**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices for one of four sampled residents (Resident 3) when the facility failed to accurately document Resident 3's diagnosis. This deficient practice resulted in inaccurate documentation in Resident 3's records.Findings: During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted Resident 3 on 9/11/2024 and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and chronic kidney disease (CKD- condition where the kidneys are damaged and cannot function properly over an extended period). During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool) dated 6/17/2025, the MDS indicated Resident 3 sometimes understood and was sometimes understood. The MDS indicated Resident 3 was dependent (helper does all of the effort) with eating, oral hygiene, toileting, showering, upper and lower body dressing, putting on and taking off footwear, and personal hygiene. During a review of Resident 3's General Acute Care Hospital (GACH) 1 Discharge summary dated [DATE], the GACH 1 Discharge Summary indicated Resident 3's discharge diagnosis as scabies (a highly contagious skin condition caused by the infestation of the skin by the human itch mite, a tiny parasite that burrows into the skin to live and lay eggs). The GACH 1 Discharge Summary indicated discharge instructions to repeat ivermectin (a medication used to kill or paralyze parasites like worms, mites, and lice in both humans and animals) and continue isolation. During a review of Resident 3's Surveillance Data Collection Form Scabies dated 8/7/2025, the Data Collection form Scabies indicated Resident 3 was admitted from hospital, resident with diagnosis of scabies from GACH 1. Per doctor continue ivermectin oral tablet give 12 milligrams (mg- a unit of measurement) via gastrostomy tube (g-tube: a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) one time only for scabies until 8/11/25, 8/18/25, and 8/25/25 with ongoing treatment. Resident 3 still noted with generalized flaky skin and dry with no itchiness and no redness noted at this time. During an interview on 9/22/2025 at 4:30 p.m. with the Director of Nursing (DON), the DON stated Resident 3 does have a history of scabies. During a concurrent interview and record review of Resident 3's diagnosis on 9/22/2025 at 4:50 p.m. with the DON, the DON reviewed Resident 3's diagnosis and stated diagnosis does not indicate Resident 3 has a history of scabies. The DON stated for Resident 3 must indicate Resident 3's history of scabies even if it was resolved, because it is an overall synopsis of the resident's condition. The DON stated not including Resident 3's history of scabies in his diagnosis can result in inaccurate records. During a review of the facility's Policy and Procedures (P&P) titled, Charting and Documentation, last reviewed on 4/16/2025, the P&P indicated documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2), who was on a self-release belt restraint (a device, often used in healthcare settings, designed to secure a patient to a bed or chair while still allowing them to move or sit up), was free from unnecessary physical restraint (a strap or other thing that holds a person in place) when on 4/2/2025 at 8:56 a.m., Resident 2's lap was observed covered with a white blanket covering his lower abdomen to his knees with edges wrapped around to his (Resident 2) sides and secured to Resident 2's wheelchair. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated the facility admitted Resident 2 on 2/13/2025, with diagnoses that included metabolic encephalopathy (change in how your brain works due to an underlying condition), acute respiratory failure (when the lungs cannot release enough oxygen into your blood) and unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities). During a review of Resident 2 ' s History and Physical (H&P- a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 2/13/2025, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2's physician order, dated 2/13/2025 at 6 p.m., the physican order indicated for Resident 2 to be on a self-release seat belt while in wheelchair. The physician order indicated there was consent (the process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention) obtained by the physician. During a review of Resident 2 ' s Minimum Data Set (MDS – a resident assessment tool), dated 2/20/2025, the MDS indicated Resident 2 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 2 was dependent from staff for all activities of daily living (ADL - activities such as bathing, dressing and toileting a person performs daily). During an observation on 4/2/2025, at 8:56 a.m., inside Resident 2 ' s room, observed Resident 2 seated on a wheelchair with a white blanket covering his (Resident 2) lap, covering his lower abdomen to his knees with edges wrapped around to his (Resident 2) sides and secured to Resident 2's wheelchair. Observed Resident 2 also had a self-release belt. During an interview on 4/2/2025, at 9:45 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 2 had a self-release belt that he can remove but the white blanket tied at the back of the wheelchair was not a self- release. LVN 1 stated Resident 2 should not have that white blanket tied on his (Resident 2) back. LVN 1 stated staff should not tie it at the back of Resident 2. During an interview on 4/2/2025, at 10:22 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated she (CNA 1) was the assigned CNA for Resident 2, and when she (CNA 1) came in the morning, Resident 2 was already seated on the wheelchair, but she (CNA 1) did not notice that he (Resident 2) was tied. CNA 1 stated it was another CNA (CNA 2) who fed Resident 2 at breakfast. During an interview on 4/2/2025, at 10:45 a.m., with CNA 2, CNA 2 stated she (CNA 2) had fed Resident 2 today 4/2/2025 at 7:30 a.m. and Resident 2 was already seated in the wheelchair. CNA 2 stated she (CNA 2) did not notice that Resident 2 was tied at the back. CNA 2 stated Resident 2 cannot reach out on his back to tie himself in the wheelchair. CNA 2 stated she (CNA 2) should have checked Resident 2 to make sure residents are not on unnecessary restraints. CNA 2 stated Resident 2 had a self-release belt to prevent fall. CNA 2 stated if Resident 2 was tied that means he (Resident 2) was on restraint. CNA 2 stated Resident 2 will have limited movement due to the restraint. During an interview on 4/2/2025, at 10:57 a.m., with the Assistant Director of Nursing (ADON), the ADON stated LVN 1 notified him (ADON) that Resident 2 was tied up in the wheelchair. The ADON stated he (ADON) went to Resident 2 ' s room and saw the restraint. The ADON stated he (ADON) noted the blanket around Resident 2 tied on the back of the wheelchair. The ADON stated he (ADON) untangled and removed the tied blanket. The ADON stated if resident are tied it is considered a restraint. The ADON stated they do not have a physician order to use blanket as a restraint. The ADON stated if no physician order for use of restraint, it is a violation of resident's right to be free of restraint. The ADON stated the use of blanket as a restraint can cause entrapment and injury to Resident 2. The ADON stated the use of a restraint needs a physician order and residents need to be monitored and both (physician order and monitoring) were not done. During an interview on 4/2/2025, at 11:19 a.m., with the Director of Nursing (DON), the DON stated Resident 2 had an order for self-release belt but not for the use of a blanket tied at the back of Resident 2. The DON stated it was wrong to apply blanket as a restraint and the facility does not have an excuse for it. The DON stated the nurses failed to use restraint only with physician order and failed to check Resident 2 was on restraint. The DON stated residents should be restraint free. The DON stated their policy for physical restraint was not followed. The DON stated the facility have a process of starting a restraint by assessing the resident, obtaining a physician order, and monitoring the resident. The DON stated they (facility staff) cannot just tie Resident 2. During a review of facility ' s policy and procedure (P&P) titled, Physical Restraint, undated and last reviewed on 4/17/2024, the P&P indicated, Physical Restraint are any manual method, or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, and which restrict freedom of movement or normal access to the use of one's body. Physical restraint assessment and use shall be managed accordingly: 2. If other interventions such as lowering bed, using pillows, alarms, wedge cushions, did not work, a physical restraint assessment shall be completed by the licensed nurse with input from the interdisciplinary team (IDT-a coordinated group of experts from several different fields who work together). 5. The licensed nurse shall be responsible for obtaining an order from the attending which is to include: a. Specific type of restraint. b. Purpose of the restraint. c. Time and place of application. d. Approaches to prevent decreased functioning when applicable. e. Informed consent obtained from resident or from surrogate decision maker. 13. Staff members are to be in-service on proper application of restraints. A restraint shall be applied in such a manner that speedy removal is possible in the event of a fire or other emergency.

Based on observation, interview, and record review, the facility failed to ensure the resident received care consistent with professional standards of practice to prevent pressure ulcer (a localized injury to the skin and or underlying tissue usually over a bone prominence as a result of pressure or pressure in combination with shear [occur between the internal body structures and skin tissues typically moving in opposite directions and may lead to deep tissue injury]) for one of three sampled residents (Resident 5) by failing to ensure no excessive padding was placed over the low air loss mattress (LALM-a mattress designed to distribute the patient's body weight over a broad surface area to prevent skin breakdown and treat pressure ulcers) as indicated in the manufacturer ' s manual and facility ' s policy. This deficient practice had the potential for the development and worsening of pressure ulcers or injuries for Resident 5. Findings: During a review of Resident 5 ' s admission Record, the admission Record indicated the facility admitted Resident 5 on 1/22/2021, with diagnoses that included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), unspecified (unconfirmed) heart failure (the heart can't pump enough blood to meet the body's needs, often due to weakened or stiff heart muscle, and can lead to symptoms like shortness of breath and fatigue), and paroxysmal atrial fibrillation (a fast, irregular heartbeat that only lasts a few hours or days). During a review of Resident 5 ' s History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 10/11/2024, the H&P indicated Resident 5 did not have the capacity to understand and make decisions. During a review of Resident 5 ' s Minimum Data Set (MDS – a resident assessment tool), dated 1/31/2025, the MDS indicated Resident 5 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 5 was dependent to staff for toileting, showering and personal hygiene. The MDS indicated Resident 5 was always incontinent (unable to control) of bowel and bladder functions. The MDS indicate Resident 5 was at risk for developing pressure ulcers and injuries. During a review of Resident 5 ' s Physician Order, dated 2/6/2025, the Physician Order indicated LALM for wound care and management. During a concurrent observation and interview on 4/4/2025, at 8:34 a.m., with Certified Nursing Assistant 3 (CNA 3), at Resident 5 ' s bedside. Observed Resident 5 on LALM with multiple layers of linen. CNA 3 counted each layer. CNA 3 stated there were one bed sheet, one linen folded into four, two washable chux, and Resident 5 was on incontinent brief. CNA 3 stated there were a total of eight layers between Resident 5 and Resident 5 ' s LALM. CNA 3 stated there should only be one linen and one incontinence brief (a disposable, absorbent garment designed to absorb urine and/or feces). During an interview on 4/4/2025, at 8:36 a.m. with Registered Nurse 1 (RN 1), RN 1 stated Resident 5 on LALM needed four layers of linen in between the resident (Resident 5) and LALM. RN 1 stated Resident 5 needed bed sheet, chux, linen, and incontinence brief. During an interview on 4/4/2025, at 8:25 a.m., with the Infection Preventionist (IP) who was covering for the Director of Staff Development (DSD), the IP stated there should only be two layers including incontinence brief between Resident 5 and LALM. The IP stated RN 1 should know as she (RN 1) was already inserviced (educated). The IP stated multiple layers of linen in between can put Resident 5 at risk for pressure ulcer. During an interview on 4/4/2025 at 11:14 a.m., with the Director of Nursing (DON), the DON stated the facility ' s standard was only two layers between a resident and LALM. The DON stated multiple layers can cause skin breakdown. The DON stated the LALM Operation Manual indicated no excessive layers. During a review of facility ' s Operation Manual for LALM, undated and last reviewed on 4/17/2024, the Operation Manual indicated, The LALM system is designed for prevention, treatment and management of pressure ulcers. Secure sheets loosely enough to ensure they do not interfere with cell alternation. When the mattress had been adjusted to a desired level of firmness, the patient can then lie on the mattress. During a review of facility ' s P&P titled, Care and Prevention of Pressure Sores, undated and last reviewed on 4/17/2024, the P&P indicated, The Charge Nurse and Treatment Nurse are to be responsible for determining which resident requires special supports, mattresses, foam padding. foot boarding or other preventative measures and for instructing the assigned nurse assistant in their use. Nursing and Care Duties: Making beds properly (example given, no wrinkles in linen, no excessive padding for incontinent residents).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive care plan for three of three sampled residents (Residents 1, 2, and 3) by failing to ensure a care plan was develop on residents ' potential exposure to scabies (a skin condition caused by tiny mites that burrow [a hole or tunnel] under the skin, leading to intense itching and a rash which is contagious [disease that they can pass to other people] and can spread through prolonged skin-to-skin contact). This deficient practice had the potential for delayed provision of necessary care and services and spread of scabies among residents. Findings: a. During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 12/3/2019, with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic pain syndrome (ongoing pain that persists beyond the expected healing time or occurs with a chronic health condition, lasting for months or years and significantly impacting daily life) and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 1 ' s History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 12/18/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool), dated 1/1/2025, the MDS indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 required supervision from staff for toileting, showering, dressing and personal hygiene. The MDS indicated Resident 1 was always continent (able to control) of bowel and bladder functions. During a review of Resident 1 ' s Physician Order, dated 2/18/2025, the Physician Order indicated Elimite (medication used to treat scabies) 5 percent (%- per one hundred) cream, apply from neck to toes, leave on for 12 hours, then wash off one time only for asymptomatic (no symptoms) prophylaxis (an attempt to prevent disease)related to probable exposure to scabies for one day. During a review of Resident 1 ' s Treatment Administration Record (TAR-daily documentation record used by a licensed nurse to document treatments given to a resident), dated 2/2025, the TAR indicated on 2/20/2025, at 9:18 p.m., Licensed Vocational Nurse 4 (LVN 4) applied Elimite 5% cream to Resident 1 from neck to toes related to probable exposure to scabies. b. During a review of Resident 2 ' s admission Record, the admission Record indicated the facility admitted Resident 2 on 11/2/2022, with diagnoses that included metabolic encephalopathy (brain dysfunction caused by imbalances in the body's metabolism or underlying medical conditions, leading to changes in mental status), generalized muscle weakness and unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities). During a review of Resident 2 ' s H&P, dated 2/13/2025, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2 ' s MDS, dated [DATE], the MDS indicated Resident 2 ' s cognitive skills for daily decisions were severely impaired. The MDS indicated Resident 2 was dependent to staff for all activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 2 ' s Physician Order, dated 2/18/2025, the Physician Order indicated Elimite 5% cream, apply from neck to toes, leave on for 12 hours, and then wash off one time only for asymptomatic prophylaxis treatment related to probable exposure to scabies for one day. During a review of Resident 2 ' s TAR, dated 2/2025, the TAR indicated on 2/20/2025, at 9:18 p.m., LVN 4 applied Elimite 5% cream to Resident 2 from neck to toes related to probable exposure to scabies. c. During a review of Resident 3 ' s admission Record, the admission Record indicated the facility admitted Resident 3 on 11/14/2023, with diagnoses that included atherosclerosis heart disease, (when the blood vessels that carry oxygen and nutrients from the heart to the rest of the body become thick and stiff) unspecified chest pain and cardiomegaly (yourheart is larger than it should be). During a review of Resident 3 ' s H&P, dated 7/24/2024, the H&P indicated Resident 3 did not have the capacity to understand and make decisions. During a review of Resident 3 ' s MDS, dated [DATE], the MDS indicated Resident 3 ' s cognitive skills for daily decisions were moderately impaired. The MDS indicated Resident 3 needed moderate assistance from staff for toileting and showering. During a review of Resident 3 ' s Physician Order, dated 2/18/2025, the Physician Order indicated Elimite 5% cream, apply from neck to toes, leave on for 12 hours, and then wash off one time only for asymptomatic prophylaxis treatment related to probable exposure to scabies for one day. During a review of Resident 3 ' s TAR, dated 2/2025, the TAR indicated on 2/20/2025 at 9:18 p.m., LVN 4 applied Elimite 5% cream to Resident 3 from neck to toes related to probable exposure to scabies. During a concurrent interview and record review on 4/3/2025, with the Director of Nursing (DON), Resident 1, 2, and 3 ' s Care Plans were reviewed. The DON stated there were no care plans developed for Residents 1, 2, and 3 ' s possible exposure to scabies. The DON stated the nurses should have developed care plans for treatment and monitoring of scabies. The DON stated nurses might not follow plan of care for scabies treatment and prevention causing possible spread of scabies. During a review of facility ' s policy and procedure (P&P) titled, The Resident Care Plan, undated and last reviewed on 4/17/2024, the P&P indicated, To provide an individualized nursing care plan and to promote continuity of resident care. An initial care plan to provide immediate needs will be developed timely. 2. Record the following: 1. Procedures directly ordered by the physician. 2. Procedures associated with specific resident teaching. 3. Care necessitated by the resident s individual needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for two of four sampled residents (Resident 1 and 2) by: 1. Failing to ensure Resident 1 ' s physician order was followed for oxycodone (medication used to treat pain) for severe pain level between seven to ten. 2. Failing to ensure Resident 2 ' s physician order was followed to hold diltiazem (medication used to treat high blood pressure) for systolic blood pressure (sbp - the top number in a blood pressure reading, indicating the pressure in your arteries when your heart beats) below 110. This failure had the potential to result in medication error and can cause hypotension (low blood pressure). Findings: a. During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 12/3/2019, with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), unspecified (unconfirmed) low back pain, and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 1 ' s History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 12/18/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool) dated 1/1/2025, the MDS indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 required supervision from staff for toileting, showering, dressing and personal hygiene. The MDS indicated Resident 1 was always continent (able to control) of bowel and bladder functions. During a review of Resident 1 ' s Physician Order dated 11/26/2022, the Physician Order indicated oxycodone hydrochloride tablet 30 milligram (mg- metric unit of measurement, used for medication dosage and/or amount), give 30 mg by mouth every six hours as needed for severe pain level of seven to ten. During a review of Resident 1 ' s Medication Administration Record (MAR-a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 3/2025, the MAR indicated Licensed Vocational Nurse 6 (LVN 6) and LVN 7 had administered oxycodone 30 mg to Resident 1 with a pain level six on the following dates: a. 3/1/2025 at 10 a.m. b. 3/7/2025 at 10 p.m. c. 3/8/2025 at 4 p.m. d. 3/8/2025 at 10 p.m. e. 3/14/2025 at 10 p.m. f. 3/15/2025 at 10 p.m. g. 3/21/2025 at 10 p.m. h. 3/28/2025 at 10 p.m. i. 3/29/2025 at 10 p.m. During a concurrent interview and record review on 4/3/2025, at 12:30 p.m., with the Director of Nursing (DON), Resident 1 ' s Physician Order dated 11/26/2022, and MAR dated 3/2025, were reviewed. The DON stated LVN 6 and LVN 7 should have provided the correct pain medication according to Resident 1 ' s pain level. The DON stated LVN 6 and LVN 7 should perform a proper pain assessment, call the physician to adjust the physician order. The DON stated with pain level of six, acetaminophen (medication used to treat pain and fever) should have been administered. The DON stated the licensed nurses did not follow Resident 1's physician order. The DON stated oxycodone is habit forming (addictive) medication and can cause Resident 1 to ask for oxycodone even when he (Resident 1) did not have severe pain. b. During a review of Resident 2 ' s admission Record, the admission Record indicated the facility admitted Resident 2 on 11/2/2022, with diagnoses that included metabolic encephalopathy (brain dysfunction caused by imbalances in the body's metabolism or underlying medical conditions, leading to changes in mental status), other secondary hypertension (specific type of high blood pressure that has a known underlying cause) and unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities). During a review of Resident 2 ' s H&P, dated 2/13/2025, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2 ' s MDS, dated [DATE], the MDS indicated Resident 2 ' s cognitive skills for daily decisions were severely impaired. The MDS indicated Resident 2 was dependent to staff for all activities of daily living (ADL-activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 2 ' s Physician Order dated, 2/13/2025, the Physician Order indicated diltiazem hydrochloride (medication used to treat hypertension) oral tablet 60 mg, give one tablet by mouth every six hours for high blood pressure, hold for systolic blood pressure below 110. During a review of Resident 2 ' s MAR dated 3/2025, the MAR indicated on 3/31/205, LVN 5 administered diltiazem to Resident 2 with a blood pressure of 108/70 millimeters of mercury (mmHg- a unit of measurement for pressure). During a concurrent interview and record review on 4/3/2025, at 12:30 p.m., with the DON, Resident 2 ' s Physician Order dated 2/13/2025, and MAR dated 3/2025, were reviewed. The DON stated Resident 2 ' s blood pressure on 3/31/2025, at 12 noon was 108/70 mmHg and physician order was to hold (stop) the diltiazem for sbp below 110. The DON stated LVN 5 should have held the medication to prevent further decrease in blood pressure. During a concurrent interview and record review on 4/4/2025 at 11:14 a.m., with the DON, facility ' s policy and procedure (P&P) tilted, Med Pass, undated and last reviewed on 4/17/2024, the P&P indicated A. Basic procedure: Prepare the medication correctly, administer the medication correctly, and chart the medication pass correctly. Make sure that during the course of a medication pass. The 5 Rights: Make sure that medications are administered according to: a. Right resident b. Right medications c. Right dose d. Right route/method e. Right time B. Do not administer medications according to memory. Never administer medications just because they are available, just because the family or resident requests, or just because certain meds are normally given in that dose at that time. C. Vital Signs When vital signs are included in med order, vital signs are to be taken just before medication is administered and by the med nurse. A vital sign taken by a Certified Nursing Assistant (CNA) at the beginning of a shift shall not be valid. The DON stated the facility ' s policy was to follow the physician's order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure three of four sampled residents (Residents 1, 2, and 3) who had no scabies (a parasitic infestation caused by tiny mites that burrow into the skin and lay eggs, causing intense itching and a rash) was not given Elimite (medication used to treat scabies) cream. This failure had the potential to result in Residents 1, 2, and 3 to receive unnecessary medications. Findings: a. During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 12/3/2019, with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic pain syndrome (ongoing pain that persists beyond the expected healing time or occurs with a chronic health condition, lasting for months or years and significantly impacting daily life), and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 1 ' s History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 12/18/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool), dated 1/1/2025, the MDS indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 required supervision from staff for toileting, showering, dressing and personal hygiene. The MDS indicated Resident 1 was always continent (able to control) of bowel and bladder functions. During a review of Resident 1 ' s Physician Order, dated 2/18/2025, the Physician Order indicated Elimite 5 percent (%- per one hundred) cream, apply from neck to toes, leave on for 12 hours, and then wash off one time only for asymptomatic (no symptoms) prophylaxis (an attempt to prevent disease) related to probable exposure to scabies for one day. During a review of Resident 1 ' s Treatment Administration Record (TAR-daily documentation record used by a licensed nurse to document treatments given to a resident), dated 2/2025, the TAR indicated on 2/20/2025, at 9:18 p.m., Licensed Vocational Nurse 4 (LVN 4) applied Elimite cream to Resident 1 from neck to toes related to probable exposure to scabies. During an interview on 4/2/2025, at 8:46 a.m., with Resident 1, Resident 1 stated he (Resident 1) received Elimite cream for scabies, but he (Resident 1) was not tested for scabies. Resident 1 stated he (Resident 1) got confused if he (Resident 1) had the scabies or not. During an interview on 4/2/2025, at 10:06 a.m., with the Treatment Nurse 1 (TN 1), TN 1 stated Resident 1 had no diagnosis of scabies but received Elimite cream on 2/18/2025, as prophylaxis for possible exposure to scabies. b. During a review of Resident 2 ' s admission Record, the admission Record indicated the facility admitted Resident 2 on 11/2/2022, with diagnoses that included metabolic encephalopathy (brain dysfunction caused by imbalances in the body's metabolism or underlying medical conditions, leading to changes in mental status), generalized muscle weakness and unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities). During a review of Resident 2 ' s H&P dated 2/13/2025, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2 ' s MDS dated [DATE], the MDS indicated Resident 2 ' s cognitive skills for daily decisions were severely impaired. The MDS indicated Resident 2 was dependent to staff for all activities of daily living (ADL-personal hygiene, bed mobility, dressing, and transfers). During a review of Resident 2 ' s Physician Order dated 2/18/2025, the Physician Order indicated Elimite five % cream, apply from neck to toes, leave on for 12 hours, then wash off one time only for asymptomatic prophylaxis treatment related to probable exposure to scabies for one day. During a review of Resident 2 ' s TAR dated 2/2025, the TAR indicated on 2/20/2025, at 9:18 p.m., LVN 4 applied Elimite cream to Resident 2 from neck to toes related to probable exposure to scabies. During an interview on 4/2/2025, at 9:45 a.m., with LVN 1, LVN 1 stated Resident 2 had no diagnosis of scabies. c. During a review of Resident 3 ' s admission Record, the admission Record indicated the facility admitted Resident 3 on 11/14/2023, with diagnoses that included atherosclerosis heart disease, (when the blood vessels that carry oxygen and nutrients from the heart to the rest of the body become thick and stiff) unspecified chest pain and cardiomegaly (your heart is larger than it should be). During a review of Resident 3 ' s H&P, dated 7/24/2024, the H&P indicated Resident 3 did not have the capacity to understand and make decisions. During a review of Resident 3 ' s MDS, dated [DATE], the MDS indicated Resident 3 ' s cognitive skills for daily decisions were moderately impaired. The MDS indicated Resident 3 needed moderate assistance from staff for toileting and showering. During a review of Resident 3 ' s Physician Order, dated 2/18/2025, the Physician Order indicated Elimite 5% cream, apply from neck to toes, leave on for 12 hours, and then wash off one time only for asymptomatic prophylaxis treatment related to probable exposure to scabies for one day. During a review of Resident 3 ' s TAR, dated 2/2025, the TAR indicated on 2/20/2025 at 9:18 p.m., LVN 4 applied Elimite cream to Resident 3 from neck to toes related to probable exposure to scabies. During an interview on 4/2/2025, at 9:45 a.m., with LVN 1, LVN 1 stated Resident 3 had scabies treatment but no diagnosis of scabies. During an interview on 4/2/2025, at 10:06 a.m., with TN 1, TN 1 stated no cases of scabies in the facility. During an interview on 4/2/2025, at 10:29 a.m., with the Infection Preventionist (IP), the IP stated Resident 4 was transferred out to the General Acute Care Hospital (GACH) on 2/13/2025, and his (Resident 4) roommates that time were Resident 1 and Resident 3. The IP stated Resident 4 was readmitted from the GACH with positive for scabies on 2/17/2025. The IP stated he (IP) and the TNs gave Elimite to the residents (Residents 1, 2, and 3) in Station B as prophylaxis. The IP stated Resident 1 and Resident 3 were not tested for the presence of scabies. During an interview on 4/2/2025, at 11:19 p.m., with the Director of Nursing (DON), the DON stated the facility ' s policy for scraping (this involves using a tool, often a scalpel or blade, to gently scrape the skin surface) resident was if the facility suspected cases of scabies. The DON stated there were no new suspected cases during the residents (Residents 1, 2, and 3) skin checks. The DON stated because there was one positive case of scabies in the facility reason that was why she (DON) did prophylaxis administration of Elimite. The DON stated it was an unnecessary medication administration because we were not on scabies outbreak. The DON stated scabies outbreak means two confirmed cases of scabies. During a concurrent interview and record review on 4/4/2025, at 11:14 a.m., with the DON, facility ' s policy and procedure (P&P) titled, Consultant Pharmacist services Provider Requirements, dated 10/2017, and last reviewed on 4/17/2025, the P&P indicated, A resident ' s drug regimen must be free of unnecessary drugs. An unnecessary drug is any drug when used in: i. Excessive dose (including a duplicate drug) ii. Excessive duration iii. Without adequate monitoring iv. Without adequate indication for its use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement infection control measures for three of four sampled residents (Resident 1, 2, and 3) by. 1. Failing to ensure Resident 1 was placed on contact isolation after physician ordered skin scraping (a medical procedure where a sample of skin cells is collected by gently scraping the surface of the skin with a sterile blade) to test for presence of scabies (a contagious skin condition caused by microscopic [so small as to visible only with microscope] mites [tiny bugs] burrowing [made a hole] into the skin). 2. Failed to ensure skin monitoring was done and documented in Residents 1, 2, and 3 ' s medical records after physician ordered the monitoring on 2/18/2025. These failures had the potential for the spread of scabies among residents and staff. Findings: a. During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 12/3/2019, with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic pain syndrome (ongoing pain that persists beyond the expected healing time or occurs with a chronic health condition, lasting for months or years and significantly impacting daily life) and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 1 ' s History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 12/18/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool), dated 1/1/2025, the MDS indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 required supervision from staff for toileting, showering, dressing and personal hygiene. The MDS indicated Resident 1 was always continent (able to control) of bowel and bladder functions. During a review of Resident 1 ' s Physician Order, dated 4/3/2025, the Physician Order indicated skin scraping to rule out scabies. During an observation on 4/4/2025, at 8:23 a.m., at Resident 1 ' s door. Observed there was no contact isolation (are measures taken in healthcare settings to prevent the spread of germs through direct or indirect contact with a resident or their environment including the use of personal protective equipment [PPE- wearable equipment that is intended to protect healthcare personnel and the public from exposure to or contact with infectious agents] like gowns and gloves, using dedicated equipment, and careful hand hygiene) signage posted on the door and no PPE noted by Resident 1 ' s door. During an interview on 4/4/2025, at 9:02 a.m. with Treatment Nurse 2 (TN 2), TN 2 stated Resident 1 ' s skin was scraped yesterday (4/3/2025 which was after the surveyor's visit) to rule out scabies. During an interview on 4/4/2025, at 9:35 a.m., with the Infection Preventionist (IP), the IP stated the physician saw Resident 1 on 4/2/2025 (during the surveyor's visit) and ordered skin scraping to rule out scabies and he (IP) tested and obtained the specimen from Resident 1 ' s left arm. The IP stated since the order was to rule out scabies, Resident 1 should have been on contact isolation. The IP stated contact isolation should have been started on 4/3/2025. The IP stated scabies can spread if Resident 1 was not placed on contact isolation. During an interview on 4/4/2025, at 11:14 a.m., with the Director of Nursing (DON), the DON stated Resident 1 should have been on contact isolation when the physician ordered the skin scraping to rule out scabies to prevent the spread of scabies. During a review of facility ' s policy and procedure (P&P) titled, Outbreak of Communicable Diseases, dated 4/2023 and last reviewed on 4/17/2024, the P&P indicated, The Infection Preventionist and the Director of Nursing are responsible for: a. Managing surveillance data. b. Monitoring ill residents and staff, c. Initiating transmission-based precautions (extra steps taken in healthcare settings to prevent the spread of infections from one person to another, especially when standard precautions like handwashing might not be enough), as appropriate. During a review of facility ' s P&P titled, Isolation-Categories of Transmission-Based Precautions, dated 4/2023, and last reviewed on 4/17/2024, the P&P indicated, When a resident is placed on transmission-based precautions. appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors aware of the need for and the type of precaution. The signage informs the staff of the type of precaution(s), instructions for use of PPE and or instructions to see a nurse before entering the room. Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. b. During a review of Resident 1 ' s Physician Order, dated 2/18/2025, the Physician Order indicated monitor skin of generalized body for rashes (changes in the skin's appearance or texture, often characterized by redness, bumps, itching, or swelling), papules (a raised area of skin tissue), and itching. During a review of Resident 1 ' s Treatment Administration Record (TAR-a daily documentation record used by a licensed nurse to document treatments given to a resident), dated 2/2025, the TAR indicated Resident 1 ' s skin monitoring was started on 2/20/2025. During a review of Resident 2 ' s admission Record, the admission Record indicated the facility admitted Resident 2 on 11/2/2022, with diagnoses that included metabolic encephalopathy (brain dysfunction caused by imbalances in the body's metabolism or underlying medical conditions, leading to changes in mental status), generalized muscle weakness and unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities). During a review of Resident 2 ' s H&P, dated 2/13/2025, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2 ' s MDS, dated [DATE], the MDS indicated Resident 2 ' s cognitive skills for daily decisions were severely impaired. The MDS indicated Resident 2 was dependent to staff for all activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 2 ' s Physician Order, dated 2/18/2025, the Physician Order indicated monitor skin of generalized body for rashes, papules and itching. During a review of Resident 2 ' s TAR, dated 2/2025, the TAR indicated Resident 2 ' s skin monitoring was started on 2/20/2025. During a review of Resident 3 ' s admission Record, the admission Record indicated the facility admitted Resident 3 on 11/14/2023, with diagnoses that included atherosclerosis heart disease (when the blood vessels that carry oxygen and nutrients from the heart to the rest of the body become thick and stiff) unspecified chest pain and cardiomegaly (your heart is larger than it should be). During a review of Resident 3 ' s H&P, dated 7/24/2024, the H&P indicated Resident 3 did not have the capacity to understand and make decisions. During a review of Resident 3 ' s MDS, dated [DATE], the MDS indicated Resident 3 ' s cognitive skills for daily decisions was moderately impaired. The MDS indicated Resident 3 needed moderate assistance from staff for toileting and showering. During a review of Resident 3 ' s Physician Order, dated 2/18/2025, the Physician Order indicated monitor skin of generalized body for rashes, papules, and itching. During a review of Resident 3 ' s TAR dated 2/2025, the TAR indicated Resident 3 ' s skin monitoring was started on 2/20/2025. During a concurrent interview and record review on 4/4/2025, at 9:02 a.m., with TN 2, Residents 1, 2, and 3 ' s Physician Order dated 2/18/2025, TAR dated 2/2025 and Progress Notes dated 2/18/2025 to 2/19/2025 were reviewed. TN 2 stated physician ordered the skin monitoring on 2/18/2025 and TAR indicated monitoring was documented starting on 2/20/2025. TN 2 stated they missed two days of skin monitoring from 2/18/2025 to 2/19/2025. TN 2 stated Residents 1, 2, and 3 ' s skin condition can get worst, and residents can be uncomfortable. TN 2 stated it can cause a delay in care and can result in the spread of scabies. During an interview on 4/4/2025, at 9:35 a.m., with the IP, the IP stated skin monitoring should be started and documented on the TAR on 2/18/2025. The IP stated there were no documented skin monitoring on Residents 1, 2, and 3 ' s Progress Notes. The IP stated the importance of skin monitoring was to identify change in condition and to report to the physician and give appropriate care and treatment. The IP stated not monitoring the skin and not documenting can cause a delay in the care. During an interview on 4/4/2025, at 11:14 a.m., with the DON, the DON stated nurses should start the monitoring and documentation on 2/18/2025, when the physician made the order. The DON stated the importance of monitoring was to ensure resident's skin was assessed for possible signs of scabies to prevent delay in care. During a review of facility ' s P&P titled, Outbreak of Communicable Diseases, dated 4/2023 and last reviewed on 4/17/2024, the P&P indicated, The Infection Preventionist and the Director of Nursing are responsible for: a. Managing surveillance data. b. Monitoring ill residents and staff, c. Initiating transmission-based precautions, as appropriate. The Nursing staff is responsible for . b. providing infection surveillance data in a timely manner. During a review of facility ' s P&P titled, Scabies- Prevention and Control, undated and last reviewed on 4/17/2024, the P&P indicated, Nurses and other healthcare workers will be trained to recognize and report any patient themselves or other healthcare worker with signs and symptoms compatible with scabies infestation.

Based on interview and record review, the facility failed to ensure the Attending Physician (AP) was notified timely for one of four sampled residents (Resident 1). This deficient practice resulted in a delay of obtaining appropriate instructions from the physician for proper management. Findings: During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 2/1/2025, with diagnoses that included urinary tract infection (UTI- an infection in the bladder/urinary tract), age related osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D) with current pathological vertebra fracture (broken bone caused by disease) and unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities). During a record review of Resident 1's Change of Condition (COC), dated 2/1/2025, timed at 10:20 p.m., the COC indicated Resident 1 was found sitting on the floor mat. The COC indicated on 2/1/2025, at 10:20 p.m., Certified Nursing Assistant 1 (CNA 1) notified Licensed Vocational Nurse 1 (LVN 1) that Resident 1 was sitting on the floor mat. The COC indicated the AP was notified on 2/1/2025, at 10:20 p.m., and the AP ordered a stat (immediately) left leg X-ray (a diagnostic imaging test to create pictures of the inside of the body). During a record review of Resident 1's Physician Order, dated 2/1/2025, the Physician order indicated an order for stat left leg X-ray. During a record review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 2/2/2025, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. During a record review of Resident 1's Interdisciplinary Team (IDT-a coordinated group of experts from several different fields who work together) Fall Risk, dated 2/5/2025, the IDT indicated on 2/2/2025 at 6 a.m., LVN 2 notified AP that stat X-ray was not done. During a concurrent interview and record review on 2/13/2025, at 9:53 a.m., with Registered Nurse 1 (RN 1), Resident 1's COC, dated 2/1/2025, was reviewed. RN 1 stated if AP ordered stat X-ray and was not done within two hours, staff should have called to notify the AP. RN 1 stated the importance of notifying the AP within two hours was to get further orders as soon as possible. During an interview on 2/13/1025, at 10:10 a.m., with the Director of Nursing (DON), the DON stated if stat X-ray was ordered and not done within four to six hours, nurses should have notified the AP. The DON stated LVN 2 called AP on 2/2/2025 at 6 a.m. and it was a late notification. During a record review of facility's policy and procedure (PnP) titled, Change of Condition, dated 1/24/2017, and last reviewed on 4/17/2024, the PnP indicated, Upon a change in condition for any reason, nursing staff members are to take the following actions. Physician shall be called promptly.

Based on interview and record review, the facility failed to maintain accurate and complete medical record for one of four sampled residents (Resident 1). This deficient practices had the potential to cause confusion in care and the medical records containing inaccurate documentation. Findings: During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 2/1/2025, with diagnoses that included urinary tract infection (UTI- an infection in the bladder/urinary tract), age related osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D) with current pathological vertebra fracture (broken bone caused by disease) and unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities). During a record review of Resident 1's Change of Condition (COC), dated 2/1/2025, timed at 10:20 p.m., the COC indicated Resident 1 was found sitting on the floor mat. The COC indicated Responsible Party (RP) was notified on 2/1/2025 at 12:00 a.m. During a record review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 2/2/2025, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. During a concurrent interview and record review on 2/13/2025, at 9:53 a.m. with Registered Nurse 1 (RN 1), Resident 1's COC, dated 2/1/2025 was reviewed. RN 1 stated Resident 1's COC for RP notification was documented wrong. RN 1 stated COC should indicate RP was notified on 2/2/2025 at 12 a.m. RN 1 stated the importance of complete and accurate records was to show that intervention was done timely to keep Resident 1 safe. During a concurrent interview and record review on 2/13/2025, at 10:10 a.m. with the Director of Nursing (DON), Resident 1's COC dated 2/1/2025 and Resident 1's Progress Notes dated 2/1/2025 and 2/2/2025 were reviewed. The DON stated time RP was called was not documented in COC and Progress Note. The DON stated the importance of documenting accurately was to prove that RP was notified right away. During a concurrent interview and record review on 2/13/2025 at 10:28 a.m., with the DON, facility's policy and procedure (PnP) titled, Charting and Documentation, dated 7/2017 and last reviewed on 4/17/2024, the PnP indicated All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team (IDT- a coordinated group of experts from several different fields who work together) regarding the resident's condition and response to care. Documentation in the medical record will be objective (not opinionated or speculative) complete and accurate. The DON stated the facility's PnP indicated to document accurately. During an interview on 2/13/2025 at 1:31 p.m., with RN 2, RN 2 stated she (RN 2) called RP on 2/1/2025 between 11 p.m. to 2/2/2025 at 12 a.m., RN 2 admitted she documented the wrong date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three of five sampled residents (Resident 3, Resident 4, and Resident 5) were provided a safe and homelike environment. The facility failed to: 1. Ensure the facility temperature was between 71 degrees Fahrenheit (°F, unit of measurement for temperature) to 81°F as indicated in the facility's policy and procedure (PnP). 2. Ensure safe and clean shower rooms were provided for the residents. These deficient practices had the potential to cause serious medical problems and altered comfort level. In addition, based on the Reasonable Person Concept (refers to a tool to assist the survey team's assessment of the severity level of negative, or potentially negative, psychosocial outcome the deficiency may have had on a reasonable person in the resident's position), due to Residents 3, 4, and 5's impaired cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) and medical condition, a homelike environment that were not provided may have psychological (mental or emotional) effects including feelings of hopelessness (a feeling or state of despair or lack of hope) and helplessness (the belief that there is nothing that anyone can do to improve a bad situation). Findings: During a record review of Resident 3's admission Record, the admission Record indicated the facility admitted the resident on 3/30/2022 with diagnoses including metabolic encephalopathy (an alteration in consciousness due to brain dysfunction), adult failure to thrive (an older person experiences a significant decline in their overall health), and unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a record review of Resident 3's Care Plan on self-care, last revised on 4/9/2024, the Care Plan indicated Resident 3 had self-care deficit and was dependent on facility staff on activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The Care Plan Interventions included to assist Resident 3 with ADLs as needed and to provide a safe environment. During a record review of Resident 3's History and Physical (H and P), dated 12/5/2024, the H and P indicated the resident had no capacity to understand and make decisions. During a record review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 1/6/2025, the MDS indicated the resident's cognitive skills was severely impaired. During a record review of Resident 4's admission Record, the admission Record indicated the facility admitted the resident on 3/15/2023 with diagnoses including adult failure to thrive, and unspecified dementia, and bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) During a record review of Resident 4's H and P, dated 6/13/2024, the H and P indicated the resident had no capacity to understand and make decisions. During a record review of Resident 4's MDS, dated [DATE], the MDS indicated the resident's cognitive skills was severely impaired. The MDS indicated Resident 4 had functional limitation in range of motion (ROM - extent of movement of a joint) on both sides of both the upper extremity (shoulder, elbow, wrist, and hand) and the lower extremity (hip, knee, ankle, and foot). During a record review of Resident 4's Care Plan on self-care, last revised on 12/24/2024, the Care Plan indicated Resident 4 had self-care deficit and required maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) on the ADLs. The Care Plan Interventions included to assist Resident 4 with ADLs as needed and to provide a safe environment. During a record review of Resident 5's admission Record, the admission Record indicated the facility admitted the resident on 10/17/2019 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), unspecified dementia, and seizures (a sudden, uncontrolled burst of electrical activity in the brain) During a record review of Resident 5's H and P, dated 10/24/2023, the H and P indicated the resident had no capacity to understand and make decisions. During a record review of Resident 5's Care Plan on self-care, last revised on 4/29/2024, the Care Plan indicated Resident 5 had self-care deficit and dependent on facility staff on ADLs. The Care Plan Interventions included to assist Resident 5 with ADLs as needed and to provide a safe environment. During a record review of Resident 5's MDS, dated [DATE], the MDS indicated the resident's cognitive skills was severely impaired. During a concurrent observation and interview on 2/12/2025 with the Maintenance Assistant (MA), MA was observed checking the facility temperature using a temperature gun (a hand-held device that measures the temperature of something without touching it) and the following readings were observed: a. At 6:59 a.m., the temperature in the dining room was 70.7°F. b. At 7:01 a.m., the temperature inside Resident room [ROOM NUMBER] (RR 1) was 70.8°F. c. At 7:03 a.m., the temperature at subacute nurse station was 69.8°F. d. At 7:04 a.m., the temperature inside RR 3 was 70.7°F and the temperature inside RR 4 was 69.5°F. e. At 7:07 a.m., the temperature inside RR 5 was 68.1°F. The hallway in front of RR 5 had a temperature of 63.5°F. RR 6 had a temperature on 60°F. Observed RR 6's window was open. MA stated the windows in the facility should be closed to keep the warm air inside the facility. f. At 7:12 a.m., the temperature inside RR 7 was 61.5°F. g. At 7:19 a.m., the temperature inside RR 8 was 68.8°F. During a follow up interview on 2/12/2025 at 7:33 a.m. with MA, MA stated the facility temperature was cold. MA stated on 2/6/2025, station 2's heater that supplied warm air on RR 6 and RR 7 was not working. MA stated the facility hired an outside company and had the heater fixed on 2/6/2025. During a concurrent observation and interview on 2/12/2025 with Maintenance Supervisor (MS), MS was observed checking the facility temperature using a temperature gun and the following readings were observed: a. At 9:57 a.m., the temperature inside RR 10 was 69°F. b. At 10:03 a.m., the temperature inside RR 6 was 65°F and the temperature in the hallway was 65.5°F. c. At 10:05 a.m., the temperature in station 2 dining room was 64.5°F d. At 10:15 a.m., the temperature at the subacute nurse station was 69.4°F and the temperature in the hallway was 66°F. e. At 10:16 a.m., the temperature inside RR 4 was 67°F and the temperature inside RR 3 was 65.3°F. f. At 10:17 a.m., the temperature inside RR 1 was 67.8°F. g. At 10:18 a.m., the temperature inside RR 2 was 70.8°F. During a follow up interview on 2/12/2025 at 10:19 a.m. with MS, MS stated the facility temperature taken did not meet the required facility temperature of 71°F to 81°F. During an interview on 2/12/2025 at 10:51 a.m. with the Director of Nursing (DON), the DON stated the facility temperature was not within the regulation of 71°F to 81°F. The DON stated facility temperature that were not between 71°F to 81°F had the potential to cause the residents' discomfort. The DON stated the facility failed to ensure the facility temperature was within 71°F to 81°F per the facility's PnP. During a record review of the facility's policy and procedure (PnP) titled, Homelike Environment, last reviewed on 4/17/2024, the PnP indicated residents were provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. The PnP indicated the facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting that included a. clean, sanitary, and orderly environment and h. comfortable and safe temperatures (71°F to 81°F). 2. During a concurrent observation and interview on 2/12/2025 at 7:14 a.m. with Licensed Vocational Nurse 2 (LVN 2), observed towels and a box of gloves on the floor inside shower room [ROOM NUMBER]. Observed one of three shower chairs inside shower room [ROOM NUMBER] with smudges of feces on the shower chair seat. LVN 2 stated shower chairs and equipments used for residents should be cleaned and disinfected after each resident use. LVN 2 stated feces left on the shower chair and towels on the shower room floor was unsanitary and had the potential to cause infection to the residents. LVN 2 stated residents were not provided a home like environment. During a concurrent observation and interview on 2/12/2025 at 7:23 a.m. with MA, observed shower room [ROOM NUMBER] with a disposable brief on the glove box holder. Observed a pack of unused razors on top of the sharp container. MA stated disposable briefs, and the razors should not be left inside the resident shower rooms unattended. MA stated there were bins for designated for sharps, linens and trash. During an interview on 2/12/2025 at 10:51 a.m. with the DON, the DON stated the facility staff did not clean the equipments and the residents' shower rooms after providing resident care. The DON stated shower rooms and equipments not cleaned and disinfected after use meant the facility did not provide a clean and homelike environment for the residents. During a record review of the facility's policy and procedure (PnP) titled, Homelike Environment, last reviewed on 4/17/2024, the PnP indicated residents were provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. The PnP indicated the facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting that included a. clean, sanitary, and orderly environment and h. comfortable and safe temperatures (71°F to 81°F).

Based on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding (EF - a form of nutrition that is delivered into the digestive system as a liquid) for two (2) out of 2 sampled residents (Residents 30 and 367) investigated under the tube feeding care area by failing to ensure Registered Nurse 6 (RN 6) obtained a physician's order for a tube feeding replacement when Jevity 1.2 (a high-protein, fiber-fortified formula that provides complete, balanced nutrition for long- or short-term tube feeding) was unavailable for immediate use by the resident. This deficient practice had the potential to place Residents 30 and 367 at risk for complications of enteral feeding such as diarrhea (loose, watery stools) or vomiting which may lead to dehydration (loss or removal of water). Findings: a.During a review of Resident 30's admission Record, the admission Record indicated the facility admitted the resident on 6/6/2014 and readmitted the resident on 6/4/2024 with diagnoses including but not limited to dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), adult failure to thrive (a condition that happens when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal), and gastrostomy status (a surgical procedure used to insert a tube, through the abdomen and into the stomach to provide a route for tube feeding. During a review of Resident 30's History and Physical (H&P) dated 6/5/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 30's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/13/2024, the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and require total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 30 was receiving tube feeding. During a review of Resident 30's Order Summary Report6/17/2024, the report indicated the following orders: 6/17/2024 Enteral Feed Order[Enteral feeding: Jevity 1.2 at 65 milliliters per hour (ml/hr - a unit of measurement) for 20 hours via pump to provide 1300 ml/1560 kilocalories (Kcal - a unit of measurement) per day. 6/4/2024 Enteral Feed Order [Enteral] feeding: Turn pump on at 12 p.m. and turn off at 8 a.m. (or until dose is completed). During a concurrent observation and interview on 8/20/2024 at 10:30 a.m., inside Resident 30's room with Licensed Vocational Nurse 3 (LVN 3), observed an EF bag of Fibersource HN (a type of feeding formula formulated with fiber to meet the nutritional needs for tube feeding patients with normal or elevated calorie and/or protein requirements) hanging on the pole the resident's bedside. The enteral feeding bag tubing was connected to the resident's gastrostomy tube (a tube inserted through the wall of the abdomen directly into the stomach) and was delivering the EF via pump with infusion rate at 65 milliliters per hour (ml/hr - a unit of measurement). LVN 3 verified Resident 30's was receiving Fibersource HN. During a concurrent interview and record review on 8/20/2024 at 12:30 p.m., with LVN 3, reviewed Resident 30's physician's orders. with LVN 3. LVN 3 verified Resident 30's EF formula order was Jevity 1.2 and the bag hanging and currently infusing at 65 ml/hr was Fibersource HN. LVN 3 stated she did not know the reason why the resident was receiving Fibersource HN instead of Jevity 1.2. LVN 3 stated there was no report from the night shift nurse that Jevity 1.2 was out of stock. LVN 3 stated if an EF is out of stock, the licensed nurse should notify the physician and obtain an order to use another feeding formula while waiting for Jevity 1.2 to be delivered to ensure the resident was getting the correct type of feeding and their caloric needs are being met. During a concurrent observation and interview on 8/20/2024 at 12:45 p.m., with the Director of Staff Development (DSD), observed the Enteral Room (a locked closet where all the EF formulas in the facility are stored) and the DSD stated there is no Jevity 1.2 stocked in the room. The DSD stated she is not aware if the facility had run out of of Jevity 1.2. The DSD stated the Central Supply Supervisor (CSS) is responsible for ordering EF formulas. During an interview on 8/20/2024 at 1:18 p.m., with the CSS, the CSS stated Jevity 1.2 is on back order since 8/16/2024 and the supplier does not have a projected date of when it will be back on stock. During an interview on 8/23/2024 at 7:20 a.m., with Registered Nurse 3 (RN 3), RN 3 stated that he used Fibersource HN as a substitute for Jevity 1.2 because Jevity 1.2 is out of stock. RN 3 stated that he should have called the physician to obtain an order to change the feeding formula to ensure Resident 30 was getting the type of feeding to address the resident's caloric needs. RN 3 stated he did not notify or gave a hand off report that Jevity 1.2 was out of stock. During an interview on 8/23/2024 at 7:45 p.m., with the Director of Nursing (DON), the DON stated all EF formulas should have a physician's order. The DON stated RN 3 should have notified the physician when the facility ran out of Jevity 1.2 supply and obtain an order to change the formula until Jevity 1.2 was available to ensure Resident 30 was receiving the appropriate feeding in meeting the resident's caloric needs. During a review of the facility's policy and procedure (P&P) titled, Enteral Feeding Monitoring, last reviewed 4/17/2024, the P&P indicated the facility will ensure that the total enteral feeding prescribed is administered as ordered. The policy indicated licensed nurse will check physician's order for formula type, rate, hours and total to be delivered. During a review of the facility's policy and procedure titled, Enteral Tube Feeding via Continuous Pump, last reviewed 4/17/2024, the P&P indicated to verify that there is a physician's order for the feeding. The policy indicated to check the enteral nutrition label against the order before administration and check the following information such as the type of formula and the rate of administration. b. During a review of Resident 367' s admission Record, the admission Record indicated the facility admitted the resident on 5/22/2024 and readmitted the resident on 8/8/2024 with diagnoses including but not limited to dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), adult failure to thrive (a condition that happens when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal), and gastrostomy status (a surgical procedure used to insert a tube, through the abdomen and into the stomach to provide a route for tube feeding. During a review of Resident 367's History and Physical (H&P) dated 8/8/2024, the H&P indicated the resident did not indicate capacity to understand and make decisions. During a review of Resident 367's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/15/2024, the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required substantial/maximal assistance with mobility and total assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 30 was receiving tube feeding. During a review of Resident 367's Order Summary Report dated 8/15/2024, the report indicated the following order: Enteral feeding: Jevity 1.2 at 70 milliliters per hour (ml/hr - a unit of measurement) per hour for 20 hours via pump to provide 1400 ml/1680 kilocalories (kcal - a unit of measurement) per day. Enteral: Turn pump on at 12 p.m. and turn off at 8 a.m. (or until dose is completed). During a concurrent observation and interview on 8/20/2024 at 10:30 a.m., inside Resident 367's room with Licensed Vocational Nurse 3 (LVN 3), observed an s EF bag of Fibersource HN (a type of feeding formula formulated with fiber to meet the nutritional needs for tube feeding patients with normal or elevated calorie and/or protein requirements) hanging on the pole at the resident's bedside. The enteral feeding bag tubing was connected to the resident's gastrostomy tube (a tube inserted through the wall of the abdomen directly into the stomach) and was delivering the EF via pump with infusion rate at 60 milliliters per hour (ml/hr - a unit of measurement). LVN 3 verified Resident 367 was receiving Fibersource HN. During a concurrent interview and record review on 8/20/2024 at 12:30 p.m., with LVN 3, reviewed Resident 367's physician's orders. LVN 3 verified Resident 367's EF formula order was Jevity 1.2 at 70 ml/hr and the bag hanging and currently infusing at 60 ml/hr is Fibersource HN. LVN 3 stated she did not know the reason why the resident was receiving Fibersource HN instead of Jevity 1.2. LVN 3 stated there was no report from the night shift nurse that Jevity 1.2 was out of stock. LVN 3 stated if an EF is out of stock, the licensed nurse should notify the physician and obtain an order to use another feeding formula while waiting for Jevity 1.2 to be delivered to ensure the resident was getting the correct type of feeding and their caloric needs are being met. During a concurrent observation and interview on 8/20/2024 at 12:45 p.m., with the Director of Staff Development (DSD), observed the Enteral Room (a locked closet where all the EF formulas in the facility are stored) and the DSD stated there is no Jevity 1.2 stocked in the room. The DSD stated she is not aware if the facility had run out of of Jevity 1.2. The DSD stated the Central Supply Supervisor (CSS) is responsible for ordering EF formulas. During an interview on 8/20/2024 at 1:18 p.m., with the CSS, the CSS stated Jevity 1.2 is on back order since 8/16/2024 and the supplier does not have a projected date of when it will be back on stock. During an interview on 8/23/2024 at 7:20 a.m., with Registered Nurse 3 (RN 3), RN 3 stated that he used Fibersource HN as a substitute for Jevity 1.2 because Jevity 1.2 is out of stock. RN 3 stated that he should have called the physician to obtain an order to change the feeding formula to ensure Resident 367 was getting the type of feeding to address the resident's caloric needs. RN 3 stated he did not notify or gave a hand off report that Jevity 1.2 was out of stock. During an interview on 8/23/2024 at 7:45 p.m., with the Director of Nursing (DON), the DON stated all EF formulas should have a physician's order. The DON stated RN 3 should have notified the physician when the facility ran out of Jevity 1.2 supply and obtain an order to change the formula until Jevity 1.2 was available to ensure Resident 367 was receiving the appropriate feeding in meeting the resident's caloric needs. During a review of the facility's policy and procedure (P&P) titled, Enteral Feeding Monitoring, last reviewed 4/17/2024, the P&P indicated the facility will ensure that the total enteral feeding prescribed is administered as ordered. The policy indicated licensed nurse will check physician's order for formula type, rate, hours and total to be delivered. During a review of the facility's policy and procedure titled, Enteral Tube Feeding via Continuous Pump, last reviewed 4/17/2024, the P&P indicated to verify that there is a physician's order for the feeding. The policy indicated to check the enteral nutrition label against the order before administration and check the following information such as the type of formula and the rate of administration.

Based on observation, interview and record review, the facility failed to administer parenteral fluids (the intravenous administration of medication) consistent with professional standards of practice for one (1) out of 1 sampled resident (Resident 104) during random observation of residents with intravenous (IV) catheter (a thin, flexible tube that is inserted into a vein to draw blood and give treatments including IV fluids, drugs, or blood transfusions) by: 1. Failing to indicate the insertion date and the licensed nurse's initials on the peripheral intravenous line (PIV - a soft, flexible tube placed inside a vein, usually in the hand or arm to give a person medicine or fluids) dressing. 2. Failing to place a sterile injection cap over the injection port of the PIV line. These deficient practices placed the residents at risk for developing complications such as inflammation of the vein and infection. Findings: During a review of Resident 104' admission Record, the admission Record indicated the facility admitted the resident on 8/24/2020 and readmitted the resident on 3/14/2024 with diagnoses including but not limited to chronic respiratory failure (a long-term condition in which your lungs have a hard time loading your blood with oxygen and can leave you with low oxygen), paraplegia (refers to total paralysis on both sides of the body), and anoxic brain damage (a condition that refers to an injury to the brain due to complete loss of oxygen). During a review of Resident 104's History and Physical (H&P) dated 3/15/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 104's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/4/2024, the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 104 had impairment on both upper and lower extremities. During a review of Resident 104's physician's orders dated 8/17/2024 indicated the following: Peripheral site care: every 96 hours for site care, restart IV and subcutaneous site (additional physician's order required for insertion of IV catheter into lower extremities) and as needed for complications may extend IV site for poor venous access if no complications are present. Change dressing with site change and as needed. May insert peripheral IV in lower extremities if unable to get access in upper extremities. During a concurrent observation and interview on 8/20/2024 at 1:20 p.m., inside Resident 104's room with Licensed Vocational Nurse 4 (LVN 4), observed the resident with a PIV on the right foot. The PIV line dressing did not indicate the insertion date and the initials of the licensed nurse who inserted the PIV. LVN 4 stated the PIV line dressing should indicate the insertion date and initials of the licensed nurse (LN) so the LNs would know when the next PIV and dressing change is due and to prevent complications such as swelling and infection. During a concurrent observation and interview on 8/20/2024 at 1:45 p.m., inside Resident 104's room, with Registered Nurse 3 (RN 3), observed the resident's PIV line on the right foot. The PIV line dressing did not indicate the insertion date and the initials of the licensed nurse who inserted the PIV. There was no injection cap placed over the injection port of the PIV catheter. RN 3 stated the injection port should have a sterile injection cap over the injection port and the PIV line dressing should indicate the insertion date and initials of the LN so the LNs would know when the next PIV and dressing change is due and to prevent complications such as swelling and infection. During a review of the facility's policy and procedure (P&P) titled, Peripheral Venous Catheter Insertion, last reviewed 4/17/2024, indicated PIV catheter sites will be changed every 96 hours or more frequently if catheter related complications develop and write the date, time, and initials on the dressing label.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents receive the necessary respiratory care and services that is in accordance with professional standards of practice by failing to place a fenestrated gauze (a type of wound care product that has cuts, or fenestrations, cut through the entire thickness of the material to allow exudate to drain from a wound) under the flange (is the part of the tracheostomy tube [a metal or plastic tube placed in surgically created opening in the windpipe to keep it open] that extends from the outer part of the tracheostomy [an opening surgically created through the neck into the windpipe] and has holes to attach the tracheostomy tube tie) around the tracheostomy opening for two out of three sampled resident (Residents 468 and 112) investigated during review of respiratory care area The deficient practice had a potential to cause Residents 468 and 112 to develop pressure injury (areas of skin damage caused by prolonged or severe pressure on the skin and underlying soft tissue) and infection on the tracheostomy site. Findings: a. During a review of Resident 468's admission Record, then admission Record indicated the facility admitted the resident on 8/14/2024, with diagnoses including dependence on respirator (if a resident is unable to wean off a ventilator and breathe independently), tracheostomy, and pneumonia (an infection that affects one or both lungs). During a review of Resident 468's History and Physical (H&P), dated 8/15/2024, the H&P indicated the resident is incapacitated and requires visit for safety and the resident did not have the capacity to make decisions. During a review of Resident 468's Order Summary Report, dated 8/15/2024, the report indicated an order to change dressing as needed for when soiled or pulled out. During a concurrent observation and interview on 8/20/2024, at 10:25 a.m., with Respiratory Therapist 1 (RT 1), inside Resident 468's room, observed the resident's tracheostomy tube without a fenestrated gauze under the flange. RT 1 stated there should have been a fenestrated gauze underneath the tracheostomy flange to protect the skin on the tracheostomy site from breaking down. During an interview on 8/23/2024, at 7:10 p.m., with the Director of Nursing (DON), the DON stated staff should ensure there is a fenestrated gauze underneath Resident 468's tracheostomy flange to prevent infection and pressure injury (a breakdown of skin integrity due to pressure) on the tracheostomy site. b. During a review of Resident 112's admission Record, the admission record indicated the facility admitted the resident on 3/20/2021, and readmitted the resident on 6/28/2024, with diagnoses including chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and tracheostomy. During a review of Resident 112's H&P, dated 6/28/2024, the H&P indicated the incapacitated resident requires visit for safety. During a review of Resident 112's MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident was dependent on personal hygiene and was on tracheostomy care. During a review of Resident 112's Care Plan (CP) titled, Excoriation Trach: Resident is at risk for excoriation around the trach stoma site secondary to caustic secretion leakage from the tracheostomy, initiated on 4/9/2021, the CP indicated an intervention to keep dressing clean and dry at stoma site, keep trach/stoma site clean and dry, and observe for signs or symptoms of infection i.e. redness at site, drainage, odor, elevated temp, coughing, rapid pulse or congestion and notify MD as indicated. During a concurrent observation and interview on 8/20/2024, at 9:48 a.m., with Respiratory Therapist 2 (RT 2), inside Resident 112's room, observed the resident's tracheostomy tube without a fenestrated gauze under the flange. RT 1 stated there should have been a fenestrated gauze underneath the tracheostomy flange to protect the skin on the tracheostomy site from breaking down. During an interview on 8/23/2024, at 7:10 p.m., with the Director of Nursing (DON), the DON stated staff should ensure there is a fenestrated gauze underneath Resident 468's tracheostomy flange to prevent infection and pressure injury (a breakdown of skin integrity due to pressure) on the tracheostomy site. During a review of the facility's recent policy and procedure (P&P) titled, Tracheostomy Care (a routine procedure that involves keeping a tracheostomy [trach] tube and the surrounding are clean to prevent bacteria from entering the lungs and trachea), last reviewed on 4/17/2024, the P&P indicated the purpose of this procedure is to guide tracheostomy care and cleaning of reusable tracheostomy cannulas. Site and Stoma (a surgically created opening) Care: 7. Apply a fenestrated gauze pad around the insertion site. The facility must ensure that a resident that needs respiratory care including tracheostomy care and tracheal suctioning, is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Consultant Pharmacist's (CP) recommendation for June 2024 Medication Regimen Review ([MRR] - a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) note was reviewed, addressed or carried out as per facility policy and procedure for one of five sampled residents (Resident 56). The deficient practice increased the risk of receiving medication that was not optimal for Resident 56's medical condition, that would not maintain the resident's highest level of physical, mental and psychosocial well-being and/or increase the risk of side effects (a type of adverse effects [unwanted, uncomfortable, or dangerous effects that a drug may have]) from the medication therapy. Findings: During a review of Resident 56's admission Record (a document containing demographic and diagnostic information,) dated 8/21/24, indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including Gastro-Esophageal Reflux Disease ([GERD] - a condition where there is a backward flow of stomach acid into the tube that connects the mouth to the stomach.) During a review of Resident 56's Order Summary Report, dated 8/21/24, indicated Resident 56 was prescribed pantoprazole (a proton pump inhibitor [PPI] medication used for GERD) 40 milligrams ([mg] - unit of measure of mass) to give 1 tablet orally once a day AC (before) breakfast for GERD, starting 10/12/23. During a review of Resident 56's Medication Administration Record ([MAR] - a document of the medications administered to a resident that is part of the resident's permanent medical record,) for August 2024, the MAR indicated Resident 56 was prescribed pantoprazole 40 mg to give 1 tablet orally once a day AC breakfast for GERD, at 6:30 AM. During a review of the MRR note by the CP for Resident 56 on 8/22/24 at 10:17 AM, the note was dated 6/26/24 and indicated Resident has been taking pantoprazole 40 mg daily for GERD since 10/13/2023. Long term use of PPIs may increase the risk of Clostridioides difficile ([C.diff] - a bacteria that causes diarrhea,) osteoporosis (a condition where bones are weakened, become brittle and break), hypomagnesemia (having low magnesium levels in the blood,) and Chronic Kidney Disease ([CKD]- a condition where the kidneys [organ that filters waste] are damaged.) Recommendation is to re-evaluate use after 8 to 12 weeks to reduce risk of long term side effects. Please evaluate Risks/Benefits of pantoprazole for this patient. If appropriate, may we consider dose reduction to pantoprazole 20 mg QD at this time? YES___NO___ Thank you. The document did not contain a response from a physician and was not signed or dated by a physician. During an interview on 8/22/24 at 11:29 AM, with Registered Nurse (RN) 9, RN 9 stated RN 9 was unable to locate a signed response from the physician for the pantoprazole MRR note by the CP for Resident 56. RN 9 stated that the MRR notes should be addressed within 30 days from the date written and that the pantoprazole note for Resident 56 was not documented timely. RN 9 stated that RN 9 contacted the physician prior to the interview and obtained a telephone order addressing the CP MRR note for Resident 56. RN 9 stated continuing pantoprazole longer than necessary increases the risk of hypomagnesemia, C.diff, osteoporosis and CKD for Resident 56., During an interview on 8/23/24 at 10:19 AM, with the Director of Nursing (DON,) the DON stated per facility policy the MRR irregularity notes by the CP needed to be reviewed and documented within 30 days of the written report. The DON stated it was important to review the irregularities timely to ensure residents were receiving treatment that was optimal for their condition, to maintain their highest level of well-being, and be free from unnecessary medications and harm from their side effects. The DON stated the facility and physician failed to timely review and address the CP MRR note written on 6/26/24 for the continued use of pantoprazole and failed to timely document a clinical rationale for continuing the pantoprazole 40 mg daily, as originally prescribed for GERD on 10/13/23 for Resident 56. Review of facility policy and procedure (P&P) titled Medication Regimen Review (Monthly Review), dated December 2016, the policy indicated: The consultant pharmacist performs a comprehensive MRR at least monthly. The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy. E. Recommendations are acted upon and documented by the facility staff and or the prescriber. 1) Physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing by the next physician visit. Review of facility P&P titled Consultant Pharmacist Services Provider Requirements, dated October 2017, the policy indicated: 5. Identifying one or more current medication references to facilitate the identification of medications and information on contraindications, side effects and/or adverse effects, dosage levels and other pertinent information E. Activities that the consultant pharmacist or off-site pharmacist performs includes, but is not limited to: a. A residents drug regime must be free from unnecessary drugs. An unnecessary drug is any drug when used in: i. excessive dose ii. excessive duration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of five sampled residents (Residents 126) was free from unnecessary medications by not implementing adequate monitoring for Melatonin (a medication used to regulate circadian rhythm [body's sleep and wake cycle]). As a result, Resident 126 was not monitored for hours of sleep and for the effectiveness and side effects (also known as adverse effects - unwanted, uncomfortable, or dangerous effects that a drug may have) of Melatonin since 7/8/24. This deficient practice had the potential to cause Resident 126 to receive suboptimal (less than the highest standard or quality) care, and inability to assess the effectiveness of Melatonin for sleep, leading to the use of unnecessary medications causing potential side effects and negatively impacting their physical, mental, and psychosocial well-being. Cross reference F656 Findings: During a review of Resident 126's admission Record (a document containing demographic and diagnostic information,) dated 8/22/24, the admission Record indicated Resident 126 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis including depression (a mental health condition that can cause feelings of sadness, loss of interest in activities and difficulty sleeping.) During a review of Resident 126's Order Summary Report, dated 8/22/24, the report indicated Resident 126 was prescribed Melatonin 5 milligram ([mg] - a unit of measure of mass) to give one tablet by mouth at bedtime for supplement, starting 3/30/22. During a review of Resident 126's Medication Administration Record ([MAR] - a record of mediations administered to residents,) for August 2024, the MAR indicated Resident 126 was prescribed Melatonin 5 mg to give one tablet by mouth at bedtime for supplement, at 9 PM. During a review of Resident 126's Care Plan, initiated 7/8/24, the Care Plan indicated a goal of sleep of 6 hours per night. During a review of the facility's Consultant Pharmacist's (CP) Medication Regimen Review ([MRR] - a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication,) document review dated 6/26/24, the document indicated Resident has been on order for Melatonin 5 mg qhs (at bedtime) for supplement. Please consider changing the indication of Melatonin use to: 'for supplement to regulate Circadian rhythm.' Also consider monitor for 'hours of sleep qPM (at evening) and qNOC (at bedtime) shifts' to facilitate drug therapy monitoring. The column marked 'Follow-Through, was empty and did not contain any documentation, dates, or signatures for the review of the CP's recommendations. During a review of Resident 126's Minimum Data Set (MDS - a comprehensive resident assessment tool), dated 7/6/24, the MDS indicated resident was severely impaired with cognition (mental action or process of acquiring knowledge and understanding) based on the results of the Brief Interview for Mental Status ([BIMS] - a mandatory tool used to screen and identify cognitive condition of residents upon admission into a long-term care facility,) and that symptom presence and frequency for trouble falling or staying asleep, or sleeping too much was not marked. During an interview on 8/22/24 at 1:14 PM, with the Director of Nursing (DON,) the DON stated that Resident 126's care plan dated 7/8/24 indicated a goal of sleep of 6 hours per night. The DON stated after a thorough search of Resident 126's clinical record the DON was unable to locate documentation for monitoring the number of hours of sleep. The DON stated without monitoring hours of sleep it was unknown if non-pharmacological (that do not involve medications or drugs) interventions (therapies) and/or Melatonin were effective in reaching the goal of 6 hours of sleep and when to make changes to medications such as lowering the dose or discontinuing, leading to the use of unnecessary medications for Resident 126. The DON stated that the indication for Melatonin was also not updated to specify use for regulating circadian rhythm. The DON stated that facility failed to monitor for hours of sleep and indicate specific use of Melatonin, and that it will be immediately initiated for Resident 126. Review of the facility's Policy & Procedures, titled Section A Resident Assessment, dated 4/2014, the P&P indicated: 14. Resident Rights - Care Planning B. The resident has the right to receive the services and/or items included in the plan of care. Review of facility P&P titled Consultant Pharmacist Services Provider Requirements, dated October 2017, the policy indicated: 5. Identifying one or more current medication references to facilitate the identification of medications and information on contraindications, side effects and/or adverse effects, dosage levels and other pertinent information E. Activities that the consultant pharmacist or off-site pharmacist performs includes, but is not limited to: a. A residents drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in: iii. without adequate monitoring iv. without adequate indication for its use.

Based on observation, interview, and record review, the facility failed to provide meals at regular times comparable to normal mealtimes in the community for one of 16 sampled residents (Resident 162) investigated under the dining observation care area when Resident 162 was served his lunch tray after the facility's scheduled lunch time. This deficient practice had the potential to affect the temperature of the food served and negatively affect the resident's psychosocial wellbeing. Findings: During a review of Resident 162's admission Record, the admission Record indicated the facility admitted the resident on 7/24/2024 with diagnoses including, but not limited to, type two diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]) and heart failure (a progressive heart disease that affects pumping action of the heart muscles). During a review of Resident 162's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 7/31/2024, the MDS indicated Resident 162 was able to understand and make decisions, required setup assistance to supervision with activities of daily living including eating, hygiene, dressing, mobility, and surface-to-surface transfers, and was dependent on staff for bathing or showering. During a review of Resident 162's History and Physical (H&P), dated 7/24/2024, the H&P indicated Resident 162 has the capacity to understand and make decisions and is able to make decisions for activities of daily living. During a review of Resident 162's Order Summary Report, dated 7/24/2024, the order summary report indicated Resident 162 was ordered consistent carbohydrate, no added salt, diet (specialized diet that helps keep blood sugars stable) with regular texture and thin liquid consistency. During an interview with Resident 162, on 8/21/2024, at 11:47 a.m., Resident 162 stated the food delivered to his station comes in later than the other stations. Resident 162 stated the other stations get their lunch served at 12:00 p.m. and his station gets their meals served at 1:00 p.m. Resident 162 further stated that because the meals are served late, his meals come in cold. During a concurrent observation and interview with the Activities Director (AD), on 8/21/2024, at 12:54 p.m., inside the dining room, the AD confirmed there were no residents in the dining room. The AD stated residents that decide to eat in the dining room are served lunch at 12:00 p.m., finish up around 12:45 p.m., and are brought back to their rooms so that the dining room can be cleaned for later use. During a concurrent observation and interview with Resident 162, on 8/21/2024, at 1:12 p.m., a facility staff member brought a meal tray to Resident 162's room and placed the tray on the resident's bedside table. Resident 162 stated his trays are usually served around this time. During a concurrent interview and record review with the Director of Nursing (DON), on 8/23/2024, at 7:10 p.m., the facility's policy and procedure (P&P) titled, Frequency of Meals, last reviewed 4/17/2024, indicated each resident shall receive at least three meals daily, at times comparable to typical mealtimes in the community and that lunch times are between 12:00 p.m. to 12:25 p.m. The DON stated Resident 162's bedroom and the adjacent rooms had their meal trays distributed late. The DON stated it is important that residents receive their meals according to the facility's meal schedule to make sure the residents meet their nutritional needs and make sure they are all fed at the same time. The DON stated when residents are not served on time, there is a potential that the food temperatures could be affected, the residents would feel hungry, and the residents can potentially feel disrespected. During a review of the facility's P&P titled, Frequency of Meals, last reviewed 4/17/2024, the P&P indicated each resident shall receive at least three meals daily, at times comparable to typical mealtimes in the community. The P&P further indicated mealtimes for lunch are between 12:00 p.m. to 12:45 p.m.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program (measures to eradicate and contain common household pests [e.g., bed bugs, lice, roaches, ants, mosquitoes, flies, mice, and rats]) so that the facility is free of pests and rodents for one of three sampled residents (Resident 162) investigated under the environment care area when ants were observed inside Resident 162's room. This deficient practice had the potential to negatively affect the resident's psychosocial wellbeing and promote the spread of infection. Findings: During a review of Resident 162's admission Record, the admission record indicated the facility admitted the resident on 7/24/2024 with diagnoses including, but not limited to, type two diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]) and heart failure (a progressive heart disease that affects pumping action of the heart muscles). During a review of Resident 162's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 7/31/2024, the MDS indicated Resident 162 was able to understand and make decisions, required setup assistance to supervision with activities of daily living including eating, hygiene, dressing, mobility, and surface-to-surface transfers, and was dependent on staff for bathing or showering. During a review of Resident 162's History and Physical (H&P), dated 7/24/2024, the H&P indicated Resident 162 has the capacity to understand and make decisions and is able to make decisions for activities of daily living. During an interview with Resident 162, on 8/21/2024, at 11:47 a.m., Resident 162 stated he has ants in his room. Resident 162 stated the facility staff cleans the rooms in the mornings, but they do not clean the room enough. Resident 162 stated after his roommates finish eating, they sometimes leave a mess, and it attracts the ants. Resident 162 further stated the ants make him feel uncomfortable and if the ants go on his food, he would not eat his food. During an observation on 8/21/2024, at 12:40 p.m., inside Resident 162's room, ants were crawling in the corner of the room, against the wall, next to a doorway leading to an outdoor area in the facility. During a concurrent observation and interview with the Maintenance Supervisor (MS), on 8/21/2024, at 4:00 p.m., inside Resident 162's room, the MS confirmed the presence of ants in the room. The MS stated housekeeping had just recently cleaned the room. The MS stated the facility's contracted pest control service came in today to perform their service. The MS stated the facility's contracted pest control service usually comes to the facility twice a month and are available as needed to perform services. The MS stated it important to not have ants in residents' rooms to prevent an infestation. The MS further stated having ants in the room can cause residents to feel uncomfortable and make the environment less homelike. During an interview with the Director of Nursing (DON), on 8/23/2024, at 7:10 p.m., the DON stated there should not be any ants in residents' rooms because they can be a source of infection or they can make the residents feel uncomfortable. During a review of the facility's Pest Control Service Report, dated 8/21/2024, the report indicated the pest control recommended to keep floors clean from food debris and taking trash out regularly and keeping trash containers covered to prevent pest entry and ant activity. The service report further indicated the pest findings included ants. During a review of the facility's policy and procedure (P&P) titled, Pest Control, last reviewed 4/17/2024, the P&P indicated the facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. The P&P further indicated maintenance services assist, when appropriate and necessary, in providing pest control services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 144's admission Record, the admission Record indicated the facility admitted the resident on 1/22/2024, and readmitted the resident on 5/14/2024, with diagnoses including traumatic subdural hemorrhage (a serious condition that occurs when blood collects between the skull and the surface of the brain) and history of traumatic fracture (occurs when significant or extreme force is applied to a bone). During a review of Resident 144's History and Physical (H&P), dated 5/14/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 144's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/29/2024, the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severely impaired vision. The MDS indicated the resident was dependent on mobility and activities of daily living (ADLs, all the essential, basic self-care tasks that people need to do every day to keep themselves safe, healthy, clean, and feeling good). During a review of Resident 144's Order Summary Report, dated 7/10/2024, the report indicated an order for frequent visual monitoring due to high risk for fall and injury. Document every shift. During a review of Resident 144's Fall Risk Assessment, dated 7/25/2024, the assessment indicated the resident was high risk for falls. During a review of Resident 144's Care Plan (CP) titled, Resident is at risk for falls/injury related to generalized weakness, impaired cognition (problems with a person's ability to think, learn, remember, use judgement, and make decisions), impaired vision, poor body balance/control, poor safety awareness/judgement, initiated on 1/31/2024, the CP indicated an intervention to keep call light within easy reach and encourage resident to use it to get assistance. During a concurrent observation and interview on 8/20/2024, at 10:43 a.m., with Certified Nursing Assistant 3 (CNA 3), inside Resident 144's room, observed Resident 4 lying in bed. The resident's pad call light placed on top of the bed side drawer away from the resident's reach. CNA 3 stated the call light should be within reach of the resident so the resident can call for help when needed. During an interview on 8/23/2024, at 7:10 p.m., with the DON, the DON stated the pad call light should be near the resident's body so they can have access to call the staff. The DON stated not having the pad call light within reach of the resident could result in the resident not being able to call for help and could possibly fall trying to reach for the pad call light. During a review of the facility's recent policy and procedure P&P) titled, Call Lights, last revised on 4/17/2024, the P&P indicated to assure resident receive prompt assistance. Ensuring that the call light is within the resident's reach when in his/her room or when on the toilet. Based on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach for one of three residents (Resident 35 and 144) reviewed during the Environment task and for two of four sampled residents (Residents 104 and 134) observed during a random observation. This deficient practice had the potential to result in the delay of care and services and possible injury to residents when they are unable to ask assistance from facility staff. Findings: a.During a review of Resident 35's admission Record, the admission Record indicated the facility admitted the resident on 6/22/2024 with diagnoses that included cerebral infarction (stroke, when blood flow to the brain is blocked or there is sudden bleeding in the brain), unspecified abnormalities of gait (manner of walking) and mobility, muscle weakness, and encephalopathy (a change in your brain function due to injury or disease). During a review of Resident 35's Minimum Data Set (MDS - an assessment and care screening tool) dated 6/29/2024, the MDS indicated the resident rarely/never was able to understand others and rarely/never was able to make herself understood. The MDS indicated the resident was dependent on staff for oral hygiene, toileting, bathing, dressing, personal hygiene, and mobility. During a review of Resident 35's Fall Risk Assessment form, dated 6/22/2024, the form indicated the resident was a high risk for falls with intermittent confusion or poor safety awareness. During a review of Resident 35's Physician Orders Summary Report, the report indicated an order for the Falling Star Program with frequent visual monitoring due to high risk for fall and injury, every shift, dated 6/22/2024. During a review of Resident 35's Care Plan (CP) titled, Resident is at risk for falls/injury . initiated 7/9/2024, the CP indicated to keep the call light within easy reach and encourage resident to use it to get assistance. During an observation on 8/20/2024 at 10:17 a.m., observed Resident 35 lying in bed with the bed in low position and fall mat on the floor. Observed the call light resting on the floor at the left side of the bed. The call light was visible from the door and foot of the bed. Observed Certified Nursing Assistant 4 (CNA 4) enter Resident 35's room, look at the resident, and walked to the right side of the resident's bed. Observe CNA 4 then walk past the foot of the Resident's bed, look at the resident, and exit the room. Observed the call light remained on the floor. During a concurrent observation and interview on 8/20/2024 at 10:28 a.m., observed Restorative Nursing Assistant 3 (RNA 3) enter Resident 35's room. RNA 3 stated the call light was on the floor and should have been closer to the resident. RNA 3 stated the call light should have been on the resident's bed and within reach of the resident to make sure the resident had access to it. RNA 3 stated if the call light was not within reach anything could happen. During a follow up interview on 8/22/2024 at 10:32 a.m., with CNA 4, CNA 4 stated the call light should always be within reach of residents and she (CNA 4) did not see that Resident 35's call light was on the floor. During an interview on 8/22/2024 at 12:03 p.m., with Licensed Vocational Nurse 8 (LVN 8), LVN 8 stated she was caring for Resident 35 and every time the CNA enters the room the resident's environment should be checked, including the placement of the call light. LVN 8 stated if the call light is not within reach, staff would not know if the resident needed assistance. LVN 8 stated when residents are unable to call for assistance there is a potential for falls. During an interview on 8/23/2024 at 7:10 p.m., with the Director of Nursing (DON), the DON stated there is a potential risk for falls when the resident's call light is out of reach and staff are not aware that the resident needs assistance. During a review of the facility policy and procedure (P&P) titled, Call Lights, last reviewed 4/17/2024, the P&P indicated the purpose of the policy was to assure residents receive prompt assistance. Nursing and care duties include to ensure that the call light is within the resident's reach when in his/her room. c. During a review of Resident 104' admission Record, the admission Record indicated the facility admitted the resident on 8/24/2020 and readmitted in the facility 3/14/2024 with diagnoses including but not limited to chronic respiratory failure (a long-term condition in which your lungs have a hard time loading your blood with oxygen and can leave you with low oxygen), paraplegia (refers to total paralysis on both sides of the body), and anoxic brain damage (a condition that refers to an injury to the brain due to complete loss of oxygen). During a review of Resident 104's History and Physical dated 3/15/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 104's MDS, dated [DATE], the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 104 had impairment on both upper and lower extremities. During a review of Resident 134's Fall Risk Assessments dated 3/14/2024, 5/6/2024, and 7/29/2024, the assessments indicated the resident was a high risk for falls. During a review of Resident 104's care plan (CP), the CP indicated the following: 1.Resident is at risk for falls/injury related but not limited to history of falls, impaired cognition, impaired vision, poor body balance/ control, poor safety awareness/judgment, and collapse initiated 8/26/2020 target date 11/2/2024 indicated a goal to reduce risk of falls and injury. The care plan indicated to keep call light within easy reach and encourage resident to use it to get assistance as on the interventions. 2. At risk for falls related but not limited to cognitive impairment, decreased strength/endurance, unsteady gait, and visual deficits initiated 7/10/2024 target date 11/2/2024 indicated a goal to reduce risk of falls and/or injury thru appropriate intervention(s) daily until the next assessment. The care plan indicated to attach call light to bed within access of resident as one of the interventions. During a concurrent observation, and interview on 8/20/2024 at 1:20 p.m. with Licensed Vocational Nurse 4 (LVN 4) inside Resident 104's room, observed the resident lying in bed facing the left side. Observed Resident 104's call light on top of the left uppermost side of the bed and away from resident's reach. LVN verified the pad call light was not within the resident's reach. LVN 4 stated Resident 104 is at risk for falls or injury when the resident cannot use the pad call light to call for assistance to meet the resident's needs. During an interview on 8/23/2024 at 7:10 p.m., the DON, the DON stated the pad call light is sensitive and should be placed adjacent to any part of the resident's body so the resident can use it to call for assistance. The DON stated the pad call light will not activate if it is not close to the resident's body. During a review of the facility's policy and procedure (P&P) titled, Call Lights, last reviewed 4/17/2024, the P&P indicated to ensure residents receive prompt assistance by ensuring the call light is within the resident's reach when in his/her room or when on the toilet. d. During a review of Resident 134' admission Record, the admission Record indicated the facility admitted the resident on 3/4/2023 with diagnoses including but not limited to respiratory failure (a serious condition that makes it difficult to breathe on your own), encounter for tracheostomy (a surgical procedure to create an opening through the neck into the windpipe to facilitate breathing), and traumatic brain injury (a condition that occurs when a sudden trauma, such as a blow or jolt to the head, causes damage to the brain) with loss of consciousness. During a review of Resident 134's History and Physical (H&P) dated 3/6/2024, the H&P indicated the resident was incapacitated (incapable of normal functioning). During a review of Resident 134's MDS, dated [DATE], the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 134 had impairment on both upper and lower extremities. During a review of Resident 134's Fall Risk Assessments dated 12/11/2023, 3/9/2024, and 6/8/2024, the assessments indicated the resident was a high risk for falls. During a review of Resident 134's care plan (CP), the CP indicated: 1.Resident is at risk for falls/injury related to fracture, generalized weakness, impaired cognition, impaired vision, poor body balance/ control, poor safety awareness/judgment, involuntary movements, spontaneous movements, resident requiring total care, resident requiring turning and repositioning initiated 3/8/2023 target date 9/9/2024 indicated a goal to reduce risk of falls and injury daily. The care plan indicated to keep call light within easy reach and encourage resident to use it to get assistance as one of the interventions. 2. Falling Star Program (a patient assessment program that identifies residents who are at high risk for falling). At risk for falls related but not limited to cognitive impairment, decreased strength/endurance, and history of falls initiated 7/10/2024 target date 9/9/2024 indicate a goal to reduce risk of falls and/or injury thru appropriate intervention(s) daily until the next assessment. The care plan indicated to attach call light to bed within access of resident. During a concurrent observation and interview on 8/20/2024 at 2:41 p.m. with Licensed Vocational Nurse 4 (LVN 4) inside Resident 134's room, observed the resident lying in bed facing the right side. Observed Resident 134's call light placed on top of the bedside table on the right side of the bed, next to the suction machine. LVN 4 verified the pad call light was not within the resident's reach. LVN 4 stated the resident moves a lot in bed and is at risk for falls or injury when the resident cannot use the call light to call for assistance to meet the resident's needs. During an interview on 8/23/2024 at 7:10 p.m., the DON, the DON stated the pad call light is sensitive and should be placed adjacent to any part of the resident's body so the resident can use it to call for assistance. The DON stated the pad call light will not activate if it is not close to the resident's body. During a review of the facility's policy and procedure (P&P) titled, Call Lights, last reviewed 4/17/2024, the P&P indicated to ensure residents receive prompt assistance by ensuring the call light is within the resident's reach when in his/her room or when on the toilet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During a review of Resident 9's admission Record, the admission Record indicated the facility admitted the resident on 10/23/2018, and readmitted the resident on 7/26/2022, with diagnoses including age-related osteoporosis (a condition in which there is a decrease in the amount and thickness of bone tissue), dementia (a group of symptoms affecting memory, thinking, and social abilities), and history of falling. During a review of Resident 9's H&P, dated 9/20/2023, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 9's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident had impairment on both sides of the upper extremity and needed substantial to partial assistance on mobility and activities of daily living (ADLs, all the essential, basic self-care tasks that people need to do every day to keep themselves safe, healthy, clean, and feeling good). During a review of Resident 9's Fall Risk Assessment, dated 8/5/2024, the assessment indicated the resident was high risk for falls. During an observation on 8/20/2024, at 1:24 p.m., during resident screening, inside Resident 9's room, observed Resident 9's bed was placed against the wall on her right side of the bed. During an interview and record review on 8/22/2024, at 3:06 p.m., with RN 4, Resident 9's Order Summary Report, Physical Restraint Assessment Forms, and consents were reviewed. RN 4 confirmed the resident's bed was placed against the wall. RN 4 stated placing the bed against the wall would be considered a restraint. RN 4 stated the resident did not have an order, a restraint assessment and informed consent for placing the resident's bed against the wall. RN 4 stated it is important to obtain an informed consent to honor the resident's right to consent or refuse the treatment. RN 4 stated there should be a restraint assessment and a physician's order for placing the bed against the wall to ensure resident safety During an interview on 8/23/2024, at 7:10 p.m., with the DON, the DON stated placing the bed against the wall would be considered a restraint. The DON stated the staff should have obtained a consent from the resident or resident representative, performed a restraint assessment, and obtained a physician's order prior to placing the bed against the wall to prevent injuries and to ensure the resident's right to consent or refuse a treatment was not violated. During a review of the facility's recent policy and procedure (P&P) titled, Physical Restraint, last reviewed on 4/17/2024, the P&P indicated Physical Restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, and which restrict movement or normal access to the use of one's body. The licensed nurse shall be responsible for obtaining an order from the attending physician, which include: a. Specific type of restraint. b. Purpose of the restraint. c. Time and place of application. d. Approaches to prevent decreased functioning when applicable. e. Informed consent obtained from resident or from surrogate decision-maker. During a review of the facility provided user manual Bed Frame 2 (BF 2), copyright 2005, the manual indicated to evaluate patients for entrapment risk according to facility protocol and monitor patients appropriately. Siderails are intended to be a reminder to the patient of the bed's edges, not a patient-retraining device. During a review of the facility provided Bed Frame 1 (BF 1), copyright 2021, indicated under safety bed positions to make sure the bed is in the low position when the patient is unattended. This may help reduce the possibility of patient falls and the severity of any resultant injuries. Siderails are not intended to be used as restraint devices. Medical personnel should determine the appropriate use of siderails and ensure patient safety. During a review of the facility provided user manual basic care bed from Bed Frame 3 (BF 3), copyright 2005, indicated to evaluate patients for entrapment risk according to facility protocol, and monitor patients appropriately. Make sure all siderails are fully latched when in the raised position. Failure to do either of these could result in serious injury or death. 4. During a review of Resident 467's admission Record, the admission Record indicated the facility admitted the resident on 1/26/2024, and readmitted the resident on 8/8/2024, with diagnoses including encephalopathy (a change in how the brain functions), seizures (a sudden, uncontrollable burst of electrical activity in the brain), and altered mental status. During a review of Resident 467's H&P, dated 8/8/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 467's MDS, dated [DATE], the MDS indicated the resident sometimes had the ability to make self-understood and usually understand others. The MDS indicated the resident was dependent on mobility and ADLs. During a review of Resident 467's Fall Risk Assessment, dated 8/8/2024, the assessment indicated the resident was high risk for falls. During an observation on 8/20/2024, at 10:09 a.m., inside Resident 467's room, observed the resident lying in bed with all four side rails up. During a concurrent observation, interview and record review on 8/21/2024, at 12:45 p.m., with RN 7, inside Resident 467's room, RN 7 stated placing all four side rails up would be considered a restraint. Reviewed Resident 467's Order Summary Report, Physical Restraint Assessment Forms, and consents. RN 7 stated the resident did not have an order, a restraint assessment, and informed consent for using all four side rails up. RN 7 stated it is important to have physician's order and perform a restraint assessment to ensure resident safety. RN 7 further stated it is important to obtain an informed consent to honor the resident's right to consent or refuse treatment. During an interview on 8/23/2024, at 7:10 p.m., with the DON, the DON stated raising all four side rails up would be considered a restraint. The DON stated the staff should have obtained a consent from the resident or resident representative, performed a restraint assessment, and obtained a physician's order prior to using all four side rails up to prevent injuries and to ensure the resident's right to consent or refuse a treatment was not violated. During a review of the facility's recent policy and procedure (P&P) titled, Bed Safety and Bed Rails, last reviewed on 4/17/2024, the P&P indicated the use of bed rails is prohibited unless the criteria for use of bed rails have been met. The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. Before using bed rails for any reason, the staff shall inform the resident or resident representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The following information will be included in the consent: a. The assessed medical needs that will be addressed with the use of bed rails; g. The resident's risks from the use of bed of bed rails and how these will be mitigated; h. The alternatives that were attempted but failed to meet the resident's needs; and i. The alternatives that were considered but not attempted and the reasons. During a review of the facility's recent policy and procedure titled, Physical Restraint, last reviewed on 4/17/2024, the P&P indicated Physical Restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, and which restrict movement or normal access to the use of one's body. The licensed nurse shall be responsible for obtaining an order from the attending physician, which include: a. Specific type of restraint. b. Purpose of the restraint. c. Time and place of application. d. Approaches to prevent decreased functioning when applicable. e. Informed consent obtained from resident or from surrogate decision-maker. During a review of the facility provided user manual Bed Frame 2 (BF 2), copyright 2005, the manual indicated to evaluate patients for entrapment risk according to facility protocol and monitor patients appropriately. Siderails are intended to be a reminder to the patient of the bed's edges, not a patient-retraining device. During a review of the facility provided Bed Frame 1 (BF 1), copyright 2021, it indicated under safety bed positions to make sure the bed is in the low position when the patient is unattended. This may help reduce the possibility of patient falls and the severity of any resultant injuries. Siderails are not intended to be used as restraint devices. Medical personnel should determine the appropriate use of siderails and ensure patient safety. During a review of the facility provided user manual basic care bed from Bed Frame 3 (BF 3), copyright 2005, it indicated to evaluate patients for entrapment risk according to facility protocol, and monitor patients appropriately. Make sure all siderails are fully latched when in the raised position. Failure to do either of these could result in serious injury or death. 5. During a review of Resident 30's admission Record, the admission Record indicated the facility admitted the resident on 6/6/2014 and readmitted in the facility on 6/4/2024 with diagnoses including but not limited to dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), adult failure to thrive (a condition that happens when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal), and gastrostomy status (a surgical procedure used to insert a tube, through the abdomen and into the stomach to provide a route for tube feeding. During a review of Resident 30's History and Physical (H&P), dated 6/5/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 30's MDS, dated [DATE], the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and require total assistance from staff with all ADLs. The MDS indicated a physical restraint was not used on the resident. During a concurrent observation and interview on 8/20/2024 at 11:00 a.m., inside Resident 30's room, with LVN 3, observed Resident 30 lying in bed with pillows tucked under the fitted sheets on both sides of the resident's lower legs. LVN 3 stated the pillows are usually placed by the Certified Nursing Assistant (CNA) on both sides to prevent Resident 30 from falling out of bed due to restlessness. LVN 3 stated the pillows restrict the resident's movements. During a concurrent interview and record review on 8/23/2024 at 4:43 p.m., with MDSC 2, reviewed Resident 30's physician's order, MDS assessment, physical restraint assessments, and informed consents. MDSC 2 stated Resident 30 did not have a physician's order, an informed consent and physical restraint assessment prior to placing the pillows tucked under the fitted sheets. MDSC 2 stated he cannot say that the use of the pillows tucked under the fitted sheet was considered a restraint as the incident may just be an isolated incident to prevent the resident from getting out of bed. During an interview on 8/23/2024 at 7:30 p.m., with the DON, the DON stated placing the pillows under the fitted sheet to prevent the resident from falling out of the bed would be considered a restraint as it restricts the resident's movements by preventing the resident from getting out of bed. The DON stated there should be a physician's order, an informed consent and a physical restraint assessment completed prior to use of pillows tucked under the fitted sheet. During a review of the facility's policy and procedure (P&P) titled, Physical restraints, last reviewed 4/17/2024, the P&P indicated: Physical restraints are a manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, and which restrict freedom of movement or normal access to the use of one's body. The licensed nurse shall be responsible for obtaining an order from the attending physician, which is to include: - Specific type of restraint. - Purpose of the restraint. - Time and place of application. - Approaches to prevent decreased functioning when applicable. - Informed consent obtained from resident or from surrogate decision-maker. The licensed nurse shall complete the Informed Consent Acknowledgement Form. Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body, cannot be removed easily by the resident, and restricts the resident's freedom of movement or normal access to his/her body) for four of six sampled residents (Resident 6,126, 9, and 467) investigated during review of the physical restraints care area and one of one sampled resident (Resident 30) investigated during random observation when the facility failed to: 1. Obtain a physician's order, obtain an informed consent from the resident or resident representative, and perform a restraint use assessment for use of left-and-right hand mitten (a large, soft glove that covers a resident's hand to prevent them from inadvertently dislodging medical equipment) restraints timely for Resident 6. 2. Obtain a physician's order, obtain an informed consent from the resident or resident representative, and perform an assessment prior to placing Resident 126's bed against the wall as a restraint 3. Obtain a physician's order, obtain an informed consent from the resident or resident representative, and perform an assessment prior to placing Resident 9's bed against the wall as a restraint. 4. Obtain a physician's order, obtain an informed consent from the resident or representative, and perform an assessment prior to use of four bed rails up for Resident 467. 5. Obtain a physician's order, informed consent, and perform an assessment prior to use of pillows tucked under fitted sheets bilaterally (both sides) for Resident 30. These deficient practices had the potential for residents and their representatives to be unaware of the risks and benefits for use of restraints and may result in the restriction of residents' freedom of movement, a decline in physical functioning, psychosocial harm, physical harm from entrapment (a state in which a person is trapped by the bed rail in a position that they cannot move from), death of residents, and violate the resident's rights to be free from any restraints that are imposed for reasons other than the treatment of the resident's medical symptoms. Cross-reference F656. Findings: 1. During a review of Resident 6's admission Record, the admission Record indicated the facility originally admitted Resident 6 on 11/28/2007 and readmitted the resident on 4/11/2024 with diagnoses including, but not limited to, attention for gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food via a tube). During a review of Resident 6's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 6/21/2024, the MDS indicated Resident 6 was rarely or never understood, was dependent on staff for activities of daily living, including bathing/showering, dressing, toileting, hygiene, and surface-to-surface transfers, and was not using restraints. During a review of Resident 6's History and Physical (H&P), dated 4/12/2024, the H&P indicated Resident 6 does not have the capacity to understand and make decisions. During a review of Resident 6's Care Plans, last revised 6/26/2024, the care plan indicated the use of right- and left-hand mitten restraints and to release every two hours and as needed to check for circulation and skin integrity. During an observation on 8/20/2024, at 9:50 a.m., inside Resident 6's room, Resident 6 was lying down in bed with mittens on his left and right hands. During an observation on 8/22/2024, at 12:56 p.m., inside Resident 6's room, Resident 6 was lying down in bed with mittens on his left and right hands. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 5, on 8/22/2024, at 1:13 p.m., Resident 6's medical record was reviewed and LVN 5 confirmed Resident 6 did not have a consent for use of mitten restraints. LVN 5 stated Resident 6 has left and right mitten restraints because he has a history of pulling his gastrostomy tube and pulling it out. LVN 5 stated Resident 6 has had the mitten restraints for a while and was unable to give an exact date of how long the resident has been on restraints. LVN 5 further stated it is important to have a consent for use of restraints to determine if the resident or resident's responsible party is agreeable to the use of restraints. During a concurrent interview and record review with Registered Nurse (RN) 5, on 8/22/2024, at 1:40 p.m., Resident 6's medical record was reviewed, and RN 5 confirmed Resident 6 did not have an active order for use of mitten restraints. RN 5 stated there should be an order for use of mitten restraints because without an order, the staff would not be able to perform the intervention. RN 5 reviewed Resident 6's medical record and confirmed the last assessment performed for Resident 6's mitten restraint use was performed 8/3/2023. RN 5 stated assessments for restraint use should be performed annually, on readmissions, and during a change of condition. RN 5 further stated without an assessment, the facility would not be able to determine if the resident still requires the restraints or not. During a concurrent interview and record review with the Medical Records Director (MRD), on 8/22/2024, at 3:15 p.m., Resident 6's Order Summary Report, dated 2/28/2024, was reviewed and the MRD confirmed Resident 6's order for left- and right-hand mittens to decrease potential injury due to resident behavior of attempting to pull on life sustaining equipment was discontinued. 2. During a review of Resident 126's admission Record, the admission Record indicated the facility originally admitted Resident 126 on 3/30/2022 and readmitted the resident on 4/11/2022 with diagnoses including, but not limited to, history of falling and difficulty in walking. During a review of Resident 126's MDS, dated [DATE], the MDS indicated Resident 126 had severe cognitive impairment (difficulty understanding and making decisions), required maximal assistance with rolling left to right in bed, and was dependent on facility staff for other activities of daily living, including eating, dressing, bathing, or showering, hygiene, toileting, and surface-to-surface transfers. Resident 126's MDS indicated the facility used a limb restraint less than daily while in bed and other restraints were not used while in bed. During a review of Resident 126's H&P, dated 3/20/2024, the H&P indicated Resident 126 did not have the capacity to understand and make decisions. During a concurrent observation and interview with LVN 10, on 8/22/2024, at 9:55 a.m., inside Resident 126's room, LVN 10 confirmed Resident 126's bed was placed against the wall with the left side of the bed touching the wall, the head of the bed pointing towards the doorway, and the foot of the bed pointing toward the windows in the room. LVN 10 stated placing the bed against the wall would be considered a restraint because if the resident wanted to get out of bed from her left side, the resident would not be able to. LVN 10 reviewed Resident 126's medical record and confirmed Resident 126 did not have an informed consent to place the bed against the wall and an assessment for placing the resident's bed against the wall. LVN 10 stated Resident 126 has a conservator (a court appointed person or organization that is legally responsible for a person who cannot manage alone) and it is important to obtain an informed consent from the conservator so that they are aware of the risks and benefits for placing the bed against the wall. LVN 10 further stated it is important to perform an assessment prior to placing the bed against the wall to see if it is safe for the resident. During an interview with the Director of Nursing (DON) on 8/23/2024, at 7:10 p.m., the DON stated placing the bed against the wall is considered a restraint. The DON stated the process for using restraints includes obtaining a physician's order, assessing the resident, obtaining a consent for the use of restraints, and creating a care plan. The DON stated it is important to assess residents prior to the use of restraints to check if the restraint is safe to use and if it is appropriate for use. The DON stated assessments should be performed on admission, quarterly, and as needed to evaluate and reevaluate the effectiveness of restraint use and to see if there are less restrictive measures that can be implemented. The DON further stated it is important to obtain an informed consent for the use of restraints to respect the resident or resident's responsible party's right to decide for themselves. During a review of the facility's policy and procedure (P&P) titled, Physical Restraint, last reviewed 4/17/2024, the P&P indicated the licensed nurse shall be responsible for obtaining an order from the attending physician which is to include the specific type of restraint, purpose of the restraint, time and place of application, approaches to prevent decreased functioning when applicable, informed consent obtained from resident or from surrogate decision-maker. The P&P indicated the licensed nurse shall complete the informed consent acknowledgement form. The P&P indicated the facility is to engage in a systematic and gradual process toward reducing restraints. The P&P further indicated when there is a significant decline or improvement in resident's condition, and when physical restraint is no longer effective or appropriate an attempt to discontinue, reduce or modify restraints shall be discussed at the quarterly care plan conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for: 1. Two of six sampled residents (Resident 9 and 126) for placement of bed against the wall as a physical restraint (the use of a manual hold to restrict freedom of movement of all or part of a person's body, or to restrict normal access to the person's body) during review of physical restraints. 2. One of six sampled residents (Resident 467) for using all four side rails up during review of physical restraints. 3. One out of six sampled residents (Resident 116) addressing use of urinary catheters (a flexible tube used to empty the bladder and collect urine in a drainage bag). 4. One of six sampled residents (Resident 30) for using pillows tucked under a fitted sheet during review of physical restraints care area. 5. 1 out of 6 sampled residents (Resident 59) for using a self-release seat belt during review of physical restraints. 6. 1 out of 1 sampled resident (Resident 111) with a diagnosis of Post Traumatic Stress Disorder (PTSD - a condition that develops when a person has experienced or witnessed a scary, shocking, terrifying, or dangerous event) investigated during review of behavioral-emotional care area. These deficient practices had the potential to result in inconsistent implementation of the care plan that may lead to a delay in or lack of delivery of care and services. 7. One of five residents (Resident 126) failing to implement the Care Plan (a document outlining a detailed approach to care customized to an individual resident's need) for reaching a goal of 6 hours of sleep reviewed for unnecessary medications. As a result, Resident 126 did not have monitoring for hours of sleep and for the effectiveness and side effects (also known as adverse effects - unwanted, uncomfortable, or dangerous effects that a drug may have) of Melatonin (a medication used to regulate circadian rhythm [body's sleep and wake cycle]), since 7/8/24. This deficient practice had the potential to cause Resident 126 to receive suboptimal (less than the highest standard or quality) care, and inability to assess the effectiveness of Melatonin for sleep, leading to the use of unnecessary medications causing potential side effects (unwanted, unpleasant results of a medication) and negatively impacting their physical, mental, and psychosocial well-being. Findings: 1.a During a review of Resident 9's admission Record, the admission Record indicated the facility admitted the resident on 10/23/2018, and readmitted the resident on 7/26/2022, with diagnoses including age-related osteoporosis (a condition in which there is a decrease in the amount and thickness of bone tissue), dementia (a group of symptoms affecting memory, thinking, and social abilities), and history of falling. During a review of Resident 9's History and Physical (H&P), dated 9/20/2023, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 9's Set (MDS, a standardized assessment and care screening tool), dated 8/4/2024, the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident had impairment on both sides of the upper extremity and needed substantial to partial assistance on mobility and activities of daily living (ADLs, all the essential, basic self-care tasks that people need to do every day to keep themselves safe, healthy, clean, and feeling good). During a review of Resident 9's Order Summary Report, dated 7/26/2024, the report indicated an order for: -Facility may use less restricting measures prior to initiating resident with physical or chemical restraints. During a review of Resident 9's Fall Risk Assessment, dated 8/5/2024, the assessment indicated the resident was high risk for falls. During an observation on 8/20/2024, at 1:24 p.m., inside Resident 9's room, observed Resident 9's right side of the bed placed against the wall. During an interview and record review on 8/22/2024, at 3:06 p.m., with Registered Nurse 4 (RN 4), reviewed Resident 9's care plans (CP). RN 4 stated placing the resident's bed against the wall is considered a restraint. RN 4 stated the resident did not have a care plan for placing the bed against the wall. RN 4 stated it is important to develop and implement a care plan for placement of bed against the wall to ensure resident safety and to provide consistent care to the resident. During an interview on 8/23/2024, at 7:10 p.m., with the Director of Nursing (DON), the DON stated placing the bed against the wall would be considered a restraint and there should have been a care plan developed to ensure resident safety. The DON stated the failure of the staff to develop a care plan on the use of restraint bed placed against the wall could lead to variations in the care of urinary catheter that can lead to substandard care. During a review of the facility's recent policy and procedure (P&P) titled, The Resident Care Plan, last reviewed on 4/17/2024, the P&P indicated to provide an individualized nursing care plan and to promote continuity of resident care. The nursing care plan acts as a communication instrument between nurses and other disciplines. It contains information of importance for all nurses concerning nursing approach and problem solving. 2. During a review of Resident 467's admission Record, the admission Record indicated the facility admitted the resident on 1/26/2024, and readmitted the resident on 8/8/2024, with diagnoses including encephalopathy (a change in how the brain functions), seizures (a sudden, uncontrollable burst of electrical activity in the brain), and altered mental status. During a review of Resident 467's H&P, dated 8/8/2024, the H&P, indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 467's MDS, dated [DATE], the MDS indicated the resident sometimes had the ability to make self-understood and usually understand others. The MDS indicated the resident was dependent on mobility and activities of daily living (ADLs). During a review of Resident 467's Fall Risk Assessment, dated 8/8/2024, indicated the resident was high risk for falls. During an observation on 8/20/2024, at 10:09 a.m., inside Resident 467's room, observed the resident lying in bed with all four side rails up. During a concurrent observation, interview and record review on 8/21/2024, at 12:45 p.m., with Registered Nurse 7 (RN 7), inside Resident 467's room, observed resident was lying in bed with all four side rails up. RN 7 stated placing all four side rails up is considered a restraint. Reviewed Resident 467's care plans RN 7 stated there is no care plan for using four side rails up. RN 7 stated it is important to develop and implement a care plan for using all four side rails up to ensure safety of the resident. During an interview on 8/23/2024, at 7:10 p.m., with the DON, the DON stated raising all four side rails up is considered a restraint. The DON stated Resident 467 should have had a care plan for using four side rails up to ensure safety and consistency in care, and to prevent injuries and delivery of substandard quality of care. During a review of the facility's recent policy and procedure (P&P) titled, The Resident Care Plan, last reviewed on 4/17/2024, the P&P indicated to provide an individualized nursing care plan and to promote continuity of resident care. The nursing care plan acts as a communication instrument between nurses and other disciplines. It contains information of importance for all nurses concerning nursing approach and problem solving. 3. During a review of Resident 116's admission Record, the admission Record indicated the facility admitted the resident on 5/23/2024, with diagnoses including type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as fuel), acute kidney failure (when the body suddenly lose their ability to function), and urinary tract infection (a condition in which bacteria invade and grow in the urinary tract). During a review of Resident 116's H&P, dated 5/24/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 116's MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident had an indwelling catheter (a catheter which is inserted into the bladder, via the urethra and remains in situ to drain urine). During a review of Resident 116's Order Summary Report, dated 5/23/2024, the report indicated an order for Foley Catheter French (Fr, the relative size of a catheter) (16)/ (10) milliliters (ml, a unit of volume) attached to bedside drainage bag due to unspecified anatomy anomaly. Every shift. During an observation on 8/20/2024, at 10:32 a.m., inside Resident 116's room, observed the resident with a urinary catheter with a dignity bag (a bag used to cover and hold the catheter drainage/collection bag, so it is not visible) hanging on the right side of the bed frame. During a concurrent interview and record review on 8/23/2024, at 9:18 a.m., with Registered Nurse 5 (RN 5), reviewed Resident 116's Order Summary Report and care plans. RN 5 stated there was an order for the urinary catheter, however, there is no care plan for its (urinary catheter) use. RN 5 stated it was important to have a care plan for using a urinary catheter to document the reason for the insertion, to set goals, and to indicate interventions to mitigate untoward effects of inserting a catheter. RN 5 further stated having a care plan helps in the decision-making process for discontinuation of the catheter. During an interview on 8/23/2024, at 7:10 p.m., with the DON, the DON stated the resident should have a care plan for using a urinary catheter to ensure provision of individualized and relevant care to the resident. The DON stated not having a care plan may result in inconsistent care that may cause resident harm. During a review of the facility's recent policy and procedure (P&P) titled, The Resident Care Plan, last reviewed on 4/17/2024, the P&P indicated to provide an individualized nursing care plan and to promote continuity of resident care. The nursing care plan acts as a communication instrument between nurses and other disciplines. It contains information of importance for all nurses concerning nursing approach and problem solving. 4. During a review of Resident 30's admission Record, the admission Record indicated the facility admitted the resident on 6/6/2014 and readmitted the resident on 6/4/2024 with diagnoses including but not limited to dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), adult failure to thrive (a condition that happens when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal), and gastrostomy status (a surgical procedure used to insert a tube, through the abdomen and into the stomach to provide a route for tube feeding. During a review of Resident 30's History and Physical (H&P) dated 6/5/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 30's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/13/2024, the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and require total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS did not indicate the resident had restraints. During a concurrent observation and interview on 8/20/2024 at 11:00 a.m., inside Resident 30's room, with Licensed Vocational Nurse 3 (LVN 3), observed Resident 30 lying in bed with pillows tucked under the fitted sheets on both sides of the resident's lower legs. LVN 3 stated the pillows are usually placed by the Certified Nursing Assistants (CNAs) on both sides to prevent Resident 30 from getting out of bed due to restlessness. LVN 3 stated the pillows restrict the resident's movements by keeping the legs from dangling at the edge of the bed. During a concurrent interview and record review on 8/23/2024 at 4:43 p.m., with Minimum Data Set Coordinator 2 (MDSC 2). reviewed Resident 30's care plans. MDSC 2 stated Resident 30 does not have a care plan addressing the use of pillows tucked under the fitted sheet to prevent the resident from getting out of bed. During an interview on 8/23/2024 at 7:30 p.m., with the Director of Nursing (DON), the DON stated placing the pillows under the fitted sheet to prevent the resident from falling out of the bed is considered a restraint because it restricts the resident's movements and prevents Resident 30 from getting out of bed. The DON stated the resident should have had a care plan for using pillows under the fitted sheet to make staff aware of the goals and interventions to ensure the safety of the resident. During a review of the facility's policy and procedure (P&P) titled, The Resident Care Plan, last reviewed 4/17/2024, the P&P indicated an objective to provide an individualized nursing care plan and to promote continuity of resident care. The policy indicated the nursing care plan acts as a communication instrument between nurses and other disciplines and contains information of importance for all nurses concerning nursing approach and problem solving. 5. During a review of Resident 59's admission Record, the admission Record indicated the facility admitted the resident on 6/6/2014 and readmitted the resident on 6/4/2024 with diagnoses including but not limited to dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), adult failure to thrive (a condition that happens when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal), and generalized muscle weakness. During a review of Resident 59's History and Physical (H&P) dated 1/27/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 59's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/13/2024, the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and require total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated the resident had trunk restraints. During a review of resident 59's Order Summary Report dated 1/27/2024, the report indicated the following order: - Self-release seat belt (SRSB) while in wheelchair for positioning. Informed consent by physician from responsible party after explanation of risks and benefits. Ensure equipment is in place and functioning properly every shift. During a review of Resident 59's care plans, there was no documented evidence the resident has a care plan for using a self-release belt. During an observation on 8/20/2024 at 12:00 p.m. observed Resident 59 up in the wheelchair with a seat belt around the waist with the string tied at the back of the wheelchair. During a concurrent observation and interview on 8/22/2024 at 11:56 a.m., inside Resident 59's room with the Director of Staff Development Assistant (DSD Asst), observed the resident with SRSB while up in the wheelchair. The DSD Asst demonstrated how the SRSB works. The DSD Asst stated the SRSB has a Velcro (a hook-and-loop fastening system) and buckles that can be easily removed. During a concurrent interview and record review on 8/23/2024 at 2:20 p.m., with Minimum Data Set Coordinator 1 (MDSC 1), reviewed Resident 59's care plans. MDSC 1 stated the resident does not have a care plan addressing the use of SRSB. MDSC 1 stated it is important to develop a care plan, so staff are aware of the interventions in place to ensure resident safety. During an interview on 8/23/2024 at 7:30 p.m., with the Director of Nursing (DON), the DON Resident 59 should have had a care plan for using SRSB, so staff are aware of the interventions in place to meet the resident's needs and ensure resident safety. During a review of the facility's policy and procedure (P&P) titled, The Resident Care Plan, last reviewed 4/17/2024, the P&P indicated an objective to provide an individualized nursing care plan and to promote continuity of resident care. The policy indicated the nursing care plan acts as a communication instrument between nurses and other disciplines and contains information of importance for all nurses concerning nursing approach and problem solving. 6. During a review of Resident 111's admission Record, the admission Record indicated the facility admitted the resident on 1/11/2021 and readmitted the resident on 2/10/2021 with diagnoses including but not limited to PTSD, schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), and dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). During a review of Resident 111's History and Physical (H&P) dated 9/20/2023, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 111's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/18/2024, the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision from staff with eating, partial/moderate assistance with upper body dressing, substantial/maximal assistance with rolling left and right, and dependent on staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS Section I6100 indicated Resident 111 has a diagnosis of PTSD. During a review of Resident 111's care plan, the resident does not have a care plan developed addressing the resident's diagnosis of PTSD. During a concurrent interview and record review on 8/23/2024 at 3:08 p.m., with Minimum Data Set Coordinator 1 (MDSC 1), Resident 111's care plans were reviewed. MDSC 1 stated Resident 111 does not have a care plan addressing the resident's diagnosis of PTSD. MDSC 1 stated there should have been a care plan created so staff are aware of proper interventions to assist the resident cope with life stressors. During an interview on 8/23/2024 at 7:30 p.m., with the Director of Nursing (DON), the DON stated there should have been a care plan developed and implemented to address resident 11's diagnosis of PTSD for the staff to be aware of the plan of care and interventions in place to assist the resident and prevent a delay in the care and services needed. During a review of the facility's policy and procedure (P&P) titled, The Resident Care Plan, last reviewed 4/17/2024, the P&P indicated an objective to provide an individualized nursing care plan and to promote continuity of resident care. The policy indicated the nursing care plan acts as a communication instrument between nurses and other disciplines and contains information of importance for all nurses concerning nursing approach and problem solving. During a review of the facility's policy and procedure titled, Trauma-Informed and Culturally Competent Care, last reviewed 4/17/2024, indicated to develop individualized care plans that address past trauma in collaboration with the resident and family as appropriate. 7. During a review of Resident 126's admission Record (a document containing demographic and diagnostic information,) dated 8/22/24, the admission Record indicated Resident 126 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis including depression (a mental health condition that can cause feelings of sadness, loss of interest in activities and difficulty sleeping.) A review of Resident 126's Minimum Data Set (MDS - a comprehensive resident assessment tool), dated 7/6/24, indicated resident was severely impaired with cognition (mental action or process of acquiring knowledge and understanding) based on the results of the Brief Interview for Mental Status ([BIMS] - a mandatory tool used to screen and identify cognitive condition of residents upon admission into a long-term care facility,) and that symptom presence and frequency for trouble falling or staying asleep, or sleeping too much was not marked. During a review of Resident 126's Order Summary Report, dated 8/22/24, the report indicated Resident 126 was prescribed Melatonin 5 milligram ([mg] - a unit of measure of mass) to give one tablet by mouth at bedtime for supplement, starting 3/30/22. During a review of Resident 126's Medication Administration Record ([MAR] - a record of mediations administered to residents,) for August 2024, the MAR indicated Resident 126 was prescribed Melatonin 5 mg to give one tablet by mouth at bedtime for supplement, at 9 PM. During a review of Resident 126's Care Plan, initiated 7/8/24, the Care Plan indicated a goal of sleep of 6 hours per night. During a review of the facility's Consultant Pharmacist's (CP) Medication Regimen Review ([MRR] - a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication,) document review dated 6/26/24, the document indicated Resident has been on order for Melatonin 5 mg qhs (at bedtime) for supplement. Please consider changing the indication of Melatonin use to: 'for supplement to regulate Circadian rhythm.' Also consider monitor for 'hours of sleep qPM (at evening) and qNOC (at bedtime) shifts' to facilitate drug therapy monitoring. The column marked 'Follow-Through, was empty and did not contain any documentation, dates, or signatures for the review of the CP's recommendations. During an interview on 8/22/24 at 1:14 PM, with the Director of Nursing (DON,) the DON stated that Resident 126's care plan dated 7/8/24 indicated a goal of sleep of 6 hours per night. The DON stated after a thorough search of Resident 126's clinical record the DON was unable to locate documentation for monitoring the number of hours of sleep. The DON stated without monitoring hours of sleep it was unknown if non-pharmacological (that do not involve medications or drugs) interventions (therapies) and/or Melatonin were effective in reaching the goal of 6 hours of sleep and when to make changes to medications such as lowering the dose or discontinuing, leading to the use of unnecessary medications for Resident 126. The DON stated that facility failed to implement the care plan for monitoring for hours of sleep, and that it will be immediately initiated for Resident 126. During a review of the facility's Policy & Procedures, titled Section A Resident Assessment, dated 4/2014, the P&P indicated: 8. The Care Plan shall include: a. Services that are to be furnished to attain or measurable objectives and maintain the resident's highest practicable, physical, mental and psychosocial well-being; d. The resident's goals for admission and desired outcomes; Components of the resident's care plan include: b. Measurable, resident centered goals c. Plan of action 13. Care Plans shall be updated more often, as the resident's condition or needs change. 14. Resident Rights - Care Planning B. The resident has the right to receive the services and/or items included in the plan of care. Review of facility P&P titled Consultant Pharmacist Services Provider Requirements, dated October 2017, the policy indicated: 5. Identifying one or more current medication references to facilitate the identification of medications and information on contraindications, side effects and/or adverse effects, dosage levels and other pertinent information E. Activities that the consultant pharmacist or off-site pharmacist performs includes, but is not limited to: a. A residents drug regime must be free from unnecessary drugs. An unnecessary drug is any drug when used in: iii. without adequate monitoring iv. without adequate indication for its use. 1.b. During a review of Resident 126's admission Record, the admission Record indicated the facility originally admitted Resident 126 on 3/30/2022 and readmitted the resident on 4/11/2022 with diagnoses including, but not limited to, history of falling and difficulty in walking. During a review of Resident 126's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 7/6/2024, then MDS indicated Resident 126 had severe cognitive impairment (difficulty understanding and making decisions), required maximal assistance with rolling left to right in bed, and was dependent on facility staff for other activities of daily living, including eating, dressing, bathing or showering, hygiene, toileting, and surface-to-surface transfers. Resident 126's MDS indicated the facility used a limb restraint less than daily while in bed and other restraints were not used while in bed. During a review of Resident 126's History and Physical (H&P), dated 3/20/2024, the H&P indicated Resident 126 did not have the capacity to understand and make decisions. During a review of Resident 126's Fall Risk Assessment, dated 7/8/2024, the fall risk assessment indicated Resident 126 was at high risk for falls. During an observation on 8/20/2024, at 10:43 a.m., inside Resident 126's room, Resident 126 was lying down in bed. Resident 126's bed was placed against the wall, with the head of the bed facing the doorway, the foot of the bed facing towards the windows in the room, and the left side of the resident's bed touching the wall. During a concurrent observation and interview on 8/22/2024, at 9:43 a.m., inside Resident 126's room, with Licensed Vocational Nurse (LVN) 10, LVN 10 confirmed Resident 126's bed was placed against the wall, with the left side of the bed touching the wall, the head of the bed facing towards the doorway, and the foot of the bed facing the room's windows. LVN 10 stated placing the bed against the wall is considered a restraint because if the resident wanted to get out from her left side, she would not be able to. LVN 10 reviewed Resident 126's medical record and confirmed Resident 126 does not have a care plan for placing the resident's bed against the wall. LVN 10 further stated care plans help guide staff with providing care for residents. During an interview with the Director of Nursing (DON) on 8/23/2024, at 7:10 p.m., the DON stated placing beds against the wall restricts the movement of residents and can be considered a restraint. The DON stated care plans identify the plan of care for residents during their stay. The DON stated staff, residents, and their responsible parties have access to their care plans. The DON stated when using restraints, the facility should develop a care plan. The DON further stated failing to create a care plan can cause a potential delay in care. During a review of the facility's policy and procedure (P&P) titled, Physical Restraint, last reviewed 4/17/2024, the P&P indicated the plan of care shall specify the reason for the use of the restraint, the type, and when and where it is to be used. During a review of the facility's P&P titled, The Resident Care Plan, last reviewed 4/17/2024, the P&P indicated the nursing care plan acts as a communication instrument between nurses and other disciplines and contains information of importance for all nurses concerning nursing approach and problem solving.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide care in accordance with professional standards: 1. For five of seven sampled residents (Resident 12, 38, 56, 116 125, and 49) investigated for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous ([SQ] -beneath the skin) insulin administration sites. 2. For one of one sampled resident (Resident 38) investigated during review of anticoagulant use by failing to rotate enoxaparin (medication to prevent and treat blood clots) subcutaneous injection sites. The deficient practice increased the risk that Residents Resident 12, 38, 56, 116, 125, and 49 could experience adverse effects (unwanted, unintended result) from same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross Reference F760 Findings: a. During a review of Resident 116's admission Record, the admission Record indicated the facility admitted the resident on 5/23/2024, with diagnoses including type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as fuel), acute kidney failure (when the body suddenly lose their ability to function), and urinary tract infection (a condition in which bacteria invade and grow in the urinary tract). During a review of Resident 116's History and Physical (H&P), dated 5/24/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 116's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/30/2024, the MDS indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident was on a high-risk drug class hypoglycemic (medication that lowers blood sugar) (including insulin). During a review of Resident 116's Order Summary Report, dated 5/25/2024, the report indicated an order for: - insulin regular human injection solution (Insulin Regular [Human]) Inject as per sliding scale (varies the dose of insulin based on blood sugar level): if 61-150= 0. If blood sugar (BS) less than (<) 60 may administer 8 ounces (oz., a unit of weight measurement) orange juice and call MD; 151-200= 2; 201-250= 4; 251-300= 6; 301-350= 8; 351-399= 10; 400+ If BS greater than (>) 400, administer12 units (the amount required to lower the blood sugar) and notify MD, subcutaneously every 6 hours for diabetes mellitus (DM) rotate site. During a review of Resident 116's Location of Administration of insulin for 6/2024 to 8/2024, it indicated Insulin Regular Human Injection Solution was administered on the following dates and sites: 6/11/2024 at 5:27 p.m. on the Abdomen-Left Lower Quadrant (LLQ) 6/12/2024 at 11:38 p.m. on the Abdomen-LLQ 6/19/2024 at 6:27 p.m. on the Abdomen-Right Lower Quadrant (RLQ) 6/20/2024 at 11:35 p.m. on the Abdomen-RLQ 6/20/2024 at 5:32 a.m. on the Abdomen-RLQ 6/24/2024 at 5:13 p.m. on the Abdomen-LLQ 6/25/2024 at 11:20 p.m. on the Abdomen-LLQ 7/1/2024 at 5:06 a.m. on the Abdomen-LLQ 7/2/2024 at 11:06 p.m. on the Abdomen-LLQ 7/2/2024 at 1:31 p.m. on the Abdomen-LLQ 7/10/2024 at 5:09 p.m. on the Abdomen-LLQ 7/11/2024 at 11:16 p.m. on the Abdomen-LLQ 7/22/2024 at 11:12 p.m. on the Abdomen-LLQ 7/23/2024 at 11:58 p.m. on the Abdomen-LLQ 7/25/2024 at 11:15 p.m. on the Abdomen-LLQ 7/26/2024 at 11:16 p.m. on the Abdomen-LLQ 8/8/2024 at 12:54 a.m. on the Abdomen-LLQ 8/9/2024 at 11:49 p.m. on the Abdomen-LLQ 8/12/2024 at 5:17 p.m. on the Abdomen-Right Upper Quadrant (RUQ) 8/14/2024 at 12:50 p.m. on the Abdomen-RUQ During a concurrent interview and record review on 8/22/2024, at 3:09 p.m., with Registered Nurse 4 (RN 4), reviewed Resident 116's Order Summary Report, Medication Administration Record (MAR), and Location of Administration sites of insulin for 6/2024 to 8/2024. RN 4 stated there were multiple instances where the insulin administration sites was not rotated. RN 4 stated insulin administration sites should be rotated to prevent bruising and swelling of the skin and to prevent lipodystrophy. During an interview on 8/23/2024, at 7:20 p.m., with the Director of Nursing (DON), the DON stated insulin injections sites should be rotated to prevent skin irritation and lipodystrophy. During a review of the facility's recent policy and procedure (P&P) titled, Insulin Administration, last reviewed on 4/17/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility provided Instructions for Use of Humulin ([NAME]-mu-[NAME]) R (insulin human) injection for subcutaneous or intravenous use 3 ml or 10 ml multiple-dose vial (100 units/ML), copyright 1997, it indicated change (rotate) your injection sites within the area you choose for each dose to reduce your risk of getting lipodystrophy (pits in skin or thickened skin) and localized cutaneous amyloidosis (skin with lumps) at the injection sites. b. During a review of Resident 38's admission Record, the admission Record indicated the facility admitted the resident on 4/17/2012, and readmitted the resident on 12/19/2023, with diagnoses including functional quadriplegia (a condition that causes complete immobility due to a severe physical disability or frailty, but it is not a true paralysis), type 2 diabetes mellitus, and anoxic brain damage (caused by a complete lack of oxygen to the brain, which results in the death of brain cells after approximately four minutes of oxygen deprivation). During a review of Resident 38's H&P, dated 12/19/2023, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 38's MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident was on high-risk drug class hypoglycemic (including insulin). During a review of Resident 38's Order Summary Report, the report indicated the following orders: -7/2/2024 Enoxaparin Sodium Injection Solution Prefilled Syringe (anticoagulant) 40 milligrams (mg, a unit of weight)/0.4 milliliters (ml, a unit of volume) (Enoxaparin Sodium). Inject 0.4 ml subcutaneously in the morning for deep vein thrombosis (DVT, the formation of one or more blood clots) prophylaxis (ppx, measures designed to preserve health and prevent the spread of disease) rotate site (as maintenance for long term DVT PPX). -5/28/2024 Novolog Injection Solution (Insulin Aspart). Inject as per sliding scale: if 70-140= 0 < 70 may give 8 oz orange juice and notify MD; 141-220= 1 unit; 221-260= 2 units; 261-280= 3 units; 281-300= 4 units; 301-350= 5 units; 351+= 6 units >350 give 6 units and notify MD, subcutaneously every 12 hours for DM rotate site. During a review of Resident 38's Care Plan (CP) titled, Anticoagulant, (a substance that is used to prevent and treat blood clots), and At risk for bleeding and bruises due to anticoagulant therapy, last revised on 12/20/2023, the CP indicated an intervention to administer medication as ordered. During a review of Resident 38's Location of Administration of Enoxaparin Sodium Injection Solution Prefilled Syringe 40 mg/0.4 ml for 5/2024 to 8/2024, it indicated the following dates and sites of administration: 5/5/2024 at 9:25 a.m. on the Abdomen-Left Upper Quadrant (LUQ) 5/6/2024 at 9:23 a.m. on the Abdomen-LUQ 5/9/2024 at 9:02 a.m. on the Abdomen-LUQ 5/10/2024 at 8:49 a.m. on the Abdomen-LUQ 5/11/2024 at 9:12 a.m. on the Abdomen-LUQ 6/11/2024 at 9:02 a.m. on the Abdomen-LUQ 6/12/2024 at 9:09 a.m. on the Abdomen-LUQ 8/8/2024 at 8:43 a.m. on the Abdomen-RLQ 8/9/2024 at 9:31 a.m. on the Abdomen-RLQ 8/17/2024 at 9:33 a.m. on the Abdomen-RUQ 8/18/2024 at 9:13 a.m. on the Abdomen-RUQ During a review of Resident 38's Location of Administration of Novolog Injection Solution for 6/2024 to 8/2024, it indicated the following dates and sites of administration: 6/9/2024 at 5:11 p.m. on the Abdomen-LLQ 6/20/2024 at 5:37 a.m. on the Abdomen-LLQ 6/21/2024 at 5:27 a.m. on the Abdomen-LLQ 7/8/2024 at 5:20 p.m. on the Abdomen-RLQ 7/9/2024 at 5:13 a.m. on the Abdomen-RLQ 7/14/2024 at 5:13 a.m. on the Abdomen-LLQ 7/16/2024 at 5:18 a.m. on the Abdomen-LLQ 7/17/2024 at 5:03 a.m. on the Abdomen-RLQ 7/18/2024 at 5:06 a.m. on the Abdomen-RLQ 7/23/2024 at 5:12 a.m. on the Abdomen-RLQ 7/24/2024 at 5:31 a.m. on the Abdomen-RLQ During a concurrent interview and record review on 8/22/2024, at 3:15 p.m., with RN 4, reviewed Resident 38's Order Summary Report, MAR, and Location of Administration sites of insulin from 6/2024 to 8/2024 and Enoxaparin Sodium Injection from 5/2024 to 8/2024. RN 4 stated there were multiple instances where the insulin and enoxaparin administration sites were not rotated. RN 4 stated the insulin and enoxaparin administration sites should be rotated to prevent bruising and swelling of the skin and to prevent lipodystrophy. During an interview on 8/23/2024, at 7:20 p.m., with the DON, the DON stated insulin and enoxaparin injection sites should be rotated to prevent skin irritation and lipodystrophy. During a review of the facility's recent policy and procedure (P&P) titled, Insulin Administration, last reviewed on 4/17/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility provided instructions for use of Enoxaparin Sodium Injection for subcutaneous use single-dose prefilled syringe, undated, it indicated to alternate between the left or the right side of the stomach each time an injection is given. During a review of the facility provided Instructions for Use of Humulin ([NAME]-mu-[NAME]) R (insulin human) injection for subcutaneous or intravenous use 3 ml or 10 ml multiple-dose vial (100 units/ML), copyright 1997, it indicated change (rotate) your injection sites within the area you choose for each dose to reduce your risk of getting lipodystrophy (pits in skin or thickened skin) and localized cutaneous amyloidosis (skin with lumps) at the injection sites. During a review of the facility provided Highlights of Prescribing Information for Insulin Aspart injection, for subcutaneous or intravenous use, with initial U.S. approval in 2000, indicated to rotate the injection sites within the same region from one injection to the next to reduce the risk of lipodystrophy and localized cutaneous amyloidosis. c. During a review of Resident 125's admission Record, the admission Record indicated the facility admitted the resident on 2/26/2022, and readmitted the resident on 3/1/2024, with a diagnosis of type 2 diabetes mellitus. During a review of Resident 125's H&P, dated 3/1/2024, the H&P indicated the incapacitated resident requires visit for safety. During a review of Resident 125's MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and sometimes understands others. The MDS indicated the resident was on a high-risk drug class hypoglycemic (including insulin). During a review of Resident 125's Order Summary Report, dated 4/2/2024, the report indicated an order for Insulin Aspart FlexPen Solution Pen-injector 100 unit/ml (Insulin Aspart). Inject as per sliding scale: if 60-150= 0 units; 151-199= 2 units; 200-249= 3 units; 250-299= 5 units; 300-349= 7 units; 350-400= 10 units; subcutaneously every 12 hours for diabetes type 2 (DM II) (rotate injection sites) finger-stick blood sugar (FSBS, a method of monitoring blood sugar) monitoring. Notify MD if BS < 70 mg/dl or >400 mg/dl. May give 8 oz orange juice if BS < 70 mg/dl and notify MD. During a review of Resident 125's Location of Administration of Insulin Aspart FlexPen Solution Pen-injector 100 unit/ml from 6/2024 to 8/2024, it indicated the following administration dates and sites: 6/4/2024 at 5:15 a.m. on the Abdomen-LLQ 6/7/2024 at 5:06 a.m. on the Abdomen-LLQ 6/10/2024 at 5:38 a.m. on the Abdomen-LLQ 6/11/2024 at 5:26 a.m. on the Abdomen-LLQ 6/12/2024 at 5:05 a.m. on the Abdomen-LLQ 6/13/2024 at 5:33 a.m. on the Abdomen-LLQ 6/17/2024 at 5:36 a.m. on the Abdomen-LLQ 6/19/2024 at 5:14 a.m. on the Abdomen-LLQ 6/20/2024 at 5:31 a.m. on the Abdomen-LLQ 6/21/2024 at 5:19 a.m. on the Abdomen-LLQ 6/24/2024 at 5:19 a.m. on the Abdomen-RLQ 6/26/2024 at 5:15 a.m. on the Abdomen-RLQ 6/27/2024 at 5:24 a.m. on the Abdomen-RLQ 7/8/2024 at 5:12 a.m. on the Abdomen-RLQ 7/9/2024 at 5:15 a.m. on the Abdomen-RLQ 7/10/2024 at 5:11 a.m. on the Abdomen-RLQ 7/11/2024 at 5:09 a.m. on the Abdomen-RLQ 7/12/2024 at 5:07 a.m. on the Abdomen-RLQ 7/15/2024 at 5:16 a.m. on the Abdomen-RLQ 7/17/2024 at 5:07 a.m. on the Abdomen-RLQ 7/18/2024 at 5:08 a.m. on the Abdomen-RLQ 7/21/2024 at 5:30 a.m. on the Abdomen-RLQ 7/22/2024 at 5:10 a.m. on the Abdomen-RLQ 7/23/2024 at 5:16 a.m. on the Abdomen-RLQ 7/24/2024 at 5:33 a.m. on the Abdomen-RLQ 7/25/2024 at 5:20 a.m. on the Abdomen-RLQ 8/1/2024 at 5:07 a.m. on the Abdomen-RLQ 8/2/2024 at 5:03 a.m. on the Abdomen-RLQ During a review of Resident 125's Care Plan (CP) titled, Resident at risk for hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) related to diabetes mellitus, last revised on 3/9/2022, the CP indicated an intervention to administer medications as ordered. During a concurrent interview and record review on 8/22/2024, at 3:19 p.m., with RN 4, reviewed Resident 125's Order Summary Report, MAR, and Location of Administration sites of insulin from 6/2024 to 8/2024. RN 4 stated there were multiple instances where the insulin administration sites were not rotated. RN 4 stated insulin administration should be rotated to prevent bruising and swelling of the site and to prevent lipodystrophy. During an interview on 8/23/2024, at 7:20 p.m., with the DON, the DON stated insulin injections sites should be rotated to prevent skin irritation and lipodystrophy. During a review of the facility's recent policy and procedure (P&P) titled, Insulin Administration, last reviewed on 4/17/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility provided Highlights of Prescribing Information for Insulin Aspart injection, for subcutaneous or intravenous use, with initial U.S. approval in 2000, it indicated to rotate the injection sites within the same region from one injection to the next to reduce the risk of lipodystrophy and localized cutaneous amyloidosis. e. During a review of Resident 49's admission Record, the admission Record indicated the facility admitted the resident on 8/4/2021 and readmitted in the facility on 5/8/2024 with diagnoses including but not limited to heart failure (a long-term condition that happens when the heart cannot pump blood well enough to give the body a normal supply), type two diabetes mellitus (DM 2 - a long term condition that causes the level of sugar [glucose] in the blood to become too high), and dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). During a review of Resident 49's History and Physical (H&P) dated 5/10/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 49's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/13/2024, the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and require total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 49 received insulin. During a review of Resident 49's Order Summary Report, the report indicated the following physician's order dated 5/8/2024: o Basaglar KwikPen (insulin glargine - a long-acting insulin used to control high blood sugar) subcutaneous solution pen-injector 100 unit per milliliter (unit/ml - a unit of measurement) inject 20 units subcutaneously in the morning for DM rotate sites. o Basaglar KwikPen (insulin glargine - a long-acting insulin used to control high blood sugar) subcutaneous solution pen-injector 100 unit per milliliter (unit/ml - a unit of measurement) inject 20 units subcutaneously at bedtime for DM rotate sites. o Humalog KwikPen (insulin lispro - a quick acting insulin used to improve blood sugar control in people with DM) subcutaneous solution Pen-injector 100 unit/ml (insulin lispro) inject subcutaneously per sliding scale: if 60 - 130 = 0; 131 - 160 = 2; 161 - 200 = 3; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10 more than 400= 10 units and call physician ,before meals and at bedtime for DM [ROTATE SITE] notify physician if blood sugar is above 400 milligram per deciliter (mg/dl - a unit of measurement or below 60mg/dl, may give five 8 ounces (oz - a unit of measurement) orange juice by mouth if blood sugar is below 60mg/dl. o Fiasp injection solution (insulin aspart with niacinamide - a rapid acting insulin indicated to improve glycemic control in patients with DM) 100 unit /ml inject seven (7) unit subcutaneously before meals for DM 2 (ROTATE SITES) notify physician if blood sugar is above 400 mg/dl or below 60mg/dl, may give 8oz orange juice by mouth if blood sugar is below 60mg/dl. Hold for blood sugar less than 100 administer 10-15 minutes prior to eating meals or as close as possible to mealtime. During a review of Resident 49's Medication Administration Record (MAR) from 6/2024 to 8/2024, the MAR indicated Basaglar insulin injection solution was administered as follows: 6/7/2024 9:00 a.m. subcutaneously Abdomen Right lower Quadrant (RLQ) 6/7/2024 9:00 p.m. subcutaneously Abdomen RLQ 6/8/2024 9:00 a.m. subcutaneously Abdomen Right Upper Quadrant (RUQ) 6/8/2024 9:00 p.m. subcutaneously Abdomen RUQ 6/13/2024 9:00 a.m. subcutaneously Right Arm (RA) 6/13/2024 9:00 p.m. subcutaneously RA 6/14/2024 9:00 a.m. subcutaneously Abdomen RUQ 6/14/2024 9:00 p.m. subcutaneously Abdomen RUQ 6/22/2024 9:00 a.m. subcutaneously Abdomen RLQ 6/22/2024 9:00 p.m. subcutaneously Abdomen RLQ 7/1/2024 9:00 a.m. subcutaneously Abdomen RUQ 7/1/2024 9:00 p.m. subcutaneously Abdomen RUQ 7/12/2024 9:00 a.m. subcutaneously Abdomen Left Upper Quadrant (LUQ) 7/12/2024 9:00 p.m. subcutaneously Abdomen LUQ 7/15/2024 9:00 a.m. subcutaneously Abdomen Left Lower Quadrant (LLQ) 7/15/2024 9:00 p.m. subcutaneously Abdomen LLQ 7/17/2024 9:00 a.m. subcutaneously Abdomen Left Lower Quadrant (LLQ) 7/17/2024 9:00 p.m. subcutaneously Abdomen LLQ 7/19/2024 9:00 a.m. subcutaneously Abdomen RLQ 7/19/2024 9:00 p.m. subcutaneously Abdomen RLQ 7/23/2024 9:00 a.m. subcutaneously Abdomen RLQ 7/23/2024 9:00 p.m. subcutaneously Abdomen RLQ 7/25/2024 9:00 a.m. subcutaneously Abdomen LUQ 7/25/2024 9:00 p.m. subcutaneously Abdomen LUQ 7/31/2024 9:00 a.m. subcutaneously Abdomen RLQ 7/31/2024 9:00 p.m. subcutaneously Abdomen RLQ During a review of Resident 49's Medication Administration Record (MAR) from 6/2024 to 8/2024, the MAR indicated Humalog insulin injection solution was administered as follows: 06/20/2024 9:00 p.m. subcutaneously Abdomen - Left Lower Quadrant (LLQ) 06/21/2024 11:30 subcutaneously Abdomen - LLQ 06/23/2024 11:30 subcutaneously Abdomen - LLQ 06/23/2024 21:00 subcutaneously Abdomen - LLQ 07/04/24 21:00 subcutaneously Abdomen - LUQ 07/06/24 11:30 subcutaneously Abdomen - LUQ 07/16/24 21:00 subcutaneously Abdomen - Left Lower Quadrant (LLQ) 07/17/24 11:30 subcutaneously Abdomen - LLQ 08/01/24 11:30 subcutaneously Abdomen - LLQ 08/01/24 16:30 subcutaneously Abdomen - LLQ 08/19/24 11:30 subcutaneously Abdomen - LLQ 08/19/24 16:30 subcutaneously Abdomen - LLQ During a review of Resident 49's Medication Administration Record (MAR) from 6/2024 to 8/2024, the MAR indicated Fiasp insulin injection solution was administered as follows: 06/08/24 16:30 subcutaneously Abdomen - LUQ 06/09/24 11:30 subcutaneously Abdomen - LUQ 08/08/24 11:30 subcutaneously Abdomen - LUQ 08/08/24 16:30 subcutaneously Abdomen - LUQ 08/10/24 16:30 subcutaneously Abdomen - LUQ 08/11/24 06:30 subcutaneously Abdomen - LUQ 08/19/24 11:30 subcutaneously Abdomen - LLQ 08/19/24 16:30 subcutaneously Abdomen - LLQ During a concurrent interview and record review on 8/23/2024 at 3:30 p.m., with Minimum Data Set Coordinator 2 (MDSC 2), reviewed Resident 49's physician's orders, MAR, and location of administration sites from 6/2024 to 8/2024. MDSC 2 verified the physician's order that indicated to rotate insulin administration sites. MDSC 2 stated there were multiple repeated insulin administration on the same sites between 6/2024 to 8/2024. During an interview on 8/23/2024 at 7:10 p.m., the Director of Nursing (DON), the DON stated the licensed nurses should rotate the insulin administration site to prevent residents from developing lipodystrophy. During a review of the facility's policy and procedure (P&P) titled, Insulin Administration, last reviewed 4/17/2024, the P&P indicated a purpose to provide guidelines for the safe administration of insulin to residents with diabetes. The policy indicated: o Insulin maybe injected into the SQ tissues of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately two (2) inches around the navel. o Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility provided manufacturer's guideline for Basaglar (insulin glargine), undated, it indicated to rotate injection sites into the abdominal area, thigh, or deltoid to reduce the risk of lipodystrophy and localized cutaneous amyloidosis. During a review of the facility provided manufacturer's guideline for Humalog (insulin lispro), undated, it indicated: - Change (rotate) your injections sites within the area you choose for each dose to reduce your risk of getting lipodystrophy and localized cutaneous amyloidosis. - Do not inject where the skin has pits, is thickened, or has lumps. - Do not inject where the skin is tender, bruised, scaly or hard, or into scars or damaged. During a review of the facility provided manufacturer's guideline for Fiasp (insulin aspart), undated, it indicated to rotate injection sites within the same region to reduce the risk of lipodystrophy and localized cutaneous amyloidosis. d.1 During a review of Resident 12's admission Record (a document containing demographic and diagnostic information,) dated 8/22/24, it indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including Type 2 Diabetes Mellitus 2 ([DM2] - a condition where there is high blood sugar levels.) During a review of Resident 12's Order Summary Report, dated 8/22/24, it indicated Resident 12 was prescribed Lantus (long-acting insulin) to inject 20 units ([un] - a measure of dosage for insulin) SQ at bedtime for DM rotate sites, starting 2/21/24. During a review of Resident 12's Medication Administration Record ([MAR] - a record of mediations administered to residents), for August 2024, the MAR indicated Resident 12 was prescribed Lantus 20 un SQ to give at bedtime for DM rotate sites, at 9 PM. During the same review, the MAR indicated Lantus 20 units SQ was administered at bedtime on the following days and sites: 8/13/24 at 9 PM on Right Upper Quadrant ([RUQ] - upper right side of abdomen) 8/14/24 at 9 PM on RUQ d.2 During a review of Resident 56's admission Record (a document containing demographic and diagnostic information,) dated 8/21/24, it indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including DM2. During a review of Resident 56's Order Summary Report, dated 8/21/24, it indicated Resident 56 was prescribed Novolog (fast-acting insulin) to inject per sliding scale (insulin dosing plan whereby the amount of insulin administered depends on the resident's blood sugar level,) SQ before meals for DM2 (rotate site,) starting 10/13/23. During a review of Resident 56's MAR for June and July 2024, the MAR indicated Resident 56 was prescribed Novolog to inject per sliding scale SQ before meals for DM2 (rotate site,) at 6:30 AM, 11:30 AM and 4:30 PM. During the same review, the MAR's indicated Novolog SQ was administered on the following days, times and sites: 6/27/24 at 6:30 AM on Left Lower Quadrant ([LLQ] - lower left side of abdomen) 6/27/24 at 4:30 PM on LLQ 6/28/24 at 6:30 AM on Right Lower Quadrant ([RLQ] - right left side of abdomen) 6/27/24 at 4:30 PM on RLQ 6/30/24 at 11:30 AM on RLQ 6/30/24 at 4:30 PM on RLQ 7/10/24 at 4:30 PM on LLQ 7/11/24 at 4:30 PM on LLQ 7/23/24 at 4:30 PM on LLQ 7/24/24 at 4:30 PM on LLQ During a concurrent interview and record review on 8/23/24 at 8:57 AM, with Registered Nurse (RN) 7, RN 7 reviewed Resident 12's and 56's MAR for August 2024 and for June and July 2024, respectively. RN 7 stated that Resident 12 MAR indicated to rotate injection sites for Lantus and Resident 56 MARs indicated to rotate injection site for Novolog. RN 7 stated that for Resident 12 and 56 the MARs indicated there were multiple instances where the insulin administration sites were not rotated by several licensed nurses, as expected by standard of practice, manufacturer guidelines, and MAR order instructions. RN 7 stated the failure of the licensed nurses to rotate insulin administration sites could cause harm to Resident 12 and 56 by causing skin abnormalities such as lumps in the skin or thickened skin. During an interview on 8/23/24, at 10:19 AM, with the Director of Nursing (DON,) the DON stated that per facility policy and manufacturer guidelines it was common knowledge for licensed nurses to rotate insulin administration sites to prevent lipodystrophy to the sites that was frequently administered with insulin. The DON stated that several licensed nurses failed to rotate the insulin administration sites for Resident 12 and 56 and placed the residents at risk of harm from lipodystrophy. A review of facility's Policy and Procedures (P&P) titled, Insulin Administration, dated September 2014, the P&P indicated: To provide guidelines for the safe administration of insulin to residents with diabetes. 3. The type of insulin, .and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's order. 16.b. injection sites should be rotated, preferably within the same general area. A review of manufacturer's guide for Injecting Lantus with a vial and syringe, dated 2022, the guide indicated to Change (rotate) your injection sites within the area you chose with each dose to reduce your risk of getting lipodystrophy (pitted or thickened skin) and localized cutaneous amyloidosis (skin with lumps) at the injection sites. Do not use the same spot for each injection or inject where the skin is pitted, thickened, lumpy, tender, bruised, scaly, hard, scarred or damaged. A review of manufacturer's guide for Instructions for use for Novolog, dated 1/2015, the guide indicated Injection sites should be rotated within the same region to reduce the risk of lipodystrophy. For each injection, change (rotate) your injection site within the area of skin that you use. Do not use the same injection site for each injection.

Based on observation, interview, and record review the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injury (the breakdown of skin integrity due to pressure) for two of four sampled residents (Residents 67 and 469) investigated during review of pressure injury by failing to: 1. Ensure Resident 67's low air loss mattress' (LALM, designed to distribute the resident's body weight over a broad surface area and help prevent skin breakdown) power was turned on. 2. Ensure Resident 469's LALM was set according to the resident's weight. The deficient practices had the potential for the development and worsening of the resident's pressure ulcers/injuries. Findings: 1. During a review of Resident 67's admission Record, the admission Record indicated the facility admitted the resident on 5/2/2018, and readmitted the resident on 10/9/2023, with diagnoses including hemiplegia (one-sided muscle paralysis or weakness) and hemiparesis (one-sided muscle weakness), peripheral vascular disease (a slow and progressive disorder of the blood vessels), and venous thrombosis (a blood clot that blocks the flow of blood through the veins) and embolism (a block in an artery caused by blood clots or other substances, such as fat globules, infected tissue, or cancer cells). During a review of Resident 67's History and Physical (H&P), dated 10/9/2023, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 67's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/28/2024, the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident had an impairment on one side of the upper and lower extremity. The MDS indicated the resident was dependent on mobility and activities of daily living (ADLs, all the essential, basic self-care tasks that people need to do every day to keep themselves safe, healthy, clean, and feeling good) and was incontinent of urine and bowel (feces). The MDS further indicated the resident was at risk for developing pressure ulcer/injuries and used a pressure reducing device for bed. During a review of Resident 67's Order Summary Report, dated 10/10/2023, the report indicated an order for Low Air Loss Mattress for wound care and management. During a review of Resident 67's Wound Risk Assessment, dated 5/30/2024, the assessment indicated the resident was high risk for skin breakdown. During a review of Resident 67's Care Plan (CP) titled, Low-Air Loss Mattress. At risk for falling from Low-Air-Loss Mattress due to: Specify (involuntary movements, spontaneous movements, large or heavy patients, resident with contractures, resident requiring total care, resident requiring turning and repositioning), initiated on 8/20/2024, the CP indicated an intervention to ensure LAL mattresses are inflated and recommended. During a concurrent observation and interview on 8/20/2024, at 12:34 p.m., with Licensed Vocational Nurse 5 (LVN 5), inside Resident 67's room, observed the resident's LALM power off. LVN 5 stated the resident's LALM is off, and it should have been set at 150 to prevent the resident from developing pressure injury. During an interview on 8/23/2024, at 7:10 p.m., with the Director of Nursing (DON), the DON stated staff should have turned on the power of the LALM to provide therapy to the resident. The DON stated the failure of staff to turn the power on could result to therapy not being provided and predisposes the resident to developing or worsening of pressure injuries. During a review of the facility provided Operation Manual for Low Air Loss Mattress (LALM), undated, the manual indicated press Power key on the panel, the pump will start/stop operation. Users can adjust air mattress to a desired firmness according to patient's weight or the suggestion from a health care professional. 2. During a review of Resident 469's admission Record, the admission Record indicated the facility admitted the resident on 8/8/2024, with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe), tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow air to fill the lungs), and traumatic subdural hemorrhage (happens when blood is leaking out of a torn blood vessel and below the space of the brain and the skull). During a review of Resident 469's History and Physical (H&P), dated 8/8/2024, The H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 469's Order Summary Report, the report indicated the following orders: -8/19/2024 Low Air Loss Mattress for wound care and management. -8/14/2024 Sacral area pressure ulcer (P.U.). Cleanse with normal saline (NS, a mixture of water and salt for washing wounds). Pat dry. Apply Santyl ointment (a topical medication used for removing damaged or burned skin to allow for wound healing and growth of healthy skin). Cover with dry dressing (DD) then bordered gauze (an absorptive dressing consisting of three layers). Every day shift for 30 days. During a review of Resident 469's Care Plan titled, Actual Pressure Sore. Resident is noted with stage 3 P.U. (a full-thickness loss of skin that extends into the subcutaneous tissue, but does not reach muscle, tendon, or bone), initiated on 8/9/2024, the CP indicated an intervention of using pressure relieving devices as needed. During a review of Resident 469's Wound Risk Assessment, dated 8/15/2024, the assessment indicated the resident was high risk for skin breakdown. During a review of Resident 469's Weight Summary, dated 8/15/2024, it indicated the resident's weight was 136 pounds (lbs., a unit of weight). During a concurrent observation and interview on 8/20/2024, at 11:22 a.m., with Certified Nursing Assistant 3 (CNA 3), inside Resident 469's room, observed the LALM set at 160 and the sticker on the device indicated to set at 200. CNA 3 stated the LALM was set at 160 but the the sticker indicated to set the LALM at 200. During a concurrent interview and record review on 8/23/2024, at 11:33 a.m., with Treatment Nurse 3 (TN 3), reviewed Resident 469's Weight Summary. TN 3 stated the LALM is set according to the weight of the resident. TN 3 stated the resident's latest weight on 8/15/2024 was 136 lbs. TN 3 stated the sticker should not indicate to set at 200. TN 3 stated the sticker could be misleading and could cause staff to set the LALM in an inappropriate setting that can cause the development or worsening of a pressure injury. TN 3 stated they should have clarified with the attending physician as to what the LALM setting should be. During an interview on 8/23/2024, at 7:10 p.m., with the Director of Nursing (DON), the DON stated the LALM should be set according to the resident's weight. The DON stated the staff should have clarified with the attending physician the order for the LALM setting. The DON stated the failure of the staff to clarify the order could lead to provision of inappropriate therapy that can cause the development or worsening of the pressure injury. During a review of the facility provided Operation Manual for the LALM , undated, the manual indicated press Power key on the panel, the pump will start/stop operation. Users can adjust air mattress to a desired firmness according to patient's weight or the suggestion from a health care professional.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide appropriate treatments and services to minimize decline in joint range of motion (ROM, full movement potential of a joint) and mobility for three of five sampled residents (Residents 6, 138, and 125) who had limited ROM by failing to: 1. Provide Resident 6 with a right knee splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) during Restorative Nursing Aide Program (RNA, nursing aide program that help residents to maintain their function and joint mobility) seven (7) times a week as ordered and report to nursing when Resident 6 did not complete range of motion exercises or wear the right knee splint. 2. Provide Resident 125 with a left elbow splint and both hand rolls (device to keep fingers open) 7 times a week as ordered and report to nursing when Resident 125 did not wear a left elbow splint and both hand rolls. 3. Provide Resident 138 with left elbow splint, left resting hand splint, and right hand roll 7 times a week as ordered and report to nursing when Resident 138 did not wear left elbow splint, left resting hand splint, and right hand roll. The deficient practices had the potential to cause decline in ROM, mobility, and overall physical functioning in Resident 6, 125 and 138. Findings: a. During a review of Resident 6's admission Record (AR) dated 8/22/24, the AR indicated Resident 6 initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including respiratory failure (any condition that affects breathing function and result in lungs not functioning properly), Parkinson's disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement) without dyskinesia (involuntary movements of extremities), and functional quadriplegia (weakness or paralysis to all four extremities). During a review of Resident 6's History and Physical (H&P) dated 4/12/24, the H&P indicated Resident 6 did not have the capacity to understand and make decisions. During a review of Resident 6's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 6/21/24, the MDS indicated Resident 6 was severely impaired in cognitive skills for daily decision making. The MDS indicated Resident 6 required dependent assistance (helper does all of the effort) with dressing, oral hygiene, toileting hygiene, and bathing. The MDS also indicated Resident 6 had functional limitations in range of motion impairments on both sides of the upper extremities (UE, shoulder, elbow, wrist/hand) and both sides of lower extremities (LE, hip, knee, ankle/foot). During a review of Resident 6's Order Summary Report dated 8/1/24, the Order Summary Report indicated an order dated 5/9/24 for RNA/Nursing Program established for active assistive range of motion (AAROM, movement at a given joint with a person's own effort and assistance from an external force or another person) for both UE (BUE), passive range of motion (PROM, movement at a given joint with full assistance from another person) for both LE (BLE) as tolerated followed by right knee splint, and both ankle foot orthosis (AFO, an orthotic device designed to correct or address problems with the ankle and foot) for four to six (4-6) hours or as tolerated, once a day, 7 times a week. During a review of Resident 6's care plan dated 5/9/24, the care plan indicated Resident 6 had limitations in range of motion and contractures (loss of motion of a joint). The care plan goal was to minimize complications related to decreased mobility or contractures through appropriate interventions through the next assessment. The care plan interventions indicated restorative nursing for AAROM to BUE, PROM to BLE, right knee splint and both AFOs for 4-6 hours or as tolerated 7 times a week, and orthotic application and skin integrity management. During a review of Resident 6's Physical Therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) Discharge Summary (PT DC) dated 5/9/24, the PT DC indicated discharge recommendations for an RNA program for PROM for BLE followed by right knee splint and B AFOs for 4-6 hours or as tolerated 7 times a week. During a review of Resident 6's Documentation Survey Report for RNA intervention/task dated July 2024, the RNA report indicated Resident 6 completed 15 minutes of PROM 7 days a week. The RNA report did not indicate when Resident 6 did or did not wear the right knee splint or AFOs. During a review of Resident 6's Documentation Survey Report for RNA intervention/task dated August 2024, the RNA report indicated Resident 6 completed 15 minutes of PROM 7 days a week. The RNA report did not indicate when Resident 6 did or did not wear the right knee splint or AFOs. During a review of Resident 6's Restorative Nursing Weekly Summary - Splint Care dated 8/16/24, the Splint Care Weekly Summary indicated Resident 6 had right knee splint and both AFO with a wearing schedule of four to six hours in AM. The Splint Care Weekly Summary indicated not applicable to questions in other, refuses to wear, resident takes off, and indicated no for change of condition. During a review of Resident 6's Physical Therapy Joint Mobility Screening (PT JMS) dated 8/21/24, the PT JMS indicated Resident 6 had severe ROM loss (more than 50 percent (%) loss) in both hips and in the right knee, minimal ROM loss (less than 25% loss) in both ankles. The PT JMS indicated Resident 6 had minimal to severe loss of lower extremity passive ROM, and chart review indicated Resident 6 had a diagnosis or condition that put him at risk for contracture development. The recommendation was to continue RNA program. During a concurrent observation and interview on 8/22/24 at 9:24 AM with Restorative Nursing Aide (RNA 1) of Resident 6's RNA treatment session in Resident 6's room, RNA 1 stated Resident 6 had an RNA order for AAROM for BUE and PROM for BLE and a right knee splint and both AFOs. RNA 1 removed a white hand mitten from Resident 6's right hand and started to bend and straighten Resident 6's right knee. Resident 6's right knee was in a fully bent position and RNA 1 could straighten the right knee a little. RNA 1 moved the right leg outward and in towards the body, and ankle away and towards the body. RNA 1 was able to move the ankles a little. RNA 1 stated Resident 6 had pain with moving lower extremity so RNA 1 would try the upper extremity. RNA 1 attempted to straighten right elbow which were in bent position. RNA 1 stated Resident 6 was resisting, stopped the RNA treatment, left the room, and reported to Licensed Vocational Nurse (LVN 5). RNA 1 returned to Resident 6's room and stated RNA 1 would put on the AFOs. RNA 1 attempted to move left arm up, stated Resident 6 was resistive and stopped. RNA 1 retrieved both AFOs from cabinet and put on both ankles/feet. RNA 1 retrieved a blue right knee splint, attempted to straighten the right knee, stated Resident 6 was resisting and did not put right knee splint on. LVN 5 entered the room and RNA 1 reported to LVN 5 that Resident 6 could not put on the right knee splint. RNA 1 stated Resident 6 was able to wear the right knee splint yesterday for about four to six hours, but usually Resident 6 could not wear the knee splint about four times a week. During a concurrent interview and record review on 8/22/24 at 9:52 AM, RNA 1 stated on 8/18/24 Resident 6 did not tolerate the right knee splint. RNA 1 reviewed RNA daily task documentation on 8/18/24 and stated no, he did not document that Resident 6 did not tolerate the right knee splint. RNA 1 stated he did not report this to the charge nurse. RNA 1 stated Resident 6 had not been tolerating the right knee splint about three to four times a week for many weeks but could not remember for how long. RNA 1 stated he should have documented and reported to nursing and rehabilitation department whenever Resident 6 did not tolerate any part of the RNA treatment, including when Resident 6 was resisting range of motion and ROM could not be completed or could not wear the right knee splint. During an interview on 8/22/24 at 11:43 AM, LVN 5 stated today was the first time that RNA 1 reported that Resident 6 did not tolerate the ROM exercises or did not wear the right knee splint. During an interview and record review on 8/22/24 at 1:52 PM with Physical Therapist (PT 1), the PT DC Summary dated 5/9/24 was reviewed. PT 1 stated the PT recommended an RNA program for BLE PROM followed by putting on right knee splint and both AFOs for 4-6 hours. PT 1 stated PTs recommend RNA program for PROM and splinting to help stretch the muscle and prevent further contractures. PT 1 stated contractures can limit a person's mobility, for example a contracture can prevent you from sitting, transferring to a shower chair, and moving around in bed. PT 1 stated when an RNA program was created, it was the expectation that the RNAs follow the whole RNA program, because the RNA program was established specifically for Resident 6 to help prevent contractures. PT 1 stated today was the first time PT 1 was aware that Resident 6 could not tolerate the right knee splint. PT 1 stated it was important for RNA to report if Resident 6 could not tolerate any part of the RNA program because PT could assess and complete an PT evaluation if needed and to assess of the current RNA program and knee splint was still appropriate for Resident 6. During an interview and record review on 8/22/24 at 2:36 PM with Registered Nurse (RN 1) and Registered Nurse (RN 5), Resident 6's clinical records were reviewed. RN 1 and RN 5 stated they were both the RN supervisors for Resident 6. RN 1 and RN 5 reviewed Resident 6's orders and stated Resident 6 had an RNA order for AAROM BUE, PROM BLE, R knee splint and both AFOs for 4-6 hours or as tolerated 7 days a week. RN 1 and RN 5 stated the RNA should be completing the whole RNA treatment order and that if Resident 6 could not complete any part of the order, then the RNA should report that to nursing and rehab dept. RN 1 and RN 5 stated they had not received any reports from RNA or nursing that Resident 6 could not tolerate any part of the RNA program in the last three months. RN 1 and RN 5 stated if Resident 6 could not tolerate any part of the RNA program, then the RNAs should document that the resident could not tolerate the RNA treatment. After a review of Resident 6's RNA documentation, RN 1 and RN 5 stated the RNAs did not document that Resident 6 did not tolerate any part of the RNA program. RN 1 and RN 5 stated the RNAs should report the first time Resident 6 did not tolerate the splint and that it was important to report, because it was a change of condition and because Resident 6 could get worse. RN 1 and RN 5 stated if nursing was aware, then they could complete a change of condition report, inform the physician, and get orders or referrals as needed, so that the facility can start to intervene, so it did not get worse. During an interview on 8/22/24 at 2:56 PM, the Certified Nursing Assistant (CNA 1) he was a regular CNA for Resident 6. CNA 1 stated sometimes Resident 6 had a right knee splint and sometimes Resident 6 did not. CNA 1 stated Resident 6 did not wear a right knee splint every day. During an interview on 8/22/24 at 4:41 PM, the Director of Nursing (DON) stated the RNA program was a restorative nursing program to help make sure the mobility of residents was maintained. DON stated if the RNAs were not following the RNA order, then there was a risk of decline in function for the residents. DON stated it was important for RNAs to notify nursing so that they could notify the physician and rehab dept so that the facility could further assess and intervene. During a review of the facility's policy and procedure titled, Restorative Nursing Program, last reviewed 4/17/24, the P&P indicated the purpose of the RNA program was to maintain residents functional ability and to reduce further decline. The P&P also indicated weekly assessments are to be made of the resident's progress in the RNP by the restorative nurse and documented in the resident's medical record. Any change in the resident's condition or response to treatment is reported to nursing and documented in the medical record. 2. During a review of Resident 125's AR dated 8/22/24 indicated Resident 125 initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to acute and chronic respiratory failure, acquired absence of right leg above knee, acquired absence of left leg above knee, hemiplegia (weakness to one side of the body) affecting left nondominant side. During a review of Resident 125's MDS dated [DATE], the MDS indicated Resident 125 was severely impaired in cognitive skills for daily decision making. The MDS indicated Resident 125 had functional limitations in ROM impairments on BUE and BLE. The MDS also indicated Resident 125 required dependent assistance with oral hygiene, dressing, toileting hygiene, and bathing. During a review of Resident 125's Order Summary Report dated 8/1/24, the Order Summary Report indicated an order dated 4/11/24 for RNA/Nursing program for PROM for BUE and BLE as tolerated followed by both hand rolls, both AFOs, and left elbow splint for 4-6 hours or as tolerated, once a day, 7 times a week. During a review of Resident 125's care plan dated 4/11/24, the care plan indicated Resident 125 had limitations in range of motion and contractures. The care plan goal was to minimize complications related to decreased mobility or contractures through appropriate interventions through the next assessment. The care plan interventions indicated restorative nursing for PROM for BUE and BLE, splinting with both hand rolls, and left elbow splint for 4-6 hours or as tolerated 7 times a week, with orthotic application and skin integrity management for BUE. During a review of Resident 125's Occupational Therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Discharge Summary (OT DC) dated 4/11/24, the OT DC indicated Resident 125 had ROM limitations in both shoulders and both elbows/forearms. The OT DC indicated a recommendation for RNA to facilitate resident maintaining current level of performance to prevent decline for splint care and PROM. During a review of Resident 125's Documentation Survey Report for RNA intervention/task dated July 2024, the RNA report indicated Resident 125 put on a splint every day (except 7/6/24) for either 4 or 6 hours. The RNA report did not indicate what splint was put on (left elbow splint or right or left hand rolls and time each splint was worn). The RNA report did not indicate if Resident 125 completed PROM exercises for BUE or BLE. During a review of Resident 125's Documentation Survey Report for RNA intervention/task dated August 2024, the RNA report indicated Resident 125 put on a splint every day (except 8/15/24) for either 2,4, or 6 hours. The RNA report did not indicate what splint was put on (left elbow splint or right or left hand rolls and time each splint was worn). The RNA report did not indicate if Resident 125 completed PROM exercises for BUE or BLE. During a review of Resident 125's Restorative Nursing Weekly Summary - Splint Care dated 5/5/24, the RNA Weekly Summary indicated Yes to splint, hand roll, and brace on right and left hand/arm splint and right and left leg. The RNA Weekly Summary indicated a wearing schedule of 6 hours in AM and no change of condition. The RNA Weekly Summary also indicated resident will continue with RNA orders. During a review of Resident 125's Restorative Nursing Weekly Summary - Splint Care indicated there were no other RNA Splint Care Weekly Summaries completed after 5/5/24. During a review of Resident 125's Occupational Therapy Joint Mobility Screening (OT JMS) dated 7/24/24, the OT JMS indicated Resident 125 had minimal passive ROM loss (less than 25% loss) on both wrists, minimal loss on both hands/fingers, minimal loss on right elbow, moderate loss (less than 50% loss) on left elbow, and moderate loss on both shoulders. The OT JMS indicated Resident 125 had minimal to severe loss of UE PROM and chart review indicated Resident 125 had a diagnosis/condition that puts him at risk for contracture development. During an observation on 8/20/24 at 11:37 AM in Resident 125's room, Resident 125 was asleep, and the left elbow was bent more than halfway. Resident 125 did not have any splints or hand rolls on the LUE. Resident 125 had above knee amputations on both legs. During an observation on 8/20/24 at 1:55 PM in Resident 125's room, Resident 125 was awake and able to move the right arm to grab the upper side rail on the right side. Resident 125's left elbow was bent more than halfway and left hand was relaxed and resting on the body. Resident 125 did not have any hand rolls or elbow splints on BUE. During an observation on 8/21/24 at 8:30 AM in Resident 125's room, Resident 125 was awake, and the left elbow was bent more than halfway, the left wrist was slightly bent and the left fingers were straight. Resident 125 did not have any splints or hand rolls on BUE. During an observation on 8/21/24 at 11:03 AM in Resident 125's room, Resident 125 was awake, and the left elbow was bent more than halfway, left wrist slightly bent and left hands were relaxed. Resident 125 did not have any splints or hand rolls on BUE. During an observation on 8/21/24 at 1:52 PM in Resident 125's room, Resident 125 was awake, and the left elbow was bent fully, left wrist slightly bent and left fingers were straight. Resident 125 did not have any splints or hand rolls on BUE. During an observation and interview on 8/22/24 at 8:13 AM with Restorative Nursing Aide (RNA 2) of Resident 125's RNA treatment session in Resident 125's room, RNA 2 bent and straightened Resident 125's left elbow. RNA 2 was able to straighten the left elbow to about halfway. RNA 2 completed PROM to both UE and lifted both amputated legs up and down. RNA 2 completed the PROM exercises and did not put on any splints or hand rolls on Resident 125 during the RNA treatment session. During an interview and record review on 8/22/24 at 8:32 AM with RNA 2, RNA 2 stated he worked with Resident 125 a lot because they were assigned certain stations and residents. RNA 2 stated he performed PROM with Resident 125 everyday and RNA 2 stated he did not think Resident 125 had any splints because Resident 125's hands were not contracted. RNA 2 reviewed Resident 125's RNA orders and RNA documentation and stated Resident 125 had an RNA order for PROM for BUE and BLE followed by both hand rolls and left elbow splint for 4-6 hours as tolerated seven times a week. RNA 2 stated he was not putting hand rolls of left elbow splint on Resident 125, because he thought Resident 125 graduated from that. RNA 2 stated he informed the DOR. RNA 2 confirmed Resident 125 had an order to put on a left elbow splint and both hand rolls and that Resident 125 should wear the elbow splint and hand rolls. RNA 2 confirmed the RNA daily documentation indicated that RNA 2 was putting on the splint every day. RNA 2 stated that he should have put N/A if he was not putting on the elbow splint or hand rolls. RNA 2 stated he should have documented whenever he reported to nursing and DOR that Resident 125 did not put on elbow splint and hand rolls. RNA 2 reviewed the RNA weekly summaries for splint care and confirmed the last one completed was 5/5/24. RNA 2 stated he never put on any UE splints for Resident 125. RNA 2 stated it was only for the BLE but Resident 125 had an amputation, so he stopped putting on the LE splints for Resident 125. RNA 2 confirmed he continued to document in RNA daily task that he spent 15 min putting on splints and that Resident 125 tolerated the splints for 4 or 6 hours. RNA 2 stated that the documentation was not accurate and did not reflect what RNA 2 completed with Resident 125 during RNA treatment. During an interview and record review on 8/22/24 at 10:57 AM, Registered Nurse (RN 4) stated the purpose of the RNA program was for RNAs to perform ROM and put splints on the residents in order to prevent contractures. RN 4 stated the RNAs should follow and complete the orders for RNA program for each resident. RN 4 stated if the resident could not tolerate any part of the order due to pain, then the RNA should notify the charge nurse or RN supervisor to inform nursing that the resident was in pain. RN 4 stated that if the resident could not put on a splint for any reason as ordered, then the RNA should report it so it could be documented. RN 4 stated she was not aware that Resident 125 was not wearing the splints or hand rolls. RN 4 stated the RNA documentation should reflect that Resident 125 was not wearing the elbow splint or hand rolls. RN 4 reviewed the RNA documentation in August 2024 and stated the RNA documentation indicated Resident 125 was wearing the splint every day. RN 4 stated it was important to document correctly to show if the resident was getting worse or better and to show what actually happened. RN 4 stated RNAs should be documenting N/A if they were not putting on the splints or hand rolls. During an interview on 8/22/24 at 3:32 PM, the DOR stated he was not aware that Resident 125 was not wearing the left elbow splint or hand rolls. DOR stated the RNAs should have been putting on the left elbow splint and both hand rolls because that was the RNA order. DOR stated the RNAs should be reporting to their nursing supervisor if they were not putting on the splints and hand rolls and should not be a decision that RNA could make to not put on the splint. During an interview on 8/22/24 at 4:27 PM, DON stated RNAs should be following the RNA orders and that if Resident 125 was not tolerating or completing any part of the RNA order, then the RNA should report it. DON stated the RNA documentation was not accurate since May 2024 since the RNAs were not putting on the splints and hand rolls. DON stated the RNAs need to communicate and report to nursing who can then report to the physician and therapy or complete a change of condition to assess so that the facility can intervene and do something about it. During a review of the facility's policy and procedure titled, Restorative Nursing Program, last reviewed 4/17/24, the P&P indicated the purpose of the RNA program was to maintain residents functional ability and to reduce further decline. The P&P also indicated weekly assessments are to be made of the resident's progress in the RNP by the restorative nurse and documented in the resident's medical record. Any change in the resident's condition or response to treatment is reported to nursing and documented in the medical record. 3. During a review of Resident 138's AR dated 8/22/24, the AR indicated Resident 138 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to chronic respiratory failure, intracerebral hemorrhage (bleeding in the brain). During a review of Resident 138's MDS dated [DATE], the MDS indicated Resident 138 was severely impaired in cognitive skills for daily decision making. The MDS indicated Resident 138 required dependent assistance with dressing, oral hygiene, toileting hygiene, and bathing. The MDS also indicated Resident 138 had functional limitations in range of motion impairments on BUE and BLE. During a review of Resident 138's Order Summary Report dated 8/1/24, the Order Summary Report indicated an order dated 7/1/24 for RNA/Nursing Program for active range of motion (AROM, movement at a given joint when the person moves voluntarily) or AAROM for BUE and BLE as tolerated followed by sitting at edge of bed as tolerated followed by left resting hand splint, left elbow extension splint, and right hand roll for 4-6 hours or as tolerated, once a day, seven times a week. During a review of Resident 138's care plan dated 7/1/24, the care plan indicated Resident 138 had limitations in range of motion and contractures. The care plan goal was to minimize complications related to decreased mobility or contractures through appropriate interventions through the next assessment. The care plan interventions indicated restorative nursing for AAROM to BUE and BLE, left resting hand splint, left elbow extension splint and right hand roll for 4-6 hours or as tolerated seven times a week, and orthotic application and skin integrity management, and sitting at edge of bed as tolerated. During a review of Resident 138's OT JMS dated 7/1/24, the OT JMS indicated Resident 138 had full range of motion in right wrist, right hand/fingers, and right elbow and minimal ROM loss in left wrist. The OT JMS also indicated Resident 138 had moderate ROM loss in left elbow and left hand/fingers. The OT JMS indicated chart review indicated Resident 138 had a diagnosis or condition that put him at risk for contracture development and RNA training was completed with 100% return demonstration. During a review of Resident 138's Documentation Survey Report for RNA intervention/task dated August 2024, the RNA report indicated Resident 138 tolerated a splint for 4 hours on 8/16/24, 8/17/24, 8/18/24, 8/19/24, 8/20/24, and 8/21/24. The RNA report did not indicate if which splint was put on for 4 hours, if ROM exercises were completed, or if sitting edge of bed activity was completed. During a review of Resident 138's Restorative Weekly Summary - Splint Care dated 8/19/24, the RNA Weekly Summary indicated no for splint, yes for hand roll, not applicable for hand/arm splint with a wearing schedule of 4-6 hours in AM. The RNA Weekly Summary indicated no for refuses to wear, no for resident takes off, no for change of condition, no for charge nurse notified. During an observation and interview on 8/20/24 at 1:55 PM in Resident 138's room, Resident 138 was lying in bed. Resident 138's left and right elbows were bent and the left hand was in a fisted position. Resident 138 did not have any splints or hand rolls. Resident 138 stated he did not receive any splints for the hand today. During an observation and interview on 8/21/24 at 11:03 AM in Resident 138's room, Resident 138 stated he received exercises today, but did not have a hand roll or any splints. Resident 138 was using his left hand to hold a tablet. During an observation and interview on 8/21/24 at 1:52 PM in Resident 138's room, Resident 138 stated he used to wear a left elbow splint, but they stopped putting it on. Resident 138 proceeded to use his right arm to grab his left wrist and attempted to straighten his left arm but could not fully straighten the left elbow. Resident 138 stated he used to have a hand roll for the left hand, but it got lost and he never received another one. Resident 138 was able to open the left hand and straighten the left fingers. Resident 138 stated he received his exercises but not the splints or hand rolls. During an interview and record review on 8/22/24 at 8:32 AM, RNA 2 stated he performed AAROM for BUE and BLE and sitting edge of bed with Resident 138. RNA 2 stated sometimes he put on the hand roll and left elbow splint and sometimes Resident 138 wore the splint and hand roll for 1-2 hours. RNA 2 stated if Resident 138 only wore left elbow splint and hand roll for 1-2 hours, then he should document it. RNA 2 stated if Resident 138 did not wear the splints or hand roll, then he should document that Resident 138 did not wear the splints. RNA 2 reviewed the August RNA treatment record and stated the August RNA documentation showed Resident 138 wore the splints every day for 4 hours. RNA 2 stated it was not documented that Resident 138 only wore the left elbow splint and hand roll for 1-2 hours. RNA 2 stated there was no place to document if Resident 138 completed ROM or sat edge of bed. RNA 2 stated Resident 138 did not complete sitting edge of bed exercises every day, but there was nowhere to document that. During an interview and record review on 8/22/24 at 11:15 AM, RN 4 stated she was not aware of Resident 138 not wearing or tolerating the elbow splint or hand rolls. RN 4 stated she did not see Resident 138 wearing an elbow splint or hand splints. RN 4 stated Resident 138 was alert and oriented and was able to tell you if he put on an elbow splint, hand splint, or hand rolls. RN 4 reviewed Resident 138's RNA daily documentation in August 2024 and stated the RNA documentation indicated the resident was wearing the splints for 4 hours on 8/21/24. RN 4 stated if Resident 138 was wearing the splint for only 1 hour, then the documentation should indicate the resident wore it for 1 hour and not 4 hours. RN 4 stated the RNA documentation was not accurate. RN 4 stated the documentation should be accurate because we would think Resident 138 was wearing the splint for 4 hours, but in reality, he was only wearing it for 1 hour so we are not getting accurate information for assessments and to make decisions on his care. During an interview on 8/22/24 at 4:35 PM, DON stated RNA program was a restorative nursing program to help make sure the mobility of residents was maintained. DON stated if the RNAs were not following the RNA order, then there was a risk of decline in function for the residents. DON stated it was important for RNAs to notify nursing so that they could notify the physician and rehab dept so that the facility could further assess and intervene. DON stated the RNA documentation for Resident 138 was not accurate and RNAs should not put 4 hours if the RNA was not putting on the splints or only putting on splints for 1 hour. DON stated the RNA should report to nursing anytime they were not following the RNA order for any reason. DON also stated there was nowhere in the RNA documentation to document if the resident completed the edge of bed exercises or ROM, it only indicated if the resident put on the splint and for how long. During a review of the facility's policy and procedure titled, Restorative Nursing Program, last reviewed 4/17/24, the P&P indicated the purpose of the RNA program was to maintain residents functional ability and to reduce further decline. The P&P also indicated weekly assessments are to be made of the resident's progress in the RNP by the restorative nurse and documented in the resident's medical record. Any change in the resident's condition or response to treatment is reported to nursing and documented in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident's environment was free of accident hazards for four out of four sampled residents (Residents 74, 73, 30, and 19) by failing to ensure: 1. Resident 74's oxygen concentrator (a medical device that separates nitrogen from the air so that 95% of pure oxygen can be breathed in) was not placed on top of the fall mat (safety features that are placed on the floor along the side of the bed in the home or next to a hospital bed). The deficient practice lessened the effectiveness of the fall mat to prevent falls with injury by placing a heavy equipment and furniture on top of the fall mat, decreasing its effectiveness to lessen the impact of a fall due to permanent dented mat surface and potential of the residents hitting the hard surfaces of the heavy equipment and furniture. 2. Resident 73's low bed (a bed less than a foot from the floor) was placed at the lowest position after performing resident care. The deficient practice of not keeping the bed in its lowest position placed the resident at risk for falls resulting in injuries, and even death. 3. Resident 30's long pull cord for the resident's tab alarm (fall management device system that enables reliable monitoring of individuals at risk of falls, whether in a bed, wheelchair, or the restroom) was not long enough to entangle and choke the resident. This deficient practice had the potential to result in resident sustaining injury caused by the length of the string attached to the resident with a with a clip from the tab alarm device. 4. Resident 19's one open tube of hydrocortisone cream (a topical medication used to treat skin conditions such as itching and swelling) one percent (%, a unit of measurement) and one tube of petroleum jelly (a topical ointment used to treat or prevent minor skin irritations) were not left unattended and readily available at the resident's bedside. This deficient practice had the potential to result in residents self-administering medications without staff knowledge resulting in overdose, poisoning from ingestion, or a delay in care and services. Findings: 1. During a review of Resident 74's admission Record, the admission Record indicated the facility admitted the resident on 5/11/2024, and readmitted the resident on 5/23/2024, with diagnoses including tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow air to fill the lungs), dementia (a range of neurological conditions affecting the brain that worsens over time), and transient ischemic attack (TIA, a stroke that lasts only a few minutes). During a review of Resident 74's History and Physical (H&P), dated 5/23/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 74's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/18/2024, the MDS indicated the resident rarely to never had the ability to make-self understood and sometimes understand others. The MDS indicated the resident was dependent on mobility and activities of daily living (ADLs, all the essential, basic self-care tasks that people need to do every day to keep themselves safe, healthy, clean, and feeling good). During a review of Resident 74's Order Summary Report indicated the following orders: -7/10/2024 Frequent visual monitoring due to high risk for fall and injury. Document every shift. -6/20/2024 Low bed with floor mat to decrease potential injury. (informed consent obtained from resident representative [RP] after explanation of risks and benefits and verified with MD). Ensure equipment is in place and functioning well. Every shift. During a review of Resident 74's Fall Risk Assessment, dated 8/20/2024, the assessment indicated the resident was high risk for falls. During a review of Resident 74's Care Plan (CP) titled, Resident is at risk for falls/injury related to cerebrovascular accident (CVA, an interruption in the flow of blood to cells in the brain)/TIA, dementia, difficulty walking, generalized weakness, impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life), impaired vision, poor body balance/control, poor safety awareness/judgment, use of medications such as (antihypertensive [medications that lower blood pressure], psychotropic [medications that affect the mind, emotions, and behavior], hypoglycemic agents [medications that lower blood sugar]), initiated on 5/18/2024, the CP indicated an intervention to provide resident with a safe and clutter-free environment. During a concurrent observation and interview on 8/20/2024, at 12 p.m., with the Director of Nursing (DON), inside Resident 74's room, observed the bilateral fall mats of the resident with oxygen concentrators on top of them . The DON stated there should be no heavy equipment or furniture on top of the fall mats to prevent denting them permanently, lessening the effectiveness of the mat to lessen the impact of the fall. The DON further stated placing the heavy equipment and furniture on top of the fall mat can cause injury to the resident as they could land on the hard and sharp surfaces of the equipment and furniture resulting in injuries or even death. During a review of the facility's recent policy and procedure (P&P) titled, Accident/Incident Prevention, last reviewed on 4/17/2024, the P&P indicated this facility strives to prevent accidents by providing an environment that is free from accident hazards over which the facility has control, as well as identification of each resident at risk for accidents/incidents and the provision of adequate care plans with procedures to prevent accidents. 2. During a review of Resident 73's admission Record, the admission Record indicated the facility admitted the resident on 4/5/2017, and readmitted the resident on 5/2/022, with diagnoses including epilepsy (a disorder of the brain characterized by repeated seizures), hemiplegia (one-sided muscle paralysis or weakness), and hemiparesis (one-sided muscle weakness), and nontraumatic intracerebral hemorrhage (bleeding in the brain that occurs without trauma or surgery). During a review of Resident 73's H&P, dated 5/4/2024, the H&P indicated the resident is incapacitated resident requires visit for safety. During a review of Resident 73's MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS also indicated the resident had highly impaired vision and was dependent on mobility and activities of daily living (ADLs). During a review of Resident 73's Order Summary Report, dated 7/10/2024, the report indicated an order for Falling Star Program (a patient assessment program that identifies residents who are at high risk for falling). Frequent visual monitoring due to high risk for fall and injury. Document every shift. During a review of Resident 73's Fall Risk Assessment, dated 7/12/2024, the assessment indicated the resident was high risk for falls. During a review of Resident 74's Care Plan (CP) titled, Falling Star Program. At risk for falls related to antihypertensive medications, balance deficit, bladder/bowel dysfunction(s), cognitive impairment, decreased strength/endurance, seizure disorder, initiated on 7/10/2024, the CP indicated an intervention to provide low bed if indicated. During a concurrent observation and interview on 8/20/2024, at 11:07 a.m., with Certified Nursing Assistant 3 (CNA 3), inside Resident 74's room, observed the resident's bed left in the high position. CNA 3 measured the height of the bed using a tape measure and the bed was 31 inches off the floor. CNA 3 stated the bed was too high and should be placed at the lowest position after providing resident care to prevent falls that can result to injuries. During an interview on 8/23/2024, at 7:10 p.m., with the DON, the DON stated the beds should be left at the lowest position when not providing care to residents to prevent falls resulting in injuries and possibly death. During a review of the facility's recent policy and procedure (P&P) titled, Accident/Incident Prevention, last reviewed on 4/17/2024, the P&P indicated this facility strives to prevent accidents by providing an environment that is free from accident hazards over which the facility has control, as well as identification of each resident at risk for accidents/incidents and the provision of adequate care plans with procedures to prevent accidents. During a review of the facility provided Bed Frame 1 (BF 1) manual, copyright 2021, it indicated under safety bed positions to make sure the bed is in the low position when the patient is unattended. This may help reduce the possibility of patient falls and the severity of any resultant injuries. 4. During a review of Resident 19's admission Record, the admission Record indicated the facility admitted the resident on 6/24/2024 with diagnoses that included unspecified fracture (break in the bone) of the lower right end of the right femur (upper bone of the leg), cognitive (mental action or process of acquiring knowledge and understanding) communication deficit (lack thereof), and unspecified dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). During a review of Resident 19's Minimum Data Set (MDS - an assessment and care screening tool) dated 7/1/2024, the MDS indicated the resident required substantial/maximal assistance with toileting and dressing; and required supervision with oral and personal hygiene. During a review of Resident 19's History and Physical (H&P) dated 6/24/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 19's Self-Administration of Drugs Assessment form, dated 6/24/2024, the form indicated the interdisciplinary team determined that it was not safe for the resident to self-administer drugs due to physical/functional impairment secondary to multiple diagnosis. During a concurrent observation and interview on 8/20/2024 at 9:34 a.m., observed Resident 19 lying in bed, observed an open container of hydrocortisone 1 % cream and one open container of petroleum jelly on the resident's rolling bedside table, no staff were present. Resident 19 stated she applies both medications on her lips every now and then. During an observation on 8/20/2024 at 9:41 a.m., observed Restorative Nursing Assistant 3 (RNA 3) enter Resident 19's room, speak with resident, and then exit the room. Observed the hydrocortisone cream and petroleum jelly remained visible on the bedside table. During a concurrent observation and interview on 8/20/2024 at 10:06 a.m., observed Certified Nursing Assistant 2 (CNA 2) stood in Resident 19's doorway and stated there were two ointments on the resident's nightstand. CNA 2 stated Resident 19 likes to have the ointments on her bedside table to use for her lips. CNA 2 stated Resident 19 applies the ointments herself. Observed CNA 2 walked away from Resident 19's room and the hydrocortisone and petroleum jelly remained at bedside. During a concurrent interview and record review on 8/22/2024 at 11:57 a.m., Licensed Vocational Nurse 8 (LVN 8) reviewed Resident 19's physician orders. LVN 8 stated residents should not have medications left at bedside because staff would not know if the resident needed or used the medication. LVN 8 stated all medications require physician orders that indicates the dosage, route, frequency, and reason for the medication. LVN 8 stated Resident 19 did not have an order for hydrocortisone or petroleum jelly. LVN 8 stated Resident 19 should not have hydrocortisone left at bedside, but she can have petroleum jelly for her lips. LVN 8 stated the CNA should have known to remove the hydrocortisone from Resident 19's bedside because there was a chance the resident would overuse the medication and there was a potential for other residents to get the medication. During an interview on 8/23/2024 at 1:33 p.m., with the Assistant Director of Nursing (ADON), the ADON stated Resident 19 was not safe for self-administration of medication and hydrocortisone and petroleum jelly should not be left at bedside. The ADON stated anything applied topically to the resident required an order. The ADON stated a physician's order is required for self-administration, and Resident 19 did not have an order self-administration. The ADON stated when medications are left at bedside there is a potential that other residents may ingest the medication causing them harm. During a review of the facility policy and procedure (P&P) titled, Administering Medications, last reviewed 4/17/2024, the P&P indicated medications are administered in a safe manner. Residents may self-administer their own medication only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. During a review of the facility policy and procedure (P&P) titled, Self-Administration of Medications, last reviewed 4/17/2024, the P&P indicated residents who desire to self-administer medications are permitted to do so if the facilities interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility. All nurses and aides are required to report to the charge nurse on duty any medications found at bedside not authorized for bedside storage and to give unauthorized medications to the charge nurse for return to the family or responsible party. During a review of the facility policy and procedure (P&P) titled, Accident/Incident Prevention, last reviewed 4/17/2024, the (P&P) indicated the facility strives to prevent accidents by providing an environment that is free from accident hazards over which the facility has control, as well as identification of each resident at risk for accidents/incidents and the provision of adequate care plans with procedures to prevent accidents. 3. During a review of Resident 30's admission Record, the admission Record indicated the facility admitted the resident on 6/6/2014 and readmitted the resident on 6/4/2024 with diagnoses including but not limited to dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), adult failure to thrive (a condition that happens when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal), and gastrostomy status (a surgical procedure used to insert a tube, through the abdomen and into the stomach to provide a route for tube feeding. During a review of Resident 30's History and Physical (H&P) dated 6/5/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 30's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/13/2024, the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and require total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 30 had a bed alarm. During a review of Resident 30's Order Summary Report dated 6/4/2024 indicated: [Non-restraint] Tab alarm when in bed and wheelchair/gerichair to alert/remind resident to ask for assistance when transferring or ambulating. (Informed consent obtained by physician from responsible party after explanation of risks and benefits and verified with physician). Ensure equipment is in place and functioning properly every shift. During a Resident 30's care plan (CP), the CP on tab alarm, last revised on 7/22/2024 with target date 10/18/2024, indicated when in wheelchair/bed/gerichair to alert/remind the resident to ask for assistance when transferring or ambulating and to monitor the alarm for good working condition and proper placement as needed as one of the interventions. During a review of Resident 30's fall risk assessments dated 4/13/2024, 6/4/2024, and 7/22/2024, the assessments indicated the resident is a high risk for falls. During a concurrent observation and interview on 8/21/2024 at 12:36 p.m. inside Resident 30's room with Licensed Vocational Nurse 3 (LVN 3), observed the resident in bed using a tab alarm. attached to the left upper siderail with a strap with the long pull cord attached to the resident's clothing secured by a clip. LVN 3 stated the long pull cord was long enough and can potentially cause injury to the resident by getting wrapped around the neck or arm of the resident resulting in an injury such as entanglement or choking. LVN 3 verified the current length of the cord did not activate the tab alarm even when the resident was moving a lot in bed. LVN 3 stated the pull cord should be short enough to prevent any injury and for the pull cord to detach from the tab alarm to alert the staff and the resident. During an interview on 8/23/2024 at 7:40 p.m., with the Director of Nursing (DON), the DON stated the tab alarm should be at a length that will activate the alarm by detaching the sensor from the sensor area when the resident moves to ensure resident safety. The DON stated the long pull cord could potentially wrap around any part of the resident's arm or neck causing injury resulting from entanglement or choking. During a review of the facility's policy and procedure (H&P) titled, Accident/Incident Prevention, last reviewed on 4/17/2024, the H&P indicated the facility strives to prevent accidents by providing an environment that is free from accident hazards over which the facility has control, as well as identification of each resident at risk for accidents/incidents and the provision of adequate care plans with procedures to prevent accidents. During a review of the facility provided manufacturer's guideline for Medical Equipment 1 (ME 1), undated, it indicated the alarm improves patient safety by alerting caregivers when a patient attempts to get out of a wheelchair or bed without assistance. The manufacturer's guideline indicated: - Be sure that the long pull cord cannot entangle or choke the user. Use the pull cord adjuster to adjust the length of the pull cord. - A pull on the cord from any direction will cause the magnetic sensor to release from the sensor area therefore sounding the alarm. - Long pull cord can entangle the patient and be potentially dangerous. Use with care and supervision.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 158's admission Record, the admission Record indicated the facility admitted the resident on 6/28/2024, with diagnoses including sepsis (a serious condition in which the body responds improperly to an infection), acute kidney failure (a sudden and often reversible reduction in kidney function), and artificial opening of urinary tract (a urostomy is a stoma, or opening, in the abdomen that connects the urinary tract to allow urine to drain freely from the body). During a review of Resident 158's History and Physical (H&P), dated 6/28/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 158's Order Summary Report, dated 6/29/2024, the report indicated an order for catheter, secure suprapubic catheter tubing (a thin, flexible rubber or plastic tube that healthcare providers use to drain urine from the urinary bladder when unable to urinate) with anchor every day shift (to minimize dislodging of catheter). During a review of Resident 158's Care Plan (CP) titled, Alteration in urinary elimination and at risk for UTI secondary to use of Foley Catheter (suprapubic cath) and nephrostomy tubes due to obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow), history of prostate abscess (a localized collection of purulent fluid within the prostate) status post (s/p) transurethral resection of the prostate (TURP, a surgical procedure that removes part of the prostate gland), initiated on 7/6/2024, the CP indicated an intervention of Foley catheter care (keeping the catheter and the area around it clean to prevent infection) every (q) shift or as needed. Maintain proper alignment of foley catheter to promote proper drainage. During a concurrent observation and interview on 8/20/2024, at 11:07 a.m., with Certified Nursing Assistant 3 (CNA 3), inside Resident 158's room, observed the suprapubic catheter of the resident without a securement device or anchor. CNA 3 stated the suprapubic catheter should have a securement device/anchor to prevent pulling out the tube causing trauma and possibly infection. During an interview on 8/23/2024, at 7:10 p.m., with the Director of Nursing (DON), the DON stated the suprapubic catheter should have a securement device or an anchor to prevent pulling of the nephrostomy tube that can cause trauma and bleeding to the site resulting in an infection. During a review of the facility's recent policy (P&P) and procedure titled, Male Catheterization, last reviewed on 4/17/2024, the P&P indicated use of Foley catheter anchors is required. During a review of the facility's recent policy and procedure titled, Indwelling (Foley) Catheter Insertion, Male Resident, last reviewed on 4/17/2024, the P&P indicated to secure catheter and/or bag to resident with approved catheter securement device. c. During a review of Resident 150's admission Record indicated the facility admitted the resident on 5/22/2024, with diagnoses including sepsis and urinary tract infection. During a review of Resident 150's H&P, dated 5/23/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 150's MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident was dependent on personal hygiene and had an indwelling catheter (a catheter which is inserted into the bladder, via the urethra and remains in situ to drain urine). During a review of Resident 150's Order Summary Report, dated 5/22/2024, the report indicated an order for [CATHETER] Secure foley catheter tubing with anchor every day shift (to minimize dislodging of catheter). During a review of Resident 150's Interdisciplinary Team (IDT, a group of people from different backgrounds who work together to achieve a common goal)- Catheter Assessment & Care Plan, dated 5/23/2024, it indicated an approach of foley catheter care daily or as ordered. During an observation and interview on 8/20/2024, at 10:27 a.m., with Licensed Vocational Nurse 6 (LVN 6), inside Resident 150's room, observed the urinary catheter not secured with an anchor/securement device. LVN 6 stated the resident's catheter was not secured because the securement device/anchor was worn out. LVN 6 stated not anchoring the urinary catheter with a securement device can cause tugging and pulling of the catheter that can result in trauma and skin tear and infection can set in. During an interview on 8/23/2024, at 7:10 p.m., with the DON, the DON stated the suprapubic catheter should have a securement device or an anchor to prevent pulling of the urinary catheter that can result in trauma and bleeding, and infection. During a review of the facility's recent policy and procedure (P&P) titled, Male Catheterization, last reviewed on 4/17/2024, the P&P indicated use of Foley catheter anchors is required. During a review of the facility's recent policy and procedure titled, Indwelling (Foley) Catheter Insertion, Male Resident, last reviewed on 4/17/2024, the P&P indicated to secure catheter and/or bag to resident with approved catheter securement device. Based on observation, interview, and record review the facility failed to ensure residents with urinary incontinence (loss of bladder control) received appropriate treatment and services to prevent urinary tract infections (UTI, an infection in the urinary system) for three of six sampled residents (Resident 417, 158 and 150) investigated during review of urinary catheters (indwelling catheter/Foley catheter/FC, a flexible tube inserted into the bladder to drain urine into a collection bag) care area by failing to: 1. Ensure an evaluation for the need of the FC was completed prior to the removal of Resident 417's FC for on 8/14/2024. 2. Ensure Treatment Nurse 1 (TN 1) did not remove Resident 417's FC without a physician's order on 8/14/2024. 3. Ensure TN 1 documented the removal of Resident 417's FC on 8/14/2024. 4. Ensure to monitor for urinary retention (a condition that occurs when the bladder is unable to empty urine) after Resident 417's FC was removed on 8/14/2024. 5. Ensure Registered Nurse 8 (RN 8) used sterile technique (the act of ensuring germs do not enter a resident's body during an invasive procedure) to re-insert Resident 417's FC on 8/14/2024. 6. Ensure between 8/15/2024 to 8/21/2024 Resident 417's FC urine output was measured and documented. 7. Place a securement device/anchor on Resident 158's nephrostomy tube (a tube that lets urine drain from the kidney through an opening in the skin on the back). 8. Place a securement device/anchor on the Resident 150's urinary catheter. These deficient practices had the potential for residents to develop catheter associated urinary tract infections (CAUTI, an infection of the urinary tract caused by an indwelling catheter) and resulted in hospitalization of Resident 417 for evaluation of decreased urinary output. Findings: a.1. During a review of Resident 417's admission Record, the admission record indicated the facility admitted the resident on 8/13/2024 and readmitted the resident on 8/22/2024 with diagnoses that included hepatic encephalopathy (a change in your brain function due to injury or disease), acute kidney failure (condition in which the kidneys suddenly cannot filter waste from the blood), and UTI. During a review of Resident 417's admission Assessment, dated 8/13/2024, the assessment indicated the resident had clear communication and required assistance with mobility, personal hygiene/grooming, bathing, oral hygiene, and dressing. The assessment further indicated the resident arrived at the facility with an indwelling catheter on 8/13/2024. During a review of Resident 417's Physician Orders Summary Report, the report indicated orders for the following: -FC French 16 (a unit of measurement for the diameter of the FC) attached to bedside drainage bag due to obstructive uropathy (condition in which the flow of urine is blocked) every shift, dated 8/14/2024. During a review of Resident 417's Baseline Care Plan (CP) for admission dated 8/13/2024, the CP indicated the resident had impaired urinary elimination related to indwelling catheter use with an initial goal that the resident would have reduced risk for UTI. During an observation and interview on 8/20/2024 at 9:58 a.m., observed Resident 417 lying in bed with a FC. Resident 417 stated his FC was removed and reinserted after admission to the facility. During a concurrent interview and record review on 8/22/2024 at 12:22 p.m., TN 1 reviewed Resident 417's physician orders. TN 1 stated Resident 417 was admitted from the General Acute Care Hospital (GACH) on 8/13/2024 with a FC. TN 1 stated in the morning of 8/14/2024 she removed Resident 417's FC because she believed the resident did not need the FC. TN 1 stated she did not have a physician's order to remove Resident 417's FC. TN 1 stated she did not need an order to remove Resident 417's FC. TN 1 stated Resident 417's family member (FM 1) called later in the day on 8/14/2024 and informed that the resident had a history of urinary retention and needed a FC. TN 1 stated Resident 417's FC was reinserted on 8/14/2024 by RN 8. During an interview on 8/22/2024 at 12:38 p.m., the Assistant Director of Nursing (ADON) stated there must be a physician's order to remove a FC prior to the removal. The ADON stated Resident 417 arrived at the facility with a FC and TN 1 should not have removed the FC without a physician's order. The ADON stated Resident 417's FC was removed too soon, and this should not have happened. The ADON stated TN 1 should have clarified the resident's diagnosis and need for the FC with the physician or RN, but she did not. During a follow up interview on 8/22/2024 at 12:39 p.m., TN 1 stated in the past when residents have arrived from the hospital with a FC, she assumed they did not need the FC and removed it. TN 1 stated when she removed Resident 417's FC, she did not know she needed a physician's order to remove the FC. TN 1 stated now she knows that she should not have removed Resident 417's FC without a physician's order. During an interview on 8/22/2024 at 12:52 p.m., with the ADON and TN 1, the ADON stated it was basic nursing knowledge that any resident device or equipment required a physician's order for removal. TN 1 stated when a FC is removed there should be documentation regarding the removal procedure and monitoring for urinary retention. TN 1 stated the importance of monitoring for urinary retention is to re-insert the FC if the resident does not have urinary output. TN 1 stated she did not document that she removed Resident 417's FC and she did not monitor the resident for urinary retention after removing the FC. During an interview on 8/22/2024 at 1:02 p.m., with Registered Nurse 1 (RN 1), RN 1 stated if a resident arrives from the hospital with a FC, the primary physician must be notified to determine if there is a need for the FC and to obtain an order to remove it. RN 1 stated she arrived at work on 8/14/2024 at about 7:30 a.m. and TN 1 notified her that she had removed Resident 417's FC. RN 1 stated she did not assess the resident, monitor for urinary retention, or check for a physician's order to remove the FC. During a review of the facility policy (P&P) and procedure titled, Urinary Continence and Incontinence - Assessment and Management, last reviewed 4/17/2024, the P&P indicated the staff and practitioner will appropriately screen for, and manage, individuals with urinary incontinence. The physician and staff will provide appropriate services and treatment to prevent urinary tract infections to the extent possible. As part of the initial assessments, the nursing staff and physician will screen for information related to urinary continence. Examples of sources of such information may include residents, family, or a hospital discharge summary describing placement of an indwelling urinary catheter during recent hospitalization. If a resident is admitted from the hospital with a newly placed indwelling catheter, the attending physician and staff will evaluate the potential for removing it, depending on the current condition and rationale for its original placement. During a review of the facility procedure titled, Foley Catheter Removal, last reviewed 4/17/2024, the P&P indicated to verify there is a physician order; to chart the date, time, and volume and color of urine; and to observe the resident for urinary retention. During a review of the facility policy and procedure titled, Charting and Documentation, last reviewed 4/17/2024, the P&P indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The following information will be documented in the resident medical record: treatments or services performed. Documentation of procedures and treatments will include care-specific details, including: the date and time the procedure/treatment was provided, the name and title of the individuals who provided care, how the resident tolerated the procedure, and the signature and title of the individual documenting. During a review of the Licensed Vocational Nurse Job Description, approval date 3/7/2024, indicated the LVN's essential job duties and responsibilities include to perform resident treatments in accordance with physician orders and evaluate and document the resident's response to treatments; to contact the physician for required orders; assure that documentation is timely and completed, and to record fluid intake and output for each patient with an indwelling catheter. The job description further indicated to perform the job successfully, an individual should demonstrate the following competencies: exhibit sound and accurate judgement and have the ability to apply common sense understanding to carry out instructions. a.2. During an interview on 8/22/2024 at 2:28 p.m., FM 1 stated Resident 417 is unable to urinate and requires a FC. FM 1 stated the following occurred while in the facility: -On 8/14/2024 Resident 417's FC was removed and then reinserted after FM 1 called the resident's physician. FM 1 stated Resident 417's FC should not have been removed. -On 8/14/2024, RN 8 re-inserted Resident 417's FC, RN 8 did not use sterile gloves (individually packaged in pairs that are treated to ensure they are free from microorganisms) or provide a sterile field (a surface considered to be free from microorganisms). FM 1 stated RN 8 used clean gloves (typically packaged in bulk and used for general purposes) for the FC insertion. -On 8/21/2024, Resident 417 was hospitalized because the facility did not accurately monitor and measure Resident 417's urine output which resulted in the need for an evaluation of Resident 417's kidney (organ that remove waste and extra water from the blood as urine) function. During a concurrent interview and record review on 8/22/2024 at 4:23 p.m., with RN 8 reviewed Resident 417's physician orders, Medication Administration Record dated 8/2024, and Treatment Administration Record dated 8/2024. RN 8 stated she re-inserted Resident 417's FC using only clean gloves obtained from inside Resident 417's room. RN 8 stated sterile gloves should be worn for FC insertion to prevent contamination and to prevent infection. RN 8 stated she knew she should use sterile gloves, but she could not find any. RN 8 stated there should also be a sterile drape place under the resident to provide a sterile field during FC insertion, but she did not use a sterile drape because she did not have one. RN 8 further stated residents with foley catheters should have documented measurements of urine output. RN 8 stated it was important to document urine output to determine if the resident is not producing enough urine or if there is a problem with the FC. RN 8 stated between 8/14/2024 and 8/21/2024 there was no documented evidence of Resident 417's measured urine output. RN 8 stated when a resident does not have documented evidence of measured urine output there is the potential that staff would not know the resident had a change of condition and was retaining urine or that there was a problem with the FC. RN 8 stated it was important to identify this change of condition to notify the physician to formulate interventions because there is the potential that the resident may develop urosepsis (a medical emergency that occurs when a UTI spreads to the kidneys). During a concurrent interview and record review on 8/23/2024 at 11 a.m., with the Director of Nursing (DON), the DON reviewed the facility policy and procedures regarding FCs and documentation. The DON stated the facility policy indicated to provide a sterile field and to wear sterile gloves for FC insertion. The DON stated RN 8 told the DON that she did not use a sterile technique when inserting Resident 417's FC. The DON stated the facility had a FC sterile kit in the supply room and RN 8 had the keys to the supply room and should have used the sterile kit. The DON stated it was important to use a sterile technique with FC insertion because there was a risk for infection. The DON further stated FC urine output should be measured and documented every shift. The DON stated on 8/21/24, FM 1 requested the urine output measurement of Resident 417, but there was no documented evidence of the urine output measurements between 8/14/2024 and 8/21/2024. The DON stated because there was no documented measurements of urine output, Resident 417's physician agreed to send the resident to GACH for an evaluation. The DON stated the importance of documentation is so everyone knows what is going on with a resident. The DON stated when everyone is unaware of a resident's status it affects their plan of care. The DON stated the facility policies were not followed when there was no documentation for Resident 417's FC removal, no documented monitoring for retention, RN 8 did not use a sterile technique for FC insertion, and FC urine output was not monitored. The DON stated when the policy was not followed there was a potential for further complications of Resident 417's FC resulting in a decline in the resident with possible further hospitalizations. During a review of the facility policy and procedure (P&P) titled, Indwelling (Foley) Catheter Insertion, Male Resident, last reviewed 4/17/2024, the P&P indicated the purpose of the procedure was to provide guidelines for the aseptic insertion of an indwelling urinary catheter in a male resident. Aseptic technique is maintained throughout the insertion of a catheter. Equipment and supplies include the catheter insertion tray, which includes some of the following: sterile fenestrated drape with center opening, sterile square drape, and sterile gloves. Steps in the procedure include the following: set up a sterile field and prepare for catheter insertion: open the catheter kit using a sterile technique, apply sterile gloves, open sterile cloth and establish sterile field, remove top tray and place within the sterile field, position square drape over the thighs, and place fenestrated drape. During a review of the facility procedure titled, Foley Catheter Maintenance, last reviewed 4/17/2024, the P&P indicated the objective of the procedure was to maintain a closed drainage system, to prevent bacterial contamination, and to prevent backflow. The procedure indicated to measure urine drainage at the end of each eight-hour shift unless it is needed or ordered more often. During a review of the facility policy and procedure titled, Urinary Incontinence - Clinical Protocol, last reviewed 4/17/2024, the P&P indicated the staff and physician will monitor an individual for complications of indwelling catheters. During a review of the facility policy and procedure titled, Output, Measuring and Recording, last reviewed 4/17/2024, the P&P indicated the purpose of the procedure is to accurately determine the amount of urine that a resident excretes in a 24-hour period. Document the date and time the resident's urine output was measured and recorded. Document the amount in milliliters (a unit of measurement) of the output. During a review of the Registered Nurse Job Description, approval date 8/18/2011, the job description indicated the RN's essential job duties and responsibilities include the skills and knowledge of long-term care patient needs and the ability to deal with problems involving several concrete variables in standardized situations. The job duties also include the RN will assist in providing a clean, safe, and healthy environment for residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to: 1. Account for five doses of Controlled Medications (also known as Controlled Drug and Controlled Substance [CM, CD, CS]- medications which have a potential for abuse and may also lead to physical or psychological dependence) for Residents 30, 42, 60, 123, and 317 in one of five inspected medication carts (Medication Cart Station 1) 2. Document and dispose (remove or destroy) an Ativan (a CM) vial for Resident 143 in the presence of two witnesses, in one of three inspected medication rooms (Medication Room Subacute.) As a result, control and accountability of CMs did not follow state and federal regulations and facility policy and procedures. These deficient practices increased the opportunity for CM diversion (the transfer of a controlled medication or other medication from a lawful to an unlawful channel of distribution or use), the risk that Residents 30, 42, 60, 123, and 317 could have delayed medication treatment and continuity of care due to lack of availability of the CM, and the potential for accidental exposure to harmful medications to all residents, possibly leading to physical and psychosocial harm and hospitalization. Findings: During an observation on [DATE] at 12:30 PM in Medication Room Subacute, in the presence of Licensed Vocational Nurse (LVN) 4 and Registered Nurse (RN) 4, the Antibiotic or Controlled Drug Record accountability log was found without the date and signatures of the licensed staff (RN or Director of Nursing [DON] and Consultant Pharmacist [CP]) involved in the disposition of 22.5 milliliter ([ml] - a unit of measure of volume) remaining in the Ativan vial for Resident 143. During a concurrent interview, in the presence of LVN 4, RN 4 stated that RN 4 disposed 22.5 ml remaining in the Ativan vial for Resident 143 on [DATE] in the pharmaceutical bin located in the Medication Room Subacute because the Ativan vial was expired, and forgot to hand over the vial along with the Antibiotic or Controlled Drug Record accountability log to the DON for disposal and documentation with the CP. RN 4 stated that usually RN 4 hands over the CM pending disposal to the DON along with the Antibiotic or Controlled Drug Record accountability log so that the DON disposes in the presence of the CP. RN 4 stated that RN 4 overlooked that the Ativan was a CM and failed to follow the CM disposal policy compromising accountability of CM. RN 4 stated that failure to follow CM disposal policy and process can create opportunity for diversion, and harm staff and residents by exposing them to harmful substances. During an observation on [DATE] at 2:06 PM, with LVN 3, in Medication Cart Station 1, there was a discrepancy in the count between the Antibiotic or Controlled Drug Record accountability log and the amount of medication remaining in the medication bubble pack (medication packaging system that contains individual doses of medication per bubble) for the following residents: 1. One dose of hydrocodone with acetaminophen (a combination CM used for pain) 10-325 milligram ([mg] - a unit of measure of mass) tablet was missing from the medication bubble pack compared to the count indicated on the Antibiotic or Controlled Drug Record accountability log for Resident 30. The Antibiotic or Controlled Drug Record accountability log for hydrocodone with acetaminophen indicated the medication bubble pack should have contained a total of 13 hydrocodone with acetaminophen 10-325 mg tablets, after the last administration of hydrocodone with acetaminophen 10-325 mg tablet documented/signed-off on [DATE] at 11:39 PM, however the medication bubble pack contained 12 hydrocodone with acetaminophen 10-325 mg tablets and contained no other documentation of subsequent administrations. 2. One dose of lacosamide (a CM used for seizure [bursts of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle movements, behaviors, sensations, or states of awareness) 100 mg tablet was missing from the medication bubble pack compared to the count indicated on the Antibiotic or Controlled Drug Record accountability log for Resident 42. The Antibiotic or Controlled Drug Record accountability log for lacosamide indicated the medication bubble pack should have contained a total of 13 lacosamide 100 mg tablets, after the last administration of lacosamide 100 mg tablet documented/signed-off on [DATE] at 5:35 PM, however the medication bubble pack contained 12 lacosamide 100 mg tablets and contained no other documentation of subsequent administrations. 3. One dose of Ativan (a CM used for anxiety) 0.25 mg tablet was missing from the medication bubble pack compared to the count indicated on the Antibiotic or Controlled Drug Record accountability log for Resident 60. The Antibiotic or Controlled Drug Record accountability log for Ativan indicated the medication bubble pack should have contained a total of 24 Ativan 0.25 mg tablets, after the last administration of Ativan 0.25 mg tablet documented/signed-off on [DATE] at 8:05 PM, however the medication bubble pack contained 23 Ativan 0.25 mg tablets and contained no other documentation of subsequent administrations. 4. One dose of Ativan 0.5 mg tablet was missing from the medication bubble pack compared to the count indicated on the Antibiotic or Controlled Drug Record accountability log for Resident 123. The Antibiotic or Controlled Drug Record accountability log for Ativan indicated the medication bubble pack should have contained a total of 7 Ativan 0.5 mg tablets, after the last administration of Ativan 0.5 mg tablet documented/signed-off on [DATE] at 5:11 PM, however the medication bubble pack contained 6 Ativan 0.5 mg tablets and contained no other documentation of subsequent administrations. 5. One dose of viberzi (a CM used for Irritable Bowel Syndrome [IBS] - a condition that causes stomach cramps, bloating, diarrhea and constipation) 75 mg tablet was missing from the medication bubble pack compared to the count indicated on the Antibiotic or Controlled Drug Record accountability log for Resident 317. The Antibiotic or Controlled Drug Record accountability log for viberzi indicated the medication bubble pack should have contained a total of 5 viberzi 75 mg tablets, after the last administration of diphenoxylate with viberzi 75 mg tablet documented/signed-off on [DATE] at 6:05 PM, however the medication bubble pack contained 4 viberzi 75 mg tablets and contained no other documentation of subsequent administrations. During a concurrent interview, LVN 3 stated LVN 3 administered hydrocodone with acetaminophen 10-325 mg tablet to Resident 30, lacosamide 100 mg tablet to Resident 42, Ativan 0.5 mg tablets to Resident 60 and 123, and viberzi 75 mg tablet to Resident 317 that morning and forgot to sign the Antibiotic or Controlled Drug Record accountability logs. LVN 3 stated LVN 3 failed to follow the facility's policy of signing each CM dose on the Antibiotic or Controlled Drug Record accountability log after preparing the dose for the resident. LVN stated LVN 3 understood it was important to sign each dose once administered to ensure accountability, prevention of CM diversion, and accidental exposures of harmful substances to residents. LVN 3 stated if documentation was not accurate then it can lead to medication error by overdosing (administering more than the prescribed dose) leading to stoppage of breathing, hospitalization and possibly death for Residents 30, 42, 60, 123 and 317. During an interview on [DATE] at 10:19 AM, with the DON, the DON stated that the Antibiotic or Controlled Drug Record accountability logs should be dated and signed by the DON or RN and CP when disposing of CMs. The DON stated that the Antibiotic or Controlled Drug Record accountability log for Ativan 22.5 ml disposal for Resident 143 missing the date and signatures of RN/DON and CP. The DON stated that proper CM disposition was important to prevent diversion and prevent harm to residents by the accidental use and administration of harmful substances. The DON stated that RN 4 failed to follow CM disposal policy and properly document the disposal of Ativan for Resident 143. During the same interview, the DON stated LVN 3 failed to follow facility policy of documenting the preparation of CM immediately on the Antibiotic or Controlled Drug Record accountability log for Resident 30, 42, 60, 123 and 317. The DON stated not documenting the Antibiotic or Controlled Drug Record timely can lead to accountability failures, CM diversion, inaccurate clinical records, overdose, and accidental use of harmful substances causing adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) to residents such as respiratory depression (stoppage of breathing) and hospitalization, negatively impacting their health and wellbeing. During a review of Resident 30's admission Record (a document containing demographic and diagnostic information,) dated [DATE], the admission Record indicated Resident 30 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis including respiratory (related to breathing) failure, injury of the head, fracture (breakage) of left humerus (the long bone in the upper arm) and polyneuropathy (a condition that affects many nerves in the body causing pain.) During a review of Resident 30's Order Summary Report, dated [DATE], the report indicated Resident 30 was prescribed hydrocodone with acetaminophen 10-325 mg to give 1 tablet via Gastrostomy tube ([G-tube]- a tube inserted in the stomach used to provide nutrition and medications) every 4 hours as needed for moderate to severe pain (pain level 4-10 out of 10,) starting [DATE]. During a review of Resident 30' s (Medication Administration Record ([MAR] - a record of mediations administered to residents), for [DATE], the MAR indicated Resident 30 was prescribed hydrocodone with acetaminophen 10-325 mg to give 1 tablet via G-tube every 4 hours as needed for moderate to severe pain (pain level 4-10 out of 10,) and was administered a dose on [DATE] at 1:21 PM. During a review of Resident 42's admission Record, dated [DATE], the admission Record indicated Resident 42 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis including seizure. During a review of Resident 42's Order Summary Report, dated [DATE], the report indicated Resident 42 was prescribed lacosamide 100 mg to give 1 tablet by mouth two times a day for seizure, starting [DATE]. During a review of Resident 42's MAR for [DATE], the MAR indicated Resident 42 was prescribed lacosamide 100 mg to give 1 tablet by mouth two times a day for seizure, at 9 AM and 5 PM. During a review of Resident 60's admission Record, dated [DATE], the admission Record indicated Resident 60 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis including anxiety. During a review of Resident 60's Order Summary Report, dated [DATE], the report indicated Resident 60 was prescribed Ativan 0.25 mg to give via G-tube every 12 hours for anxiety, starting [DATE]. During a review of Resident 60's MAR for [DATE], the MAR indicated Resident 60 was prescribed Ativan 0.25 mg to give via G-tube every 12 hours for anxiety, at 9 AM and 9 PM. During a review of Resident 123's admission Record, dated [DATE], the admission Record indicated Resident 123 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis including anxiety. During a review of Resident 123's Order Summary Report, dated [DATE], the report indicated Resident 123 was prescribed Ativan 0.5 mg to give 1 tablet by mouth two times a day for anxiety, starting [DATE]. During a review of Resident 123's MAR for [DATE], the MAR indicated Resident 42 was prescribed Ativan 0.5 mg to give 1 tablet by mouth two times a day for anxiety, at 9 AM and 5 PM. During a review of Resident 317's admission Record, dated [DATE], the admission Record indicated Resident 317 was originally admitted to the facility on [DATE] with a diagnosis including dysphagia (difficulty swallowing.) During a review of Resident 317's Order Summary Report, dated [DATE], the report indicated Resident 317 was prescribed viberzi 75 mg to give 1 tablet by mouth two times a day for IBS, starting [DATE]. During a review of Resident 317's MAR for [DATE], the MAR indicated Resident 317 was prescribed lacosamide 100 mg to give 1 tablet by mouth two times a day for seizure, at 9 AM and 5 PM. Review of the policy and procedures (P&P), titled Controlled Medications, dated [DATE], the P&P indicated that Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations. A. The DON and the CP maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications. C. When a controlled mediation is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the MAR: a. Date and time of administration b. Amount administered c. Signature of the nurse administering the dose on the accountability record at the time the medication is removed from the supply. D. When a dose of a CM is removed from the container for administration but refused by the resident or not given for any reason .It must be destroyed according to facility policy in the presence of two licensed nurses and the disposal documented on the accountability record .The same process applies to the disposal of unused partial tablets and unused portions of single dose ampules. Review of the P&P titled Controlled Medication Storage, dated [DATE], the P&P indicated Medications included in the DEA classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations. A. The DON and the CP maintain the facility's compliance with federal and state laws and regulations in the handling of CMs. H. CM remaining in the facility after the order has been discontinued are retained in the facility in a securely double locked area with restricted access until destroyed by the facility's DON or a RN employed by the facility and a pharmacist. Review of the P&P, titled Controlled Medication Disposal, dated [DATE], the P&P indicated Medications included in the DEA classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations. A. The DON and the CP maintain the facility's compliance with federal and state laws and regulations in the handling of CMs. B. When a dose of a CM is removed from the container for administration but refused by the resident or not given for any reason .It must be destroyed according to facility policy in the presence of two licensed nurses and the disposal documented on the accountability record .The same process applies to the disposal of unused partial tablets and unused portions of single dose ampules and doses of CS wasted for any reason. D. Schedule II-V CS remaining in the facility after a resident has been discharged , or the order discontinued, are disposed of in the facility by the DON or designated facility RN in conjunction with the pharmacist.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Two medication errors out of 31 total opportunities contributed to an overall medication error rate of 6.45% affecting one of four residents observed for medication administration (Resident 56.) The medication errors were as follows: 1. Resident 56 did not receive docusate (a medication used for bowel [intestine] management) as ordered by Resident 56's physician, and 2. Resident 56 received metformin (a medication used to treat high blood sugar levels) at a different time than ordered by Resident 56's physician. These failures had the potential to result in Resident 56 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and the potential to result in Residents 56's health and well-being to be negatively impacted. Findings: During an observation on 8/21/24 at 9:06 AM, in Medication Cart Station 1, Licensed Vocational Nurse (LVN) 2 was observed administering metformin 500 milligram ([mg]-a unit of measure of mass) tablet to Resident 56. Resident 56 was observed swallowing the metformin tablet whole with ensure (a nutritional drink.) LVN 2 was observed not administering docusate 100 mg tablet to Resident 56. During an interview on 8/21/24 11:07 AM, with LVN 2, LVN 2 stated that LVN 2 administered metformin 500 mg tablet and failed to prepare and administer docusate 100 mg tablet during the morning medication administration at 9:06 AM to Resident 56, as prescribed by Resident 56's physician. LVN 2 acknowledged the physician's order specified to administer metformin at 7:30 AM with meals and docusate 100 mg at 9 AM. LVN 2 stated, per facility policy, there was a 60-minute window for medication administration and LVN 2 administered the metformin later than that timeframe. LVN 2 stated that Resident 56 was at risk of having stomach irritation from not administering metformin with meals at 7:30 AM, and at risk of having constipation from not administering docusate. LVN 2 stated these were considered medication errors. LVN 2 stated that LVN 2 will notify the physician for not administering docusate to Resident 56 and obtain additional orders as necessary. During an interview on 8/23/24 10:19 AM, with the Director of Nursing (DON), the DON stated that LVN 2 failed to administer metformin 500 mg tablet and docusate 100 mg tablet according to physician orders, to Resident 56. The DON stated that Resident 56 may be at risk for developing stomach irritation from receiving metformin around 9 AM without a meal, and possibly experience constipation by not receiving docusate. The DON stated that licensed nurses should follow facility medication administration guidelines to ensure physician orders are followed and the right medications at the right times are administered to residents. During a review of Resident 56's admission Record (a document containing demographic and diagnostic information,) dated 8/21/24, the admission Record indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including Diabetes Mellitus 2 ([DM2] - a condition where there is high blood sugar levels) and gastritis (inflammation of the stomach lining.) During a review of Resident 56's Order Summary Report, dated 8/21/24, indicated Resident 56 was prescribed docusate 100 mg tablet twice a day for bowel management, and metformin 500 mg twice a day for diabetes to give with breakfast and dinner, starting 10/13/23. During a review of Resident 56's Medication Administration Record ([MAR] - a record of mediations administered to residents), for August 2024, the MAR indicated Resident 56 was prescribed docusate 100 mg tablet to be given orally twice a day for bowel management at 9 AM and 5 PM, and metformin 500 mg to be given twice a day orally for diabetes to give with breakfast and dinner at 7:30 AM and 5 PM. The clinical record contained no documentation that the resident should be given metformin at a time different than the one ordered by the physician, and no documentation that the resident should not be given the docusate at the time ordered by the physician. During a review of the facility's policy and procedures (P&P), titled Administering Medications, dated April 2019, the P&P indicated Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. During a review of the facility's P&P, titled Adverse consequences and Medication Errors, dated March 2023, the P&P indicated: 5. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. 6. Examples of medication error include: a. Omission - a drug is ordered but not administered; b. Wrong time c. Failure to follow manufacturer instructions and/or accepted professional standards.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards): 1. For five of seven sampled residents (Resident 12, 38, 49, 56, 116 and 125) investigated for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous ([SQ] -beneath the skin) insulin administration sites for 2. For one of one sampled resident (Resident 38) investigated during review of anticoagulant use by failing to rotate enoxaparin (medication to prevent and treat blood clots) subcutaneous injection sites. The deficient practice increased the risk that Residents Resident 12, 38, 49, 56, 116 and 125 could experience adverse effects (unwanted, unintended result) from same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross Reference F658. Findings: a. During a review of Resident 116's admission Record, the admission Record indicated the facility admitted the resident on 5/23/2024, with diagnoses including type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as fuel), acute kidney failure (when the body suddenly lose their ability to function), and urinary tract infection (a condition in which bacteria invade and grow in the urinary tract). During a review of Resident 116's History and Physical (H&P), dated 5/24/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 116's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/30/2024, the MDS indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident was on a high-risk drug class hypoglycemic (medication that lowers blood sugar) (including insulin). During a review of Resident 116's Order Summary Report, dated 5/25/2024, the report indicated an order for: - insulin regular human injection solution (Insulin Regular [Human]) Inject as per sliding scale (varies the dose of insulin based on blood sugar level): if 61-150= 0. If blood sugar (BS) less than (<) 60 may administer 8 ounces (oz., a unit of weight measurement) orange juice and call MD; 151-200= 2; 201-250= 4; 251-300= 6; 301-350= 8; 351-399= 10; 400+ If BS greater than (>) 400, administer12 units (the amount required to lower the blood sugar) and notify MD, subcutaneously every 6 hours for diabetes mellitus (DM) rotate site. During a review of Resident 116's Location of Administration of insulin for 6/2024 to 8/2024, it indicated Insulin Regular Human Injection Solution was administered on the following dates and sites: 6/11/2024 at 5:27 p.m. on the Abdomen-Left Lower Quadrant (LLQ) 6/12/2024 at 11:38 p.m. on the Abdomen-LLQ 6/19/2024 at 6:27 p.m. on the Abdomen-Right Lower Quadrant (RLQ) 6/20/2024 at 11:35 p.m. on the Abdomen-RLQ 6/20/2024 at 5:32 a.m. on the Abdomen-RLQ 6/24/2024 at 5:13 p.m. on the Abdomen-LLQ 6/25/2024 at 11:20 p.m. on the Abdomen-LLQ 7/1/2024 at 5:06 a.m. on the Abdomen-LLQ 7/2/2024 at 11:06 p.m. on the Abdomen-LLQ 7/2/2024 at 1:31 p.m. on the Abdomen-LLQ 7/10/2024 at 5:09 p.m. on the Abdomen-LLQ 7/11/2024 at 11:16 p.m. on the Abdomen-LLQ 7/22/2024 at 11:12 p.m. on the Abdomen-LLQ 7/23/2024 at 11:58 p.m. on the Abdomen-LLQ 7/25/2024 at 11:15 p.m. on the Abdomen-LLQ 7/26/2024 at 11:16 p.m. on the Abdomen-LLQ 8/8/2024 at 12:54 a.m. on the Abdomen-LLQ 8/9/2024 at 11:49 p.m. on the Abdomen-LLQ 8/12/2024 at 5:17 p.m. on the Abdomen-Right Upper Quadrant (RUQ) 8/14/2024 at 12:50 p.m. on the Abdomen-RUQ During a concurrent interview and record review on 8/22/2024, at 3:09 p.m., with Registered Nurse 4 (RN 4), reviewed Resident 116's Order Summary Report, Medication Administration Record (MAR), and Location of Administration sites of insulin for 6/2024 to 8/2024. RN 4 stated there were multiple instances where the insulin administration sites was not rotated. RN 4 stated insulin administration sites should be rotated to prevent bruising and swelling of the skin and to prevent lipodystrophy. RN 4 stated not rotating insulin administration sites constitutes as a medication error. During an interview on 8/23/2024, at 7:20 p.m., with the Director of Nursing (DON), the DON stated insulin injections sites should be rotated to prevent skin irritation and lipodystrophy. The DON stated not rotating insulin administration sites is considered a medication error. During a review of the facility's recent policy and procedure (P&P) titled, Insulin Administration, last reviewed on 4/17/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility provided Instructions for Use of Humulin ([NAME]-mu-[NAME]) R (insulin human) injection for subcutaneous or intravenous use 3 ml or 10 ml multiple-dose vial (100 units/ML), copyright 1997, indicated change (rotate) your injection sites within the area you choose for each dose to reduce your risk of getting lipodystrophy (pits in skin or thickened skin) and localized cutaneous amyloidosis (skin with lumps) at the injection sites. b. During a review of Resident 38's admission Record, the admission Record indicated the facility admitted the resident on 4/17/2012, and readmitted the resident on 12/19/2023, with diagnoses including functional quadriplegia (a condition that causes complete immobility due to a severe physical disability or frailty, but it is not a true paralysis), type 2 diabetes mellitus, and anoxic brain damage (caused by a complete lack of oxygen to the brain, which results in the death of brain cells after approximately four minutes of oxygen deprivation). During a review of Resident 38's H&P, dated 12/19/2023, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 38's MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident was on high-risk drug class hypoglycemic (including insulin). During a review of Resident 38's Order Summary Report, the report indicated the following orders: -7/2/2024 Enoxaparin Sodium Injection Solution Prefilled Syringe (anticoagulant) 40 milligrams (mg, a unit of weight)/0.4 milliliters (ml, a unit of volume) (Enoxaparin Sodium). Inject 0.4 ml subcutaneously in the morning for deep vein thrombosis (DVT, the formation of one or more blood clots) prophylaxis (ppx, measures designed to preserve health and prevent the spread of disease) rotate site (as maintenance for long term DVT PPX). -5/28/2024 Novolog Injection Solution (Insulin Aspart). Inject as per sliding scale: if 70-140= 0 <70 may give 8 oz orange juice and notify MD; 141-220= 1 unit; 221-260= 2 units; 261-280= 3 units; 281-300= 4 units; 301-350= 5 units; 351+= 6 units >350 give 6 units and notify MD, subcutaneously every 12 hours for DM rotate site. During a review of Resident 38's Care Plan (CP) titled, Anticoagulant, (a substance that is used to prevent and treat blood clots), and At risk for bleeding and bruises due to anticoagulant therapy, last revised on 12/20/2023, the CP indicated an intervention to administer medication as ordered. During a review of Resident 38's Location of Administration of Enoxaparin Sodium Injection Solution Prefilled Syringe 40 mg/0.4 ml for 5/2024 to 8/2024, it indicated the following dates and sites of administration: 5/5/2024 at 9:25 a.m. on the Abdomen-LUQ 5/6/2024 at 9:23 a.m. on the Abdomen-LUQ 5/9/2024 at 9:02 a.m. on the Abdomen-LUQ 5/10/2024 at 8:49 a.m. on the Abdomen-LUQ 5/11/2024 at 9:12 a.m. on the Abdomen-LUQ 6/11/2024 at 9:02 a.m. on the Abdomen-LUQ 6/12/2024 at 9:09 a.m. on the Abdomen-LUQ 8/8/2024 at 8:43 a.m. on the Abdomen-RLQ 8/9/2024 at 9:31 a.m. on the Abdomen-RLQ 8/17/2024 at 9:33 a.m. on the Abdomen-RUQ 8/18/2024 at 9:13 a.m. on the Abdomen-RUQ During a review of Resident 38's Location of Administration of Novolog Injection Solution for 6/2024 to 8/2024, it indicated the following dates and sites of administration: 6/9/2024 at 5:11 p.m. on the Abdomen-LLQ 6/20/2024 at 5:37 a.m. on the Abdomen-LLQ 6/21/2024 at 5:27 a.m. on the Abdomen-LLQ 7/8/2024 at 5:20 p.m. on the Abdomen-RLQ 7/9/2024 at 5:13 a.m. on the Abdomen-RLQ 7/14/2024 at 5:13 a.m. on the Abdomen-LLQ 7/16/2024 at 5:18 a.m. on the Abdomen-LLQ 7/17/2024 at 5:03 a.m. on the Abdomen-RLQ 7/18/2024 at 5:06 a.m. on the Abdomen-RLQ 7/23/2024 at 5:12 a.m. on the Abdomen-RLQ 7/24/2024 at 5:31 a.m. on the Abdomen-RLQ During a concurrent interview and record review on 8/22/2024, at 3:15 p.m., with RN 4, reviewed Resident 38's Order Summary Report, MAR, and Location of Administration sites of insulin from 6/2024 to 8/2024 and Enoxaparin Sodium Injection from 5/2024 to 8/2024. RN 4 stated there were multiple instances where the insulin and enoxaparin administration sites were not rotated. RN 4 stated the insulin and enoxaparin administration sites should be rotated to prevent bruising and swelling of the skin and to prevent lipodystrophy. RN 4 stated not rotating insulin and enoxaparin administration sites constitutes as a medication error. During an interview on 8/23/2024, at 7:20 p.m., with the DON, the DON stated insulin and enoxaparin injection sites should be rotated to prevent skin irritation and lipodystrophy. The DON stated not rotating insulin and enoxaparin administration sites is considered a medication error. During a review of the facility's recent policy (P&P) and procedure titled, Adverse Consequences and Medication Errors, last reviewed on 4/17/2024, the P&P indicated a medication error is defined as the preparation of drugs and biological which is not in accordance with physician's orders, manufacturers specifications, or accepted professional standards and principles of the professional(s) providing services. During a review of the facility's recent policy and procedure (P&P) titled, Insulin Administration, last reviewed on 4/17/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility provided instructions for use of Enoxaparin Sodium Injection for subcutaneous use single-dose prefilled syringe, undated, it indicated to alternate between the left or the right side of the stomach each time an injection is given. During a review of the facility provided Instructions for Use of Humulin ([NAME]-mu-[NAME]) R (insulin human) injection for subcutaneous or intravenous use 3 ml or 10 ml multiple-dose vial (100 units/ML), copyright 1997, it indicated change (rotate) your injection sites within the area you choose for each dose to reduce your risk of getting lipodystrophy (pits in skin or thickened skin) and localized cutaneous amyloidosis (skin with lumps) at the injection sites. During a review of the facility provided Highlights of Prescribing Information for Insulin Aspart injection, for subcutaneous or intravenous use, with initial U.S. approval in 2000, indicated to rotate the injection sites within the same region from one injection to the next to reduce the risk of lipodystrophy and localized cutaneous amyloidosis. c. During a review of Resident 125's admission Record, the admission Record indicated the facility admitted the resident on 2/26/2022, and readmitted the resident on 3/1/2024, with a diagnosis of type 2 diabetes mellitus. During a review of Resident 125's H&P, dated 3/1/2024, the H&P indicated the incapacitated resident requires visit for safety. During a review of Resident 125's MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and sometimes understands others. The MDS indicated the resident was on a high-risk drug class hypoglycemic (including insulin). During a review of Resident 125's Order Summary Report, dated 4/2/2024, the report indicated an order for Insulin Aspart FlexPen Solution Pen-injector 100 unit/ml (Insulin Aspart). Inject as per sliding scale: if 60-150= 0 units; 151-199= 2 units; 200-249= 3 units; 250-299= 5 units; 300-349= 7 units; 350-400= 10 units; subcutaneously every 12 hours for diabetes type 2 (DM II) (rotate injection sites) finger-stick blood sugar (FSBS, a method of monitoring blood sugar) monitoring. Notify MD if BS < 70 mg/dl or >400 mg/dl. May give 8 oz orange juice if BS < 70 mg/dl and notify MD. During a review of Resident 125's Location of Administration of Insulin Aspart FlexPen Solution Pen-injector 100 unit/ml from 6/2024 to 8/2024, it indicated the following administration dates and sites: 6/4/2024 at 5:15 a.m. on the Abdomen-LLQ 6/7/2024 at 5:06 a.m. on the Abdomen-LLQ 6/10/2024 at 5:38 a.m. on the Abdomen-LLQ 6/11/2024 at 5:26 a.m. on the Abdomen-LLQ 6/12/2024 at 5:05 a.m. on the Abdomen-LLQ 6/13/2024 at 5:33 a.m. on the Abdomen-LLQ 6/17/2024 at 5:36 a.m. on the Abdomen-LLQ 6/19/2024 at 5:14 a.m. on the Abdomen-LLQ 6/20/2024 at 5:31 a.m. on the Abdomen-LLQ 6/21/2024 at 5:19 a.m. on the Abdomen-LLQ 6/24/2024 at 5:19 a.m. on the Abdomen-RLQ 6/26/2024 at 5:15 a.m. on the Abdomen-RLQ 6/27/2024 at 5:24 a.m. on the Abdomen-RLQ 7/8/2024 at 5:12 a.m. on the Abdomen-RLQ 7/9/2024 at 5:15 a.m. on the Abdomen-RLQ 7/10/2024 at 5:11 a.m. on the Abdomen-RLQ 7/11/2024 at 5:09 a.m. on the Abdomen-RLQ 7/12/2024 at 5:07 a.m. on the Abdomen-RLQ 7/15/2024 at 5:16 a.m. on the Abdomen-RLQ 7/17/2024 at 5:07 a.m. on the Abdomen-RLQ 7/18/2024 at 5:08 a.m. on the Abdomen-RLQ 7/21/2024 at 5:30 a.m. on the Abdomen-RLQ 7/22/2024 at 5:10 a.m. on the Abdomen-RLQ 7/23/2024 at 5:16 a.m. on the Abdomen-RLQ 7/24/2024 at 5:33 a.m. on the Abdomen-RLQ 7/25/2024 at 5:20 a.m. on the Abdomen-RLQ 8/1/2024 at 5:07 a.m. on the Abdomen-RLQ 8/2/2024 at 5:03 a.m. on the Abdomen-RLQ During a review of Resident 125's Care Plan (CP) titled, Resident at risk for hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) related to diabetes mellitus, last revised on 3/9/2022, the CP indicated an intervention to administer medications as ordered. During a concurrent interview and record review on 8/22/2024, at 3:19 p.m., with RN 4, reviewed Resident 125's Order Summary Report, MAR, and Location of Administration sites of insulin from 6/2024 to 8/2024. RN 4 stated there were multiple instances where the insulin administration sites were not rotated. RN 4 stated insulin administration should be rotated to prevent bruising and swelling of the site and to prevent lipodystrophy. RN 4 stated not rotating insulin administration sites constitutes as a medication error. During an interview on 8/23/2024, at 7:20 p.m., with the DON, the DON stated insulin and enoxaparin injections sites should be rotated to prevent skin irritation and lipodystrophy. The DON stated not rotating insulin and enoxaparin administration sites is considered a medication error. During a review of the facility's recent policy (P&P) and procedure titled, Adverse Consequences and Medication Errors, last reviewed on 4/17/2024, the P&P indicated a medication error is defined as the preparation of drugs and biological which is not in accordance with physician's orders, manufacturers specifications, or accepted professional standards and principles of the professional(s) providing services. During a review of the facility's recent policy and procedure (P&P) titled, Insulin Administration, last reviewed on 4/17/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility provided instructions for use of Enoxaparin Sodium Injection for subcutaneous use single-dose prefilled syringe, undated, it indicated to alternate between the left or the right side of the stomach each time an injection is given. During a review of the facility provided Instructions for Use of Humulin ([NAME]-mu-[NAME]) R (insulin human) injection for subcutaneous or intravenous use 3 ml or 10 ml multiple-dose vial (100 units/ML), copyright 1997, it indicated change (rotate) your injection sites within the area you choose for each dose to reduce your risk of getting lipodystrophy (pits in skin or thickened skin) and localized cutaneous amyloidosis (skin with lumps) at the injection sites. During a review of the facility provided Highlights of Prescribing Information for Insulin Aspart injection, for subcutaneous or intravenous use, with initial U.S. approval in 2000, indicated to rotate the injection sites within the same region from one injection to the next to reduce the risk of lipodystrophy and localized cutaneous amyloidosis. e. During a review of Resident 49's admission Record, the admission Record indicated the facility admitted the resident on 8/4/2021 and readmitted in the facility on 5/8/2024 with diagnoses including but not limited to heart failure (a long-term condition that happens when the heart cannot pump blood well enough to give the body a normal supply), type two diabetes mellitus (DM 2 - a long term condition that causes the level of sugar [glucose] in the blood to become too high), and dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). During a review of Resident 49's History and Physical (H&P) dated 5/10/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 49's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/13/2024, the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and require total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 49 received insulin. During a review of Resident 49's Order Summary Report, the report indicated the following physician's order dated 5/8/2024: o Basaglar KwikPen (insulin glargine - a long-acting insulin used to control high blood sugar) subcutaneous solution pen-injector 100 unit per milliliter (unit/ml - a unit of measurement) inject 20 units subcutaneously in the morning for DM rotate sites. o Basaglar KwikPen (insulin glargine - a long-acting insulin used to control high blood sugar) subcutaneous solution pen-injector 100 unit per milliliter (unit/ml - a unit of measurement) inject 20 units subcutaneously at bedtime for DM rotate sites. o Humalog KwikPen (insulin lispro - a quick acting insulin used to improve blood sugar control in people with DM) subcutaneous solution Pen-injector 100 unit/ml (insulin lispro) inject subcutaneously per sliding scale: if 60 - 130 = 0; 131 - 160 = 2; 161 - 200 = 3; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10 more than 400= 10 units and call physician ,before meals and at bedtime for DM [ROTATE SITE] notify physician if blood sugar is above 400 milligram per deciliter (mg/dl - a unit of measurement or below 60mg/dl, may give five 8 ounces (oz - a unit of measurement) orange juice by mouth if blood sugar is below 60mg/dl. o Fiasp injection solution (insulin aspart with niacinamide - a rapid acting insulin indicated to improve glycemic control in patients with DM) 100 unit /ml inject seven (7) unit subcutaneously before meals for DM 2 (ROTATE SITES) notify physician if blood sugar is above 400 mg/dl or below 60mg/dl, may give 8oz orange juice by mouth if blood sugar is below 60mg/dl. Hold for blood sugar less than 100 administer 10-15 minutes prior to eating meals or as close as possible to mealtime. During a review of Resident 49's Medication Administration Record (MAR) from 6/2024 to 8/2024, the MAR indicated Basaglar insulin injection solution was administered as follows: 6/7/2024 9:00 a.m. subcutaneously Abdomen Right lower Quadrant (RLQ) 6/7/2024 9:00 p.m. subcutaneously Abdomen RLQ 6/8/2024 9:00 a.m. subcutaneously Abdomen Right Upper Quadrant (RUQ) 6/8/2024 9:00 p.m. subcutaneously Abdomen RUQ 6/13/2024 9:00 a.m. subcutaneously Right Arm (RA) 6/13/2024 9:00 p.m. subcutaneously RA 6/14/2024 9:00 a.m. subcutaneously Abdomen RUQ 6/14/2024 9:00 p.m. subcutaneously Abdomen RUQ 6/22/2024 9:00 a.m. subcutaneously Abdomen RLQ 6/22/2024 9:00 p.m. subcutaneously Abdomen RLQ 7/1/2024 9:00 a.m. subcutaneously Abdomen RUQ 7/1/2024 9:00 p.m. subcutaneously Abdomen RUQ 7/12/2024 9:00 a.m. subcutaneously Abdomen Left Upper Quadrant (LUQ) 7/12/2024 9:00 p.m. subcutaneously Abdomen LUQ 7/15/2024 9:00 a.m. subcutaneously Abdomen Left Lower Quadrant (LLQ) 7/15/2024 9:00 p.m. subcutaneously Abdomen LLQ 7/17/2024 9:00 a.m. subcutaneously Abdomen Left Lower Quadrant (LLQ) 7/17/2024 9:00 p.m. subcutaneously Abdomen LLQ 7/19/2024 9:00 a.m. subcutaneously Abdomen RLQ 7/19/2024 9:00 p.m. subcutaneously Abdomen RLQ 7/23/2024 9:00 a.m. subcutaneously Abdomen RLQ 7/23/2024 9:00 p.m. subcutaneously Abdomen RLQ 7/25/2024 9:00 a.m. subcutaneously Abdomen LUQ 7/25/2024 9:00 p.m. subcutaneously Abdomen LUQ 7/31/2024 9:00 a.m. subcutaneously Abdomen RLQ 7/31/2024 9:00 p.m. subcutaneously Abdomen RLQ During a review of Resident 49's Medication Administration Record (MAR) from 6/2024 to 8/2024, the MAR indicated Humalog insulin injection solution was administered as follows: 06/20/2024 9:00 p.m. subcutaneously Abdomen - Left Lower Quadrant (LLQ) 06/21/2024 11:30 subcutaneously Abdomen - LLQ 06/23/2024 11:30 subcutaneously Abdomen - LLQ 06/23/2024 21:00 subcutaneously Abdomen - LLQ 07/04/24 21:00 subcutaneously Abdomen - LUQ 07/06/24 11:30 subcutaneously Abdomen - LUQ 07/16/24 21:00 subcutaneously Abdomen - Left Lower Quadrant (LLQ) 07/17/24 11:30 subcutaneously Abdomen - LLQ 08/01/24 11:30 subcutaneously Abdomen - LLQ 08/01/24 16:30 subcutaneously Abdomen - LLQ 08/19/24 11:30 subcutaneously Abdomen - LLQ 08/19/24 16:30 subcutaneously Abdomen - LLQ During a review of Resident 49's Medication Administration Record (MAR) from 6/2024 to 8/2024, the MAR indicated Fiasp insulin injection solution was administered as follows: 06/08/24 16:30 subcutaneously Abdomen - LUQ 06/09/24 11:30 subcutaneously Abdomen - LUQ 08/08/24 11:30 subcutaneously Abdomen - LUQ 08/08/24 16:30 subcutaneously Abdomen - LUQ 08/10/24 16:30 subcutaneously Abdomen - LUQ 08/11/24 06:30 subcutaneously Abdomen - LUQ 08/19/24 11:30 subcutaneously Abdomen - LLQ 08/19/24 16:30 subcutaneously Abdomen - LLQ During a concurrent interview and record review on 8/23/2024 at 3:30 p.m., with Minimum Data Set Coordinator 2 (MDSC 2), reviewed Resident 49's physician's orders, MAR, and location of administration sites from 6/2024 to 8/2024. MDSC 2 verified the physician's order that indicated to rotate insulin administration sites. MDSC 2 stated there were multiple repeated insulin administration on the same sites between 6/2024 to 8/2024. During an interview on 8/23/2024 at 7:10 p.m., the Director of Nursing (DON), the DON stated the licensed nurses should rotate the insulin administration site to prevent residents from developing lipodystrophy. The DON stated if the licensed nurses do not rotate the insulin administration it is considered a medication error due to not following physician's order and the manufacturer's guideline. During a review of the facility's policy and procedure titled, Adverse Consequences and Medication Errors, last reviewed on 4/17/2024, indicated: 1. The staff and practitioner shall strive to minimize adverse consequences by following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication. 2. A medication error is defined as the preparation of drugs and biological which is not in accordance with physician's orders, manufacturers specifications, or accepted professional standards and principles of the professional(s) providing services. 3. Example of medication errors include failure to follow manufacturer instructions and/or accepted professional standards. During a review of the facility's policy and procedure (P&P) titled, Insulin Administration, last reviewed 4/17/2024, the P&P indicated a purpose to provide guidelines for the safe administration of insulin to residents with diabetes. The policy indicated: o Insulin maybe injected into the SQ tissues of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately two (2) inches around the navel. o Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility provided manufacturer's guideline for Basaglar (insulin glargine), undated, it indicated to rotate injection sites into the abdominal area, thigh, or deltoid to reduce the risk of lipodystrophy and localized cutaneous amyloidosis. During a review of the facility provided manufacturer's guideline for Humalog (insulin lispro), undated, it indicated: -Change (rotate) your injections sites within the area you choose for each dose to reduce your risk of getting lipodystrophy and localized cutaneous amyloidosis. -Do not inject where the skin has pits, is thickened, or has lumps. -Do not inject where the skin is tender, bruised, scaly or hard, or into scars or damaged. During a review of the facility provided manufacturer's guideline for Fiasp (insulin aspart), undated, it indicated to rotate injection sites within the same region to reduce the risk of lipodystrophy and localized cutaneous amyloidosis. d.1. During a review of Resident 12's admission Record (a document containing demographic and diagnostic information,) dated 8/22/24, it indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including Type 2 Diabetes Mellitus 2 ([DM2] - a condition where there is high blood sugar levels.) During a review of Resident 12's Order Summary Report, dated 8/22/24, it indicated Resident 12 was prescribed Lantus (long-acting insulin) to inject 20 units ([un] - a measure of dosage for insulin) SQ at bedtime for DM rotate sites, starting 2/21/24. During a review of Resident 12's Medication Administration Record ([MAR] - a record of mediations administered to residents), for August 2024, the MAR indicated Resident 12 was prescribed Lantus 20 un SQ to give at bedtime for DM rotate sites, at 9 PM. During the same review, the MAR indicated Lantus 20 units SQ was administered at bedtime on the following days and sites: 8/13/24 at 9 PM on Right Upper Quadrant ([RUQ] - upper right side of abdomen) 8/14/24 at 9 PM on RUQ During a review of Resident 56's admission Record dated 8/21/24, it indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including DM2. d.2. During a review of Resident 56's Order Summary Report, dated 8/21/24, it indicated Resident 56 was prescribed Novolog (fast-acting insulin) to inject per sliding scale (insulin dosing plan whereby the amount of insulin administered depends on the resident's blood sugar level,) SQ before meals for DM2 (rotate site,) starting 10/13/23. During a review of Resident 56's MAR for June and July 2024, the MAR indicated Resident 56 was prescribed Novolog to inject per sliding scale SQ before meals for DM2 (rotate site,) at 6:30 AM, 11:30 AM and 4:30 PM. During the same review, the MAR indicated Novolog SQ was administered on the following days, times and sites: 6/27/24 at 6:30 AM on Left Lower Quadrant ([LLQ] - lower left side of abdomen) 6/27/24 at 4:30 PM on LLQ 6/28/24 at 6:30 AM on Right Lower Quadrant ([RLQ] - right left side of abdomen) 6/27/24 at 4:30 PM on RLQ 6/30/24 at 11:30 AM on RLQ 6/30/24 at 4:30 PM on RLQ 7/10/24 at 4:30 PM on LLQ 7/11/24 at 4:30 PM on LLQ 7/23/24 at 4:30 PM on LLQ 7/24/24 at 4:30 PM on LLQ During a concurrent interview and record review on 8/23/24 at 8:57 AM, with Registered Nurse (RN) 7, RN 7 reviewed Resident 12's and 56's MAR for August 2024 and for June and July 2024, respectively. RN 7 stated that Resident 12 MAR indicated to rotate injection sites for Lantus and Resident 56 MARs indicated to rotate injection site for Novolog. RN 7 stated that for Resident 12 and 56 the MARs indicated there were multiple instances where the insulin administration sites were not rotated by several licensed nurses, as expected by standard of practice, manufacturer guidelines, and MAR order instructions. RN 7 stated the failure of the licensed nurses to rotate insulin administration sites could cause harm to Resident 12 and 56 by causing skin abnormalities such as lumps in the skin or thickened skin. RN 7 stated not rotating insulin administration sites was considered a medication error. During an interview on 8/23/24, at 10:19 AM, with the Director of Nursing (DON,) the DON stated that per facility policy and manufacturer guidelines it was common knowledge for licensed nurses to rotate insulin administration sites to prevent lipodystrophy to the sites that was frequently administered with insulin. The DON stated that several licensed nurses failed to rotate the insulin administration sites for Resident 12 and 56 and placed the residents at risk of harm from lipodystrophy. The DON stated not rotating insulin administration sites was considered a medication error. Review of the facility's P&P, titled Adverse consequences and Medication Errors, dated March 2023, the P&P indicated: 2. An 'adverse consequence' is defined as an unpleasant symptoms or event that is due to or associated with a medication, such as an impairment or decline in an individual's mental or physical condition or functional or psychosocial status. An adverse consequence may include: a.adverse drug/medication reaction 3. The staff and practitioner shall strive to minimize adverse consequences by: a.Following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication; 5. A medication error is defined as the preparation or administration of drugs or

Based on observation, interview, and record review the facility failed to: 1. Remove and discard from use one open lorazepam (a controlled substance [CS]- medications which have potential for abuse and may also lead to physical or psychological dependence that is used for anxiety and agitation) vial for Resident 28, in accordance with manufacturer's requirements and facility policy and procedures, in two of two inspected medication rooms (Medication Room Station 3.) 2. Remove and discard from use one open, expired lorazepam vial for Resident 78 and one open Aplisol (medication used to diagnose tuberculosis [infection in the lungs]) vial for facility stock, in accordance with manufacturer's requirements and facility policy and procedures in two of two inspected medication rooms (Medication Room Station 1.) These deficient practices increased the risk that Resident 28, 78 and other residents in the facility to receive medication that had become ineffective or toxic due to improper storage or labeling, possibly leading to health complications resulting in hospitalization. Findings: During an observation, on 8/20/24 at 2:06 PM, with Licensed Vocational Nurse (LVN) 3, in Medication Room Station 1, the following medication was found expired and not discarded, or stored contrary to facility policies: 1. One open lorazepam multi-dose (containing more than one dose) vial for Resident 78 was found stored in the refrigerator and labeled with a date indicating that use of the vial began on 7/6/24. According to the manufacturer's product storage and labeling, open lorazepam multi-dose vials should be stored in a refrigerator between 36 and 46 degrees Fahrenheit and used or discarded from use within 28 days of opening the vial. During a concurrent interview with LVN 3, LVN 3 stated the lorazepam vial for Resident 78 was open and labeled with a date indicating that use of the vial began on 7/6/24. LVN 3 stated lorazepam multi-use vials are good for 28 days from when first used and that the vial was expired. LVN 3 stated that expired lorazepam has decreased potency (effectiveness) and sterility (free from germs like bacteria and virus.) LVN 3 stated the vial should be removed from the refrigerator to prevent accidental use. LVN 3 stated using expired lorazepam could potentially lead to infections, be ineffective and not treat or control Resident 78's seizures possibly leading to hospitalization and death. During an observation, on 8/20/24 at 3:16 PM, with LVN 9, in Medication Room Station 3, the following medication was found either stored and not labeled with an open date as required by their respective manufacturer's specifications, expired and not discarded, or stored contrary to facility policies: 2. One open lorazepam multi-dose vial for Resident 28 was found stored in the refrigerator without a label indicating when use began. According to the manufacturer's product storage and labeling, open lorazepam multi-dose vials should be stored in a refrigerator between 36 and 46 degrees Fahrenheit and used or discarded from use within 28 days of opening the vial. During a concurrent interview with LVN 9, LVN 9 stated the lorazepam vial for Resident 28 was open and not labeled with the date when use of the vial began. LVN 9 stated lorazepam multi-use vials are good for 28 days from when first used and without knowing when use began the vial was considered expired and should not be used due to unknown expiration date. LVN 9 stated the expired vial should be removed from the refrigerator to prevent accidental use. LVN 9 stated expired lorazepam has decreased sterility and potency and when used in error could potentially lead to infections, be ineffective by not treating or controlling Resident 28's seizures possibly leading to hospitalization and death. During an observation, on 8/21/24 at 12:06 PM, with Registered Nurse (RN) 5, in Medication Room Station 1, the following medication was found either stored and not labeled with an open date as required by their respective manufacturer's specifications, expired and not discarded, or stored contrary to facility policies: 3. One open Aplisol multi-dose vial for facility stock was found stored in the refrigerator without a label indicating when storage or use began. During a review of the manufacturer's product storage and labeling, it indicated Aplisol vials should be stored in the refrigerator between 36 and 46 degrees Fahrenheit and used or discarded from use within 30 days of opening the vial. During a concurrent interview, RN 5 stated that the Aplisol vial in the refrigerator in Medication Room Station 1 was open and did not have a label indicating when the vial was opened. RN 5 stated without a label indicating when the vial was opened it would be unknown when the Aplisol would expire. RN 5 stated the vial was considered expired and should be removed from the refrigerator and placed in the expired medication bin to be disposed of and not accidentally used for residents. RN 5 stated administering expired Aplisol to residents may result in inaccurate results (either false negative or false positive) and therefore lead to providing the incorrect treatment to the residents. During an interview, on 8/23/24 at 10:19 AM, with the Director of Nursing (DON,) the DON stated the Aplisol vial for facility stock was not labeled with a date indicating when use began. The DON stated multi-dose products should be labeled with a date open to know when they expire and not to be used beyond that date as the sterility and potency of the medication will be affected. The DON stated using Aplisol vials beyond the expiration date in error may potentially provide inaccurate results leading to inaccurate treatment for residents. The DON stated the Aplisol vial was considered expired and needed to be removed from the medication room and be discarded to prevent accidental use. During the same interview, the DON stated the lorazepam vials for Resident 28 and 78, was stored in the medication room refrigerators and not labeled with a date indicating when use began and expired, respectively. The DON stated multi-dose vials should be used within 28 days of opening the vial. The DON stated expired lorazepam vials have decreased potency and sterility and when used may potentially cause infections and be ineffective in treating causing Resident 28's and 78's seizures. The DON stated both vials were considered expired and needed to be disposed of to prevent accidental use. The DON stated several LVN's failed to label and remove expired medications from the refrigerators which can potentially lead to the accidental use of expired medications and harm residents. Duirng a review of facility's Policy and Procedures (P&P) titled, Storage of Medications, dated April 2008, indicated that Medications and biologicals ae stored safely, and properly, following manufacturer's recommendations or those of the supplier. M. Outdated, contaminated, or deteriorated medications .are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. During a of the facility's P&P, titled Administering Medications, dated April 2019, the P&P indicated Medications are administered in a safe and timely manner, and as prescribed. 12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. During a review of facility's P&P titled, Vials and Ampules of Injectable Medications, dated April 2008, the P&P indicated that Vials and ampules of injectable medications are used in accordance with the manufacturer's recommendations or the provider pharmacy's directions for storage, use, and disposal. B. The date opened and the initials of the first person to use the vial are recorded on the multi-dose vials (on the vial label or an accessory label affixed for that purpose). F. Medications in multi-dose vials may be used until manufacturer's expiration date or 6 months after opening unless otherwise specified. Refer to Guide for Special Handling of Medications. During a review of facility's P&P, titled Guide for Special Handling of Medications, dated September 2023, the P&P listed the following: Multi-Dose Vials for Injection - date when opened and discard unused portions after 28 days or in accordance with manufacturer's recommendations. Aplisol Injection - Store in the refrigerator. Protect from light. Do not freeze. Date when opened and discard unused portion after 30 days.

b/c. A review of the facility's summer menu spreadsheets (a list containing types and amount of foods of what each diet type would receive) dated 8/21/2024, indicated regular texture diet included the following food items on the tray: Fish Italiano 3 ounces (oz, unit of measurement) Tartar sauce 1 tablespoon (Tbsp, household measurement. Scalloped potatoes ½ cup (c) Italian Herb Vegetables ½ c Red and green salad ½ c Dressing ½ oz Peach crisp (3x2 ½ inches [in.]) Milk 4 oz During a trayline (an area where food was assembled) observation on 8/21/2024 at 11:33 a.m., staff started placing cold salad on the trays in the cart. There was a pan of Italian herb vegetables in the oven covered with foil. During a trayline observation on 8/21/2024 at 12:36 p.m. a pan of vegetables from the oven was placed on the team table looked mushy and served to regular diet textures. During the end of trayline service observation on 8/21/2024 at 12:58 p.m. 20 resident's trays on regular diet texture was served mushy vegetables. During a test tray conducted with the Dietary Director (DD), Registered Dietitian (RD) and [NAME] 1 on 8/21/2024 at 12:59 p.m. for regular diet (diet with no restrictions), the Italian herb vegetables was mushy, and overcook. The peach crisp looked soggy and the red and green salad looked wilted. Red and green salad was at 54°F. DD stated the cold items particularly the red and green vegetables could be dish out better as it looked like the staff just dumped it. DD stated it looked soggy and the peach crisp was not crispy. DD stated the peach crisp was recommended to be served hot or room temperature. DD stated the Italian herb vegetables were overcooked. [NAME] 1 stated she placed the cooked vegetables inside the oven while waiting for it to be served. DD stated it is important not to overcook vegetables as it loses its nutrients. RD stated it was important to have a presentable food as it could stimulate appetite of the residents to prevent weight loss. During an interview with the Director of Nursing (DON), on 8/23/2024, at 7:10 p.m., the DON stated it is important that residents are served food that is palatable because it can affect residents' appetites which can lead to potential weight loss and weakness. A review of the facility's diet manual titled Regular diet dated 4/17/2024, indicated DESCRIPTION: The regular diet is designed to meet the nutritional needs of resident who do not need dietary modification or restriction. Individual preferences or intolerances may necessitate the exclusion of certain food items. During a review of the facility's recipe titled Recipe: Italian Herb Vegetables dated week 4, Wednesday, 2024, it indicated Temperature: steam or simmer. During a review of the facility's recipe titled Recipe: Red and [NAME] Salad undated, it indicated Serve on trayline at a recommended temperature of 41°F or less. During a review of the facility's policies and procedures (P&P) titled Food Preparation dated 4/17/2024, it indicated POLICY. Food is to be prepared in such a manner as to maximize flavor, appearance, and nutritional value. Procedure: (1) All food will be prepared by methods that preserve nutritive value, flavor, and appearance and will be attractively served at the proper temperature and in a form to meet the individual needs of the resident. (2) All recipes in use shall be standardized and will be maintained in a file or book accessible to the dietary staff. Recipes used are consistent to what is on the menu. (6) Prepare foods as close as possible to serving time in order to preserve the nutritive value, freshness, and to prevent overcooking. Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor, appearance, and temperature when a. one of three sampled residents (Resident 128) investigated under the food care area when Resident 128 was served food that did not appear attractive to the resident on 8/20/2024. b. Italian herb vegetables were mushy and overcooked. Red and green salad and peach crisp looked saggy (wet and soft). c. Red and green salad was at 54 degrees Fahrenheit ([°F] a scale of temperature). These deficient practices resulted in Resident 128 not eating their meal and placed 20 of 44 facility residents on regular consistency texture (texture with no restriction) at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen. Findings: a. During a review of Resident 128's admission Record, the admission record indicated the facility admitted Resident 128 on 7/30/2022 with diagnoses including, but not limited to, unspecified protein-calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and function) and generalized weakness. During a review of Resident 128's Minimum Data Set (a standardized assessment and care screening tool), dated 7/22/2024, the MDS indicated Resident 128 was able to understand and make decisions, requires setup or clean-up assistance with eating, and requires touching assistance to moderate assistance for activities of daily living such as hygiene, dressing, toileting, and mobility. During a review of Resident 128's Order Summary Report, dated 7/16/2024, indicated Resident 128 was ordered a no added salt diet, with a mechanical soft texture (a texture-modified diet that makes foods easier to chew and swallow by reducing the size and softening them). During a review of Resident 128's Task titled, Nutritional - Amount Eaten, dated 8/20/2024, indicated Resident 128 ate 40 percent of their first meal, zero percent of their second meal, and refused his third meal. During an interview with Resident 128, on 8/20/2024, at 9:40 a.m., Resident 128 stated the food he is served in the facility is bland (lacking taste or seasoning) and does not look appetizing. During a concurrent observation and interview with Resident 128, on 8/20/2024, at 1:06 p.m., inside Resident 128's room, Resident 128's bedside table had a meal tray containing a plate with a bread roll, whole broccoli, a scoop sized portion of brown colored shredded meat, and a scoop sized portion of brown colored moist and mashed breading. Resident 128 stated the food he was served did not look appetizing to him.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to accommodate food preferences and provide appealing options of similar nutritive value to residents who choose not to eat food that is initially served for two of sixteen sampled residents (Resident 122 and 84) reviewed during the Dining task by failing to: a. Ensure Resident 122 was offered a food substitute after verbalizing that they did not like the meat provided with lunch. b. Ensure Resident 84 did not receive pasta with lunch when Resident 84 had a dislike of pasta. This deficient practice had the potential to result in further weight loss in Resident 122 and not respect Resident 84's wishes. Findings: a. During a review of Resident 122's admission Record, the admission Record indicated the facility admitted the resident on 10/4/2022 with diagnoses that included metabolic encephalopathy (an alteration in consciousness due to brain dysfunction), moderate protein-calorie malnutrition (an energy deficit due to a lack of dietary protein [a nutrient needed for the body to function properly]), and unspecified dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). During a review of Resident 122's Minimum Data Set (MDS - an assessment and care screening tool) dated 7/19/2024, the MDS indicated the resident was able to understand others and was able to make herself understood. The MDS indicated the resident required setup or clean-up assistance with eating. The MDS further indicated the resident had a weight loss of five percent (a unit of measurement) or more in the last month or loss of ten percent or more in the last six months. During a review of Resident 122's History and Physical (H&P) dated 7/12/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 122's Care Plan (CP) titled, Alteration in nutritional status secondary to poor oral intake . initiated 10/5/2022 and revised on 5/1/2024, the CP indicated to offer food substitutes if resident refuses meal tray or has poor intake. During a concurrent observation and interview on 8/20/2024 at 12:32 p.m., Resident 122 sat in a wheelchair in the Rec Dining Room and was observed self-feeding. Observed the resident did not eat the meat on the plate. Resident 122 stated she did not like the meat. Resident 122 stated this facility does not offer food substitutes. During an observation on 8/20/2024 at 12:40 p.m., observed Resident 122 stated to Licensed Vocational Nurse 10 (LVN 10) that she did not like the meat on the tray. Observed LVN 10 repeated to the resident you do not like the meat. During a concurrent observation and interview on 8/20/2024 at 12:45 p.m., observed Resident 122 self-propelled in her wheelchair toward the door. Observed Treatment Nurse 1 (TN 1) asked the resident if she did not like the meat. Resident 122 replied she did not like the meat. Observed TN 1 placed Resident 122's dirty tray in the meal cart. TN 1 stated Resident 122 did not eat the meat served at lunch. Observed the meat remained on Resident 122's plate. During an interview on 8/20/2024 at 1:55 p.m., Resident 122 sat on her bed and stated she was never offered an alternative to the meat provided at lunch. Resident 122 again stated alternatives are not offered in this facility. Resident 122 stated she was still a little hungry. During an interview on 8/20/2024 at 2:15 p.m., TN 1 stated she did not offer an alternative food choice to Resident 122 when the resident stated she did not like the meat, but she should have. TN 1 stated the facility provides an alternative menu and she should have offered it to Resident 122 for the resident's nutrition and because she may still be hungry. During an interview on 8/20/2024 at 2:20 p.m., LVN 10 stated she did not offer Resident 122 an alternative food choice at lunch because the resident stated that she was going to eat the meat even though she didn't like it. During an interview on 8/23/2024 at 12:11 p.m., the Assistant Director of Nursing (ADON) stated alternative food choices should be offered when a resident verbalizes that they don't like the food provided. The ADON stated it was a team effort and TN 1 and LVN 10 should have offered Resident 122 an alternative even if the resident stated she would eat the meat. The ADON stated it was important to offer alternatives to meet the nutritional needs of the resident and meat is an important protein needed for resident strength and muscle mass. During a review of the facility policy and procedure titled, Weight Assessment and Intervention, last reviewed 4/17/2024, the policy indicated resident weights are monitored for undesirable or unintended weight loss. Interventions for undesirable weight loss are based on careful consideration of resident choices and preferences. During a review of the Licensed Vocational Nurse Job Description, approval date 3/7/2024, indicated the LVN's essential job duties and responsibilities include to make sure residents are provided with good nutrition. b. During a concurrent observation and interview on 8/20/24 at 12:18 PM with Resident 84 in the dining room during lunch, Resident 84 had a vegetable soup with pasta shells inside the soup bowl. Resident 84 stated she told the facility that she did not like pasta, but she still received pasta in her meals. Resident 84 had a white paper slip on the lunch tray and the white paper slip indicated Resident 84's name, diet, and no pasta. During a review of Resident 84's admission Record dated 8/22/24, the admission Record indicated Resident 84 admitted to the facility on [DATE] with diagnoses including but not limited to Type 2 Diabetes Mellitus (condition in which the body does not metabolize blood sugar correctly) without complications and morbid (severe) obesity (disorder involving excessive body fat that increased risk for health problems) due to excess calories. During a review of Resident 84's Physician History and Physical (H&P) dated 12/12/23, the H&P indicated Resident 84 had the capacity to understand and make decisions. During a review of Resident 84's Order Summary dated 8/1/24, the Order Summary Report indicated an order dated 7/15/24 for controlled carbohydrate diet (CCHO, diet that focuses on eating the same amount of carbohydrates each day to help keep blood sugar levels stable), no added salt diet, regular texture, thin consistency, non-fat milk, no pasta, soup with lunch and dinner. During a review of Resident 84's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 6/23/24, the MDS indicated Resident 84 had intact cognition and required set up or clean-up assistance with eating. During a review of Resident 84's Dietary Services Progress notes dated 7/15/24, the Dietary Director (DD) indicated Resident 84 wanted soup with lunch and dinner, non-fat milk, and no pasta. During a review of Resident 84's Dietary Services Progress notes dated 8/16/24, DD indicated DD reviewed food preferences and Resident 84 indicated no pasta. During a review of the facility's undated recipe for minestrone soup, the recipe indicated one of the ingredients was pasta. During an interview on 8/21/24 at 3:52 PM, DD stated the vegetable minestrone soup contained pasta inside the soup. DD stated Resident 84 did not like pasta and should not have been served pasta inside the resident's soup. DD stated the facility should honor all residents' food preferences and offer alternatives with similar nutritional value. During an interview on 8/22/24 at 4:20 PM, the Director of Nursing (DON) stated residents should not be served foods they did not like and that their food preferences should be honored. DON stated it was important to honor the resident's food preferences so that resident eat and maintain their nutrition. During a review of the facility's policy titled, Resident Food Preferences, last reviewed 4/17/24 the policy indicated the DSS will visit resident periodically to ensure food preferences are being honored.

d. During concurrent observation of the mixer and interview with DD on 8/21/2024 at 9:11 a.m. the mixer had dry food buildup and residue. DD stated they used the mixer to make pudding and cake and it was last used on 8/19/2024, Monday. DD stated mixer must be cleaned every after use. DD stated the inside parts of the mixer had dust and dry food buildup and it was not acceptable because it was risky for the residents for cross-contamination. DD stated they used to cover the mixer with plastic when not in used and after cleaning, but they did not do it anymore due to humidity build up. A review of the facility's P&P titled Sanitizing Equipment and Surfaces dated 4/17/2024 indicated Sanitizing solution will be used to sanitize equipment and surfaces after each use or as often as needed. A review of Food Code 2017 indicated 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be clean to sight and touch. 4-701.10 Food Contact Surfaces and Utensils shall be sanitized. 4-702.11 Before use After cleaning. Utensils and Food-Contact Surfaces of Equipment shall be sanitized before use after cleaning. e. During an observation of clean pans on 8/21/2024 at 9:29 a.m., pans had burnt food residue. During a concurrent observation of the washed pans in the clean area and interview with DD on 8/22/2024 at 9:39 a.m., DD stated the buildup on the pans could be dry butter or burnt butter and it was not acceptable due to physical contamination. DD stated he would replace the pans with new pans. DS stated cross-contamination could make the residents sick of food poisoning as a potential outcome. A review of the facility's P&P titled Cleaning Schedule dated 4/17/2024 indicated The assigned dietary personnel will deep clean the area equipment assigned for them for that day using the dietary cleaning schedule. f. During a concurrent observation of the kitchen hood and interview with DD on 8/21/2024 at 9:33 a.m., the kitchen hood had dust buildup. DD stated they washed the hood filters once a week and the last time it was cleaned was last Thursday. DD stated the hood filters were dusty and dust could fall on the food in the uncovered pots and pans used for cooking. DD stated this could cause cross-contamination and fire hazard. A review of the facility's P&P titled Kitchen Hood Cleaning dated 4/17/2024 indicated Dietary staff will clean the hood on a weekly base. Hood cleaning company will perform: clean and decontaminate exhaust ducts for grease deposits and other combustible contaminants. Clean and decontaminate baffle filters for grease and other combustible contaminants. A review of Food Code 2017 indicated 3-307.11 Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301-3-306. Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: a. The walk-in refrigerator, walk-in freezer, and dedicated ice cream freezer did not have a thermometer separate from the built-in thermometer. b. Two dented cans were placed in the non-dented can area in the dry storage area. c. The sprinkler in the walk-in refrigerator had dust and dirt buildup. d. Mixer had dirt and dry food buildup. e. Kitchen hood had dust buildup. f. Pans in the clean area had food burned residue. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (transfer of bacteria from one object to another) in 117 of 161 medically compromised residents who received food and ice from the kitchen. Findings: a. During an observation on 8/20/2024, at 7:58 a.m., inside the kitchen walk-in refrigerator, a separate thermometer was not present. During an observation on 8/20/2024, at 8:27 a.m., inside the kitchen walk-in freezer, a separate thermometer was not present. During a concurrent observation and interview with the Dietary Director (DD), on 8/20/2024, at 8:30 a.m., inside the facility kitchen, the DD confirmed the dedicated ice cream freezer, walk-in refrigerator, and walk-in freezer did not have a separate thermometer from the built-in thermometers. The DD stated it was important to have a separate thermometer to make sure the temperature readings were correct and to have a backup thermometer in case the built-in thermometers fail. The DD stated if there is no other thermometer, there is a potential that the facility would not be able to detect if the refrigerator and freezer were not working and cause the stored food to spoil. During an interview with the Director of Nursing (DON), on 8/23/2024, at 7:10 p.m., the DON stated it is important to have a separate thermometer inside the kitchen refrigerator and freezer so that staff are aware and able to monitor the temperatures. The DON stated if the temperatures were not monitored, there was a potential that the food can become spoiled. During a review of the facility's policy and procedure (P&P) titled, Refrigerator/Freezer Storage, last reviewed 4/17/2024, the P&P indicated dietary staff will check the inside temperature of refrigerators and freezers. b. During an observation on 8/20/2024, at 8:05 a.m., inside the dry storage area in the kitchen, near the canned goods storage area, one can of cream of mushroom with a label indicating a delivery date of 8/9/2024 had a dent on the lid of the can and one can of chicken noodle soup with a label indicating a delivery date of 8/16/2024 had a dent on the top of the can. During a concurrent observation and interview with the DD, on 8/20/2024, at 8:30 a.m., inside the dry storage area, near the canned goods storage area, the DD confirmed the presence of a dented can of cream of mushroom and a dented can of chicken noodle soup. The DD stated dented cans should not be stored with the undented cans. The DD stated cans are checked on delivery and sorted and placed in the designated dented can area. The DD stated it was important to sort the dented cans to avoid cross-contamination (the transfer of harmful substances or disease-causing microorganisms to food). During an interview with the DON, on 8/23/2024, at 7:10 p.m., the DON stated dented cans should be sorted and placed in the dented can area to prevent the potential spread of botulism (food poisoning caused by bacteria growing on improperly sterilized canned meats and other preserved foods) to residents. During a review of the facility's P&P titled, Storage of Canned and Dry Goods, last reviewed 4/17/2024, the P&P indicated canned items should be inspected for damage such as dented, leaking, or bulging can. The P&P further indicated these items will be stored separately in the designated area - DENTED CANS for return to the vendor or disposed of properly. A review of Food Code 2017 indicated 3-101.11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under 3-601.12, honestly presented. 3-201.11 Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of §3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victim to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard. c. During an observation of the fire sprinkler in the walk-in refrigerator on 8/21/2024 at 8:45 a.m., the fire sprinkler had dust and dirt buildup. During a concurrent observation of the walk-in refrigerator and interview with Dietary Director (DD) on 8/21/2024 at 8:53 a.m., DD stated the fire sprinkler had dust buildup and it was not acceptable as it could go to the resident's food. DD stated they cleaned the walk-in refrigerator daily in the morning and in the afternoon and deep cleaned it every week however, housekeeping was responsible in deep cleaning the fire sprinkler. DD stated the dirt could go to the food and residents could get sick of food poisoning, diarrhea and stomachache or infection as a potential outcome. A review of facility's Policies and Procedures (P&P) titled Cleaning Schedule dated 4/17/2024 indicated All areas and equipment in the kitchen should be cleaned daily. A review of Food Code 2017 indicated 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be clean to sight and touch. (B) NonFood-Contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris.

Based on observation, interview, and record review the facility failed to have a policy regarding the use and storage of food brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption when the policy did not include the facility's responsibility for storing food brought in by family and other visitors as it indicated The facility cannot store outside food. This deficient practice had the potential to cause a decrease food intake resulting to unintentional (without trying) weight loss, frustrations, and psychosocial harm to 117 of 161 facility residents. Findings: During a review of the facility's Policies and Procedures (P&P) untitled dated 4/17/2024, the P&P indicated Policy: This policy is for all residents in the facility in regard to outside food. Background: This policy was created to increase compliance with diet orders and prevent foodborne illness. Procedure: All food and beverage brought into the facility from outside, and those obtained from vending machines within the facility, must be cleared through the charge nurse before being given to any resident. The quantity of perishable food kept at bedside shall not be more than one meal that can easily be used by the resident within 4 hours. All foods must be kept in sealed packages or airtight containers. The facility cannot store outside food. All must meet current diet orders. During an interview with the Dietary Director (DD) on 8/21/2024 at 3:19 p.m., the DD stated he has to review the food from home policy however he was aware they were not allowed to take prepared food from the outside because the resident had no control of the temperature of the food as there were no refrigerator in the nurse's station, in the residents room and in the kitchen designated for food from the outside source. The DD stated the only food they were allowed to take from the visitors were packaged food. During an interview with Licensed Vocational Nurse 2 (LVN2) on 8/21/2024 at 3:25 p.m., LVN2 stated their procedure for resident's bringing food from the outside either coming from the visitors or relatives were as follows: (1) she checked the diet orders and allergies to ensure residents could have the food. (2) they check with the Registered Nurse (RN) Supervisors. (3) they have a refrigerator in the kitchen for resident's food storage however they did not have any storage of food in station one (1), two (2), three (3), four (4) and subacute units. (4) she would ask the kitchen staff to store the food from the outside. LVN2 stated residents were allowed to bring food from the outside source as part of their resident's rights and they tried to accommodate resident's request in the best way they could as residents considered the facility their home. LVN2 stated it was important to store resident's food in the refrigerator to keep it fresh and prevent it from spoiling as it could cause food poisoning as a possible outcome. LVN 2 stated she would say no for residents who wanted to consume food a later time due to food safety. LVN 2 stated the residents could get upset and unhappy as a potential outcome of not being able to consume food later. During an interview with Director of Nursing (DON) on 8/23/2024 at 3:38 p.m., the DON stated their food from the outside policy allowed the family to bring food for one serving only as there was no personal storage or refrigerators in the resident's room or in the nurse's stations. The DON stated residents could only keep the food for four (4) hours. The DON stated it was part of the resident's rights for the residents to be allowed to bring food from outside sources however it had to be safe and refrigerated. The DON stated they would say no to residents who would not consume food within 4 hours and encouraged the resident's family to bring food in portions and come back the following day. The DON stated residents could be upset and unhappy as a potential outcome for not allowing them to bring food from the outside source to be consumed later. During an interview with the Administrator (ADM) on 8/23/2024 at 4:15 p.m., the ADM stated residents were allowed to bring from the outside and any perishable items needed to be consumed right away as they could not keep the resident's food from the outside too long. The ADM stated they gave residents a storage box for non-perishable food from outside however they did not have storage for perishable foods. ADM stated they encouraged families to bring 1 meal for single consumption. ADM stated they did not have a storage for perishable foods, but it could be stored if needed however they have a space and accessibility challenges. The ADM stated they would try to bring the residents and family what they needed like purchasing food for them. The ADM stated residents brining outside food has not been an issue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Certified Occupational Therapy Assistant (COTA 1) had an active California occupational therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) license to perform occupational therapy treatments at the facility. COTA 1's California Board of Occupational Therapy license expired [DATE] and COTA 1 continued to perform occupational therapy treatments at the facility as of [DATE]. This deficient practice resulted in an unlicensed COTA performing occupational therapy treatment for at least three months. Findings: During a review of the facility's Rehabilitation Staff Work Schedule on [DATE] at 1:25 PM, the Work Schedule indicated COTA 1 was scheduled to work [DATE], [DATE], [DATE], [DATE], and [DATE]. During a review of California Board of Occupational Therapy (CBOT) licenses for OT staff at the facility, the CBOT website indicated COTA 1's license expired [DATE]. During an interview on [DATE] at 1:41 PM, the Director of Rehabilitation (DOR) confirmed that according to CBOT website, COTA 1's California OT license was expired as of [DATE]. DOR stated according to CBOT, it was a system error, but the facility had not received anything in writing from CBOT indicating COTA 1 could continue to practice OT as of [DATE]. DOR stated COTA 1 was still working at the facility as of [DATE]. the DOR stated COTA 1 was not working at the facility today. During an interview and record review on [DATE] at 3:48 PM, the DOR provided an email from CBOT dated [DATE] indicating COTA 1's license renewal was being held and the renewal process for COTA 1's license was not complete. DOR reviewed the facility's policy on credentials validation and stated COTA 1 should not have been scheduled to work and COTA 1's access should have been deactivated on [DATE] when the facility did not receive a copy of COTA 1's active and renewed license by [DATE]. The DOR confirmed the facility continued to schedule COTA 1 to perform OT treatments as of yesterday, [DATE]. During an interview on [DATE] at 4:14 PM, the Director of Nursing (DON) stated the rehabilitation staff are contracted with a rehabilitation company. DON stated the rehabilitation company's policies were facility's policies and the facility was expected to follow the same policies. DON stated that all occupational therapists should have an active license to provide occupational therapy treatment to the facility's residents. During a review of the facility's job description for a COTA dated [DATE], the job description indicated a license as a COTA in the State of California was required. During a review of the facility's policy titled, Credentials Validation and Notification Guideline, dated [DATE], the policy indicated, any employee with any of the expired credentials will not be scheduled to work. HR is responsible for deactivating employee's access to the Net Health if the license is expired .employee is responsible to renew and submit all the credential to Human Resources. The policy indicated required credentials include a professional license.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain accurate and complete clinical records in accordance with accepted professional standards and practices for four of 21 sampled residents (Residents 122, 125, 138, and 6) when: a. Certified Nursing Assistant 5 (CNA 5) did not accurately document the percentage (%, a unit of measurement) of Resident 122's meal intake. b. Resident 6's August 2024 Restorative Nursing Aide (RNA, nursing aide program that help residents to maintain their function and joint mobility) Documentation Survey Report (record of nursing aide tasks) was not accurately documented when it did not indicate whether the right knee splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) and both ankle foot orthosis (AFO, an orthotic device designed to correct or address problems with the ankle and foot) were put on and for how long. c. Resident 6's August 2024 Restorative Nursing Weekly Summary - Splint Care was not accurately documented when it indicated Resident 6 received RNA for right knee splint seven (7) times a week when Resident 6 did not receive RNA treatment for right knee splint at least three to four times a week. d. Resident 125's July 2024 and August 2024 RNA Documentation Survey Report was not accurately documented when it indicated Resident 125 received RNA for left elbow splint and both hand rolls (device to keep fingers open) 7 times a week when Resident 125 did not receive RNA treatment for left elbow splint and both hand rolls during RNA treatment. e. Resident 138's August 2024 RNA Documentation Survey Report and Restorative Weekly Summary - Splint Care dated 8/5/24, 8/12/24, and 8/19/24 were not accurately documented when it indicated Resident 138 received RNA for left elbow splint, left resting hand splint, and right hand roll 7 times a week when Resident 138 did not receive RNA treatment for left elbow splint, left resting hand splint, and right hand roll 7 times a week. f. Resident 138's August 2024 RNA Documentation Survey Report was also not accurately documented when it did not indicate whether Resident 138 completed sitting edge of bed or range of motion exercises during RNA treatment. These deficient practices contributed to inaccurate documentation in Residents 122, 6, 125, and 138's medical charts and had the potential for inaccurate reporting of joint range of motion limitations and assessment of RNA program for Residents 6, 125, and 138 and cause a delay in provision of appropriate interventions. Findings: a. During a review of Resident 122's admission Record, the admission Record indicated the facility admitted the resident on 10/4/2022 with diagnoses that included metabolic encephalopathy (an alteration in consciousness due to brain dysfunction), moderate protein-calorie malnutrition (an energy deficit due to a lack of dietary protein [a nutrient needed for the body to function properly]), and unspecified dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). During a review of Resident 122's Minimum Data Set (MDS - an assessment and care screening tool) dated 7/19/2024, the MDS indicated the resident was able to understand others and was able to make herself understood. The MDS indicated the resident required setup or clean-up assistance with eating. The MDS further indicated the resident had a weight loss of five % or more in the last month or loss of ten % or more in the last six months. During a review of Resident 122's History and Physical (H&P) dated 7/12/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 122's Nutritional Amount Eaten form, dated 8/20/2024 at 1:38 p.m., the form indicated the resident ate 100 % (all) of the meal. During a concurrent observation and interview on 8/20/2024 at 12:32 p.m., Resident 122 sat in a wheelchair in the Recreation Dining Room and was self-feeding. Observed the resident did not eat the meat on the plate. Resident 122 stated she did not like the meat. During a concurrent observation and interview on 8/20/2024 at 12:45 p.m., observed Resident 122 self-propelled in her wheelchair toward the door. Observed Resident 122 stated to TN 1 that she did not like the meat. Observed TN 1 placed Resident 122's dirty tray in the meal cart. TN 1 stated Resident 122 did not eat the meat served at lunch. Observed the meat remained on Resident 122's plate. During a concurrent interview and record review on 8/20/2024 at 2:30 p.m., Certified Nursing Assistant 5 (CNA 5) reviewed Resident 122's Nutritional Amount Eaten form, dated 8/20/2024 at 1:38 p.m. CNA 5 stated she documented Resident 122 ate 100 % of lunch. CNA 5 stated she did not see Resident 122's tray and she could not remember who told her that Resident 122 ate 100% of the meal. During an interview on 8/20/2024 at 2:40 p.m., TN 1 stated that she put Resident 122's dirty tray on the meal cart and did not tell CNA 5 that Resident 122 ate 100 % of the lunch meal. TN 1 stated she told CNA 5 where Resident 122's dirty tray was located, and she thought CNA 5 would look at the tray to determine the amount eaten. TN 1 stated CNA 5's documentation that indicated Resident 122 ate 100 % of the lunch meal was not accurate and CNA 5 should not have documented if she did not know how much the resident ate. During an interview on 8/23/2024 at 12:11 p.m., the Assistant Director of Nursing (ADON) stated CNA 5 and TN 1 did not properly communicate when CNA 5 documented Resident 122 ate 100% of the lunch meal. The ADON stated CNA 5 was responsible to look at the tray to determine the amount eaten. The ADON stated a resident's chart should contain accurate information, but Resident 122's chart was not accurate when CNA 5 documented the resident ate 100%. The ADON stated when a resident's chart contains documentation of inaccurate meal percentage intake, it would create discrepancies that may potentially result in a decline in the resident's nutrition and further weight loss. During a review of the facility policy and procedure titled, Charting and Documentation, last reviewed 4/17/2024, indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation in the medical record will be objective and accurate. Certified nursing assistants may only make entries in the resident's medical chart as permitted by facility policy. During a review of the facility policy and procedure titled, Resident Food Preferences, last reviewed 4/17/2024, the policy indicated nursing staff will document the resident's food intake in the chart. During a review of the Certified Nursing Assistant Job Description, approval date 8/23/2011, indicated the CNA's essential job duties and responsibilities include observing and documenting the percentage of meal intake. b.c. During a review of Resident 6's admission Record (AR) dated 8/22/24, the AR indicated Resident 6 initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including respiratory failure (any condition that affects breathing function and result in lungs not functioning properly), Parkinson's disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement) without dyskinesia (involuntary movements of extremities), and functional quadriplegia (weakness or paralysis to all four extremities). During a review of Resident 6's Order Summary Report dated 8/1/24, the Order Summary Report indicated an order dated 5/9/24 for RNA/Nursing Program established for active assistive range of motion (AAROM, movement at a given joint with a person's own effort and assistance from an external force or another person) for both UE (BUE), passive range of motion (PROM, movement at a given joint with full assistance from another person) for both LE (BLE) as tolerated followed by right knee splint, and both AFOs for four to six (4-6) hours or as tolerated, once a day, 7 times a week. During a review of Resident 6's care plan dated 5/9/24, the care plan indicated Resident 6 had limitations in range of motion and contractures (loss of motion of a joint). The care plan goal was to minimize complications related to decreased mobility or contractures through appropriate interventions through the next assessment. The care plan interventions indicated restorative nursing for AAROM to BUE, PROM to BLE, right knee splint and both AFOs for 4-6 hours or as tolerated 7 times a week, and orthotic application and skin integrity management. During a review of Resident 6's Documentation Survey Report for RNA intervention/task dated August 2024, the RNA report indicated Resident 6 completed 15 minutes of PROM 7 days a week. The RNA report did not indicate when Resident 6 did or did not wear the right knee splint or AFOs. During a review of Resident 6's Restorative Nursing Weekly Summary - Splint Care dated 8/2/24, the Splint Care Weekly Summary indicated Resident 6 had right knee splint and both AFO with a wearing schedule of four to six hours in AM. The Splint Care Weekly Summary indicated not applicable to questions in other, refuses to wear, resident takes off, and indicated no for change of condition. During a review of Resident 6's Restorative Nursing Weekly Summary - Splint Care dated 8/9/24, the Splint Care Weekly Summary indicated Resident 6 had right knee splint and both AFO with a wearing schedule of four to six hours in AM. The Splint Care Weekly Summary indicated not applicable to questions in other, refuses to wear, resident takes off, and indicated no for change of condition. During a review of Resident 6's Restorative Nursing Weekly Summary - Splint Care dated 8/16/24, the Splint Care Weekly Summary indicated Resident 6 had right knee splint and both AFO with a wearing schedule of four to six hours in AM. The Splint Care Weekly Summary indicated not applicable to questions in other, refuses to wear, resident takes off, and indicated no for change of condition. During a concurrent observation and interview on 8/22/24 at 9:24 AM with Restorative Nursing Aide (RNA 1) of Resident 6's RNA treatment session in Resident 6's room, RNA 1 stated Resident 6 had an RNA order for AAROM for BUE and PROM for BLE and a right knee splint and both AFOs. RNA 1 removed a white hand mitten from Resident 6's right hand and started to bend and straighten Resident 6's right knee. Resident 6's right knee was in a fully bent position and RNA 1 could straighten the right knee a little. RNA 1 moved the right leg outward and in towards the body, and ankle away and towards the body. RNA 1 was able to move the ankles a little. RNA 1 stated Resident 6 had pain with moving lower extremity so RNA 1 would try the upper extremity. RNA 1 attempted to straighten right elbow which were in bent position. RNA 1 stated Resident 6 was resisting, stopped the RNA treatment, left the room, and reported to Licensed Vocational Nurse (LVN 5). RNA 1 returned to Resident 6's room and stated RNA 1 would put on the AFOs. RNA 1 attempted to move left arm up, stated Resident 6 was resistive and stopped. RNA 1 retrieved both AFOs from cabinet and put on both ankles/feet. RNA 1 retrieved a blue right knee splint, attempted to straighten the right knee, stated Resident 6 was resisting and did not put right knee splint on. LVN 5 entered the room and RNA 1 reported to LVN 5 that Resident 6 could not put on the right knee splint. RNA 1 stated Resident 6 was able to wear the right knee splint yesterday for about four to six hours, but usually Resident 6 could not wear the knee splint about four times a week. During a concurrent interview and record review on 8/22/24 at 9:52 AM, RNA 1 stated on 8/18/24 Resident 6 did not tolerate the right knee splint. RNA 1 reviewed RNA daily task documentation on 8/18/24 and stated no, he did not document that Resident 6 did not tolerate the right knee splint. RNA 1 stated he did not report this to the charge nurse. RNA 1 reviewed RNA Weekly Summary for Splint Care dated 8/16/24 and stated he did not document that Resident 6 did not tolerate the right knee splint for at least one day. RNA 1 stated Resident 6 had not been tolerating the right knee splint about three to four times a week for many weeks but could not remember for how long. RNA 1 stated he should have documented and reported to nursing and rehabilitation department whenever Resident 6 did not tolerate any part of the RNA treatment, including when Resident 6 was resisting range of motion and ROM could not be completed or could not wear the right knee splint. RNA 1 stated it was important to document what happened daily during RNA treatment because documentation needed to be accurate and he would not remember how many times a week Resident 6 did not wear the splint in order to document the RNA Weekly Summary accurately. During a concurrent interview and record review on 8/21/24 at 9:55 AM, the Director of Rehabilitation (DOR) reviewed Resident 6's RNA daily documentation and stated if the RNA completed the whole RNA treatment order, then they just answer the questions for the daily RNA task, but if the RNA did not complete any part of the RNA treatment order, then the RNA would document that separately. DOR stated the RNA daily documentation for Resident 6 did not have a question on whether RNAs put on the right knee splint or both AFOs and how long they put on the splints for. DOR stated it was important for RNAs to document how long a resident was tolerating the splints, because the RNA documentation was information staff reviewed to see if a resident was tolerating the splint, if the splint still fit, if the resident was getting worse. During an interview and record review on 8/22/24 at 2:36 PM with Registered Nurse (RN 1) and Registered Nurse (RN 5), Resident 6's clinical records were reviewed. RN 1 and RN 5 stated they were both the RN supervisors for Resident 6. RN 1 and RN 5 reviewed Resident 6's orders and stated Resident 6 had an RNA order for AAROM BUE, PROM BLE, R knee splint and both AFOs for 4-6 hours or as tolerated 7 days a week. RN 1 and RN 5 stated if Resident 6 could not tolerate any part of the RNA program, then the RNAs should document that the resident could not tolerate the RNA treatment. After a review of Resident 6's RNA documentation, RN 1 and RN 5 stated the RNAs did not document that Resident 6 did not tolerate any part of the RNA program. During an interview on 8/22/24 at 2:56 PM, the Certified Nursing Assistant (CNA 1) he was a regular CNA for Resident 6. CNA 1 stated sometimes Resident 6 had a right knee splint and sometimes Resident 6 did not. CNA 1 stated Resident 6 did not wear a right knee splint every day. During an interview on 8/22/24 at 4:41 PM, the Director of Nursing (DON) stated the RNA program was a restorative nursing program to help make sure the mobility of residents was maintained. DON stated if the RNAs were not following the RNA order, then there was a risk of decline in function for the residents. DON reviewed Resident 6's August 2024 RNA Documentation Survey Report and August RNA Weekly Summary - Splint Care and stated the RNA documentation was not accurate, because the RNA did not complete the whole order and did not document whether the splint was put on and for how long. DON stated documentation should be accurate and complete. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, last reviewed 4/17/24, the P&P indicated all services provided to the resident, progress toward the care plan goals, or any changes in physical, functional or psychosocial condition shall be documented in the resident's medical record .The following information is to be documented in the resident medical record: treatments or services performed, changes in the resident's condition .Documentation in the medical record will be objective, complete, and accurate .documentation of procedures and treatments will include care-specific details, including how the resident tolerated the procedure/treatment, whether the resident refused the procedure/treatment. During a review of the facility's policy and procedure titled, Restorative Nursing Program, last reviewed 4/17/24, the P&P indicated weekly assessments are to be made of the resident's progress in the RNP by the restorative nurse and documented in the resident's medical record. Any change in the resident's condition or response to treatment is reported to nursing and documented in the medical record. d. During a review of Resident 125's AR dated 8/22/24 indicated Resident 125 initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to acute and chronic respiratory failure, acquired absence of right leg above knee, acquired absence of left leg above knee, hemiplegia (weakness to one side of the body) affecting left nondominant side. During a review of Resident 125's Order Summary Report dated 8/1/24, the Order Summary Report indicated an order dated 4/11/24 for RNA/Nursing program for PROM for BUE and BLE as tolerated followed by both hand rolls, both AFOs, and left elbow splint for 4-6 hours or as tolerated, once a day, 7 times a week. During a review of Resident 125's care plan dated 4/11/24, the care plan indicated Resident 125 had limitations in range of motion and contractures. The care plan goal was to minimize complications related to decreased mobility or contractures through appropriate interventions through the next assessment. The care plan interventions indicated restorative nursing for PROM for BUE and BLE, splinting with both hand rolls, and left elbow splint for 4-6 hours or as tolerated 7 times a week, with orthotic application and skin integrity management for BUE. During a review of Resident 125's Documentation Survey Report for RNA intervention/task dated July 2024, the RNA report indicated Resident 125 put on a splint every day (except 7/6/24) for either 4 or 6 hours. The RNA report did not indicate what splint was put on (left elbow splint or right or left hand rolls and time each splint was worn). The RNA report did not indicate if Resident 125 completed PROM exercises for BUE or BLE. During a review of Resident 125's Documentation Survey Report for RNA intervention/task dated August 2024, the RNA report indicated Resident 125 put on a splint every day (except 8/15/24) for either 2,4, or 6 hours. The RNA report did not indicate what splint was put on (left elbow splint or right or left hand rolls and time each splint was worn). The RNA report did not indicate if Resident 125 completed PROM exercises for BUE or BLE. During an observation and interview on 8/22/24 at 8:13 AM with Restorative Nursing Aide (RNA 2) of Resident 125's RNA treatment session in Resident 125's room, RNA 2 bent and straightened Resident 125's left elbow. RNA 2 was able to straighten the left elbow to about halfway. RNA 2 completed PROM to both UE and lifted both amputated legs up and down. RNA 2 completed the PROM exercises and did not put on any splints or hand rolls on Resident 125 during the RNA treatment session. During an interview and record review on 8/22/24 at 8:32 AM with RNA 2, RNA 2 stated he worked with Resident 125 a lot because they were assigned certain stations and residents. RNA 2 stated he performed PROM with Resident 125 every day and RNA 2 stated he did not think Resident 125 had any splints because Resident 125's hands were not contracted. RNA 2 reviewed Resident 125's RNA orders and RNA documentation and stated Resident 125 had an RNA order for PROM for BUE and BLE followed by both hand rolls and left elbow splint for 4-6 hours as tolerated seven times a week. RNA 2 stated he was not putting hand rolls of left elbow splint on Resident 125, because he thought Resident 125 graduated from that. RNA 2 confirmed Resident 125 had an order to put on a left elbow splint and both hand rolls and that Resident 125 should wear the elbow splint and hand rolls. RNA 2 confirmed the RNA daily documentation indicated that RNA 2 was putting on the splint every day. RNA 2 stated that he should have put N/A if he was not putting on the elbow splint or hand rolls. RNA 2 stated he should have documented whenever he reported to nursing and DOR that Resident 125 did not put on elbow splint and hand rolls. RNA 2 confirmed he continued to document in RNA daily task that he spent 15 min putting on splints and that Resident 125 tolerated the splints for 4 or 6 hours. RNA 2 stated that the documentation was not accurate and did not reflect what RNA 2 completed with Resident 125 during RNA treatment. During an interview and record review on 8/22/24 at 10:57 AM, Registered Nurse (RN 4) stated the purpose of the RNA program was for RNAs to perform ROM and put splints on the residents in order to prevent contractures. RN 4 stated the RNAs should follow and complete the orders for RNA program for each resident. RN 4 stated that if the resident could not put on a splint for any reason as ordered, then the RNA should report it so it could be documented. RN 4 stated she was not aware that Resident 125 was not wearing the splints or hand rolls. RN 4 stated the RNA documentation should reflect that Resident 125 was not wearing the elbow splint or hand rolls. RN 4 reviewed the RNA documentation in August 2024 and stated the RNA documentation indicated Resident 125 was wearing the splint every day. RN 4 stated it was important to document correctly to show if the resident was getting worse or better and to show what actually happened. RN 4 stated RNAs should be documenting not applicable if they were not putting on the splints or hand rolls. During an interview on 8/22/24 at 4:27 PM, DON stated RNAs should be following the RNA orders and report if Resident 125 was not tolerating or completing any part of the RNA order. DON stated the RNA documentation was not accurate since May 2024 since the RNAs were not putting on the splints and hand rolls. DON stated documentation should be accurate and complete. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, last reviewed 4/17/24, the P&P indicated all services provided to the resident, progress toward the care plan goals, or any changes in physical, functional or psychosocial condition shall be documented in the resident's medical record .The following information is to be documented in the resident medical record: treatments or services performed, changes in the resident's condition .Documentation in the medical record will be objective, complete, and accurate .documentation of procedures and treatments will include care-specific details, including how the resident tolerated the procedure/treatment, whether the resident refused the procedure/treatment. During a review of the facility's policy and procedure titled, Restorative Nursing Program, last reviewed 4/17/24, the P&P indicated weekly assessments are to be made of the resident's progress in the RNP by the restorative nurse and documented in the resident's medical record. Any change in the resident's condition or response to treatment is reported to nursing and documented in the medical record. e.f. During a review of Resident 138's AR dated 8/22/24, the AR indicated Resident 138 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to chronic respiratory failure, intracerebral hemorrhage (bleeding in the brain). During a review of Resident 138's Order Summary Report dated 8/1/24, the Order Summary Report indicated an order dated 7/1/24 for RNA/Nursing Program for active range of motion (AROM, movement at a given joint when the person moves voluntarily) or AAROM for BUE and BLE as tolerated followed by sitting at edge of bed as tolerated followed by left resting hand splint, left elbow extension splint, and right hand roll for 4-6 hours or as tolerated, once a day, seven times a week. During a review of Resident 138's care plan dated 7/1/24, the care plan indicated Resident 138 had limitations in range of motion and contractures. The care plan goal was to minimize complications related to decreased mobility or contractures through appropriate interventions through the next assessment. The care plan interventions indicated restorative nursing for AAROM to BUE and BLE, left resting hand splint, left elbow extension splint and right hand roll for 4-6 hours or as tolerated seven times a week, and orthotic application and skin integrity management, and sitting at edge of bed as tolerated. During a review of Resident 138's Documentation Survey Report for RNA intervention/task dated August 2024, the RNA report indicated Resident 138 tolerated a splint for 4 hours on 8/16/24, 8/17/24, 8/18/24, 8/19/24, 8/20/24, and 8/21/24. The RNA report did not indicate which splint was put on for 4 hours, if ROM exercises were completed, or if sitting edge of bed activity was completed. During a review of Resident 138's Restorative Weekly Summary - Splint Care dated 8/5/24, the RNA Weekly Summary indicated no for splint, yes for hand roll, not applicable for hand/arm splint with a wearing schedule of 4-6 hours in AM. The RNA Weekly Summary indicated no for refuses to wear, no for resident takes off, no for change of condition, no for charge nurse notified. During a review of Resident 138's Restorative Weekly Summary - Splint Care dated 8/12/24, the RNA Weekly Summary indicated no for splint, yes for hand roll, not applicable for hand/arm splint with a wearing schedule of 4-6 hours in AM. The RNA Weekly Summary indicated no for refuses to wear, no for resident takes off, no for change of condition, no for charge nurse notified. During a review of Resident 138's Restorative Weekly Summary - Splint Care dated 8/19/24, the RNA Weekly Summary indicated no for splint, yes for hand roll, not applicable for hand/arm splint with a wearing schedule of 4-6 hours in AM. The RNA Weekly Summary indicated no for refuses to wear, no for resident takes off, no for change of condition, no for charge nurse notified. During an observation and interview on 8/21/24 at 1:52 PM in Resident 138's room, Resident 138 stated he used to wear a left elbow splint, but they stopped putting it on. Resident 138 proceeded to use his right arm to grab his left wrist and attempted to straighten his left arm but could not fully straighten the left elbow. Resident 138 stated he used to have a hand roll for the left hand, but it got lost and he never received another one. Resident 138 was able to open the left hand and straighten the left fingers. Resident 138 stated he received his exercises but not the splints or hand rolls. During an interview and record review on 8/22/24 at 8:32 AM, RNA 2 stated he performed AAROM for BUE and BLE and sitting edge of bed with Resident 138. RNA 2 stated sometimes he put on the hand roll and left elbow splint and sometimes Resident 138 wore the splint and hand roll for 1-2 hours. RNA 2 stated if Resident 138 only wore left elbow splint and hand roll for 1-2 hours, then he should document it. RNA 2 stated if Resident 138 did not wear the splints or hand roll, then he should document that Resident 138 did not wear the splints. RNA 2 reviewed the August 2024 RNA treatment record and stated the August 2024 RNA documentation showed Resident 138 wore the splints every day for 4 hours. RNA 2 stated it was not documented that Resident 138 only wore the left elbow splint and hand roll for 1-2 hours. RNA 2 stated there was no place to document if Resident 138 completed ROM or sat edge of bed. RNA 2 stated Resident 138 did not complete sitting edge of bed exercises every day, but there was nowhere to document that. During an interview and record review on 8/22/24 at 11:15 AM, RN 4 stated she was not aware of Resident 138 not wearing or tolerating the elbow splint or hand rolls. RN 4 stated she did not see Resident 138 wearing an elbow splint or hand splints. RN 4 stated Resident 138 was alert and oriented and was able to tell you if he put on an elbow splint, hand splint, or hand rolls. RN 4 reviewed Resident 138's RNA daily documentation in August 2024 and stated the RNA documentation indicated the resident was wearing the splints for 4 hours on 8/21/24. RN 4 stated if Resident 138 was wearing the splint for only 1 hour, then the documentation should indicate the resident wore it for 1 hour and not 4 hours. RN 4 stated the RNA documentation was not accurate. RN 4 stated the documentation should be accurate because we would think Resident 138 was wearing the splint for 4 hours, but in reality, he was only wearing it for 1 hour so we are not getting accurate information for assessments and to make decisions on his care. During an interview on 8/22/24 at 4:35 PM, DON stated RNA program was a restorative nursing program to help make sure the mobility of residents was maintained. DON stated if the RNAs were not following the RNA order, then there was a risk of decline in function for the residents. DON stated the RNA documentation for Resident 138 was not accurate and RNAs should not put 4 hours if the RNA was not putting on the splints or only putting on splints for 1 hour. DON stated the RNA should report to nursing anytime they were not following the RNA order for any reason. DON also stated there was nowhere in the RNA documentation to document if the resident completed the edge of bed exercises or ROM, it only indicated if the resident put on the splint and for how long. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, last reviewed 4/17/24, the P&P indicated all services provided to the resident, progress toward the care plan goals, or any changes in physical, functional or psychosocial condition shall be documented in the resident's medical record .The following information is to be documented in the resident medical record: treatments or services performed, changes in the resident's condition .Documentation in the medical record will be objective, complete, and accurate .documentation of procedures and treatments will include care-specific details, including how the resident tolerated the procedure/treatment, whether the resident refused the procedure/treatment. During a review of the facility's policy and procedure titled, Restorative Nursing Program, last reviewed 4/17/24, the P&P indicated weekly assessments are to be made of the resident's progress in the RNP by the restorative nurse and documented in the resident's medical record. Any change in the resident's condition or response to treatment is reported to nursing and documented in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to ensure: 1. One of one sampled resident's (Resident 74) oxygen's tubing was not touching the floor investigated during a random observation. 2. Licensed Vocational Nurse 1 (LVN 1) tied the gown at the waist before performing care to residents (Resident 89, 119 and 157) who were place on enhanced barrier precaution (an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities) during review of infection control task. 3. Linen carts A, B, C were not covered with a loosely woven/permeable (having pores or openings that permit liquids or gases to pass through) material to protect the linens inside the cart observed during infection control task. 4. The facility has at least two weeks supply of surgical mask during review of infection control task. 5. The water temperature in the facility was above 113 degrees Fahrenheit (a scale for measuring temperature) per Centers for Disease Control and Prevention (CDC, a US federal government agency that works to protect public health) guidelines to prevent the growth of Legionella (a severe form of pneumonia) during review of infection control task. 6. One of five sampled residents (Resident 121) investigated under the urinary catheter (a flexible tube used to empty the bladder) or urinary tract infection (UTI - an infection in any part of the urinary system [kidneys, bladder, or urethra])) care area did not have their urinary catheter bag (a bag used to collect urine from a connected urinary catheter) touching the floor when Resident 121's urinary catheter bag was observed touching the floor on 8/20/2024. 7. a. One of one sampled resident's (Resident 30) handheld nebulizer (HHN - a medical device that turns liquid medication into a very fine mist that a person can inhale through a face mask or mouthpiece) tubing was not touching the floor investigated during a random observation. b.One of one sampled resident's (Resident 30) oxygen concentrator (a machine that uses the air around you to make oxygen) was free of light brown colored material on top of the unit investigated during a random observation. 8. Certified Nursing Assistant 2 (CNA 2) was wearing a gown while providing activities of daily living (ADL - basic tasks that must be accomplished every day for an individual to thrive) care to a resident (Resident 111) who was on enhanced barrier precautions (EBP - refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO - microorganisms, mainly bacteria, that are resistant to one or more classes of antimicrobial agents] that requires gown and glove use during high contact resident care activities) investigated during a ramdom observation. Findings: 1. During a review of Resident 74's admission Record, the admission Reord indicated the facility admitted the resident on 5/11/2024, and readmitted the resident on 5/23/2024, with diagnoses including tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow air to fill the lungs), dementia (a group of neurological conditions that affect the brain and cause a loss of cognitive functioning), and transient ischemic attack (a stroke that lasts only a few minutes). During a review of Resident 74's History and Physical (H&P), dated 5/23/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 74's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/18/2024, the MDS indicated the resident rarely to never had the ability to make self-understood and sometimes understand others. During a review of Resident 74's Order Summary Report, dated 7/22/2024, the resport indicated an order for [RT] 5 liters per minute (LPM, the rate at which one liter of matter crosses a given surface during a period of time) oxygen (O2) via T-Piece /T-Collar/M-Mask/Cool Aerosol (an instrument used in weaning of a resident from ventilator during spontaneous breathing trials) as tolerated 24/7 every shift. During a review of Resident 74's Care Plan (CP) titled, Resident is at risk for Coronavirus Disease 2019 (COVID-19 -a highly contagious disease spread from person to person through droplets released when an infected person coughs, sneezes, or talks) infection due to refusal of vaccine/immunization, revised on 8/13/2024, the CP indicated to continue infection control practices to prevent the spread of infection. During a concurrent observation and interview on 8/20/2024, at 11:49 a.m., with Licensed Vocational Nurse 7 (LVN 7), inside Resident 74's room, observed the oxygen tubing of the resident touching the floor. LVN 7 stated the tubing should not be touching the floor to prevent ascending infection to the resident. During an interview on 8/23/2024, at 7:10 p.m., with the Director of Nursing (DON), the DON stated the oxygen tubing should not be touching the floor to prevent infection. During a review of the facility's recent policy and procedure (P&P) titled, Infection Prevention and Control Program, last reviewed on 4/17/2024, the P&P indicated an infection control prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. 2. During a review of Resident 89's admission Record, the admission Record indicated the facility admitted the resident on 3/14/2019, and readmitted the resident on 5/6/2024, with diagnoses including respiratory failure (a serious condition that makes it hard to breathe on your own), tracheostomy, and history of COVID-19. During a review of Resident 89's H&P, dated 5/7/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 89's MDS, dated [DATE], indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident has an order tracheostomy care (a procedure performed routinely to keep the flange, tracheostomy dressing, ties, or straps, and surrounding are clean to reduce the introduction of bacteria into the trachea and lungs). During a review of Resident 89's Order Summary Report, dated 6/25/2024, the report indicated an order for Enhanced Barrier Precaution every shift. During a review of Resident 89's Care Plan titled, Enhanced Barrier Precaution, last revised on 6/24/2024, the CP indicated an intervention to provide Enhanced Barrier precaution gloves, gowns, masks. During a review of Resident 119's admission Record indicated the facility admitted the resident on 1/3/2023, with diagnoses including respiratory failure and tracheostomy. During a review of Resident 119's H&P, dated 1/3/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 119's MDS, dated [DATE], indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident had a stage 3 pressure injury (a full-thickness loss of skin that exposes adipose [fat]) and was on suctioning, tracheostomy care, and on an invasive mechanical ventilator (a lifesaving procedure that uses tube to deliver positive pressure air to a resident's lungs to help them breathe). During a review of Resident 119's Order Summary Report, dated 6/25/2024, indicated an order for On Enhanced Barrier Precautions every shift. During a review of Resident 119's Care Plan titled, Enhanced Barrier Precaution, last revised on 6/24/2024, the CP indicated an intervention to provide Enhanced Barrier precaution gloves, gowns, masks. During a Review of Resident 151's admission Record, the admission Record indicated the facility admitted the resident on 6/5/2024, with diagnoses including acute respiratory failure, tracheostomy, and gastrostomy. During a review of Resident 151's H&P, dated 6/8/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 151's MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident was on a feeding tube (a flexible plastic tube that is inserted into the gastrointestinal tract to provide nutrition, fluids, medicines, or to remove stomach contents) and had an unstageable- deep tissue injury (a full-thickness tissue loss where the base of the ulcer is covered by dead tissue, making it difficult to determine the stage of the injury), suctioning, tracheostomy care, and on an invasive mechanical ventilator. During a review of Resident 151's Order Summary Report, dated 6/25/2024, the order indicated an order for Enhanced Barrier Precautions every shift. During a review of Resident 151's Care Plan titled, Enhanced Barrier Precaution, last revised on 6/24/2024, the CP indicated an intervention to provide Enhanced Barrier precaution gloves, gowns, masks. During a concurrent observation and interview on 8/22/2024, at 8:39 a.m., with LVN 1, inside Residents 89, 119, and 151's room, observed LVN 1 administering medication to residents who were placed on enhanced barrier precaution, wearing a gown that was untied at the waist. LVN 1 stated he should have tied the gown at the back of the waist to ensure he was protected from splashes and contact from the residents' contaminated environment. LVN 1 stated not tying the gown at the waist exposes him from splashes and sprays while giving medication to gastrostomy tubes (a tube inserted through the wall of the abdomen directly into the stomach). During an interview on 8/23/2024, at 7:10 p.m., with the DON, the DON stated LVN 1 should have tied the gown at the waist to ensure protection from splashes and spills. During a review of the facility provided CDC's Sequence for Putting on Personal Protective Equipment (PPE, clothing or equipment that people wear to reduce the risk of injury and illness from exposure to hazards in the workplace), undated, it indicated the type of PPE used will vary based on the level of precautions required, such as standard (barriers that separate people from germs to prevent the spread of microorganism in healthcare and residential settings) and contact (used to prevent the spread of diseases that can be spread through contact with open wounds), droplet (steps that healthcare facilities take to prevent the spread of germs from patients who have infections that can be transmitted through coughing, sneezing, or talking) , or airborne (a way to isolate patients who are infected with airborne pathogens that can spread through droplet nuclei) infection isolation precautions. The procedure for putting on and removing PPEs should be tailored to the specific type of PPE. 1. Gown -Fully cover torso from neck to knees, arms to end of wrists, and wrap around the back -Fasten in back of neck and waist. 3. During a concurrent observation and interview on 8/22/2024, at 8:23 a.m., with Treatment Nurse 3 (TN 3), on the unit hallway, observed linen CART C covered with loosely woven/ permeable cover to protect the clean linens inside the cart. TN 3 stated the cover had tiny holes that bacteria and viruses could go through, and liquid can permeate the cover and will not totally protect the linens from environmental contaminants. During a concurrent observation an interview on 8/22/2024, at 9:28 a.m., with Registered Nurse 4 (RN 4), on the unit hallway, observed linen CART A&B covered with loosely woven/permeable cover to protect the clean linens inside the cart. RN 4 stated the cover was not totally protecting the linens inside the carts as air and water can penetrate the cover. RN 4 stated viruses and bacteria were minute and can penetrate the cover and settle on the linen causing infection to residents. During an interview on 8/22/2024, at 9:31 a.m., with the Maintenance Supervisor (MS), the MS stated the covers for the linens were not totally protecting the linens from environmental contaminants because air and water can seep through the covers. During an interview on 8/23/2024, at 7:10 p.m., with the DON, the DON stated they should use non-permeable cover to protect the clean linens and to prevent spread of infection. During a review of the facility's recent policy and procedure (P&P) titled, Infection Prevention and Control Program, last reviewed on 4/17/2024, the P&P indicated an infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. During a review of the facility's recent policy and procedure titled, Laundry and Bedding, Soiled, last reviewed on 4/17/2024, indicated clean linen is protected from dust and soiling during transport and storage to ensure cleanliness. 4. During an observation, interview, and record review on 8/22/2024, with the Central Supply Staff (CSS), inside the Central Supply Room, reviewed the facility's spread sheet of PPE supplies. The CSS stated the burn rate (average consumption rate) for surgical mask per day was 900 pieces. The CSS stated they should have at least 2 weeks supply of PPEs in the facility. The CSS calculated the number of surgical masks needed for 2 weeks and stated he needed to have 12,600 pieces of surgical masks on hand. The CSS stated he did not have enough supply of surgical mask for 2 weeks as he only has 12 boxes or 3,600 pieces currently. The CSS stated it was important to have at least 2 weeks supply of surgical mask in the facility to prevent the spread of infection. During an interview on 8/23/2024, at 7:10 p.m., with the DON, the DON stated they should have at least 2 weeks of PPE supplies in the facility to ensure [NAME] are ready when there is an outbreak such as COVID-19. During a review of the facility's recent policy and procedure titled, Inventory Control, last reviewed 4/17/2024, it indicated our facility maintains an inventory control of our supplies and equipment. The purchasing agent is responsible for maintaining a perpetual inventory of our supplies and equipment. 5. During an interview and record review on 8/22/2024, at 10:22 a.m., with the Administrator (ADM), reviewed the facility's Water Management System Program, the water system diagram, the program membership, the P&P, and the Water Temperature log for 3 months. The ADM stated they are following the CDC guidelines on maintaining water temperatures above 113 degrees Fahrenheit to prevent growth of Legionella in their water system. During a review of the facility provided Daily Water Temperature Log for the month of 8/2024, the log indicated the following: 9:00 am Date ROOM Number Water Temperature (degrees Fahrenheit) 8/1/2024 1 112 8/2/2024 2 112 8/3/2024 2B 112 8/4/2024 3 111 8/5/2024 4 112 8/6/2024 5 112 8/7/2024 6 112 8/8/2024 7 110 8/9/2024 8 112 8/10/2024 9 112 8/11/2024 10 112 8/12/2024 11 112 During an interview and record review on 8/22/2024, at 10:22 a.m., the ADM stated there were multiple days where the temperature was below 113 degrees Fahrenheit from 6/2024 to 8/2024. The ADM stated temperatures below 113 predisposes the facility's water system to develop Legionella that can harm the residents. During an interview and record review on 8/22/2024, at 11:10 p.m., with the Infection Preventionist (IP), reviewed the Water Temperature Log from 6/2024 to 8/2024. The IP stated there were multiple instances where the temperature was below 113 degrees Fahrenheit predisposing the growth of Legionella in the water system of the facility that could cause the resident to get sick. During an interview on 8/23/2024, at 7:10 p.m., with the DON, the DON stated they should keep the temperature of the water at the facility above 113 to ensure Legionella does not grow. During a review of the facility provided Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings by CDC, dated 2/24/2020, it indicated factors internal to buildings can lead to Legionella growth. Water temperature fluctuations: Provide conditions where Legionella grows best (77 degrees F - 113 degrees F); Legionella can still grow outside this range. 7. a. and b. During a review of Resident 30's admission Record, the admission Record indicated the facility admitted the resident on 6/6/2014 and readmitted the resident on 6/4/2024 with diagnoses including but not limited to dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), adult failure to thrive (a condition that happens when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal), and gastrostomy status (a surgical procedure used to insert a tube, through the abdomen and into the stomach to provide a route for tube feeding. During a review of Resident 30's History and Physical (H&P) dated 6/5/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 30's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/13/2024, the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and require total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 30's Order Summary Report, the report indicated: 6/25/2024: On enhanced barrier precautions every shift. 6/4/2024: albuterol sulfate nebulization solution (2.5 milligrams per milliliters (mg/ml - a unit of measurement) 0.083 percent (% - a unit of measurement three (3) ml inhale orally via nebulizer every six (6) hours for acute hypoxemic respiratory failure (severe form of respiratory failure that occurs when there is not enough oxygen in the blood). 6/4/2024: ipratropium-albuterol solution 0.5-25 mg/3 ml 3 ml inhale orally via nebulizer every four (4) hours as needed for shortness of breath or wheezing (a high-pitched whistling sound made while breathing). During a review of Resident 30's care plan (CP), the CP indicated 1. Resident is at risk for shortness of breath, irregular respiration, cough, activity intolerance, fever, nausea and vomiting, sore throat, runny nose initiated 3/19/2020 target date 10/18/2024, indicated to apply oxygen as needed/ordered as on the of the interventions. 2. Enhanced Barrier Precaution: moderate risk for infection initiated 6/18/2024 target date 10/18/2024 with a goal to reduce risk for active infection daily for 3 months. The care plan indicated cleaning and disinfection of equipment as needed as one of the interventions. During a concurrent observation interview and record review on 8/20/2024 at 10:30 am., inside Resident 30's room with Licensed Vocational Nurse 3 (LVN 3), observed Resident 30's HHN tubing touching the floor and the oxygen concentrator had dried light brown colored materials on top of the concentrator. LVN 3 stated the oxygen tubing should not be touching the floor as the tubing was contaminated and the resident can acquire infection. LVN 3 stated the dried light brown colored materials on top the oxygen concentrator was dried feeding formula. LVN 3 stated the equipment should have been cleaned for infection control. During an interview with the Director of Nursing (DON) on 8/23/2024 at 7:45 p.m., the DON stated the Licensed Nurses (LN) are responsible for cleaning any resident equipment while in the room. The DON stated the oxygen concentrator should have been cleaned as soon as the feeding formula spilled on the equipment for infection control. The DON stated the HHN tubing should not be touching the floor as the tubing can get contaminated and resident can acquire infection. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, last reviewed on 4/17/2024, the P&P indicated an infection control prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. 8. During a review of Resident 111's admission Record the admission Record indicated the facility admitted the resident on 1/11/2021 and readmitted the resident on 2/10/2021 with diagnoses including but not limited to PTSD, schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), and dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). During a review of Resident 111's History and Physical (H&P) dated 9/20/2023, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 111's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/18/2024, the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision from staff with eating, partial/moderate assistance with upper body dressing, substantial/maximal assistance with rolling left and right, and dependent on staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 111's Order Summary Report, the report indicated: On enhanced barrier precaution every shift dated 6/18/2024. During an observation 8/20/2024 at 9:43 a.m., observed outside the residents's door a sign Indicating Enhanced Barrier Precautions. During an observation inside Resident 111's room, observed Certified Nursing Assistant 2 (CNA 2) providing ADL care to Resident 111 without wearing a gown, During an interview on 8/20/2024 at 9:51 a.m., with CNA 2, CNA 2 stated the sign by the door means that staff must wear a gown and gloves while providing care to residents with open wound to prevent spread of infection to other residents and/or staff. During an interview on 8/23/2024 at 10 a.m., with the DSD, the DSD stated all staff must wear a gown and gloves during high contact activities to residents who have open wounds or invasive lines. During an interview on 8/23/2024 at 7:45 p.m., with the Director of Nursing (DON), the DON stated for residents who were placed on enhanced barrier precautions, the staff should wear gown and gloves during high contact activities to protect the residents who are vulnerable and prevent cross contamination to other residents and staff. The DON stated residents who have active infection, open wounds, GTF, and/or indwelling urinary catheter are placed on enhanced barrier precautions. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, last reviewed on 4/17/2024, the P&P indicated an infection control prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. During a review of the facility's policy and procedure titled, Enhanced Barrier Precautions. Last reviewed 4/17/2024, indicated: EBP are used as an infection prevention and control intervention to reduce the spread of multidrug resistant organisms (MDROs) to residents. EBP's employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Gowns and gloves are applied prior to performing the high contact resident care activity. Example of high contact resident care activities requiring the use of gowns and gloves for EBPs include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care. 6. During a review of Resident 121's admission Record, the admission record indicated the facility originally admitted Resident 121 on 12/3/2021 and readmitted the resident on 6/16/2022 with diagnoses including, but not limited to, benign prostatic hyperplasia without lower urinary tract symptoms (enlargement of the prostate [gland surrounding the neck of the bladder] that can lead to difficulty in urination) and obstructive uropathy (disorder of the urinary tract that occurs due to obstructed urinary flow and can be either structural or functional). During a review of Resident 121's MDS, dated [DATE], the MDS indicated Resident 121 had moderate cognitive impairment (difficulty understanding and making decisions), required supervision to maximal assistance with activities of daily living, including eating, showering/bathing, hygiene, dressing, and surface-to-surface transfers, and had an indwelling catheter. During a review of Resident 121's H&P, dated 6/10/2024, the H&P indicated Resident 121 had the capacity to understand and make decisions, and had a suprapubic catheter (a hollow flexible tube that is used to drain urine from the bladder). During a review of Resident 121's Order Summary Report, dated 5/21/2024, urinary catheter 18 French (a unit of measure for catheter tubing size) by 10 milliliters (ml - a unit of measure for volume) attached to a bedside drainage bag due to obstructive uropathy with urinary retention (inability to completely empty the bladder). During a review of Resident 121's Care Plan, last reviewed 6/19/2024, the care plan indicated Resident 121 had a care plan for alteration in urinary elimination and at risk for urinary tract infection secondary to use of urinary catheter, suprapubic catheter, due to obstructive uropathy with interventions including, but not limited to, urinary catheter care every shift and maintain proper alignment of urinary catheter to promote proper drainage. During an observation on 8/20/2024, at 10:21 a.m., inside Resident 121's room, a urinary catheter bag, connected to Resident 121, was lying on the floor with a basin lined with a white towel next to the catheter bag. During a concurrent observation and interview with Certified Nursing Assistant (CNA) 6, on 8/20/2024, at 10:23 a.m., inside Resident 121's room, CNA 6 confirmed Resident 121's urinary catheter bag was on the ground next to a basin lined with a white towel. CNA 6 stated it is important to keep a resident's urinary catheter bag in the basin to reduce contamination, which could potentially be a source for infection. During an interview with the DON, on 8/23/2024, at 7:10 p.m., the DON stated urinary catheters should be placed below the bladder so that it can drain. The DON further stated the urinary catheter should be placed in the basin to prevent the spread of infection and prevent the urinary catheter bag from touching the ground. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, last reviewed, 4/17/2024, the P&P indicated an infection prevention and control program is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain an informed consent (a process during which residents or caregivers are educated regarding the potential risks and benefits of medication therapy) from the resident or their responsible party (a person delegated to make medical decisions for the resident in the event they are unable to do so) prior to application of a self-released seat belt for one of three sampled residents (Resident 1). This deficient practice violated the resident's right to be informed of and participate in the resident's treatment. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 3/27/2024 and readmitted the resident on 6/7/2024 with diagnoses including muscle weakness, type 2 diabetes mellitus (DM- a disease that occurs when your blood glucose, also called blood sugar, is too high), and obsessive-compulsive behavior (a long-lasting disorder in which a person experiences uncontrollable and recurring thoughts [obsessions], engages in repetitive behaviors [compulsions], or both). The admission Record indicated the Primary Decision Maker was Responsible Party 1 (RP 1). A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/23/2024, indicated Resident 1 was moderately impaired (decision making poor, requires cues and supervision). The MDS indicated Resident 1 required moderate assistance with showering and requires touching assistance with oral hygiene, toileting, lower body dressing, putting on and taking off footwear, and with personal hygiene. A review of Resident 1's Care Plan, developed on 5/23/2024 indicated Resident 1 was at risk for fall and or injuries secondary to poor safety awareness and actual fall on 5/23/2024. The interventions included to bring the resident to activities, have CNA take the resident to the bathroom as indicated and before bringing to activities and if in wheelchair place at the table and lock wheelchair near activity department. A review of Resident 1's Medication Administration Record (MAR- a report detailing the drugs administered to a patient by a healthcare professional at a treatment facility) dated 6/23/2024 for insulin regular human injection solution inject as per sliding scale, indicated Resident 1 ' s blood sugar was 315 and was given 8 units of insulin by Licensed Vocational Nurse 2 (LVN 2) on 6/23/2024. A review of Resident 1's Fall Risk assessment dated [DATE] indicated Resident 1 had a fall risk score of 24 (a score of 18 or more is High Risk). A review of Resident 1's Physician Orders dated 6/23/2024 at 5 p.m. indicated an order for self-release seat belt (SRSB) while in wheelchair for positioning. Informed consent obtained by medical doctor from RP after explanation of risk and benefits. Ensure equipment is in place and functioning properly. A review of Resident 1's Restraint-Physical dated 6/23/2024 at 5 p.m. indicated Resident 1 had unsteady gait, frequent falls and was agitated, and unable to be redirected. The summary indicated to use self-release belt while in wheelchair for proper positioning secondary to leaning forward. The date and time of first application indicated 6/23/2024 at 5 p.m., the doctor was notified on 6/23/2024 at 5 p.m. and Family Member 1 (FM 1) was notified on 6/23/2024 (no time indicated). A review of Resident 1's Physician Orders dated 6/23/2024 at 8 p.m. indicated to discontinue use of self-release seat belt (SRSB) while in wheelchair for positioning. Informed consent obtained by medical doctor from RP after explanation of risk and benefits. Ensure equipment is in place and functioning properly, per RP request. During an interview on 6/27/2024 at 11:42 a.m., with FM 1, FM 1 stated the Director of Nursing (DON) spoke to her recently (unsure of the date and time) and the DON stated that Resident 1 was improperly restrained and (the DON) wanted Resident 1 to use a lap buddy, to which RP 1 agreed to. FM 1 stated the facility did not obtain FM 1 and RP 1 ' s consent before using the self-release seat belt on Resident 1 on 6/23/2024. FM 1 stated she came into the facility on 6/23/2024 and observed Resident 1 with a restraint. During an interview on 6/27/2024 at 2 p.m. with the DON, the DON stated RP 1 had a concern regarding the use of self- release belt on 6/23/2024. The DON stated Registered Nurse 1 (RN 1) called the doctor on 6/23/2024 around 5 p.m. because Resident 1 was agitated, and staff was not able to redirect Resident 1. The DON stated Resident 1's family was not notified of Resident 1 using the self-release belt. The DON stated the self-release belt was applied on Resident 1 on 6/23/2024 at 5 p.m. and was discontinued on 6/23/2024 at 8 p.m. The DON stated the resident's family must be notified if there is an emergent situation that requires the use of a restraint. During an interview on 6/27/2024 at 2:45 p.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated on 6/23/204 around 4:30 p.m. LVN 2 checked Resident 1's blood sugar and it was low (cannot recall the level) and offered Resident 1 orange juice. LVN 2 stated Resident 1 was leaning forward, with an unsteady gait while the resident was sitting in the wheelchair, due to low blood sugar and the resident kept getting up to go to the bathroom without assistance. LVN 2 stated a CNA was assigned to Resident 1 to monitor and to remind the resident to not get up without assistance, but the CNA had to leave to assist other residents with their meals and that is when LVN 2 asked Registered Nurse 1 (RN 1) for an order for the self-release belt. LVN 2 stated the self-release belt was applied to Resident 1 around on 6/23/2024 at 5 p.m., but she did not call RP 1 or the resident ' s family for a consent. LVN 2 stated FM 1 came to facility around 6:30 p.m. and the self-release belt was taken off around 7:30 p.m. or 8 p.m. LVN 2 stated the resident ' s family should have been informed prior to application of the restraint so they can consent or refuse its use. During an interview on 6/27/2024 at 3:26 p.m. with RN 1, RN 1 stated on 6/23/2024 at 5 p.m. LVN 2 told RN 1 that Resident 1 was agitated, kept going to the bathroom and was unable to be redirected. RN 1 stated, LVN 2 was afraid Resident 1 would fall so RN 1 stated she called the doctor and got an order to apply the self-release belt to Resident 1. 1 RN 1 stated FM 1 came between 6:30 pm and 7 p.m. and stated to LVN 2 FM 1 did not want the self-release belt on Resident 1. RN 1 stated she informed the doctor that FM 1 refused the use of the self-release belt, and the doctor discontinued the order. RN 1 stated the self-release belt was discontinued around 8 p.m. RN 1 stated she did not obtain consent from Resident 1's RP or family member prior to application of the self-release belt to Resident 1. During a concurrent record review and interview on 6/27/2024 at 3:50 p.m. with the DON, Resident 1 ' s Physician Orders dated 6/23/2024 at 5 p.m. and the facility policy Physical Restraint were reviewed. The DON stated the seat release bealt was ordered by the doctor for positioning. The DON stated the informed consent was not obtained from the resident or the surrogate decision-maker before the self-release belt was applied. The DON stated the resident ' s RP must be informed before applying the self-release belt to the resident to ensure the resident ' s rights are being respected. During a concurrent observation and interview on 6/27/2024 at 4:02 p.m. with the DON, inside Resident 1's room, the DON asked Resident 1 if she can unbuckle the self-release belt. Resident 1 was observed attempting to unbuckle the self-release belt and stated, I can't. The DON stated since Resident 1 was unable to unbuckle the self-release belt, the self-release belt is considered a restraint. A review of Posey Self-Releasing Padded Belt manufactures guidelines indicated, Caution this product is designed for self-release. If the patient is not able to easily self-release, it is considered a restraint and must be prescribed by a physician. The manufactures guidelines further indicates: Before applying any restraint: - Use restraint only when all other options have failed. Use the least restrictive device for the shortest time, until you find a less restive alternative. Patients have the right to be free from restraint. - Obtain informed consent from the patient or guardian prior to use. Explain the reason for restraint use to the patient and/or guardian to help ensure cooperation. - A restraint must only be used in accord with the patient ' s individualized Care plan. A review of the facility ' s P&P titled, Physical Restraint, with no revision date, indicated a physical restraint is any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident ' s body that the individual cannot remove easily, and which restrict freedom of movement or normal access to the use of one ' s body. 5. The licensed nurse shall be responsible for obtaining an order from the attending physician, which is to include: a. specific type of restraint. b. purpose of the restraint. c. time and place of application. d. approaches to prevent decreased function when applicable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the patient ' s body that he or she cannot easily remove that restricts freedom of movement or normal access to one ' s body) to one of three sampled residents (Resident 1) by failing to obtain an informed consent from Resident 1 ' s representative prior to application of a restraint (self-release seat belt). This deficient practice had the potential to result in the restriction of residents ' freedom of movement, a decline in physical functioning, psychosocial harm, and physical harm. A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 3/27/2024 and readmitted the resident on 6/7/2024 with diagnoses including muscle weakness, type 2 diabetes mellitus (DM- a disease that occurs when your blood glucose, also called blood sugar, is too high), and obsessive-compulsive behavior (a long-lasting disorder in which a person experiences uncontrollable and recurring thoughts [obsessions], engages in repetitive behaviors [compulsions], or both). The admission Record indicated the Primary Decision Maker was Responsible Party 1 (RP 1). A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/23/2024, indicated Resident 1 was moderately impaired (decision making poor, requires cues and supervision). The MDS indicated Resident 1 required moderate assistance with showering and requires touching assistance with oral hygiene, toileting, lower body dressing, putting on and taking off footwear, and with personal hygiene. A review of Resident 1's Care Plan, developed on 5/23/2024 indicated Resident 1 was at risk for fall and or injuries secondary to poor safety awareness and actual fall on 5/23/2024. The interventions included to bring the resident to activities, have CNA take the resident to the bathroom as indicated and before bringing to activities and if in wheelchair place at the table and lock wheelchair near activity department. A review of Resident 1's Medication Administration Record (MAR- a report detailing the drugs administered to a patient by a healthcare professional at a treatment facility) dated 6/23/2024 for insulin regular human injection solution inject as per sliding scale, indicated Resident 1 ' s blood sugar was 315 and was given 8 units of insulin by Licensed Vocational Nurse 2 (LVN 2) on 6/23/2024. A review of Resident 1's Fall Risk assessment dated [DATE] indicated Resident 1 had a fall risk score of 24 (a score of 18 or more is High Risk). A review of Resident 1's Physician Orders dated 6/23/2024 at 5 p.m. indicated an order for self-release seat belt (SRSB) while in wheelchair for positioning. Informed consent obtained by medical doctor from RP after explanation of risk and benefits. Ensure equipment is in place and functioning properly. A review of Resident 1's Restraint-Physical dated 6/23/2024 at 5 p.m. indicated Resident 1 had unsteady gait, frequent falls and was agitated, and unable to be redirected. The summary indicated to use self-release belt while in wheelchair for proper positioning secondary to leaning forward. The date and time of first application indicated 6/23/2024 at 5 p.m., the doctor was notified on 6/23/2024 at 5 p.m. and Family Member 1 (FM 1) was notified on 6/23/2024 (no time indicated). A review of Resident 1's Physician Orders dated 6/23/2024 at 8 p.m. indicated to discontinue use of self-release seat belt (SRSB) while in wheelchair for positioning. Informed consent obtained by medical doctor from RP after explanation of risk and benefits. Ensure equipment is in place and functioning properly, per RP request. During an interview on 6/27/2024 at 11:42 a.m., with FM 1, FM 1 stated the Director of Nursing (DON) spoke to her recently (unsure of the date and time) and the DON stated that Resident 1 was improperly restrained and (the DON) wanted Resident 1 to use a lap buddy, to which RP 1 agreed to. FM 1 stated the facility did not obtain FM 1 and RP 1 ' s consent before using the self-release seat belt on Resident 1 on 6/23/2024. FM 1 stated she came into the facility on 6/23/2024 and observed Resident 1 with a restraint. During an interview on 6/27/2024 at 2 p.m. with the DON, the DON stated RP 1 had a concern regarding the use of self- release belt on 6/23/2024. The DON stated Registered Nurse 1 (RN 1) called the doctor on 6/23/2024 around 5 p.m. because Resident 1 was agitated, and staff was not able to redirect Resident 1. The DON stated Resident 1's family was not notified of Resident 1 using the self-release belt. The DON stated the self-release belt was applied on Resident 1 on 6/23/2024 at 5 p.m. and was discontinued on 6/23/2024 at 8 p.m. The DON stated the resident's family must be notified if there is an emergent situation that requires the use of a restraint. During an interview on 6/27/2024 at 2:45 p.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated on 6/23/204 around 4:30 p.m. LVN 2 checked Resident 1's blood sugar and it was low (cannot recall the level) and offered Resident 1 orange juice. LVN 2 stated Resident 1 was leaning forward, with an unsteady gait while the resident was sitting in the wheelchair, due to low blood sugar and the resident kept getting up to go to the bathroom without assistance. LVN 2 stated a CNA was assigned to Resident 1 to monitor and to remind the resident to not get up without assistance, but the CNA had to leave to assist other residents with their meals and that is when LVN 2 asked Registered Nurse 1 (RN 1) for an order for the self-release belt. LVN 2 stated the self-release belt was applied to Resident 1 around on 6/23/2024 at 5 p.m., but she did not call RP 1 or the resident ' s family for a consent. LVN 2 stated FM 1 came to facility around 6:30 p.m. and the self-release belt was taken off around 7:30 p.m. or 8 p.m. LVN 2 stated the resident ' s family should have been informed prior to application of the restraint so they can consent or refuse its use. During an interview on 6/27/2024 at 3:26 p.m. with RN 1, RN 1 stated on 6/23/2024 at 5 p.m. LVN 2 told RN 1 that Resident 1 was agitated, kept going to the bathroom and was unable to be redirected. RN 1 stated, LVN 2 was afraid Resident 1 would fall so RN 1 stated she called the doctor and got an order to apply the self-release belt to Resident 1. RN 1 stated FM 1 came between 6:30 pm and 7 p.m. and stated to LVN 2 FM 1 did not want the on Resident 1. RN 1 stated she informed the doctor that FM 1 refused the use of the self-release belt, and the doctor discontinued the order. RN 1 stated the self-release belt was discontinued around 8 p.m. RN 1 stated she did not obtain consent from Resident 1's RP or family member prior to application of the self-release belt to Resident 1. During a concurrent record review and interview on 6/27/2024 at 3:50 p.m. with the DON, Resident 1 ' s Physician Orders dated 6/23/2024 at 5 p.m. and the facility policy Physical Restraint were reviewed. The DON stated the seat release belt was ordered by the doctor for positioning. The DON stated the informed consent was not obtained from the resident or the surrogate decision-maker before the self-release belt was applied. The DON stated the resident ' s RP must be informed before applying the self-release belt to the resident to ensure the resident ' s rights are being respected. During a concurrent observation and interview on 6/27/2024 at 4:02 p.m. with the DON, inside Resident 1's room, the DON asked Resident 1 if she can unbuckle the self-release belt. Resident 1 was observed attempting to unbuckle the self-release belt and stated, I can't. The DON stated since Resident 1 was unable to unbuckle the self-release belt, the self-release belt is considered a restraint. A review of Posey Self-Releasing Padded Belt manufactures guidelines indicated, Caution this product is designed for self-release. If the patient is not able to easily self-release, it is considered a restraint and must be prescribed by a physician. The manufactures guidelines further indicates: Before applying any restraint: - Use restraint only when all other options have failed. Use the least restrictive device for the shortest time, until you find a less restive alternative. Patients have the right to be free from restraint. - Obtain informed consent from the patient or guardian prior to use. Explain the reason for restraint use to the patient and/or guardian to help ensure cooperation. - A restraint must only be used in accord with the patient ' s individualized Care plan. A review of the facility ' s P&P titled, Physical Restraint, with no revision date, indicated a physical restraint is any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident ' s body that the individual cannot remove easily, and which restrict freedom of movement or normal access to the use of one ' s body. 5. The licensed nurse shall be responsible for obtaining an order from the attending physician, which is to include: a. specific type of restraint. b. purpose of the restraint. c. time and place of application. d. approaches to prevent decreased function when applicable.

Based on interview and record review, the facility failed develop a comprehensive person-centered care plan for one of three sampled residents (Resident 1) for the use of self-release seat belt. This deficient practice had the potential to negatively affect the resident's physical wellbeing and inhibit Resident 1's freedom of movement and activity. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 3/27/2024 and readmitted the resident on 6/7/2024 with the diagnoses that included muscle weakness, type 2 diabetes mellitus (DM- a disease that occurs when your blood glucose, also called blood sugar, is too high), and obsessive-compulsive behavior (a long-lasting disorder in which a person experiences uncontrollable and recurring thoughts [obsessions], engages in repetitive behaviors [compulsions], or both). The admission Record indicated Primary Decision Maker was Responsible Party 1 (RP 1). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/23/2024, indicated Resident 1 was moderately impaired (decision making poor, requires cues and supervision). The MDS indicated Resident 1 required moderate assistance with showering and requires touching assistance with oral hygiene, toileting, lower body dressing, putting on and taking off footwear, and with personal hygiene. A review of Resident 1's Physician Orders dated 6/23/2024 at 5 p.m. indicated an order for self-release seat belt (SRSB) while in wheelchair for positioning. Informed consent obtained by medical doctor from RP after explanation of risk and benefits. Ensure equipment is in place and functioning properly. A review of Resident 1's Restraint-Physical dated 6/23/2024 at 5 p.m. indicated Resident 1 had unsteady gait, frequent falls and was agitated, and unable to be redirected. The summary indicated to use self-release belt while in wheelchair for proper positioning secondary to leaning forward. The date and time of first application indicated 6/23/2024 at 5 p.m., the doctor was notified on 6/23/2024 at 5 p.m. and Family Member 1 (FM 1) was notified on 6/23/2024 (no time indicated). During an interview on 6/27/2024 at 3:50 p.m. with the DON, the DON stated there was no care plan created for Resident 1's use of self-release belt. The DON stated there should be a care plan for the use of a restraint. During a concurrent observation and interview on 6/27/2024 at 4:02 p.m. with the DON, inside Resident 1's room, DON asked Resident 1 if she can unbuckle the self-release belt. Resident 1 was observed attempting to unbuckle the self-release belt and stated, I can't. The DON stated since Resident 1 was unable to unbuckle the self-release belt, the self-release belt is considered a restraint. A review of Posey Self-Releasing Padded Belt manufactures guidelines indicated, Caution this product is designed for self-release. If the patient is not able to easily self-release, it is considered a restraint and must be prescribed by a physician. The manufactures guidelines further indicates: Before applying any restraint: - Use restraint only when all other options have failed. Use the least restrictive device for the shortest time, until you find a less restive alternative. Patients have the right to be free from restraint. - Obtain informed consent from the patient or guardian prior to use. Explain the reason for restraint use to the patient and/or guardian to help ensure cooperation. - A restraint must only be used in accord with the patient's individualized Care plan. A review of the facility's P&P titled, Physical Restraint, with no revision date, indicated a physical restraint is any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, and which restrict freedom of movement or normal access to the use of one's body. 5. The licensed nurse shall be responsible for obtaining an order from the attending physician, which is to include: a. specific type of restraint. b. purpose of the restraint. c. time and place of application. d. approaches to prevent decreased function when applicable. e. informed consent obtained from resident or from surrogate decision-maker. 10. The plan of care shall specify the reason for the use of the restraint, the type, when and where it is to be used. A review of the facility's P&P titled, The Resident Care Plan , with no revision date, indicated to provide an individualized nursing care plan and to promote continuity of resident care.

Based on observation, interview and record review, the facility failed to post the daily staffing information accurately in the sub-acute unit on 5/14/2024. The posted daily staffing information posted was for 5/15/2024. This deficient practice had the potential to result in residents, visitors, and facility staff not knowing how many staff were available to provide care to the residents. Findings: During a concurrent observation and interview on 5/14/2024 at 4:45p.m., with the Infection Preventionist (IP), the IP stated the posted nursing staffing information posted in the subacute unit nursing station is dated for 5/15/2024. The IP stated the posted nursing staffing information for 5/14/2024, is behind the 5/15/2024 nursing staffing information. During a concurrent observation and interview on 5/14/2024 at 5:06 p.m. with the Director of Nursing (DON), the DON stated the posted nursing staffing information is dated 5/15/2024. The DON stated that the Director of Staff Development (DSD) is the one responsible for posting the nursing staffing information. The DON stated the DSD posted the nursing staffing information for the next day before she left facility at 3 p.m. The DON stated the posted nursing staffing information should should be the current nursing staffing information to show the accurate hours worked by the nursing staff. A review of the facility ' s policies and procedures, titled, Posting Direct Care Daily Staffing Numbers, last revised on 8/2022 indicated facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents. Within two hours of the beginning of each shift, the number of licensed nurses (RNs, LPN, LVNs, and the number of unlicensed nursing personnel (CNA and NAs) directly responsible for resident care is posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. The information recorded on the form shall include the following: b. The current date (the date for which the information is posted).

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program regarding Coronavirus disease 2019 (COVID-19, a viral infection that is highly contagious and easily transmits from person to person, causing respiratory problems and may cause death) for four of 12 facility staff (Activity Assistant 1 [AA 1], Business Office Assistant [BOA], Certified Nursing Assistant 1 [CNA 1], and Housekeeping 3 [HKP 3]), by failing to ensure AA 1, BOA, CNA 1, and HKP 3 wore the N95 mask (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) properly. This deficient practice placed other residents and staff at risk for exposure and contracting COVID-19. Findings: On 1/9/2024 at 10:35 a.m., during a concurrent observation and interview, observed AA 1's N95 mask was not properly worn. The elastic straps of AA 1's N95 mask were both on the lower back of the neck under her hair. AA 1 stated that the N95 mask top elastic strap must have fallen while she was running around during activities. AA 1 stated that one of the N95 mask elastic strap should be on top of the head and the other elastic strap should be on the neck area to keep an airtight seal around the face. AA 1 stated that not wearing the N95 mask properly had the potential to be exposed to COVID-19 and had the potential to spread the infection to others. AA 1 adjusted her N95 mask with one elastic strap on top of the head and the other on the neck. On 1/9/2024 at 10:45 a.m., during a concurrent observation and interview, observed BOA passed thru resident rooms in the hallway with both the elastic straps of the N95 mask on the neck area over BOA's hair. During the interview, observed BOA touching her N95 mask and lifting it up to cover her nose. BOA stated that the N95's elastic strap slipped down on her way to the elevator. Observed BOA's N95 mask without a tight seal. BOA stated that one of the N95's elastic strap should be above the ears and the other elastic strap on the bottom around the neck area. BOA adjusted her N95 mask and stated that not wearing the N95 mask properly had the potential to spread infections to the residents and staff. On 1/9/2024 at 10:55 a.m., during a concurrent observation and interview, observed CNA 1's N95 mask was not worn properly. The elastic straps of CNA 1's N95 mask were both on the lower back of the neck and there was a visible space between CNA 1's nose and the N95 mask. During the interview, observed CNA 1 pushing her N95 mask to cover her nose. CNA 1 stated that the N95 mask straps slid down while she was working. CNA 1 adjusted her N95 mask and stated that one of the N95's elastic strap should be above the ears and the other elastic strap on the bottom around the neck area. BOA stated that not wearing the N95 mask properly had the potential to spread infections such as COVID-19 to the residents, other staff, and her family. On 1/9/2024 at 11:42 a.m., during a concurrent observation and interview, observed HKP 3 in the hallway, changing the boxes of gloves from the residents' rooms and hallway containers. The elastic straps of HKP 3's N95 mask were both on the lower back of the neck and there was a visible space between HKP 3's nose and the N95 mask. During the interview, observed HKP 3 pushing his N95 mask to cover his nose. HKP 3 stated that one of the N95's elastic straps should be on the head and the other elastic strap on the neck area. HKP 3 stated that he refused to wear the N95 mask properly because the elastic straps hurt his ears. HKP 3 stated that N95 mask that were not worn properly had the potential to spread infections to residents and his coworkers. On 1/9/2024 at 2:23 p.m., during an interview, the Infection Preventionist Nurse (IPN) stated that facility staff were in-serviced and educated on the proper use of the N95 mask. The IPN stated that N95 masks should be worn with one strap on the head and one strap on the neck to create an airtight seal. The IPN stated that wearing the N95 mask properly prevents the spread of infection to other residents and staff. On 1/9/2024 at 3:29 p.m., during an interview, the Director of Nursing (DON) stated that the N95 mask should be well-fitted, on top of the nose bridge creating an airtight seal. The DON stated the one of the N95 mask's elastic strap should be on top of the head and the other elastic strap on the neck area. The DON stated that not wearing the N95 mask properly had the potential to break the seal of the respirator and cause the spread of infection to staff and residents. A review of the facility-provided manufacturer's guidelines on use of N95 mask indicated the N95 mask was designed to help provide respiratory protection for the user. The N95 mask wearing instructions section indicated to place the elastic bands around the neck and head respectively. The N95 mask instructions indicated to put the mask against the face covering both the nose and mouth. It also indicated to adjust the metallic strip cover bridge of the nose using two fingers to press down until achieving a close fit. A review of the facility's policy and procedures titled, COVID-19 Policy, dated 4/19/2023, indicated the purpose to describe the facility's approach to handling the impact of COVID-19 to the facility. The policy and procedures indicated one of the objectives was to maintain a safe and secure environment for resident, staff, and visitors. The face mask and N95 mask section indicated that employees would wear a well fitted surgical mask when providing care to or working in person with residents and in patient care areas. A review of the facility's policy and procedures titled, Infection Control, dated 4/19/2023, indicated the process of donning (putting on) N95 mask was to secure elastic bands at the middle of the head and neck, fit flexible band to the nose bridge, fit snug to the face below the chin, and fit check.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents receive the necessary care based on the assessed individual needs to prevent accidents and minimize injuries for one of the three sampled residents (Residents 1). The facility failed to ensure Resident 1 was provided postural support while sitting in the wheelchair due to abnormalities of gait and mobility. As a result, on 10/7/2023 at 1:55 p.m., Resident 1 fell out of the wheelchair hitting the floor face first. Resident 1 sustained facial lacerations (a cut or tear in the soft tissue of the face). Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) where resident was diagnosed with nasal (nose) bone fractures (broken bones) and facial laceration (a skin wound or cut) repair. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 1/12/2019 with diagnoses including type two diabetes mellitus (a disease that occurs when the blood sugar was too high), secondary hypertension (high blood pressure that was caused by another medical condition), and osteoporosis (a disease in which bones become fragile and more likely to fracture). A review of Resident 1 ' s Care Plan, initiated on 1/31/2019, for the resident ' s risk for falls indicated the goal of reducing risk of falls and injury. The interventions included physical therapy (PT) to assess Resident 1 quarterly and as needed for safety of gait, transfer, sitting balance, and need for safety device. The intervention indicated to provide Resident 1 with a safe environment. A review of resident 1 ' s Care Plan, initiated on 7/27/2019, for the resident ' s risk for falls indicated the intervention to position Resident 1 ' s wheelchair at the table near the activity staff for closer observation and supervision. A review of Resident 1 ' s Change of Condition (COC)/Interact Assessment Form, dated 3/5/2023, indicated that the Resident 1 was found on the floor next to the resident ' s wheelchair in the resident ' s room and sustained bleeding in the nose with redness at the nasal bridge (bony part of the nose). The COC indicated that Resident 1 was sent to the hospital for further evaluation. A review of Resident 1 ' s Care Plan, initiated on 3/5/2023, for the resident ' s actual fall indicated the goal of minimizing the risk of falls and injury thru appropriate interventions. The interventions indicated Resident 1 ' s PT and Occupational Therapy (OT) assessment and training. A review of Resident 1 ' s PT Evaluation and Plan of Treatment, dated 3/6/2023, indicated a treatment diagnosis including abnormal posture. A review of Resident 1 ' s PT Discharge summary, dated [DATE], indicated the resident ' s discharge recommendation was to provide a low bed. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 7/23/2023, indicated the resident had cognitive impairment (conscious mental activities including thinking, reasoning, understanding, learning, and remembering). Resident 1 was unable to walk and was dependent on staff with locomotion on unit (how resident moves between location in her room and adjacent corridor on same floor), locomotion off unit (how resident moves to and returns from off-unit locations). The MDS indicated that Resident 1 ' s balance moving from seated to standing position was not steady and required staff assistance to stabilize. Resident 1 used a wheelchair as mobility device. A review of Resident 1 ' s Fall Risk Assessment, dated 7/26/2023, indicated the resident had a total score of 28. A total score of 18 or more represented high risk for falls. A review of Resident 1 ' s Physician Orders, dated 10/4/2023, indicated physical therapy skilled treatment every day, four times a week for four weeks for the treatment diagnosis of abnormalities of gait and mobility. A review of Resident 1 ' s Licensed Nurses Note, dated 10/4/2023, indicated the resident had impaired decision-making skills and was dependent with two persons assist on sit to stand transfer. A review of Resident 1 ' s re-admission Rehabilitation Screening PT, dated 10/4/2023, indicated that Resident 1 ' s sitting balance was unsteady and required total dependence on staff with one person assist. A review of Resident 1 ' s COC/Interact Assessment Form, dated 10/7/2023, indicated that the resident fell from the wheelchair in the dining room and sustained a cut on the nose bridge and laceration on the right forehead. The attending physician (MD 1) and the responsible party (RP 1) were notified. A review of Resident 1 ' s GACH 1 Emergency Department Encounter Note, dated 10/7/2023, indicated Resident 1 had a two-centimeter (cm – unit of measurement) laceration on the right forehead and a 0.5 cm abrasion on the nasal bridge. The procedure section indicated that Resident 1 had a repair of the right forehead laceration. A review of Resident 1 ' s GACH 1 computed tomography (CT, a procedure that uses a computer to make a series of detailed pictures of areas inside the body) of the maxillofacial (a region in the body that includes the mouth, face, and jaw) report, dated 10/8/2023, indicated nasal bone fractures. A review of Resident 1 ' s GACH 1 History and Physical, dated 10/8/2023, indicated that Resident 1 had a facial laceration repair in the ED. The Assessment section indicated Resident 1 had a nasal fracture noted on the CT of the maxillofacial. A review of Resident 1 ' s GACH 1 Discharge summary, dated [DATE], indicated the resident was admitted for fall with head trauma. Resident 1 ' s discharge diagnoses included nasal fracture noted on CT. On 10/23/2023 at 1:03 p.m., during a telephone interview, Activity Assistant 1 (AA 1) stated that Resident 1 was sitting on a regular wheelchair in the activities room watching tv when the resident leaned forward and fell out of the wheelchair hitting the floor face first. On 10/23/2023 at 2:51 p.m., during a follow up interview, AA 1 stated that Certified Nursing Assistant 1 (CNA 1) brought Resident 1 in the activities room and positioned the resident diagonal to the table. AA 1 stated that the table was in front of Resident 1 ' s right side of the body leaving an open space on the resident ' s left side. On 10/23/2023 at 3:04 p.m., during a concurrent interview and record review, the Director of Rehabilitation (DOR) defined Resident 1 ' s treatment diagnosis of unspecified abnormalities of gait and mobility as the resident was either weak, cannot stand or walk safely, or had dynamic balance concerns. The DOR defined dynamic balance as the resident ' s control over the center of gravity while in motion and a static balance was a resident ' s control over the center of gravity without movement. Resident 1 ' s PT Evaluation and Plan of Treatment, dated 10/4/2023, was reviewed with the DOR and indicated that Resident 1 did not have a static and dynamic balance control. The DOR stated that Resident 1 had the potential to fall and sustain serious injuries. Resident 1 ' s OT Evaluation and Plan of Treatment, dated 10/4/2023, was reviewed with the DOR and indicated that the resident ' s sitting balance during activities of daily living (ADL- skills required to manage basic physical needs such as personal hygiene, grooming, transferring, or ambulating) was poor. The DOR stated that poor sitting balance indicated that Resident 1 required a second person to help perform the ADL tasks. There were no recommendations to use supporting device while sitting to improve posture and safety. On 10/23/2023 at 4:12 p.m., during an interview, the Director of Nursing (DON) stated that resident care plans and rehab evaluation and recommendations should be communicated to the staff including the CNAs. The DON stated that the care plan was not followed which resulted to Resident 1 ' s fall. A review of the facility ' s policy and procedure titled, Accident/Incident Prevention, reviewed on 4/19/2023, indicated the facility identify each resident at risk for accidents/incidents and the provision of adequate care plans with procedures to prevent accidents. The policy indicated the facility monitors accidents or injuries that include falls, assessment/reassessment of residents who had falls, and care planning with implementation plans to provide an environment that were free of accident hazards.

Based on interview and record review, the facility failed to provide the requested medical records to the legal representative of one of three sampled residents (Resident 1). The facility received the request to release Resident 1 ' s medical records on 9/6/2023. This deficient practice violated Resident 1 ' s rights to secure personal medical records. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 7/3/2023 with diagnoses including metabolic encephalopathy (a problem in the brain due to chemical imbalance caused by an illness or organs that are not functioning as well as they should), congestive heart failure (a condition that develops when the heart does not pump enough blood for the body ' s needs), and benign prostatic hyperplasia (enlarged prostate). A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 7/10/2023, indicated the resident ' s cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was severely impaired. A review of the facility ' s fax transmission, dated 9/6/2023, indicated Resident 1 ' s legal representative ' s medical record requests were sent to the facility ' s legal department. A review of the facility ' s Log of Requests for Access to Protected Health Information, dated 9/6/2023, indicated that Resident 1 ' s requested medical records were not provided. The log indicated that the facility ' s response to the request were pending copier and legal communicating with the attorney. On 9/20/2023 at 9:22 a.m., during an interview, the Medical Records Director (MRD) stated that once the authorization to release records were completed, the facility had 72 hours to release the resident ' s medical records. On 9/20/2023 at 10:18 a.m., during a follow up interview, the MRD stated that the facility received Resident 1 ' s legal representative ' s medical record request on 9/6/2023. The MRD stated that Resident 1 ' s medical records were not released to the resident ' s legal representative as of 9/20/2023. A review of the facility ' s policy and procedure titled Release of Information, dated 4/19/2023, indicated that all information contained in the resident ' s medical record were confidential and may only be released by the written consent of the resident or the legal representative, consistent with state laws and regulations. The policy indicated that a resident may have access to his records within hours of the resident ' s written or oral request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents on invasive mechanical ventilators (a lifesaving intervention for patients with respiratory failure) were provided good mucosal (relating to the thin skin inside the mouth) care to the lips and the nasal (relating to the nose) passages to three of three sampled residents (Residents 2, 3, and 4). This deficient practice had the potential for residents on invasive mechanical ventilators to have dry and cracked lips and nasal passages. Findings: A review of Resident 2 ' s admission Record indicated the facility admitted Resident 2 on 7/17/2023 and the facility readmitted Resident 2 on 9/8/2023, with diagnoses including chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), unspecified whether with hypoxia (a condition of the body in which the tissues are starved of oxygen) or hypercapnia (high levels of carbon dioxide in the blood), dependence on respirator (a mask worn over the mouth and nose to protect the respiratory system by filtering out dangerous substances from inhaled air), and tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow air to fill the lungs). A review of Resident 2 ' s History and Physical (H&P), dated 9/11/2023, indicated Resident 2 does not have the capacity to understand and make decisions. A review of Resident 2 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/12/2023, indicated Resident 2 rarely to never had the ability to make self-understood and understand others. The MDS indicated Resident 2 was on oxygen therapy (a treatment that provides with supplemental, or extra, oxygen), suctioning (the mechanical aspiration of pulmonary secretions), tracheostomy care (to ensure airway patency by keeping the tube free from mucus buildup), and on invasive mechanical ventilator. A review of Resident 2 ' s Order Summary Report, dated 9/9/2023, indicated an order for Resident 2 ' s invasive mechanical ventilator on assist control (AC, describe the number of breaths a patient is receiving from the breathing machine) of 18, tidal volume (VT, essentially every breath a person takes) of 450, positive end-expiratory pressure (PEEP, is a pressure applied by the ventilator at the end of each breath) of 5 at 5 liters per minute (LPM, a measurement of the velocity at which air flows into the sample probe) of oxygen (O2) every shift. A review of Resident 2 ' s Care Plan, initiated on 9/12/2023, indicated a care plan for Resident 2 to have oral care, aspiration-related pneumonia (occurs when food or liquid is breathed into the airways or lungs, instead of being swallowed) reduction and prevention. The care plan indicated an intervention for Resident 2 to have daily and every shift order for oral care. Oral care every shift including lips, teeth, tongue, buccal wall, and pharynx (the tube or cavity, with its surrounding membrane and muscles, that connects the mouth and nasal passages). Lip balm as needed. Removal of oropharyngeal (the part of the throat at the back of the mouth behind the oral cavity) secretions. During a concurrent observation and interview on 9/12/2023, at 10:35 a.m., observed with Licensed Vocational Nurse 1 (LVN 1) Resident 2 ' s lips and nasal passages were dry. LVN 1 stated she did not know who was in charge of making sure the nasal passages and the lips of the resident were clean and moist. Respiratory Therapist 1 (RT 1) stated he did not know who was responsible to makes sure the lips and the nasal passages of the residents on ventilator were moist and clean. LVN 1 and RT 1 stated they did not know what to use to moisturize the lips and the nasal passages of the resident. A review of Resident 3 ' s admission Record indicated the facility admitted Resident 3 on 4/25/2023, with diagnoses including chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, dependence on respirator, and tracheostomy. A review of Resident 3 ' s MDS, dated [DATE], indicated Resident 3 had rarely to never had the ability to make self-understood and understand others. The MDS indicated Resident 3 was on oxygen therapy, suctioning, tracheostomy care, and on invasive mechanical ventilator. The MDS also indicated Resident 3 was totally dependent on personal hygiene. A review of Resident 3 ' s Order Summary Report, dated 8/9/2023, indicated an order for: -Resident 3 ' s invasive mechanical ventilator on AC, VT of 400, PEEP of 12 at 5 LPM of O2 as needed for shortness of breath (SOB)/respiratory distress. -May place patient on tbar/tmask (used in weaning of a patient from ventilator during spontaneous breath trials) via 5 LPM O2 6 a.m. to 6 p.m. as tolerated every day and evening shift. A review of Resident 3 ' s Care Plan, initiated on 8/7/2023, indicated a Care plan for Resident 3 to have oral care, ventilator associated pneumonia ([NAME], a lung infection that develops in a person who is on a ventilator) /aspiration-related pneumonia (occurs when food or liquid is breathed into the airways or lungs, instead of being swallowed) reduction and prevention. The care plan indicated an intervention for Resident 3 to have daily and every shift order for oral care. Oral care every shift including lips, teeth, tongue, buccal wall, and pharynx. Lip balm as needed. Removal of oropharyngeal secretions. During a concurrent observation and interview on 9/12/2023, at 10:40 a.m., observed with Licensed Vocational 2 (LVN 2) Resident 3 ' s lips and the nasal passages were dry. LVN 2 stated not knowing what to apply to moisten the nasal passages and the lips of the resident. A review of Resident 4 ' s admission Record indicated the facility admitted Resident 4 on 7/11/2019 and the facility readmitted Resident 4 on 1/6/2022, with diagnoses of chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, dependence on respirator, and tracheostomy. A review of Resident 4 ' s History and Physical (H&P), dated 1/3/2023, indicated Resident 4 did not have the capacity to understand and make decisions. A review of Resident 4 ' s MDS, dated [DATE], indicated Resident 4 rarely to never had the ability to make self-understood and understand others. The MDS indicated Resident 4 was on oxygen therapy, suctioning, tracheostomy care, and on invasive mechanical ventilator. The MDS also indicated Resident 4 was totally dependent on personal hygiene. A review of Resident 4 ' s Order Summary Report, dated 2/9/2023, indicated an order for Resident 4 ' s invasive mechanical ventilator on AC, VT of 500, PEEP of 5, Rate of 12 at 5 LPM of O2 as needed. A review of Resident 4 ' s Care Plan, initiated on 7/20/2023, indicated a care plan for Resident 4 to have oral care, [NAME]/Aspiration-related pneumonia reduction and prevention. The care plan indicated an intervention for Resident 4 to have daily and every shift order for oral care. Oral care every shift including lips, teeth, tongue, buccal wall, and pharynx. Lip balm as needed. Removal of oropharyngeal secretions. During an observation on 9/12/2023, at 11:10 a.m., observed with LVN 2 Resident 4 ' s nasal passages and lips were dry. During an interview on 9/12/2023, at 3:44 p.m., the Director of Staff Development (DSD) stated both respiratory therapist (RT) and licensed nurses were responsible for keeping the lips of the residents moist using lip balm and the nasal passages can be cleaned with a damp cloth to remove encrusted mucus. The DSD stated that moisturizing the lips of the resident was a part of the oral care. The DSD stated failure to perform the care could result to dryness of the mucosa that could lead to skin breakdown. During an interview on 9/12/023, at 3:49 p.m., the Infection Preventionist (IP) stated everybody (RT, licensed nurses, Certified Nursing Assistant [CNA]) should be responsible for moistening the lips and the nose of ventilator residents to prevent dry skin that could crack and cause a skin breakdown. During an interview on 9/12/2023, at 4:44 p.m. the Director of Nursing (DON) stated both the RT and the licensed nurses should have cleaned and moisturized the lips and the nose of ventilator residents to prevent skin from cracking. A review of the facility ' s recent in-service education titled, Oral Hygiene and Dental Care, conducted on 9/7/2023 to 9/8/2023, indicated importance of routine daily oral care: 1. Control infection by removing dental plaque, food particles, and stimulating gums. 2. Make sure the patient is more comfortable by freshening the breath and moisten mouth. Oral care to unconscious resident: Mouth care kit commercially prepared swabs. Or if kit is not available: -tongue depressor -Applicators or sponges -lubricant such as glycerin or substance used by your facility, a solution of lemon juice and glycerin A review of the facility ' s recent policy and procedure titled, A.M. Care, last reviewed on 4/19/2023, indicated the purpose of the policy was to clean resident ' s face and hands before breakfast. Provide a washcloth for each resident and assure that resident ' s hands and face are washed.

Based on observation, interview and record review, the facility failed to anchor (to secure) the urinary indwelling catheter (a thin, hollow tube inserted through the urethra [the tube that lets urine leave your bladder and your body] into the urinary bladder to collect and drain urine) on the leg of a resident to prevent tugging and pulling of the urinary catheter to one of four sampled residents (Resident 3). The deficient practice had the potential for Resident 3 ' s catheter to tug and pull causing trauma to the urinary meatus [duct that transmits urine from the bladder to the exterior of the body during urination] that could lead to infection. Findings: A review of Resident 3 ' s admission Record indicated the facility admitted Resident 3 on 4/25/2023, with diagnoses including acute kidney failure with tubular necrosis (part of the body ' s kidneys are damaged when the flow of blood and oxygen is compromised), hypo-osmolality (the most common disorder of fluid and electrolyte balance encountered in hospitalized patients) and hyponatremia (the sodium level in the blood is below normal), and dehydration (an abnormal loss of water from the body). A review of Resident 3 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/2/2023, indicated Resident 3 had rarely to never had the ability to make self-understood and understand others. The MDS indicated Resident 3 had an indwelling catheter. A review of Resident 3 ' s Order Summary Report, dated 5/26/2023, indicated an order for Resident 3 to secure Foley catheter [a thin, flexible catheter used especially to drain urine from the bladder by way of the urethra] tubing with anchor every day shift (to minimize dislodging of catheter). A review of Resident 3 ' s Care Plan, initiated on 8/7/2023, indicated a care plan for Resident 3 of alteration in urinary elimination and at risk for urinary tract infection (UTI, common infections that happen when bacteria, often from the skin or rectum, enter the urethra, and infect the urinary tract) secondary to use of indwelling catheter. During a concurrent observation and interview on 9/12/2023, observed with Licensed Vocational Nurse 2 (LVN 2) Resident 3 ' s urinary catheter not anchored to the resident ' s leg. LVN 2 stated the urinary catheter should have an anchoring device attached to the leg to prevent pulling of the catheter that causes trauma and infection to set in. During an interview on 9/12/2023, at 3:44 p.m., the Director of Staff Development (DSD) stated there should be an anchoring device on Resident 3 ' s urinary catheter to prevent pulling on the urinary catheter that causes trauma that could lead to infection. During an interview on 9/12/2023, at 3:49 p.m., the Infection Preventionist (IP) stated there should be an anchoring device attached to the urinary catheter of Resident 3 to prevent pulling causing trauma and infection. During an interview on 9/12/2023, at 4:44 p.m., the Director of Nursing (DON) stated the urinary catheter should have a statlock (a strap free device which locks the Foley catheter in place, stabilizes the catheter and eliminates any chance of a sudden pull) or a leg strap to prevent pulling that cause trauma and infection. A review of the facility ' s recent policy and procedure titled, Urinary Tract Infections (Catheter-Associated), Guidelines for Preventing, last reviewed on 4/19/2023, indicated to follow facility procedures for insertion and care of indwelling urinary catheters. It is the responsibility of the interdisciplinary team to maintain vigilant practices to prevent CAUTIs and to recognize and report early indications that a UTI may be developing. Secure catheter after insertion to prevent movement. A review of the facility ' s recent policy and procedure titled, Male Catheterization, last reviewed on 4/19/2023, indicated use of Foley (brand of an indwelling catheter) catheter anchors is required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the intravenous (IV, within a vein) tubing set were affixed with the date, time and initials of the licensed nurse who initiated the IV fluid therapy (is a way to give fluids, medicine, nutrition, or blood directly into the blood stream through a vein) to one of four sampled residents (Resident 2). The deficient practice had the potential for prolonged IV set use predisposing Resident 2 to infection. Findings: A review of Resident 2 ' s admission Record indicated the facility admitted Resident 2 on [DATE] and the facility readmitted Resident 2 on [DATE], with diagnoses including chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), unspecified whether with hypoxia (a state in which oxygen is not available in sufficient amounts at the tissue level to maintain adequate balance in the body) or hypercapnia (high levels of carbon dioxide in the blood), dependence on respirator (a mask or device worn over the mouth and nose to protect the respiratory system by filtering out dangerous substances [such as dusts, fumes, or bacteria] from inhaled air), and tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow air to fill the lungs). A review of Resident 2 ' s History and Physical (H&P), dated [DATE], indicated Resident 2 did not have the capacity to understand and make decisions. A review of Resident 2 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated [DATE], indicated Resident 2 rarely to never had the ability to make self-understood and understand others. The MDS indicated Resident 2 was on parenteral (outside of the digestive tract)/IV feeding and IV medications. A review of Resident 2 ' s Order Summary Report, dated [DATE], indicated an order of: -0.9 % NaCl (used to replenish lost water and salt in the body) at 100 milliliters per hour (ml/hr, flow rate using an intravenous pump [a medical device that delivers fluids] every 72 hours tubing change. -O.9% NaCl at 100 ml/hr every shift. During a concurrent observation and interview on [DATE], at 10:35 a.m., observed with Licensed Vocational Nurse 1 (LVN 1) Resident 2 had an IV infusion of 0.9% NaCl 1 liter running through a triple lumen catheter (TLC, three lumen catheter) peripherally inserted central catheter (PICC, is a long, thin tube that is inserted through a vein in the arm and passed through to the larger veins near the heart) with no date, time and initial of the licensed nurse who initiated the IV therapy. LVN 1 stated the tubing should be dated with initial to make sure the tubing was not used for a prolonged time that could cause infection. During an interview on [DATE], at 3:32 p.m., the Director of Staff Development (DSD) stated the IV tubing set of Resident 2 should have been dated, timed, and initialed by the licensed nurse upon initiation of the IV therapy to prevent prolonged use of the IV tubing set that could cause infection. During an interview on [DATE], at 3:49 p.m., the Infection Preventionist (IP) stated the staff should have dated the IV tubing to know when to change it and for infection control. During an interview on [DATE], at 4:44 p.m., the Director of Nursing (DON) stated the IV bags and the IV tubing should be labeled with date, time, and nurses initial, on initiation of IV therapy to prevent infection because the tubing has expiration. The DON added using an expired IV tubing can lead to infection. A review of the facility ' s recent policy and procedure titled, Administration of an Intermittent Infusion Policy: IV 803, last reviewed on [DATE], indicated administration sets used for intermittent therapy will be changed every 24 hours. Label container and administration set with: 1. Date and time 2. Nurse ' s initials

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program to two of four sampled residents (Residents 2 and 3) by failing to ensure oxygen tubing (used for oxygen delivery during at-home oxygen therapy or in-clinic procedures) were labeled with a date. The deficient practice had the potential for cross contamination (unintentional transfer of bacteria/germs or other contaminants from one surface to another) of infection among residents. Findings: A review of Resident 2 ' s admission Record indicated the facility admitted Resident 2 on 7/17/2023 and the facility readmitted Resident 2 on 9/8/2023, with diagnoses including chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), unspecified whether with hypoxia (a state in which oxygen is not available in sufficient amounts at the tissue level to maintain adequate balance in the body) or hypercapnia (high levels of carbon dioxide in the blood), dependence on respirator (a mask or device worn over the mouth and nose to protect the respiratory system by filtering out dangerous substances [such as dusts, fumes, or bacteria] from inhaled air), and tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow air to fill the lungs). A review of Resident 2 ' s History and Physical (H&P), dated 9/11/2023, indicated Resident 2 did not have the capacity to understand and make decisions. A review of Resident 2 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/12/2023, indicated Resident 2 rarely to never had the ability to make self-understood and understand others. The MDS indicated Resident 2 was on oxygen therapy (a treatment that provides with supplemental, or extra, oxygen), suctioning (the mechanical aspiration of pulmonary secretions), tracheostomy care (to ensure airway patency by keeping the tube free from mucus buildup), and on invasive mechanical ventilator (an advanced airway modality used in patients with immediate or impending respiratory failure). A review of Resident 2 ' s Order Summary Report, dated 9/9/2023, indicated an order for Resident 2 ' s invasive mechanical ventilator on assist control (AC, describe the number of breaths a patient is receiving from the breathing machine) of 18, tidal volume (VT, essentially every breath a person takes) ) of 450, positive end-expiratory pressure (PEEP, is a pressure applied by the ventilator at the end of each breath) of 5 at 5 liters per minute (LPM, a measurement of the velocity at which air flows into the sample probe) of oxygen (O2) every shift. During a concurrent observation and interview on 9/12/2023, at 10:35 a.m., observed with Respiratory Therapist 1 (RT 1) Resident 2 ' s oxygen tubing attached to the ventilator not labeled with a date. RT 1 stated the tubing should be dated to know when the tubing should be replaced and to prevent infection. A review of Resident 3 ' s admission Record indicated the facility admitted Resident 3 on 4/25/2023, with diagnoses including chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, dependence on respirator, and tracheostomy. A review of Resident 3 ' s MDS, dated [DATE], indicated Resident 3 had rarely to never had the ability to make self-understood and understand others. The MDS indicated Resident 3 was on oxygen therapy, suctioning, tracheostomy care, and on invasive mechanical ventilator. A review of Resident 3 ' s Order Summary Report, dated 8/9/2023, indicated an order for: -Resident 3 ' s invasive mechanical ventilator on AC, VT of 400, PEEP of 12 at 5 LPM of O2 as needed for shortness of breath (SOB)/respiratory distress. -May place patient on tbar/tmask (used in weaning of a patient from ventilator during spontaneous breath trials) via 5 LPM O2 6 a.m. to 6 p.m. as tolerated every day and evening shift. During a concurrent observation and interview on 9/12/2023, at 10:40 a.m., observed with Licensed Vocational Nurse 2 (LVN 2) Resident 3 ' s oxygen tubing was not labeled with a date. RT 1 stated the tubing should be dated to know when the tubing should be replaced and to prevent infection. During an interview on 9/12/2023, at 3:44 p.m., the Director of Staff Development (DSD) stated the respiratory therapists should have dated the tubing to know when to change the tubing that could lead to infection. During an interview on 9/12/2023, at 3:49 p.m., the Infection Preventionist (IP) stated the oxygen tubing should be dated, for infection control issues. During an interview on 9/12/2023, at 4:44 p.m. the Director of Nursing (DON) stated there should be a date on the oxygen tubing because it must be changed weekly and as needed for infection control. A review of the facility ' s recent policy and procedure titled, Oxygen Administration, last reviewed on 4/19/2023, indicated the oxygen tubing should be changed weekly as needed, including changing the mask, cannula, nebulizer equipment etc. When not in use, the oxygen tubing should be stored in a clean bag; for example, a Ziplock bag, etc. The date, time and initials should be noted on the oxygen equipment when it is initially used and when changed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, Licensed Vocational Nurse 5 (LVN 5) failed to protect the resident's rights of four out of four sampled residents (Residents 9, 11, 12, and 13) by: 1. Leaving the laptop opened to Resident 11 ' s Medical Record unattended facing the hallway with the picture of the resident and medical information showing. 2. Leaving a handwritten physician order for Resident 13 and barcode stickers for medications with Resident 9 and Resident 12's names on a legal-sized (8.5 inch x 14 inch in measurement) white paper on top of the medication cart. These deficient practices violated the resident's right to privacy. Findings: 1. A review of Resident 11 ' s admission Record indicated the facility admitted the resident on 8/1/2014 and eadmitted the resident on 6/8/2022, with diagnoses including chronic respiratory failure (a condition that results in the inability to effectively exchange carbon dioxide and oxygen, and induces chronically low oxygen levels or chronically high carbon dioxide levels) whether with hypoxia (insufficient oxygen supply to the tissues to maintain cellular function) or hypercapnia (too much carbon dioxide in the blood), tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow air to fill the lungs), and gastrostomy (a surgical opening through the skin of the abdomen to the stomach). A review of Resident 11 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/14/2023, indicated the resident sometimes had the ability to make self-understood and understand others. During a concurrent observation and interview on 8/30/2023, at 11:42 a.m., observed LVN 5 left the laptop opened to Resident 8 ' s Medical Record unattended facing the hallway with the picture of the resident and medical information exposed. LVN 5 stated the laptop should not be left opened because it contains resident information. LVN 5 stated leaving the resident's medical information unattended vilated the resident's right to privacy. 2. A review of Resident 13 ' s admission Record indicated the facility admitted the resident on 9/19/2022, with diagnoses including respiratory failure whether with hypoxia or hypercapnia. A review of Resident 13 ' s MDS, dated [DATE], indicated the resident sometimes had the ability to make self-understood and understand others. A review of Resident 9 ' s admission Record indicated the facility admitted the resident on 9/19/2023, with diagnoses including chronic respiratory failure whether with hypoxia or hypercapnia, tracheostomy, and gastrostomy. A review of Resident 9 ' s MDS, dated [DATE], indicated the resident had rarely to never had the ability to make self-understood and understand others. A review of Resident 12 ' s admission Record indicated the facility admitted the resident on 6/14/2023 and the facility readmitted the resident on 4/23/2023, with diagnoses including acute respiratory failure whether with hypoxia or hypercapnia, tracheostomy, and gastrostomy. A review of Resident 12 ' s MDS, dated [DATE], indicated the resident rarely to never make self-understood and understand others. During an observation on 8/30/2023, at 11:48 a.m., observed a paper with the following resident information: - a paper with two barcode stickers with resident names and medication of Residents 6 and 9 and a handwritten physician's order for Resident 10 on the same paper left on top of the medication cart. During a concurrent observation and interview on 8/30/2023, at 11:50 a.m., LVN 5 stated that the he should not have left a paper with resident information on the cart unattended due to health insurance portability and accountability act (HIPAA, is a federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient ' s consent or knowledge). LVN 5 stated leaving the resident's medical information unattended violated the resident's right to privacy. During an interview on 8/30/2023, at 1:43 p.m., the Infection Preventionist (IP) stated the point click care (PCC, web-based electronic health record) should be locked when unattended to avoid HIPAA violation. During an interview on 8/30/2023, at 2:09 p.m., the DSD stated that she had shown a video during staff orientation regarding protecting resident information. The DSD stated they have a compliance video for HIPAA that she shows to new hires on orientation. The DSD stated that she taught the staff that they cannot leave the laptop opened and unattened becasue it violates the residents' rights to privacy. A review of the facility ' s recent in-service titled Confidentiality/HIPPA, dated 6/2/2023 to 6/3/2023, indicated a purpose of ensuring staff are able to safeguard resident healthcare information from unauthorized viewing or use. The objective of the in-service was after in-service, the participant will have the following knowledge and be able to: 1. Identify additional healthcare information risk of improper disclosure including medical records, IV bags, medication cards. Not only the medical record is at risk. Other items can contain protected information. 2. Remember when cleaning rooms, items in the room could contain protected information. Please ensure that all items are secured/covered. A review of the facility ' s recent policy and procedure titled Notice of Privacy Practices, undated, indicated the facility is required by law to: (1) make sure that medical information that identifies you is kept private.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement infection control practices to four out of six sampled residents (Residents 2, 8, 9, and 10) by: 1. Failing to ensure Certified Nursing Assistant 1 (CNA 1) removed used protective gown before walking in the hallway. 2. Failing to ensure Licensed Vocational Nurse 2 (LVN 2) performed hand hygiene before donning (put on) gloves and wear a protective gown before touching the urine drainage dignity cover of Resident 2 who was on enhanced standard precaution (an infection control intervention designed to reduce transmission [transfer] of multidrug-resistant organisms [MDRO- bacteria that have become resistant to certain antibiotics that can no longer be used to control or kill the bacteria]). 3. Failing to ensure Licensed Vocational Nurse 5 (LVN 5) tied the back of the gown upon entry to an enhanced isolation precaution (an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes) room in the subacute unit (comprehensive inpatient care designed for patients with acute illness, injury, or exacerbation of a disease process). These deficient practices had the potential for cross contamination (unintentional transfer of bacteria/germs or other contaminants from one surface to another) of infection among residents. Findings: a. During a concurrent observation and interview on 8/25/2023 at 5:50 a.m., with Licensed Vocational Nurse 1 (LVN 1) in the nurse ' s station, observed Certified Nursing Assistant 1 (CNA 1) wearing a yellow protective gown carrying trash in a clear bag in the hallway. Observed CNA 1 dropping trash in the large gray bin, doff (remove) her protective gown, and remove gloves and dispose of it in the large gray bin. LVN 1 stated CNA 1 should have removed her protective gown before leaving the resident's room and not to walk in the hallway with it due to infection control. During an interview on 8/25/2023 at 6:16 a.m., CNA 1 stated she should have removed the protective gown before she left the residents room to prevent the spread of germs and infection. CNA 1 stated they are not allowed to dispose (throw away) used incontinent brief (diaper) inside the room and was taught to throw it in the large bins in the hallway. During an interview on 8/25/2023 at 7:22 a.m. Registered Nurse 1 (RN 1) stated CNA 1 should remove the protective gown before going out of the room because she had been in contact with the resident and to prevent spread of germs. During an interview on 8/25/2023 at 9 a.m. the Assistant Director of Nursing (ADON) stated to prevent the spread of any infection, staff should not wear protective gown in the hallway. During an interview on 8/25/2023 at 9:27 a.m., the Infection Preventionist (IP) stated CNA 1 should have brought the trash bin just outside of resident ' s room so she can easily dispose the trash without walking in the hallway. A review facility ' s policy and procedure titled, Personal Protective Equipment-Using Gowns dated 4/2023, indicated Use gowns only once and then discard into the appropriate receptacle inside the exam or treatment room. After completing the treatment and procedure, gowns must be discarded in the appropriate container located inside the room. b. A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 3/14/2022 with diagnoses including respiratory failure (develops when the lungs can't get enough oxygen into the blood), dependence on respirator (ventilator-device that enables the delivery or movement of air and oxygen into the lungs of a patient whose breathing has ceased (stop), is failing, or is inadequate) with tracheostomy (a hole that surgeons make through the front of the neck and into the windpipe then a tube is placed into the hole to keep it open for breathing) and sepsis (the body's extreme response to an infection). A review of Resident 2 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 6/9/2023, indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 2 was totally dependent from staff for all activities of daily living (ADL-personal hygiene, bed mobility, dressing, and transfers). Resident 2 had a catheter (a thin, sterile tube inserted into the bladder to drain urine) and was always incontinent (unable to control) of bowel functions. A review of Resident 2 ' s Care Plan on risk for infection dated 2/20/2023 indicated an intervention to provide enhanced standard precaution (an infection control intervention designed to reduce transmission (transfer) of multidrug-resistant organisms (MDRO- bacteria that have become resistant to certain antibiotics that can no longer be used to control or kill the bacteria). A review of Resident 2 ' s Care Plan on Enhanced Precaution isolation dated 3/15/2023 indicated an intervention to observe contact isolation precaution (touching an infected person and their dirty items such as clothing and surfaces). During an observation on 8/25/2023 at 6:09 a.m. by Resident 2 ' s doorway. Observed LVN 2 wearing N95 mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) inside the room. LVN 2 step out of Resident 2 ' s room but turned around and went back in. Observed LVN 2 don (put on) gloves without performing hand hygiene, bent down and pulled the dignity bag to cover Resident 2 ' s urine drainage bag. During an interview on 8/25/2023 at 7:22 a.m., Registered Nurse 1 (RN 1) stated Resident 2 ' s room is on enhanced standard precaution and LVN 2 should perform hand hygiene before gloving and wore a protective gown before fixing the dignity cover of the urine drainage bag for infection control. During an interview on 8/25/2023 at 9:00 a.m. the Assistant Director of Nursing (ADON) stated Resident 2 is on enhanced precaution and staff should perform hand hygiene or sanitize before and after gloving. The ADON stated if staff needed to touch the dignity cover, they should wear protective gown and gloves for infection prevention. During an interview on 8/25/2023 at 9:27 a.m. the Infection Preventionist (IP) stated staff should perform hand hygiene before and after gloving. A review of facility ' s policy and procedure titled Policy-Hand Washing undated but reviewed on 4/19/2023, indicated Hand washing must also be performed as follows: 1. Before and after direct care of individual patients. 2. In between performance of routine procedures (handling urinals, bedpans, catheters, changing dressings, collecting specimens etc.) A review of facility ' s policy and procedure titled Enhanced Standard Precautions (ESP) dated 4/2023 indicated ESP employ targeted gown and glove use during high contact resident care activities when contact precaution do not otherwise apply. Examples of high contact resident care activities requiring the use of gown and gloves for ESPs include: g. device care or use (central line [a tube that doctors place in a large vein in the neck, chest, groin, or arm to give fluids, blood, or medications or to do medical tests], urinary catheter [a flexible tube used to empty the bladder and collect urine in a drainage bag], feeding tube [a flexible plastic tube placed into your stomach or bowel to help you get nutrition when you're unable to eat as well as you need to], tracheostomy/ventilator). c. A review of Resident 8 ' s admission Record indicated the facility admitted the resident on 8/4/2020 and the facility readmitted the resident on 1/28/2021, with diagnoses including chronic respiratory failure (a condition that results in the inability to effectively exchange carbon dioxide and oxygen and induces chronically low oxygen levels or chronically high carbon dioxide levels), tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow air to fill the lungs), and gastrostomy (a surgical opening through the skin of the abdomen to the stomach). A review of Resident 8 ' s History and Physical (H&P), dated 1/3/2023, indicated Resident 5 did not have the capacity to understand and make decisions. A review of Resident 8 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/6/2023, indicated Resident 5 rarely to never had the ability to make self-understood and understand others. A review of Resident 8 ' s Order Summary Report indicated an order of: -Enteral feed order of Isosource 1.5 (nutritionally complete formulas intended for the dietary management of undernourished patient or those at risk for malnutrition) at 50 cubic centimeter (cc, unit of volume) per hour times 20 hours via gastrostomy tube (GT, tube inserted through the belly that brings nutrition directly to the stomach) continuous pump to provide 1000 cc per 1500 kilocalories (kcal, a measure of energy in nutrition and exercise) per day on 7/5/2023. -Apply skin barrier cream to sacral area (located below the lumbar spine and above the tailbone) externally to bilateral buttocks as needed for skin management on 1/28/2023. -Tracheostomy site: Monitor tracheostomy site for signs and symptoms of infection daily on 1/29/2021. -Suction to maintain patent airway indicate oral removal of saliva yes or no (y/n); tracheostomy tie secure (y); change of condition (y/n)- if yes, document in respiratory progress note every 2 hours on 1/28/2021. A review of Resident 8 ' s Care Plan, initiated on 8/10/2023, indicated a plan of high risk for infection on Resident 8 secondary to trach and GT status was placed on enhanced precaution isolation. The care plan indicated an intervention to perform hand hygiene, wear gowns and gloves while performing high contact activities. d. A review of Resident 9 ' s admission record indicated the facility admitted the resident on 9/19/2023, with diagnoses including chronic respiratory failure, tracheostomy, and gastrostomy. A review of Resident 9 ' s H&P, dated 10/3/2023, indicated Resident 9 did not have the capacity to understand and make decisions. A review of Resident 9 ' s MDS, dated [DATE], indicated Resident 9 rarely to never had the ability to make self-understood and understand others. A review of Resident 9 ' s Order Summary Report indicated an order of: -Enteral feed order of Diabetisource AC (a unique carbohydrate blend includes pureed fruits and vegetables to help with the nutritional management of patients with diabetes [a disease that occurs when your blodd glucose, also called blood sugar, is too high) or stress-induced hyperglycemia [is an acute response of the bodies to many critical illnesses]) at 40 cc per hour times 20 hours via GT continuous pump to provide 800 cc per 96 kcal per day on 6/8/2023. -Sacrococcyx (pertaining to both the sacrum and coccyx [tailbone]) scar tissue cleanse with normal saline (NS, is a fluid electrolyte replenisher used as source of water and electrolytes) pat dry, apply skin barrier cream. Leave on the area (LOA) skin management every day shift on 1/28/2023. - Tracheostomy site: Monitor tracheostomy site for signs and symptoms of infection daily on 2/8/2019. - Suction to maintain patent airway indicate oral removal of saliva (y/n); tracheostomy tie secure (y); change of condition (y/n)- if yes, document in respiratory progress note every 2 hours on 2/21/2020. A review of Resident 9 ' s Care Plan, initiated on 6/27/2023, indicated the resident was placed on enhanced precaution isolation. e. A review of Resident 10 ' s admission Record indicated the facility admitted the resident on 8/23/2023 with diagnoses including respiratory failure whether with hypoxia (low levels of oxygen in the body tissues) or hypercapnia (high levels of carbon dioxide in the blood), tracheostomy, and gastrostomy. A review of Resident 10 ' s Physician ' s Progress Notes, dated 8/25/2023, indicated the resident was able to open eyes but remained nonverbal. A review of Resident 10 ' s Order Summary Report indicated an order of: -Enteral feed order every 6 hours via gravity or bolus of Isosource 1.5 at 250 cc every 4 hours via bolus (a single, large dose) or gravity per GT to provide 1000 cc per 1500 kcal per day on 8/23/2023. -Monitor skin integrity around trach tie for signs of breakdown on 8/24/2023. -Bilateral groin moisture-associated skin damage (MASD). cleanse with NS, pat dry. Apply Calazime cream (used to treat or prevent diaper rash). LOA every day shift for 30 days on 8/24/2023. -Suction to maintain patent airway every 2 hours on 8/23/2023. A review of Resident 10 ' s Care Plan, initiated on 8/23/2023 indicated the resident was placed on enhanced precaution isolation. During a concurrent observation and interview on 8/30/2023, at 11:48 a.m., observed LVN 5 wearing an untied gown going inside an enhanced isolation precaution room to perform resident care. LVN 5 stated he should have fully close the gown by using ties to cover his back before entering the room. LVN 5 stated not using the gown properly had the potential of not protecting himself from infection and may lead to cross contamination of infection to residents. During an interview on 8/30/2023, at 1:43 p.m., the IP stated the gown should be donned outside the room and the staff should tie the neck and the back of the gown for staff protection and prevent cross contamination of infection to other residents. During an interview on 8/30/2023, at 2:09 p.m., the DSD stated the staff should have tied the back of the gown prior to entering the room of a resident placed on enhanced precaution isolation for infection control purposes and prevent contamination. A review of the facility ' s recent policy and procedure titled Personal Protective Equipment, last reviewed on 4/2023, indicated gowns shall be large enough to cover all of the wearer ' s clothing, and they must tightly be cuffed at the sleeves. Overlap the gown at the back. Be sure clothing is completely covered. A review of the facility ' s recent in-service dated 8/25/2023, topics discussed were the following: Infection Prevention; handwashing; Donning and Doffing of Gowns; Enhanced Standard Precautions; and Covid Mitigation. The in-service indicated for Donning and Doffing of Gowns, they used the CDC guidelines Sequence for Donning Personal Protective Equipment (PPE), undated, gowns should fully cover torso from neck to knees, arms to end of wrists, and wrap around the back. Fasten in back of neck and waist.

Based on observation, interview, and record review, the facility failed to implement infection control measures for one of one sample resident (Resident 2) by, failing to ensure Certified Nursing Assistant 1 (CNA 1) wore an isolation gown (a personal protective equipment [PPE] intended to be worn by health care personnel to protect against potential hazards or infections) before providing incontinence care to Resident 2 who was placed in enhanced standard precautions (ESP, a set of additional infection control measures taken to prevent the spread of diseases in the healthcare settings). This deficient practice had the potential to increase the risk of transmitting infections and diseases among healthcare personnel and residents. Findings: A review of Resident 2 ' s admission Record indicated the facility readmitted the resident on 8/7/2022 with diagnoses including attention to gastrostomy (a surgical procedure where a flexible tube inserted through the abdominal wall that directly delivers nutrition and medication to the stomach) and functional quadriplegia (complete immobility due to severe physical disability or frailty). A review of Resident 2 ' s History and Physical, dated 8/16/2022, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 2 ' s Minimum Data Set (a standardized assessment and care screening tool), dated 5/18/2023, indicated the resident had severely impaired cognitive skills for daily decision making. The MDS indicated the resident required total dependence (full staff performance every time) for bed mobility, transfer, eating, toilet use and personal hygiene with physical assistance from staff. The MDS indicated the resident always incontinent of bowel and bladder. A review of Resident 2 ' s care plan titled, Risk for Infection, revised 5/28/2023, indicated the resident with goal to reduce risk for active infection daily and included intervention such as always providing standard precaution (foundational infection control practices that include hand hygiene and the use of PPE when necessary). During an observation on 8/1/2023 at 10:06 a.m., observed enhanced standard precaution sign posted outside of Resident 2 ' s room. Observed CNA 1 entered room with linen cart right at the door of Resident 2 ' s room. Observed CNA 1 put on gloves and carried clean linen and sheet to Resident 2. CNA 1 did not wear gown and drawn the curtains. During a concurrent observation and interview on 8/1/2023 at 10:08 a.m., at Resident 2 ' s bedside, CNA 1 stated he almost done changing Resident 2. CNA 1 stated he provided incontinence care to Resident 2, changed his briefs, and his linen sheets. CNA 1 stated he did not wear gown because he forgot. CNA 1 stated he was supposed to wear gown because resident has a g-tube and to prevent the spread of infection. During an interview on 8/1/2023 at 11:51 a.m., the Infection Preventionist (IP) stated all residents are assessed for the need of Enhanced Standard Precaution. The IP stated residents including residents with feeding tube, etc. The IP stated when a resident is on an enhanced standard precaution, all staff are expected to put on gown, gloves, and mask while performing any care activity where they have close contact with the resident including changing of incontinence briefs. During an interview on 8/3/2023 at 1:37 p.m., the Director of Nursing (DON) stated the purpose of ESP is to minimize the spread of multidrug resistant organisms (MDROs, are bacteria or other microorganisms that have developed resistance to multiple types of antibiotics, making them difficult to treat) among residents. The DON stated CNA 1 should have put on the gown before providing incontinence care to Resident 2. A review of the facility ' s policy and procedure titled, Enhanced Standard Precaution, reviewed and approved on 4/19/2023, indicated that ESP is an infection control intervention designed to reduce transmission of MDROs. The procedure indicated healthcare personnel providing any care activity where close contact with the resident is expected to occur such as bathing, peri-care (refers cleaning and care of the perineal area, which includes the genitals and anus, to maintain hygiene and prevent infections), assisting with toileting, and changing incontinence briefs.

Based on observation, interview and record review, the facility failed to provide care in a manner that maintained a resident's dignity for one of three sampled residents (Resident 2) by failing to ensure the resident's indwelling urinary catheter ((a flexible tube that drains urine from the bladder) drainage bag was covered with a privacy bag. This deficient practice had the potential to affect the self-esteem and self-worth of Resident 2. Findings: A review of Resident 2's admission Record (Face Sheet) indicated the facility admitted the resident on 3/19/2015 with diagnoses that included respiratory failure (condition in which not enough oxygen passes the lungs into the blood), dependent on respirator (ventilator- a machine used to support or replace the breathing of a person who is ill), hypertension (uncontrolled elevated blood pressure) and heart failure (heart does not pump enough blood). A review of Resident 2 ' s History and Physical dated 6/23/2022, indicated, Resident 2 did not have capacity to understand and make decisions. A review of Resident 2's Minimum Data Set (MDS- a standardized assessment and care-screening tool) dated 2/8/2023, indicated resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated resident was totally dependent to staff for all activities of daily living (ADLs - personal hygiene, bed mobility, dressing, and transfers). Resident 2 was always incontinent (unable to control) of bowel and bladder functions. During a concurrent observation and interview on 4/22/2023 at 11:01 a.m., with the Infection Preventionist (IP), observed Resident 2 ' s indwelling urininary catheter drainage bag hanging on the bed frame with clear yellow urine. The IP stated that the urinary catheter drainage bag did not have a privacy bag. The IP stated that the urinary catheter drainage bag should be covered for privacy purposes. During an interview on 4/22/2023 at 11:05 a.m., Registered Nurse 1 (RN 1) stated the urinary catheter drainage bag hould be covered to provide Resident 2 privacy. During an interview on 5/5/2023 at 10:44 a.m., the Director of Nursing (DON) stated the facility uses privacy bag to cover the residents' urinary catheter drainage bag. A review of facility ' s policy and procedure titled, Indwelling Catheter Urinary Bag Maintenance undated but reviewed on 4/19/2023 indicated, Cover urinary collection bags with privacy bag to ensure dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that one out of three residents (Resident 1) was monitored and supervised from keeping metal butter knives in his bed. This deficient practice placed Resident 1 at risk for injury to self and/or an endangerment to others. Findings: A review of Resident 1 ' s admission Record, indicated that the resident was initially admitted on [DATE] with diagnoses including acute respiratory failure (ARF- caused by a disease or injury that affects your breathing), traumatic subdural hemorrhage (bleeding in the brain caused by trauma), and secondary hypertension (high blood pressure that's caused by another medical condition). A review of Resident 1 ' s Minimum Data Set (MDS- a standardized tool for assessment), dated 1/19/2023, indicated that the resident had severely impaired cognitive skills (relating to thinking, reasoning, or remembering) for daily decision making. Resident 1 ' s MDS also indicated that the resident needed limited assistance with transfers and bathing; extensive assistance with bed mobility, eating, and personal hygiene; and was totally dependent with locomotion and toilet use. A review of Resident 1 ' s Care Plan on altered behavior patterns related to psychosis (characterized as disruptions to a person's thoughts and perceptions that make it difficult for them to recognize what is real and what isn't), initiated on 8/31/2022, had a goal of reducing the episodes of daily behavior. The interventions included to assess what may cause and trigger the behavior, approach resident in a calm and friendly manner, provide redirection, and respect resident rights to refuse treatment and care. On 2/17/2023 at 11:50 a.m., during an interview, Restorative Nursing Assistant 1 (RNA 1) stated that about two months ago, while trying to cover Resident 1 with a sheet, RNA 1 found a butter knife on the resident ' s bed. RNA 1 stated that he took away the knife. RNA 1 stated that he told the certified nurse assistants (CNAs) to remove the butter knives and forks whenever serving tray for Resident 1. RNA 1 stated he did not inform the charge nurse (CN) of what he found. RNA 1 stated that with the resident ' s frequent outbursts, the resident could hurt anyone with the butter knife. On 2/17/2023 at 12:11 p.m., during an interview, Certified Nurse Assistant 3 (CNA 3) stated Resident 1 liked to keep butter knives and forks. CNA 3 stated that she did not inform the charge nurse or the Director of Staff Development (DSD). On 2/17/2023 at 1:17 p.m., during a follow-up interview with CNA 3, in the presence of the Social Services Director (SSD), CNA 3 stated that it was easier for her to throw the butter knives away than to tell the CN. When asked what CNA 3 ' s reasons were for not telling the charge nurse, CNA 3 stated that she had nothing to say but knew that she should have reported the situation to her CN. CNA 3 stated that she had never witnessed Resident 1 being physically aggressive to others but with the butter knives, the resident could hurt someone. On 2/17/2023 at 12:28 p.m., during an interview, the DSD stated that if the staff reported that Resident 1 was keeping butter knives, the DSD stated that she could have educated the staff what to do, they could have called the physician, they could have created a care plan, and they could have monitored the resident. The DSD stated that the resident could have attacked other residents and staff with a butter knife. On 2/17/2023 at 1:49 p.m., during an interview, the Director of Nursing (DON) stated that if the staff only reported that Resident 1 was keeping butter knives, the CN could have created a care plan, the behavior could have been addressed, they could have changed his utensils to plastic, and they could have monitored the resident. The DON stated that any resident keeping a butter knife is a safety concern. The DON stated that Resident 1 was a danger to himself and to others. During a concurrent interview and review of the facility ' s policies and procedures, The DON stated that there was no policy specific to safety and supervision. A review of the facility ' s policy and procedure on Abuse and Mistreatment of Residents, undated, indicated that the facility shall ensure comprehensive assessment and care planning for residents with needs and behaviors which might lead to conflict or neglect are initiated; residents identified with behaviors and manifestations shall be assessed by members of the interdisciplinary team (IDT) and referred to appropriate healthcare professionals as deemed necessary to ensure adequacy of appropriate care planning and interventions needed to treat, modify, and address such problems.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program regarding Coronavirus 2019 (COVID-19, a viral infection that is highly contagious and easily transmits from person to person, causing respiratory problems and may cause death) for one of seven sampled residents (Resident 2), by failing to ensure the staff disinfected the equipment before and after use. This deficient practice placed other residents and staff at risk for exposure and contracting COVID-19. Findings: A review of Resident 2's admission Record indicated the facility admitted the resident on 6/17/2022, with diagnoses including hemiplegia (paralysis of the muscles of the lower face, arm, and leg on one side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating and dressing), chronic obstructive pulmonary disease (COPD – a group of disease that causes airflow blockage and breathing-related problems), and heart failure (a condition that develops when the heart doesn't pump enough blood for the body's needs). A review of Resident 2's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/24/2022, indicated the resident's cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was intact. It indicated the resident required supervision on most activities of daily living (ADL – the tasks of everyday life). During an observation on 1/18/2023 at 10:27 a.m., observed Certified Nursing Assistant 1 (CNA 1) assisting Resident 2 in ambulating in the hallway using a cloth gait belt (a device put on a patient who has mobility issues, by a caregiver prior to that caregiver moving the patient) and a front wheel walker. CNA 1 assisted Resident 2 back to the room, folded the front wheel walker, placed it against the wall, and placed the cloth gait belt in CNA 1's back pants pocket without disinfecting the walker and the gait belt. During an interview on 1/18/2023 at 10:29 a.m. with CNA 1, CNA 1 stated that multiple residents use the facility walker and gait belt provided for ambulating Resident 2. CNA 1 further stated that the walker and gait belt were not disinfected after resident use. CNA 1 stated that equipment used by residents should be disinfected before and after use to prevent spread of infection. During an interview on 1/18/2023 at 1:40 p.m. with the Rehab Director (RD), the RD stated that the rehab department disinfects all the equipment every morning and equipment used by residents should be disinfected before and after use. During an interview on 1/18/2023 at 1:05 p.m. with the Infection Preventionist Nurse (IPN), the IPN stated that shared equipment used by residents should be disinfected before and after resident use to prevent cross contamination and infection. A review of the facility's policy and procedure titled, COVID-19 Policy, dated on 6/9/2022, indicated under environmental cleaning that shared or non-dedicated equipment is cleaned and disinfected after use according to the manufacturer's recommendation. A review of the facility's undated policy and procedure titled, Infection Control, indicated all rehab equipment should be cleaned daily with a facility approved disinfection solution or wipes. Each piece of equipment that is used for patient care will be cleaned after contact.

Based on interview and record review, the facility failed to screen for signs and symptoms of coronavirus disease 2019 infection (COVID-19- an acute respiratory illness in human s capable of producing severe symptoms, and in some cases death) for three out of eight visitors, on 11/17/2022. This deficient practice has the potential for spreading the COVID-19 infection to residents, employees, and visitors. Findings: During a concurrent interview and record review with the Infection Preventionist (IP), on 11/17/2022 at 4:15 p.m., the IP stated visitors were screened once they enter the building. IP stated visitors were considered all people entering the building who were not facility staff. IP stated upon entering the building, the screener would check the visitor ' s temperature. Then the screener would ask several questions regarding signs and symptoms of COVID-19 such as if the visitor was experiencing cough, difficulty breathing, chills, fatigue, body aches, headache, loss of taste/smell, sore throat, congestion, vomiting, or diarrhea; contact with anyone with COVID -19 within last 24 hours. The screener would then provide education regarding COVID-19 and would ask about the visitor ' s vaccination status. After asking the questions, the screener would document on the Visitor ' s Screening For COVID-19 log. The screener must document a telephone number just in case we needed to inform the visitor of exposure. If the visitor answered yes to any of the questions asked, the visitor would not be allowed to enter our facility. The IP reviewed the facility document titled, Visitor ' s Screening For COVID-19, dated 11/17/2022. IP confirmed that the facility document was incomplete. IP stated proper documentation was important to ensure that the visitors were asked the necessary questions to ensure our residents ' safety. During a concurrent interview and record review with the Director of Nursing (DON), on 11/17/2022 at 4:10 p.m., the DON stated that she was the one who screened the three visitors. The DON stated that she had the three visitors check their temperature however, she did not continue with the screening process and did not ask the questions related to COVID-19 signs and symptoms. When asked why she did not ask the necessary questions, the DON did not answer. A review of the facility ' s document titled, Visitor ' s Screening for COVID-19, dated 11/17/2021, indicated missing documentation for 3 visitors for the following columns: 1.Travel History 2.Temperature sign out 3. Cough, Difficulty breathing, Chills, Fatigue, Body Aches, Headache, Loss of Taste/Smell, Sore Throat, Congestion, Vomiting, or Diarrhea 4. contact with anyone with PUI (someone who has symptoms, However, has not yet tested positive for COVID-19)/COVID+ within last 24hrs 5. Provided education (COVID-19, Handwashing, PPE, etc.) 6.Vaccination Information 7.Visitor ' s Contact Info A review of the facility provided COVID-19 mitigation plan dated 9/7/2021 indicated under COVID-19 Visitation indicated the facility will ensure the health and safety of residents, visitors, and staff. Due to the facility ' s high-risk population, appropriate precautions will be initiated to help control and prevent the spread of the virus. Facility will actively screen and will restrict visitation by those who meet the following criteria: Signs and symptoms of COVID-19, such as fever or chills, cough, shortness of breath, sore throat, headache, muscle or body aches, fatigue, new loss of taste or smell, congestion, nausea or vomiting, and/or diarrhea; In the last 14 days, has had contact with someone with a diagnosis of COVID-19, or under investigation for COVID-19, or are ill with respiratory illness; Unvaccinated visitors returning from international trip are required to quarantine for 14 days; Provide proof of vaccination (must be fully vaccinated) or testing results. This will be documented as part of the screening process. A review of the facility provided policy titled COVID-19 Policy, dated 10/28/2022 indicated under Visitations: All visitors will conduct screening and document the screening information on a visitor ' s log.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of the admission Records indicated Resident 101 was originally admitted to the facility, on 09/08/2017, with diagnosis that included muscle weakness, type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), chronic kidney disease, stage 3 unspecified (condition in which blood cannot filter blood), anemia (condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues), bradycardia (a hear rate that's too slow), and hypoglycemia (a condition in which your blood sugar (glucose) level is lower than normal). A review of the MDS, dated [DATE], indicated Resident 101 needed extensive assistance from the staff for the activities of daily living. The MDS indicated Resident 101's BIMs (Brief Interview for Mental Status) score was 5 (severe cognitive impairment). During an observation and interview, on 11/16/21 at 12:43 p.m., CNA 3 was observed standing over Resident 101 while assisting her to eat. CNA 3 stated she was aware that she should be sitting while feeding resident. CNA 3 stated standing over resident while feeding her may cause resident to feel disrespected. During an interview, on 11/19/21 at 10:34 a.m. the DON stated residents were to be treated with dignity which included providing chairs so that the staff's eye level was with the resident while assisting them with meals to provide dignity. A review of the facility's policy titled Residents' Rights: Purpose and Policies, reviewed and approved on 04/09/2021, indicated the facility shall recognize and respect the individuality of each resident and encourage expression of capabilities and independence. Therefore, compliance with the Federal and State regulations for resident' rights shall be maintained and utilized to enhance comfort and well-being of each resident. Failure to ensure these rights will not be tolerated by facility management. The facility shall treat each resident with consideration, respect, and full recognition of his/her dignity and individuality. A review of facility document titled Residents have the right to be treated with dignity and respect, indicated all residents will be treated in a manner which maintains and enhances their dignity. Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhance a resident's dignity when Certified Nurses Assistants (CNA 1 and 3) were standing over the residents while assisting them to eat, for two of two sampled residents (Residents 43 and 101), investigated for dignity. These deficient practices had the potential to affect the residents' sense of self-esteem and self-worth. Findings: a. A review of the admission Record indicated Resident 43 was originally admitted to the facility, on 11/23/2019 and was readmitted on [DATE], with diagnosis that included sepsis unspecified organism (body's overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure, and death), urinary tract infection (an infection in any part of the urinary system which includes kidneys, bladder, ureters, and urethra), and cardiomegaly (enlarged heart because of damage to the heart muscle). A review of the History and Physical, dated 04/15/2021, indicated Resident 43 did not have the capacity to understand and make decisions. A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 08/29/2021, indicated Resident 43 was totally dependent on staff for locomotion on and off the unit, dressing, eating, and toilet use. During an observation, on 11/16/2021, at 1:04 p.m., CNA 1 was observed standing over Resident 43 while assisting her to eat. During an interview, on 11/16/2021, at 1:14 p.m., CNA 1 stated she was standing while feeding Resident 43 and should have been sitting. CNA 1 stated she was trained to sit down when assisting residents with meals. During an interview, on 11/18/2021, at 10:50 a.m., the Licensed Vocational Nurse 1 (LVN 1) stated CNAs should be sitting down at eye level when assisting residents with meals. LVN 1 stated the purpose of sitting at eye level next to resident while feeding them, was for residents to feel comfortable and maintain their dignity. During an interview, on 11/19/2021, at 2:09 p.m., the Director of Nursing (DON) stated CNAs should provide dignity to residents and should be sitting at eye level when assisting residents with meals. A review of the facility's policy titled, Residents' Rights: Purpose and Policies, reviewed and approved on 04/09/2021, indicated the facility shall recognize and respect the individuality of each resident and encourage expression of capabilities and independence. Therefore, compliance with the Federal and State regulations for resident' rights shall be maintained and utilized to enhance comfort and well-being of each resident. Failure to ensure these rights will not be tolerated by facility management. The facility shall treat each resident with consideration, respect, and full recognition of his/her dignity and individuality.

Based on observation, interview, and record review the facility failed to ensure call light was within reach for one of one sampled resident (Resident 163) investigated under the Environmental task. This deficient practice has the potential to result in Resident 163 not being able to call for facility staff assistance. Findings: A review of admission record indicated Resident 163 was admitted to the facility, on 08/08/2020, with diagnoses including dysphagia (swallowing difficulty), seizures (a sudden, uncontrolled electrical disturbance in the brain), history of falls, anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar). A review of the Fall Risk assessment, dated 11/09/2021, indicated Resident 163's fall risk score was 28 (a score of 18 or more was high risk and care plan would be developed to reduce falls and injuries). A review of Resident 163's Care Plan, revised on 10/25/2021, indicated Resident was at risk for falls/injury. The care plan indicated staff's interventions to keep call light within easy reach and encourage resident to use it to get assistance. A review of the Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 10/22/2021, indicated Resident 163's BIMs (Brief Interview for Mental Status) score was 07 (severe cognitive impairment). During an observation and interview, on 11/16/2021 at 02:22 p.m., Resident 163 was observed up in wheelchair. Resident 163's call light was observed on the bed not within reach. Resident 163 stated she was not able to reach call light from where she was sitting. During an interview, on 11/16/2021 at 02:25 p.m., Certified Nurse Assistant 4 (CNA 4) stated Resident 163's call light was not within reach of Resident 163. CNA 4 stated Resident 4 should have a call light and she could fall if not assisted by staff. CNA 4 was then observed providing Resident 163 the call light. During an interview, on 11/19/21 at 11:46 a.m., the Director of Nursing (DON) stated call lights must be within the reach of all resident and answered promptly. DON stated Resident 163 was a fall risk and would have not been able to ask for help or assistance. A review of the facility's policy titled, Call lights, indicated all staff shall know how to place the call light for a resident and how to use the call light system.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an allegation of verbal abuse and follow facility's abuse protocol, for one of one sampled resident (Resident 132). This deficient practice had the potential to place Resident 132 at risk for further verbal abuse. Findings: A review of the admission Record (Face Sheet) indicated Resident 132 was admitted to the facility, on 7/17/2018 and readmitted on [DATE], with diagnoses that included atherosclerotic heart disease (condition caused by plaque buildup in the wall of the arteries that supply blood to the heart), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (an intense, excessive, and persistent worry or fear about everyday situations). A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 10/19/2021, indicated Resident 132 had the ability to make self-understood and to understand others. During an interview, on 11/16/2021 at 2:42 p.m., Resident 132 stated that she was called filthy names including the B word by Resident 131. Resident 132 stated Resident 131 had been calling her names and directing foul language towards her about four months ago. Resident 132 stated that this was still ongoing. Resident 132 stated she would turn down the lights and television volume to the lowest setting but Resident 131 would still scream and call her dirty names. Resident 132 stated she had told staff and Certified Nurse Assistant (CNA 8). During an interview, on 11/18/2021 at 3:12 p.m., CNA 8 stated Resident 132 had told her that Resident 131 would yell at her and call her names that include foul language. CNA 8 stated she had heard Resident 131 scream while in the room but have not witnessed Resident 131 using foul language toward Resident 132. CNA 8 stated Resident 132 had told her, You would not believe the names she called me, but would not repeat what was said to her. CNA 8 stated verbal abuse was anything threatening and intimidating as well as any sort of foul language from one resident to another. CNA 8 stated verbal abuse should be reported. CNA 8 confirmed that she did not report this to charge nurse or supervisor. CNA 8 stated verbal abuse allegation should be reported immediately to charge nurse and supervisor. During an interview, on 11/19/2021 at 8:45 a.m., CNA 8 stated she did report the verbal abuse to a charge nurse. CNA 8 stated Resident 132 complained that Resident 131 was going at it again and yelled at her. CNA 8 stated she did not remember the charge nurse whom she reported to as well as the date of when it happened. During an interview, on 11/19/2021 at 10:43 a.m., the Administrator (ADM) stated she was not aware of the verbal abuse allegation made by Resident 132 until she was notified by Social Services Director (SSD) who had informed her on 11/16/2021. The ADM read the definition of verbal abuse included in the facility's policy which defined verbal abuse as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability and confirmed demeaning words and foul language directed to a resident is considered verbal abuse. The ADM stated the verbal abuse allegation should have been reported to her immediately once staff was notified by Resident 132 alleging verbal abuse by another resident. During an interview, on 11/19/2021 at 3:41 p.m., in the presence of the ADM, CNA 8 denied Resident 132 reported to her that she was called names by Resident 131. CNA 8 stated what she meant was that she did not think they were compatible, and they were fussing back and forth. CNA 8 stated Resident 132 had told her that Resident 131 said not nice things about her but was not informed of any name calling. When CNA 8 was asked if she had stated what the Resident 132 had told her which was You would not believe the names she called me. CNA 8 stated she may have felt a little stressed. A review of the facility's policy titled, Policy: Abuse and Mistreatment of Residents, reviewed and approved on 4/9/2021, indicated it is the facility's policy for any mandated reporter working in a facility to report abuse to their supervisor as well as the California Department of Public Health (CDPH). The policy defined a mandated reporter as any person who has assumed full or intermittent responsibility for care or custody of an elder or dependent adult, whether or not that caretaker receives compensation. This includes administrators, supervisors, and any staff of a public or private facility that provides care or services for elder of dependent adults, or any elder or dependent adult care custodian, health practitioner, or employee of a county adult protective services agency or a local law enforcement agency. The policy further stated, any mandated reporter in his or her professional capacity, or within the scope of his or her employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse, abandonment, isolation, financial abuse, or neglect, or reasonably suspects of abuse, shall report the known or suspected instance of abuse by telephone immediately or as soon as practically possible, and by written report sent within two hours, to the local Ombudsman and the local law enforcement agency shall report any case of known or suspected abuse to the State Department of Health Services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS- as assessment and care screening tool) accurately reflected the resident's discharge status for a resident that left against medical advice for one resident (Resident 173) investigated for closed record review. This deficient practice had the potential to inaccurately reflect the plan of care for residents Findings: A review of the admission Record indicated Resident 173 admitted to the facility, on 08/31/2021, with a diagnosis that included cognitive communication deficit, chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe), Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors), unspecified dementia without behavioral disturbance (describe a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), cachexia (wasting disorder that causes extreme weight loss and muscle wasting, and can include loss of body fat) and heart failure (chronic condition in which the heart doesn't pump blood as well as it should). A review of Resident 173's record titled Leaving Facility Against Medical Advice (AMA), indicated the resident signed the AMA form on 09/08/2021. A review of Discharge Summary Report, dated 09/08/2021, indicated Resident 173 left against medical advice, dated 09/08/2021. A review of the Minimum Data Set (MDS), dated [DATE], indicated Resident 173 was discharged to an acute care hospital. A review of Progress Notes, dated 09/08/2021 at 1:14 p.m., indicated Resident left AMA. Per RP (responsible party) request MD (medical doctor) to call. During a concurrent interview and record review, on 11/19/2021, at 08:43a.m., the Minimum Data Set Nurse (MDS 2) verified that Section A, identification information, subsection discharge status of the Minimum Data Set, was coded incorrectly as discharge to hospital and further stated it should have been coded as discharge to community because resident was discharged home. The MDS 2 stated the importance of documenting correctly was to ensure accuracy. During an interview and record review, on 11/19/21 at 10:38 a.m., the Director of Nursing (DON) stated the facility's policy was to ensure they have the correct discharge coding and it was part of the assessment. DON stated the facility should have accurately coded discharge to family-initiated discharge instead of discharge to acute hospital. A review of the facility's policy titled Resident Assessment, indicated health care professionals completing portions of the MDS are to certify the accuracy of the section (s) they have completed by entering the signature, title, date completed, and section (s) completed. Accuracy of transcription of the data and computer data entry are important and special attention must be given to correct these errors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement an activities care plan for Resident 27. This deficient practice had the potential to result in inconsistent implementation of the care approaches that may lead to a delay in delivery of care and services. Findings: A review of the admission Record indicated Resident 27 was admitted to the facility, on 05/12/2021 and readmitted on [DATE], with diagnoses that included chronic respiratory failure (condition that results in the inability to effectively exchange carbon dioxide and oxygen that caused difficulty in breathing), heart failure (chronic, progressive condition in which the heart muscle was unable to pump enough blood to meet the body's needs for blood) and dysphagia (difficulty swallowing). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 08/18/2021, indicated Resident 27 was moderately impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) in daily decision making and needed one-person total dependence with bed mobility, transfer, dressing, and personal hygiene. A review of the History and Physical, dated 06/29/2021, indicated Resident 27 had the capacity to understand and make decisions A review of the Activity Assessment, dated 06/29/2021, indicated activity staff would offer and provide one-to-one room visits for sensory stimulation such as music, hand massage, aroma therapy and reality awareness. A review of the Activity Progress Notes, dated 08/17/2021, indicated for activity staff to play various kinds of music, to read to resident, to provide aromatherapy (a holistic healing treatment that uses lotions to promote health and well-being by smell), and that resident was limited to speech, made facial expressions and for staff to anticipate needs. A review of Resident 27's Activity Care Plan, initiated 07/13/2021 and revised on 11/17/2021, indicated a goal that Resident 27 would participate in one-to-one activities without disruptive behavior three times a week for sensory stimulation such as music, hand massage, aroma therapy and reality awareness. The care plan indicated for staff to provide one of the interventions indicated, to conduct rounds to monitor activity needs and to offer appropriate interventions. A review of Resident 27's Activity Progress Notes, dated 11/17/2021, indicated for staff to provide all kinds of music, to provides supplies, to provide television shows, music, hand massage, aroma therapy, and reality awareness. The record further indicated resident was alert and oriented. The record indicated the resident was able to make needs known and communicated via writing through white board and mouth words. During a record review and concurrent interview, on 11/18/2021 at 9:15 a.m., the Activities Director (AD) stated the activities assistants were conducting room visits to Resident 27. The AD stated the resident liked various kinds of music but was unable to state what kind of music Resident 27 enjoyed. The AD stated the resident could go outside with the staff but has not seen Resident 27 outside yet. The AD stated Resident 27's care plan should be more specific to Resident 27's wants and needs. During an interview, on 11/18/2021 at 4:15 p.m., the Director of Nursing (DON) stated Resident 27 should have a more specific person-centered care plan for activities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement an activities program designed specifically to the needs of the individual residents, for one of two sampled residents (Resident 168). This deficient practice had the potential for a decreased quality of life and meaningless purpose in the facility for Resident 168. Findings: A review of Resident 168's admission Record (face sheet) indicated the resident, was initially admitted to the facility on [DATE], and was re-admitted on [DATE], with diagnoses that included psychosis (condition that affects the way your brain processes information and causes you to lose touch with reality), abnormalities of gait (a person's manner of walking) and mobility (the ability to move freely or be easily moved), diabetes mellitus (high blood sugar), and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A review of Resident 168's Minimum Data Set (MDS, a standardized assessment tool and care screening tool) dated 10/24/2021, indicated the resident had adequate hearing and vision, had no speech, rarely/never made self understood and rarely/never understood others, and had severe cognitive (ability to make decisions, understand, learn) impairment. The MDS indicated the resident required extensive assistance from staff for activities of daily living including transfer, bed mobility, walk in room and corridor, locomotion on unit and off unit, dressing, eating. The MDS also indicated resident was dependent on staff with toileting, personal hygiene, and bathing. The MDS indicated the resident preferred activities that included (snacks between meals, staying up past 8:00 p.m., receiving showers, listening to music, doing things with group of people, participating in favorite activities). A review of Resident 168's History and Physical signed by the physician dated 6/5/2021, indicated the resident did not have the capacity to understand and make decisions. During observation on 11/17/2021, at 9:23 a.m., observed Resident 168 in the room up in her wheelchair. Room was observed to be dark, lights were off, and the window curtains were closed. The resident had no music, the television (TV) was turned on, but the screen was black and indicated error. There was no activity staff at the bedside. During a concurrent observation and interview on 11/17/2021 at 9:23 a.m., observed Certified Nurse Assistant 6 (CNA 6) inside Resident 168's room getting linens from the linen cart and placed them on a bedside table. When asked why Resident 168 was sitting on her wheelchair in a dark room with no music and the TV with a black screen, CNA 6 stated the activity room was not open until 10 a.m. CNA 6 stated she had not seen any activity staff visit resident since resident was out of bed. CNA 6 stated she could not turn on the TV for resident and maintenance department was notified. CNA 6 stated leaving resident in a dark room, without any music or TV on could leave the resident bored and can cause depression. During an interview on 11/17/2021 at 9:27 a.m., Activities Director (AD) stated residents were brought to the activity room as soon as ready. AD stated in-room visits were provided to residents if unable to go to the activity room. During an observation on 11/17/2021 at 9:35 a.m., observed Maintenance Supervisor (MS 1) in Resident 168's the room fixing the TV. MS 1 stated that the wrong button was pressed on the remote control. During a concurrent interview and record review on 11/19/2021 at 11:50 a.m., the Activity Director (AD) stated, upon review of care plan titled Activity Participation,, the resident needed one on one activities at least three times a week for sensory stimulation such as music, hand massage, aroma therapy, and reality awareness. AD stated resident should have been provided music or have the TV fixed immediately. AD further stated Resident 168 and had the potential that resident would feel alone and lonely. During an interview on 11/19/2021 at 1:17 p.m., with Director of Nursing (DON), the DON stated Resident 148 should have been provided activities of preference and not left alone. The DON also stated the resident had the potential for feeling of isolation. A review of undated facility policy and procedures titled Participation in Activities, indicated, residents have the right to attend and participate in activities of their choice, and residents will be permitted to participate in all activities provided by the facility unless instructed by the attending physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement an element of the care plan for a resident with a pressure ulcer (injury to skin and underlying tissue due to prolonged pressure over a bony structure) by failing to reposition as scheduled, for one of eight sampled residents (Resident 140), investigated for pressure ulcers/injury. This deficient practice had the potential to result in the development of worsening and newly acquired pressure ulcers for Resident 140. Findings: A review of Resident 140's admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with diagnoses that included encephalopathy (damage or disease that affects the brain), abnormalities of gait and mobility (deviation from normal walking), and muscle weakness (decrease in strength in one or more muscles). A review of Resident 140's History and Physical Examination, dated 10/22/2021, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 140's Minimum Date Set (MDS - a standardized assessment and care screening tool), dated 10/28/2021, indicated the resident was totally dependent with staff with bed mobility, transfer, dressing, eating, toilet use, personal hygiene and bathing. The MDS further indicated Resident 140 was at risk of developing pressure ulcers/injuries. A review of Resident 140's Wound Risk Assessment, dated 10/22/2021, indicated resident was considered high risk for skin breakdown. A review of Resident 140's Wound Progress Report, dated 10/22/2021, indicated sacrococcyx (bottom of the spine and the tailbone) stage III pressure ulcer (full thickness skin loss potentially extending into the subcutaneous [under skin layer] tissue layer). The Wound Progress Report further indicated repositioning for pain management and other interventions included reposition frequently. A review of Resident 140's Interdisciplinary Team ([IDT] (IDT - a group of healthcare providers from different fields who work together or toward the same goal to provide the best care or best outcome for a resident) wound management care plan, dated 10/22/2021, indicated altered skin integrity manifested by sacrococcyx stage III pressure ulcer. The IDT care plan indicated approach to reposition every two hours or as often as necessary/indicated. A review of Resident 140's care plan, dated 11/10/2021, indicated goals to minimize the risk of skin breakdown/ pressure sore (injury to the skin and its underlying tissue due to prolonged pressure on it) daily with interventions to turn and position as needed when in bed or wheelchair. During an observation, on 11/16/2021, at 9:51 a.m., observed Resident 140 in a geriatric chair (also known as a geri chair or medical recliner chair designed to allow residents to get out of the confines of their bed and be able to sit comfortably in a variety of position while being fully supported) in the hallway. During an observation, on 11/16/2021, at 12:30 p.m., observed Resident 140 in a geri chair, in resident's room. A record review of Resident 140's Point of Care Response History for monitoring to turn and reposition every two hours, dated 11/06/2021 to 11/19/2021, indicated the resident was repositioned on 11/16/2021, at 6:51 a.m., and at 1:30 p.m. During a concurrent observation and interview, on 11/17/2021, at 7:55 a.m., with Certified Nurse Assistant 1 (CNA 1), CNA 1 confirmed and stated Resident 140 was in the geri chair. During a concurrent observation and interview, on 11/17/2021, at 9:20 a.m., with Licensed Vocational Nurse 5 (LVN 5), LVN 5 stated confirmed and stated Resident 140 was the geri chair. During an interview, on 11/17/2021, at 9:30 a.m., with CNA 1, CNA 1 stated Resident 140 had been in geri chair since 06:30 a.m. CNA 1 stated Resident 140 was only repositioned when in bed and was not repositioned while in the geri chair. CNA 1 was asked what the importance of repositioning was, CNA 1 stated to alleviate pain and relieve pressure and important to reposition every two hours. A record review of Resident 140's Point of Care Response History for monitoring to turn and reposition every two hours, dated 11/06/2021 to 11/19/2021, indicated the resident was repositioned on 11/17/2021, at 2:20 a.m., and at 2:02 p.m. During a concurrent observation and interview, on 11/18/2021, at 8 a.m., with CNA 1, observed Resident 140 in a geri chair. CNA 1 confirmed and stated Resident 140 was in the geri chair. During a concurrent observation and interview, on 11/18/2021, at 10:07 a.m., with Licensed Vocational Nurse 2 (LVN 2), in the recreation room. LVN 2 confirmed and stated Resident 140 was in the geri chair. During a concurrent observation and interview, on 11/18/2021, at 11:50 a.m., with Licensed Vocational Nurse 1 (LVN 1), in the recreation room. LVN 1 confirmed and stated Resident 140 was in the gerichair. LVN 1 stated Resident 140 should be repositioned every two hours and as needed when resident was in geri chair or in bed. A record review of Resident 140's Point of Care Response History for monitoring to turn and reposition every two hours, dated 11/06/2021 to 11/19/2021, indicated the resident was repositioned on 11/18/2021, at 6:57 a.m., and at 2:17 p.m. During an interview with the Director of Nursing (DON), on 11/19/2021, at 2:14 p.m., the DON stated Resident 140 should be repositioned every two hours with pillows, regardless whether in bed or in the geri chair. The DON states for skin management it is important to reposition every two hours to offload the other side because Resident 140 has a pressure ulcer. During a concurrent interview and record review, on 11/19/2021, at 2:20 p.m., with the DON, of the facility policy and procedures titled, Policy: Pressure Sore Management, reviewed and approved 04/09/2021, indicated all available measure shall be taken to reduce skin breakdown and pressure sores. The policy indicated the resident is to be re-positioned as scheduled. The DON confirmed and stated repositioned as scheduled means for the resident to be repositioned every two hours. A review of the facility policy and procedures titled, Policy: Care & Prevention of Pressure Sores, reviewed and approved 04/09/2021, indicated certified nurse assistant as professional responsible for nursing and care duties for turning and repositioning as often as needed for the individual resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a tab alarm (sensor that alerts caregivers if a resident is getting up from bed or chair) was placed while resident was in bed per physician order for one of two sampled residents (Resident 127). This deficient practice placed Resident 127 at risk for falls and serious injuries that include possible fracture (break in the bone) and bleeding. Findings: A review of Resident 127's admission Record (face sheet) indicated the resident admitted to the facility on [DATE] with diagnoses that included encephalopathy (disease or damage that affects the brain), abnormalities of gait (pattern of walking or moving on foot) and mobility, and dementia (group of symptoms affecting memory, language, problem-solving, and other thinking abilities). A review of Resident 127's Physician History and Physical, dated 10/7/2021, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 127's Physician's Order, ordered on 10/7/2021, indicated an order to place tab alarm (sensor that alerts caregivers if a resident is getting up from bed or chair) when in bed and when in wheelchair or geri-chair (medical recliner chair that allows residents to sit in a variety of positions while being fully supported) to alert/remind resident to ask for assistance when transferring or ambulating. The order further indicated to ensure equipment is in place and functioning properly every shift. A review of Resident 127's care plan, initiated on 10/13/2021, indicated a tab alarm when in bed and when in wheelchair or geri-chair to alert/remind resident to ask for assistance when transferring or ambulating and to alert staff from any unsafe mobility. The interventions for the tab alarm included applying tab alarm as ordered and monitoring the alarm for good working condition and proper placement as needed. During an observation, on 11/18/2021 at 7:55 a.m., observed Resident 127 laying in bed without a tab alarm. During a concurrent observation, interview, and record review, on 11/18/2021 at 8:07 a.m., Licensed Vocational Nurse 2 (LVN 2) observed and verified Resident 127 was in bed and did not have a tab alarm. LVN 2 reviewed Resident 127's chart and confirmed physician's order for tab alarm while in bed. LVN 2 stated Resident 127 was a high fall risk with a fall risk assessment score of 26 (score of 18 or more indicates high fall risk) and had a history of falls. LVN 2 stated Resident 127 should have a tab alarm per physician's order to alert staff that the resident was trying to get up unassisted and attend to the resident immediately. During a concurrent interview and record review, on 11/19/2021 at 3:21 p.m., the Director of Nursing (DON) confirmed Resident 127's physician order for tab alarm when in bed and when in wheelchair. The DON stated Resident 127 is a high fall risk and should have had a tab alarm on the bed if the resident was laying on his bed. The DON stated the purpose of the tab alarm is to alert staff that the resident is out of bed and to check on the resident to prevent a fall. The DON further stated the tab alarm alerts the resident to call for help. The DON stated that the potential outcome for not following the physician's order for tab alarm would be another fall and possible injury. A review of the facility's policy and procedures titled, Use of Sentry/Bed Sensor Alarm, reviewed and approved on 4/9/2021, indicated the facility will use, as indicated, a bed pad that conveniently sound as audible alarm when the sensor detect a patient rising out of the bed, reminding the resident to return to a safe position while alerting staff to a potential fall. A review of the facility's policy and procedures titled, Physician's Orders: Follow Up, updated and approved on 4/9/2021, indicated physician's orders will be noted and followed up as indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow physician's orders for the care of gastrostomy tube (g-tube - tube placed into stomach for nutritional support and administering medications) by: 1. Failing to ensure Resident 105's gastrostomy tube insertion site was covered with dry dressing as ordered for one of two sampled residents (Resident 105). 2. Failing to use an abdominal binder (wide compression belt that encircles the abdomen) as ordered for one of two sampled residents (Resident 105). These deficient practices had the potential for contaminating Resident 105's g-tube insertion site and increasing the resident's risk for infection; and also had the potential for Resident 105, who has a history of pulling out his gastrostomy tube, to pull out his g-tube again and increase the risk for injury to the g-tube site. Findings: a. A review of Resident 105's admission Record (face sheet) indicated the resident was admitted to the facility on [DATE], and was readmitted on [DATE], with diagnoses that included gastrostomy (surgical procedure used to insert a feeding tube through the abdomen and into the stomach), diabetes mellitus type 2 (chronic condition characterized by high blood sugar), and vascular dementia (changes to memory, thinking, and behavior caused by reduced blood flow to the brain) with behavioral disturbance. A review of Resident 105's History and Physical, dated 5/21/2021, indicated Resident 105 did not have the capacity to understand and make decisions. A review of Resident 105's Physician's Order, ordered on 5/22/2021, indicated a treatment order to the gastrostomy tube (g-tube - tube placed into stomach for nutritional support and administering medications) site with instructions to cleanse with normal saline (NS - cleansing solution for irrigating wounds), pat dry, and cover with dry dressing every day shift and as needed for when soiled or pulled out. During an observation, on 11/16/2021 at 11:40 a.m., observed Resident 105 with no dressing covering the g-tube site. During a concurrent observation, interview, and record review on 11/16/2021 at 11:41 a.m., Licensed Vocational Nurse 6 (LVN 6) verified there was no dressing covering Resident 105's g-tube site upon observation. LVN 6 reviewed Resident 105's chart and confirmed the physician's order regarding treatment for the g-tube site with instructions to clean site with NS, pat dry, and cover with dry dressing. LVN 6 stated the treatment nurse normally does the wound treatments including changing dressings to g-tube site daily. However, LVN 6 stated the assigned licensed nurses can provide care for the g-tube site and change dressings too. LVN 6 further stated Resident 105 should have had a dressing to cover the g-tube insertion site per physician's order and to keep the site clean for infection control purposes. During a concurrent interview and record review, on 11/19/2021 at 3:06 p.m., the Director of Nursing (DON) reviewed Resident 105's medical records and verified the physician's treatment order for the g-tube site to include covering the site with dry dressing. The DON confirmed Resident 105's g-tube site should be covered with a dressing because there is an order and to prevent contamination of site since it is an open stoma (an artificial opening made into a hollow organ). A review of the facility's policy and procedures titled, Physician's Orders: Follow Up, updated and approved on 4/9/2021, indicated physician's orders will be noted and followed up as indicated. b. A review of Resident 105's admission Record (face sheet) indicated the resident was admitted to the facility on [DATE], and was readmitted on [DATE], with diagnoses that included gastrostomy (surgical procedure used to insert a feeding tube through the abdomen and into the stomach), diabetes mellitus type 2 (chronic condition characterized by high blood sugar), and vascular dementia (changes to memory, thinking, and behavior caused by reduced blood flow to the brain) with behavioral disturbance. A review of Resident 105's History and Physical, dated 5/21/2021, indicated Resident 105 did not have the capacity to understand and make decisions. A review of Resident 105's Physician's Order, ordered on 5/21/2021, indicated an order for abdominal binder (wide compression belt that encircles the abdomen, while covering the gastrostomy tube [g-tube - tube placed into stomach for nutritional support and administering medications] site) to decrease potential injury due to resident behavior of attempting to pull on life sustaining equipment. The order further indicated to ensure equipment is in place and functioning properly. A review of Resident 105's care plan, revised on 10/13/2021, indicated for the resident to utilize an abdominal binder to minimize the risk of having the g-tube pulled out secondary to dementia (a group of thinking and social symptoms that interferes with daily functioning), restlessness, agitation, and altered mental status through appropriate interventions that included applying abdominal binder as ordered. During a concurrent observation and interview, on 11/18/2021 at 11:24 a.m., Certified Nursing Assistant 7 (CNA 7) observed and verified that Resident 105 did not have an abdominal binder on to cover to the g-tube site. Registered Nurse 1 (RN 1), who was translating for CNA 7, also verified that Resident 105 did not have an abdominal binder in place. CNA 7 stated she had removed the abdominal binder earlier in the morning around 7:30 a.m. since it was dirty. CNA 7 further stated she took it to laundry but did not get a new abdominal binder for the resident. During a concurrent observation and interview, on 11/18/2021 at 11:42 a.m., Licensed Vocational Nurse 4 (LVN 4) observed and verified that Resident 105 did not an abdominal binder and confirmed there was a physician's order to apply the abdominal binder. LVN 4 stated Resident 105 should have an abdominal binder in place to prevent the resident from pulling on the g-tube since the resident had history of pulling it out. LVN 4 further stated Resident 105 had removed his g-tube as recently as two weeks ago. During a concurrent interview and record review, on 11/19/2021 at 3:16 p.m., the Director of Nursing (DON) reviewed Resident 105's chart and verified the resident had an order for an abdominal binder. The DON explained the purpose of the abdominal binder was to prevent the resident from pulling on the g-tube. The DON confirmed that the abdominal binder should have been in place to cover Resident 105's g-tube site as ordered by the physician since the resident had history of pulling out his g-tube multiple times in the past. The DON further stated the potential outcome of not having the abdominal binder in place was for the resident to pull out the g-tube again more easily and cause potential injury to the g-tube site. A review of the facility's policy and procedures titled, Abdominal Binder, updated and approved on 4/9/2021, indicated abdominal binder will be applied as indicated. A review of the facility's policy and procedures titled, Physician's Orders: Follow Up, updated and approved on 4/9/2021, indicated physician's orders will be noted and followed up as indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility failed to meet professional standards of quality for two of two sampled residents (Residents 148 and 107) by failing to administer blood pressure medication according to parameters (limit or range) set by physician. These deficient practices have the potential to result in Resident 148 and 107 in unintended complications related to the management of blood pressure such as hypotension (abnormally low blood pressure and can lead to falls). Findings: a. A review of Resident 148's admission Record (face sheet) indicated the resident was initially admitted to the facility on [DATE], and was re-admitted on [DATE], with diagnosis that included secondary hypertension (high blood pressure that's caused by another medical condition) and hyperlipidemia (a condition in which there are high levels of fat particles in the blood). A review of Resident 148's Minimum Data Set (MDS- an assessment and care screening tool) dated 11/1/2021 indicated the resident had adequate hearing and vision, was able to make self-understood and was able to understand others, and had moderate cognitive (ability to make decisions, understand, learn) impairment. The MDS indicated the resident was dependent on staff for all activities of daily living (ADL - transfer, bed mobility, locomotion on unit and off unit, dressing, eating, toilet use, personal hygiene, and bathing). A review of Resident 148's physician orders indicated metoprolol 25 milligrams (mg - unit of measurement) by mouth every 8 hours for hypertension (high blood pressure). Hold (do not administer) if systolic blood pressure (SBP - the top number, measures the force your heart exerts on the walls of your arteries each time it beats) was less than 110 or heart rate less than 60, ordered on 10/25/2021. A record review of Resident 148's Medication Administration Record (MAR) indicated resident's blood pressure on 11/3/2021 at 10 p.m. was 102/66 and heart rate was 64. Metoprolol was marked with a check. During an interview on 11/19/2021 at 12:48 p.m., Licensed Vocational Nurse 7 (LVN 7) stated when giving blood pressure medications, the resident's blood pressure is checked first and then the order is checked if there are any parameters (limit or range). LVN 7 stated check mark in the MAR indicated the medication was administered. LVN 7 stated blood pressure medication orders usually indicate hold if systolic blood pressure less than 110. LVN 7 stated if SBP is less than 110, the medication should not be administered. LVN 7 further stated the resident's SBP was less than 110 at least 80% of the time. LVN 7 stated giving blood pressure medication below the parameter set by physician could further lower the resident's blood pressure and also lower the heart rate. During a concurrent interview and record on 11/19/2021 at 1:17 p.m., the Director of Nursing (DON), verified that Resident 148's MAR indicated metoprolol was given on 11/3/2021 at 10 p.m. when Resident 148's blood pressure was 102/66 as indicated by the check mark. The DON stated parameters are ordered so that the medication can be held so it doesn't further lower the blood pressure. The DON stated the medication should have been held and giving the medication can further lower resident's blood pressure. A review of the facility's policy and procedures titled, Preparation and General Guidelines, dated 10/2017, indicated, medications are administered in accordance with written orders of the attending physician. b. A review of Resident 107's admission Record indicated the resident was admitted to the facility on [DATE] with a readmission date of 6/8/2021 with diagnoses that included respiratory failure (condition in which not enough oxygen passes from your lungs into your blood), encounter for attention to gastrostomy (a surgery that places a gastric tube, GT or g-tube [a flexible tube inserted through the abdominal wall that directly delivers nutrition to the stomach]) and hypertension (high blood pressure). A review of Resident 107's Minimum Data Set (MDS - an assessment and care screening tool) dated 10/12/2021 indicated the resident rarely/never made self-understood and rarely/never had the ability to understand others. A review of Resident 107's physician's orders indicated the following: 1. Amlodipine besylate (hypertension medication) tablet 5 milligrams (mg - unit of measurement give 1 tablet via g-tube one time a day for hypertension, hold (do not administer) if systolic blood pressure (SBP - the top number, measures the force your heart exerts on the walls of your arteries each time it beats) was less than 110, ordered on 6/8/2021. 2. Metoprolol tartrate (hypertension medication) tablet 25 mg give 1 tablet via g-tube two times a day for hypertension, hold if SBP less than 110 or HR less than 60, ordered on 6/8/2021. During a concurrent interview and record review on 11/18/2021 at 1:57 p.m., with Licensed Vocational Nurse 8 (LVN 8), Resident 107's Medication Administration Record (MAR) was reviewed. LVN 8 stated when giving blood pressure medications, the resident's blood pressure is checked first and then the order is checked to see if there are any parameters (limit or range). LVN 8 stated the order will usually indicate hold if systolic blood pressure less than 110. LVN 8 stated if the SBP is less than 110, the medication should be held. LVN 8 further stated there are some blood pressure medications which affect the heart rate and will indicate to hold medication if heart rate less than 60 beats per minute. LVN 8 stated if the MAR has a check mark, that means the medication was given. LVN 8 verified that according to Resident 107's MAR, Resident 107 was administered amlodipine and metoprolol on 11/16/2021 at 9 a.m. as indicated by the check mark. LVN 8 stated Resident 107's blood pressure on 11/16/2021 at 9 a.m. was 103/61 and had a heart rate of 76. LVN 8 stated the medications should have been held due to Resident 107's systolic blood pressure. LVN 8 stated it could further lower the resident's blood pressure. During a concurrent interview and record on 11/18/2021 at 2:42 p.m., with the Director of Nursing (DON), the DON verified that Resident 107's MAR indicated amlodipine and metoprolol was given on 11/16/2021 at 9 a.m. when Resident 107's blood pressure was 103/61 as indicated by the check mark. The DON stated there are parameters so that the medication can be held so it doesn't further decrease. The DON stated there was a risk for hypotension (low blood pressure) if the resident was given the medication when it should have been held. The DON stated it should have been held and verified there were no progress notes indicating that the medication was held. A review of the facility's policy and procedures itled, Preparation and General Guidelines, dated 10/2017, indicated, medications are administered in accordance with written orders of the attending physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. On 11/16/2021 at 12:46 p.m. during dining observation, observed Certified Nurse Assistant 5 (CNA 5) enter a person under investigation's (PUI - resident with risk factors for a specific infectious disease) room, wearing face shield and surgical mask. On 11/16/2021 at 01:14 p.m. during an interview with CNA 5, CNA 5 stated he did not put a gown when entering the PUI room. CNA 5 stated when entering the PUI room he should be wearing gloves, gown, N95 (a mask containing multiple layers of protective fabric that they can capture up to 95% of bacteria and viruses and provide good protection against infection), and face shield. CNA 5 stated when he entered the PUI room, he was wearing a surgical mask but should have been wearing an N95. CNA 5 stated N95 provides a better protection than the surgical mask. CNA 5 further stated not wearing the appropriate personal protective equipment (PPE - equipment worn to minimize exposure to hazards like infections that cause serious workplace injuries and illnesses) can cause the spread of infection to everyone. On 11/19/2021 at 10:46 a.m. during an interview with the Director of Nursing (DON), the DON stated CNA 5 should have worn the appropriate PPE as the situation placed the facility at risk for spread of infection. A review of the facility's policy and procedures titled Infection Control, revised in 01/2016, indicated the facility has established and will maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. The policy and procedures further indicated the utilization of infection control program components that included the implementation of measures to prevent transmission of infectious agents and to reduce risks for device and procedure-related infections. c. On 11/16/2021 at 12:58 p.m. during an observation, observed the Hospice Nurse (HN) exiting a person under investigation's (PUI - resident with risk factors for a specific infectious disease) room, wearing gown, gloves, face shield, and N95 (a mask containing multiple layers of protective fabric that they can capture up to 95% of bacteria and viruses and provide good protection against infection) in the hallway. Observed Certified Nurse Assistant 5 (CNA 5) and Licensed Vocational Nurse 6 (LVN 6) speaking to the HN nurse. Neither CNA 5 nor LVN 6 told the HN to remove the personal protective equipment (PPE - equipment worn to minimize exposure to hazards like infections that cause serious workplace injuries and illnesses). On 11/16/2021 at 01:06 p.m. during an interview with LVN 6, LVN 6 stated rooms have garbage bins inside that should be used after removing PPEs. LVN 6 stated that they should have oriented the Hospice Nurse (HN) her and told her to remove her PPEs and to wash hands. LVN 6 stated the HN hospice nurse was placing the facility at risk for contaminating the area, a risk for infection especially since she just went to a PUI room. On 11/19/2021 at 10:46 a.m. during an interview with the Director of Nursing (DON), the DON stated PUI residents' staff and visitors should be wearing N95, face shield, gown, and gloves. On 11/19/2021 at 10:48 a.m. during an interview, the DON stated the facility was responsible to educate all visitors on how to don (put on) and doff (remove) PPE, the Hospice Nurse (HN) should have taken all her PPEs off except face shield and N95. The DON stated her staff should have told the Hospice Nurse (HN) right then and there to remove her PPE before exiting the PUI room. The DON stated all visitors are verbally educated when entering the facility how to don and doff PPE and it is posted throughout the facility. The DON stated the Hospice Nurse (HN) placed the facility at risk for spread of infection. A review of the facility's policy and procedures titled Infection Control, revised in 01/2016, indicated the facility has established and will maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. The policy and procedures further indicated the utilization of infection control program components that included the implementation of measures to prevent transmission of infectious agents and to reduce risks for device and procedure-related infections. Based on observation, interview, and record review, the facility failed to implement infection control policy and procedures by failing to ensure: 1. The urinary catheter (a flexible tube that collects urine from the bladder and leads to a drainage bag) tubing was kept off the floor for one of four sampled residents (Resident 76) investigated under the care area of urinary catheter. 2. Certified Nursing Assistant 5 (CNA 5) don (put on) the proper personal protective equipments (PPE - equipment worn to minimize exposure to hazards like infections that cause serious workplace injuries and illnesses) when entering a person under investigation's (PUI - resident with risk factors for a specific infectious disease) room. 3. The staff notified the Hospice Nurse (HN) to remove the PPEs when leaving a PUI room. Findings: a. A review of Resident 76's admission Record (face sheet) indicated the resident was originally admitted to the facility on [DATE], and was readmitted on [DATE], with diagnoses that included urinary tract infection (UTI - an infection in any part of the urinary system), obstructive and reflux uropathy (disorder of the urinary tract that occurs due to obstructed urinary flow leading to a backward flow of urine into the kidney and causing damage to the kidneys), and dementia (changes to memory, thinking, and behavior caused by reduced blood flow to the brain). A review of Resident 76's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/21/2021, indicated the resident had severe cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) impairment. The MDS also indicated Resident 76 had the ability to usually make self understood and the ability to usually understand others. The MDS further indicated Resident 76 required extensive assistance and total dependence on staff with most areas of activities of daily living (ADLs- term used in healthcare to refer to daily self-care activities). During an observation, on 11/16/2021 at 12:21 p.m., observed urinary drainage covered with a dignity bag (discreetly hides urine drainage bag) and positioned inside a basin. However, observed the catheter tubing was touching the floor. During a concurrent observation and interview, on 11/16/2021 at 12:29 p.m., Licensed Vocational Nurse 6 (LVN 6) verified the urinary catheter tubing was touching the floor. LVN 6 stated the catheter tubing should not be touching the floor for infection control purposes. Observed LVN 6 pulling the tubing up from the floor and placing it inside the basin. During an interview, on 11/18/2021 at 2:38 p.m., the Infection Control Preventionist (IP) stated the catheter tubing should be in the basin and not touching the floor for infection control purposes. The IP confirmed there is potential for contamination of the tubing and places the resident at risk for developing infection by allowing the tubing to touch the floor. A review of the facility's policy and procedures titled, Foley (name of an indwelling urinary catheter) Catheter Care, updated and approved on 4/9/2021, indicated the foley catheter drainage bag and tubing should be used in a manner that prevents it from touching the floor.

Based on interview and record review, the facility failed to ensure residents were informed of the rules of the facility for two of 11 alert residents who attended the Resident Council Meeting Interview. This deficient practice has the potential to result in misinformation of rules. Findings: During the Resident Council Meeting Interview on 12/10/19 at 10:44 a.m., two of 11 resident council attendees stated they were not informed of the rules in the facility. During an interview on 12/11/19 at 2:44 p.m., the Activities Director (AD) stated rules are not discussed during resident council meetings. During an interview on 12/13/19 at 2:58 p.m., the Director of Nursing (DON) stated the residents are informed during admission of the rules of the facility including the facility is a non-smoking facility, there are visiting hour restrictions, the facility is locked at 9 p.m. and leave from the facility. The DON stated there are some family members they accommodate including new admits who verbalize they are scared of the new environment, and accommodate to ensure residents are okay, especially for those who share a room. Accommodation also depends on the administrator for the day. A review of the facility's policy and procedure titled Resident Council reviewed and approved on 4/17/19, indicated it is the facility's policy to support resident's desires to be involved and have input in the operation of the facility through the Resident Council.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safety for one of one resident (Resident 93), reviewed for accidents and supervision, by failing to ensure side rails were completely padded. This deficient practice had the potential for injury to Resident 93 related to resident's diagnosis of seizure (sudden, uncontrolled movements of the body caused by a person's brain disorder). Findings: A review of Resident 93's Face Sheet (admission record) indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including generalized muscle weakness, dysphagia (difficulty swallowing), diabetes mellitus (abnormally high blood sugar). A review of Resident 93's History and Physical (H&P), dated 10/15/19, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 93's Minimum Data Set (MDS - a residents' assessment and screening tool) dated 9/16/19, indicated the resident had severe impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making. The MDS indicated the resident required extensive physical assistance for bed mobility, transfer, toileting, dressing, personal hygiene and eating. During an observation, on 12/10/19, at 9:07 A.M., Resident 93 was observed lying in bed asleep with his right bed side rails incompletely wrapped with old and torn foam pads. During an observation and concurrent interview, on 12/10/19, at 9:08 A.M., CNA 6 validated that the resident's right side rail padding was torn, and incompletely padded. CNA 6 stated the side rail padding should completely wrap the rails. CNA 6 stated the padding should not be torn so the resident will not to hurt himself, when the resident accidentally hit his head on the side rails. During an interview, on 12/13/19, at 12:08 P.M., the Director of Staff Development (DSD) stated that the purpose of the side rail paddings are used for the residents to not to hurt themselves due to their diagnosis of seizures. The DSD stated that the side rail padding needs to be changed or replaced, if the paddings are old or torn. A review of the facility's Policy and Procedures (P&P), titled Accident/Incident Policy, with a review date of 4/17/19, indicated that the facility has systems in place to prevent, monitor, and record accidents and incidents: in-service education will be provided for facility staff that includes proper lifting, care of residents, as well as environmental considerations.

Based on interview and record review, the facility failed to ensure the change of shift Controlled Medications Reconciliation record (accountability record of medications that are considered to have strong potential for abuse) was properly filled and signed by the licensed nurse in one out of five medication carts (Med Cart 1) reviewed under the facility task of medication storage. This deficient practice had the potential for inability to readily identify loss and drug diversion (illegal distribution or abuse of prescription drugs or their use for unintended purposes) of controlled medications. Findings: On 12/12/19 at 6:55 AM, during an interview with Licensed Vocational Nurse 10 (LVN 10) and a concurrent review of the change of shift Controlled Medications Reconciliation record (accountability record of medications that are considered to have strong potential for abuse) for Med Cart 1, there was no signature of the outgoing (leaving the shift) 7:00 AM to 3:00 PM licensed nurse on 12/8/19. LVN 10 stated the outgoing licensed nurse should have signed the Controlled Medications Reconciliation record to validate the controlled drug counts are accurate. On 12/13/19 at 2:30 p.m., during an interview, the Director of Nursing (DON) stated after counting the controlled medications, both of the licensed nurses who counted should sign the Controlled Medications Reconciliation record after. In the above case, only the incoming (starting the shift) licensed nurse signed the record. The DON stated the outgoing licensed nurse should have also signed to show that they have reconciled (counted accurately) the controlled medications. A review of the facility's policies and procedures titled Controlled Medication Storage, dated 8/2014, indicated at each shift change, a physical inventory of all controlled medications, including the emergency supply is conducted by two licensed nurses and is documented on the controlled medication accountability record (Controlled Medications Reconciliation record).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services by: 1. Failing to indicate the date when Resident 251's foil pack (medication container) of Ipratropium-Albuterol (breathing treatment medication) was opened, in one out of five medication carts (Med Cart 1) investigated under the facility task of medication storage and labeling. 2. Failed to remove the Ipratropium Bromide (breathing treatment medication) from the medication cart after Resident 1 was discharged , in one of five medication carts (Med Cart 1) investigated under the facility task of medication storage and labeling. The medication was still stored inside the medication cart with the current residents' medications. These deficient practices had the potential for unintentional medication administration of possibly expired breathing treatment medications to the residents. Findings: a. A review of Resident 251's admission Record (face sheet) indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE], with diagnosis that included chronic obstructive pulmonary disease (COPD - lung disease marked by permanent damage to tissues in the lungs which makes breathing difficult). A review of Resident 251's Minimum Data Set (MDS - a standardized assessment and screening tool) dated [DATE], indicated the resident had intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated the resident needed total assistance with most activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 251's Order Summary Report indicated a physician's order dated [DATE], to administer DuoNeb Solution (Ipratropium-Albuterol - breathing treatment medication) one unit via mask every four hours as needed for shortness of breath/COPD. On [DATE] at 6:47 AM, during an observation of Medication Cart 1 and a concurrent interview, an opened foil pack (container) of Resident 251's Ipratropium-Albuterol was observed stored inside the medication cart. The foil pack did not indicate the date on when it was opened. Licensed Vocational Nurse 10 (LVN 10) stated the resident's opened foil pack should have indicated the date, when it was opened, so they would know how many vials are left inside the box. On [DATE] at 2:25 PM, during an interview, the Director of Nursing (DON) stated Resident 251's opened foil pack of Ipratropium-Albuterol should have indicated an opened date to readily identify that it has to be discarded after 14 days of opening. A review of the facility's policies and procedures titled Vials and Ampules of Injectable Medications, dated 4/2008 and reviewed on [DATE], indicated the date opened and the initials of the first person to use the vial are recorded on the multi-dose (containing more than one dose of medication) on the vial label or an accessory label affixed for that purpose). b. A review of Resident 1's admission Record (face sheet) indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE], with diagnoses that included bronchitis (inflammation of the airways that carry air to the lungs) and chronic obstructive pulmonary disease (COPD - lung disease marked by permanent damage to tissues in the lungs which makes breathing difficult). The resident was discharged to home on [DATE]. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and screening tool) dated [DATE], indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated the resident needed extensive assistance with most activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 1's Order Summary Report indicated a physician's order dated [DATE], to administer Atrovent (Ipratropium Bromide - breathing treatment medication) one unit via nebulizer every four hours as needed for two weeks for shortness of breath/COPD. On [DATE] at 6:50 AM, during an observation of Medication Cart 1 and a concurrent interview, an opened foil pack (container) of Resident 1's Ipratropium Bromide was observed stored inside the medication cart with the other current residents' medications. Licensed Vocational Nurse 10 (LVN 10) stated Resident 1 has already been discharged . LVN 10 stated the resident's medication should have been stored in the left, lower drawer of the medication cart, intended for medications of residents who were discharged . The medication should have been stored there after Resident 1 was discharged . At the end of the shift, LVN 10 stated the resident's medication should have been stored inside the medication room for destruction (disposal). On [DATE] at 2:27 PM, during an interview, the Director of Nursing (DON) stated after Resident 1 was discharged , the resident's medication should have been stored inside the medication room and not the medication cart, because it is their policy. A review of the facility's policies and procedures titled Discontinued Medications, dated 12/2018, indicated when medications are expired, discontinued by a prescriber, when a resident is transferred or discharged and does not take medications with him/her, or in the event of a resident's death, the medications are marked as discontinued or stored in a separate location and later destroyed. Medications awaiting disposal, are stored in a locked secure area designated for that purpose until destroyed. Medications are removed from the medication cart or storage area prior to expiration and immediately upon receipt of an order to discontinue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 252's admission Record (face sheet) indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnosis that included diabetes mellitus (DM - a condition that affects how the body processes blood sugar). A review of Resident 252's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 11/23/19 indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS also indicated the resident needed extensive to total assistance with most activities of daily living (ADL - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 252's Order Summary Report indicated the following physician's orders to administer: 1. Lantus insulin (long-acting hormone that lowers the level of blood sugar) 20 units subcutaneously (SQ - injecting medication into the tissue layer between the skin and the muscle) every 12 hours for DM. The order date was 10/24/19. 2. Insulin Lispro (rapid-acting hormone that lowers the level of blood sugar) per sliding scale coverage (progressive increase in the insulin dose based on pre-defined blood glucose ranges) subcutaneously before meals and at bedtime for DM. The order date was 9/18/19. On 12/13/19 at 11:44 AM, during an interview and concurrent record review of Resident 252's Medication Administration Records (MARs), Registered Nurse 3 (RN 3) stated Lantus doses were administered to: 1. The left deltoid (muscle covering the shoulder joint) on 12/7/19 for the 9:00 PM dose and on 12/8/19 for the 9:00 AM dose. 3. The right deltoid on 12/8/19 for the 9:00 PM dose. RN 3 also stated Resident 252's Lispro doses were administered to the right deltoid on 12/8/19 and 12/11/19 for the 5:00 PM doses. On 12/13/19 at 2:30 PM, during an interview, the Director of Nursing stated the licensed nurses should have been accurate with their documentation; they should have documented that insulin doses were administered subcutaneously. A review of the facility's policies and procedures titled Subcutaneous Medication Administration, dated 12/2015 indicated the purpose of administering medication into the subcutaneous tissues was to promote slow medication absorption and prolonged medication action. It indicated to document the injection on the MAR along with the site used. A review of the facility's policies and procedures titled Medication and Treatment Administration Record, dated 6/2004 and reviewed on 4/7/19, indicated medications and treatments shall be administered as prescribed by the physician and shall be recorded by the responsible licensed nurse as the medication and/or treatment is provided. Based on interview and record review, the facility failed to maintain accurate medical records two of five residents, including one of one resident (Resident 152) investigated under medication storage and labeling, and one of four diabetic residents investigated under medication administration (Resident 252). These deficient practices had the potential to result in confusion on the delivery of care and services rendered and may lead ineffective management of Resident 152's low back pain and arthropathy (disease of the joints) and ineffective management of Resident 252's diabetes mellitus (DM - a condition that affects how the body processes blood sugar). Finding: a. A review of Resident 152's admission Record (face sheet) indicated the resident was admitted to the facility on [DATE], with diagnosis that included arthropathy (pain is the main symptom associated with arthropathy ) and low back pain. A review of Resident 152's History and Physical (an important reference document that provides concise information about a patient's history and exam findings at the time of admission) dated 12/5/19, indicated the resident has the capacity to understand and make decisions. A review of Resident 152's physician's orders at the time of admission, included, Oxycodone HCL (used to help relieve moderate to severe pain) 30 milligram (mg) tablet, 1 tablet by mouth every six hours as needed for severe pain. On 12/11/19 at 2:30 p.m., during a medication cart inspection in Nursing Station 2, with Licensed Vocational Nurse 1 (LVN 1) who was the medication nurse at that time, indicated a discrepancy in the Controlled Drug Record (COD) of Oxycodone HCL 30 mg. During the inspection, the COD for Oxycodone HCL 30 mg indicated that there should be two tablets left. During the discussion with LVN 1 of the findings, LVN 1 then verified the Medication Administration Record (MAR) and compare it with the COD for Oxycodone HCL 30 mg. LVN 1 explained that he/she administered a dose in the morning around 8:30 a.m. but forgot to sign out the medication in the COD. LVN 1 stated that he/should have immediately signed out the medication from the COD as it is the correct practice and not after six hours later. A review of the facility's Policy and Procedure titled Medication Administration-General Guidelines, last reviewed and approved on 4/17/19, indicated that the individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. A review of Resident 158's admission Record indicated the resident was admitted on [DATE], with diagnosis including dementia (a loss of mental ability severe enough to interfere with normal activities of daily living) and Alzheimer's disease (a brain disease that slowly destroys brain cells). A review of Resident 158's admission assessment dated [DATE], indicated the resident's mood wanders mentally and disoriented to time and place. The admission Assessment indicated the resident is dependent with grooming and dressing. A review of Resident 158's History and Physical dated 12/8/19 indicated the resident does not have capacity to understand and make decisions. During an observation on 12/13/19 at 10:57 a.m., Resident 158 was ambulating in hallway with a front wheel walker (FWW) with Physical Therapy Assistant (PTA 1) and Occupational Therapy Assistant (OTA 1). Resident 158's brief was exposed while ambulating out in the hallway. During an interview on 12/13/19 at 11:20 a.m., the Licensed Vocational Nurse (LVN 6) stated he was going to change Resident 158 and went to change another resident because resident's family member and PTA 1 was at bedside. LVN 6 stated resident was lying in bed and was wearing two patient gowns. LVN 6 stated the family member and PTA 1 was at bedside and was getting the resident up. LVN 6 he told PTA 1 that he will come back change resident and went to change another resident. During an interview on 12/13/19 at 11:25 a.m., PTA 1 stated he talked with LVN 6, that he was coming around that time for Resident 158's therapy. PTA 1 stated when he went to the resident, the resident's wife was already there, and insisted to do the resident's therapy right then. PTA 1 stated the resident has Alzheimer's, has behavior issues and talked about not getting dressed today. PTA 1 told the resident's wife to double gown the resident. PTA 1 stated he did warm up exercises such as sit to stand exercise in the room. PTA 1 stated the resident's wife insisted for resident to ambulate and ended up ambulating in the hallway. PTA 1 stated he was made aware by OTA 1 that resident's diaper was exposed. During an interview on 12/13/19 at 11:28 a.m., OTA 1 stated they were not expecting for Resident 158 to ambulate out in the hallway. OTA 1 stated she noticed resident's brief was exposed and asked for resident to sit down. OTA 1 stated the resident's wife was grabbing and pulling the walker insisting the resident to take steps. OTA 1 stated the resident is a new admit and is confused with poor safety awareness. OTA 1 stated they needed to take control of the situation. During an interview on 12/13/19 at 3:17 p.m., the Director of Nursing (DON) stated residents have the right to be treated with respect and dignity. The DON stated for Resident 158, the resident should have been covered to ensure his brief was not exposed while ambulating . A review of the facility's policy and procedure titled Residents have the Right to be treated with Dignity and Respect reviewed and approved on 4/17/19, indicated residents have the right to be treated with respect. Residents will have their privacy requests respected. Privacy curtains are pulled when giving care and residents are fully covered when taking them to shower. All residents will be treated in a manner which maintains and enhances their dignity. Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced the resident's dignity and respect for three of three residents (Resident 12, 67, and 158 by: 1. Failing to ensure Resident 12 is provided privacy while receiving personal care. 2. Failing to ensure Resident 67 is provided privacy during medication administration. 3. Failing to ensure Resident 158's brief was not exposed during ambulation exercise. These deficient practices violated resident's rights to be treated with consideration, respect and full recognition of dignity and individuality that may affect the residents' sense of self-worth. Findings: a. A review of Resident 12's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses of heart failure (occurs when your heart muscle doesn't pump blood as well as it should), anxiety disorder (excessive and persistent worry and fear about everyday situations), and dementia with behavioral disturbances (a group of symptoms that affects memory, thinking and interferes with daily life). A review of Resident 12's Minimum Data Set (MDS- an assessment and screening tool) dated 5/29/19, indicated Resident 12 has the ability to usually make self understood and the ability to usually understand others. The MDS also indicated that Resident 12 required limited assistance with dressing, personal hygiene, toilet use (using the bathroom), and extensive assistance with bathing. On 12/10/19 at 9:13 a.m., during the initial tour, while passing by the hallway, Resident 12 was observed sitting close to the door while his face was shaved by Certified Nurse Assistant 1 (CNA 1). Resident 12 was six feet away from the door and visible to anyone passing thru the hallway. On 12/10/19 at 12:26 p.m., during an interview, CNA 1 recalled that while he was shaving Resident 12, he did not ensure privacy and dignity was maintained. CNA 1 stated that he should have provided care to Resident 12 while protecting his/her privacy and maintaining his dignity. b. A review of Resident 67's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of hypertension (high blood pressure), anxiety disorder (excessive and persistent worry and fear about everyday situations), and dementia with behavioral disturbances (a group of symptoms that affects memory, thinking and interferes with daily life). A review of Resident 67's Minimum Data Set (MDS- an assessment and screening tool) dated 7/01/19, indicated Resident 67 has the ability to usually make self understood and the ability to usually understand others. The MDS also indicated that Resident 67 required extensive assistance with personal hygiene, toilet use (using the bathroom), and with bathing. On 12/13/19 at 8:47 a.m., during a medication pass observation, Licensed Vocational Nurse 2 (LVN 2) was followed while administering medication to Resident 67. When LVN 2 administered Resident 67's 9:00 a.m., medications, LVN 2 poured the scheduled medications, proceeded to Resident 67's bedside, but did not draw the privacy curtain. Resident 67 was in view of another resident in the room who was pacing and sat down across from Resident 67's bed. LVN 2 administered Resident 67's medications, but did not provide privacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide reasonable accommodation of resident needs for four (4) of four (4) residents investigated under reasonable accommodation of resident needs and preferences by failing to: 1. Ensure two of two residents (Resident 79 and 299), did not wait for 15 to 20 minutes when using the call light to request assistance. 2. Ensure two of two residents (Resident 93 and 300), have their call light within reach. These deficient practices had the potential to result in the delay of the provision of necessary care and services for Resident 79, 299, 93, and 300. Findings: a. A review of Resident 79's Face Sheet (admission record) indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including sciatica (a common type of pain affecting a large nerve extending from the lower back down the back of each leg), and hypertension (abnormally high blood pressure). A review of Resident 79's History and Physical (H&P), dated 1/9/19, indicated the resident had the capacity to understand and make decisions. A review of Resident 79's Minimum Data Set (MDS - a residents' assessment and screening tool) dated 9/13/19, indicated the resident had severe impairment in cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making. The MDS indicated the resident required extensive physical assistance for bed mobility, transfer, toileting, dressing, and personal hygiene, and required limited physical assistance for eating. A review of Resident 79's self-care deficit Care Plan (CP) interventions dated 10/29/19, included staff should place the resident's call light within reach and staff are to attend to the resident's needs promptly. During an initial screening interview, on 12/10/19, at 8:45 A.M., Resident 79 stated she did not have her incontinence brief on because after a nurse assisted to change in the restroom, she was put back to bed. The resident stated she had to wait for 15 minutes after pressing the call light to ask for assistance. Resident 79 stated she had been waiting for a long time and she did not want to miss her physical therapy schedule. During an interview, on 12/10/19, at 8:50 A.M., Licensed Vocational Nurse 9 (LVN 9) stated that she does not know who assisted the resident. LVN 9 stated that she will help Resident 79 to get ready for physical therapy as soon as possible. b. A review of Resident 299's Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE], with diagnoses including generalized muscle weakness, and diabetes mellitus (abnormally high blood sugar). A review of Resident 299's History and Physical (H&P) dated 12/1/19, indicated the resident had the capacity to understand and make decisions. A review of Resident 299's Minimum Data Set (MDS - a residents' assessment and screening tool) dated 12/8/19, indicated the resident had no impairment in cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making. The MDS indicated the resident required extensive physical assistance for bed mobility, transfer, toileting and dressing, and limited physical assistance for personal hygiene and supervision for eating. During initial screening interview, on 12/10/19, at 9:06 A.M., Resident 299 stated he had been in the facility for 10 days and he had to wait for 20 minutes when using the call light to request assistance to be repositioned. A review of Resident 299's Baseline Care Plan (BCP) interventions dated 12/1/19, indicated staff are to place the call light within reach and for staff to encourage the resident to ask for assistance. c. A review of Resident 93's Face Sheet (admission record) indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including generalized muscle weakness, dysphagia (difficulty swallowing), and diabetes mellitus (abnormally high blood sugar). A review of Resident 93's History and Physical (H&P), dated 10/15/19, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 93's Minimum Data Set (MDS - a residents' assessment and screening tool) dated 9/16/19, indicated the resident had severe impairment in cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making. The MDS indicated the resident required extensive physical assistance for bed mobility, transfer, toileting, dressing, personal hygiene and eating. During an observation and concurrent interview, on 12/10/19, at 9:06 A.M., Resident 93 was observed lying in bed with his call light on the floor, hanging on the left side of his bed. During a concurrent interview, Certified Nursing Assistant 6 (CNA 6) verified that the resident's call light was on the floor. CNA 6 acknowledged the resident's call light should be placed within reach and not on the floor, for the resident to get assistance when needed. d. A review of Resident 300's Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE], with diagnoses including Parkinson's disease (a nerve disorder that causes muscle stiffness, slowness of movement and balance problems), and diabetes mellitus (abnormally high blood sugar). A review of Resident 300's History and Physical (H&P), dated 1/9/19, indicated the resident had the capacity to understand and make decisions. A review of Resident 300's Minimum Data Set (MDS - a residents' assessment and screening tool) dated 9/13/19, indicated the resident had no impairment in cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making. The MDS indicated the resident required extensive physical assistance for transfer, toileting, dressing, and personal hygiene, and required supervision from staff for bed mobility and eating. A review of Resident 300's self-care deficit Care Plan (CP) interventions, dated 12/10/19, included staff should place the resident's call light within reach and staff are to attend to the resident's needs promptly. During an observation and concurrent interview, on 12/10/19, at 9:10 A.M., Resident 300 was observed in lying in bed with his call light on the floor, hanging on the left side of his bed. During a concurrent interview, Certified Nursing Assistant 6 (CNA 6) verified that the resident's call light was on the floor. CNA 6 acknowledged the resident's call light should be placed within reach, and not on the floor for the resident to get assistance when needed. During an interview, on 12/13/19, at 12:08 PM, the Director of Staff Development (DSD), stated that the residents' call light should be placed within reach at all times and answered promptly by all staff. A review of the facility's Policy and Procedures (P&P), titled Call Lights, with a review date of 4/17/19, indicated that nursing and care duties included that the call light is within the resident's reach when in his/her room or when on the toilet. The P&P indicated staff is to monitor the call lights and make sure that call lights are answered promptly, regardless of who is assigned to each resident.

Based on interview and record review, the facility failed to ensure residents were informed of their right to contact the state for three of 11 alert residents who attended the Resident Council Meeting Interview. This deficient practice has the potential to result in a delay of necessary care and services. Findings: During the Resident Council Meeting Interview on 12/10/19 at 10:44 a.m., three of 11 resident council attendees did not know how to file a complaint to the State. During an interview on 12/11/19 at 2:45 p.m., the Activities Director (AD) stated the Ombudsman posting is in the Dining Room. The AD stated she provides the Ombudsman telephone number when the residents ask, and she refers to the Director of Nursing or supervisor if needing to investigate more. The AD stated she does not have the number of the State or the Health Department. During an interview on 12/13/19 at 3:01 p.m., the Director of Nursing (DON) stated the residents are informed upon admission of the right to file a complaint to the State. A review of the facility's policy and procedure titled Resident Council reviewed and approved on 4/17/19, indicated that it is the facility's policy to support the resident's desires to be involved and have input in the operation of the facility through the Resident Council. The responsibilities of the Group Council: Assist in the development of resident grievance and complaint procedures, resident's rights and responsibilities, make recommendations for the improvement of resident services, review reports, making recommendations for solutions and serving as advisory group between residents and facility management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the bed side rail foam padding wrapped around residents' side rails were clean and free of tears for three out of four residents observed under environment facility task (Residents 250, 249, and 62). This deficient practice violated the residents' rights to a safe, clean, comfortable, sanitary, and homelike environment. Findings: a. A review of Resident 250's admission Record (face sheet) indicated the resident was admitted to the facility on [DATE], with diagnoses that included generalized weakness and multiple sclerosis (a progressive disease involving damage to part of the nerve cells in the brain and spinal cord). On 12/10/19 at 9:36 AM, during an observation and interview, Resident 250 was observed on a bed. The resident's side rails were wrapped with foam padding that had tears. Resident 250 stated she does not remember anyone disinfecting the foam padding. On 12/13/19 at 1:27 PM, during an observation of Resident 250's bed rails and a concurrent interview, the Maintenance Supervisor (MS) stated there were some tears on the foam padding wrapped around the bed side rails. The MS stated it is the responsibility of the maintenance department to make sure the foam paddings are intact. The MS also stated it is the responsibility of the housekeeping department to make sure the foam paddings are cleaned. The MS stated Resident 250's bed side rail foam padding needs to be replaced. The MS also stated any staff member could have reported to him that the foam padding needs to be checked and maybe needs to be fixed or replaced. The MS stated no staff member reported to him. On 12/13/19 at 2:39 PM, during an interview, the Director of Nursing (DON) stated nursing staff is responsible in reporting to maintenance for any issues that need to be fixed. A review of an undated facility policy and procedure titled, Maintenance and Plant Operations, indicated the facility shall properly maintain the building, its fixtures, systems, and equipment in order to ensure that the entire facility is clean, free of environmental pollutants, and in good repair and safe operating condition at all times. b. A review of Resident 249's admission Record (face sheet) indicated the resident was admitted to the facility on [DATE] with diagnoses that included fracture (broken bone) of right humerus (long bone from the shoulder to the elbow) and history of infectious diseases. On 12/10/19 at 9:44 AM, during an observation and interview, Resident 249 was observed on a bed. The resident's side rails were wrapped with foam padding that had tears. Resident 249 stated he does not remember anyone disinfecting the foam padding and that he is conscious of what's going on around him. On 12/13/19 at 1:36 PM, during an observation of Resident 249's bed rails and a concurrent interview, the Maintenance Supervisor (MS) stated there were some tears on the foam padding wrapped around the bed side rails. The MS stated it is the responsibility of the maintenance department to make sure the foam paddings are intact. The MS also stated any staff member could have reported to him that the foam padding needs to be checked and maybe needs to be fixed or replaced. The MS stated no staff member reported to him. On 12/13/19 at 2:39 PM, during an interview, the Director of Nursing (DON) stated nursing staff is responsible in reporting to maintenance for any issues that need to be fixed. A review of an undated facility policy and procedure titled, Maintenance and Plant Operations, indicated the facility shall properly maintain the building, its fixtures, systems, and equipment in order to ensure that the entire facility is clean, free of environmental pollutants, and in good repair and safe operating condition at all times. c. A review of Resident 62's admission Record (face sheet) indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE], with diagnoses that included acute respiratory failure and dependence on ventilator (a life support device that breathes for individuals who lost all ability to breathe on their own). A review of Resident 62's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 10/9/19, indicated the resident had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making. The MDS also indicated the resident needed total assistance with activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). On 12/10/19 at 10:51 AM, during an observation, Resident 62 was on a bed with a tracheostomy (a surgical incision made through the neck into the windpipe to allow direct access to the breathing tube). The resident's side rails were wrapped with foam padding that had tears. On 12/13/19 at 1:41 PM, during an observation of Resident 62's bed rails and a concurrent interview, the Maintenance Supervisor (MS) stated there were some tears on the foam padding wrapped around the bed side rails. The MS stated it is the responsibility of the maintenance department to make sure the foam paddings are intact. The MS also stated any staff member could have reported to him that the foam padding needs to be checked and maybe needs to be fixed or replaced. The MS stated no staff member reported to him. On 12/13/19 at 2:39 PM, during an interview, the Director of Nursing (DON) stated nursing staff is responsible in reporting to maintenance for any issues that need to be fixed. A review of an undated facility policy and procedure titled, Maintenance and Plant Operations, indicated the facility shall properly maintain the building, its fixtures, systems, and equipment in order to ensure that the entire facility is clean, free of environmental pollutants, and in good repair and safe operating condition at all times.

Based on interview and record review, the facility failed to ensure residents were informed of their right to file a grievance for three of 11 alert residents who attended the Resident Council Meeting Interview. This deficient practice has the potential to result in delay of response to resolve the residents' grievances and concerns. Findings: During the Resident Council Meeting Interview on 12/10/19 at 10:44 a.m., three of 11 residents in attendance did not know how to file a grievance. During an interview on 12/11/19 at 2:38 p.m., the Activities Director (AD) stated there is a resident rights posting in the Dining Room and another one located on the board close to the entrance. The AD stated she is not able to recall which resident rights were discussed in the monthly meeting. During an interview on 12/13/19 at 2:56 p.m., the Director of Nursing (DON) stated residents are informed of how to file a grievance, the staff can write it down for them and the resident can also file. The DON stated the residents' responsible party are informed upon admission, and for initial new admission, the staff talks to the family members. A review of the facility's policy and procedure titled Resident Council reviewed and approved on 4/17/19, indicated it is the facility's policy to support resident's desires to be involved and have input in the operation of the facility through the Resident Council. The responsibilities of the Group Council: Assist in the development of resident grievance and complaint procedures, resident's rights and responsibilities, make recommendations for the improvement of resident services, review reports, making recommendations for solutions and serving as advisory group between residents and facility management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. A review of Resident 88's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included a respiratory failure (condition in which not enough oxygen passes from your lungs into your blood), hemiplegia (paralysis of one side of the body), hemiparesis (weakness of one side of the body), and diabetes mellitus (high blood sugar levels). A review of Resident 88's Minimum Data Set (MDS- an assessment and care screening tool) dated 10/25/19, indicated the resident rarely/never makes self understood and rarely/never understands others. During a concurrent observation and record review on 12/10/19 at 8:55 AM, Registered Nurse 2 (RN 2) verified that Resident 88 did not have any heel protectors on. RN 2 verified that Resident 88 had a physician order, ordered on 10/1/19, indicating to apply heel protectors for skin integrity management. RN 2 stated that a possible complication due to not wearing heel protectors could be an injury to the resident, such as redness or opening of the skin. RN 2 stated that Resident 88 should have had heel protectors on. A review of Resident 88's Wound Risk Assessment, dated 11/1/19, indicated the resident has a total score of 18 (8 and above indicates high risk for skin breakdown). A review of Resident 88's Care Plan titled, Risk for developing pressure sore, indicated an intervention for pressure relieving devices as needed. During an interview on 12/13/19 at 9:57 AM, the Director of Nursing (DON) stated the facility has policies regarding staging and treatment of pressure wounds but no policy regarding prevention of wounds or skin management. d. A review of Resident 114's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included respiratory failure, hemiplegia (hemiparesis- paralysis of one side of the body). A review of Resident 114's MDS dated [DATE], indicated the resident rarely/never makes self understood and rarely/never understands others. During a concurrent observation and record review on 12/10/19 at 9:02 AM, RN 2 verified that Resident 114 only had a heel protector on the left foot and did not have a heel protector on the right foot. RN 2 verified that Resident 114 had a physician order, ordered on 1/17/19, indicating to apply heel protectors for skin integrity management. RN 2 stated that a possible complication due to not wearing heel protectors could be an injury to the resident such as redness or opening of the skin. RN 2 stated that Resident 114 should have had both heel protectors on. A review of Resident 114's Wound Risk Assessment, dated 11/6/19, indicated the resident has a total score of 18 (8 and above indicates high risk for skin breakdown). A review of Resident 114's Care Plan titled, Skin impairment, indicated an intervention to provide pressure relief that is appropriate and/or ordered. A review of Resident 114's Care Plan titled, Risk for developing pressure sore, indicated an intervention for pressure relieving devices as needed. During an interview on 12/13/19 at 9:57 AM, the Director of Nursing (DON) stated the facility has policies regarding staging and treatment of pressure wounds but no policy regarding prevention of wounds or skin management. Based on observation, interview, and record review, the facility failed to ensure four of seven residents (Resident 24, 55, 88, and 114) investigated under pressure ulcer investigations were provided necessary treatments and services for prevention of pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin), and to promote healing of pressure ulcer by: 1. Failing to implement the facility's pressure ulcer policy for Resident 24, who was identified with a facility-acquired stage II on right 1st metatarsal (bone in the foot behind the great toe), right 5th metatarsal head (the long bone on the outside of the foot that connects to the little toe), and right medial ankle. 2. Failing to develop and implement interventions to promote the prevention of pressure ulcer for Resident 55's sacral (low back) area who was observed with a sacral gauze dressing on site. 3. Failing to assess and evaluate Resident 55's sacral area and surrounding tissue for presence or absence of drainage or infection, and report to the resident's physician as indicated. This deficient practice had the potential to result in the delay of necessary care and treatment to promote healing of pressure ulcers and increased the risk for development of infection of pressure ulcers from contamination (making something impure by contact with something unclean). 4. Failing to provide heel protectors as ordered for Resident 88 and 114 identified as high risk for skin breakdown. This deficient practice had the potential to place Resident 88 and 114 at an increased risk for pressure ulcer development. Findings: a. A review of Resident 24's admission Record indicated the resident was readmitted on [DATE], with diagnoses including hemiplegia (complete paralysis of half of the body) and hemiparesis (weakness of one entire side of the body) affecting the right dominant side. A review of Resident 24's History and Physical dated 10/12/19, indicated the resident does not have the capacity to understand and make decisions. A review of Resident 24's Wound Risk assessment dated [DATE], indicated the resident has a pressure ulcer assessment score of 16. A score of 16 indicates the resident is a high risk for skin breakdown. A review of Resident 24's Physician's Orders of 11/21/19, indicated to provide the following: - First (1st) metatarsal blister (a small pocket of body fluid within the upper layers of the skin) cleanse with normal saline (NS-a salt solution with sterile water), pat dry, apply Silvadene 1 percent (%) cream (a topical, for the skin, antibiotic used to treat or prevent infections on areas of burned skin), cover with dry dressing, wrap with kerlix (material to cover the area), daily. - Right fifth (5th) metatarsal blister, cleanse with NS, pat dry, apply Silvadene 1% cream, cover with dry dressing wrap with kerlix daily. - Right medial ankle blisters, cleanse with NS, pat dry, apply Silvadene cream 1%, cover with dry dressing daily. A review of Resident 24's care plan goals for Risk for Developing Pressure Ulcer revised on 10/18/19, indicated to minimize the risk of skin breakdown or bruising or pressure ulcer daily. The interventions included assessing risk using wound risk assessment on admission, quarterly, and as needed, assessing skin integrity during care, providing the treatments as ordered, and notifying the physician of any changes. During an interview on 12/11/19 at 10:02 a.m., Family Member 1 (FM 1) stated Resident 24 has pressure ulcers on multiple sites. During an interview on 12/12/19 at 9:08 a.m., the Licensed Vocational Nurse (LVN 4) stated Resident 24 does not have pressure ulcers. LVN 4 stated the resident has wounds classified as open blisters. During a wound treatment observation on 12/12/19 at 9:17 a.m., LVN 4 provided wound treatment and measured the following: Right anterior ankle 1.8-centimeter (cm) x 1.7 cm Right foot 5th metatarsal 1 cm x 1 cm with pinkish skin Left buttock 0.8 cm x 0.9 cm with pinkish tissue no drainage Right buttock 0.4 cm x 0.5 cm with small open area During a record review of Resident 24's admission assessment dated [DATE] on 12/13/19, at 8:12 a.m., the Assistant Director of Nursing (ADN 1) confirmed the resident upon admission had three sites on the foot-deep tissue injury (DTI-a pressure-related injury to subcutaneous tissues under intact skin.) During a concurrent interview and record review of Resident 24's Wound Skin Treatment Assessment on 12/13/19 at 8:20 a.m., the Licensed Vocational Nurse (LVN 5) confirmed the following wound assessment notes: On 10/12/19: 1. 1st metatarsal of the right foot DTI, 1 cm x 1 cm 2. right lateral foot DTI, 1 cm x 1 cm 3. right 5th metatarsal 2 cm x 2 cm On 10/28/19 three sites were resolved: 1. 1st metatarsal 2. right 5th metatarsal 3. right lateral foot On 11/16/19 1. right 5th metatarsal had fluid filled blister On 11/21/19 1. right 1st metatarsal, right 5th metatarsal head, and right medial ankle were classified as pressure ulcer stage II (partial-thickness skin loss into but no deeper than the dermis-skin). During an interview on 12/13/19 at 9:46 a.m., LVN 5 stated blister is caused by friction on the bed and foot, and Resident 24 was diagnosed of bullous pemphigoid (autoimmune skin condition causing large, fluid-filled blisters) on 11/26/19, and had flare ups to previous admission. LVN 5 stated deep tissue injury or DTI has a purple or maroon color and do not know how deep the tissue damage is. LVN 5 stated for the resident with pressure ulcer was prescribed hydrogel (a type of synthetic dressing that is particularly good for wounds that need to be kept moist) and was changed to Silvadene because it needed to be debrided (remove damaged tissue). During an interview on 12/13/19 at 10:14 a.m., LVN 5 stated Resident 24's right foot wound was diagnosed as blister and treated as a pressure ulcer. LVN 5 stated she will clarify with the physician regarding Resident 24's pressure ulcer classification. A review of the facility's policy and procedure titled Staging Pressure Sores reviewed and approved on 4/17/19, indicated to provide appropriate staging of pressure sores. b. A review of Resident 55's admission Record indicated the resident was readmitted on [DATE], with diagnoses including hemiparesis (weakness of one entire side of the body) and hemiplegia (complete paralysis of half of the body) and dementia (a loss of mental ability severe enough to interfere with normal activities of daily living). A review of Resident 55's History and Physical dated 11/26/19, indicated the resident does not have capacity to understand and make decisions. A review of Resident 55's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 9/28/19, indicated the resident with adequate hearing and vision, clear speech, made self-understood and understood others. The MDS assessment indicated the resident requires total assistance with transferring, ambulation, dressing, eating, toileting, and personal hygiene with one-person physical assistance. The MDS assessment indicated the resident with impairment on both sides of the upper and lower extremities on both side that interfered with daily functions or placed the resident at risk of injury. Under Section M of the MDS, indicated the resident is at risk of developing pressure ulcers/injuries (injuries to skin and underlying tissue resulting from prolonged pressure on the skin). A review of Resident 55's Wound Risk assessment dated [DATE] indicated the resident has a score of 21. A score of 21 indicates the resident is a high risk for skin breakdown. A review of Resident 55's Physician's Orders indicated to apply zinc oxide cream (forming a barrier on top of the skin that protects the area from moisture and irritants) to Sacro coccyx (tailbone) scar tissue every day shift for skin maintenance ordered on 12/19/18. A review of Resident 55's Interdisciplinary Team notes (IDT-when different disciplines meet to address a resident's problem) dated 6/28/19, indicated the resident had intact skin. During a concurrent observation and interview on 12/10/19 at 11:48 a.m., the Certified Nurse Assistant (CNA 4) provided peri-care for Resident 55, with assistance of Licensed Vocational Nurse (LVN 7). CNA 4 removed the gauze dressing from the sacral area with blood-tinged stain on the chux (bed pads that protect beds and other surfaces from bodily fluids). CNA 4 asked LVN 7 if she wanted to change the gauze dressing on the resident's sacral area. LVN 7 told CNA 4 to continue placing the resident's briefs. During a concurrent interview and record review of Resident 55's IDT and care plan on 12/12/19 at 11:00 a.m., LVN 7 confirmed the last IDT review addressing the resident's pressure ulcer skin maintenance was on 1/10/17. LVN 7 confirmed the resident does not have a current or active care plan addressing the resident's at risk for skin breakdown and risk for pressure ulcer. LVN 7 confirmed the resident has current physician's order for skin maintenance. During an interview on 12/13/19 at 3:05 p.m., the Director of Nursing (DON) stated if the resident has a gauze on the sacral area there should be an assessment and should have a physician's order. The DON stated it is considered a treatment and should have been on the care planned. A review of the facility's policy and procedure titled Pressure Sores - Risk Factors & Common Causes reviewed and approved on 4/17/19, indicated common risk factors and causes for the development of pressure sores to guide the healthcare professional in assessing the potential of a resident to develop pressure ulcers despite proper skin care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatments and services to maintain or prevent further decrease in joint range of motion and/or mobility for three of three sampled residents (Resident 44, 78, and 88) by failing to ensure the following: a) Resident 78 received ordered Restorative Nursing Aide (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatments seven times a week. b) Resident 88 received ordered RNA treatments seven times a week. c) Resident 88 received ordered splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) during RNA treatment. d) Resident 44 did not have a decline in range of motion and mobility. These failures led to the decline in joint range of motion and mobility in Resident 44 and had the potential to lead to further contractures (a condition of shortening and hardening of muscles or other tissue, often leading to deformity and rigidity of joints) for Residents 78 and 88 and put all residents at risk for further decline. Findings: a. A review of Resident 78's clinical record indicated the resident initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of respiratory failure (any condition that affects breathing function and result in lungs not functioning properly), cerebrovascular disease (disease of the blood vessels, especially blood vessels to the brain), and hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body). A review of Resident 78's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 10/18/19 indicated the resident required total dependence (full staff performance) for bed mobility (moving in bed such as side to side or positioning while in bed), transfers (moving from one surface to another such as bed to chair), dressing, toileting, and bathing. It also indicated the resident had functional limitations in range of motion on both sides of the upper extremities (UE, shoulder, elbow, wrist, and hand) and lower extremities (LE, hip, knee, ankle, foot). A review of Resident 78's physician's orders for the month of December 2019 indicated the resident had an order dated 9/25/19 for RNA nursing program for passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises for both upper extremities and lower extremities as tolerated followed by right elbow splint, right hand splint, and both knee extension (straight position of knee) splint for four to six hours as tolerated once a day, seven days a week. On 12/10/19 at 9:31 a.m., during an observation, Resident 78 was lying in bed, was not able to respond verbally to any stimuli. Resident 78 was observed to have his right wrist in bent position and had a small rolled up hand towel in his right hand. Resident 78 had his left hand opened and wrist in straight position. No splints were observed on the resident. On 12/10/19 at 12:21 p.m., during an observation, Resident 78 was in bed and was not wearing any splints. On 12/10/19 at 3:21 p.m., during an observation, Resident 78 was in bed and did not have any splints. On 12/11/19 at 10:31 a.m., during an observation, Resident 78 was lying in bed with his right elbow bent and did not any have splints on his upper extremities. On 12/11/19 at 10:35 a.m., during an interview and record review with Restorative Nursing Aide (RNA 1), RNA 1 stated he was the RNA for this resident and has worked as an RNA for about two years. RNA 1 stated he did not see Resident 78 for RNA treatment yesterday on 12/10/19. RNA 1 stated he was assisting other staff with transfers and did not have time to see this resident. RNA 1 reviewed the daily RNA documentation for December 2019 and stated he initialed on 12/10/19 that the RNA treatments were completed for Resident 78 but forgot to write in the back that the splints were not put on. RNA 1 stated he performed the range of motion exercises part of the RNA treatments, but did not put on any of the splints. RNA 1 stated that if he did not complete the RNA treatment, he should write that on the back in the comments section. RNA 1 also stated that he did not indicate that he did not document he did not perform the splinting portion of the RNA treatment on the weekly summary that he documented on 12/10/19. RNA 1 stated that if he did not perform these RNA treatments as ordered and did not inform his supervising nurse, these residents could get worse and the facility staff would not know. These residents did not move on their own and needed the exercises and splints that the therapists ordered. On 12/11/19 at 10:41 a.m., during an interview and record review with the Director of Staff Development (DSD) who was also a licensed vocational nurse, stated that she was in charge of the RNAs. DSD stated that when the RNAs document in their daily notes, if they initial it means they completed the treatment ordered that day. If they did not do any part of the order, they should document in the back in the comments section and inform the charge nurse to cosign the notes. In review of the daily and weekly RNA documentation for Resident 78, DSD stated the RNA did not write in the comments sections or the weekly summary that any part of the RNA treatment was not completed. DSD stated she was not aware that the RNA treatment was not completed as ordered. DSD stated that if residents do not receive their RNA treatments as ordered, then they could get contractures (loss of motion of a joint) or their contractures could get worse. The splints were ordered to help with their contractures and circulation and they should be put on as ordered. A review of the resident's care plan dated 7/17/19, indicated the resident was at risk for declines in range of motion secondary to quadriplegia (weakness of all four extremities), hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body). It indicated under interventions to position resident to prevent further contractures with pillow or splints as needed, provide ROM exercises if ordered. A review of the resident's care plan dated 9/25/19, indicated the resident had limitations in range of motion/contractures, bed mobility, and ADLs. It indicated under approaches to include restorative nursing treatment once a day for seven days a week for passive range of motion to both upper and lower extremities and splinting to right hand, right elbow, and both knees four to six hours as tolerated. A review of the facility's undated policy and procedure titled range of motion in sub-acute unit indicated, this facility will provide ROM to residents in the sub-acute unit as indicated, based on assessment by therapists, that includes measures to reduce decline and improve quality of life. A review of the facility's undated policy and procedure titled joint mobility contracture management program indicated nursing shall ensure that the program is being followed daily. It also indicated under RNA responsibilities to apply splint daily according to instructions. b. A review of Resident 88's clinical record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including respiratory failure, cerebrovascular disease. A review of Resident 88's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 10/25/19 indicated the resident required total dependence with bed mobility, transfers, dressing, toileting, and bathing. It also indicated the resident had functional limitations on both upper and lower extremities. A review of Resident 88's physician's order summary for December 2019, indicated an order dated 10/20/19 for RNA program for both UE and both LE passive ROM exercises as tolerated followed by both hand splints, both elbow splints, both knee extension splints, and both ankle/foot orthosis (AFO, an orthotic device designed to correct or address problems with the ankle and foot) for four to six hours as tolerated once a day, seven days a week. On 12/10/19 at 9:31 a.m., during an observation, Resident 88 was lying in bed with both knees bent, both elbows bent, his right wrist was bent. His eyes were opened and could not speak. The resident was not wearing any splints. On 12/10/19 at 12:21 p.m., during an observation, Resident 88 was in bed and had a rolled up hand towel in his right hand. Resident 88 did not have any splints on his extremities. On 12/10/19 at 3:21 p.m., during an observation, Resident 88 was in bed and was not wearing any splints. On 12/11/19 at 10:31 a.m., during an observation, Resident 88 was in bed and both of his elbows and right wrist were bent. The resident was not wearing any splints. On 12/11/19 at 10:35 a.m., during an interview and record review with Restorative Nursing Aide (RNA 1), RNA 1 stated he was the RNA for this resident and has worked as an RNA for about two years. RNA 1 stated he did not see Resident 88 for RNA treatment yesterday on 12/10/19. RNA 1 stated he was assisting other staff with transfers and did not have time to see this resident. RNA 1 reviewed the daily RNA documentation for December 2019 and stated he initialed on 12/10/19 that the RNA treatments were completed for Resident 88 but forgot to write in the back that the splints were not put on. RNA 1 stated he performed the range of motion exercises part of the RNA treatments, but did not put on any of the splints. RNA 1 stated that if he did not complete the RNA treatment, he should write that on the back in the comments section. RNA 1 also stated that he did not indicate that he did not document he did not perform the splinting portion of the RNA treatment on the weekly summary that he documented on 12/10/19. RNA 1 stated that if he did not perform these RNA treatments as ordered and did not inform his supervising nurse, these residents could get worse and the facility staff would not know. These residents did not move on their own and needed the exercises and splints that the therapists ordered. On 12/11/19 at 10:41 a.m., during an interview and record review with the Director of Staff Development (DSD) who was also a licensed vocational nurse, stated that she was in charge of the RNAs. DSD stated that when the RNAs document in their daily notes, if they initial it means they completed the treatment ordered that day. If they did not do any part of the order, they should document in the back in the comments section and inform the charge nurse to cosign the notes. In review of the daily and weekly RNA documentation for Resident 88, DSD stated the RNA did not write in the comments sections or the weekly summary that any part of the RNA treatment was not completed. DSD stated she was not aware that the RNA treatment was not completed as ordered. DSD stated that if residents do not receive their RNA treatments as ordered, then they could get contractures (loss of motion of a joint) or their contractures could get worse. The splints were ordered to help with their contractures and circulation and they should be put on as ordered. A review of the Resident 88's care plan dated 10/20/19 indicated the resident had limitations in range of motion/contractures and bed mobility. It indicated under approach for restorative nursing treatment once a day seven days a week for passive ROM to both UE and LE and splinting for both hands, both elbows, both knee for extension, and both AFO for four to six hours. A review of the facility's undated policy and procedure titled range of motion in sub-acute unit indicated, this facility will provide ROM to residents in the sub-acute unit as indicated, based on assessment by therapists, that includes measures to reduce decline and improve quality of life. A review of the facility's undated policy and procedure titled joint mobility contracture management program indicated nursing shall ensure that the program is being followed daily. It also indicated under Nursing/RNA responsibilities to apply splint daily according to instructions. c. On 12/11/19 at 1:06 p.m., during an observation of RNA treatment for Resident 88, RNA 1 first took out from the resident's bedside closet, two hand splints, two elbow splints, two knee extension splints, and two black soft heel protectors and wiped them down with a sanitizing wipe. RNA 1 then completed the PROM for RUE and put on R elbow splint and R hand splint. RNA 1 completed RLE PROM ex and stated he would not put on the right knee extension splint today because the resident had a bowel movement and needed to be changed. RNA 1 stated he would just put on the AFO and proceeded to put on a black soft heel protector on resident's right ankle/foot. RNA 1 was about to move to the resident's left side to complete LUE ROM exercises when RNA 1 was asked if the black soft heel protector was an AFO. RNA 1 said yes. Then he stated the black heel protector was put in the resident's closet and he was not sure who put it there. He then stated that the AFO should be a hard device and blue in color, because the black soft one does not help with the resident's ankle contracture and that the right ankle with the black soft heel protector, the resident's ankle still goes forward. RNA 1 left the resident's room and returned with two blue rigid devices and stated these were the resident's AFOs but it did not have the resident's name on it. RNA 1 stated none of the devices have the resident's names but that he knew which devices belonged to all residents. RNA 1 then removed the black soft heel protectors and put the blue rigid AFO on the resident's right foot. On 12/11/19 at 4:05 p.m., during an observation and interview with Physical Therapist (PT 1), PT 1 stated the blue rigid device on Resident 88's ankle/foot was an AFO. PT 1 stated Resident 88 was prone for contractures due to decreased mobility and that's why he was ordered for knee extension splints and AFO for both ankles. PT 1 stated that the black soft devices located in the resident's closet were foot protectors. PT 1 stated that if the therapist determined through assessment that the resident required splints or orthotics, then an orthotics vendor will come and assess the resident individually per their need. Each splint ordered is individualized to that resident's specific needs. Most of the time, if it belongs to the resident, the devices were in their closet. The therapists did not label them. On 12/12/19 at 12:45 p.m., during an interview with PT 1 and DOR, both PT 1 and DOR confirmed the black soft heel protector was a heel protector and was not an ankle/foot orthosis. The blue rigid device was an AFO and was what the physical therapist ordered for Resident 88 as a part of RNA program. The black soft heel protector could not be used interchangeably in place of the blue AFO that was ordered. PT 1 and DOR stated that the black soft heel protectors should be put on before or after use of the AFO but not in place of the AFO. The RNA should have put on the blue rigid device. A review of Resident 88 care plan dated 10/20/19 indicated the resident had limitations in range of motion/contractures and bed mobility and approach indicated a restorative nursing treatment once a day, seven days per week for PROM to both UE and LE, splinting to both hands, both elbows, both knee extension, and both AFO for four to six hours. A review of the facility's undated policy and procedure titled, joint mobility contracture management program, indicated the therapist shall make recommendations regarding special positioning, range of motion or stretching program, hand rolls or splints and any special adaptive or positioning equipment. It also indicated under Nursing/RNA responsibilities, to apply splint daily according to instructions. d. A review of Resident 44's clinical records indicated the resident originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses of osteoarthritis (loss of protective cartilage that cushions the ends of your bones), muscle weakness, and dementia (loss of thinking, remembering, and reasoning skills). A review of Resident 44's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 6/20/19 indicated the resident had functional limitations in range of motion on one side of both the UE and LE. A review of Resident 44's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 9/18/19 indicated the resident had functional limitations in range of motion on both sides of both the UE and LE. A review of Resident 44's Physical Therapy (PT) Discharge summary dated [DATE] indicated the resident, upon discharge from PT, was able to walk 125 feet with contact guard assistance (CGA, close physical contact from another person, but no actual physical support). PT recommended and ordered, upon discharge from PT treatment, an RNA program for ambulation using front-wheeled walker and arm bike as tolerated once a day, five days a week. A review of Resident 44's Physical Therapy Evaluation dated 8/15/19 indicated the resident previously was able to walk 150 feet with CGA. It indicated that upon evaluation on 8/15/19, Resident 44 now required maximum assistance (another person performing at least 75 percent or greater of the task) to walk and could only walk 20 feet. It indicated the resident had range of motion impairments in both hips, knees, and ankles. A review of Resident 44's RNA weekly summary dated 5/7/19, 5/14/19, 5/21/19, 5/28/19, 6/4/19, 7/30/19 indicated the resident required moderate and maximum assistance with ambulation but no documentation indicating RNAs notifying nursing or rehabilitation staff regarding the decline and increased assistance with ambulation. It was reported on 8/10/19, 8/11/19, and 8/12/19 that the resident was unsafe during daily routine activities and a risk for falls and further decline. It indicated that the rehabilitation department was notified. A review of Resident 44's Licensed Nurse Records weekly summaries dated 7/2/19, 7/9/19, 7/23/19, 7/30/19, 8/13/19 indicated the resident was not ambulating, but no documentation indicating the licensed nurse notifying the rehabilitation department or the interdisciplinary team (IDT). On 12/11/19 at 11:10 a.m., in an interview and record review with the Director of Nursing (DON) and DOR, DOR stated the joint mobility screening completed by physical therapy and occupational therapy on 9/11/18 and again on 8/15/19 demonstrated a decline in range of motion in multiple joints. There were noted declines in Resident 44's right shoulder range of motion from moderate limitation to severe limitation. It also demonstrated declines in both hips from no limitations to minimal limitations, right knee from no limitations to minimal limitations, and both ankle/foot from no limitations to minimal limitations. DOR stated that the Physical Therapy Evaluation dated 8/15/19 indicated the resident had a decline in strength, range of motion, and functional mobility. In the same interview and record review, both DOR and DON, through review of Resident 44's clinical record, stated the resident did not have any conditions that could explain why the resident had declines in range of motion in multiple joints, especially from no limitations to now minimal limitations since the resident was on an RNA program. DON stated that although the resident did have a urinary tract infection around the time of when the RNA notified therapy staff that the resident was unsafe during daily activities, DON stated that a UTI would not be a reason for the decline in range of motion in multiple joints and mobility. In the same interview, DON and DOR stated that Resident 44's decline should have been identified earlier so that the appropriate treatments and services could be provided to prevent or minimize declines in range of motion and function. DOR stated that the rehabilitation staff complete joint mobility screenings annually and as needed basis such as if there was a reported decline. DOR stated the quarterly rehabilitation screenings were based on chart review and did not include a joint mobility screening. DOR and DON stated the current process to monitor joint mobility and functional declines were based on nursing staff reporting, such as the RNAs. DOR and DON stated it would be beneficial to have more disciplines assessing the residents who are at risk for these functional declines. DON stated that in reviewing the resident's clinical record, quarterly assessments of joint mobility completed by licensed nurses did not pick up any declines in joint mobility. The quarterly rehabilitation screenings completed by therapy also did not pick any declines in joint mobility or function. A review of Resident 44's care plan dated 12/31/18 and revised on 9/30/19 indicated the resident had alteration in joint mobility as evidenced by limitations in both UE and LE. The goal was to minimize the risk of further loss of ROM daily through the following interventions: a) initial, quarterly, annual assessment of joint mobility or as needed, b) monitor for pain or stiffness, c) provide ROM exercises if ordered, d) therapy intervention as indicated. A review of the undated facility's policy and procedures titled restorative nursing program (RNP) indicated the purpose of the RNP was to maintain resident's functional ability, and to reduce further decline. It indicated weekly assessments to be made of the resident's progress in the RNP by the restorative nurse and documented in the resident's medical record. Any change in resident's condition or response to treatment is reported to nursing and documented in the medical record. A significant decline is to trigger an interdisciplinary meeting to restructure the restorative program so that it meets the resident's needs. A review of the undated facility's policy and procedures titled joint mobility contracture management program indicated all residents are to be assessed upon admission and quarterly for joint mobility and functional limitation due to limited mobility. All residents are to be reviewed quarterly by the nursing staff utilizing the joint mobility assessment form. Any changes or new contracture concerns shall be noted and therapy intervention recommended. Nursing shall ensure that the appropriate Medical Doctor orders have been obtained, the care plan has been entered in the resident's chart; and that the program is being followed daily.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record reviews, the facility failed to ensure five of five residents (Resident 63, 87, 35, 2 and 109), investigated for the use of unnecessary medications were free from unnecessary psychotropic (any drug capable of affecting mood, emotions, behavior) medications, as evidenced by: 1. Failing to indicate the specific behavior monitored for the use of Seroquel (a psychotropic medication used to treat bipolar disorder- a severe mental disorder that causes periods of depression and abnormally elevated moods) for Resident 63. 2. Failing to indicate the specific behavior monitored for the use of Trazadone (an antidepressant used for sleep, pain and anxiety- excessive worry or fear) for Resident 87. 3. Failing to ensure specific behavior was indicated for Resident 35's use of Zyprexa (Olanzapine, an antipsychotic medication-used to treat certain mental/mood conditions). 4. Failing to ensure specific behavior was indicated for Resident 2's use of Ativan (an antianxiety medication used to treat anxiety). 5. Failure to ensure Residents 109 and Resident 2 with diagnoses of dementia (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily functioning) did not receive psychotropic (medications capable of affecting the mind, emotions, and behavior) medication unless it was necessary to treat a specific condition. These deficient practices had the potential to result in Resident 63, 87, 35, 2 and 109, experiencing unrecognized adverse side effects related to unnecessary use of antipsychotic medication use including daytime drowsiness, dizziness, blurred vision, restlessness, muscle spasms, confusion and may increase the risk of stroke, falls and injuries, and are associated with higher rates of death in the elderly. Findings: a. A review of Resident 63's Face Sheet (admission record) indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including generalized muscle weakness and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 63's History and Physical (H&P), dated 9/20/19, indicated the resident had the capacity to understand and make decisions. A review of Resident 63's Minimum Data Set (MDS - a residents' assessment and screening tool) dated 10/10/19, indicated the resident had moderate impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making. The MDS indicated the resident required extensive physical assistance for dressing, required limited assistance for eating and is totally dependent on staff for bed mobility, transfer, toileting and personal hygiene. A review of Resident 63's Physician Orders dated 9/20/19, indicated to give the resident Seroquel 50 mg (milligrams- unit of measure) by mouth at bedtime and 25 mg twice a day by mouth for psychosis (a severe mental illness) manifested by inability to cope with internal stimuli leading to episodes of delusions (beliefs that conflict with reality) of persecutions and emotional distress. On 12/12 /19 at 7:52 A.M., during an interview and record review of Resident 63's Physician Orders the Licensed Vocational Nurse/Minimum Data Set Coordinator (LVN/MDS) stated that Resident 63 had tendencies of fabricating stories and is sometimes forgetful. The LVN/MDS validated that the behavior being targeted for the use of Seroquel is very vague and not specific. b. A review of Resident 87's Face Sheet (admission record) indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including diabetes mellitus (abnormally high blood sugar and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 87's History and Physical (H&P), dated 9/25/19, indicated resident had the capacity to understand and make decisions. A review of Resident 87's Minimum Data Set (MDS - a residents' assessment and screening tool) dated 10/24/19, indicated the resident had no impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making. The MDS indicated the resident required limited physical assistance for eating and totally dependent on staff for bed mobility, transfer, toileting, dressing and personal hygiene. A review of Resident 87's Physician Orders dated 9/22/19, indicated to give the resident Trazadone HCL (hydrochloride) 50 mg (milligrams- unit of measure) by mouth at bedtime for insomnia (sleep disorder that is characterized by difficulty falling and/or staying asleep) manifested by inability to sleep. During an interview and record review of Resident 87's Medication Administration Record (MAR), on 12/12 /19 at 12:32 P.M., the LVN/MDS stated that the monitoring for the behavior should not be tallied by hashmarks (count) for 3 p.m. to 11 p.m. shift and the 11 p.m. to 7 a.m. shift. The LVN/MDS acknowledged the resident's number of hours of sleep needed monitoring. During an interview and record review of Resident 87's Psychotropic Summary Sheet, on 12/12/19, at 2:49 P.M., the Director of Nursing (DON) stated that the Psychotropic Summary Sheet should match the total 31 doses that were administered to the resident, with the total hours of sleep on the Psychotropic Summary Sheet indicated, and not 31, the number of behavior episodes/shift for the whole month of October 2019. c. A review of Resident 35's admission Record indicated the resident was readmitted on [DATE], with diagnoses including dementia (a loss of mental ability severe enough to interfere with normal activities of daily living) and Alzheimer's disease (a brain disease that slowly destroys brain cells). A review of Resident 35's History and Physical dated 10/15/19, indicated the resident does not have the capacity to understand and make decisions. A review of Resident 35's MDS dated [DATE], indicated the resident has clear speech, adequate vision and moderate hearing difficulty. The MDS assessment indicated the resident usually made self understood and usually understood others. The MDS assessment indicated the resident required extensive assistance with bed mobility, transferring, dressing, eating, toileting, and personal hygiene with physical assistance from nursing staff. A review of Resident 35's Physician's Orders indicated to give the resident Zyprexa 2.5 milligrams (mg) by mouth every hours of sleep for psychosis (severe mental illness) for behavior episodes manifested by inability to cope with internal stimuli leading to episodes of stress and frustration ordered on 8/30/19. A review of Resident 35's Psychotropic Summary Sheet for Zyprexa indicated the following: - For month of 8/30/19 - 9/30/19 had missing documentation for the tally of behavior episodes. - For month of 10/1/19 - 10/31/19 indicated had zero behavior episodes manifested. - For month of 11/1/19 - 11/30/19 indicated the resident with a total of 69 behavior episodes. A review of Resident 35's Physician Psychotherapeutic Intervention Progress Note dated 12/3/19, indicated environmental or behavioral therapy approaches attempted included communication in the resident's native language as needed, continue to encourage family to visit, acknowledge verbalization and provide reassurance or reality orientation or redirection as needed. During a concurrent observation and interview on 12/11/19 at 8:05 a.m., Resident 35 was lying in a bed, awake, attempting to sit up in bed. The Certified Nurse Assistant (CNA 6) stated the resident moans or cries and does not eat breakfast. CNA 6 asked the resident if she is okay. CNA 6 stated the resident speaks another language not English. CNA 6 stated she does not know if there is anyone available that can speak the resident's language. During a concurrent observation and interview on 12/13/19 at 10:59 a.m., CNA 2 was assisting Resident 35 with ADL care. CNA 2 stated the resident makes crying sound every day especially in the morning. CNA 2 stated she does not understand what the resident is saying but understood what the resident needs. CNA 2 placed the resident's wheelchair on the left side of the bed, placed the bed side rail down and instructed the resident to sit up in bed and ready for transfer from bed to wheelchair. The resident's lips were observed touching CNA's left arm kissing motion. CNA 2 instructed the resident to transfer to wheelchair and to hold on to her. The resident completed the transfer to the wheelchair. CNA 2 asked the resident toilet? to which the resident nodded her head up and down. During an interview on 12/13/19 at 12:22 p.m., CNA 2 stated she has taken care of Resident 35 before. CNA 2 stated the resident is very sweet with her, pleasant, and has not had any behaviors of hitting or fighting when she provides care. CNA 2 stated the resident speaks in a language that is not the dominent language used in the facility and she does not know exactly what the resident is saying, but either the resident is hungry, wants to use the toilet, or does not want to sleep. CNA 2 stated the resident has always made the crying sound as long as she has taken care of her. During an interview on 12/13/19 at 3:11 p.m., the Director of Nursing (DON) stated Resident 35's responsible party speaks her language and they said they do not understand what the resident is saying. The DON stated psychotropic medications should have specific behavior for monitoring purposes. The DON stated the psychotropic summary sheet should be done monthly for tally of behavior episodes every shift. d. A review of Resident 2's Face Sheet (admission record) indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included, dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) and anxiety disorder (persistent, excessive fear or worry in situations that are not threatening). A review of Resident 2's Minimum Data Set (MDS- as assessment and care screening tool) dated 11/18/19, indicated the resident's cognitive skills for daily decision making are moderately impaired. A review of Resident 2's physician's order dated 11/25/19, included Ativan (used to treat anxiety) 0.5 milligram (mg) by mouth as needed (Medicines that are taken as needed are known as PRN medicines.) until 2/26/20 for anxiety manifested by recurrent outburst of anger. On 12/13/19 at 10:03 a.m., during an interview and record review of Resident 2's Medication Administration Record (MAR) with the Assistant Director of Nursing, indicated that on 12/10/19, Resident 2 receive two doses of Ativan 0.5 mg. The MAR of 12/10/19, for the first dose given, has no documentation of hashmarks to indicate that the resident was exhibiting outburst of anger. There was no documentation that a non pharmacologic intervention was provided prior to the medication administration. The ADON stated that nurse's should indicate the behavior and non pharmacologic intervention in the MAR, whenever a PRN psychotropic medication is administered. e. A review of Resident 109's admission Record indicated Resident 109 was admitted to the facility on [DATE] with a re-admission date of 10/13/19. Resident 109's diagnoses included dementia without behavioral disturbances, mild cognitive impairment, and unspecified psychosis. On 10/13/19, Resident 109 was diagnosed with history of falling, contusion (an injury causing a bruise) of scalp, unspecified injury of head, and syncope (temporary loss of consciousness caused by a fall in blood pressure) and collapse (falling down). A review of Resident 109's Minimum Data Set (MDS - standardized assessment and care-screening tool) dated 4/29/19, indicated the resident had impaired memory. Resident 109 required limited supervision with one-person physical assistance with eating and personal hygiene and extensive assistance with dressing, toilet use, transfers, and locomotion. The Behavior section for Potential Indicator of Psychosis: Hallucinations (perception of experiences that are not present) and Delusions (beliefs that conflict with reality) indicated not present. The Behavior section for Behavioral Symptoms - Presence and Frequency: Physical (e.g. hitting or pacing) and Verbal (e.g. screaming or disruptive sounds) symptoms directed toward others indicated not exhibited. A review of Resident 109's History and Physical (H&P) Examination, dated 10/16/19 by the attending physician, indicated Resident 2 does not have the capacity to understand and make decisions. Diagnoses documented syncope and fall precaution. A review of Resident 109's Initial Psychiatric (psych) Interview dated 11/10/19, documented past psych history indicated, history of head injury, cognitive decline, and no known history of schizophrenia, with a history of falling. A review of Resident 109's Physician's Order Summary Report for the month of December 2019, included the following psychotropic medication physician orders: a. Seroquel (an antipsychotic medication used to treat mental disorders, including schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves) 25 milligrams (mg), give one-half (12.5 mg) tablet by mouth one time a day for psychosis manifested by inability to cope with internal stimuli leading to episodes of anger and frustration with an order date of 10/13/19. b. Seroquel 25 mg, give one and one-half (37.5 mg) by mouth at bedtime for psychosis manifested by inability to cope with internal stimuli leading to episodes of anger and frustration with an order date of 10/13/19. c. Remeron 15 mg, give one-half (7.5 mg) by mouth at bedtime for depression manifested by verbalization of sadness with an order date of 10/13/19. A review of Resident 109's Care Plan for Antipsychotic (Seroquel) Drug and Dementia revised 11/5/19, indicated Resident 109 was, At risk for complications such as movement disorders, falls, hip fractures, cerebrovascular adverse events and FDA (Food and Drug Administration) Black Box Warning (is the strongest warning by the FDA [Food and Drug Administration] which indicates that a drug carries a significant risk of serious or even life-threatening adverse effects) related to use of antipsychotic drugs for elderly residents with dementia that is associated with psychosis and dementia. The goal for Resident 109 indicated, Antipsychotic drug GDR, Antipsychotic drug D/C (discontinue). The intervention for Resident 109 indicated, GDR as ordered, D/C of antipsychotic drug as ordered, monitor for adverse drug complications, monitor for effectiveness of GDR/increase/decrease in behaviors individualized, person-centered approach to address expressions of distress, non-pharmacological (non-drug treatment) approaches. A review of Resident 109's Interdisciplinary Team (IDT- a group of experts from several different fields) Conference Record dated 10/15/19, documented the resident experienced four falls with two witnessed falls on, 8/1/19, 9/8//19, and two unwitnessed falls on 10/11/19, and 10/14/19. The IDT report documented risk factors that included Resident 109's unsteady gait. The IDT plan to prevent recurrence indicated to anticipate needs and increase supervision. The IDT conference did not indicate that Resident 109's psychotropic (Seroquel and Remeron) medications were reviewed as potentially contributing to the resident's repeated falls. On 12/11/19 at 11:49 a.m., during an observation with a licensed vocational nurse (LVN 1) Resident 109 was observed sitting in a wheelchair inside her room. On 12/12/19 at 9:58 a.m., during an interview the Nurse Practitioner (NP 1) for Resident 109's neurologist's stated, She is pretty advanced with dementia and do not need dementia medication. She is very calm. She smiles and has been stable. Most of the time she is in bed. She knows her name. She is a nice lady. She had an unspecified head injury on 10/13/19. She might have fallen. On 12/12/19 at 10:23 a.m., during an interview Resident 109's Clinical Psychologist with behavioral health stated, I saw her when she was first admitted for a couple of months before she had severe cognitive decline. Before she was able to participate in communication/conversation. She has dementia related psychosis. On 12/12/19 at 11:09 a.m., during an interview and a review of Resident 109's clinical records, the Assistant Director of Nursing (ADON) stated the resident has been on Remeron since 5/9/19, for lack of appetite. There was a discrepancy for the indication for use of Remeron between, verbalization of sadness, dated 10/13/19, and for lack of appetite, dated 5/9/19. After reviewing Resident 109's the Certified Nursing Assistant (CNA) Activities of Daily Living (ADL) record for the month of 12/19, the ADON stated the documentation indicated the resident was eating 80 percent (%) to 100 % of breakfast daily, 60 % - 100 % of lunch and dinner daily. The ADON stated the record also indicated Resident 109 was documented to have accepted hydration between meals at 10 a.m. and 2 p.m., and received nightly snacks at 8 p.m. The ADON was unable to determine how the nurses were to monitor and assess Resident 109 to determine if the use of Remeron was appropriate or needed. A review of Resident 109's Care Plan for Antidepressant (Remeron) revised 11/5/19, indicated Resident 109, Has episodes of depression manifested by persistent loss of appetite. Intervention indicated, Administer antidepressant medications as per physician's orders. Assess for pain or discomfort and medicate as ordered. The care plan failed to include a goal for Resident 109's meal intake, what behaviors the nurses were to monitor to determine whether the medication was effective or not; and when to notify the physician once behaviors for which the medication was prescribed were no longer present. On 12/12/19 at 11:18 a.m., during an interview and concurrent review of Resident 109's records, LVN 11 stated the hashmarks for behavior in the MAR for Resident 109, means the resident's behavior is saying she wants to go home. LVN 11 stated she would put a hashmark on the MAR even when the non-pharmacological interventions were effective and the resident's behavior of wanting to go home had stopped. LVN 11 stated, The Seroquel does not always help her (Resident 109) to go to sleep. She sleeps late in the morning and is up at night sometimes. On 12/12/19 at 3:15 p.m., Resident 109 was observed in her room asleep in bed. On 12/12/19 at 4:31 p.m., during an interview the Director of Nursing (DON) stated Resident 109 had a fall on 10/11/19, and was transferred to the hospital and returned to the facility on [DATE], and had another fall at the facility on 10/14/19. The DON stated the antipsychotic medication could have contributed to Resident 109's falls. During a concurrent interview and record review the DON provided a drug reference titled, Nursing 2020 Drug Handbook, for Seroquel the reference indicated, Black Box Warning: Drug is not indicated for use in elderly patients with dementia related psychosis because of increased risk of death from CV (cardiovascular, heart disorder) disease or infection, could exacerbate fall risk, report all adverse reactions and be alert for,anxiety, agitation, insomnia, irritability, hostility, aggressiveness, motor restlessness, and sensory instability, which may lead to falls, fractures, or other injuries. f. A review of Resident 2's admission Record indicated the facility admitted Resident 2 on 8/22/17 with a re-admission dated 11/11/19. Resident 2's diagnoses included Dementia and unspecified psychosis. On 2/1/19, Resident 2 was diagnosed with history of falling, syncope and collapse. On 11/11/19, Resident 2 was diagnosed with unspecified fall and contusion of scalp. A review of Resident 2's MDS dated [DATE], indicated the resident requires supervision and setup help only for eating, and extensive one-person physical assistance with dressing, toilet use, personal hygiene, and locomotion. The Behavior section for Potential Indicator of Psychosis: Hallucinations (perception of experiences that are not present) and Delusions (beliefs that conflict with reality) indicated not present. The Behavior section for Wandering - Presence and Frequency: indicated behavior of this type occurred daily. A review of Resident 2's History and Physical (H&P) Examination dated 11/20/19, by the attending physician, indicated Resident 2 does not have the capacity to understand and make decisions and documented a fall precaution for Resident 2. A review of Resident 2's Psychiatric Progress Note dated 11/25/19, documented, Chief complaint: Dementia, history of depression and anxiety, concentration poor, memory poor. A review of Resident 2's Physician's Order Summary Report for the month of December 2019, included the following physician orders: a. Zyprexa (an antipsychotic medication used to treat mental disorders, including schizophrenia) 2.5 mg by mouth every 12 hours for psychosis manifested by inability to cope with internal stimuli leading to episodes of compulsive attempts to elope with an order date of 11/25/19. b. Zyprexa 2.5 mg order was clarified on 12/11/19, to indicate, Zyprexa 2.5 mg by mouth every 12 hours for schizoaffective (a mental health condition including schizophrenia and mood disorder symptoms) disorder manifested by inability to cope with internal stimuli causing extreme anxiety and fear leading to episodes of compulsive attempts to elope and possible harm. c. Ativan (a sedative used to treat anxiety) 0.5 mg by mouth every 6 hours as needed (PRN) for three months until 2/26/20, for anxiety manifested by recurrent outburst of anger. Monitor for adverse side effects every shift with an order date of 11/25/19. d. Restoril (a sedative used to treat insomnia) 7.5 mg by mouth nightly PRN for three months until 2/26/19, for insomnia manifested by inability to sleep/sleeplessness. Monitor for adverse side effects every shift with an order date of 11/25/19. On 12/12/19 at 10:23 a.m., during an interview NP 1 stated Resident 2 was one of his residents and that the resident has a diagnosis of dementia. During a concurrent observation, Resident 2 was observed walking independently in the hallway. A review of NP 1's Neurology Notes for Resident 2 indicated, reorient as needed; supportive care; provide consistency with daily activities; avoid sedative agents during the day. On 12/12/19 at 10:23 a.m., during an interview and concurrent interview the Clinical Psychologist stated that Resident 2 had dementia related psychosis. A review of a general acute care hospital (GACH) report dated 11/7/19, indicated Resident 2 was transferred from the facility to the GACH's emergency department for evaluation after experiencing an unwitnessed fall at the facility. A review of the Resident 2's IDT Conference Record indicated the resident was readmitted to the facility on [DATE], with diagnoses that included history of falls, muscle weakness, and dementia. The IDT team's intervention did not indicate that Resident 2's psychotropic (Zyprexa) medication was reviewed as potentially contributing to the resident's risk for falls and fractures. A review the drug reference provided by the DON titled, Nursing 2020 Drug Handbook, for Zyprexa included a, Black Box Warning: Drug is not indicated for use in elderly patients with dementia related psychosis, could exacerbate fall risk, and sensory instability, which may lead to falls, fractures, or other injuries. A review of an undated facility's policy titled, Psychotherapeutic Medications, indicated, Documentation on the MAR will include a tally of the hash-marks for behavior not controlled through intervention and explanation on the reverse (side of the) MAR. An attempt shall be made by staff to modify the behavior using approaches specific to the resident. To promote gradual dose reduction or discontinuation of psychotherapeutic medications: a. Must have proper diagnosis b. Must have identified documented behavioral symptoms c. Alternative to antipsychotic drugs attempted and documented A review of an undated facility's policy titled, Antipsychotic Drug Use with Dementia, indicated, This facility will assess residents who have dementia and have order for antipsychotic medications, Monitor the resident closely for improvement, stabilization, or decline. A review of the facility's Policy and Procedures (P&P), titled Psychotherapeutic Drug Overview, with a review date of 4/17/19, indicated to promote gradual dose reduction or discontinuation of psychotherapeutic medications: must have proper diagnosis, must have identified documented behavioral symptoms.

Based on observation, staff interviews, review of facility records and policies and procedures, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety, in addition facility failed to develop a system to identify, report and control unsafe food practices in the Food and Nutrition Services Department when: 1. Nutritional supplements labeled store Frozen with manufacture's instruction to use within 14 days of thawing, were not monitored for the date they were thawed to ensure expired shakes were discarded after this timeframe. Four trays of health shakes were stored in facility reach in refrigerator with no thaw date. The improper storage of food can result in decrease quality of food, cross contamination and growth of microorganism that could cause food borne illness. These failures had the potential to result in food borne illness in 29 residents who are on the nutrition supplement of 167 residents at the facility. 2. Refrigerators and freezers were stored in the employee lounge area, accessible to staff other than dietary service personnel. This deficient practice had the potential to contaminate food and cause food borne illness in resident population of 125 who receive food from the kitchen of 167 residents at the facility. 3. One staff did not practice personal hygiene when he did not wear facial hair restraints (beard cover) in the kitchen. Hair can be a source of food contamination. This had the potential to cross contaminate food and clean equipment causing food borne illness in 125 residents who consume the food prepared in the kitchen. 4.Pots and Pans were not sanitized with adequate amount of sanitizer per manufactures guidelines. Sanitizers and disinfectants are used on food contact surfaces to prevent foodborne illness. Sanitizers are used to reduce microorganisms to safe levels determined by public health codes and regulations. This deficient practice had the potential to contaminate food and effect 125 residents who eat food in the facility of 167 residents at the facility. Findings: 1. During an observation in the kitchen on December 11, 2019 at 9:19AM, there were four trays of mixed flavor health shakes stored in the reach in refrigerator. The trays of health shakes were marked with 12/11/19 date. During a concurrent interview with the Dietary Supervisor (DS), he stated the health shakes are delivered frozen and are stored in the refrigerator that is located outside of the kitchen to thaw. The date on the trays indicates when the health shakes were brought in to the kitchen from the other refrigerator located outside of the kitchen. The DS did not know when the shakes were thawed. The DS also stated that the expiration dates are on the individual health shake cartons and they last a long time. The DS was not able to locate the expiration date., the DS did not know expiration date is 14 days after product is thawed. During an observation in the refrigerator located outside of the kitchen on December 11, 2019 at 10:45AM, there were 2 boxes of vanilla flavor health shakes and 1 box of chocolate flavor health shakes stored in the reach in refrigerator. During a concurrent observation and interview, the DS stated these are new boxes of health shakes, he added that the health shakes inside the kitchen refrigerator on trays did not come from these boxes. The DS agreed that health shakes should be marked with a use by date to allow food service staff to identify when the product is expired. A review of facility policy titled refrigerator/Freezer storage (revised2019), indicated, All meat and perishable food, e.g. milkshakes, pies, etc. placed in the refrigerator for thawing must be labelled and re dated with the date the item was transferred to the refrigerator. A review of the 2017 U.S. Food and Drug Administration Food Code indicated, Ready-to-eat, Time/Temperature control for safety food should be marked by date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed, sold or discarded. It further states Time/Temperature control for safety refrigerated food must be consumed, sold or discarded by the expiration date. 2.During an observation in the employee lounge and locker room on December 11, 2019, at 10:45AM, Two reach in freezers and two reach in refrigerators were stored in the employee lounge and locker room. There were employees inside the lounge taking a break. The refrigerator and freezers were not locked during the observation. The doors could open and contents accessible. During a concurrent observation and interview, the DS stated that the walk in cooler and freezer was removed to be replace. He added the project is on hold pending further approvals. He stated that due to limited space in the kitchen, the rented refrigerators and freezer were stored in the employee locker and break room. When asked how does he assure that the food is safe, he replied the locker room is closed and only employees can access. He also stated there are signs on the refrigerator and freezers indicating for kitchen use only. He further stated employees know better and would not open the doors or take the food. During an interview with Administrator (ADM) on December 12, 2019, at 10:15AM, ADM stated that locker rooms are locked after 8PM and no one enters the locker room in the evening. She added that evening staff keep their belongings with them during the shift, in addition there are cameras in the hallway leading to the locker rooms for security. ADM stated the best place to keep the coolers and freezer was the staff locker rooms during the kitchen construction project. ADM understands that food needs to be protected and locked to prevent access by anyone who is not dietary staff. She further stated that she will try to contact manufacturer to find out if cooler and freezer doors can be locked. During an interview with Administrator (ADM) on December 12, 2019, at 2:24PM, she stated that the facility does not have a policy for the alternate plan to store food in the employee locker room. A review of facility policy titled Sanitation and Infection control (revised 2019) indicated, Only authorized personnel will be allowed in the kitchen to prevent chances of outside contamination; Admittance to the department will be limited to persons performing duties related to the dietary department; unauthorized personnel will be directed to stay behind boundaries identified per facility; The dietary department will enforce traffic control procedures; access doors to the department should have signs posted Authorized Personnel Only. A review of Title 22 dietetic service requirements 72351(h) indicated, persons other than dietetic service personnel shall not be allowed in the kitchen areas unless required to do so in the performances of their duties. A review of the 2017 U.S. Food and Drug Administration Food code 2-103.11 indicated, any individual present in areas of a food establishment where food and food contact items are exposed presents a potential contamination risk. In addition, Food Code 2-103.11B indicates, persons unnecessary to the food establishment operation are not allowed in the Food preparation, food storage or ware washing areas, except that brief visits and tours may be authorized by the person in charge if steps are taken to ensure that exposed food, clean equipment, utensils, are protected from contamination. 3.During an observation in the kitchen on December 11, 2019, at 12:18PM, Dietary Aid (DA1) was not wearing a beard cover. The (DA1) was making sandwiches for residents for snacks and nourishment. (DA1) was standing next to the tray line service for lunch area (resident lunch assembly area). DA1 had thin facial hair but long, DA1 facial hair long to cover upper lip and was not wearing a beard cover. During a concurrent observation and interview, (DA1) stated that he was taught that beard covers are necessary only for a full beard. During an interview with the on December 11, 2019, at 12:20PM, he stated that only a full beard requires beard covers. He also stated that he will ask staff to trim facial hair. He added that they do not have beard covers in the kitchen and will order immediately. A review of facility policy titled Sanitation and Infection Control (revised 2019) indicated, Beard and or mustaches should be closely trimmed or must be covered at all times. According to the 2017 U.S. Food and Drug Administration Food Code, Hair can be both a direct and indirect vehicle of contamination. Employees shall wear hair restrains such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens and unwrapped single service and single use articles. 4.During an observation of the manual dish washing area on December 11, 2019, at 12:30PM, [NAME] 1 filled the third compartment of the manual ware washing sink with 25 gallons of water. [NAME] 1 then added 1 cup (8 ounces) oz. of bleach (Chlorine) to make the chlorine based sanitizer in the third compartment of the sink. During a concurrent observation and interview, cook 1 was asked to check the effectiveness of the sanitizer used. [NAME] 1 took a test strip and immersed it in the solution in the sink for 5 seconds and then compared the color of the test strip to the color chart. The test strip indicated a color change that showed sanitizer was not within range. The recommended concentration level for chlorine sanitizer is 50 parts per million (PPM). The test strip read was at 200PPM. A high concentration of sanitizer solution may be potentially hazardous and may be a chemical contaminant of food. During a concurrent interview with Cook1, she stated it should be 100PPM and proceeded to test again. The DS asked [NAME] 1 to immerse the test strip for 1 second per manufactures guideline indicated on the test strip container. The DS stated if you immerse the test strip for too long then the color would be darker indicating a result of more than 100 PPM. During a concurrent interview with the DS he stated he came up with the calculation of 1 cup of beach to 25 gallons of water solution. The DS stated he followed the instruction on the bottle of the bleach to prepare this amount of sanitizer solution. The DS was not able to locate the instructions of the calculation and it was not on the bottle of the bleach container. The DS stated he does not have a policy and procedure on how to make bleach sanitizer solution to sanitize the pots and pans in the manual ware washing. During an interview with administrator on December 12, 2019, at 2:24PM, she stated the facility does not have a policy on how to make the chlorine sanitizer solution for the dish washing. She sated she will contact manufacturer for guidance. A review of facility policy titled Manual Dish Washing - 3 Compartment Sink (revised 2019) indicated, The third compartment will be labeled sanitize. Sanitize dishes using one of the following methods: a. Immersion for at least 30 seconds in hot water temperature of a least 171 degrees F, or b. Immersion for at least 30 seconds in solution containing 100PPM chlorine, or c. Immersion for at least 1 minute in solution containing 200PPM quaternary ammonium.

Based on observation, interview, and record review, the facility failed to observe infection control measures by: 1. Failing to measure and document washing machine temperatures for five of five washing machines on 12/11/19. This deficient practice had the potential for the water to not be at a temperature necessary to provide disinfection of soiled linen. 2. Failing to properly place trash in the appropriate disposal bin and not have it mixed in with soiled linen in the laundry bags found in one of one laundry rooms. This deficient practice had the potential for the spread of infection and created an unsanitary environment for laundry staff. 3. Failing to ensure 57 of 57 residents, who were ordered padded siderails, were provided infection control measures. This deficient practice had the potential for contamination of padded siderails that may lead to resident's communicable diseases (an infection transmissible by direct contact with an affected individual or by indirect means e.g. contaminated object). Findings: a. During a concurrent interview and record review on 12/12/19 at 9:20 AM, reviewed the washing machine temperature log with the Maintenance Supervisor (MS). The MS verified that the temperature for the washing machines were not taken or documented on the temperature log for 12/11/19. The MS stated it should have been done to verify that the washing machines are working at the correct temperature to provide disinfection. A review of the facility's policy and procedure titled, Laundry Water Temperature, revised on 8/2019, indicated, Water temperature for laundry using ozone cleaning equipment will be maintained at or above 130 degrees Fahrenheit to ensure proper disinfection is provided. The Laundry personnel will maintain a log of daily water temperatures to ensure that water is maintained at the appropriate temperature to provide disinfection of soiled linen. b. During a concurrent observation and interview on 12/12/19 at 9:35 AM, when asked if laundry bags contain any other items other than linen and clothes, Laundry Aide 1 (LA 1) and Laundry Aide 2 (LA 2) both stated that about 2-3 times a week, they will find trash such as cups, spoons, and gloves mixed in the linen when sorting linen out of the laundry bags. LA 1 and LA 2 both stated that they will find soiled diapers mixed in the linen every day. LA 2 stated she found a disposable razor used for shaving once mixed with the linen. LA 1 was observed to open a laundry bag and found disposable bed pads (protective covering placed between person and bed linen) and used gloves. LA 1 stated that she observed soiled diapers earlier and had already thrown away a trash bag filled with trash and diapers that was collected from the laundry bags. LA 2 stated that the Maintenance Supervisor (MS) is aware of this issue. During a concurrent observation and interview on 12/12/19 at 11:35 AM, LA 1 was observed with a trash bag filled with soiled, disposable, bed pads, multiple diapers, and soiled gloves. LA 1 stated that was the trash that was collected since the last observation was made. LA 1 was observed to open a laundry bag and found a disposable bed pad, soiled with feces. During an interview on 12/12/19 at 3:13 PM, the MS stated that he was told by laundry staff before of this issue of having trash and diapers in the laundry bags and that he has brought this up in the facility staff meetings. The MS stated that the nursing staff on the units were inserviced (training) regarding this issue. During an interview on 12/12/19 at 4:23 PM, the Administrator (ADM) stated that she is aware of this issue and that the staff have been inserviced before. The ADM stated this should not be happening. During an interview on 12/13/19 at 9:51 AM, the Director of Nursing (DON) was asked about what the procedure should be when disposing of trash such as disposable bed pads, diapers, and gloves after cleaning a resident. The DON stated that the licensed nurse or nurse aide should clean the resident and then dispose of any trash in the appropriate bin. The DON stated that there is a separate bin for soiled linen and one for trash. The DON stated that there is no reason or excuse why diapers are found mixed in with the linen. The DON stated the facility does not have a policy and procedure regarding proper way to dispose of trash and not having it mixed in the laundry bags with the soiled linen. During a concurrent interview and record review on 12/13/19 at 10:09 AM, of the inservice documents dated 8/22/19, from the Director of Staff Development (DSD), the DSD stated the inservice topic was in regards to sorting dirty linen and trash before putting it in the laundry chute and to make sure that there are no sharps such as razors. c. During an interview, on 12/13/19, at 1:20 P.M., Housekeeping Aide 1 (HA 1) stated that she has been working in the facility for 15 years, and one of her responsibilities is cleaning the padded side rails for all the resident's beds located in the Sub-acute Unit, by wiping the padded side rails with bleach wipes and letting the pads air dry. HA 1 stated that she would only call the maintenance department to change and replace the padded side rails if the pads are broken and dirty. During an interview, on 12/13/19, at 1: 35 P.M., Housekeeping Aide 2 (HA 2) stated that she has been working in the facility for 13 years, and one of her responsibilities is cleaning the padded side rails for all the resident's beds located outside the Sub-acute Unit, by mixing two ounces (oz- unit of measure of mass) of bleach with 18 oz of water in a spray bottle, and spraying the bleach mixture on the padded side rails and let the pads air dry. HA 2 validated that she would only call the maintenance department to change the padded side rails if the pads are was torn or old. HA 2 acknowledged that whenever a resident is discharged to home and the padded side rails are not old or torn, there is no need to change the pads for the resident, who is incoming as a new admission. During interview and concurrent record of review of the facility's Order Listing Report, printed and dated 12/13/19, on 12/13/19, at 2:00 P.M., the Maintenance Supervisor (MS), stated that there are 57 residents in the facility who were ordered padded side rails to minimize injury to residents' secondary to resident's diagnosis of seizure. A review of the Standard Operations Manual for Long Term Care Facilities, dated 1/22/17, indicated the facility's infection prevention control included equipment or items in the patient environment likely to have been contaminated with infectious body fluids must be handled in a manner to prevent transmission of infectious agents (e.g., wear gloves for direct contact, properly clean and disinfect or sterilized reusable equipment before use on another patient). A review of the facility's Policy and Procedures (P&P) titled, Infection Control, with a review date of 4/17/19, indicated effective infection control program components will be utilized: Prevention: implementation of measures to prevent transmission of infectious agents and to reduce risks for device and procedure-related infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement antibiotic stewardship program (a coordinated program that promotes the appropriate use of drugs used to treat infections, including antibiotics-a medicine that inhibits the growth of or destroys microorganisms) by: 1. Failing to ensure residents meet the criteria for infection for the appropriate usage (route and indication) of antibiotics for one of four residents (Resident 8) investigated under the infection control task. 2. Failing to ensure the types and routes of antibiotics were tracked per facility policy for 11 of 11 months. This deficient practice has the potential to result in unnecessary medication complications and increase risk for antibiotic resistance (when bacteria/germs change in some way that reduces or eliminates the effectiveness of drugs, chemicals, or other agents designed to cure or prevent infections) Findings: A review of Resident 8's admission Record indicated the resident was readmitted on [DATE], with diagnoses including cystitis and overactive bladder. A review of Resident 8's Physician's Orders indicated the resident has an order of Rocephin (antibiotic) 1 gram every 24 hours for seven days for Urinary Tract Infection (UTI-infection that affects part of the urinary tract-kidneys, ureters, urinary bladder and the urethra), ordered 7/1/19. A review of Resident 8's Interdisciplinary Team (IDT - a group of experts from several different fields) Conference Record dated 7/1/19, indicated the resident has a health associated infection with date of onset 7/1/19, no documented evidence of resident's signs and symptoms of infection. During an interview on 12/12/19 at 10:45 a.m., the Infection Preventionist Nurse (IP Nurse) stated part of her responsibilities include checking resident's clinical record for any changes of condition and nursing progress notes and ensure resident's physician was informed. The IP Nurse stated at every end of the month she generates a report and gather the types of antibiotics, types of infection, and monthly reports from diagnostics. During an interview on 12/13/19 at 7:10 a.m., the IP nurse stated she requested the information from the contracted pharmacy dispensary for the antibiotic routes report since January. The IP Nurse confirmed she does not use the report from the pharmacy dispensary for the types of antibiotics and routes. The IP Nurse stated she would have to add each one manually, since January 2019. During an interview on 12/13/19 at 11:33 a.m., the IP Nurse stated the purpose of an antibiotic stewardship program is to prevent cross-contamination of infection and prevent unnecessary use of antibiotics. The IP Nurse stated for the prevention of unnecessary antibiotics she checks resident's labs, change of condition assessments, and use the McGeer's criteria. The IP Nurse stated, she will call the residents' physician and inform the physician of the resident not meeting the criteria, for a true infection, such as lab results and resident's signs and symptoms. During a concurrent interview and record review on 12/13/19 at 2:31 p.m., the IP Nurse confirmed for Resident 8 no checks noted on the Urinary Tract Infection criteria (a standard by which something may be decided). The IP Nurse stated the column should be checked to determine if the resident met the criteria and document under the additional notes that the physician was notified. During an interview on 12/13/19 at 3:19 p.m., the Director of Nursing (DON) stated for antibiotic stewardship she will inform the doctor if the resident met the criteria or not, and it is up to the physician to make the determination, if they wanted to order an antibiotic based on the information provided. The DON stated the column should be checked on the surveillance data collection form, to show if the resident met or did not met the criteria. A review of the facility's policy and procedure titled Antimicrobial Stewardship Program reviewed and approved 4/17/19, indicated it is the policy of the facility to implement an Antimicrobial Stewardship program that will focus on a coordinated interventions designed to improve and measure the appropriate use of antimicrobial agents by promoting the selection of optimal antimicrobial drug regimen including dosing, duration of therapy and route of administration: 5. Tracking: a. IP will be responsible for infection surveillance and MDRO tracking b. IP will collect and review: - Type of antibiotic ordered, route of administration, antibiotic costs - Whether the order was made by phone, if attending physician or on call doctor gave order. - Whether a culture was obtained before ordering antibiotic - Whether the antibiotic was changed during the course of treatment.

Based on observation, interview, and record review, the facility failed to maintain electrical equipment in the rehabilitation department by failing to ensure: a. Preventative maintenance was performed per manufacturer's guidelines for two of two powered exercise equipment. b. The powered therapy mat was functioning. These failures had the potential to cause unsafe use of the powered equipment for residents who use the equipment. Findings: a. On 12/11/19 at 9:05 a.m., during an observation of the rehabilitation department and an interview with the Director of Rehabilitation (DOR), DOR stated that the maintenance staff completed maintenance and checks of the electrical rehabilitation equipment. On 12/11/19 at 10:29 a.m., during an interview with the Maintenance Supervisor (MS), MS stated maintenance did not perform any preventive maintenance checks of any rehabilitation equipment. MS stated maintenance will fix an issue if a problem was reported on any of the equipment, but did not do any of the preventive checks. MS was not aware of any manufacturer's recommendations for maintenance of the equipment. MS stated he knew he needed to implement safety checks for the safety of the residents using the equipment and would start doing so. On 12/12/19 at 9:57 a.m., in an interview, the DOR stated he completed a safety checklist which included checking electrical equipment, cords, and switches, but it did not include preventive maintenance recommended by manufacturers. DOR stated the facility should also perform preventive maintenance of the equipment and not just report once the equipment was already broken. A review of the manufacturer's user manual for a Recumbent Cross Trainer dated 10/2010, indicated preventive maintenance intervals including, clean covers, arms, seat and display, wipe off perspiration, dirt, and dust, replace batteries, and check drive belts for sign of wear. A review of the manufacturer's user manual for a Total Body Exerciser dated 9/2016, indicated maintenance for equipment components including upholstery, base roller track, battery, and chain. A review of the facility's undated policy and procedure titled, Equipment, indicated equipment will be cleaned, maintained, and replaced as needed. b. On 12/12/19 at 9:57 a.m., during an observation and interview with the DOR, the powered therapy mat foot control (that moves the therapy mat higher and lower) did not work. DOR stepped on both controls and the therapy mat did not move. DOR stated that a few months ago this happened and the maintenance staff stated it was the electrical outlet and fixed it. DOR proceeded to plug the cord into two different outlets and stepped on the foot control. The therapy mat did not move up or down. DOR stated the powered therapy mat was not working and will report to maintenance that the mat needs to be fixed. DOR stated it was important to keep equipment working so that it was safe for residents to use during therapy treatments. A review of the facility's undated policy and procedure titled, Equipment, indicated equipment will be cleaned, maintained, and replaced as needed.

Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment for staff working in one of one laundry rooms investigated under the facility task of Environmental Conditions by not properly placing trash in the appropriate disposal bin and not have it mixed in with soiled linen in the laundry bags. This deficient practice resulted in an environmental hazard and had a potential to result in infections of the staff due to ineffective infection control measures. Findings: During a concurrent observation and interview on 12/12/19 at 9:35 AM, when asked if the laundry bag contains any other items other than linen and clothes, Laundry Aide 1 (LA 1) and Laundry Aide 2 (LA 2) both stated that about 2-3 times a week, they will find trash such as cups, spoons, and gloves mixed in the soiled linen when sorting linen out of the laundry bags. LA 1 and LA 2 both stated that they will find soiled diapers mixed in the linen every day. LA 2 stated she found a disposable razor used for shaving once mixed with the linen. LA 1 was observed to open a laundry bag and found disposable bed pads (protective covering placed between person and bed linen) and used gloves. LA 1 stated that she observed soiled diapers earlier and had already thrown away a trash bag filled with trash and diapers, that was collected from the laundry bags. LA 2 stated that the Maintenance Supervisor (MS) is aware of this issue. During a concurrent observation and interview on 12/12/19 at 11:35 AM, with LA 1, a trash bag was observed filled with soiled disposable bed pads, multiple diapers, and soiled gloves. LA 1 stated that was the trash that was collected, since the last observation made. LA 1 was observed to open a laundry bag, and found a disposable bed pad soiled with feces. During an interview on 12/12/19 at 3:13 PM, the MS stated that he was told by laundry staff before of this issue of having trash and diapers in the laundry bags. The MS stated that he has brought this up in the facility staff meetings. The MS stated that the nursing staff on the units were inserviced regarding this issue. During an interview on 12/12/19 at 4:23 PM, the Administrator (ADM) stated she is aware of this issue and that the staff have been inserviced (trained) before. The ADM stated that this should not be happening. During an interview on 12/13/19 at 9:51 AM, the Director of Nursing (DON) was asked about what the procedure should be when disposing of trash such as disposable bed pads, diapers, and gloves after cleaning a resident. The DON stated that the licensed nurse or nurse aide should clean the resident and then dispose of any trash in the appropriate bin. The DON stated that there is a separate bin for soiled linen and one for trash. The DON stated that there is no reason or excuse why diapers are found mixed in with the linen. The DON stated the facility does not have a policy and procedure regarding the proper way to dispose of trash and not having it mixed in the laundry bags, with the soiled linen. During a concurrent interview and record review on 12/13/19 at 10:09 AM, inservice documents dated 8/22/19, were received from the Director of Staff Development (DSD). The DSD stated the inservice topic was in regards to sorting dirty linen and trash before putting the linen in the laundry chute, and to make sure that there are no sharps such as razors.