**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) was within reach for two (2) of (2) sampled residents (Residents 4 and 2) reviewed under the Environment task. This deficient practice had the potential to result in the delay of care and services and possible injury to residents when they are unable to call for assistance. Findings: a. During a review of Resident 4's Admission/Registration form, the Admission/Registration form indicated the facility originally admitted the resident on 8/24/2018 and readmitted in the facility on 12/20/2024 During a review of Resident 4's History and Physical (H&P), dated 1/2/2025, the H&P indicated Resident 4 had diagnoses of chronic respiratory failure (a long-term condition in which your lungs have a hard time loading your blood with oxygen and can leave you with low oxygen), ventilator (a medical device to help support or replace breathing) dependent, and seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) disorder. During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated 2/5/2025, the MDS indicated Resident 4 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 4's SA Fall Risk Assessments (a simple method of assessing a resident's likelihood of falling), dated 8/15/2024, 11/8/2024, and 2/6/2025, the SA Fall Risk Assessments indicated the resident is a high risk for falls. During a review of Resident 4's care plan (CP) on risk for falls, initiated on 1/2/2025, the CP indicated to place call light within reach at all times as one of the interventions to prevent falls or injury. During a concurrent observation and interview, on 4/11/2025, at 8:07 p.m., inside Resident 4's room, with Certified Nursing Assistant (CNA) 1, CNA 1 confirmed and stated Resident 4's call light was hanging on the wall at the head of the bed. CNA 1 stated staff should place the call lights within resident's reach prior to leaving the room. CNA 1 stated she just finished turning and repositioning Resident 4, and she forgot to place the call light within the resident's reach. CNA 1 stated she should have ensured that Resident 4's call light was placed within the resident's reach prior to leaving the room so the resident would be able to call for assistance. During a concurrent observation and interview, on 4/11/2024, at 8:07 p.m., inside Resident 4's room, with Licensed Vocational Nurse (LVN) 8, LVN 8 confirmed and stated Resident 4's call light was hanging on the wall at the head of the bed. LVN 8 stated staff should make sure the call lights are placed within resident's reach prior to leaving the room. LVN 8 stated CNA 1 should have ensured that Resident 4's call light was placed within reach prior to leaving the room so the resident would be able to call for assistance when needed. During an interview, on 4/11/2025, 8:30 p.m., with Registered Nurse (RN) 1, RN 1 stated staff have to make sure that all call lights are within resident's reach after providing or turning and repositioning and prior to leaving the room. RN 1 stated CNA 1 should have placed Resident 4's call light within reach after turning and repositioning and prior to leaving the room to make sure that Resident 4 would be able to call for assistance and prevent delay in meeting the resident's needs. During a review of the facility's policy and procedure (P&P) titled, Call System, last reviewed on 2/2025, the P&P indicated a purpose to provide a mechanism for residents to communicate to staff a need for assistance. The P&P further indicated to make sure call cords are always placed within the resident's reach. b. During a review of Resident 2's Admission/Registration Record, the Admission/Registration Record indicated the facility admitted Resident 2 on 4/4/2025. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 was rarely/never understood and never/rarely made decisions. The MDS further indicated Resident 2 was dependent on facility staff for activities such as eating, hygiene and dressing. During a review of Resident 2's Nutritional Screening, dated 4/11/2025, the Nutritional Screening indicated Resident 2's diagnoses included chronic respiratory failure (a long-term condition where the lungs are unable to adequately exchange oxygen [gas used for breathing]and carbon dioxide [gas given off from breathing]), chronic encephalopathy (group of conditions that cause brain dysfunction), tracheostomy, cerebral palsy (a group of disorders that affect movement and posture due to damage to the developing brain before, during, or shortly after birth), and seizure disorder (a sudden, temporary disturbance of the brain's electrical activity). During a review of Resident 2's CP titled, Need Assist with ADLs, dated 4/4/2025, the CP indicated an intervention to keep call light with reach at all times. During an observation, on 4/11/2025, at 7:27 p.m., in Resident 2's room, Resident 2 laid in bed with his call light behind the head of his bed and out of reach. During a concurrent observation and interview, 4/11/2025, at 7:27 p.m., in Resident 2's room, with CNA 1, CNA 1 confirmed and stated the call light should not be behind Resident 2's head of bed and should be next to him so he could reach it and call for help if he had an emergency. During an interview, on 4/13/2025, at 9:10 a.m., with RN 6, RN 6 stated staff did not follow the P&P when it instructed the staff to make sure the call light was always placed within the resident's reach. RN 6 further stated there could be a delay in care if the call light was not within the resident's reach. During a review of the facility's P&P titled Call System, last reviewed 2/2023, the P&P indicated to make sure call light was always placed within the resident's reach.

Based on interview and record review, the facility failed to ensure the Attending Physician (AP) was notified timely for one of four sampled residents (Resident 16) when Resident 16 had a change in condition. This failure resulted in delay of obtaining appropriate instructions from the AP for proper management of Resident 16's health condition. Findings: During a review of Resident 16's Admission/Registration Record, the Admission/Registration Record indicated the facility admitted Resident 16 on 1/1/2025 due to chronic respiratory failure (occurs when the respiratory system cannot adequately provide oxygen to the body). During a review of Resident 16's Physician's Order dated 1/22/2024, the Physician's Order indicated Resident 16's diagnoses included seizure disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), traumatic brain injury (TBI- a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head) from motor vehicle accident, and respiratory failure with tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck). During a review of Resident 16's Minimum Data Set (MDS - a resident assessment tool), dated 3/10/2025, the MDS indicated Resident 16 was on vegetative state (a condition where someone appears awake but lacks awareness of their surroundings, and they can't engage in purposeful actions or communicate). The MDS indicated Resident 16 was dependent to staff for all activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 16 was always incontinent (unable to control) of bowel and bladder functions. During a review of Resident 16's Nurses Notes, dated 3/12/2025, timed at 11 p.m., the Nurses Notes indicated Resident 16 had a temperature of 101.2 Fahrenheit (F-unit of measuring temperature) and increased thick, dark yellow secretions. During a review of Resident 16's Nurses Notes, dated 3/13/2025, timed at 6:32 a.m., the Nurses Notes indicated the AP was notified of Resident 16's change in condition - fever, increased yellow secretions, excessive coughing and emesis (act of vomiting) twice. The Nurses notes indicated Resident 16's temperature was 99.5 F and heart rate at 120 beats per minute (bpm-normal heart rate ranges from 60-100) with oxygen saturation (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage) of 95 percent (%). The Nurses Notes indicated the AP had new orders. During a review of Resident 16's Physician's Order, dated 3/13/2025, timed at 6:25 a.m., the Physician's Order indicated the following orders: 1. Blood culture (a laboratory test to check for bacteria or other germs in a blood sample), 2. Complete blood count (CBC- common blood test that measures the number and types of cells in your blood). 3. Comprehensive metabolic panel (CMP- a blood test that provides a broad overview of your body's chemical balance and metabolism), 4. Intravenous fluid (IVF-liquids injected into a person's veins through an intravenous tube) for hydration. 5. Zosyn (medication used to treat infection) IV (refers to the practice of administering fluids, medications, or other substances directly into a vein through a needle or tube), 4.5 grams (gm- unit of measurement, used for medication dosage and/or amount) every six hours for seven days for fever. 6. Vancomycin (medication used to treat infection) IV pharmacy to dose (physicians order a specific drug or drug class, and the pharmacist selects an appropriate dose for the individual patient). During a concurrent interview and record review on 4/12/2025 at 3.47 p.m., with Registered Nurse 3 (RN 3), Resident 16's Nurses Notes dated 3/12/2025 to 3/13/2025 were reviewed. RN 3 stated Resident 16 had a change in condition when he (Resident 16) had a fever and excessive secretions on 3/12/2025 at 11 p.m. RN 3 stated the Nurses Notes on 3/12/2025 at 11 p.m. did not indicate the AP was notified. RN 3 stated the Nurses Notes indicated the AP was notified on 3/13/2025 at 6:32 a.m., six hours after Resident 16 had a change in condition. RN 3 stated she (RN 3) would call the AP at around 11 p.m. on 3/12/2025 because of the change in condition. RN 3 stated it was a delay in the AP notification that can result in delay of care. During an interview on 4/13/2025 at 5:31 p.m. with the Director of Subacute (DSA), the DSA stated the AP should have been notified promptly when Resident 16 had a change in condition. The DSA stated the AP notification six hours after Resident 16 had a change in condition is a delay of notification. The DSA stated delay in the AP notification can result to delay in treatment. The DSA stated the importance of timely AP notification was to address the change in condition and provide care timely. During a review of the facility's policy and procedures (P&P) titled, Change in Resident Condition/Notification of Changes, dated 2/2025, the P&P indicated, To clearly define guidelines for timely notification of a change in resident condition and notification of changes as required by regulations. A. Acute Medical Change: Any sudden or serious change in a resident's condition manifested by a marked change in physical, mental, or psychosocial status. 1. The licensed nurse in charge will notify the physician promptly with a request for physician visit, recommendations, and/or evaluation. 2. If unable to contact attending physician or alternate physician timely, notify the Medical Director for follow-up of change in resident condition. B. Routine Medical Changes/Need to Alter Treatment Significant: A minor change in physical, mental or psychosocial status with the potential need to discontinue an existing form of treatment or to commence a new form of treatment. 1. All signs and symptoms of the condition change will be communicated to the physician promptly. 2. The nurse in charge is responsible for notification of physician and family or legal representative prior to end of assigned shift when a change in a resident's condition is noted. 3. If unable to reach physician or family/legal representatives, the notifications, including calls to physicians or exchanges/requesting callbacks, will be documented on the Nursing Flow sheet. 4. If the physician has not returned the call by the end of the shift, the incoming nurse will be notified for follow up.

Based on observation, interview, and record review the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries (PI/PU - localized damage to the skin and/or underlying tissue usually over a bony prominence) by failing to ensure heels were floated on two pillows for one of one sampled resident (Resident 14) during a random observation. This deficient practice had the potential for Resident 14's deep tissue injury (damage to the deeper layers of the skin and underlying tissues, like muscle and fat, caused by pressure or shear forces) to reappear or form new PI. Findings: During a review of Resident 14's Admission/Registration Record, the Admission/Registration Record indicated the facility admitted Resident 14 on 1/12/2025. During a review of Resident 14's History and Physical (H&P), dated 12/25/24, the H&P indicated Resident 14 was unable to provide meaningful information. During a review of Resident 14's Minimum Data Set (MDS - a resident assessment tool), dated 3/7/2025, the MDS indicated Resident 14 was rarely/never understood and never/rarely made decisions. The MDS further indicated Resident 14 was dependent on facility staff for activities such as eating, hygiene and dressing. During a review of Resident 14's Physician's Orders, dated between 4/1/2025 to 4/30/2025, the physician's orders indicated the resident had diagnoses including chronic respiratory failure (a long-term condition where the lungs are unable to adequately exchange oxygen [gas used for breathing]and carbon dioxide [gas given off from breathing]) with vent (machine that breathes for a person when they cannot breathe on their own), chronic encephalopathy(group of conditions that cause brain dysfunction), and dementia (a progressive state of decline in mental abilities). The Physician's Orders further indicated Resident 14 was ordered to float heels on two pillows on 1/16/2025. During a review of Resident 14's Deep Tissue Injury Care Plan (CP), initiated on 1/16/2025, the CP indicated Resident 14 had a dry, intact, dark brown wound bed on the left heel. The CP further indicated interventions to float heels on two pillows. During a concurrent observation and interview, 4/13/2025, at 7:46 a.m., inside Resident 14's room, with Registered Nurse (RN) 3, Resident 14 laid in bed and RN 3 lifted the covers from Resident 14's legs. Resident 14's heels touched the mattress and RN 3 stated Resident 14's heels were touching the mattress, and they should be propped up on two pillows so they would float. RN 3 stated Resident 14 has an order to float her heels on two pillows to prevent skin breakdown and it was not followed by the facility staff. RN 3 further stated the deep tissue injury to Resident 14's heel has resolved, but the facility must continue to float her heels to prevent another one. During a review of the facility's policy and procedure (P&P) titled, Pressure/Vascular (relating to blood vessels) Ulcer Management last reviewed 2/2025, the P&P indicated to use pressure relief device, as appropriate.

Based on observation, interview, and record review, the facility failed to provide an environment that is free from accidents or hazards by failing to ensure the brakes were set on the hospital bed for one of four sampled residents (Resident 14) during a random observation. This deficient practice placed Resident 14 at risk for hazard or injury such as a fall. Findings: During a review of Resident 14's Admission/Registration Record, the Admission/Registration Record indicated the facility admitted Resident 14 on 1/12/2025. During a review of Resident 14's History and Physical (H&P), dated 12/25/24, the H&P indicated Resident 14 was unable to provide meaningful information. During a review of Resident 14's Minimum Data Set (MDS - a resident assessment tool), dated 3/7/2025, the MDS indicated Resident 14 was rarely/never understood and never/rarely made decisions. The MDS further indicated Resident 14 was dependent on facility staff for activities such as eating, hygiene and dressing. During a review of Resident 14's Physician's Orders, dated between 4/1/2025 to 4/30/2025, the physician's orders indicated the resident had diagnoses including chronic respiratory failure (a long-term condition where the lungs are unable to adequately exchange oxygen [gas used for breathing]and carbon dioxide [gas given off from breathing]) with vent (machine that breathes for a person when they cannot breathe on their own), chronic encephalopathy(group of conditions that cause brain dysfunction), and dementia (a progressive state of decline in mental abilities). During an observation, 4/11/2025, at 7:14 p.m., inside Resident 14's room, Resident 14 laid in bed and the brakes to her bed were unlocked without staff in the room. During a concurrent observation and interview, 4/11/2025, at 7:17 p.m., inside Resident 14's room, with Registered Nurse (RN) 4, Resident 14 was in bed and RN 3 looked down at the brakes and stated it was dangerous to have the brakes unlocked on Resident 14's bed and could cause a fall or injury. During a review of the [Hospital Bed 1] Medical Bed operations manual, undated, the manual indicated to always keep the brakes applied when a resident is on the bed. The operations manual further indicated after the brake is applied, push on the bed to ensure the brakes are locked.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent (lacks voluntary control over urination) of bladder (organ in the pelvis that stores urine) received appropriate treatment and services to prevent urinary tract infections (UTI - an infection in the bladder/urinary tract) for one of five sampled residents (Resident 2) observed during the screening process by failing to keep Resident 2's urinary catheter tubing (also known as an indwelling catheter, a hollow tube inserted into the bladder to drain or collect urine) from looping and allowing the contents to flow freely into the urinary catheter bag (container that connects to a urinary catheter and collects urine). This deficient practice had the potential for Resident 2 to develop catheter associated urinary tract infection (CAUTI - an infection of the urinary tract caused by a urinary catheter). Findings: During a review of Resident 2's Admission/Registration Record, the Admission/Registration Record indicated the facility admitted Resident 2 on 4/4/2025. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 3/7/2025, the MDS indicated Resident 2 was rarely/never understood and never/rarely made decisions. The MDS further indicated Resident 2 was dependent on facility staff for activities such as eating, hygiene and dressing. During a review of Resident 2's Nutritional Screening, dated 4/11/2025, the Nutritional Screening indicated Resident 2's diagnoses included chronic respiratory failure (a long-term condition where the lungs are unable to adequately exchange oxygen [gas used for breathing]and carbon dioxide [gas given off from breathing]), chronic encephalopathy (group of conditions that cause brain dysfunction), tracheostomy, cerebral palsy (a group of disorders that affect movement and posture due to damage to the developing brain before, during, or shortly after birth), and seizure disorder (a sudden, temporary disturbance of the brain's electrical activity). During a review of Resident 2's Care Plan (CP) titled, Potential for infection [related to] presence of indwelling catheter, dated 4/4/2025, the CP indicated an intervention to check that the urinary catheter tubing was not kinked and there is a free flow of urine at all times. During an observation, on 4/13/2025, at 7:40 a.m., inside Resident 2's room, Resident 2 laid in bed with a urinary catheter bag hanging on the right side of the resident's bedframe. The urinary catheter tubing hung below the middle-right side of the bed and had a large loop. The looped portion of the urinary catheter tubing contained yellow liquid with a small amount of sediment. During a concurrent observation and interview, 4/13/2025, at 7:46 a.m., inside Resident 2's room, with Registered Nurse (RN) 6, RN 6 confirmed and stated Resident 2's urinary catheter tubing was looped and contained yellow liquid with white sediment. RN 6 stated the urinary catheter tubing should be straight in order drain the urine into the urinary catheter bag. RN 6 further stated if the urine is not draining properly, Resident 2 can possibly get an infection because the urine might backflow into his body. During a review of the facility's policy and procedure (P&P) titled, Catheter Care, Routine Daily, last reviewed 2/2025, the P&P indicated to ensure the catheter tubing is free of kinks and obstruction, allowing urine to flow freely.

Based on observation, interview, and record review, the facility failed administer total parenteral nutrition (TPN - a method of feeding that delivers nutrients directly into the bloodstream through a hollow tube, bypassing the digestive system) consistent with professional standards of practice by failing to label the TPN bag and PICC (peripherally inserted central catheter - thin, flexible tube inserted into a vein in the upper arm and guided to a large vein near the heart) line tubing with the date and time it was started on one of one resident (Resident 2) during a random screening. This deficient practice had the potential to increase Resident 2's risk for complications from TPN such as bacteria growth in the tubing. Findings: During a review of Resident 2's Admission/Registration Record, the Admission/Registration Record indicated the facility admitted Resident 2 on 4/4/2025. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 3/7/2025, the MDS indicated Resident 2 was rarely/never understood and never/rarely made decisions. The MDS further indicated Resident 2 was dependent on facility staff for activities such as eating, hygiene and dressing. During a review of Resident 2's Nutritional Screening, dated 4/11/2025, the Nutritional Screening indicated Resident 2's diagnoses included chronic respiratory failure (a long-term condition where the lungs are unable to adequately exchange oxygen [gas used for breathing]and carbon dioxide [gas given off from breathing]), chronic encephalopathy (group of conditions that cause brain dysfunction), tracheostomy, cerebral palsy (a group of disorders that affect movement and posture due to damage to the developing brain before, during, or shortly after birth), and seizure disorder (a sudden, temporary disturbance of the brain's electrical activity). During a review of Resident 2's Care Plan (CP) titled, Potential for Infection Related to the Presence of a PICC Line, the CP indicated an intervention to change tubing according to protocol. During an observation, on 4/13/2025, at 7:40 a.m., inside Resident 2's room, Resident 2 laid in bed with TPN running and connected to his PICC line on his right upper arm. The TPN bag and tubing did not have a date or time it was started. During a concurrent observation and interview, 4/13/2025, at 7:46 a.m., inside Resident 2's room, with Registered Nurse (RN) 6, RN 6 confirmed and stated Resident 2's TPN bag and tubing were not labeled with the date and time it was started. RN 6 stated it was the facility's practice and policy to indicate the date and time started on every bag of TPN, medication, and tubing so other nurses will know what time it was started and to reduce confusion. RN 6 further stated Resident 2 had the potential to acquire an infection from the unlabeled TPN bag and tubing. During a review of the facility's policy and procedure (P&P) titled, IV (intravenous - through the vein) Therapy Protocol, last reviewed 2/2025, the P&P indicated the nurse starting the bag dates and initials the bag and can be done by writing on the resident's name label or use an auxiliary (something that gives aid/helps of any kind) label.

Based on observation, interview and record review, the facility failed to ensure respiratory care provided to residents were consistent with professional standards of practice for one (1) of 1 sampled residents (Resident 9) reviewed for respiratory care by failing to ensure the Yankauer suction catheter (long plastic tool used to remove secretions [thick or thin sticky fluids from the mouth and throat]) was labeled with the date when the catheter will be changed next. This deficient practice placed the resident at risk for acquiring infection from possibly contaminated equipment. Findings: During a review of Resident 9's Admission/Registration form, the Admission/Registration form indicated the facility originally admitted the resident on 10/9/2018 and readmitted in the facility on 12/31/2024 During a review of Resident 9's History and Physical (H&P), dated 1/2/2025, the H&P indicated Resident 9 had diagnoses of respiratory failure (a long-term condition in which your lungs have a hard time loading your blood with oxygen and can leave you with low oxygen), ventilator (a medical device to help support or replace breathing) dependent, and seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) disorder. During a review of Resident 9's Minimum Data Set (MDS - a resident assessment tool), dated 1/17/2025, the MDS indicated Resident 9 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). The MDS indicated Resident 9 received suctioning treatments. During a review of Resident 9's Physician's Orders, dated 10/9/2018, the Physician's Orders indicated an order to suction retained or increased secretions every two (2) hours and as needed. During a review of Resident 9's care plan (CP) on potential for infection, last revised on 12/31/2024, the CP indicated to suction every 2 hours and as needed retained or increased secretions and oral care every shift and as needed as a few of the interventions to minimize risk for signs and symptoms of respiratory infection. During an observation, on 4/11/2025, at 7:02 p.m., inside Resident 9's room, Resident 9's Yankauer suction catheter, inside an opened storage bag, did not have a label with an opened date. During a concurrent observation and interview, on 4/11/2025, at 7:10 p.m., inside Resident 9's room, with Licensed Vocational Nurse (LVN) 9, LVN 9 stated night shift licensed nurses change all resident respiratory equipment, including Yankauer suction catheters, every morning at 6 am prior to end of shift and place a sticker indicating the date and time the equipment will be changed next. LVN 9 stated she did not know what happened with the sticker indicating that she changed the Yankauer suction catheter on 4/11/2025 at 6 a.m. and will be changed 4/12/2025 at 6 a.m. LVN 9 stated if the suction catheter was changed during the morning shift, the storage bag should have a sticker indicating to change on 4/12/2025 at 6 a.m. LVN 9 stated Resident 9's Yankauer suction catheter should have a sticker of when it will be changed next so the staff would know that the Yankauer suction catheter was changed as scheduled and was not old which placed Resident 9 at risk for infection if the suction catheter was possibly contaminated. During an interview, on 4/13/2025, at 8:28 a.m., with the Director of Sub Acute (DSA), the DSA stated all respiratory equipment in the resident room such as the suction canisters and Yankauer suction catheters are changed every morning by the night shift licensed nurse prior to end of shift. The DSA stated Resident 9's Yankauer suction catheter should have indicated the date and time of when it would be changed next. The DSA stated when the staff change the Yankauer suction catheter to a new one and indicate the date and time of when it would be changed, the other staff would know that the suction catheter was not old. The DSA stated an unlabeled Yankauer suction catheter could possibly be contaminated which can lead to residents acquiring an infection. During a review of the facility's policy and procedure (P&P) titled, Changing & Emptying of Suction Set Ups, last reviewed on 2/2025, the P&P indicated a purpose to minimize risk of infection. The P&P further indicated: - All suction extension tubing and Yankauer suction devices will be changed daily and as needed and the Yankauer rinsed after each use. - During equipment changing, gather needed clean or sterile disposable items, label with date it will be changed, and initials of staff member making the change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review. the facility failed to maintain accurate and complete medical record for two of five sampled residents (Residents 18 and 19) by: 1. Failing to ensure Resident 18's medical record was accurate when the written order for docusate sodium (medication used to soften stool) was in soft gel (capsule) form and the electronic order was in liquid form. 2. Failed to ensure Resident 19's medical record was accurate when Licensed Vocational Nurse 7 (LVN 7) documented presence of bleeding and administered Eliquis (medication used to prevent blood clot). These failures had the potential to cause confusion in care and the medical records containing inaccurate documentation. Findings: 1. During a review of Resident 18's Physician's Order, dated 7/25/2024, the Physician's Order indicated the facility admitted Resident 18 on 7/25/2024, with diagnoses that included chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood), ventilator dependent (a person that requires a medical device to help support or replace breathing) and dysphagia (swallowing difficulty) with gastrostomy tube (g-tube, a feeding tube inserted into the stomach through the abdominal wall, sued to deliver nutrition, fluids and medications). The Physician's Order indicated docusate sodium soft gel 100 milligram (mg- metric unit of measurement, used for medication dosage and/or amount) capsule, give one capsule via g-tube three times a day as stool softener. During a review of Resident 18's Minimum Data Set (MDS - a resident assessment tool) dated 2/4/2025, the MDS indicated Resident 18's cognitive (mental action or process of acquiring knowledge and understanding) skills for decision making were severely impaired. The MDS indicated Resident 18 was dependent to staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Residents 18 had a feeding tube (g-tube). During an observation on 4/12/2025, at 8:44 a.m., inside Resident 18's room, observed LVN 1 administer docusate sodium 50 mg/5 milliliter (ml-unit of measurement), gave 10 ml liquid to Resident 18's g-tube. During a concurrent interview and record review on 4/12/2025, at 3:37 p.m., with Minimum Data Set Nurse (MDSN), Resident 18's Physician's Order dated 7/25/2024, was reviewed. The Physician's Order indicated docusate sodium soft gel 100 mg capsule, give one capsule via g-tube three times a day as stool softener. The MDSN stated the physician's order should have been clarified with the physician. During an interview on 4/12/2025 at 3:47 p.m., with Registered Nurse (RN) 3, RN 3 stated there were inaccurate documentation between the written order for docusate sodium compared to the electronic order. RN 3 stated order should have been corrected and should match during the monthly recapitulation of physician order (a summary or review of all orders placed within a given month). RN 3 stated the physician should have been called to change the physician's order to liquid. 2. During a review of Resident 19's Admission/Registration Record, the Admission/Registration Record indicated the facility admitted Resident 19 on 2/12/2025, with diagnoses that included acute hypoxic respiratory failure (a serious condition where the lungs fail to adequately oxygenate the blood, leading to low oxygen levels in the bloodstream). During a review of Resident 19's Physician's Order dated 2/12/2025, the Physician's Order indicated Resident 19 had diagnoses that included acute hypoxic respiratory failure, tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck) and sepsis (a serious condition in which the body responds improperly to an infection). During a review of Resident 19's Care Plan on at risk for bruise (a discoloration of the skin caused by blood leaking from broken blood vessels beneath the skin), skin tear and abrasion (a superficial rub or wearing off of the skin, usually caused by a scrape or a brush burn) due to anticoagulant therapy (also known as blood thinning, involves using medications to reduce the ability of blood to clot) dated 2/14/2025, the Care plan indicated the following interventions: 1. Monitor and report any bruises, skin tears, and abrasions. 2. Monitor for signs and symptoms of bleeding, report hematuria (blood in the urine), blood stool, nose bleeding, hemoptysis (coughing of blood), and bleeding gums. During a review of Resident 19's MDS, dated [DATE], the MDS indicated Resident 19 was on vegetative state. The MDS indicated Resident 19 was dependent to staff for all ADLs. The MDS indicated Resident 19 was on anticoagulant. During a review of Resident 19's Physician's Order dated 2/21/2025, the Physician's Order indicated resume Eliquis 5 mg via g-tube every 12 hours. During a concurrent interview and record review on 4/12/2025 at 8:05 p.m., with the MDSN, Resident 19's Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 4/8/2025 for Eliquis was reviewed. The MAR indicated Eliquis was given to Resident 19 on 4/8/2025 at 9:33 p.m., with documented signs of bleeding. The MDSN stated if bleeding was noted, Eliquis should have been held (not administered). During an interview on 4/13/2025, at 5:31 p.m. with the Director of Subacute (DSA), the DSA stated Eliquis is an anticoagulant and had a side effect of bleeding. The DSA stated residents on Eliquis are monitored for signs of bleeding and if residents had signs of bleeding, Eliquis should have been held to prevent further bleeding that can lead to complication. The DSA stated LVN 7 made an incorrect documentation. The DSA stated the importance of accurate documentation was to prevent miscommunication. The DSA stated the facility's policy was to document accurately the things observed and care provided. During a review of facility's policy and procedure (P&P) titled, Charting Guidelines dated 6/2024 was reviewed. The (P&P) indicated, It is the policy of this facility that: 1. All documentation will be completed as required for each resident. 2. Charting should include all assessments of resident condition, all interventions taken to resolve a problem and the progress/lack of progress with the written care plan 8. Keep entries factual and specific. They must be accurate and informative. Document any changes in resident condition as well as steps taken in response to the change. 9. Document normal findings as well as abnormal findings as this shows that the resident was being assessed. 10. When physician intervention is required, document the time the physician was contacted and the time he responded. When new orders are implemented, the chart needs to reflect the resident notification and response to the intervention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to implement policy for antibiotic (medication used to treat infection) stewardship (efforts in doctors' offices, hospitals, long-term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate, means prescribing the right drug at the right dose at the right time for the right duration) for two of five sampled residents (Resident 16 and 19) by: 1. Failing to monitor Resident 16 for antibiotic use, side effects or adverse reaction (unintended pharmacologic effects that occur when a medication is administered correctly while a side effect is a secondary unwanted effect). 2. Failing to ensure Infection Control Surveillance Log (record that involves the systematic collection, analysis, and interpretation of data related to infections within a healthcare setting) for Resident 19's antibiotics was completely filled up in 3/2025. These failures had the potential to increase antibiotic resistance (don't respond to a drug) from unnecessary or inappropriate antibiotic use. Findings: a. During a review of Resident 16's Physician's Order dated 1/22/2024, the Physician's Order indicated the facility admitted Resident 16 on 1/22/2024, with diagnoses that included seizure disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), traumatic brain injury (TBI- a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head) from motor vehicle accident, and respiratory failure (occurs when the respiratory system cannot adequately provide oxygen to the body), with tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck). During a review of Resident 16's Minimum Data Set (MDS - a resident assessment tool) dated 3/10/2025, the MDS indicated Resident 16 was on vegetative state (a condition where someone appears awake but lacks awareness of their surroundings, and they cannot engage in purposeful actions or communicate). The MDS indicated Resident 16 was dependent to staff for all activities of daily living (ADL- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 16 was always incontinent (unable to control) of bowel and bladder functions. During a review of Resident 16's Nurses Notes dated 3/12/2025, timed at 11 p.m., the Nurses Notes indicated Resident 16 had a temperature of 101.2 Fahrenheit and an increased thick, dark yellow secretion. During a review of Resident 16's Physician's Order dated 3/13/2025, timed at 6:25 a.m., the Physician's Order indicated the following orders. 1. Zosyn (medication used to treat infection) 4.5 grams (gm- unit of measurement, used for medication dosage and/or amount) intravenous (IV- refers to the practice of administering fluids, medications, or other substances directly into a vein through a needle or tube) every six hours for seven days due to fever (a rise in body temperature, typically indicated by a reading of 100.4°F or higher). 2. Vancomycin (medication used to treat infection) IV, pharmacy to dose (physicians order a specific drug or drug class, and the pharmacist selects an appropriate dose for the individual patient). During a review of Resident 16's Physician's Order dated 3/13/2025, timed at 10:26 a.m., the Physician's Order indicated to start Vancomycin 1250 mg IV every 12 hours until further orders for fever. During a review of Resident 16's Nurses Notes from 3/13/2025, to 3/20/2025, the Nurses Notes indicated no documented monitoring for Zosyn and Vancomycin use and adverse reactions. During a review of Resident 16's Care plan on IV antibiotic treatment related to fever dated 3/14/2025, the Care Plan indicated an intervention to observe Resident 16 for any adverse reactions to antibiotic such as rash (a change in the appearance or feel of the skin, often appearing as redness, bumps, or itching), nausea, vomiting or gastrointestinal distress (encompasses a range of uncomfortable digestive symptoms like abdominal pain, bloating, gas, and changes in bowel habits). During an interview on 4/11/2025, at 7:29 p.m., with the Minimum Data Set Nurse (MDSN), the MDSN stated nurses monitors resident for antibiotic use and nurses documents it in Nurses Notes. During an interview on 4/12/2025, at 10:37 a.m., with the Infection Preventionist (IP), the IP stated nurses monitor the antibiotic use and nurses documents it every shift. The IP stated the importance of monitoring for antibiotic use was to make sure residents receives the antibiotic medication and it does not cause resistance. The IP stated the importance of antibiotic monitoring was to find out if the antibiotic given, works for the resident, if it was the right antibiotic, the right dose and if it was administered correctly to treat residents' infection. During an interview on 4/12/2025, at 5:26 p.m., with the Pharmacist (Pharm 1), Pharm 1 stated the Pharmacy's responsibility on antibiotic use was to monitor its usage, its side effects and how long should resident be on antibiotic. Pharm 1 stated they (Pharm 1) based their monitoring from the physician and nurses' notes. b. During a review of Resident 19's Admission/Registration Record, the Admission/Registration Record indicated the facility admitted Resident 19 on 2/12/2025, due to acute hypoxemic respiratory failure (a serious condition where the lungs fail to adequately oxygenate the blood, leading to low oxygen levels in the bloodstream). During a review of Resident 19's Physician's Order dated 2/12/2025, the Physician's Order indicated Resident 19 had diagnoses that included acute hypoxic respiratory failure, tracheostomy and sepsis (a serious condition in which the body responds improperly to an infection). During a review of Resident 19's MDS dated [DATE], the MDS indicated Resident 19 was on vegetative state. The MDS indicated Resident 19 was dependent to staff for all ADL. The MDS indicated Resident 19 was on antibiotic. During a review of Resident 19's Physician's Order dated 3/19/2025, the Physician's Order indicated the following for wound infection. 1. Cefepime (medication used to treat infection) one gram IV every 12 hours for 14 days. 2. Fluconazole (medication used to treat fungal [diseases caused by a yeast or mold] infection) 200 milligram (mg- metric unit of measurement, used for medication dosage and/or amount) thru gastrointestinal tube (g-tube, a medical device used to deliver fluids, nutrients, or medications directly into the gastrointestinal tract) daily for 14 days. During a review of facility's Infection Control Log dated 3/2025, the Infection Control Log indicated Resident 19's date of admission, signs and symptoms, organism location and date infection resolved were left blank. During a concurrent interview and record review on 4/11/2025, at 7:29 p.m., with the MDSN, facility's Infection Control Log dated 3/2025 was reviewed. The MDSN stated facility's Infection Control Log was incomplete for Resident 19. During a concurrent interview, and record review on 4/11/2025, at 8:06 p.m., with Registered Nurse (RN) 1, Resident 19's wound culture (a test to identify germs that may be causing an infection in a wound, it involves taking a sample from the wound and growing the germs in a laboratory to see what they are that helps healthcare providers determine the best course of treatment, such as antibiotics) dated 3/16/2025, was reviewed. RN 1 stated wound culture collected on 3/16/2025, indicated gram negative rods (bacteria that, when stained using the Gram staining method, appear pink or red instead of blue or purple, they are rod-shaped and have a unique cell wall structure with an outer membrane, making them more resistant to certain antibiotics compared to gram-positive bacteria) and moderate growth. RN 1 stated she (RN 1) did not document in the Infection Control Log the result of the wound culture. RN 1 stated the Infection Control Log also had no documented date of admission. RN 1 stated whoever receives the antibiotic order should document in the Infection Control Log. During a concurrent interview and record review on 4/12/2025 at 10:11 a.m., with the IP, the facility's Infection Control Log dated 3/2025 was reviewed. The IP stated the Infection Control Log was the antibiotic surveillance and was not complete. The IP stated the Infection Control Log had missing date of admission, some signs and symptoms, organism and date infection was resolved. The IP stated the assigned nurse, or the charge nurse completes the Infection Control Log. The IP stated the importance of monitoring use of antibiotic was to make sure it was the right medication for the organism detected. During an interview on 4/13/2025 at 5:31 p.m., with the Director of Subacute (DSA), the DSA stated the Pharmacist was tracking the antibiotics usage. The DSA stated the IP should have monitored the antibiotic use and effect of antibiotic as part of the surveillance. The DSA stated the importance of tracking and monitoring was to identify pattern and determine the infection rate if increasing or trending. The DSA stated it is the facility's policy to perform antibiotic surveillance as part of the antibiotic stewardship. During a review of facility's policy and procedure (P&P) titled, Antibiotic Stewardship dated 2/2024, the P&P indicated, The Antibiotic Stewardship Program (ASP) includes a subcommittee of staff to promote the appropriate antimicrobial usages, to monitor the progress, to recommend and to modify therapy as indicated, and to perform functions for a successful ASP. The ASP team, as lead by the Infectious Disease specialist (a medical doctor with specialized training in diagnosing, treating, and preventing infections caused by things like bacteria, viruses, fungi, and parasites) who monitors the use, the pattern of use as pertained to antimicrobial use. Aside from the ASP subcommittee meeting, the ASP team sets initiative toward proper usage of antibiotics. In addition to the established functions such as IV or by mouth conversion, dosing guidelines, renal dose adjustment, initiatives such as concurrent monitoring is established. Another example may be double-checking of drug of choice, dose and duration within 48 hours of antibiotic initiation thereby influencing the prescribing oof antibiotics. The ASP team gathers and monitors antibiotic prescribing and follow and report resistance patterns. The ASP monitors the hospital antibiotic use by analyzing the data on days of therapy per 1000 patient days. The ASP collects, analyzes and reports data to hospital leadership and prescribers. The ASP Team regularly informs staff on antibiotic prescribing and resistance information and recommended changes to improve results.

Based on interview and record review, the facility failed to ensure one of five sampled staff (Infection Preventionist [IP]) was qualified and competent in implementing the facilities infection control program by: 1. Failing to monitor Resident 16 for antibiotic (medication used to treat infection) use, side effects or adverse reaction (unintended pharmacologic effects that occur when a medication is administered correctly while a side effect is a secondary unwanted effect). 2. Failing to ensure Infection Control Surveillance Log (a documented record used to systematically track and analyze healthcare-associated infections and other infectious diseases within a healthcare facility) for Resident 19's antibiotics was completely filled in 3/2025. These failures had the potential to increase antibiotic resistance (don't respond to a drug) from unnecessary or inappropriate antibiotic use. Findings: a. During a review of Resident 16's Physician's Order dated 1/22/2024, the Physician's Order indicated the facility admitted Resident 16 on 1/22/2024, with diagnoses that included seizure disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), traumatic brain injury (TBI- a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head) from motor vehicle accident, and respiratory failure (occurs when the respiratory system cannot adequately provide oxygen to the body), with tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck). During a review of Resident 16's Minimum Data Set (MDS - a resident assessment tool) dated, 3/10/2025, the MDS indicated Resident 16 was on vegetative state (a condition where someone appears awake but lacks awareness of their surroundings, and they cannot engage in purposeful actions or communicate). The MDS indicated Resident 16 was dependent to staff for all activities of daily living (ADL- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 16 was always incontinent (unable to control) of bowel and bladder functions. During a review of Resident 16's Physician's Order, dated 3/13/2025, timed at 6:25 a.m., the Physician's Order indicated the following orders: 1. Zosyn (medication used to treat infection) 4.5 grams (gm- unit of measurement, used for medication dosage and/or amount) intravenous (IV- refers to the practice of administering fluids, medications, or other substances directly into a vein through a needle or tube) every six hours for seven days due to fever (a rise in body temperature, typically indicated by a reading of 100.4°F or higher). 2. Vancomycin (medication used to treat infection) IV, pharmacy to dose (physicians order a specific drug or drug class, and the pharmacist selects an appropriate dose for the individual patient). During a review of Resident 16's Nurses Notes from 3/13/2025 to 3/20/2025, the Nurses Notes indicated no documented monitoring for Zosyn and Vancomycin use and adverse reactions. During a review of Resident 16's Care plan on IV antibiotic treatment related to fever dated 3/14/2025, the Care Plan indicated an intervention to observe Resident 16 for any adverse reactions to antibiotic such as rash (a change in the appearance or feel of the skin, often appearing as redness, bumps, or itching), nausea, vomiting or gastrointestinal distress (encompasses a range of uncomfortable digestive symptoms like abdominal pain, bloating, gas, and changes in bowel habits). b. During a review of Resident 19's Admission/Registration Record, the Admission/Registration Record indicated the facility admitted Resident 19 on 2/12/2025, with diagnoses that included acute hypoxic respiratory failure (a serious condition where the lungs fail to adequately oxygenate the blood, leading to low oxygen levels in the bloodstream). During a review of Resident 19's Physician's Order dated 2/12/2025, the Physician's Order indicated Resident 19 had diagnoses that included acute hypoxic respiratory failure, tracheostomy and sepsis (a serious condition in which the body responds improperly to an infection). During a review of Resident 19's MDS dated , 2/19/2025, the MDS indicated Resident 19 was on vegetative state. The MDS indicated Resident 19 was dependent to staff for all ADL. The MDS indicated Resident 19 was on antibiotic. During a review of Resident 19's Physician's Order, dated 3/19/2025, the Physician's Order indicated the following for wound infection. 1. Cefepime (medication used to treat infection) 1 gram IV every 12 hours for 14 days. 2. Fluconazole (medication used to treat fungal [diseases caused by a yeast or mold] infection) 200 milligram (mg- metric unit of measurement, used for medication dosage and/or amount) thru gastrointestinal tube (GT- a medical device used to deliver fluids, nutrients, or medications directly into the GI tract) daily for 14 days. During a review of facility's Infection Control Log, dated 3/2025, the Infection Control Log indicated Resident 19's date of admission, signs and symptoms, organism location and date infection resolved were left blank. During a concurrent interview, and record review on 4/11/2025, at 7:29 p.m., with the Minimum Data Set Nurse (MDSN), the facility's Infection Control Log dated 3/2025 was reviewed. The MDSN stated the facility's Infection Control Log was incomplete for Resident 19. During a concurrent interview and record review on 4/11/2025, with Registered Nurse (RN) 1, the facility's Infection Control Log, dated 3/2025, was reviewed. RN 1 stated the Infection Control Log had no date of admission for Resident 19 who had antibiotics. RN 1 stated the Infection Control Log also had missing entry on organism location and signs and symptoms for Resident 19. During an interview on 4/12/2025, at 10:11 a.m., with the Infection Preventionist (IP), the IP stated she (IP) started as an IP on 5/2024. The IP stated the Infection Control Log is the facility's Antibiotic Surveillance. The IP stated the antibiotic surveillance was not complete and had missing date of admissions, signs and symptoms, organism location and if infection was resolved. The IP stated Pharm 1 is in charge of the antibiotic surveillance and the nurses are in charge of completing the Infection Control Log. The IP stated the importance of monitoring use of antibiotic was to make sure it was the right medication for the organism detected. During an interview on 4/12/2025, at 10:37 a.m., with the IP, the IP stated she (IP) was informed on 1/2025, to create her (IP) own Infection Control Antibiotic Surveillance Log but as of 4/12/2025, she (IP) had not started it yet. The IP stated it was in her (IP)'s Job Description to do antibiotic surveillance and complete the infection control log, but she had not started on it. The IP stated the importance of antibiotic surveillance and completing the infection control log was to know the reason for the antibiotic use if it was the right antibiotic and if infection was resolved. The IP stated the monitoring of antibiotic use was documented by nurses every shift and she (IP) cannot do it alone. The IP stated she (IP) did not have time to check the nurse's documentation every shift for monitoring of antibiotic use. The IP stated she (IP) was the IP for General Acute Care Hospital 1 (GACH 1) and GACH 2 including the Skilled Nursing Facility 1 (SNF 1) and SNF 2. The IP stated the importance of monitoring for antibiotic use was to check if nurses had administered the antibiotic, checked laboratory result for antibiotic resistance and to find out if the chosen antibiotic was effective to treat residents' infection. During an interview on 4/13/2025, at 2:37 p.m., with the IP, the IP stated she (IP) was a member of the Association for Professionals in Infection Control and Epidemiology (APIC-provides evidence-based, scientific, and proven resources to infection preventionists, healthcare professionals, and patients) since 10/15/2024. The IP stated she had not attended the annual convention (a large, formal meeting that is held each year) and plans to join and attend in 6/2025. The IP stated it's her (IP) first time to attend in 6/2025. During a concurrent interview and record review on 4/13/2025, at 5:31 p.m., with the Director of Subacute (DSA), the IP's Job Description dated 4/2021 was reviewed. The IP's Job Description indicated, The Director of Infection Control supervises, assesses, plans, implements and evaluates the hospital surveillance, prevention/control of infection management. Infection Control Preventionist Director will conduct and or facilitate internal audits, reviewing supporting documentation, and appraise preparedness of the other infection prevention personnel in the hospital /department. Required to work close with colleagues in producing information analysis for retro, concurrent, and real time monitoring. Education, Experience, Training . 6. APIC membership and attendance. Duties and Responsibilities: 1. Conducts regular surveillance to determine the presence of infections. 2. Screens all patients and identifies those with active infection potential from the neonate through geriatric adults. 3. Review all culture reports to identify cultures in which a specific pathogen has been isolated and makes appropriate recommendations. 4. Makes patient rounds on each unit to identify possible infectious processes and to evaluate previously institutes infection control measure. The DSA stated Infection Control log is part of the antibiotic surveillance. The DSA stated the IP should have monitored the use and effects of antibiotics. The DSA stated the importance of monitoring and tracking antibiotic use was to identify the pattern and determine the infection rate if increasing or trending (observing and analyzing changes in a patient's health status over time). The DSA stated the importance of the IP role was that the IP was in charge of prevention and control of infection and tracking of infection. The DSA stated the IP's Job description should have been updated to fit her qualification. The DSA stated the IP should have created her own tracking log for antibiotic use. During an interview on 4/13/2025 at 6:19 p.m., with the Chief Nursing Officer (CNO), the CNO stated the IP will attend the APIC convention this coming 6/2025. The ADM stated the IP is learning the process of the antibiotic surveillance. The ADM stated based on the IP's job description, the IP fell short on the qualifications to be the IP.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for three of five sampled residents (Residents 4, 3, and 18) by: 1. Failing to ensure Registered Nurse (RN) 2 administered 20-50 milliliter (ml - unit of volume) of water after medication administration to Resident 4 as per physician's order. 2. Failing to ensure Licensed Vocational Nurse (LVN) 1 flushed (also known as rinsing) Resident 3's gastrostomy tube (g-tube, a feeding tube inserted into the stomach through the abdominal wall, used to deliver nutrition, fluids, and medications directly to the stomach when someone cannot eat or drink adequately by mouth) with water in between medication administration as per facility's policy and procedures. 3. Failing to ensure LVN 2 flushed Resident 18's g-tube with water in between medication administration as per facility's policy and procedure. These failures had the potential to result in medication error and can result in medication drug interaction (a change in how the body responds to one medication when it's taken with another, or when it interacts with food, drinks, or even certain medical conditions can make a drug less effective, cause unwanted side effects, or even increase the action of a drug). Findings: 1. During a review of Resident 4's Physician's Orders, dated 10/18/2024, the Physician's order indicated the facility admitted Resident 4 on 10/18/2024, with diagnoses that included chronic respiratory failure (the lungs are unable to get enough oxygen into the blood or get rid of enough carbon dioxide, leading to breathing difficulties and fatigue over a long period), ventilator dependent (a resident requires medical device to help support or replace breathing), and dysphagia (difficulty swallowing). The Physician's Order indicated to flush feeding tube (g-tube) with 20-50 ml of water before and after medication administration. During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated 2/5/2025, the MDS indicated Resident 4's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 4 was dependent to staff for all activities of daily living (ADL- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 4 had a feeding tube (g-tube). During a review of Resident 4's Care Plan on at risk for aspiration (accidentally inhaling something other than air into your lungs, like food, water, or stomach contents) due to tube feeding (g-tube), dated 1/2/2025, the Care Plan indicated an intervention to maintain patency of feeding tube (g-tube), by flushing with water at a minimum of one ounce (oz = 30 ml) every shift and after medication administration. During a concurrent observation and interview on 4/12/2025 at 8:27 a.m., with RN 2, inside Resident 4's room, observed RN 2 administer 30 ml of water in between medication administration but administered 10 ml of water after the third and last medication administration. RN 2 stated the last medication she administered was Protonix (medication used to decrease acid in the stomach) then flushed Resident 4's g-tube with 10 ml of water. During a concurrent interview and record review on 4/12/2025 at 11:23 a.m., with RN 2, Resident 4's Physician's Order dated 10/18/2024, was reviewed. RN 2 stated the Physician's Order indicated to flush g-tube with 20-50 ml of water after medication administration. RN 2 stated 10 ml of water flush may not be enough and can clog Resident 4's g-tube. During an interview on 4/13/2025 at 5:31 p.m., with the Director of Subacute (DSA), the DSA stated g-tube should be flushed with 30 ml to 50 ml of water before and after medication administration. The DSA stated medication cannot be fully absorb if RN 2 flushed only 10 ml of water after medication administration. The DSA stated the importance of flushing g-tube with enough water was for hydration and also to make sure all the medication will reach the resident and not just left in the g-tube. The DSA stated the facility's policy was to flush g-tube with water after medication administration. 2. During a review of Resident 3's Physician's Order dated 2/7/2025, the Physician's Order indicated the facility admitted Resident 3 on 2/7/2025, with diagnoses that included chronic hypoxemic respiratory failure (a long-term condition where the lungs struggle to provide enough oxygen to the blood), tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe)] from outside the neck) and pneumonia (an infection/inflammation in the lungs). The Physician's Order indicated to flush feeding tube (g-tube) with 20-50 ml of water before and after giving medication. During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3's cognitive skills for decision making were severely impaired. The MDS indicated Resident 3 was dependent to staff for ADL. The MDS indicated Resident 3 had a feeding tube (g-tube). During a review of Resident 3's Care Plan on the resident's risk for aspiration due to tube feeding (g-tube), dated 1/2/2025, the Care Plan indicated an intervention to maintain patency of feeding tube by flushing with water at a minimum of 30 ml every shift and after medication administration. During an observation on 4/12/2025 at 9 a.m., observed LVN 1 administer crushed levetiracetam (also known as Keppra, medication used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] mixed with water to Resident 3's g-tube. Observed undissolved Keppra remaining in the medication cup and LVN 1 poured water in the remaining Keppra and administered to Resident 3's g-tube. Observed then LVN 1 administer crushed fluconazole (medication used to treat serious fungal [organisms that can live in various environments like soil, air, plants, and the human body] or yeast [a living microorganism naturally present in the environment and in our gut] infection) mixed with water thereafter. During an interview on 4/12/2025 at 5:36 p.m., with the Pharmacist (Pharm 1), Pharm 1 stated Keppra followed by fluconazole g-tube administration had moderate interaction (signifies a level of interaction that may warrant adjustments or monitoring by a healthcare provider) that could cause Resident 3 to be at low risk for QTc prolongation (means it takes the heart longer than usual to fully recharge between beats). During a concurrent interview and record review on 4/12/2025, at 7:05 p.m., with Pharm 1, an online Drug Interaction dated 2025 provided by Pharm 1 was reviewed. The Drug Interaction indicated Keppra was a QT prolonging agents (Intermediate Risk-moderate chance of a negative outcome or potential issues) and fluconazole was a QT-prolonging agents (moderate risk-these drugs can increase the risk of Torsade's de Pointes [TdP-a potentially life-threatening heart rhythm disturbance]). The Drug Interaction indicated no action was required for the majority of residents. The Drug Interaction indicated increased electrocardiogram (ECG-a test that records the electrical activity of the heart, helping doctors diagnose and monitor heart condition) monitoring may be considered in residents at high risk for QT interval prolongation (example older age, female .).The Drug Interaction indicated the risk of combining these agents is unclear, but product labelling for at least some of these indeterminate risk drugs suggest additional caution and increased ECG monitoring may be warranted when combined with drugs that prolong the QT interval. 3. During a review of Resident 18's Physician's Order, dated 7/25/2024, the Physician's Order indicated the facility admitted Resident 18 on 7/25/2024, with diagnoses that included chronic respiratory failure, ventilator dependent, and dysphagia with gastrostomy tube. The Physician's Order indicated flush feeding tube (g-tube) with 20-50 ml of water before and after giving medication. During a review of Resident 18's MDS dated [DATE], the MDS indicated Resident 18's cognitive skills for decision making were severely impaired. The MDS indicated Resident 18 was dependent to staff for ADL. The MDS indicated Residents 18 had a feeding tube (g-tube). During a review of Resident 18's Care Plan on the resident's risk for aspiration due to tube feeding dated 12/31/2024, the Care Plan indicated an intervention to maintain patency of feeding tube by flushing with water at a minimum of 30 ml every shift and after medication administration. During a concurrent observation and interview on 4/13/2025 at 12:30 p.m., with LVN 2, at Resident 18's bedside, observed LVN 2 administer liquid docusate (also known as Colace, medication used to soften stool) and then followed by crushed bethanechol (also known as Urecholine, medication used to treat urinary retention [the inability to completely empty the bladder]) mixed with water to Resident 18's g-tube. LVN 2 stated she missed flushing Resident 18's g-tube in between the two medications (Colace and Urecholine). LVN 2 stated she should have flushed Resident 18's g-tube with water in between medication administration. During an interview on 4/13/2025 at 5:31 p.m., with the DSA, the DSA stated g-tube should be flushed with water in between medication administration. The DSA stated LVN 1 and LVN 2 should have given free water in between medication administration to prevent possible drug interaction. The DSA stated it is the facility's policy to flush g-tube in between medication administration. During a review of facility's policy and procedure (P&P) titled, Medication Administration dated 2/2025, the P&P indicated, Procedure: Tube Administration , . 10. Draw the liquefied medications into the feeding syringe or pour into connected feeding syringe by gravity. Allow medications to flow by gravity through the enteral tube. Gentle pressure with the syringe plunger may be used, if necessary. Never 'force' medications/fluids through tubing. 11. Rinse medication cup and administering rinsing to assure compete dose. 12. Flush tube with a minimum of 50 ml of water. 13. Reconnect the administration set tubing, unclamp and start the enteral pump (a medical device that is used to deliver nutrients directly into the gastrointestinal tract of a resident who is unable to take food or liquids orally) if needed and double check the flow rate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%- per one hundred), four medication errors out of 26 total opportunities contributed to an overall medication error rate of 15.38% affecting two of five sampled residents (Resident's 3 and 18) observed for medication administration by: 1. Failing to ensure Licensed Vocational Nurse 1 (LVN 1) flushed Resident 3's gastrostomy tube (g-tube, a feeding tube inserted into the stomach through the abdominal wall, used to deliver nutrition, fluids, and medications directly to the stomach when someone cannot eat or drink adequately by mouth) with water in between medication administration as per facility's policy and procedure. 2. Failing to ensure LVN 2 flushed Resident 18's g-tube with water in between medication administration as per facility's policy and procedure. These failures had the potential to result in residents experiencing medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and medication error. Findings: 1. During a review of Resident 3's Physician's Order, dated 2/7/2025, the Physician's Order indicated the facility admitted Resident 3 on 2/7/2025, with diagnoses that included chronic hypoxemic respiratory failure (a long-term condition where the lungs struggle to provide enough oxygen to the blood), tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe)] from outside the neck) and pneumonia (an infection/inflammation in the lungs). The Physician's Order indicated flush feeding tube (g-tube) with 20-50 milliliter (ml-unit of volume) of water before and after giving medication. During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 2/20/2025, the MDS indicated Resident 3's cognitive skills for decision making were severely impaired. The MDS indicated Resident 3 was dependent to staff for ADL. The MDS indicated Resident 3 had a feeding tube (g-tube). During a review of Resident 3's Care Plan on risk for aspiration due to tube feeding (g-tube), dated 1/2/2025, the Care Plan indicated an intervention to maintain patency of feeding tube by flushing with water at a minimum of 30 ml every shift and after medication administration. During an observation on 4/12/2025, at 9 a.m., observed LVN 1 administer crushed Keppra (medication used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] mixed with water to Resident 3's g-tube. Observed undissolved Keppra remaining in the medication cup and LVN 1 poured water in the remaining Keppra and administered to Resident 3's g-tube. Observed LVN 1then administer crushed fluconazole (medication used to treat serious fungal [organisms that can live in various environments like soil, air, plants, and the human body] or yeast [a living microorganism naturally present in the environment and in our gut] infection) mixed with water thereafter. During an interview on 4/12/2025, at 5:36 p.m., with th e Pharmacist (Pharm 1), Pharm 1 stated Keppra followed with fluconazole g-tube administration had moderate interaction (signifies a level of interaction that may warrant adjustments or monitoring by a healthcare provider) that could cause Resident 3 to be at low risk for QTc prolongation (means it takes the heart longer than usual to fully recharge between beats). During a concurrent interview and record review on 4/12/2025, at 7:05 p.m., with Pharm 1, an online Drug Interaction dated 2025 provided by the Pharm 1 was reviewed. The Drug Interaction indicated Keppra was a QT prolonging agents (Intermediate Risk-moderate chance of a negative outcome or potential issues) and fluconazole was a QT-prolonging agents (moderate risk-these drugs can increase the risk of Torsade's de Pointes [TdP-a potentially life-threatening heart rhythm disturbance]). The Drug Interaction indicated no action was required for the majority of residents. The Drug Interaction indicated increased electrocardiogram (ECG-a test that records the electrical activity of the heart, helping doctors diagnose and monitor heart condition) monitoring may be considered in residents at high risk for QT interval prolongation (example older age, female .).The Drug Interaction indicated the risk of combining these agents is unclear, but product labeling for at least some of these indeterminate risk drugs suggest additional caution and increased ECG monitoring may be warranted when combined with drugs that prolong the QT interval. 2. During a review of Resident 18's Physician's Order, dated 7/25/2024, the Physician's Order indicated the facility admitted Resident 18 on 7/25/2024, with diagnoses that included chronic respiratory failure, ventilator dependent (a resident requires medical device to help support or replace breathing), and dysphagia (swallowing problem) with gastrostomy tube. The Physician's Order indicated flush feeding tube (g-tube) with 20-50 ml of water before and after giving medication. During a review of Resident 18's MDS dated [DATE], the MDS indicated Resident 18's cognitive skills for decision making were severely impaired. The MDS indicated Resident 18 was dependent to staff for ADL. The MDS indicated Residents 18 had a feeding tube (g-tube). During a review of Resident 18's Care Plan on risk for aspiration due to tube feeding dated 12/31/2024, the Care Plan indicated an intervention to maintain patency of feeding tube by flushing with water at a minimum of 30 ml every shift and after medication administration. During a concurrent observation and interview on 4/13/2025, at 12:30 p.m., with LVN 2, at Resident 18's bedside, observed LVN 2 administer liquid Colace (medication used to soften stool) and then followed by crushed Urecholine (medication used to treat urinary retention [the inability to completely empty the bladder]) mixed with water to Resident 18's g-tube. LVN 2 stated she (LVN 2) missed flushing Resident 18's g-tube in between the two medication (Colace and Urecholine). LVN 2 stated she (LVN 2) should have flushed Resident 18's g-tube with water in between medication administration. During an interview on 4/13/2025 at 5:31 p.m., with the Director of Subacute (DSA), the DSA stated g-tube should be flushed with water in between medication administration. The DSA stated not flushing Resident 3 and 18's g-tube in between medication administration was a medication error. The DSA stated LVN 1 and LVN 2 should have given free water in between medication administration to prevent possible drug interaction. The DSA stated it is the facility's policy to flush g-tube in between medication administration. During a review of facility's policy and procedure (P&P) titled , Medication Administration dated 2/2025, the P&P indicated, Procedure: Tube Administration, . 10. Draw the liquefied medications into the feeding syringe or pour into connected feeding syringe by gravity. Allow medications to flow by gravity through the enteral tube. Gentle pressure with the syringe plunger may be used, if necessary. Never 'force' medications/fluids through tubing. 11. Rinse medication cup and administering rinsing to assure compete dose. 12. Flush tube with a minimum of 50 ml of water. 13. Reconnect the administration set tubing, unclamp and start the enteral pump (a medical device that is used to deliver nutrients directly into the gastrointestinal tract of a resident who is unable to take food or liquids orally) if needed and double check the flow rate .

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when the kitchen failed to label: 1 box of bacon 1 box of sausages 1 tray of eggs These failures had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, and other toxins) in one out of twenty medically compromised residents who receive food from the kitchen. Findings: During an initial kitchen tour observation, on 4/11/2025, at 7:32 p.m., inside refrigerator 10, a large box of sausage, a large box of bacon, and a large open carton of eggs were unsealed and without an open or use by date written on the two boxes and the carton of eggs. During a concurrent observation and interview, with the Dietary Clerk (DC), on 4/11/2025, at 6:20 p.m., the DC looked into refrigerator 10 and stated the cook is in charge of labeling items and the cook did not label the boxes of sausage, bacon, and eggs with an open/best by date. The DC further stated without an open date, the facility will not know if the food is safe to serve. During an interview, on 4/13/2025, at 2:15 p.m., with the Food and Nutrition Director (FND), the FND stated every food item received must have a received and best by date and every food item opened must have an open date to prevent food borne illnesses. During a review of the facility's policy and procedure (P&P) titled, Food Storage, last revised on 2/2025, the P&P indicated food are to be stored in a safe and sanitary manner to prevent chemical and bacteriological contamination as well as time/temperature abuse. The P&P further indicated to rotate produce, frozen foods, dairy products etc. so that the oldest dates are used first.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan on enhanced barrier precaution isolation (an infection control intervention designed to reduce transmission of resistant organisms) to two out of four residents (Residents 10 and 13) investigated during review of medication administration facility task. The deficient practice had a potential to spread infection among residents and staff. Cross reference F837 and F880. Findings: 1. A review of Resident 10's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/23/2024, indicated the facility admitted the resident on 1/11/2024, with diagnoses including chronic respiratory failure (a serious condition that makes it difficult to breathe) with hypoxia (a low level of oxygen in the blood) or hypercapnia (a buildup of carbon dioxide in the blood), enterocolitis (an inflammation that occurs throughout the intestines) due to clostridium difficile (a germ that causes diarrhea), and tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs) status. The MDS indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident required oxygen therapy, suctioning, and tracheostomy care (a procedure performed routinely to keep the flange, tracheostomy dressing, ties or straps, and surrounding area clean to reduce the introduction of bacteria into the trachea [wind pipe] and lungs). The MDS indicated the resident was placed on isolation or quarantine for active infectious disease. A review of Resident 10's Physician's Orders indicated the following: -1/11/2024 Type: Percutaneous endoscopic gastrostomy (PEG, the placement of feeding tube through the skin and the stomach wall) -1/11/2024 Suction retained or increased secretion every 2 hours. -3/28/2024 Sacral (tail bone) wound stage 4 pressure injury (full thickness tissue loss with exposed bone, tendon, or muscle); cleanse with normal saline (NS, mixture of salt and water for cleansing wounds), pack with calcium alginate (used in the fabrication of wound dressing), apply 2 guard (adhesive consisting of two parts) to peri wound (the area around the wound) then cover with optiform dressing (a foam dressing that has a silicone adhesive border) every (q) bed time (HS) and if needed (PRN) if soiling for 30 days then re-eval. During an observation on 4/17/2024, at 8:30 a.m., with Licensed Vocational Nurse 1 (LVN 1), observed Resident 10's room without an enhanced barrier precaution sign and isolation cart (designed to provide a storage spot for personal protective equipment [PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses] protection apparel when in a patient is in isolation) outside of the resident's room. Observed LVN 1 with mask and gloves on but was not wearing a gown during medication administration to Resident 2. During an interview and record review on 4/17/2024, at 2:38 p.m., with LVN 1, LVN 1 stated she did not wear a gown while administering medications to Resident 10 during the morning medication pass. Resident 10's care plans were reviewed with LVN 1. LVN 1 stated the resident does not have a care plan on enhanced barrier precautions. LVN 1 stated it was important to have a care plan on enhanced barrier precautions to ensure appropriate infection control procedures are being practiced by staff during resident care. During an interview on 4/17/2024, at 2:44 p.m., with the Nurse Manager (NM), the NM stated it was important to develop a care plan on enhanced barrier precautions to guide licensed nurses on how to prevent Resident 10 from getting an infection. A review of the facility's recent policy and procedure titled, Care Planning, last reviewed on 2/12/2024, indicated to assure a coordinated and comprehensive written plan is developed based on the resident assessment instrument and on the individual needs of the resident. Within 24 hours of admission, the facility will initiate a care plan based on the resident assessment and on the individual needs of the resident. A comprehensive care plan must be developed by the seventh day and completed by the twenty first day after admission. Resident care planning includes participation from all involved health care disciplines at resident care conferences with continual reassessment, and updating at least quarterly, and upon change of condition, until resident's discharge. 2. A review of Resident 13's MDS, dated [DATE], indicated the facility admitted the resident on 9/20/2023, with diagnoses including chronic respiratory failure with hypoxia, tracheostomy status, and gastrostomy status. The MDS indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident was receiving oxygen therapy, suctioning, and tracheostomy care. A review of Resident 13's Physician's Orders indicated the following: -4/2/2024 Penile moisture associated skin damage (MASD, caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, saliva, and their contents). Cleanse with soap and water, pat dry, apply triple antibiotic ointment (an antibiotic medication used to reduce the risk of infections) q shift X 14 days. -9/20/2023 Type: PEG -9/20/2023 G-tube feeding. -9/20/2023 Suction retained or increased secretion every 2 hours. -11/28/2023 Trach Tube (a tube constructed of polyvinyl chloride that is placed between the vocal cords through the trachea): Type shiley (brand name associated with medical devices, specifically tracheostomy tubes) size #6, cuffed. During an observation on 4/17/2024 at 9:35 a.m., with LVN 1, observed Resident 13's room without an enhanced barrier precaution sign and an isolation cart outside of the resident's room. Observed LVN 1 with mask and gloves on but was not wearing a gown during medication administration to Resident 13. During an interview and record review on 4/17/2024, at 2:38 p.m., with LVN 1, LVN 1 stated she did not wear a gown while administering medications to Resident 10 during the morning medication pass. Resident 10's care plans were reviewed with LVN 1. LVN 1 stated the resident does not have a care plan addressing enhanced barrier precautions. LVN 1 stated it was important to have a care plan on enhanced barrier precautions to ensure appropriate infection control procedures are being practiced by staff during resident care. A review of the facility's recent policy and procedure titled, Care Planning, last reviewed on 2/12/2024, indicated to assure a coordinated and comprehensive written plan is developed based on the resident assessment instrument and on the individual needs of the resident. Within 24 hours of admission, the facility will initiate a care plan based on the resident assessment and on the individual needs of the resident. A comprehensive care plan must be developed by the seventh day and completed by the twenty first day after admission. Resident care planning includes participation from all involved health care disciplines at resident care conferences with continual reassessment, and updating at least quarterly, and upon change of condition, until resident's discharge. A review of the facility's recent policy and procedure titled, Care Planning, last reviewed on 2/12/2024, indicated to assure a coordinated and comprehensive written plan is developed based on the resident assessment instrument and on the individual needs of the resident. Within 24 hours of admission, the facility will initiate a care plan based on the resident assessment and on the individual needs of the resident. A comprehensive care plan must be developed by the seventh day and completed by the twenty first day after admission. Resident care planning includes participation from all involved health care disciplines at resident care conferences with continual reassessment, and updating at least quarterly, and upon change of condition, until resident's discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision to prevent accidents by failing to ensure a medication cup containing clear and white ointment was not left unattended and readily accessible in the residents' shared room for two of two sampled residents (Resident 18 and 5) observed during screening. This deficient practice had the potential to result in residents obtaining topical medication without staff knowledge resulting in accidental ingestion causing harm to residents. Findings: 1. A review of Resident 18's MDS, dated [DATE], indicated the facility admitted the resident on 6/1/2023 and readmitted the resident on 1/22/2024. The MDS indicated the resident was in a persistent vegetative state (a person is awake but shows no signs of awareness) with no discernible consciousness (awareness of internal and external existence). The MDS indicated the resident was totally dependent on staff for mobility, dressing, bathing, toilet hygiene, and personal hygiene. A review of Resident 18's History and Physical (H&P), dated 1/1/2024 indicated the resident had diagnoses that included traumatic brain injury (a disruption in the normal function of the brain that caused by a bump, blow, or jolt to the head) respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen), tracheostomy (opening surgically created through the front of the neck and into the trachea [windpipe]), and functional quadriplegia (the inability to move due to another medical condition). A review of Resident 18's Physician Orders indicated the following orders: -Buttocks / sacral area (base of the spine): cleanse with soap and water, pat dry, apply z-guard (zinc oxide [medication] paste, a topical skin protectant) every shift for skin management, dated 1/22/2024. -Bilateral feet dryness: cleanse with soap and water, pat dry, apply vitamin A&D ointment (a medication to treat or prevent dry, rough, itchy skin) every shift for skin maintenance. A review of Resident 18's Care Plan (CP) titled, High risk for skin breakdown, initiated 1/2/2024, indicated the resident had a Braden Scale of 9 indicating severe risk for skin breakdown. The CP indicated to use ointment barriers to protect the skin exposed to soilage or wetness, to apply A&D ointment to the bilateral feet for dryness, and to apply Z-guard to the buttock / sacral region. 2. A review of Resident 5's MDS, dated [DATE], indicated the facility admitted the resident on 3/6/2013 and readmitted the resident on 7/3/2023. The MDS indicated the resident sometimes was able to make himself understood and sometimes understood others. The MDS indicated the resident was totally dependent on staff for mobility, dressing, bathing, and toilet hygiene. A review of Resident 5's H&P, dated 1/1/2024 indicated the resident had diagnoses that included chronic respiratory failure, tracheostomy, and non-alcoholic steatohepatitis cirrhosis (a condition that leads to scarring and permanent damage of the liver). A review of Resident 5's Physician Orders indicated the following orders: -Buttocks area: cleanse with soap and water, pat dry, apply vitamin A&D ointment every shift for maintenance, dated 1/28/2023. During an observation and interview on 4/16/2024 at 9:54 a.m. with Certified Nursing Assistant 1 (CNA 1), observed Resident 5 unable to verbalized, alert and awake, sitting in a wheelchair in the shared room with Resident 18. Observed Resident 5 make grabbing attempts at the intravenous pole (IV pole, medical device designed as a slender iron or aluminum portable pole with adjustable height) in the room. CNA 1 stated Resident 5 has some agitation at times. During an observation on 4/16/2024 at 10:13 a.m., observed Resident 18 lying in bed in the shared room with Resident 5. Resident 18 was not alert or awake. Observed a wall mounted workstation across from the foot of Resident 18's bed. Observed a medication cup containing clear and white ointments placed on top of the wall mounted workstation. During an observation and interview on 4/16/2024 at 10:20 a.m. with CNA 1, CNA 1 stood inside Resident 18 and 5's shared room. CNA 1 stated she did not place the medication cup on the workstation, and she did not know it was there. CNA 1 stated somebody probably placed the cup on the workstation and forgot about it. CNA 1 removed the cup from the wall mounted workstation and stated there was a white and clear ointment in the cup and she did not know which resident it was intended for. CNA 1 placed the cup in the trash. CNA 1 stated ointments should be thrown away after each use and the cup should not have been left in the residents' room. During an interview on 6/16/2024 at 10:48 a.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated she made rounds that morning and did not see the cup with ointment in Resident 18 and 5's shared room. LVN 2 stated she did not know which resident the ointment was intended for because it was not labeled. LVN 2 stated ointments in medication cups should be labeled and discarded once used, but it was not. LVN 2 stated medication should not be left in the resident's room. During an interview on 4/16/2024 at 2:26 p.m. with Registered Nurse 1 (RN 1), RN 1 stated both Resident 18 and Resident 5 had physician's orders for the administration of ointments. RN 1 stated medication should never be left in the residents' rooms because it posed a risk to the welfare of the residents. RN 1 stated residents could potentially get ahold of the cup and ingest the topical medication with the potential for harm or even death. During a concurrent interview and record review on 4/17/2024 with the Nurse Manager (NM), the facility policy and procedure regarding medication administration was reviewed. The NM stated licensed staff should not leave medication in residents' rooms. The NM stated the facility policy was not followed and medication should not be left at bedside to prevent accidental use by other residents. A review of the facility provided policy and procedure titled, Medication Administration, last reviewed 2/12/2024, indicated the policies and procedures are established to assure the most complete and accurate implementation of physician's medication orders and to optimize drug therapy for each resident by providing for administration of drugs in an accurate, safe, timely, and sanitary manner. Medications shall not be left with residents to self-administer unobserved.

Based on observation, interview and record review, the facility failed to administer parenteral fluids (the intravenous administration of medication) consistent with professional standards of practice for two (2) out of 2 sampled resident (Residents 1 and 2) investigated during random observations of residents with peripheral intravenous (IV) catheter (a thin, flexible tube that is inserted into a vein to draw blood and give treatments including IV fluids, drugs, or blood transfusions) by: 1. Failing to label Resident 1's midline catheter (a long, thin, flexible tube that is inserted into a large vein in the upper arm with the tip located just below the underarm) with the date of the last dressing change. 2. Failing to provide and document midline catheter care and dressing changes to Resident 2's midline catheter per facility policy. These deficient practices placed the residents at risk for developing complications such as inflammation of the vein and infection. Findings: a. A review of Resident 1's Admission/Registration Record indicated the facility admitted the resident on 7/1/2023 and readmitted the resident on 1/27/2024 with diagnoses including chronic respiratory failure, tracheostomy, and pneumonia. A review of Resident 1 's Minimum Data Set (MDS, a standardized assessment and screening tool) dated 4/1/2024, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs, basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 1 had an IV catheter. A review of Resident 1's Physician's Orders dated 2/23/2024 indicated the following: - Change right upper arm midline dressing every seven (7) days and as needed for soiling. - Right upper arm midline flush with normal saline (NS - a mixture of salt and water that closely resembles the concentration of salt found in blood and tears) ten(10) milliliters (ml - a unit of measurement for liquids) every shift. A review of Resident 1's care plan on risk for potential for infection presence to presence of right upper arm midline initiated 2/23/2024 with target date 4/23/2024 review every 30 days indicated to change IV tubing and dressing per protocol or physician orders. During an observation on 4/16/2024 at 9:30 a.m. at Resident 1's bedside observed Resident 1 with a midline catheter on the right upper arm with dressing that was mot labeled with the date of when the dressing was last changed. During a concurrent observation and interview on 4/16/2024 at 9:54 a.m. with Registered Nurse 1 (RN 1) at Resident 1's bedside, RN 1 verified that Resident 1' midline dressing did not indicate the date of the last dressing change. RN 1 stated midline catheter dressings are changed every 7 days and as needed. RN 1 stated the dressing should indicate the date of the last dressing change in order to inform the nurses when the next dressing change is due. RN 1 stated, not dating the midline catheter dressing can result in nurses not knowing when to change the dressing timely which may lead to an infection. During an interview on 4/18/2024 at 2:35 p.m. with the MDS Coordinator-Registered Nurse (MDSC-RN), MDSC-RN stated midline catheter dressing changes are done every 7 days and as needed for soiling. The MDSC-RN stated if the date of the last dressing change is not indicated on the dressing, the nurses would not know when the next dressing change is due. MDSC-RN stated not changing the midline catheter dressing timely had the potential to cause complications to the IV site such as infection. A review of the facility's policy and procedure titled, Midline Catheter management, last reviewed 2/24/2024, indicated midline catheter dressing shall be changed every 7 days as ordered by the physician. The policy indicated to inspect the exit site for swelling, redness, exudate (fluid that leaks out of blood vessels into nearby tissues), and signs of phlebitis (inflammation of a vein). A review of the facility's policy and procedure titled, Charting Guidelines, the policy indicated a purpose to provide guidelines for appropriate documentation in the health record. The policy indicated the following: - All documentation will be completed as required for each resident. - Charting should include all assessments of resident condition, all interventions taken to resolve a problem and the progress/lack og progress with the written care plan. - All charting should be done as soon as possible after a given event. - Document normal findings as well as abnormal findings as this shows that the resident was being assessed. b. A review of Resident 2's Admission/Registration Record indicated the facility admitted the resident on 2/24/2015 and readmitted the resident on 1/1/2024 with diagnoses including chronic respiratory failure (a serious condition that happens when not enough oxygen passes from the lungs to the blood), multiple sclerosis (an autoimmune disease [a condition in which the body attacks itself by mistake] that affects the brain and spinal cord which could potentially disable a person), and quadriplegia (paralysis of all four extremities). A review of Resident 2 's Minimum Data Set (MDS, a standardized assessment and screening tool) dated 4/1/2024, indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs, basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 2's Physician's Orders dated 3/29/2024 indicated the following: - Right forearm (RFA)midline catheter change dressing every 7 days and as needed for soiling. - Right forearm (RFA) midline catheter flush with normal saline (NS - a mixture of salt and water that closely resembles the concentration of salt found in blood and tears) ten (10) milliliters (ml - a unit of measurement for liquids) every shift. A review of Resident 2's care plan on potential for infection related to presence of RFA midline catheter initiated 4/1/2024 with target date 5/1/2024, indicated to assess IV site every shift for signs and symptoms of infection and report any redness, swelling, and pain. The care plan indicated to change IV tubing and dressing per protocol or physician's order. During an observation on 4/16/2024 at 11:30 a.m. at Resident 2's bedside, observed Resident 2 with midline catheter on the RFA with dressing, dated 4/15/2024. During a concurrent interview and record review on 4/16/2024 at 3:00 p.m., with Registered Nurse 1 (RN 1), Resident 2's nursing documentation every shift dated 4/15/2024 was reviewed. RN 1 verified there was no documented evidence that the dressing on the RFA midline catheter was changed on 4/15/2024. Resident 2's nursing documentation every shift from 3/29/2024 to 4/15/2024 were reviewed with RN 2. RN 2 verified that there were no documented evidence of when the last dressing change was done. RN 2 verified there was no documented evidence that the midline catheter care was provided on 4/11/2024 and 4/12/2024 day shift. RN 2 stated dressing changes and midline catheter care should have been documented in the shift nursing documentation to inform the nurses when the next dressing change is due and to ensure the IV site was assessed for signs and symptoms of infection. During a concurrent interview and record review on 4/18/2024 at 2:30 p.m. with the MDS Coordinator - Registered Nurse (MDSC-RN), the MDSC-RN stated dressing changes and midline catheter care should be documented every shift in the shift nursing documentation to ensure the dressing was changed and the midline catheter was assessed every shift for signs and symptoms of infection. A review of the facility's policy and procedure titled, Midline Catheter management, last reviewed 2/24/2024, indicated midline catheter dressing shall be changed every 7 days as ordered by the physician. The policy indicated to inspect the exit site for swelling, redness, exudate (fluid that leaks out of blood vessels into nearby tissues), and signs of phlebitis (inflammation of a vein). A review of the facility's policy and procedure titled, Charting Guidelines, the policy indicated a purpose to provide guidelines for appropriate documentation in the health record. The policy indicated the following: - All documentation will be completed as required for each resident. - Charting should include all assessments of resident condition, all interventions taken to resolve a problem and the progress/lack og progress with the written care plan. - All charting should be done as soon as possible after a given event. - Document normal findings as well as abnormal findings as this shows that the resident was being assessed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services during inspection of one of two medication carts (Medication Cart 2) investigated during the Medication Storage and Labeling task by failing to ensure an opened and unlabeled single-use vitamin A&D ointment (a medication to treat or prevent dry, rough, itchy skin) packet was not stored and readily available for use in Medication Cart #2. This deficient practice had the potential to result in topical medication being used for multiple residents with the potential for cross contamination and decreased efficacy of topical medications. Findings: During a medication storage inspection of Medication Cart 2 on [DATE] at 7:35 a.m. with Licensed Vocational Nurse 3 (LVN 3), observed in the top drawer of Medication Cart 2 an unlabeled vitamin A&D, 5-gram (g, a unit of measurement) packet of ointment with the top portion cut off and the packet was open with clear medication inside. LVN 3 stated the ointment packet was single use and should be discarded in the resident's room after use. LVN 3 stated she did not open the ointment packet, did not know what resident it was opened for, and did not know if it was used. LVN 3 stated the night shift nurse probably opened the ointment packet and should have thrown it away, but they did not. LVN 3 stated there was a potential that an opened and used ointment could be used on another resident and that could lead to cross contamination and possible infection of a resident. During an interview on [DATE] at 8:10 a.m. with the Nurse Manager (NM), the NM stated vitamin A&D ointment packets should be disposed of after the packet is opened and used. The NM stated A&D ointment packets are not meant to be used on multiple residents. The NM stated if an A&D ointment packet is unused and opened in the medication cart it should be labeled with the resident's name. The NM stated there was a potential for cross contamination if the A&D ointment was used on multiple residents. A review of the facility provided policy and procedure titled, Pharmacy Manual, Storage: General, last reviewed [DATE], indicated drugs and devices shall be stored to ensure stability and integrity. Drugs shall be stored under the proper conditions of sanitation. The hospital removes all expired, damaged, and/or contaminated medications and stores them separately from medication available for administration. A review of the facility policy and procedure titled, Labeling of Meds in All Areas, last reviewed 1/2023 indicted the purpose of the policy was to ensure that all medications are appropriately labeled, prepared safely and properly to promote safety in administering the right drug, in the right quantity, to the right patient. Anytime medication containers are prepared but not administered immediately, the container must be labeled.

Based on observation, interview, and record review, the facility failed to maintain a mechanical, electrical, and patient care equipment in safe operational condition by failing to the ensure handheld nebulizer compressor (an electrically powered device that turns liquid medication into a fine mist for inhalation [breathing in]) was inspected by the labeled next inspection due date of 7/2023 for one of two sampled residents (Resident 18) investigated under the Respiratory care area. This deficient practice had the potential to result in delay in care and services of essential respiratory treatments for residents and had the potential for device electrical malfunction resulting in fire. Findings: A review of Resident 18's Minimum Data Set (MDS- an assessment and care screening tool), dated 1/18/2024, indicated the facility admitted the resident on 6/1/2023 and readmitted the resident on 1/22/2024. The MDS indicated the resident was in a persistent vegetative state with no discernible consciousness. The MDS indicated the resident was totally dependent on staff for mobility, dressing, bathing, toilet hygiene, and personal hygiene. A review of Resident 18's History and Physical (H&P), dated 1/1/2024 indicated the resident had diagnoses that included traumatic brain injury (a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head), respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen), tracheostomy (opening surgically created through the front of the neck and into the trachea [windpipe]), and functional quadriplegia (the inability to move due to another medical condition). A review of Resident 18's Physician Orders indicated the following orders: -Albuterol sulfate (a medication to treat difficulty with breathing) 2.5 milligrams (mg, a unit of measurement) / 3 milliliters (mL, a unit of measurement), inhale one unit dose via handheld nebulizer every six hours routinely for bronchospasm (tightening of the muscles in the airway), shortness of breath, dated 2/15/2024. - Albuterol sulfate 2.5 mg/3 mL, inhale one unit dose via handheld nebulizer every four hours as needed for bronchospasm, shortness of breath, order dated 2/15/2024. - Ipratropium bromide (a medication to treat difficulty with breathing) inhale 0.02 percent (%, a measurement of concentration) (0.5 gm / 2.5 mL) solution, one unit dose via handheld nebulizer every six hours routinely for shortness of breath, order dated 2/15/2024. - Ipratropium bromide, inhale 0.02 % (0.5 gm/2.5 mL) solution, inhale 1 mL as directed via handheld nebulizer every four hours as needed for shortness of breath, order dated 2/15/2024. A review of Resident 18's Care Plan titled, Potential for impaired gas exchange, initiated 1/2/2024, indicated interventions to provide breathing treatments as ordered and monitor for effectiveness. During an observation on 4/16/2024 at 10:13 a.m., observed Resident 18 lying in bed; the resident was not alert or awake. Observed on Resident 18's bedside nightstand a handheld nebulizer compressor labeled Biomed Services Next Inspection date 2023 JUL. During a concurrent observation and interview on 4/16/2024 at 2:21 p.m., Registered Nurse 1 (RN 1) stated Resident 18 uses a nebulizer for routine and as needed breathing treatments with a handheld nebulizer. RN 1 stated nebulizers are inspected to make sure they are working properly. RN 1 assessed Resident 18's nebulizer compressor and stated it was labeled with the next inspection due date of 7/2023. RN 1 stated the nebulizer should have been inspected before 7/2023 and then labeled with the next inspection due date. RN 1 stated the facility Biomed Services (responsible for ensuring all facility machines are in good and safe working condition) inspects all facility machines, but she was not sure how often they come to the unit. RN 1 stated staff should have assessed Resident 18's environment and called to have Biomed inspect the nebulizer. RN 1 stated the respiratory therapists provide nebulizer treatments and it was also their responsibility to call Biomed because they operate the nebulizers. RN 1 stated if the nebulizer compressor was not inspected it could have potentially resulted in the resident not effectively receiving the breathing treatments or it could have resulted in mechanical issues that were not apparent. During an interview on 4/16/2024 at 4:11 p.m., Respiratory Therapist 1 (RT 1) stated Biomed was responsible for nebulizer inspections and they have a list and come by automatically to inspect the nebulizers. RT 1 stated he provides respiratory treatments for Resident 18, and he was not aware the nebulizer was labeled for a 7/2023 inspection. RT 1 stated nebulizers need to be inspected because they have a motor and need to be cleaned and ensure that they are properly functioning including the electrical wiring. During an interview on 4/17/2024 at 2:15 p.m., the Nurse Manager (NM) stated unit equipment is checked for proper functioning annually by Biomed. The NM stated it was an oversite that Resident 18's nebulizer was not inspected. The NM stated the nebulizer label should have been noticed over the last nine months. The NM stated the importance of ensuring the nebulizer is inspected is for preventative maintenance to make sure the device is functioning well to provide respiratory breathing treatments for pulmonary function. During an interview and record review on 4/18/2024 at 9:53 a.m. with the Biomed Engineering Site Lead (BESL), the facility Environment of Care Manual regarding equipment management was reviewed. The BESL stated he was made aware there was a nebulizer on the unit that was out of date for inspection. The BESL stated the facility policy did not indicate that nebulizers are to be inspected yearly, but it was the standard of practice and Biomed follows the manufacture instructions. The BESL stated Biomed keeps track of equipment and preventative maintenance with a list that is printed out with the location of the equipment, but the equipment can move throughout the facility. The BESL stated if they are unable to locate the equipment for six months then the equipment is placed in out of service status. The BESL stated Resident 18's nebulizer was placed in out of service status because it was not located by Biomed. The BESL stated all staff are continually in-serviced and educated to look at the inspection dates labeled on equipment to check if they are out of date and then to notify Biomed. The BESL stated nebulizers are inspected for functionality and for damage or exposed wires. The BESL stated staff may not be aware that a nebulizer was malfunctioning, so it was important that nebulizers are inspected. A review of the facility-provided Environment of Care Manual: Medical Equipment Management Plan, last reviewed 2/12/2024, indicated the Medical Equipment Management Program includes a description and maintenance procedure for all equipment that is used for the diagnosis and treatment of patients in the facility. The establishing of criteria for identifying, evaluating, and taking inventory of medical equipment to be included in the program before the equipment is used is based on equipment function, physical risks associated with use, and maintenance requirements. The assessing and minimizing of clinical and physical risks of equipment use through inspection, testing and maintenance is a combined effort of the Biomed Department, Engineering Department, designated users, and contract services. Maintenance will be current within a month.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility's failed to provide care in accordance with professional standards to three out of five sampled residents (Resident 7, 9, and 13) investigated during review of unnecessary medications by failing to: 1. Ensure licensed nurses rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) administration sites of heparin (a substance that slows the formation of blood clots) to Resident 7. 2. Ensure licensed nurses rotate subcutaneous administration sites of enoxaparin sodium (Lovenox, used to prevent blood clots) to Resident 9. 3. Ensure licensed nurses rotate subcutaneous administration sites of Lantus insulin (a drug used to control the amount of sugar in the blood) to Resident 13. The deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin and anticoagulants (a substance that is used to prevent and treat blood clots in blood vessels and the heart) such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a rare disease that occurs when a protein called amyloid builds up in organs). Cross reference F760 Findings: 1. A review of Resident 7's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/26/2024, indicated the facility admitted the resident on 9/15/2019, with diagnoses including hemiplegia (weakness or paralysis on one side of the body) or hemiparesis (one-sided muscle weakness), anoxic brain damage (caused by a complete lack of oxygen to the brain, which results in the death of brain cells), and history of other diseases of the circulatory system (made up of blood vessels that carry blood away and towards the heart). The MDS indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident was taking a high-risk drug class anticoagulant. A review of Resident 7's Physician's Orders, dated 10/31/2023, indicated an order for heparin sodium SDV 5000 unit/1 milliliter (unit/ml, a unit of fluid volume equal to one-thousandth of a liter) vial (RO: Heparin 5000 un/ml (SB). Inject 1 milliliters (ml, a unit of volume) (5000 units) subcutaneously every 12 hours (deep vein thrombosis [DVT, a blood clot in a deep vein of the leg, pelvis, and sometimes the arm] prophylaxis [preventive]). During a concurrent interview and record review on 4/16/2023, at 1:46 p.m., with the Minimum Data Set Coordinator- Registered Nurse (MDSC-RN), reviewed Resident 7's Medication Administration Record dated 1/2024 to 4/16/2024. The MDSC-RN stated the heparin injection site should be rotated to prevent bruising and bleeding. The MDSC-RN verified the subcutaneous injection site for heparin were not rotated on the following dates, times, and locations: 1/8/2024 at 9:42 p.m. on the Right Upper Abdomen 1/9/2024 at 9 a.m. on the Right Upper Abdomen 2/6/2024 at 9 a.m. on the Right Lower Abdomen 2/6/2024 at 9:13 p.m. on the Right Lower Abdomen 2/7/2024 at 8:24 p.m. on the Right Upper Abdomen 2/8/2024 at 9:12 a.m. on the Right Upper Abdomen 2/16/2024 at 9 a.m. on the Right Lower Abdomen 2/16/2024 at 9:34 p.m. on the Right Lower Abdomen During an interview on 4/17/2023, at 12:06 p.m., with Pharmacist 1 (PHARM 1), PHARM 1 stated the licensed nurse should have rotated heparin injection sites to prevent fat accumulation and bruising at the frequented administration site. During an interview on 4/17/2024, at 12:34 p.m., with the Nurse Manager (NM), the NM stated heparin subcutaneous administration sites should be rotated to prevent bruising. A review of the facility provided, Highlights of Prescribing Information- for Heparin Sodium Injection, initial U.S. Approval in 1939, indicated for deep subcutaneous (Intrafat) Injection Use a different site for each injection. A review of the facility's policy and procedure titled, Medication Administration, last reviewed on 1/2023, indicated insulin/anticoagulant site locator, changing sites daily on a good plan lessens pain and damage to your body from injections. 2. A review of Resident 9's MDS, indicated the facility admitted the resident on 7/14/2020, with diagnoses including anemia (a condition in which the body does not have enough healthy red blood cells), coronary artery disease (a disease in which there is a narrowing or blockage of the coronary arteries), and persistent vegetative state (unconscious, unaware, and unresponsive). The MDS indicated the resident was taking a high-risk drug class anticoagulant. A review of Resident 9's Physician's Orders, dated 2/13/2021, indicated an order for enoxaparin sodium outer, SUV, P/F, L/F 40 mg/0.4 ml syringe (RP: Lovenox PFS). Inject 40 milligrams (mg, a unit of weight) (0.4 ml) subcutaneously every day (DVT prophylaxis). Medication has boxed warning (warning given by the FDA [Food and Drug Administration] for drugs or dug classes that may cause serious harm or death). During a concurrent interview and record review on 4/16/2023, at 1:46 p.m., with the Minimum Data Set Coordinator- Registered Nurse (MDSC-RN), reviewed Resident 9's Medication Administration Record dated 1/2024 to 4/16/2024. The MDSC-RN stated the enoxaparin sodium (Lovenox) injection site should be rotated to prevent bruising and bleeding. The MDSC-RN verified the subcutaneous injection sites were not rotated on the following dates, times, and locations: 4/8/2024 at 9:55 a.m. on the Right Lower Abdomen 4/9/2024 at 9:28 a.m. on the Right Lower Abdomen 4/10/2024 at 9:51 a.m. on the Left Upper Abdomen 4/11/2024 at 9:49 a.m. on the Left Upper Abdomen During an interview on 4/17/2023, at 12:06 p.m., with the PHARM 1, the PHARM 1 stated the licensed staff should have rotated Lovenox injection sites to prevent fat accumulation and bruising at the frequented administration site. During an interview on 4/17/2024, at 12:34 p.m., with the Nurse Manager (NM), the NM stated heparin subcutaneous administration sites should be rotated to prevent bruising. A review of the facility provided, Highlights of Prescribing Information- for Enoxaparin Sodium Injection, initial U.S. Approval in 1993, indicated to alternate injection sites between the left and right anterolateral and left and right posterolateral abdominal wall. A review of the facility's recent policy and procedure titled, Medication Administration, last reviewed on 1/2023, indicated on insulin/anticoagulant site locator, changing sites daily on a good plan lessens pain and damage to your body from injections. 3. A review of Resident 13's MDS, dated [DATE], indicated the facility admitted the resident on 9/20/2023, with diagnoses including diabetes mellitus (DM, a disease that occurs when the blood glucose, also called blood sugar, is too high), malnutrition (deficiencies or excess in nutrient intake), and dysphagia (difficulty swallowing). The MDS indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident was on a high-risk drug class hypoglycemic (low blood sugar) insulin (a hormone that lowers the level of blood sugar). A review of Resident 13's Physician's Order Sheet, dated 4/6/2024, indicated an order for Lantus 18 units q a.m. subcutaneously for DM and Lantus 14 units subcutaneously at bedtime for DM. During a concurrent interview and record review on 4/16/2023, at 1:46 p.m., with the Minimum Data Set Coordinator- Registered Nurse (MDSC-RN), reviewed Resident 13's Medication Administration Record dated 1/2024 to 4/16/2024. The MDSC-RN stated Lantus injection site should be rotated to prevent bruising and bleeding. The MDSC-RN verified the subcutaneous injection sites were not rotated on the following dates, times, and locations: 1/12/2024 at 9:49 p.m. on the Right Upper Quadrant 1/13/2024 at 9:54 p.m. on the Right upper Quadrant 1/15/2024 9:50 p.m. on the Left Deltoid 1/16/2024 at 9 p.m. on the Left Deltoid 1/17/2024 at 9:52 p.m. on the Right Lower Quadrant 1/18/2024 at 10 p.m. on the Right Lower Quadrant 1/20/2024 at 9:55 p.m. on the Right Lower Quadrant 1/21/2024 at 9:11 p.m. on the Right Lower Quadrant 1/24/2024 at 8:44 a.m. on the Left Lower Quadrant 1/25/2024 at 9:12 a.m. on the Left Lower Quadrant 1/27/2024 at 9:37 a.m. on the Left Deltoid 1/28/2024 at 9:54 a.m. on the Left Deltoid 2/2/2024 at 9:53 a.m. on the Right Lower Quadrant 2/3/204 at 9:26 a.m. on the Right Lower Quadrant 2/6/2024 at 9:13 a.m. on the Right Upper Quadrant 2/7/2024 at 9:30 a.m. on the Right Upper Quadrant 2/10/2024 at 9:19 p.m. on the Right Lower Quadrant 2/11/2024 at 9 p.m. on the Right Lower Quadrant 2/20/2024 at 9:42 a.m. on the Left Deltoid 2/21/2024 at 10:02 a.m. on the Left Deltoid 2/23/2024 at 9:47 p.m. on the Right Lower Quadrant 2/24/2024 at 9:18 p.m. on the Right Lower Quadrant 2/28/2024 at 9:19 p.m. on the Left Upper Quadrant 2/29/2024 at 9:17 p.m. on the Left Upper Quadrant 3/1/2024 at 8:51 p.m. on the Left Upper Quadrant 3/2/2024 at 9:15 p.m. on the Left Upper Quadrant 3/3/2024 at 8:05 p.m. on the Left Lower Quadrant 3/4/2024 at 8:15 p.m. on the Left Lower Quadrant 3/5/2024 at 8:34 a.m. on the Right Upper Quadrant 3/6/2024 at 9:13 a.m. on the Right Upper Quadrant 3/7/2024 at 9:17 a.m. on the Left Lower Quadrant 3/8/2024 at 9:42 a.m. on the Left Lower Quadrant 3/13/2024 at 9 a.m. on the Left Lower Quadrant 3/14/2024 at 9:23 a.m. on the Left Lower Quadrant 3/22/2024 at Left Upper Quadrant 3/23/2024 at 9:13 a.m. on the Left Upper Quadrant 3/24/2024 at 8:38 p.m. on the Left Deltoid 3/25/2024 at 8:45 p.m. on the Left Deltoid 3/25/2024 at 9:28 a.m. on the Right Lower Quadrant 3/27/2024 at 9:58 p.m. on the Right Lower Quadrant 3/28/2024 at 8:57 p.m. on the Right Lower Quadrant 4/3/2024 at 9:33 p.m. on the Right Upper Quadrant 4/4/2024 at 8:19 p.m. on the Right Upper Quadrant 4/5/2024 at 8:25 p.m. on the Right Upper Quadrant 4/6/2024 at 9:22 p.m. on the Right Lower Quadrant 4/7/2024 at 9:39 p.m. on the Right Lower Quadrant 4/10/2024 at 9:01 a.m. on the Right Lower Quadrant 4/11/2024 at 9:29 a.m. on the Right Lower Quadrant 4/12/2024 at 9:17 a.m. on the Left Lower Quadrant 4/13/2024 at 9:16 a.m. on the Left Lower Quadrant 4/14/2024 at 9 p.m. on the Left Lower Quadrant 4/15/2024 at 9:25 p.m. on the Left Lower Quadrant During an interview on 4/17/2023, at 12:06 p.m., with the PHARM 1, the PHARM 1 stated the licensed nurses should have rotated Lantus injection sites to prevent fat accumulation and bruising at the frequented administration site. During an interview on 4/17/2024, at 12:34 p.m., with the NM, the NM stated Lantus subcutaneous administration sites should be rotated to prevent bruising. A review of the facility provided, Highlights of Prescribing Information- for Lantus, initial U.S. Approval in 2000, indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. A review of the facility's recent policy and procedure titled, Medication Administration, last reviewed on 1/2023, indicated on insulin/anticoagulant site locator, changing sites daily on a good plan lessens pain and damage to your body from injections.

3. A review of Resident 7's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/26/2024, indicated the facility admitted the resident on 9/15/2019, with diagnosis of respiratory failure (a serious condition that makes it difficult to breathe) and tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow air to fill the lungs) status. The MDS indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident was on oxygen therapy, suctioning, and tracheostomy care (a procedure performed routinely to keep flange [faceplate that rest on the neck], tracheostomy dressing, ties or straps, and the surrounding area clean to reduce the introduction of bacteria into the trachea and lungs). A review of Resident 7's Physician's Orders, dated 12/28/2021, indicated an order for tussin CF 100-10-5 milligrams (mg, a unit of weight) liquid (RP: Tussex Cough Syrup). Take 15 milligrams (mls, a unit of volume) (1 tablespoonfuls) via gastrostomy tube (g-tube, a tube inserted through the wall of the abdomen directly into the stomach) every 6 hours as needed (PRN) for cough. A review of Resident 7's Medication Regimen Review, dated 4/4/2024, indicated a recommendation from the pharmacist to consider discontinuing Robitussin if not being used. During a concurrent interview and record review on 4/18/2024, at 12:16 p.m., with the Minimum Data Set Coordinator- Registered Nurse (MDSC-RN), reviewed Resident 7's Physician's Orders, Progress Notes, and Active Medication list. The MDSC-RN stated there was no documentation the pharmacist's recommendation to consider discontinuing the Robitussin if not being used, was acted upon by the Nurse Manager and the physician. The MDSC-RN stated the order, guaifenesin 300 mg every 6 hours PRN for cough with a start date of 1/2/2024, did not have a stop date, and was still showing as active on the resident's medication regimen. The MDSC-RN stated it is important to act upon the pharmacist's recommendation to ensure the resident was not getting any unnecessary medications and to prevent side effects of prolonged use of Robitussin. During an interview on 4/18/2024, at 2:47 p.m., with the Nurse Manager (NM), the NM stated the physician should have been notified of the pharmacist recommendation to discontinue the Robitussin if not being used and document on the resident's progress notes the physician's recommendation. The NM stated the purpose of the medication regimen review was to evaluate if the resident's medications are still necessary. A review of the facility's recent policy and procedure titled, Skilled Nursing- Medication Review by Pharmacist, last reviewed on 2/12/2024, indicated drug therapy monitoring shall be an ongoing, prospective, or concurrent process to assure effective, appropriate, and safe drug therapy for the patient. Each patient's drug regimen must be free from unnecessary drugs. A pharmacist shall perform a monthly chart review of each resident's drug therapy (drug regimen review) to assure appropriateness of medication usage. Reviews and reports from the pharmacist and nurse will be evaluated when considering whether to continue or modify the patient's current drug therapy. Based interview and record review, the facility failed to the facility failed to act upon the recommendations of the consultant pharmacist to two of five sampled residents investigated during review of unnecessary medications by: 1. Failing to taper (to gradually reduce dosage over time) down dosage of methadone (a powerful drug used for pain relief and treatment of drug addiction) for Resident 2. 2. Failing to indicate the behavior episodes of respiratory distress or heart rate (HR) more than (>) 120 per minute in the electronic medication administration record (eMAR) for 1 out of 5 sampled residents (Resident 17) investigated under unnecessary medications for the administration of lorazepam (a type of medication prescribed to treat conditions such as anxiety disorders [persistent and excessive worry that interferes with daily activities]. 3. Failing to act upon the recommendation of the pharmacist on 4/4/2024, to consider discontinuing Robitussin (a cough and cold medicine) if not being used for Resident 7. These deficient practices placed the residents at risk for receiving unnecessary medication and potential for adverse (unwanted) consequences of the medication. Findings: 1.A review of Resident 2's Admission/Registration Record indicated the facility admitted the resident on 2/24/2015 and readmitted the resident on 1/1/2024 with diagnoses including chronic respiratory failure (a serious condition that happens when not enough oxygen passes from the lungs to the blood), multiple sclerosis (an autoimmune disease [a condition in which the body attacks itself by mistake] that affects the brain and spinal cord which could potentially disable a person), and quadriplegia (paralysis of all four extremities). A review of Resident 2 's Minimum Data Set (MDS, a standardized assessment and screening tool) dated 4/1/2024, indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs, basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 2's Physician's Orders dated 10/17/2023 indicated the following: - Methadone (a powerful drug used for pain relief and treatment of drug addiction) 10 milligrams (mg - a unit of measurement) give one (1) tablet via gastrostomy tube (GT - a tube inserted through the abdomen that brings nutrition directly to the stomach) every 12 hours for severe chronic pain. - Pain assessment every shift - pain scale 1-10 to indicate pain status. A review of Resident 2's Medication Regimen Review (MRR - a review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions) dated 4/5/2024 indicated a recommendation to consider tapering down methadone to 10 mg every 24 hours. During a concurrent interview and record review on 4/17/2024 at 2:54 p.m., with MDS Coordinator - Registered Nurse (MDSC - RN), reviewed Resident 2's MRR dated 4/5/2024, Interdisciplinary Team (IDT - a group of professionals from different disciplines that work together to plan, coordinate, and deliver personalized health care for the patient) dated 4/5/2024, and Physician Progress Note dated 4/8/2024. The MDSC-RN verified the MRR indicated a recommendation of the pharmacist to consider tapering down methadone to 10 mg every 24 hours. The MDSC-RN verified there was no documented evidence in the resident's medical records that the methadone recommendation was addressed by the physician. The MDSC-RN verified the Physician Progress note indicated to continue pain management with methadone. The MDSC-RN verified the note did not indicate the rationale for not tapering the methadone dose to every 24 hours as recommended by the pharmacist. During a concurrent interview and record review on 4/18/2024 at 3;15 p.m., with Pharmacist 1 (PHARM 1), reviewed Resident 17's MRR dated 4/5/2024. PHARM 1 stated that she communicates the recommendations to the physician and the Nurse Manger (NM). PHARM 1 stated the physician declined to taper down the methadone dose to 10 mg every 24 hours due to the resident's history of chronic pain. PHARM 1 was unable to provide documentation that she spoke with physician and that the physician declined the recommendations. PHARM 1 stated she should have documented her conversation with the physician in the resident's medical record to ensure the healthcare team is aware of the rationale for not tapering down the resident's medication. A review of the facility's policy and procedure titled, Medication Review by Pharmacists, last reviewed 2/12/2024 indicated a policy that each resident's drug regimen must be free from unnecessary drugs and a pharmacist shall perform a monthly chart review of each resident's drug therapy to assure appropriateness of medication usage. The policy indicated the following: - The pharmacist shall communicate any irregularities identified in the drug regimen review to the patient's primary or attending physician. - Problems requiring urgent attention will be immediately called to the prescriber. - Less urgent items will be documented on a clinical pharmacy communication note to the prescriber. These notifications will be recorded on the Physician Intervention Log. - Identification of problems in the patient's drug regimen shall also be communicated to the Nurse Manage of the Skilled Nursing Facility (SNF) Unit. 2. A review of Resident 17's Admission/Registration Record indicated the facility admitted the resident on 9/3/2021 and readmitted the resident on 1/1/2024 with diagnoses including chronic respiratory failure (a serious condition that happens when not enough oxygen passes from the lungs to the blood), tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck, and ventilator dependent (means the use of any type of mechanical ventilation to sustain daily respiration for any part of the day) A review of Resident 17 's Minimum Data Set (MDS, a standardized assessment and screening tool) dated 3/17/2024, indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs, basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 17's Physician's Orders dated 3/7/2024 indicated the following: - Lorazepam (a type of medication prescribed to treat conditions such as anxiety disorders [persistent and excessive worry that interferes with daily activities], insomnia [a sleep disorder in which a person has trouble falling and/or staying asleep], or seizures[a sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain]) one (1) milligram (mg - a unit of measurement) tablet give 1 tablet via gastrostomy tube (GT - a tube inserted through the abdomen that brings nutrition directly to the stomach) every six (6) hours as needed for respiratory distress or heart rate (HR) more than (>) 120 for 60 days then re-evaluate. - Monitor episodes of respiratory distress or elevated heart rate greater than 120 every shift. A review of Resident 17's care plan for need for anti-anxiety medication for respiratory distress and HR > 120 initiated 1/4/2024 with target date 6/19/2024, indicated to administer medication as ordered and monitor and record episodes of behavior every shift. During a concurrent interview and record review on 4/18/2024 at 9:10 a.m., with Registered Nurse 1 (RN 1), reviewed Resident 17's Medication Regimen Review (MRR - a review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions) dated 2/7/2024, and electronic Medication Administration Record (eMAR). RN 1 stated the MRR indicated lorazepam was administered on 1/28/2024 at 6 a.m., 2/8/2024 at 6:29 p.m., 3/4/2024 at 6 a.m., and 3/5/2024 at 6:47 a.m., with no documented evidence for episodes of respiratory distress. RN 1 stated licensed nurses should have documented the episode of respiratory distress or HR > 120 when the medication was administered to Resident 17 to inform the care team the resident had episodes of respiratory distress and to ensure the medication was necessary. RN 1 stated unnecessary medications can result in adverse effects which may cause injuries to the resident. During a concurrent interview and record review on 4/18/2024 at 11:20 a.m., with the MDS Coordinator-Registered Nurse (MDSC-RN), Resident 17's Controlled or Antibiotic Drug Record and eMAR were reviewed. The MDSC-RN stated licensed nurses must document in the controlled drug record the date and time of when the medication was dispensed and the signature of the licensed nurse who dispensed the medication. The MDSC-RN verified lorazepam was signed out on 1/28/2024 at 6:47 p.m., 2/8/2024 6:56 p.m., 3/4/2024 4:52 a.m., and 3/5/2024 4:28 p.m.; however, the MDSC-RN stated the eMAR did not indicate the resident's episodes of respiratory distress or HR >120. The MDSC-RN stated the resident's episodes of respiratory distress or HR>120 should have been documented in the eMAR to ensure the medication was used appropriately. During a concurrent interview and record review on 4/18/2024 at 11:50 a.m., Licensed Vocational Nurse 1 (LVN 1) verified her signature in the Controlled or Antibiotic Drug Record that she dispensed the medication for 2/8/2024 at 6:56 p.m.; however, LVN 1 stated she did not document in the eMAR Resident 17's episode of respiratory distress or HR>120. LVN 1 stated she should have documented the episode in the eMar so the care team will be aware of the resident's condition and to ensure the resident did not receive an unnecessary dose of lorazepam. A review of the facility's policy and procedure titled, Charting Guidelines, the policy indicated a purpose to provide guidelines for appropriate documentation in the health record. The policy indicated the following: - All documentation will be completed as required for each resident. - Charting should include all assessments of resident condition, all interventions taken to resolve a problem and the progress/lack og progress with the written care plan. - All charting should be done as soon as possible after a given event. - Document normal findings as well as abnormal findings as this shows that the resident was being assessed. A review of the facility's policy and procedure titled, Medication Review by Pharmacists, last reviewed 2/12/2024 indicated a policy that each resident's drug regimen must be free from unnecessary drugs and a pharmacist shall perform a monthly chart review of each resident's drug therapy to assure appropriateness of medication usage. The policy indicated the following: - The pharmacist shall communicate any irregularities identified in the drug regimen review to the patient's primary or attending physician. - Problems requiring urgent attention will be immediately called to the prescriber. - Less urgent items will be documented on a clinical pharmacy communication note to the prescriber. These notifications will be recorded on the Physician Intervention Log. - Identification of problems in the patient's drug regimen shall also be communicated to the Nurse Manage of the Skilled Nursing Facility (SNF) Unit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free of any significant medication errors to three out of five sampled residents (Resident 7, 9, and 13) investigated during review of unnecessary medications by failing to: 1. Ensure licensed nurses rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) administration sites of heparin (a substance that slows the formation of blood clots) to Resident 7. 2. Ensure licensed nurses rotate subcutaneous administration sites of enoxaparin sodium (Lovenox, used to prevent blood clots) to Resident 9. 3. Ensure licensed nurses rotate subcutaneous administration sites of Lantus insulin (a drug used to control the amount of sugar in the blood) to Resident 13. The deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin and anticoagulants (a substance that is used to prevent and treat blood clots in blood vessels and the heart) such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a rare disease that occurs when a protein called amyloid builds up in organs). Cross reference F658 Findings: 1.A review of Resident 7's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/26/2024, indicated the facility admitted the resident on 9/15/2019, with diagnoses including hemiplegia (weakness or paralysis on one side of the body) or hemiparesis (one-sided muscle weakness), anoxic brain damage (caused by a complete lack of oxygen to the brain, which results in the death of brain cells), and history of other diseases of the circulatory system (made up of blood vessels that carry blood away and towards the heart). The MDS indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident was taking a high-risk drug class anticoagulant. A review of Resident 7's Physician's Orders, dated 10/31/2023, indicated an order for heparin sodium SDV 5000 unit/1 milliliter (unit/ml, a unit of fluid volume equal to one-thousandth of a liter) vial (RO: Heparin 5000 un/ml (SB). Inject 1 milliliters (ml, a unit of volume) (5000 units) subcutaneously every 12 hours (deep vein thrombosis [DVT, a blood clot in a deep vein of the leg, pelvis, and sometimes the arm] prophylaxis [preventive]). During a concurrent interview and record review on 4/16/2023, at 1:46 p.m., with the Minimum Data Set Coordinator- Registered Nurse (MDSC-RN), reviewed Resident 7's Medication Administration Record dated 1/2024 to 4/16/2024. The MDSC-RN stated the heparin injection site should be rotated to prevent bruising and bleeding. The MDSC-RN verified the subcutaneous injection site for heparin were not rotated on the following dates, times, and locations: 1/8/2024 at 9:42 p.m. on the Right Upper Abdomen 1/9/2024 at 9 a.m. on the Right Upper Abdomen 2/6/2024 at 9 a.m. on the Right Lower Abdomen 2/6/2024 at 9:13 p.m. on the Right Lower Abdomen 2/7/2024 at 8:24 p.m. on the Right Upper Abdomen 2/8/2024 at 9:12 a.m. on the Right Upper Abdomen 2/16/2024 at 9 a.m. on the Right Lower Abdomen 2/16/2024 at 9:34 p.m. on the Right Lower Abdomen During an interview on 4/17/2023, at 12:06 p.m., with Pharmacist 1 (PHARM 1), PHARM 1 stated the licensed nurse should have rotated heparin injection sites to prevent fat accumulation and bruising at the frequented administration site. PHARM 1 stated not rotating heparin injection sites is considered a medication error. During an interview on 4/17/2024, at 12:34 p.m., with the Nurse Manager (NM), the NM stated heparin subcutaneous administration sites should be rotated to prevent bruising. The NM stated not rotating heparin injection sites is considered a medication error. A review of the facility provided, Highlights of Prescribing Information- for Heparin Sodium Injection, initial U.S. Approval in 1939, indicated for deep subcutaneous (Intrafat) Injection Use a different site for each injection. A review of the facility's policy and procedure titled, Medication Administration, last reviewed on 1/2023, indicated insulin/anticoagulant site locator, changing sites daily on a good plan lessens pain and damage to your body from injections. 2. A review of Resident 9's MDS, indicated the facility admitted the resident on 7/14/2020, with diagnoses including anemia (a condition in which the body does not have enough healthy red blood cells), coronary artery disease (a disease in which there is a narrowing or blockage of the coronary arteries), and persistent vegetative state (unconscious, unaware, and unresponsive). The MDS indicated the resident was taking a high-risk drug class anticoagulant. A review of Resident 9's Physician's Orders, dated 2/13/2021, indicated an order for enoxaparin sodium outer, SUV, P/F, L/F 40 mg/0.4 ml syringe (RP: Lovenox PFS). Inject 40 milligrams (mg, a unit of weight) (0.4 ml) subcutaneously every day (DVT prophylaxis). Medication has boxed warning (warning given by the FDA [Food and Drug Administration] for drugs or dug classes that may cause serious harm or death). During a concurrent interview and record review on 4/16/2023, at 1:46 p.m., with the Minimum Data Set Coordinator- Registered Nurse (MDSC-RN), reviewed Resident 9's Medication Administration Record dated 1/2024 to 4/16/2024. The MDSC-RN stated the enoxaparin sodium (Lovenox) injection site should be rotated to prevent bruising and bleeding. The MDSC-RN verified the subcutaneous injection sites were not rotated on the following dates, times, and locations: 4/8/2024 at 9:55 a.m. on the Right Lower Abdomen 4/9/2024 at 9:28 a.m. on the Right Lower Abdomen 4/10/2024 at 9:51 a.m. on the Left Upper Abdomen 4/11/2024 at 9:49 a.m. on the Left Upper Abdomen During an interview on 4/17/2023, at 12:06 p.m., with PHARM 1, PHARM 1 stated the licensed staff should have rotated Lovenox injection sites to prevent fat accumulation and bruising at the frequented administration site. PHARM 1 stated not rotating Lovenox injection sites is considered a medication error. During an interview on 4/17/2024, at 12:34 p.m., with the Nurse Manager (NM), the NM stated heparin subcutaneous administration sites should be rotated to prevent bruising. The NM stated not rotating Lovenox injection sites is considered a medication error. A review of the facility provided, Highlights of Prescribing Information- for Enoxaparin Sodium Injection, initial U.S. Approval in 1993, indicated to alternate injection sites between the left and right anterolateral and left and right posterolateral abdominal wall. A review of the facility's recent policy and procedure titled, Medication Administration, last reviewed on 1/2023, indicated on insulin/anticoagulant site locator, changing sites daily on a good plan lessens pain and damage to your body from injections. 3. A review of Resident 13's MDS, dated [DATE], indicated the facility admitted the resident on 9/20/2023, with diagnoses including diabetes mellitus (DM, a disease that occurs when the blood glucose, also called blood sugar, is too high), malnutrition (deficiencies or excess in nutrient intake), and dysphagia (difficulty swallowing). The MDS indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident was on a high-risk drug class hypoglycemic (low blood sugar) insulin (a hormone that lowers the level of blood sugar). A review of Resident 13's Physician's Order Sheet, dated 4/6/2024, indicated an order for Lantus 18 units q a.m. subcutaneously for DM and Lantus 14 units subcutaneously at bedtime for DM. During a concurrent interview and record review on 4/16/2023, at 1:46 p.m., with the Minimum Data Set Coordinator- Registered Nurse (MDSC-RN), reviewed Resident 13's Medication Administration Record dated 1/2024 to 4/16/2024. The MDSC-RN stated Lantus injection site should be rotated to prevent bruising and bleeding. The MDSC-RN verified the subcutaneous injection sites were not rotated on the following dates, times, and locations: 1/12/2024 at 9:49 p.m. on the Right Upper Quadrant 1/13/2024 at 9:54 p.m. on the Right upper Quadrant 1/15/2024 9:50 p.m. on the Left Deltoid 1/16/2024 at 9 p.m. on the Left Deltoid 1/17/2024 at 9:52 p.m. on the Right Lower Quadrant 1/18/2024 at 10 p.m. on the Right Lower Quadrant 1/20/2024 at 9:55 p.m. on the Right Lower Quadrant 1/21/2024 at 9:11 p.m. on the Right Lower Quadrant 1/24/2024 at 8:44 a.m. on the Left Lower Quadrant 1/25/2024 at 9:12 a.m. on the Left Lower Quadrant 1/27/2024 at 9:37 a.m. on the Left Deltoid 1/28/2024 at 9:54 a.m. on the Left Deltoid 2/2/2024 at 9:53 a.m. on the Right Lower Quadrant 2/3/204 at 9:26 a.m. on the Right Lower Quadrant 2/6/2024 at 9:13 a.m. on the Right Upper Quadrant 2/7/2024 at 9:30 a.m. on the Right Upper Quadrant 2/10/2024 at 9:19 p.m. on the Right Lower Quadrant 2/11/2024 at 9 p.m. on the Right Lower Quadrant 2/20/2024 at 9:42 a.m. on the Left Deltoid 2/21/2024 at 10:02 a.m. on the Left Deltoid 2/23/2024 at 9:47 p.m. on the Right Lower Quadrant 2/24/2024 at 9:18 p.m. on the Right Lower Quadrant 2/28/2024 at 9:19 p.m. on the Left Upper Quadrant 2/29/2024 at 9:17 p.m. on the Left Upper Quadrant 3/1/2024 at 8:51 p.m. on the Left Upper Quadrant 3/2/2024 at 9:15 p.m. on the Left Upper Quadrant 3/3/2024 at 8:05 p.m. on the Left Lower Quadrant 3/4/2024 at 8:15 p.m. on the Left Lower Quadrant 3/5/2024 at 8:34 a.m. on the Right Upper Quadrant 3/6/2024 at 9:13 a.m. on the Right Upper Quadrant 3/7/2024 at 9:17 a.m. on the Left Lower Quadrant 3/8/2024 at 9:42 a.m. on the Left Lower Quadrant 3/13/2024 at 9 a.m. on the Left Lower Quadrant 3/14/2024 at 9:23 a.m. on the Left Lower Quadrant 3/22/2024 at Left Upper Quadrant 3/23/2024 at 9:13 a.m. on the Left Upper Quadrant 3/24/2024 at 8:38 p.m. on the Left Deltoid 3/25/2024 at 8:45 p.m. on the Left Deltoid 3/25/2024 at 9:28 a.m. on the Right Lower Quadrant 3/27/2024 at 9:58 p.m. on the Right Lower Quadrant 3/28/2024 at 8:57 p.m. on the Right Lower Quadrant 4/3/2024 at 9:33 p.m. on the Right Upper Quadrant 4/4/2024 at 8:19 p.m. on the Right Upper Quadrant 4/5/2024 at 8:25 p.m. on the Right Upper Quadrant 4/6/2024 at 9:22 p.m. on the Right Lower Quadrant 4/7/2024 at 9:39 p.m. on the Right Lower Quadrant 4/10/2024 at 9:01 a.m. on the Right Lower Quadrant 4/11/2024 at 9:29 a.m. on the Right Lower Quadrant 4/12/2024 at 9:17 a.m. on the Left Lower Quadrant 4/13/2024 at 9:16 a.m. on the Left Lower Quadrant 4/14/2024 at 9 p.m. on the Left Lower Quadrant 4/15/2024 at 9:25 p.m. on the Left Lower Quadrant During an interview on 4/17/2023, at 12:06 p.m., with PHARM 1, PHARM 1 stated the licensed nurses should have rotated Lantus injection sites to prevent fat accumulation and bruising at the frequented administration site. PHARM 1 stated not rotating Lovenox injection sites is considered a medication error. During an interview on 4/17/2024, at 12:34 p.m., with the NM, the NM stated Lantus subcutaneous administration sites should be rotated to prevent bruising. The NM stated not rotating Lovenox injection sites is considered a medication error. A review of the facility provided, Highlights of Prescribing Information- for Lantus, initial U.S. Approval in 2000, indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. A review of the facility's recent policy and procedure titled, Medication Administration, last reviewed on 1/2023, indicated on insulin/anticoagulant site locator, changing sites daily on a good plan lessens pain and damage to your body from injection.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety by failing to: 1. Store the ice scooper in a covered container when not being used. 2. Ensure Food Service Worker (FSW 1) was wearing a hairnet (a covering that will hold any dislodged hair in place, so it does not fall into the food or onto other equipment) while inside the kitchen. 3. Ensure an opened bottle of 90/10 blend canola/extra virgin olive oil was labeled with an open date and discard date. These deficient practices had the potential to place residents at increased risk of experiencing foodborne illness (an illness that comes from eating contaminated food or drinks). Findings: During an observation and interview on 4/16/2024, at 7:52 a.m., with the Director of Food and Nutrition (DFN), observed an ice scooper in an uncovered holder mounted of the side of the machine. The DFN stated they sanitize the ice scooper with a sanitizing solution after use and place them on the ice scooper holder. The DFN stated the ice scooper should be stored in a closed container to prevent outside contaminants to settle in the scooper that could cause food borne illnesses. A review of the facility's recent policy and procedure titled, Dispensing of Ice, last reviewed on 1/2023, indicated bulk ice is dispensed by using scoop stored in a covered container. During an observation and interview on 4/16/2024, at 7:55 a.m., with the DFN, in the kitchen, observed FSW 1 not wearing a hairnet. The DFN stated Food Service Worker 1 (FSW 1) should wear a hairnet at all times when working in the kitchen to keep hair from contaminating food and equipment. The DFN stated failure to wear a hairnet could result in serving contaminated food that could cause residents to get sick. A review of the facility's recent policy and procedure titled, Dress Code, last reviewed on 1/2023, indicated hair net or covering must be worn when working in the kitchen or cafeteria unless head is shaved. During an observation and interview on 4/16/2024, at 8:02 a.m., with the DFN, in the kitchen, observed an opened container of 90/10 blend canola/extra virgin olive oil without an open date. The DFN stated there should be an open date label on the canola/extra virgin oil container to inform the kitchen staff when to discard the canola/extra virgin oil. The DFN stated not labeling the container with the open date could potentially result in staff using expired canola/extra virgin oil which can cause residents food borne illnesses. A review of the facility's recent policy and procedure titled, Food Labeling and Dating, last reviewed on 1/2023, indicated all stored foods shall be labeled to indicate type of product and date prepared or date the product is to be discarded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.a. A review of Resident 10's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/23/2024, indicated the facility admitted the resident on 1/11/2024 with diagnoses including chronic respiratory failure (a serious condition that makes it difficult to breathe) with hypoxia (a low level of oxygen in the blood) or hypercapnia (a buildup of carbon dioxide in the blood), enterocolitis (an inflammation that occurs throughout the intestines) due to clostridium difficile (a germ that causes diarrhea), and tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs) status. The MDS indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident was on oxygen therapy, suctioning, and tracheostomy care (a procedure performed routinely to keep the flange, tracheostomy dressing, ties or straps, and surrounding area clean to reduce the introduction of bacteria into the trachea [windpipe] and lungs). The MDS indicated the resident was on isolation or quarantine (separates and restricts the movement of residents who were exposed to a contagious disease to see if they become sick) for active infectious disease. A review of Resident 10's Physician's Orders indicated the following: 1/11/2024 Type: Percutaneous endoscopic gastrostomy (PEG, the placement of feeding tube through the skin and the stomach wall) 1/11/2024 Suction retained or increased secretion every (q) 2 hours. 3/28/2024 Sacral (tail bone) wound stage 4 pressure injury (full thickness tissue loss with exposed bone, tendon, or muscle); cleanse with normal saline (NS, mixture of salt and water for cleansing wounds), pack with calcium alginate (used in the fabrication of wound dressing), apply 2 guard (adhesive consisting of two parts) to peri wound (the area around the wound) then cover with optiform dressing (a foam dressing that has a silicone adhesive border) q bed time (HS) and if needed (PRN) if soiling for 30 days then re-evaluate. During an observation, on 4/17/2024 at 8:30 a.m., with Licensed Vocational Nurse 1 (LVN 1), inside Resident 10's room, observed Resident 10's room without any enhanced barrier precaution sign and no isolation cart (designed to provide a storage spot for personal protective equipment [PPE, specialized clothing, including isolation gowns and gloves, used to protect from exposure to potentially infectious materials to avoid injury or disease]) at the entrance of the room. LVN 1 prepared medications for administration to Resident 10. Observed LVN 1 with a surgical mask, washed her hands, placed a new pair of gloves, and pulled out all due medications for administration. LVN 1 removed her gloves and sanitized her hands. LVN 1 brought the medication tray with the medications inside the resident's room without donning (to put on) a gown on. LVN 1 sanitized her hands and placed new gloves on. After medication administration, LVN 1 removed her gloves, sanitized her hands, and documented her medication administration. 3.b. A review of Resident 13's MDS, dated [DATE], indicated the facility admitted the resident on 9/20/2023, with diagnoses including chronic respiratory failure with hypoxia, tracheostomy status, and gastrostomy status. The MDS indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident was on oxygen therapy, suctioning, and tracheostomy care. A review of Resident 13's Physician's Orders indicated the following: 4/2/2024 Penile moisture associated skin damage (MASD, caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, saliva, and their contents). Cleanse with soap and water, pat dry, apply triple antibiotic ointment (an antibiotic medication used to reduce the risk of infections) every shift for 14 days. 9/20/2023 Type: PEG 9/20/2023 G-tube feeding. 9/20/2023 Suction retained or increased secretion every 2 hours. 11/28/2023 Tracheostomy Tube (a tube constructed of polyvinyl chloride that is placed between the vocal cords through the trachea): Type shiley (brand name associated with medical devices, specifically tracheostomy tubes) size #6, cuffed. During an observation on 4/17/2024, 9:35 a.m., with LVN 1, inside Resident 13's room, observed Resident 13's room without any enhanced barrier precaution sign and no isolation cart at the entrance of the room. LVN 1 prepared medications for administration to Resident 13. Observed LVN 1 with a surgical mask, washed her hands, placed a new pair of gloves on, and pulled out all due medications for administration. LVN 1 removed her glove, sanitized her hands. LVN 1 brought the medication tray with the medications inside the resident's room without donning a gown on. LVN 1 sanitized her hands and placed a new pair of gloves on. After medication administration, LVN 1 removed her gloves, sanitized her hands. LVN 1 placed another pair of gloves on her hands, took the glucometer (an instrument for measuring the concentration of glucose [blood sugar] in the blood) machine, wiped them with a sanitizing wipe and left for few minutes to dry. LVN 1 removed her gloves, sanitized her hand, and got the insulin (a hormone that lowers the level of glucose in the blood) pen on her medication tray ready. LVN 1 placed a new glove on. LVN 1 discarded all supplies used for medication administration. LVN 1 removed her gloves, sanitized her hands, and documented her medication administration. During an interview and record review on 4/17/2024, at 2:38 p.m., LVN 1 stated she did not wear a gown while administering medications to Resident 10 and 13 during the morning medication pass. LVN 1 stated she cannot remember if she had a training regarding enhanced barrier precautions. During an interview on 4/17/2024, at 2:44 p.m., the NM stated Residents 10 and 13 should have been placed on enhanced barrier precaution due to both residents had a trach, g-tube, open wounds, and had aerosolization (dispersal of substance in the form of aerosol) procedures such as suctioning. The NM stated they have not implemented the isolation procedure in the facility. The NM stated she knew about the new isolation procedure since last year. The NM stated it was important to place the Residents 10 and 13 on enhanced barrier precautions to prevent spread of infection to residents and staff. During an interview on 4/17/2024, at 2:54 p.m., the IP stated he was aware of the enhanced barrier precaution and they were still in the planning stage of developing a policy and procedure. he IP stated he was aware of the enhanced barrier precaution since last year. The IP stated there had been no education rolled out for the enhanced barrier precaution. The IP stated for enhanced barrier precaution, the staff should be wearing mask, gloves, gowns, and if there was high probability of splashes, they need to wear goggles or face shield to prevent spread of infection among residents and staff. A review of the facility's recent policy and procedure titled, Isolation Precautions, last reviewed on 1/2024, did not include enhanced barrier precaution isolation procedure. A review of the facility's Infection Prevention 2023 Program Assessment and 2024 Annual Plan, undated, indicated a goal for 2023 was to ensure compliance with isolation precautions. A review of Centers for Disease Control and Prevention (CDC's) Considerations for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities, dated 6/2021, indicated EBP may be applied (when Contact Precautions [intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or patient's environment] do not otherwise apply) to residents with any of the following: o Wounds or indwelling medical devices, regardless of multi-resistant organisms' colonization status (germs are on the body but do make a person sick). o Infection or colonization with an MDRO. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE with hand hygiene products at the point of care. Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable (capable of being passed by physical contact from one person to another) diseases and infections by failing to: 1. Ensure the barcode scanner (handheld device used to decode data contained on a barcode [a printed series of parallel bars or lines of varying width] that is then sent to a computer) was sanitized (disinfect [kill viruses and bacteria on surfaces using chemicals]) prior to use and after being placed on the resident's tablet (type of computer) for two of four sampled residents (Resident 12 and 14) observed during the Medication Administration task. 2. Ensure Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs, germ that is resistant to many antibiotics] in nursing homes. EBPs involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition) were implemented during gastrostomy tube (GT or g-tube, a tube that is inserted into the stomach used for the administration of medication or feeding) medication administration for four of four sampled residents (Resident 12, 14, 10, and 13) observed during the Medication Administration task. 3. Discard two opened and partially used normal saline solution unit dose vials (a light plastic container of solution used for respiratory treatments, sinus irrigation, eye care, and wound care) inside a box after use for one of five sampled residents (Resident 3) observed during random observations. These deficient practices had the potential to transmit infectious microorganisms and placed the residents at risk for infection. Cross reference to F656 and F837. Findings: 1.a. A review of Resident 12's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/18/2024, indicated the facility admitted the resident on 1/9/2018. The MDS indicated the resident sometimes was able to make himself understood and sometimes understood others. The MDS indicated the resident was totally dependent on staff for mobility, dressing, bathing, toilet hygiene, and personal hygiene. A review of Resident 12's History and Physical (H&P), dated 4/20/2023, indicated the resident had diagnoses that included hypoxic respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen), dependence on a ventilator (a machine that takes over the work of breathing when a person is not able to breathe on their own), tracheostomy (opening surgically created through the front of the neck and into the trachea [windpipe]), and g-tube placement. A review of Resident 12's Care Plan (CP) titled, Resident at risk for infection at GT site, initiated 1/2/2024, indicated to observe good infection control practices before and after handling resident. 1.b.A review of Resident 14's MDS, dated [DATE], indicated the facility admitted the resident on 1/8/2024 and readmitted the resident on 4/3/2024. The MDS indicated the resident rarely/never was able to make himself understood and rarely/never understood others. The MDS indicated the resident was totally dependent on staff for mobility, dressing, bathing, toilet hygiene, and personal hygiene. A review of Resident 14's H&P, dated 4/4/2024, indicated the resident had diagnoses that included chronic respiratory failure, dependence on a ventilator, tracheostomy, and g-tube placement. During a medication administration observation, on 4/17/2024 at 8:05 a.m., with Licensed Vocational Nurse 4 (LVN 4) at Medication Cart 1, observed LVN 4 moved Medication Cart 1 to the doorway of Resident 12 and 14's shared room. Observed LVN 4 remove the handheld barcode scanner from the charging station on Medication Cart 1 and entered the residents' room. LVN 4 placed the barcode scanner on Resident 12's tablet resting on the bedside table, walked to the door to sanitize her hands, then removed the barcode scanner from the tablet and scanned Resident 12's wristband. LVN 4 returned to Medication Cart 1 and placed the scanner in the charging station without sanitizing the scanner. LVN 4 removed Resident 12's medications from the cart, then administered the medications via g-tube, washed her hands, returned to the medication cart and documented in the computer. LVN 4 stated she was done with Resident 12's medication pass. During a continued medication administration observation, on 4/17/2024 at 8:37 a.m., with LVN 4 at Medication Cart 1, LVN 4 stated she would pass medications for Resident 14. LVN 4 sanitized the work surface of Medication Cart 1 but did not sanitize the barcode scanner. LVN 4 partially prepared Resident 14's medications, performed hand hygiene, removed the barcode scanner from the charging station, scanned Resident 14's wristband, and replaced the scanner in the charging station. LVN 4 continued preparing Resident 14's medications, administered the medications, and then exited the residents' room. During an interview, on 4/17/2024 at 9:25 a.m., LVN 4 stated she did not clean the barcode scanner that day. LVN 4 stated she assumed the previous shift had cleaned the scanner. LVN 4 stated she placed the scanner on Resident 12's tablet and returned it to the charger without sanitizing it prior to using it for Resident 14 and preparing the resident's medication. LVN 4 stated she should have sanitized the scanner and she did not. LVN 4 stated the importance of sanitizing was to prevent cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another), to not introduce anything that had contaminated the scanner to the medication cart then to another resident. During an interview, on 4/17/2024 at 2:15 p.m., the Nurse Manager (NM) stated the standard of practice for infection control is that all multiple use equipment should be disinfected between use of residents to prevent cross contamination. The NM stated cross contamination occurs when possibly contaminated equipment is used for one resident, not disinfected, and then used on the next resident. The NM stated the barcode scanners are considered multiple use equipment and should be routinely disinfected to prevent the spread of, or transfer of, infections. The NM stated Resident's 12's tablet is considered a possibly contaminated surface and the scanner should be disinfected after being placed on the tablet. The NM stated one importance of disinfecting multiple use equipment was to prevent the spread of multidrug-resistant organisms. A review of the facility provided policy and procedure titled, Medication Administration, last reviewed 2/12/2024, indicated the policies and procedures are established to optimize drug therapy for each resident by providing for administration of drugs in sanitary manner. A review of the facility-provided policy and procedure titled, Infection Control [NAME], Isolation Precautions, last reviewed 2/12/2024, indicated standard precautions are designed for the care of all patients in hospitals regardless of their diagnosis or presumed infection status. Standard precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection. A variety of infection measures are used for decreasing the risk of transmission of microorganisms in hospitals. Contaminated, reusable devices or patient-care equipment are sterilized or disinfected after use to reduce the risk of transmission of microorganisms to other patients. 2.a. A review of Resident 12's MDS, dated [DATE], indicated the facility admitted the resident on 1/9/2018. The MDS indicated the resident sometimes was able to make himself understood and sometimes understood others. The MDS indicated the resident was totally dependent on staff for mobility, dressing, bathing, toilet hygiene, and personal hygiene. A review of Resident 12's H&P, dated 4/20/2023 indicated the resident had diagnoses that included hypoxic respiratory failure, dependence on a ventilator, tracheostomy, and g-tube placement. A review of Resident 12's CP titled, Resident at risk for infection at GT site, initiated 1/2/2024, indicated to observe good infection control practices before and after handling resident. During a medication administration observation on 4/17/2024 at 8:05 a.m. with LVN 4 at Medication Cart 1, observed LVN 4 wore a surgical mask and gloves, entered Resident 12's room, and administered medication to Resident 12 via g-tube. Observed no signs (signage/postings) indicating the use of EBPs. LVN 4 did not don [put on] an isolation gown. During an interview on 4/17/2024 at 2:35 p.m., LVN 4 stated during the medication pass for Resident 12 she wore a surgical mask and gloves, but she did not don an isolation gown. LVN 4 stated in this facility she only dons isolation gowns for residents in contact isolation (measure aimed to prevent spread of infection by direct or indirect contact) rooms and Resident 12 was not in contact isolation. LVN 4 stated Resident 12 had indwelling devices including g-tube and tracheostomy and had conditions that made the resident prone to infection. LVN 4 stated she was aware from her job at a similar facility of EBPs. LVN 4 stated EBPs are used to prevent the spread of infection for all residents when anything is physically done to them. LVN 4 stated EBPs include full personal protective equipment (PPE, specialized clothing, including isolation gowns and gloves, used to protect from exposure to potentially infectious materials to avoid injury or disease) should be used when providing resident care. LVN 4 stated this facility does not use EBPs. During an interview, on 4/17/2024 at 2:44 p.m., the NM stated EBPs are used for residents with wounds or indwelling devices including tracheostomies and g-tubes. The NM stated she has been aware of EBPs since last year. The NM stated the facility has not implemented the practice of EBPs and they do not have a policy for EBPs, but EBPs have been discussed in the infection control committee. The NM stated it takes a lot of resources for EBPs, but she does not know why there was a delay in implementing the practice. During an interview, on 4/17/2024 at 2:51 p.m., the Infection Preventionist (IP) stated he was aware of EBPs for about a year. The IP stated he asked to extend the implementation of EBPs because of recent surveys (used to assess compliance with Federal health, safety, and quality standards) and the need for involving resources and educating staff. During an interview, on 4/18/2024 at 7:20 a.m., the Chief Nursing Officer (CNO) stated he was apprised of EBPs and EBPs should have been implemented, but they were not. The CNO stated the EBP policy was in the works and should have already been implemented, but the policy was not finalized or implemented. The CNO stated the facility had a lot going on. 2.b. A review of Resident 14's MDS, dated [DATE], indicated the facility admitted the resident on 1/8/2024 and readmitted the resident on 4/3/2024. The MDS indicated the resident rarely/never was able to make himself understood and rarely/never understood others. The MDS indicated the resident was totally dependent on staff for mobility, dressing, bathing, toilet hygiene, and personal hygiene. A review of Resident 14's H&P, dated 4/4/2024 indicated the resident had diagnoses that included chronic respiratory failure, dependence on a ventilator, tracheostomy, and g-tube placement. During a medication administration observation, on 4/17/2024 at 8:37 a.m. with LVN 4 at Medication Cart 1, observed LVN 4 wore a surgical mask and gloves, entered Resident 14's room, and administered medication to Resident 14 via g-tube. Observed no signs indicating EBPs and LVN 4 did not don an isolation gown. During an interview, on 4/17/2024 at 2:35 p.m., LVN 4 stated during the medication pass for Resident 14 she wore a surgical mask and gloves, but she did not don an isolation gown. LVN 4 stated in this facility she only dons isolation gowns for residents in contact isolation rooms and Residents 14 was not in contact isolation. LVN 4 stated Resident 14 had indwelling devices including a g-tube and tracheostomy and had conditions that made the resident prone to infection. LVN 4 stated she was aware from her job at a similar facility of EBPs. LVN 4 stated EBPs are used to prevent the spread of infection for all residents when anything is physically done to them. LVN 4 stated EBPs include full PPE should be used when providing resident care. LVN 4 stated this facility does not use EBPs. During an interview, on 4/17/2024 at 2:44 p.m., the NM stated EBPs are used for residents with wounds or indwelling devices including tracheostomies and g-tubes. The NM stated she has been aware of EBPs since last year. The NM stated the facility has not implemented the practice of EBPs and they do not have a policy for EBPs, but EBPs have been discussed in the infection control committee. The NM stated it takes a lot of resources for EBPs, but she does not know why there was a delay in implementing the practice. During an interview, on 4/17/2024 at 2:51 p.m., the IP indicated he was aware of EBPs for about a year. The IP stated he asked to extend the implementation of EBPs because of recent surveys and the need for involving resources and educating staff. During an interview, on 4/18/2024 at 7:20 a.m., the CNO stated he was apprised of EBPs and EBPs should have been implemented, but they were not. The CNO stated the EBPs policy was in the works and should have already been implemented, but the policy was not finalized or implemented. The CNO stated the facility had a lot going on. A review of the facility-provided policy and procedure titled, Infection Control [NAME], Isolation Precautions, last reviewed 2/12/2024, indicated there was no written procedure for EBPs. A review of the Centers for Disease Control (CDC) Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities PDF (available from: https://www.cdc.gov/hicpac/workgroup/EnhancedBarrierPrecautions.html), dated 6/2021, indicated MDRO transmission is common in skilled nursing facilities, contributing to significant morbidity and mortality for residents. Reside to resident pathogen transmission in skilled nursing facilities occurs, in part, via healthcare personnel, who may transiently carry and spread MDROs on their hands and clothing during resident care activities. Residents who have complex medical needs involving wound and indwelling devices are at higher risk of both acquisition and colonization by MDROs. Residents who are MDRO colonized are not often recognized by healthcare personnel based on available clinical cultures or medical history. EBP is an approach to targeted gown and glove use during high contact resident care activities designed to reduce transmission of MDROs. EBP may be applied to residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status. Effective implementation of EBP requires staff training on the proper use of PPE and the availability of PPE with hand hygiene products at the point of care. 4. A review of Resident 3's Admission/Registration Record indicated the facility admitted the resident on 12/3/2021 and readmitted the resident on 1/1/2024 with diagnoses including chronic respiratory failure, spastic quadriplegia cerebral palsy (a form of cerebral palsy [caused by abnormal brain development or damage to the developing brain that affects a person's ability to control his or her muscles] that affects both arms and legs and often the torso and face), tracheostomy, and spastic quadriplegia (paralysis of all four extremities). A review of Resident 3's H&P dated 1/1/2024 did not indicate the capacity to understand and make decisions. A review of Resident 3's MDS dated [DATE], indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs, basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 3's Physician's Orders dated 12/3/2021 indicated the following orders: -Tracheostomy site care with half strength hydrogen peroxide (cleaning agent) and normal saline every shift. -Suction retained or increased secretions as needed. During a concurrent observation and interview on 4/16/2024 at 9:06 a.m., Registered Nurse 1 (RN 1) verified two opened and partially used normal saline solution unit dose vials inside a box. RN 1 verified the vials were covered with gauze. RN 1 stated normal saline solutions vials were used by staff during suctioning resident and/or cleaning the wounds. RN 1 stated the normal saline solution vials are single use only and should have been discarded. RN 1 stated it was an infection control issue and placed Resident 3 at risk for acquiring infection if the solution in the opened vial was used again on the resident. During an interview on 4/18/2023 at 11:30 a.m., Respiratory Therapist 1 (RT 1) stated the normal saline solution unit dose vials are single use only and should have been discarded after use regardless even if with solution left in the vial. RT 1 stated respiratory therapists use the solution during suctioning of residents and during tracheostomy site care. RT 1 stated it was an infection control issue. During a concurrent interview and record review on 4/18/2024 at 1:00 p.m., reviewed facility's policy and procedure titled, Irrigation Solution, last reviewed 2/12/2024, with the NM. The NM verified and stated the policy and procedure indicated all saline solution unit dose vials are single use and should have been discarded after use. The NM it was an infection control issue. The policy and procedure indicated sterile water and saline for irrigation, such as bullets (vials/containers) is intended for single use. A review of the facility's Infection prevention 2023 Program Assessment and 2024 Annual Plan last reviewed 2/12/2024, indicate all employees have responsibility for adherence to infection prevention and infection control processes/strategies. A review of the facility's policy and procedure titled, Reuse of Disposable Products, last reviewed 2/12/2024, indicated disposable supply items that have been placed in patient rooms and have been opened are to be discarded and no attempt will be made to recover or use such items.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure they have established and implemented policies in managing the facility by failing to develop and implement a policy and procedure on enhanced barrier precaution (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs, germ that is resistant to many antibiotics] in nursing homes. EBPs involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition) to four out of four sampled residents (Residents 10, 13, 12, and 14) during Medication Administration facility task. The deficient practice had a potential to spread infection among residents and staff. Cross reference to F656 and F880. Findings: 1. A review of Resident 10's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/23/2024, indicated the facility admitted the resident on 1/11/2024 with diagnoses including chronic respiratory failure (a serious condition that makes it difficult to breathe) with hypoxia (a low level of oxygen in the blood) or hypercapnia (a buildup of carbon dioxide in the blood), enterocolitis (an inflammation that occurs throughout the intestines) due to clostridium difficile (a germ that causes diarrhea), and tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs) status. The MDS indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident was on oxygen therapy, suctioning, and tracheostomy care (a procedure performed routinely to keep the flange, tracheostomy dressing, ties or straps, and surrounding area clean to reduce the introduction of bacteria into the trachea [windpipe] and lungs). The MDS indicated the resident was on isolation or quarantine (separates and restricts the movement of residents who were exposed to a contagious disease to see if they become sick) for active infectious disease. A review of Resident 10's Physician's Orders indicated the following: 1/11/2024 Type: Percutaneous endoscopic gastrostomy (PEG, the placement of feeding tube through the skin and the stomach wall) 1/11/2024 Suction retained or increased secretion every (q) 2 hours. 3/28/2024 Sacral (tail bone) wound stage 4 pressure injury (full thickness tissue loss with exposed bone, tendon, or muscle); cleanse with normal saline (NS, mixture of salt and water for cleansing wounds), pack with calcium alginate (used in the fabrication of wound dressing), apply 2 guard (adhesive consisting of two parts) to peri wound (the area around the wound) then cover with optiform dressing (a foam dressing that has a silicone adhesive border) q bed time (HS) and if needed (PRN) if soiling for 30 days then re-evaluate. During an observation, on 4/17/2024 at 8:30 a.m., with Licensed Vocational Nurse 1 (LVN 1), inside Resident 10's room, observed Resident 10's room without any enhanced barrier precaution sign and no isolation cart (designed to provide a storage spot for personal protective equipment [PPE, specialized clothing, including isolation gowns and gloves, used to protect from exposure to potentially infectious materials to avoid injury or disease]) at the entrance of the room. LVN 1 prepared medications for administration to Resident 10. Observed LVN 1 with a surgical mask, washed her hands, placed a new pair of gloves, and pulled out all due medications for administration. LVN 1 removed her gloves and sanitized her hands. LVN 1 brought the medication tray with the medications inside the resident's room without donning (to put on) a gown on. LVN 1 sanitized her hands and placed new gloves on. After medication administration, LVN 1 removed her gloves, sanitized her hands, and documented her medication administration. During an interview on 4/17/2024, at 2:44 p.m., the Nurse Manager (NM) stated Resident 10 should have been placed on enhanced barrier precaution due to the resident had a tracheostomy, g-tube, open wounds, and had aerosolization (dispersal of substance in the form of aerosol) procedures such as suctioning. The NM stated they have not implemented the enhanced barrier precaution procedure in the facility. The NM stated she knew about the enhanced barrier precaution procedure since last year. The NM stated she does not know why it was not implemented in the facility yet. The NM stated it was important to have a policy and procedure for enhanced barrier precaution so the staff can have a guide on how to prevent spread of infection to vulnerable residents with g-tubes and tracheostomy. During an interview on 4/17/2024, at 2:54 p.m., the Infection Preventionist (IP) stated he was aware of the enhanced barrier precautions and they were still in the planning stage of developing the policy and procedures. The IP stated he was aware of the enhanced barrier precautions since last year. The IP stated there had been no education rolled out for the enhanced barrier precaution. The IP stated it was important to have a policy and procedure for enhanced barrier precaution to serve as a guide for the staff on how to prevent infection to spread to the residents and the staff by wearing appropriate personal protective equipment. The IP stated for enhanced barrier precaution, the staff should be wearing a mask, gloves, gowns, and if there was high probability of splashes, they need to wear goggles or face shield. During an interview on 4/18/2024, at 7:20 a.m., the Chief Nursing Officer (CNO) stated that he was aware of the enhanced barrier precautions to residents on ventilator (vent, a life support device that breathes for individuals who lost all ability to breathe on their own), tracheostomy, g-tube, and with pressure injuries. The CNO stated the enhanced barrier precautions should have been implemented already in the Subacute Unit (SA, is a unit within the facility where residents with level of skilled nursing care needs more intensive than the care provided to the majority of residents in the facility). The CNO stated the policy was still being developed. The CNO stated there was a lot going on in the facility. The CNO stated he, the NM, and the IP were responsible for the development and implementation of the policy and procedure for enhanced barrier precautions, and they have not finalized and implemented the policy yet. The CNO stated it was important to have a policy and procedure for enhanced barrier precaution to prevent spread of infection among residents and staff. A review of the facility's recent policy and procedure titled, Isolation Precautions, last reviewed on 1/2024, did not include enhanced barrier precaution procedure. A review of the facility's recent policy and procedure titled, Policy and Procedure Development, Review, and Approval, last reviewed on 2/12/2024, indicated the facility policies are developed or revised based on current practice and/or scientific knowledge. The Hospital Administrator/designee shall have the following responsibility for hospital policies: 1.1 Review hospital policies prior to distribution to ensure accuracy and content are consistent with CMS (Centers for Medicare and Medicaid Services) and licensing standards and state law/administrative rules. A review of Centers for Disease Control and Prevention (CDC's) Considerations for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities, dated 6/2021, indicated EBP may be applied (when Contact Precautions [intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or patient's environment] do not otherwise apply) to residents with any of the following: o Wounds or indwelling medical devices, regardless of multi-resistant organisms (MDRO) colonization status (germs are on the body but do make a person sick). o Infection or colonization with an MDRO. Effective implementation of EBP requires staff training on the proper use of personal protective equipment and the availability of PPE with hand hygiene products at the point of care. 2. A review of Resident 13's MDS, dated [DATE], indicated the facility admitted the resident on 9/20/2023, with diagnoses including chronic respiratory failure with hypoxia, tracheostomy status, and gastrostomy (GT or g-tube, a tube that is inserted into the stomach used for the administration of medication or feeding) status. The MDS indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident was on oxygen therapy, suctioning, and tracheostomy care. A review of Resident 13's Physician's Orders indicated the following: 4/2/2024 Penile moisture associated skin damage (MASD, caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, saliva, and their contents). Cleanse with soap and water, pat dry, apply triple antibiotic ointment (an antibiotic medication used to reduce the risk of infections) every shift for 14 days. 9/20/2023 Type: PEG 9/20/2023 G-tube feeding. 9/20/2023 Suction retained or increased secretion every 2 hours. 11/28/2023 Tracheostomy Tube (a tube constructed of polyvinyl chloride that is placed between the vocal cords through the trachea): Type shiley (brand name associated with medical devices, specifically tracheostomy tubes) size #6, cuffed. During an observation on 4/17/2024, 9:35 a.m., with LVN 1, inside Resident 13's room, observed Resident 13's room without any enhanced barrier precaution sign and no isolation cart at the entrance of the room. LVN 1 prepared medications for administration to Resident 13. Observed LVN 1 with a surgical mask, washed her hands, placed a new pair of gloves on, and pulled out all due medications for administration. LVN 1 removed her glove, sanitized her hands. LVN 1 brought the medication tray with the medications inside the resident's room without donning a gown on. LVN 1 sanitized her hands and placed a new pair of gloves on. After medication administration, LVN 1 removed her gloves, sanitized her hands. LVN 1 placed another pair of gloves on her hands, took the glucometer (an instrument for measuring the concentration of glucose [blood sugar] in the blood) machine, wiped them with a sanitizing wipe and left for few minutes to dry. LVN 1 removed her gloves, sanitized her hand, and got the insulin (a hormone that lowers the level of glucose in the blood) pen on her medication tray ready. LVN 1 placed a new glove on. LVN 1 discarded all supplies used for medication administration. LVN 1 removed her gloves, sanitized her hands, and documented her medication administration. During an interview and record review on 4/17/2024, at 2:38 p.m., LVN 1 stated she did not wear a gown while administering medications to Resident 13 during the morning medication pass. LVN 1 stated she cannot remember if she had a training regarding enhanced barrier precautions. During an interview on 4/17/2024, at 2:44 p.m., the NM stated Resident 13 should have been placed on enhanced barrier precaution due to the resident had a tracheostomy, g-tube, open wounds, and had aerosolization (dispersal of substance in the form of aerosol) procedures such as suctioning. The NM stated they have not implemented the isolation procedure in the facility. The NM stated she knew about the new isolation procedure since last year. The NM stated she does not know why it was not implemented in the facility yet. The NM stated it was important to have a policy and procedure for enhanced barrier precaution so the staff can have a guide on how to prevent spread of infection to vulnerable residents with g-tubes and tracheostomy. During an interview on 4/17/2024, at 2:54 p.m., with the Infection Preventionist (IP), the IP stated he was aware of the new isolation procedure, and they were still in the planning stage of developing a policy and procedure for the enhanced barrier precaution. The IP stated he was aware of the new isolation procedure since last year. The IP stated there had been no education rolled out for the enhanced barrier precaution. The IP stated it was important to have a policy and procedure for enhanced barrier precaution to serve as a guide for the staff on how to prevent infection to spread to the residents and the staff by wearing appropriate personal protective equipment. The IP stated for enhanced barrier precaution, the staff should be wearing a mask, gloves, gowns, and if there was high probability of splashes, they need to wear goggles or face shield. During an interview on 4/18/2024, at 7:20 a.m., the CNO stated that he was aware of the enhanced barrier precautions to residents on ventilator (vent, a life support device that breathes for individuals who lost all ability to breathe on their own), tracheostomy, g-tube, and with pressure injuries. The CNO stated the enhanced barrier precautions should have been implemented already in the Subacute Unit. The CNO stated the policy was still being developed. The CNO stated there was a lot going on in the facility. The CNO stated he, the NM, and the IP were responsible for the development and implementation of the policy and procedure for enhanced barrier precautions, and they have not finalized and implemented the policy yet. The CNO stated it was important to have a policy and procedure for enhanced barrier precaution to prevent spread of infection among residents and staff. A review of the facility's recent policy and procedure titled, Isolation Precautions, last reviewed on 1/2024, did not include enhanced barrier precaution procedure. A review of the facility's recent policy and procedure titled, Policy and Procedure Development, Review, and Approval, last reviewed on 2/12/2024, indicated the facility policies are developed or revised based on current practice and/or scientific knowledge. The Hospital Administrator/designee shall have the following responsibility for hospital policies: 1.2 Review hospital policies prior to distribution to ensure accuracy and content are consistent with CMS and licensing standards and state law/administrative rules. A review of Centers for Disease Control and Prevention (CDC's) Considerations for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities, dated 6/2021, indicated EBP may be applied (when Contact Precautions do not otherwise apply) to residents with any of the following: o Wounds or indwelling medical devices, regardless of multi-resistant organisms' colonization status. o Infection or colonization with an MDRO. Effective implementation of EBP requires staff training on the proper use of personal protective equipment and the availability of PPE with hand hygiene products at the point of care. 3. A review of Resident 12's MDS, dated [DATE], indicated the facility admitted the resident on 1/9/2018. The MDS indicated the resident sometimes was able to make himself understood and sometimes understood others. The MDS indicated the resident was totally dependent on staff for mobility, dressing, bathing, toilet hygiene, and personal hygiene. A review of Resident 12's History and Physical (H&P), dated 4/20/2023, indicated the resident had diagnoses that included hypoxic respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen), dependence on a ventilator, tracheostomy, and gastrostomy tube placement. A review of Resident 12's Care Plan (CP) titled, Resident at Risk for infection at GT site, initiated 1/2/2024, indicated to observe good infection control practices before and after handling resident. During a medication administration observation, on 4/17/2024 at 8:05 a.m., with LVN 4 at Medication Cart 1, observed LVN 4 wore a surgical mask and gloves, entered Resident 12's room, and administered medication to Resident 12 via g-tube. Observed no signs (signage/postings) indicating EBPs and LVN 4 did not don an isolation gown. During an interview, on 4/17/2024 at 2:35 p.m., LVN 4 stated during the medication administration for Residents 12, she wore a surgical mask and gloves, but she did not don an isolation gown. LVN 4 stated in this facility she only dons isolation gowns for residents in contact isolation (measure aimed to prevent spread of infection by direct or indirect contact) rooms and Residents 12 was not in contact isolation. LVN 4 stated Resident 12 had indwelling devices including g-tube and tracheostomy and has conditions that make the resident prone to infection. LVN 4 stated she was aware of EBPs from her job at a similar facility. LVN 4 stated EBPs are used to prevent the spread of infection for all residents when anything is physically done to them. LVN 4 stated EBPs include full personal protective equipment when providing resident care. LVN 4 stated the facility does not implement EBPs. During an interview on 4/17/2024 at 2:44 p.m., the NM stated EBP are used for residents with wounds or indwelling devices including tracheostomies and g-tubes. The NM stated she has been aware of EBPs since last year. The NM stated the facility has not implemented the practice of EBPs and they do not have a policy for EBPs, but EBPs have been discussed in the infection control committee. The NM stated she does not know why there was a delay in implementing the practice, but it takes a lot of resources to implement EBPs. The NM stated the importance of policies is they are guidelines that are used for nursing practice. The NM stated without a policy and procedure it can ultimately lead to the transfer of organisms to residents and staff. The NM stated the facility administration including the NM, the CNO, the IP, and the Medical Director are responsible for ensuring policies are in place for the facility. During an interview on 4/17/2024 at 2:51 p.m., the IP indicated he had been aware of EBPs for about a year. The IP stated he requested to extend the implementation of EBPs because of recent surveys (regulatory assessments for compliance with Federal health, safety, and quality standards) and the need for involving resources and educating staff. The IP stated the importance of a policy is it is the bible that determines what should be done and staff refers to a policy as a guide for care. The IP stated without a policy then staff will all do their own thing. During an interview on 4/18/2024 at 7:20 a.m., the CNO stated he was apprised of EBPs and EBPs should have been implemented, but they were not. The CNO stated the EBPs policy was in the works and should have already been implemented, but the policy was not finalized or implemented. The CNO stated the facility had a lot going on. A review of the facility-provided policy and procedure titled, Infection Control [NAME], Isolation Precautions, last reviewed 2/12/2024, indicated there was no written procedure for EBPs. A review of the facility provided policy and procedure titled, Administrative Manual: Policy and Procedure Development, Review, and Approval, last reviewed 2/12/2024, indicated the purpose of the policy was to provide a systematic procedure for developing, reviewing, updating, approving, and distributing hospital policies. Facility policies contain information relative to policies, programs, standard procedures, regulations, requirements, committees, and other areas relative to overall hospital philosophy and operation. Facility policies are developed or revised based on current practice and/or scientific knowledge. The hospital will maintain an up-to-date policy manual available to all staff members. Development of policies will be a collaborative process involving representatives from all areas that have a responsibility to carry out the policy. Department Directors have the responsibility to determine the need for a hospital policy. The policy must be consistent with current standards and requirements of the Department of Public Health and Human Services, external surveying bodies such as CMS, state licensing bodies, and state statute/administrative rules. A review of the Centers for Disease Control (CDC) Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities PDF (available from: https://www.cdc.gov/hicpac/workgroup/EnhancedBarrierPrecautions.html), dated 6/2021, indicated MDRO transmission is common in skilled nursing facilities, contributing to significant morbidity and mortality for residents. Resident to resident pathogen transmission in skilled nursing facilities occurs, in part, via healthcare personnel, who may transiently carry and spread MDROs on their hands and clothing during resident care activities. Residents who have complex medical needs involving wound and indwelling devices are at higher risk of both acquisition and colonization by MDROs. Residents who are MDRO colonized are not often recognized by healthcare personnel based on available clinical cultures or medical history. EBP is an approach to targeted gown and glove use during high contact resident care activities designed to reduce transmission of MDROs. EBP may be applied to residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status. Effective implementation of EBP requires staff training on the proper use of PPE and the availability of PPE with hand hygiene products at the point of care. 4. A review of Resident 14's MDS, dated [DATE], indicated the facility admitted the resident on 1/8/2024 and readmitted the resident on 4/3/2024. The MDS indicated the resident rarely/never was able to make himself understood and rarely/never understood others. The MDS indicated the resident was totally dependent on staff for mobility, dressing, bathing, toilet hygiene, and personal hygiene. A review of Resident 14's H&P, dated 4/4/2024 indicated the resident had diagnoses that included chronic respiratory failure, dependence on a ventilator, tracheostomy, and g-tube placement. During a medication administration observation, on 4/17/2024 at 8:37 a.m. with LVN 4 at Medication Cart 1, observed LVN 4 wore a surgical mask and gloves, entered Resident 14's room, and administered medication to Resident 14 via g-tube. Observed no signs indicating EBPs and LVN 4 did not don an isolation gown. During an interview, on 4/17/2024 at 2:35 p.m., LVN 4 stated during the medication observation for Resident 14, LVN 4 wore a surgical mask and gloves but she did not don an isolation gown. LVN 4 stated in the facility she only dons isolation gowns for residents in contact isolation rooms and Residents 14 was not in contact isolation. LVN 4 stated Resident 14 had indwelling devices including g-tube and tracheostomy and has conditions that make the resident prone to infection. LVN 4 stated she was aware of EBPs from her job at a similar facility. LVN 4 stated EBPs are used to prevent the spread of infection for all residents when anything is physically done to them. LVN 4 stated EBPs include full personal protective equipment when providing resident care. LVN 4 stated this facility does not implement EBPs. During an interview on 4/17/2024 at 2:44 p.m., the NM stated EBP are used for residents with wounds or indwelling devices including tracheostomies and g-tubes. The NM stated she has been aware of EBPs since last year. The NM stated the facility has not implemented the practice of EBPs and they do not have a policy for EBPs, but EBPs have been discussed in the infection control committee. The NM stated she does not know why there was a delay in implementing the practice, but it takes a lot of resources to implement EBPs. The NM stated the importance of policies is they are guidelines that are used for nursing practice. The NM stated without a policy and procedure it can ultimately lead to the transfer of organisms to residents and staff. The NM stated the facility administration including the NM, the CNO, the IP, and the Medical Director are responsible for ensuring policies are in place for the facility. During an interview on 4/17/2024 at 2:51 p.m., the IP indicated he had been aware of EBPs for about a year. The IP stated he requested to extend the implementation of EBPs because of recent surveys (regulatory assessments for compliance with Federal health, safety, and quality standards) and the need for involving resources and educating staff. The IP stated the importance of a policy is it is the bible that determines what should be done and staff refers to a policy as a guide for care. The IP stated without a policy then staff will all do their own thing. During an interview on 4/18/2024 at 7:20 a.m., the CNO stated he was apprised of EBPs and EBPs should have been implemented, but they were not. The CNO stated the EBPs policy was in the works and should have already been implemented, but the policy was not finalized or implemented. The CNO stated the facility had a lot going on. A review of the facility-provided policy and procedure titled, Infection Control [NAME], Isolation Precautions, last reviewed 2/12/2024, indicated there was no written procedure for EBPs. A review of the facility provided policy and procedure titled, Administrative Manual: Policy and Procedure Development, Review, and Approval, last reviewed 2/12/2024, indicated the purpose of the policy was to provide a systematic procedure for developing, reviewing, updating, approving, and distributing hospital policies. Facility policies contain information relative to policies, programs, standard procedures, regulations, requirements, committees, and other areas relative to overall hospital philosophy and operation. Facility policies are developed or revised based on current practice and/or scientific knowledge. The hospital will maintain an up-to-date policy manual available to all staff members. Development of policies will be a collaborative process involving representatives from all areas that have a responsibility to carry out the policy. Department Directors have the responsibility to determine the need for a hospital policy. The policy must be consistent with current standards and requirements of the Department of Public Health and Human Services, external surveying bodies such as CMS, state licensing bodies, and state statute/administrative rules. A review of the Centers for Disease Control (CDC) Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities PDF (available from: https://www.cdc.gov/hicpac/workgroup/EnhancedBarrierPrecautions.html), dated 6/2021, indicated MDRO transmission is common in skilled nursing facilities, contributing to significant morbidity and mortality for residents. Resident to resident pathogen transmission in skilled nursing facilities occurs, in part, via healthcare personnel, who may transiently carry and spread MDROs on their hands and clothing during resident care activities. Residents who have complex medical needs involving wound and indwelling devices are at higher risk of both acquisition and colonization by MDROs. Residents who are MDRO colonized are not often recognized by healthcare personnel based on available clinical cultures or medical history. EBP is an approach to targeted gown and glove use during high contact resident care activities designed to reduce transmission of MDROs. EBP may be applied to residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status. Effective implementation of EBP requires staff training on the proper use of PPE and the availability of PPE with hand hygiene products at the point of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident's right to a dignified existence by failing to ensure an indwelling urinary catheter (a flexible tube inserted into the bladder and left in place to continuously drain urine) and nephrostomy (an opening between the kidney and skin in which a flexible tube is placed to drain urine) collection bags (attached to the catheter tube for the purpose of collecting urine) were covered with privacy bags (dignity bag, a bag that conceals urine in the collection bag) for one of one sampled residents (Resident 1) investigated under the Dignity care area. This deficient practice had the potential to result in psychosocial harm to the resident as a result of the visibility of the resident's urine to visitors and staff. Findings: A review of Resident 1's MDS, dated [DATE], indicated the facility admitted the resident on 2/24/2015 and readmitted the resident on 2/6/2023. The MDS indicated the resident usually was able to make himself understood and usually understood others. The MDS indicated the resident was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. A review of Resident 1's History and Physical, dated 2/9/2023 indicated the resident had diagnoses including multiple sclerosis (MS, a disease that impacts the brain, spinal cord, and optic nerves) obstructive uropathy (condition in which the flow of urine is blocked) and nephrostomy. A review of Resident 1's Physician's Order summary, dated 3/25/2023, indicated the following orders: -indwelling catheter to dependent drainage for a diagnosis of obstructive uropathy, dated 2/6/2023. -empty nephrostomy drainage bag before completely full, dated 2/6/2023. During an observation on 3/31/2023 at 6:40 p.m., observed Resident 1 lying in bed, alert, able to respond to questions with simple one-word answers. Observed indwelling catheter urine collection bag and nephrostomy urine collection bag hanging from right side of bed containing yellow urine. During a concurrent observation and interview on 4/1/2023 at 9 a.m., with Licensed Vocational Nurse 4, (LVN 4) stated Resident 1 had an indwelling catheter and nephrostomy. LVN 4 assessed Resident 1 lying in bed and stated Resident 1's indwelling catheter and nephrostomy bags were not covered, and the urine was visible to anyone passing by the room. LVN 4 stated the bags should have been covered. LVN 4 stated she works every Saturday, and she was not sure when the last time the collection bags were covered. LVN 4 stated the importance of covering urine collection bags was for privacy, for resident's identity and self-esteem, and dignity. LVN 4 stated it was important for a (resident) to be treated equal regardless of their medical condition. During an interview on 4/1/2023 at 1:50 p.m., Registered Nurse 1 (RN 1) stated catheters (collection bags) should be covered with a blue cover that is for dignity purposes. RN 1 stated (residents) would not want people passing by to know they have a tube attached to them. During an interview and record review on 4/1/2023 at 2:17 p.m., the Nurse Manager (NM) stated the urine collection bags should be covered for privacy and dignity. The NM stated (residents) live there (in facility) and it is their home and they do not want others to see their urine. The NM reviewed the facility policy and procedures and stated covering urine collection bags was not specified, but it was a standard of practice and included in the resident's right to dignity policy. A review of the facility policy and procedure titled, The Joint Commission Resident Rights, dated 7/2022 indicted the organization respects the rights of residents. Residents receive information about their rights. The organization respects the needs of residents for confidentiality, privacy, and security. Residents have the right to an environment that preserves dignity and contributes to positive self-image.

Based on observation, interview and record review facility failed to maintain privacy of confidential information for one (Resident 10) of one sampled resident when Respiratory Therapist (RT 2) left the resident's electronic health record (EHR- a digital version of a patient's paper chart) open and unattended. This deficient practice violated Resident 10's right to privacy and confidentiality of their medical records. Findings: A review of Resident 10's admission record indicated the facility admitted the resident on 1/1/2023 with diagnoses including chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) with tracheostomy (surgery to create an opening [stoma] into the windpipe), seizure disorder (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain), and chronic encephalopathy (a progressive and fatal brain disease associated with repeated traumatic brain injuries [TBIs], including concussions and repeated blows to the head). A review of Resident 10's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/3/2023 indicated Resident 10 rarely understand other and is rarely understood by others. The MDS indicated Resident 10 was totally dependent on bed mobility, dressing, eating, personal hygiene, and toilet use. During a concurrent observation and interview on 4/1/2023 at 1:40 p.m., outside Resident 10's room, observed Respiratory Therapist (RT 2) in front of the computer. Observed RT 2 walk away from computer and went to the nurses' station with EHR open to Resident 10's chart, unattended and out of RT 2's line of sight. RT 2 stated he usually takes the computer with him, RT 2 stated he should have locked the privacy screen. RT 2 stated leaving EHR unlocked is a risk for an unauthorized person to get access to residents' information. During an interview on 4/1/2023 at 2:47 p.m., with the Nurse Manager (NM), the NM stated when staff is not directly in front of the computer, it needs to be locked. The NM stated leaving computer open and unattended was a violation of privacy of confidential information, as anyone can get it and access all confidential information. A review of facility's policies and procedures titled Workstation Use Policy, revised on 2/3/2022 indicated computers located in public areas will be situated as to block unauthorized viewing and/or will have screen savers that black out the screen.

Based on observation, interview, and record review, the facility failed to post daily nurse staffing information in a prominent place readily accessible to residents and visitors. As a result, nurse staffing information was not readily accessible to residents and visitors. Findings: During a concurrent observation and interview on 5/20/2023 at 9:55 a.m., with Registered Nurse (RN 1), RN 1 stated nurse staffing information is usually posted on the board next to the nursing station. RN 1 stated the nurse staffing information was not posted today. RN 1 stated it is a regulation to post nursing staffing information daily so that it is available to resident and visitors. During an interview on 5/20/2023 at 7 p.m., the Nurse Manager (NM) stated posting of staffing information is done at the beginning of the shift by the charge nurse. The NM stated the staffing information is based on the facility census and should be posted daily so that everyone knows the staffing hours needed to care for the residents. The NM stated the charge nurse should have posted the nurse staffing information this morning at the beginning of the shift because it a regulation that the facility needs to follow. A review of facility's policies and procedures titled Scope of Care Sub acute Unit, revised on 2/2023 indicated the staff work included twelve (12) hour shifts which provides consistency in patient care and increase communication between shifts. The Subacute unit staff will be based on Department of Public Health (DPH) and Centers for Medicare and Medicaid Services (CMS) established nursing hours per patient day requirements.

Based on observation, interview and record review, the facility failed to ensure licensed nurse staff completed documentation indicating reconciliation (a system of recordkeeping that ensures an accurate inventory of medications by accounting for controlled medications that have been received, dispensed, and administered) of controlled medications (substances that have an accepted medical use, have a potential for abuse, and may also lead to physical or psychological dependence) for the a.m. shift on 4/1/2023, investigated during the Medication Storage task. This deficient practice had the potential for inaccurate reconciliation of controlled medication and placed the facility at potential for inability to readily identify loss and drug diversion (illegal distribution of abuse of prescription drugs or their use for unintended purposes) of controlled medications. Findings: During an inspection of Medication Cart 1 on 4/1/2023 at 11 a.m. with Licensed Vocational Nurse 5 (LVN 5), the Narcotic Release Endorsement Sheet (form containing the reconciliation of controlled medications by licensed nurses) for the month of April 2023 was reviewed. LVN 5 stated the narcotic drawer medications are counted every shift by the oncoming and outgoing nurse and both nurses sign the endorsement sheet to verify there were no discrepancies found. LVN 5 stated there was a missing entry on 4/1/2023 for the a.m. shift for the oncoming nurse's signature and the number of discrepancies found. LVN 5 stated she was the oncoming nurse on 4/1/2023 and she did not fill out the sheet, but the outgoing nurse signed it. LVN 5 stated she should have completed the sheet when the outgoing nurse was there at the beginning of her shift (7 a.m.). LVN 5 stated she would be worried if she was the outgoing nurse, and the oncoming nurse did not sign because a signature indicates you are attesting that there were or were not any discrepancies in the medication count (at the end of the shift). During an interview on 4/1/2023 at 1:50 pm, Registered Nurse 1 (RN 1) stated the Narcotic Release Endorsement Sheet should be completed by both nurses together because if there was an error then the outgoing nurse would be responsible. During an interview on 4/1/2023 at 2:17 pm, the Nurse Manager (NM) stated the facility policy and procedure is narcotics are counted by both nurses together at the beginning and end of their shifts and documented. The NM stated the importance was to ensure the correct amount and all narcotics are accounted for. The NM stated if not completed by both nurses, there was a potential for diversion (of narcotics). A review of the facility policy and procedure titled, Controlled Substances: Management of Controlled Meds in Areas Not Using Automated Dispensing Cabinets, dated 1/2023, indicated the purpose of the policy was to ensure the proper management of controlled substances in areas not using automated dispensing cabinets. All controlled substances will be issued to units for specific patients. The shift audit of controlled substances must be performed and documented by on-coming and off-going licensed nurse each nursing shift. The on-coming licensed nurse will: state the name of the drug, the dosage, and the remaining amount of each drug. The out-going nurse will: compare the stated drug information with the name, dosage, and balance on the Controlled Substance Administration Record. The off-going licensed nurse will: acknowledge the information as correct or incorrect as appropriate. If any discrepancies are noted, guidelines for handling discrepancies must be followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to dispose of expired medical supplies during medication storage room observation for one out of one medication room. (Med Storage 1). This deficient practice had the potential to result in the use of ineffective medical device for the residents. Findings: On [DATE] at 10:07 a.m., during a concurrent observation (inspection) of Med Storage 1 and an interview with Registered Nurse 1 (RN 1), observed the following: 1. Sterile foam tipped applicator (swabs) with expiration date of [DATE] (total 15). 2. BD vacutainer (used to transport and process blood for testing in the clinical laboratory) with expiration date of [DATE] (total of 13). 3. Tracheostomy (a hole that surgeons make through the front of the neck and into the windpipe [trachea]) tube with expiration date of 10/2017 (total 1). 4. Tracheostomy tube with disposable inner cannula (a tube within the outer tube with expiration date of [DATE] (total 1). 5. Hydrogen peroxide (cleaning agent) cleaner disinfectant wipes with expiration date of [DATE] (total 1). RN 1 stated the medical items were expired and should be discarded. RN 1 stated the expired tracheostomy items were no longer sterile and if used can be a risk for infection. RN 1 stated the expired swabs and vacutainer can risk the accuracy of test results while the expired disinfectant wipes would no longer have the cleaning potential. During an interview on [DATE] at 2:49 p.m., the Nurse Manager (NM) stated expired supplies need to be disposed accordingly to prevent staff from using them on residents. The NM stated the expired tracheostomy items can be a risk for infection. The NM stated the expired swabs and vacutainer (contained preserved chemicals) would not be effective anymore and can yield inaccurate test results. A review of the facility's policies and procedures, titled Storage: General, revised in 1/2023, indicated drugs shall be stored under the proper condition of sanitation, temperature, light, moisture, ventilation, organization, segregation, and security. A review of the facility's policies and procedures, titled Expiration Dates, revised in 1/2023, indicated expiration dates of drugs and devices shall be checked during the monthly medication area inspections and all drugs and devices scheduled to expire during the next month shall be removed from stock.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure 17 Certified Nursing Assistants (CNAs) had the competencies and skill sets necessary to assist residents with meals for three out three residents (Resident 1, Resident 14, and Resident 17). This deficient practice had the potential for residents not receiving the care and services necessary to meet the residents' individual needs and preferences. Findings: a. A review of Resident 1's MDS, dated [DATE], indicated the facility admitted the resident on 2/24/2015 and readmitted the resident on 2/6/2023. The MDS indicated the resident usually was able to make himself understood and usually understood others. The MDS indicated the resident was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. A review of Resident 1's History and Physical, dated 2/9/2023 indicated the resident had diagnoses including multiple sclerosis (MS, a disease that impacts the brain, spinal cord, and optic nerves) respiratory failure, and ventilator dependence. A review of Resident 1's Physician's Order summary, dated 2/6/2023, indicated puree diet full meal with honey thick liquids with strict aspiration precautions. A review of facility ADL for CNA plan indicated Resident 1 requires total assistance with eating. b. A review of Resident 17's Minimum Data Set (MDS - an assessment and screening too), dated 9/29/2022, indicated the facility admitted the resident on 3/31/2022 and the resident usually was able to understand others and usually was able to make himself understood. The MDS indicated the resident was totally dependent on staff for transfer and toilet use and required extensive staff assistance with bed mobility, dressing, eating, and personal hygiene. A review of facility Activity of daily living (ADL) for CNA plan indicated Resident 14 requires total assistance with eating. A review of Resident 17's History and Physical, dated 1/1/2023 indicated the resident had diagnoses that included respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen) and acute renal failure (sudden reduction in kidney function). A review of Resident 17's Physician's Order summary, dated 1/2/2023, indicated renal high pureed diet with thin liquids three times daily. A review of facility Patient Activity plan indicated Resident 17 requires moderate assistance with eating. c. A review of Resident 14's History and Physical, dated 2/20/2019 indicated the resident had diagnoses including chronic respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen). A review of Resident 14's Physician's Order summary, dated 5/20/2022, indicated puree diet with nectar thick liquids double portion. A review of facility ADL for CNA plan indicated Resident 14 requires total assistance with eating. During an interview on 4/2/2023 at 5:20 p.m., Certified Nursing Assistant (CNA 2), stated she has been in the facility for one and half years and she assists residents with their meals. CNA 2 stated she has not had training on how to assist residents with their meals. CNA 2 stated she received orientation from the RNAs and or RNs assigned to the residents. CNA 2 stated the residents are at risk for aspiration. During a concurrent interview and record review on 4/2/2023 at 2:06 p.m., the Nurse Manager (NM) and the MDS Coordinator (MDSC) stated the last in-service and training for assisting residents with their meals was done back in 2018. The NM and the MDSC stated there were no other records of training conducted after 2018. The NM stated if the staff are not properly trained to assist residents with meals there is a risk for residents aspirating. During an interview on 4/2/2023 at 5:50 p.m., the NM stated if staff is not trained to assist with feeding the residents there is a risk for aspiration and possibly aspiration pneumonia. The NM stated competencies are done yearly and should include demonstrating competency in assisting residents with their meals. During an interview on 4/2/2023 at 6:09 p.m., the MDSC stated that the facility has 17 CNAs and none of them have had the training to assist residents with feeding. The last training was conducted in 2018. A review of facility in-service sign in sheet dated 4/2018 indicated topic as Feeding Residents with tracheostomy/ventilator. The in-service further indicated staff would identify swallowing safety precautions. A review of facility's Job description for Certified Nursing Assistance for Subacute indicated duties and responsibilities as assist with activities of daily living e.g., feeding of patients, AM and PM care. A review of the facility policy and procedure titled Feeding Meals, Preparing Resident for, revised in 6/2016 indicated that all residents receive assistance as needed in preparation for meal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement its infection control policy and procedures by: 1. Failing to change disposable suction canisters (a temporary storage container connected to a suction machine and used to collect respiratory secretions or fluids removed through a long flexible tube) daily per policy for 16 of 16 sampled residents (Residents 10, 8, 18, 6, 3, 1, 4, 2, 11, 13, 12, 5, 7, 9, 15, and 16) with tracheostomy (opening surgically created through the front of the neck and into the trachea [windpipe]). These deficient practices had the potential to transmit infectious microorganisms and placed the residents at risk for respiratory infection. 2. Failing to adhere to infection control when personal items were found in one out of one medication room. This deficient practice had the potential for cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) of the medication room. Findings: a.1. A review of Resident 10's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/3/2023, indicated the facility admitted the resident on 1/17/2020 and readmitted the resident on 7/7/2022. The MDS indicated the resident rarely/never was able to make himself understood and rarely/never understood others. The MDS indicated the resident was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. A review of Resident 10's History and Physical, dated 1/1/2023, indicated the resident had diagnoses that included chronic respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen) and dependence on a ventilator (a machine that takes over the work of breathing when a person is not able to breathe on their own). A review of Resident 10's Physician's Order summary indicated orders for: -suction retained or increased secretion every two hours, dated 7/7/2023. -suction retained or increased secretions as needed, dated 7/7/2023. A review of Resident 10's Care Plan (CP) titled, Potential for infection related to presence of tracheostomy, initiated 1/4/2023, indicated to suction every two hours and as needed for retained or increased secretions and to properly dispose of waste. During an observation on 3/31/2023 at 7:30 p.m., Resident 10 lay in bed awake, but did not respond to questions. Observed suction canister attached to wall with 350 milliliters (ml, a unit of measurement) of fluid inside. The suction canister was labeled Change Thursday 3/30/23. a.2. A review of Resident 8's MDS, dated [DATE], indicated the facility admitted the resident on 11/20/2022 and readmitted the resident on 1/9/2023. A review of Resident 8's MDS, dated [DATE], indicated the resident was rarely/ never able to understand others and rarely/never able to make himself understood. The MDS indicated the resident was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. A review of Resident 8's Physician's Order summary, dated 2/25/2023, indicated the resident had diagnoses that included acute hypoxic respiratory failure, on mechanical ventilation and tracheostomy. The order summary further indicated orders for: -suction retained or increased secretion every two hours, dated 1/10/2023. -suction retained or increased secretions as needed, dated 1/10/2023. A review of Resident 8's CP titled, Potential for infection related to presence of tracheostomy, initiated 1/5/2023, indicated to suction every two hours and as needed for retained or increased secretions and to properly dispose of waste. During an observation on 3/31/2023 at 6:20 p.m., Resident 8 lay in bed and did not verbally respond to questions. Observed suction canister attached to wall with fluid inside. The suction canister was labeled Change Thursday 3/30/23. a.3. A review of Resident 18's MDS, dated [DATE], indicated the facility admitted the resident on 08/28/2014 and readmitted the resident on 12/6/2020. The MDS indicated the resident was in a persistent vegetative state. The MDS indicated the resident was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. A review of Resident 18's Physician's Order summary, dated 3/25/2023, indicated the resident had diagnoses that included cranial cerebral trauma (skull and brain injury), respiratory failure, ventilator dependence, and tracheostomy. The Order summary further indicated a orders for: -suction retained or increased secretion every two hours, dated 12/6/2020. -suction retained or increased secretions as needed, dated 12/6/2020. A review of Resident 18's CP titled, Potential for infection related to presence of tracheostomy, initiated 1/4/2023, indicated to suction every two hours and as needed for retained or increased secretions and to properly dispose of waste. During an observation on 3/31/2023 at 6:15 p.m., Resident 18 lay in bed and did not open eyes or verbally respond to questions. Observed suction canister attached to wall with 400 ml of fluid inside. The suction canister was labeled Change Thursday 3/30/23. a.4. A review of Resident 6's MDS, dated [DATE], indicated the facility admitted the resident on 4/1/2013 and readmitted the resident on 9/15/2019. The MDS indicated the resident rarely/never was able to make herself understood and rarely/never understood others. The MDS indicated the resident was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. A review of Resident 6's History and Physical, dated 1/1/2023 indicated the resident had diagnoses that included respiratory failure, tracheostomy, and left sided brain injury due to ruptured aneurysm (a break or burst of a blood vessel in the brain that causes bleeding) with right sided hemiplegia (mild to severe loss of strength or paralysis on one side of the body). A review of Resident 6's Physician's Order summary indicated a orders for: -suction retained or increased secretion every two hours, dated 9/15/2019. -suction retained or increased secretions as needed, dated 9/15/2019. A review of Resident 6's CP titled, Potential for infection related to presence of tracheostomy, initiated 1/4/2023, indicated to suction every two hours and as needed for retained or increased secretions and to properly dispose of waste. During an observation on 3/31/2023 at 6:25 p.m., Resident 6 lay in bed, alert, but did not respond to questions. Observed suction canister attached to wall with 200 ml of fluid inside. The suction canister was labeled Change Thursday 3/30/23. a.5. A review of Resident 3's MDS, dated [DATE], indicated the facility admitted the resident on 5/1/2015 and readmitted the resident on 8/24/2018. The MDS indicated the resident rarely/never was able to make herself understood and rarely/never understood others. The MDS indicated the resident was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. A review of Resident 3's History and Physical, dated 1/1/2023 indicated the resident had diagnoses that included Rett syndrome (a rare genetic neurological disorder that leads to severe impairments, affecting nearly every aspect of life) chronic respiratory failure, and ventilator dependence. A review of Resident 3's Physician's Order summary indicated orders for: - suction retained or increased secretion every two hours, dated 8/24/2018. - suction retained or increased secretions as needed, dated 8/24/2018. A review of Resident 3's CP titled, Potential for infection related to presence of tracheostomy, initiated 1/4/2023, indicated to suction every two hours and as needed for retained or increased secretions and to properly dispose of waste. During an observation on 3/31/2023 at 6:30 p.m., Resident 3 lay in bed, alert, but did not respond to questions. Observed suction canister attached to wall with 150 ml of fluid inside. The suction canister was labeled Change Thursday 3/30/23. a.6. A review of Resident 1's MDS, dated [DATE], indicated the facility admitted the resident on 2/24/2015 and readmitted the resident on 2/6/2023. The MDS indicated the resident usually was able to make himself understood and usually understood others. The MDS indicated the resident was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. A review of Resident 1's History and Physical, dated 2/9/2023 indicated the resident had diagnoses that included multiple sclerosis (MS, a disease that impacts the brain, spinal cord, and optic nerves) respiratory failure, and ventilator dependence. A review of Resident 1's Physician's Order summary dated 3/25/2023, indicated orders for: -suction retained or increased secretion every two hours, dated 2/6/2023. -suction retained or increased secretions as needed, dated 2/6/2023. A review of Resident 1's CP titled, Potential for infection related to presence of tracheostomy, initiated 2/7/2023, indicated to suction every two hours and as needed for retained or increased secretions and to properly dispose of waste. During an observation on 3/31/2023 at 6:40 p.m., Resident 1 lay in bed, alert, able to respond to questions with simple one-word answers. Observed suction canister attached to wall with 300 ml of fluid inside. The suction canister was labeled Change Thursday 3/30/23. During an observation and interview on 3/31/2023 at 7:30 p.m., Licensed Vocational Nurse 3 (LVN 3) assessed the suction canisters for Resident 10, 8, 18, 6, 3, and 1. LVN 3 stated all the residents' suction canister labels indicated Change Thursday 3/30/2023. LVN 3 stated the labels indicated the suction canisters should have been changed the day before. LVN 3 stated the suction canisters are changed twice a week on Tuesday and Saturday and he was a little confused why the label said to change on Thursday. LVN 3 stated the importance of changing the suction canisters was to prevent contamination of the tubing and respiratory infection. During an interview on 4/1/2023 at 2:17 p.m., the Nurse Manager stated the facility policy and procedure indicate to change suction canisters daily. The NM stated they switched to twice a week during the pandemic (widespread occurrence of an infectious disease over multiple countries and continents), but the pandemic is over, and it must be done daily. The NM stated it must be done daily for infection control reasons to prevent accumulation of organisms. The NM stated if not changed daily, (residents) could potentially get infections like pneumonia (an infection in one or both of the lungs caused by bacteria or virus) from the tubing. A review of the facility policy and procedure titled, Changing and Emptying of Suction Set Ups, last reviewed 2/6/2023, indicated the purpose of the policy was to minimize the risk of infection. All disposable suction canisters and disposable suction canister liners will be changed daily and as needed. c.1. A review of Resident 5's MDS, dated [DATE], indicated the facility admitted the resident on 9/4/2015. The MDS indicated the resident rarely/never was able to make himself understood and rarely/never understood others. The MDS indicated the resident was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. A review of Resident 5's Physician's Orders summary, dated 3/22/2022, indicated diagnoses of chronic respiratory failure, dependence on a ventilator (a machine that takes over the work of breathing when a person is not able to breathe on their own), and dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). During an observation on 3/31/2023 at 6:17 p.m. of Resident 5, observed a suction canister with sticker indicating change Thursday 3/30/2023. c.2. A review of Resident 7's MDS, dated [DATE], indicated the facility admitted the resident on 11/16/2016. The MDS indicated the resident rarely/never was able to make himself understood and rarely/never understood others. The MDS indicated the resident was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. A review of Resident 7's Physician's Orders summary, dated 11/16/2022, indicated diagnoses of chronic hypoxemic respiratory failure (not getting enough oxygen into your blood) and dependence on a ventilator. During an observation on 3/31/2023 at 6:17 p.m. of Resident 7, observed a suction canister with sticker indicating change Thursday 3/30/2023. c.3. A review of Resident 9's MDS, dated [DATE], indicated the facility admitted the resident on 7/14/2020. The MDS indicated the resident was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. A review of Resident 9's Physician's Orders summary, dated 7/14/2020, indicated diagnoses of acute respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), dependence on a ventilator, and dementia. During an observation on 3/31/2023 at 6:17 p.m. of Resident 9, observed a suction canister with sticker indicating change Thursday 3/30/2023. c.4. A review of Resident 15's MDS, dated [DATE], indicated the facility admitted the resident on 12/18/2019. The MDS indicated the resident rarely/never was able to make herself understood and sometimes understood others. The MDS indicated the resident was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. A review of Resident 15's Physician's Order summary, dated 12/18/2019, indicated a diagnosis of respiratory failure. During an observation on 3/31/2023 at 6:17 p.m. of Resident 15, observed a suction canister with sticker indicating change Thursday 3/30/2023. c.5. A review of Resident 16's MDS, dated [DATE], indicated the facility admitted the resident on 9/3/2021. The MDS indicated the resident was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. A review of Resident 16's Physician's Orders summary, dated 3/8/2023, indicated diagnoses of respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), chronic encephalopathy (a progressive and fatal brain disease associated with repeated traumatic brain injuries [TBIs], including concussions and repeated blows to the head). During an observation on 3/31/2023 at 6:17 p.m. of Resident 16, observed a suction canister with sticker indicating change Thursday 3/30/2023. During a concurrent observation and interview on 3/31/2023 at 6:54 p.m., Registered Nurse (RN 1) stated the stickers did indicate that the suction canisters needed to be changed on 3/30/2023. RN 1 stated the night shift nurses are the ones who change the suction canisters. RN 1 stated suction canister are changed on Tuesdays and Saturdays. RN 1 stated based on the date, the canisters have not been changed and should have been changed on 3/30/2023 as those can be risks for infection. During an interview on 4/1/2023 at 2:36 p.m., the NM stated suction canisters are to be changed daily. The NM stated during pandemic, suction canisters were being changed two times a week due to shortage of supply but this was no longer an issue. The NM stated their policy did not change, the canisters need to be changed daily because of infection control reason, to prevent accumulation of organisms. The NM stated residents have a potential to develop infection like pneumonia from tubing and canister not being changed. A review of the facility policy and procedure titled Changing & Emptying of Suction Set Ups, revised in 2/9/2023, indicated to minimize the risk of infection, disposable suction canisters and disposable suction canister liners will be changed daily and as needed. d. During a concurrent observation and interview of the Medication Room on 4/1/2023 at 10:07 a.m., with Registered Nurse (RN 1), observed a clear bag with a labeled ball. RN 1 stated that the ball was labeled with a staff member's name. RN 1 stated personal belonging should not be in the Medication Room it is a risk for infection. During an interview on 4/1/2023 at 2:49 p.m., the NM stated no personnel belonging should be in the medication room. The NM stated personnel belonging in medication room has the potential for contamination of medication room. The NM stated there is no policy for personal belonging in medication room, the medication room is for medications only. A review of facility policies and procedures titled Storage: General, revised on 2/9/2023, indicated drugs shall be stored under the proper conditions of sanitation, temperature, light, moisture, ventilation, organization, segregation, and security. b.1. A review of Resident 4's MDS, dated [DATE], indicated the facility readmitted the resident on 9/10/2019 and the resident's cognition (ability to think, understand, and reason) was severely impaired. The MDS indicated the resident was totally dependent on staff for locomotion on and off unit and eating; and required extensive assistance with bed mobility, transfer, walking in corridor, dressing, toilet use, and personal hygiene. A review of Resident 4's History and Physical, dated 1/14/2023, indicated the resident's diagnoses included urosepsis (an inflammation throughout the body due to bloodstream infection caused by infections of the urinary tract) and hypertension (a condition in which the blood vessels have persistently raised pressure). A review of Physician's Orders summary, dated 9/10/2019, indicated an order to suction retained or increased secretions as needed. A review of Resident 4's Care Plan, titled Potential for infection related to presence of trach, initiated 1/4/2023, indicated to suction every two hours and as needed for retained secretions. During a concurrent observation and interview on 3/31/2023 at 7:08 p.m., LVN 1 confirmed Resident 4's suction canister had a label indicating dated 3/30/2023, change Thursday and contained less than 100 milliliters (ml, a unit of measure) of fluid. LVN 1 stated suction canisters are changed every Tuesdays, Wednesdays, and as needed if above 500 ml. b.2. A review of Resident 2's MDS, dated [DATE], indicated the facility admitted the resident on 12/3/2021. The MDS indicated and the resident was sometimes made self understood and rarely/never understood others. The MDS indicated the resident never/rarely made decisions. A review of Resident 2's History and Physical, dated 1/1/2023, indicated the resident's diagnoses included chronic respiratory failure, tracheostomy, and hypertension. A review of Resident 2's Physician's Order summary, dated 12/3/2021, indicated an order to suction retained or increased secretions as needed. A review of Resident 2's Patient Plan of Care titled, Potential for infection related to presence of trach, initiated 1/4/2023, indicated to suction every two hours as needed. During a concurrent observation and interview on 3/31/2023 at 7:08 p.m., LVN 1 confirmed Resident 2's suction canister had a label indicating dated 3/30/2023, change Thursday and contained 300 ml of fluid. LVN 1 stated suction canisters are changed every Tuesdays, Wednesdays, and as needed if above 500 ml. b.3. A review of Resident 11's MDS, dated [DATE], indicated the facility admitted the resident on 10/9/2018. The MDS indicated the resident sometimes made self understood and understood others. The MDS indicated the resident was totally dependent with staff on bed mobility, dressing, eating, toilet use, and personal hygiene. A review of Resident 11's History and Physical, dated 1/3/2023, indicated the resident's diagnoses included chronic respiratory failure ventilator dependent and dysphagia (difficulty or discomfort in swallowing) with gastrostomy tube (g-tube, a flexible tube inserted through the abdominal wall that directly delivers nutrition to the stomach). A review of Resident 11's Physician Orders summary, dated 10/9/2018, indicated an order: suction retained or increased secretions every two hours. A review of Resident 11's Patient Plan of Care, titled Potential for infection related to presence of (tracheostomy) trach, initiated1/4/2023, indicated to suction every two hours as needed. During a concurrent observation and interview on 3/31/2023 at 7:08 p.m., LVN 1 confirmed Resident 11's suction canister had a label indicating dated 3/30/2023, change Thursday and contained more than 500 ml of fluid. LVN 1 stated suction canisters are changed every Tuesdays, Wednesdays, and as needed if above 500 ml. LVN 1 stated she should have changed it and she endorsed it to the oncoming nurse. b.4. A review of Resident 13's MDS, dated [DATE], indicated the facility admitted the resident on 9/30/2019. The MDS indicated the resident rarely/never understood self and rarely/never understood others. The MDS indicated the resident was totally dependent with staff on bed mobility, dressing, eating, toilet use, and personal hygiene. A review of Resident 13's History and Physical, dated 1/5/2023, indicated the resident's diagnoses included chronic respiratory failure and tracheostomy status. A review of Resident 13's Physician' Orders summary, dated 1/1/2020, indicated an order to suction every two hours and as needed for retained or increased secretions. A review of Resident 13's Patient Plan of Care titled Potential for infection related to presence of trach, initiated 1/4/2023, indicated to suction every two hours as needed. During a concurrent observation and interview on 3/31/2023 at 7:08 p.m., LVN 1 confirmed Resident 13's suction canister had a label indicating dated 3/30/2023, change Thursday and contained less than 300 ml of fluid. LVN 1 stated suction canisters are changed every Tuesdays, Wednesdays, and as needed if above 500 ml. b.5. A review of Resident 12's MDS, dated [DATE], indicated the resident was readmitted on [DATE]. The MDS indicated resident rarely/never understood others and rarely/never understood others. The MDS indicated the resident was totally dependent on staff with bed mobility, dressing, eating, toilet use, and personal hygiene. A review of Resident 12's History and Physical, dated 1/14/2023, indicated the resident's diagnoses included non-vent-dependent respiratory failure and grand mal seizure (a type of seizure that involves a loss of consciousness and violent muscle contractions). A review of Resident 12's Physician's Orders summary, dated 11/28/2017, indicated an order to suction retained or increased secretions as needed. A review of Resident 12's Care Plan titled Potential for infection related to presence of trach, initiated 1/3/2023, indicated to suction every two hours as needed. During a concurrent observation and interview on 3/31/2023 at 7:08 p.m., LVN 1 confirmed Resident 12's suction canister had a label indicating dated 3/30/2023, change Thursday and contained 400 ml of fluid. LVN 1 stated suction canisters are changed every Tuesdays, Wednesdays, and as needed if above 500 ml. During an interview on 4/1/2023 at 2:36 p.m., the NM stated suction canisters are to be changed daily. The NM stated during pandemic, suction canisters were being changed two times a week due to shortage of supply but this was no longer an issue. The NM stated their policy did not change, the canisters need to be changed daily because of infection control reason, to prevent accumulation of organisms. The NM stated potential for residents have a potential to develop infection like pneumonia from tubing and canister not being changed. A review of the facility policy and procedure titled Changing & Emptying of Suction Set Ups, revised in 2/9/2023, indicated to minimize the risk of infection, disposable suction canisters and disposable suction canister liners will be changed daily and as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident has the right to be treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) when all side rails (SRs, also referred to as bed rails or bed side rails, are adjustable metal or rigid plastic bars that attach to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) were placed in raised (up) position on bilateral (two sides) upper (area including arms, shoulders and head) and bilateral lower (area including legs) for 18 of 19 sampled residents (Resident 17, 10, 8, 18, 6, 3, 1, 4, 14, 2, 11, 13, 12, 5, 7, 9, 15, and 16). This deficient practice had the potential to result in negative psychosocial outcome, decline in mobility, isolation, physical harm from entrapment (occurs when a resident is caught between the mattress and SR or within the SR itself) and becoming a falling hazard. Findings: a. A review of Resident 17's admission Record (Face Sheet) indicated the facility admitted the resident on 3/31/2022 with diagnoses that included respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen) and acute renal failure (sudden reduction in kidney function). A review of Resident 17's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 9/29/2022, indicated the resident was usually able to understand and be understood. Resident 17 was totally dependent on staff for transfers and toilet use and required extensive staff assistance with bed mobility, dressing, eating, and personal hygiene. The MDS further indicated the resident did not use SRs up as a physical restraint. A review of the Physician's Order for Resident 17, dated 10/11/2022, indicated an order for two SRs as enablers and for turning and repositioning. A review of Resident 17's Plan of Care (POC) developed for the resident's risk for injury or falls, initiated 1/4/2023, indicated the resident had a history of trying to get out of bed unassisted, moved a lot on bed. An added note to the (POC) indicated Resident 17 was found on the floor next to the bed on 6/23/2023 with no injuries. The POC interventions included applying SRs when in bed as ordered. During an observation on 3/31/2023 at 7 p.m., Resident 17 was lying in bed awake with the four (two halves on each side) SRs in raised position. Resident did not respond when asked why all the SRs were up. On 4/1/2023 at 7:15 a.m., during an observation of Resident 17 in bed with Licensed Vocational Nurse 3 (LVN 3), the resident had all four SRs up. LVN 3 stated they (nursing staff) always kept all four SRs up for all the residents at night and it had been, and this facility practice was in place for a long time. LVN 3 stated most residents were not able to walk and had minimal movement. LVN 3 stated sometimes the residents move to the side of the bed and having the SR up was a safety measure and fall precaution. LVN 3 stated Resident 17 was unpredictable, moved a lot in bed, and could turn side to side. On 4/1/2023 at 7:20 a.m., LVN 3 reviewed the physician's orders for Resident 17 and stated the order indicated to have the upper two SRs up, but the resident had all four SRs up because he could fall. During an interview on 4/1/2023 at 7:35 a.m., Registered Nurse 1 (RN 1) stated there are times when Resident 17 tries to put his legs out of the bed, and they use four SRs to prevent him from falling. RN 1 stated they do not always use four SRs, sometimes two. RN 1 stated Resident 17 did not try to get out of bed. RN 1 stated the use of four SRs up was restraint and the physician's order was not followed. b. A review of Resident 10's admission Record indicated the facility admitted the resident on 1/17/2020 with the last readmission dated 7/7/2022. Resident 10's diagnoses included chronic respiratory failure, dependence on a ventilator (a machine that takes over the work of breathing when a person is not able to breathe on their own), and dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 10's MDS, dated [DATE], indicated the resident rarely/never communicated and was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS further indicated the resident did not use SRs up as physical restraint. A review of the Physician's Order for Resident 10, dated 7/7/2022, indicated to have four SRs padded for seizures disorder. A review of Resident 10's POC developed on 1/4/2023 for the resident's risk for injury or fall related to seizure, dementia, torso cough reflex (an involuntary response of the body to clear the airway and lungs of irritants) from spontaneous coughing due to tracheostomy, episodes of restlessness, dangling legs over the SRs, history of being found sitting next to bed, the interventions included applying SRs up when in bed as ordered. During an observation on 3/31/2023 at 7:30 p.m., Resident 10 was lying in bed awake, but did not respond to questions. The four SRs were up and padded. On 4/1/2023 at 7:15 a.m., during an observation with LVN 3, Resident 10 was in bed with all four SRs up. During an interview and record review on 4/1/2023 at 5 p.m., RN 1 stated the risk of SRs is (residents) can get injury from being stuck. RN 1 after reviewing the physician's orders, care plans, informed consents, interdisciplinary team (IDT) notes, and assessments for Resident 10, RN 1 stated Resident 10 sometimes slides due to the use of a low air loss mattress (LALM - a mattress composed of inflatable air cushions that is used to relieve pressure on body parts). RN 1 stated there was no documented evidence of informed consent for SRs, initial assessment for SR use, or care plan for restraints. c. A review of Resident 8's admission Record indicated the facility admitted the resident on 11/20/2022 with a readmission dated 1/9/2023. Resident 8's diagnoses included acute hypoxic respiratory failure (sudden inability of the lungs to maintain normal respiratory function occurs when there is not enough oxygen in the blood) and on mechanical ventilation and tracheostomy (opening surgically created through the front of the neck and into the trachea [windpipe]) A review of Resident 8's MDS, dated [DATE], indicated the resident rarely / never understood others or make himself understood. The MDS indicated the resident was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS further indicated the resident did not have SRs up used as a physical restraint. A review of the Physician's Order for Resident 8, dated11/20/2022, indicated two SRs up for torso cough reflex. A review of Resident 8's POC initiated on 1/5/2023 for Resident 8's risk for fall related to torso reflex from spontaneous coughing due to tracheostomy, included in the interventions applying SRs up when in bed as ordered. On 3/31/2023 at 6:20 p.m., Resident 8 was observed lying in bed with four SRs in raised position. On 4/1/2023 at 7:15 a.m., during an observation with LVN 3, Resident 1 was in bed and upon interview LVN 3 stated Resident 8 had all four SRs up. During an interview and record review on 4/1/2023 at 5 p.m., RN 1 stated one of the risks of the use of SRs up was entrapment (residents can get injury from being stuck). RN 1 after reviewing Resident 8's physician's orders, care plans, informed consents, IDT notes, and assessments, stated there was no documented evidence of informed consent for SRs, initial assessment for SR use, or care plan for restraints. d. A review of Resident 18's admission Record indicated the facility admitted the resident on 8/28/2014 with a readmission dated 12/6/2020. Resident 18's diagnoses included cranial cerebral trauma (skull and brain injury), respiratory failure, ventilator dependence, and tracheostomy A review of the Physician's Order for Resident 18, dated 11/20/2022, indicated four SRs up for seizure precaution. A review of Resident 18's POC initiated 1/5/2023, for the resident's risk for injury or fall related to torso reflex from spontaneous coughing due to tracheostomy and taking anti-seizure medication, included in the interventions applying SRs up when in bed as ordered. A review of Resident 18's MDS, dated [DATE], indicated the resident was in a persistent vegetative state (unaware of self or the environment). The MDS indicated the resident was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS further indicated the resident did not have SRs up used as physical restraint. During an observation on 3/31/2023 at 6:15 p.m., Resident 18 was lying in bed and did not open eyes or verbally respond to questions. Resident 18 had four SRs in raised position. During an observation and interview on 4/1/2023 at 7:15 a.m., LVN 3 stated Resident 18 had all four SRs up. On 4/1/2023 at 5 p.m., during an interview, record review RN 1 stated the risk of SRs is (residents) can get injury from being stuck. RN 1 reviewed Resident 18's physician's orders, care plans, informed consents, IDT notes, and assessments. RN 1 stated Resident 18 had a diagnosis of brain trauma and brain related issues. RN 1 stated there was a physician's order for four SRs for seizures. RN 1 stated there was no documented evidence of informed consent for SRs, initial assessment for SR use, or care plan for restraints. e. A review of Resident 6's admission Record indicated the facility admitted the resident on 4/1/2013 with a readmission dated 9/15/2019. Resident 6's diagnoses including respiratory failure, tracheostomy, and left sided brain injury due to ruptured aneurysm (a break or burst of a blood vessel in the brain that causes bleeding) with right sided hemiplegia (mild to severe loss of strength or paralysis on one side of the body). A review of the Physician's Order for Resident 6, dated 11/20/2022, indicated to have four SRs up for seizures disorder. A review of Resident 6's MDS, dated [DATE], indicated the resident rarely/never understood others or made herself understood. Resident 6 was totally dependent on staff for care and did not have SRs up used as physical restraint. A review of Resident 6's POC initiated on 1/4/2023, for the resident's risk for injury due to seizure disorder, included applying SRs up as ordered. During an observation on 3/31/2023 at 6:25 p.m., Resident 6 was lying in bed with four SRs in raised position. During an interview and record review on 4/1/2023 at 5 p.m., RN reviewed Resident 6's physician's orders, care plans, informed consents, IDT notes, and assessments. RN 1 stated there was no documented evidence of informed consent for SRs, initial assessment for SRs up use, or care plan for restraints. f. A review of Resident 3's admission Record indicated the facility admitted the resident on 5/1/2015 with a readmission dated 8/24/2018. Resident 3's diagnoses included Rett syndrome (a rare genetic neurological disorder that leads to severe impairments, affecting nearly every aspect of life), chronic respiratory failure, and ventilator dependence. A review of the Physician's Order for Resident 3, dated 8/24/2018, indicated to have four SRs up for seizures disorder. A review of Resident 3's MDS, dated [DATE], indicated the resident rarely/never made herself understood or understood others. The resident was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS further indicated the resident did not have SRs up used as physical restraint. A review of Resident 3's POC initiated on 1/4/2023 for the resident's risk for injury due to seizure disorder, included in the interventions applying SRs up when in bed as ordered. During an observation on 3/31/2023 at 6:30 p.m., Resident 3 was lying in bed with two SRs in raised position. During an observation on 4/1/2023 at 7:05 a.m., Resident 3 was lying in bed with four SRs in raised position. During an observation and interview on 4/1/2023 at 7:15 a.m., LVN 3 states Resident 3 had all four SRs up. During an interview and record review on 4/2/2023 at 7:45 a.m., RN 3 reviewed Resident 3's physician's orders, care plans, informed consents, IDT notes, and assessments. RN 3 stated there was no documented evidence of informed consent for SRs, initial assessment for SRs use, or care plan for restraints. RN 3 stated she had never gotten consent for SRs for any residents. g. A review of Resident 1's admission Record indicated the facility admitted the resident on 2/24/2015 with a readmission dated 2/6/2023. Resident 1's diagnoses included multiple sclerosis (MS, a disease that impacts the brain, spinal cord, and optic nerves), respiratory failure, and ventilator dependence. A review of Resident 1's MDS, dated [DATE], indicated the resident usually made himself understood and usually understood others. The MDS indicated the resident was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS further indicated the resident did not use SRs up as physical restraint. A review of the Physician's Order, dated 2/6/2023, indicated two SRs up for torso cough reflex. A review of Resident 1's POC initiated 2/7/2023 for the resident's risk for injury or fall related to advanced MS and torso reflex from spontaneous coughing due to tracheostomy, included in the interventions applying SRs when in bed as ordered. During an observation on 3/31/2023 at 6:40 p.m., Resident 1 lying in bed with two SRs in raised position. During an observation on 4/1/2023 at 7:05 a.m., Resident 1 lying in bed with four SRs in raised position. During an observation and interview on 4/1/2023 at 7:15 a.m., LVN 1 observed Resident 1 and stated all four SRs were up. During an interview and record review on 4/1/2023 at 5 p.m., RN 1 stated there was no documented evidence of informed consent for SRs, initial assessment for SR use, or care plan for restraints. During an interview on 4/1/2023 at 2:17 p.m., the Nurse Manager (NM) stated the use of SRs depends on the order. SRs were used for medical reasons like poor balance due to a medical condition and they do not get consent for residents with an order for the use of four SRs because it is not considered a restraint. During an interview on 4/1/2023 at 7 p.m., the Minimum Data Set Coordinator (MDSC) stated SRs are used for safety for torso cough reflex and seizure movement and for few residents, the SRs up are used for enablers for bed mobility. The MDSC stated SRs were not restraints and a restraint assessment was not completed. During an interview on 4/2/2023 at 8:05 a.m., The NM stated she had worked at the facility for five years and there was no documented evidence that a SRs risk assessment was completed, informed consent was signed, or that a less restrictive alternative measure was tried prior to the use of side rails. The NM stated it has been the practice to just get an order for SRs. The NM stated it was her understanding that they did not need to get informed consent for the usage of side rails if they were not used as a restraint. During a telephone interview on 4/2/2023 at 1:23 p.m., the Medical Director (MD) stated some (residents in subacute unit) can voluntarily move, but SRs are not ordered for getting out of bed or behavior issues. The MD stated side rail usage on the subacute unit is related to safety for coughing spasms and (residents) can get in a position that is unsafe. The MD stated there is a risk that a (resident) could move their body against the rail, but the risk is greater for injury from a fall from coughing reflex. The MD stated it was reasonable that residents would benefit from SRs. The MD stated risk should always be assessed in medicine and treatments, but for the majority the benefit outweighs the risk. The MD stated he did not get consent for SRs usage. During an interview and record review on 4/2/2023 at 3:45 p.m., the Chief Nursing Officer (CNO) reviewed the hospital wide policy for restraint management. The CNO stated if a (resident) had an order for two SRs and four were up and the resident had mobility, then four SRs up would be a restraint. n. A review of Resident 5's admission Record indicated the facility admitted the resident on 9/4/2015 with diagnoses of chronic respiratory failure, dependence on a ventilator, and dementia A review of Resident 5's MDS, dated [DATE], indicated the resident was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS further indicated the resident did not use SRs up as physical restraint. A review of the Physician's Order dated 3/22/2022, indicated to apply two SRs up for torso cough reflex. A review of Resident 5's POC initiated on 1/5/2023 for the resident's risk for injury or falls related to torso reflex from spontaneous coughing due to tracheostomy, the interventions included to apply SRs up when in bed as ordered. During a concurrent observation and interview on 4/1/2023 at 7:10 a.m., CNA 3 at Resident 5's bedside stated all four SRs were up. During an interview and Resident 5's record review on 4/1/2023 at 5 p.m., RN reviewed the physician's orders, care plans, informed consents, IDT notes, and assessments. RN 1 stated there was no documented evidence of informed consent for the use of SRs, initial assessment for SRs use, or care plan for restraints. o. A review of Resident 7's admission Record indicated the facility admitted the resident on 11/16/2016 with diagnoses including chronic hypoxemic respiratory failure and dependence on a ventilator. A review of Resident 7's MDS, dated [DATE], indicated the resident was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS further indicated the resident did not use bed SRs up as physical restraint. A review of the Physician's Order, dated 11/16/2022, indicated two SRs up for torso cough reflex. A review of Resident 7's POC initiated on 1/5/2023, for the resident's risk for injury or falls related to torso reflex from spontaneous coughing due to tracheostomy, included in the interventions applying two SRs up when in bed as ordered. During a concurrent observation and interview on 4/1/2023 at 7:10 a.m., CNA 3 at Resident 7's bedside stated all four SRs were up. During an interview and Resident 7's record review on 4/1/2023 at 5 p.m., RN 1 reviewed the physician's orders, care plans, informed consents, IDT notes, and assessments. RN 1 stated there was no documented evidence of informed consent for the use of the SRs, initial assessment for SRs use, or care plan for restraints. p. A review of Resident 9's admission Record indicated the facility admitted the resident on 7/14/2020 with diagnoses including acute respiratory failure and dependence on a ventilator. A review of Resident 9's MDS, dated [DATE], indicated the resident was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS further indicated the resident did not use SRs up as physical restraint. A review of the Physician's Order for Resident 9, dated 7/14/2020, indicated two SRs up for torso cough reflex. A review of Resident 9's POC initiated on 1/5/2023, for the resident's risk for injury or falls related to torso reflex from spontaneous coughing due to tracheostomy, included in the interventions applying two SRs as ordered. During a concurrent observation and interview on 4/1/2023 at 7:10 a.m., CNA 3 at Resident 9's bedside stated all four SRs were up. During an interview and Resident 9's record review on 4/1/2023 at 5 p.m., RN 1 stated there was no documented evidence of informed consent for SRs, initial assessment for SR use, or care plan for restraints. q. A review of Resident 15's admission Record indicated the facility admitted the resident on 12/18/2019 with diagnoses including respiratory failure. A review of Resident 15's MDS, dated [DATE], indicated the resident was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS further indicated the resident did not use SRs up as physical restraint. A review of the Physician's Order, dated 12/18/2019, indicated two SRs up for torso cough reflex and seizure disorder. A review of Resident 15's POC initiated on 1/3/2023, for the resident's risk for injury or falls related to torso reflex from spontaneous coughing due to tracheostomy, the interventions included applying SRs up as ordered. During a concurrent observation and interview on 4/1/2023 at 7:10 a.m., CNA 3 at Resident 15's bedside stated all four SRs were up. During an interview and Resident 15's record review on 4/1/2023 at 5 p.m., RN 1 stated there was no documented evidence of informed consent for SRs, initial assessment for SR use, or care plan for restraints. r. A review of Resident 16's admission Record indicated the facility admitted the resident on 9/3/2021 with diagnoses including respiratory failure. A review of Resident 16's MDS, dated [DATE], indicated the resident was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS further indicated the resident did not have SRs as physical restraint. A review of the Physician's Order, dated 3/8/2023, indicated two SRs up for torso cough reflex dated 3/8/2023. A review of Resident 16's POC initiated 1/5/2023, for the resident's risk for injury or falls related to torso reflex from spontaneous coughing due to tracheostomy, included in the intervention applying SRs as ordered. During a concurrent observation and interview on 4/1/2023 at 7:10 a.m., CNA 3 at Resident 16's bedside stated all 4 side rails were up. During an interview and Resident 16's record review on 4/1/2023 at 5 p.m., RN 1 stated there was no documented evidence of informed consent for the use of SRs, initial assessment for SRs use, or care plan for restraints. A review of the facility policy and procedure titled, Restraint/Seclusion Management Protocol, last reviewed 2/6/2023, indicated the purpose of the protocol was the following: to provide guidelines for the provision of a safe environment in which restraints are distinguished from devices not used as restraints and the least restrictive alternative to the use of restraints are pursued in order to reduce and minimize the utilization of restraints; to ensure safe practice and observance of patient's rights when restraints are required; to distinguish between devices and/or techniques used as restraint; and to maximize safety and prevent patient and personnel injury. The use of restraint and seclusion poses an inherent risk to the physical safety and psychological wellbeing of the patient. The use of restraints is a last resort, after alternative less restrictive interventions have been considered and/or attempted. The use of restraints is not based on diagnosis, but rather on a multidisciplinary comprehensive individualized assessment. A physical restraint is any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body. The only acceptable forms of restraint in the sub-acute unit shall be cloth vests, soft ties, soft cloth mittens, seat belts and trays with springs release devices. Postural support means a method used to assist patient to achieve proper body position and balance. Postural supports may only include soft ties, seatbelts, spring released trays or cloth vests and shall only be used to improve a patient's mobility and independent functions, to prevent the patient from falling out of bed or for positioning, rather than to restrict movement. These methods shall not be considered a restraint. The following is, by definition, not considered to be restraint and is specifically excluded from this policy: the use of side rails to assist with safety, unless the use is such that the side rails prevent patient mobility (e.g. all four side rails up), is used to achieve proper body position, balance, alignment, or to allow greater mobility. The use of restraint for the following reasons is strictly prohibited: use as a convenience for staff. h. A review of Resident 4's admission Record indicated the facility re-admitted the resident on 9/10/2019 with diagnoses including hypertension (a condition in which the blood vessels have persistently raised pressure). A review of Resident 4's MDS, dated [DATE], indicated the resident's cognition (ability to think, understand, and reason) was severely impaired. The MDS indicated the resident was totally dependent on staff for locomotion on and off unit, eating and required extensive assistance with bed mobility, transfer, walk in corridor, dressing, toilet use, and personal hygiene. The MDS further indicated the resident did not have SRs up as physical restraint. A review of the Physician's Order for Resident 4, dated 9/10/2019, indicated applying four SRs up padded for safety due to seizure disorder. A review of Resident 4's POC initiated 1/3/2023, for the resident's risk for injury or falls indicated the resident moved a lot on bed, dangled legs over rail, and stood up unassisted when agitated. The POC interventions included applying SRs up when in bed as ordered. During an observation on 3/31/2023 at 6:41 p.m., observed Resident 4 lying in bed with all four SRs up. During a concurrent observation and interview on 4/1/2023 at 7:16 a.m., Certified Nursing Assistant 1 (CNA 1) confirmed Resident 4 was lying in bed with all four SRs up for safety. During an interview on 4/2/2023 at 5:48 p.m., the MDSC stated Resident 4 was able to stand up without assistance and walk with two-person assist. During a concurrent interview and Resident 4's record review on 4/1/2023 at 6:44 p.m., RN 1 reviewed the physician's orders, care plans, informed consents, IDT notes, and assessments. RN 1 confirmed there were no documented evidence of informed consent for the use of SRs, initial assessment for SRs use, or care plan for restraints. i. A review of Resident 14's admission Record indicated the facility admitted the resident on 2/20/2019 with diagnoses including respiratory failure status-post (s/p) tracheostomy and functional quadriplegia (complete immobility due to severe physical disability or frailty). A review of Resident 14's MDS, dated [DATE], indicated the resident's cognition was intact (not affected). Resident 14 was totally dependent on staff for bed mobility, dressing, bathing, eating, toilet use, and personal hygiene. The MDS further indicated the resident did not use SRs up as physical restraint. A review of the Physician's Order for Resident 14, dated 2/20/2019, indicated to apply two SRs up for safety due to torso cough reflex. A review of Resident 14's POC initiated 1/3/2023, for the resident's risk for injury or falls, included in the interventions applying SRs up when in bed as ordered. During an observation on 3/31/2023 at 6 p.m., observed Resident 14 lying with all four SRs raised. During a concurrent observation and interview on 4/1/2023 at 7:20 a.m., CNA 1 stated during her shift she did not lower any of Resident 14's SRs for the resident's safety and to prevent falls. During a concurrent interview and record review on 4/1/2023 at 6:28 p.m., RN 1 reviewed Resident 14's physician's orders, care plans, informed consents, IDT notes, and assessments. RN 1 confirmed there were no documented evidence of informed consent for SRs, initial assessment for SRs up use, or care plan for restraints. j. A review of Resident 2's admission Record indicated the facility admitted the resident on 12/3/2021 with diagnoses including chronic respiratory failure, status post tracheostomy, and hypertension A review of Resident 2's MDS, dated [DATE], indicated the resident had communication deficit and did not have SRs up as physical restraint. A review of Resident 2's Physician's Order, dated 12/3/2021, indicated two SRs up for safety due to torso cough reflex. A review of Resident 2's POC initiated on 1/4/2023, for the resident's risk for injury or falls included in the interventions applying SRs up when in bed as ordered. During an observation on 3/31/2023 at 6:47 p.m., Resident 2 was lying in bed with all four SRs raised. During a concurrent observation and interview on 4/1/2023 at 7:18 a.m., CNA 1 stated all four SRs were raised for Resident 2 due to safety and to prevent from falling. During a concurrent interview and Resident 2's record review on 4/1/2023 at 6:13 p.m., RN 1 reviewed the physician's orders, care plans, informed consents, IDT notes, and assessments. RN 1 confirmed there were no documented evidence of informed consent for the use of SRs, initial assessment for SRs use, or care plan for restraints. k. A review of Resident 11's admission Record indicated the facility admitted the resident on 10/9/2018 with diagnoses including chronic respiratory failure ventilator dependent and dysphagia (difficulty or discomfort in swallowing) with gastrostomy tube (g-tube, a flexible tube inserted through the abdominal wall that directly delivers nutrition to the stomach). A review of Resident 11's MDS, dated [DATE], indicated the resident had communication deficit and was totally dependent with staff on bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS further indicated the resident did not have SRs up as physical restraint. A review of the Physician's Order for Resident 11, dated 1/30/2020, indicated to apply four SRs up for torso cough reflex/seizure disorder. A review of Resident 11's POC initiated on 1/4/2023, for the resident's risk for injury or falls, included in the interventions to apply SRs up when in bed. During an observation on 3/31/2023 at 6:50 p.m., Resident 11 was lying in bed with all four SRs raised. During a concurrent observation and interview on 4/1/2023 at 7:18 a.m., CNA 1 at bedside, stated all four SRs were raised for Resident 11's safety and to prevent from falling. During a concurrent interview and Resident 11's record review on 4/1/2023 at 6:20 p.m., RN 1 reviewed the physician's orders, care plans, informed consents, IDT notes, and assessments. RN 1 confirmed there were no documented evidence of informed consent for the use of SRs up, initial assessment for SRs use, or care plan for restraints. l. A review of Resident 13's admission Record indicated the facility admitted the resident on 9/30/2019 with diagnoses including chronic respiratory failure and tracheostomy status. A review of Resident 13's MDS, dated [DATE], indicated the resident was totally dependent with staff on bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS further indicated the resident did not use SRs up as physical restraint. A review of the Physician' Order for Resident 13, dated 9/30/2019, indicated to apply four SRs up padded for seizure disorder. A review of Resident 13's POC initiated on 1/5/2023, for the resident's risk for injury or falls, included in the interventions to apply SRs up when in bed as ordered. During an observation on 3/31/2023 at 6 p.m., Resident 13 was lying in bed with all four SRs raised. During a concurrent interview and Resident 13's record review on 4/1/2023 at 6:34 p.m., RN 1 reviewed the resident's physician's orders, c[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the safe and appropriate use of side rails (also referred to as bed rails and bed side rails, are adjustable metal or rigid plastic bars that attach to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) for 18 of 19 sampled residents (Resident 17, 10, 8, 18, 6, 3, 1, 4, 14, 2, 11, 13, 12, 5, 7, 9, 15, and 16). The facility failed to: 1. Attempt to use appropriate alternatives prior to using SRs 2. Conduct an assessment including the risk for entrapment from SRs. 3. Review the risk and benefits of side or bed rails with the resident or resident representative and obtain informed consent. This deficient practice had the potential to result in decline in residents' functions, negative psychosocial outcome, physical harm from entrapment (occurs when a resident is caught between the mattress and bed rail or within the bed rail itself) or falls and injuries from climbing over the SRs. Findings: a. A review of Resident 17's admission Record (Face Sheet) indicated the facility admitted the resident on 3/31/2022 with diagnoses that included respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen) and acute renal failure (sudden reduction in kidney function). A review of Resident 17's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 9/29/2022, indicated the resident was usually able to understand and be understood. Resident 17 was totally dependent on staff for transfers and toilet use and required extensive staff assistance with bed mobility, dressing, eating, and personal hygiene. The MDS further indicated the resident did not use SRs up as a physical restraint. A review of the Physician's Order for Resident 17, dated 10/11/2022, indicated an order for two SRs as enablers and for turning and repositioning. A review of Resident 17's Plan of Care (POC) developed for the resident's risk for injury or falls, initiated 1/4/2023, indicated the resident had a history of trying to get out of bed unassisted, moved a lot on bed. An added note to the (POC) indicated Resident 17 was found on the floor next to the bed on 6/23/2023 with no injuries. The POC interventions included applying SRs when in bed as ordered. During an observation on 3/31/2023 at 7 p.m., Resident 17 was lying in bed awake with the four (two halves on each side) SRs in raised position. Resident did not respond when asked why all the SRs were up. On 4/1/2023 at 7:15 a.m., during an observation of Resident 17 in bed with Licensed Vocational Nurse 3 (LVN 3), the resident had all four SRs up. LVN 3 stated they (nursing staff) always kept all four SRs up for all the residents at night and it had been, and this facility practice was in place for a long time. LVN 3 stated most residents were not able to walk and had minimal movement. LVN 3 stated sometimes the residents move to the side of the bed and having the SR up was a safety measure and fall precaution. LVN 3 stated Resident 17 was unpredictable, moved a lot in bed, and could turn side to side. On 4/1/2023 at 7:20 a.m., LVN 3 reviewed the physician's orders for Resident 17 and stated the order indicated to have the upper two SRs up, but the resident had all four SRs up because he could fall. During an interview on 4/1/2023 at 7:35 a.m., Registered Nurse 1 (RN 1) stated there are times when Resident 17 tries to put his legs out of the bed, and they use four SRs to prevent him from falling. RN 1 stated they do not always use four SRs, sometimes two. RN 1 stated Resident 17 did not try to get out of bed. RN 1 stated the use of four SRs up was restraint and the physician's order was not followed. b. A review of Resident 10's admission Record indicated the facility admitted the resident on 1/17/2020 with the last readmission dated 7/7/2022. Resident 10's diagnoses included chronic respiratory failure, dependence on a ventilator (a machine that takes over the work of breathing when a person is not able to breathe on their own), and dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 10's MDS, dated [DATE], indicated the resident rarely/never communicated and was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS further indicated the resident did not use SRs up as physical restraint. A review of the Physician's Order for Resident 10, dated 7/7/2022, indicated to have four SRs padded for seizures disorder. A review of Resident 10's POC developed on 1/4/2023 for the resident's risk for injury or fall related to seizure, dementia, torso cough reflex (an involuntary response of the body to clear the airway and lungs of irritants) from spontaneous coughing due to tracheostomy, episodes of restlessness, dangling legs over the SRs, history of being found sitting next to bed, the interventions included applying SRs up when in bed as ordered. During an observation on 3/31/2023 at 7:30 p.m., Resident 10 was lying in bed awake, but did not respond to questions. The four SRs were up and padded. On 4/1/2023 at 7:15 a.m., during an observation with LVN 3, Resident 10 was in bed with all four SRs up. During an interview and record review on 4/1/2023 at 5 p.m., RN 1 stated the risk of SRs is (residents) can get injury from being stuck. RN 1 after reviewing the physician's orders, care plans, informed consents, interdisciplinary team (IDT) notes, and assessments for Resident 10, RN 1 stated Resident 10 sometimes slides due to the use of a low air loss mattress (LALM - a mattress composed of inflatable air cushions that is used to relieve pressure on body parts). RN 1 stated there was no documented evidence of informed consent for SRs, initial assessment for SR use, or care plan for restraints. c. A review of Resident 8's admission Record indicated the facility admitted the resident on 11/20/2022 with a readmission dated 1/9/2023. Resident 8's diagnoses included acute hypoxic respiratory failure (sudden inability of the lungs to maintain normal respiratory function occurs when there is not enough oxygen in the blood) and on mechanical ventilation and tracheostomy (opening surgically created through the front of the neck and into the trachea [windpipe]) A review of Resident 8's MDS, dated [DATE], indicated the resident rarely / never understood others or make himself understood. The MDS indicated the resident was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS further indicated the resident did not have SRs up used as a physical restraint. A review of the Physician's Order for Resident 8, dated11/20/2022, indicated two SRs up for torso cough reflex. A review of Resident 8's POC initiated on 1/5/2023 for Resident 8's risk for fall related to torso reflex from spontaneous coughing due to tracheostomy, included in the interventions applying SRs up when in bed as ordered. On 3/31/2023 at 6:20 p.m., Resident 8 was observed lying in bed with four SRs in raised position. On 4/1/2023 at 7:15 a.m., during an observation with LVN 3, Resident 1 was in bed and upon interview LVN 3 stated Resident 8 had all four SRs up. During an interview and record review on 4/1/2023 at 5 p.m., RN 1 stated one of the risks of the use of SRs up was entrapment (residents can get injury from being stuck). RN 1 after reviewing Resident 8's physician's orders, care plans, informed consents, IDT notes, and assessments, stated there was no documented evidence of informed consent for SRs, initial assessment for SR use, or care plan for restraints. d. A review of Resident 18's admission Record indicated the facility admitted the resident on 8/28/2014 with a readmission dated 12/6/2020. Resident 18's diagnoses included cranial cerebral trauma (skull and brain injury), respiratory failure, ventilator dependence, and tracheostomy A review of the Physician's Order for Resident 18, dated 11/20/2022, indicated four SRs up for seizure precaution. A review of Resident 18's POC initiated 1/5/2023, for the resident's risk for injury or fall related to torso reflex from spontaneous coughing due to tracheostomy and taking anti-seizure medication, included in the interventions applying SRs up when in bed as ordered. A review of Resident 18's MDS, dated [DATE], indicated the resident was in a persistent vegetative state (unaware of self or the environment). The MDS indicated the resident was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS further indicated the resident did not have SRs up used as physical restraint. During an observation on 3/31/2023 at 6:15 p.m., Resident 18 was lying in bed and did not open eyes or verbally respond to questions. Resident 18 had four SRs in raised position. During an observation and interview on 4/1/2023 at 7:15 a.m., LVN 3 stated Resident 18 had all four SRs up. On 4/1/2023 at 5 p.m., during an interview, record review RN 1 stated the risk of SRs is (residents) can get injury from being stuck. RN 1 reviewed Resident 18's physician's orders, care plans, informed consents, IDT notes, and assessments. RN 1 stated Resident 18 had a diagnosis of brain trauma and brain related issues. RN 1 stated there was a physician's order for four SRs for seizures. RN 1 stated there was no documented evidence of informed consent for SRs, initial assessment for SR use, or care plan for restraints. e. A review of Resident 6's admission Record indicated the facility admitted the resident on 4/1/2013 with a readmission dated 9/15/2019. Resident 6's diagnoses including respiratory failure, tracheostomy, and left sided brain injury due to ruptured aneurysm (a break or burst of a blood vessel in the brain that causes bleeding) with right sided hemiplegia (mild to severe loss of strength or paralysis on one side of the body). A review of the Physician's Order for Resident 6, dated 11/20/2022, indicated to have four SRs up for seizures disorder. A review of Resident 6's MDS, dated [DATE], indicated the resident rarely/never understood others or made herself understood. Resident 6 was totally dependent on staff for care and did not have SRs up used as physical restraint. A review of Resident 6's POC initiated on 1/4/2023, for the resident's risk for injury due to seizure disorder, included applying SRs up as ordered. During an observation on 3/31/2023 at 6:25 p.m., Resident 6 was lying in bed with four SRs in raised position. During an interview and record review on 4/1/2023 at 5 p.m., RN reviewed Resident 6's physician's orders, care plans, informed consents, IDT notes, and assessments. RN 1 stated there was no documented evidence of informed consent for SRs, initial assessment for SRs up use, or care plan for restraints. f. A review of Resident 3's admission Record indicated the facility admitted the resident on 5/1/2015 with a readmission dated 8/24/2018. Resident 3's diagnoses included Rett syndrome (a rare genetic neurological disorder that leads to severe impairments, affecting nearly every aspect of life), chronic respiratory failure, and ventilator dependence. A review of the Physician's Order for Resident 3, dated 8/24/2018, indicated to have four SRs up for seizures disorder. A review of Resident 3's MDS, dated [DATE], indicated the resident rarely/never made herself understood or understood others. The resident was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS further indicated the resident did not have SRs up used as physical restraint. A review of Resident 3's POC initiated on 1/4/2023 for the resident's risk for injury due to seizure disorder, included in the interventions applying SRs up when in bed as ordered. During an observation on 3/31/2023 at 6:30 p.m., Resident 3 was lying in bed with two SRs in raised position. During an observation on 4/1/2023 at 7:05 a.m., Resident 3 was lying in bed with four SRs in raised position. During an observation and interview on 4/1/2023 at 7:15 a.m., LVN 3 states Resident 3 had all four SRs up. During an interview and record review on 4/2/2023 at 7:45 a.m., RN 3 reviewed Resident 3's physician's orders, care plans, informed consents, IDT notes, and assessments. RN 3 stated there was no documented evidence of informed consent for SRs, initial assessment for SRs use, or care plan for restraints. RN 3 stated she had never gotten consent for SRs for any residents. g. A review of Resident 1's admission Record indicated the facility admitted the resident on 2/24/2015 with a readmission dated 2/6/2023. Resident 1's diagnoses included multiple sclerosis (MS, a disease that impacts the brain, spinal cord, and optic nerves), respiratory failure, and ventilator dependence. A review of Resident 1's MDS, dated [DATE], indicated the resident usually made himself understood and usually understood others. The MDS indicated the resident was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS further indicated the resident did not use SRs up as physical restraint. A review of the Physician's Order, dated 2/6/2023, indicated two SRs up for torso cough reflex. A review of Resident 1's POC initiated 2/7/2023 for the resident's risk for injury or fall related to advanced MS and torso reflex from spontaneous coughing due to tracheostomy, included in the interventions applying SRs when in bed as ordered. During an observation on 3/31/2023 at 6:40 p.m., Resident 1 lying in bed with two SRs in raised position. During an observation on 4/1/2023 at 7:05 a.m., Resident 1 lying in bed with four SRs in raised position. During an observation and interview on 4/1/2023 at 7:15 a.m., LVN 1 observed Resident 1 and stated all four SRs were up. During an interview and record review on 4/1/2023 at 5 p.m., RN 1 stated there was no documented evidence of informed consent for SRs, initial assessment for SR use, or care plan for restraints. During an interview on 4/1/2023 at 2:17 p.m., the Nurse Manager (NM) stated the use of SRs depends on the order. SRs were used for medical reasons like poor balance due to a medical condition and they do not get consent for residents with an order for the use of four SRs because it is not considered a restraint. During an interview on 4/1/2023 at 7 p.m., the Minimum Data Set Coordinator (MDSC) stated SRs are used for safety for torso cough reflex and seizure movement and for few residents, the SRs up are used for enablers for bed mobility. The MDSC stated SRs were not restraints and a restraint assessment was not completed. During an interview on 4/2/2023 at 8:05 a.m., The NM stated she had worked at the facility for five years and there was no documented evidence that a SRs risk assessment was completed, informed consent was signed, or that a less restrictive alternative measure was tried prior to the use of side rails. The NM stated it has been the practice to just get an order for SRs. The NM stated it was her understanding that they did not need to get informed consent for the usage of side rails if they were not used as a restraint. During a telephone interview on 4/2/2023 at 1:23 p.m., the Medical Director (MD) stated some (residents in subacute unit) can voluntarily move, but SRs are not ordered for getting out of bed or behavior issues. The MD stated side rail usage on the subacute unit is related to safety for coughing spasms and (residents) can get in a position that is unsafe. The MD stated there is a risk that a (resident) could move their body against the rail, but the risk is greater for injury from a fall from coughing reflex. The MD stated it was reasonable that residents would benefit from SRs. The MD stated risk should always be assessed in medicine and treatments, but for the majority the benefit outweighs the risk. The MD stated he did not get consent for SRs usage. During an interview and record review on 4/2/2023 at 3:45 p.m., the Chief Nursing Officer (CNO) reviewed the hospital wide policy for restraint management. The CNO stated if a (resident) had an order for two SRs and four were up and the resident had mobility, then four SRs up would be a restraint. o. A review of Resident 7's admission Record indicated the facility admitted the resident on 11/16/2016 with diagnoses including chronic hypoxemic respiratory failure and dependence on a ventilator. A review of Resident 7's MDS, dated [DATE], indicated the resident was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS further indicated the resident did not use bed SRs up as physical restraint. A review of the Physician's Order, dated 11/16/2022, indicated two SRs up for torso cough reflex. A review of Resident 7's POC initiated on 1/5/2023, for the resident's risk for injury or falls related to torso reflex from spontaneous coughing due to tracheostomy, included in the interventions applying two SRs up when in bed as ordered. During a concurrent observation and interview on 4/1/2023 at 7:10 a.m., CNA 3 at Resident 7's bedside stated all four SRs were up. During an interview and Resident 7's record review on 4/1/2023 at 5 p.m., RN 1 reviewed the physician's orders, care plans, informed consents, IDT notes, and assessments. RN 1 stated there was no documented evidence of informed consent for the use of the SRs, initial assessment for SRs use, or care plan for restraints. p. A review of Resident 9's admission Record indicated the facility admitted the resident on 7/14/2020 with diagnoses including acute respiratory failure and dependence on a ventilator. A review of Resident 9's MDS, dated [DATE], indicated the resident was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS further indicated the resident did not use SRs up as physical restraint. A review of the Physician's Order for Resident 9, dated 7/14/2020, indicated two SRs up for torso cough reflex. A review of Resident 9's POC initiated on 1/5/2023, for the resident's risk for injury or falls related to torso reflex from spontaneous coughing due to tracheostomy, included in the interventions applying two SRs as ordered. During a concurrent observation and interview on 4/1/2023 at 7:10 a.m., CNA 3 at Resident 9's bedside stated all four SRs were up. During an interview and Resident 9's record review on 4/1/2023 at 5 p.m., RN 1 stated there was no documented evidence of informed consent for SRs, initial assessment for SR use, or care plan for restraints. q. A review of Resident 15's admission Record indicated the facility admitted the resident on 12/18/2019 with diagnoses including respiratory failure. A review of Resident 15's MDS, dated [DATE], indicated the resident was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS further indicated the resident did not use SRs up as physical restraint. A review of the Physician's Order, dated 12/18/2019, indicated two SRs up for torso cough reflex and seizure disorder. A review of Resident 15's POC initiated on 1/3/2023, for the resident's risk for injury or falls related to torso reflex from spontaneous coughing due to tracheostomy, the interventions included applying SRs up as ordered. During a concurrent observation and interview on 4/1/2023 at 7:10 a.m., CNA 3 at Resident 15's bedside stated all four SRs were up. During an interview and Resident 15's record review on 4/1/2023 at 5 p.m., RN 1 stated there was no documented evidence of informed consent for SRs, initial assessment for SR use, or care plan for restraints. r. A review of Resident 16's admission Record indicated the facility admitted the resident on 9/3/2021 with diagnoses including respiratory failure. A review of Resident 16's MDS, dated [DATE], indicated the resident was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS further indicated the resident did not have SRs as physical restraint. A review of the Physician's Order, dated 3/8/2023, indicated two SRs up for torso cough reflex dated 3/8/2023. A review of Resident 16's POC initiated 1/5/2023, for the resident's risk for injury or falls related to torso reflex from spontaneous coughing due to tracheostomy, included in the intervention applying SRs as ordered. During a concurrent observation and interview on 4/1/2023 at 7:10 a.m., CNA 3 at Resident 16's bedside stated all 4 side rails were up. During an interview and Resident 16's record review on 4/1/2023 at 5 p.m., RN 1 stated there was no documented evidence of informed consent for the use of SRs, initial assessment for SRs use, or care plan for restraints. A review of the facility policy and procedure titled, Restraint/Seclusion Management Protocol, last reviewed 2/6/2023, indicated the purpose of the protocol was the following: to provide guidelines for the provision of a safe environment in which restraints are distinguished from devices not used as restraints and the least restrictive alternative to the use of restraints are pursued in order to reduce and minimize the utilization of restraints; to ensure safe practice and observance of patient's rights when restraints are required; to distinguish between devices and/or techniques used as restraint; and to maximize safety and prevent patient and personnel injury. The use of restraint and seclusion poses an inherent risk to the physical safety and psychological wellbeing of the patient. The use of restraints is a last resort, after alternative less restrictive interventions have been considered and/or attempted. The use of restraints is not based on diagnosis, but rather on a multidisciplinary comprehensive individualized assessment. A physical restraint is any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body. The only acceptable forms of restraint in the sub-acute unit shall be cloth vests, soft ties, soft cloth mittens, seat belts and trays with springs release devices. Postural support means a method used to assist patient to achieve proper body position and balance. Postural supports may only include soft ties, seatbelts, spring released trays or cloth vests and shall only be used to improve a patient's mobility and independent functions, to prevent the patient from falling out of bed or for positioning, rather than to restrict movement. These methods shall not be considered a restraint. The following is, by definition, not considered to be restraint and is specifically excluded from this policy: the use of side rails to assist with safety, unless the use is such that the side rails prevent patient mobility (e.g. all four side rails up), is used to achieve proper body position, balance, alignment, or to allow greater mobility. The use of restraint for the following reasons is strictly prohibited: use as a convenience for staff. h. A review of Resident 4's admission Record indicated the facility re-admitted the resident on 9/10/2019 with diagnoses including hypertension (a condition in which the blood vessels have persistently raised pressure). A review of Resident 4's MDS, dated [DATE], indicated the resident's cognition (ability to think, understand, and reason) was severely impaired. The MDS indicated the resident was totally dependent on staff for locomotion on and off unit, eating and required extensive assistance with bed mobility, transfer, walk in corridor, dressing, toilet use, and personal hygiene. The MDS further indicated the resident did not have SRs up as physical restraint. A review of the Physician's Order for Resident 4, dated 9/10/2019, indicated applying four SRs up padded for safety due to seizure disorder. A review of Resident 4's POC initiated 1/3/2023, for the resident's risk for injury or falls indicated the resident moved a lot on bed, dangled legs over rail, and stood up unassisted when agitated. The POC interventions included applying SRs up when in bed as ordered. During an observation on 3/31/2023 at 6:41 p.m., observed Resident 4 lying in bed with all four SRs up. During a concurrent observation and interview on 4/1/2023 at 7:16 a.m., Certified Nursing Assistant 1 (CNA 1) confirmed Resident 4 was lying in bed with all four SRs up for safety. During an interview on 4/2/2023 at 5:48 p.m., the MDSC stated Resident 4 was able to stand up without assistance and walk with two-person assist. During a concurrent interview and Resident 4's record review on 4/1/2023 at 6:44 p.m., RN 1 reviewed the physician's orders, care plans, informed consents, IDT notes, and assessments. RN 1 confirmed there were no documented evidence of informed consent for the use of SRs, initial assessment for SRs use, or care plan for restraints. i. A review of Resident 14's admission Record indicated the facility admitted the resident on 2/20/2019 with diagnoses including respiratory failure status-post (s/p) tracheostomy and functional quadriplegia (complete immobility due to severe physical disability or frailty). A review of Resident 14's MDS, dated [DATE], indicated the resident's cognition was intact (not affected). Resident 14 was totally dependent on staff for bed mobility, dressing, bathing, eating, toilet use, and personal hygiene. The MDS further indicated the resident did not use SRs up as physical restraint. A review of the Physician's Order for Resident 14, dated 2/20/2019, indicated to apply two SRs up for safety due to torso cough reflex. A review of Resident 14's POC initiated 1/3/2023, for the resident's risk for injury or falls, included in the interventions applying SRs up when in bed as ordered. During an observation on 3/31/2023 at 6 p.m., observed Resident 14 lying with all four SRs raised. During a concurrent observation and interview on 4/1/2023 at 7:20 a.m., CNA 1 stated during her shift she did not lower any of Resident 14's SRs for the resident's safety and to prevent falls. During a concurrent interview and record review on 4/1/2023 at 6:28 p.m., RN 1 reviewed Resident 14's physician's orders, care plans, informed consents, IDT notes, and assessments. RN 1 confirmed there were no documented evidence of informed consent for SRs, initial assessment for SRs up use, or care plan for restraints. j. A review of Resident 2's admission Record indicated the facility admitted the resident on 12/3/2021 with diagnoses including chronic respiratory failure, status post tracheostomy, and hypertension A review of Resident 2's MDS, dated [DATE], indicated the resident had communication deficit and did not have SRs up as physical restraint. A review of Resident 2's Physician's Order, dated 12/3/2021, indicated two SRs up for safety due to torso cough reflex. A review of Resident 2's POC initiated on 1/4/2023, for the resident's risk for injury or falls included in the interventions applying SRs up when in bed as ordered. During an observation on 3/31/2023 at 6:47 p.m., Resident 2 was lying in bed with all four SRs raised. During a concurrent observation and interview on 4/1/2023 at 7:18 a.m., CNA 1 stated all four SRs were raised for Resident 2 due to safety and to prevent from falling. During a concurrent interview and Resident 2's record review on 4/1/2023 at 6:13 p.m., RN 1 reviewed the physician's orders, care plans, informed consents, IDT notes, and assessments. RN 1 confirmed there were no documented evidence of informed consent for the use of SRs, initial assessment for SRs use, or care plan for restraints. k. A review of Resident 11's admission Record indicated the facility admitted the resident on 10/9/2018 with diagnoses including chronic respiratory failure ventilator dependent and dysphagia (difficulty or discomfort in swallowing) with gastrostomy tube (g-tube, a flexible tube inserted through the abdominal wall that directly delivers nutrition to the stomach). A review of Resident 11's MDS, dated [DATE], indicated the resident had communication deficit and was totally dependent with staff on bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS further indicated the resident did not have SRs up as physical restraint. A review of the Physician's Order for Resident 11, dated 1/30/2020, indicated to apply four SRs up for torso cough reflex/seizure disorder. A review of Resident 11's POC initiated on 1/4/2023, for the resident's risk for injury or falls, included in the interventions to apply SRs up when in bed. During an observation on 3/31/2023 at 6:50 p.m., Resident 11 was lying in bed with all four SRs raised. During a concurrent observation and interview on 4/1/2023 at 7:18 a.m., CNA 1 at bedside, stated all four SRs were raised for Resident 11's safety and to prevent from falling. During a concurrent interview and Resident 11's record review on 4/1/2023 at 6:20 p.m., RN 1 reviewed the physician's orders, care plans, informed consents, IDT notes, and assessments. RN 1 confirmed there were no documented evidence of informed consent for the use of SRs up, initial assessment for SRs use, or care plan for restraints. l. A review of Resident 13's admission Record indicated the facility admitted the resident on 9/30/2019 with diagnoses including chronic respiratory failure and tracheostomy status. A review of Resident 13's MDS, dated [DATE], indicated the resident was totally dependent with staff on bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS further indicated the resident did not use SRs up as physical restraint. A review of the Physician' Order for Resident 13, dated 9/30/2019, indicated to apply four SRs up padded for seizure disorder. A review of Resident 13's POC initiated on 1/5/2023, for the resident's risk for injury or falls, included in the interventions to apply SRs up when in bed as ordered. During an observation on 3/31/2023 at 6 p.m., Resident 13 was lying in bed with all four SRs raised. During a concurrent interview and Resident 13's record review on 4/1/2023 at 6:34 p.m., RN 1 reviewed the resident's physician's orders, care plans, informed consents, IDT notes, and assessments. RN 1 confirmed there were no documented evidence of informed consent for the use of SRs up, initial assessment for SRs use, or care plan for restraints. m. A review of the admission Record for Resident 12 indicated the resident was readmitted on [DATE] with diagnoses including non-vent-dependent respiratory failure and grand mal seizure (a type of seizure that involves a loss of consciousness and violent muscle contractions). A review of Resident 12's MDS, dated [DATE], indicated the resident was totally dependent on staff with bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS further indicated the resident did not use SRs up as physical restraint. A review of the Physician's Order for Resident 12, dated 11/29/2017, indicated to apply four padded SRs up for safety due to seizure and torso cough reflex. A review of Resident 12's POC initiated on 1/3/2023, for the resident's risk for injury or falls, included in the interventions to apply SRs up when in bed as ordered. During an observation on 3/31/2023 at 6:08 p.m., observed Resident 12 lying in bed with all four SRs raised. During a concurrent interview and Resident 12's record review on 4/1/2023 at 6:40 p.m., RN 1 reviewed the physician's orders, care plans, informed consents, IDT notes, and assessments. RN 1 confirmed there were no documented evidence of informed consent for [TRUNCATED]