**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident's medical record were clear and complete when licensed nurses (LN) did not consistently sign the Medication Administration Record (MAR) when the tube feeding (TF) formula was administered, and a TF order did not have a rate (the speed of the TF delivered to the stomach) order for 1 of 3 sampled residents (Resident 4). As a result, Resident 4's medical record was incomplete, which compromised the ability to track and verify the amount of TF formula administered. Findings: Resident 4 was admitted to the facility on [DATE] with diagnoses that included gastrostomy ( a surgical procedure to create an opening in the abdomen and into the stomach to allow for the insertion of a feeding tube) status. A review of Resident 4's medical record was conducted on 4/15/25. Per the hospital discharge record dated 2/26/25, under Order Instructions for preparing TF formula, give one pouch for the formula to be warmed in a warm water bath, poured into a TF bag, and diluted with 120 milliliters (ml) of sterile water. Once this was done. Hang the bag and set the TF rate at 60 ml per hour continuously. Resident 4 should receive three pouches of TF formula per day. Per the Facility Physician's Order Summary Report dated 2/27/25, Resident 4 had an order of every 24 hours 1 pouch of [name of the formula] has to be warmed in warmed water bath, poured into a TF bag, and diluted with 120 ml of warm sterile water. Once this is done, can hang bag and set TF rate. The TF rate and the total number of pouches were not written in the Order Summary. Per the Medication Administration Record, dated 2/27/25 through 3/4/25, Resident 4 had an order of every 24 hours 1 pouch of [name of the formula] has to be warmed in warmed water bath, poured into a TF bag, and diluted with 120 ml of warm sterile water. Once this is done, can hang bag and set TF rate. The TF rate and the total number of pouches were not recorded, and only one licensed nurse signed the MAR each day. On 4/15/25 at 3 P.M., an interview and joint record review was conducted with LN 2. LN 2 stated the licensed nurses had to administer the TF formula once every eight hours. LN 2 stated that he administered the TF formula to Resident 4 without signing the MAR. LN 2 stated he should have signed the MAR every time the TF was administered to Resident 4, so there would be a record of the number of pouches given per day, and there would be a record of the work he had done. LN 2 also stated that the MAR and the order summary should have a complete order that included the TF rate. LN 2 stated he could not be sure what Resident 4's TF rate was when the TF was administered to Resident 4. On 4/15/25 at 4:15 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated that the TF order in the MAR, and the order summary should include the TF rate. In addition, the DON stated that the LNs should have signed the MAR every time they started (began/provided) a new pouch, to ensure that the resident was provided three pouches per day. Per the facility's policy and procedure, dated 1/1/12, titled Enteral Feeding, .Calculate [the] amount of formula to be given per shift .document administration of enteral feeding .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to follow its animal policy and infection control protocols by allowing a cat to roam in and out of the facility unsupervised without documented flea and tick treatment, proper registration, or adherence to resident preferences. As a result, the facility failed to maintain a sanitary environment placing residents at risk of infection, allergic reactions, and environmental contamination. Findings: Resident 1 was admitted to the facility on [DATE] with a diagnosis of asthma (a chronic respiratory condition that causes inflammation and breathing difficulty) per the facility admission record. Resident 2 was admitted to the facility on 12.31/24 per the facility admission record. During an observation of the facility building and grounds on 1/28/25 at 2:25 PM a long black pole with a blue feather toy and a silver bell was seen propped up against the wall in the hallway of the facility outside administrative offices. A cat scratching post and a pet food water dish were observed on the back patio nearby a small shelter resembling a cat house was also visible. During an observation on 1/28/25 at 2:30 PM in the activity room, the facility activities director (AD) was seen interacting with residents watching television and painting one resident ' s fingernails. During an observation and interview on 1/28/25 at 2:45 PM the facility case manager/infection preventionist (CM IP) was seen carrying a gray colored cat down the hallway inside the facility. The cat appeared agitated with claws extended and was yowling. The CM/IP initially stated the cat belonged to a neighbor and had entered the facility but then admitted the cat belonged to the facility. The CM/IP acknowledged the cat was in and out of the facility and was a potential infection control risk if left unsupervised. During an interview and review of the cat ' s file and facility animal policy, on 1/28/25 at 3:28 PM, the AD stated she was responsible for the supervision of the cat. The AD stated that the facility used a cat spray on the floor in front of the doors of residents who did not want the cat in their room. The AD stated the cat was not registered. The AD stated the cat ' s file did not include documentation of flea and tick treatment or a formal bathing and grooming schedule for the cat. The AD acknowledged the facility policy on animals required the cat to be registered and have documentation of regular flea and tick treatment and a formal bathing and grooming schedule. The AD acknowledged the facility policy on animals was not being followed. The AD acknowledged residents were at risk of being exposed to infectious diseases and parasites carried by fleas and ticks if treatments were not completed and the cat did not have a bathing schedule. The AD acknowledged that the cat was seen in the facility unsupervised. During an interview at the facility on 1/28/25 at 3:53 PM, Certified Nursing Assistant (CNA) 1 stated the cat lays down in the nurse ' s station. CNA 1 stated the cat is put outside, unsupervised, to sleep at night. During an interview at the facility on 1/28/25 at 4:21 PM, Licensed Nurse (LN) 1 stated the activity department was responsible the cat ' s care. LN 1 stated the cat was allowed to roam inside and outside the facility. LN 1 stated the cat had been seen inside resident rooms. LN 1 stated there were multiple cats who wandered outside the facility. During an observation and interview on 1/28/25 at 4:52 PM at the facility, Resident 1 stated she was allergic to cats and did not want them in her room. Resident 1 stated she had found the cat lying at the bottom of her bed in the middle of the night. Resident 1 stated the cat had entered her room multiple times despite staff applying a spray to keep it out. Resident 1 stated the spray the facility used was ineffective because it was mopped up daily with bleach by housekeeping. Resident 1 further stated that she witnessed the cat in the hallway with a mouse in its mouth. Resident 1 stated she felt the cat was an infection control problem. During the interview a second black and white cat was seen outside Resident 1 ' s window inside of the locked and gated back patio. The cat was seen walking towards the laundry room. During an interview on 1/28/25 at 4:58 PM at the facility, Resident 2 stated the cat had entered the room on multiple occasions and that she had informed the facility she was allergic to cats. Resident 2 stated the facility used a spray on the floor outside the room to keep the cat out but that it did not work. During an interview on 1/28/25 at 3:33 PM, the DON stated she was familiar with the facility animal policy. The DON stated the AD is responsible for supervising the facility cat and making sure the facility is compliant with the animal policy. The DON stated she was aware the cat had not been registered. The DON stated she was aware the cat ' s file did not contain documentation of flea and tick treatments or include a bathing and grooming schedule as required by facility policy. The DON stated if the facility was not following the animal policy, then the facility was not implementing infection control measures to keep residents safe. The DON stated the cat should always supervised and should be going home with the AD at night. The DON stated she was aware the cat had been left at the facility unsupervised. The DON acknowledged the facility was not respecting resident rights if the cat was allowed to enter rooms of residents who had a cat allergy or expressed a desire to not have the cat in their room. A review of the facility policy, revised 1/1/2012, titled, Infection Control- Policies & Procedures; Infection Control Manual, indicated, Purpose: to provide infection control policies and procedures required for a safe and sanitary environment. Policy: The Facility ' s Infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections . A review of the facility policy, revised 11/1/2013, titled, Animals at the Facility, indicated, Purpose: to provide residents with the opportunity to enjoy pets in a safe and sanitary manner, as preferred. Policy: The Facility will ensure that all animals brought to the Facility are healthy and supervised. Additionally, Facility pets will be cared for in a manner that ensures the health of the animals and residents. Procedure: I. Facility Pets: A. The activity department will be responsible for maintaining a file on each facility pet. The file will include . v. Documentation of registration, vi. Documentation of flea/tick control . vii. Bathing and grooming schedule . D. Pets shall be kept on a leash when walking outside of the Facility, E. Pets will be supervised at all times by activity staff or designee . F. Pets will have a designated area to sleep in at night, or be taken home by a Facility Staff member . H. The Director of Activities will assume the responsibility of care for pets . Based on observation, interview and record review the facility failed to follow its animal policy and infection control protocols by allowing a cat to roam in and out of the facility unsupervised without documented flea and tick treatment, proper registration, or adherence to resident preferences. As a result, the facility failed to maintain a sanitary environment placing residents at risk of infection, allergic reactions, and environmental contamination. Findings: Resident 1 was admitted to the facility on [DATE] with a diagnosis of asthma (a chronic respiratory condition that causes inflammation and breathing difficulty) per the facility admission record. Resident 2 was admitted to the facility on 12.31/24 per the facility admission record. During an observation of the facility building and grounds on 1/28/25 at 2:25 PM a long black pole with a blue feather toy and a silver bell was seen propped up against the wall in the hallway of the facility outside administrative offices. A cat scratching post and a pet food water dish were observed on the back patio nearby a small shelter resembling a cat house was also visible. During an observation on 1/28/25 at 2:30 PM in the activity room, the facility activities director (AD) was seen interacting with residents watching television and painting one resident's fingernails. During an observation and interview on 1/28/25 at 2:45 PM the facility case manager/infection preventionist (CM IP) was seen carrying a gray colored cat down the hallway inside the facility. The cat appeared agitated with claws extended and was yowling. The CM/IP initially stated the cat belonged to a neighbor and had entered the facility but then admitted the cat belonged to the facility. The CM/IP acknowledged the cat was in and out of the facility and was a potential infection control risk if left unsupervised. During an interview and review of the cat's file and facility animal policy, on 1/28/25 at 3:28 PM, the AD stated she was responsible for the supervision of the cat. The AD stated that the facility used a cat spray on the floor in front of the doors of residents who did not want the cat in their room. The AD stated the cat was not registered. The AD stated the cat's file did not include documentation of flea and tick treatment or a formal bathing and grooming schedule for the cat. The AD acknowledged the facility policy on animals required the cat to be registered and have documentation of regular flea and tick treatment and a formal bathing and grooming schedule. The AD acknowledged the facility policy on animals was not being followed. The AD acknowledged residents were at risk of being exposed to infectious diseases and parasites carried by fleas and ticks if treatments were not completed and the cat did not have a bathing schedule. The AD acknowledged that the cat was seen in the facility unsupervised. During an interview at the facility on 1/28/25 at 3:53 PM, Certified Nursing Assistant (CNA) 1 stated the cat lays down in the nurse's station. CNA 1 stated the cat is put outside, unsupervised, to sleep at night. During an interview at the facility on 1/28/25 at 4:21 PM, Licensed Nurse (LN) 1 stated the activity department was responsible the cat's care. LN 1 stated the cat was allowed to roam inside and outside the facility. LN 1 stated the cat had been seen inside resident rooms. LN 1 stated there were multiple cats who wandered outside the facility. During an observation and interview on 1/28/25 at 4:52 PM at the facility, Resident 1 stated she was allergic to cats and did not want them in her room. Resident 1 stated she had found the cat lying at the bottom of her bed in the middle of the night. Resident 1 stated the cat had entered her room multiple times despite staff applying a spray to keep it out. Resident 1 stated the spray the facility used was ineffective because it was mopped up daily with bleach by housekeeping. Resident 1 further stated that she witnessed the cat in the hallway with a mouse in its mouth. Resident 1 stated she felt the cat was an infection control problem. During the interview a second black and white cat was seen outside Resident 1's window inside of the locked and gated back patio. The cat was seen walking towards the laundry room. During an interview on 1/28/25 at 4:58 PM at the facility, Resident 2 stated the cat had entered the room on multiple occasions and that she had informed the facility she was allergic to cats. Resident 2 stated the facility used a spray on the floor outside the room to keep the cat out but that it did not work. During an interview on 1/28/25 at 3:33 PM, the DON stated she was familiar with the facility animal policy. The DON stated the AD is responsible for supervising the facility cat and making sure the facility is compliant with the animal policy. The DON stated she was aware the cat had not been registered. The DON stated she was aware the cat's file did not contain documentation of flea and tick treatments or include a bathing and grooming schedule as required by facility policy. The DON stated if the facility was not following the animal policy, then the facility was not implementing infection control measures to keep residents safe. The DON stated the cat should always supervised and should be going home with the AD at night. The DON stated she was aware the cat had been left at the facility unsupervised. The DON acknowledged the facility was not respecting resident rights if the cat was allowed to enter rooms of residents who had a cat allergy or expressed a desire to not have the cat in their room. A review of the facility policy, revised 1/1/2012, titled, Infection Control- Policies & Procedures; Infection Control Manual, indicated, Purpose: to provide infection control policies and procedures required for a safe and sanitary environment. Policy: The Facility's Infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections . A review of the facility policy, revised 11/1/2013, titled, Animals at the Facility, indicated, Purpose: to provide residents with the opportunity to enjoy pets in a safe and sanitary manner, as preferred. Policy: The Facility will ensure that all animals brought to the Facility are healthy and supervised. Additionally, Facility pets will be cared for in a manner that ensures the health of the animals and residents. Procedure: I. Facility Pets: A. The activity department will be responsible for maintaining a file on each facility pet. The file will include . v. Documentation of registration, vi. Documentation of flea/tick control . vii. Bathing and grooming schedule . D. Pets shall be kept on a leash when walking outside of the Facility, E. Pets will be supervised at all times by activity staff or designee . F. Pets will have a designated area to sleep in at night, or be taken home by a Facility Staff member . H. The Director of Activities will assume the responsibility of care for pets .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to obtain a physician order to provide services in accordance with standards of care when admission orders for one resident, (Resident 1), did not include blood glucose monitoring (a process of regularly measuring the amount of sugar in the blood) before each meal and before bed. This failure had the potential for Resident 1 ' s blood glucose level to be undetected and untreated. Findings: On 10/17/24 the State Agency (SA) received a complaint that indicated Resident 1 ' s blood glucose was checked once per day and reached 477 (elevated above 70-99, a recommended range). Resident 1 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus type two (a disease in which blood sugar is higher than normal and can cause permanent damage to the body). On 10/21/24 at 12:10 P.M. an unannounced visit was conducted at the facility. Resident 1 was discharged from the facility on 9/30/24. On 10/21/24 at 12:30 P.M. an interview was conducted with Licensed Nurse (LN) 2 who stated, We do blood glucose checks before meals. If there ' s no order for that, I ' d call the doctor. On 10/21/24 at 4:10 P.M. an interview and concurrent record review were conducted with the Director of Nursing (DON). Resident 1 ' s physician orders indicated she was receiving two types of insulin upon admission. The admission orders indicated blood glucose monitoring was to be performed once per day at 5 P.M. A joint review of Resident 1 ' s blood glucose monitoring indicated documentation started on 9/13/24 at 8:24 A.M. and continued once per day until 9/25/24 when monitoring happened three times, four times on 9/26/24, two times on 9/27/24, four times on 9/28/24, five times on 9/29/24, and three times on 9/30/24 which was the date of Resident 1 ' s discharge. A joint review of a change of condition document dated 9/25/24 indicated, Patient ' s husband requested to have her blood sugar checked as he stated she was acting differently.Blood sugar check result 477. MD (Medical Doctor) notified. 9/25/24 2030 (8:30 P.M.) awaiting reply. The DON stated when they come from the hospital we continue the orders. The physician ordered monitoring once per day. We did not question the frequency of monitoring that was ordered. The order for blood glucose checks increased to four times a day on 9/26/24 after her husband brought up a concern. The DON stated the facility practice regarding blood glucose monitoring of a resident on insulin was usually before each meal and sometimes also at bedtime. A joint review of the facility policy titled Diabetic Care indicated, A Licensed Nurse will monitor the resident ' s blood glucose per the Attending Physician ' s order and will administer medication as indicated. The policy was requested but not received from the facility. On 10/22/24 at 12:15 P.M. a telephone interview was conducted with the DON who stated, The resident did not receive any extra insulin for the blood glucose of 477. An internet search for standard of care for blood glucose monitoring was performed. A review of National Institute of Health, National Library of Medicine StatPearls titled Blood Glucose Monitoring dated April 23, 2023 indicated, Blood glucose testing is recommended before meals and bedtime for clients who can eat retrieved 10/22/24 from https://www.ncbi.nlm.nih.gov/books/NBK555976.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a written notice of discharge to one of three sampled discharged residents (8). As a result, Resident 8 was not fully informed regarding his discharge. Findings: Per the facility's admission Record, Resident 8 was admitted to the facility on [DATE] with diagnoses to include osteomyelitis (bone infection). On 9/12/24 a review was conducted of Resident 8's medical record. Per the facility's Progress Note, dated 9/4/24 at 12:42 P.M., Resident 8 was transferred to an acute care hospital for a change in condition and was awake at the time of transfer. There was no documentation on 9/4/24 that Resident 8 was provided with a Notice of Proposed Transfer and Discharge form prior to his transfer. On 9/12/24 at 3:26 P.M., an interview was conducted with Licensed Nurse (LN) 6. LN 6 stated, Resident 8 went to the hospital due to a change in his condition and was awake at the time of discharge. LN 6 further stated, he did not provide any paperwork to Resident 8 at the time of discharge, and he was not familiar with the Notice of Proposed Transfer and Discharge form. On 9/12/24 at 4:02 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated, when a resident was sent to an acute care hospital the Social Worker (SW) was responsible for providing the Notice of Proposed Transfer and Discharge form to the resident. On 9/13/24 at 8:28 A.M., an interview was conducted with the SW. The SW stated, the licensed nurses were responsible for providing the Notice of Proposed Transfer and Discharge form to residents when they were transferred to an acute care hospital. Per the facility's policy, titled Discharge and Transfer of Residents, revised February 2018, .The resident/resident representative will be provided with a Notice of Proposed Transfer and Discharge 30 days prior to discharge or as soon as practicable .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a written notice of the facility's bed hold policy at the time of discharge to one of three sampled discharged residents (8). As a result, Resident 8 was not fully informed of his bed hold rights. Findings: Per the facility's admission Record, Resident 8 was admitted to the facility on [DATE] with diagnoses to include osteomyelitis (bone infection). On 9/12/24 a review was conducted of Resident 8's medical record. Per the facility's Progress Note, dated 9/4/24 at 12:42 P.M., Resident 8 was transferred to an acute care hospital for a change in condition and was awake at the time of transfer. There was no documentation on 9/4/24 or 9/5/24 that Resident 8 was provided with a written notice of the facility's bed hold policy. Per the facility's Bed Hold Agreement, signed by Resident 8 on 1/17/24 (at the time of admission), the portion of the form titled, Notification of Bed Hold Option Upon Transfer/Therapeutic Leave was not completed. The form was blank for the sections on which acute care hospital Resident 8 transferred to, what day and time he left, who notified him of the bed hold option, when he was notified, and the location for staff to sign that they completed the form. On 9/12/24 at 3:26 P.M., an interview was conducted with Licensed Nurse (LN) 6. LN 6 stated, Resident 8 went to the hospital due to a change in his condition and was awake at the time of discharge. LN 6 further stated, he transferred Resident 8 to the hospital and did not provide a written notice of bed hold. On 9/12/24 at 3:38 P.M., an interview was conducted with the Admissions Coordinator (AC). The AC stated, when a resident was sent to a hospital, the licensed nurses were responsible for offering the bed hold at the time of discharge if the resident was awake, otherwise she would notify the resident's responsible part by phone the following day. The AC stated that when she called to offer the bed hold, she did not provide a written notice of bed hold to the resident or resident representative. On 9/12/24 at 4:02 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated, when a resident was sent to an acute care hospital the facility did not provide a written notice of the facility's bed hold policy. Per the facility's policy, titled Bed Hold, revised July 2017, .The Facility notifies the resident and/or representative, in writing, of the bed hold, option any time the resident is transferred to an acute care hospital .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physician of a resident's low blood sugar readings, and did not monitor fluid intake and output for two of 12 sampled residents (1, 29). As a result, Resident 1 did not receive treatment for low blood sugar, and the facility could not determine if Resident 29 had proper fluid intake and adequate output, which may have lead to the late detection of fluid abnormalities in the body. Findings: 1. Per the facility's admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses to include diabetes (disease of abnormal blood sugar). A record review was conducted. Per the facility's Orders, there was an order on 11/29/23 to check Resident 1's blood sugar before giving insulin (a medication to lower blood sugar), and to notify the physician if it was less than 70 milligrams (mg)/deciliter (dl). Per the facility's Weights and Vitals Summary, on 8/9/24 at 4:46 P.M., Resident 1's blood sugar reading was 13 mg/dl, and on 8/17/24 at 12:13 P.M., Resident 1's blood sugar reading was 59 mg/dl. On 9/12/24 a review was conducted of Resident 1's medical record. There was no documentation on 8/9/24 or 8/17/24 to show that staff notified Resident 1's physician of the blood sugar readings less than 70 mg/dl, any attempts to raise Resident 1's blood sugar, or any rechecks of Resident 1's blood sugar. Licensed Nurse (LN) 1 was not available for interview. On 9/12/24 at 3:43 P.M., an interview was conducted with LN 2. LN 2 stated, she should have offered Resident 1 a snack, rechecked the blood sugar, notified the physician, and documented what she did. On 9/12/24 at 3:53 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated, for Resident 1's low blood sugar readings on 8/9/24 and 8/17/24, the nurses should have given Resident 1 a sugary snack, rechecked the blood sugar, notified the physician, and documented what they did. Per the facility's policy, titled Blood Glucose Monitoring, revised 4/27/23, .Notify the healthcare provider of a Blood Sugar Level lower than 70 . 2. Per the facility's admission Record, Resident 30 was admitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease (kidney problem). A review of Resident 30's medical record was conducted. Per the Order Summary, dated 5/15/24, Resident 30's fluid intake and output were to be monitored. Per the same document, dated 7/26/24, Resident 30 was to restrict fluid intake to one liter daily. There was no evidence that Resident 30's fluid intake and output were being monitored and assessed. On 9/13/24 at 8:09 A.M., an interview and record review was conducted with LN 6. LN 6 stated he could not show evidence that the fluid restriction was consistently followed or if the assessments were done. On 9/13/24 at 9:19 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated fluid intake and output should have been monitored and evaluated after seven days. Per the facility's policy and procedure, dated 4/15/21, titled Intake and Output Recording, .Fluid Restriction after seven days of the initial order will be reevaluated .Intake and output will be monitored and recorded per the physician's order.

Based on observation, interview, and record review, the facility failed to ensure that opened dressings in the refrigerator were labeled with an open date and that the freezer's foods were stored per the facility's policy and procedure. These failures placed residents at risk of acquiring foodborne illness and may have caused the texture of the food in the freezer to become less palatable. Findings: On 9/10/24 at 7:42 A.M., an initial tour of the kitchen was conducted with the Dietary Manager (DM). It was observed in the reach-in refrigerator that two large jars of dressings were opened, and there was no date. In addition, inside the reach-in freezer, there was a large sealable bag full of air, containing chicken thighs that had icicles built up on the meat. There was also an opened clear bag of diced chicken which was manually tied to close the item. On 9/10/24 at 8:07 A.M., an interview was conducted with the DM. The DM stated that opened items should be labeled and dated. Items in the freezer should have been stored appropriately. Per the facility's policy and procedure, dated 6/4/24, titled Dietary Services: Food Storage and Handling, .Refreezing of defrosted food is not recommended .Foods to be frozen should be stored in airtight containers or wrapped in heavy-duty aluminum foil or special laminated papers .label and date all food items .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed when: (1) The nebulizer (a small machine that turns liquid medicine into a mist that gets inhaled into the lungs), mask, and cup (contains liquid medicine for the nebulizer) were not cleaned and bagged after each use, per the facility's policy, and (2) The water waste management program was not implemented. These deficient practices placed residents at risk for infections. Findings: 1. Resident 29 was re-admitted to the facility on [DATE] with diagnoses which included Respiratory Failure (breathing problem), per the admission Record. On 9/11/24 at 10:09 A.M., Resident 29's nebulizer machine was observed on top of the dresser with a long clear tubing attached to the machine. The clear tubing was hung on the privacy curtain and down tuck inside the drawer. Inside the drawer were opaque-colored nebulizer cup and masks attached to the tubing. On 9/11/24 at 10:12 A.M., Resident 29 stated the licensed nurse (LN) administered his nebulizer treatment this morning. On 9/11/24 at 2:18 P.M., a joint observation and interview was conducted with LN 5. LN 5 stated he administered the nebulizer treatment to Resident 29 at 9 A.M. and 1 P.M. LN 5 further stated he did not clean the nebulizer mask and cup after administering the medication to Resident 29, but he should have. On 9/13/24 at 9:50 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated that the nebulizer mask and cup should be rinsed with water, dried, and placed in the bag after use. Per the facility's policy and procedure, dated 10/15/20, titled Nebulizer (small volume), .Drain any condensate from the nebulizer, rinse nebulizer cup with sterile normal saline or water and empty. Dry the nebulizer cup by placing the nebulizer in the Resident's equipment bag and leaving the compressor on for approximately ten minutes . 2. On 9/13/24 at 8:45 A.M., an interview and record review of the waste management program was conducted with the Maintenance Director (MAIN). The MAIN stated he was testing the water monthly and quarterly but ran out of the testing kit two months ago. In addition, the MAIN could not provide documented evidence of monitoring and tracking the water system. Per the facility's policy and procedure, dated 5/25/23, titled Water Management, .Quarterly measurement of the water quality throughout the system to ensure changes that may lead to Legionella growth are not occurring .Monthly monitoring of chlorine levels .

Based on interview and record review, the facility failed to ensure the Infection Control Preventionist (ICP) completed the specialized infection and prevention training. This failure could result in the ICP not being knowledgeable or qualified to perform the duties to prevent the spread of infection. Findings: On 9/13/24 at 9:37 A.M., an interview and record review was conducted with the Infection Preventionist Nurse (IPN). The IPN stated she was helping with the infection control prevention program, and the designated IPN quit, leaving her to do the job. IPN further stated she did not have the chance to do the required specialized training. On 9/13/24 at 11:38 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the designated ICP should have had the required training. Per the facility's policy and procedure, dated 2/19/21, titled Infection Preventionist, .[The Infection Preventionist] Have education, training, expertise or certification in specialized infection control and prevention practices .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to fully prepare three of four sampled residents, (1, 2, 4) for discharge in accordance with the facility discharge policy. Findings: A review of the facility policy entitled Discharge and Transfer of Residents revised February 2018 indicated, .When a resident is admitted to the Facility, Facility Staff will initiate a discharge plan. The resident/ resident representative will be provided with a Notice of Proposed Transfer and Discharge 30 days prior to discharge or as soon as practicable. When the resident is near a planned discharge, the Interdisciplinary Team (IDT) will complete a Discharge Summary/ Post Discharge Plan of Care. Nursing Staff will complete a Discharge Summary/ Post Discharge Plan of Care for each resident, which will include a recapitulation of the resident ' s stay and final summary of the resident ' s status . 1. Resident 1 was admitted to the facility on [DATE] with diagnoses that included bilateral lower extremity lymphedema (a condition in which fluid that comes from the liquid part of the blood builds up in tissues causing swelling) with cellulitis (an infection of the skin) and maggot infestation and homelessness. Resident 1 was discharged from the facility on 4/6/24. Resident 1 was not provided with a Notice of Proposed Discharge. 2. Resident 2 was admitted to the facility on [DATE] with diagnoses that included rhabdomyolysis (breakdown of muscle tissue that releases chemicals into the blood that can cause kidney damage), difficulty in walking, and need for assistance with personal care. Resident 2 was discharged from the facility on 4/1/24. Resident 2 received a Notice of Proposed discharge on [DATE], the same date as her discharge. 3. Resident 4 was admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit (difficulty communicating because of injury to the brain), toxic encephalopathy (brain dysfunction caused by exposure to a toxin), acute systolic heart failure (failure of the bottom left chamber of the heart), obstructive sleep apnea (a disorder in which a person frequently stops breathing during sleep), acquired absence of right leg below knee (removal of the leg below the knee), unsteadiness on feet, and need for assistance with personal care. Resident 4 was discharged from the facility on 4/23/24. Resident 4 received a Notice of Proposed discharge on e day prior to discharge. Direct care staff for Residents 1, 2 and 4 were not available for interview during the on-site investigation. On 5/6/23 at 1:25 P.M., an interview and concurrent record review were conducted with the Director of Nursing (DON) and Social Worker (SW). The SW stated her role in the discharge process was to assist with resources, find placements, create referrals for Home Health/ ILF/ ALF. The SW stated, I find out where they live during the first interview with the resident. I ask if they have income. I ask where they want to go, and invite them to CP/ IDT meetings, talk with them about their plans. The DON stated Resident 1 ' s discharge care plan was template interventions (a software generated selection that is not specialized to a patient), not resident centered and specific, and there were no interventions for adjustment to living in a shelter or car with new medical needs. The SW stated the facility did not provide Resident 1 with a Notice of Proposed Discharge. A concurrent record review of a nursing discharge note dated 4/6/24 at 11 A.M. indicated, discharge: friend ' s business (address). A record review of the IDT Discharge Planning Review note dated 4/5/24 signed by the SW indicated the review was done one day prior to Resident 1 ' s discharge. On 5/6/23 at 2:30 P.M., an interview and concurrent record review were conducted with the DON and SW regarding Resident 2. The DON stated Resident 2 ' s discharge care plan did not have specific interventions regarding her goals. A concurrent review of the Notice of Proposed Transfer and discharge date d 4/1/24 was conducted. The SW stated Resident 2 had been in the facility for several months but was not given the notice 30 days prior to discharge. The SW stated, There was no notice given in advance, she got it the same day she discharged . A review of the IDT Discharge Planning Review note dated 3/31/24 signed by the SW indicated the review was done one day prior to Resident 2 ' s discharge. No nursing discharge note was produced during or after the onsite investigation. On 5/6/24 at 3:20 P.M., an interview and concurrent record review were conducted with the DON and SW regarding Resident 4. The DON stated Resident 4 did not have a discharge care plan. The SW stated the first discharge planning note was on 4/19/24, one month after Resident 4 was admitted . The SW stated, Patient was aware of discharge to shelter, he has no home. No one at a shelter can be relied on to provide needed assistance. I didn ' t document his last covered day. We could have still skilled him (changed billing status within the facility), I don ' t know what happened. Everyone at IDT knew he needed assistance. He wanted to try ALF/ ILF. I don ' t know why we discharged this resident. The SW stated no 30-day notice of discharge was given though Resident 4 was at the facility for more than 30 days. The DON stated, We do not have a discharge note. The DON and SW acknowledged the facility did not implement all steps of the facility discharge process as indicated in the facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide supervised and assisted ambulation to one of one sampled Residents, (1), at high risk for falls. This failure resulted in Resident 1 experiencing an unwitnessed fall that resulted in a broken bone in her left ankle. Findings: Resident 1 ' s admission Record indicated admission to the facility on 5/5/22, and included diagnoses of paranoid schizophrenia (a pattern of thoughts, feelings and behaviors that include suspicion of others), generalized muscle weakness, essential hypertension (high blood pressure often requiring medication that can have side effects increasing risk for falls) and cognitive communication deficit (difficulty with thinking and communication). A review of the Minimum Data Set (MDS) section GG dated 11/11/23 indicated Resident 1 required supervision or touching assistance (assistance from one person) for toileting hygiene, lower body dressing, chair and bed to chair transfer, walking 10 feet or more. The MDS indicated Resident 1 required set up or clean up assistance with toilet transfer. A review of facility Change of Condition (COC) note dated 1/26/23 indicated Resident 1 had an unwitnessed fall on her right knee on the physical therapy patio. A review of the facility COC note dated 2/28/23 indicated Resident 1 had a witnessed fall on the floor with her walker directly in front of her. A review of the facility COC note dated 3/14/23 indicated Resident 1 had an unwitnessed fall and was found on the left side of her bed with her head between her bed and the side dresser, Patient said she hit her head and has level seven out of ten pain in her right leg. A review of the facility COC noted dated 5/3/25 indicated Resident 1 had an unwitnessed fall and was found kneeling by her bedside. A review of the facility COC note dated 2/2/24 indicated Resident 1 had an unwitnessed fall and was found on the floor in front of toilet with her underwear on but pants around calves and stated I fell. ' An observation of Resident 1 ambulating in the hallway with a walker was conducted on 2/15/24 at 1:10 P.M. During the observation, Resident 1 did not have assistance or supervision from a staff member. Resident 1 was noted to walk with a limp on her left side. In an interview with the Director of Nursing (DON) conducted on 2/15/24 at 1:30 P.M., the DON stated at the time of the most recent fall (Resident 1) had a Brief Interview for Mental Status (BIMS) of 11 (moderate cognitive impairment). The DON stated, (Resident 1) was heard by a nurse asking for help in the bathroom. The nurse went in and saw the resident on the floor. A concurrent review of the Change of Condition (COC) note by Licensed Nurse (LN) 1 indicated, On 2/2/24 at approximately 9:20 P.M. the call light was on. Someone mumbled ' help me. ' Upon entry resident found on floor with pants down and underwear on. Resident stated, ' I fell. ' In an interview with LN 2 conducted on 2/15/24 at 1:50 P.M., LN 2 stated, She needs set up and clean up assistance for toilet transfer and ability to get on and off commode. You can ' t see her room from the nurse ' s station. In a joint interview with LN 3 and the DON conducted on 2/15/24 at 2:15 P.M., LN 3 stated Resident 1 was not on a bowel and bladder program (a schedule for elimination of the bladder and bowel). The DON stated, Bowel and bladder training means a staff member goes to help the Resident use the restroom every two hours, after meals and before sleep at night. An interview with LN 3 was conducted on 3/13/24 at 1:10 P.M. LN 3 stated the most recent interventions in Resident 1 ' s fall care plan dated 5/5/23 included anticipate and meet resident needs. A toileting program is a way to anticipate a resident need. A review of the Physical Therapy evaluation dated 5/5/22 indicated Resident 1 could walk 10 feet with maximum assistance (assistance of 75% or more from one person), move from sitting to standing with maximum assistance, transfer to a toilet with maximum assistance, and that both of her legs were impaired. A review of Resident 1 ' s fall risk assessment dated [DATE], prior to the fall on 2/2/24, indicated her score was 12 which was noted as high risk r/t (related to) taking more narcotic (prescribed controlled substance for pain relief which may increase risk of falls)/ psychotropic (prescribed medication for some psychiatric diagnoses which may increase risk of falls) meds (medications). A review of the facility policy titled Fall Management Program revised March 13, 2021 indicated The Facility will implement a Fall Management Program that supports providing an environment free from fall hazards. A review of the facility policy titled Ambulation of a Resident revised January 1, 2012 indicated, Unless contraindicated, all assisted ambulation will utilize gait belts for resident and staff safety. Offer verbal encouragement and physical support.

Based on observation, interview and record review, the facility failed to provide resident safety for 1 resident (Resident 1) when Resident 1 eloped (leaving the facility unsafely or unescorted) from the facility ' s exit door which was equipped with an audible alarm. As a result, Resident 1 had a successful elopement and there was the potential risk for the elopement of other residents. Findings: On 11/22/23 the Department of Public Health received a facility report of an elopement for Resident 1 on 11/22/23 at 4:30 A.M. During a review of Resident 1 ' s facility record on 11/22/23 at 7:05 A.M., the record indicated .around 4;30[sic] am resident up on wheelchair and verbally responsive, no c/o[sic] and any discomfort.at[sic] 5Am[sic] went to resident room and unable to find resident on her room checked the whole building. But resident nowhere to found and call 911 and informed resident is missing and gave description of resident . During a review of Resident 1 ' s facility record on 11/23/23 at 7:41 A.M., the record indicated, .Spoke to Sheriff .Deputy will give the facility a call if they find the resident. If ever they don ' t call. That means she is not found yet . On 11/22/23 at 1: 38 P.M., an observation of the facility was conducted. The facility building had two entrances/exits. The facility entrance/exit had one main entrance with steps from outside and one entrance/exit with a ramp from outside. These two entrances/exits were connected to the two hallways in the building where resident rooms were located. On 11/22/23 at 2: 45 P.M., a phone interview was conducted with CNA 1 with the DON 1 present. CNA 1 stated Resident 1 was last seen on 9/2/23 around 4:30 A.M. near the hallway in a wheelchair. CNA 1 stated around 5:20 A.M. to 5:30 A.M., LN 2 was looking for Resident 1. CNA 1 stated he was making rounds on the other side of the building on the other hallway. CNA 1 stated he was inside another resident's room attending to the morning care and could not hear when the entrance/exit audible alarm sounded. On 11/22/23 at 3:30 P.M., an observation and interview was conducted with CNA 2. The entrance/exit with ramp from outside made an audible alarm when opened. CNA 2 stated the purpose of the audible alarm was to alert staff when residents were going out the building. On 11/22/23 at 3: 39 P.M. an observation and interview was conducted with LN 1. LN 1 demonstrated how the audible alarm could be heard as long as the entrance/exit door was held open. LN 1 stated the audible alarm was to alert staff and prevent elopement of residents. On 11/22/23 at 3: 40 P.M. a phone interview with LN 2 was conducted with the DON 1 present. LN 2 stated Resident 1 was out of bed on 11/22/23 early around 4:30 AM. to 5:30 A.M. LN 2 stated Resident 1 was looking for coffee but informed her the kitchen was still closed. LN 2 stated this was during LN 2 ' s med pass (administration of medications to residents). LN 2 stated when it was time to give medication to Resident 1, Resident 1 was nowhere to be found. LN 2 stated we looked for Resident 1 in every room and around the building. LN 2 stated around 4:30 to 5 A.M. he was on the other side of the building. LN 2 stated the entrance/exit doors were closed which meant no one from outside could open them. LN 2 stated people from inside the building could push open the entrance/exit door per fire safety compliance. LN 2 stated the entrance/exit door audible alarm was on at the time of Resident 1 ' s elopement. LN 2 stated Resident 1 must have eloped from the entrance/exit with ramp outside because he was passing medications on the other side of the building and Resident 1 was in a wheelchair. LN 2 stated the CNAs working that time were providing care in other resident rooms. LN 2 stated the purpose of the audible alarm was to alert staff that someone was going out the entrance/exit door. LN 2 stated the employees were not able to hear the audible alarm when inside other resident ' s rooms and Resident 1 eloped as a result of staff not hearing the audible alarm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their abuse policy when Resident 1 claimed an allegation of sexual abuse. This failure had the potential for Resident 1 to not receive the appropriate follow up care. Findings: Resident 1 was admitted to the facility on [DATE], per the undated admission Record. A record review was conducted on 7/27/23. Per a Minimum Data Set (an assessment tool) Basic interview for Mental Status (BIMS) score, dated 7/1/23, Resident 1 had mildly impaired cognition. Per an Alert Note, dated 7/26/23 at 11:42 A.M., Licensed Nurse (LN) 1 documented Resident 1 had reported being sexually assaulted the previous night. LN 1 documented she conducted an assessment and found no evidence of bruising, abrasions, or discoloration on Resident 1's skin. Per a Progress Note, dated 7/26/23 at 11:50 A.M., the Administrator (Admin) documented she had received a report that Resident 1 had been sexually assaulted by another resident. The Admin and LN 1 documented an interview with Resident 1. Per a Progress Note, dated 7/26/23 at 2:46 P.M., the Admin documented she had reported the allegation to the police, and alerted other agencies of the incident. Per a facility policy, revised March 2018 and titled, Abuse-Reporting & Investigations, Purpose To protect the health, safety, and welfare of facility residents by ensuring that all reports of resident abuse .and suspicion of crimes are promptly reported and thoroughly investigated .II. Immediate Action .iv. Upon receiving allegations of sexual abuse, the Administrator or designated representative will notify the Attending Physician to promptly examine the resident or obtain an order to transfer Resident to the acute hospital for examination . On 7/27/23 at 12 P.M., an interview was conducted with the Director of Nursing. The DON stated two nurses had examined Resident 1 following her allegation, but they had not requested the physician to either examine the resident or send her out to the hospital as directed by their policy. On 7/27/23 at 12:20 P.M., an interview was conducted with LN 1. LN 1 stated she had examined Resident 1 for injury following the report of sexual abuse. LN 1 stated she looked for signs of bruising on Resident 1's thighs and legs but did not remove her brief. LN 1 stated she had not been told by the Admin to send Resident 1 to the hospital or to request the physician come in to conduct an exam. On 7/27/23 at 12:34 P.M., an interview was conducted with the Admin. The Admin stated she was the Abuse Coordinator for the facility. The Admin stated she did not direct LN 1 to call the physician to examine Resident 1, or to send her to the acute hospital for evaluation per policy. The Admin stated she did not provide a copy of the policy to LN 1, and as the Abuse Coordinator she was responsible for following all aspects of the Abuse policy. On 7/27/23 at 1 P.M., an interview was conducted with the [NAME] President of Operations (VPO). The VPO stated, An incident like this is escalated through Corporate, we take this seriously. Even if the allegation is unbelievable. Escalation includes a review of the policy.

Based on observation, interview and record review, the facility did not deliver mail to four of four Confidential Residents (CR 1, CR2, CR3, CR4) on Saturdays. This deficient practice did not ensure the resident's right to receive and send mail was met. Findings: On 02/16/22 at 10 A.M., the resident council meeting took place in the conference room. CR 2 stated, We haven't been getting mail on Saturdays for several months now. I would like to get my mail on Saturdays. CR 3 stated, I have never received mail on Saturdays. I would like to get mail on Saturday or Sunday. CR 1 stated, No, I've never gotten my mail on Saturday or Sunday. CR 4 stated, I would like to get mail on Saturday or Sunday. CR 1, 2, 3 and 4 all stated they did not get mail delivered to them on Saturdays. On 02/16/22 at 4:51 P.M., an interview was conducted with the MRD (Medical Records Director) and ICP (Infection Control Preventionist). The MRD stated, The Activities department was responsible for passing out mail. The ICP stated, If mail came in on Saturday, it should have been delivered to the residents the following Monday by the Activities Director (AD). Per the facility's policy titled Resident Rights-Mail dated 1/1/2012, .Procedure . IV. Mail is delivered to the resident within twenty-four (24) hours of delivery to premises or to the Facility's post office box (including Saturday deliveries).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to give a complete and accurate Notice of Medicare Non-Coverage (NOMNOC) for one of three sampled residents (100) reviewed for beneficiary notification. As a result, Resident 100 did not receive adequate information to make an appeal. Findings: Resident 100 was admitted to the facility on [DATE] with diagnoses which included asthma (breathing problem) and hypertension (high blood pressure), and congestive heart failure (congestion in the heart) per the facility's admission Record and physician's history and physical. On 2/17/22, a record review was conducted of Resident 100. Resident 100 was discharged to an independent living facility on 9/4/21. The facility's form titled Notice of Medicare Provider Non-Coverage form contained blank lines under the sections, Date, Time, Spoke to, at:, Relationship to Patient, Signature, and Title. In addition, the facility's typewritten telephone number on the form was missing a digit making it impossible to contact the facility for any questions. On 2/18/22 at 8:28 A.M., an interview was conducted with the MRD (Medical Records Director). The MRD stated staff should have signed their name and filled out the form completely to indicate that the resident received the explanation and understood the notice. In addition, the MRD acknowledged the facility's telephone number was missing a digit making it difficult to residents to contact the facility. On 2/18/22 at 8:37 A.M., an interview was conducted with the SSD (Social Services Director). The SSD stated the process was to explain the coverage days to the resident or the family member then sign the form to indicate an explanation was done. The SSD reviewed Resident 100's NOMNOC form and acknowledged that the form was incomplete, and the facility's telephone number was missing a digit. The SSD further stated, The resident could not call the facility if he had any questions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to safeguard and accurately identify a resident's medical record for one of 12 sampled residents (156). This failure had the potential for residents' private medical information to be visible to unauthorized persons. Findings: Resident 156 was admitted to the facility on [DATE] with diagnoses which included Covid-19 (an infectious virus (corona virus) affecting respiratory system) per the physician's history and physical note. On 2/16/22 at 7:58 A.M., an observation was conducted of the facility's hallway. Next to a zippered plastic divider was an isolation cart. On top of the cart were two facility documents titled Activities of Daily Living (ADL) and one titled Bowel and Bladder Tracking form. The forms indicated a resident's name and room number, and their abilities to function with daily activities and bowel and bladder regimen. There was no staff present near the cart were documents were located. Resident 156 medical information was visible and accessible to the public or visitors, visiting the facility. On 2/16/22 at 8 A.M., an interview was conducted with Certified Nurse Assistant (CNA) 11. CNA 11 stated resident medical records should not be left in plain view for resident's privacy. CNA 11 stated she did not know how long the forms were on top of the cart. On 2/16/22 at 8:04 A.M., an interview was conducted with CNA 12. CNA 12 stated forms that contained resident's medical information should not be left visible to anyone for HIPAA (Health Insurance Portability and Accountability Act) purposes. On 2/16/22 at 8:06 A.M., an interview was conducted with Licensed Nurse (LN) 13. LN 13 stated medical forms with resident's information should not be left on common areas for privacy purposes. On 2/16/22 at 8:12 A.M., an interview was conducted with LN 14. LN 14 stated staff should not leave resident information visible to the public because it was a violation of privacy of resident's health information. On 2/16/22 at 10:50 A.M., a joint interview and record review was conducted of Resident 156 with the Administrator (ADM). The ADM stated the forms had an incorrect resident's name and the forms were intended for Resident 156. The ADM further stated there were two issues that could happen if a resident's medical record was left unattended, Not correctly identifying the resident, and a breakdown in communication among staff. In addition, the ADM stated staff should have looked at the resident's identification band or confirmed with the LN if it was the right resident. On 2/17/22 at 9:32 A.M., an interview was conducted with LN 1. LN 1 stated the process to identify a resident was to ask their name and check the identification band. LN 1 further stated resident's medical information should not be visible to the public for privacy and HIPAA purposes. Per the facility's policy dated 3/17 titled Resident's Rights-Quality of Life, .IX. Facility Staff shall maintain an environment in which confidential clinical information is protected .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C. Resident 153 was admitted to the facility on [DATE] with diagnoses which included malignant neoplasm (cancer) of skin on left ear per the facility's admission Record. Resident 153's clinical record was reviewed on 2/16/22 with the Infection Control Preventionist (ICP). The ICP stated during resident admission, a baseline care plan should be created which included a skin integrity care plan. The ICP stated Resident 153 was admitted with a skin issue on his left ear and it was an expectation to have a skin care plan. The ICP acknowledged that Resident 153 did not have a care plan about skin integrity. On 2/16/22 at 2:50 P.M., a concurrent interview and record review was conducted of Resident 153 with the Director of Nursing (DON). The DON stated baseline care plans should be initiated at the time of admission. The DON stated if a resident had skin issues, there should be a skin integrity care plan. The DON reviewed Resident 153's care plan then stated, No, I don't see any skin or wound care plan and there should be one. The DON further stated that care plans should have been created within 24-48 hours upon admission. On 2/17 22 at 9:32 A.M., an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated the expectation was to do a baseline care plan on admission to include skin integrity if the resident had some wound or skin problem. Per the facility's policy titled Comprehensive Person-Centered Care Planning dated 11/2018, . c. I. The baseline care plan will be initiated upon admission by the admitting nurse using the necessary combination of specific problem specific care plans to promote continuity of care and communication among nursing home staff . iii. A. The baseline care plan summary will be developed within 48 hours of admission . Based on observation, interview and record review, the facility failed to develop and implement a baseline care plan for three of 12 residents (160, 102, 153). This deficient practice did not ensure provision of effective and person-centered care for these residents. Findings: A. Per the admission Record, Resident 0 was admitted to the facility on [DATE] with diagnoses which included Urinary Tract Infection (an infection in any part of your urinary system ) and Schizoaffective Disorder, Bipolar type (a mental illness that can affect your thoughts, mood and behavior). On 2/16/22 at 9:30 A.M., Resident 160 was observed walking out of her room using a walker. As Resident 160 walked down the hall, Resident 160's pants were observed to have brown stains and brown substance on her ankle and in her shoe. Certified Nurse Assistant (CNA) 1 stated, She had a bowel movement, she has a brief on. On 2/18/22 at 10:45 AM, a joint interview and record review for Resident 160's clinical record was conducted with Licensed Nurse (LN) 1. LN 1 stated, When a new admission comes in, the Resident admission Assessment is done by the admitting nurse. LN 1 further stated, The Resident admission Assessment is a template which includes the bowel and bladder assessment. It shoud be completed within 24 hours. Upon further review of Resident 160's records, LN 1 stated, There was no bowel and bladder assessment done. Per the faciliity's policy titled, admission Assessment, dated, August 21, 2020 . Procedure . I. Upon admission a licensed nurse will conduct an admission assessment on the Resident. II. The admission assessment will be included in the resident's medical record and will be used to create appropriate care plans for the Resident. B. Per the admission Record, Resident 102 was admitted to the facility on [DATE] with diagnosis including Type 2 Diabetes Mellitus (abnormal blood sugar in the body) and Chronic Obstructive Pulmonary disease (Lung disease) On 2/15/22 at 8:20 AM, Resident 102 was observed in bed with a urinal at his bed side. Resident 102 stated, I used my call light when I need my brief changed. On 2/18/22 at 10:45 AM, an interview and record review of Resident 102's clinical record was conducted with LN 1. LN 1 stated, The Resident admission Assessment was not completed and the bowel and bladder assessment was not done for Resident 102. LN1 further stated, The assessment should have been done within 24 hours of admission. It's important to know if the resident is capable of using the urinal or if he needs a brief. Per the faciliity's policy titled, admission Assessment, dated, August 21, 2020 . Procedure . I. Upon admission a licensed nurse will conduct an admission assessment on the Resident. II. The admission assessment will be included in the resident's medical record and will be used to create appropriate care plans for the Resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C. Resident 153 was admitted to the facility on [DATE] with diagnoses which included malignant neoplasm (cancer) of skin on left ear per the facility's admission Record. Resident 153's clinical record was reviewed on 2/16/22 with the Infection Control Preventionist (ICP). The ICP stated during resident admission, a baseline care plan should be created which included a skin integrity care plan. The ICP stated Resident 153 was admitted with a skin issue on his left and it was an expectation to have a skin care plan. The ICP acknowledged Resident 153 did not have a care plan for skin integrity. On 2/16/22 at 2:50 P.M., a concurrent interview and record review was conducted of Resident 153 with the Director of Nursing (DON). The DON stated baseline care plans should be initiated at the time of admission. The DON stated if a resident had skin issues, there should be a skin integrity care plan. The DON reviewed Resident 153's care plan then stated, No, I don't see any skin or wound care plan and there should be one. The DON further stated that care plans should have been created within 24-48 hours upon admission. On 2/17 22 at 9:32 A.M., an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated the expectation was to do a baseline care plan on admission to include skin integrity if the resident had some wound or skin problem. Per the facility's policy titled Comprehensive Person-Centered Care Planning dated 11/2018, . IV. Comprehensive Care Plan. a. Within 7 days from the completion of the comprehensive Minimum Data Set (MDS - an assessment tool) assessment, the comprehensive care plan will be developed . c. The comprehensive care plan will be periodically reviewed and revised by the Interdisciplinary Team (IDT) after each assessment . Based on observation, interview and record review, the facility failed to develop a comprehensive care plan for three of 12 sampled residents (160, 102, 153). Failure to develop a comprehensive care plan had the potential for residents to not receive accurate medical needs and appropriate treatment goals. Findings: A. Per the admission Record, Resident 160 was admitted on [DATE] with diagnoses which included, Urinary Tract Infection (problem with urination) and Schizoaffective Disorder (mental problem), Bipolar type. On 2/16/22 at 9:30 A.M., Resident 160 was observed walking out of her room using a walker. As Resident 160 walked down the hall, Resident 160's pants were observed to have brown stains and brown substance on her ankle and in her shoe. Certified Nurse Assistant (CNA) 1 stated, She had a bowel movement, she has a brief on. On 2/18/22 at 10:45 A.M., a joint interview and record review was conducted with Licensed Nurse (LN) 1. LN 1 stated, When a new admission comes in, the Resident admission Assessment is done by the admitting nurse. LN 1 further stated, The Resident admission Assessment is a template which includes the bowel and bladder assessment. It should be completed within 24 hours. Upon further review of Resident 160's records, LN 1 stated, There was no bowel and bladder assessment done. Per the facility's policy titled Comprehensive Person-Centered Care Planning dated 11/2018, . IV. Comprehensive Care Plan. a. Within 7 days from the completion of the comprehensive Minimum Data Set (MDS - an assessment tool) assessment, the comprehensive care plan will be developed . c. The comprehensive care plan will be periodically reviewed and revised by the Interdisciplinary Team (IDT) after each assessment . B. Resident 102 was admitted to the facility on [DATE] with diagnosis including Type 2 Diabetes Mellitus (abnormal blood sugar in the body) and chronic obstructive pulmonary disease (Lung disease). On 2/15/22 at 8:20 A.M., an observation was made at Resident 102's bedside. Resident 102 had a urinal at his bed side. Resident 102 stated, I use my call light to have my brief changed. On 2/18/22 at 10:45 A.M., an interview and record review was conducted with Licensed Nurse (LN) 1. LN 1 stated, The Resident admission Assessment was not completed and the bowel and bladder assessment was not done for Resident 102. LN 1 stated, The assessment should have been done within 24 hours of admission. It's important to know if the resident is capable using the urinal or if he needs a brief. Per the facility's policy titled Comprehensive Person-Centered Care Planning dated 11/2018, . IV. Comprehensive Care Plan. a. Within 7 days from the completion of the comprehensive Minimum Data Set (MDS - an assessment tool) assessment, the comprehensive care plan will be developed . c. The comprehensive care plan will be periodically reviewed and revised by the Interdisciplinary Team (IDT) after each assessment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain an accurate and complete physician discharge summary on three of three sampled residents reviewed for closed records (52, 53, 54). Failure to keep a physician discharge summary had the potential for residents to not receive a safe transition between care settings. Findings: Resident's 52, 53, and 54's clinical record was reviewed on [DATE]. Resident 52 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive respiratory disease (a lung disease) per the facility's admission Record. Resident 52 expired at the facility on [DATE]. Resident 53 was admitted to the facility on [DATE] with diagnoses which included kidney (body organ that produces urine) failure per the facility's admission Record. Resident 53 was discharged from the facility on [DATE]. Resident 54 was admitted to the facility on [DATE] with diagnoses which included diabetes (abnormal blood sugar in the body) per the facility's admission Record. Resident 54 was discharged against medical advice (AMA) from the facility on [DATE]. Resident 52, 53, and 54's clinical record contained a form titled Physician's Discharge Summary. All three Residents did not have a physician's discharge summary note, and the forms did not contain a physician's signature. On [DATE] at 3:04 P.M., a joint interview and record review of Resident 52, 53, and 54 was conducted with the Medical Records Director (MRD). The MRD stated physician's have a whole month to do a discharge summary on residents. The MRD reviewed Resident 52, 53, and 54's chart and acknowledged that there was no discharge summary completed on all three residents. In addition, the MRD stated it had been more than a month since the residents were discharged . Per the facility's policy titled Establishing and closing the Record dated 01/2012, . II. Discharge. J. Call the Attending Physician's office and request the return of forms if the physician does not return the discharge summary or other forms sent for signature within 2 weeks .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to safeguard a gated fence that led to the parking lot. As a result, Resident 152 eloped from the facility. Findings: Resident 152 was admitted to the facility on [DATE] with diagnoses which included dementia (memory loss) per the facility's admission Record. An observation was conducted of the facility's smoking patio on 2/16/22. The patio had a gate and had an opened padlock. The gate was partially open which led to a small trail going to the facility's back parking lot. The gated fence had a laminated sign which indicated, This door must remain locked at all times. On 2/16/22 at 10:02 A.M., a joint interview was conducted with the MA (Maintenance Assistant) and HSK (Housekeeper). The MA and the HSK both stated the gate should always be locked so residents could not leave without being noticed. The MA acknowledged the gate's padlock was unlocked and did not know how long it had been open. On 2/16/22 at 10:06 A.M., an interview was conducted with the Administrator (ADM). The ADM acknowledged the gate's padlock was open. The ADM stated he did not know how long the gate was unlocked and it should always be locked at all times to prevent residents from leaving the facility. On 2/17/21 at 9:32 A.M., an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated the back gate should be locked at all times to ensure residents would not elope. On 2/18/22 at 9:38 A.M., an interview was conducted with the Medical Director (MD). The MD stated the back gate should always be locked to prevent residents from going out of the building.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an oxygen nasal cannula (device used to deliver oxygen to a person) was changed on one of one sampled resident (154) reviewed for oxygen use. Failure to change an oxygen cannula had the potential for residents to be placed at risk for infection. Findings: Resident 154 was admitted to the facility on [DATE] with diagnoses which included oxygen dependent user and COPD (Chronic Obstructive Pulmonary Disease - lung problem) per the facility's admission Record and physician's history and physical. During the tour of the facility on 2/15/22, Resident 154 was observed laying on her bed wearing an oxygen nasal cannula. The nasal cannula did not have a date when it was placed. Resident 154 was interviewed on 2/15/22 at 9:04 A.M. Resident 154 stated she could not remember when was the last time the nasal cannula was changed. Resident 154 stated they changed the nasal cannula, every month. On 2/15/22 at 9:15 A.M., a concurrent interviews was conducted with Licensed Nurse (LN) 16 and LN 4. LN 16 stated he noticed that there was no date on the oxygen nasal cannula. LN 4 stated nasal cannulas were supposed to be changed on Sundays. LN 4 further stated the oxygen nasal cannula should have been dated for staff to know when to replace it. On 2/17/21 at 9:32 A.M., an interview was conducted with LN 1. LN 1 stated the protocol was to ensure the nasal cannula was clean and changed every week. LN 1 further stated that the nasal cannula should have been labeled with a date it was changed. Per the facility's policy titled Oxygen Therapy dated 11/2017, . Procedure. E. The humidifier and tubing should be changed no more than every 7 days and labeled with the date of change .

Based on observation, interview, and record review, the facility failed to have a system for receiving, reviewing and recording irregularities identified by the pharmacist during the MRR Medication Regimen Review). This deficient practice did not ensure the irregularities identified by the pharmacist was acted upon. Findings: On 2/18/22 at 10:30 A.M., a concurrent review of the MRR and interview with the Director of Nursing (DON) was conducted. The MRR binder contained the Pharmacist's report for December 2021. The binder did not have the MRR for January 2022. The DON stated, I just started reviewing the MRR from December 2021 and I haven't gotten to the January 2022 MRR yet. On 2/18/22 at 10:45 A.M., the December 2021 MRR was reviewed. The MRR indicated, Executive Summary of Consultant Pharmacist's medication Regimen Review .Data compiled on: 12/13/2021 for outcomes entered between 12/10/2021 and 12/13/2021 . These visits, 40 recommendations were forwarded to the following disciplines . 32 written to Nursing. On 2/18/22 at 10:51 A.M., an interview was conducted with the Pharmacy Consultant (PC) via telephone. The PC stated, My expectation is that the MRR recommendations are reviewed as soon as possible. On 2/18/22 at 12:30 P.M., the January 2022 MRR was reviewed. The January 2022 MRR indicated, Executive Summary of Consultant Pharmacist's medication Regiment Review . Date compiled on: 1/10/2022 and 01/14/2022 . these visits, 27 recommendations were forwarded to the following disciplines . 26 written to Nursing. On 2/18/22 at 2:30 P.M., the DON was interviewed during the Quality Assurance Performance Improvement (QAPI) meeting. The DON stated, I'm responsible for reviewing the monthly MRRs but I have not gotten to reviewing the MRRs from December 2021 or January 2022. The DON did ensure the MRR recommendations had been reviewed, acted upon, or communicated with the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure; 1. A medication cart was locked and, 2. A medication with an unknown expiration date was disposed of. Failure to lock a medication cart had the potential for drug diversion, and failure to dispose a medication with an unknown expiration date had the potential for all residents to receive an ineffective and expired medication. Findings: 1. A tour of the facility's red zone (Covid-19 zone- an area where people with infectious respiratory disease are placed) unit was conducted on [DATE]. Upon entrance to the red zone, there was a medication cart that was unlocked and unattended. On the first drawer of the medication cart were medication bubble packs with resident names. On [DATE] at 4:02 P.M., an interview was conducted with Licensed Nurse (LN) 15. LN 15 stated she should have locked the medication cart for safety reasons because they had ambulatory residents. 2. On [DATE] at 4:22 P.M., a joint observation of the treatment cart and interview with LN 1 was conducted. On the top drawer of the treatment cart was an orange container with the date, 12/19 written on the lid. Inside the container was a white powdery substance. The container had a cut out label that indicated, Derma Col 100, type 1 Bovine. LN 1 stated she was not sure if the date on the lid meant the year 2019 or the day [DATE]. LN 1 stated the container, Should have a name of a resident. On [DATE] at 4:44 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated this was not the right way to store a medication. The DON stated she was not sure when the medication would expire inside the container. The DON stated the facility had a whole box of this medication stored in the medication room. The DON reviewed the manufacturer's package guideline. The manufacturer's medication guideline indicated, Discard all open and unused portions of the product. The DON stated, the left over medication should have been disposed on the day it was opened. In addition, the DON stated all medication carts should be locked at all times for safety purposes. On [DATE] at 10:18 A.M., an interview was conducted with the Pharmacy Consultant (PC). The PC stated all medication carts should be locked at all times for safety reasons. The PC stated the medication, Derma Col was sterile and once exposed to the environment, the medication looses its effectiveness. In addition, the PC stated that this medication was patient-specific and could not be used with other residents. Per the facility's policy titled Medication Storage in the Facility dated [DATE], . Policy. Medications and biologicals are stored safely, securely, and properly, and following the manufacturer's recommendations or those of the supplier . Procedures. A . Transfer of medications from one container to another is done only by the pharmacy .

Based on observation, interview and record review, the facility did not maintain proper infection control practices based on current standards when a staff opened and walked through a barrier that separated a Covid-19 red zone (an area where people with infectious respiratory disease are placed) and a green zone (an area where there was no infection). This failure had the potential to spread infection throughout the facility affecting residents' quality of life and care. Findings: During the initial tour of the facility on 2/15/22, a staff was observed unzipping a taped plastic barrier from the Covid-19 red zone area. The staff proceeded to walk in the hallway of the green zone area carrying a ladder and a clear bag with an unknown material inside. On 2/15/22 at 3:35 P.M., an interview was conducted with Certified Nurse Assistant (CNA) 17. CNA 17 stated staff who came from the red zone should not unzip the barrier to go out in the green zone because they came from an infectious unit. On 2/15/22 at 3:39 P.M., an interview was conducted with the facility's Regional Consultants (RC1, RC2). RC 1 and RC 2 both stated they had observed what the staff did and it should not have happened. On 2/15/22 at 3:45 P.M., an interview was conducted with the Maintenance Assistant (MA). The MA stated, I'm sorry, I should not have come out of that barrier because I came from the red zone unit. The MA further stated he should have gone out from the proper exit side. On 2/15/22 at 3:56 P.M., an interview was conducted with Licensed Nurse (LN) 18. LN 18 stated that the protocol was to go out the other exit area when coming from the red zone. LN 5 stated no one should come out from the red zone then walk to the green zone for infection control purposes. On 2/15/22 at 3:59 P.M., an interview was conducted with LN 16. LN 16 stated no one from the red zone should come out of the barrier then walk in the hallway because it was an infection control issue. On 2/18/22 at 9:38 A.M., an interview was conducted with the Medical Director (MD). The MD stated there should only be one entrance and one exit to the red zone to stop the infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the corridor had firmly secured handrails on each side. This deficient practice had the potential for harm to all residents. Findings: On 2/15/22 at 9:30 A.M., a loose hand rail next to the physical therapist's room was observed. On 2/16/22 at 11 A.M., Resident was observed in the hall near the kitchen. Resident 18 was observed using the handrail to propel along the hall while in his wheelchair. On 2/17/22 at 8:15 A.M., the Physical Therapy Assistant (PTA) was interviewed. The PTA stated, the hand rails are sometimes used by the residents to assist in standing. On 2/17/22 at 11:15 A.M., an interview was conducted with the Maintenance Assistant (MA). The MA acknowledged the loose rails They need to be fixed. On 2/17/22 8:25 A.M., an observation and interview was conducted with the Director of Nursing (DON) and Administrator (ADM). The observations were discussed with the ADM and DON: The hand rail near room [ROOM NUMBER] was observed to not be secured to the wall. A hand rail next to the kitchen was observed to be broken and the corner of the rail was missing, and had sharp edges where the rail broke off. A hand rail next to the conference room was observed to not be secured to the wall. A hand rail next to room [ROOM NUMBER] was observed to not be secured to the wall. The ADMIN and DON acknowledged the sharp edges on the broken hand rails next to the kitchen, and the broken handrails that were identified during the tour of the corridors. The ADM acknowledged it was a safety issue and potential for injury and needs to be fixed.

Based on interview and record review, the facility failed to properly prevent COVID-19 (a respiratory infection) when three sampled residents (10, 13, 24) and six unsampled residents (161, 17, 31, 37, 42, 49) were not offered vaccines when they were due. Findings: On 2/16/22 at 2:40 P.M., an interview with resident 13's Responsible Party (RP 13) was conducted. RP 13 stated, My mom was in the Covid unit last week. She just moved to a regular room this week. RP 13 further stated, I was wondering why they didn't offer her the COVID-19 booster vaccine. On 2/17/22 at 9 A.M., a document titled, Respiratory Illness Case Log for Residents and Staff dated, 2/4/2022 was reviewed with the Infection Control Preventionist (ICP). The ICP stated, The resident's Covid tests and vaccinations have been recorded on the line list. Review of the list indicated: Resident 161 received 1st Covid vaccine on 2/3/21 the 2nd on 2/24/21, and the booster dose on 2/1/22. Resident 161's Covid-19 PCR test result was Positive on 2/1/22. Resident 10 received 1st Covid vaccine on 1/7/21, the 2nd on 2/4/21, and the booster dose on 2/1/22. Resident 10's Covid-19 PCR test result was Positive on 2/1/22. Resident 13 received 1st dose of Covid vaccine on 1/7/21, the 2nd on 2/1/22, and no record of 3rd dose/booster Covid-19 vaccine. Resident 13's Covid-19 PCR test result was Positive on 2/1/22. Resident 17 received 1st Covid vaccine on 3/29/21, the 2nd on 4/29/21, the booster dose on 2/1/22. Resident 17's Covid-19 PCR test result was Positive on 2/1/22. Resident 24 received 1st dose of Covid vaccine on 1/7/21, the 2nd on 2/4/21, the booster dose on 2/1/22. Resident 24's Covid-19 PCR test result was Positive on 2/7/22. Resident 31 received 1st Covid vaccine on 1/7/21, the 2nd dose on 2/4/21, the booster dose on 2/1/22. Resident 31's Covid-19 PCR test result was Positive on 2/1/22. Resident 37 received 1st Covid vaccine on 1/7/21, the 2nd vaccine had no record and no record of booster shot. Resident 37's Covid-19 PCR test result was Positive on 2/1/22. Resident 42 received 1st Covid vaccine on 1/7/21, the 2nd dose on 2/4/21, and the booster dose on 2/1/22. Resident 42's Covid-19 PCR test result was Positive on 2/7/22. Resident 49 received 1st Covid vaccine on 2/4/21, the 2nd dose on 2/25/21, and the booster dose on 2/1/22. Resident 49's Covid-19 PCR test result was Positive on 2/1/22. On 2/17/22 at 4 P.M., an interview was conducted with the Infection Control Preventionist (ICP). The ICP stated she was not made aware of when the residents' vaccines were due. The ICP stated, We set up the vaccination clinic and gave booster shots to all eligible residents. On 2/18/22 at 11 A.M. a telephone interview was conducted with the Medical Director (MD). The MD stated, The booster shots should be given after 5 months. The shots should be given continuously, they should be available before they are due. The MD further stated, I had an in-service with the whole staff. I told them to make sure each vaccination was available and offered when they were due and to mention the booster to the residents before the 5 months. The booster makes a huge difference especially with elderly patients, even if one was infected with Omicron they would likely recover with the booster and easily die without the booster. According to the facility's COVID-19 Mitigation Plan, revised January 11, 2022 .SARS-CoV-2 VACCINATION PROGRAM . Vaccination of Residents .COVID-19 vaccine and booster will be offered to residents within seven days of admission (or readmission). If they never received a COVID-19 vaccine, the first dose will be given. If the first vaccine dose was already administered, the second dose of the vaccine will be administered when it is due (see vaccine manufacturer's guidance on clinical considerations, deferral of vaccine, precautions and contraindications). Boosters will also be offered when due.

Based on interview and record review, the facility failed to ensure three of seven Confidential Residents (CR) 2,3,4 received their mail on Saturdays. This failure had the potential to violate Residents' rights. Findings: A group meeting was held with facility residents on 3/4/20 at 10:07 A.M. CR 2, CR 3, and CR 4 each stated that mail was not delivered on Saturdays. An interview was conducted with the AD on 3/5/20 at 11:39 A.M. The AD stated, I am in charge of mail delivery for residents; mail is not always delivered on Saturday. An interview was conducted with the AA on 3/5/20 at 11:56 A.M. The AA stated, I don't always deliver the mail on Saturdays. A joint interview was conducted with the Admin and DON on 3/6/20 at 9:14 A.M. The Admin stated, It (mail delivery) is their right. A review of the facility's policy,dated,1/1/12, titled, Resident Rights-Mail, indicated, Purpose: to ensure that residents have access to mail delivery .Procedure IV: mail is delivered to the resident within twenty-four (24) hours of delivery to the premises or to the facility's post office box (including Saturday deliveries).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident's representative (RR) when Resident 13 was transferred to general acute care hospital (GACH) due to change of condition for one of three closed record reviews. This failure violated resident's rights and potential to cause anxiety on resident's RR. Findings: On 3/5/20 at 11:37 A.M., a closed record review was conducted. Resident 13 was admitted to the facility on [DATE] with diagnoses which included asthma (lung disease), per the facility's Face Sheet. The face sheet indicated Resident 13's RR's contact number. The H & P dated 12/26/19 indicated, Resident 13's RR was informed of the resident's change in medical condition. A review of the nursing progress notes dated 2/17/20 at 8 A.M., Resident 13 was transported to GACH for distress. There was no documentation found in the licensed progress notes related to notifying the RR. In addition, there was no documentation from the social services related to notifying Resident 13's RR upon transfer to GACH. On 3/5/20 at 2:57 P.M., a joint interview and record review with the DON was conducted. The DON stated there was no documentation in Resident 13's medical record. On 3/6/20 at 11:34 A.M., a joint interview with the Admin and the DON was conducted. The DON stated the RR should have been notified regarding Resident 13's transfer to GACH, so the RR would know what happened to their loved ones. A review of the facility's policy titled, Notice of Transfer/Discharge, revised 10/2017, indicated, . III. Before the transfer . the facility must notify the resident and if known, the responsible party . of the transfer and reasons for the transfer, and document in the resident's clinical record .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow a care plan for a cardiac assistive device for one of 13 residents reviewed for care plan. This failure had the potential for inconsistent care provided to the resident. Findings: Per the Face sheet, Resident 24 was admitted on [DATE] with diagnoses which included End Stage Heart Failure. On 3/3/20 at 9 A.M., Resident 24 was observed sitting on his bed. There was a dressing on his right lower abdomen and a small, long tube coming out from the dressing. The tube was connected to a machine the size of a lap top. Resident 24 said, I have a left ventricular assistive device (LVAD), (a pump that is used for patients who have reached end-stage heart failure, a battery operated, mechanical pump which helps the left ventricle pump blood to the rest of the body.) Resident 24 stated, This machine is keeping me alive. On 3/5/20, a document titled, Left Ventricular Device short term care plan dated 2/21/20 was reviewed, Problem/need: Resident with LVAD for Hemodynamic support. GOAL: Patient will tolerate LVAD: with no complications no systemic or driveline site infection . No signs/symptoms of heart failure while on VAD. GOAL date: 5/21/20 Approach: A. Patient monitor: B/P & Map: Goal MAP (BLANK) A Document titled, (name of hospital) .Blood pressure guidelines for VAD patients .Resident Goal MAPs [NAME] 3: 65-105 mmHg. Exercise Goal MAPs +20-30 mmHg. Resting Goal HR<120bpm. On 3/6/20 at 10 A.M., a joint interview with the DON, LN 21, and the DSD was conducted. The DSD stated, I've given in-services on the care of this device. The only instruction given to us by (hospital name) was to do the MAP . During the same interview, LN 21 stated, The MAP (Mean Arterial Pressure) is obtained by calculating the diastolic (bottom number of the blood pressure reading) number of the residents blood pressure x2 then adding the systolic (the top number of the blood pressure reading) number. The total is divided by three. The answer gives you the MAP. We have a flow sheet which we keep in the MAR (Medication Administration Record). On 3/6/20 at 11 A.M., a document titled, Heartware Flow Sheet was reviewed with LN 21. Vital signs which included the systolic and diastolic blood pressure numbers were missing for 7 AM on the following days: 2/19, 2/29, 3/1, 3/2, 3/4, and 3/5/20. LN 21 stated, Vital signs should be done at the beginning of every shift by the licensed nurse. LN 21 further stated, The vital signs show how the resident is doing. It's important to get vital signs every shift especially for this patient who has this heart device and is on antiarrhythmic medication. On 3/6/20 at 2 P.M., an interview with the Admin was conducted. The Admin acknowledged Resident 24's vital signs were missing in the flow sheet. The Admin stated the vital signs were essential assessment for Resident 24's care. A review of the facility's policy titled, Comprehensive Person-Centered Care Planning, revised 11/2018, indicated, . Policy: It is the policy of this facility to provide person-centered, comprehensive and interdiscilplinary care that reflects best practice standards for meeting health, safety . needs of residents .

Based on observation, interview, and record review, the facility failed to label tuberculin test solution (used for testing tuberculosis) with open date. In addition, the facility failed to ensure medication refrigerator temperature was monitored per the facility's policy for one of one medication refrigerator inspected. This failure had the potential to alter medication efficacy and unsafe storage of the refrigerated medications. Findings: 1. On 3/5/20 at 3:12 P.M., a joint inspection of the medication refrigerator, and an interview with LN 21 was conducted. LN 21 took out an opened tuberculin test solution from the refrigerator, and stated there was no date when the solution was opened. LN 21 stated the tuberculin solution should have been dated so as to know when the solution should have been discarded. A review of the undated medication insert, indicated a vial (small glass or plastic bottle, often used to store medication as liquids) of opened tuberculin solution should be discarded within 30 days. On 3/6/20 at 9:48 A.M., an interview with the DON was conducted. The DON stated the LNs should have labeled and dated the tuberculin solution once it was opened. The DON stated the LNs would not be able to know when to discard the solution when there was no open date. 2. On 3/5/20 at 4:10 P.M., a concurrent interview and record review with the DON was conducted. The DON stated they were using the Refrigerator/ Freezer temperature log form. The form indicated, Refrigerator temperatures should be at 41 degree Fahrenheit (° F) or below. The DON stated the range would be 0 to 41 ° F. The DON stated they were using the form based on their policy. The DON gave their policy indicating Refrigerator/ Freezer temperature log- Operational manual- Dietary services. The DON stated it was not the right form and she did not realize the form/log was for use with food refrigerators. A review of the undated medication insert, under storage, tuberculin test solution should be stored at 35°- 46° F. The medication insert also indicated, Discard product if exposed to freezing. On 3/6/20 at 8:25 A.M., a joint interview and record review with LN 21 was conducted. LN 21 took out the medication refrigerator log and stated they were logging the temperature in the Refrigerator/ Freezer temperature log- dietary services. LN 21 stated there should be a temperature range for the medication refrigerator, to maintain the efficacy of the refrigerated medication. LN 21 further stated the temperature of the refrigerator should have been maintained to the temperature range so that we knew when to report if there was an issue with the medication refrigerator and not to alter the potency of the medication. On 3/6/20 at 9:48 A.M., a joint interview with the Admin and the DON was conducted. The DON stated the temperature log form would be changed appropriate for monitoring the temperature range of the refrigerated medication. A review of the facility's policy titled, Temperature of Medications, revised 11/2017, indicated, Drugs shall be stored in appropriate temperatures . B. Drugs requiring refrigeration shall be stored in a refrigerator between 2 degrees Celsius (36 ° F) and 8 degrees Celsius (46 ° F) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 35 was admitted to the facility on [DATE], per the facility's Face Sheet. During a review of the resident's History and Physical (H & P) dated 1/17/20, the H & P indicated, Resident 35 had the capacity to understand and make decisions. On 3/3/20 at 8:56 A.M., a tour of the facility and observation was conducted in a shared bedroom. Inside the shared bedroom, there were three residents. Resident 35's bed was located by the door, an unsampled resident in the middle, and Resident 29's bed was located by the window. Each resident had their own television (TV) and TV remote control. On 3/4/20 at 10:07 A.M., an interview with Resident 35 was conducted. Resident 35 stated his roommate (Resident 29) would usually ask the CNA assigned to him (Resident 29) to either change the volume of his TV or turn it off, or shut the door when he wished to. Resident 35 stated he felt claustrophobic. On 3/4/20 at 3:48 P.M., an interview with CNA 21 was conducted. CNA 21 was the assigned CNA for Resident 29. CNA 21 stated Resident 29 was a bully to Resident 35. CNA 21 stated Resident 29 would either turn off or increase the volume of Resident 35's TV. The TV remote had a universal control for the volume and power. In addition, Resident 29 wanted the door shut opposite to what Resident 35 wanted. On 3/5/20 at 2:40 P.M., an interview with CNA 22 was conducted. CNA 22 was the assigned CNA in the shared room. CNA 22 stated Resident 29 turned off or turned down the volume of Resident 35's TV. Resident 29 also wanted the door of the room closed while Resident 35 wanted the door of the room opened. CNA 22 stated this had been ongoing since Resident 35 was transferred to this room. CNA 22 stated Resident 35 would just leave the room. On 3/6/20 at 8:43 A.M., an interview with LN 21 was conducted. LN 21 stated there had been an issue between Resident 29 and Resident 35 and was aware regarding preferences of keeping the door or window closed or opened. LN 21 stated the issue should have been addressed right away because it was a dignity issue and to ensure the residents were safe and happy. On 3/6/20 at 9:59 A.M., a joint interview with the Admin and the DON was conducted. The DON stated the LNs should have communicated Resident 35's issues so it could have been addressed. A review of the facility's policy titled, Resident Rights, revised 1/2012, indicated, Purpose- to promote and protect the rights of all residents at the facility . Policy . The facility will promote and protect those rights . Employees are to treat all residents with kindness, respect, and dignity and honor the exercise of residents' rights . Based on interview and record review, the facility did not ensure three of seven confidential residents who were eligible to vote, were assisted to vote. In addition, the facility did not ensure a resident's rights related to self determination were addressed. This failure had the potential to cause emotional distress to the residents. Findings: 1. A confidential group meeting with the facility residents was conducted on 3/4/20 at 10:07 A.M. Confidential Residents (CR) 1, 2 and 4 stated they were very concerned they would not be able to vote. CR 1 stated, I feel very strongly to vote! I need to vote! CR 2 stated, It is too late, the election was yesterday. CR 4 stated, Voting is important to me too; nobody told me. An interview was conducted with the SSD on 3/5/20 at 8:06 A.M. The SSD stated, I don't vote and didn't realize it was important to the residents. I am not sure of the process to register; it is important to the residents because they want to feel like part of the outside community and what it is going on. A joint interview was conducted with the Admin and DON on 3/6/20 at 9:14 A.M. The Admin stated, It is their right to vote; we should help with that. A review of the facility's policy, dated, 11/1/13, titled, Voting, indicated, Purpose: to assist residents with voting .Policy: the facility will respect and honor the resident's right to vote. The facility will keep residents informed of upcoming elections, and will provide residents with assistance to exercise their right to vote .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a clean environment for residents related to dust-covered air vents for 10 of 24 resident rooms. This failure had the potential to expose residents to environmental hazards. Findings: During the initial tour on 3/3/20 at 3:24 P.M., Resident 7 in room [ROOM NUMBER]A was observed in bed, with a towel on his head. Resident 7 stated, I had a towel on my head because the air vent blows on me and the air vent is covered with dust. The air vent was noted to be covered in dust and was rusty. In addition, the air vent was not flush with the wall and had dust behind it. On 3/4/20 at 8:37 A.M., the air vent was again observed and was still covered in dust and rust. Additional air vents in other residents' rooms were observed on 3/4/20: 8:52 A.M. room [ROOM NUMBER]: the air vent had stringy dust on it. 8:54 A.M. room [ROOM NUMBER]: the air vent was dusty. 9:03 A.M. room [ROOM NUMBER]: the air vent was dusty. 9:03 A.M. Room17: the air vent was dusty. On 3/4/20 at 3:21 P.M., a concurrent tour/observation of Rooms 10,12,16,17, and an interview was conducted with the Admin and the Hskg Lead. The Admin stated, The vents were dusty and were an infection control issue for residents. Additionally, the Admin stated that the facility currently had no Maintenance Supervisor and borrowed one from another facility when needed. Additional air vents in other residents' rooms were observed on 3/5/20: 9:52 A.M. room [ROOM NUMBER]: the air vent was dusty. 9:54 A.M. room [ROOM NUMBER]: the air vent was dusty. 9:56 A.M. room [ROOM NUMBER]: the air vent was dusty. 9:58 A.M. room [ROOM NUMBER]: the air vent was dusty. On 3/5/20 at 10:33 A.M., a concurrent tour/observation of Rooms 21, 22, 23, 24 and an interview was conducted with the DON. The DON acknowledged the air vents were dirty, dusty and rusty. A review of the facility's policy, dated, 1/1/12, titled, Cleaning and Disinfection of Environmental Surfaces, indicated, .Policy: Environmental surfaces are cleaned and disinfected according to current CDC recommendations for disinfection .

Based on observation, interview and record review, the facility failed to serve food at proper temperatures for five out of seven confidential residents. As a result, the improper temperatures did not ensure food safety and palatability. Findings: On 3/4/20 at 10 A.M., during a group meeting with the facility residents, five out of seven confidential residents stated when breakfast was served, hot foods were often not hot and cold drinks were not so cold. The residents stated when this happened, they usually did not eat that food item. On 3/5/20 at 7:04 A.M., breakfast tray line was observed. The last tray prepared was a regular diet which consisted of Baked Spanish Omelet, sausage, hot cereal, milk and juice. The last tray was placed on the last tray cart and brought to the dining room. On 3/5/20 at 8:25 A.M., a concurrent interview with the [NAME] (C1) and observation of the last tray was conducted in the dining room. C1 placed the tray on the dining table and measured the temperature of each food item. The temperatures of the food items were the following: Eggs-151.2 degrees Fahrenheit Sausage-124 degrees Fahrenheit Hot cereal- 143.2 degrees Fahrenheit Milk- 51.4 degrees Fahrenheit Juice- 53.4 degrees Fahrenheit On 3/5/20 at 8:26 A.M., the test tray was tested for palatability. The egg omelet temperature was warm. The sausage temperature was tepid (only slightly warm). The hot cereal was hot. The Milk was tepid. The juice was tepid. On 3/5/20 at 8:27 A.M., an interview with C1 was conducted. C1 stated, The temperature of hot foods should be 135 degrees Fahrenheit or higher and cold foods should be 41 degrees Fahrenheit or colder. According to the facility's policy titled, Food Temperatures, dated July 1, 2014, .II. Acceptable Serving Temperatures .Meats, entrees temperature required >140 degrees Fahrenheit .Milk, juice temperature required <41 degrees Fahrenheit .

2a. On 3/5/20 at 7:29 A.M., an observation of LN 22 passing the medication was conducted. LN 22 put a pair of gloves, took out the sanitary wipes, wiped the medication tray, removed the gloves, touched the lid of the trash bin with bare hands, threw the pair of gloves, then touched the surface of the medication cart, without performing hand hygiene and took out the glucometer (used to measure blood sugar) from the cart. On 3/5/20 at 7:37 A.M., LN 22 went back to the medication cart number two, and did the same process without performing hand hygiene after touching the lid of the trash bin with bare hands. LN 22 then opened the drawer where the medications were stored and started popping the medication in the medicine cup. LN 22 was observed touching the lid of the trash bin several times with bare hands, then touched the medication cart and drawers without performing hand hygiene. On 3/5/20 at 1:07 P.M., an interview with LN 22 was conducted. LN 22 stated the sharp container down the trash bin was considered dirty. LN 22 stated she did not consistently perform hand hygiene after touching the lid of the trash can. LN 22 stated hands should be sanitized to prevent the spread of germs. 2b. On 3/5/20 at 9:11 A.M., an observation of LN 23 passing the medication was conducted. LN 23 drew insulin from a vial (small glass or plastic bottle, often used to store medication as liquids, powders), placed the syringe with insulin in the medication tray, touched the lid of the trash bin with bare hands to throw a piece of paper, did not perform hand hygiene. LN 23 then took a spoon and scooped some applesauce and placed in a plastic cup. LN 23 went to the resident's room. On 3/5/20 at 9:19 A.M., LN 23 went back to medication cart number one, touched the lid of the trash bin with bare hands, did not perform hand hygiene. LN 23 then opened the drawer and took out the resident's bubble packs (prepackaged medications in pill pockets) and a liquid medication bottle and placed them on top of the cart. LN 23 gave the medication to the resident touching the lip of the cup. On 3/5/20 at 9:53 A.M., a concurrent observation of the medication cart one and an interview with LN 23 was conducted. The trash bin was observed to have brown streak material on the outside. LN 23 stated he was not sure which of the medication cart was considered clean, but the trash bin was considered dirty. LN 23 stated he did not perform hand hygiene after touching the lid of the trash bin. LN 23 stated he should have sanitized his hands to prevent cross contamination and not to spread infections. On 3/6/20 at 9:39 A.M., a joint interview with the Admin and the DON was conducted. The DON stated the LNs should have observed infection control and should have sanitized their hands to prevent contaminating the medications. A review of the facility's policy titled, Hand Hygiene, revised 2/2013, indicated, The Facility considers hand hygiene the primary means to prevent the spread of infections .IV. Facility staff .must perform hand hygiene . A review of the facility's policy titled, Medication-Administration, revised 1/2012 was conducted. The policy did not provide instructions or guidance related to performing hand hygiene after touching an unclean area while administering medication. Based on observation, interview and record review, hand washing supplies were not available in the laundry room. In addition, the staff failed to consistently perform hand hygiene during medication administration. This failure had the potential to increase the infection rate among staff, residents, and visitors. Findings: 1. A tour/observation of the facility's laundry area was conducted on 3/5/20 at 2:53 P.M. with the hskg lead. In the room containing the washer and dryer there was a sink, but no hand soap. An interview was conducted on 3/5/20 at 2:55 P.M. with the hskg lead. The hskg lead stated there was no hand soap near the sink. An interview was conducted on 3/6/20 at 8:41 A.M. with the ICN. The ICN stated that the laundry staff should have soap available to wash their hands. A joint interview was conducted on 3/6/20 at 9:14 A.M. with the Admin and the DON. The Admin and DON both stated that laundry staff should have soap available to wash their hands. A review of the facility's policy, dated, 2/1/13, titled, Hand Hygiene, indicated, Purpose: to ensure that all individuals use appropriate hand hygiene while at the facility .Policy . the facility considers hand hygiene the primary means to prevent the spread of infection .III. Hand hygiene products and supplies (sinks, soaps .etc) are readily available and convenient for staff use to encourage compliance with hand hygiene policy .