Based on interview and record review, the facility failed to ensure that resident rights were honored for one out of twelve sampled residents (Resident 5) when Resident 5's repeated requests to speak to the dietician on 4/2/25, 5/7/25, and 6/4/25 were not honored. These failures denied Resident 5 of her right to a dignified existence, failed to encourage Resident 5's independence, and prevented Resident 5's dietary preferences from being addressed. Findings: A review of documents titled, RESIDENT COUNCIL [a gathering of residents to discuss and address concerns, share information, and make decisions about their living environment] REPORT dated 4/2/25, 5/7/25, and 6/4/25, indicated Resident 5 repeatedly requested to see the dietician. On the same documents under item PLAN OF ACTION, the following was noted: - On 4/2/25 staff documented, .Request to see Dietician: [Resident 5] . - On 5/7/25 staff documented, Resident 5's request to see the dietician was .referred to Activities Supervisor and nursing . - On 6/4/25 staff documented, .Sent email for Resident 5 to see Dietician .Given to Supervisor . During an interview with Resident 5 on 6/18/25 at 11:27 a.m., Resident 5 stated during the past Resident Council Meetings she had requested to speak with the dietician because her meals were very dry, especially the meats, and she wanted gravy with each meal. Resident 5 specified, she likes her gravy in a separate container for breakfast, lunch, and dinner. Resident 5 stated she was not happy about her food and feels disappointed that no one has spoken with her yet. A review of Observation Details List Report, dated 3/13/25, completed by Registered Dietician (RD) 1, indicated the following records for Resident 5: - Under item, Swallowing Disorder staff documented that Resident 5 was noted to have .coughing or choking during meals or when swallowing medications . - Under item, Oral Problems staff documented that Resident 5 was noted to have .a. chewing problem .b. Swallowing problem . - Under item, Diet staff documented that Resident 5 was noted to have .Gluten [a protein found in the wheat plant and some other grains] Free .Mechanical Soft [easy to chew and swallow] . - Under item Dietary Preference (Cultural, Religious, Likes/Dislikes) staff documented, .No rice it makes [Resident 5] cough/choke. Likes (GF (Gluten Free)) gravy with meat and starches . - Under item, PLAN OF CARE and sub-item Nutrition Diagnosis staff documented that Resident 5 was noted to have .Chewing/swallowing difficulty .inability to tolerate regular texture .need for Mechanical Soft diet/coughing when eating . Also, RD 1 wrote, .Requests brown gravy, which may be difficult to obtain [gluten free] . A review of Observation Details List Report, dated 6/9/25, completed by (RD) 2, showed no follow-up or mention of Resident 5's request for gravy. During a phone interview on 6/19/25, at 8:28 a.m., RD 1 confirmed she had been exploring options to accommodate Resident 5's request for gravy because it was difficult for the kitchen to prepare gravy for just one resident every meal. RD 1 stated she had been working with kitchen staff in finding either a pre-made, packaged, or jarred, gluten free gravy for Resident 5. However, RD 1 admitted that she had not spoken with Resident 5 since documenting the request in March of 2025. RD 1 acknowledged there was a failure to follow up and communicate with Resident 5 after her repeated requests. A review of the Facility's undated Policy titled, RESIDENT RIGHTS indicated, .The resident has a right to a dignified existence .communication with and access to persons and services inside and outside the facility .A facility must care for its residents in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life. (a) Dignity. The Facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. (b) Self-determination and participation. The resident has the right to - (1) choose .health care consistent with his or her assessment .(3) Make choices about aspects of his or her life in the facility that are significant to the resident .

1c. Review of Resident 33's physician's order for lorazepam dated 8/16/24, indicated, .Start date 8/16/24 .End Date .Open Ended .lorazepam .tablet .0.5 mg [mg-a unit of measure] .1 tab .Every 12 hours .PRN . Review of the document did not include an end date for the PRN lorazepam. During a concurrent interview and record review on 6/18/25, at 1:56 p.m., the DON reviewed Resident 33's clinical record and confirmed the order for PRN lorazepam with a start date of 8/16/24. The DON acknowledged the order had no end date. The DON confirmed Resident 33's physician progress notes did not contain a rational or justification for Resident 33's use of the PRN lorazepam. The DON stated the PRN lorazepam should have had a physician progress note that included a justification for the medication's continued use and the lorazepam order should have had a stop date. 1d. Review of Resident 49's physician's order for lorazepam dated 8/21/24, indicated, .Start Date .2/17/2025 .End Date .Open Ended .lorazepam .tablet 0.5 mg .1 tablet .Every 12 Hours .PRN for anxiety . Review of the document noted no end date on the PRN lorazepam prescription order. During a concurrent interview and record review on 6/18/25, at 1:56 p.m., the DON reviewed Resident 49's lorazepam prescription order and confirmed there was no stop date and stated it was open ended. The DON explained a stop date was important due to the medication being a sedative (a medication that can make a person sleepy) and would want to make sure there was not an overuse of the medication. The DON stated the risk involved if the medication was not monitored was the resident becoming a fall risk and medication dependance since some psychotropics were addictive. The DON agreed all psychotropic medications should have an end date and stated this was important for lorazepam. Through review of Resident 49's physician progress notes for the months of 5/2025 and 6/2025, the DON confirmed there was no rational or justification given for the continued use of lorazepam for Resident 49. 1e. Review of Resident 54's Medication Administration History, dated 6/2025, indicated, .lorazepam .tablet 0.5 mg .1 tablet .Every 6 Hours PRN .Special instructions .*May give 1 tablet 0.5 mg 1 hour prior to shower days (Monday and Thursday PM [night] shift) Diagnosis [area blank] .Start/End Date .5/27/25-Open Ended . During a concurrent interview and record review on 6/18/25, at 1:56 p.m., the DON reviewed Resident 54's medical record and confirmed the order for PRN lorazepam had no stop date and lacked rational or justification in the physician progress notes for the continued use of lorazepam for Resident 54. During an interview on 6/18/25, at 3:36 p.m., the ADM acknowledged the facility was currently not following regulation for PRN psychotropic medications. The ADM stated her expectation was for the facility to follow the regulation to protect residents from chemical restraints (the use of medication to control or restrict a person's behavior). The ADM stated her understanding was for PRN psychotropic medications to be stopped after 14 days or require a justification be documented in the resident's medical record of why the medication would continue. The ADM explained this justification would be from the physician and should be written in the physician's progress note. During a phone interview on 6/27/25, at 12:01 p.m. with the Medical Director (MD), the MD stated he was aware of the limitations of ordering PRN psychotropics and it was his understanding they can be written for up to 14 days unless otherwise indicated. The MD explained he can order PRN psychotropics for up to six months if the residents' behavior warrants. Through review of Resident 33, Resident 34, Resident 43, Resident 49, and Resident 54's PRN lorazepam medication orders, the MD acknowledged the lorazepam medication orders were open ended and without a stop date. The MD stated that when he initially orders PRN psychotropics he will have an automatic stop date for 14 days. The MD further explained that the nurse will send him a message to continue the PRN psychotropic medication, and he will approve continuing the medication for up to six months due to chronic symptoms of some nature that he anticipates will continue for the resident for the next six months. The MD stated the nurse will write the extension of the phone order for the PRN psychotropic and then he would sign off on the order later. The MD acknowledged he does not write or document a rationale or justification of the continued use of the PRN psychotropic in a progress note. The MD stated he felt like as long as the nurse documents the PRN psychotropic order extension in the medical record of the resident and he signs off on the extension, this would suffice. The MD stated he was not aware that this process was a problem. Review of a facility Policy and Procedure (P&P) titled, FACILITY POLICY: RESTRAINTS:POLICY ON PHYSICAL AND CHEMICAL RESTRAINTS AND DEVICES, revised 6/28/24, indicated, .A chemical restraint is a drug used to control behavior and used in a manner not required to treat the resident's symptoms .Compliance .Each resident shall receive, and the facility shall provide, the necessary care and services to attain and maintain the highest practicable physical, mental, and psychosocial well being . Review of facility P&P titled, FACILITY POLICY: MEDICAL DIRECTOR, RESPONSIBILITES, OF, revised 5/18/22, indicated, .The .Medical Director .is responsible for overseeing the implementation of resident care policies and the coordination of medical care in the facility to ensure to the extent possible that care is adequate and appropriate steps are taken to correct identified problems .Medical care direction and coordination of patient/resident care provided in the facility .Supervision and evaluation of patient/resident care programs ensuring compliance with policies and procedures .Consultation with the Administrative Director .and Inter Department Team in the development of patient/resident care policies and to assure that such policies are implemented and followed .Participate in surveys and inspections with responsibility for follow-up and remedial action, if needed .Intervene and report incidents of inadequate/inappropriate care or practice . 1b. Review of Resident 43's physician order for PRN lorazepam indicated, .Start Date .6/12/25 .lorazepam tablet .0.5mg .amt [amount] .0.25mg .Once a Day .PRN .End Date .open ended . During an interview with the Administrative Director of Post Acute Services (ADM) on 6/18/25 at 3:36 p.m., the ADM acknowledged the facility was currently not following regulation for PRN psychotropic medications. The ADM further stated her expectation was for there to be a stop date after 14 days of PRN use or a physician's justification or rationale documented in the resident's medical record for continued use. Based on interview and record review, the facility failed to ensure safe use and monitoring of psychotropic medication (mind altering drugs) for 5 out of 5 sampled residents (Resident 33, Resident 34, Resident 43, Resident 49 and Resident 54) reviewed for unnecessary medication when Resident 33, Resident 34, Resident 43, Resident 49 and Resident 54's physician orders for PRN (as needed) lorazepam (a psychotropic medication used to treat anxiety) was ordered without a stop date. In addition, Resident 33, Resident 34, Resident 43, Resident 49, and Resident 54's medical record showed no evidence of documented clinical justification or a rationale for the continued use of PRN lorazepam by the physician. These failures placed Resident 33, Resident 34, Resident 43, Resident 49 and Resident 54 at risk for adverse effects of unsafe medication use and monitoring including drowsiness, falls, or other injuries. Findings: 1a. Review of Resident 34's medical record titled, Medications Administration Record [MAR], for the months of May 2025 and June 2025 indicated, .lorazepam 0.5 mg (milligram: unit of measurement) .Amount to Administer 0.25 mg .Twice a day .Q 8 hrs (every 8 hours) PRN , Max of 2 doses in 24 hours .Start/End Date .5/13/2025 - Open Ended . During a concurrent interview and record review with the DON (Director of Nursing) on 6/18/25, at 12:48 PM, the DON acknowledged there was no stop date for Resident 34's PRN Lorazepam order and confirmed there was no documented rational or justification in the physician progress notes for the continued use of PRN lorazepam for Resident 34.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure foods were stored and prepared in accordance with professional standards for food service for 57 residents who ate facility prepared meals when: 1. A one-gallon plastic container of [NAME] wine (a type of wine used for cooking) had a sticker which indicated the product was past the used by date (the last day for food to be consumed or eaten); 2. Four 16 ounce plastic containers of Tahini paste (a smooth, savory condiment made from ground, hulled sesame seeds) lacked dates that indicated a recieved date (a date a food item was received in a facility), a manufacturer's expiration date (the date when the maker of a product indicates it was no longer expected to be at its optimal quality or may become unsafe to eat), the date the product was opened, or a use by date; and 3. Seven kitchen cutting boards contained deep grooves and had visible stains. These failures had the potential to put residents who received food from the kitchen at risk for foodborne illnesses (an illness resulting from eating contaminated food or beverages) and unintended weight loss. Findings: 1. During a concurrent observation and interview on 6/16/25 at 9:15 a.m. with the Director of Nutrition Services (DNS) during the initial kitchen tour, a one-gallon plastic container of [NAME] wine was on a shelf in the dry storage room, had been opened, and attached to the container was a sticker that indicated a use by date of 5/13/25. The DNS confirmed the observation and stated it was not acceptable to store food items past their used by date. The DNS stated, if food or cooking ingredients were consumed past the used by date, the food may not taste good and could become contaminated. The DNS further stated, if food becomes contaminated, it could cause residents to get sick. During a concurrent observation and interview on 6/18/25 at 2:47 p.m. with the DNS and the Dietary Supervisor Nutrition Services (DSNS) in person, and Registered Dietician (RD) 1 and RD 2 via a video call platform (VCP-online service that allows users to communicate with each other using live video and sound) images of a one-gallon container of [NAME] wine were reviewed. RD 1 affirmed if a container had a use by sticker dated 5/13/25 it was expired. RD 1 stated expired food items could break down into something unappealing, residents would not want to eat it, and it could spoil and become harmful. RD 1 continued, if residents ate spoiled food, it could make them sick, lead to food borne illness, and lead to unintended weight loss. 2. During a concurrent observation and interview on 6/16/25 at 9:15 a.m. with the DNS during the initial kitchen tour, four 16 ounce, white containers of Tahini paste were located on a shelf in the dry storage room. All four containers of Tahini paste lacked manufacturer expiration dates, recieved dates, open dates, or use by dates. The DNS confirmed the observation and stated it was not acceptable to store undated food items which should indicate the timeframe for safe consumption. The DNS stated the purpose of a date recieved label was to know when food items were received at the facility. The DNS continued, if undated food was used it could cause residents to get sick and lead to food borne illness. During a concurrent observation and interview on 6/18/25 at 2:47 p.m. with the DNS and the DSNS in person, and with RD 1 and RD 2 via VCP, images of four Tahini past containers were reviewed. RD 1 verified that undated Tahini paste containers did not meet her expectations of the facility's food labeling requirements. RD 1 stated if residents consumed food which was outside safe consumption parameters, it could lead to resident illness, weight loss, and ultimately resident death. During a review of the facility's Policy & Procedure (P&P) titled, MODEL POLICY: FOOD STORAGE, revision date 10/14/24, the P&P indicated, .General Food Storage Requirements .Food is routinely rotated first in, first out .All stored food must be properly labeled and dated .The use-by date or date marked may not exceed the manufacturer's use-by date .Dry or staple items, including spices, must be used by the manufacturer's use-by date or if that is not available, within one year from the date received . A review of the US Food and Drug Administration (FDA) 2022 Food Code, version dated 1/18/23, indicated, .Section 3-501.17 (A) (B) (C) (D) .required food labeling and dating .the day the original container is opened in the food establishment shall be counted as Day 1 .The date marked shall not exceed a manufacturer's use-by date .mark the date or day of preparation, with a procedure to discard the food on or before the last date or day . 3. During a concurrent observation and interview on 6/16/25 at 9:15 a.m. with the DNS during the initial kitchen tour, green, yellow, red, purple, brown, blue, and white cutting boards, located in a clean storage rack had deep grooves and visible stains. The DNS confirmed the observation and stated the cutting boards looked old. The DNS stated deep grooves in cutting boards could provide a place for bacteria (germs) to grow which could increase the risk for residents to contract food borne illness. During a concurrent observation and interview on 6/18/25 at 2:47 p.m. with the DNS and the DSNS in person, and with RD 1 and RD 2 via VCP, images of the cutting boards were reviewed. RD 1 affirmed cutting boards with deep grooves and stains should be replaced. RD 1 stated, deep grooves in cutting boards could harbor bacteria which could grow and cause cross contamination that could lead to residents contracting food borne illness. RD 1 further stated, when residents get sick, they were at higher risk for weight loss and ultimately death. During a review of the facility's P&P titled, STANDARD POLICY: SANITATION [the process of disinfection and cleaning of an area of an item] OF WORK AREAS AND EQUIPMENT, revision date 11/29/18, the P&P indicated, .All kitchen and food contact areas shall be kept clean and sanitized .All utensils used for eating, drinking and in the preparation and serving of food and drink shall be cleaned and disinfected .Equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas where food may become trapped .Fixed and mobile equipment shall be washed, rinsed, sanitized . A review of the US FDA 2022 Food Code, version 1/18/23, indicated, .Section 4-202.11 .Multiuse FOOD-CONTACT SURFACES shall be .Smooth .Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections .Free of sharp internal angles, corners, and crevices . A review of the US FDA 2022 Food Code, version 1/18/23, indicated, .Section 4-501.12 .Cutting Surfaces .Cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize .As a result, pathogenic microorganisms [germs that could make you sick] transmissible through food may build up or accumulate .These microorganisms may be transferred to foods that are prepared on such surfaces .

Based on interview and record review, the facility failed to use its Quality Assurance Performance Improvement (QAPI- a data driven and proactive approach to improvement used to ensure services are meeting quality standards) program to address PRN (given as needed or requested) psychotropic medication (a drug that affects brain activities associated with mental processes and behavior) use, for a census of 57 residents, when the facility did not collect data (information) or identify corrective measures for PRN psychotropic medication use without a stop date (date indicated on physicians orders for when the use of the medication would end) and/or without a documented rationale for ongoing use of PRN psychotropic medication in the affected residents' medical record. These failures led to ongoing PRN psychotropic medication use without proper documentation and justification in the affected residents' medical record and had the potential to negatively impact the affected residents' psychosocial health and well-being. Findings: During a concurrent interview and record review on 6/19/25 at 1:39 PM, the Director of Nursing (DON) reviewed the previous survey's (assessment of a healthcare facility's compliance with established standards, quality of care, and safety protocols) plan of correction (POC -a document that outlines the steps a facility will take to address and correct deficiencies identified during a survey) dated 5/22/24, for PRN psychotropic medication use. The DON confirmed the POC indicated PRN psychotropic medication use would be added to their QAPI program monitoring and the pharmacist would review the psychotropic medication use monthly, during the QAPI meetings (QAPI meetings are usually held monthly and/or quarterly). The DON further stated the POC indicated, .Reports and corrective action from any findings will be reported at QAPI monthly . The DON confirmed these corrective measures were not added to the QAPI program and were never addressed. The DON further stated the corrective measures were missed due to the QAPI committees focus being on another portion of the POC. The DON explained it was the facility's procedure to add all deficiencies from the previous survey to QAPI, so all items were addressed to prevent the deficiencies from reoccurring. During an interview on 6/23/25, at 10:57 AM, the Administrative Director (ADM) confirmed the facility's process after survey was to add all survey deficiencies to the QAPI program. The ADM further confirmed the PRN psychotropic medication use was not addressed and was not added to the QAPI program as they had indicated they would on their POC. The ADM further stated the risk of not addressing the PRN psychotropic medication use in their QAPI program was that the problem reoccurred this year during the current survey. The ADM further stated PRN psychotropic medication use was important to address for resident rights and safety. A review of the facility's policy and procedure (P&P) titled, FACILITY POLICY: QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT (QAPI), SNF, revised 8/16/23, indicated, . QAPI takes a systematic, interdisciplinary, comprehensive, and data driven approach to maintaining and improving safety and quality in nursing homes .Quality Assurance/QAA committee responsibilities include identifying and responding to quality deficiencies throughout the facility, and oversight of the QAPI program when fully implemented, develop and implement corrective action when necessary .

Based on observation, interview, and record review, the facility failed to implement infection control measures for a census of 57 residents when: 1. The bathroom toilets were dirty in both Resident 27, Resident 54, Resident 14, and Resident 5's shared bathroom; and in Resident 50 and Resident 37's shared bathroom along with the sink; 2. Licensed Nurse (LN) 4 did not store Resident 15's used feeding tube syringe (a medical device that helps deliver liquid nutrients, medications, or fluids directly into a resident's stomach/intestines via an external tube) back in the manufactures packaging or a sealed bag; and, 3. LN 7 did not perform hand hygiene prior to and after entering and exiting resident rooms during a medication pass and/or in between passing medications to Resident 5, Resident 17, Resident 42, Resident 407, and Resident 39. These deficient practices had the potential to result in the transmission and spread of infection among staff and residents of the facility as well as negatively impacting residents' health and well-being. Findings: 1a. During a concurrent observation and interview on 6/16/25, at 10:05 a.m., with LN 5, in the shared bathroom of Resident 37 and Resident 50, LN 5 acknowledged the bathroom toilet and sink was dirty. LN 5 stated the risk to residents of the toilet and sink being dirty would be the spread of infections and was a dignity issue. LN 5 stated the bathroom toilet had a dirty ring in it and should be cleaned daily and deep cleaned once a month. During an interview on 6/16/25, at 10:11 a.m., with the Environmental Services (ES, housekeeper), the ES stated she had cleaned Resident 37 and Resident 50's shared bathroom the day before. b. During a concurrent observation and interview on 6/16/25, at 10:36 a.m., with LN 5, in the shared bathroom of Resident 27, Resident 54, Resident 14, and Resident 5, it was observed that the toilet was dirty. LN 5 stated the ring in the toilet looked moldy. LN 5 stated in her opinion the toilet did not look like it had been cleaned in a while. LN 5 stated it was her understanding the bathrooms and toilets were cleaned daily. LN 5 stated Resident 54 uses the bathroom on occasion. LN 5 stated the expectation would be the bathroom would be a clean area for residents to use as this was important for their dignity and was an infection control issue. During an interview on 6/16/25, at 12:09 p.m., the Director of Environmental Services (DES) stated the expectation was that the resident's bathroom and rooms are cleaned daily and receive a deep clean once a month. The DES stated there should not be a ring around the toilet and a ring would not accumulate within a day. The DES explained dirty bathrooms did not represent the standard. The DES further explained that the hazard of dirty bathrooms was the spread of infection since residents share bathrooms frequently. The DES stated the dirty bathrooms could also affect resident dignity. During an interview on 6/18/25, at 1:56 p.m., the DON stated her expectation was that EVS for all departments provided a clean homelike environment for residents. The DON explained the Residents dirty bathrooms was not reflective of that expectation. Review of facility policy and procedure (P&P) titled, FACILITY POLICY: All PATIENT ROOM AND BATHROOM CLEANING, revised 4/25/24, indicated, .To ensure the complete and systematic daily cleaning and disinfection of each occupied patient room .Toilet: Wipe and disinfect in the following order .Toilet handle .Toilet seat .Under the bowel .Toilet rim .Clean inside of bowl with disinfectant cleaner and toilet brush . 2. During an observation on 6/16/25, at 11:26 a.m., LN 4 was observed performing Resident 15's tube feeding. At the conclusion of the feeding, LN 4 was observed washing the used syringe in Resident 15's shared bathroom sink. LN 4 then placed the syringe in an open bin, along with other feeding supplies including containers of formula, on Resident 15's side table. It was observed the syringe was not placed back into the dated syringe package from which it was originally removed. During an interview on 6/16/25, at 11:40 a.m., with LN 4 in the hallway, LN 4 acknowledged she left Resident 15's used syringe out and exposed to air, in the open bin, on the side table. LN 4 stated the syringe should have gone back into the plastic sleeve when she was finished rinsing it. LN 4 stated the syringe should be stored in the sleeve for infection control purposes. During an interview on 6/16/25, at 4:08 p.m., LN 6 stated the syringe used during the administration of a tube feeding was changed out every 24 hours and the new sleeve it came in was to be dated. LN 6 explained after use, the syringe should be cleaned and placed back in the sleeve to keep it clean. LN 6 further explained this was done for infection prevention and cleanliness and for the prevention of bacterial (germs) growth. During an interview on 6/18/25, at 1:56 p.m., the DON stated her expectation for residents with feeding tubes would be the LN was to follow the tube feeding policy. The DON stated a syringe used for administering a feeding should be placed back in the sleeve or placed in a zip lock bag. The DON explained this protects the syringe from air while awaiting reuse. The DON stated the risk of the syringe being improperly stored was introducing more bacteria and germs to the resident during the administration of the tube feedings. Review of facility P&P titled, FACILITY POLICY: ENTERAL TUBE FEEDING, revised 8/14/24, indicated, .Procedure .Follow good infection control practice . 3. During an observation on 6/16/25, at 11:45 a.m., LN 7 was observed in unit 6 (where residents are housed), performing a medication pass for Resident 39. LN 7 was observed not performing hand hygiene in the preparation of Resident 39's medication. LN 7 was observed not performing hand hygiene prior to entering and upon exiting Resident 39's room. During an observation on 6/16/25, at 11:47 a.m., LN 7 was observed in unit 6, performing a medication pass for Resident 5. It was observed LN 7 did not perform hand hygiene in the preparation of Resident 5's medication. It was observed LN 7 did not perform hand hygiene prior to entering and upon exiting Resident 5's room. During an observation on 6/16/25, at 11:59 a.m., LN 7 was observed in unit 6, performing a medication pass for Resident 406. It was observed LN 7 did not perform hand hygiene in the preparation of Resident 406's medication. It was observed LN 7 did not perform hand hygiene prior to entering and upon exiting Resident 406's room. During an observation on 6/16/25, at 12:50 p.m., LN 7 was observed in unit 6, performing a medication pass for Resident 17. It was observed LN 7 did not perform hand hygiene in the preparation of Resident 17's medication. It was observed LN 7 entered the Activity Room and performed Resident 17's medication administration. It was observed LN 7 did not perform hand hygiene prior to Resident 17's medication administration. LN 7 was observed performing hand hygiene in the sink in the Activity Room after Resident 17's medication administration. During an observation on 6/16/25, at 12:56 p.m., LN 7 was observed in unit 6, performing a medication pass for Resident 42. It was observed LN 7 entered the Activity Room and performed Resident 42's medication administration. After Resident 42's medication administration, LN 7 was not observed performing hand hygiene upon entering or exiting the Activity Room. During an interview on 6/16/25, at 2:05 p.m., LN 7 acknowledged during the medication passes she performed for Resident 5, Resident 39, Resident 406, Resident 17, and Resident 42, she did not perform hand hygiene prior to or after administering medications to the residents. LN 7 acknowledged hand hygiene was not performed including the use of hand sanitizer and/or washing hands in a sink prior to entering or exiting the resident's rooms. LN 7 explained she does not like the hand sanitizer and preferred to wash her hands in the sink. LN 7 confirmed she had only washed her hands in the sink once during her medication administration for five residents. LN 7 stated she should be performing hand hygiene prior to and after administering medications and upon entering and exiting resident rooms. LN 7 explained hand hygiene was performed to prevent cross-contamination from one resident to the other and for infection control purposes. During an interview on 6/18/25, at 1:56 p.m., the DON stated her expectation regarding LN's administering medications was the LNs should gel (hand sanitizer) upon entering and exiting rooms or wash their hands prior to and after administering medications. The DON stated the risk if hand hygiene was not performed would be the spread of unwanted germs and bacteria. During a concurrent interview on 6/19/25, at 11:27 a.m., with Infection Prevtionist (IP) 1 and IP 2, IP 1 stated her expectation was for the LN to perform hand hygiene prior to and after medication passes for each individual resident. IP 1 explained for hand hygiene the LN could use hand sanitizer or wash their hands in the sink and the goal was to prevent infection and/or the spread of infection. Review of a facility P&P titled, FACILITY POLICY: MEDICATION ADMINISTRATION RECORD (MAR), revised 5/14/25, indicated .Use Aseptic [germ free] non-touch medication administration to prevent infection .Perform proper hand hygiene . Review of a facility P&P titled, FACILITY POLICY: HANDWASHING / HAND HYGIENE, revised 11/30/23, indicated, .Effective handwashing/hand hygiene is performed by all personnel to prevent the spread of infection .Handwashing .Washing the hands with plain (i.e., non-antimicrobial) soap and water .Hand Hygiene .All personnel are instructed about proper hand hygiene techniques during orientation with demonstration and return demonstration. These techniques are reviewed annually .Decontaminate hands with alcohol based hand rub .After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide radiology services (a branch of medicine that uses imaging technology to diagnose and treat disease) for one resident (Resident 1) in a sample of five residents when the Medical Doctor (MD) ordered an x-ray (a photographic or digital image of the internal composition of a part of the body) three days after a known injury and the x-ray was not done until five days after the injury. These failures put Resident 1 at risk for increased pain and delayed the identification of a left finger fracture (a partial or complete break in a bone) that could lead to loss of normal finger use. Findings: During a concurrent interview and record review with the Practice Administrator (PA) of Resident 1's electronic medical record on 5/20/25, at 12:49 p.m., the PA stated Resident 1 sustained an injury to his left hand and fourth finger on 11/8/25, orders for ice and splint (device used to support and protect a body part, often one with a fracture or injury) were obtained, but no x-ray order was received until 11/11/24. The PA confirmed Resident 1 did not have an x-ray of the injured hand and fingers until 11/13/25 which was five days after the injury occurred. During an interview on 5/20/25 at 1:35 p.m. with the Interim Director of Nursing (IDON), the IDON stated, Resident 1 was taken to the hospital on [DATE] as an outpatient (medical services, treatments, and diagnostic tests that are provided to patients who do not require hospitalization) via facility transport, the hospital's radiology department did not accept the x-ray order as it was not written by the MD, and Resident 1 was brought back to the facility. The IDON further stated, on 11/13/24 at 6:15 p.m. she was made aware Resident 1 had not gotten the x-ray of the injured finger and hand, contacted the MD, and obtained a new order to send Resident 1 to the ED (emergency department) via ambulance for the x-ray. The IDON confirmed, her expectations were not met when Resident 1 had to wait five days for an x-ray of his left hand and fingers as Resident 1 was experiencing pain and swelling. The IDON explained, she did not know why obtaining the x-ray took so long, it should have been done earlier, and the situation did not meet her expectations for care. During an interview on 5/20/25 at 4:40 p.m. with the Administrative Director (ADMIN), the ADMIN stated Resident 1 not having an x-ray done for five days after an injury when a fracture was suspected, did not meet her expectations. During an interview on 5/20/25 at 5:50 p.m. with the Director of Nursing (DON), the DON stated, the incident with Resident 1 did not meet her expectations. The DON stated the risk of harm to Resident 1 was the injury could get worse or result in a contracture (permanent tightening of muscles, tendons, skin, and nearby tissues that could cause a joint to shorten and become very stiff, preventing normal movement). During a telephone interview on 5/22/25 at 3:06 p.m. the MD stated he did not think the injury was too serious, did not merit an ambulance ride to the hospital for an x-ray, and the order should not have been too difficult to carry out. The MD further stated, his thought was to have the x-ray done after the weekend, as there was not a transport driver on weekends. The MD continued, sometimes there were delays when radiology orders were placed, and if the x-ray took a couple of days to obtain, he was not worried about it. The MD stated, he would expect a charge nurse or other Licensed Nurse (LN) to notify him if an order was not carried out. The MD confirmed he was notified on 11/13/24 the x-ray had not been done and gave another order to send Resident 1 to the ED for an x-ray as they should not wait any longer. Review of a facility document titled, Resident Progress Notes: [Resident 1], dated 11/08/24 at 8:50 p.m., e-Signed by Licensed Nurse (LN) 1, LN 1 indicated, .bruise on top of left knuckle and swollen/painful left ring finger noted after assessment .MD with new order for an Xray of the affected finger to r/o [rule out] fracture .4th left finger immobilized [to prevent something from being moved freely] at this time . Review of a facility document titled, Resident Progress Notes: [Resident 1], dated 11/09/24 at 7:14 a.m., e-Signed by LN 2 indicated, .did c/o [complain of] pain on his left ring finger 5/10 pain scale [0=no pain 10=worst pain] at 0002 [12:02 a.m.] .per resident statement ' it's tight it feels it's going to burst, give me a scissor, give me ice pack' .resident was given PRN [as needed] Tylenol & applied ice pack on top left knuckle/left ring finger .Md [MD] was also notified regarding resident's request for the ice pack to left knuckle/left ring finger prn pain/swelling, order received to apply ice pack to left knuckle /left ring finger prn pain/swelling x 20 minutes . Review of a facility document titled, Resident Progress Notes: [Resident 1], dated 11/10/24 at 8:27 p.m., e-Signed by LN 1 indicated, .Tylenol given for left hand pain with good relief, CMS [circulation, motion, sensation] WNL [within normal limits], Immobilizer removed and reapplied, able to move fingers but remained swollen and discolored/bruised . Review of a facility document titled, Resident Progress Notes: [Resident 1], dated 11/11/24 at 2:47 p.m., e-Signed by LN 4 indicated, .Left hand/ involved fingers are immobilized, hand is swollen and bruised, wrap adjusted, arm/ hand elevated on the pillow and ice pack was applied for 20 min .Pt was also given Tylenol in the morning for pain . Review of a facility document titled, Resident Progress Notes: [Resident 1], dated 11/12/24 at 3:00 p.m., e-Signed by LN 4 indicated, .Left hand remain[s] swollen and severely bruised .points to middle and ring finger as being painful .MD is aware, RN [Registered Nurse] requested [MD] to place X-Ray order in the computer so patient can be taken to the hospital and have Xray done . Review of a facility document titled, Resident Progress Notes: [Resident 1], dated 11/13/24 at 1:49 p.m., e-Signed by LN 4 indicated, .Resident noted with swelling/bruising to left hand and fingers, able to move and feel fingers on bilateral [both] hands, denies pain or numbness to right hand, states left hand hurts .Attempt to have xray done today was unsuccessful, spoke with radiology admitting, order not in computer, spoke with person in [MD] office made aware of [MD] need to put in computer order .Spoke with transport unable to obtain xray, there was an order but it was not signed by the doctor . Review of a facility document titled, Resident Progress Notes: [Resident 1], dated 11/13/24 at 5:05 p.m., e-Signed by the IDON, indicated, .[I]DON reached out to MD to get the order signed for the resident to have his hand xray tomorrow .Waiting for response[.] .MD responded that he entered the order when he was called from the outpatient radiology .However there seems to be a different approach for the technician [a specialist in the technical details of an occupation] to read the order .Per Md [MD] we are to make sure that they are looking at the order before the resident is going to the radiology department MD followed up with this nurse and stated to send the resident now with a non-emergent ambulance transport for the hand x ray . Review of a facility document titled, Resident Progress Notes: [Resident 1], dated 11/13/24 at 8:49 p.m., e-Signed by LN 1 indicated, .1815 Resident sent to AHS-ER [Adventist Hospital-Emergency Room] for left hand Xray .back from ER at 2000pm [8:00 p.m.] via ambulance with left 4th finger splint r/t [related to] Fracture .with order to keep splint applied in place until finger pain and swelling subsides . During a review of Resident 1's ED Physician Notes Final Report, dated 11/13/24, indicated, .History of Present Illness .presents with concern for swollen left hand and fingers .reportedly punched a wall 5 days ago, and has been demonstrating swelling and bruising of the left hand and fingers .Musculoskeletal [having to do with the body's muscles, bones, tendons, ligaments, and joints] .Edema [swelling caused by too much fluid trapped in the body's tissues] left dorsal [the back or upper surface of a body part] hand with edema and ecchymotic [a medical term for a bruise] changes in the fingers, most pronounced in the left ring and long fingers .Medical Decision Making .Hand x-ray demonstrating proximal phalanx [the bone closest to the hand] fracture of the fourth digit, without other obvious fractures . A review of a facility document titled, General Order, Received Date 11/8/24, indicated, .Received by: [LN 1] .Start Date: 11/8/24 .End Date: 11/11/24 .Order Description: XRAY OF LEFT 4THFINGER R/O [rule out] FRACTURE .Frequency: One time .07:00 [7:00 a.m.] - 15:00 [3:00 p.m.] .Order Source: Telephone .Verified by: [LN 1] .Verify Date: 11/8/24 .Signed By: [MD] .Signed Date: 11/19/24 . A review of the facility's policy and procedure titled, Status Changes, Revision Official Date 5/24/23, indicated, .If the physician phones back with orders follow phone order procedure . Based on interview and record review, the facility failed to provide radiology services (a branch of medicine that uses imaging technology to diagnose and treat disease) for one resident (Resident 1) in a sample of five residents when the Medical Doctor (MD) ordered an x-ray (a photographic or digital image of the internal composition of a part of the body) three days after a known injury and the x-ray was not done until five days after the injury. These failures put Resident 1 at risk for increased pain and delayed the identification of a left finger fracture (a partial or complete break in a bone) that could lead to loss of normal finger use. Findings: During a concurrent interview and record review with the Practice Administrator (PA) of Resident 1 ' s electronic medical record on 5/20/25, at 12:49 p.m., the PA stated Resident 1 sustained an injury to his left hand and fourth finger on 11/8/25, orders for ice and splint (device used to support and protect a body part, often one with a fracture or injury) were obtained, but no x-ray order was received until 11/11/24. The PA confirmed Resident 1 did not have an x-ray of the injured hand and fingers until 11/13/25 which was five days after the injury occurred. During an interview on 5/20/25 at 1:35 p.m. with the Interim Director of Nursing (IDON), the IDON stated, Resident 1 was taken to the hospital on [DATE] as an outpatient (medical services, treatments, and diagnostic tests that are provided to patients who do not require hospitalization) via facility transport, the hospital ' s radiology department did not accept the x-ray order the way it was written by the MD, and Resident 1 was brought back to the facility. The IDON further stated, on 11/13/24 at 6:15 p.m. she was made aware Resident 1 had not gotten the x-ray of the injured finger and hand, contacted the MD, and obtained a new order to send Resident 1 to the ED (emergency department) via ambulance for the x-ray. The IDON confirmed, her expectations were not met when Resident 1 had to wait five days for an x-ray of his left hand and fingers as Resident 1 was experiencing pain and swelling. The IDON explained, she did not know why obtaining the x-ray took so long, it should have been done earlier, and the situation did not meet her expectations for care. During an interview on 5/20/25 at 4:40 p.m. with the Administrative Director (ADMIN), the ADMIN stated Resident 1 not having an x-ray done for five days after an injury when a fracture was suspected, did not meet her expectations. During an interview on 5/20/25 at 5:50 p.m. with the Director of Nursing (DON), the DON stated, the incident with Resident 1 did not meet her expectations. The DON stated the risk of harm to Resident 1 was the injury could get worse or result in a contracture (permanent tightening of muscles, tendons, skin, and nearby tissues that could cause a joint to shorten and become very stiff, preventing normal movement). During a telephone interview on 5/22/25 at 3:06 p.m. the MD stated he did not think the injury was too serious, did not merit an ambulance ride to the hospital for an x-ray, and the order should not have been too difficult to carry out. The MD further stated, his thought was to have the x-ray done after the weekend, as there was not a transport driver on weekends. The MD continued, sometimes there were delays when radiology orders were placed, and if the x-ray took a couple of days to obtain, he was not worried about it. The MD stated, he would expect a charge nurse or other Licensed Nurse (LN) to notify him if an order was not carried out. The MD confirmed he was notified on 11/13/24 the x-ray had not been done and gave another order to send Resident 1 to the ED for an x-ray as they should not wait any longer. Review of a facility document titled, Resident Progress Notes: [Resident 1], dated 11/08/24 at 8:50 p.m., e-Signed by Licensed Nurse (LN) 1, LN 1 indicated, .bruise on top of left knuckle and swollen/painful left ring finger noted after assessment .MD with new order for an Xray of the affected finger to r/o [rule out] fracture .4th left finger immobilized [to prevent something from being moved freely] at this time . Review of a facility document titled, Resident Progress Notes: [Resident 1], dated 11/09/24 at 7:14 a.m., e-Signed by LN 2 indicated, .did c/o [complain of] pain on his left ring finger 5/10 pain scale [0=no pain 10=worst pain] at 0002 [12:02 a.m.] .per resident statement ' it's tight it feels it's going to burst, give me a scissor, give me ice pack ' .resident was given PRN [as needed] Tylenol & applied ice pack on top left knuckle/left ring finger .Md [MD] was also notified regarding resident's request for the ice pack to left knuckle/left ring finger prn pain/swelling, order received to apply ice pack to left knuckle /left ring finger prn pain/swelling x 20 minutes . Review of a facility document titled, Resident Progress Notes: [Resident 1], dated 11/10/24 at 8:27 p.m., e-Signed by LN 1 indicated, .Tylenol given for left hand pain with good relief, CMS [circulation, motion, sensation] WNL [within normal limits], Immobilizer removed and reapplied, able to move fingers but remained swollen and discolored/bruised . Review of a facility document titled, Resident Progress Notes: [Resident 1], dated 11/11/24 at 2:47 p.m., e-Signed by LN 4 indicated, .Left hand/ involved fingers are immobilized, hand is swollen and bruised, wrap adjusted, arm/ hand elevated on the pillow and ice pack was applied for 20 min .Pt was also given Tylenol in the morning for pain . Review of a facility document titled, Resident Progress Notes: [Resident 1], dated 11/12/24 at 3:00 p.m., e-Signed by LN 4 indicated, .Left hand remain[s] swollen and severely bruised .points to middle and ring finger as being painful .MD is aware, RN [Registered Nurse] requested [MD] to place X-Ray order in the computer so patient can be taken to the hospital and have Xray done . Review of a facility document titled, Resident Progress Notes: [Resident 1], dated 11/13/24 at 1:49 p.m., e-Signed by LN 4 indicated, .Resident noted with swelling/bruising to left hand and fingers, able to move and feel fingers on bilateral [both] hands, denies pain or numbness to right hand, states left hand hurts .Attempt to have xray done today was unsuccessful, spoke with radiology admitting, order not in computer, spoke with person in [MD] office made aware of [MD] need to put in computer order .Spoke with transport unable to obtain xray, there was an order but it was not signed by the doctor . Review of a facility document titled, Resident Progress Notes: [Resident 1], dated 11/13/24 at 5:05 p.m., e-Signed by the IDON, indicated, .[I]DON reached out to MD to get the order signed for the resident to have his hand xray tomorrow .Waiting for response[.] .MD responded that he entered the order when he was called from the outpatient radiology .However there seems to be a different approach for the technician [a specialist in the technical details of an occupation] to read the order .Per Md [MD] we are to make sure that they are looking at the order before the resident is going to the radiology department MD followed up with this nurse and stated to send the resident now with a non-emergent ambulance transport for the hand x ray . Review of a facility document titled, Resident Progress Notes: [Resident 1], dated 11/13/24 at 8:49 p.m., e-Signed by LN 1 indicated, .1815 Resident sent to AHS-ER [Adventist Hospital-Emergency Room] for left hand Xray .back from ER at 2000pm [8:00 p.m.] via ambulance with left 4th finger splint r/t [related to] Fracture .with order to keep splint applied in place until finger pain and swelling subsides . During a review of Resident 1 ' s ED Physician Notes Final Report, dated 11/13/24, indicated, .History of Present Illness .presents with concern for swollen left hand and fingers .reportedly punched a wall 5 days ago, and has been demonstrating swelling and bruising of the left hand and fingers .Musculoskeletal [having to do with the body ' s muscles, bones, tendons, ligaments, and joints] .Edema [swelling caused by too much fluid trapped in the body's tissues] left dorsal [the back or upper surface of a body part] hand with edema and ecchymotic [a medical term for a bruise] changes in the fingers, most pronounced in the left ring and long fingers .Medical Decision Making .Hand x-ray demonstrating proximal phalanx [the bone closest to the hand] fracture of the fourth digit, without other obvious fractures . A review of a facility document titled, General Order, Received Date 11/8/24, indicated, .Received by: [LN 1] .Start Date: 11/8/24 .End Date: 11/11/24 .Order Description: XRAY OF LEFT 4THFINGER R/O [rule out] FRACTURE .Frequency: One time .07:00 [7:00 a.m.] - 15:00 [3:00 p.m.] .Order Source: Telephone .Verified by: [LN 1] .Verify Date: 11/8/24 .Signed By: [MD] .Signed Date: 11/19/24 . A review of the facility ' s policy and procedure titled, Status Changes, Revision Official Date 5/24/23, indicated, .If the physician phones back with orders follow phone order procedure .

Based on observation, interview, and record review, the facility failed to ensure residents' right to a dignified existence was honored for 1 of 18 sampled residents (Resident 309), when Resident 309's urinary catheter bag (a drainage bag attached to a catheter (tube) that is inside the bladder to collect urine) was exposed and was not placed in a dignity bag (a bag used to the cover and hold the catheter drainage/collection bag so it is not visible) in the dining room. This failure had the potential of emotional harm for Resident 309. Findings: During an observation on 5/7/24, at 1:14 PM, Resident 309 ate lunch in the dining room. Resident 309's urinary catheter bag was exposed, was not in a dignity bag, and was hanging on a walker. During an interview on 5/7/24, at 1:18 PM, Licensed Nurse (LN) 7 stated residents who ate lunch in the dining room were alert. LN 7 confirmed Resident 309's urinary bag was not in a dignity bag in the dining room. LN 7 stated a resident's urinary bag had to be placed in a dignity bag for privacy. LN 7 further stated, People don't like other people see their bag with urine. During an interview on 5/8/24, at 4:55 PM, the Director of Nursing (DON) stated the importance of keeping a urinary bag covered in a dignity bag was to provide residents' dignity. The DON further stated, People don't like to see urine, we don't carry our urine with us. Review of a facility policy titled, URINARY CATHETERS, revised 5/24/23, indicated, .Catheter maintenance .Cover bag with clean pillow case or other covering for privacy and dignity . Review of facility policy titled, RESIDENT RIGHTS, revised 5/23/23, indicated, .In accordance with the State and Federal Regulations, the facility adopts the list of resident rights (Resident [NAME] of Rights) .It is implied that this list may not be all inclusive and that rights whether on this list or not are respected . Review of a facility document titled, RESIDENT BILL OF RIGHTS, dated 2/2009, indicated, .Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated .Patients shall have the right .To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs .Dignity. The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality .

Based on observation, interview, and record review, the facility failed to provide a home-like environment for two of eighteen sampled residents (Resident 47 and Resident 57), when Resident 47's personal items were displayed on Resident 57's side of the room and Resident 57's items were displayed on Resident 47's side of the room. This failure had the potential to negatively impact Resident 47 and Resident 57's psychosocial well-being. Findings: 1. A review of Resident 47's Resident Face Sheet, indicated, she was admitted to the facility in 2023, with diagnoses which included dementia. A review of Resident 47's care plan dated 5/7/24, indicated, .Problem .memory/recall problem R/T [related to] dementia .avoid change in routine .Provide familiar items in room . A review of Resident 47's care plan dated 5/2/24, indicated, .Psychosocial Well- Being .Actual or Potential Adjustment Impairment .Provide privacy, personal objects. Encourage family to bring items of personal meaning to increase comfort . A review of Resident 47's clinical document titled, RESIDENT INCIDENT REVIEW, dated 5/1/24, indicated, .Trial bed [change] move from B bed to A bed . 2. A review of Resident 57's Resident Face Sheet, indicated, she was admitted to the facility in 2024. A review of Resident 57's care plan dated 3/5/24, indicated, .Problem .memory/recall problem .Provide familiar items in room . A review of Resident 57's care plan dated 4/26/24, indicated, .Psychosocial Well-Being .Actual or Potential Adjustment Impairment .Help [Resident 57] identify areas where they can maintain control .Provide privacy, personal objects . A review of Resident 57's NURSE'S PROGRESS NOTES, dated 5/1/24, indicated, .Pt will move to bed B by the window . During a concurrent observation and interview on 5/6/24, at 9:56 AM, in Resident 47 and Resident 57's room, a poster board above Resident 47's bed indicated, Happy Birthday [Resident 57]. A poster board above Resident 57's bed indicated, Happy Birthday [Resident 47]. Resident 47 stated the row of family photos displayed on the wall beside her bed did not belong to her, they belonged to her roommate. During an interview on 5/6/24, at 12:08 PM, Resident 47 stated she needed to adjust to the situation of her roommate's family pictures displayed around her. Resident 47 further stated, .I am getting tired of it . During an interview on 5/7/24, at 8:55 AM, Resident 57 stated she was not sure why they had moved her and there was no space for her belongings. During a concurrent observation and interview on 5/8/24, at 7:46 AM, Certified Nurse Assistant (CNA) 3 confirmed the items at Resident 47 and Resident 57 bedsides, which included the signs above their beds with their names, did not belong to them. During an interview on 5/8/24, at 7:52 AM, Licensed Nurse (LN) 1 stated Resident 47 and Resident 57 switched beds on 5/2/24. LN 1 further stated it was important for residents to have their own belongings at their bedsides to provide them with familiar objects and make them feel at home. LN 1 stated there was the potential for Resident 47 and/or Resident 57 to be misidentified due to the signs over their beds which could lead to an error in the care they received. During an interview on 5/9/24, at 2 PM, the Director of Nurses (DON) stated it was her expectation that the correct residents' belongings would be at their bedside. The DON further stated there was the potential for Resident 47 and Resident 57 to receive incorrect care if they were misidentified. The DON stated residents' rooms should provide a home-like environment which included having their own personal belongings. A review of a facility policy and procedure titled, ENVIRONMENT OF CARE BUILDING AND SPACE CONSIDERATIONS, dated 3/20/24, indicated, .To provide guidelines for providing a safe, functional, supportive, and effective environment for patients .This is crucial in promoting healing and caring as well as facilitating quality patient care, achieving positive outcomes .Patients have the right to an environment that preserves dignity and contributes to a positive self-image .supports and maintains patient dignity and personhood .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide a copy of written Notice of Transfer or Discharge of a facility-initiated transfer to the appropriate parties for one of one sampled resident (Resident 13), when Resident 13 or Resident 13's representative (RR) and the Long Term Care (LTC) Ombudsman (a patient rights advocate) were not notified in writing of Resident 13's transfer to the emergency room (ER) on 3/11/24. This failure resulted in the State LTC Ombudsman not being informed of the resident's transfer, removed the opportunity for the State LTC Ombudsman to advocate on the resident's behalf, deprived the resident to be informed of resident rights regarding transfer/discharge, and had the potential for Resident 13 being inappropriately discharged . Findings: Review of Resident 13's SNF [Skilled Nursing Facility]/LTC Status Notification record dated 3/11/24, indicated Resident 13 was transferred to the ER on [DATE] for intractable pain (a permanent severe pain condition) of left lower abdomen (stomach) and nausea. Review of Resident 13's nurses progress note dated 3/11/24, indicated, .Asked resident if she want to be send out but refused x [times] 3 attempts until resident feel very severe pain .Sent out to ER . Further review of Resident 13's record failed to show Resident 13 or Resident 13's representative was provided a notice of transfer in writing and that a copy of the notice was provided to the LTC Ombudsman. During an interview on 5/8/24, at 12:33 PM, the admission Coordinator (AC) stated they did not notify the LTC Ombudsman of residents' transfer to the ER when a return was expected. During an interview on 5/8/24, at 1:51 PM, the AC stated a representative of the LTC Ombudsman informed her today that the facility was required to notify them of all discharges and transfers using a specific form. The AC stated they were not notifying the LTC Ombudsman of transfers with an expected return. The AC confirmed as per facility policy they should have notified the LTC Ombudsman of all discharges and transfers. During a concurrent interview and record review on 5/8/24, at 3:10 PM, Medical Records (MR) verified Resident 13 and their RR was not provided a notice of transfer in writing. During a concurrent interview and record review on 5/8/24, at 3:36 PM, MR verified the LTC Ombudsman was not notified of Resident 13's transfer to the ER on [DATE]. During an interview on 5/8/24 at 5:07 PM, the Director of Nursing (DON) stated she did not think residents/RR were given notice of transfers in writing. The DON stated the LTC Ombudsman needed to be notified of all transfers because they were the residents' advocate, resource, and sometimes helped residents with decisions. Review of a facility policy and procedure titled, DISCHARGE AND TRANSFER, revised 11/30/23, indicated, .TRANSFER TO ACUTE OR OTHER HEALTH CARE AGENCY .Inform resident, family or representative of transfer. provide a copy of Transfer Notice to resident, family or representative and one copy filed in the resident's medical record .Complete and fax Discharge/transfer Form to .Ombudsman .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to ensure residents had access to their bilateral hearing aids and failed to assist in locating and/or arranging for audiologist (ear doctor) referral consult services for two of two sampled residents (Resident 311 and Resident 309) when: 1. A Certified Nursing Assistant (CNA) asked Resident 311's wife to take Resident 311's hearing aids home; and, 2. The facility did not assist or refer for follow-up auditory services for Resident 309 to obtain hearing aids. These failures had the potential to impede Resident 311's and Resident 309's maintaining and/or achieving independent functioning, dignity, and well-being due to not being able to hear adequately during a conversation. Findings: 1. Review of Resident 311's Initial Care Plan, dated 2/24/24 [sic], indicated, .Initial information .Hearing .Hearing adequate .Hearing impaired . was marked. Review of Resident 311's undated Resident Belongings Sheet, indicated that Resident 311 had a right and left hearing aid. The document included a handwritten note in the hearing aid section that stated .R/L [right and left] red & blue BRANDNAME [NAME]-WIFE BROUGHT IT HOME 4/24 . During a concurrent interview and observation on 5/7/24, at 1:41 p.m., with Resident 311 it was observed that Resident 311 was sitting in a wheelchair and was leaning forward when his wife was speaking to him. When asked if Resident 309 was hard of hearing Resident 309 stated he was and stated he wears hearing aids in both ears. During an interview on 5/7/24, at 1:41p.m., with Family Member (FM) 2, FM 2 stated that Resident 311 was hard of hearing and wears hearing aids in both ears. FM 2 stated that up until Resident 311 got sick a few weeks ago he wore them every day and that hearing aids helped Resident 311 to hear better. FM 2 stated that when Resident 311 was admitted to the facility staff were aware that Resident 311 wore hearing aids. FM 2 stated that Resident 311 needed to get them adjusted and that she needed help from the facility with that. FM 2 stated that a couple of week ago a staff member told her that Resident 311 did not want to wear his hearing aids and told FM 2 to take them home. FM 2 stated she did take them home and Resident 311 has not worn them since and is not able to hear very well. During an interview on 5/8/24 at 10:14 a.m., CNA 4 stated that Resident 311 was hard of hearing and had hearing aids but that he did not like to wear them. CNA 4 stated that the hearing aids were kept in the top drawer next to his bed. CNA 4 stated that during his first week at the facility, Resident 311 did not like to wear his hearing aids. CNA 4 stated that FM 2 asked her why Resident 311 was not wearing his hearing aids and CNA 4 told FM 4 that Resident 311 did not want to wear them and told FM 2 that she could take them home. During an interview on 5/8/24, at 10:44 a.m., with License Nurse (LN) 8, LN 8 stated she was not aware that Resident 311 had hearing issues or needed hearing aids. LN 8 stated that the CNA was responsible for placing and assisting residents with their hearing aids. LN 8 stated she was not sure if she would send a resident's hearing aids home because families usually wanted the resident to wear them while in the facility. During an interview on 5/09/24, at 12:55 p.m., Resident 311 stated that he would wear his hearing aids if he had them. During an interview on 5/9/24, at 12:55 p.m., with FM 2, FM 2 stated that Resident 311 had hearing aids on the list of belongings when Resident 311 was admitted to the facility. FM 2 stated that when Resident 311 wears his hearing aids he can hear better and was able to communicate more. FM 2 stated she would like Resident 311 to wear his hearing aids. During an interview on 5/9/24 at 1:10 p.m., CNA 4 stated that she did not let a LN know that Resident 311 was not wearing his hearing aids and stated she did not inform a LN that she sent Resident 311's hearing aids home with his wife. 2. Review of Resident 309's admission Assessment Sheet, dated .indicated Resident 309 was hearing impaired. Review of Resident 309's undated Initial Care Plan, indicated that resident was hearing impaired. The Initial Care Plan did not list interventions or goals regarding Resident 309's hearing impairment. During an interview on 5/9/24, at 1:14 p.m., with Licensed Nurse (LN) 8, LN 8 stated that she was aware that Resident 309 was hard of hearing she but did not notify other staff regarding his hearing impairment. During a concurrent interview and observation on 5/7/24, at 9:09 a.m., Resident 309 was observed sitting on a chair next to his bed wearing glasses. Resident 309 stated he was hard of hearing and had previously worn hearing aids. Resident 309 stated he had not had his hearing aids for a while and needed new hearing aids. Resident 309 said his last set were stolen when he was at another facility. During a concurrent interview on 5/8/24, at 10:21 a.m., with Family Member (FM) 1, FM 1 stated Resident 309 had worn hearing aids in both ears and it has been a long time since he had them. FM 1, in regards to Resident 309, stated, he definitely needs hearing aids. FM 1 stated facility staff said they were going to help get Resident 309 with obtaining new hearing aids when Resident 1 was first admitted . During an interview on 5/8/24, at 10:25 a.m., CNA 4 stated that she was not aware of Resident 311 being hard of hearing or wearing hearing aids. During a concurrent interview and observation on 5/9/24, 1:03 p.m., Resident 309 stated the facility had not spoken to him regarding his hearing aids. Resident 309 stated, I cannot hear, and it makes me feel dumb and like an idiot. Resident 309 stated that when he first was admitted to the facility, facility staff stated they would help him get new hearing aids. During an interview on 5/9/24, at 4:21 p.m., with the Director of Nursing (DON), the DON stated that at admission if the facility was aware that a resident was hard of hearing or wore hearing aids than a 48 initial care plan would be created. The DON stated that the care plan would include interventions and goals. The DON stated the care plan would include future follow-up and/or appointments needed to be scheduled for the resident to address the resident's hearing problem. The DON stated that if it was identified that a resident had hearing aids, or it comes to staff's attention that a resident is hard of hearing then staff need to share this information with the charge nurse so it can be addressed and care planned. The DON stated that if a resident had hearing aids and does not want to wear them, the CNA should let the charge nurse (CN) know so it can be addressed. The DON stated it was her expectation that the CNA would not send hearing aids home and the protocol would be for the CNA to bring the issue of the resident not wanting to wear their hearing aids to the attention of the CN so the CN could address the reason the resident does not want to wear their hearing aids. The DON stated that if this was not done it could cause a delay in proper care for the resident. The DON stated that the resident's communication ability, overall socialization, and dignity could be negatively affected and place the resident at risk for injury if they could not adequately hear.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide restorative services (activities to assist residents with maintaining or improving physical function) for one of twenty residents (Resident 310) referred to the RNA program (Restorative Nursing Aide; administers restorative services) when, a recommendation for RNA services was written for Resident 310 on 4/23/24 by the Physical Therapy (PT) Department, but was not relayed to the skilled nursing facility to initiate. This failure resulted in the potential for Resident 310 for not attaining and maintaining their highest possible level of physical and functional well-being. Findings: Review of Resident 310's Resident Face Sheet, indicated Resident 310 was admitted to the facility on [DATE]. Review of Resident 310's Physician Order Report, indicated that Resident 310 had an admitting diagnosis which included but not limited to cerebral infarction due to embolism unspecified (blood supply to the brain is blocked or reduced and prevents brain tissue from getting oxygen and nutrients), and unspecified symptoms and signs involving the musculoskeletal system. The report indicated that on 4/18/24 an order was placed by Medical Director (MD) 1 for Rehabilitation Therapy: Rehab Potential: Fair .PT (Physical Therapy) Referral and Treatment . During an interview on 5/6/24, at 10:09 a.m., Resident 310 stated, I was offered physical therapy but have yet to see it. Resident 310 stated he has been waiting since he arrived at the facility and was supposed to get physical therapy. Resident 310 stated that he was very interested in receiving physical therapy since having a stroke. During an interview and observation on 5/6/24, at 1:42 p.m., Resident 310 stated that he was assessed a week ago but was still waiting for PT and was feeling frustrated. Resident 310 stated that Restorative Nursing Assistant (RNA) 1 told him that they were still waiting for physical therapy documents regarding the treatment plan. During an interview and observation on 5/7/24, at 2:04 p.m., Resident 310 stated that he needs rehabilitation, and he has asked staff repeatedly about it. During an interview on 5/8/24 at 11:08 a.m., with Licensed Nurse (LN) 8, LN 8 stated that she was not sure if Resident 310 had physical therapy orders but had seen Restorative Nursing Assistant (RNA) 1 walking Resident 310. During a concurrent interview and record review on 5/8/24 at 2:50 p.m., with RNA 1, RNA 1 stated no paperwork or recommendations had been received for RNA services for Resident 310. RNA 1 stated she had been trying to work with Resident 310 by walking him and providing stretch exercise's but technically could not add Resident 310 to the RNA program because Resident 310 was not referred for the RNA program yet by PT. RNA 1 reviewed the RNA binder (which contained resident specific PT/OT recommendations, exercises, and daily documentation of RNA completion for all residents receiving RNA services) and confirmed there was no PT referral in the RNA binder for Resident 310. RNA 1 stated a referral would include a form that indicated the type of exercises and repetitions (number of times to complete each exercise) for the resident to do along with instructions for her that included pictures of the exercises for a resident to complete. During a concurrent interview and record review on 5/8/24, at 3:13 p.m., with the Physical Therapist Lead (PTL) on a phone call and with the Administrative Director of Post-Acute Services (AD) who was present in room. The PTL stated that both physical and occupational therapy assessments were completed for Resident 310 and Resident 310 was discharged back to nursing care. The PTL stated the PT recommendation and referral was for the RNA to work with Resident 310. The AD and the PTL confirmed Resident 310's PT assessment and RNA referral was completed on 4/23/24. The AD reviewed the RNA binder and confirmed that there was no referral or documentation for Resident 310 in the RNA binder. The PTL stated that the RNA binder should include PT orders and referrals for Resident 310. The PTL stated she did not know why Resident 310 did not have the PT referral in RNA binder. The PTL was not aware that Resident 310 was not currently working with the RNA. The PTL stated that the PT orders and RNA referral must not have been transmitted by the PT department and she was not aware Resident 310 was not receiving RNA services. The PTL stated it was her understanding that once the referral was made by PT that RNA services would start as soon as possible. The PTL stated that RNA services helped to maintain function and independence for residents. During an interview and record review on 5/8/24, at 3:40 p.m., the AD stated her expectation would be for PT to hand off to the RNA so that the PT could answer questions and provide instructions for exercises required for the resident. Review of Resident 310's Physical Therapy and Initial Evaluation, that was completed on 4/23/24, indicated under assessment, .Recommend referral to RA [restorative aide] to assist with supervised amb [ambulation (walking)] and exercise program to maintain function .Referral .referral to RA to maintain functional mobility and strengthen as able-recommend supervised Review of a facility policy and procedure titled, FACILITY PROCEDURE: FUNCTIONAL MANAGEMENT CARE POLICY, dated 10/1/20, indicated, .[Facility name] Skilled Nursing Units shall provide .restorative care to meet each resident's individual needs as required in each resident's plan of care .residents will receive care that enables them to achieve and/or maintain their highest practicable level of physical independence and provide a continuity of care .Functional Management (FM) primary focus is to attain or maintain the highest practicable physical, mental and psychosocial well being of each resident and shall be directed to prevent deterioration .Therapies, Physical .Performs Therapy Evaluations and Treatments as ordered by physician .Works with Charge Nurse regarding appropriate FM goals and programs individualized for the resident, and trains CNA's [certified nursing assistance] if needed .Serve as educational resources.

Based on interview, observation, and record review, the facility failed to ensure respiratory care was provided in accordance with professional standards of practice for two of two sampled residents (Resident 311 and Resident 48) when: 1. There was no oxygen safety signage posted outside Resident 311's room; and, 2. Oxygen tubing was not labeled and was not changed out within seven days for Resident 48 and Resident 311's oxygen tubing was not labeled. These deficient practices had the potential for Resident 48 and Resident 311 to have complications related to improper treatment while receiving oxygen therapy. Findings: 1. During a review of Resident 311's Physician Order Report, indicated that Resident 311 had an admitting diagnosis which included acute respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body). During an interview and observation on 5/6/24, at 10:05 a.m., Resident 311 was observed in his room sitting in a wheelchair next to his bed and was receiving oxygen at one point five liters per minute (LPM) via nasal canula (a nasal cannula is a device that delivers extra oxygen through a tube inserted into your nostrils). During a concurrent interview and observation on 5/6/24, at 10:56 a.m., with Licensed Nurse (LN) 8, LN 8 stated that Resident 311 was placed on oxygen this last Saturday. LN 8 confirmed that there was no oxygen in use signage posted outside of Resident 311's room. LN 8 stated the risk to the resident could be injury since oxygen was combustible (the process where a substance burns in the presence of oxygen, giving off heat and light in the process). During an interview on 5/9/24, at 4:21 p.m., with the Director of Nursing (DON), the DON stated that if a resident had orders for oxygen, then her expectation would be that an oxygen warning signage would be posted outside the residents' room. The DON stated the risk to not having the oxygen warning signage posted could result in injury and/or explosion. 2a. During a review of Resident 311's Physician Order Report, indicated that Resident 311 had an admitting diagnosis which included but not limited to diastolic (congestive) heart failure (a condition in which your heart's main pumping chamber (left ventricle) becomes stiff and unable to fill properly), and acute respiratory failure with hypoxia. During an interview and observation on 5/6/24, at 10:05 a.m., Resident 311 was observed in his room sitting in a wheelchair next his bed and was receiving oxygen at 1.5 LPM via nasal canula. It was observed the oxygen tubing had no label with a date indicating when it was first applied for Resident 311. During a concurrent interview and observation on 5/6/24, at 10:56 a.m., with LN 8, LN 8 stated that Resident 311 was placed on oxygen this last Saturday (5/4/24) and confirmed that Resident 311's oxygen tubing was not labeled with a date of when it was first applied to Resident 311. LN 8 stated that oxygen tubing was changed once a week on Sunday evenings. LV 8 stated the oxygen tubing should be labeled with the date of when it was first applied for resident use and oxygen tubing was changed once a week for cleanliness and to prevent infection to resident. During a concurrent interview and observation on 5/7/24, at 9:38 a.m., with the Infection Preventionist (IP), the IP was observed writing the tubing date on Resident 311's oxygen tubing. The IP confirmed Resident 311 did not have his tubing labeled with a date of application. The IP stated she likes to write the date directly on the tubing itself and not on the bag the tubing rests in because the bag could be changed and redated and tubing could still be outdated. The IP stated the oxygen tubing was changed every seven days. The IP stated there could be a buildup of bacteria in the tubing when the tubing was not changed out every seven days. 2b. During a review of Resident 48's Physician Order Report, indicated that Resident 48 had an admitting diagnosis which included but not limited to shortness of breath. During an observation on 5/6/24, at 10:31 a.m., Resident 48 was observed sleeping in his bed. Resident 48 was receiving oxygen at 2.5 LPM via nasal canula. It was observed the oxygen tubing was not dated to indicate when it was first used for Resident 48 and the tubing was partially laying on the floor next to the bed. During a concurrent observation and interview on 5/6/24, at 11 a.m., the Lead Charge Nurse (CN) 1 confirmed that Resident 48 was receiving oxygen via a nasal canula, the tubing was on the floor, and the tubing was not dated. CN 1 stated that a date of 4/28/24 was handwritten on the bag containing some of the tubing. CN 1 stated that the tubing was nine days old if she goes off the date written on the bag. CN 1 stated that the oxygen tubing should be changed every seven days and confirmed the tubing was outdated. During an interview on 5/9/24, at 1:08 p.m., with the IP and the Infection Prevention and Quality Director (ID), the IP stated that the tubing should be changed once a week or every seven days to prevent infection. The IP stated that the tubing should be changed immediately if the tubing touches the floor. The IP stated that if the tubing was not changed every seven days or if it touches the floor, then it would place the resident at risk for infection. During an interview on 5/9/24, at 4:21 p.m., with the Director of Nursing (DON), the DON stated that if a resident had orders for oxygen, then her expectation for staff would be that the oxygen orders were followed, and that the oxygen tubing was labeled with the start date of the tubing application. The DON stated that the risk to the resident if the tubing was not labeled would be that it could be used longer then the seven days.The DON stated that if the oxygen tubing was older than seven days the risk to the resident could be infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide Physical Therapy (PT- the treatment of disease, injury, or deformity by physical methods such as message, heat treatment, and exercise) as ordered by the physician for one of three sampled residents (Resident 309) with physical therapy orders when, Medical Director (MD) 1 had ordered PT on 4/26/24 for Resident 309, but the services had not yet been provided by the PT department. This failure resulted in the potential for Resident 309 for not attaining and maintaining their highest possible level of physical and functional well-being. This failure also had the potential to delay necessary treatment and delay necessary assistive services needed for Resident 309. Findings: Review of Resident 309's Resident Face Sheet, indicated Resident 309 was admitted to the facility on [DATE] with diagnosis which included but not limited to history of falling, other sequelae of cerebral infarction (stroke; blood supply to the brain is blocked or reduced and prevents brain tissue from getting oxygen and nutrients), pain in the left hip, and muscle weakness (generalized). During an interview on 5/6/24, at 9:58 a.m., Resident 309 stated that that he had a stroke a few years back and was supposed to be receiving physical therapy. Resident 309 stated that he has not been receiving physical therapy nor had he been seen by a physical therapist. During an interview on 5/8/24, at 10:21 a.m., with Family Member (FM) 1, FM 1 stated that during the admission meeting with the facility, a facility representative stated that Resident 309 was going to be offered physical therapy because Resident 309 had two prior strokes and was dragging his right leg. FM 1 stated that Resident 309 was living with him prior to being admitted to the facility, but that Resident 309 was falling a lot at home, and it was no longer safe for him to live there. Review of Resident 309's Physician Order Report, indicated that on 4/26/24 an order was placed by the MD 1 for Rehabilitation Therapy: Rehab Potential: Fair .PT (Physical Therapy) Referral and Treatment for RNA services [restorative nurse aide; provides rehabilitative care such as walking, exercise, and/or other activities for residents as recommended by the PT department]. During an interview with Licensed Nurse (LN) 8, on 5/8/24 at 11:06 a.m., LN 8 stated that she was aware that Resident 309 needed physical therapy and was told by the RNA that they were waiting for physical therapy to come do their assessment of Resident 309 before RNA services could start. During a concurrent interview and record review on 5/8/24, at 3:13 p.m., with the Physical Therapist Lead (PTL) and the Administrative Director (AD), Resident 309's physician orders were reviewed. The PTL stated that she was the lead in charge of the Physical Therapy Department for the hospital and the skilled nursing facility. The PTL stated she oversaw PT and came to the skilled nursing facility to perform her PT assessments when ordered by the doctor. The PTL stated that when there was a new admission, she received an email and the doctors order sets, which then generated the PT referral. She stated that the time frame for PT to assess a resident was one week. She stated that Resident 309 has been in the facility for two weeks and that she had not been able to come out to the skilled nursing facility to perform Resident 309's initial PT assessment. The PTL stated that PT and RNA therapy could be helpful for a resident adjusting to a new living situation such as when residents were newly admitted to the facility. The PTL was not aware that Resident 309 had a fall in the dining hall on 5/1/24. During an interview on 5/8/24, at 3:40 p.m., with the AD, the AD stated her expectation was for a resident to be seen by a Physical Therapist within a week of a doctor's order. The AD stated that one week was a reasonable time period for PT to assess a resident. Review of a facility policy and procedure (P&P) titled, FACILITY PROCEDURE: FUNCTIONAL MANAGEMENT CARE POLICY, revised 10/1/20, indicated, .[facility name] Skilled Nursing Units shall provide .restorative care to meet each resident's individual needs as required in each resident's plan of care .residents will receive care that enables them to achieve and/or maintain their highest practicable level of physical independence and provide a continuity of care .Functional Management (FM) primary focus is to attain or maintain the highest practicable physical, mental and psychosocial well being of each resident and shall be directed to prevent deterioration .Therapies, Physical .Performs Therapy Evaluations and Treatments as ordered by physician .Works with Charge Nurse regarding appropriate FM goals and programs individualized for the resident, and trains CNA's [certified nursing assistant] if needed .Serve as educational resources .

Review of Resident 309's Resident Face Sheet, indicated Resident 309 was admitted to the facility with a diagnosis which included but not limited to, urinary tract infection (UTI). During an interview and observation on 5/7/24, at 9:13 a.m., Resident 309 stated that he had a urinary foley catheter (a tube placed in the body to drain and collect urine from the bladder) for the last eight to nine months. Resident 309 stated that he emptied his urinary catheter bag himself into the urinal and would then leave the urinal that contained his urine hanging off the footboard and staff would come in and empty it. It was observed that there was a urinal that was one-third filled with a yellow liquid hanging off the footboard of Resident 309's bed. It was observed that the room was occupied by four residents. During a concurrent interview and observation on 5/7/24, at 9:13 a.m., with the IP, the IP was observed picking up a urinal that was one-third filled with a yellow liquid that was attached to Resident 309's foot of bed. The IP stated the urinal must have belonged to another resident in the room and she did not know who the urinal belonged to or why it was on Resident 309's bed and stated it must have been placed there by mistake. Resident 309 stated to the IP that the urinal belonged to him, and he left it there for staff to empty. Resident 309 stated to the IP that he emptied his own urinary catheter bag into the urinal by himself. The IP stated that she was not aware that Resident 309 emptied his own urinal because he was a new admit. The IP confirmed that the urinal did not have the resident's name, or another resident identifier written on the urinal. During a concurrent interview and observation on 5/8/24, at 10:01 a.m., with Certified Nurse Assistant 4 (CNA) in Resident 309's room, CNA 4 stated that Resident 309 liked to empty his own urinary catheter bag by himself. CNA 4 further stated that Resident 309 sometimes would let her know when the urinal was full. CNA 4 stated the urinal got changed weekly and that she would dump it out in the bathroom and clean it. CNA 4 further stated that usually the room number was listed on the urinal. CNA 4 stated Resident 309 was on Enhanced Barrier Precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). During a concurrent observation and interview on 5/8/24, at 10:56 a.m., with LN 8 in Resident 309's room, LN 8 stated she must gown up to prevent infection for any resident who had a urinary catheter to prevent infection to the resident and confirmed that Resident 309 had a urinary catheter. LN 8 stated she was aware of Resident 309 being able to empty his own urine. LN 8 stated urinals should be labeled with the date and resident's name and that night shift usually changed the urinal once a month unless it was dirtied and soiled. LN 8 stated that if a urinal was not labeled with the resident's name, then the risk would be another resident grabbing it and using which could spread infection to the residents. During an interview on 5/8/24, at 11:18 a.m., with the IP, the IP stated that the urinal should have listed the bed number on it to identify the resident it belonged to and was not sure how often the urinals were changed. The IP stated that the risk for not labeling the urinal would be that it could be interchanged by staff or other residents, and the risk could be cross-contamination of germs and infection that could cause a Urinary Tract Infection (UTI) in residents. The IP stated staff labeled items so they knew what resident the items belonged to. During an interview on 5/9/24, at 1:08 p.m., with the IP and the Infection Prevention and Quality Director (ID), the IP stated that regarding Resident 309's urinal not being labeled with resident identifier that the risk would be not knowing who the urinal belongs to. The IP stated that Resident 309 was on EBP due to resident having a urinary catheter. The IP stated that Resident 309 was at higher risk of Multidrug Resistant Organisms (MDRO; germs resistant to medication used to treat infections) and that if Resident 309 had an infection it could spread to another resident in the room if his urinal was used by another resident. The IP stated the risk of not using identifier on urinal was that another resident or staff member could accidently use it for another resident. The IP stated that they did not want residents to share collection devices because they could share germs and the risk would be to all residents who share the room. Review of a facility policy and procedure titled, FACILITY PROCEDURE: BEDSIDE ITEMS, dated 8/16/23, indicated, .Bedside items shall not be shared between residents to prevent the spread of infection Disposable items shall be marked with the resident's initials, room number and stored at their bedside .the following items may be kept at bedside .urinal 3. During an observation on 5/7/24, at 1:14 PM, Resident 309 was observed eating lunch in the dining room. Resident 309's urinary bag was hanging on Resident 30's walker who was sitting next to him. Resident 309's walker was behind his chair about 2-3 feet (measure of distance) away. Resident 309 finished his meal and started to leave the dining room using his walker while his urinary bag was hanging on Resident 30's walker. During continued observation on 5/7/24, at 1:16 PM, LN 7 walked into the dining room. LN 7 then grabbed Resident 309's urinary bag from Resident 30's walker and hanged it on Resident 309's walker. During an interview on 5/7/24, at 1:18 PM, LN 7 confirmed Resident 309's urinary bag was hanging on Resident 30's walker. LN 7 stated Resident 309's walker should not have been placed at Resident 30's walker due to an infection control issue. During an interview on 5/8/24, at 4:55 PM, the Director of Nursing (DON) stated she heard that Resident 309's urinary bag was found on Resident 30's walker. The DON stated it was not a clean practice and it was not Resident 30's belonging. The DON further stated it should not have been on her walker and it placed Resident 30 at risk for a fall. Review of Resident 309's physician order dated 5/3/24, indicated Resident 309 was on enhanced barrier precautions due to urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag). Review of a facility policy titled, ENHANCED STANDARD PRECAUTIONS FOR SKILLED NURSING, dated 12/12/19, indicated, .Always follow standard precautions, including .environmental infection control in all care setting for all residents . Review of a facility policy titled, ISOLATION: STANDARD AND TRANSMISSION BASED PRECAUTIONS, dated 7/27/22, indicated, .Standard Precautions: Are a set of infection control practices that .reduce the risk of transmission (spread) of infectious agents to both healthcare personnel and patients in the healthcare setting .Standard precautions are utilized at all times with all patients regardless of patient status or diagnosis. All blood, body fluids, excretions, or secretions must be considered potentially infectious . Based on observation, interview, and record review, the facility failed to ensure safe infection prevention practices for a census of 60 when: 1. When Licensed Nurse (LN) 8 carried the stock bottle of test strips (test strip used to measure blood sugar) into an isolation room (restricted room to prevent the spread of infection) without cleaning or sanitization before and after use, 2. Resident 309's urinal (a bottle used for urination) was not labeled with Resident 309's name or another identifier; and, 3. Resident 309 's urinary bag (a drainage bag attached to a catheter (tube) that is inside the bladder to collect urine) was hanging on Resident 30's walker. These failed practices could contribute to spread of infection in the facility. Finding: During a medication administration observation with LN 8, in the facility's Unit 7, on 5/7/24, at 11:25 AM, LN 8 gathered the blood sugar measurement supplies including a glucometer (a device that measured blood sugar), test strip bottle (stock bottle of test strip; when single test strip was soaked with blood, inserted into glucometer to measure blood sugar), one lancet (single use small sharp needle-like device used to poke the finger to get drops of blood for sugar measurement), and alcohol pads (small sanitizing pad) into the Resident 20s room. Resident 20's room was marked with a sign Enhanced Barrier Precautions (meant before entering room one needed to use protective means to prevent spread of infection) and the sign indicated Clean Hands; Providers and Staff must also wear Gloves and Gown for High-Contact Resident care Activities. LN 8 placed the supplies including the bottle of the test strips, on bed-side counter while Resident 20 was sitting on a wheelchair. LN 8 removed one test strip from the container and attached it to the glucometer. When the test strip bottle fell on the floor, LN 8 picked it up and put it in her pants pocket till she exited the room. LN 8 did not clean and sanitize the outer surface of the test trip bottle when it was returned to the box container storing all blood sugar measurment supplies. During an interview with LN 8, in Unit 7's hallway, on 5/7/24, at 11:40 AM, LN 8 stated she took the test strip bottle in the room just in case she needed to re-do the testing. During an interview with Infection Prevention nurse (IP), in unit 7, on 5/7/24, at 11:52 AM, the IP stated the nurse should had taken only the needed supplies for testing blood sugar in the isolation room and the reusable items such as glucometer should be cleaned and sanitized. The IP stated the whole bottle of test strip should not have been taken into the isolation room. During a review of the facility's policy titled, Enhanced Standard Precaution for Skilled Nursing, dated 5/24/23, the policy on section D indicated, Implement Enhanced Standard Precaution for High Risk residents .Tasks: Wear gloves and gowns while performing the following tasks associated with the greatest risk of MDRO (or Multi-Drug Resistant Organism-infections that are resistant to antibiotics treatment) contamination of HCP's (Health Care Personnel) hands, clothes and the environment: a. Any care activity involving contact with environmental surfaces likely contaminated by the residents .C. Any care activity where close contact with the residents exposed to occur . During a review of the facility's policy titled, Glucometer Cleaning/Disinfection, dated 12/12/19, the policy indicated, Blood glucose (sugar) monitors are cleaned and disinfected after each use in order to prevent cross contamination between patients. Disposable, self-retracting lancets (sharp device used to poke the finger for blood droplet) are used for staff safety .All meter external surfaces should be cleaned and disinfected with a bleach wipe between uses .Dispose of any used wipe and gloves in an appropriate container. Wash hands with soap and water . The policy did not address how to handle use of test strips or if the test strip bottle should have been cleaned /disinfected if taken inside a resident's room and/or an isolation room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop baseline care plans for all of the identified problems noted on admission, within 48 hours of admission, to address resident-specific care needs for 3 of 18 sampled residents (Resident 309, Resident 310, and Resident 311), when Resident 309, Resident 310, and Resident 311's admission documentation indicated potential health care problem areas, but care plans were not developed for all of the identified problem areas within 48 hours of admission. These failures resulted in Resident 309, Resident 310, and Resident 311 having the potential for bodily harm, injury, and had the potential for not providing effective and person-centered care for the residents. Findings: 1. Review of Resident 309's Resident Face Sheet, indicated Resident 309 was admitted to the facility on [DATE]. Review of Resident 309's admission Assessment Sheet, indicated Resident 309 had a speech impairment (slur), vision impairment, hearing impairment, falls in the past thirty days, unsteady gait (persons manner of walking), ambulation (ability to walk without the need for any kind of assistance) deficit (loss of), transfer deficit, weakness, and required assistive devices. In the section of the document titled, .Care Plan Needs Identified, the sections marked included .Hearing Impairment, Fall Risk, Chewing Difficulty, and Diabetic (a disease that affects how the body uses blood sugar) Management . Review of Resident 309's undated Initial Care Plan, indicated that Resident 309 was hearing impaired and had a urinary foley catheter (a tube placed in the body to drain and collect urine from the bladder). In the section titled, Safety .History of falls: 3 falls in 45 days. In the section titled, Therapy Services .PT: Eval for RNA .Restorative functional goals: Program: PT Eval .Resident's functional goals .Improvement was marked or written out. Review of Resident 309's Fall Risk Assessment, indicated that Resident 309 had a total score of twenty on 4/26/24. The Fall Risk Assessment indicated, .Instructions: Upon admission .If the score is 10 or greater, the resident should be considered at High Risk for potential falls. A prevention protocol should be initiated immediately and documented on the care plan . During a concurrent interview and record review on 5/8/24, at 4:10 p.m., with the Minimum Data Set Coordinator (MDSC; MDS, an assessment tool), Resident 309's care plans and medical chart was reviewed. The MDSC stated the admitting nurse created the initial forty-eight-hour care plans from the information gathered on admission. The MDSC stated that care plans included a problem, a goal for the problem, and interventions to meet the goal. During a review of Resident 309's undated Initial Care Plan, the MDSC stated that was the only care plan document that was created for Resident 309 and was his forty-eight-hour care plan. The MDSC confirmed that Resident 309's undated Initial Care Plan, document contained identified problem areas, but no interventions or goals. The MDSC stated she was not sure why the document did not have interventions or goals listed for Resident 309, but the Initial Care Plan, document was used for all residents in the facility as their forty-eight-hour care plan. The MDSC stated the purpose of care plans would be for them to be individualized to the resident and to help with instructions for staff on providing care to residents. During a concurrent record review and interview on 5/8/24, at 4:52 p.m., with the Administrative Director of Post-Acute Services (AD), Resident 309's care plans and medical chart was reviewed. The AD stated care plans should contain three components which included the problem, interventions, and goals. The AD stated it was her expectation that staff would create a 48-hour baseline care plan for Resident 309 by 4/28/24 since he was admitted on [DATE]. The AD confirmed that Resident 309's chart included a diagnosis of urinary catheter, history of falls, monitor for hydration, diabetes, hypertension, and pain. The AD stated that care plans should be created on admission regarding current diagnosis and/or the problem list. The AD reviewed Resident 309's undated Initial Care Plan, to check and confirm if all components of a care plan were contained within the document. The AD confirmed that this document did not contain all components of a care plan and her expectation would be that it would contain all three areas. The AD confirmed that Resident 309 did not have a completed baseline care plan in his chart within forty-eight hours of admission based off of Resident 309's diagnosis listed in the medical record. The AD confirmed that Resident 309 had a care plan for falls dated 5/1/24 at 2:30 p.m. which was created for Resident 309 after he had a fall in the dining hall. The AD confirmed that Resident 309's Fall Risk Assessment, was completed on his admission date of 4/26/24. The AD confirmed that Resident 309's fall risk score was a twenty and this placed Resident 309 at high risks for falls. The AD confirmed that due to Resident 309's history of falls, history of strokes and the Fall Risk Assessment, score, Resident 309 should have had a care plan for falls created within 48 hours of admittance. The AD stated this could have prevented Resident 309's fall if measures were in place to address Resident 309's high fall risk. The AD stated the value of a care plan was for communication between staff and safety for the resident. 2. During a review of Resident 310's Resident Face Sheet, indicated Resident 310 was admitted to the facility on [DATE]. During a review of Resident 310's Physician Order Report, indicated that Resident 310 had an admitting diagnosis which included but not limited to cerebral infarction due to embolism unspecified (blood supply to the brain is blocked or reduced and prevents brain tissue from getting oxygen and nutrients), and unspecified symptoms and signs involving the musculoskeletal system. During a concurrent interview and record review on 5/8/24, at 5:36 p.m., with AD, Resident 310's care plans and medical chart was reviewed. The AD confirmed that Resident 310 was admitted on [DATE]. The AD confirmed that the only care plan that was created for Resident 310 upon admission was the .Psychotropic Med [medication] Care Plan The AD confirmed Resident 310 was admitted with diagnosis that included GERD (stomach acid repeatedly flows back into the tube connecting your mouth and stomach), diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high, hyperlipidemia (an excess of fats in your blood) , and CVA (stroke; occurs when a blood clot blocks or plugs an artery (blood vessel) leading to the brain). The AD confirmed that a fall risk assessment was completed on 5/1/24, which was fourteen days after Resident 310's admission to the facility. The AD confirmed that there should have been care plans in place within forty-eight hours of Resident 310's admission based off the mentioned diagnosis, and this was not done. The AD stated her expectation from staff would be that Resident 310 would have had a care plan addressing falls and diabetes within 48 hours of admission to the facility. 3. During a review of Resident 311's Physician Order Report, indicated that Resident 311 was admitted into the facility on 4/16/24. Resident 311 had an admitting diagnosis which included but not limited to diastolic (congestive) heart failure (a condition in which your heart's main pumping chamber (left ventricle) becomes stiff and unable to fill properly), acute respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body), urinary tract infection (infection in any part of the urinary system), and pain. Review of Resident 311's Initial Care Plan, dated 2/24/24 [sic], indicated that Resident 311 had a urinary foley catheter (a tube placed in the body to drain and collect urine from the bladder). In the section titled Safety .History of falls: 1-2 falls in past 30 days . was noted. Review of Resident 311's Fall Risk Assessment indicated that Resident 311 had a total score of fourteen on 4/16/24. Resident 311's 4/16/24 Fall Risk Assessment indicated, .Instructions: Upon admission If the score is 10 or greater, the resident should be considered at High Risk for potential falls. A prevention protocol should be initiated immediately and documented on the care plan . During a concurrent interview and record review on 5/8/24 at 5:18 p.m. with the AD, Resident 311's care plans and medical chart was reviewed. The AD confirmed that Resident 311 was admitted on [DATE]. The AD confirmed that Resident 311's Fall Risk Assessment was completed on his admission date of 4/16/24. The AD confirmed that Resident 311's fall risk score was a fourteen and this placed Resident 311 at high risks for falls. The AD verified that Resident 311 had a psychosocial care plan and discharge care plan within 48 hours of admittance. The AD confirmed that Resident 311's Initial Care Plan, dated 2/24/24 [sic], did not contain all the components of a care plan. The AD confirmed that a care plan should have the identified problem, interventions, and goals and the Initial Care Plan created for Resident 311 only contained the problems. The AD confirmed that there were no care plans created within forty-eight hours of Resident 311's admittance to the facility to address Resident 311's high risk for falls, his identified foley catheter, and other pertinent diagnosis. Review of a facility policy and procedure titled, FACILITY PROCEDURE: CARE PLANS / RAI revised 5/24/23, indicated, .[Facility name] Definitions: Care Plans-will identify problems, include short and long term goals with realistic, measurable and time limited objectives. It will describe resident specific interventions / approaches with disciplines responsible identified .A nursing care plan will be initiated by the RN at the time of admission, and will be added to by the appropriate disciplines as full assessment is complete .A Base Line Care Plan must be developed and implemented by the IDT [inter-disciplinary team] within 48 hours of a resident's admission .

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent accident hazards for 12 of 60 residents (Resident 2, Resident 20, Resident 21, Resident 30, Resident 34, Resident 40, Resident 41, Resident 44, Resident 50, Resident 54, Resident 55, Resident 56, and Resident 309), when: 1. Resident 20 and Resident 40's wander guard (a bracelet that triggers alarms when resident attempts to leave the facility unattended) were not monitored for functioning, 2. Wander guard system (a device/sensor that trigger alarms if a wander guard wearer approaches near it) was not working at the front gate in Unit 7, 3. Wander guard system was not checked monthly for functioning; and, 4. Staff was not present during lunch on 5/7/24 in the dining room in Unit 7. These failures had the potential for Resident 20, Resident 40, Resident 41, Resident 50, and Resident 55 for elopement (running away/wandering off without staff knowledge that poses serious safety risk), accidents, injury, and had the potential for Resident 2, Resident 21, Resident 30, Resident 34, Resident 44, Resident 54, Resident 56, and Resident 309 in the dining of choking and safety risk. Findings: 1a. Review of admission Record indicated Resident 20 was admitted to the facility with multiple diagnoses including but not limited to dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with behavioral disturbance, mood disorder, and depressive disorder. Review of Resident 20's care plan dated 7/31/20, indicated, Problem .[Resident 20] with WANDERING BEHAVIOR] HX [History of] attempts to leave facility unattended. Elopement attempts. Impaired safety awareness; potential injury .Approach .Provide wander alarm (placed in wheelchair) . During an interview on 5/8/24, at 10:09 AM, Licensed Nurse (LN) 7 stated Resident 20 had a behavior of wanting to go home and was at risk of elopement. LN 7 further stated Resident 20 would go to the front gate and would try to get out. LN 7 stated Resident 20 was able to propel herself in the wheelchair. LN 7 further stated Resident 20 had a wander guard and the front gate would keep her from eloping. During an observation on 5/8/24, at 10:39 AM, a wander guard was observed on Resident 20's wheelchair. During an interview on 5/8/24, at 10:45 AM, the MDS (Minimum Data Set nurse who collects and assesses information for the health and well-being of residents in nursing homes) stated Resident 20 was at risk of elopement. The MDS stated Resident 20 would try to get out and had attempted a couple of times. The MDS stated Resident 20 had a wander guard. The MDS stated they checked the alarms periodically for functioning and did not keep a log of it. During an interview on 5/8/24, at 11:01 AM, LN 7 stated they were not monitoring residents' wander guards for functioning to her knowledge. During a concurrent interview and record review on 5/8/24, at 4:17 PM, LN 8 stated wander guards were used for residents with elopement behaviors. LN 8 stated Resident 20 was at risk of eloping. LN 8 added Resident 8 would open the door. LN 8 stated wander guards should be checked for functioning and placement every shift to make sure it was working. Resident 8's Treatment Administration Record (TAR) was reviewed with LN 8. LN 8 verified the record only indicated Resident 20 had a wander guard for safety and did not indicate to check the wander guard for functioning, placement and the frequency of how often the wander guard needed to be checked. LN 8 verified there was no record indicating Resident 20's wander guard was checked for functioning and placement. During a concurrent interview and record review on 5/8/24, at 5:15 PM, the Director of Nursing (DON) stated wander guards should be checked for functioning as per physician order, she believed it was monthly. The DON stated it should be on the TAR. The DON stated she did not believe they checked resident wander guards for placement. The DON stated it would be team effort to check wander guard placement. The DON added licensed nurses would check wander guard placement during the residents' skin check. Resident 20's TAR was reviewed with the DON. The DON verified there was no record of Resident 20's wander guard monitoring. The DON stated she did not understand why there was not an order for Resident 20's wander guard monitoring. 1b. A review of Resident 40's Resident Face Sheet, indicated she was admitted to the facility in 2022 with diagnoses which included unspecified dementia. A review of Resident 40's care plan dated 4/1/24, indicated, Problem .[Resident 40] has wandering behavior r/t [related to] confusion d/t [due to] dementia .Elopement risk .Impaired safety awareness; potential injury .Goal .will wander safely within specified boundaries .will not leave facility unattended .Approach .Provide wander alarm . During an interview on 5/7/24, at 9:03 AM, LN 5 stated Resident 40 wore a wander guard alarm on her left leg to prevent elopement from the facility. LN 5 stated the wander guard battery was checked weekly by licensed staff to ensure functioning. During an interview on 5/9/24, at 1:28 PM, LN 4 stated Resident 40 attempted to leave the building every time a door opened. LN 4 further stated the facility added another gate last year due to Resident 40's elopement from the facility. A review of Resident 40's Treatments Flowsheet, dated 5/1-5/31/24 indicated, .Wander Guard for safety Once a Day on Wed [Wednesday] Check Battery weekly . The space provided for staff to initial the battery check for the date of 5/8/2024 was blank. During a concurrent interview and record review on 5/9/24, at 7:32 AM, the Infection Preventionist (IP) confirmed there was no documentation to indicate Resident 40's wander guard battery had been checked on 5/8/24. During an interview on 5/9/24, at 1:43 PM, LN 1 stated it was important to check Resident 40's wander guard battery weekly due to the potential of the battery to randomly stop working. LN 1 further stated if the wander guard was not working Resident 40 could elope from the facility. LN 1 stated if Resident 40 eloped from the facility there was the potential for her to be hit by a car, suffer a fall, or become lost. During a concurrent interview and record review on 5/8/24, at 1:40 PM, the Practice Administrator (PA) stated nursing staff checked residents' wander guards weekly for proper functioning. The PA further stated the weekly check should be documented on the Resident's treatment flowsheet. The PA stated the purpose of monitoring for placement and functioning weekly was to ensure the system was working and operational for the safety of the residents who were high wander/elopement risks. The PA verified the facility policy indicated alarms to be checked for activation/functioning periodically every shift. The PA stated alarm in the policy meant wander guard on resident. The PA stated their policy was conflicting. The PA further stated they checked wander guards every week. The PA stated per policy residents' wander guard should be checked every shift for functioning. The PA confirmed they were not following their current policy for monitoring resident's wander guard every shift. During a concurrent interview and record review on 5/9/2024, at 2:04 PM, the DON confirmed there was no documentation to indicate Resident 40's wander guard battery was checked on 5/8/24. The DON further stated if the wander guard battery was not checked there was the potential risk for Resident 40 to elope from the facility. A review of a facility policy titled, WANDER, revised 5/24/23, indicated, .Provide a safe environment for residents .Any resident observed to exhibit behavior or symptoms of potential elopement or wandering will be assessed for cause and patterns .Doors and exits accessible to residents are alarmed, gated or both .Resident Assessment Coordinator will monitor the care plans of residents assessed to be at risk. Alarms will be periodically checked for activation by staff on each shift . 2. During a concurrent observation and interview on 5/8/24, at 11:01 AM, LN 7 took Resident 20 near the wander guard system at the front gate in unit 7 to check if it was working. The Wander guard system did not trigger an alarm. LN 7 stated someone might have silenced the monitor. LN 7 turned the silence mode off on the monitor by the nurses' station. LN 7 took Resident 20 again near wander guard system at the front gate. The wander guard system did not trigger an alarm. Housekeeper (HK) standing near the nurses' station stated, That's odd. It didn't go off. LN 7 tested the wander guard system at the front gate for functioning with a brand-new unused wander guard. The wander guard system did not trigger an alarm. LN 7 stated she tested the wander guard system with two wander guards. LN 7 stated it must be the wander guard system at the front gate that was not working. LN 7 stated there was no one in-charge of checking the wander guard system to ensure it was working. During an interview on 5/8/24, at 1:40 PM, the PA stated wander guard systems were checked monthly for proper functioning. The PA stated wander guard systems should be checked for functioning to protect confused, in-cognitively residents' from wandering to unsafe areas. The PA stated if wander guard system was not working then residents with wandering behavior were at risk of elopement and injury. Review of undated and untitled facility provided list of residents with wander guards indicated Resident 20, Resident 41, Resident 50, and Resident 55 had a wander guard in unit 7. 3. During an interview on 5/8/24, at 11:11 AM, Plant Maintenance (PM) 2 stated he checked the wander guard system once a month. During an interview on 5/8/24, at 3:45 PM, Director of Plant Maintenance (DPM) stated they oversaw the wander guard alarm system. The DPM stated they checked the wander guard system monthly for maintenance and functioning. The DPM stated they did not have a policy on the wander guard system. Review of untitled facility document dated 4/1/24, indicated, .Facility Inspections .Facility Ensure wonder[sic] guard system is functioning properly .Schedule .Monthly .Wonder[sic] Guard System Inspection .Activity Log .Completed .At 4/3/2024 . During concurrent interview and record review on 5/8/24, at 5:15 PM, the DON verified the wander guard system was last checked for functioning on 4/3/24. The DON stated it should be done within a month. The DON stated the wander guard system should have been inspected for functioning by 5/3/24. The DON stated when the wander guard system was not checked within the month, it delayed ensuring proper functioning of the wander guard system and posed elopement and safety risk for residents. The DON acknowledged a month was a long period to check the wander guard system for functionality. The DON stated a lot could happen, could pose safety risk if the wander guard system stopped working/dysfunction in between month period. 4. During an observation on 5/7/24, at 1:05 PM, Resident 2, Resident 21, Resident 30, Resident 34, Resident 44, Resident 54, Resident 56, and Resident 309 were eating lunch in the dining room in unit 7. There was no staff member present in the dining room. During continued observation on 5/7/24, at 1:14 PM, Resident 309's urinary catheter bag (a drainage bag attached to a catheter (tube) that is inside the bladder to collect urine) was hanging on Resident 30's walker who was sitting next to him. Resident 309's walker was behind his chair about 2-3 feet away. Resident 309 finished his meal and started to leave the dining room using his walker while his urinary bag was hanging on Resident 30's walker. During continued observation on 5/7/24, at 1:16 PM, Licensed Nurse (LN) 7 walked into the dining room. LN 7 grabbed Resident 309's urinary bag from Resident 30's walker and hanged on Resident 309's walker. During an interview on 5/7/24, at 1:18 PM, LN 7 confirmed Resident 309's urinary bag was hanging on Resident 30's walker. LN 7 stated Resident 309 might have hanged his urinary bag on Resident 30's walker. LN 7 stated she did not see Resident 309 doing it because she was not present in the dining room. LN 7 stated there was no staff member present in the dining room. LN 7 stated a staff member would be present in the dining room only if a resident needed assistance with feeding or was at choking hazard. LN 7 stated residents in the dining were alert and able to feed themselves. During an interview on 5/8/24, at 4:55 PM, the DON stated staff should be present in the dining room after food was served for supervision, in case of choking, and to meet residents' needs. The DON stated she heard that Resident 309's urinary bag was hanging at Resident 30's walker. The DON stated Resident 309 would get confused about his urinary bag and might have hanged his urinary bag at Resident 30's walker. The DON stated staff presence in the dining room would have absolutely prevent it from happening. The DON stated her expectation was staff to be present in the dining room since they had confused residents.

Based on observation and interview, the facility failed to ensure safe medication monitoring practices for a census of 60 when: 1. Vital Signs (or VS, markers such as heartbeat or Heart Rate [HR] and Blood Pressure [or BP, the pressure of blood flow into the arteries]) hold parameters (conditions in which nursing staff to hold the medication and/or call the doctor) were not ordered for cardiac (heart) and blood pressure medications for safe monitoring for Resident 28, Resident 11, and Resident 2; and, 2. Resident 28's high risk (drug with risk of adverse effects even with appropriate dose and indication) blood thinner medication, called Apixaban (or Eliquis, used to treat or prevent blood clot and can cause bleeding) did not have monitoring parameters in the Medication Administration Record (or MAR, a document that listed drugs administered and the daily nursing monitoring at the point of drug administration) to assess or prevent the risk of bleeding. These failures could contribute to unsafe monitoring and medication use. Findings: 1a. During a review of Resident 28's MAR, dated 5/2024, the MAR indicated the following medications that could affect Resident 28's Heart Rate (HR) and Blood Pressure (BP): -Carvedilol (or Coreg, a drug belongs to a class drugs known as beta blockers, that slows down the heart rate and blood pressure) ordered to be given as twice daily. -Spironolactone (or Aldactone, used to lower the blood pressure) ordered to be given once a day. -Furosemide (or Lasix, also known as water pill, drug used to treat edema, water retention in the body, could affect blood pressure) Further review of the MAR indicated an order to only check blood pressure once a week on Monday's. The MAR did not have a slot to document recorded BP, pulse, or the HR when measured. During an interview with Licensed Nurse (LN) 1, on 5/9/24, at 8:04 AM, LN 1 stated the nurses used a guideline sheet posted on a binder at the nursing station to guide them for usual normal limits on HR, BP, and other vital signs. Review of an undated guideline sheet titled, Vital sign (V.S.)- Normal Limits, in a binder at the nurse station at unit 6, the sheet indicated the normal HR as Heart Rate: 60-90 beats per minutes (BPM) and the normal BP as Blood Pressure: Systolic (SBP):90-150 mm/Hg; Diastolic (DBP):60-80 mm/Hg (Blood Pressure is measured in units of millimeters of mercury (mmHg);The readings given in pairs, with the upper [systolic] value first, followed by the lower [diastolic] value). Review of the Resident 28's medical record titled, Weight and Vital Sign record, with a date range of 1/1/23 to 3/24/24, the record posted the Heart Rate (HR) below 60 as follows: 2/19/24: HR= 58, 12/1/23: HR= 58, 11/1/23: HR= 50, 9/1/23: HR= 58, 4/1/23: HR= 50. Further review of the record indicated the vital signs were documented once a month during January 2023 to February of 2024. 1b. During a review of Resident 11's medical record titled, Physician Order Report, dated 5/2024, the record indicated a medication order for metoprolol (or Lopressor, drug used to treat BP and lower the heart rate) to be given twice a day since 9/5/23 with no hold parameters to monitor the vital signs. Further review of the record indicated an order dated 8/3/22 to check vital sign once a month with no instruction on how to address the measurement. Review of Resident 11's medical record titled, Weight and Vital Sign Record, with a date range of 2/26/24 to 5/1/24, the record indicated the Heart Rate (HR) below 60 as follows: 2/26/24: HR= 59, 3/4/24: HR= 58, 3/6/24: HR= 53, 3/22/24: HR= 57, 4/11/24: HR= 54. The record did not show any documentation of nursing intervention under action column of the record. 1c. During a review of Resident 2's medical record titled, Physician Order Report, dated 5/2024, the record indicated two medication orders for Valsartan (or Diovan, used to treat BP and heart failure) to be given once a day since 11/10/23 and hydrochlorothiazide (or HCTZ, or water pill used to treat BP and used as diuretic) to be given once a day since 7/10/23 for diagnosis of Essential Hypertension (or high blood pressure). Further review of the record did not show any parameters to monitor the medications. The record did not show any order to measure the vital signs or BP on a regular basis. During a review of Resident 2's MAR, dated 4/2024 and 5/2024, the record did not show any documentation or order to record the vital signs or BP in the MAR. During an interview with LN 6 on 5/9/24, at 10:25 AM, LN 6 stated the workflow on checking and assessing the vital signs was to notify the doctor if needed. LN 6 stated it was a basic nursing care function to address vital signs if not within normal range. During an interview with Certified Nurse Assistant (CNA) 1 on 5/9/24, at 10:30 AM, CNA 1 stated one of her job functions was to measure and record the vital signs and not all resident's VS were recorded on daily basis. CNA 1 stated she recorded her measurements in a sheet of paper located at the nursing station. CNA 1 stated she would notify the licensed nurse if the VS were not normal. During an interview with the Director of Nursing (DON) on 5/8/24, at 5:40 PM, the DON stated it was the doctor's responsibility to order vital sign monitoring parameters. The DON stated nursing staff followed the doctor's order. During an interview with the DON on 5/9/24, at 4:03 PM, the DON stated Vital Sign (VS) recording was updated recently to include checking the VS every Monday and Wednesday and the previous policy was old. The DON stated she looked forward to incorporating monitoring parameters for high-risk drugs with the new planned electronic medical record roll out. In a telephone interview with the Medical Doctor (MD) 1, on 5/9/24, at 5 PM, the MD 1 stated he usually did not order hold parameters (conditions in which nursing staff to hold the medication and/or call the doctor) for medication orders and the general parameters could not be applied to every resident. MD 1 stated there needed to be a standard protocol to double check the vital sign and contact the doctor if parameters were not within normal limit on a symptomatic or at-risk resident. Review of the facility's policy titled, Facility Procedure: Medication Administration Record (MAR), with a revision date of 2/15/24, the policy indicated, Purpose: To administer appropriate medication to the correct patient with the correct dosage at the correct time and route. The policy, in the Procedure, section indicated, .Prepare medication and verify with the 6 rights of safe medication administration .Check apical pulse [or heart rate] or BP per physician orders . The policy did not elaborate on medications requiring vital sign monitoring without a doctor's order. Review of the facility's policy titled,, Facility Policy: Medical Director, Responsibility Of, with a review date of 8/18/23, the policy indicated, The SNF [Skilled Nursing Facility] Medical Director (practitioner) is responsible for overseeing the implementation of resident care policies and the coordination of medical care in the facility to ensure to the extent possible that care is adequate and appropriate steps are taken to correct identified problems. Review of the facility's policy titled, Vital Sign Policy, with a revision date of 2/15/24, the policy indicated, Vital signs are taken and documented on: each admission every shift for two weeks, every shift on residents on occurrence charting, every shift on all residents covered by Medicare A (government insurance), on care conference day vital signs with orthostatic Blood pressure (a form of low blood pressure might cause dizziness, lightheadedness or fainting when rising from sitting or lying down) checks will be taken for MDS (or Minimum Data Set, a report sent to federal government on resident status) assessment purposes. Residents on hypertensive medication will have the blood pressure monitored per MD orders. Resident with a stable BP will be monitored each week or per MD order. If blood pressure is outside of residents' normal range, MD will be notified, and vital sign will be monitored per MD orders. BP will be checked with each administration of hypertension medication if parameters are ordered. Vital signs may be taken at any time per nursing judgment. Abnormal findings will be reported to the MD. All residents will have vital signs taken and documented every month. A licensed nurse will check vital signs prior to administration of a medication for which parameters are ordered/indicated. 2. During a review of Resident 28's MAR, dated 5/2024, the MAR indicated a blood thinner medication called Eliquis (apixaban), ordered for twice a day administration since 8/21/23 for prevention of stroke. The order was highlighted as a Black Box Warning label with no explanation. Further review of the MAR did not show any monitoring parameters for nursing staff to watch for possible side effects on a daily basis. Review of Resident 28's care plan (a nursing plan of care, with goals, and monitoring), the care plan under the problem column, last edited on 4/2/24, indicated, Resident 28 with Hx [history] of CVA [or Cerebral Vascular Accident, or brain stroke] with RX [Prescription] for Eliquis; potential for adverse s/e [side effects]. The care plan under the approach column, last edited on 4/10/23, indicated, Provide medication per orders. Assess for adverse effects and report .Assess skin integrity for bruises, skin tears, bleeding . During an interview with the DON on 4/9/24, at 4:03 PM, the DON stated the medication monitoring including blood thinners were addressed on case-by-case basis per the doctor's order. The DON stated it was important to check for bleeding and/or bruises on the skin and report it to doctor. Review of the facility's consultant Pharmacist (CP) record titled, Medication Regimen Review, dated from 4/13/23 to 3/19/24, the handwritten record for Resident 28, on 4/13/23, noted labs okay; Eliquis dose okay. Review of the facility policy titled, Medications With Black Box Warning, with a revision date of 11/30/23, the policy under Intent indicated, To promote safe and effective use of medication with Black Box Warnings, nursing will identify symptoms that indicate a significant adverse reaction might be occurring . the policy on procedure section indicated, Medication side effects and/or Black Box Warning printouts will be used on the Medication Administration Record .Nursing will monitor for the described adverse drug reactions and report any suspected adverse drug reactions to the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure safe use and monitoring of psychotropic (mind altering drugs) medication in 3 out of 5 sampled residents (Resident 209, Resident 20, and Resident 1) reviewed for unnecessary medication when: 1. Resident 209's specific behavior monitoring, and expression of distress was listed as resistant to care which did not pose a harm to resident or others when the root cause of resistance to care may have been an attempt to communicate unmet needs and a discomfort unable to articulate to nursing staff, 2. Resident 209 and Resident 20's psychotropic drug dosage range did not fit the usual dose range for elderly residents with dementia diagnosis and were not discussed with Resident's Representatives; and 3. Resident 209 and Resident 1's anxiety medication called lorazepam (or Ativan, medication used to treat anxiety) for PRN or as needed basis (PRN or Latin word pro re nata means as the thing is needed) was renewed for 6 months or longer without any clinical justification for its use, risk, or the need. These failures had the potential for unsafe medication use and monitoring. Findings: 1. During a review of Resident 209's medical record titled, Medication Administration Record, (MAR, a document that listed medications to begiven and the daily monitoring) dated 5/2024, the record indicated the following psychotropic orders and the resident specific behavior monitoring as follows: Quetiapine tablet 25 mg (mg or milligram, a unit of measure; also known as Seroquel) .oral Twice a Day; Black Box Warning (or BBW- highest level of warning given to the drug when used in elderly with dementia) . [unspecified Dementia, unspecified severity, with other behavioral disturbance]; 4/11/24- open ended Quetiapine Target Behavior: Resistant to Care (R), Intrusiveness (I) Every Shift; 4/11/24- Open Ended The record did not specify the reason for resistant to care and why this behavior could have posed harm to the resident or others. A review of Resident 209's medical record titled, Psychopharmacologic Drug Summary Sheet, (summary of use and monitoring of mind-altering drugs) dated 4/2024, indicated two episodes of the resistance to care during the month of April 2024. The record did not elaborate the root cause of the resistant to care and if it contributed to resident harm to self or others. During an interview with Certified Nursing Assistant (CNA) 4 on 5/8/24, at 1:50 PM, at Unit 6 hallway, CNA 4 stated Resident 209 felt uncomfortable when her body was exposed during showering, bathing, and peri care. CNA 4 stated Resident 209 was hard of hearing for her to understand the staff talking to her. CNA 4 stated Resident 209 was most anxious and uncooperative during shower time, and it took two persons to help with a shower. CNA 4 stated Resident 209 had gotten better with routine care and seeing the same care givers. During an interview with the Director of Nursing (DON), on 5/8/24, at 5:40 PM, the DON stated the behavior to monitor had to be the one that could pose harm to resident or staff and residents had the right to refuse care. The DON stated the monitoring could have been worded differently. In a telephone interview with Resident 209's Representative (RR) 1 on 5/9/24, at 1:40 PM, RR 1 stated Resident 209 was uncomfortable and fearful of bathing and the facility's staff had done a great job on calming her down. 2a. During a review of Resident 209's medical record titled, Facility Verification of Resident Informed Consent for .psychotherapeutic drugs ., dated 4/8/24, the record signed by MD 1, indicated Resident 209's legal representative gave consent for use of mind-altering drug called quetiapine with Potential Dose Range of 12.5mg to 800 mg for Diagnosis: dementia with behavioral disturbances such as resistant to care. In a telephone interview with RR 1 on 5/9/24, at 1:40 PM, RR 1 stated Resident 209 was uncomfortable and fearful of bathing and the facility's staff had done a great job on calming her down. RR 1 stated the facility called her for changes in condition such as falling down or if she had a fever. RR 1 stated she did not recall receiving phone call about the medication use and the dosage of her mind-altering medications has not changed as far as she knew. During an interview with LN 6 on 5/9/24, at 12:38 PM, LN 6 stated the admission workflow included addressing mind-altering medication use and the consent form. LN 6 stated as the resource nurse, after review of prior health records, she filled out the form which included resident specific behaviors and a dose range with minimum to maximum dose allowable. LN 6 stated she looked at the drug reference book to come up with a maximum dose range. LN 6 stated the paper consent form then was used by the doctor to sign and/or contact family and explain the mind-altering medication use. During an interview with the DON on 5/8/24, at 4:53 PM, the DON stated the consent paper for mind-altering drug was prepared by the resource nurse for the doctor to sign and address. The DON stated the form which was created by the facility asked for a dosage range. The DON stated nurses used a drug information book to put a maximum allowable dose range on the form. The DON acknowledged maximum dosage for elderly dementia residents may not be the same as other mental health diseases. 2b. During a review of Resident 20's medical record titled, Facility Verification of Resident Informed Consent for .psychotherapeutic drugs ., dated 4/8/24, the record signed by MD 1, indicated Resident 20's legal representative gave consent for use of mind-altering drug called quetiapine with Potential Dose Range of 12.5mg to 750mg for Diagnosis: dementia with behavioral disturbances. During a review of Resident 20's medical record titled Medication Administration Record, (a document that listed medications to begiven and the daily monitoring) dated 5/2024, the record indicated the following mind-altering psychotropic order: Quetiapine tablet 25 mg (also known as Seroquel) .oral Twice a Day; Black Box Warning .(or BBW- highest level of warning given to the drug when used in elderly with dementia) .[unspecified Dementia, unspecified severity, with other behavioral disturbance]; 1/17/23- Open Ended. In a telephone interview with Resident 20's Representative (RR) 2 on 5/9/24, at 11:17 AM, RR 2 stated he did not recall receiving any call from the doctor or the facility about medication use or dosage ranges as he was not closely involved with the detail of care provided. During an interview with LN 6 on 5/9/24, at 12:38 PM, LN 6 stated the admission workflow included addressing mind-altering medication use and the consent form. LN 6 stated as the resource nurse, after review of prior health records, she filled out the form which included resident specific behaviors and a dose range with minimum to maximum dose allowable. LN 6 stated she looked at the drug reference book to come up with a maximum dose range. LN 6 stated the paper consent form then was used by the doctor to sign and/or contact family and explain the mind-altering medication use. During an interview with the DON on 5/8/24, at 4:53 PM, the DON stated the consent paper for mind-altering drug was prepared by the resource nurse for the doctor to sign and address. The DON stated the form which was created by the facility asked for a dosage range. The DON stated nurses used a drug information book to put a maximum allowable dose range on the form. The DON stated most recently the facility had initiated a process to renew the consent for mind-altering medication use every 6 months. The DON acknowledged maximum dosage for elderly dementia residents may not be the same as other mental health diseases. Review of the online drug information UpToDate [NAME] Drug, on quetiapine medication use in elderly, last accessed on 5/13/24, it indicated, Avoid for behavioral problems associated with dementia or delirium unless alternative nonpharmacologic [Nondrug approaches] therapies have failed, and patient may harm self or others. If used, consider deprescribing attempts to assess continued need and/or lowest effective dose. The document under dosing for Agitation/Aggression and psychosis associated with dementia, indicated Oral: Initial: 25 mg at bedtime; may increase dose gradually (eg, weekly) based on response and tolerability up to 75 mg twice daily. The facility's staff were not using an age and diagnosis appropriate dose range per doctor's assessment of resident's medication needs. 3a. During a review of the Resident 209's medical record titled, Medication Administration Record [MAR], dated 5/2024 and 4/2024, the MAR record indicated orders for lorazepam as follows: lorazepam 0.5 mg table; 0.5 mg, oral, As Needed, PRN, QHS (at bedtime); For Generalized anxiety disorder; Start date: 4/29/24; Stop Date: 10/29/24. lorazepam 0.5 mg tablet; 0.5 mg, oral, As Needed, PRN, QHS; Generalized anxiety disorder; Start Date: 4/11/24; Stop Date:4/11/24. Further review of the record indicated the lorazepam was renewed on 4/29/24 for a duration of 6 months after a 15-day trial. The MAR record indicated evening time restlessness by resident and no documentation of non-drug approaches prior to using the PRN lorazepam and renewal for 6 more months. Review of Resident 209's MAR further indicated the lorazepam which was ordered for bed-time use was administered between 6:30 PM to 7:25 PM. Review of the Resident 209's medical record titled, Status Change Notification and /or Orders, dated 4/26/24, the paper record which was faxed to Medical Doctor (MD) 1's office indicated, Request for Orders; Res. (Resident 209) Lorazepam order expired on 4/25/24; Would you like to extend for another 6 months? . signed by a nurse. The record signed by MD 1 with a note Cont. (Continue) PRN lorazepam x 6 Mon. (for 6 months) for chronic anxiety; dated 4/29/24. Review of Resident 209's medical record titled, Nurse's Progress Note, dated 5/4/24, the record written on 5/4/24, at 6:56 AM, indicated, Resident noted with statement of I am Dizzy x2 times per CNA (Certified Nurse Assistant) report, Plus her gait is unsteady, shuffles backward . In an interview with facility's Consultant Pharmacist (CP) on 5/9/24, at 12:50 PM, the CP stated she had been asked to review medication profile if they could contribute to the fall. The CP stated she reviewed the medication profile once a month and shared her finding with DON and medical doctor if indicated. During an interview with the DON on 5/7/24, at 9:49 AM, the DON stated the Medical Doctor made the decision to use or continue duration of the medications. The IDT team (Intradisciplinary Team- a group of clinical staff who reviewed and addressed resident specific progress and challenges) reported the resident care issues to the team and medical director to review them. 3b. During a review of the Resident 1's medical record titled, Medication Administration Record, (or MAR) dated 5/2024, the MAR record indicated an order for lorazepam as follows: lorazepam .0.5 mg, oral, As Needed, BID (twice per day) PRN; For anxiety disorder; Start date: 1/19/24; Open Ended. Further review of the MAR indicated the medication was administered twice a day regularly with a nursing note indicating the Reason Behavior was being Stressed despite non-drug approaches. Further review of Resident 1's MAR, dated 5/2024 and 4/2024, indicated Resident 1 was receiving 3 other opioid medications concurrently with lorazepam as follows: Oxycodone 10 mg (strong pain medication) every 4 hours around the clock, Methadone 10 mg (strong and long-acting pain medication) Twice daily, Morphine 5 mg (strong pain medication) as needed (Given once or twice per day). Further review of administration record by nursing staff, indicated these three opioid medications were administered within 1 hour of lorazepam use. Review of Resident 1's Care Plan document (a document that listed resident's plan of medical and mental health care and progress), dated 2021- 2023, the care plan indicated the same dose and frequency of lorazepam since 6/18/2021. During a review of the MD 1's progress note, dated 2/4/24, the note indicated a long list of medical problems including Chronic Pain and noted Stable on present regimen of methadone, Percocet, liquid morphine for severe breakthrough symptoms. The note listed lorazepam was used as needed for anxiety and muscle spasm. The note did not document risk versus benefits of using lorazepam on as needed basis when resident was using it regularly. Review of Resident 1's medical record titled Quarterly Interdisciplinary Resident Care Conference, dated 3/25/24, the record indicated use of lorazepam 0.5 mg BID PRN [twice daily as needed] and it was included in the Black Box Meds list along with the opioid pain medications (Black Box Med same as Black Box Warning (BBW) issued by FDA [Food and Drug Administration], a US agency that regulated drug use as its highest level of warning given to a drug for the risks it may pose). In an interview with MD 1 on 5/9/24, at 5:03 PM, MD 1 stated Resident 1's opioid use in combination with lorazepam had been challenging as resident refused to accept any changes. MD 1 stated he kept the lorazepam on an as needed basis although Resident 1 had been taking it twice daily regularly. MD 1 stated overall he had reduced the opioid burden during Resident 1's stay at the nursing home. In an interview with CP on 5/9/24, at 12:50 PM, the CP stated she reviewed the medication profile once a month and shared her finding with DON and medical doctor if indicated. The CP shared her note to MD 1, dated 5/9/24, which indicated It's required the care center attempt a Gradual Dose Reduction (GDR) quarterly unless clinically contraindicated .Patient is also on baclofen 10 mg [drug used for muscle spasm] QID (Four times Daily] for muscle spasm. The note did not have a response from MD 1 as of 5/9/24. The CP stated Resident 1's opioid medication use had been reduced by half since he was admitted to the facility in April of 2019. Review of the FDA's web site titled, FDA requiring Boxed Warning updated to improve safe use of benzodiazepine drug class [same class as lorazepam], dated 1/14/22, and last accessed on 5/14/24 via https://www.fda.gov/drugs/fda-drug-safety-podcasts/fda-requiring-boxed-warning-updated-improve-safe-use-benzodiazepine-drug-class, the warning indicated Health care professionals should consider the patient's condition and other medicines being taken, and assess the risk of abuse, misuse, and addiction when prescribing benzodiazepines. Caution should be taken when prescribing with opioids and other medicines that depress the central nervous system. Review of the facility's policy titled Psychopharmacologic [Mind altering drugs] Drug Summary, last revised on 11/30/23, the policy indicated, Monitor psychotropic [mind altering] drugs for effectiveness in controlling targeted behaviors and associated adverse drug reactions .When psychopharmacologic drugs are used, the following shell apply: 1. PRN orders for such drugs shall be subject to the requirements of this section. 2. The data collected shall be made available to the prescriber in a consolidated manner at least monthly .4. The specific behavior manifestation of disordered thought process to be treated with the drug is identified in the resident's health record. 5. Prior to administration of psychotropic drugs, a consent is obtained and kept on file. The policy referenced federal and state regulations at the end.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food practices in accordance with professional standards for food service safety for a total of 59 residents who received food from the kitchen when: 1. A half-filled pancake mix container was expired and available for use in the kitchen; and 2. A double oven located in the kitchen was not clean. These failures placed facility residents at risk of food borne illnesses (eating or drinking something that is contaminated with germs that can cause illness) and had a potential of fire hazard. Findings: 1. During an initial tour of the kitchen on 5/6/24, at 9:28 AM, the Production Supervisor (PS) verified a half-filled pancake mix container on a rack in the kitchen was labeled with use by date of 4/9/24. The PS stated it was expired. The PS further stated expired food should be thrown away and should not be available for use. During an interview on 5/6/24, at 3:50 PM, the PS stated expired food should not be available to use for food safety. The PS stated there was a risk of serving expired food to the residents. The PS further stated expired food would make residents sick and could cause food borne illness. Review of a facility policy titled, Food Storage revised 10/25/2018, indicated, .To ensure the hospital stores food and nutrition products using proper sanitation, temperature, light, moisture, ventilation, and security .All stored food must be properly labeled and dated with .Use-by date .The use-by day or date marked may not exceed the manufacturer's use-by date .Dry or staple items, including spices, must be used by the manufacturer ' s use-by date . 2. During a continued initial tour of the kitchen on 5/6/24, at 9:28 AM, the PS verified the double ovens in the kitchen were not clean and had cooked on grease. The PS stated ovens were cleaned only as needed. The Lead Food Services Associate (LFSA) stated ovens were cleaned weekly. During an interview on 5/6/24, at 3:50 PM, the PS stated the double ovens were not cleaned to their standards and could have been cleaned better. The PS stated unclean ovens posed a risk of cross contamination (transfer of harmful bacteria from one person, object, or place to another) and food borne illness. Review of a facility policy titled Ovens/Toasters, revised 5/1/2013, indicated, .Ovens/Toasters will be operated safely and efficiently to bake and roast food products. They will be cleaned daily and deep cleaned weekly to prevent fires and odor development .OVEN .SANITATION .Daily .Weekly (deep clean) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of eight sampled residents (Resident 2) who used the Sara Steady (a manual sit-to-stand transfer aid that enables one caregiver to transfer patients safely and with ease) device environment was free of accident hazards when staff left Resident 2 unattended while the Sara Steady device was in front of Resident 2. This failure had the potential to place Resident 2 at risk of falls and possible injury. Findings: During an interview on 3/21/24 at 10:15 am with Certified Nursing Assistant (CNA) 1, CNA 1 stated that she placed the Sara Steady device in front of Resident 2 while she used the commode (a portable toilet or a chair with a container underneath) in the room. CNA 1 further stated she would leave the call light within reach for Resident 2 to call her when she was done using the commode or the restroom. During an interview on 3/21/24 at 10:30 am with the Director of Staff Development (DSD), the DSD stated the residents who used the Sara Steady device were not to be left alone. The DSD's expectations were that there should be two staff members to assist with transfers when residents are using mechanical lifts. The DSD further stated that a staff member should be within arm's reach of the resident while using a mechanical lift. During an interview on 3/21/24 at 11:30 am with CNA 3, CNA 3 stated that she placed the Sara Steady device in front of Resident 2 when Resident 2 used the commode. CNA 3 further stated she would leave the call light within reach for Resident 2 while she used the commode and typically come back to the room to check on her in about 15 to 20 minutes. During an interview on 3/21/24 at 11:40 am with Restorative Nursing Assistant (RNA) 1, RNA 1 stated that she could not leave a Sara Steady device in front of residents alone because it could be a restraint. RNA 1 further stated that if the Sara Steady device was left in front of a resident without staff present, the resident might not be able to move around. During an interview on 3/21/24 at 11:55 am with the Practice Administrator, the Practice Administrator stated staff should not be leaving lifts unattended while in use. During an interview on 3/21/24 at 12:55 pm with Resident 2, Resident 2 stated the staff left the Sara Steady device in front of her while she used the commode. During an interview on 3/21/24 at 1:10 pm with Licensed Nurse (LN) 1, LN 1 stated that a resident could be a fall risk if the staff leaves mechanical lifts in the resident's room. During an interview on 3/21/24 at 2 pm with the Director of Nurses (DON), the DON stated that it was not the status quo to leave mechanical lifts in front of residents. The DON's expectation was for the staff to stay in the room with the resident when the lifts were placed in front of residents. During an exit interview on 3/21/24 at 3:30 pm with the DON and the Practice Administrator, the DON confirmed that Resident 2 did not have a Risks vs Benefits form to leave the Sara Steady device in front of her alone. Review of Resident 2's Activities of Daily Living (ADL) care plan, dated 2/6/24, in the section Approach, indicated, .Provide assistive devices: [NAME] steady, wheelchair . During a review of the Sara Steady Instructions for Use Manual, dated 2/3/14, the section Safety Instructions, indicated, .This mobile patient lift must be used by a caregiver trained with these instructions and qualified to work with the patient to be transferred and should never be used by patients on their own .

Based on interview and record review, the facility failed to ensure one of two residents (Resident 1) with self-release seatbelts, remained free from a physical restraint, when Resident 1 was not able to buckle and unbuckle the seatbelt consistently on her own. Staff applied and removed Resident 1's seatbelt rather than reminding Resident 1 to apply the safety belt on her own per Resident 1's care plan intervention implemented on 2/6/24 related to the seatbelt use, following a fall in the bathroom on 2/2/24. This failure resulted in loss of freedom of movement for Resident 1, with the possibility of injury and psychosocial distress. Findings: During an interview on 2/20/24, at 4:12 pm, Resident 1 stated that she could not unbuckle the seatbelt and could only ever do it one time during the demonstration of how to use the seatbelt. Resident 1 stated after the demonstration she tried to unbuckle the seatbelt, but she could not do it. Resident 1 confirmed that she could also not buckle the seatbelt on her own. Resident 1 stated she felt perturbed [feeling anxiety or concern; unsettled] that she could not unbuckle the seatbelt and then stated, I am not sure they want me to unbuckle it. Resident 1 stated that she had told her Certified Nursing Assistant's (CNA) repeatedly that she was not able to unbuckle the seatbelt. Resident 1 stated she could not move her fingers very well because her fingers were crooked which made it difficult to do things. During an interview on 2/20/24 at 4:38 p.m. CNA 2 stated she was instructed in shift report by another CNA to put the seatbelt on Resident 1 while she was in the bathroom but did not receive any other training on the seatbelt use for Resident 1. CNA 2 stated she was not aware if Resident 1 could buckle or unbuckle the seat belt on her own. CNA 2 stated the seatbelt could be considered a restraint if the resident could not unclip the seatbelt on their own. During an interview on 2/20/24 at 4:52 p.m., CNA 1 stated when Resident 1 used the bathroom, Resident 1 was to wear the seatbelt. CNA 1 stated she hooked the seatbelt in place when Resident 1 used the bathroom. CNA 1 stated she would then unhook the seatbelt when Resident 1 was done with the bathroom. CNA 1 stated she had never witnessed Resident 1 unhook the seatbelt herself nor had she asked Resident 1 to buckle the seatbelt or unbuckle it herself. CNA 1 explained the seatbelt had helped Resident 1 from standing up on her own when she was done on the toilet. CNA 1 explained she had witnessed Resident 1 standing up at the sink in the bathroom alone prior to the seatbelt being implemented. During an interview on 2/20/24 at 5:15 p.m., the Director of Nursing (DON) stated the purpose of a care plan was to guide staff on how to take care of a problem and the interventions were to assist with the goals of the problem and the approach to use. The DON stated there was a potential for harm to the resident if the interventions were not implemented. The DON stated all staff had access to the care plans for each resident. The DON stated if Resident 1 was unable to unbuckle the seatbelt on her own then that would be a problem. The DON stated that Resident 1 had bad arthritis (swelling and tenderness in one or more joints, causing joint pain or stiffness that often gets worse with age) and it did take Resident 1 three to four attempts to unbuckle the seatbelt during the initial seatbelt use demonstration. When asked for documentation of the initial assessment conducted by the DON of the ability for Resident 1 to buckle and unbuckle the seatbelt, the DON stated she could not locate the information in Resident 1's medical record. Review of Resident 1's IDT [Interdisciplinary Team] RESIDENT INCIDENT REVIEW, dated 2/5/24, indicated, .IDT met to discuss [Resident 1's] fall 2/2/24. Res [resident] had a fall after attempting to get herself off toilet without staff assistance . Review of Resident 1's PHYSICIAN'S TELEPHONE ORDERS, dated 2/6/24, indicated, .Seat-belt alarm to be used in restroom [with] staff assist, attached to either side of toilet while resident is in restroom . Review of Resident 1's BENEFITS VS. [versus] RISK (Refusal to Treat), dated 2/7/24, indicated, .At risk for injury due to fall while sitting on toilet. Resident may use self-alarm safety belt while using toilet - allowing staff to assist with transfers on and off toilet .Benefits Resident allowed to have privacy while toileting Risks Related to Noncompliance Injury from fall if resident removes belt and gets up unassisted . Review of Resident 1's care plan, dated 11/17/23, in the section titled PROBLEM, indicated, .Prolonged used and sleeping in the bathroom . Review of Resident 1's care plan, dated 2/6/24, in the section titled INTERVENTIONS, indicated, .Staff will assist resident [with] transfers to/from toilet & remind resident to apply safety belt while using toilet . Review of Resident 1's NURSES'S PROGRESS NOTES, dated 2/8/24, indicated, .Res [resident] up to bathroom .Seat belt in place. Res. c/o [complains of] seatbelt - as she is unable to wipe herself without help. She reluctantly accepts the CNA help with wiping . Review of Resident 1's NURSES'S PROGRESS NOTES, dated 2/8/24, indicated, .When up to the toilet unhappy with seat belt for safety. Wanted to perform her usual toileting routines [without] assist. Tried to take seatbelt off [without] assist doing so. Resident verbalizes understanding of the rationale behind safety device however, still frustrated . Review of a facility policy and procedure (P&P) titled FACILITY POLICY: RESTRAINTS: POLICY ON PHYSICAL AND CHEMICAL RESTRAINTS AND DEVICES, revised 5/24/23, indicated, .Residents have the right to be free from any of the physical and chemical restraints imposed for purposes of discipline or staff convenience and not required to treat the resident's medical symptoms .Physical Restraint .Any manual method or physical or mechanical device or material or equipment attached or adjacent to the resident's body that the resident cannot easily remove, which has the effect of restricting the resident's freedom of movement or the resident's access to his or her body .Staff Convenience is any action taken by the facility to control resident behavior or maintain residents with the least amount of effort by the facility and not in the resident's best interest . Review of a facility P&P titled FACILITY PROCEDURE: CARE PLANS / RAI [Resident Assessment Instrument], revised 6/24/23, indicated, PROCEDURE SUMMARY/ INTENT .To identify resident care needs and develop an individualized plan of care which indicates the care to be given, the goals desired and the approach to achieve these goals .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record and policy and procedure review, the facility failed to protect one of three sampled residents (Resident 1) from sexual abuse, when Resident 2 who had a known history of inappropriate sexual comments and gestures was sitting in close proximity to her with no staff supervision. This failure resulted in Resident 2 rubbing Resident 1's inner thigh and placed other vulnerable residents residing in the facility at risk for abuse. Findings: According to the admission record, Resident 1 was admitted to the facility early this year with diagnoses which included anxiety disorder (excessive and persistent worry and fear about everyday situation) and Parkinson's disease (a progressive disease of the nervous system characterized by shaking, stiffness, and difficulty with mobility). A review of the Minimum Data Set (MDS, an assessment tool) dated, 9/12/23 indicated Resident 1 scored 7 out of 15 on the cognitive assessment, which indicated she had severe memory impairment and cognitive skills for daily decision making. A review of Resident 1's care plan dated 9/25/23, indicated that the resident had a memory/recall problem. The care plan directed staff to provide a calm atmosphere and safe environment. A review of Resident 1's nursing progress note dated 12/3/23, at 5:10 p.m., indicated Resident 2 was observed rubbing [Resident 1's] inner thigh up to her groin area when they were sitting beside each other near the nursing station. The nurse documented that the incident was witnessed by two Certified Nursing Assistants (CNA 1 and CNA 4). A review of Resident 1's care plan dated 12/3/23, indicated that the resident experienced sexual abuse from another resident and had the potential for emotional distress and impaired coping. A review of Resident 2's admission record indicated he was admitted to the facility in 2023 with multiple diagnoses which included anxiety. A review of Resident 2's MDS dated [DATE] indicated the resident had severe and impaired cognitive skills for daily decision making. A review of Resident 2's care plan initiated on 10/24/23 indicated the resident was displaying sexual behaviors toward female and male staff with comments and gestures. The interventions addressing the resident's sexual behaviors were to redirect and reorient the resident and notify the family if Resident 2's behaviors were to be an issue. The care plan did not contain interventions to protect vulnerable residents residing in the facility from his sexual behaviors. A review of the physician progress notes dated 12/1/23, indicated that the Resident 2 had increased behavioral issues, some inappropriateness towards staff members and other residents, and is repetitive and persistent .with difficulty redirecting him at times. A review of a nursing progress note dated 12/3/23, and timed at 5:10 p.m., indicated Resident 2 was started on alert charting for sexual abuse toward other resident and was a perpetuator. The note indicated the nurse reported the incident to the local police department. During an interview on 12/13/23, at 11:55 a.m., with CNA 1 who witnessed the incident, she stated the incident happened on 12/3/23 toward the end of day shift. Resident 1 and Resident 2 were sitting next to each other by the nursing station, while staff were further away down the hall. CNA 2 added, I looked over where they were sitting and could not believe my eyes, [I] saw that [Resident 2] was rubbing [Resident 1's] inner thigh. CNA 1 stated CNA 2 was walking by, and she alerted him to what was happening. CNA 1 stated both residents were separated immediately. During a concurrent observation and interview on 12/13/23, at 12 p.m., Resident 1 was in her bed in the room. Resident 1 smiled when the Department called her name. Resident 1 stated, I don't remember when asked about the incident of being touched inappropriately by another resident. Resident 1 was unable to provide information related to the incident of inappropriate touching by Resident 2. During an observation and interview on 12/13/23, at 12:10 p.m., Resident 2 was walking in the hall by the activity room. Resident 2 responded in a language other than English. CNA 1 assisted with interpretation. According to CNA 1, Resident 2 was unable to recall the incident when staff witnessed him touching Resident 1 inappropriately and was unable to provide information related to the incident. During a telephone interview on 12/15/23, at 12:50 p.m., CNA 4 stated on 12/3/23, he was walking in the hall and noted both residents sitting across from the nursing station. CNA 4 stated there was no staff nearby. CNA 4 explained, When I looked that way, I saw [Resident 2's] hand was between [Resident 1's] legs and he was rubbing her inner thigh. Neither of them were talking . I alerted other staff, and they were separated without much commotion. CNA 4 stated he was aware of Resident 2's history of inappropriate gestures toward some staff. CNA 4 added, Aware that he is being sexual .had a prior history of inappropriate sexual advances toward staff. Always reminded him not to do it. CNA 4 stated that the facility was aware of Resident 2's sexual comments and inappropriate behaviors. During a concurrent interview and record review on 12/13/23, at 11:05 a.m., the Director of Nursing (DON) stated the incident when Resident 2 inappropriately touched and rubbed Resident 1's thigh on 12/3/23 was witnessed by CNA 1 and CNA 2. The DON stated that Resident 1 was not able to recall the incident and Resident 2 denied the allegation of inappropriate touching. The DON acknowledged that Resident 2 had a history of innappropriate behaviors and making sexual comments towards staff. The DON explained the interventions included redirecting Resident 2, setting boundaries for his comments and gestures of sexual nature, and he was placed on alert monitoring and charting for 72 hours after each incident of inappropriate behaviors. The DON agreed that Resident 2 could exhibit inappropriate behaviors and gestures toward vulnerable residents who were easy targets because they were not able to defend themselves. When the DON was asked what measures the facility took to keep residents safe and prevent Resident 2's further sexual behaviors she stated the facility started monitoring Resident 2 for his sexual behaviors after the incident with Resident 1. The DON stated Resident 2 did not have one-on-one continuous staff supervision due to staffing problems. The DON did not respond when asked how the facility ensured a safe environment for Resident 1. A review of the facility's undated policy titled, Abuse and Neglect Prevention and Investigation indicated its purpose was to ensure that residents were free from abuse. The policy stipulated, The resident has the right to be free from verbal, sexual, physical and mental abuse .Abuse .of .residents by anyone, including .other residents .is not condoned by the facility.''

Based on interview and record review, the facility failed to submit a summary of investigation of an alleged sexual abuse to the Department within five (5) working days of an incident for one of three sampled residents (Resident 1). This failure placed Resident 1 at potential risk for further abuse. Findings: Resident 1 was admitted to the facility early this year with diagnoses which included anxiety disorder (excessive and persistent worry and fear about everyday situation) and Parkinson's disease (a progressive disease of the nervous system characterized by shaking, stiffness, and difficulty with mobility). Resident 2 was admitted to the facility in 2023 with multiple diagnoses which included anxiety and heart disease. A review of Resident 1's nursing progress note, dated 12/3/23 and timed at 5:10 p.m., indicated Resident 2 was observed rubbing [Resident 1's] inner thigh up to her groin area when they were sitting beside each other near the nursing station. The nurse documented the incident was witnessed by two Certified Nursing Assistants (CNA 1 and CNA 4). The note indicated the writer reported the incident to the resident's physician, family, the Director of Nursing (DON), the Department, and police. A review of the Resident 1's medical record reflected a document titled, Abuse and Neglect Reporting and Investigation Checklist. The document listed steps to be taken by the facility staff when an abuse was identified. The document indicated that the Director of Nursing or the designee were responsible for the investigation of abuse allegations and were to complete the report and send it to the Department within five days. During an interview on 12/13/23, at 11:20 a.m., the DON stated the investigation was completed by social services, but the results of investigation were not reported to the Department. The DON stated she was aware of the five working day requirement for the report to be submitted to the Department. A review of the facility's undated policy and procedure titled, Abuse and Neglect Prevention and Investigation, indicated, When an incident of abuse .is suspected or determined .an immediate investigation will be made by the Director of nursing or designee and a copy of the findings of such investigation will be provided to . [Department] within five working days of occurrence of such incident.

Based on observation, interview, and record review, the facility failed to ensure reasonable accommodation of needs were honored for two of 21 sampled residents (Resident 27 and Resident 30) when: 1. There was no documented attempt of an alternative call light used for Resident 27; and, 2. Resident 27 and Resident 30's call light were not within reach. These failure had the potential for Resident 27's and Resident 30's needs to go unmet with the potential to cause physical and/or psychosocial harm. Findings: 1. During a concurrent observation and interview on 03/13/23, at 9:23 a.m., Certified Nurse Assistant (CNA) 1 stated Resident 27 was unable to use the call light and was unable to speak. During an interview on 3/16/23, at 2:48 p.m., the Practice Administrator (PA) confirmed there was no record that other calls light types had been attempted in the past for Resident 27. During an interview on 3/15/23, at 4:29 p.m., the Director of Nursing (DON) stated she did not recall if other types of call lights had been tried in the past for Resident 27. The DON stated the facility had different types of call lights that could be used. The DON confirmed it was important to attempt to try different call lights in order to accommodate the residents' needs. The DON expressed they had used different types of call lights in the past for other resident that had worked for them. 2. During a concurrent observation and interview on 03/13/23, at 9:23 a.m., in Resident 27 and Resident 30's room, Certified Nurse Assistant (CNA) 1 confirmed Resident 30 was in bed and Resident 30's call light was located at the end of the bed underneath a blanket. CNA 1 stated Resident 30 would be unable to reach or see the call light where it was located. CNA 1 stated when the call light was not within reach Resident 30 would not be able to call for the help that she needed and there was a risk for Resident 30 to fall out of bed. CNA 1 confirmed Resident 27 was in bed and the call light was located on the night stand. CNA 1 stated Resident 27 was unable to use the call light and believed that was why it was placed on the night stand, out of Resident 27's reach. CNA 1 stated Resident 27 was unable to speak. During an interview on 3/15/23, at 4:29 p.m., the Director of Nursing (DON) stated, Resident 27 still had capacity and could make some movements so she might still be able to use the call light. The DON stated all residents should be treated the same and all residents should have their call light within reach. The DON stated if the intervention was in the care plan to keep the call light within reach then it should be done. Review of Resident 30's Activities of Daily Living care plan, initiated on 3/23/21, indicated, .Keep call bell within reach . Review of Resident 30's fall care plan, initiated on 3/23/21, indicated, [Resident 30] is at risk for falls .Keep call light and most frequently used items within reach . Review of Resident 27's Impaired Communication care plan, initiated on 8/28/19, indicated, [Resident 27] for Impaired Communication r/t [related to]: end-stage dementia [a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life], unable to verbalize needs .Keep call light within reach . Review of a facility policy titled FACILITY POLICY: CALL BELL / LIGHT SYSTEM, revised 9/14/22, indicated, .A nurse call button will be available and within reach for all residents to contact nursing personnel. The call system cord will be attached to the pillow or bed if necessary .

Based on interview and record review, the facility failed to ensure individual financial records were received on a quarterly basis for twenty residents who had a trust account with the facility, when there was no documented evidence that quarterly statements were provided to residents with facility managed funds. This failure had the potential for Resident 25 to be unaware of the amount of money available. Findings: During an interview on 3/13/23, at 9:48 a.m., when asked if a quarterly statement was received from the facility regarding money held in the trust account, Resident 25 stated she had never received anything, but would like to be aware of what money she had. During an interview on 3/15/23, at 9:16 a.m., the Practice Administrator (PA) stated the facility held resident trust accounts for a total of twenty residents. The PA confirmed Resident 25 had a trust account with the facility. The PA stated that residents who had a trust account received quarterly statements, with the last statement being provided in January of 2023. The PA stated it was important to provide residents with a quarterly statement so they knew how much money they had, even if it was just 10 dollars. The PA went on to explain, the residents lose so much when they come here, it was important to them, and the trust account is their fun money. The PA confirmed she was not able to provide documentation of quarterly statements being provided to residents. Review of a facility document titled [Facility Name] Patient Trust Current Account Listings, dated 3/16/23, listed Resident 25 as a resident with a trust account with the facility.

Based on interview, and record review, the facility failed to have a process to provide a beneficiary notification form when two of two sampled residents (Resident 5 and Resident 9) did not receive the Notice of Medicare Non-Coverage (NOMNC, a form which indicates that Medicare might not pay for skilled services and how to appeal). This failure had the potential for Resident 5, Resident 9 and their representatives to be uninformed regarding their specific rights and protections related to financial liability for potential incurred medical expenses as well as the right to appeal. Findings: A review of Resident 5's admission Record indicated Resident 5 was admitted to the facility in 2022. A review of Resident 9's admission Record indicated Resident 9 was admitted to the facility in 2022. During a concurrent interview and record review with the Director of Nursing (DON) on 3/15/23, at 3:12 p.m., the DON confirmed the facility did not provide a NOMNC to Resident 5 and Resident 9. The DON stated the facility was not aware a NOMNC needed to be provided because they handled very few discharges. The DON further stated the NOMNC had information about appeals so the form should have been given to Resident 5 and Resident 9. The DON explained the risk included the residents' rights would be restricted.

Based on observation, interview, and record review, the facility failed to implement a care plan intervention for two of 21 sampled residents (Resident 27 and Resident 30) when the care plan intervention of a stop sign barrier (a yellow banner with a stop sign on it that was placed across the doorway) was not in place over Resident 27's and Resident 30's doorway. This failure had the potential for Resident 27 and Resident 30's privacy to be invaded by unwanted persons, with a potential risk to safety. Findings: During an observation on 3/13/23, at 9:15 a.m., a stop sign barrier was hanging from the right side of the door frame of Resident 30's and Resident 27's shared room. During a concurrent observation and interview on 03/13/23, at 9:23 a.m., Certified Nurse Assistant (CNA) 1 confirmed Resident 30 and Resident 27 were in bed. CNA 1 confirmed the stop sign barrier was not across the doorway of Resident 30 and Resident 27's room. CNA 1 stated the stop sign barrier was used to prevent residents who wandered from going into other residents' rooms. During an interview on 3/15/23, at 2:10 p.m., Licensed Nurse (LN) 1 stated the stop sign barrier went all the way across the door and should be in place all of the time. LN 1 stated the family requested the barrier to be in place to prevent wandering residents from coming into Resident 27's room and going through Resident 27's personal belongings. LN 1 explained the barrier was used to prevent Resident 42 who wandered and wanted to help everyone from going into resident rooms. LN 1 stated there was a potential for Resident 42 to go into Resident 27's room and attempt to provide her with fluids. LN 1 explained, because Resident 27 required thickened liquids there was a potential for Resident 27 to aspirate (when fluid goes into the lungs). LN 1 stated when the banner was not in place there was a potential for Resident 27's privacy to be invaded. During an interview on 3/15/23, at 4:29 p.m., the Director of Nursing (DON) stated the expectation was for the stop sign barrier to be up across Resident 27 and Resident 30's doorway, if Resident 42 was awake. The DON stated the stop sign barrier was to prevent intrusive behaviors from residents who wandered the facility. The DON stated if it was care planned to use the stop sign barrier then it should be used. During an observation on 3/13/23, at 9:14 a.m., Resident 42 was sitting on the side of the bed, eating the breakfast meal. Review of Resident 30's Psychosocial Well-Being care plan, initiated on 11/3/22, indicated, .Potential for confused/wandering peers to enter [Resident 30's] room/personal space. her roommate's [Resident 27] family request use of stop sign at doorway to deter potentially wandering peers. [Resident 30's] RP [resident representative] in agreement with use of stop sign .Use STOP sign banner at room/doorway PRN [as needed] to redirect and deter confused/wandering peers .

Based on observation, interview, and record review, the facility failed to implement care planned fall precautions for Resident 10 and Resident 17, when the beds were not in low position and Resident 10's call light was not in reach. This failure had the potential to result in physical and psychosocial harm. Findings: During an interview on 3/14/23, at 9:50 AM, in Resident 10's room, Resident 10 stated she fell in November, which resulted in a shoulder injury that required surgery to repair. During a concurrent interview and record review on 3/14/23, at 9:57 AM, in Unit 6 nursing station, Licensed Nurse (LN) 3 stated Resident 10 had care planned interventions for fall risk and stated if Resident 10's bed was not in the lowest position, she could fall and hurt herself again. During a concurrent observation and interview on 3/15/23, at 8:28 AM, in Resident 10's room, Certified Nurse Assistant (CNA) 4 checked to see if Resident 10's bed was in the lowest position. CNA 4 pressed the bed controller, and Resident 10's bed moved lower. CNA 4 stated the risk to the resident was they could fall and hurt themselves. During interview on 3/15/23 at 8:40 AM, at Unit 6 nursing station, LN 3 stated Resident 10's bed should be in the lowest position for resident safety because she fell and broke her shoulder in November which required surgical intervention. During concurrent observation, interview, and record review, on 3/15/23, at 7:40 AM, in Resident 17's room, CNA 7 used the bed controller to lower the bed. CNA 7 stated Resident 17's bed should have been lowered for safety if she was a fall risk. Care plan reviewed and CNA 7 stated care planned interventions for Resident 17 included bed in lowest position. CNA 7 stated care plans were available at the nursing station and in the residents' rooms at each resident's bedside footboard. CNA 7 stated the nurses often updated the CNA's verbally to care plan changes. During concurrent observation and interview on 3/15/23, at 11:46 AM, in Resident 17's room, CNA 3 verified Resident 17's bed was not in lowest position by using bed controller to lower bed. CNA 3 stated they didn't know who raised the bed, but that it should be lowered for resident safety. During interview with the Director of Staff Development (DSD), on 3/15/23, at 2:15 PM, DSD stated if a resident was considered a fall risk, the expectation was for the resident's bed to be placed in the lowest position. DSD stated CNA charting included a 'Fall Prevention Log' and 'Bedside Care Sheets'. DSD stated these forms were kept at the resident's bedside footboard. DSD stated CNA's charted on these forms during regular rounding which occurred at a minimum of every two hours. DSD stated nurses updated the Bedside Care Sheets. DSD stated they or the Charge nurse reminded CNAs regularly about resident safety. During interview with Director of Nursing, on 3/15/23, at 3:44 PM, DON stated it was important for CNA's and nurses to know which residents were at high risk for falling. DON stated at the beginning of each shift, charge nurses explained to staff which residents required frequent checks. DON stated the expectation was to anticipate a resident's needs. DON stated that staff should check on residents every two hours and should have monitored that care planned interventions were implemented, such as verifying that bed was in the lowest position. Review of facility policy titled 'Facility Procedure: Falls Prevention Plan with review date of 7/18/2018, indicated, .Any resident identified as at risk for falls shall have an individual plan of care that includes interventions to prevent falls from occurring .Typical interventions may include but are not limited to: a. Keep call light within residents reach . and d. Keep bed in low position . Review of Resident 10's clinical record titled, Fall Risk Assessment, dated 12/9/22, indicated Resident 10 had a fall risk score of 21. Resident 10's 'Fall Risk Assessment' record indicated total score above 10 represents High Risk. Review of Resident 10's clinical record, Care Plan, initially dated 7/2/2022 and reviewed on 12/18/22 indicated Resident 10 had a care planned problem for falls. The care plan indicated Resident 10 had a history of falls with injury. Resident 10's care plan indicated Keep call light .within reach .Bed in low position . Review of Resident 17's clinical record, Care Plan, initially dated 3/17/2017 and reviewed on 1/30/2023 indicated Resident 17 had a care planned problem for falls. The care plan indicated Resident 17 had impaired mobility and dementia. Resident 17's care plan intervention indicated . Bed in low position .

Based on observation, interview, and record review, the facility failed to ensure one of twenty-one sampled residents (Resident 30) had access to fluid to maintain hydration when, Resident 30's drinking fluids were not within reach. This failure had the potential to result in a decline in Resident 30's health (dehydration) with the potential to result in physical harm (fall). Findings: During a concurrent observation and interview on 3/13/23, at 9:23 a.m., Certified Nurse Assistant (CNA) 1 confirmed Resident 30 was in bed and Resident 30's tray table with drinks on it was about two feet from the bed. CNA 1 confirmed Resident 30's call light was also not within reach. During an interview on 3/15/23, at 2:10 p.m., Licensed Nurse (LN) 1 stated resident drinks were located on the bedside table and the bedside table should be within the resident's reach. LN 1 stated the drinks should be with in reach so if the resident wants a drink they can get one. LN 1 explained a resident could try and reach for a drink and fall out of the bed. During an interview on 3/15/23, at 4:29 p.m., the Director of Nursing (DON) stated she expected the tray table be placed within reach so residents could get their drinks. The DON explained residents should be able to drink their drinks when they wanted to. The DON stated when the drinks were not within reach there was a risk for dehydration, a bladder infection, and a possibility that a resident could fall attempting to reach their drinks. Review of Resident 30's care plan initiated on 3/23/21, indicated, .[Resident 30] is potential for CONSTIPATION .potential for low fiber and fluid intake .Encourage fiber foods and adequate fluid intake . Review of Resident 30's Activities of Daily Living care plan, initiated on 3/23/21, indicated, .Keep needed items within reach for resident use . Review of Resident 30's fall care plan initiated on 3/23/21, indicated, .[Resident 30] is at risk for falls .Keep call light and most frequently used items within reach . Review of Resident 30's [Facility name] Nutrition Assessment Form, dated 2/20/23, in the section Fluid Intake, indicated, .Resident is encouraged to drink fluids . Review of a facility policy titled FACILITY POLICY: NOURISHMENTS, revised 5/18/22, indicated, .Each resident shall be provided with good nutrition and with necessary fluids for hydration .

Based on observation, interview, and record review, the facility failed to ensure respiratory care was provided in accordance with professional standards of practice for one of twenty-one sampled residents (Resident 21), when Resident 21's oxygen order had no indicated flow rate (the volume of oxygen delivered over time). This failure had the potential to result in negative impacts on Resident 21's health and safety including risks for ineffective oxygen therapy, and respiratory distress. Findings: A review of Resident 21's admission Record indicated Resident 21 was admitted to the facility in 2021 with diagnoses which included dependence on supplemental oxygen. During an observation on 3/13/23, at 1:19 p.m., Resident 21 was observed in his room with the oxygen concentrator on and running at a flow rate of 2 liters per minute (LPM, unit of measurement for oxygen delivery) via nasal cannula (a small flexible tube that contains two open prongs intended to sit just inside the nostrils). During a concurrent observation and interview on 3/13/23, at 1:24 p.m., with licensed nurse (LN) 1 in Resident 21's room, LN 1 confirmed Resident 21's oxygen concentrator was running at a flow rate of 2 LPM. During a concurrent interview and record review with LN 1 on 3/15/23, at 9:40 a.m., LN 1 confirmed Resident 21's oxygen order had no flow rate. LN 1 stated she expected the oxygen order to have a flow rate and would also refer to the previous oxygen order for an indicated flow rate. LN 1 further stated she would also call the physician to clarify the oxygen order. During an interview on 3/15/23, at 5:13 p.m., the Director of Nursing (DON) stated she expected licensed nurses to call the physician to clarify a resident's oxygen order to make sure it was a complete order including how many liters was listed as the flow rate. The DON stated the risk included patient safety and the resident would receive too much oxygen. Review of the facility policy, titled, Oxygen Administration, dated 5/18/22, indicated .Oxygen orders shall include a flow rate .Set flow rate to prescribed physician's order .

2. During a concurrent observation and interview on 03/15/23, at 11:42 a.m., the Warehouse Distribution Technician (WDT) was observed on Unit 7 at the medication storage room door holding a red container. The WDT entered the code on the door keypad and walked into the medication storage room. The WDT exited the medication storage without the red container. The WDT stated, .I put the box on the counter in the back of the med room. If a nurse is available, I give it to them. If not I put it in the med room. I don't want to leave it on the counter where a resident could get it. The WDT further stated he was provided the code to the medication room one year ago by the individual who trained him. The WDT confirmed he was not licensed personnel nor was his trainer. The WDT looked at the sign on the medication room door that reads: Restricted Entry-Licensed Staff Only and stated, I should not go in there, I'm not licensed staff, I didn't know. During an interview on 3/15/23, at 11:59 a.m., LN 2 was unaware the WDT had the code to the medication storage room. LN 2 confirmed the risk of WDT having access to the medication storage room was a potential for drug diversion. During a phone interview on 3/15/23, at 2:48 p.m., the Pharmacy Manager (PM) confirmed that the medication storage room should be kept locked and only licensed personnel, such as pharmacist, pharmacy staff, licensed staff and the Medical Doctor (MD) should have access. During an interview on 3/15/23, at 5:13 p.m., the DON stated all licensed personnel had access to the medication storage room and no unlicensed personnel should have access. The DON further stated there was a potential for medication diversion if unlicensed personnel had access to the medication storage room. Review of the facility's policy and procedure titled, FACILITY POLICY: STORAGE OF MEDICATION, last revised on 9/5/2019, indicated, .Medication shall be accessible only to responsible and authorized personnel designated by the Pharmacist-in-Charge (PIC) . Based on observation, interview, and record review the facility failed to maintain proper labeling and authorized use in one of two medication storage rooms when: 1. A bottle of glucometer strips (test strips used to measure blood sugar) was undated. 2. Unauthorized personnel had access to the medication storage room. These failures had the potential risk for resident safety and medication diversion. Findings: 1. During a concurrent observation and interview on 3/15/23, at 8:13 a.m., Licensed Nurse (LN) 1 confirmed a bottle of glucometer strips was opened and undated in the medication storage room on Unit 6. LN 1 stated there should be an open date as the risk of an undated glucometer strip could give inaccurate glucose readings. During an interview on 3/15/23, at 5:13 p.m., the Director of Nursing (DON) stated she expected staff to date the bottle of glucometer test strips on the day they opened it and with an expiration date. The DON further stated if the bottle was undated the risk would be inaccurate glucose readings and potential risk for resident's safety. Review of the facility's policy titled FACILITY PROCEDURE: NOVA STATSTRIP GLUCOSE METER, last revised on 5/18/2022, indicated, .StatStrip Glucose Test Strips .Once opened, strips are stable 6 months .

Based on observation, interview, and record review, the facility failed to maintain infection prevention and control practices for a census of 50 when: 1. One staff member did not follow infection control practices when Resident 20's wound dressing was changed; and, 2. One kitchen staff member was not wearing his mask correctly during the tray line prep. These failures had the potential risk for the development and transmission of diseases and infection to residents in the facility. Findings: 1. A review of Resident 20's admission Record indicated Resident 20 was admitted to the facility in mid-2022 with diagnoses which included a non-pressure chronic ulcer (an open wound with an exposed implanted device) of left lower leg, osteomyelitis (bone infection), and methicillin resistant staphylococcus aureus (MRSA, a bacteria that is responsible for several difficult to treat infections) infection. A review of Residents 20's Treatment Flowsheet indicated, .wound left knee once a day remove dressing, clean with chlorhexidine [topical antiseptic] and irrigate with NS [normal saline, a mixture of sodium chloride (salt) and water] bullet, pat dry with gauze, skin prep to peri [around] wound, apply iodosorb [an antimicrobial gel] and foam dressing. Change Qday [every day] and PRN [as needed] . During a wound care observation on 3/13/23, at 10:46 a.m., licensed nurse (LN) 2 was observed placing clean wound care supplies on a clean disposable pad on Resident 20's bed. LN 2 was further observed removing Resident 20's soiled dressing and placing it and the soiled prep pads, (cleansing wipes used to clean the wound) on the clean disposable pad. During an interview on 3/15/23, at 8:21 a.m., LN 2 confirmed the soiled dressing and prep pads were placed on the disposable pad that contained the clean dressing and supplies used for wound care. LN 2 further stated there was risk of contaminating clean supplies and the potential for infection. LN 2 confirmed the soiled dressing should have been disposed of somewhere else. During an interview on 3/15/23, at 4:59 p.m., the Infection Preventionist (IP), stated the expectation during wound care would be for licensed nurses to place clean supplies on a clean field. The IP further stated a trash can should be at the bedside for soiled dressings. The IP explained if a soiled dressing was put on a clean field, it could contaminate the other supplies and the LN would need to throw all supplies away. The IP stated a soiled dressing in a clean field could lead to risk of multi-drug resistant organisms (MDRO, infections that are resistant to three or more drugs that kill infection) or reinfection with bacteria. During an interview on 3/16/23, at 8:25 a.m., the Director of Staff Development (DSD) stated she expected the nurses to use an aseptic (free from contamination) field and dispose of soiled dressings away from the clean supplies. The DSD further stated there was a risk of infection if there was no separation between clean and dirty. Review of the facility's Policy and Procedure titled, FACILITY POLICY: BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN-STANDARD PRECAUTIONS, last revised on 12/12/2019, indicated . Infectious waste disposal .Place articles that are grossly contaminated with blood in red plastic infectious waste bags labeled with biohazard warning label . Articles with very small amounts of blood contaminants are placed in regular trash as they are considered to be low risk for spreading infection . Review of an undated facility document, titled, NURSING SKILL ASSESSING WOUNDS, indicated, .Discard gloves and other soiled materials into appropriate receptacles . discard dressings soiled with blood/bodily fluids into a biohazard bag . 2. During an observation of the breakfast tray line on 3/14/23, at 7:02 a.m., Food Service Associate (FSA) 1 was observed with his cloth mask below his nose while plating food for the facility. FSA 1 was further observed to move his mask up when prompted by the Dietary Service Supervisor (DSS). During a subsequent observation on 3/14/23, at 7:11 a.m., FSA 1 was noted with his mask below his nose and lip while he prepared the breakfast tray line. During an observation on 3/14/23, at 7:17 a.m., FSA 1 was noted with his mask resting on his chin as he continued to prepare the breakfast tray line. During an interview on 3/14/23, at 7:20 a.m., FSA 1 confirmed his mask was down during the tray line and it should have been worn correctly by covering his nose and mouth. FSA 1 stated the mask was down because it was loose. FSA 1 further stated he had not reported to his supervisor that he was having issues with his mask. FSA 1 explained the risk included spreading germs. During an interview on 3/14/23, at 7:23 a.m., the DSS acknowledged FSA 1's mask was not worn correctly during the tray line, and it should have been. The DSS stated he expected the hospital kitchen staff to follow the hospital's infection control policy which required them to always wear a mask. The DSS further stated he expected the kitchen staff to wear their masks correctly to cover their nose and mouth. The DSS explained the risk included infection control and spreading illness. During an interview on 3/14/23, at 10:56 a.m., the Director of Nursing (DON) acknowledged the hospital kitchen staff not wearing their mask correctly. The DON stated she expected kitchen staff to always wear a mask, hair net and gloves when preparing meals for residents. The DON further stated the facility was following the Centers for Disease Control and Prevention (CDC) guidelines for the masking of kitchen staff. During an interview on 3/16/23, at 11:11 a.m., Registered Dietician (RD) stated kitchen staff were expected to wear masks according to the state mandate and the masks should be worn correctly. The RD stated the risk was an infection control issue. Review of facility document titled, Use of Respirators, Facemask, and Cloth Face Coverings in the Food and Agriculture Sector During Coronavirus Disease (COVID-19) Pandemic, dated, 3/10/23, indicated, .proper wear and care of a cloth face covering .Cloth face coverings should: Cover the nose and below the chin .Fit snuggly but comfortably against the side of the face .

Based on interview and record review, the facility failed to ensure that one of five sampled resident's (Resident 42) medical record indicated if immunizations were received and/or refused and education was provided on the risks and benefits of the immunization when, Resident 42's medical record did not indicate if the pneumococcal vaccine (protects against serious and potentially fatal pneumococcal infections caused by bacteria) was offered and/or refused and there was no documented evidence of the risk versus benefit education being provided. This failure had the potential for Resident 42 to go unvaccinated with the risk for serious health related illness and/or death and Resident 42 and/or Resident 42's responsible party to not make an informed decision in regards to the risk versus benefits of receiving the vaccine. Findings: During an interview on 3/15/23, at 2:28 p.m., the Director of Staff Development (DSD) confirmed there was no record of the pneumoccocal vaccine being offered to Resident 42, no documented refusal of the vaccine, and no documentation to show that the risks versus benefits of the vaccine had been provided. The DSD explained, when a resident and/or the residents responsible party declined a vaccination then a risk versus benefit form was completed and would be signed by the resident and/or the responsible party. The DSD stated the risk to not receiving the vaccination would include an increased chance of death and a serious infection of pneumonia. The DSD explained, it was important to provide the risk versus benefit education so the residents and/or the resident responsible party could make the best informed decision. Review of Resident 42's FACILITY TRANSFER SUMMARY / PHYSICIAN ADMITTING ORDERS, dated 6/23/22, indicated, .Resident May .have Pneumococcal Vaccination . Review of an undated facility document titled, Unit 6 PNA [pneumococcal] Vaccines, listed Resident 42's name, but all of the columns titled as [Type of pneumococcal vaccine] Given, Date Given, Date Refused, were blank for Resident 42. Review of a facility policy titled FACILITY POLICY: SKILLED NURSING - PNEUMOCOCCAL VACCINE ADMINISTRATION, revised 8/18/21, indicated, .Pneumococcal vaccination will be provided to all Skilled Nursing residents .The resident's medical record shall include documentation that indicates, at a minimum, the following: a. Resident or resident's legal representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and b. That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal .Resident refusal of vaccine or medical contraindications will be documented in the Medication Administration Record. Benefit vs. [versus] Risk form completed on all vaccination refusals . Review of the Centers for Disease Control and Prevention (CDC) webpage titled Pneumococcal Vaccination: What Everyone Should Know, dated 1/20/23, indicated, .Pneumococcal disease is common in young children, but older adults are at greatest risk of serious illness and death .CDC recommends pneumococcal vaccination for all children younger than 5 years old and all adults 65 years or older .Some pneumococcal infections are invasive. Invasive disease means that germs invade parts of the body, such as blood, that are normally free from germs. Invasive disease is usually very serious and can sometimes result in death. Vaccines that help protect against pneumococcal disease work well but cannot prevent all cases . (https://www.cdc.gov/vaccines/vpd/pneumo/public/index.html)

2. During a concurrent observation and interview on 3/14/23, at 7:29 AM, in Resident 17's room, CNA 2 stood at the side of the bed when assisting Resident 17 with breakfast. CNA 2 acknowledged standing, stated some of the chairs were occupied, and instead raised the bed height. CNA 2 stated the facility's policy was to sit when feeding residents because it offered face to face interaction at eye level, conveyed respect, and was a quality-of-life issue. CNA 2 stated the bed was not raised to eye level. During an interview on 3/15/23, at 11:30 AM, at Unit 6 hallway, CNA 3 stated there were residents who preferred the CNA to sit when assisting with meals, but sometimes there were not enough chairs. CNA 3 stated when there were not enough chairs, the bed was raised with the resident placed in a sitting position. CNA 3 stated some residents didn't like to be hovered over when being assisted to eat. CNA 3 stated when she stood to help a resident eat, sometimes the movements were awkward and things like badges that hang on lanyards (a cord around the neck that holds work/security badges) got in the way. CNA 3 stated it was better to sit and that's how she was trained. CNA 3 stated staff should be at a resident's eye level when assisting with meals so that the residents feel comfortable. CNA 3 stated sometimes it was not possible to raise the bed to eye level, because the beds had a limit to how high they could be raised. During a concurrent interview and record review with the Director of Staff Development (DSD), on 3/15/23, at 2:24 PM, DSD stated staff were trained to sit at eye level and stated, The biggest thing is to not stand over them. DSD stated if a CNA stood to feed a resident, they needed to raise the bed to eye level, and acknowledged sometimes that was not always possible. DSD stated if a CNA could not find a chair, they could pull one from the charting room or living room areas. DSD stated there was no specific policy that instructed staff to sit while helping a resident to eat. DSD stated the expectation was that staff would sit at a resident's eye level when helping them to eat and stated this was part of the CNA skills check off list in the sections titled Activities of Daily Living and Nutrition. CNA skills checklist reviewed with DSD, who stated the checklist was used during orientation. The DSD stated instruction included demonstration of how to assist a resident to eat. The DSD stated instruction was given to take small, slow bites with sips of fluid in between bites of food, and to assist residents at eye level. During an interview with the Director of Nursing (DON), on 3/15/23, at 3:32 PM, the DON stated residents should be fed at eye level. The DON stated it was important for nurses and CNAs to sit when assisting a resident to eat and not rush. The DON stated it was important to be seated because cues and direction were provided during meals. Based on observation, interview, and record review, the facility failed to ensure residents were treated with dignity for a census of 50 when: 1. Staff placed Resident 15 and Resident 47 in double incontinence briefs; and, 2. Staff stood while assisting Resident 17 with meals. These failures had the potential to negatively impact the residents' psychosocial well-being and physical health. Findings: 1. A review of Resident 15's admission Record indicated Resident 15 was admitted to the facility in 2020 with diagnoses which included urinary tract infection. A review of Resident 47's admission Record indicated Resident 47 was admitted to the facility in 2023. During a concurrent observation and interview on 3/15/23, at 6:10 a.m., with certified nursing assistant (CNA) 5 in Resident 15's room, CNA 5 confirmed she removed two incontinence briefs as she changed Resident 15. CNA 5 stated she did not know who placed double briefs on Resident 15 because she had started her shift late. CNA 5 further stated the expectation was for all residents to wear only one incontinence brief. CNA 5 explained the risk included infections and skin wounds. During an interview on 3/15/23, at 6:23 a.m., licensed nurse (LN) 5 stated she was not aware Resident 15 had two incontinence briefs on. LN 5 further stated the facility did not allow double briefing because it would destroy the resident's skin integrity. During a concurrent observation and interview on 3/15/23, at 6:52 a.m., with CNA 6 in Resident 47's room, CNA 6 confirmed she removed two incontinence briefs as she changed Resident 47. CNA 6 stated she did not know Resident 47 was double briefed and received no information regarding Resident 47 during shift report. CNA 6 further stated Resident 47 was supposed to have only one incontinence brief on because there was a risk for skin issues. During an interview on 3/15/23, at 7:17 a.m., LN 2 acknowledged Resident 15 and Resident 47 were found with double briefs when being changed. LN 2 stated sometimes a resident would request to be double briefed so the expectation would be for the LN to educate the resident, a benefits versus risk form would be filled out along with the resident's signature and the double briefing request would also be care planned. During a concurrent interview and record review with LN 2 on 3/15/23, at 7:26 a.m., LN 2 confirmed he could not find a care plan for double briefing for Resident 15 and Resident 47. LN 2 further confirmed there was no benefits versus risk form regarding double briefing found for Resident 15 and Resident 47. LN 2 stated residents should only have one brief on because it was a risk for skin breakdown. LN 2 further stated residents wearing double briefs without their knowledge or consent would be a dignity issue. During an interview on 3/15/23, at 3:16 p.m., the Director of Nursing (DON) stated the facility policy was for all residents to wear only one incontinence brief. The DON further stated it was not appropriate for staff to be placing double briefs on residents who did not request it. The DON explained she expected the CNAs to notify the LN if a resident was refusing to only wear one incontinence brief. Review of the facility policy titled, Resident Rights, dated, 7/19/2018, indicated, .It is the intent of [Facility Name] Skilled Nursing Units to provide care while ensuring Resident's Rights .

Based on observation, interview, and record review, the facility failed to ensure that petty cash was available for a total of twenty residents who had a trust account with the facility, when personal funds were not available after business hours or on weekends. This failure resulted in personal funds not being available after business hours, with the potential to negatively effect a resident's psychosocial well-being. Findings: During an interview on 3/16/23, at 9:10 a.m., Resident 28 stated to obtain resident held money from the facility a request had to be made Monday through Friday. Resident 28 stated if you requested money late on Friday then you would not receive your money request until Monday. Resident 28 stated to have money on the weekend a request would have had to be made ahead of time. Resident 28 explained, if you did not request the money in advanced then you would be out of luck for the weekend. During an interview on 3/13/23, at 9:48 a.m., Resident 25 stated she was unaware if she could obtain money on the weekend. During an interview on 3/15/23, at 9:16 a.m., the Practice Administrator (PA) stated the facility held resident trust accounts for a total of twenty residents. The PA stated that the activities department handled the resident requests for smaller amounts of cash and had access to the petty cash. The PA stated the activities department staff was in the facility from 8 a.m. to 5 p.m. during the week and was also in the facility on the weekends. The PA stated it was important for residents to have access to the petty cash as residents did not always know what was to come, unexpected things come up, and if they wanted to treat themselves or someone else they should have access to their funds. The PA confirmed Resident 28 and Resident 25 had a trust account with the facility. During a concurrent observation, interview, and record review on 3/15/23, at 10:10 a.m., Activities Associate (AA) 1 stated the facility process for residents to request small amounts of money from their trust account included a form for the resident to fill out and the facility requested at least a 24 hour notice of the request. AA 1 stated, she was the only one that had access to the safe where the petty cash was kept. AA 1 stated her work schedule consisted of working Monday, Tuesday, and Wednesday, with Thursday and Friday off and the next week scheduled consisted of working Saturday, Sunday, Monday, Tuesday, Wednesday, and Thursday, with Friday, Saturday, and Sunday off. AA 1 stated residents would not be able to obtain petty cash on the days that she was not at the facility. AA 1 stated it was important for residents to have access to their money as it was their right. AA 1 explained the risk to a resident not having access to their money could result in a resident being deprived of doing an activity they wanted to do and could be detrimental to their well-being. AA 1 stated there was a sign posted outside of the activities department door which indicated the process for accessing resident funds from the trust fund. AA 1 pointed to an undated piece of paper posted outside of the door that was titled Resident Shopping and indicated, .Cash Trust Fund withdrawals will be taken Monday-Friday 8:30AM to 4:00PM and be provided by the following business day in most cases . Review of a facility document titled [Facility Name] Patient Trust Current Account Listings, dated 3/16/23, listed Resident 25 and Resident 28 as a resident with a trust account with the facility.

2. A review of Resident 34's admission Record indicated Resident 34 was admitted to the facility in 2021 with diagnoses which included left sided weakness. A review of Resident 40's admission Record indicated Resident 40 was admitted to the facility in 2021 with diagnoses which included osteoarthritis (a condition which affects joints). During an interview on 3/16/23, at 11:06 a.m., licensed nurse (LN) 6 stated all residents who were assigned to functional management care were expected to have a flowsheet to document their interventions by the CNAs. LN 6 further stated a resident would be discharged from their functional management interventions if a resident met their goal or if a resident refused their intervention three consecutive times. LN 6 explained the reasoning for the discharge would be documented on the flowsheet. During a concurrent interview and record review on 3/16/23, at 2:08 p.m., LN 6 confirmed there were no refusals documented on the flowsheets for Resident 40. LN 6 further confirmed Resident 34's flowsheet had no consecutive refusals documented. LN 6 stated Resident 34 and Resident 40 were inappropriately discharged from their functional management interventions and staff should have continued their interventions. Review of the facility policy titled, Functional Management Care Policy, dated, 8/27/21, indicated, .[Facility Name] Skilled Nursing Units shall provide functional maintenance/ restorative care to meet each resident's individual needs as required .Residents will receive care that enables them to achieve and/or maintain their highest practicable level of physical independence . Based on observation, interview, and record review, the facility failed to ensure three of nine residents (Resident 27, Resident 34, and Resident 40) who required assistance to maintain mobility received required services, when: 1. Resident 27's hand contracture (muscles, tendons, joints, or other tissues tighten or shorten causing a deformity which can result in pain and loss of movement) cushion was not present in both hands; and, 2. Resident 34 and Resident 40 were improperly discharged from their functional management interventions (nursing intervention to increase or maintain resident's mobility and to prevent further decline in mobility). These failures had the potential risk for Resident 27, Resident 34 and Resident 40 to not maintain their highest level of range of motion (ROM-the degree of movement that occurs at a given joint during an exercise) and mobility functioning. Findings: 1. During a concurrent observation and interview on 3/13/23, at 9:23 a.m., Certified Nurse Assistant (CNA) 1 confirmed Resident 27 had a blue contracture cushion in the right hand only. CNA 1 stated Resident 27 used the cushion because her fingers were contracted and to keep them from contracting more. CNA 1 stated Resident 27 used the hand contracture cushion all day and was unaware if there was supposed to be a hand contracture cushion in the left hand as well. CNA 1 confirmed there were additional hand contracture cushions on top of Resident 27's night stand. During an interview on 3/15/23, at 2:25 p.m., the Director of Staff Development (DSD) stated Resident 27's hand contracture cushions should be placed in both hands. Review of Resident 27's care plan, initiated on 8/28/19, indicated, .[Resident 27] requires assist with ADLs [Activities of Daily Living] related to: immobility .contractures, bilateral [both] upper and lower extremities [arms and legs] .Place braces. Ensure proper position, check fingers, skin, nails. Clean skin and braces. If unable to place braces, place wash clothes in hands. as she will tolerate . Review of Resident 27's Treatments Flowsheet, dated 3/1/23-3/31/23, in the section Order, indicated, .Brace to Left and Right hand when awake Twice A Day .

Based on interview and record review, the facility failed to provide adequate and sufficient nursing staff to ensure the Restorative Nursing Aide program (RNA, nursing aide program that helps residents to maintain their function and joint mobility) treatments and services were available for a census of 50. This deficient practice had the potential to decrease the residents' range of motion and mobility, which could affect the residents' overall function. Findings: During an interview on 3/15/23, at 11:44 a.m., licensed nurse (LN) 1 stated the facility did not have an RNA program. LN 1 further stated the CNAs were responsible for completing certain mobility interventions for residents on certain days and had to document on a resident's flowsheet. During an interview on 3/15/23, at 1:23 p.m., LN 3 stated the facility had no RNA program for at least 6 months. LN 3 further stated sometimes functional management interventions were not possible to complete depending on how many CNAs were on the floor. LN 3 explained certain functional management interventions were removed because they did not have the staff to complete them. During an interview on 3/15/23, at 3:32 p.m., the Director of Nursing (DON), confirmed the facility currently did not have an RNA program because their previous RNA left. The DON stated the facility was short staffed and they were prioritizing the care residents received. The DON further stated since the RNA left, the facility had assigned the functional management interventions to be completed by the CNAs. The DON explained the risk for not completing a resident's functional management intervention would be loss of functional mobility. Review of the facility policy titled, Functional Management Care Policy, dated, 8/27/21, indicated, .[Facility Name] Skilled Nursing Units shall provide functional maintenance/ restorative care to meet each resident's individual needs as required .Residents will receive care that enables them to achieve and/or maintain their highest practicable level of physical independence .

3. Review of Resident 21's admission Record indicated Resident 21 was admitted to the facility in 2021 with diagnoses which included urine retention (a condition in which urine cannot empty from the bladder), urinary tract infection, hydronephrosis (swelling of the kidney that develops due to improper drainage of urine from the kidney to the bladder) with kidney stones (hard deposits made of minerals and salts that form inside the kidneys). Review of Resident 21's Medications Flowsheet indicated Resident 21 took Nitrofurantoin (medication used to treat an infection) 50 milligram (mg, a unit of measurement) 1 capsule by mouth once a day for personal history of urinary tract infections. Further review of the document indicated Resident 21 had been taking his antibiotic order since 11/17/22 with no end date listed. During an interview on 3/15/23, at 11:15 a.m., the Infection Preventionist (IP) stated she was not aware Resident 21 was on an antibiotic for four months and there was no end date to the antibiotic order. During an interview on 3/16/23, at 10:19 a.m., the Pharmacy Manager (PM) confirmed Resident 21 had a history of recurrent urinary tract infections (UTIs) and was taking antibiotic Nitrofurantoin for prophylactic use (intended to prevent disease) prescribed by his primary physician. The PM further confirmed she did not have a conversation with Resident 21's physician regarding the resident's antibiotic use for the past four months or how there was no end date to the antibiotic order. The PM stated she was not aware an antibiotic order for prophylactic treatment needed an end date. The PM further stated she made no recommendations for Resident 21's antibiotic order for the resident's medication regimen reviews for 11/22, 12/22, 1/23, and 2/23. The PM explained she was involved in the facility's antibiotic stewardship program to focus on proper dosage, and indication. The PM stated the risk involved with any resident taking an antibiotic for long term use would include antibiotic resistance. Review of a facility policy titled MODEL POLICY: ANTIMICROBIAL STEWARDSHIP, revised 6/4/20, indicated, .Antimicrobial Stewardship [ASP] Actions .The ASP will implement specific actions to optimize antimicrobial use in accordance with the CDC [Centers for Disease Control and Prevention] Core Elements of Hospital Antibiotic Stewardship Programs. These actions include but are not limited to: a. Required documentation of dose, route, duration, and indication for all antimicrobial orders . Review of an online article published by the Agency for Healthcare Research and Quality (AHRQ) titled, Asymptomatic Bacteriuria, dated June 2021, indicated, .Asymptomatic bacteriuria (ASB) is a positive urine culture from a person with NO symptoms of a urinary tract infection (UTI) .The majority of people with ASB and/or asymptomatic pyuria [presence of pus in the urine] SHOULD NOT be treated with antibiotics .Treatment of ASB is associated with adverse events related to antibiotic use and can increase the likelihood of developing future UTIs that are antibiotic resistant . (https://www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/one-pager-asymptomatic-bacteriuria.pdf) Review of an online article published by the Agency for Healthcare Research and Quality (AHRQ) titled, Antibiotic Stewardship FAQs [frequently asked questions], dated June 2017, indicated, .There are no benefits of antibiotic prophylaxis in patients who have short-and long-term urinary catheterization .residents with or without urinary catheters, with asymptomatic bacteriuria, should not be treated with antimicrobial therapy. Overuse of antibiotics can lead to antimicrobial resistance, medication adverse events, and potential Clostridium difficile (C. diff) infection . (https://www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/resources/tools/reduce/antibiotic-faqs.html) Based on interview and record review, the facility failed to develop and implement antibiotic (medication used to treat bacterial infections) use protocols within the antibiotic stewardship program for a census of 50 residents when; 1. No antibiotic use protocol was developed and implemented; 2. Minimum use criteria for the use of antibiotics was not applied for Resident 6 and Resident 45; and, 3. Resident 21's antibiotic order did not have an end date. These failures increased residents' risk to develop infections with bacterial organisms resistive to certain antibiotics (MDRO; multidrug-resistant organisms, germs that are resistant to many antibiotics) with the potential to result in adverse outcomes (allergic reactions, organ damage, subsequent infection with antibiotic-resistant organisms, and clostridium difficile infection(bacteria that causes an infection of the large intestine)) associated with the inappropriate/unnecessary use of antibiotics. Findings: 1. During a concurrent interview and record review on 3/15/23, at 11:12 a.m., facility documents titled FACILITY POLICY: ANTIMICROBIAL STEWARDSHIP, revised 4/29/21 and MODEL POLICY: ANTIMICROBIAL STEWARDSHIP, dated 6/4/20, was reviewed with the Infection Preventionist (IP). The IP confirmed the two policies did not contain information in regards to minimum use criteria of antibiotics usage at the point of care or an antibiotic use protocol (specific criteria (signs and symptoms) used to determine if an antibiotic is truly needed for possible infections such as urinary tract infections (UTI, an infection in any part of the urinary system), lower respiratory tract infections (an infection in the lungs), and skin and soft tissue infections). During an interview on 3/15/23 at 2:50 p.m., the Director of Nursing (DON) confirmed the facility did not have an antibiotic use protocol and one would be developed in the future. Review of an undated online document published by the Centers for Disease Control and Prevention (CDC) titled, The Core Elements of Antibiotic Stewardship for Nursing Homes APPENDIX A: Policy and Practice Actions to Improve Antibiotic Use, in the section Infection specific interventions to improve antibiotic use, indicated, Reduce antibiotic use in asymptomatic bacteriuria (ASB) [the presence of bacteria in the properly collected urine of a patient that has no signs or symptoms of a urinary tract infection]. The prevalence of ASB, bacteriuria without localizing signs or symptoms of infection, ranges from 25% to 50% in non-catheterized nursing home residents and up to 100% among those with long-term urinary catheters. Antibiotic use for treatment of ASB in nursing home residents does not confer any long-term benefits in preventing symptomatic urinary tract infections (UTI) or improving mortality, and may actually increase the incidence of adverse drug events and result in subsequent infections with antibiotic-resistant pathogens. The unreliable clinical assessment for infections in nursing home residents coupled with the diagnostic uncertainties in differentiating ASB from infection contributes greatly to inappropriate antibiotic use and its related complications. Suspected UTIs account for 30% to 60% of antibiotic prescriptions in nursing homes. Implementing a set of diagnostic testing and management algorithms to help providers differentiate ASB from symptomatic UTI has been shown to reduce inappropriate antibiotic use for ASB . In the section titled, Broad interventions to improve antibiotic use, indicated, Develop and implement algorithms for the assessment of residents suspected of having an infection using evidence-based guidance (https://www.cdc.gov/antibiotic-use/core-elements/nursing-homes.html) Review of an undated online document published by the CDC titled, Core Elements for Antibiotic Stewardship in Nursing Homes Creating a Culture to Improve Antibiotic Use in Nursing Homes, indicated, .Antibiotics are some of the most commonly prescribed medications in nursing homes. Over the course of a year, up to 70% of nursing home residents get an antibiotic. Roughly 40% to 75% of antibiotics are prescribed incorrectly. In nursing homes, high rates of antibiotics are prescribed to prevent urinary tract infection (UTI) and respiratory tract infection (RTI). Prescribing antibiotics before there is an infection often contributes to misuse. Often residents are given antibiotics just because they are colonized with (carrying) bacteria that are not making the person sick. Prescribing antibiotics for colonization contributes to antibiotic overuse . In the section What Can I Do as a Leader to Improve Antibiotic Use? indicated, .Have clear policies to improve prescribing practices for staff to ensure patients are not started on antibiotics unless needed. Establish minimum criteria for prescribing antibiotics . (https://www.cdc.gov/antibiotic-use/core-elements/pdfs/Factsheet-Core-Elements-Creating-Culture-Improve-Use-508.pdf) 2a. During an interview on 3/15/23, at 11:12 a.m., the Infection Preventionist (IP) stated the facility used criteria to evaluate the use of antibiotics after the start of an antibiotic for an infection to determine if the antibiotic was appropriate. The IP confirmed the facility did not have criteria that was used prior to initiation of an antibiotic. The IP stated antibiotics were ordered based off of the urine test results. When asked how do you determine if there was a current infection or if the bacteria was colonized (germs on the body, but do not make you sick) based off of urine test results, without the presence of symptoms, the IP was unable to answer. During an interview on 3/15/23, at 2:50 p.m., the Director of Nursing (DON) stated a change in mental status meant the resident had a urinary tract infection and the doctor would be asked to order a urine test. When asked what evidence that was based on, the DON was unable to answer. During a concurrent interview and record review on 3/15/23, at 11:12 a.m., Resident 45's Long Term Care Data Collection Form, dated 1/31/23, was reviewed with the IP. The IP confirmed Resident 45 was on an antibiotic for an UTI, but did not meet the criteria for antibiotic usage post initiation of the antibiotic. The form indicated .UTI Resident does not have indwelling catheter Criteria 1 and 2 must be met . No criteria related to signs and symptoms of an UTI was marked in the first section (criteria 1). Review of Resident 45's NURSE'S PROGRESS NOTES, dated 1/31/23, indicated, -NOTED RESIDENT WAS ANXIOUS - RESTLESS SINCE THIS MORNING, WANTING TO GO HOME - INFORMED MD [medical doctor] ORDERED UA [urinary analysis] . No recorded symptoms noted of a suspected infection in the documentation. Review of Resident 45's GRAPHIC RECORD dated 1/28/23 through 2/9/23, did not indicated that Resident 45 had an elevated temperature. On 1/31/23 Resident 45's temperature was recorded as 97 degrees Fahrenheit (a unit of temperature measurement). Review of Resident 45's NURSE'S PROGRESS NOTES, dated 2/3/23, indicated, Resident is alert with confusion per baseline .She was prescribed with order ATB [antibiotics] for UTI . Review of an online document published by the Agency for Healthcare Research and Quality (AHRQ) titled, Suspected Urinary Tract Infection (UTI) In Long-Term Care Residents, dated 6/2021, indicated, Signs & Symptoms of a UTI For Residents Without a Urinary Catheter [:] Dysuria [discomfort when urinating] OR Fever (>100°F [greater than 100 degrees Fahrenheit; a unit of temperature measurement] or >2°F [greater than] above baseline) AND at least one of the following symptoms that is new or worsening: Urgency Frequency Suprapubic pain [lower abdomen near where your hips are] Gross hematuria [blood in the urine] Costovertebral angle tenderness [pain that results from touching an area on your back at the bottom of your ribcage] Urinary incontinence .[For dysuria OR fever AND at least one symptom listed above] Send a urinalysis (UA) & urine culture (UCx) Increase hydration Start antibiotics before UA and UCx results, if resident appears ill If UA & UCx are positive and the resident has ongoing UTI symptoms, modify antibiotics or start antibiotics (if not receiving active antibiotics) Do NOT Send a Urinalysis and Urine Culture: If the urine is foul smelling or cloudy, without other urinary symptoms Routinely after urethral catheter change Routinely upon admission After treatment to document care or test of cure For mental status changes (without vital sign changes or urinary symptoms for noncatheterized residents) . (www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/poster-4x6-UTI.pdf) 2b. Review of Resident 6's STATUS CHANGE NOTIFICATION AND/OR ORDERS, dated 5/17/22, indicated, .Specifics of Concern: RESIDENT NOTED [with] EXTREMELY DARK URINE, [increased] BEHAVIORS, [increased] CONFUSION, C/O [complained of] STOMACH PAIN. CAN WE HAVE AN ORDER FOR UA .PHYSICIANS'S RESPONSE .ok . The documented indicated Resident 6's temperature was 96.2 degrees Fahrenheit. Review of Resident 6's STATUS CHANGE NOTIFICATION AND/OR ORDERS, dated 5/24/22, indicated, Specifics of Concern .Please review results of final C&S [culture and sensitivity; A culture is a test to find germs (such as bacteria or a fungus) that can cause an infection. A sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection] .We see less PO [by mouth] intake lately too .PHYSICIAN'S RESPONSE .CEPHALEXIN [medication used to treat certain infections caused by bacteria] 500MG [milligrams, a unit of measurement] PO TID [three times a day] x 5D [for 5 days] . Review of the Agency for Healthcare Quality and Research's (AHRQ) Minimum Criteria for Antibiotics Tool, dated 9/2017, indicated, for a potential infection of a urinary tract infection smelly or cloudy urine is not a symptom of a UTI . If the resident does not have acute dysuria (pain when peeing) or a fever (higher then 100 degrees Fahrenheit or two repeated temperatures of 99 degrees Fahrenheit) and not at least two of the following symptoms: urgency, frequency, suprapubic pain (pain near the lower part of your stomach by your bladder), gross hematuria (blood in the urine), urinary incontinence (the loss of control of your urine), then the following was indicated: .Minimum criteria for initiating antibiotics are NOT MET .Consider initiating the following: Encourage liquid intake daily until urine is light yellow in color (suggest an amount and duration). Record fluid intake (suggest frequency and duration). Assess vital signs, including temp (suggest frequency and duration). Request notification if symptoms worsen or if unresolved (suggest duration) . (https://www.ahrq.gov/nhguide/toolkits/determine-whether-to-treat/antibiotic-tool.html)