**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident`s dignity and respect in full recognition of their individuality when Certified Nursing Assistant 1 (CNA 1) was standing over a resident while assisting the resident during a meal for one of three sampled residents (Resident 25). This deficient practice had the potential to negatively affect the resident`s psychosocial wellbeing and loss of dignity. Findings: During a review of Resident 25's admission Record (face sheet), the admission Record indicated that the facility originally admitted the resident on 9/3/2020, and readmitted on [DATE], with diagnoses including absolute glaucoma (a condition marked by complete vision loss and uncontrolled eye pressure), dysphagia (difficulty swallowing), and history of falling. During a review of Resident 25's Minimum Data Set (MDS - a resident assessment tool) dated 11/14/2024, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated that Resident 25 was dependent to staff (helper does all of the effort) for eating, oral hygiene, toileting hygiene, showering and bathing, upper and lower body dressing, putting on/talking off footwear, and personal hygiene. During a review of Resident 25's Nutritional Care Assessment Form dated 5/3/2024, the assessment form indicated that the resident was dependent to staff for eating. During a concurrent observation and interview on 2/15/2025 at 8:30 a.m., inside Resident 25`s room, Certified Nursing Assistant 1 (CNA 1) was standing over Resident 25 while feeding her. CNA 1 stated that she always stands over residents and feed them because it is easier for her. During a concurrent observation and interview on 2/15/2025 at 8:40 a.m. with the facility`s Director of Nursing (DON), inside Resident 25`s room, observed CNA1 standing over Resident 25 while assisting her with her breakfast. The DON stated staff are required to assist residents with feeding in a sitting position to promote the resident's dignity. During a review of facility`s Policy and Procedure (P&P) titled Resident`s Dignity, last reviewed 1/15/2025, the P&P indicated each resident shall be cared for in manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be treated with dignity and respect at all times. Promote resident independence and dignity while dining by avoiding staff standing over the residents while assisting them to eat.

Based on observation, interview, and record review, the facility failed to ensure that the call light (an alerting device for nurses to assist a patient when in need) was within a resident`s reach while in bed for one of one sampled resident (Resident 18) reviewed under the environment task. This deficient practice had the potential to result in Resident 18 not being able to call for facility staff assistance and delay in the provision of necessary care and services that can negatively affect resident's comfort and well-being Findings: During a review of Resident 18's admission Record (face sheet), the admission Record indicated that the facility admitted the resident on 10/9/2020, with diagnoses including vascular dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (a condition in which a person has excessive worry and feelings of fear). During a review of Resident 18's Minimum Data Set (MDS - a resident assessment tool) dated 2/7/2025, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated that Resident 18 was dependent to staff (helper does all of the effort) for toileting hygiene, showering and bathing, lower body dressing, putting on/talking off footwear, and personal hygiene. During a review of Resident 18's care plan (written guide that organizes information about the resident's care) for communication problem related to dementia initiated on 10/16/2020 and last revised on 2/10/2025, the care plan indicated a goal that the resident`s need will be rendered daily through review date. The care plan interventions were to ensure that the resident`s environment is safe, and the call light is answered promptly (immediately). During a concurrent observation and interview on 2/14/2025 at 6:43 p.m., inside Resident 18`s room, the resident was observed sitting on her bed with her call light hanging on the wall behind her head. Resident 18 stated that there is a button she presses when she needs help, and she started searching for it. Resident 18 was not able to find the call light and stated sometimes she screams for help. During a concurrent observation and interview on 2/14/2025 at 6:45 p.m., with Licensed Vocational Nurse 2 (LVN 2) inside Resident 18`s room, LVN 2 stated that Resident 18's call light was hung on the wall behind the resident`s head away from her reach. LVN 2 stated the call light should be always within the resident's reach so she can call for help. During an interview on 2/16/2025 at 2:04 p.m., with the Director of Nursing (DON), the DON stated residents` call lights are required to be accessible to the residents at all times. The DON stated the potential outcome of staff not placing the call lights within residents` reach is the inability of residents to call for help when they need it. During review of the facility's Policy and Procedure (P&P) titled, Answering the Call Light, reviewed on 1/15/2025, the P&P indicated to explain the call light to the new residents, be sure that the call light is plugged in at all times and when the resident in in bed or confined to a chair be sure the call light is within easy reach of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain privacy of confidential information for one of one sampled residents (Resident 48), when Licensed Vocational Nurse 1 (LVN 1) left the resident's electronic health record (EHR- a digital version of a patient's paper chart) open and unattended. This deficient practice violated the residents' right to privacy and confidentiality of medical records. Findings: During a review of Resident 48's admission Record, the admission Record indicated that the facility initially admitted Resident 48 on 9/11/2023 with diagnoses including body myositis( IMB- a muscle disease where muscles gradually weaken over time due to the build-up of abnormal protein clumps inside the muscle fiber), generalized anxiety disorder (persistent and excessive worry that interferes with daily activities), and essential hypertension (a condition in which blood pressure is higher than [NAME]). During a review of Resident 48's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 12/2/2024, the MDS indicated that the resident had intact cognition (undamaged mental abilities, including remembering things, making decisions, concentrating, or learning). The MDS further indicated that Resident 48 required moderate-to-maximal assistance of one-to-two helpers for showering, toileting and personal hygiene, dressing and chair-to-bed transfer, and was not able to walk. During a concurrent medication pass observation and interview on 2/16/2025 at 8:02 a.m., in the main dining room, observed Licensed Vocational Nurse 1 (LVN 1) left the computer screen open, displaying Resident 8's medication list, while stepping away from the medication cart to administer the resident's medications. During an interview, LVN 1 stated that she should have ensured that Resident 48`s EHR was not accessible and open while she stepped away from the medication cart LVN 1 stated that it is a violation of the Health Insurance Portability and Accountability Act (HIPAA) to have the resident's health information visible to unauthorized persons. During a review of The Health Insurance Portability and Accountability Act (HIPAA) of 1996, it indicated the HIPAA Security Rule protects specific information cover the Privacy Rule law applies fully to nursing homes, requiring them to protect the privacy of residents' health information (PHI) by implementing appropriate safeguards, including technical, administrative, and physical measures to prevent unauthorized access, use, or disclosure of this information, particularly electronic protected health information (ePHI). During a review of the facility's policy and procedure (P&P), titled, Data Privacy and Security, last reviewed on 1/15/2025, the policy indicated that the policy outlines the requirements and guidelines for ensuring the privacy and security of sensitive data within the healthcare organization`s IT systems .

Based on observation, interview, and record review, the facility failed to obtain a physician order for a resident's Low Air Loss Mattress (LALM - a pressure-relieving mattress used to prevent and treat pressure injuries) setting for one of three sampled residents (Resident 1) reviewed under the pressure ulcer/injury (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) care area. This deficient practice had the potential to place Resident 1 at risk for discomfort and development of pressure ulcers/injuries. Findings: During a review of Resident 1's admission record, the admission record indicated the facility admitted Resident 1 on 4/13/2021 and readmitted the resident on 9/20/2024 with diagnoses including quadriplegia (a form of paralysis that affects all four limbs, plus the torso), epilepsy (a broad term used for a brain disorder that causes seizures [may cause loss of consciousness, falls, or massive muscle spasms]), and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). During a review of Resident 1's Minimum Data Set (MDS- a comprehensive assessment and care screening tool), dated 11/7/2024, the MDS indicated Resident 1 was cognitively severely impaired (never/rarely made decisions) and was totally dependent on 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 1's Care Plan (a document that outlines the actions and interventions needed to address a resident's health and care needs) initiated on 4/15/2021 and revised on 2/11/2025, the care plan indicated Resident 1 had potential for impairment to skin integrity (a condition where the skin is damaged or broken) related to decreased mobility. The care plan indicated an intervention to provide LALM to Resident 1. During a concurrent observation and interview on 2/14/2025 at 7:15 AM, with the Director of Nursing (DON), in Resident 1's room, the resident's LALM setting was at 350 pounds (lbs. - weight measurement). The DON stated the LALM was supposed to be set at around 180 lbs. She stated the LALM is an intervention to promote wound healing and prevent pressure injuries. The DON stated if the LALM is not set at the correct setting then it will not be effective to prevent further pressure injuries. During a concurrent record review and interview on 2/15/2024 at 2:25 PM, with Minimum Data Set Nurse 1 (MDSN1) reviewed Resident 1's physician orders for 2/2025. MDSN 1 stated that there was no physician order for Resident 1 to use the LALM. MDSN 1 reviewed Resident1's chart and stated an order was initially placed on 2/22/2022 to use a LALM for skin integrity but was discontinued on 9/24/2024 when Resident 1 was transferred to the hospital. MDSN 1 stated a licensed nurse should have called the physician to renew the order for Resident 1's LALM. MDSN 1 stated the LALM setting should be set according to Resident 1's weight, which was 180 lbs., to be effective in maintaining the resident's skin integrity. During a review of the facility's policy and procedure titled, Policy and Procedure on Pressure Ulcer, dated 1/152025, the policy and procedure indicated, A program of prevention, care and treatment of pressure ulcers is carried out all residents to prevent skin breakdown and promote healing .Institute a preventive plan for any residents who has the potential for developing pressure ulcers. This plan may include the following: Reduce pressure by placing resident on therapeutic foam mattress, alternative pressure mattress, turn and positioned as needed by resident. During a review a Med-Air8 Alternating Pressure Mattress Replacement System with Low Air Loss user manual, the manual indicated, Users can adjust the pressure level of the air mattress, using the analog pressure dial, to desired firmness based on personal comfort or weight setting.

Based on interview, and record review, the facility failed to ensure one of one sampled resident (Resident 45) received treatment and services to prevent decrease in range of motion (ROM- full movement potential of a joint) by failing to Provide Restorative Nursing exercises as ordered by the physician. This deficient practice had the potential to place the resident in further decline of her range of motion and developing contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Findings: During a review of Resident 45's admission Record, the admission Record indicated that the facility admitted the resident on 12/25/2024, with diagnoses including unspecified dementia (a progressive state of decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), lack of coordination, and repeated falls. During a review of Resident 45's Minimum Data Set (MDS-a resident assessment tool) dated 12/31/2024, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was moderately impaired (decisions poor, cues/supervision required). The MDS indicated that Resident 45 was dependent on the staff (helper does all of the effort) for showering and bathing. The MDS indicated that Resident 45 required staff partial/moderate assistance (helper does less than half effort) for toileting hygiene, upper and lower body dressing, and personal hygiene. During a review of Resident 45's Physician Order Summary Report dated 1/2/2025, it indicated an order for Restorative Nursing Assistant (RNA- nursing aide program that helps residents to maintain their function and joint mobility) program for ambulation with hand-held assistance every day, five times a week as tolerated during day shift. During a review of Resident 45's Restorative Treatment Record (program that help residents to maintain their function and joint mobility) dated 1/3/2025- 2/14/2025, the record did not indicate any entries for treatment. During a concurrent interview and record review on 2/16/2025 at 9:37 a.m., with MDS Nurse 1 (MDSN 1), Resident 45`s physician orders, care plans, and restorative treatment records were reviewed. MDSN1 stated Resident 45`s physician ordered for Resident 45 to have an RNA ambulation program every day, five times a week on 1/2/2025. MDSN1 stated Resident 45`s restorative treatment records dated 1/3/2025-2/14/2025 did not indicate any entries for treatment. MDSN1 stated that she (MDSN1) is unsure if Resident 45 received RNA treatment during that time. During a concurrent interview and record review on 2/16/2025 at 11:51 a.m., with the Director of Rehabilitation (DOR), Resident 45`s RNA ambulation task log dated 1/20/2024-2/14/2025 was reviewed. The DOR stated that he referred Resident 45 to begin an RNA ambulation program after the resident was discharged from physical therapy treatment. The DOR stated that he was the one who placed an order for RNA ambulation. However, due an error in his computer entry, the RNA ambulation task was scheduled for the night shift instead of day shift resulting in night shift nurses documenting the administration of RNA ambulation as Not Applicable. The DOR stated Resident 45 has not received any RNA ambulation treatment since 1/3/2025. The DOR stated that he evaluated Resident 45 on 2/14/2025, and the resident will have physical therapy three times a week for four weeks thereafter. The DOR stated the potential outcome of not providing RNA treatment as ordered by the physician to a resident is decline in Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily), and muscle weakness. During an interview on 2/16/2025 at 2:15 p.m., with the Director of Nursing (DON), the DON stated Resident 45 has not received RNA ambulation treatment as ordered by her physician since 1/3/2025. The DON stated the potential outcome of not providing RNA treatment to a resident is the decline in ADLs and decrease in ROM. During review of the facility's Policy and Procedure (P&P) titled, RNA Services, last reviewed 1/15/2025, the P&P indicated that it is the policy of the facility to provide range of motion and other activities during routine care and upon order for a resident in the RNA program. It is the policy of the facility to transition residents from therapy to RNA programs if indicated and pursuant to physician orders. RNA services will be per physician orders. For RNA ambulation or standing activities, any devices to be used may be included in addition to the frequency of the activity.

Based on observation, interview and record review, the facility failed to ensure the resident environment was free of accident hazards for two of eight residents (Resident 20 and 49) reviewed under the Accidents care area by failing to: 1. Ensure the television in the Resident 20's room is strapped or bolted to prevent it from falling. 2. Ensure licensed nurses did not leave Resident 20's medications at bedside and unattended. Resident 49 was not capable of self-administration of medications. These deficient practices placed the residents at risk for injury and harm. Findings: 1. During review of Resident 20's admission Record, the admission Record indicated the facility admitted the resident on 01/23/2023, with diagnoses including gastro esophageal reflux disease (a digestive disease in which stomach acid or bile irritates the food pipe lining) and Alzheimer`s disease (a progressive disease that destroys memory and other important mental functions). During a review of Resident 20's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 09 /30/2024, the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was severely impaired. The resident required substantial/maximal assistance for eating, upper body dressing and totally dependent on staff for oral hygiene, toileting hygiene, shower, lower body dressing and personal hygiene. During a concurrent observation and interview on 02/15/25 at 10:14 a.m., with the Director of Nursing (DON), in the resident's room, observed Resident 20`s television on top of a drawer cabinet with no strap or any anchor to prevent the television from falling. The DON stated that televisions in the residents` rooms should be secured with a strap to prevent it from falling, resulting to resident injury. During a review of the facility`s policy and procedure titled Television Policy, last reviewed on 1/15/2025, the policy indicated that All televisions must be securely mounted or placed on stable surfaces to prevent tipping or falling .in case of an emergency, ensure that television is secured to prevent falling . 2. During review of Resident 49 admission Record, the admission Record indicated the facility originally admitted the resident on 02/08/2023 and readmitted the resident on 05/15/2023, with diagnoses including emphysema (a long-term lung condition that causes shortness of breath) and rheumatoid arthritis (a chronic autoimmune disease that primarily affects the joints). During a review of Resident 49's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 01 /30/2025, the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was moderately impaired. The resident required substantial/maximal assistance for oral hygiene, upper body dressing and totally dependent on staff for toileting hygiene, shower, lower body dressing and personal hygiene. During a concurrent observation and interview on 02/14/25 at 06:51 p.m., observed Resident 49 sitting in bed, eating her dinner. Observed a white pill inside a medicine cup on the meal tray. Resident 49 stated the pill was salt pill and hates it because it doesn`t swallow easily. Resident 49 stated the white pill in the medicine cup was left by one of the nurses. During a concurrent observation and interview on 02/14/25 at 07:04 p.m., with the Director of Nursing, in the resident's room, the DON confirmed that there was a white round pill in a medication cup on the meal tray. The DON stated Resident 49`s medication is administered by the nurses since the resident does not have the capacity to self-administer medications based on their assessment criteria. The DON stated that nurses should not leave the medications with the residents so they can observe the residents taking their medications. The DON stated there is a potential for the resident to choke on the medication because the resident was not assessed as capable to self-administer medications. During a review of the facility`s policy and procedure titled Policy and Procedure for Self-Administration,, last reviewed on 1/15/2025, the policy indicated that Resident who desire to self-administer medications are permitted to do so if the facility`s interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 13) with an indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine) received proper care and services by failing to: 1. Update/revise the care plan (a document outlining a detailed approach to care customized to an individual resident's need) for Resident 13`s indwelling catheter after 6/3/2024. 2. Implement the care plan intervention of monitoring for sign and symptoms of Urinary Tract Infection (UTI-an infection in the bladder/urinary tract) such as pain, burning, blood-tinged urine (red or pink urine), and foul smelling (bad-smelling) urine. These deficient practices had the potential to result in Resident 13 receiving inadequate care and supervision at the facility. Findings: During a review of Resident 13's admission Record (face sheet), the admission Record indicated that the facility admitted the resident on 5/31/2024, with diagnoses including unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), benign prostatic hypertension (BPH-a condition in which the prostate gland grows larger than normal), and uninhibited neuropathic bladder (lack of bladder control due to a brain, spinal cord or nerve problem). During a review of Resident 13's Minimum Data Set (MDS - a resident assessment tool) dated 12/4/2024, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated that Resident 13 was dependent to staff (helper does all of the effort) for toileting hygiene, showering and bathing, upper and lower body dressing, putting on/talking off footwear, eating, and personal hygiene. The MDS further indicated that Resident 13 had an indwelling catheter. During a review of Resident 13's Physician Order Summary Report dated 10/3/2024, the order summary report indicated to attach the resident`s indwelling catheter to a bag, change if dislodged (disconnected), pulled out, or removed. During a review of Resident 13's care plan for indwelling catheter initiated on 6/3/2024, the care plan indicated a goal that the resident will remain free from catheter related trauma through review date. The care plan interventions were to monitor resident`s fluid intake and urine output for 30 days, monitor for sign and symptoms of discomfort, and to monitor/record and report to the physician sign and symptoms of UTI such as pain, burning, blood tinged urine, urinary frequency (the need to urinate many times during the day), foul smelling urine, fever, chills, altered mental status, and change in behavior and eating patterns. During a review of Resident 13`s SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form dated 1/17/2025, the SBAR communication form indicated that Resident 13`s Family Member 1 (FM1) reported to the nurse that she observed blood inside the resident`s indwelling catheter bag. During a concurrent interview and record review on 2/15/2025 at 4:00 p.m., with MDS Nurse 1 (MDSN 1), Resident 13`s care plans were reviewed. The MDSN 1 stated that she initiated Resident 13`s indwelling catheter care plan on 6/4/2024. The MDSN 1 stated Resident 13`s indwelling catheter care plan interventions were all initiated on 6/4/2024, but they have not been revised or updated since then. The MDSN 1 stated that one of the care plan interventions for Resident 13 was to monitor his fluid intake and urine output for 30 days. The MDSN 1 stated this intervention was developed upon the resident`s admission on [DATE] and has been completed. However, this intervention remains as part of the resident`s current care plan. The MDSN 1 residents` care plans are required to be revised/updated after completion of a care plan intervention, quarterly, and after resident`s change of condition. The MDSN 1 stated residents` care plans are required to show the current interventions that are implemented for the resident. The MDSN 1 stated one of Resident 13`s indwelling catheter care plan intervention was to monitor/record and report to the physician sign and symptoms of UTI. The MDSN 1 stated there is no documentation regarding this monitoring anywhere in the resident`s chart. The MDSN 1 stated licensed staff are required to monitor Resident 13`s indwelling catheter for sign and symptoms of infection and document as indicated in his care plan. The MDSN 1 stated the potential outcome of not revising a resident`s care plan and not implementing care plan intervention is the inability to provide appropriate care and services to the resident. During a review of the facility's policy and procedure (P&P) titled Catheter Care-Indwelling urinary Catheter, last reviewed on 1/15/2025, the P&P indicated a resident with or without a catheter, receives the appropriate care and services to prevent infections to the extent possible. During review of the facility's Policy and Procedure (P&P) titled, Care Plan-Comprehensive, last reviewed 1/15/2025, the P&P indicated that the facility`s care planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative, develops and maintains care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. Each resident`s comprehensive care plan is designed to incorporate identified problem areas, risk factors associated with identified problems, reflect treatment goal, timetables and objectives in measurable outcomes and reflects currently recognized standards of practice for problem areas and conditions. Care plans are reviewed by the care planning team at least quarterly. The Interdisciplinary team will review the attending physician`s orders (e.g. dietary needs, medications, and routine treatments, etc.) and implement a nursing care plan to meet the resident`s immediate care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain acceptable parameters of nutritional status for one of one sampled resident (Resident 25) reviewed under the nutrition task, by failing to assess and monitor the resident after having weight loss. This deficient practice had the potential to place Resident 25 at risk for further weight loss. Findings: During a review of Resident 25's admission Record (face sheet), the admission Record indicated that the facility originally admitted the resident on 9/3/2020, and readmitted on [DATE], with diagnoses including absolute glaucoma (a condition marked by complete vision loss and uncontrolled eye pressure), dysphagia (difficulty swallowing), and history of falling. During a review of Resident 25's Minimum Data Set (MDS - a resident assessment tool) dated 11/14/2024, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated that Resident 25 was dependent to staff (helper does all of the effort) for eating, oral hygiene, toileting hygiene, showering and bathing, upper and lower body dressing, putting on/talking off footwear, and personal hygiene. The MDS further indicated that Resident 25 had either a weight loss of 5% or more within the last month or a weight loss of 10% or more in the last six months. During a review of Resident 25's Physician Order Summary Report dated 10/24/2024, the order indicated that the resident should be provided with a fortified (a food that has extra nutrients added to it), mechanical soft texture diet (a soft food diet focuses on easy digestion and easy chewing) with a nectar thick consistency fluid (fluids that are thicken than regular fluids, but still pour easily). During a review of Resident 25`s Nutritional Care Assessment Form dated 5/3/2024, the assessment form indicated the following: 1. Resident 25`s diet order was regular mechanical soft diet; 2. Resident 25`s meal intake percentage was 25-50%; and 3. Resident 25 did not have any recent weight changes. The nutritional care assessment form further indicated that the RD would monitor Resident 25`s weight, meal intakes, and skin condition and will follow up as needed. During a review of Resident 25`s SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form dated 6/5/2024, the SBAR communication form indicated that the resident lost five pounds (lbs.- a unit of weight) in one month. The SBAR communication form indicated that Resident 25`s physician recommended the facility's Registered Dietician to evaluate the resident`s weight loss and changed Resident 25`s order from a regular to a fortified diet. During a review of Resident 25`s SBAR Communication Form dated 7/4/2024, the SBAR communication form indicated that the resident lost six lbs. in the last month. The SBAR communication form indicated that Resident 25`s physician ordered 13 milligrams (mg-a unit of measure of mass) of Remeron (antidepressant [a type of medication used to treat depression] that can also raise your appetite and put you at risk for weight gain) by mouth to be administered at nights in order to manage her weight loss. During a review of Resident 25`s Nutritional Status care plan (written guide that organizes information about the resident's care) initiated on 4/23/2024 and last revised on 2/13/2025, the care plan indicated a goal that the resident will tolerate foods provided to her with 75-100% meal intake and will not have significant weight loss of 5% or more in 30 days or 10% or more in 180 days. The care plan interventions were to provide the diet as ordered by the physician, assist with feeding as needed, encourage adequate nutrition and fluid intake, monitor monthly weights and RD to evaluate the resident as needed. During a concurrent interview and record review on 2/15/2025 at 4:35 p.m. with the MDS Nurse 1 (MDSN 1), Resident 25`s physician orders, nutritional assessments and RD notes were reviewed. MDSN 1 stated that the last time Resident 25 was evaluated by an RD was on 5/3/2024. The MDSN 1 stated that there were no nutritional assessments or progress notes by RD after Resident 25`s change of conditions for weight loss on 6/5/2024 and 7/4/2024. The MDSN 1 stated that Resident 25`s physician managed the resident`s weight loss by changing her diet and adding new medication. However, there is no documentation regarding management of Resident 25`s weight loss by the facility`s RD in the resident`s medical record. During a telephone interview on 2/15/2025 at 5:15 p.m., with the current RD, the RD stated that she started working in the facility on 10/2024. The RD stated that she works at the facility onsite once a week. The RD stated that she has never assessed and saw Resident 25 and she does not know anything about the resident and her weight loss. During a concurrent interview and record review on 2/15/2025 at 6:00 p.m. with the Director of Nursing (DON), Resident 25`s physician orders, nutritional assessments and RD notes were reviewed. The DON stated that the RD is required to conduct an assessment for residents upon admission, quarterly, and when the resident loses weight. The DON stated that the last time RD assessed and evaluated Resident 25 was on 5/4/2024 prior to her significant weight loss. The DON stated that the RD did not perform any nutritional assessments for Resident 25 after her change of conditions for weight loss on 6/5/2024 and 7/4/2024. The DON stated that the facility had a high turnover rate for RDs. The DON stated that the high turnover rate may be the reason that there were no assessments or dietary notes developed by an RD after 5/4/2024 for Resident 25`s. The DON stated the potential outcome of an RD not assessing a resident`s weight loss is the inability to detect, care, and manage the increasing weight loss of a resident. During a review of the facility`s Policy and Procedure (P&P) titled Nutritional Assessment, last reviewed on 1/15/2025, the P&P indicated that all residents would have a nutritional assessment completed within 14 days from admission. All residents are reviewed at least quarterly to update the nutritional assessment, care plan and to document resident changes. Residents at nutritional risk are identified and monitored closely to prevent or minimize deterioration. At risk residents are monitored, at least monthly by the Food Service Supervisor and/or Consultant Dietician. Nutrition interventions to prevent deterioration are selected based on resident`s individual needs. Interventions are periodically evaluated for effectiveness and results documented in the dietary progress note section. Interventions and overall goals are documented in the resident`s care plan and dietary progress notes.

Based on observation, interview and record review the facility failed to ensure licensed nurses check for gastrostomy tube (G-tube, a tube inserted through the abdomen to deliver nutrition and medications directly to the stomach) placement (verifying that a G-tube, is positioned correctly in the stomach and not in another location by aspirating stomach contents through the tube using a syringe) before administration of medications as indicated in the resident's care plan for one of two sampled residents (Resident 4) reviewed under the Tube Feeding care area. This deficient practice had the potential to increase Resident 4's risk of aspiration (the accidental inhalation of foreign material, such as food, liquid into lungs). Findings: During a review of Resident 4's admission Record, the Administration Record indicated that the facility initially admitted Resident 4 on 11/22/2021 and readmitted the resident on 07/02/2023 with diagnoses including gastrostomy tube, Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), and atrial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate). During a review of Resident 4's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 1/20/2025, the document indicated that the resident had severely impaired cognition (a severely damaged mental abilities, including remembering things, making decisions, concentrating, or learning). The MDS further indicated that Resident 4 was totally dependent on 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 4's care plan (a document that outlines the actions and interventions needed to address a resident's health and care needs) initiated on 11/21/2021 and revised on 1/21/2025, the care plan indicated that Resident 4 was unable to take food or fluids orally and was at risk for aspiration, The care plan interventions included to check placement and patency of feeding tube prior to administering formula, water and medication. During the review of Resident 47's Order Summary Report, the Order Summary Report indicated the following orders: 1.Eliquis (a medication used to treat blood clots) 2.5 milligram (mg - unit of measurement) via G tube two times a day, dated 11/14/2023. 2.Docusate sodium (a medication used to treat constipation) 100 milligram (mg - unit of measurement) 1 tab via G tube two times a day dated, 03/05/2022. 3.Metoprolol (a medication used to treat high blood pressure) 25 (mg - unit of measurement) 1 tab via G -Tube two times a day, 11/14/2023. During a medication administration observation on 2/15/2025 at 5:07 p.m. in Resident 4's room, LVN 4 did not check for G-tube placement before administering the following medications via G-tube: 1.Eliquis 2.5 mg 2.Docusate sodium 100 mg 1 tablet 3.Metoprolol 25 mg 1 tablet During an interview on 2/15/2025 at 5:15 p.m., with LVN 4, LVN 4 stated that he (LVN 4) did not check the placement of G-Tube with stethoscope (medical instrument used to listen to sounds inside the body) of Resident 4's . LVN 4 stated that placement of G-Tube has to be checked before medication administration to achieve a medication therapeutic effect of medication. During an interview on 2/15/2025 at 7 p.m. with the Director of Nursing (DON), the DON stated that the LVN 4 should follow nursing procedure during medication administration and check the placement of Resident 4's G-Tube before administering medication. The DON stated that this deficient practice had the potential to increase the risk of aspiration for Resident 4. During a review of the facility policy named Enteral Feeding Tube Drug Administration, last reviewed on 1/15/2025, the policy stated: The facility assures the safety and effective administration of enteral formulas and medications via enteral tubes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During a review of Resident 45's admission Record, the admission Record indicated that the facility admitted the resident on 12/25/2024, with diagnoses including unspecified dementia (a progressive state of decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), lack of coordination, and repeated falls. During a review of Resident 45's Minimum Data Set (MDS-a resident assessment tool) dated 12/31/2024, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was moderately impaired (decisions poor, cues/supervision required). The MDS indicated that Resident 45 was dependent on the staff (helper does all of the effort) for showering and bathing. The MDS indicated that Resident 45 required partial/moderate assistance (helper does less than half effort) for toileting hygiene, upper and lower body dressing, and personal hygiene. During a review of Resident 45's Physician`s Order Summary Report dated 1/2/2025, the Physician`s Order Summary Report indicated an order for Restorative Nursing Assistant (RNA- nursing aide program that helps residents to maintain their function and joint mobility) program for ambulation with hand-held assistance every day, five times a week as tolerated during day shift. During a review of Resident 45's Restorative Treatment Record (program that help residents to maintain their function and joint mobility) dated 1/3/2025- 2/14/2025, the record did not indicate any entries for treatment. During a review of Resident 45`s care plans, the care plans did not indicate a documented evidence of a comprehensive care plan with goals and person-centered interventions addressing Resident 45`s RNA program. During a concurrent interview and record review on 2/16/2025 at 9:37 a.m., with MDS Nurse 1 (MDSN 1), Resident 45`s physician orders, care plans, and restorative treatment records were reviewed. MDSN 1 stated Resident 45`s physician ordered for RNA ambulation program every day, five times a week on 1/2/2025. MDSN1 stated Resident 45`s restorative treatment records dated 1/3/2025-2/14/2025 did not indicate any entries for treatment. MDSN1 stated that she (MDSN 1) is unsure if Resident 45 received RNA treatment during that time. MDSN 1 further indicated that licensed staff did not develop a comprehensive care plan with person-centered interventions for the resident`s RNA program. MDSN 1 stated a care plan with person-centered intervention is required to monitor Resident 45`s ROM improvement. MDSN 1 stated the potential outcome of not developing a person-centered care plan with goal and intervention is the lack of care and the inability to implement the specific services and monitoring that resident requires. During a concurrent interview and record review on 2/16/2025 at 11:51 a.m., with the Director of Rehabilitation (DOR), Resident 45`s RNA ambulation task log dated 1/20/2024-2/14/2025 was reviewed. The DOR stated that he referred Resident 45 to begin an RNA ambulation program after the resident was discharged from physical therapy treatment. The DOR stated Resident 45`s physician ordered RNA program for ambulation with hand-held assistance every day, five times a week as tolerated during day shift on 1/2/2025. However, Resident 45 did not receive any RNA ambulation treatment since 1/3/2025. The DOR stated licensed staff did not develop a comprehensive care plan with person-centered interventions for the resident`s RNA program. The DOR stated a care plan with person-centered intervention is required to monitor Resident 45`s ROM and ambulation. The DOR stated the potential outcome of not developing a person-centered care plan with goal and intervention is the lack of care and the inability to implement the specific services and monitoring that resident requires. During an interview on 2/16/2025 at 2:15 p.m., with the Director of Nursing (DON), the DON stated licensed staff are required to develop a person-centered care plan based on the residents` needs and identified problems. The DON stated licensed staff did not develop a care plan with goal and interventions for Resident 45`s RNA treatment. The DON stated that the potential outcome of not developing a care plan with goal and interventions is the inability to monitor for decline or improvement in the resident`s condition, resulting in inadequate care for the resident. During review of the facility's Policy and Procedure (P&P) titled, Care Plan-Comprehensive, last reviewed 1/15/2025, the P&P indicated that the facility`s care planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative, develops and maintains care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. Each resident`s comprehensive care plan is designed to incorporate identified problem areas, risk factors associated with identified problems, reflect treatment goal, timetables and objectives in measurable outcomes. Care plans are reviewed by the care planning team at least quarterly. The Interdisciplinary team will review the attending physician`s orders (e.g. dietary needs, medications, and routine treatments, etc.) and implement a nursing care plan to meet the resident`s immediate care needs. Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan (CP- a plan for an individual's specific health needs and desired health outcomes) for three of three sampled residents (Resident 33, 34, and 45) by failing to: 1. a. Monitor Resident 33 for signs and symptoms of bleeding as indicated in the care plan. This deficient practice placed Resident 33 at risk for undetected blood loss due to lack of monitoring. 1.b. Develop a person-centered Care Plan (CP- a plan for an individual's specific health needs and desired health outcomes) for Resident 33 who was assessed as high risk for fall. This deficient practice placed the resident at risk for recurring falls with injuries. 2. Provide Resident 34 with bilateral (both sides) floormats (padding placed on the floor to help prevent injuries related to falls) as indicated in the care plan. This deficient practice placed Resident 34 at risk for injury in the event of a fall. 3. Develop and implement a comprehensive person-centered care plan addressing Resident 45`s Restorative Nursing Assistant program (RNA-nursing aide program that helps residents to maintain their function and joint mobility). This deficient practice had the potential to result in Resident 45`s inadequate care. Findings: 1. During review of Resident 33's admission Record, the admission Record indicated the facility admitted the resident on 10/31/2024, with diagnoses including history of falling and dementia (a group of thinking and social symptoms that interferes with daily functioning). During a review of Resident 33's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/14/2024, the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was severely impaired. The resident required substantial/maximal assistance for eating, oral hygiene, upper body dressing and totally dependent on staff for toileting hygiene, shower, lower body dressing and personal hygiene. During a review of Resident 33`s Order Summary Report, included an order for Apixaban (used to treat and prevent blood clots) Oral Tablet 5 milligram (mg), to give 1 tablet two times a day for Deep Vein Thrombosis (a condition where a blood clot forms in a deep vein, typically in the legs), dated 10/31/2024. During a concurrent interview and record review on 02/15/25 at 4:23 p.m., with the Director of Nursing (DON), Resident 33`s Medication Administration Record (MAR- includes key information about the individual's medication including, the medication name, dose taken, special instructions and date and time) for the month of January 2025 and February 2025 and care plans. The CP for Anticoagulant Therapy dated 2/16/2025, indicated a goal that the resident will free be from discomfort or adverse reactions related to anticoagulant use. The DON stated one of the care plan interventions was to monitor the resident for signs and symptoms of bleeding. The DON stated that there is no documentation in any of the resident`s clinical record, including the MAR for January and February 2025 indicating that signs and symptoms of bleeding were monitored. The DON stated monitoring for signs and symptoms of bleeding is important so that timely intervention can be implemented such as notifying the provider to obtain an order to continue or hold the Apixaban. The DON stated that Resident 33 may experience bleeding due to anticoagulant use, and without monitoring, this could lead into hemorrhage. During a review of Resident 33`s Care Plan Report for Anticoagulant Therapy, initiated on 11/12/2024 and last revised on 2/16/2025, the CP goal is for the resident to be free from discomfort or adverse reaction related to anticoagulant use through the review date. The CP interventions included, but not limited to, monitor for signs and symptoms of bleeding such as easy bruising, syncope (a temporary loss of consciousness that occurs when the brain does not receive enough blood flow) and hematuria (a condition where blood is present in the urine). During a review of the facility`s policy and procedure titled Care Plan Policy, last reviewed on 1/15/2025, the policy and procedure indicated that The comprehensive Care Plan is based through assessment that includes, but is not limited to, the MDS Assessments of residents are ongoing, and care plans are revised as information about the resident and the resident`s condition change .reflect treatment goals, timetables and objectives and measurable outcomes . 1.b. During a review of Resident 33's admission Record, the admission Record indicated the facility admitted the resident on 10/31/2024, with diagnoses including history of falling and dementia (a group of thinking and social symptoms that interferes with daily functioning). During a review of Resident 33's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/14/2024, the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was severely impaired. The resident required substantial/maximal assistance for eating, oral hygiene, upper body dressing and totally dependent on staff for toileting hygiene, shower, lower body dressing and personal hygiene. The MDS indicated that Resident 33 had a history of fall in the last 2-6 months and sustained a fracture prior to admission. The MDS further indicated that care planning for fall is necessary to address the problem. During a concurrent observation and interview on 02/14/2025 at 06:40 p.m., observed Resident 33 lying in bed awake. The resident's bed had padded side rails and there was a landing mat on the floor. Resident 33 had a cut approximately measuring 2 centimeter on her forehead, that appeared to be healing. Resident 33 stated that the cut on her forehead resulted from a fall while she was trying to go to the toilet. During a concurrent interview and record review on 02/15/25 09:16 a.m., with the Director of Nursing (DON), reviewed Resident 33`s admission Fall Risk assessment dated [DATE], SBAR dated 02/03/2025, and MDS Section J and MDS Section V- Care Area Assessment (CAA) Summary. Resident 33`s admission Fall Risk assessment dated [DATE], the assessment indicated a score of 20, high risk for falls. Resident 33`s Situation, Background, Assessment, Recommendation (SBAR- an acronym for Situation, Background, Assessment, Recommendation; a technique that can be used to facilitate prompt and appropriate communication) form dated 02/03/2025, indicated that Resident 33 was found on the floor in her room at around 6:35 a.m. with a cut over the forehead measuring 2 centimeters (cm) by 2 cm, and able to move all extremities with no change in the level of consciousness. The DON stated that Resident 33 had a recent fall incident and sustained a laceration on her forehead. The DON stated that when the resident fell there was no floor mat on the floor next to the resident's bed. The DON stated that the resident was not sent out for further evaluation because there was no change in her level of consciousness and was able to move her extremities. The DON stated if there was a floor mat when she fell, the laceration on her forehead could be minimal as the floor mat will soften the impact. The DON stated that based on the Fall Risk Assessment and the history of fall as documented in the MDS, there should have been a care plan and interventions addressing the resident's fall risk. The DON stated that the x-ray results of Resident 33`s head was normal with no fractures. The DON the care plan for Resident 33's risk for fall was not done. During a review of the facility`s policy and procedure titled Policy and Procedure on Falls, last reviewed on 1/15/2025, the policy indicated that The fall policy at the facility is designed to minimize the risk of falls or accidents and reduce the risk of serious injury associated with such events .Care Plan: Residents identified as at risk for falls must have a care plan that outlines their specific risk factors and appropriate interventions,. 2. During review of Resident 34's admission Record, the admission Record indicated the facility originally admitted the resident on 10/11/2021 and readmitted on [DATE], with diagnoses that included repeated falls and dementia (a group of thinking and social symptoms that interferes with daily functioning). During a review of Resident 34's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/13/2025, the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was severely impaired. The resident is totally dependent on staff for activities of daily living (refer to basic tasks that individuals perform to maintain their daily life and personal care). During an interview and record review on 02/15/2025 at 6:34 p.m., with Minimum Data Set Nurse 1 (MDSN 1), reviewed Resident 34`s CP for High Risk for Unavoidable Falls, initiated on 10/14/2021 and revised 02/14/2025. The CP for High Risk for Unavoidable Fall indicated a goal for Resident 34 to be free of minor injury through the review date. The CP for High Risk for Unavoidable Falls outlined several interventions, including but not limited to, providing floor mats at bedside and frequent visual check throughout the shift. MDSN 1 stated that floor mats can lessen or minimize the impact if the resident would have a fall incident. MDSN 1 stated without a floor mat, Resident 34 can sustain serious injury if she falls directly into the concrete. During an observation on 02/15/2025 at 6:50 p.m., with the MDSN1 , observed and verified with MDSN 1 that Resident 34 has no floor mat. During a review of the facility`s Policy and Procedure on Falls, last reviewed on 1/15/2025, the policy indicated that the fall policy is designed to minimize the risk for falls or accidents and reduce the risk of serious injury associated with such events .Care Plan: Residents identified as at risk for falls must have a care plan that outlines their specific risk factor and appropriate interventions . During a review of the facility`s policy and procedure titled Care Plan Policy, last reviewed on 1/15/2025, indicated that The comprehensive Care Plan is based through assessment that includes, but is not limited to, the MDS Assessments of residents are ongoing, and care plans are revised as information about the resident and the resident`s condition change .reflect treatment goals, timetables and objectives and measurable outcomes .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. During a review of Resident 11's admission record, the admission Record indicated the facility admitted Resident 11 on 12/10/2020 and readmitted the resident on 11/25/2024 with diagnoses including multiple sclerosis (a chronic disease that damaged the central nervous system), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood well), and type 2 diabetes mellitus (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly). During a review of Resident 11's Minimum Data Set (MDS- a comprehensive assessment and care screening tool), dated 1/31/2025, the MDS indicated Resident 11 was cognitively severely impaired (never/rarely made decisions) and was totally dependent on staff on toileting hygiene, shower and lower body dressing, need supervision with eating and required maximal assistance with oral and personal hygiene. During a review of Resident 11's Care Plan (a document that outlines the actions and interventions needed to address a resident's health and care needs) initiated on 12/15/2020, the Care Plan indicated Resident 11 has a seizure disorder. The Care Plan interventions indicated to protect the resident from injury. During a review of Resident 11 History and Physical (H&P), dated 1/23/2024, the HP indicated the resident did not have the capacity to understand and make decisions. During a review of a nursing note dated 02/12/2025, the note indicated that Resident 11 was transferred from room [ROOM NUMBER]A to room [ROOM NUMBER]A, and responsible party was informed and agreed. During an observation on 2/14/2025 at 6:57 PM, in Resident 11's room, the resident was observed in her bed with bilateral full side rails up. During a concurrent record review and interview on 2/15/2025 at 2:25 PM with Minimum Data Set Nurse 1 (MDSN 1), reviewed Resident 11's physician orders. MDSN 1stated that there was no physician order, assessment or consent for using full bed side rails for Resident 11. MDSN 1 reviewed Resident 1's chart and stated Resident 11 was transferred from another room on 01/12/2025 to current room and probably was accidently put in a bed with full side rails. MDSN 1 stated placing a resident in a bed with full side rails without a physician's order, consent and assessment put Resident 11 at risk for entrapment and injury. During an interview with the Director of Nursing (DON) on 12/15/ 2025 at 7 PM, the DON stated using a bed with full side rails bed without assessment and physician order can lead to resident injury and entrapment. During a review of the facility's policy and procedure titled, Policy and Procedure Restrains (Physical), dated 1/15/2025, the policy and procedure indicated: Physician restraints are defined as 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 which restricts freedom of movement or normal access to one's body .Assess resident's needs for restrain. Obtain physician order for restrain. During a review of the facility`s policy and procedures titled Policy Side Rails, last reviewed on 1/15/2025, the facility indicated that The policy for the use of side rails are as follows: Entrapment Assessment: If the bed rails are used for any reason, an assessment must be completed and documented. This assessment should be conducted at least semiannually, whenever the mattress is changed or an overlay is added, when new rails are installed, or when new resident occupies the bed. These assessments are maintained separately from the clinical record . Based on observation, interview, and record review, the facility failed to assess residents for risk of entrapment (when a resident is trapped in the spaces in between or around the bed rails [adjustable metal or rigid plastic bars that attach to the bed that are available in a variety of types, shapes, and sizes], mattress, or bed frame), obtained an informed consent and a physician order for the use of bed rails for two of eight residents (Resident 14 and 50) reviewed under the Accidents care area and for one of one (Resident 11) resident reviewed under the Restraints care area. These deficient practices placed the residents at risk for potential accidents such as a body part being caught between the rails, falls if a resident attempts to climb over, around, between, or through the rails and potentially violate the residents' rights. Findings: a. During review of Resident 14's admission Record, the admission Record indicated the facility admitted the resident on 1/23/2023 with diagnoses including Alzheimer`s disease (a progressive brain disorder that causes memory loss and other cognitive decline) and gastro esophageal reflux disease (a condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach). During a review of Resident 14's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/13/2025, the MDS indicated the resident had the ability to make self-understood and the ability to understand others. The resident required maximal assistance from staff for toileting hygiene, shower, upper body dressing, lower body dressing and dependent on staff for shower. During an observation and interview on 02/14/2025 at 6:30 a.m., with Resident 14, observed Resident 14 seated upright in bed working on a puzzle and with half bed siderails up on both sides of the bed. The resident stated he did not have any concerns about his care. During a concurrent interview and record review with the Director of Nursing (DON) on 2/15/2025 at 5:20 p.m., reviewed Resident 14 `s Side Rail Use Assessment (SRUA) dated 1/23/2023 and physician`s orders which included an order for both half bed rails while in bed for turn and repositioning, supporting self during care and getting out of bed. Also reviewed Resident 14's. The DON stated that this assessment is not the Risk for Entrapment Assessment. The DON verified that there is 1/2 side rail attached to the resident`s bed. The DON stated any resident using a bed siderails must be assessed for safety and risk for entrapment to prevent potential injury to the resident`s limbs. The DON stated that Resident 14 could suffer an injury if a part of her body is entrapped in the gaps of the siderails. During a review of the facility`s policy and procedures titled Policy Side Rails, last reviewed on 1/15/2025, the facility indicated that The policy for the use of side rails are as follows: Entrapment Assessment: If the bed rails are used for any reason, an assessment must be completed and documented. This assessment should be conducted at least semiannually, whenever the mattress is changed or an overlay is added, when new rails are installed, or when new resident occupies the bed. These assessments are maintained separately from the clinical record . b. During review of Resident 50's admission Record, the admission Record indicated the facility originally admitted the resident on 4/03/2023 with diagnoses b including major depressive disorder (a common mental health condition characterized by persistent feelings of sadness, loss of interest, and other symptoms that significantly interfere with daily life) and gastro esophageal reflux disease (a condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach). During a review of Resident 50 's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 3/28/2024, the MDS indicated the resident had the ability to sometime make self-understood and the ability to sometimes understand others. The resident is totally dependent on staff for self-care including, toileting hygiene, shower, upper body dressing, lower body dressing. During an observation on 02/14/2025 at 6:30 p.m., observed Resident 50 lying in bed sleeping with siderails up on both sides of the bed. During a record review and interview with the Director of Nursing (DON) on 2/15/2025 at 6:20 p.m., reviewed Resident 50 `s Side Rail Use Assessment (SRUA) dated 12/18/2024 and physician`s orders which included an order for both half bed rails while in bed for turn and repositioning, supporting self during care and getting out of bed, dated 12/17/2024. The DON stated that this assessment is not the same as the Risk for Entrapment Assessment. The DON verified there was a 1/2 side rail attached to the resident`s bed. The DON stated any resident using a bed siderails must be assessed for safety and risk for entrapment to prevent potential injury to the resident`s limbs. The DON stated that Resident 50 could suffer an injury if a part of her body is entrapped in the gaps on the siderails. During a review of the facility`s policy and procedures titled Policy Side Rails, last reviewed on 1/15/2025, the facility indicated that The policy for the use of side rails are as follows: Entrapment Assessment: If the bed rails are used for any reason, an assessment must be completed and documented. This assessment should be conducted at least semiannually, whenever the mattress is changed or an overlay is added, when new rails are installed, or when new resident occupies the bed. These assessments are maintained separately from the clinical record .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During the Treatment Cart 1 inspection and observation, on 2/16/2025 at 3:24 p.m., and a concurrent interview with Licensed Vocational Nurse 3 (LVN 3), an expired vaginal cream was observed stored in the cart. LVN 3 confirmed that the observed vaginal cream did expire on 9/2024 and belonged to a resident who has already been discharged from the facility. The LVN 3 stated that licensed staff is required to immediately remove all expired medications from treatment carts. During a concurrent observation and interview on 2/16/2025 at 3:28 p.m. with LVN 3, four expired povidone-iodine swab sticks were observed inside Treatment Cart 1. LVN 3 stated these povidone-iodine swab sticks were expired on 10/2023, and should have been removed and disposed of. The LVN 3 stated that the potential outcome of using expired medical supplies is the inability to ensure the intended result of a valid and unexpired medical supply. During an interview on 2/16/2025 at 3:40 p.m., with Registered Nurse 1 (RN 1), the RN 1 stated licensed nurses are required to inspect the medication and treatment carts during every shift and remove the expired medications and supplies and replace them. The RN 1 stated this is important to avoid a medication error by the administration of the expired medication or expired medical supplies. The RN 1 stated the potential outcome of not disposing expired medication and supplies from the treatment cart is the administration and use of a less effective medication or supply which may not produce the expected result. During a review of the facility`s Policy and Procedure (P&P) titled Storage of Medication, last reviewed 1/15/2025, the P&P indicated outdated, contaminated, discontinued, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. Based on observation, interview and record review, the facility failed to ensure that drugs and biologicals were stored in accordance with accepted professional principles by failing to: 1. Ensure an insulin (hormone that lowers the level of glucose [sugar] in the blood) pen that was past the discard date, was not stored in one of two three medication carts (Medication Cart 1) affecting one of one sampled resident (Resident 53). This deficient practice had the potential for an expired insulin to be administered to Resident 53 which could result in uncontrolled blood glucose (the primary sugar in the blood and the body's main source of energy). 2.a. Ensure an expired vaginal cream (topical medication inserted into the vagina to treat infection) belonging to a discharged resident was removed and disposed of in one of two Treatment Carts inspected (Treatment Cart 1). 2.b. Ensure an expired povidone-iodine swab sticks (used to kill germs and prevent infection in small skin cuts and burns) were removed and disposed of in one of two Treatment Carts inspected (Treatment Cart 1). These deficient practices had the potential for the administration and use of a less effective medication or supply which may not produce the expected results. Findings: 1.During a review of Resident 53's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnosis including diabetes mellitus (DM - high blood sugar) and hypertension (high blood pressure). During a review of Resident 53`s admission History and Physical (H&P- a medical exam that includes a patient interview, physical exam, and documentation of findings) dated 4/5/2024, the H&P indicated that Resident 53`s cognitive functions are intact. During a review of Resident 53's Order Summary Report indicated a physician's order dated 1/03/2025 to administer Insulin Lispro Injection Solution (Humalog- a fast-acting insulin for adults and children with diabetes) 100 unit per milliliters (ml) per sliding scale (varies the dose of insulin based on blood glucose level) subcutaneously (administering medication where a short needle is used to inject a medication into the tissue layer between the skin and the muscle) one time a day for DM. During a medication cart inspection on 2/15/2025 at 2:44 p.m. with Licensed Vocational Nurse 2 (LVN 2), inspected Medication Cart 1 (MC 1). Resident 53's Humalog Insulin Lispro pen labeled with the open date of 12/29/2025, was observed inside the cart. LVN 2 stated that insulin in vials or pens are supposed to be used only for 28 days and if it is past the 28 days the insulin may have lost its efficacy. LVN 2 stated that the insulin used to manage Resident 53`s diabetes, may not be effective, and the resident may experience hyperglycemia (high blood sugar) which could lead to complications such as nausea and vomiting, blurred vision and could potentially result to falls or injuries. During an interview on 2/15/2025 at 3:13 p.m., with the Director of Nursing (DON), the DON stated if an insulin is used beyond 28 days, it might no longer be effective in managing Resident 53`s diabetes. The DON stated that Resident 53`s blood sugar may not be controlled and may result in hyperglycemia (high blood sugar) which can lead to serious complications. During a review of the Humalog (Insulin lispro) manufacturer's literature (provided by the facility) indicated that once opened, Humalog vials, prefilled pens, and cartridges should be thrown away after 28 days even if it still contains insulin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure adequate oversight of the Food and Nutrition Services by qualified personnel when two of two sampled resident (Resident 25 and Resident 53) reviewed under the nutrition task were not assessed and evaluated by a Registered Dietitian (RD- a health professional who has special training in diet and nutrition) after having weight loss. This deficient practice had a potential to result in ineffective nutrition intervention and goals and an increased weight loss for Resident 25 and Resident 53. Findings: a. During a review of Resident 25's admission Record (face sheet), the admission Record indicated that the facility originally admitted the resident on 9/3/2020, and readmitted on [DATE], with diagnoses including absolute glaucoma (a condition marked by complete vision loss and uncontrolled eye pressure), dysphagia (difficulty swallowing), and history of falling. During a review of Resident 25's Minimum Data Set (MDS - a resident assessment tool) dated 11/14/2024, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated that Resident 25 was dependent to staff (helper does all of the effort) for eating, oral hygiene, toileting hygiene, showering and bathing, upper and lower body dressing, putting on/talking off footwear, and personal hygiene. The MDS further indicated that Resident 25 had either a weight loss of 5% or more within the last month or a weight loss of 10% or more in the last six months. During a review of Resident 25's Physician Order Summary Report dated 10/24/2024, the order indicated that the resident should be provided with a fortified (a food that has extra nutrients added to it), mechanical soft texture diet (a soft food diet focuses on easy digestion and easy chewing) with a nectar thick consistency fluid (fluids that are thicken than regular fluids, but still pour easily). During a review of Resident 25`s Nutritional Care Assessment Form dated 5/3/2024, the assessment form indicated the following: 1. Resident 25`s diet order was regular mechanical soft diet; 2. Resident 25`s meal intake percentage was 25-50%; and 3. Resident 25 did not have any recent weight changes. The nutritional care assessment further indicated that the RD would monitor Resident 25`s weight, meal intakes and skin condition and will follow up as needed. During a review of Resident 25`s SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form dated 6/5/2024, the SBAR communication form indicated that the resident lost five pounds (lbs.- a unit of weight) in one month. The SBAR communication form indicated that Resident 25`s physician recommended the facility's Registered Dietician to evaluate the resident`s weight loss and changed Resident 25`s order from a regular to a fortified diet. During a review of Resident 25`s SBAR Communication Form dated 7/4/2024, the SBAR communication form indicated that the resident lost six lbs. in the last month. The SBAR communication form indicated that Resident 25`s physician ordered 13 milligrams (mg-a unit of measure of mass) of Remeron (antidepressant [a type of medication used to treat depression] that can also raise your appetite and put you at risk for weight gain) by mouth to be administered at nights in order to manage her weight loss. During a review of Resident 25`s Nutritional Status care plan (written guide that organizes information about the resident's care) initiated on 4/23/2024 and last revised on 2/13/2025, the care plan indicated a goal that the resident will tolerate foods provided to her with 75-100% meal intake and will not have significant weight loss of 5% or more in 30 days or 10% or more in 180 days. The care plan interventions were to provide the diet as ordered by the physician, assist with feeding as needed, encourage adequate nutrition and fluid intake, monitor monthly weights and RD to evaluate the resident as needed. During a concurrent interview and record review on 2/15/2025 at 4:35 p.m. with the MDS Nurse 1 (MDSN 1), Resident 25`s physician orders, nutritional assessments and RD notes were reviewed. MDSN 1 stated that the last time Resident 25 was evaluated by an RD was on 5/3/2024. MDSN 1 stated that there were no nutritional assessments or progress notes by RD after Resident 25`s change of conditions for weight loss on 6/5/2024 and 7/4/2024. MDSN 1 stated that Resident 25`s physician managed the resident`s weight loss by changing her diet and adding new medication. However, there is no documentation regarding management of Resident 25`s weight loss by the facility`s RD in the resident`s medical record. During a telephone interview on 2/15/2025 at 5:15 p.m., with the facility current RD, the RD stated that she started working in the facility on 10/2024. The RD stated that she works at the facility onsite once a week and works remotely for the rest of her shifts. The RD stated that she has never assessed and visited Resident 25 and she does not know anything about the resident and her weight loss. During a concurrent interview and record review on 2/15/2025 at 6:00 p.m. with the Director of Nursing (DON), Resident 25`s physician orders, nutritional assessments and RD notes were reviewed. The DON stated that the RD is required to conduct an assessment for residents upon admission, quarterly and when the resident loses weight. The DON stated that the last time RD assessed and evaluated Resident 25 was on 5/4/2024 prior to her significant weight loss. The DON stated that the RD did not perform any nutritional assessments for Resident 25 after her change of conditions for weight loss on 6/5/2024 and 7/4/2024. The DON stated that the facility had a high turnover rate for RDs. The DON stated that the high turnover rate may be the reason that there were no assessments or dietary notes developed by an RD after 5/4/2024 for Resident 25`s. The DON stated the potential outcome of an RD not assessing a resident`s weight loss is the inability to detect, care, and manage the increasing weight loss of a resident. During an interview on 2/16/2025 at 6:20 p.m., with the Administrator (ADM), the ADM stated that the facility faced staffing challenges for contracted RDs in the facility since last summer. The ADM stated that he is trying his best to ensure there is sufficient and qualified staff with the appropriate competencies and skill sets to carry out food and nutrition services in the facility. The ADM stated that Registered Dietitians are required to complete initial and quarterly assessments for all residents, especially residents who have lost weight. The ADM stated RDs are required to access the effectiveness of nutritional interventions developed for the residents. The ADM stated that the potential outcome of not always having an available RD in the facility, or a high RD turnover rate is the inability to timely monitor and access the residents and prevention of further weight loss. During a review of the facility`s Procedure titled Job Description-independent Dietician, last reviewed on 1/15/2025, the job description indicated that the key responsibilities of the dieticians are to conduct comprehensive nutritional assessments for new admission, quarterly reviews, and as needed for residents with significant changes in health status, monitor residents` nutritional progress and adjust care plans as needed, document assessments, care plans, and progress notes in compliance with regulatory standards and advise on therapeutic diets and special dietary modifications. During a review of the facility`s Policy and Procedure (P&P) titled Nutritional Assessment, last reviewed on 1/15/2025, the P&P indicated that all residents would have a nutritional assessment completed within 14 days from admission. All residents are reviewed at least quarterly to update the nutritional assessment, care plan and to document resident changes. Residents at nutritional risk are identified and monitored closely to prevent or minimize deterioration. At risk residents are monitored, at least monthly by the Food Service Supervisor and/or Consultant Dietician. Nutrition interventions to prevent deterioration are selected based on resident`s individual needs. Interventions are periodically evaluated for effectiveness and results documented in the dietary progress note section. Interventions and overall goals are documented in the resident`s care plan and dietary progress notes. b. During a review of Resident 53's admission Record, the admission Record indicated that the facility admitted Resident 53 on 3/22/2024 and readmitted the resident on 12/26/2024 with diagnoses including type 2 diabetes mellitus (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly), legal blindness (having vision that is 20/200 or worse even with prescription eyewear), and hypertension (a condition in which blood pressure is higher than normal). During a review of Resident 53's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 01/27/2025, the MDS indicated that the resident had mildly impaired cognition (a slight decline in mental abilities, memory and completing complex tasks). The MDS further indicated that Resident 53 needed moderate-to- maximal assistance with all Activities of Dayli Living (ADL- activities such as bathing, dressing and toileting a person performs daily). During a review Resident 53's Nutritional Status care plan last reviewed on 02/06/2025, the Care Plan (a document that outlines the actions and interventions needed to address a resident's health and care needs) indicated that the resident lost 13 lb. in one month. The care plan indicated an intervention for the Registered Dietician (RD) to evaluate resident as needed and increase health shake to three times a day. During a concurrent record review and interview on 2/15/2024 at 2:25 PM, with the Minimum Data Set Nurse 1 (MDSN 1), reviewed Resident 53 's registered dietitian notes and weight log. MDSN 1 stated that Resident 53's weight on 01/01/2025 was 120 lbs. and on 02/05/2025 was 107 pounds (lb.- measurement of the weight). MDSN 1 stated Resident 53 lost 13 lbs. 10 percent of the resident's weight in one month, and it is considered a severe weight loss. The MDSN stated than RD assessed Resident 53 on 4/21/2024. The MDSN stated she could not find any other RD notes. During a concurrent interview and record review on 2/15/2025 at 2:25 p.m. with Minimum Data Set Nurse 1 (MDSN 1), Resident 53`s physician orders, nutritional assessments and RD notes were reviewed. MDSN 1 stated that the last time Resident 53`s was evaluated by an RD was on 4/21/2024. MDSN 1 stated there are no Nutritional assessments or progress notes from RD after Resident 53 had weight loss on 12/26/2024 . The MDSN 1 stated that Resident 53`s physician managed the resident`s weight loss by increasing health shake in her diet to three times a day. However, there is no documentation regarding managing Resident 53`s weight loss by the facility's RD in the resident's medical record. During a telephone interview on 2/15/2025 at 4:26 p.m., with the facility's current RD, the RD stated that she started working in the facility in October 2024. The RD stated she works onsite in the facility once a week and does remote documentations the rest of the week. The RD stated that she has never assessed and visited Resident 53, and she does not know anything about the resident and her weight loss. During a concurrent interview and record review on 2/15/2025 at 7:00 p.m. with the facility`s Director of Nursing (DON), Resident 53`s SBAR communication Form, nutritional assessments and RD notes were reviewed. The DON stated the RD is required to conduct an assessment for residents who have lost weight. The DON stated the last time the RD assessed and evaluated Resident 53 was on 4/21/2024 before she had a significant weight loss. The DON stated the RD did not perform any nutritional assessments for Resident 53 after she had weight loss on 12/26/2024 and RD was not part of SBAR dated 2/6/2025. The DON stated that the facility had a quick turnover rate for RDs during 06/2024 and 07/2024. The DON stated this might be the reason that there was no assessments or notes developed by RDs to manage Resident 53`s weight loss and all the interventions to prevent weigh loss were initiated by the resident`s physician. The DON stated the potential outcome of RD not assessing residents who lost weight or are at risk for weight loss is the inability to detect, care, and manage resident`s increased weight loss. During an interview on 2/16/2025 at 6:00 p.m., with the Administrator (ADM), the ADM stated that the facility faced challenges to staff contracted RDs to work in the facility since last summer. The ADM stated he is trying his best to ensure there is sufficient and qualified staff with the appropriate competencies and skill sets to carry out food and nutrition services in the facility. The ADM stated Registered Dietitians are required to complete initial and quarterly assessments for all residents, especially residents who have lost weight. The ADM stated RDs are required to access the effectiveness of nutritional interventions developed for the residents. The ADM stated the potential outcome of not having a contracted RD in the facility or changing RDs quickly in the facility is the inability to monitor and access the residents on time and causing unwanted weight loss. During a review of the facility`s Procedure titled Job Description-independent Dietician, last reviewed on 1/15/2025, the job description indicated that the key responsibilities of the dieticians are to conduct comprehensive nutritional assessments for new admission, quarterly reviews, and as needed for residents with significant changes in health status, monitor residents` nutritional progress and adjust care plans as needed, document assessments, care plans, and progress notes in compliance with regulatory standards and advise on therapeutic diets and special dietary modifications. During a review of the facility`s Policy and Procedure (P&P) titled Nutritional Assessment, last reviewed on 1/15/2025, the P&P indicated that all residents would have a nutritional assessment completed within 14 days from admission. All residents are reviewed at least quarterly to update the nutritional assessment, care plan and to document resident changes. Residents at nutritional risk are identified and monitored closely to prevent or minimize deterioration. At risk residents are monitored, at least monthly by the Food Service Supervisor and/or Consultant Dietician. Nutrition interventions to prevent deterioration are selected based on resident`s individual needs. Interventions are periodically evaluated for effectiveness and results documented in the dietary progress note section. Interventions and overall goals are documented in the resident`s care plan and dietary progress notes.

Based on observation, interview, and record review, the facility failed to ensure proper food storage practices by failing to ensure food stored in the facility's dry storage and refrigerator were labeled with an expiration date and opened dated. This deficient practice had the potential to place three of 53 residents who receive food from the facility's kitchen at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). Findings: During a concurrent kitchen observation and interview on 2/15/2025 at 7:30 a.m., with Dietary Supervisor 1 (DS 1) in the facility's kitchen, observed in the dry storage room, one jar of olives without an expiration date and a five (5) pound (lb. - unit of measurement) bag of buttermilk mix without an open date. Observed in the refrigerator, one (1) gallon of regular milk without an open date. DS 1 stated all food items are to be dated upon receipt with month, day and year. DS 1 stated that the jar of olives should have an expiration date, and the milk and buttermilk mix should have an open date to assure that food will be discarded after the expiration date. This deficient practice put facility's resident at risk for foodborne illnesses. During a review of the facility's policy and procedure titled, Recommended Storage Practices, last reviewed on 1/30/2025, the policy indicated in the procedure to Do not store scoops in food containers .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Ensure Licensed Vocational Nurse 4 (LVN 4) washed their hands before administering eye drops to one of five sampled residents (Resident 4). 2. Ensure LVN 4 removed their isolation gown prior to leaving a resident's room for one of five sampled residents (Resident 4) who was on enhanced barrier precautions (EBP - a set of infection control practices that use personal protective equipment [PPE - equipment worn to reduce exposure to hazards in the workplace] to reduce the spread of multidrug-resistant organisms [MDROs - microorganisms that are resistant to multiple classes of antibiotics and antifungals] in nursing homes). 3. Ensure a resident's urinal (a container used to collect urine) was labeled with the resident's name for one of two sample residents (Residents 48). These deficient practices had the potential to cause cross contamination (unintentional transfer of bacteria/germs or other contaminants from one surface to another) and increase the risk of spreading infection to other residents and staff members. Findings: 1. During a review of Resident 4's admission Record, the admission Record indicated that the facility initially admitted Resident 4 on 11/22/2021 and readmitted the resident on 7/2/2023 with diagnoses including gastrostomy (G-tube- a tube inserted through the abdomen that delivers nutrition directly to the stomach), Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), and atrial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate). During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated 1/20/2025, the MDS indicated that the resident had severely impaired cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses). The MDS further indicated that Resident 4 was totally dependent on staff with all activities of daily living (ADLs- activities related to personal care). During a review of Resident 4's Order Summary Report dated 2/2025, the Order Summary Report indicated a physician order for lubricate eye drops solution 0.4-0.3% (eye drops used to treat eye dryness) instill one (1) drop in both eyes two times a day for eye dryness. During a concurrent observation and interview on 2/15/2025 at 5:07 p.m., with LVN 4, observed Resident 4's room with signage that indicated Resident 4 was on EBP. Observed LVN 4 administering medication to Resident 4 via g-tube, then observed LVN 4 not remove their gloves before administering lubricate eye drops solution to Resident 4's eyes. Observed LVN 4 exit Resident 4's room while still wearing an isolation gown. Observed one of LVN 4's gowned arms touch the medication cart. When asked why LVN 4 was still wearing the isolation gown after exiting a resident's room on EBP precautions, LVN 4 stated LVN 4 should have removed the isolation gown before exiting Resident 4's room. LVN 4 stated it is important to follow EBP guidelines to prevent the spread of infection. LVN 4 stated he (LVN 4) should have removed his gloves and washed his hands after administering the g-tube medications and before administering the eye drops to Resident 4. During an interview on 2/15/2025 at 6:25 p.m., with the Infection Preventionist (IP), the IP stated that LVN 4 should have washed their hands before administering eye drops to Resident 4. The IP stated staff who provide care for residents who are on EBP should remove the isolation gown and gloves before leaving a resident's room. The IP stated LVN 4 should have removed the gown before exiting Resident 4's room. The IP stated this was important to prevent the spread of infection. During a review of the facility's policy and procedure titled, Eye Drop Administration, last reviewed on 1/15/2025, the policy indicated to wash hands to administer ophthalmic solution into and around eye in safe and accurate manner. During a review of the facility's policy and procedure titled, Hand Hygiene Program, last reviewed on 1/15/2025, the policy indicated, It is the policy of this facility to promote an environment that minimizes the risk of transmission of bacteria between residents, staff, and visitors. During a review of the facility's policy and procedure titled, Enhanced Barrier Precautions, last reviewed on 1/15/2025, the policy indicated, Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. 2. During a review of Resident 48's admission Record, the admission Record indicated that the facility initially admitted Resident 48 on 9/11/2023 with diagnoses including body myositis (IMB- a muscle disease where muscles gradually weaken over time due to the build-up of abnormal protein clumps inside the muscle fiber), generalized anxiety disorder (persistent and excessive worry that interferes with daily activities), and essential hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]). During a review of Resident 48's MDS dated [DATE], the MDS indicated that the resident had intact cognition. The MDS further indicated that Resident 48 required moderate-to-maximal assistance of one-to-two helpers for showering, toileting and personal hygiene, dressing and chair-to-bed transfer, and was not able to walk. During a review of Resident 48's Care Plan (a document that outlines the actions and interventions needed to address a resident's health and care needs) indicated that Resident 48 was at risk for bladder incontinence (loss of bladder control). The care plan interventions indicated to provide urinal at bedside. During a concurrent observation and interview on 2/14/2025 at 7:12p.m., with the Director of Nursing (DON), Resident 48 was observed lying in the bed with a urinal on the bedside table with no name and room number on it. The DON stated that the urinal should be marked with the resident's name and room number to prevent cross contamination. During an interview on 2/15/2025 at 6:25 p.m., with the IP, the IP stated urinals should be marked with a resident's name to prevent cross contamination.

Based on observation, interview, and record review, the facility failed to ensure call lights (device used by residents that when pressed informs facility staff that assistance is being requested) were within resident's reach while in bed for one of three sampled residents (Resident 27). This deficient practice had the potential to delay the provision of services and resident's needs not being met. Findings: A review of Resident 27's admission Record indicated the facility readmitted the resident on 1/15/2024 with diagnoses that included unspecified dementia (a general term for loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) and unspecified glaucoma (a group of eye conditions that can cause blindness). A review of Resident 27's History and Physical (H&P - a formal assessment of a patient and their problem) dated 2/28/2024 indicated Resident 27 could make needs known but could not make medical decisions. A review of Resident 27's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 3/4/2024, indicated Resident 27's speech is clear. The MDS indicted Resident 27 had severely impaired cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making. The MDS indicated Resident 27 was dependent with eating, oral hygiene, toileting hygiene, and personal hygiene. During an observation on 3/10/2024 at 9:30 a.m., observed Resident 27 on her bed with their bedside table behind them. Observed Resident 27's call light hanging off Resident 27's bedside table and not within reach. During a concurrent observation and interview on 3/10/2024 at 9:45 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 observed Resident 27 and stated Resident 27's call light was not within reach. When asked to describe the location of Resident 27's call light, CNA 1 stated that Resident 27's call light was located behind Resident 27, hanging on her bedside table. When asked where the call light should be, CNA 1 stated that all call lights should be within the resident's reach for their safety. CNA 1 continued to state that the Director of Nursing (DON) said that because Resident 27 does not have the mental capacity to use the call light, it is ok that the call light is not with Resident 27's reach. During an interview on 3/10/2024 at 7:36 p.m., with the Director of Nursing (DON), the DON stated that everyone is assessed to see if they are able to use a call light. If a resident is assessed to not have the ability to use a call light, they care plan it and they anticipate their needs. The DON further stated not everyone needs a call light. A review of the facility-provided policy and procedure titled, Policy & Procedure on Call light, reviewed 1/17/2024, indicated when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse 1 (LVN 1) did not leave residents' electronic medical records (a digital version of a patient's medical history) open on the medication cart (a device used to store, transport, and organize medications and medical equipment) while the cart was left unattended in the hallway for two of two sampled residents (Resident 1 and 54) investigated for privacy and confidentiality. This deficient practice violated the resident's right to privacy. Findings: a. A review of Resident 1's admission Record indicated the facility originally admitted the resident on 4/13/2021 and readmitted the resident on 4/24/2023 with diagnoses including dementia (a general term for loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) and quadriplegia (a symptom of paralysis [complete or partial loss of function] that affects all a person's limbs and body from the neck down). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/16/2024, indicated the resident had severely impaired cognition (a term for the mental processes that take place in the brain) and was dependent on staff for most activities of daily living (ADLs - activities related to personal care). During an observation on 3/9/2024 at 4:48 p.m., observed LVN 1 preparing medications for Resident 1. During a concurrent observation and interview on 3/9/2024 at 4:56 p.m., with LVN 1, LVN 1 stated she needed to find a stethoscope (a medical instrument for listening to the action of someone's heart or breathing). Observed LVN 1 walk away from her medication cart with Resident 1's medical record open on the computer. During an interview on 3/9/2024 at 6:36 p.m., with LVN 1, LVN 1 verified observations by stating she left Resident 1's medical record open on the computer. During an interview on 3/10/2024 at 3:16 p.m., with the Director of Nursing (DON), the DON stated that the nurses should lock the laptop screen before walking away from it to secure the resident's privacy. The DON stated that if the laptop is not locked, then anyone passing by can have unauthorized access to sensitive patient information. A review of the facility's policy and procedure titled, IT Policy: Data Privacy and Security, last reviewed on 1/17/2024, indicated that it was the policy of the facility to ensure the privacy and security of sensitive data within the healthcare organization's IT systems. b. A review of Resident 54's admission Record indicated the facility originally admitted the resident on 2/8/2023 and readmitted the resident on 5/15/2023 with diagnoses including congestive heart failure (a serious condition that occurs when the heart can't pump blood efficiently). A review of Resident 54's MDS, dated [DATE], indicated the resident had moderately impaired cognition and required moderate assistance for most ADLs. During an observation on 3/9/2024 at 5:14 p.m., observed LVN 1 preparing medications for Resident 54. During a concurrent observation and interview on 3/9/2024 at 5:23 p.m., with LVN 1, LVN 1 stated she needed to get a medication from the medication room. Observed LVN 1 walk away from the medication cart with Resident 54's medical record open on the computer. During an interview on 3/9/2024 at 6:36 p.m., with LVN 1, LVN 1 verified observations by stating she left Resident 1's medical record open on the computer. During an interview on 3/10/2024 at 3:16 p.m., with the DON, the DON stated that the nurses should lock the laptop screen before walking away from it to secure the resident's privacy. The DON stated that, if the laptop is not locked, then anyone passing by can have unauthorized access to sensitive patient information. A review of the facility's policy and procedure titled, IT Policy: Data Privacy and Security, last reviewed on 1/17/2024, indicated that it was the policy of the facility to ensure the privacy and security of sensitive data within the healthcare organization's IT systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident's low air loss mattress (LAL - designed to distribute a patient's body weight over a broad surface area and help prevent skin breakdown) was set to the resident's weight per manufacturer's guidelines for one of one sampled resident (Resident 1) investigated for pressure ulcer/injury (a skin and soft tissue injury that occurs when skin is under pressure). This deficient practice placed the resident at risk of discomfort and development of new pressure ulcers. Findings: A review of Resident 1's admission Record indicated the facility originally admitted the resident on 4/13/2021 and readmitted on [DATE] with diagnoses including epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures [sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain]), quadriplegia (a symptom of paralysis [complete or partial loss of function] that affects all a person's limbs and body from the neck down), and gastro esophageal reflux disease (a digestive disease in which stomach acid or bile irritates the food pipe lining). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/16/2024, indicated the resident had severely impaired cognition (the mental process of gaining knowledge and understanding through thought, experience, and the senses) and was totally dependent on staff for bed mobility, transfers, locomotion on the unit, dressing, eating, toilet use, and personal hygiene. A review of Resident 1's physician's order, dated 9/2/2022, indicated to provide a low air loss mattress for skin maintenance. During a concurrent observation and interview on 3/9/2024 at 8:56 p.m., with Licensed Vocational Nurse 2 (LVN 2), observed Resident 1 awake in bed on a LAL mattress. Observed Resident 1's LAL mattress and LVN 2 stated that the setting on the LAL mattress indicated a setting of 350 pounds (lbs., a unit of weight). LVN 2 checked Resident 1's current weight on her medication cart mounted computer, which showed a weight of 169 lbs. as of 3/5/2024. LVN 2 explained that the use of the LAL mattress was for skin management and pressure ulcer prevention. LVN 2 stated an inaccurate weight, and a firm setting may cause skin breakdown and can be uncomfortable for the resident. During a concurrent interview and record review on 03/10/24 at 10:10 a.m., with the Minimum Data Set Coordinator (MDSC), reviewed Resident 1's current weight and Care Plan titled, Potential for Further Impairment to Skin Integrity related to decrease mobility, fragile skin and incontinence, revised on 3/9/2024. The review indicated that Resident 1 weighed 169 lbs. as of 3/5/2024 and the care plan included an intervention to provide a LAL mattress. The MDSC stated the LAL mattress should be set according to the manufacturer's guidelines and if incorrectly set, there is a chance that it will not be effective in preventing skin impairment or skin breakdown. A review of the LAL mattress' Operational Manual undated, indicated that users can adjust the pressure level of the air mattress, using the analog pressure dial, to a desired firmness based on personal comfort or weight setting.

Based on observation, interview and record review, the facility failed to ensure that a resident received continuous oxygen as ordered by the physician for one of three sampled residents (Resident 46). This deficient practice had the potential to result in Resident 46 not receiving the needed oxygen that Resident 46 required. Findings: A review of Resident 46's admission Record indicated the facility admitted the resident on 8/3/2021 with diagnosis that included heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). A review of Resident 46's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 1/18/2024, indicated Resident 46's speech was clear, sometimes made self-understood, and sometimes had the ability to understand others. The MDS indicted Resident 46 had moderately impaired cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making. The MDS indicated Resident 46 required substantial/maximal assistance with eating and oral hygiene and was dependent with toileting hygiene and personal hygiene. A review of Resident 46's Order Summary Report indicated oxygen (O2) inhalation two (2) liters (L- a unit of volume)/minute (LPM) via nasal canula (device used to deliver supplemental oxygen placed directly on a resident's nostrils) continuous to keep O2 saturation (the amount of oxygen that's circulating in the blood) more than 92% (normal reference range 92-100%) due to hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions) secondary to congestive heart failure (CHF- (a chronic condition in which the heart doesn't pump blood as well as it should) every shift, ordered on 12/12/2021. A review of Resident 46's care plan titled, Resident has altered cardiovascular (relating to the heart and blood vessels) status, revised on 2/29/2024 indicated CHF. Under interventions indicated: Oxygen setting- O2 at 2 L/minute via nasal canula continuous to keep O2 saturation >92%. During an observation on 3/9/2024 at 2:28 p.m., observed Resident 46 in bed and not connected to oxygen therapy. During a concurrent observation and interview on 3/10/2024 at 12:06 p.m., with Licensed Vocational Nurse 2 (LVN 2), observed Resident 46 in the dining room. LVN 2 stated that Resident 46 is on her wheelchair in the dining room and does not have an oxygen tank attached to her wheelchair and observed oxygen therapy not connected to Resident 46. During a concurrent interview and record review on 3/10/2024 at 6:07 p.m., with the Minimum Data Set Coordinator (MDSC), reviewed Resident 46's physician's orders. The MDSC stated that Resident 46 had a physician order for O2 inhalation 2 LPM via nasal canula continuous to keep O2 saturation over 92% due to hypoxia secondary to CHF every shift, ordered on 12/12/2021. During a concurrent observation and interview on 3/10/2024 at 6:11 p.m., with the MDSC, observed Resident 46 in the activity room participating in activities. The MDSC stated that Resident 46 does not have oxygen therapy connected. The MDSC stated that Resident 46 should have oxygen therapy on at all times because there is a physician's order for Resident 46 to have continuous oxygen and the oxygen is for her safety. A review of the facility's policy and procedure titled, Oxygen Administration, reviewed on 1/17/2024, indicated it is the policy of this facility that oxygen therapy be administered upon a physician order.

Based on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse 1 (LVN 1) administered a resident's metoprolol (medication that treats high blood pressure [the force of the blood pushing on the blood vessel walls is too high]) with food, as prescribed by the physician for one of five sampled resident (Resident 54). This deficient practice had the potential to place the resident at increased risk of adverse side effects (undesired harmful effect resulting from a medication or other intervention). Findings: A review of Resident 54's admission Record indicated the facility originally admitted the resident on 2/8/2023 and readmitted the resident on 5/15/2023 with diagnoses including congestive heart failure (a serious condition that occurs when the heart can't pump blood efficiently). A review of Resident 54's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/8/2024, indicated the resident had moderately impaired cognition (a term for the mental processes that take place in the brain) and required moderate assistance for most activities of daily living (ADLs - activities related to personal care). During an observation on 3/9/2024 at 5:14 p.m., observed LVN 1 administer the following medications to Resident 54: - Apixaban (medication that prevents blood clots [gel-like clumps of blood]) 2.5 milligrams (mg - unit of measurement) - Furosemide (helps the kidneys produce more urine) 40 mg - Gabapentin (treats neuropathy [nerve condition that can lead to pain, numbness, weakness or tingling in one or more parts of the body] 300 mg - Polyethylene glycol (relieves constipation [problem with passing stool]) 17 grams (gm - unit of measurement) - Sodium chloride (electrolyte replenisher) 1 gm - Docusate sodium (stool softener) 100 mg - Metoprolol 25 mg Observed Resident 54 ingest her medications. Resident 54's dinner tray had not arrived yet. A review of Resident 54's physician's orders indicated to give one tablet of metoprolol 25 mg by mouth two times a day for hypertension (high blood pressure). Hold for systolic blood pressure (SBP, measures the pressure in your arteries [pathway that carries blood away from the heart]) of less than 110 millimeters of mercury (mmHg - unit of measurement). Give with food, ordered on 9/18/2023. During an interview on 3/9/2024 at 6:36 p.m., with LVN 1, LVN 1 verified by stating that she did not administer metoprolol to Resident 54 with food. During an interview on 3/10/2024 at 3:16 p.m., with the Director of Nursing (DON), the DON stated that nurses should administer medications with food if that is what was ordered by the physician. The DON stated the resident can possibly experience adverse side effects such as an upset stomach if the medication is taken without food. A review of the facility's policy and procedure titled, Medication Administration - General Guidelines, last reviewed on 1/17/2024, indicated that medications are administered in accordance with written orders of the attending physician.

Based on observation, interview, and record review, the facility failed to: 1. Ensure Licensed Vocational Nurse 1 (LVN 1) did not leave medications unattended on top of the medication cart (a device used to store, transport, and organize medications and medical equipment) in the hallway when she walked away from it for one of five sampled residents (Resident 54) observed during the medication administration task. This deficient practice placed residents or unauthorized personnel at risk of accessing the medications. 2. Ensure an unopened insulin (hormone that lowers the level of glucose [sugar] in the blood) pen was refrigerated and not placed in the medication cart for one of five sampled residents (Resident 44) investigated under medication storage and labeling. This deficient practice had the potential for the insulin to lose effectiveness and could result in uncontrolled blood glucoses over time. Findings: 1. A review of Resident 54's admission Record indicated the facility originally admitted the resident on 2/8/2023 and readmitted the resident on 5/15/2023 with diagnoses including congestive heart failure (a serious condition that occurs when the heart can't pump blood efficiently). A review of Resident 54's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/8/2024, indicated the resident had moderately impaired cognition (a term for the mental processes that take place in the brain) and required moderate assistance for most activities of daily living (ADLs - activities related to personal care). During an observation on 3/9/2024 at 5:14 p.m., observed LVN 1 administer the following medications to Resident 54: - Apixaban (medication that prevents blood clots [gel-like clumps of blood]) 2.5 milligrams (mg - unit of measurement) - Furosemide (helps the kidneys produce more urine) 40 mg - Gabapentin (treats neuropathy [nerve condition that can lead to pain, numbness, weakness or tingling in one or more parts of the body] 300 mg - Polyethylene glycol (relieves constipation [problem with passing stool]) 17 grams (gm - unit of measurement) - Sodium chloride (electrolyte replenisher) 1 gm - Metoprolol (medication that treats high blood pressure [the force of the blood pushing on the blood vessel walls is too high]) 25 mg During a concurrent observation and interview on 3/9/2024 at 5:23 p.m., with LVN 1, LVN 1 stated she had to get Resident 54's docusate sodium (stool softener) from the medication room. Observed LVN 1 walk away from the medication cart with Resident 54's medications left unattended on top of the cart. During an interview on 3/9/2024 at 6:36 p.m., with LVN 1, LVN 1 confirmed by stating that she had left Resident 54's medications on top of the medication cart unattended. During an interview on 3/10/2024 at 3:16 p.m., with the Director of Nursing (DON), the DON stated that residents' medications should not be left unattended when walking away from the medication cart due to safety reasons. The DON stated that another resident can come along and grab the medications. The DON stated it can be dangerous if they take medications that is not theirs because they can experience adverse side effects (undesired harmful effect resulting from a medication or other intervention). A review of the facility's policy and procedure titled, Medication Administration - General Guidelines, last reviewed on 1/17/2024, indicated that during administration of medications, the medication cart is kept closed, locked, and secured. The medication cart needs to be secured and locked when unattended. 2. A review of Resident 44's admission Record indicated the facility admitted the resident on 6/8/2020 with diagnosis of diabetes mellitus (DM, a chronic condition that affects the way the body processes blood glucose). A review of Resident 44's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 1/22/2024, indicated the resident had severely impaired cognitive skills for daily decision-making. The MDS indicated the resident needed supervision with eating and extensive assistance with bed mobility, transfer, walking, locomotion, dressing, toilet use, and personal hygiene. A review of Resident 44's Order Summary Report indicated a physician's order dated 1/31/2022, to administer Lantus (long-acting insulin) SoloStar Pen-Injector 100 Unit/milliliter (U/ml, a unit of measurement) insulin 50 units subcutaneously (administering medication where a short needle is used to inject a medication into the tissue layer between the skin and the muscle) at bedtime for DM. During an observation of Medication Cart 1 on 3/9/2024 at 9:56 a.m., and a concurrent interview with Licensed Vocational Nurse 3 (LVN 3), observed Resident 44's unopened Lantus SoloStar insulin pen with a delivery date of 2/28/2024. LVN 3 stated that the Lantus insulin pen should be stored in the refrigerator if unopened. During a concurrent interview and record review on 3/9/2024 at 4:09 p.m., with the Minimum Data Set Coordinator (MDSC), reviewed Resident 44's Lantus Solostar insulin pen, which contained a sticker that indicated, Refrigerate until used, once in use, store at room temperature. The MDSC stated that before an insulin pen is to be used, it should be kept in the refrigerator and once it is used, it will be discarded after 28 days. The MDSC stated that following the manufacturer's instructions on storage will maintain the efficacy of the medication. The MDSC stated that an uncontrolled blood sugar level can result to hyperglycemia (high blood sugar which can result in eye damage, kidney problems, and heart disease, among others) which is a complication of diabetes. A review of the facility's policy and procedure titled, Storage of Medications, last revised on 1/17/2024, indicated, Medications and biological are stored safely, securely, and properly, following manufacturer`s recommendations or those of the supplier. A review of the facility-provided Lantus Solostar insulin manufacturer's literature dated 2020, indicated that Lantus Solostar Insulin Pen if unopened, should be refrigerated with temperature range of 36 degrees- 46 degrees Fahrenheit (F, a unit of temperature) until expiration date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During a concurrent interview and record review on 3/10/2024 at 9:45 a.m., with the Infection Preventionist (IP), reviewed the facility's policy and procedure titled, Water Management Program (WMP), Legionella and other harmful waterborne pathogens, revised 4/19/2023. The IP stated she did not in-service (training intended for those actively engaged in a profession or activity) licensed nurses and certified nursing assistants about the facility's policy and procedure on the WMP. The IP stated that she only in-serviced maintenance staff and housekeeping staff. When asked why licensed nurses and certified nursing assistants were not in-serviced, the IP was unable to answer. When asked about the importance of in-servicing licensed nurses and certified nursing assistants about the facility's WMP, the IP stated that all staff should have been in-serviced so that the licensed nurses and certified nursing assistants will be aware of our facility's policy. During an interview on 3/10/2024 at 7:00 p.m., with Licensed Vocational Nurse 4 (LVN 4), LVN 4 was asked if she was in-serviced regarding the facility's WMP policy. LVN 4 stated she was not in-serviced about the facility's WMP policy. When asked if LVN 4 had any knowledge of Legionnaire's disease, LVN 4 stated No what is that? During an interview on 3/10/2024 at 7:04 p.m., with Registered Nurse 1 (RN 1), RN 1 was asked if she was in-serviced regarding the facility's WMP policy. RN 1 stated she was not in-serviced about the facility's WMP policy. When asked if RN 1 had any knowledge of Legionnaire's disease, RN 1 stated she did not have any knowledge of that disease. A review of the facility's policy and procedure titled, Water Management Program (WMP) Legionella and other harmful waterborne pathogens, revised 4/19/2023, indicated the Director of Nursing (DON) and/or IP will in-service staff at least annually on policy and procedure on Facility Water Management Program. Based on observation, interview, and record review, the facility failed to: 1. Ensure Licensed Vocational Nurse 1 (LVN 1) disinfected a blood pressure cuff (an inflatable device that measures blood pressure [the pressure of circulating blood against the walls of blood vessels) before and after medication administration for one of five sampled residents (Resident 54) observed during the medication administration task. This deficient practice placed the resident at increased risk of contracting an infection. 2. Ensure a resident's nasal cannula (a medical device that delivers supplemental oxygen therapy to people with low oxygen levels) oxygen tubing was not touching the floor for one of one sampled resident (Resident 2) investigated for infection control. This deficient practice had the potential to result in contamination of the resident's care equipment and risk of transmission of bacteria that can lead to infection. 3. Implement the facility's Water Management Program policy regarding Legionella (waterborne bacteria). This deficient practice had the potential to place residents at risk for Legionnaire's disease (a severe form of pneumonia [lung inflammation usually caused by infection]). Findings: 1. A review of Resident 54's admission Record indicated the facility originally admitted the resident on 2/8/2023 and readmitted the resident on 5/15/2023 with diagnoses including congestive heart failure (a serious condition that occurs when the heart can't pump blood efficiently). A review of Resident 54's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/8/2024, indicated the resident had moderately impaired cognition (a term for the mental processes that take place in the brain) and required moderate assistance for most activities of daily living (ADLs - activities related to personal care). During an observation on 3/9/2024 at 5:14 p.m., observed LVN 1 preparing medications for Resident 54. Observed LVN 1 take Resident 54's blood pressure. LVN 1 was observed not disinfecting the blood pressure cuff either before or after using it on Resident 54. During an interview on 3/9/2024 at 6:36 p.m., with LVN 1, LVN 1 verified by stating that she did not disinfect the blood pressure cuff before and after using it on Resident 54. During an interview on 3/10/2024 at 3:16 p.m., with the Director of Nursing (DON), the DON stated that resident care equipment should be disinfected before and after each use in order to prevent the spread of infection. The DON stated if disinfection is not done, then infection can potentially spread among residents. A review of the facility's policy and procedure titled, Infection Control, last reviewed on 1/17/2024, indicated it was the policy of the facility to implement infection control measures to prevent the spread of communicable diseases and conditions. Disinfection of soiled surfaces and equipment daily or more frequently by the designated staff member(s) should be done in order to prevent the spread of multi-drug resistant organisms (MDROs - bacteria that are resistant to multiple antibiotics or antifungals) and other pathologic microorganisms (an organism causing disease to its host). 2. A review of Resident 2's admission Record indicated the facility originally admitted the resident on 2/28/2011 and readmitted on [DATE] with diagnoses including dementia (a general term for loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) and chronic kidney disease (a gradual loss of kidney function). A review of Resident 2's MDS dated [DATE], indicated the resident's cognitive skills for daily decision making was moderately impaired. The MDS further indicated that Resident 2 was totally dependent on staff for oral hygiene, toileting hygiene, shower, upper body dressing and lower body dressing. A review of Resident 2's physician's orders dated 12/16/2022, included an order to administer oxygen at two (2) liters per minute (LPM- unit of measurement) via nasal cannula as needed for shortness of breath or if oxygen saturation (the amount of oxygen that's circulating in the blood) is below 93% (normal reference range 92-100%). During a concurrent observation and interview on 3/8/2024 at 7:26 p.m., with Licensed Vocational Nurse 3 (LVN 3), observed Resident 2 sleeping on her bed with the nasal cannula oxygen tubing on the floor. LVN 3 stated oxygen tubing are replaced every two weeks and if not in use, should be placed inside a plastic bag. LVN 3 stated that she would replace the tubing because the nasal cannula oxygen tubing is already contaminated and can potentially introduce infection to the resident if it is used. A review of the Centers for Disease Control and Prevention (CDC, national public health agency) source material, Guidelines for Environmental Infection Control in Health-Care Facilities, updated 7/2019, indicated floors can become rapidly contaminated from airborne microorganisms and those transferred from shoes, equipment wheels, and body substances.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its policy and procedures (P&P) for ensuring the reporting of a reasonable suspicion of a crime in accordance with Section 1150B of the Act by failing to report for one of four sampled residents (Resident 1) the result of the investigation of an injury of unknown origin (the source of the injury was not observed by any person; and the source of the injury could not be explained by the resident; and the injury is suspicious) within five (5) working days of the incident. This deficient practice had the potential to result in delay of necessary actions to oversee the protection of the residents in the facility by CDPH. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 10/11/2021 with diagnoses including dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), psychotic disorder (mental disorder that cause abnormal thinking and perceptions), and repeated falls. A review of Resident 1 ' s History and Physical exam, dated 10/27/2023, indicated Resident 1 did not have the capacity to understand and make decisions due to dementia. A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care-planning tool), dated 8/28/2023, indicated Resident 1 was rarely able to communicate, make needs known, make decisions, and remember. Resident 1 needed extensive assistance from one staff with bed mobility, transfer, dressing, and toilet use. A review of Resident 1 ' s Situation-Background-Assessment-Recommendation Form (SBAR - Communication and Progress Note for Changes in Condition), dated 11/4/2023, indicated that at 11:30 a.m., staff noted Resident 1 to have pain to the left upper arm. Resident 1 ' s physician was informed and ordered to continue monitoring Resident 1 ' s left arm pain. The SBAR further indicated that at 5 p.m. Resident 1 had discoloration and swelling in the inner left upper arm. Resident 1 ' s physician was informed and ordered X-rays (used to generate images of tissues and structures inside the body) of Resident 1 ' s left shoulder and left forearm (the section of the upper limb from the elbow to the wrist). A review of Resident 1 ' s X-ray report dated 11/6/2023, indicated a fracture (broken bone) of the proximal humerus (a long bone located in the upper arm, between the shoulder joint and elbow joint) with age indeterminate (unable to determine when the fracture occurred, it could be new or old). A review of Resident 1 Physician ' s Order on 11/6/2023, indicated to transfer Resident 1 to General Acute Care Hospital 1 (GACH 1) for evaluation and treatment. A review of the facility Transmission Verification Report, dated 11/6/2023, indicated the facility made the initial report of Resident 1 ' s left shoulder injury of unknown origin to the local California Department of Public Health (CDPH) office at 3:35 p.m. The facility did not send a final investigation report to CDPH within five days. On 11/20/2023 at 12:40 p.m., during an interview, the Director of Nursing (DON) was asked about the result of the investigation and evidence it was sent to CDPH. The DON stated the Administrator (ADM) would be the one making the report to CDPH. The DON further stated Resident 1 ' s injury was considered as the injury of unknown origin because the source of injury was not found. During an interview on 11/20/2023 at 1:20 p.m., the ADM stated he should have reported the Five-Day Investigation Summary to the local CDPH office but forgot. A review of the facility ' s policy and procedure (P&P) titled, Prevention, Reporting and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of Residents and Investigation of Injuries of Unknown Origin, revised 1/18/2023, indicated Injuries of Unknown Source - An injury should be considered as an injury of unknown source when both of the following conditions are met: (1) the source of the injury could not be explained by the resident; and (2) the injury is suspicious because of the extent of the injury of the location of the injury. The P&P further indicated, Reporting: The administrator in coordination with Compliance Officer will either verify or report all allegations of abuse or neglect in accordance with state and federal regulations including but not limited to the [NAME] Justice Act.

Based on interview and record review, the facility failed to provide timely radiology service for one of four sampled residents (Resident 1). On 11/4/2023, Resident 1 had pain and swelling on the left upper arm of unknown origin (the source of the injury was not observed by any person; and the source of the injury could not be explained by the resident; and the injury is suspicious); the same day the physician ordered X-rays, but they were not taken until 4/6/2023. This deficient practice resulted in a two-day delay of care and services to treat Resident 1 fracture of the left upper arm. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 10/11/2021 with diagnoses including dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), psychotic disorder (mental disorders that cause abnormal thinking and perceptions), and repeated falls. A review of Resident 1 ' s History and Physical exam, dated 10/27/2023, indicated Resident 1 did not have the capacity to understand and make decisions due to dementia. A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care-planning tool), dated 8/28/2023, indicated Resident 1 was rarely able to communicate, make needs known, make decisions, and remember. Resident 1 needed extensive assistance from one staff with bed mobility, transfer, dressing, and toilet use. A review of Resident 1 ' s Situation-Background-Assessment-Recommendation Form (SBAR - Communication and Progress Note for Changes in Condition), dated 11/4/2023, indicated that at 11:30 a.m., the staff noted Resident 1 had pain to the left upper arm. The physician was informed and ordered at 5 p.m. X-rays (diagnostic machine used to generate images of tissues and structures inside the body) of Resident 1 ' s left shoulder and left arm. A review of Resident 1 ' s physician order dated 11/4/2023 at 4 p.m., indicated, the physician ordered to check an X-ray for Resident 1 ' s left forearm (the section of the upper limb from the elbow to the wrist), and the physician order was further indicated on that day at 9:42 p.m., Resident 1 ' s physician ordered to check the X-ray of Resident1 ' s left shoulder and left upper arm. A review of Resident 1 ' s X-ray report dated 11/6/2023, indicated as follow: On 11/6/2023 the facility received the report indicating Resident 1 had a fracture (broken bone) of the proximal humerus (a long bone located in the upper arm, between the shoulder joint and elbow joint), age indeterminate (unable to determine when the bone broke, it could be new or old). The physician when informed, ordered to transfer Resident 1 to General Acute Care Hospital 1 (GACH 1). On 11/20/2023 at 11:50 a.m., during an interview with Licensed Vocational Nurse 1 (LVN 1) and a concurrent review of the SBAR and nursing notes from 11/4/2023 through 11/6/2023, LVN 1 was asked the reason the X-rays result took two days which delayed the identification of the fracture for two days. LVN 1 stated that the licenses nurses kept calling the radiology company several times, but the X-ray service did not come until two days later, on 11/6/2023. On 11/20/2023 at 12:40 p.m., during an interview, the Director of Nursing (DON) reviewed Resident 1 Physician ' s orders dated 11/4/2023 and X-ray reports. The DON stated the X-rays should have been done within 24 hours from the time of the order. A review of the facility ' s policy and procedure (P&P) titled, Request for Diagnostic Services reviewed on 1/18/2023, indicated, Orders for diagnostic services will be promptly carried out as instructed by the physician ' s order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement infection control policy and procedures by failing to: 1. Ensure residents who tested negative for Coronavirus disease-2019 (COVID-19, a highly contagious viral infection that can trigger respiratory tract infection) were not cohorted (practice of grouping patients infected with the same infectious agent together to confine their care to one area and prevent contact with susceptible patients) in the same room with residents who tested positive for COVID-19 on 7/8/2023 for six (Residents 5, 16, 17, 18, 19, and 20) of 41 residents who tested negative for COVID-19. 2. Ensure three staff members (Certified Nursing Assistant 4 [CNA 4], CNA 5, and CNA 6) performed hand hygiene (a way of cleaning one's hands that substantially reduces potential pathogens [bacteria, virus, or other microorganism that can cause disease] on the hands) before entering and/or after exiting a transmission-based precaution (TBP- measures used to help stop the spread of germs from one person to another) room for five out of 13 sampled residents (Residents 6, 8, 10, 11, 13). 3. Ensure three staff members (CNA 4, CNA 5, and CNA 6) donned (to put on) an isolation gown (used by medical personnel to avoid exposure to blood, body fluids, and other infectious materials) and/or put on gloves before entering an isolation room for three out of 13 sampled residents (Resident 6, 8, and 13). 4. Ensure one staff member (CNA 5) disinfected (to clean something, especially with a chemical, in order to destroy bacteria) patient care equipment between three out of 13 sampled residents (Residents 8, 10, and 11). These deficient practices placed the residents and staff at risk for infection and had the potential to increase the risk of spreading COVID-19 infection throughout the facility. Findings: 1. A review of Resident 5's admission Record indicated the facility admitted the resident on 11/30/2022 with diagnoses including dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 5's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/29/2023, indicated the resident had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required extensive assistance with bed mobility, transfers, and toilet use. A review of Resident 5's progress notes, dated 7/8/2023, indicated the resident tested negative for COVID-19. A review of Resident 16's admission Record indicated the facility admitted the resident on 4/5/2021 with diagnoses including Alzheimer's disease (a brain disorder that causes a decline in memory, thinking, learning, and organizing skills over time). A review of Resident 16's MDS, dated [DATE], indicated the resident had intact cognition and required limited one-person assistance for bed mobility, transfers, walking in the room and in the corridor, dressing, toilet use, and personal hygiene. A review of Resident 16's progress note, dated 7/8/2023, indicated the resident tested negative for COVID-19. A review of Resident 17's admission Record indicated the facility originally admitted the resident on 11/22/2021 and readmitted the resident on 7/2/2023 with diagnoses including encounter for attention to gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food). A review of Resident 17's MDS, dated [DATE], indicated the resident had moderately impaired cognition and required extensive one-person assistance for bed mobility, dressing, eating, toilet use, and personal hygiene. A review of Resident 17's progress notes, dated 7/8/2023, indicated the resident tested negative for COVID-19. A review of Resident 18's admission Record indicated the facility originally admitted the resident on 8/27/2015 and readmitted the resident on 11/17/2015 with diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). A review of Resident 18's MDS, dated [DATE], indicated the resident had moderately impaired cognition and was totally dependent on staff for locomotion on and off the unit and personal hygiene. A review of Resident 18's progress notes, dated 7/8/2023, indicated the resident tested negative for COVID-19. A review of Resident 19's admission Record indicated the facility originally admitted the resident on 4/8/2013 and readmitted the resident on 1/12/2018 with diagnoses including contractures (occurs when your muscles, tendons, joints, or other tissues tighten or shorten causing a deformity) of the upper body and dementia. A review of Resident 19's MDS, dated [DATE], indicated the resident was severely impaired in cognitive skills for daily decision making and was totally dependent on staff for bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. A review of Resident 19's progress notes, dated 7/8/2023, indicated the resident tested negative for COVID-19. A review of Resident 20's admission Record indicated the facility admitted the resident on 2/9/2022 with diagnoses including Alzheimer's disease. A review of Resident 20's MDS, dated [DATE], indicated the resident had severe impairment in cognition and required extensive assistance from staff for bed mobility, transfers, dressing, eating, and personal hygiene. A review of Resident 20's progress notes, dated 7/8/2023, indicated the resident tested negative for COVID-19. During an interview on 7/12/2023 at 1:05 p.m., with the IP, the IP stated that Residents 5, 16, 17, 18, 19, and 20 tested negative for COVID-19 and were kept isolated inside the same room as their roommate who tested positive. During an interview on 7/12/2023 at 1:35 p.m., with the Director of Nursing (DON), the DON stated the COVID-19 negative residents, Residents 5, 16, 17, 18, 19, and 20, were not moved from their rooms, which included COVID-19 positive residents, per their assigned Public Health Nurse's (PHN) guidance. During an interview on 7/12/2023 at 1:45 p.m., with the PHN, the PHN stated she did not advise the facility to leave the COVID-19 positive residents and the COVID-19 negative residents inside the same room. The PHN stated the facility should have created a designated COVID-19 isolation area as soon as any resident tested positive. During an interview on 7/12/2023 at 2:38 p.m., with the DON, the DON stated that, instead of isolating the COVID-19 positive residents from the COVID-19 negative residents, they decided to leave the residents where they were since the residents who tested negative had already been exposed. During a concurrent interview and record review on 7/13/2023 at 11 a.m., with the DON, reviewed the facility's COVID-19 Mitigation Plan last reviewed on 1/18/2023. The facility's mitigation plan indicated Confirmed COVID-19 Case- to isolate residents in a designated COVID-19 isolation area. The DON stated she did not see that guidance but should have been following it. During a concurrent interview and record review on 7/17/2023 at 3:16 p.m., with the IP, reviewed the facility's COVID-19 Mitigation Plan last reviewed on 1/18/2023. The IP stated that, according to the guidance for confirmed COVID-19 cases, the facility should have isolated the residents who tested positive for COVID-19 on 7/8/2023, to a designated COVID-19 isolation area. The IP stated they should have tried to cohort residents who were COVID-19 positive together and exposed residents separately in order to prevent further infections, since COVID-19 is transmitted through the air. When asked if the facility spoke to the residents to discuss possible room changes, the IP stated they did not. A review of the facility's policy & procedure titled, Infection Control, last reviewed on 1/18/2023, indicated it is the policy of the facility to implement infection control measures to prevent the spread of communicable diseases (illness that spread from one person to another or from an animal to a person) and conditions. A review of the facility's policy & procedure titled, Droplet Precautions, last reviewed on 1/18/2023, indicated droplet precautions (used to prevent the spread of pathogens that are passed through respiratory secretions and transmitted through coughing, sneezing, and talking) are designed to reduce the risk of droplet transmission of infectious agents .Place the resident in a private room .When a private room is not available, place the resident in a room with a resident who has active infection with the same microorganism. A review of the facility's policy & procedure titled, Airborne Precautions, last reviewed on 1/18/2023, indicated that microorganisms carried by airborne transmission (spread through coughing, sneezing, laughing, and close personal contact) can be dispersed widely by air currents and may become inhaled by or deposited on a susceptible host within the same room or over a long distance from the source resident, depending on environmental factors .Place the resident in a private room .When a private room is not available, place the resident in a room with a resident who has active infection with the same microorganism. 2. a. A review of Resident 6's admission Record indicated the facility originally admitted the resident on 7/17/2019 and readmitted the resident on 3/11/2022 with diagnoses that included COVID-19 and dementia. A review of Resident 6's MDS, dated [DATE], indicated the resident had moderately impaired cognitive skills for daily decision making and required limited assistance from staff for bed mobility, transfers, walking in the room and in the corridor, locomotion off the unit, and toilet use. During an observation on 7/12/2023 at 12:14 p.m., observed Certified Nursing Assistant 4 (CNA 4) go into a transmission-based precaution (TBP- measures used to help stop the spread of germs from one person to another) room without performing hand hygiene to provide a lunch tray to Resident 6, who was positive for COVID-19. During an interview on 7/12/2023 at 12:47 p.m., with CNA 4, CNA 4 stated he did not perform hand hygiene before entering Resident 6's room. CNA 4 stated he should have performed hand hygiene. During an interview on 7/13/2023 at 3:53 p.m., with the DON, the DON stated that staff should always perform hand hygiene before entering a TBP room. During an interview on 7/17/2023 at 3:16 p.m., with the IP, the IP stated that staff should perform hand hygiene prior to entering a TBP room in order to minimize the spread of COVID-19 among the residents. The IP stated that if staff are not following these protocols, then there is a potential for COVID-19 to spread to residents who have not been infected. A review of the facility's policy and procedure titled, Infection Control, last reviewed on 1/18/2023, indicated it is the policy to implement infection control measures to prevent the spread of communicable diseases and conditions .Standard precautions include contact precautions. Handwashing - before and after resident contact and after removing gloves is the single most effective infection control measure known to reduce the potential for transmission of microorganisms. A review of the facility's policy and procedure titled, Contact Precautions, last reviewed on 1/18/2023, indicated that contact precautions reduce the risk of transmission of microorganisms by direct or indirect contact. Direct-contract transmission involves skin-to-skin contact and physical transfer of microorganisms to a susceptible host from an infected or colonized person, such as occurs when staff members perform resident care activities that require physical contact. Indirect-contact transmission involves contact of a susceptible host with a contaminated intermediate object, usually inanimate, in the resident's room. b. A review of Resident 8's admission Record indicated the facility admitted the resident on 5/2/2023 with diagnoses that included urinary tract infection (UTI - an infection in any part of the urinary system). A review of Resident 8's MDS, dated [DATE], indicated the resident had severely impaired cognition and required extensive assistance from staff for bed mobility, transfers, walking in the corridor, locomotion on and off the unit, dressing, toilet use, and personal hygiene. A review of Resident 10's admission Record indicated the facility admitted the resident on 4/3/2023 with diagnoses that included dementia and Parkinson's disease. A review of Resident 10's MDS, dated [DATE], indicated the resident was severely impaired in cognitive skills for daily decision making and was totally dependent on staff for locomotion on and off the unit and toilet use. The MDS also indicated the resident required extensive assistance from staff for bed mobility, transfers, walking in the corridor, dressing, eating, and personal hygiene. A review of Resident 11's admission Record indicated the facility originally admitted the resident on 9/19/2022 and readmitted the resident on 5/15/2023 with diagnoses including dementia. A review of Resident 11's MDS, dated [DATE], indicated the resident had severely impaired cognitive skills for daily decision making and was totally dependent on staff for locomotion on and off the unit, toilet use, and personal hygiene. The MDS also indicated the resident required extensive assistance from staff for bed mobility, transfers, and dressing. During a concurrent observation and interview on 7/12/2023 at 4 p.m., observed CNA 5 enter Resident 8's TBP room without performing hand hygiene. Observed CNA 5 take Resident 8's blood pressure (measurement of the pressure of circulating blood against the walls of blood vessels). Did not observe CNA 5 perform hand hygiene when he left Resident 8's room. Observed CNA 5 go into Resident 11's room to take their vital signs (measurement of the body's basic functions such as body temperature, heart rate [rate of your heartbeat], respiratory rate [rate of breathing, blood pressure, and oxygen saturation [amount of oxygen circulating in your blood]). Did not observe CNA 5 perform hand hygiene upon exiting Resident 11's room. Upon interview, CNA 5 stated he failed to perform hand hygiene between residents. During an interview on 7/13/2023 at 3:53 p.m., with the DON, the DON stated staff should perform hand hygiene between each resident to prevent cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). During an interview on 7/17/2023 at 3:16 p.m., with the IP, the IP stated that staff should perform hand hygiene prior to entering a TBP room in order to minimize the spread of COVID-19 among the residents. The IP stated that if staff are not following these protocols, then there is a potential for COVID-19 to spread to residents who have not been infected. A review of the facility's policy and procedure titled, Infection Control, last reviewed on 1/18/2023, indicated it is the policy to implement infection control measures to prevent the spread of communicable diseases and conditions .Standard precautions include contact precautions. Handwashing - before and after resident contact and after removing gloves is the single most effective infection control measure known to reduce the potential for transmission of microorganisms. A review of the facility's policy and procedure titled, Contact Precautions, last reviewed on 1/18/2023, indicated that contact precautions reduce the risk of transmission of microorganisms by direct or indirect contact. Direct-contract transmission involves skin-to-skin contact and physical transfer of microorganisms to a susceptible host from an infected or colonized person, such as occurs when staff members perform resident care activities that require physical contact. Indirect-contact transmission involves contact of a susceptible host with a contaminated intermediate object, usually inanimate, in the resident's room. c. A review of Resident 13's admission Record indicated the facility originally admitted the resident on 4/25/2023 and readmitted the resident on 5/17/2023 with diagnoses that included COVID-19 and dementia. A review of Resident 13's MDS, dated [DATE], indicated the resident had severely impaired cognition and was totally dependent on staff for locomotion on and off the unit and toilet use. The MDS also indicated the resident required extensive assistance for bed mobility, transfers, dressing, and personal hygiene. During a concurrent observation and interview on 7/13/2023 at 9:09 a.m., observed CNA 6 go into Resident 13's TBP room without performing hand hygiene. Observed CNA 6 assisting Resident 13 with his breakfast. CNA 6 stated he was assigned to care for residents who were positive for COVID-19. During an observation on 7/13/2023 at 9:17 a.m., observed CNA 6 exiting Resident 13's room and entering again without performing hand hygiene. During an interview on 7/13/2023 at 9:26 a.m., with CNA 6, CNA 6 stated he did not perform hand hygiene before entering Resident 13's room. During an interview on 7/13/2023 at 3:53 p.m., with the DON, the DON stated that staff should always perform hand hygiene before entering a TBP room. During an interview on 7/17/2023 at 3:16 p.m., with the IP, the IP stated that staff should perform hand hygiene prior to entering a TBP room in order to minimize the spread of COVID-19 among the residents. The IP stated that if staff are not following these protocols, then there is a potential for COVID-19 to spread to residents who have not been infected. A review of the facility's policy and procedure titled, Infection Control, last reviewed on 1/18/2023, indicated it is the policy to implement infection control measures to prevent the spread of communicable diseases and conditions .Standard precautions include contact precautions. Handwashing - before and after resident contact and after removing gloves is the single most effective infection control measure known to reduce the potential for transmission of microorganisms. A review of the facility's policy and procedure titled, Contact Precautions, last reviewed on 1/18/2023, indicated that contact precautions reduce the risk of transmission of microorganisms by direct or indirect contact. Direct-contract transmission involves skin-to-skin contact and physical transfer of microorganisms to a susceptible host from an infected or colonized person, such as occurs when staff members perform resident care activities that require physical contact. Indirect-contact transmission involves contact of a susceptible host with a contaminated intermediate object, usually inanimate, in the resident's room. 3. a. A review of Resident 6's admission Record indicated the facility originally admitted the resident on 7/17/2019 and readmitted the resident on 3/11/2022 with diagnoses that included COVID-19 and dementia. A review of Resident 6's MDS, dated [DATE], indicated the resident had moderately impaired cognitive skills for daily decision making and required limited assistance from staff for bed mobility, transfers, walking in the room and in the corridor, locomotion off the unit, and toilet use. During an observation on 7/12/2023 at 12:14 p.m., observed CNA 4 go into a TBP room without donning an isolation gown and gloves to provide a lunch tray to Resident 6, who was positive for COVID-19. During an interview on 7/12/2023 at 12:47 p.m., with CNA 4, CNA 4 stated he should have donned an isolation gown and gloves before entering Resident 6's room. CNA 4 stated he was currently assigned to care for residents negative for COVID-19. During an interview on 7/13/2023 at 3:53 p.m., with the DON, the DON stated that staff should always don the appropriate Personal Protective Equipment (PPE - protective clothing designed to protect the wearer's body from injury or the spread of infection or illness) before entering a TBP room. The DON stated that the purpose of wearing appropriate PPE is to protect the staff and residents from infection. The DON stated that if the appropriate PPE is not worn between resident care, it can cause cross contamination. During an interview on 7/17/2023 at 3:16 p.m., with the IP, the IP stated that staff should don PPE prior to entering a TBP room in order to minimize the spread of COVID-19 among the residents. The IP stated that if staff are not following these protocols, then there is a potential for COVID-19 to spread to residents who have not been infected. A review of the facility's policy and procedure titled, Infection Control, last reviewed on 1/18/2023, indicated it is the policy to implement infection control measures to prevent the spread of communicable diseases and conditions .Standard precautions including contact precautions. Protective barriers: Gloves - put gloves on immediately prior to anticipated contact with blood and other body fluids or when touching surfaces soiled with blood or other body fluids. Gowns - wear gowns when it is anticipated that clothing will become soiled with blood or other body fluids or when contact with soiled surfaces is anticipated. A review of the facility's policy and procedure titled, Contact Precautions, last reviewed on 1/18/2023, indicated that contact precautions reduce the risk of transmission of microorganisms by direct or indirect contact. Direct-contact transmission involves skin-to-skin contact and physical transfer of microorganisms to a susceptible host from an infected or colonized person, such as occurs when staff members perform resident care activities that require physical contact. Indirect-contact transmission involves contact of a susceptible host with a contaminated intermediate object, usually inanimate, in the resident's room. b. A review of Resident 8's admission Record indicated the facility admitted the resident on 5/2/2023 with diagnoses that included urinary tract infection. A review of Resident 8's MDS, dated [DATE], indicated the resident had severely impaired cognition and required extensive assistance from staff for bed mobility, transfers, walking in the corridor, locomotion on and off the unit, dressing, toilet use, and personal hygiene. During a concurrent observation and interview on 7/12/2023 at 4 p.m., observed CNA 5 enter Resident 8's TBP room without donning a gown. Observed CNA 5 take Resident 8's blood pressure. Upon interview, CNA 5 stated he failed to don a gown prior to entering Resident 8's TBP room. During an interview on 7/13/2023 at 3:53 p.m., with the DON, the DON stated that staff should always don a gown before entering a TBP room. The DON stated that the purpose of wearing appropriate PPE is to protect the staff and residents from infection. The DON stated that if the appropriate PPE is not worn between resident care, it can cause cross contamination. During an interview on 7/17/2023 at 3:16 p.m., with the IP, the IP stated that staff should don PPE prior to entering a TBP room in order to minimize the spread of COVID-19 among the residents. The IP stated that if staff are not following these protocols, then there is a potential for COVID-19 to spread to residents who have not been infected. A review of the facility's policy and procedure titled, Infection Control, last reviewed on 1/18/2023, indicated it is the policy to implement infection control measures to prevent the spread of communicable diseases and conditions .Standard precautions including contact precautions. Protective barriers: Gowns - wear gowns when it is anticipated that clothing will become soiled with blood or other body fluids or when contact with soiled surfaces is anticipated. A review of the facility's policy and procedure titled, Contact Precautions, last reviewed on 1/18/2023, indicated that contact precautions reduce the risk of transmission of microorganisms by direct or indirect contact. Direct-contract transmission involves skin-to-skin contact and physical transfer of microorganisms to a susceptible host from an infected or colonized person, such as occurs when staff members perform resident care activities that require physical contact. Indirect-contact transmission involves contact of a susceptible host with a contaminated intermediate object, usually inanimate, in the resident's room. c. A review of Resident 13's admission Record indicated the facility originally admitted the resident on 4/25/2023 and readmitted the resident on 5/17/2023 with diagnoses that included COVID-19 and dementia. A review of Resident 13's MDS, dated [DATE], indicated the resident had severely impaired cognition and was totally dependent on staff for locomotion on and off the unit and toilet use. The MDS also indicated the resident required extensive assistance for bed mobility, transfers, dressing, and personal hygiene. During a concurrent observation and interview on 7/13/2023 at 9:09 a.m., observed CNA 6 go into Resident 13's TBP room without donning a gown. Observed CNA 6 assisting Resident 13 with his breakfast. CNA 6 stated he was assigned to care for residents who were positive for COVID-19. During an observation on 7/13/2023 at 9:17 a.m., observed CNA 6 exiting Resident 13's room and entering again without donning a gown. During an interview on 7/13/2023 at 9:26 a.m., with CNA 6, CNA 6 stated he did not don a gown before entering Resident 13's room. During an interview on 7/13/2023 at 3:53 p.m., with the DON, the DON stated that staff should always don the appropriate PPE before entering a TBP room. The DON stated that the purpose of wearing appropriate PPE is to protect the staff and residents from infection. The DON stated that if the appropriate PPE is not worn between resident care, it can cause cross contamination. During an interview on 7/17/2023 at 3:16 p.m., with the IP, the IP stated that staff should don PPE prior to entering a TBP room in order to minimize the spread of COVID-19 among the residents. The IP stated that if staff are not following these protocols, then there is a potential for COVID-19 to spread to residents who have not been infected. A review of the facility's policy and procedure titled, Infection Control, last reviewed on 1/18/2023, indicated it is the policy to implement infection control measures to prevent the spread of communicable diseases and conditions .Standard precautions including contact precautions. Protective barriers: Gowns - wear gowns when it is anticipated that clothing will become soiled with blood or other body fluids or when contact with soiled surfaces is anticipated. A review of the facility's policy and procedure titled, Contact Precautions, last reviewed on 1/18/2023, indicated that contact precautions reduce the risk of transmission of microorganisms by direct or indirect contact. Direct-contract transmission involves skin-to-skin contact and physical transfer of microorganisms to a susceptible host from an infected or colonized person, such as occurs when staff members perform resident care activities that require physical contact. Indirect-contact transmission involves contact of a susceptible host with a contaminated intermediate object, usually inanimate, in the resident's room. 4. A review of Resident 8's admission Record indicated the facility admitted the resident on 5/2/2023 with diagnoses that included urinary tract infection. A review of Resident 8's MDS, dated [DATE], indicated the resident had severely impaired cognition and required extensive assistance from staff for bed mobility, transfers, walking in the corridor, locomotion on and off the unit, dressing, toilet use, and personal hygiene. A review of Resident 10's admission Record indicated the facility admitted the resident on 4/3/2023 with diagnoses that included dementia and Parkinson's disease. A review of Resident 10's MDS, dated [DATE], indicated the resident was severely impaired in cognitive skills for daily decision making and was totally dependent on staff for locomotion on and off the unit and toilet use. The MDS also indicated the resident required extensive assistance from staff for bed mobility, transfers, walking in the corridor, dressing, eating, and personal hygiene. A review of Resident 11's admission Record indicated the facility originally admitted the resident on 9/19/2022 and readmitted the resident on 5/15/2023 with diagnoses including dementia. A review of Resident 11's MDS, dated [DATE], indicated the resident had severely impaired cognitive skills for daily decision making and was totally dependent on staff for locomotion on and off the unit, toilet use, and personal hygiene. The MDS also indicated the resident required extensive assistance from staff for bed mobility, transfers, and dressing. During a concurrent observation and interview on 7/12/2023 at 4 p.m., observed CNA 5 enter Resident 8's TBP room and placed his paperwork, thermometer, and pulse oximeter (an electronic device that measures oxygen saturation) on the floor while he took Resident 8's blood pressure. Did not observe CNA 5 disinfect the patient care equipment when he left Resident 8's room. Observed CNA 5 go into Resident 10's room to take their vital signs. Did not observe CNA 5 disinfect the patient care equipment before or after interacting with Resident 10. Observed CNA 5 go into Resident 11's room to take their vital signs. Did not observed CNA 5 disinfect the patient care equipment before or after interacting with Resident 11. Upon interview, CNA 5 stated he failed to keep patient care equipment off the floor and failed to disinfect the patient care equipment between use for each resident. During an interview on 7/13/2023 at 3:53 p.m., with the DON, the DON stated staff should disinfect patient care equipment between each resident to prevent cross contamination. During an interview on 7/17/2023 at 3:16 p.m., with the IP, the IP stated that placing patient care equipment on the floor is an infection control issue because the floor can contaminate the patient care equipment. The IP stated that contaminated equipment has the potential to spread microorganisms among residents. The IP stated it was important to disinfect patient care equipment between residents in order to prevent microorganisms from transferring to each resident. A review of the facility's policy and procedure titled, Infection Control, last reviewed on 1/18/2023, indicated it is the policy to implement infection control measures to prevent the spread of communicable diseases and conditions. Disinfection of soiled surfaces and equipment daily or more frequently by the designated staff member should be done in order to prevent the spread of antibiotic resistant microorganisms and other pathologic microorganisms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for two of 18 sampled residents (Resident 22 and 299). This deficient practice had the potential in the residents not being able to summon health care workers for assistance when needed. Findings: A. A review of Resident 22's Face Sheet (admission record) indicated Resident 22 was admitted into the facility on 7/16/2018 with diagnoses that included, Alzheimer's disease (progressive condition in which death of brain cells causes memory loss and decline in cognitive [thinking process] function) and hypertension (elevated blood pressure). A review of Resident 22's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/28/2021, indicated Resident 22's cognitive skills for daily decision making were severely impaired. The MDS further indicated Resident 22 required extensive assistance with dressing, eating, toilet use and was totally dependent on staff for personal hygiene. During an observation, on 5/4/2021 at 8:55 a.m., Resident 22 was observed sitting in his wheelchair next to his bed. The call light was observed on his bed, out of reach. During a concurrent observation and interview, on 5/4/2021 at 9:06 a.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 confirmed Resident 22 is unable to reach his call light since he is not able to move his body. CNA 1 stated that the call light should be placed closer to the resident within reach. During an interview on 5/7/2021, at 1:11 p.m., with the Director of Nursing (DON), DON stated that call lights should be placed within reach for residents with limited range of motion where it is easily accessible. The DON confirmed that the call light should have been placed within easy reach for Residents 22 so that they are able to call staff for assistance if they need help. A review of the facility's policy titled, Answering the Call Light, dated 1/15/2021, indicated, when the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident. b. A review of Resident 299's Face Sheet indicated Resident 299 was admitted into the facility on 4/13/2021 with diagnoses that included, nondisplaced fracture (broken parts of the bone are aligned) of second cervical vertebra (bony ring in neck), epilepsy (disorder associated with sudden recurrent episodes of abnormal electrical activity in the brain), and quadriplegia (paralysis of both legs and both arms). A review of Resident 299's MDS, dated [DATE], indicated that Resident 299 displayed severely impaired cognitive skills for daily decision making. The MDS further indicated that Resident 299 was totally dependent on staff for dressing, eating, toilet use, and personal hygiene. During an observation, on 5/4/2021 at 9:11 a.m., Resident 299 was observed lying in bed with the call light out of reach. The call light was secured using the lamp light string located behind the resident. During a concurrent observation and interview, on 5/4/2021 at 9:19 a.m., with Certified Nursing Assistant 2 (CNA 2), CNA 2 verified the call light was out of reach for Resident 299. CNA 2 had to unfasten the call light and place it within reach of Resident 299. CNA 2 stated the call light is supposed to be next to the residents where they can notify staff if something is happening and call for assistance. During an interview, on 5/7/2021 at 1:11 p.m., with the DON, the DON stated that call lights should be placed within reach for residents with limited range of motion where it is easily accessible. The DON confirmed that the call light should have been placed within easy reach for Residents 299 so that they are able to call staff for assistance if they need help. A review of the facility's policy titled, Answering the Call Light, dated 1/15/2021, indicated, when the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Social Services discussed Advance Directives (a legal document that explains how one wants medical decisions about one to be made if one cannot make the decisions for oneself) or offered to assist residents with formulating an Advance Directive for two (Residents 31 and 7) of seven sampled residents investigated for Advance Directives. This deficient practice violated residents' and/or their representatives' right to be fully informed of the option to formulate an Advance Directive and had the potential to cause conflict due to lack of communication regarding residents' wishes about their medical treatment. Findings: a. A review of Resident 31's admission Record indicated the resident was admitted on [DATE] with a diagnosis of multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves, disrupting communication between the brain and body). A review of Resident 31's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 03/15/2021, indicated the resident was cognitively (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) intact and required limited assistance (resident highly involved in activity, staff provided guided maneuvering of limbs or other non-weight-bearing assistance) from staff for bed mobility, transfers, walking in the room and corridor, toilet use, and personal hygiene. A review of Resident 31's Physician Orders for Life-Sustaining Treatment (POLST - a medical order that tells emergency health care professionals what to do during a medical crisis where the patient cannot speak for him or herself), dated 12/16/2020, indicated the section addressing Advance Directives was left blank. On 05/05/2021 at 3:09 p.m., during a concurrent interview and record review, Social Services Director (SSD) stated that Resident 31 does not have an Advance Directive, and there is no documentation in the resident's medical record that it was discussed with the resident or resident's responsible party upon admission or any time after. On 05/06/2021 at 9:57 a.m., during an interview, the Director of Nursing (DON) stated the purpose of the Advance Directive was that it was the basis for residents' care when they came to a nursing home, and if they had an emergency it would reflect their wishes for treatment. The DON stated the facility would have to follow the Advance Directive if anything should happen to the resident. The DON stated it was the responsibility of the SSD to discuss Advance Directives with residents or family members upon admission. DON stated that if residents do not have one, the SSD should offer to assist them in formulating one. A review of the facility's undated policy and procedures titled, Advanced Directive/POLST, indicated it is the policy of the facility to assure that all residents have the right to a dignified existence and self-determination. The Social Service Department, in conjunction with nursing, will assure that each resident's desires regarding making medical decisions. During the admission process, staff will inquire about an Advance Directive, give information about making medical decisions and inquiring if desire to execute an Advance Directive along with explaining the POLST form with the resident and/or their responsible agent. b. A review of Resident 7's admission Record indicated the resident was admitted on [DATE] with a diagnosis of dementia (a general term for loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) with behavioral disturbance. A review of Resident 7's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 04/19/2021, indicated the resident was moderately impaired (decisions poor; cues/supervision required) in cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making and was totally dependent on staff for transfers, locomotion on and off the unit, toilet use, and personal hygiene. A review of Resident 7's Physician Orders for Life-Sustaining Treatment (POLST - a medical order that tells emergency health care professionals what to do during a medical crisis where the patient cannot speak for him or herself), dated 02/06/2019, indicated in the section addressing Advance Directives that it was discussed with the legally recognized decisionmaker. However, it did not indicate if the resident had an Advance Directive or not. On 05/05/2021, during a concurrent interview and record review, the Social Services Director (SSD) stated the resident did not have an Advance Directive in her medical record, and she could not find any documentation indicating she offered written information to the resident's responsible party in regards to the resident's right to formulate an Advance Directive. On 05/06/2021 at 9:57 a.m., during an interview, the Director of Nursing (DON) stated the purpose of the Advance Directive was that it was the basis for residents' care when they came to a nursing home, and if they had an emergency it would reflect their wishes for treatment. The DON stated the facility would have to follow the Advance Directive if anything should happen to the resident. The DON stated it was the responsibility of the SSD to discuss Advance Directives with residents or family members upon admission. If residents do not have one, the SSD would offer to assist them in formulating one. A review of the facility's undated policy and procedures titled, Advanced Directive/POLST, indicated it is the policy of the facility to assure that all residents have the right to a dignified existence and self-determination. The Social Service Department, in conjunction with nursing, will assure that each resident's desires regarding making medical decisions. During the admission process, staff will inquire about an Advance Directive, give information about making medical decisions and inquiring if desire to execute an Advance Directive along with explaining the POLST form with the resident and/or their responsible agent.

Based on interview and record review, the facility failed to develop and implement individualized plans of care for one of 18 residents (Resident 23) by failing to ensure that Resident 23 had a resident-centered care plan for limited range of motion (measurement of the distance and direction a joint is able to move) of the resident's upper extremities (upper limbs consisting of shoulder, upper arm, elbow, forearm, wrist, hand). This deficient practice had the potential to negatively affect the delivery of care and services to Resident 23. Findings: A review of Resident 23's Face Sheet (admission record) indicated that the facility admitted the resident on 2/17/2015 with diagnosis of bilateral primary osteoarthritis (joint disease in which tissues in the joint break down over time) of knee. A review of Resident 23's Minimum Data Set (an assessment and care screening tool), dated 3/1/2021, indicated that the resident rarely or never made herself understood and rarely or never has the ability to understand others. The MDS further indicated that Resident 23 has impairment and limited range of motion on both sides of her upper (arms) extremities. A review of the physician's order indicated for the restorative nursing assistant (RNA) to perform passive range of motion (someone physically moves or stretches a part of your body) exercises to both upper and lower (legs) extremities daily, three times per week as tolerated, ordered on 6/5/2020. The physician's order further indicated for RNA to apply both elbow splints (a strip of rigid material used for supporting and immobilizing) and a right hand splint daily three times per week as tolerated, ordered on 6/5/2020. During a concurrent interview and record review, on 5/6/2021, at 1:25 p.m., with the Minimum Data Set Coordinator (MDS Coordinator), Resident 23's care plan was reviewed. The MDS Coordinator verified that there was no care plan addressing the limited range of motion for the upper extremities. The MDS Coordinator stated that care plans are reviewed quarterly and a care plan for limited range of motion involving the upper extremities should have been done. The MDS further stated that the purpose of the care plan is to provide care that addresses resident's needs and monitor the interventions for effectiveness. A review of the facility's policy and procedure titled, Care Plan Policy, dated 1/15/2021, indicated, Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative, develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. The policy further indicated, each resident's comprehensive care plan is designed to reflect treatment goals, timetables and objective in measurable outcomes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of the admission Record indicated Resident 299 was admitted to the facility on [DATE] with diagnoses that included non-displaced fracture of second cervical vertebra (a fracture in the spine in which the bone is broken but has not shifted or moved out of position), quadriplegia (paralysis from the neck down, including the trunk, legs, and arms), and encounter for attention to gastrostomy. A review of the MDS, dated [DATE], indicated Resident 299 was severely impaired (never/rarely made decisions) in cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making and was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. On 05/05/2021 at 8:30 a.m., during medication administration observation, LVN 1 disinfected a small pair of scissors and then used the scissors to cut open a docusate sodium medication. LVN 1 proceeded to squeeze the contents of the capsule into a plastic cup. A review of the Order Summary Report indicated Resident 299 had physician's order for Colace capsule 100 milligrams (mg) (docusate sodium) give one capsule via g-tube in the morning for constipation, hold if loose bowel movement (LBM), dated 04/13/2021. During an interview, on 05/06/2021 at 11:17 a.m., the DON stated if the nurse was not able to get the physician to change the order of the medication to a liquid form, the licensed nurses could clean their scissors, cut the gel capsule open, and squeeze the medication out. The DON stated the licensed nurses should call the physician first to try to change the medication to a liquid form. During an interview, on 05/06/2021 at 1:15 p.m., the LVN 2 stated if she came across a gelatin capsule while preparing to administer g-tube medications, she would call the doctor first to see if the form of the medication could be changed to a liquid form. LVN 2 stated it was possible to take a pair of scissors to poke the gel capsule and squeeze the content out, however it was impossible to know if 100% of the medication was retrieved. During an interview, on 05/06/2021 at 2:46 p.m., LVN 1 stated she called the physician to change the order for the docusate sodium to a liquid form. A review of the Handbook of Drug Administration via Enteral Feeding Tubes, indicated in certain circumstances it may be possible to pierce the capsule shell using a pin and squeeze out the contents, however accurate dosing cannot be guaranteed. The volume contained in the capsule can vary depending on the skill of the person expelling the contents; for these reasons this method is unreliable and is not recommended. A review of the facility's policy titled, Medication Administration - General Guidelines, dated 10/2017, indicated medications are administered as prescribed in accordance with good nursing principles and practices. Liquid dosage forms may be a practical alternative in place of solid tablets, especially if tablets have a coating and will not crush finely. The nurse checks with the provider pharmacy to determine if a liquid form is available. Based on observation, interview, and record review, the facility failed to ensure services being provide met professional standards of quality as evidenced by: 1. Resident 6's blood pressure medication, Losartan, was held without a physician's order, for one of four sampled residents. 2. Resident 299's solid form of docusate sodium (stool softener medication) soft gelatin capsules (an oral dosage form for medicine in the form of a specialized capsule consisting of a gelatin based shell surrounding a liquid fill) was changed to a liquid formulation to be administered via gastrostomy tube (g-tube - a tube inserted through the belly that brings nutrition directly to the stomach), for one out of three sampled residents observed during medication administration. These deficient practices had the potential to cause the residents to receive an inaccurate dosage of the medications. Findings: a. During a concurrent medication administration observation and interview, on 5/6/2021 at 9:33 a.m., Licensed Vocational Nurse (LVN 2) took Resident 6's blood pressure. Resident 6's systolic blood pressure (the first number in a blood pressure reading - indicates how much pressure the blood is exerting against the artery walls when the heart beats) was observed to have a measure in the nineties (95). LVN 2 stated she would not be administering the Losartan (a medication to lower blood pressure) and Amlodipine (a medication to lower blood pressure) because Resident 6's blood pressure was too low to give. A review of the admission Record indicated Resident 6 was admitted to the facility, on 2/28/2011, with diagnoses that included stroke, hemiplegia (that results in a varying degree of weakness and lack of control in one side of the body), and hypertension (high blood pressure). A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/24/2021, indicated Resident 6 was moderately impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) in skills required for daily decision making. The MDS indicated Resident 6 required two-person extensive assistance (resident involved in activity, staff provide weight bearing support) with transfer, mobility and dressing. A review of the Physician's Orders indicated the following: Resident 6 was to receive Losartan tablet 50 milligrams (mg) by mouth in the morning for hypertension (HTN, high blood pressure), dated 3/16/2017. Resident 6 was to receive Amlodipine tablet 5 mg by mouth two times a day for HTN, hold if SBP is less than 110, dated 3/17/2017. During a concurrent interview and record review, on 5/06/2021 at 9:53 a.m., LVN 2 stated the two medications were not given on 5/6/2021. LVN 2 stated there was a hold parameter (if the blood pressure was low and needed to not be given as to not decrease the blood pressure to a dangerous level) to hold the Amlodipine tablet if the SBP was less than 110, but there was no hold parameter for the Losartan. LVN 2 stated there should be a hold parameter for Losartan and she would notify the doctor of Resident 6's low blood pressure. LVN 2 stated Resident 6's physician would decide if there needed to be a hold parameter for the Losartan. During an interview, on 5/07/2021 at 9:34 a.m., the Director of Nursing (DON) stated there needed to be a hold parameter for holding a blood pressure medication such as Losartan. The DON stated the physician should make the decision to hold the medication. A review of the facility's policy titled, Medication Orders, dated1/15/21, indicated the prescriber is to be contacted to verify or clarify an order (e.g., there are contraindications to the medication).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. A review of the admission record indicated Resident 45 was admitted to the facility, on 4/2/2021, with diagnoses that included major depressive disorder (mood disorder that causes persistent feeling of sadness and loss of interest) and anxiety. A review of the MDS, dated [DATE], indicated Resident 45 had the ability to make self-understood and to understand others. A review of Resident 45's Physician's Orders indicated an order for Ativan 0.5 mg give by mouth every 12 hours as needed related to anxiety disorder manifested by constant worrying about health decline, ordered on 4/14/2021. The order did not specify an end date. During a concurrent interview and record review on 5/5/2021, at 1:15 p.m., the DON stated there was no end date for Resident 45's Ativan as needed (PRN) order. The DON stated there should be a 14-day duration period for all PRN psychotropic medications including Ativan. The DON further stated if a resident still needed the PRN psychotropic medication after 14 days, the licensed nurse should call the physician and renew the order with the duration period. The DON stated it was important to specify duration for PRN psychotropic medications to ensure that the medications were discontinued if they were no longer necessary. A review of the facility's policy titled, Psychoactive Medications, dated 1/15/2021, did not indicate the requirement for duration of PRN psychotropic medications. Based on interview and record review, the facility failed to ensure three of five residents (Resident 26, 17, and 45) reviewed for unnecessary medications, were free from unnecessary psychotropic medications (medications capable of affecting the mind, emotions, and behavior), by: 1. Failing to ensure Resident 17's have documented rationale for physician disagreeing with the pharmacist's recommendation to do a gradual dose reduction (GDR) for resident's use of Risperdal (an antipsychotic/psychoactive medication, used to treat certain mental/mood conditions). 2. Failing to ensure Resident 26 have documented specific rationale for physician disagreeing with the pharmacist's recommendation to do a GDR for resident's use of Buspar (a psychoactive medication, used to treat certain mental/mood conditions). 3. Failing to ensure Resident 45's Ativan (medication used to treat anxiety [an intense, excessive, and persistent worry or fear about everyday situations]) PRN (as needed) had a 14-day duration. These deficient practices had the potential to result in adverse reaction or impairment in the resident's mental or physical condition. Findings: a. A review of the admission Record indicated Resident 26 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia (brain disease causing memory problems) with behavioral disturbance, generalized anxiety disorder (characterized by persistent and excessive worry about a number of different things), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with one's daily functioning). A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 03/07/2021, indicated Resident 26 was severely impaired in cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required extensive assistance (resident involved in activity, staff provide weight-bearing support) from staff for bed mobility, transfers, walking in the corridor, dressing, toilet use, and personal hygiene. A review of the Order Summary Report, with active orders as of 04/29/2021, indicated an order for buspirone hydrochloride (an antianxiety medication) 10 milligrams (mg) by mouth (PO) two times a day (BID) for anxiety manifested by constant wheeling of wheelchair to dining room and back and going to other resident rooms, ordered on 08/02/2019. A review of Resident 26's care plan indicated the resident had episodes of anxiety manifested by constant wheeling wheelchair to dining room and back interfering with ability to execute activities of daily living (ADLs - a term used to collectively describe fundamental skills that are required to independently care for oneself such as eating, bathing, and mobility) and functioning. The care plan indicated non-pharmacological interventions included to redirect behavior to something positive, attempt to resolve real problems and/or alleviate any related discomfort, encourage resident to be involved in activities, encourage resident to ventilate feelings, and provide reassurance. On 05/04/2021 at 11:54 a.m., Resident 26 was observed awake sitting on her wheelchair in her room. Resident 26 was calm but confused when asked questions. During a concurrent interview and record review, on 05/04/2021, at 4:07 p.m., the Director of Nursing (DON) stated a GDR had not been done for Resident 26's medication (buspirone). During a concurrent interview and record review, on 05/06/2021 at 10:06 a.m., the DON stated that every time there was a recommendation from the pharmacist to do a GDR for buspirone, the psychiatrist disagreed with the recommendation. The DON stated that if medication therapy was to continue, the facility should document risk versus benefit assessment. The DON stated that there was no rationale that of why it should be continued documented in the record. The DON further stated the licensed nurses did not document any non-pharmacological interventions were attempted when the resident exhibited behaviors. b. A review of the admission Record indicated Resident 17 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), major depressive disorder and anxiety disorder. A review of the MDS, dated [DATE], indicated Resident 17 was severely impaired in cognitive skills for daily decision making and required extensive assistance from staff for bed mobility, transfers, locomotion on the unit, dressing, and personal hygiene. A review of Resident 17's Order Summary Report, with active orders as of 04/29/2021, indicated an order for Risperdal tablet (antipsychotic medication-mood altering medication) 0.25 milligram by mouth at bedtime for psychosis manifested by yelling/screaming, ordered on 04/20/2018. A review of Resident 17's care plan indicated the resident had episodes of screaming/yelling related to psychosis. The care plan indicated the non-pharmacological interventions included to assess and anticipate the resident's needs for food, thirst, toileting needs, comfort levels, body positioning, and pain and to redirect the resident. During a concurrent interview and record review, on 05/05/2021 at 4:05 p.m., the Minimum Data Set Nurse (MDSN) stated the resident had been on Risperdal 0.25 mg for psychosis since 09/07/2017. The MDSN stated the resident still had behaviors of yelling and screaming from time to time and had improved. The MDSN stated in 4/2021, the resident only had one episode of yelling/screaming. The MDSN stated the resident's psychiatrist and daughter were both adamant about keeping the resident on Risperdal because her behavioral episodes were so bad before. The MDSN stated the most recent letter they had from the psychiatrist discouraged a GDR and was noted from the year, 2019. The MDSN stated there was no documentation indicating licensed nurses attempted non-pharmacological interventions when the resident exhibited behaviors. During a concurrent interview and record review, on 05/06/2021 at 10:06 a.m., the Director of Nursing (DON) stated the resident had no behavioral episodes of yelling and screaming in February and March 2021. The DON stated she communicated to the psychiatrist to write a rationale for not conducting a GDR for Risperdal. The DON stated that the psychiatrist was against GDR because there would have been negative physical and psychosocial consequences on the resident. The DON stated the only recent documentation the facility had was in regards to the psychiatrist's response to disagreeing with the pharmacist's recommendation. The DON stated the licensed nurses should attempt non-pharmacological interventions when the resident exhibited behaviors. A review of the facility's undated policy titled, Psychoactive Medications, indicated it is the policy of the facility that residents on psychoactive medications are assessed at least quarterly for the effectiveness of interventions and that residents have psychoactive drugs reduced as indicated based on their comprehensive assessment. The Interdisciplinary Team (IDT - involves team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) will ensure that as the plan of care is accelerated for changes in the resident's condition (better or worse) that there are dates with appropriate interventions to show the progression of the plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to properly storage and label medications and biologicals in one of one medication storage rooms (Med Room Nursing Station) and two of two medication carts (Green Med Cart, Pink Med Cart) by: 1. Failing to ensure Resident 38's pneumonia vaccine was discarded following discontinued use. 2. Failing to ensure Resident 300's expired vancomycin liquid bottles (antibiotic medication) were discarded immediately. 3. Failing to ensure Resident 45's opened duoneb (breathing treatment medication) foil was labeled with an open date. 4. Failing to ensure Resident 23's discontinued albuterol nebulizer (breathing treatment medication) was discarded immediately. 5. Failing to ensure opened Humalog insulin (used to treat high blood sugar) was labeled with open date and resident information. 6. Failing to ensure Resident 32's expired tramadol (used to treat moderately severe pain) was discarded immediately. Resident 32 was administered three expired doses. These deficient practices increased the risk that Residents 38, 300, 45, 23, and 32 could have received medication that had become ineffective or toxic due to improper storage or labeling possibly leading to health complications resulting in hospitalization or death. Findings: During a concurrent observation and interview on [DATE] at 2:33 p.m., Licensed Vocational Nurse 2 (LVN 2) confirmed the following inside the refrigerator in the medication storage room: 1. Resident 38's pneumonia vaccine with filled date [DATE] not administered. 2. Resident 300's vancomycin oral 125 milligram (mg-unit of measurement)/2.5 milliliter (ml-unit of measurement) oral liquid. i) lot # 7605577 expiration date [DATE] ii) lot # 163015 expiration date [DATE] iii) lot # 163013 expiration date [DATE] During a concurrent observation and interview on [DATE] at 2:46 p.m., the LVN 2 confirmed the following inside the [NAME] Med Cart: 1. Resident 45's Duoneb fill date [DATE], opened inside foil, and with no open date 2. Resident 23 Albuterol 0.083% inhalation via nebulizer, fill date [DATE], opened inside foil, with no label of open date. LVN 2 stated Resident 23's albuterol treatment is no longer ordered and has been discontinued and should have been removed from the medication cart. During a concurrent observation and interview on [DATE] at 1:10 p.m., the LVN 1 confirmed the following inside the Pink Med Cart: 1. Resident 32's Tramadol 50 milligrams (mg) take 1 tab by mouth every 8 hours as needed for pain management expiration date [DATE]. 2. Humalog insulin opened with no label of date of when it was opened and which resident it belongs to. LVN 1 stated she does not know who the Humalog insulin belongs to. During an interview on [DATE] at 10:40 a.m., the Director of Nursing (DON) stated expired medication should be disposed right away and should not be in the medication cart. During an interview on [DATE] at 10:43 a.m., the DON confirmed Resident 32 was administered three doses of expired tramadol on dates [DATE], [DATE], and [DATE]. DON stated resident was assessed and resident's physician and representative was notified of the error. DON stated the licensed nurse should not have administered the expired tramadol. A review of the facility's policy and procedure titled Medication Labels dated [DATE], indicated medications are labeled in accordance with facility requirement and state and federal laws. Labels are permanently affixed to the outside of the prescription container. A review of the facility's policy and procedure titled Storage of Medications dated [DATE], indicated that medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists.

Based on observation, interview, and record review, the facility failed to ensure the Director of Dietary Services (DDS) labeled opened bags of penne pasta and rotini pasta with the open dates (the date the package was opened) before placing them back on the shelf in the dry storage room. This deficient practice had the potential to cause foodborne illness for 49 residents on oral feeding. Findings: On 05/04/2021 at 8:09 a.m., during the initial tour of the kitchen alongside the Director of Dietary Services (DDS) , observed was an opened bag of penne brown rice pasta and an opened bag of rotini pasta in the dry storage room with no date indicating when they were opened. The DDS confirmed the observation and stated there should be open date written on both the penne pasta and the rotini pasta. DDS stated that the facility staff who opens sealed bags should write an open date. The DDS stated the purpose of labeling the bags with an open date was so the staff can know when they need to be rotated out of the kitchen, to ensure food was fresh. A review of the facility's undated policy and procedures titled, Food Storage, indicated all dry, refrigerated, and frozen items are to be rotated on shelves using the first-in, first-out method. All foods that have been opened and partially used shall be dated and sealed before returning to a storage area.

c. During an observation, on 5/6/2021 at 11:05 a.m., Resident 299 was observed in bed receiving enteral nutrition (tube feeding). The tubing connected to the enteral nutrition bag was observed without a label indicating the date and time of when the tubing was previously changed. During a concurrent observation and interview, on 5/6/2021 at 11:33 a.m., LVN 1 was observed entering Resident 299's room. LVN 1 checked the tubing and verified there was no label on the tubing. LVN 1 stated that the tubing was changed daily along with the enteral nutrition bag by the night shift nurse. LVN 1 confirmed there should have been a label on the tubing with the date and time. During an interview, on 5/6/2021 at 3:20 p.m., the DON stated the licensed nurses were to change the tubing every time the feeding bottle was changed. The DON stated the tubing should be labeled with the date and time of tubing change so staff are aware when it was last changed. A review of the facility's policy titled, Best Practice Guidelines for Tube Feeding, dated 1/15/2021, indicated wash to change container/tubing at least every 24 hours. Based on observation, interview, and record review, the facility failed to implement infection control measures for two of two sampled residents (Resident 49 and Resident 299) investigated under the Infection Control facility task to prevent the spread of infection by: 1. Failing to ensure that facility staff wore an N95 mask (a filtering face piece respirator) PPE (personal protective equipment) while cleaning inside Resident 49's room, designated as a yellow zone (mixed quarantine and symptomatic cohort). 2. Failing to ensure the Licensed Vocational Nurse 1 (LVN 1) disinfected bedside table before place Resident 299's medication for gastrostomy tube (g-tube) medication pass observation. 3.Failing to ensure Resident 299's tube feeding was labeled with the date and time the tubing was changed for the tube feeding. These deficient practices increase the risk for the spread of infection to residents and staff. Findings: a. During an observation on 5/4/2021 at 11:33 a.m., Housekeeping Staff 1 (HSK 1) entered Resident 49's room designated as yellow zone with resident inside. HSK 1 wore face mask while cleaning inside resident's room and restroom. During an interview on 5/4/2021 at 11:43 a.m., HSK 1 stated Resident 49's room was a droplet isolation (precautions used to prevent large particles in the air) room and should wear an N95 mask. HSK staff stated he was wearing a regular face mask and that he should wear an N95 mask. HSK 1 stated he had finished cleaning the resident's room. During an interview on 5/7/21 at 10:38 a.m., the Director of Nursing (DON) stated the facility staff should have worn an N95 instead of face mask as a required PPE in the yellow zone. A review of the Los Angeles County Public Health Guidelines Coronavirus Disease (COVID-19, a highly contagious viral infection that can trigger respiratory tract infection) 2019: Guidelines for Preventing & Managing COVID-19 in Skilled Nursing Facilities updated 4/11/2021 indicated yellow cohort (mixed) required PPE use of N95 should be worn for duration of shift and doffed when contaminated. b.A review of the admission Record indicated Resident 299 was admitted to the facility, on 04/13/2021, with diagnoses that included non-displaced fracture of second cervical vertebra (a fracture in the spine in which the bone is broken but has not shifted or moved out of position), quadriplegia (paralysis from the neck down, including the trunk, legs, and arms), and encounter for attention to gastrostomy (g-tube - an opening into the stomach from the abdominal wall, made surgically for the introduction of food). A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 04/18/2021, indicated Resident 299 was severely impaired (never/rarely made decisions) in cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making and was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. During an observation of medication administration, on 05/05/2021 at 8:53 a.m., Licensed Vocational Nurse 1 (LVN 1) was observed to place a medication tray holding Resident 349's medications and a g-tube syringe on the resident's bedside table without sanitizing the table. During an interview with LVN 1, on 05/05/2021 at 9:09 a.m., she stated the bedside table was cleaned every morning. LVN 1 stated it was good practice to sanitize the bedside table before using it. During an interview, on 05/06/2021 at 11:17 a.m., the Director of Nursing (DON) stated she expected the licensed nurses to first sanitize the resident's bedside table before placing medications and the syringe. The DON stated the purpose of sanitizing the table was to prevent cross contamination and for infection control. The facility's policy titled, Infection Control, indicated it was the policy of the facility to implement infection control measures to prevent the spread of communicable diseases and conditions. Disinfection of soiled surfaces and equipment daily or more frequently by the designated staff member(s) should be done in order to prevent the spread of multidrug resistant organisms (MDRO - microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents) and other pathologic microorganisms.