For Resident 4's room, the side rails had no gaps; - For Resident 16's room, the side rails had no gaps; - For Resident 56's room, the side rails had no gaps; and - For Resident 569's room, there were no side rails. Further review of the document showed no documented evidence the entrapment zones were assessed. The Director of Facilities verified no entrapment zones assessment had been done for all the bed with bed rails in the facility and he was not familiar with the entrapment zones. On 9/13/24 at 1545 hours, an interview was conducted with the DON and Administrator. The DON and Administrator acknowledged the above findings. 9. Medical record review for Resident 52 was initiated on 9/10/24. Resident 52 was admitted to the facility on [DATE], and readmitted back to the facility on 5/4/23. Review of Resident 52's H&P examination dated 3/6/24, showed Resident 52 had the capacity to understand and make decisions. Review of Resident 52's Order Summary Report dated September 2024 showed a physician's order dated 6/9/23, for bilateral ¼ bed rails in place to assist with bed mobility. Review of Resident 52's Bed Rail Assessment and Consent dated 9/10/24, showed the resident had the right and left ¼ length rails for mobility and transferring assistance. Review of Resident 52's Bed Rails Safety Check dated 6/5/24 showed no documented evidence the entrapment zones were assessed. 10. Medical record review for Resident 53 was initiated on 9/10/24. Resident 53 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 53's H&P examination dated 5/31/24, showed Resident 53 had the capacity to understand and make decisions. Review of Resident 53's Order Summary Report dated September 2024 showed a physician's order dated 5/31/24, for bilateral ¼ bed rails in place to assist with bed mobility. Review of Resident 53's Bed Rail Assessment and Consent dated 9/5/24, showed the resident had the right and left ¼ length rails for mobility and transferring assistance. Review of the facility document titled Bed Maintenance and Inspection dated 7/2/24, showed Resident 52's side rails had no gaps. Further review of the document showed no documented evidence entrapment zones were assessed. 11. Medical record review for Resident 57 was initiated on 9/10/24. Resident 57 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 57's H&P examination dated 7/16/24, showed Resident 57 had the capacity to understand and make decisions. Review of Resident 57's Order Summary Report dated September 2024, showed a physician's order dated 11/6/23, for bilateral ¼ bed rails in place to assist with bed mobility. Review of Resident 57's Bed Rail Assessment and Consent dated 6/17/24, showed the resident had the right and left ¼ length rails for mobility and transferring assistance. Review of Resident 57's Bed Rails Safety Check dated 6/21/24, showed no documented evidence the entrapment zones were assessed. On 9/13/24 at 1436 hours, an interview with CNA 5 was conducted outside of Resident 57's room. CNA 5 verified Residents 52, 53, and 57 used the ¼ length side rails for mobility, repositioning, and transfers. On 9/13/24 at 1443 hours, an interview with LVN 1 was conducted outside of Resident 57's room. LVN 1 stated Resident 52, 53, and 57 used the ¼ length side rails for repositioning and transfers in and out of bed. 09/13/24 at 1619 hours, an interview was conducted with the DON. The DON acknowledged the above findings for Residents 52, 53, and 57. Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were complete and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of side rails for 16 of 53 residents with bed rails (Residents 1, 4, 8, 10, 16, 27, 37, 43, 52, 53, 56, 57, 320, 569, 620, and 669). These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. The seven areas in the bed system where there is a potential for entrapment are: - Zone 1: within the rail; - Zone 2: under the rail, between the rail supports or next to a single rail support; - Zone 3: between the rail and the mattress; - Zone 4: under the rail, at the ends of the rail; - Zone 5: between split bed rails; - Zone 6: between the end of the rail and the side edge of the head or foot board; and - Zone 7: between the head or foot board and the mattress end. Review of the facility's P&P titled Bed Rails revised ate 4/2/18, showed the following: - Entrapment is an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail; and - If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including, but not limited to, the following elements: assess the resident for risk of entrapment from ed rails prior to installation, ensure the bed's dimensions are appropriate for the resident's size and weight, and ensure the mattress, bed frame and bed rail leave no gap wide enough to entrap the resident's head or body. Review of the facility's document titled Order Listing Report dated 9/12/24, showed the facility had 53 residents who used bed rails, including Residents 1, 4, 8, 10, 16, 27, 37, 43, 52, 53, 56, 57, 320, 569, 620, and 669. A concurrent observation, interview, medical record review, and facility document review for Residents 1, 4, 8, 10, 16, 27, 37, 43, 52, 53, 56, 57, 320, 569, 620, and 669 showed the residents' bed entrapment assessments were not completed and the bed inspection gap measurements for the entrapment zones were not recorded. 1. On 9/10/24 at 0904 hours, 9/11/24 at 0941 and 1326 hours, 9/12/24 at 0801, 1008, 1358, and 1550 hours, and on 9/13/24 at 1532 hours, Resident 43 was observed in bed with bilateral ¼ side rails elevated. Medical record review for Resident 43 was initiated on 9/10/24. Resident 43 was admitted to the facility on [DATE]. Review of Resident 43's MDS dated [DATE], showed Resident 43 had severe cognitive impairment, with no impairment to the upper and lower extremities; and required partial/moderate assistance for mobility. Review of Resident 43's Bed Rail Assessment and Consent dated 8/9/24, showed the bed rails were requested for mobility/transferring assistance. The form showed the potential risks of bed rails included acts as a restraint by hindering the resident from independently getting out of bed, creates a barrier to performing activities such as going to the bathroom or retrieving items in the room, poses a potential for significant risk for injury, a potential hazard for getting caught between rails or bedrails and mattress, and a potential for negative physical outcomes such as decreased muscle functioning and balance, skin integrity, ADL cares (continence, eating, hydration, walking, and mobility). The form showed the IDT recommended ¼ bed rails were to be used at all times while the resident was in bed. Review of Resident 43's Order Summary Report dated 9/12/24, showed a physician's order dated 8/9/24, to provide bilateral ¼ bed rails in place to assist with bed mobility. Review of Resident 43's plan of care showed a care plan problem dated 8/9/24, to address the safety risk related to the use of bilateral ¼ side rails used to assist bed mobility. The goal was for the resident to attain the highest practicable level of function and safety without harm and/or entrapment through the next review. The interventions included to conduct the bed rail assessment prior to utilization for appropriateness, quarterly and as needed. On 9/12/24 at 0802 hours, an interview was conducted with CNA 1. When asked about Resident 43's use of bed rails, CNA 1 stated Resident 43 could move his arms, and used the bed rails when turning. 2. On 9/10/24 at 0817 hours, during the initial tour of the facility, Resident 320 was observed lying in bed with bilateral ¼ bed rails elevated. Resident 320 stated she held on to the bed rails when she was repositioned to her side. On 9/11/24 at 0937 hours, and 9/12/24 at 0801 and 1358 hours, Resident 320 was observed lying in bed with bilateral ¼ bed rails elevated. Medical record review for Resident 320 was initiated on 9/10/24. Resident 320 was admitted to the facility on [DATE]. Review of Resident 320's MDS dated [DATE], showed Resident 320 was cognitively intact with impairment to both upper extremities, and dependent of staff assistance for mobility. Review of Resident 320's Bed Rail Assessment and Consent dated 8/28/24, showed the bed rails were requested for mobility/transferring assistance. The form showed the potential risks of bed rails included acts as a restraint by hindering resident from independently getting out of bed, creates a barrier to performing activities such as going to the bathroom or retrieving items in the room, poses a potential for significant risk for injury, a potential hazard for getting caught between rails or bedrails and mattress, and a potential for negative physical outcomes such as decreased muscle functioning and balance, skin integrity, ADL cares (continence, eating, hydration, walking, and mobility). The form showed the IDT recommended ¼ bed rails were to be used at all times while the resident was in bed. Review of Resident 320's Order Summary Report dated 9/12/24, showed a physician's order dated 8/28/24, to provide bilateral ¼ bed rails in place to assist with bed mobility. Review of Resident 320's plan of care showed a care plan problem dated 8/28/24, addressing the safety risk related to the use of bilateral ¼ side rails used to assist bed mobility. The goal was for the resident to attain the highest practicable level of function and safety without harm and/or entrapment through the next review. The interventions included to conduct bed rail assessment prior to utilization for appropriateness, quarterly and as needed. On 9/12/24 at 0801 hours, an interview was conducted with CNA 2. When asked about Resident 320's use of bed rails, CNA 2 stated Resident 320 could move her arms and held on to the bed rails when turned to her side. 3. On 9/10/24 at 0849 hours, 9/11/24 at 0937 and 1316 hours, and 9/12/24 at 0759, 1016, and 1359 hours, Resident 8 was observed in bed with bilateral ¼ bed rails elevated. Medical record review for Resident 8 was initiated on 9/10/24. Resident 8 was readmitted to the facility on [DATE]. Review of Resident 8's MDS dated [DATE], showed Resident 8 had moderate cognitive impairment, with no impairment to the upper extremities, and required substantial/maximal assistance for mobility. Review of Resident 8's Bed Rail Assessment and Consent dated 8/1/24, showed the bed rails were requested for mobility/transferring assistance. The form showed the potential risks of bed rails included acts as a restraint by hindering resident from independently getting out of bed, creates a barrier to performing activities such as going to the bathroom or retrieving items in the room, poses a potential for significant risk for injury, a potential hazard for getting caught between rails or bedrails and mattress, and a potential for negative physical outcomes such as decreased muscle functioning and balance, skin integrity, ADL cares (continence, eating, hydration, walking, and mobility). The form showed the IDT recommended ¼ bed rails were to be used at all times while the resident was in bed. Review of Resident 8's Order Summary Report dated 9/12/24, showed a physician's order dated 8/28/24, to provide bilateral ¼ bed rails in place to assist with bed mobility. Review of Resident 8's plan of care showed a care plan problem dated 8/1/24, to address the safety risk related to the use of bilateral ¼ side rails used to assist bed mobility. The goal was for the resident to attain the [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review and facility P&P review, the facility failed to remove a staff (CNA 1) from resident care areas pending an alleged violation of abuse for one of two sampled residents (Resident 1) as per the facility's P&P. This failure had the potential to expose Resident 1 to abuse. Findings: Review of the facility's P&P titled Reporting Allegations of Abuse/Neglect/Exploitation revised 10/21/22, showed under the Procedure for Response and Reporting Allegations of Abuse/Neglect/Exploitation section, when thereports of abuse/neglect/exploitation occur, the following procedure will be initiated: 1. The Licensed Nurse will: a. Respond to the needs of the resident and protect him/her from further incident. b. Remove the accused employee from resident care areas. 2. The Administrator or designee will: c. Suspend the accused employee pending completion of the investigation. Review of the facility's SOC 341 (a form to report suspected abuse) dated 4/8/24, showed the facility reported Resident 1 reported to a staff that CNA 1 hit her left shoulder on 4/7/24 at 2000 hours. Medical record review for Resident 1 was initiated on 4/9/24. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the facility Census dated 4/7/24, showed Resident 1 was in room [ROOM NUMBER]A. Review of the facility's Nursing Assignment Sheet on 4/7/24, for the PM shift from 1500 to 2300 hours, showed CNA 1 was assigned to Rooms 406B and 417A to 419B. On 4/9/24 at 1120 hours, a telephone interview was conducted with CNA 1. When asked about the abuse allegation related to Resident 1, CNA 1 verified she provided care for Resident 1 on 4/7/24. CNA 1 was asked if she was sent home on 4/7/24, pending the investigation of the abuse allegation with Resident 1. CNA 1 stated after the allegation reported, she was reassigned to care for another resident and remained at work until the completion of her shift. On 4/9/24 at 1457 hours, an interview was conducted with LVN 3. LVN 3 verified she provided care for Resident 1 on 4/7/24. LVN 3 stated she and LVN 1 interviewed Resident 1 regarding her allegation of abuse. LVN 3 was asked if CNA 1 was sent home after the abuse allegation. LVN 3 stated CNA 1 was not sent home. On 4/9/23 at 1555 hours, an interview was conducted with the Administrator. When asked about the facility's protocol for the allegations of abuse involving the staff to resident abuse, the Administrator stated for the abuse allegations involving staff members, the alleged staff would immediately be excused from the facility and should be suspended pending the investigation of the abuse. When asked if CNA 1 was sent home on 4/7/24, the Administrator stated CNA 1 completed her shift and clocked out at 2251 hours, on 4/7/24. When the Administrator was asked about the potential risk of having the alleged perpetrator remain in the facility, the Administrator stated if the abuse did occur, having the perpetrator in the facility may create an opportunity for retaliation against the victim. On 4/9/24 at 1651 hours, the Administrator and DON were informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide an environment free from accident hazards for one of 17 final sampled residents (Resident 10). * The facility failed to ensure safe smoking practice for Resident 10 who smoked in the facility. Resident 10 had her smoking materials in her possession when her care plan for safe smoking included the intervention for the activity staff to keep her lighter and the facility's smoking policy showed the smoking materials were to be maintained by staff. This failure posed the risk of fire and injury to the residents and staff in the facility. Findings: Review of the facility's P&P titled Resident Smoking Policy revised 3/27/17, showed the smoking materials of residents will be maintained by staff. Review of Resident 10's medical record was initiated on 11/5/21. Resident 10 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the MDS dated [DATE], showed Resident 10 was cognitively intact but needed extensive assistance with her ADL care. Review of Resident 10's IDT Assessment of Smoking dated 9/15/21, showed Resident 10 was able to smoke independently with the staff's supervision. There was no documentation to show Resident 10 could keep her cigarette lighter. Review of the Smoking Agreement dated 9/15/21, showed Resident 10 understood the facility's smoking policy. There was no documentation Resident 10 could keep her cigarette lighter. Review of the Resident Smoking Care plan showed a care plan problem addressing Resident 10's smoking safety initiated on 9/15/21. Interventions included to keep Resident 10's cigarette lighter with the activity staff for scheduled smoking time. On 11/15/21 at 1127 hours, an interview was conducted with Resident 10. Resident 10 stated she kept her cigarettes and lighter in her pink purse. Resident 10 stated she went out to smoke whenever the staff was available. On 11/17/21 at 1025 hours, a concurrent observation, interview and medical record review was conducted with the Activity Director. The Activity Director stated Resident 10's lighter was kept in the activities office. The Activity Director stated she kept three lighters for Resident 44. The Activity Director stated she was aware Resident 10 had a cigarette lighter with her. The Activity Director stated that was Resident 10's right. When asked to show Resident 10's ability to keep her smoking materials, the Activity Director verified the Smoking Assessment and Smoking Agreement did not show Resident 10 could keep the smoking material. The Activity Director verified Resident 10's care plan showed an intervention for the activity staff to keep Resident 10's cigarette lighter. The Activity Director verified Resident 10 had a lighter in her purse. The Activity Director stated it was possible Resident 10 got the cigarette lighter from someone at the hospital before she was readmitted to the facility. On 11/17/21 at 1430 hours, an interview and concurrent medical record review was conducted with the DON. When asked how the facility handled the smoking materials of residents who smoked, the DON stated the residents' smoking materials were maintained by the activity staff. The DON stated the residents followed a smoking schedule with a designated area for smoking. The DON was informed Resident 10 had been keeping the cigarettes and lighter. The DON stated Resident 10 should not keep the lighter and cigarettes as per the facility P&P. The DON verified the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for the use of a GT for one of 17 final sampled residents (Resident 37). * The facility failed to ensure Resident 37 received the accurate amount of enteral feeding as ordered by the physician. In addition, the facility failed to accurately document Resident 37's amount of enteral feeding and water flushed via enteral pump. These failures had the potential for not meeting the resident's nutritional and hydration needs. Findings: According to the facility's P&P titled Tube Feeding,Naso-Gastric, Gastrostomy, Jejunostomy, via Enteral Pump revised on 7/8/21, showed it is the policy of the facility to properly monitor Naso-Gastric, Gastrostomy, Jejunostomy feedings to provide nourishment, administer medication, and to maintain hydration. Medical record review for Resident 37 was initiated on 11/15/21. Resident 37 was admitted to the facility on [DATE]. Review if the MDS dated [DATE], showed Resident 37 had severe cognitive impairment. Resident 37 was totally dependent on staff for her ADL care. Resident 37 had a feeding tube. Review of Resident 37's Order Summary Report showed a physician's order dated 10/5/21, to administer Glucerna (enteral feeding formula) 1.2 at 60 ml/hour for 20 hours to provide 1200 ml/1440 kcals, starting at 1300 hours and continue until 0900 hours or until the volume was given and record the time dosage was completed. Another physician's order dated 10/4/21, showed to flush Resident 37's GT with water at 50 ml/hour for 20 hours to provide 1000 ml of water/day, starting at 1300 hours and continue until 0900 hours or until the volume was given in the afternoon. a. On 11/18/21 at 0721 hours, Resident 37 was observed receiving Glucerna 1.2 cal via a feeding pump. Resident 37's Glucerna 1.2 feeding bottle had 1400 ml of formula left in the bottle. Resident 37's Glucerna 1.2 feeding bottle label showed a full bottle contained 1.5 L (1500 ml), with a date written as 11/18/21, start time of 0100 hours, and rate of 60 ml per hour. Resident 37's Glucerna 1.2 feeding bottle was hung at 0100 hours, therefore, a total of 6 hours had passed. However, Resident 37 had received only 100 ml (1500 ml less 1400 ml) instead of the 360 ml (60 ml/hour x 6 hours) as prescribed by the physician. On 11/18/21 at 0822 hours, a concurrent interview and facility record review was conducted with the DON and LVN 3. LVN 3 verified Resident 37's Glucerna 1.2 full feeding bottle (1500 ml) had a label which showed it was started on 11/18/21 at 0100 hours. LVN 3 stated she hung Resident 37's Glucerna 1.2 cal at 0100 hours. The DON and LVN 3 verified Resident 37's Glucerna 1.2 bottle had 1400 ml of formula left in the bottle at 0721 hours. The DON and LVN 3 acknowledged Resident 37 had received only 100 ml for the past 6 hours instead of 360 ml (60 ml x 6 hours) as prescribed by the physician. The DON and LVN 3 stated there should have been 1140 ml of formula left in the Glucerna bottle instead of 1400 ml. Cross reference to F726. b. According to the facility's P&P titled Enteral Intake Recording revised 3/11/02, showed fluid intake shall be recorded for each resident with enteral feeding tubes as prescribed by the physician. This shall be recorded and monitored each shift by a Licensed Nurse. The intake information is to be recorded at the end of each shift by a Licensed Nurse. Residents on enteral pumps, intake total for the day shall be recorded at the end of feeding cycle shift and the 24-hour total is to be entered by the end of feeding cycle shift. Review of Resident 37's G-Tube Intake and Output Form dated 11/2021, showed the following: - On 11/4/21 for the 7-3 shift, 1300 ml of formula and 950 ml of water - On 11/5/21 for the 7-3 shift, 1400 ml of formula and 650 ml of water - On 11/6/21 for the 7-3 shift, 1500 ml of formula and 900 ml of water - On 11/15/21 for the 7-3 shift, 876 ml of formula and 724 ml of water On 11/18/21 at 0822 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated Resident 37 had a physician's order to receive a total of 1200 ml/day of Glucerna 1.2 and a total of 1000 ml of water for 20 hours. The DON stated the licensed nurses working on the 7-3 shift were responsible in documenting Resident 37's total formula and water intake. The DON verified the amounts of formula and water that Resident 37 had received was not accurately reflected in the GT intake and output for November 2021. The DON verified the amounts of formula and water documented in Resident 37's GT intake and Output were either more or less than the amount prescribed by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the respiratory care needs to two of 17 final sampled residents (Residents 30 and 44). * The facility failed to ensure Resident 44's oxygen therapy titration (adjusting oxygen level) based on her oxygen saturation level (percentage of oxygen in the blood with normal levels of 95% and higher) was monitored and documented in the medical record. * The facility failed to ensure Resident 30's oxygen was administered as ordered by the physician. These failures had the potential to put the residents at risk for adverse effects of the improper care and administration of oxygen. Findings: According to the facility's P&P titled Oxygen Therapy Misty Oxygen revised on 5/8/2017, showed oxygen therapy is administered as ordered by the physician. The licensed nurses will set the oxygen flow rate as ordered. Documentation will include the date and time of oxygen in use, oxygen flow rate and device being use, and assessment of the resident's response to therapy. 1. Medical record review for Resident 44 was initiated on 11/15/21. Resident 44 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Order Summary Report dated 10/24/21, show the physician's orders dated 10/12/21, to administer oxygen 2 liter per minute via nasal cannula at all times for SOB except during ADL care every shift and monitor the oxygen saturation levels to maintain greater or equal of 92 % every shift. The licensed nurses may titrate up to four liters and document on the reverse page of MAR. Review of the MAR for November 2021 showed Resident 44's oxygen saturation levels ranged from 92-99% for all shifts. There was no documentation to show Resident 44's oxygen was titrated to maintain oxygen saturation level at 92% and higher. Review of the Nursing Progress Notes for the month of November 2021 did not show any documentation when Resident 44's oxygen level was titrated to maintain the oxygen saturation level at 92% and higher. On 11/15/21 at 1257 hours, Resident 44 was observed having lunch in bed and receiving oxygen therapy at 3.5 liters per minute via nasal cannula. On 11/16/21 at 0855 hours, Resident 44 was observed having breakfast in bed and receiving oxygen therapy at 3.5 liters per minute via nasal cannula. On 11/16/21 at 1030 hours, a concurrent observation, interview, and medical record review was conducted with LVN 1. LVN 1 verified Resident 44 was currently receiving oxygen at 4 liters per minute. LVN 1 stated Resident 44 had a physician order for oxygen at 2 liters per minute. LVN 1 stated when Resident 44 had episodes of SOB and when the oxygen saturation level less than 92%, the oxygen rate would be titrated up to 4 liters per minute. When asked how Resident 44's titration information and the assessment of the response to the oxygen therapy, LVN 1 stated the nurses had to document the oxygen titration on the back of MAR. When asked to show the documentation, LVN 1 verified there was no documentation of oxygen titration rate in the MAR for November 2021 for Resident 44. LVN 1 acknowledged there was also no documentation in Resident 44's progress notes for the oxygen therapy titration based on the resident's oxygen saturation level. On 11/16/21 at 1335 hours, an interview and concurrent the facility P&P's review was conducted with the DON. The DON verified the findings. The DON stated whenever the oxygen rate was being titrated as ordered by the physician, the licensed nurse had to document the titration information and the assessment of the resident's response to the oxygen therapy on the back page of MAR or in the nursing progress notes. 2. On 11/15/21 at 0807 hours, during the initial tour, Resident 30 was observed receiving oxygen at 2 liters per minute via nasal cannula. Medical record review for Resident 30 was initiated on 11/15/21. Resident 30 was admitted to the facility on [DATE]. Review of the Order Summary Report showed a physician's order dated 10/7/21, for oxygen at 3 liters per minute via nasal cannula at all times for SOB except during ADL care. On 11/16/21 at 1019 hours, a concurrent observation and interview was conducted with LVN 5 for Resident 30. Resident 30 received oxygen at 2 liters per minute via nasal cannula. LVN 5 verified Resident 30's oxygen level was only at 2 liters per minute. LVN 5 verified Resident 30's oxygen rate was supposed to be at 3 liters per minute as ordered by the physician. LVN 5 stated she did not check Resident 30's oxygen at the beginning of shift and was not aware of the resident receiving only 2 liters per minute. When LVN 5 was asked what potentially could happen to Resident 30, LVN 5 stated Resident 30 could develop SOB and have a low oxygen saturation level.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the licensed nurses had the specific competencies and skill sets needed to care for the residents. * The facility failed to ensure a program was in place to check the competencies and skill sets of the licensed nurses at the facility upon hiring and ongoing basis. The DSD/IP 1, IP 2, LVNs 1, and 4 failed to demonstrate how to obtain the history of the volume of feeding and water flush via the enteral pump for Resident 37. This failure had the potential to put the residents at risk for care not provided in a safe and competent manner. Findings: According to the facility's P&P titled Competency Evaluation dated 4/1/19, showed it is the policy of the facility to evaluate each employee to assure appropriate competencies and skills for performing his or her job and to meet the needs of facility residents. Initial competency is evaluated during the orientation process. An employee remains on orientation until all competencies are verified. Subsequent and/or annual competency is evaluated at a frequency determined by the facility assessment, evaluation of the training program, and/or job performance evaluations. According to the operating manual titled Epump Enteral Feed and Flush Pump with Pole Clamp Programable, under the section History in the More Options menu, to access the History screen, press the buttons feed ml and flush ml to show the requested history time. A maximum of 72 hours of past history, excluding data from the current hour can be retrieved. On 11/16/21 at 1033 hours, Resident 37 was observed lying on her bed and receiving Glucerna 1.2 at 60 ml per hour and water at 50 ml of via enteral pump. On 11/16/21 at 1055 hours, an interview was conducted with LVN 1. When asked to demonstrate how to obtain the history of the volume fed and water flushed from Resident 37's enteral pump, LVN 1 stated she did not know how. When asked if she had received any inservices regarding the use of the enteral pump and how to obtain the feeding history, LVN 1 stated no. On 11/16/21 at 1059 hours, an interview was conducted with LVN 4. LVN 4 was asked to demonstrate how to obtain the history of the volume fed and water flushed for the past 24, 48, and 72 hours from the enteral pump for Resident 37. LVN 4 stated she just looked at the enteral pup screen to see how much feeding volume and water were administered . LVN 4 stated she did not know how to obtain the feeding history. When asked if she had received any inservices regarding the use of the enteral pump and how to obtain the feeding history, LVN 4 stated no. On 11/16/21 at 1109 hours, concurrent interviews were conducted with the DSD/IP 1 and IP 2. The DSD/IP 1 and IP 2 were asked to demonstrate how to obtain the history from the enteral pump for Resident 37. The DSD/IP 1 and IP 2 stated they did not know how to obtain the history of volume fed. When the DSD/IP 1 was asked if she had given any inservices regarding the use of the enteral pump and how to obtain history from the enteral pump, she stated not recently. When asked how the facility monitored for the staff's competency, the DSD/IP 1 did not provide further response. When asked how often the facility checked the staff's competency, she stated the competency checks should be every year. On 11/16/21 at 1130 hours, an interview was conducted with the DON. The DON acknowledged the findings. The DON stated the provision of inservices regarding the use of the enteral pump was overlooked. Cross reference to F693.

Based on observation, interview, and facility P&P review, the facility failed to ensure safe medication storage was observed in two of eight medication carts (Treatment Cart 1 and IV Cart 1). * An expired central line (catheter that is placed into a large vein) dressing kit was observed in IV (intravenous) Cart 1. * An expired tube of Remedy cream (moisture barrier cream) was observed in Treatment Cart 1. These failures had the potential for the residents to be exposed to the expired medications. Findings: According to the facility's P&P titled Storage and Expiration dating of Medications, Biologicals, Syringes and Needles, the facility should ensure that medication and biological that have expired date on the label are stored separate from other medications until destroyed or returned to the pharmacy or supplier. 1. On 11/17/2021, at 0828 hours, during the inspection of IV Cart 1 with IP 2, a central line dressing kit with an expiration date of 10/31/21 was found in the middle drawer of the IV Cart 1. IP 2 verified the findings and stated the central line dressing kit should not have been in the IV Cart 1. IP 2 stated the expired central line dressing kit should have been disposed. 2. On 11/17/2021, at 0958 hours, during the inspection of Treatment Cart 1 with LVN 2, a tube of used Remedy cream with an expiration date of 8/2021 was observed in the middle drawer of Treatment Cart 1. LVN 2 verified the findings and stated the Remedy cream should have been disposed. On 11/18/2021 at 1457 hours, an interview was conducted with the DON. The DON stated the expired central line dressing kit and tube of Remedy cream should have been disposed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to ensure the proper infection control measures were implemented as evidenced by: * LVN 1 did not perform hand hygiene when preparing Resident 207's medications. * The facility failed to ensure aseptic technique was observed during the preparation of Resident 207's heparin (medication to prevent the formation of the blood clot) medication. LVN 1 did not disinfect the self-sealing rubber topper of the medication vial with an antimicrobial swab each time she attempted to withdraw the heparin medication. LVN 1 used the same needle and syringe multiple times to withdraw the medication from the heparin vial. These failures had the potential to result in the transmission of infection for the resident. Findings: 1. Review of the facility's P&P titled Hand Hygiene revised on 04/27/21, showed the staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. On 10/16/21 at 0853 hours, a medication administration observation for Resident 207 was conducted with LVN 1. LVN 1 was observed preparing Resident 207's medications. LVN 1 dropped the following medications on the floor: - one lidocaine 4% patch ( medication to help reduce pain) - a syringe of one ml of heparin - one Dulera inhaler (a medication to treat asthma) LVN 1 picked up the above medications and discarded them. Without performing hand hygiene, LVN 1 then proceeded to prepare Resident 207's medications. LVN 1 removed one lidocaine patch from a sealed packet, then opened a syringe and withdrew the heparin medication. LVN 1 did not disinfect the Dulera inhaler. LVN 1 entered Resident 207's room and administered the medications without performing hand hygiene. On 10/16/2021, at 1423 hours, an interview was conducted with LVN 1. LVN 1 acknowledged she did not perform hand hygiene after she picked up Resident 207's medications from the floor and prior to preparing the new set of medications. On 11/17/2021, at 1512 hours, an interview was conducted with the DON. The DON stated LVN 1 should have performed hand hygiene after picking the medications from the floor and before entering the resident's room to administer the medications. 2. According to the Fundamentals of Nursing by [NAME], seventh edition, under the section Removing Medication from a Vial (a glass bottle with self sealing stopper through which a medication is removed), after the initial use of the multidose vial (contains multiple doses of medications), to wipe the rubber topper with alcohol each time the medication is removed from the vial. According to the Centers for Disease Control and Prevention (CDC) FAQs regarding Safe Practices for Medical Injections, injection safety or safe injection practices is a set of measures taken to perform injections in an optimally safe manner for patients, healthcare personnel and others. Under the section Medication Preparation Questions showed the staff should adhere to aseptic technique (using practices and procedures to prevent contamination from microorganisms) when preparing the medications. A new sterile syringe and sterile needle is used to draw up medications while preventing contact between the injection materials and the non sterile environment. The rubber septum of vials should be disinfected with alcohol prior to piercing it. According the CDC's One and Only Campaign - Injection Safety Checklist, medication vials are entered with a new needle and a new syringe, even when obtaining additional doses for the same patient. On 11/16/2021, at 0853 hours, during medication administration observation with LVN 1, LVN 1 was observed preparing Resident 207's heparin injection. Without performing hand hygiene, LVN 1 took a 1 ml syringe from a sterile packet, cleansed the self sealing topper of the mutlidose heparin vial using an alcohol wipe, pierced the self sealing topper with the syringe needle, and attempted to withdraw one ml of heparin. When LVN 1 was not able to withdraw the desired amount of heparin solution, LVN 1 then removed the needle from the vial, tapped the syringe to remove the air inside, and then reinserted the same needle back into the self sealing topper. LVN 1 did not clean the self sealing topper prior to resinserting the needle. LVN 1 attempted to remove the medication from the heparin vial multiple times using the same syringe and needle without cleaning the self sealing topper with an antimicrobial swab each time. On 11/16/2021 at 1423 hours, an interview was conducted with LVN 1. LVN 1 acknowledged she inserted the same needle into the heparin vial multiple times. LVN 1 acknowledged she did not clean the self-sealing topper of the medication vial with antimicrobial swab each time she reinserted the same needle into the heparin vial to withdraw the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the risks and benefits of influenza vaccination were reviewed with the resident for one of 17 final sampled residents (Resident 52) when Resident 52 refused the influenza vaccine. This failure had the potential for the resident not being informed of the benefits and risks of influenza vaccination to make an informed decision. Findings: Medical record review for Resident 52 was initiated on 11/17/21. Resident 52 was admitted to the facility on [DATE]. Review of the History and Physical Examination dated 10/25/21, showed Resident 52 had the capacity to understand and make decision. Review of the Nursing admission assessment dated [DATE], showed Resident 52 refused the influenza vaccine. Further review of the medical record failed to show any documentation Resident 52 was provided education on the risks and benefits of influenza vaccine. On 11/17/21 at 1012 hours, a concurrent interview and medical record review was conducted with IP 2. IP 2 verified there was no documentation to show Resident 52 was provided the education on the risks and benefits when he refused the influenza vaccine. IP 2 stated the purpose of the vaccine education was to help Resident 52 making an informed decision regarding the influenza vaccine. On 11/17/21 at 1457 hours, an interview was conducted with the DON. The DON stated even if a resident refused the influenza vaccine, there should have been documentation of the influenza vaccine education provided to the resident.