**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident rights for one resident (Resident 1), were upheld and ensured their right to receive care in a safe environment.This failure resulted in physical harm to Resident 1 by a facility staff employee with the potential to have resulted in serious injury to Resident 1.Findings:During a review of Resident 1's History and Physical (H&P), dated 4/16/2025, the H&P indicated, Resident 1 admitted to the facility on [DATE] due to dementia (a progressive state of decline in mental abilities). Resident 1 had a past medical history of multiple Venous thromboembolism (VTE - is a medical condition where a blood clot forms in blood vessel), chronic kidney disease (CKD - condition where kidneys are damaged progressively and irreversibly), fibromyalgia (a chronic condition characterized by widespread muscle pain and fatigue) and spinal stenosis (a painful condition where the spaces within spine narrow).During an interview on 8/4/2025 at 11:55 AM with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated, he had witnessed on 6/30/2025 at approximately 11:05 PM, Certified Nurse Assistant 2 (CNA 2), forcefully assist Resident 1 to the commode. CNA 1 stated he witnessed CNA 2 become frustrated while assisting Resident 1 to the commode, in which he witnessed CNA 2 manhandle Resident 1 in her armpits and slam her to the commode with aggressive and excessive force.During an interview on 8/4/2025 at 1:39 PM with the Director of Risk Management and Regulatory Affairs (DRM), the DRM stated the facility found CNA 2's behavior to have raised to a level of misconduct due to the rough handling of Resident 1.During a review of Resident 1's document titled California Standard admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities, dated 4/18/2025, the document indicated, Your Rights as a Resident[:] Residents of this Facility keep all their basic rights and liberties as a citizen or resident of the United Stated when, and after, they are admitted . Attachment F, entitled Resident [NAME] of Rights, lists your rights, as set forth in State and Federal law.During a review of the facility's document titled, Attachment F Resident [NAME] of Rights, undated, indicated, Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated . Patients shall have the right . To be free from mental and physical abuse . To be treated with consideration, respect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to enforce for one resident (Resident 1), their own policy and procedures regarding abuse prevention and reporting.This failure resulted in Resident 1 to be in an unsafe environment due to continued exposure to an alleged perpetrator.Findings:During a review of Resident 1's History and Physical (H&P), dated 4/16/2025, the H&P indicated, Resident 1 admitted to the facility on [DATE] due to dementia (a progressive state of decline in mental abilities). Resident 1 had a past medical history of multiple Venous thromboembolism (VTE - is a medical condition where a blood clot forms in blood vessel), chronic kidney disease (CKD - condition where kidneys are damaged progressively and irreversibly), fibromyalgia (a chronic condition characterized by widespread muscle pain and fatigue) and spinal stenosis (a painful condition where the spaces within spine narrow).During an interview on 8/4/2025 at 11:55 AM with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated, he had witnessed on 6/30/2025 at approximately 11:05 PM, Certified Nurse Assistant 2 (CNA 2), forcefully assist Resident 1 to the commode. CNA 1 stated he witnessed CNA 2 become frustrated while assisting Resident 1 to the commode, in which he witnessed CNA 2 manhandle Resident 1 in her armpits and slam her to the commode with aggressive and excessive force.During a review of Resident 1's medical record titled Nursing Note, dated 7/8/2025, the record indicated Resident 1 had a physical assessment completed with no injuries or discoloration noted on her body.During an interview on 8/4/2025 at 1:39 PM with the Director of Risk Management and Regulatory Affairs (DRM), the DRM stated the facility found CNA 2's behavior to have raised to a level of misconduct due to the rough handling of Resident 1.During a concurrent interview and record review, on 8/4/2025 at 12:29 PM with the DON, CNA 2's Employee Timecards, dated multiple dates was reviewed. The timecard indicated, CNA 2 had worked:- On 6/30/2025, from 11:00 PM to 7:30 AM- On 7/2/2025, from 11:00 PM to 7:30 AM- On 7/3/2025, from 11:00 PM to 7:30 AM- On 7/4/2025, from 11:00 PM to 7:30 AM- On 7/6/2025, from 3:00 PM to 11:30 PM and 11:30 PM to 7:23 AM.The DON stated CNA 2 should had been suspended the same day the incident occurred with Resident 1 on 6/30/2025 without any delay. The DON stated that by waiting the facility left Resident 1 exposed to the possibility of further abuse from CNA 2.During a review of the facility's document titled Code of Conduct, undated, the document indicated, Patients and residents shall be treated at all times with care, concern and respect.During a review of CNA 2's document titled Code of Conduct Employee Acknowledgement, dated 12/15/2017, the document indicated, CNA 2 received a copy of the facility's Code of Conduct and acknowledged an understanding to adhere to the Code of Conduct.During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention and Reporting (Suspected Elder and Dependent Adult Abuse and Neglect, dated 3/6/2025, indicated, VIII. Protection[,] During the course of an investigation, the patient and/or resident will be protected from possible harm by the suspected abused. If the suspected abused is an employee, that employee will be suspended.During a review of the facility's P&P titled, Corrective Action Disciplinary Procedures, dated 9/4/2020, indicated, Investigatory Suspension[:] An employee may be placed on a n investigatory leave, with or without notice, to permit [name of facility] to review or investigate actions including . acts endangering patients or others, or other conduct which warrants removing the employee from the work site.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report the alleged abuse incident of one resident (Resident 1), in accordance with facility policy.This failure resulted in delayed investigation of the incident by the state agency and law enforcement that may have a negative impact on the care and treatment received by patient.Findings:During a review of Resident 1's History and Physical (H&P), dated 4/16/2025, the H&P indicated, Resident 1 admitted to the facility on [DATE] due to dementia (a progressive state of decline in mental abilities). Resident 1 had a past medical history of multiple Venous thromboembolism (VTE - is a medical condition where a blood clot forms in blood vessel), chronic kidney disease (CKD - condition where kidneys are damaged progressively and irreversibly), fibromyalgia (a chronic condition characterized by widespread muscle pain and fatigue) and spinal stenosis (a painful condition where the spaces within spine narrow).During an interview on 8/4/2025 at 11:55 AM with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated, he had witnessed on 6/30/2025 at approximately 11:05 PM, Certified Nurse Assistant 2 (CNA 2), forcefully assist Resident 1 to the commode. CNA 1 stated he witnessed CNA 2 become frustrated while assisting Resident 1 to the commode, in which he witnessed CNA 2 manhandle Resident 1 in her armpits and slam her to the commode with aggressive and excessive force.During a review of Resident 1's medical record titled Nursing Note, dated 7/8/2025, the record indicated Resident 1 had a physical assessment completed with no injuries or discoloration noted on her body.During an interview on 8/4/2025 at 1:39 PM with the Director of Risk Management and Regulatory Affairs (DRM), the DRM stated the facility found CNA 2's behavior to have raised to a level of misconduct due to the rough handling of Resident 1.During a concurrent interview and record review, on 8/4/2025 at 12:29 PM with the Director of Nursing (DON), the facility's document titled, Fax, dated 7/8/2025 was reviewed. The document indicated the facility had reported the incident to licensing agency, local law enforcement and ombudsman via fax message on 7/8/2025. The DON stated the facility reported the incident late; she stated the report should have been made to the licensing agency within 24 hours of the incident occurring on 6/30/2025. The DON also stated the facility should have reported this incident to law enforcement via telephone call within 24 hours of the incident occurring on 6/30/2025, in addition to, the faxed written report sent to law enforcement.During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention and Reporting (Suspected Elder and Dependent Adult Abuse and Neglect, dated 3/6/2025, indicated, VI. Reporting/Response . If the suspected abuse does not result in serious bodily injury:1. A telephone report shall be made to the local law enforcement within 24 hours.2. Within 24 hours, a written report shall be made to local ombudsman, corresponding licensing agency (CDPH) and local law enforcement.

Based on interview and record review, the facility failed to ensure the physician or medical provider and resident's responsible party (RP) were notified for one (1) of 1 sampled resident (Resident 20) reviewed under change of condition when Resident 20 had an episode of hypoxia (low level of oxygen [O2 - a colorless and odorless gas that the body needs to work properly] in the body). This deficient practice violated Resident 20's right (including RP) to be informed and a had the potential to result in the delay of care, services and further decline of Resident 20 by failing to notify the provider. Findings: During a review of Resident 20's Face Sheet, the Face Sheet indicated the facility admitted the resident on 9/6/2023. During a review of Resident 20's Clinical Record Abstract, the Clinical Record Abstract indicated Resident 20's diagnoses including dementia (a type of progressive 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), and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During a review of Resident 20's History and Physical (H&P) dated 9/6/2024, the H&P indicated the resident was alert and oriented to full name and location, and was unable to tell the date. During a review of Resident 20's Minimum Data Set (MDS - a resident assessment tool) dated 2/25/2025, the MDS indicated Resident 20 had severely impaired cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) and usually understands others and usually able to make needs known. The MDS indicated Resident 20 required substantial/maximal assistance with bed mobility; total assistance from staff with all other activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 20's physician's order, the physician's order indicated an order dated 6/27/2024 for oxygen via nasal cannula (NC - a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) every eight (8) hours as needed at two (2) liters per minute (L/min - a unit of measurement) for hypoxia. During a review of Resident 20's Nursing Note LTC form completed by Registered Nurse (RN) 4 dated 4/4/2025, the Nursing Note LTC form indicated Resident 20 seen to assess for staff report of hypoxia with O2 saturation level (02 sat- a measurement of how much oxygen the blood is carrying as a percentage) 83 to 85 percent (% - a unit of measurement) on room air and respirations of 30 per minute. The Nursing Note LTC further indicated nasal O2 was applied to resident and titrated (adjusting a dose to achieve a desired outcome) to 1 L/min with O2 sat at 93%. The Nursing Note LTC did not indicate the medical provider and resident's RP were notified of Resident 20's change in condition. During a concurrent interview and record review on 4/11/2025 at 9:16 a.m., reviewed Resident 20's Nursing Note LTC form dated 4/4/2025, physician's orders, and nursing progress notes with RN 4. RN 4 stated she was called to Resident 20's room to assess for staff report of hypoxia with 02 sat 83 to 85 % on room air and respirations of 30 per minute. RN 2 stated she applied nasal O2 to the resident and she was able to titrate down to 1 L/min with O2 sat at 93%. RN 4 stated the Nursing Note LTC did not indicate the medical provider and resident's RP were notified of Resident 20's change in condition. RN 4 stated she did not have to notify the medical provider as Resident 20 had an existing physician's order for oxygen as needed for hypoxia. RN 4 stated the staff are supposed to notify the medical provider or resident's RP for any change in condition. RN 4 stated it violated the Resident 20's RP's right to be notified of the change in condition. RN 4 stated the medical provider should have been notified for further instructions to prevent delay in the care the resident needed. During a concurrent interview and record on 4/11/2025 at 2:05 p.m., reviewed Resident 20's physician's orders, Nursing Note LTC form dated 4/4/2025 and other nursing notes or progress notes with the Director of Long-Term Care (DLTC). The DLTC stated Resident 20 had an order for O2 via NC as needed for hypoxia. The DLTC stated the Nursing Note LTC dated 4/4/2025 indicate Resident 20 had an episode of hypoxia and O2 was applied according to the physician's order but did not indicate the medical provider and resident's responsible party were notified of Resident 20's change in condition. The DLTC stated there was no documentation anywhere in the other nurses' notes that the medical provider and Resident 20's RP were made aware of the change in condition. The DLTC stated if any residents had any change in condition, the medical provider and RP should have been notified so they can be made of the resident's current medical condition per facility policy. The DLTC stated Resident 20's episode of hypoxia was still considered a change in condition, therefore, the medical provider and Resident 20's RP should have been notified as it violated Resident 20's RP right to be informed of the resident's current condition and a possible delay in the provision of care and services the resident need if the medical provider was not notified. During a review of the facility's policy and procedure (P&P) titled, Change in Patient-Resident Status, Notification of Medical Provider, last reviewed on 12/5/2025, the P&P indicated: - The medical provider shall be notified in the event of an incident involving the patient/resident or other significant change in patient's resident's physical, mental, or emotional status. - The patient's/resident's Durable Power of Attorney for Healthcare (DPOAH) or other responsible person(s) shall also be notified. - The medical provider is to be notified of any sudden and/or marked adverse change in signs, symptoms and behavior exhibited by a patient/resident. - Necessary documentation with regard to medical provider notification such as time of attempt to notify, method of notification, name of physician/general nurse practitioner (GNP), reason for the attempt to notify, and the physician/GNP response.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident received care consistent with professional standards of practice to prevent pressure injury (PI - localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) for one (1) of 1 sampled resident (Resident 9) reviewed for pressure injury by failing to perform an accurate assessment of Resident 9's PI on the right buttock. This deficient practice placed Resident 9 at risk for developing pressure injuries and worsening of the current PI. Findings: During a review of Resident 9's Face Sheet, the Face Sheet indicated the facility admitted the resident on 3/30/2022. During a review of Resident 9's Clinical Record Abstract printed on 4/11/2025, the Clinical Record Abstract indicated Resident 39's diagnoses including 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), and abnormalities of gait and mobility. During a review of Resident 9's History and Physical (H&P) dated 3/6/2025, the H&P indicated the resident was alert. During a review of Resident 9's Minimum Data Set (MDS - a resident assessment tool) dated 3/11/2025, the MDS indicated Resident 9 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) but able to understand others and make needs known. The MDS indicated Resident 9 required partial/moderate assistance with eating; total assistance with toileting/hygiene, bathing, and transfers; substantial/maximal assistance with all other activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 9's Wound Care assessment dated [DATE], 4/2/2025, and 4/9/2025, the Wound Care Assessments indicated: - 3/26/2025: Stage 2 PI (partial-thickness loss of skin, presenting as a shallow open sore or wound) right gluteus (also known as buttock). - 4/2/2025: Unstageable PI (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone obscured with yellow or black dead tissue on the wound base) right gluteus. - 4/9/2025: Stage 2 PI right gluteus. During a concurrent interview and record review on 4/11/2025 at 8:45 a.m., reviewed Resident 9's Wound Care Assessments with Registered Nurse (RN) 2. RN 2 stated the Wound Care Assessments indicated Resident 9's PI on the right gluteus dated 3/26/2025 indicated stage 2, 4/2/2025 indicated unstageable PI, and 4/9/2025 indicated stage 2. RN 2 stated wound assessments are completed by the RN weekly and documented in the Wound Care Assessment form. RN 2 stated all wounds should be assessed properly and reverse staging (the practice of incorrectly assigning a lower classification to a wound as it heals) is not an acceptable practice. RN 2 stated Resident 9's Wound Care assessment dated [DATE] should have classified the PI on the right gluteus as healing unstageable PI instead of reverse staging to stage 2. RN 2 stated the purpose of properly assessing a wound was for the facility to ensure that the proper treatments and interventions will be provided to the resident to continue healing the wound and prevent worsening. During a concurrent interview and record review on 4/11/2025 at 9:09 a.m., reviewed Resident 9's Wound Care Assessments with RN 4. RN 4 stated the Wound Care Assessments indicated Resident 9's PI on the right gluteus dated 3/26/2025 indicated stage 2, 4/2/2025 indicated unstageable PI, and 4/9/2025 indicated stage 2. RN 4 stated wound assessments are completed by the RN weekly and documented in the Wound Care Assessment form. RN 4 stated PIs should be assessed properly, and staging cannot be reversed. RN 4 stated she did not see that the Wound Care assessment dated [DATE] indicated that Resident 9's PI was unstageable. RN 4 stated she completed Resident 9's Wound Care assessment dated [DATE] and indicated the PI as classified the PI as stage 2. RN 4 stated she should have classified Resident 9's PI on the right gluteus in the Wound Care assessment dated [DATE] as stage healing unstageable PI instead of stage 2 for the facility to ensure Resident 9 will continue to receive the proper treatments and interventions needed to continue healing the wound and prevent worsening. During a concurrent interview and record review on 4/11/2025 at 3:51 p.m. reviewed Resident 9's Wound Care Assessments with RN 2 and the Director of Long-Term Care (DLTC). The DLTC stated Wound Care Assessments are completed by the RNs weekly for any type of wounds such as PI and should be completed accurately. The DLTC stated the Wound Care Assessments indicated Resident 9's PI on the right gluteus dated 3/26/2025 indicated stage 2, 4/2/2025 indicated unstageable PI, and 4/9/2025 indicated stage 2. The DLTC stated classifying of PIs cannot be reversed. The DLTC stated if a PI is healing, the wound remains at its pervious stage and will just be classified as healing. The DLTC stated Resident 9's Wound Care Assessment should have been completed accurately on 4/9/2025 to indicate that the resident's unstageable PI on the right gluteus as healing instead of reverse staging to a stage 2. The DLTC stated it was important to accurately assess the wounds so the proper treatments and interventions will continue to be provided to the resident for continued healing of the PI and prevent worsening. During a review of the facility's policy and procedure (P&P) titled, LTC Standards of Care Nursing Protocol, last reviewed 3/6/2025, the P&P indicated good documentation practices provide an integrated, real-time method of informing the healthcare team about the resident's status and the care provided. The P&P further indicated that two of the six principles of nursing documentation are accuracy to ensure all documentation is precise and reflects the actual care provided, and completeness to include all the necessary information to provide a comprehensive view of the resident's care. During a review of the facility's P&P titled, Pressure Injury Monitoring, last reviewed on 3/6/2025, the P&P indicated a purpose to provide a comprehensive evaluation for individuals with pressure injury. The P&P further indicated to complete the Initial Pressure Injury/Vascular Wound Record in the electronic health record (EMR), initiate Weekly/Vascular Injury Record and short-term care plan, and include documentation in the weekly summary.

Based on observation, interview, and record review, the facility failed to ensure a residents with a urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) received appropriate care and services to prevent urinary tract infections (UTI, an infection in the bladder/urinary tract) for one (1) of 1 sampled resident (Resident 40) reviewed for urinary catheter or UTI by failing to ensure Resident 40's urinary catheter tubing was anchored to the statlock (a device that secures the catheter in place preventing it from being pulled out or moving around). This deficient practice had the potential for the resident's urinary catheter to be pulled out or move around which may lead to pain, trauma, and catheter blockage. Findings: During a review of Resident 40's Face Sheet, the Face Sheet indicated the facility originally admitted the resident on 9/27/2023 and readmitted the resident on 2/4/2024. During a review of Resident 40's Clinical Record Abstract, the Clinical Record Abstract indicated Resident 40's diagnoses including unspecified dementia (a progressive state of decline in mental abilities), presence of suprapubic catheter (a hollow tube inserted into the bladder through a small incision in the lower abdomen to drain or collect urine), and hypertension (HTN-high blood pressure). During a review of Resident 40's History and Physical (H&P) dated 8/28/2024, the H&P indicated Resident 40 was alert and oriented. During a review of Resident 40's Minimum Data Set (MDS, a resident assessment tool), dated 3/14/2025, the MDS indicated Resident 40 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision or touching assistance with eating; partial/moderate assistance with oral hygiene, bed mobility, and ambulation; substantial/maximal assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS further indicated Resident 40 had indwelling catheter (a type of urinary catheter). During a review of Resident 40's physician's order dated 10/4/2023, the physician's order indicated: - Suprapubic catheter French (FR - a unit of measurement) 16 per 10 milliliters (ml - a unit of measurement). - Suprapubic catheter: Monitor suprapubic catheter site daily every eight hours for any signs and symptoms of infection: redness drainage, fever, increase warmth, feeling of malaise (a feeling of weakness, overall discomfort, illness, or simply not feeling well), increased pain, swelling, and document and notify provider. - Suprapubic catheter every two (2) months: Change every 2 months and as needed for dislodgement, blockage, and bypassing (leaking). During an observation on 4/7/2025 at 9:20 a.m. inside Resident 40's room, observed Resident 40 lying on bed alert, answers appropriately and with the urinary catheter on the right leg attached to a leg bag (a type of urine collection bag that can be attached to the leg for use during the day). Observed statlock attached on the resident's right thigh and the suprapubic catheter was not anchored to the statlock. During a concurrent observation and interview on 4/7/2025 at 9:32 a.m. inside Resident 40's room with Licensed Vocational Nurse (LVN) 3, LVN 3 stated Resident 40 has a statlock on the right thigh and the suprapubic catheter was not anchored to the statlock. LVN 3 stated any type of urinary catheter should be anchored securely to the statlock to keep the catheter stable and prevent from being pulled out or moving causing pain, or trauma. LVN 3 stated Resident 40's suprapubic catheter should have been anchored to the statlock as it placed Resident 40's catheter at risk from being move around and/or pulled causing pain and trauma to the insertion site which may lead to development of UTI. During an interview on 4/11/2025 at 4:30 p.m. with the Director of Long Term Care (DLTC), the DLTC stated the staff are supposed to place a statlock on residents with any type of urinary catheters to keep the catheter stable and prevent form being pulled out or moving which can cause trauma and pain to the resident. The DLTC stated Resident 40's suprapubic catheter should have been anchored securely to the statlock to prevent Resident 40's catheter to be moving around and accidentally pulled out due to movements causing pain and trauma. The DLTC if the catheter is not anchored securely, the movement and pulling out may lead to development of urine infection. During a review of the facility's policy and procedure (P&P) titled, Urinary Catheterization, last reviewed 10/2024, the P&P indicated indwelling catheters should be properly secured after insertion to minimize movement and urethral traction.

Based on observation, interview and record review, the facility failed to ensure medication and biologicals were stored with currently accepted professional standards for one of three sampled residents (Resident 39) reviewed during the Pressure Ulcer / Injury (PI - localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) care area by failing to ensure mupirocin (a topical medication that treats skin infections caused by bacteria) was removed from the One [NAME] Treatment Cart when the medication was discontinued on 2/12/2025. This deficient practice resulted in Licensed Vocational Nurse (LVN) 1 administering the discontinued mupirocin to Resident 39 potentially resulting in a delay or decline in the resident's PI healing process. Cross reference F755 Findings: During a review of Resident 39's Face Sheet, the Face Sheet indicated the facility admitted the resident on 4/18/2018. During a record review of Resident 39's Patient Diagnosis Information, the Patient Diagnosis Information indicated the resident had diagnoses that included neurocognitive disorder with Lewy bodies (a progressive disorder characterized by the gradual decline of thinking and reasoning abilities, often accompanied by movement and sleep disturbances, and visual hallucinations) and PI of the sacral region (lower back at the base of the spine) stage two (partial-thickness loss of skin, presenting as a shallow open sore or wound). During a review of Resident 39's Minimum Data Set (MDS - resident assessment tool) dated 3/14/2025, the MDS indicated the facility most recently admitted the resident on 8/21/2018. The MDS indicated the resident was rarely/never able to understand others and was rarely/never able to make himself understood. The MDS further indicated the resident was dependent on assistance from staff for eating, toileting, bathing, dressing, personal and oral hygiene, and mobility. During a review of Resident 39's Care Plan (CP) titled, Pressure Injury Stage 2 on sacrum related to previous pressure injury on area, incontinence, impaired mobility, initiated 11/25/2024, the CP indicated a goal that the area would heal without complications in the next 120 days. During a review of Resident 39's physician orders, the physician orders indicated the following treatment orders: - Dated 3/26/2025, cleanse PI of the sacrum with wound cleansing spray, gently pat dry, apply maxorb plus silver (an antimicrobial wound dressing), cut to fit wound, cover with opti foam (a type of dressing), change dressing daily. - Dated 1/30/2025 and discontinued (DC'd) on 2/12/2025, mupirocin 2 %, apply ointment 1 dose topically twice a day. cleanse PI of the sacrum with warm cleansing wipes, gently pat dry, apply mupirocin ointment prior to application of moisture barrier cream. Indication: stage 2 pressure injury. During a concurrent observation and interview on 4/10/2025 at 11:30 a.m. with LVN 1, observed Resident 39's wound care treatment in the resident's room. LVN 1 stated the LVNs provide daily wound care for facility residents. LVN 1 gathered the following wound care supplies from the One [NAME] Treatment Cart: mupirocin ointment placed in a clear medication cup, an opti foam dressing, cleansing spray, and the maxorb dressing. LVN 1 entered Resident 39's room with the supplies, cleansed Resident 39's wound, applied the mupirocin ointment to cover the wound, placed the maxorb dressing on top of the mupirocin ointment, then applied the opti foam dressing. Upon completion of the treatment, LVN 1 exited the resident's room. During a follow up observation, interview, and record review on 4/10/2025 at 11:55 a.m. with LVN 1, LVN 1 reviewed Resident 39's physician orders. LVN 1 stated LVN 1 applied mupirocin ointment to Resident 39. LVN 1 stated LVN 1 always applies the mupirocin when providing Resident 39's wound care treatment. LVN 1 then reviewed Resident 39's treatment orders and noted Resident 39 did not have an active order to apply mupirocin. During a concurrent interview and record review on 4/10/2025 at 1:13 p.m. with RN 2, RN 2 reviewed Resident 39's physician orders. RN 2 stated when a medication is discontinued, the pharmacy and the nurse receive a notification to remove the medication from the cart. RN 2 stated Resident 39's mupirocin order was discontinued on 2/12/2025 and the medication should have been removed immediately on 2/12/2025 from the One [NAME] Treatment Cart to ensure the medication was not administered by mistake. During an interview on 4/10/2025 at 2:02 p.m. with LVN 1, LVN 1 stated it is important to remove discontinued medication from the cart to make sure the medication is not administered by mistake and without an order. LVN 1 stated Resident 39's discontinued mupirocin ointment remained in the One [NAME] Treatment Cart and LVN 1 administered the discontinued medication to Resident 39 every day that she worked this week including 4/10/2025, 4/9/2025, 4/8/2025, and 4/7/2025. LVN 1 stated LVN 1 just saw the mupirocin ointment in the cart, grabbed it, and applied it to Resident 39. During a follow up interview on 4/10/2025 at 2:12 p.m. with RN 3, RN 3 stated when the discontinued mupirocin was administered to Resident 39 there was the potential that the PI healing process would be affected causing a delay in healing or a decline in the resident's condition. During a concurrent interview and record review on 4/11/2025 at 11:15 a.m. with the Director of Long Term Care (DLTC), the DLTC reviewed the facility policy and procedure regarding medication administration and medication storage. The DLTC stated medications are discontinued for a reason. The DLTC stated discontinued medication may not be an effective treatment, or a different treatment may be more appropriate. The DLTC stated the nurse who receives the notification that a medication is discontinued is responsible for removing the medication from the cart and discarding the medication, but Resident 39's discontinued mupirocin was not removed. The DLTC stated when a discontinued medication was left in the treatment cart and administered to Resident 39, there was a potential that the mupirocin would have a negative effect on the resident's healing process. The DLTC stated the facility policy was not followed when Resident 39's discontinued mupirocin was not discarded and left in the treatment cart. A review of the facility policy and procedure (P&P) titled, Discontinued Medications, last reviewed 3/2024, the P&P indicated discontinued medications are removed from the nursing stations to prevent the inadvertent administration of discontinued medications. All discontinued medications are returned immediately to the pharmacy for proper disposal. In the event that the pharmacy is closed medications may be given to the Nursing Supervisor for storage in the night locker. All opened, used liquid ointments, lotions, creams, aerosols & powders returned from patient care areas shall be destroyed/disposed of.

Based on interview and record review, the facility failed to reduce the risk of adverse events (an undesirable experience or harm that happens to a patient as a result of medical care), including the development of antibiotic-resistant organisms (occurs when bacteria develop defenses against the antibiotics designed to kill them), from unnecessary or inappropriate antibiotic use for one of three sampled residents (Resident 21) reviewed for antibiotic use by failing to clarify with the ordering physician the appropriate indication of Azithromycin (also known as Zithromax, a type of antibiotic) used as a prophylaxis (an attempt to prevent disease) for pneumonia (an infection/inflammation in the lungs). This deficient practice had the potential to cause adverse side effects and risk for resistance associated with the use of inappropriate antibiotic therapy. Findings: During a review of Resident 21's Face Sheet, the Face Sheet indicated the facility admitted the resident on 11/30/2023. During a review of Resident 21's History and Physical (H&P), dated 11/24/2024, the H&P indicated the resident was awake, alert, pleasant, and cooperative. The H&P indicated the resident had dyslipidemia (an imbalance of lipids [fats] in the blood), chronic recurrent pneumonia (two or more episodes of pneumonia [lung infection] in twelve [12] months or three episodes altogether), and atrial fibrillation (an irregular heartbeat that occurs when the electrical signals in the atria [the two upper chambers of the heart] fire rapidly at the same time). The H&P indicated, per the primary medical doctor, the resident will continue twice weekly azithromycin life-long, and daily prednisone (medication to help relieve swelling, redness, itching, and allergic reactions). During a review of Resident 21's Minimum Data Set (MDS - a resident assessment tool), dated 2/14/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment (a decline in thinking and memory skills that are more noticeable than what's expected for someone of a given age, but not severe enough to interfere significantly with daily life). The MDS indicated the resident was on a high-risk drug class antibiotic. During a review of Resident 21's Active Orders, dated 11/25/2024, the Active Orders indicated an order for azithromycin 250 milligrams (mg - a unit of measurement for mass). Give 250 mg (one tablet) by mouth Monday and Friday per prescriber. Indication: pneumonia prophylaxis. During a review of Resident 21's Plan of Care (POC) with multiple medical conditions, dated 11/30/2023, the CP indicated an intervention of azithromycin (Zithromax) 250 mg. Give 250 mg (1 tablet) by mouth Monday and Friday per prescriber. Indication: pneumonia prophylaxis. During a concurrent interview and record review, on 4/10/2025, at 9:07 a.m., with Registered Nurse (RN) 2, Resident 21's Active Orders, Medication Administration Record (MAR), Progress Notes, and POC were reviewed. RN 2 confirmed and stated there was an order for azithromycin 250 mg 1 tablet by mouth every Monday and Friday for pneumonia prophylaxis. RN 2 stated there was no end date for the antibiotic and the indication is for pneumonia prophylaxis. RN 2 stated she received education from the facility regarding antibiotic use that it should have a stop date and an appropriate indication, if used for a longer period of time, it should have an explanation for its prolonged use. RN 2 stated their antibiotic stewardship program (a coordinated effort to ensure antibiotics are used appropriately and effectively, preventing overuse and misuse) was headed by the pharmacist and the infection prevention nurse (IP) and were responsible for making sure the antibiotics were appropriately used to prevent antibiotic resistance on residents. During a concurrent interview and record review, on 4/10/2024, at 1:20 p.m., with Nurse Practitioner (NP) 1, Resident 21's Active Orders and Progress Notes were reviewed. NP 1 stated azithromycin for pneumonia prophylaxis is very atypical (not normal). NP 1 stated antibiotics should have an end date, and the medication was prescribed by the pulmonologist (a doctor specializing in the diagnosis and treatment of diseases and conditions of the respiratory system, which includes the lungs and airways). NP 1 stated the pharmacist, and the infection preventionist are responsible for making sure the antibiotic is appropriate and had an appropriate indication. NP 1 stated the pulmonologist's notes indicated the resident was having chronic recurrent pneumonia and per the pulmonologist azithromycin will be continued twice weekly for azithromycin life-long. The NP stated she was not aware of which clinical practice guideline they were following regarding the use of azithromycin as a prophylaxis to pneumonia. The NP stated she will contact the provider and get back at the surveyor for which guideline they are following. During an interview, on 4/10/2025, at 2:40 p.m., with the Director of Pharmacy (DP), the DP stated she was aware of Resident 21 having azithromycin as prophylaxis for pneumonia and there should be no end date on the drug order. The DP stated that she had not had any discussion with the prescriber nor the IP nurse regarding its use for prophylaxis. The DP stated that if the IP brought to her attention that the indication was inappropriate, she could have asked the IP to clarify the order with the prescribing physician and asked what clinical practice guideline was used by the ordering physician. The DP stated it was important to ensure antibiotics were reviewed for its appropriate use to prevent antibiotic resistance. During an interview, on 4/11/2024, at 9:09 a.m., with the IP, the IP stated the antibiotic stewardship program starts with the pharmacist receiving the order for antibiotics. The IP stated the pharmacist notifies her when there is a new order for antibiotics. The IP stated when she gets notified of new antibiotics prescribed for residents, she goes to the electronic medical record (EMR) to check the assessment done by NP 1 or physician, she makes sure there is an indication, she checks the laboratory results and uses the Loeb's criteria (a set of minimum signs and symptoms, that indicate a high likelihood of infection in a resident of a long-term care facility, potentially justifying antibiotic treatment even before confirming the infection with diagnostic tests) to check for its appropriateness of antibiotic use. The IP stated the pharmacist does not notify her if the antibiotic is being used for prophylaxis. The IP stated if she was notified of the azithromycin used as prophylaxis for pneumonia, she could have contacted the prescriber and clarified the order because she had a recollection of discussion with a physician that azithromycin is used as a prophylaxis for bronchitis (an inflammation of the bronchial tubes, the airways that carry air to and from the lung) and chronic obstructive pulmonary disease (COPD, a group of lung diseases that cause ongoing inflammation and damage to the airways and air sacs in the lungs) only, aside from that, the order did not have a stop date, and the indication could have been clarified. The IP stated these are the type of issues she brings to Pharmacy and Therapeutics (P&T, a multidisciplinary group responsible for evaluating and recommending policies related to the safe and effective use of medications within the facility) for discussion to seek peer reviews. The IP stated the failure of the pharmacist to communicate the use of the azithromycin as a prophylaxis for pneumonia led to possible antibacterial resistance to resident. During a concurrent interview and record review, on 4/11/2025, at 1 p.m., with NP 1, NP 1 provided an article from American Journal of Translational Research, published on 6/15/2021, which according to NP 1 was provided to her by the prescriber, indicated it can be concluded from this study that azithromycin was effective in the treatment of COPD in patients with acute exacerbation of chronic bronchitis (CB). NP 1 stated there were no mention of the study using azithromycin used as prophylaxis for pneumonia. During an interview, on 4/11/2025, at 1:35 p.m., with the DP, the DP stated she is the first person to get the order, however she did not question the indication of azithromycin for pneumonia prophylaxis given the history of the resident. The DP denied discussing the issue with anybody, and the DP stated the issue should have been brought to P&T for discussion. During an interview, on 4/11/2025, at 3:23 p.m., with the Director of Long-Term Care (DLTC), the DLTC stated the pharmacist should have communicated Resident 21's use of azithromycin as prophylaxis for pneumonia to the IP to clarify why the antibiotic had no stop date and to ensure the indication is appropriate for its use. During a review of the facility's recent policy and procedure (P&P) titled, Antibiotic Stewardship, last reviewed on 6/12/2024, the P&P indicated to provide oversight of all antibiotic prescribing within the Long Term Care unit and the Center for Behavioral Health (CBH). The goals of the program are to reduce the risk of antibiotic resistance, to minimize inappropriate prescribing of antibiotics through the development and application of appropriate provider algorithms and to educate providers, nursing staff and pharmacists on the importance of antibiotic stewardship. When the order is received in the Pharmacy, the processing pharmacist will communicate the following information, via email, to the Infection Control Nurse. a. Patient/Resident Name b. Patient/Resident Location c. Diagnosis d. Drug, dose, route and duration. During a review of the facility-provided Summary of Product Characteristics of Azithromycin dihydrate 200 mg/5 ml Powder for Oral Suspension, dated 5/2024, the Summary of Product Characteristics indicated for treatment of upper and lower respiratory tract infections, skin and soft tissues infections and odontostomatological (refers to the branch of medicine and science that deals with the study of teeth, the mouth, and related structures, including the jaw and face) infections 500 mg per day taken once daily, for 3 consecutive days. The same dosage regimen can be applied to elderly patients. Since elderly patients are more susceptible to developing cardiac arrythmia, particular caution is recommended due to the risk of developing cardiac arrhythmia (a problem with the heart's rhythm) and torsade de pointes (a type of very fast heart rhythm (tachycardia) that originates in the lower chambers of the heart [ventricles]).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents and/or responsible party (RP) were informed in advance, of the risks and benefits of psychoactive medication (a drug that changes brain function and results in alterations in perception, mood, consciousness or behavior) for two of two sampled residents (Residents 21 and 3) reviewed for informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) by failing to ensure: 1. Resident 21's lorazepam (also known as Ativan, a drug that is used to treat anxiety and certain seizure disorders), mirtazapine (also known as Remeron, an antidepressant medicine), escitalopram (also known as Lexapro, a medication used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest] and generalized anxiety disorder [mental health conditions characterized by excessive and persistent worry, fear, and unease that can interfere with daily life]), and gabapentin (also known as Neurontin, a medication that works in the brain to prevent seizures and relieve pain for certain conditions in the nervous system) had informed consents from the resident or representative. 2. Resident 3's escitalopram had informed consent from the resident or representative. These deficient practices violated the residents' right to make an informed decision regarding the use of psychoactive medications. Findings: 1. During a review of Resident 21's Face Sheet, the Face Sheet indicated the facility admitted the resident on 11/30/2023. During a review of Resident 21's History and Physical (H&P), dated 11/26/2024, the H&P indicated the resident was awake, alert, pleasant, and cooperative. The H&P indicated the resident had a history of depression, insomnia (a common sleep disorder that can make it hard to fall asleep or stay asleep), and atrial fibrillation (an irregular heartbeat that occurs when the electrical signals in the atria [the two upper chambers of the heart] fire rapidly at the same time). During a review of Resident 21's Minimum Data Set (MDS - a resident assessment tool), dated 2/14/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had moderate impaired cognition (a person is experiencing significant, noticeable difficulties with thinking and memory, which starts to affect their daily activities). The MDS indicated the resident was taking the following high-risk drug class medications: antianxiety (medications or treatments that help reduce feelings of excessive worry, fear, or anxiety), antidepression (medications used to treat symptoms of depression and other mental health conditions), and anticonvulsant (A type of drug that is used to prevent or treat seizures or convulsions by controlling abnormal electrical activity in the brain) medications. During a review of Resident 21's Active Orders, the Active Orders indicated Resident 21 was ordered the following: On 5/9/2024, gabapentin 600 milligrams (mg - a unit of measurement for mass). Give 600 mg (one [1] tablet) by mouth at bedtime. Indication: anxiety. Monitor for behavior manifested by (m/b) insomnia. On 5/31/2024, escitalopram oxalate 10 mg. Give 10 mg (1 tablet) by mouth at bedtime. Indication: depression m/b verbalize sadness. On 1/6/2025, mirtazapine 15 mg. Give 15 mg (1 tablet) by mouth at bedtime. Indication: depression m/b insomnia and oral intake less than 40 percent (% - a unit of measurement). On 3/20/2025, lorazepam 0.5 mg. Give 0.5 mg (1 tablets) by mouth at bedtime. Please hold if resident is sleepy. Indication: anxiety m/b insomnia. During a review of Resident 21's Plan of Care (POC), dated 11/30/2023, regarding medical conditions, the POC indicated the following interventions: escitalopram oxalate 10 mg by mouth at bedtime, mirtazapine 15 mg by mouth at bedtime, lorazepam 0.5 mg by mouth at bedtime, and gabapentin 600 mg by mouth at bedtime. During a concurrent interview and record review, on 4/10/2025, at 9:31 a.m., with Registered Nurse (RN) 2, Resident 21's Active Orders, Medication Administration Record (MAR), Consents, and POC were reviewed. RN 2 stated she cannot find the consents for psychotropic medications Lexapro, Remeron, Ativan, and Neurontin used for anxiety and sleep. RN 2 stated before administering the medications they need a physician's order, obtain an informed consent from the resident or resident representative discussing the risk and benefits of taking the medications, monitor for adverse effects (an unwanted and harmful result, often caused by a medication, treatment, or procedure) of the medication, and develop and implement a care plan on its use. RN 2 stated it was important to obtain a consent from the resident or representative before administering the medications to honor the resident or representative's right to informed consents and to afford them an opportunity to accept or decline the use of the medications. During an interview, on 4/11/2025, at 3:23 p.m., with the Director of Long-Term Care (DLTC), the DLTC stated the licensed staff should have ensured Resident 21 had a written consent for each psychotropic medications to ensure the resident's right to informed consent is honored. The DLTC stated there should be a physician's order, an informed consent indicating the resident was presented with the risk and benefit, monitoring for adverse effects, and a care plan on psychotropic medication use. During a review of the facility's recent policy and procedure (P&P) titled, Psychotherapeutic Medication/Monitoring/Informed Consent, last approved on 12/5/2024, the P&P indicated when psychotherapeutic drugs are used: 2. Residents will be monitored to determine the drug's effectiveness for the treatment of the stated condition and any adverse reaction. f. Documentation of obtaining informed consent (if new medication or higher dose of current medication). With the exception of antidepressants, written informed consent will be obtained from the resident of the resident's representative after disclosure of the following information: a. Possible nonpharmacologic approaches that could address the resident's needs. b. Whether the drug has a current boxed warning label along with a summary of, and information about how to find, the contraindications, warnings, and precautions required by the United States Food and Drug Administration (FDA). c. Whether the proposed drug is being prescribed for a purpose that has or has not been approved by the United States FDA. d. Possible interactions with other drugs the resident is receiving. e. How the facility and prescriber will monitor and respond to any adverse side effects and inform the resident of side effects. Before prescribing a psychotherapeutic drug: c. The consent requires the signature of the healthcare professional declaring the required material information has been provided. Medical Records: a. The signed written consent must be recorded in the resident's medical record. Renewals of Informed Consent: a. The written informed consent will be renewed every six months. 2. During a review of Resident 3's Face Sheet, the Face Sheet indicated the facility admitted the resident on 11/18/2024. During a review of Resident 3's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had moderate impaired cognition. The MDS indicated the resident was on a high-risk drug class antianxiety and antidepressant medications. The MDS indicated the resident had anxiety disorder, depression, and diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 3's Active Orders, dated 12/5/2024, the Active Orders indicated an order of escitalopram oxalate 20 mg. Give 20 mg (1 tablet) by mouth daily. Indication: depression m/b anxious behavior. During a review of Resident 3's POC regarding the use of psychotropic drug use, dated 11/18/2024, the POC indicated an intervention of escitalopram oxalate (Lexapro) 20 mg daily for depression. During a concurrent interview and record review, on 4/10/2025, at 10:39 a.m., with RN 2, Resident 3's Active Orders, MAR, Consents, and POC were reviewed. RN 2 stated she cannot find the consent for psychotropic medication Lexapro. RN 2 stated before administering the medications they need a physician's order, obtain an inform consent from the resident or resident representative discussing the risk and benefits of taking the medications, monitor for adverse effects of the medication, and develop and implement a care plan on its use. RN 2 stated it was important to obtain a consent from the resident or representative before administering the medications to honor the resident or representative's right to informed consents and to afford them an opportunity to accept or decline the use of the medications. During an interview, on 4/11/2025, at 3:23 p.m., with the DLTC, the DLTC stated the licensed staff should have ensured Resident 3 had a written consent for psychotropic medication to ensure their right to informed consent is honored. The DLTC stated there should be a physician's order, an informed consent indicating the resident was presented with the risk and benefit, monitoring for adverse effects, and a care plan on psychotropic medication use. During a review of the facility's recent P&P titled Psychotherapeutic Medication/Monitoring/Informed Consent, last approved on 12/5/2024, the P&P indicated when psychotherapeutic drugs are used: 2. Residents will be monitored to determine the drug's effectiveness for the treatment of the stated condition and any adverse reaction. f. Documentation of obtaining informed consent (if new medication or higher dose of current medication). With the exception of antidepressants written informed consent will be obtained from the resident of the resident's representative after disclosure of the following information: a. Possible nonpharmacologic approaches that could address the resident's needs. b. Whether the drug has a current boxed warning label along with a summary of, and information about how to find, the contraindications, warnings, and precautions required by the United States Food and Drug Administration (FDA). c. Whether the proposed drug is being prescribed for a purpose that has or has not been approved by the United States FDA. d. Possible interactions with other drugs the resident is receiving. e. How the facility and prescriber will monitor and respond to any adverse side effects and inform the resident of side effects. Before prescribing a psychotherapeutic drug: c. The consent requires the signature of the healthcare professional declaring the required material information has been provided. Medical Records: a. The signed written consent must be recorded in the resident's medical record. Renewals of Informed Consent: a.The written informed consent will be renewed every six months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During a review of Resident 19's Face Sheet, the Face Sheet indicated the facility admitted the resident on 8/7/2024. During a record review of Resident 19's Patient Diagnosis Information, the Patient Diagnosis Information indicated the resident had diagnoses that included dementia, diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), and hyperlipidemia (high cholesterol [a waxy substance that can build up in the blood resulting in stroke or heart issues]). During a review of Resident 19's MDS, dated [DATE], the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated the resident required partial/moderate assistance for oral hygiene and dressing and required substantial/maximal assistance from staff for toileting, bathing, personal hygiene, and transferring from the bed to chair. During a review of Resident 19's Resident Smoking Assessment, dated 11/15/2024, the Resident Smoking Assessment indicated the resident expressed a desire to smoke small cigars again and was assessed by the interdisciplinary team (IDT). The IDT indicated the resident planned to smoke a few times a week with a caregiver present and Resident 19 would need to wear an apron. During a review of Resident 19's CP titled, Smokes Cigars, initiated 11/15/2025, the CP indicated a goal that the resident would comply with the smoking policy and would be assisted with lighting and extinguishing cigars. During a concurrent interview and record review, on 4/9/2025, at 3:58 p.m., with the Minimum Data Set Coordinator (MDSC), Resident 19's Care Plans and Resident Smoking Assessment, dated 11/15/2024, were reviewed. The MDSC stated Resident 19 expressed a desire to smoke after being admitted to the facility. The MDSC stated when a resident expresses a desire to smoke, an initial smoking assessment is completed by the Social Worker (SW) and a personalized CP is developed. The MDSC stated a smoking CP identifies resident specific interventions to ensure the resident complies with the smoking policy. The MDSC stated Resident 19's smoking assessment indicated the resident needs to wear a smoking apron, but Resident 19's CP did not include the use of a smoking apron. The MDSC stated it is important that Resident 19's CP include the intervention of wearing an apron because the CP is used to communicate the resident specific interventions with all the staff. During a concurrent interview and record review, on 4/10/2025, at 9:18 a.m., with the SW, Resident 19's Care Plans and Resident Smoking Assessment, dated 11/15/2024, were reviewed. The SW stated a smoking CP is completed for staff to be able to follow to keep a resident safe while smoking. The SW stated Resident 19 should wear a smoking apron while smoking. The SW stated a smoking CP should include the intervention of wearing an apron, but the SW forgot to add it to Resident 19's CP. The SW stated when the SW forgot to include the use of an apron in Resident 19's CP, there was a potential that the staff may take the resident out to smoke without an apron resulting in a burn injury to Resident 19. During an interview, on 4/11/2025, at 11:15 a.m., with the DLTC, the stated CPs are an individualized plan of care for each resident with different interventions used as guides for the appropriate care to provide. The DLTC stated the smoking apron is important for Resident 19's safety while smoking to prevent burns from falling ashes. The DLTC stated the apron is an intervention that should be in Resident 19's CP, but it was not. The DLTC stated when the use of an apron was not included in Resident 19's CP, the facility P&P were not followed and could have potentially resulted in burns to the resident. During a review of the facility provided P&P titled, Care Plan - Resident, last reviewed 10/2024, the P&P indicated the purpose of the P&P was to ensure a coordinated and comprehensive written plan is developed based on the resident assessment and the individual needs and preferences of the resident. The CP will be person-centered and reflect the needs of the resident. The CP will include the start date, goals, interventions and target date for the next review. During review of the facility provided P&P titled, Resident Smoking, last reviewed 3/6/2025, the P&P indicated any resident that smokes will be assessed to ensure resident is able to smoke safely and to determine if supervision is needed. The smoking assessment will be completed on admission, annually, and with change of condition. Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (CP - is a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting): 1. For two of three sampled residents (Residents 21 and 77) reviewed for care plans by failing to ensure identified problems were specific, grouped together, with individual goals and interventions. 2. For one of seven sampled residents (Resident 19) reviewed under the accidents care area by failing to ensure a comprehensive person-centered Care Plan for smoking was developed and implemented when the smoking CP did not include the use of an apron (a safety device that prevent burns from dropped ashes or smoking materials). These deficient practices had a potential for delay in the delivery of necessary care and services and miscommunication among healthcare providers. Findings: 1. During a review of Resident 21's Face Sheet, the Face Sheet indicated the facility admitted the resident on 11/30/2023. During a review of Resident 21's History and Physical (H&P), dated 11/26/2024, the H&P indicated the resident was awake, alert, pleasant, and cooperative. The H&P indicated the resident had dyslipidemia (means too many lipids [fats] in the blood), chronic recurrent pneumonia (two or more episodes of pneumonia in 12 months or three episodes altogether with radiographic clearance in between), and atrial fibrillation (a common heart condition where the heart's upper chambers [atria] beat irregularly, sometimes too fast, creating a quivering or fluttering sensation). During a review of Resident 21's Minimum Data Set (MDS - a resident assessment tool), dated 2/14/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had moderate impaired cognition (a noticeable but not severe decline in a person's ability to think, remember, and make decisions). The MDS indicated the resident had multiple active diagnoses. During a review of Resident 21's Plan of Care (POC), dated 11/30/2023, the POC indicated a list of all of Resident 21's medical conditions on the first column, and a list of goals on the second column. The list on the second column was not specific to the problems identified as there were multiple problems listed on the first column. The third column contained the interventions, with 89 interventions not organized according to identified problems. During a concurrent interview and record review, on 4/10/2025, at 9:07 a.m., with Registered Nurse (RN) 2, Resident 21's POC, dated 11/30/2023, was reviewed. RN 2 stated the POC written for Resident 21 was complicated to sort out. RN 2 stated the problems/medical diagnosis identified were all on the same column and the interventions were all mixed up with other identified problem interventions. RN 2 stated they have to scroll through multiple pages to check for interventions for a specific problem. RN 2 stated the POC should have one problem per care plan with specific goals and interventions. RN 2 stated the POC written for Resident 21 was disorganized and had the potential for delayed treatment and miscommunication with other healthcare providers. During an interview, on 4/11/2025, at 3:23 p.m., with the Director of Long-Term Care (DLTC), the DLTC stated the POC of Resident 21 should be organized in such a way that it can communicate the problem and interventions to healthcare workers effectively. The DLTC stated a POC should have one problem, with a goal, and interventions specific to the problem. The DLTC stated Resident 21's POC was disorganized, and it will take time for a healthcare worker to go through which interventions will be appropriate for a specific problem as it is mixed in with other problems of the resident which leads to delay of care. During a review of the facility's recent policy and procedure (P&P) titled Care Plan - Resident, last reviewed on 12/5/2024, the P&P indicated to ensure a coordinated and comprehensive written plan is developed based on the resident assessment and the individual needs and preferences of the resident. The care plan will include the start date, goals, interventions and target date for the next review. 2. During a review of Resident 77's Face Sheet, the Face Sheet indicated the facility admitted the resident on 12/27/2023. During a review of Resident 77's H&P, dated 12/17/2024, the H&P indicated the resident was alert and unable to converse. The H&P indicated the resident had Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), frontal lobe dementia (an umbrella term for a group of brain diseases that mainly affect the frontal and temporal lobes of the brain), and major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 77's MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severely impaired cognition (a person has significant difficulty with thinking, memory, and reasoning, to the point where they struggle with everyday activities and may be unable to live independently). The MDS indicated the resident had multiple active diagnoses. During a review of Resident 77's POC, dated 12/27/2023, indicated a list of all of Resident 77's medical conditions on the first column, and a list of goals on the second column. The list on the second column was not specific to the problems identified as there were multiple problems listed on the first column. The third column contained 28 interventions not organized according to identified problem. During a concurrent interview and record review, on 4/10/2025, at 9:07 a.m., with RN 2, Resident 77's POC, dated 12/27/2023, was reviewed. RN 2 stated Resident 77's POC was complicated to sort out. RN 2 stated the problems identified were all on the same column and the interventions were all mixed up with other identified problem interventions. RN 2 stated they have to scroll through multiple pages to check for interventions for a specific problem. RN 2 stated the POC should be one problem per care plan with specific goals and interventions. RN 2 stated the POC written for Resident 77 was disorganized and had the potential for delayed treatment and miscommunication with other healthcare providers. During an interview, on 4/11/2025, at 3:23 p.m., with the DLTC, the DLTC stated the POC of Resident 77 should be organized in such a way that it can communicate the problem and interventions to healthcare workers effectively. The DLTC stated a POC should have one problem, with a goal, and interventions specific to the problem. The DLTC stated the care plan of Resident 77 was disorganized and it will take time for a healthcare worker to go through which interventions will be appropriate for the problem as it is mixed in with other problems of the resident which leads to delay of care. During a review of the facility's recent P&P titled Care Plan- Resident, last reviewed on 12/5/2024, the P&P indicated to ensure a coordinated and comprehensive written plan is developed based on the resident assessment and the individual needs and preferences of the resident. The care plan will include the start date, goals, interventions, and target date for the next review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care in accordance with professional standards of practice by: 1. Failing to ensure residents' scheduled medications were administered as ordered at the scheduled time for two of five sampled residents (Resident 66 and Resident 19) who were reviewed under the Medication Administration facility task. 2. Failing to check a resident's gastrostomy tube (g-tube- a surgical opening fitted with a device to allow feedings to be administered directly to the stomach for people with swallowing problems) placement and patency before administering medications for one of five sampled residents (Resident 86) reviewed under Medication Administration facility task. 3. Failing to flush water in between medications for a resident when g-tube medications were administered for one of five sampled residents (Resident 86) reviewed under Medication Administration facility task. 4. Failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites for one (1) of 1 sampled resident (Resident 10) reviewed for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) These deficient practices had the potential for Resident 86 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have); for Residents 66 and 19's health and well-being to be negatively impacted; and for Resident 10 to experience adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat), and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross reference: F755, F759, and F760 Findings: 1. During a review of Resident 66's Face Sheet (FS- front page of the chart that contains a summary of basic information about the resident), the FS indicated the facility admitted the resident on 8/18/2023. During a review of Resident 66's Clinical Record Abstract (CRA), the CRA indicated Resident 66 had diagnoses including dementia (a progressive state of decline in mental abilities), paraplegia (loss of movement and/or sensation, to some degree, of the legs), and seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of Resident 66's Minimum Data Set (MDS-a resident assessment tool), dated 3/21/2025, the MDS indicated Resident 66 had adequate hearing, clear speech, had the ability to make self understood, and usually understand others. The MDS indicated Resident 66 required substantial assistance with eating and was dependent on staff on functional abilities in mobility. During a review of Resident 66's Orders (physician's orders), the Orders indicated: - carboxymethylcellulose sodium (Refresh Tears-eye drops) 0.5 percent (%-a unit of measurement), take two drops twice a day, indication for irritation or dry eye, dated 9/29/2023. - cetirizine hydrochloride (HCL) (Zyrtec-antihistamine helps relieve allergies), give 10 milligrams (mg-a unit of measurement), give 10 mg (1 tablet) by mouth daily, indication for pruritus (itching), dated 4/9/2024. - Eyelid cleanser (Ocusoft lid scrub), instill one pad into both eyes, twice a day, indication for blepharitis (inflammation of the eyelid), dated 12/6/2024. - lacosamide (Vimpat-antiseizure medication) give 150 mg, one tablet by mouth, twice a day, indication for seizure disorder, dated 8/31/2023. - levetiracetam (Keppra- antiseizure) 500 mg, give 750 mg (1.5 tablets) by mouth, twice a day, indication for seizure disorder, dated 2/8/2024. During a review of Resident 66's Medication Administration Record (MAR-a record of medications administered to residents), for April 2025, the MAR indicated the scheduled time for Resident 66's medications to be given at 9 a.m. included carboxymethylcellulose sodium, cetirizine hydrochloride, eyelid cleanser, lacosamide, and levetiracetam. During a concurrent observation and interview on 4/10/2025 at 7:27 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 prepared the following medications for Resident 66: lacosamide, one tablet (tab); levetiracetam 500 mg, 1.5 tabs; cetirizine 10 mg, one tab; carboxymethylcellulose eye drops; and eyelid cleanser. LVN 1 stated she has a total of 3.5 tablets and one eye drops to give. During an observation and interview on 4/10/2025 at 7:31 a.m. with LVN 1, at Resident 66's bedside, LVN 1 administered 3.5 tablets, and one eye drop medications to Resident 66. LVN 1 stated she completed medication administration for Resident 66. During a concurrent interview and record review on 4/10/2025 at 7:34 a.m. with LVN 1, reviewed Resident 66's MAR for 4/10/2025. LVN 1 stated she cannot sign Resident 66's MAR with the actual time she gave the medications because the system will not allow her until 8 a.m. LVN 1 stated the medications she gave were scheduled at 9 a.m. LVN 1 stated she will continue to pass (administer) medications. During an interview on 4/10/2025 at 7:45 a.m. with LVN 1, LVN 1 stated she has notified Residents 66's nurse practitioner weeks before (does not recall exact date) with regard to the resident's preference to administer the medications earlier than the scheduled time. LVN 1 stated they (licensed nurses) have one hour before and one after from the scheduled time to give the medications. LVN 1 stated she was informed by the nurse practitioner and/or physician (does not recall exactly who) that if the resident continues to request to receive the medications earlier than the scheduled time then the timing will be changed. LVN 1 stated she gave the medications earlier because when Resident 66 was up in the chair, it was difficult to administer the eye drops compared to when the resident is was still on bed. LVN 1 stated she also asked Resident 66 if he would like to receive his medications before the scheduled time and Resident 66 stated he would like to take his medications if they were ready. LVN 1 stated she gives the medications to Resident 66 outside the scheduled time about three times a week but not all the time. During an interview on 4/11/2025 at 11:26 a.m. with the Employee Health Manager (EHM), the EHM stated medications should be administered at the scheduled time and can be administered one hour before or one hour after the scheduled time. The EHM stated LVN 1 should have documented the reason for giving medication early for Resident 66. During an interview on 4/11/2025 at 1:18 p.m. with the Director of Pharmacy (DP), the DP stated their MARs have a built-in one hour before and one hour after (time frames to record medication administration). The DP stated if the medication nurse was unable to sign the MAR of Resident 66, they (licensed nurses) would need to check with the provider (resident's physician) if it is okay to give outside the scheduled time. The DP stated the MAR has specified window of when medications can be given because they do not want to give medications too early or too late. The DP stated she expects the medication nurse (licensed nurse) to notify the provider directly or to let the pharmacy know so they (licensed nurses) can place the order. The DP stated the medication nurse should not give the medication outside of the prescribed time because it is deviating from the current order. The DP stated all medications administered should be documented on the MAR and reflect the actual time it was given. During an interview on 4/11/2025 at 5:17 p.m. with the Director of Long-Term Care (DLTC), the DLTC stated medications should be given at the scheduled time. The DLTC stated when medications are not given at the scheduled time, Resident 66 may not get the full effect and may have potential drug interactions. The DLTC stated the medication nurse is expected to clarify with the provider regarding the timing of the medication of Resident 66 and document the communication with the provider. During a review of the facility's P&P titled, General Administrative, last reviewed 3/2024, the P&P indicated the purpose its policy to provide a safe and efficient medication distribution system which shall include the evaluation, selection, purchase, storage, control, dispensing and administration of all drugs, chemicals and pharmaceuticals used throughout the Motion Picture and Television Fund Hospital (MPTF) organization. The P&P indicated that All medications administered to patients must be first ordered by a physician on the MPTF medical staff or an individual who has been granted clinical privileges. Each dose of medication shall be accurately recorded in the patient's medical record. During a review of the facility's P&P titled, Medication Administration, last reviewed 12/5/2024, the P&P indicated Medication shall be accurately and safely administered to MPTF patients/resident by authorized personnel. The procedure P&P indicated the licensed nurses to Sign the eMAR after administration or non-administration of all medications. The P&P indicated the six (6) Rights of Safe Medication Administration are Right Medication, Right Dose, Right Patient/Resident, Right Route, Right Time, and Right Documentation. The P&P indicated the physician's order must include the date and time of the order, name of medication, dose, frequency, route, indication, duration, if appliable, and diagnosis. 2. During a review of Resident 19's FS, the FS indicated the facility admitted the resident on 8/7/2024. During a review of Resident 19's CRA, the CRA indicated Resident 19 had diagnoses including dementia, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and constipation (a problem with passing stool). During a review of Resident 19's MDS, dated [DATE], the MDS indicated Resident 19 had minimal difficulty hearing, clear speech, had the ability to make self understood and understand others. The MDS indicated Resident 19 required staff assistance with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) and mobility. During a review of Resident 19's Orders, the Orders indicated the following: - donepezil HCL (Aricept-used to treat dementia), give 5 mg, one tablet by mouth daily, indication for dementia, dated 8/7/2024. - gabapentin (Neurontin- nerve pain medication), give 100 mg, one capsule by mouth, twice a day, indication for depression m/b refusing and resistance to care, dated 12/24/2024. - metformin extended release (Glucophage Extended Release- medication that helps lower high blood sugar) 500 mg, give 1000 mg (two tablets) by mouth, twice a day, indication for diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), dated 8/7/2024. - pantoprazole (Protonix- decreases amount of acid produced in the stomach) 40 mg, give 40 mg, one tablet by mouth, daily, indication for gastroesophageal reflux disease (GERD- a condition in which the stomach contents move up into the esophagus), dated 8/7/2024. - polyethylene glycol 3350 (Miralax- used to treat constipation) 15 grams (g-a unit of measurement)/dose, give 17 g (one powder) by mouth daily, mix with eight (8) ounces (oz- a unit of measurement) of liquid or juice, indication for constipation, dated 8/7/2024. - solifenacin succinate (Vesicare- used to treat overactive bladder [OAB- a problem with bladder (organ that stores urine before leaving the body) function that causes the sudden need to urinate]) 5 mg, give 5 mg (one tablet) by mouth, daily, indication for OAB, dated 2/21/2025. During a review of Resident 19's MAR, for April 2025, the MAR indicated the scheduled time for Resident 19's medications to be given at 9 a.m. on 4/10/2025 included donepezil HCL, gabapentin, metformin extended release, pantoprazole, polyethylene glycol 3350, and solifenacin. During a concurrent observation and interview on 4/10/2025 at 7:37 a.m. with LVN 1, LVN 1 prepared Resident 19's including medications: pantoprazole 40 mg, one tab; metformin 500 mg, two tabs; gabapentin 100 mg, one capsule; solifenacin 5 mg, one tab; donepezil 5 mg, one tab; polyethylene glycol 17 g. LVN 1 stated she will administer a total of eight medications with seven tablets and one powder. LVN 1 stated she will separate buspirone and gabapentin into a separate medication cup because Resident 19 usually does not want to take all the medications. During a concurrent interview and record review on 4/10/2025 at 7:44 a.m. with LVN 1, reviewed Resident 19's MAR for 4/10/2025. LVN 1 stated she cannot sign at 7:44 a.m. the medications administered because the electronic MAR will not save the date and time she gave the medications. LVN 1 stated she will have to wait until 8 a.m. to sign Resident 19's medications. During an interview on 4/10/2025 at 7:45 a.m. with LVN 1, LVN 1 stated she has notified Resident 19's nurse practitioner weeks before (does not recall exact date) with regard to the resident's preference to administer the medications earlier than the scheduled time. LVN 1 stated they (licensed nurse) have one hour before and one after from the scheduled time to give the medications. LVN 1 stated she was informed by the nurse practitioner and/or physician (does not recall exactly who) that if the resident continues to request to receive the medications earlier than the scheduled time then the timing will be changed. During an interview on 4/11/2025 at 11:26 a.m. with the EHM, the EHM stated Resident 19's medications should be administered at the scheduled time and can be administered one hour before or one hour after the scheduled time. The EHM stated LVN 1 should have documented the reason for giving medication early. During an interview on 4/11/2025 at 1:18 p.m. with the DP, the DP stated their (facility) MARs have a built-in one hour before and one hour after time frames to record medication administration. The DP stated if the medication nurse was unable to sign Resident 19's MAR, they (licensed nurses) would need to check with the provider (resident's physician) if it is okay to give outside the scheduled time. The DP stated the MAR has specified window of when medications can be given because they do not want to give medications too early or too late. The DP stated she expects the medication nurse (licensed nurse) to notify the provider directly or to let the pharmacy know so they (licensed nurses) can place the order. The DP stated the medication nurse should not give the medication outside of the prescribed time because it is deviating from the current order. The DP stated all medications administered should be documented on the MAR and reflect the actual time it was given. During an interview on 4/11/2025 at 5:17 p.m. with the DLTC, the DLTC stated Resident 19's medications should have been given at the scheduled time. The DLTC stated when medications are not given at the scheduled time the resident may not get the full effect and may have potential drug interactions.The DLTC stated the medication nurse is expected to clarify with the provider regarding the timing of the medication and document the communication with the provider. During a review of the facility's P&P titled, General Administrative, last reviewed 3/2024, the P&P indicated the purpose its policy to provide a safe and efficient medication distribution system which shall include the evaluation, selection, purchase, storage, control, dispensing and administration of all drugs, chemicals and pharmaceuticals used throughout the Motion Picture and Television Fund Hospital (MPTF) organization. The P&P indicated that All medications administered to patients must be first ordered by a physician on the MPTF medical staff or an individual who has been granted clinical privileges. Each dose of medication shall be accurately recorded in the patient's medical record. During a review of the facility's P&P titled, Medication Administration, last reviewed 12/5/2024, the P&P indicated Medication shall be accurately and safely administered to MPTF patients/resident by authorized personnel. The procedure P&P indicated the licensed nurses to Sign the eMAR after administration or non-administration of all medications. The P&P indicated the six (6) Rights of Safe Medication Administration are Right Medication, Right Dose, Right Patient/Resident, Right Route, Right Time, and Right Documentation. The P&P indicated the physician's order must include the date and time of the order, name of medication, dose, frequency, route, indication, duration, if appliable, and diagnosis. 3. During a review of Resident 86's FS, the FS indicated the facility admitted Resident 86 on 3/5/2025. During a review of Resident 86's CRA, the CRA indicated Resident 86 had diagnoses including epilepsy (a condition that affects the brain and causes frequent seizures, muscle spasm (a sudden, involuntary movement in one or more muscles), neuralgia (a sharp, shocking pain that follows the path of a nerve and is due to irritation or damage to the nerve), and neuritis (inflammation of a nerve). During a review of Resident 86's MDS, dated [DATE], the MDS indicated Resident 86 had unclear speech, adequate hearing, rarely/never made self understood, and rarely/never understands others. The MDS indicated Resident 86 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 86 required assistance from staff with ADLs and mobility. The MDS indicated the resident had a feeding tube (a flexible tube inserted into the stomach or intestines to deliver liquid nutrition) while a resident of the facility. During a review of Resident 86's Orders, the Orders indicated: - gabapentin 300 mg, give 300 mg (one tablet) via g-tube three times a day, administer through the percutaneous endoscopic gastrostomy (PEG- a procedure for placing a feeding tube directly into the stomach through the abdominal wall, bypassing the mouth and esophagus) tube, indication for neuralgia and neuritis, dated 3/5/2025. - quetiapine fumarate (Seroquel- drug used to manage abnormal condition of the mind described as involved a loss of contact with reality) 100 mg, give 100 mg (one tablet) via g-tube three times a day via PEG tube, indications for encephalopathy (a disease that affects the function or structure of the brain) secondary to hypoxic brain injury (low levels of oxygen in the brain causing irreversible damage) m/b agitation, dated 3/6/2025. - baclofen 10 mg, give 15 mg (1.5 tablets) via g-tube, three times a day, indication for muscle spasticity of cerebral (brain) origin, dated 4/6/2025. During a review of Resident 86's MAR, for April 2025, the MAR indicated the scheduled time for Resident 86's medications to be given at 2 p.m. included gabapentin, quetiapine, and baclofen. During a concurrent observation and interview on 4/10/2025 at 1 p.m. with LVN 1, LVN 1 prepared Resident 86's medications: quetiapine 100 mg, one tab; gabapentin 300 mg, one capsule; baclofen 10 mg, 1.5 tablets. LVN 1 stated she will administer three medications, total 3.5 tablets to give. LVN 1 crushed each tablets separately in a plastic pouch and poured separately into each medication cup. Observed LVN 1 poured five to 10 ml of water into each medication cup and stirred the medications. During an observation on 4/10/2025 at 1:10 p.m. with LVN 1, at Resident 86's bedside, LVN 1 informed Resident 86 that she (LVN 1) prepared the resident's medications to administer. LVN 1 located Resident 86's g-tube and checked g-tube residual (the amount aspirated from the stomach following administration of enteral feed) which was zero (0) ml. LVN 1 flushed Resident 86's g-tube with 30 ml of water by gravity. LVN 1 administered all three medications with no flushing of water in between medications then flushed with 30 ml of water afterwards. LVN 1 stated she had completed medication pass for Resident 86. During an interview on 4/10/2025 at 1:24 p.m. with LVN 1, LVN 1 stated she prepared Resident 86's medications then she went inside Resident 86's room. LVN 1 stated she checked Resident 86's g-tube residual and there was none. LVN 1 stated she flushed the g-tube with 30 ml and gave the medications then flushed the g-tube another 30 ml afterwards. LVN 1 stated she did not check for patency during the medication pass because in the morning before the night shift nurse left, she (LVN 1) checked Resident 86's g-tube and it was patent. LVN 1 stated she uses a stethoscope to check for patency. LVN 1 stated her supervisor has told her that she did not need to check for patency every medication pass (medication administration). LVN 1 stated she checks for g-tube patency once per day at the beginning of her shift. LVN 1 stated she did not flush the g-tube in between medications because she follows the physician's order which was to flush the g-tube before and after medication administration. LVN 1 stated there was no order to flush the g-tube in between medications. During a concurrent interview and record review on 4/10/2025 at 2:15 p.m. with the DLTC, reviewed the facility's policy and procedure (P&P) titled, Tube Feeding Maintenance and Medication Administration, last reviewed 12/5/2024. The DLTC stated the P&P for g-tube medication administration is to check placement, patency, and residual before every scheduled medication administration time. The DLTC stated the P&P indicated #10 administer prepared medication separately (Do not mix medication) and flush with 15 ml to 30 ml (unless otherwise ordered) of water between each med (prevent air from entering the tube and follow feeding procedure). The DLTC stated medication nurses are expected to flush 15 to 30 ml between every medication unless there is an order to administer specific amount of water to flush. The DLTC stated if there is no physician's order; the standard of practice applicable to residents including Resident 86 is to flush 15 ml to 30 ml of water between medications. During a concurrent interview and record review on 4/10/2025 at 2:47 p.m. with LVN 1, reviewed Resident 86's MAR. LVN 1 stated there was a physician's order to flush Resident 86's g-tube with 30 ml of water before and after medication administration which she did. LVN 1 stated she did not give water flush in between medications because there was no order to flush in between medications. During a concurrent interview and record review on 4/10/2025 at 2:55 p.m. with LVN 1, reviewed the facility's P&P titled, Tube Feeding Maintenance and Medication Administration, last reviewed 12/5/2024. LVN 1 stated she did not follow their P&P to flush in between medications and did not check Resident 86's g-tube placement and patency at every scheduled medication administration. LVN 1 stated the EHM provided the instructions that there is no need to check for g-tube placement and patency at every scheduled medication administration, and that checking for g-tube placement and patency once at the beginning of the shift or the first scheduled medication during her shift was good. During an interview on 4/11/2025 at 11:26 a.m. with the EHM, the EHM stated the standard of practice for g-tube administration is to check for placement, patency, residual, flush with water before medication administration, in between medications, and after medication administration. The EHM stated she did not provide instruction to LVN 1 to only checking placement and patency at the beginning of the shift during the first scheduled medication. The EHM stated their policy is to check for placement, patency, and residual done before administering every scheduled medication to be administered. The EHM stated flushing in between medications is done as to not mix the medications. The EHM stated when flushing in between medications is not done, then it is the same as mixing the medications in the same cup. The EHM stated LVN 1 should have followed their policy when LVN 1 administered medications to Resident 86. During an interview on 4/11/2025 at 1:25 p.m. with the DP, the DP stated medications given through the g-tube should not be mixed and should be flushed in between medications to maintain g-tube patency and to ensure Resident 86 received the whole dose. The DP stated there is a potential for medication interactions and clogging of the g-tube. During an interview on 4/11/2025 at 5:17 p.m. with the DLTC, the DLTC stated it is important for the medication nurse to flush in between medications because they would not know what the drug interaction for Resident 86 and this is to ensure the patency of the g-tube and that the resident receives the medications as ordered. The DLTC stated the purpose of checking for patency and placement is to ensure the g-tube is in the right place. The DLTC stated when this is not done the resident could potentially not receive the medications or the medication could go to a different area of the body and would not be properly absorbed. During a review of the facility's P&P titled, Tube Feeding Maintenance and Medication Administration, last reviewed 12/5/2024, the P&P indicated the purpose of the policy is to provide medication administration when unable to take orally and to monitor for signs and symptoms of infection, irritation at the stoma (a surgically created opening on the abdomen) site. The P&P indicated procedure for medication administration: 1. Check doctor's order. 2. Wash hands and prepare equipment. 3. Identify patient and explain procedure. 4. Position patient; semi-Fowler's position. 5. [NAME] (put on) gloves and check feeding tube for placement, patency, and residual. 6. For GT/JT placement check: air auscultation (a method used to listen to the sounds of the body by using a stethoscope [medical device), stomach secretions, aspiration . 7. Check gastric residual before giving medication (unless otherwise ordered). 8. If residual is greater than 100 ml, hold medication for one hour and repeat check . 9. Flush tube with 30 ml of water prior to administering medication unless physician orders different amount for flush. 10. Administer prepared medication separately (Do not mix medication) and flush with 15 ml to 30 ml (unless otherwise ordered) of water between each med (Prevent air from entering the tube and follow feeding procedure). 11. After medication is administered, instill 30 mls of water to clear the tube or as GNP/ General Nurse Practitioner (GNP)/Physician order indicates. During a review of the facility's P&P titled, General Administrative, last reviewed 3/2024, the P&P indicated the purpose its policy to provide a safe and efficient medication distribution system which shall include the evaluation, selection, purchase, storage, control, dispensing and administration of all drugs, chemicals and pharmaceuticals used throughout the Motion Picture and Television Fund Hospital (MPTF) organization. During a review of the facility's P&P titled, Medication Administration, last reviewed 12/5/2024, the P&P indicated Medication shall be accurately and safely administered to MPTF patients/resident by authorized personnel. 4. During a review of Resident 10's Face Sheet, the Face Sheet indicated the facility admitted the resident on 6/30/2021 with diagnoses including type 2 diabetes mellitus (DM 2-a disorder characterized by difficulty in blood sugar control and poor wound healing), anxiety disorder (mental health condition characterized by excessive and persistent worry, fear, and unease that can interfere with daily life), and chronic pain syndrome. During a review of Resident 10's History and Physical (H&P) dated 9/27/2024, the H&P indicated Resident 10 was alert and oriented to full name, exact date, and location. During a review of Resident 10's MDS, dated [DATE], the indicated Resident 10 had an intact cognition (mental action or process of acquiring knowledge and understanding) and required substantial/maximal assistance to total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS further indicated Resident 10 received insulin. During a review of Resident 10's physician's order, the physician's order dated 10/2/2024 indicated liraglutide (Victoza - a long-acting insulin) 0.6 milligrams (mg - a unit of measurement) per 0.1 milliliter (ml - a unit of measurement), inject 1.8 mg (0.3 ml) subcutaneously daily at eight (8) a.m. for DM 2. During a review of Resident 10's care plan (CP) titled Medical Condition: related to DM2, initiated on 6/30/2021, the CP indicated to administer liraglutide (Victoza) as one of the interventions to prevent complications or problems with medical conditions. During a concurrent interview and record review on 4/11/2025 at 8:57 am., reviewed Resident 10's physician's order, subcutaneous administration sites for Victoza from 1/8/2025 to 4/11/2025, and the MDS with Registered Nurse (RN) 1. RN 1 stated Resident 10 received insulin, had a physician's order for Victoza, and were administered as follows: - 3/19/2025 9:26 a.m. left middle mid-thigh - 3/20/2025 9:10 a.m. left middle mid-thigh - 1/27/2025 9:21 a.m. right lower back of arm - 1/28/2025 8:43 a.m. right lower back of arm - 1/5/2025 8:59 a.m. right lower quadrant - 1/6/2025 8:22 a.m. right lower quadrant RN 2 stated administration sites for insulin should be rotated per standards of practice and manufacturer's guideline to prevent hardening or lumps in the skin. RN 2 stated the location of administration sites for Resident 10's insulin was not rotated. RN 2 stated Resident 10's administration sites should have been rotated to prevent pain, redness, irritation, and lumps on the resident's skin which can affect the absorption of the insulin. During an interview on 4/11/2025 at 4 p.m. with the Director of Long-Term Care (DLTC), the DLTC stated the nurses are supposed to rotate insulin administration sites according to standards of practice, and as indicated in the manufacturer's guideline. The DLTC stated the location of administration sites for Resident 10's insulin was not rotated. The DLTC stated Resident 10's administration sites for the Victoza should have been rotated to prevent adverse effects such as bruising, skin irritation, skin pits, lipodystrophy and amyloidosis which can affect absorption of the insulin. During a review of the facility-provided manufacturer's guideline for Victoza dated 11/2024, the manufacturer's guideline indicated: - Inject Victoza SQ in the abdomen, thigh, or upper arm. - Rotate injection sites within the same region in order to reduce the risk of cutan[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide appropriate treatments and services to prevent a decline in joint range of motion (ROM, full movement potential of a joint) and mobility for four out of nine sampled residents (Residents 73, 19, 23, and 4) who had limited ROM and mobility by failing to: 1a. Ensure Resident 73's Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) order for ambulation was updated after Physical Therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) recommended RNA to ambulate with a platform walker (a type of walking assistive device with forearm supports to provide extra support during walking) for stability. 1b. Ensure Resident 73 received quarterly PT and Occupational Therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) joint mobility screens (JMS, assessment of joints to monitor joint range of motion) in 2/2025. 2a. Ensure Resident 19 received RNA treatments after PT recommended RNA for ambulation upon discharge on [DATE]. RNA treatment was not ordered until 2/2/2025 (about three months later). 2b. Ensure Resident 19 received a quarterly PT JMS in 1/2025. 3. Ensure Resident 23 received quarterly PT and OT JMS in 3/2025. 4. Ensure Resident 4 received quarterly PT and OT JMS in 2/2025. These deficient practices had the potential for residents to have a further decline in Residents' 73, 19, 23, and 4's ROM and mobility due to delayed treatments and a potential for delayed identification of ROM and mobility decline. Findings: 1. During a review of Resident 73's Face Sheet (FS), the FS indicated Resident 73 was admitted to the facility on [DATE] with diagnoses including but not limited to hemiplegia (weakness to one side of the body) following cerebral infarction (bleeding in the brain) affecting left non dominant side and contracture (loss of motion of a joint) of the left hand. During a review of Resident 73's Minimum Data Set (MDS, a resident assessment tool) dated 2/18/2025, the MDS indicated Resident 73 was cognitively intact (sufficient judgement, planning, organization to manage average demands in one's environment). The MDS indicated Resident 15 had functional limitations in ROM on one side of the upper extremity (UE, shoulder, elbow, wrist/hand) and both sides of the lower extremity (LE, hip, knee, ankle/foot). The MDS indicated Resident 15 required supervision assistance for eating. The MDS indicated Resident 15 required substantial assistance for upper body dressing, toileting hygiene, sit and stand, and chair to bed transfers. During a review of Resident 73's quarterly OT JMS dated 11/12/2024, the OT JMS indicated Resident 73 had full ROM in both shoulders, elbows, and right wrist and hand. The OT JMS indicated Resident 73 had minimal ROM limitation in the left wrist and severe ROM limitations in the left hand. During a review of Resident 73's quarterly PT JMS dated 11/12/2024, the PT JMS indicated Resident 73 had full ROM in both hips, knees, and ankles. During a review of Resident 73's Orders, the Orders indicated an order dated 5/15/2024 for RNA for active range of motion (AROM, movement at a given joint when the person moves voluntarily) to lower and right UE extremities, passive range of motion (PROM, movement at a given joint with full assistance from another person) to left UE, and ambulation with front-wheeled walker (FWW, type of mobility aid with wide base of support and two wheels in the front) three to five days a week as tolerated. 1a. During an observation on 4/9/2025 at 1:08 p.m., Restorative Nursing Aide (RNA 1) walked with Resident 73 using a FWW during RNA treatment. Resident 73 walked from Resident 73's room to the hallway past the nursing station before sitting down for a rest break. During a review of Resident 73's PT Evaluation dated 8/13/2024, the PT Evaluation indicated a recommendation for PT treatment one time a week and a platform walker for improved stability and increased weightbearing (putting one's weight through an extremity) through the upper extremity. During a review of Resident 73's PT Discharge Note (PT DC) dated 9/7/2024, the PT DC indicated Resident 73 demonstrated improved ambulation with platform walker in therapy treatments and to continue RNA for ambulation and ROM exercises to help maintain strength and mobility performance and equipment needed were a platform walker and wheelchair. During an interview and record review on 4/9/2025 at 2:51 p.m., the Registered Nurse Supervisor (RN 1) stated she was the RNA program coordinator. RN 1 stated the RNA program was recommended by PT and OT after the therapists completed their evaluation and treatments with each resident. RN 1 stated the RNA programs were recommended to help maintain the resident's mobility and ROM so the residents could be as mobile as they could and not develop contractures or prevent contractures from getting worse. RN 1 stated once a resident was discharged from PT and OT, the Therapy Manager/Occupational Therapist (TM/OT) would inform RN 1 what the RNA recommendations were and RN 1 would implement the RNA program the therapists recommended. RN 1 reviewed Resident 73's PT DC dated 9/7/2024 and stated the PT recommended Resident 73 to walk with a platform walker during RNA ambulation. RN 1 stated the current RNA order indicated for Resident 73 to ambulate with a FWW. RN 1 stated the RNA order should have been revised for RNA to ambulate with platform walker after 9/7/2024. RN 1 stated the facility was not providing the quality of mobility that was determined by PT. During an interview on 4/10/2025 at 2:06 p.m., the Director of Long-Term Care (DLTC) stated the PT and OT recommended all RNA programs for the residents. DLTC stated the RNA orders and treatments should reflect the recommendations that PT indicated at discharge. During a review of the facility's policy and procedure (P&P) reviewed 4/2024, titled Restorative Nursing Program, indicated the RNP is designed to promote/improve/maintain strength, endurance, balance and mobility. Generally, RNPs are initiated when a resident is discharged from formalized physical, occupational, or speech rehabilitation therapy. A RN will review at least every month to ensure that orders are appropriate and are being provided to the residents. 1b. During an interview on 4/9/2025 at 2:51 p.m., RN 1 stated the PT and OT JMS were completed quarterly when the MDS was completed. RN 1 stated the JMS was completed to see if the resident's ROM stayed the same, improved, or declined. RN 1 stated it was important to monitor the ROM closely in case the resident's stiffened up or if the resident developed a contracture, the facility would need to know that immediately. During an interview and record review of Resident 73's JMS on 4/9/2025 at 3:43 p.m., Physical Therapist (PT 1) and TM/OT, PT 1 and TM/OT stated there was no PT or OT JMS completed after 11/12/2024. TM/OT stated Resident 73 should have a quarterly PT and OT JMS completed in 2/2025 and it was not completed. PT 1 stated the PT and OT JMS were completed quarterly for all joints to monitor a resident's ROM. PT 1 stated the purpose was to identify any changes in function or if a resident was developing contractures and see if a resident needed any skilled therapy interventions. TM/OT stated a resident could decline and contractures could get worse if therapy did not complete quarterly JMS, because the declines could be missed. During an interview on 4/10/2025 at 2:06 p.m., the DLTC stated the PT and OT JMS should be completed quarterly for all residents to monitor ROM and joint mobility. During an interview on 4/10/2025 at 1:32 p.m., DLTC stated there was no facility policy and procedure for PT and OT joint mobility screening or to monitor ROM. 2. During a review of Resident 19's Face Sheet (FS), the FS indicated Resident 19 admitted to the facility on [DATE] with diagnoses including but not limited to dementia (a progressive state of decline in mental abilities) and Type 2 Diabetes Mellitus (condition in which the body does not metabolize blood sugar correctly). During a review of Resident 19's MDS dated [DATE], the MDS indicated had moderate cognitive impairment. The MDS indicated Resident 19 had no impairment in ROM on the upper extremity and had functional limitation impairments in ROM on one side of the lower extremity. The MDS indicated Resident 19 required setup with eating, partial assistance with sit to stand, oral hygiene. The MDS indicated Resident 19 required substantial assistance with bed to chair transfers, toileting, and walking 10 feet. 2a. During a review of Resident 19's PT Evaluation dated 11/16/2024, the PT Evaluation indicated a PT recommendation for PT evaluation only and for nursing for ambulation three to five times a week per week. During a review of Resident 19's Orders indicated an order dated 2/2/2025 for RNA for ambulation with FWW three to five days per week as tolerated. During an interview and record review on 4/9/2025 at 2:51 p.m., RN 1 stated the RNA program was recommended by PT and OT after the therapists completed their evaluation and treatments with each resident. RN 1 stated the RNA programs were recommended to help maintain the resident's mobility and ROM so the residents could be as mobile as they could and not develop contractures or prevent contractures from getting worse. RN 1 stated once a resident was discharged from PT and OT, the TM/OT would inform RN 1 what the RNA recommendations were, and RN 1 would implement the RNA program the therapists recommended. RN 1 reviewed Resident 19's PT records and stated the PT evaluation dated 11/16/2024 recommended RNA for ambulation three to five times a week. RN 1 stated the RNA program should have started soon after PT discharged the resident on 11/16/2024. RN 1 confirmed RNA order for ambulation was not ordered until 2/2/2025. RN 1 stated Resident 19 could have a decline in function and muscle atrophy with a long delay in starting an RNA program that PT recommended. During an interview and record review on 4/10/2025 at 10:56 a.m., the TM/OT stated PT discharged Resident 19 in 11/2024 and PT recommended RNA for ambulation three to five times a week, but the RNA program was not ordered until 2/2/2025. TM/OT stated the RNA program should not have been delayed this long. TM/OT stated it was important to start an RNA program right after PT and OT was completed to maintain the resident's level of function and that the resident could decline if the resident did not start a recommended RNA program right away. During an interview on 4/10/2025 at 2:06 p.m., the DLTC stated once a resident was discharged from PT or OT and therapists recommend an RNA program, the RNA order should be completed right away. During a review of the facility's policy and procedure (P&P) reviewed 4/2024, titled Restorative Nursing Program, indicated the RNP is designed to promote/improve/maintain strength, endurance, balance and mobility. Generally, RNPs are initiated when a resident is discharged from formalized physical, occupational, or speech rehabilitation therapy. A RN will review at least every month to ensure that orders are appropriate and are being provided to the residents. 2b. During a review of Resident 19's quarterly OT JMS dated 1/28/2025, the OT JMS indicated Resident 19 had full range of motion in both shoulders, elbows, wrists, and hands. During an interview on 4/9/2025 at 2:51 p.m., RN 1 stated the PT and OT JMS were completed quarterly when the MDS was completed. RN 1 stated the JMS was completed to see if the resident's ROM stayed the same, improved, or declined. RN 1 stated it was important to monitor the ROM closely in case the resident's stiffened up or if the resident developed a contracture, the facility would need to know that immediately. During an interview on 4/9/2025 at 3:43 p.m., PT 1 and TM/OT stated the PT and OT JMS were completed quarterly for all joints to monitor a resident's ROM. PT 1 stated the purpose was to identify any changes in function or if a resident was developing contractures and see if a resident needed any skilled therapy interventions. TM/OT stated a resident could decline and contractures could get worse if therapy did not complete quarterly JMS, because the declines could be missed. During an interview and record review on 4/10/2025 at 10:56 a.m., the TM/OT reviewed Resident 19's medical records and stated Resident 19 was due for a quarterly PT JMS in 1/2025, but it was not completed. During an interview on 4/10/2025 at 2:06 p.m., the DLTC stated the PT and OT JMS should be completed quarterly for all residents to monitor ROM and joint mobility. During an interview on 4/10/2025 at 1:32 p.m., DLTC stated there was no facility policy and procedure for PT and OT JMS or to monitor ROM. 3. During a review of Resident 23's Face Sheet (FS), the FS indicated Resident 23 admitted to the facility on [DATE] with diagnoses including but not limited to multiple sclerosis (a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord) and functional quadriplegia (paralysis from the neck down, including legs, and arms) and contracture of right and left hand, right and left foot. During a review of Resident 23's MDS dated [DATE], the MDS indicated Resident 23 had intact cognition. The MDS indicated Resident 23 had functional limitation impairments in ROM on both sides of the upper extremities and both sides of the lower extremities. The MDS indicated Resident 23 required dependent assistance for eating, toileting, bathing, dressing, and bed to chair transfers. During a review of Resident 23's Orders, the Orders indicated an order dated 3/12/2025 for RNA for active ROM to upper extremities, passive ROM to lower extremities as tolerated three to five times a week. During an interview and record review of Resident 23's medical records on 4/9/2025 at 3:43 p.m., PT 1 and TM/OT stated Resident 23 should have received a quarterly PT and OT JMS on 3/2025, but the quarterly PT and OT JMS were not completed. PT 1 and TM/OT stated the PT and OT JMS were completed quarterly for all joints to monitor a resident's ROM. PT 1 stated the purpose was to identify any changes in function or if a resident was developing contractures and see if a resident needed any skilled therapy interventions. TM/OT stated a resident could decline and contractures could get worse if therapy did not complete quarterly JMS, because the declines could be missed. During an interview on 4/10/2025 at 2:06 p.m., the DLTC stated the PT and OT JMS should be completed quarterly for all residents to monitor ROM and joint mobility. During an interview on 4/10/2025 at 1:32 p.m., DLTC stated there was no facility policy and procedure for PT and OT joint mobility screening or to monitor ROM. 4. During a review of Resident 4's Face Sheet (FS), the FS indicated Resident 4 admitted to the facility on [DATE] with diagnoses including, but not limited to congestive heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and polyarthritis (swelling and tenderness of multiple joints causing pain and stiffness). During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4 had moderate cognitive impairment. The MDS indicated Resident 4 had no functional limitations in range of motion in both upper extremities and had impairments in range of motion on both sides of the lower extremities. The MDS indicated Resident 4 required supervision for eating, substantial assistance with toileting, bathing, sit to stand, and bed to chair transfers. During an interview on 4/9/2025 at 3:43 p.m., PT 1 and TM/OT stated the PT and OT JMS were completed quarterly for all joints to monitor a resident's ROM. PT 1 stated the purpose was to identify any changes in function or if a resident was developing contractures and see if a resident needed any skilled therapy interventions. TM/OT stated a resident could decline and contractures could get worse if therapy did not complete quarterly JMS, because the declines could be missed. During an interview and record review of Resident 4's medical records on 4/10/2025 at 11:04 a.m., TM/OT stated Resident 4 should have received a quarterly PT and OT JMS in 2/2025, but the quarterly PT and OT JMS were not completed. During an interview on 4/10/2025 at 2:06 p.m., the DLTC stated the PT and OT JMS should be completed quarterly for all residents to monitor ROM and joint mobility. During an interview on 4/10/2025 at 1:32 p.m., DLTC stated there was no facility policy and procedure for PT and OT joint mobility screening or to monitor ROM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. During a review of Resident 20's Face Sheet, the Face Sheet indicated the facility admitted the resident on 9/6/2023. During a review of Resident 20's Clinical Record Abstract, the Clinical Record Abstract indicated Resident 20's diagnoses including 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), and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During a review of Resident 20's H&P, dated 9/6/2024, the H&P indicated the resident was alert and oriented to full name and location, and unable to tell the date. During a review of Resident 20's MDS, dated [DATE], the MDS indicated Resident 20 had severely impaired cognition and usually understands others and usually to make needs known. The MDS indicated Resident 20 required substantial/maximal assistance with bed mobility and total assistance from staff with all other ADLs. During a review of Resident 20's physician's order, dated 10/25/2024, the physician's order indicated an order for beveled floor mat as directed for risk of fall with injury. During a review of Resident 20's care plan (CP) titled, Cognitive/Vision/Falls/ADL/Incontinence/Skin integrity, initiated on 9/6/2023, the CP indicated beveled floor mat as directed for risk of fall with injury as one of the interventions for Resident 20's safety and will have no falls or injury. During a concurrent observation and interview, on 4/9/2025, at 7:26 a.m., inside Resident 20's room, with CNA 7, CNA 7 stated Resident 20 had bilateral floor mats with an overbed table placed on top of each floor mat on both sides and in front of the resident. CNA 7 stated Resident 20's overbed tables should have not been placed on top of the floor mat as it places the resident at risk for getting injured when he tries to get out of bed unassisted. CNA 7 stated Resident 20 had a few incidents of falls in the past. CNA 7 stated the integrity of the floor mat can get affected if there are indentation from placing equipment or table on top of floor mat and cannot protect the resident. During an interview, on 4/10/2025, at 10:13 a.m., with RN 2, RN 2 stated Resident 20 is a risk for falls and had a few incidents of falls in the past. RN 2 stated there should be no overbed table on top of the floor mat as it can tip over and fall on the resident and residents can hit the table when they try to get out of bed unassisted which could lead to injury. RN 2 stated placing the overbed tables on top of the floor mat can affect the integrity of the floor mat and reduce the ability of the floor mat to protect the resident during a fall incident. During an interview, on 4/11/2025, at 3:23 p.m., with the DLTC, the DLTC stated there should be no furniture or medical equipment on top of the residents' floor mats. The DLTC stated the overbed tables should not have been placed on top of Resident 20's bilateral floor mats to prevent the resident from incurring injury when Resident 20 tries to get out of bed unassisted and hit the overbed table. During a review of the facility's P&P titled, Falls, last reviewed on 12/5/2024, the P&P indicated interventions will be implemented in accordance with the resident's needs which include but not limited to keeping the environment free of clutter and floors dry. The P&P further indicated to keep floor clutter free/obstacle free especially in pathway between bed and bathroom/commode as one of the general safety interventions During a review of the facility's P&P titled, Accident Prevention, last reviewed on 3/6/2025, the P&P indicated the facility will ensure the environment is as free as possible from accident hazards and identify residents who requires supervision and/or assistive devices to prevent accidents. The P&P further indicated to conduct routine rounding to identify and mitigate environmental hazards including assistive devices/equipment hazards. 5. During a review of Resident 2's Face Sheet, the Face Sheet indicated the facility admitted the resident on 9/12/2020. During a review of Resident 2's Patient Diagnosis Information, the Patient Diagnosis Information indicated the resident had diagnoses including Alzheimer's Disease, dementia, xerosis (condition characterized by rough, dry, and itchy skin), infection reaction of the left knee prosthesis (artificial replacement of the knee), and diabetes mellitus. During a review of Resident 2's MDS, dated [DATE], the MDS indicated the facility most recently admitted the resident on 4/16/202. The MDS indicated the resident was able to understand others and was able to make herself understood. The MDS further indicated the resident required substantial/maximal assistance from staff for toileting, dressing, personal hygiene, and mobility. The MDS indicated the resident was dependent on staff for bathing and putting on footwear. During a review of Resident 2's Care Plan (CP) titled, . [Resident 2] has forgetfulness, short term memory loss related to dementia .has impaired safety judgement ., initiated 9/12/2022, the CP indicated the resident wanted to be safe and remain safely within the facility. The CP indicated the resident had an intervention of petrolatum, white (a moisturizer to treat or prevent dry, rough, scaly, itchy skin) 41 percent (%, a unit of measurement), apply ointment topically every eight hours as needed to affected areas for xerosis that was discontinued on 4/2/2024. During a concurrent observation and interview, on 4/8/2025, at 10:20 a.m., Resident 2 laid wake in bed with no staff were present in the room. Resident 2's nightstand had a clear plastic medication cup with a light-yellow ointment on top of it. Resident 2 stated she needed staff assistance with a spill. Resident 2 pressed the call light (a device used to summon health care workers). During a concurrent observation and interview, on 4/8/2025, at 10:25 a.m., RNA 2 entered Resident 2's room and walked past the clear plastic cup containing ointment. RNA 2 stated the resident had a spill and RNA 2 would get the CNA to help the resident. RNA 2 exited the room and did not remove the ointment. CNA 2 entered Resident 2's room and walked past the cup with ointment. The resident requested to have the breakfast tray reheated and CNA 2 exited the room without removing the ointment. LVN 2 entered Resident 2's room and walked past the ointment. LVN 2 stated Resident 2 had a spill on the shirt that would be cleaned after the resident finished breakfast. LVN 2 exited the room. The ointment remained in Resident 2's room. During an observation, on 4/8/2025, at 10:40 a.m., CNA 2 entered Resident 2's room with clean linens. The ointment remained on Resident 2's nightstand. During a concurrent observation and interview, on 4/8/2025, at 11 a.m., CNA 2 stood at the doorway to Resident 2's room and stated there was ointment in a cup left on the resident's nightstand. CNA 2 stated somebody from nightshift must have left the ointment on the nightstand. CNA 2 stated she did not previously see the ointment but had been in the resident's room about four times since the beginning of the shift at 7 a.m. CNA 2 stated Resident 2 should not have any ointments left in the room unattended. CNA 2 stated she was not sure why ointments should not be left in resident rooms. During an interview, on 4/8/2025, at 11:05 a.m., with LVN 2, LVN 2 stated Resident 2 did not have an order for the topical ointment left in Resident 2's room and was not safe for self-administration of medication. LVN 2 stated she did not see the ointment while in Resident 2's room, but she should have. LVN 2 stated medications should never be left in a resident's room because of safety issues. LVN 2 stated all the residents on the unit had dementia, confusion, and some resident's wandered. LVN 2 stated any resident could get the ointment when the ointment was left unattended in the room, potentially resulting in the resident eating the topical medication. During a concurrent interview and record review, on 4/11/2025, at 11:15 a.m., with the DLTC, In-services titled, Plan of Correction for April 2-4, 2024, Survey Findings, dated 4/2/2024 to 4/4/2024, were reviewed. The DLTC stated all staff complete walking rounds to residents' rooms at the beginning and end of every shift. The DLTC stated every time staff enters a resident's room, the staff should assess the environment for safety. The DLTC stated the residents on Resident 2's unit have dementia. The DLTC stated for the safety of all residents on the unit, medications should never be left unattended in a resident's room. The DLTC stated staff had an in-service in 4/2024 regarding not leaving medications at bedside and staff know that medication should not be left in a resident's room. The DLTC stated when the topical medication was left out in Resident 2's room, a confused resident could put the topical medication on their body causing an allergic reaction or ingest the topical medication causing illness from poisoning. The DLTC stated the facility P&P was not followed when medication was left unattended in Resident 2's room. During a review of the facility provided In-service titled, Plan of Correction for April 2-4, 2024 Survey Findings, dated 4/2/2024 to 4/4/2024, the In-service indicated medications or treatments should never be left at the bedside without a medical provider order. This includes over the counter medications and creams. Medications or treatments left at the bedside could present a danger to the resident. Always make sure all supplies are removed from the bedside after completing a treatment or medication pass. During a review of the facility provided P&P titled, Medication Administration, last reviewed 11/2024, the P&P indicated medications shall be accurately and safely administered to facility residents by authorized personnel. Remain with the resident until the medication has been administered. Do not leave medications unattended with the resident. During a review of the facility provided P&P titled, Accident Prevention, last revised 1/2025, the P&P indicated the purpose of the P&P was to ensure the environment is as free as possible from accident hazards and to identify residents who require supervision. Conduct routine rounding to identify and mitigate environmental hazards. Based on observation, interview, and record review, the facility failed to ensure residents' environment was free of accident hazards for five of seven sampled residents (Residents 21, 338, 77, 20, and 2) reviewed for accidents by failing to ensure: 1. Resident 21, who was on a swallow precaution (steps to help someone swallow without choking or having food/liquid go down the wrong way), was sitting 90 degrees while eating her breakfast and was completely supervised on 4/8/2025. 2. Resident 338's bottle of Daikin's solution (a strong topical antiseptic widely used to clean infected wounds, ulcers, and burns) was not left at the bedside drawer mixed in with food items. 3. Resident 77's call light's (a device used to summon healthcare workers for assistance, typically found near a resident's bed or within reach of a resident) cord was free from exposed/frayed wires. 4. Resident 77 and Resident 20's bilateral fall mat (a cushioned mat that reduces the risk of injury from a fall) did not have furniture or equipment on top of them. 5. Resident 2 did not have an unattended clear medication cup containing ointment left at the bedside accessible and readily available for self-administration. These deficient practices increased the risk of accidents such as falls with injuries, electrocution, ingestion of harmful chemicals, and choking. Findings: 1. During a review of Resident 21's Face Sheet, the Face Sheet indicated the facility admitted the resident on 11/30/2023. During a review of Resident 21's History and Physical (H&P), dated 11/26/2024, the H&P indicated the resident was awake, alert, pleasant, and cooperative. The H&P indicated the resident had history of stroke (a loss of blood flow to part of the brain, which damages brain tissue) with chronic left hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and chronic recurrent pneumonia (two or more episodes of pneumonia in twelve (12) months or three episodes altogether) associated with bed-bound status with hypostasis aspiration (refers to the accumulation of fluid or blood in a dependent part of the body, especially after death, due to gravity and lack of circulation, and the subsequent aspiration [breathing in] of this fluid) and general debilitation (being in a weakened or frail state, characterized by a general lack of energy and strength). During a review of Resident 21's Minimum Data Set (MDS - a resident assessment tool), dated 2/14/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment (having noticeable difficulties with thinking, learning, and remembering things, but still able to manage some daily activities with assistance or strategies). The MDS indicated the resident was dependent to needing partial to moderate assistance on mobility and activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). The MDS indicated the resident was on a mechanically altered diet (modifying food textures to make them easier to chew and swallow). During a review of Resident 21's Active Orders, dated 8/14/2024, the Active Order indicated an order of Regular diet with meals three times a day (TID). Consistency: Regular, liquid consistency: honey. Comments: She requests only breakfast items that are not cooked, for example fruit, yogurt, muffins, oatmeal. 2/20/2024: Swallow Precautions - head of bed (HOB) elevated at 90 degrees during meals and for half hour following meals. Supervision during meal, no straw, single cup sips, ensure she is eating drinking slowly. Indication: resident complaint of difficulty with nectar thick. During a review of Resident 21's Plan of Care (POC) regarding medical conditions, dated 11/30/2023, the POC indicated an intervention of Regular, liquid consistency: honey. Comments: She requests only breakfast items that are not cooked, for example fruit, yogurt, muffins, oatmeal. 2/20/2024: Swallow Precautions - HOB elevated at 90 degrees during meals and for half hour following meals. Supervision during meal, no straw, single cup sips, ensure she is eating drinking slowly. Indication: resident complaint of difficulty with nectar thick. During a concurrent observation and interview, on 4/8/2025, at 9:22 a.m., with Restorative Nursing Aide (RNA) 3 and Resident 21, inside Resident 21's room, Resident 21 laid in bed with the HOB elevated 75 to 80 degrees, with an empty breakfast tray on top of the side table, eating a cup of yogurt by herself. Resident 21 stated she ate by herself and was just assisted by RNA 3, who cut the food into bite sized pieces and left the room. Resident 21 stated RNA 3 does not stay with her while she eats her breakfast. RNA 3 stated she assisted the resident by placing the breakfast tray on the resident's side table, adjusting the head of the bed up, setting up the food for the resident, cutting the food into bite sized pieces, leaving the room and checking on the resident occasionally while the resident is eating. RNA 3 stated the sign on the resident's wall indicated swallow guidelines, head of bed at 90-degree angle during meals and for 30 minutes following meals, and supervision during meals. RNA 3 stated the sign on the door indicated to please keep this door open while eating and risk for aspiration. RNA 3 stated her responsibility was to keep an eye on the resident, make sure the resident is sitting at a 90-degree angle, make sure the resident's mouth was clear of food, and ensure the resident was not falling asleep. RNA 3 stated she should not have left the room while the resident was eating as the resident can aspirate or choke. RNA 3 stated she was stepping out of the room because the private sitter for the resident was not in yet and she must assist other residents too. During a concurrent interview and record review, on 4/10/2025, at 9:42 a.m., with Registered Nurse (RN) 2, Resident 21's Active Orders, Posted Signage, and POC were reviewed. RN 2 stated there was an order for swallow precautions for Resident 21, head of bed at 90-degree angle during meals and for 30 minutes following meals, and supervision during meals. RN 2 stated RNA 3 should not have left the resident's room as the resident had swallowing problems and the resident can aspirate or choke on the food. During an interview, on 4/11/2025, at 3:23 p.m., with the Director of Long-Term Care (DLTC), the DLTC stated RNA 3 should have not left Resident 21 while eating her breakfast. The DLTC stated when a resident is on a swallow precaution, the staff should be always present while the resident is eating so they can supervise and intervene right away if the resident is experiencing aspiration and choking. During a review of the facility-provided Skills Inventory/Competency/Orientation Validation Tool for RNA, undated, the Skills Inventory/Competency/Orientation Validation Tool for RNA indicated safety during meals, observes residents for symptoms of dysphagia (difficulty swallowing): coughing, choking, wet voicing (refers to a voice that sounds gurgly, bubbling, or liquidy, often heard after swallowing or during a meal that is a potential sign that something, like mucus, saliva, or even food, is sitting on the vocal cords or isn't being cleared properly, possibly indicating a swallowing problem), reflux, and complaints of discomfort. Demonstrates knowledge of swallowing precautions/positioning. Observes for food pocketing during meals and provides good oral care after meals. 2. During a review of Resident 338's Face Sheet, the Face Sheet indicated the facility admitted the resident on 12/20/2024. During a review of Resident 338's H&P, dated 12/21/2024, the H&P indicated the resident was difficult to communicate with, alert, crying at times, sometimes calm, and quiet. The H&P indicated the resident had multi-infarct state (a loss of mental skills caused by a series of small strokes) with cognitive deficits (problems with mental abilities like thinking, learning, remembering, and making decisions), and chronic neuropathic pain (a long-lasting pain (lasting more than 3 months) that arises from damage or dysfunction of the nervous system). During a review of Resident 338's MDS, dated [DATE], the MDS indicated the resident sometimes had the ability to make self-understood and usually understands others and had impaired cognition (a decline in mental abilities that affects a person's thinking, memory, reasoning, judgment, and other cognitive functions). The MDS indicated the resident had diabetic foot ulcer (a slow-healing sore or wound, often on the bottom of the foot, that develops in people with diabetes [a disorder characterized by difficulty in blood sugar control and poor wound healing)]) and moisture associated skin damage (MASD - skin inflammation or breakdown caused by prolonged exposure to wetness, such as urine, feces, sweat, or wound drainage) with application of ointments/medications and application of dressings to feet. During a review of Resident 338's Discontinued Orders, dated 4/10/2025, the Discontinued Orders indicated sodium hypochlorite (Daikin's ½ Strength) 0.25%, take 30 milliliters (ml - a unit of measure for volume) twice a day, cleanse coccyx (the last bone at the bottom [base] of the spine) before application of clotrimazole/betamethasone ointments (a topical medicine used to treat fungal skin infections, like jock itch, ringworm, and athlete's foot). Indication: Stage two (2) pressure injury (PI - partial-thickness loss of skin, presenting as a shallow open sore or wound) with fungal component. During a review of Resident 338's POC regarding medical conditions, dated 12/20/2024, the POC indicated an intervention of sodium hypochlorite (Daikin's ½ Strength) 0.25%, take 30 ml twice a day cleanse coccyx before application of clotrimazole/betamethasone ointments. Indication: Stage 2 PI with fungal component. During a concurrent observation and interview, on 4/8/2025, at 10:13 a.m., with Licensed Vocational Nurse (LVN) 3, inside Resident 338's room, the top of the bedside drawer contained a bottle of Daikin's Solution labeled with the resident's name mixed with food items. LVN 3 stated there should be no medications left at the bedside as the residents can accidentally ingest them causing harm. LVN 3 stated the Daikin's solution should be placed back in the medication cart after it was administered. During an interview, on 4/11/2025, at 3:23 p.m., with the DLTC, the DLTC stated the Daikin's Solution should not have been left at Resident 338's bedside to prevent accidental chemical ingestion by the resident which can cause harm to residents. The DLTC stated the Daikin's solution should have been kept in the medication cart. During a review of the facility's recent policy and procedure (P&P) titled Accident Prevention, last reviewed on 3/6/2025, the P&P indicated to ensure the environment is as free as possible from accidents hazards and identify residents who require supervision and/or assistive devices to prevent accidents. Conduct routine rounding to identify and mitigate environmental hazards including: -Electrical safety -Other Environmental Hazards as identified During a review of the facility's recent P&P titled Medication Administration, last reviewed on 12/5/2024, the P&P indicated do not leave medications unattended with the patient/resident. 3. During a review of Resident 77's Face Sheet, the Face Sheet indicated the facility admitted the resident on 12/27/2023. During a review of Resident 77's H&P, dated 12/17/2024, the H&P indicated the resident was alert, but unable to converse. The H&P indicated the resident had Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), frontal lobe dementia (a group of conditions where the frontal and temporal lobes of the brain are damaged, leading to changes in thinking, behavior, and sometimes language or movement), and major depression (mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy). During a review of Resident 77's MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severely impaired cognition. The MDS indicated the resident was dependent on mobility and ADLs. During a review of Resident 77's Fall Risk Evaluation, dated 3/18/2025, the Fall Risk Evaluation indicated the resident was high risk for fall. During a review of Resident 77's Active Orders, dated 5/2/2024, the Active Orders indicated beveled floor mat LTC every(q) shift During a review of Resident 77's POC regarding cognitive/communication/falls/ ADL's/Incontinence/Skin Integrity problem, dated 12/27/2023, the POC indicated a goal of the resident wanting to be free of fall and complications and to place beveled floor mat when the resident is in bed and store mat when not in use with an indication for major injury prevention. During a concurrent observation and interview, on 4/8/2025, at 9:07 a.m., with Certified Nursing Assistant (CNA) 6, inside Resident 77's room, Resident 77's call light cord had exposed/frayed wires and the bilateral fall mats had two wheels of the side table and the staff chair resting on top of the right fall mat of the resident's bed while feeding the resident breakfast. CNA 6 stated there should be no exposed/frayed wires on the resident's call light cord because the resident can be electrocuted and there should be no furniture or medical equipment on the fall mat of the resident to prevent the fall mat from sustaining permanent dents that can lessen the cushioning effect of the mat when the resident falls on them, sustaining an injury. CNA 6 stated the side table could also tip over the resident and cause injury. During a concurrent interview and record review, on 4/10/2025, at 10:13 a.m., with RN 2, Resident 77's Fall Risk Assessment, dated 3/18/2025, and POC, dated 12/27/2023, were reviewed. RN 2 confirmed and stated Resident 77 was at risk for falls. RN 2 further stated there should be no frayed/exposed wires on the resident's call light cord to prevent the resident from electrocution. During an interview, on 4/11/2025, at 3:23 p.m., with the DLTC, the DLTC stated there should be no exposed/frayed wires to prevent accidental electrocution of Resident 77. The DLTC further stated no furniture, or medical equipment should be on top of Resident 77's fall mat to prevent injury to residents when they slide down on them. During a review of the facility's recent P&P titled, LTC [Long Term Care] Standard of Care Nursing Protocol, last reviewed on 3/6/2025, the P&P indicated to keep the environment free of clutter. During a review of the facility's recent P&P titled, Falls, last reviewed on 12/5/2024, the P&P indicated to keep the environment free of clutter and floors dry. Keep floor clutter/obstacles in pathway between bed and bathroom/commode. Remove excess equipment/supplies, furniture from rooms and hallways. During a review of the facility's recent P&P titled, Bed Maintenance, last reviewed on 3/1/2024, the P&P indicated to check all electrical outlets, including accessory outlets that may be mounted on resident beds, for cleanliness, physical integrity, and functionality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 39's Face Sheet (FS- front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility admitted the resident on 4/18/2018. During a record review of Resident 39's Patient Diagnosis Information, the Patient Diagnosis Information indicated the resident had diagnoses that included neurocognitive disorder with Lewy bodies (a progressive disorder characterized by the gradual decline of thinking and reasoning abilities, often accompanied by movement and sleep disturbances, and visual hallucinations) and PI of the sacral region (lower back at the base of the spine) stage two (partial-thickness loss of skin, presenting as a shallow open sore or wound). During a review of Resident 39's Minimum Data Set (MDS - resident assessment tool) dated 3/14/2025, the MDS indicated the facility most recently admitted the resident on 8/21/2018. The MDS indicated the resident was rarely/never able to understand others and was rarely/never able to make himself understood. The MDS further indicated the resident was dependent on assistance from staff for eating, toileting, bathing, dressing, personal and oral hygiene, and mobility. During a review of Resident 39's Care Plan (CP) titled, Pressure Injury Stage 2 on sacrum related to previous pressure injury on area, incontinence, impaired mobility, initiated 11/25/2024, the CP indicated a goal that the area would heal without complications in the next 120 days. During a review of Resident 39's physician orders, the physician orders indicated the following treatment orders: - Dated 3/26/2025, cleanse PI of the sacrum with wound cleansing spray, gently pat dry, apply maxorb plus silver (an antimicrobial wound dressing), cut to fit wound, cover with opti foam (a type of dressing), change dressing daily. - Dated 1/30/2025 and discontinued (DC'd) on 2/12/2025, mupirocin 2 %, apply ointment 1 dose topically twice a day. cleanse PI of the sacrum with warm cleansing wipes, gently pat dry, apply mupirocin ointment prior to application of moisture barrier cream. Indication: stage 2 pressure injury. During a concurrent observation and interview on 4/10/2025 at 11:30 a.m. with LVN 1, observed Resident 39's wound care treatment in the resident's room. LVN 1 stated the LVNs provide daily wound care for facility residents. LVN 1 gathered the following wound care supplies from the One [NAME] Treatment Cart: mupirocin ointment placed in a clear medication cup, an opti foam dressing, cleansing spray, and the maxorb dressing. LVN 1 entered Resident 39's room with the supplies, cleansed Resident 39's wound, applied the mupirocin ointment to cover the wound, placed the maxorb dressing on top of the mupirocin ointment, then applied the opti foam dressing. Upon completion of the treatment, LVN 1 exited the resident's room. During a follow up observation, interview, and record review on 4/10/2025 at 11:55 a.m. with LVN 1, LVN 1 reviewed Resident 39's physician orders. LVN 1 stated LVN 1 applied mupirocin ointment to Resident 39. LVN 1 stated LVN 1 always applies the mupirocin when providing Resident 39's wound care treatment. LVN 1 then reviewed Resident 39's treatment orders and noted Resident 39 did not have an active order to apply mupirocin. LVN 1 stated prior to administering mupirocin, LVN 1 reviewed Resident 39's treatment order. LVN 1 stated LVN 1 thought there was an order for mupirocin, but there was not. LVN 1 stated LVN 1 should have read the order more carefully. During a concurrent interview and record review on 4/10/2025 at 12:15 p.m. with Registered Nurse (RN) 3, RN 3 reviewed Resident 39's physician orders. RN 3 stated the medication and treatment administration process it to review the physician's treatment orders, remove the medication from the treatment cart, compare the medication with the order, and then apply the medication to the resident. RN 3 stated if there is no order for the mupirocin, the nurse should contact the nurse practitioner or physician to clarify if they would like to continue with the treatment. RN 3 stated there must be a physician's order prior to applying medication to a resident. RN 3 stated Resident 39 did not have an active order for mupirocin when LVN 1 applied the mupirocin to Resident 39. RN 3 stated Resident 39 previously had an order for mupirocin that was discontinued on 2/12/2025. During a concurrent interview and record review on 4/10/2025 at 1:13 p.m. with RN 2, RN 2 reviewed Resident 39's physician orders. RN 2 stated when a medication is discontinued, the pharmacy and the nurse receive a notification to remove the medication from the cart. RN 2 stated Resident 39's mupirocin order was discontinued on 2/12/2025 and the medication should have been removed immediately from the One [NAME] Treatment Cart to ensure the medication was not administered by mistake. During an interview on 4/10/2025 at 2:02 p.m. with LVN 1, stated it is important to carefully review the treatment order prior to providing the treatment to ensure errors are avoided like administering the wrong medication to the resident. LVN 1 stated Resident 39's discontinued mupirocin ointment remained in the One [NAME] Treatment Cart and LVN 1 administered the discontinued medication to Resident 39 every day that she worked this week including 4/10/2025, 4/9/2025, 4/8/2025, and 4/7/2025. LVN 1 stated LVN 1 thought Resident 39 had an order for mupirocin when LVN 1 applied the medication, but there was no order. LVN 1 stated LVN 1 just saw the mupirocin ointment in the cart, grabbed it, and applied it to Resident 39. During a follow up interview on 4/10/2025 at 2:12 p.m. with RN 3, RN 3 stated during medication and treatment administration nurses should follow the rights of safe medication administration by comparing the physician's order to the actual medication label to ensure the right resident gets the right medication at the right time and no errors are made. RN 3 stated LVN 1 did not follow the rights of safe medication administration, and it resulted in LVN 1 administering a discontinued medication to Resident 39. RN 3 stated when the discontinued mupirocin was administered to Resident 39 there was the potential that the PI healing process would be affected causing a delay in healing or a decline in the resident's condition. During a concurrent interview and record review on 4/11/2025 at 11:15 a.m. with the Director of Long Term Care (DLTC), the DLTC reviewed the facility policy and procedure regarding medication administration and medication storage. The DLTC stated medications are discontinued for a reason. The DLTC stated discontinued medication may not be an effective treatment, or a different treatment may be more appropriate. The DLTC stated when a discontinued medication was left in the treatment cart and administered to Resident 39, there was a potential that the mupirocin would have a negative effect on the resident's healing process. A review of the facility policy and procedure (P&P) titled, Pharmacy: General Administrative, last reviewed 3/2024, the P&P indicated all medications dispensed to patients must be ordered by a prescriber. A system of controlling nursing medication stock items and replacement is maintained with transaction records to maintain control and accountability of all drugs. All medications administered to patients must be first ordered by a physician or an individual who has been granted clinical privileges. Each dose of medication shall be accurately recorded in the patient's medical record. Patients administered medications shall be carefully monitored to determine whether the medication results in the therapeutically intended benefit, and to allow for early identification of adverse effects and timely initiation of appropriate corrective action. A review of the facility policy and procedure (P&P) titled, Medication Administration, last reviewed 11/2024, the P&P indicated medication shall be accurately and safely administered to residents, by authorized personnel. The procedure includes: - Access the resident's Medication Administration Record (eMAR) via the Electronic Medical Record (EMR). a. Compare the label of the unit of medication with the individual resident eMAR. b. Place medications for individual resident in a small disposable cup, tray or medication cup according to need. c. Identify the resident using two identifiers (never by room number). d. Assess/monitor a patient/resident who requires checking prior to administering e. medication, and those for whom PRN/as needed medications have been prescribed. Check for and document effectiveness in the PRN EMR. f. Remain with the patient/resident until medication has been administered. g. Discard medication packages and other waste in the mandated receptacles. h. Sign the eMAR after administration or non-administration of all medications. - Medication Safety Practices for Medication Administration include: - The 6 Rights of Safe Medication Administration are: i. The Right Medication ii. The Right Dose iii. The Right Patient/Resident iv. The Right Route v. The Right Time vi. The Right Documentation - A physician's order must include: o Date and time of the order o Name of the medication o Dose o Frequency o Route o Indication o Duration, if applicable o Diagnosis 3. During a review of Resident 66's FS, the FS indicated the facility admitted the resident on 8/18/2023. During a review of Resident 66's Clinical Record Abstract (CRA), the CRA indicated Resident 66 had diagnoses including dementia (a progressive state of decline in mental abilities), paraplegia (loss of movement and/or sensation, to some degree, of the legs), and seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of Resident 66's MDS, dated [DATE], the MDS indicated Resident 66 had adequate hearing, clear speech, had the ability to make self understood, and usually understand others. The MDS indicated Resident 66 required substantial assistance with eating and was dependent on staff on functional abilities in mobility. During a review of Resident 66's Orders (physician's orders), the Orders indicated: - carboxymethylcellulose sodium (Refresh Tears-eye drops) 0.5 percent (%-a unit of measurement), take two drops twice a day, indication for irritation or dry eye, dated 9/29/2023. - cetirizine hydrochloride (HCL) (Zyrtec-antihistamine helps relieve allergies), give 10 milligrams (mg-a unit of measurement), give 10 mg (1 tablet) by mouth daily, indication for pruritus (itching), dated 4/9/2024. - Eyelid cleanser (Ocusoft lid scrub), instill one pad into both eyes, twice a day, indication for blepharitis (inflammation of the eyelid), dated 12/6/2024. - lacosamide (Vimpat-antiseizure medication) give 150 mg, one tablet by mouth, twice a day, indication for seizure disorder, dated 8/31/2023. - levetiracetam (Keppra- antiseizure) 500 mg, give 750 mg (1.5 tablets) by mouth, twice a day, indication for seizure disorder, dated 2/8/2024. During a review of Resident 66's Medication Administration Record (MAR-a record of medications administered to residents), for April 2025, the MAR indicated the scheduled time for Resident 66's medications to be given at 9 a.m. included carboxymethylcellulose sodium, cetirizine hydrochloride, eyelid cleanser, lacosamide, and levetiracetam. During a concurrent observation and interview on 4/10/2025 at 7:27 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 prepared the following medications for Resident 66: lacosamide, one tablet (tab); levetiracetam 500 mg, 1.5 tabs; cetirizine 10 mg, one tab; carboxymethylcellulose eye drops; and eyelid cleanser. LVN 1 stated she has a total of 3.5 tablets and one eye drops to give. During an observation and interview on 4/10/2025 at 7:31 a.m. with LVN 1, at Resident 66's bedside, LVN 1 administered 3.5 tablets, and one eye drop medications to Resident 66. LVN 1 stated she completed medication administration for Resident 66. During a concurrent interview and record review on 4/10/2025 at 7:34 a.m. with LVN 1, reviewed Resident 66's MAR for 4/10/2025. LVN 1 stated she cannot sign Resident 66's MAR with the actual time she gave the medications because the system will not allow her until 8 a.m. LVN 1 stated the medications she gave were scheduled at 9 a.m. LVN 1 stated she will continue to pass (administer) medications. During an interview on 4/10/2025 at 7:45 a.m. with LVN 1, LVN 1 stated she has notified Residents 66's nurse practitioner weeks before (does not recall exact date) with regard to the resident's preference to administer the medications earlier than the scheduled time. LVN 1 stated they (licensed nurses) have one hour before and one after from the scheduled time to give the medications. LVN 1 stated she was informed by the nurse practitioner and/or physician (does not recall exactly who) that if the resident continues to request to receive the medications earlier than the scheduled time then the timing will be changed. LVN 1 stated she gave the medications earlier because when Resident 66 was up in the chair, it was difficult to administer the eye drops compared to when the resident is was still on bed. LVN 1 stated she also asked Resident 66 if he would like to receive his medications before the scheduled time and Resident 66 stated he would like to take his medications if they were ready. LVN 1 stated she gives the medications to Resident 66 outside the scheduled time about three times a week but not all the time. During an interview on 4/11/2025 at 11:26 a.m. with the Employee Health Manager (EHM), the EHM stated medications should be administered at the scheduled time and can be administered one hour before or one hour after the scheduled time. The EHM stated LVN 1 should have documented the reason for giving medication early for Resident 66. During an interview on 4/11/2025 at 1:18 p.m. with the Director of Pharmacy (DP), the DP stated their MARs have a built-in one hour before and one hour after (time frames to record medication administration). The DP stated if the medication nurse was unable to sign the MAR of Resident 66, they (licensed nurses) would need to check with the provider (resident's physician) if it is okay to give outside the scheduled time. The DP stated the MAR has specified window of when medications can be given because they do not want to give medications too early or too late. The DP stated she expects the medication nurse (licensed nurse) to notify the provider directly or to let the pharmacy know so they (licensed nurses) can place the order. The DP stated the medication nurse should not give the medication outside of the prescribed time because it is deviating from the current order. The DP stated all medications administered should be documented on the MAR and reflect the actual time it was given. During an interview on 4/11/2025 at 5:17 p.m. with the Director of Long-Term Care (DLTC), the DLTC stated medications should be given at the scheduled time. The DLTC stated when medications are not given at the scheduled time, Resident 66 may not get the full effect and may have potential drug interactions. The DLTC stated the medication nurse is expected to clarify with the provider regarding the timing of the medication of Resident 66 and document the communication with the provider. During a review of the facility's P&P titled, General Administrative, last reviewed 3/2024, the P&P indicated the purpose its policy to provide a safe and efficient medication distribution system which shall include the evaluation, selection, purchase, storage, control, dispensing and administration of all drugs, chemicals and pharmaceuticals used throughout the Motion Picture and Television Fund Hospital (MPTF) organization. The P&P indicated that All medications administered to patients must be first ordered by a physician on the MPTF medical staff or an individual who has been granted clinical privileges. Each dose of medication shall be accurately recorded in the patient's medical record. During a review of the facility's P&P titled, Medication Administration, last reviewed 12/5/2024, the P&P indicated Medication shall be accurately and safely administered to MPTF patients/resident by authorized personnel. The procedure P&P indicated the licensed nurses to Sign the eMAR after administration or non-administration of all medications. The P&P indicated the six (6) Rights of Safe Medication Administration are Right Medication, Right Dose, Right Patient/Resident, Right Route, Right Time, and Right Documentation. The P&P indicated the physician's order must include the date and time of the order, name of medication, dose, frequency, route, indication, duration, if appliable, and diagnosis. 4. During a review of Resident 19's FS, the FS indicated the facility admitted the resident on 8/7/2024. During a review of Resident 19's CRA, the CRA indicated Resident 19 had diagnoses including dementia, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and constipation (a problem with passing stool). During a review of Resident 19's MDS, dated [DATE], the MDS indicated Resident 19 had minimal difficulty hearing, clear speech, had the ability to make self understood and understand others. The MDS indicated Resident 19 required staff assistance with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) and mobility. During a review of Resident 19's Orders, the Orders indicated the following: - donepezil HCL (Aricept-used to treat dementia), give 5 mg, one tablet by mouth daily, indication for dementia, dated 8/7/2024. - gabapentin (Neurontin- nerve pain medication), give 100 mg, one capsule by mouth, twice a day, indication for depression m/b refusing and resistance to care, dated 12/24/2024. - metformin extended release (Glucophage Extended Release- medication that helps lower high blood sugar) 500 mg, give 1000 mg (two tablets) by mouth, twice a day, indication for diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), dated 8/7/2024. - pantoprazole (Protonix- decreases amount of acid produced in the stomach) 40 mg, give 40 mg, one tablet by mouth, daily, indication for gastroesophageal reflux disease (GERD- a condition in which the stomach contents move up into the esophagus), dated 8/7/2024. - polyethylene glycol 3350 (Miralax- used to treat constipation) 15 grams (g-a unit of measurement)/dose, give 17 g (one powder) by mouth daily, mix with eight (8) ounces (oz- a unit of measurement) of liquid or juice, indication for constipation, dated 8/7/2024. - solifenacin succinate (Vesicare- used to treat overactive bladder [OAB- a problem with bladder (organ that stores urine before leaving the body) function that causes the sudden need to urinate]) 5 mg, give 5 mg (one tablet) by mouth, daily, indication for OAB, dated 2/21/2025. During a review of Resident 19's MAR, for April 2025, the MAR indicated the scheduled time for Resident 19's medications to be given at 9 a.m. on 4/10/2025 included donepezil HCL, gabapentin, metformin extended release, pantoprazole, polyethylene glycol 3350, and solifenacin. During a concurrent observation and interview on 4/10/2025 at 7:37 a.m. with LVN 1, LVN 1 prepared Resident 19's including medications: pantoprazole 40 mg, one tab; metformin 500 mg, two tabs; gabapentin 100 mg, one capsule; solifenacin 5 mg, one tab; donepezil 5 mg, one tab; polyethylene glycol 17 g. LVN 1 stated she will administer a total of eight medications with seven tablets and one powder. LVN 1 stated she will separate buspirone and gabapentin into a separate medication cup because Resident 19 usually does not want to take all the medications. During a concurrent observation and interview on 4/10/2025 at 7:43 a.m. with LVN 1, at Resident 19's bedside, LVN 1 stated Resident 19 does not want to take all the medications. LVN 1 offered buspirone and gabapentin to Resident 19 which the resident took. LVN 1 offered the rest of the medications but Resident 19 refused. During a concurrent interview and record review on 4/10/2025 at 7:44 a.m. with LVN 1, reviewed Resident 19's MAR for 4/10/2025. LVN 1 stated she cannot sign at 7:44 a.m. the medications administered because the electronic MAR will not save the date and time she gave the medications. LVN 1 stated she will have to wait until 8 a.m. to sign Resident 19's medications. During an interview on 4/10/2025 at 7:45 a.m. with LVN 1, LVN 1 stated she has notified Resident 19's nurse practitioner weeks before (does not recall exact date) with regard to the resident's preference to administer the medications earlier than the scheduled time. LVN 1 stated they (licensed nurse) have one hour before and one after from the scheduled time to give the medications. LVN 1 stated she was informed by the nurse practitioner and/or physician (does not recall exactly who) that if the resident continues to request to receive the medications earlier than the scheduled time then the timing will be changed. During an interview on 4/11/2025 at 11:26 a.m. with the EHM, the EHM stated Resident 19's medications should be administered at the scheduled time and can be administered one hour before or one hour after the scheduled time. The EHM stated LVN 1 should have documented the reason for giving medication early. During an interview on 4/11/2025 at 1:18 p.m. with the DP, the DP stated their (facility) MARs have a built-in one hour before and one hour after time frames to record medication administration. The DP stated if the medication nurse was unable to sign Resident 19's MAR, they (licensed nurses) would need to check with the provider (resident's physician) if it is okay to give outside the scheduled time. The DP stated the MAR has specified window of when medications can be given because they do not want to give medications too early or too late. The DP stated she expects the medication nurse (licensed nurse) to notify the provider directly or to let the pharmacy know so they (licensed nurses) can place the order. The DP stated the medication nurse should not give the medication outside of the prescribed time because it is deviating from the current order. The DP stated all medications administered should be documented on the MAR and reflect the actual time it was given. During an interview on 4/11/2025 at 5:17 p.m. with the DLTC, the DLTC stated Resident 19's medications should have been given at the scheduled time. The DLTC stated when medications are not given at the scheduled time the resident may not get the full effect and may have potential drug interactions.The DLTC stated the medication nurse is expected to clarify with the provider regarding the timing of the medication and document the communication with the provider. During a review of the facility's P&P titled, General Administrative, last reviewed 3/2024, the P&P indicated the purpose its policy to provide a safe and efficient medication distribution system which shall include the evaluation, selection, purchase, storage, control, dispensing and administration of all drugs, chemicals and pharmaceuticals used throughout the Motion Picture and Television Fund Hospital (MPTF) organization. The P&P indicated that All medications administered to patients must be first ordered by a physician on the MPTF medical staff or an individual who has been granted clinical privileges. Each dose of medication shall be accurately recorded in the patient's medical record. During a review of the facility's P&P titled, Medication Administration, last reviewed 12/5/2024, the P&P indicated Medication shall be accurately and safely administered to MPTF patients/resident by authorized personnel. The procedure P&P indicated the licensed nurses to Sign the eMAR after administration or non-administration of all medications. The P&P indicated the six (6) Rights of Safe Medication Administration are Right Medication, Right Dose, Right Patient/Resident, Right Route, Right Time, and Right Documentation. The P&P indicated the physician's order must include the date and time of the order, name of medication, dose, frequency, route, indication, duration, if appliable, and diagnosis. 5. During a review of Resident 86's FS, the FS indicated the facility admitted Resident 86 on 3/5/2025. During a review of Resident 86's CRA, the CRA indicated Resident 86 had diagnoses including epilepsy (a condition that affects the brain and causes frequent seizures, muscle spasm (a sudden, involuntary movement in one or more muscles), neuralgia (a sharp, shocking pain that follows the path of a nerve and is due to irritation or damage to the nerve), and neuritis (inflammation of a nerve). During a review of Resident 86's MDS, dated [DATE], the MDS indicated Resident 86 had unclear speech, adequate hearing, rarely/never made self understood, and rarely/never understands others. The MDS indicated Resident 86 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 86 required assistance from staff with ADLs and mobility. The MDS indicated the resident had a feeding tube (a flexible tube inserted into the stomach or intestines to deliver liquid nutrition) while a resident of the facility. During a review of Resident 86's Orders, the Orders indicated: - gabapentin 300 mg, give 300 mg (one tablet) via g-tube three times a day, administer through the percutaneous endoscopic gastrostomy (PEG- a procedure for placing a feeding tube directly into the stomach through the abdominal wall, bypassing the mouth and esophagus) tube, indication for neuralgia and neuritis, dated 3/5/2025. - quetiapine fumarate (Seroquel- drug used to manage abnormal condition of the mind described as involved a loss of contact with reality) 100 mg, give 100 mg (one tablet) via g-tube three times a day via PEG tube, indications for encephalopathy (a disease that affects the function or structure of the brain) secondary to hypoxic brain injury (low levels of oxygen in the brain causing irreversible damage) m/b agitation, dated 3/6/2025. - baclofen 10 mg, give 15 mg (1.5 tablets) via g-tube, three times a day, indication for muscle spasticity of cerebral (brain) origin, dated 4/6/2025. During a review of Resident 86's MAR, for April 2025, the MAR indicated the scheduled time for Resident 86's medications to be given at 2 p.m. included gabapentin, quetiapine, and baclofen. During a concurrent observation and interview on 4/10/2025 at 1 p.m. with LVN 1, LVN 1 prepared Resident 86's medications: quetiapine 100 mg, one tab; gabapentin 300 mg, one capsule; baclofen 10 mg, 1.5 tablets. LVN 1 stated she will administer three medications, total 3.5 tablets to give. LVN 1 crushed each tablets separately in a plastic pouch and poured separately into each medication cup. Observed LVN 1 poured five to 10 ml of water into each medication cup and stirred the medications. During an observation on 4/10/2025 at 1:10 p.m. with LVN 1, at Resident 86's bedside, LVN 1 informed Resident 86 that she (LVN 1) prepared the resident's medications to administer. LVN 1 located Resident 86's g-tube and checked g-tube residual (the amount aspirated from the stomach following administration of enteral feed) which was zero (0) ml. LVN 1 flushed Resident 86's g-tube with 30 ml of water by gravity. LVN 1 administered all three medications with no flushing of water in between medications then flushed with 30 ml of water afterwards. LVN 1 stated she had completed medication pass for Resident 86. During an interview on 4/10/2025 at 1:24 p.m. with LVN 1, LVN 1 stated she prepared Resident 86's medications then she went inside Resident 86's room. LVN 1 stated she checked Resident 86's g-tube residual and there was none. LVN 1 stated she flushed the g-tube with 30 ml and gave the medications then flushed the g-tube another 30 ml afterwards. LVN 1 stated she did not check for patency during the medication pass because in the morning before the night shift nurse left, she (LVN 1) checked Resident 86's g-tube and it was patent. LVN 1 stated she uses a stethoscope to check for patency. LVN 1 stated her supervisor has told her that she did not need to check for patency every medication pass (medication administration). LVN 1 stated she checks for g-tube patency once per day at the beginning of her shift. LVN 1 stated she did not flush the g-tube in between medications because she follows the physician's order which was to flush the g-tube before and after medication administration. LVN 1 stated there was no order to flush the g-tube in between medications. During a concurrent interview and record review on 4/10/2025 at 2:15 p.m. with the DLTC, reviewed the facility's policy and procedure (P&P) titled, Tube Feeding Maintenance and Medication Administration, last reviewed 12/5/2024. The DLTC stated the P&P for g-tube medication administration is to check placement, patency, and residual before every scheduled medication administration time. The DLTC stated the P&P indicated #10 administer prepared medication separately (Do not mix medication) and flush with 15 ml to 30 ml (unless otherwise ordered) of water between each med (prevent air from entering the tube and follow feeding procedure). The DLTC stated medication nurses are expected to flush 15 to 30 ml between every medication unless there is an order to administer specific amount of water to flush. The DLTC stated if there is no physician's order; the standard of practice applicable to residents including Resident 86 is to flush 15 ml to 30 ml of water between medications. During a concurrent interview and record review on 4/10/2025 at 2:47 p.m. with LVN 1, reviewed Resident 86's MAR. LVN 1 stated there was a physician's order to flush Resident 86's g-tube with 30 ml of water before and after medication administration which she did. LVN 1 stated she did not give water flush in between medications because th[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs by failing to: 1. Ensure the antibiotic medications had monitoring for adverse effect (unwanted undesirable effects that are possibly related to a drug) for two of three sampled residents (Residents 21 and 4) reviewed for antibiotic use. 2. Ensure the antiplatelet (medications that prevent blood clots from forming) had monitoring for adverse effect for one of three sampled residents (Resident 338) reviewed for anticoagulant (a substance that is used to prevent and treat blood clots in blood vessels and the heart) use. This deficient practice placed the residents at risk for unnecessary medication and undetected adverse/side effects. Findings: 1. During a review of Resident 21's Face Sheet, the Face Sheet indicated the facility admitted the resident on 11/30/2023. During a review of Resident 21's History and Physical (H&P), dated 11/24/2024, the H&P indicated the resident was awake, alert, pleasant, and cooperative. The H&P indicated the resident had dyslipidemia (having too much or too little of certain fats [lipids] in the blood, like cholesterol or triglycerides), chronic recurrent pneumonia (two or more episodes of pneumonia [lung infection] in 12 months or three episodes altogether), and atrial fibrillation (a common heart condition where the heart's upper chambers [atria] beat irregularly, sometimes too fast, creating a quivering or fluttering sensation). The H&P indicated per primary medical doctor (PMD) the resident will continue twice weekly azithromycin (an antibiotic medicine) life-long, and daily prednisone (a corticosteroid medicine used to decrease inflammation). During a review of Resident 21's Minimum Data Set (MDS, a resident assessment tool), dated 2/14/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment (having noticeable difficulties with thinking and memory that start to impact daily life). The MDS indicated the resident was on a high-risk drug class antibiotic. During a review of Resident 21's Active Orders, dated 11/25/2024, the Active Orders indicated an order for azithromycin (Zithromax) 250 milligrams (mg - a unit of measure for mass). Give 250 mg (one [1] tablets) by mouth Monday and Friday per prescriber. Indication: pneumonia prophylaxis (measures taken to prevent pneumonia, a lung infection). The orders did not indicate an order for monitoring for adverse/side effects on the use of azithromycin. During a concurrent interview and record review, on 4/10/2025, at 9:07 a.m., with Registered Nurse (RN) 2, Resident 21's Active Orders, Medication Administration Record (MAR), and Care Plan were reviewed. RN 2 stated there was no order for monitoring for adverse effects of the medication azithromycin as prophylaxis for pneumonia on Resident 21. RN 2 stated it was important for Resident 21 to have a monitoring for the adverse effect on the use of antibiotic to intervene when a complication arises and to prevent antibiotic resistance (occurs when bacteria develop defenses against the antibiotics designed to kill them). During an interview, on 4/10/2025, at 2:55 p.m., with the Director of Pharmacy (DP), the DP stated there should be monitoring for adverse effect on the use of azithromycin for pneumonia prophylaxis to ensure its safe use. The DP stated it is a standard of practice to monitor the adverse effect of antibiotic medication administration on residents. During an interview, on 4/11/2025, at 3:23 p.m., with the Director of Long-Term Care (DLTC), the DLTC stated the staff should have obtained an order from the physician for monitoring of adverse effects on the use of Resident 21's antibiotic azithromycin. The DLTC stated it is important for Resident 21 to be monitored for adverse effect on the use of antibiotic to mitigate the negative reaction of the medication in a timely manner. During a review of the facility-provided Summary of Product Characteristics of Azithromycin dihydrate 200 mg/5 milliliters (ml - a unit of measure for volume) Powder for Oral Suspension, dated 5/2024, the Summary of Product Characteristics indicated for treatment of upper and lower respiratory tract infections, skin and soft tissues infections and odontostomatological (referring to the field of study and practice related to teeth, their structure, and diseases) infections 500 mg per day taken once daily, for 3 consecutive days. The same dosage regimen can be applied to elderly patients. Since elderly patients are more susceptible to developing cardiac arrythmia, particular caution is recommended due to the risk of developing cardiac arrhythmia (a problem with the rate or rhythm of the heartbeat) and torsade de pointes (a type of very fast heart rhythm [tachycardia] that starts in your heart's lower chambers [ventricles]). 2. During a review of Resident 4's Face Sheet, the Face Sheet indicated the facility admitted the resident on 12/8/2022. During a review of Resident 4's H&P, dated 9/23/2024, the H&P indicated the resident was awake, alert, coherent, oriented to place, time, and person. The H&P indicated the resident had periprosthetic fracture (a broken bone that occurs near a metal implant, often a joint replacement) of the right femur (the long bone in the upper leg, also known as the thigh bone), heart failure (a lifelong condition in which the heart muscle cannot pump enough blood to meet the body's needs for blood and oxygen), and chronic kidney disease (long-term condition where the kidneys do not work as well as they should). During a review of Resident 4's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment. The MDS indicated the resident was on a high-risk drug class antibiotic. During a review of Resident 4's Active Orders, dated 9/17/2024, the Active Orders indicated amoxicillin (Amoxil) 500 mg. Give 2000 mg (four [4] capsules) by mouth as needed (PRN). Administer two hours prior to the scheduled dental procedure. Indication: prophylaxis (measures designed to preserve health) for dental procedures etc. The Active Orders did not indicate an order for monitoring for adverse/side effects on the use of amoxicillin. During a concurrent interview and record review, on 4/10/2025, at 10:24 a.m., with RN 2, Resident 4's Active orders, MAR, and Care Plan were reviewed. RN 4 stated there was no monitoring for adverse effect on the use of amoxicillin on the resident. RN 4 stated the amoxicillin was given only once last year. RN 4 stated the order can just be made as a one-time order as opposed to having the order as PRN. RN 4 stated placing the order as PRN increases the risk of staff administering the medication for other indications increasing the risk of medication error. RN 4 stated not monitoring for adverse effect on the use of amoxicillin predisposes Resident 4 to its adverse effect. During an interview, on 4/10/2025, at 1:20 p.m., with Nurse Practitioner (NP) 1, NP 1 stated the antibiotic amoxicillin for Resident 4 should have been written as a one-time order as opposed to PRN to reduce the risk of medication error of nurse administering the medication for other indication. NP 1 also stated there should be monitoring for adverse effect on the use of amoxicillin to mitigate possible side effects of the medication. During an interview, on 4/10/2025, at 2:55 p.m., with the DP, the DP stated there should be monitoring for adverse effect on the use of amoxicillin for dental prophylaxis to ensure its safe use. The DP stated it is a standard of practice to monitor for adverse effect of antibiotic medication administration. During an interview, on 4/11/2025, at 3:23 p.m., with the DLTC, the DLTC stated the amoxicillin order of Resident 4 should have a monitoring for adverse effect to ensure the safe use of the drug and to timely mitigate the negative effects of the medication. The DLTC also stated the order should have been written as a one-time order instead of a PRN to prevent medication error. During a review of the facility-provided Highlights of Prescribing Information on the use of Amoxil (amoxicillin) capsules, tablets, or powder for oral suspension, with initial U.S. approval in 1974, the Highlights of Prescribing Information indicated an adverse reaction of Amoxil, capsules, tablets, or oral suspension were diarrhea, rash, vomiting, and nausea. Prescribing Amoxil in the absence of a proven strongly suspected bacterial infection is unlikely to provide benefit to the patient an increase the risk of the development of drug-resistant bacteria. 3. During a review of Resident 338's Face Sheet, the Face Sheet indicated the facility admitted the resident on 12/20/2024. During a review of Resident 338's H&P, dated 12/21/2024, the H&P indicated the resident was difficult to communicate with, alert, crying at times, sometimes calm and quiet. The H&P indicated the resident had multi-infarct state (someone has experienced several small strokes, often called mini-strokes or silent strokes, which cause damage to different parts of the brain) with cognitive deficits (a problem with a person's ability to think, learn, remember, and make decisions), hypertension (HTN - a condition where the force of blood pushing against your artery walls is consistently too high) and chronic neuropathic pain (nerve pain that can happen if your nervous system malfunctions or gets damaged). During a review of Resident 338's MDS, dated [DATE], the MDS indicated the resident sometimes make self-understood and usually understand others and had impaired cognition (difficulty with thinking and memory functions, including remembering things, concentrating, and making decisions). The MDS indicated the resident was on a high-risk drug class antiplatelet. During a review of Resident 338's Active Orders, dated 3/29/2025, the Active Orders indicated an order for aspirin (medication used to prevent blood clots) 81 mg. Give 81 mg (1 tablet) by mouth daily. Indication: cerebrovascular accident (CVA, also known as a stroke, medical emergency that occurs when the blood supply to the brain is interrupted, either by a blockage or a rupture of a blood vessel) prophylaxis and clopidogrel bisulfate (also known as Plavix, medication used to prevent blood clots) 75 mg. Give 75 mg (1 tablet(s)) by mouth daily. Indication: CVA prophylaxis. During a concurrent interview and record review, on 4/10/2025, at 9:58 a.m., with RN 2, Resident 338's Active Orders, MAR, and Care Plan were reviewed. RN 2 stated there was no order for monitoring of adverse effect on the use of aspirin and Plavix on Resident 338. RN 2 stated it was important to monitor for Resident 338's use of aspirin and Plavix's adverse effect to prevent undue bleeding on the resident. During an interview, on 4/11/2025, at 3:23 p.m., with the DLTC, the DLTC stated the staff should have monitored for adverse effect on the use of ASA and Plavix on Resident 338 to intervene timely to its adverse effect and prevent bleeding. During a review of the facility-provided Professional Information on the use of [NAME] Aspirin Tablets, last revised on 4/19/2013, the Professional Information indicated side effects of hemorrhage (an acute loss of blood from a damaged blood vessel), hypersensitivity, anaphylactic shock (a sudden, severe and life-threatening allergic reaction that involves the whole body), rash , urticaria (the medical term for hives), dizziness, and tinnitus (when a person experiences ringing or other noises in one or both of the ears). During a review of the facility-provided Highlights of Prescribing Information on the use of Plavix (clopidogrel tablets) for oral use, with initial approval in 1997, the Highlights of Prescribing Information indicated adverse reactions such as bleeding, including life-threatening and fatal bleeding, is the most commonly reported adverse reaction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent, when seven (7) medication errors out of 28 opportunities contributed to an overall medication error rate of 25%. The medication error rate are as follows: 1. For Residents 66 and 19, Licensed Vocational Nurse (LVN) 1 failed to administer 9 a.m. scheduled medications at the scheduled time. 2. For Resident 86, LVN 1 failed to flush the resident's gastrostomy tube (g-tube- a surgical opening fitted with a device to allow feedings to be administered directly to the stomach for people with swallowing problems) with water in between medications when LVN 1 administered the resident's g-tube medications. These deficient practices had the potential to result in Resident 86 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and the potential to result in Residents 66 and 19's health and well-being to be negatively impacted. Cross reference: F658, F755, and F760 Findings: 1. During a review of Resident 66's Face Sheet (FS- front page of the chart that contains a summary of basic information about the resident), the FS indicated the facility admitted the resident on 8/18/2023. During a review of Resident 66's Clinical Record Abstract (CRA), the CRA indicated Resident 66 had diagnoses including dementia (a progressive state of decline in mental abilities), paraplegia (loss of movement and/or sensation, to some degree, of the legs), and seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of Resident 66's Minimum Data Set (MDS-a resident assessment tool), dated 3/21/2025, the MDS indicated Resident 66 had adequate hearing, clear speech, had the ability to make self understood, and usually understand others. The MDS indicated Resident 66 required substantial assistance with eating and was dependent on staff on functional abilities in mobility. During a review of Resident 66's Orders (physician's orders), the Orders indicated: - carboxymethylcellulose sodium (Refresh Tears-eye drops) 0.5 percent (%-a unit of measurement), take two drops twice a day, indication for irritation or dry eye, dated 9/29/2023. - cetirizine hydrochloride (HCL) (Zyrtec-antihistamine helps relieve allergies), give 10 milligrams (mg-a unit of measurement), give 10 mg (1 tablet) by mouth daily, indication for pruritus (itching), dated 4/9/2024. - Eyelid cleanser (Ocusoft lid scrub), instill one pad into both eyes, twice a day, indication for blepharitis (inflammation of the eyelid), dated 12/6/2024. - lacosamide (Vimpat-antiseizure medication) give 150 mg, one tablet by mouth, twice a day, indication for seizure disorder, dated 8/31/2023. - levetiracetam (Keppra- antiseizure) 500 mg, give 750 mg (1.5 tablets) by mouth, twice a day, indication for seizure disorder, dated 2/8/2024. During a review of Resident 66's Medication Administration Record (MAR-a record of medications administered to residents), for April 2025, the MAR indicated the scheduled time for Resident 66's medications to be given at 9 a.m. included carboxymethylcellulose sodium, cetirizine hydrochloride, eyelid cleanser, lacosamide, and levetiracetam. During a concurrent observation and interview on 4/10/2025 at 7:27 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 prepared the following medications for Resident 66: lacosamide, one tablet (tab); levetiracetam 500 mg, 1.5 tabs; cetirizine 10 mg, one tab; carboxymethylcellulose eye drops; and eyelid cleanser. LVN 1 stated she has a total of 3.5 tablets and one eye drops to give. During an observation and interview on 4/10/2025 at 7:31 a.m. with LVN 1, at Resident 66's bedside, LVN 1 administered 3.5 tablets, and one eye drop medications to Resident 66. LVN 1 stated she completed medication administration for Resident 66. During a concurrent interview and record review on 4/10/2025 at 7:34 a.m. with LVN 1, reviewed Resident 66's MAR for 4/10/2025. LVN 1 stated she cannot sign Resident 66's MAR with the actual time she gave the medications because the system will not allow her until 8 a.m. LVN 1 stated the medications she gave were scheduled at 9 a.m. LVN 1 stated she will continue to pass (administer) medications. During an interview on 4/10/2025 at 7:45 a.m. with LVN 1, LVN 1 stated she has notified Residents 66's nurse practitioner weeks before (does not recall exact date) with regard to the resident's preference to administer the medications earlier than the scheduled time. LVN 1 stated they (licensed nurses) have one hour before and one after from the scheduled time to give the medications. LVN 1 stated she was informed by the nurse practitioner and/or physician (does not recall exactly who) that if the resident continues to request to receive the medications earlier than the scheduled time then the timing will be changed. LVN 1 stated she gave the medications earlier because when Resident 66 was up in the chair, it was difficult to administer the eye drops compared to when the resident is was still on bed. LVN 1 stated she also asked Resident 66 if he would like to receive his medications before the scheduled time and Resident 66 stated he would like to take his medications if they were ready. LVN 1 stated she gives the medications to Resident 66 outside the scheduled time about three times a week but not all the time. During an interview on 4/11/2025 at 11:26 a.m. with the Employee Health Manager (EHM), the EHM stated medications should be administered at the scheduled time and can be administered one hour before or one hour after the scheduled time. The EHM stated LVN 1 should have documented the reason for giving medication early for Resident 66. During an interview on 4/11/2025 at 1:18 p.m. with the Director of Pharmacy (DP), the DP stated their MARs have a built-in one hour before and one hour after (time frames to record medication administration). The DP stated if the medication nurse was unable to sign the MAR of Resident 66, they (licensed nurses) would need to check with the provider (resident's physician) if it is okay to give outside the scheduled time. The DP stated the MAR has specified window of when medications can be given because they do not want to give medications too early or too late. The DP stated she expects the medication nurse (licensed nurse) to notify the provider directly or to let the pharmacy know so they (licensed nurses) can place the order. The DP stated the medication nurse should not give the medication outside of the prescribed time because it is deviating from the current order. The DP stated all medications administered should be documented on the MAR and reflect the actual time it was given. During an interview on 4/11/2025 at 5:17 p.m. with the Director of Long-Term Care (DLTC), the DLTC stated medications should be given at the scheduled time. The DLTC stated when medications are not given at the scheduled time, Resident 66 may not get the full effect and may have potential drug interactions. The DLTC stated the medication nurse is expected to clarify with the provider regarding the timing of the medication of Resident 66 and document the communication with the provider. During a review of the facility's P&P titled, General Administrative, last reviewed 3/2024, the P&P indicated the purpose its policy to provide a safe and efficient medication distribution system which shall include the evaluation, selection, purchase, storage, control, dispensing and administration of all drugs, chemicals and pharmaceuticals used throughout the Motion Picture and Television Fund Hospital (MPTF) organization. The P&P indicated that All medications administered to patients must be first ordered by a physician on the MPTF medical staff or an individual who has been granted clinical privileges. Each dose of medication shall be accurately recorded in the patient's medical record. During a review of the facility's P&P titled, Medication Administration, last reviewed 12/5/2024, the P&P indicated Medication shall be accurately and safely administered to MPTF patients/resident by authorized personnel. The procedure P&P indicated the licensed nurses to Sign the eMAR after administration or non-administration of all medications. The P&P indicated the six (6) Rights of Safe Medication Administration are Right Medication, Right Dose, Right Patient/Resident, Right Route, Right Time, and Right Documentation. The P&P indicated the physician's order must include the date and time of the order, name of medication, dose, frequency, route, indication, duration, if appliable, and diagnosis. 2. During a review of Resident 19's FS, the FS indicated the facility admitted the resident on 8/7/2024. During a review of Resident 19's CRA, the CRA indicated Resident 19 had diagnoses including dementia, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and constipation (a problem with passing stool). During a review of Resident 19's MDS, dated [DATE], the MDS indicated Resident 19 had minimal difficulty hearing, clear speech, had the ability to make self understood and understand others. The MDS indicated Resident 19 required staff assistance with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) and mobility. During a review of Resident 19's Orders, the Orders indicated the following: - donepezil HCL (Aricept-used to treat dementia), give 5 mg, one tablet by mouth daily, indication for dementia, dated 8/7/2024. - gabapentin (Neurontin- nerve pain medication), give 100 mg, one capsule by mouth, twice a day, indication for depression m/b refusing and resistance to care, dated 12/24/2024. - metformin extended release (Glucophage Extended Release- medication that helps lower high blood sugar) 500 mg, give 1000 mg (two tablets) by mouth, twice a day, indication for diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), dated 8/7/2024. - pantoprazole (Protonix- decreases amount of acid produced in the stomach) 40 mg, give 40 mg, one tablet by mouth, daily, indication for gastroesophageal reflux disease (GERD- a condition in which the stomach contents move up into the esophagus), dated 8/7/2024. - polyethylene glycol 3350 (Miralax- used to treat constipation) 15 grams (g-a unit of measurement)/dose, give 17 g (one powder) by mouth daily, mix with eight (8) ounces (oz- a unit of measurement) of liquid or juice, indication for constipation, dated 8/7/2024. - solifenacin succinate (Vesicare- used to treat overactive bladder [OAB- a problem with bladder (organ that stores urine before leaving the body) function that causes the sudden need to urinate]) 5 mg, give 5 mg (one tablet) by mouth, daily, indication for OAB, dated 2/21/2025. - During a review of Resident 19's MAR, for April 2025, the MAR indicated the scheduled time for Resident 19's medications to be given at 9 a.m. on 4/10/2025 included donepezil HCL, gabapentin, metformin extended release, pantoprazole, polyethylene glycol 3350, and solifenacin. During a concurrent observation and interview on 4/10/2025 at 7:37 a.m. with LVN 1, LVN 1 prepared Resident 19's including medications: pantoprazole 40 mg, one tab; metformin 500 mg, two tabs; gabapentin 100 mg, one capsule; solifenacin 5 mg, one tab; donepezil 5 mg, one tab; polyethylene glycol 17 g. LVN 1 stated she will administer a total of eight medications with seven tablets and one powder. LVN 1 stated she will separate buspirone and gabapentin into a separate medication cup because Resident 19 usually does not want to take all the medications. During a concurrent observation and interview on 4/10/2025 at 7:43 a.m. with LVN 1, at Resident 19's bedside, LVN 1 stated Resident 19 does not want to take all the medications. LVN 1 offered two tablets, buspirone and gabapentin, to Resident 19, Resident 19 agreed. Resident 19 took the two tablets. LVN 1 offered the rest of the medications and Resident 19 refused. During a concurrent interview and record review on 4/10/2025 at 7:44 a.m. with LVN 1, reviewed Resident 19's MAR for 4/10/2025. LVN 1 stated she cannot sign at 7:44 a.m. the medications administered because the electronic MAR will not save the date and time she gave the medications. LVN 1 stated she will have to wait until 8 a.m. to sign Resident 19's medications. During an interview on 4/10/2025 at 7:45 a.m. with LVN 1, LVN 1 stated she has notified Resident 19's nurse practitioner weeks before (does not recall exact date) with regard to the resident's preference to administer the medications earlier than the scheduled time. LVN 1 stated they (licensed nurse) have one hour before and one after from the scheduled time to give the medications. LVN 1 stated she was informed by the nurse practitioner and/or physician (does not recall exactly who) that if the resident continues to request to receive the medications earlier than the scheduled time then the timing will be changed. During an interview on 4/11/2025 at 11:26 a.m. with the EHM, the EHM stated Resident 19's medications should be administered at the scheduled time and can be administered one hour before or one hour after the scheduled time. The EHM stated LVN 1 should have documented the reason for giving medication early. During an interview on 4/11/2025 at 1:18 p.m. with the DP, the DP stated their (facility) MARs have a built-in one hour before and one hour after time frames to record medication administration. The DP stated if the medication nurse was unable to sign Resident 19's MAR, they (licensed nurses) would need to check with the provider (resident's physician) if it is okay to give outside the scheduled time. The DP stated the MAR has specified window of when medications can be given because they do not want to give medications too early or too late. The DP stated she expects the medication nurse (licensed nurse) to notify the provider directly or to let the pharmacy know so they (licensed nurses) can place the order. The DP stated the medication nurse should not give the medication outside of the prescribed time because it is deviating from the current order. The DP stated all medications administered should be documented on the MAR and reflect the actual time it was given. During an interview on 4/11/2025 at 5:17 p.m. with the DLTC, the DLTC stated Resident 19's medications should have been given at the scheduled time. The DLTC stated when medications are not given at the scheduled time the resident may not get the full effect and may have potential drug interactions.The DLTC stated the medication nurse is expected to clarify with the provider regarding the timing of the medication and document the communication with the provider. During a review of the facility's P&P titled, General Administrative, last reviewed 3/2024, the P&P indicated the purpose its policy to provide a safe and efficient medication distribution system which shall include the evaluation, selection, purchase, storage, control, dispensing and administration of all drugs, chemicals and pharmaceuticals used throughout the Motion Picture and Television Fund Hospital (MPTF) organization. The P&P indicated that All medications administered to patients must be first ordered by a physician on the MPTF medical staff or an individual who has been granted clinical privileges. Each dose of medication shall be accurately recorded in the patient's medical record. During a review of the facility's P&P titled, Medication Administration, last reviewed 12/5/2024, the P&P indicated Medication shall be accurately and safely administered to MPTF patients/resident by authorized personnel. The procedure P&P indicated the licensed nurses to Sign the eMAR after administration or non-administration of all medications. The P&P indicated the six (6) Rights of Safe Medication Administration are Right Medication, Right Dose, Right Patient/Resident, Right Route, Right Time, and Right Documentation. The P&P indicated the physician's order must include the date and time of the order, name of medication, dose, frequency, route, indication, duration, if appliable, and diagnosis. 3. During a review of Resident 86's FS, the FS indicated the facility admitted Resident 86 on 3/5/2025. During a review of Resident 86's CRA, the CRA indicated Resident 86 had diagnoses including epilepsy (a condition that affects the brain and causes frequent seizures, muscle spasm (a sudden, involuntary movement in one or more muscles), neuralgia (a sharp, shocking pain that follows the path of a nerve and is due to irritation or damage to the nerve), and neuritis (inflammation of a nerve). During a review of Resident 86's MDS, dated [DATE], the MDS indicated Resident 86 had unclear speech, adequate hearing, rarely/never made self understood, and rarely/never understands others. The MDS indicated Resident 86 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 86 required assistance from staff with ADLs and mobility. The MDS indicated the resident had a feeding tube (a flexible tube inserted into the stomach or intestines to deliver liquid nutrition) while a resident of the facility. During a review of Resident 86's Orders, the Orders indicated: - gabapentin 300 mg, give 300 mg (one tablet) via g-tube three times a day, administer through the percutaneous endoscopic gastrostomy (PEG- a procedure for placing a feeding tube directly into the stomach through the abdominal wall, bypassing the mouth and esophagus) tube, indication for neuralgia and neuritis, dated 3/5/2025. - quetiapine fumarate (Seroquel- drug used to manage abnormal condition of the mind described as involved a loss of contact with reality) 100 mg, give 100 mg (one tablet) via g-tube three times a day via PEG tube, indications for encephalopathy (a disease that affects the function or structure of the brain) secondary to hypoxic brain injury (low levels of oxygen in the brain causing irreversible damage) m/b agitation, dated 3/6/2025. - baclofen 10 mg, give 15 mg (1.5 tablets) via g-tube, three times a day, indication for muscle spasticity of cerebral (brain) origin, dated 4/6/2025. During a review of Resident 86's MAR, for April 2025, the MAR indicated the scheduled time for Resident 86's medications to be given at 2 p.m. included gabapentin, quetiapine, and baclofen. During a concurrent observation and interview on 4/10/2025 at 1 p.m. with LVN 1, LVN 1 prepared Resident 86's medications: quetiapine 100 mg, one tab; gabapentin 300 mg, one capsule; baclofen 10 mg, 1.5 tablets. LVN 1 stated she will administer three medications, total 3.5 tablets to give. LVN 1 crushed each tablets separately in a plastic pouch and poured separately into each medication cup. Observed LVN 1 poured five to 10 ml of water into each medication cup and stirred the medications. During an observation on 4/10/2025 at 1:10 p.m. with LVN 1, at Resident 86's bedside, LVN 1 informed Resident 86 that she (LVN 1) prepared the resident's medications to administer. LVN 1 located Resident 86's g-tube and checked g-tube residual (the amount aspirated from the stomach following administration of enteral feed) which was zero (0) ml. LVN 1 flushed Resident 86's g-tube with 30 ml of water by gravity. LVN 1 administered all three medications with no flushing of water in between medications then flushed with 30 ml of water afterwards. LVN 1 stated she had completed medication pass for Resident 86. During an interview on 4/10/2025 at 1:24 p.m. with LVN 1, LVN 1 stated she prepared Resident 86's medications then she went inside Resident 86's room. LVN 1 stated she checked Resident 86's g-tube residual and there was none. LVN 1 stated she flushed the g-tube with 30 ml and gave the medications then flushed the g-tube another 30 ml afterwards. LVN 1 stated she did not check for patency during the medication pass because in the morning before the night shift nurse left, she (LVN 1) checked Resident 86's g-tube and it was patent. LVN 1 stated she uses a stethoscope to check for patency. LVN 1 stated her supervisor has told her that she did not need to check for patency every medication pass (medication administration). LVN 1 stated she checks for g-tube patency once per day at the beginning of her shift. LVN 1 stated she did not flush the g-tube in between medications because she follows the physician's order which was to flush the g-tube before and after medication administration. LVN 1 stated there was no order to flush the g-tube in between medications. During a concurrent interview and record review on 4/10/2025 at 2:15 p.m. with the DLTC, reviewed the facility's policy and procedure (P&P) titled, Tube Feeding Maintenance and Medication Administration, last reviewed 12/5/2024. The DLTC stated the P&P for g-tube medication administration is to check placement, patency, and residual before every scheduled medication administration time. The DLTC stated the P&P indicated #10 administer prepared medication separately (Do not mix medication) and flush with 15 ml to 30 ml (unless otherwise ordered) of water between each med (prevent air from entering the tube and follow feeding procedure). The DLTC stated medication nurses are expected to flush 15 to 30 ml between every medication unless there is an order to administer specific amount of water to flush. The DLTC stated if there is no physician's order; the standard of practice applicable to residents including Resident 86 is to flush 15 ml to 30 ml of water between medications. During a concurrent interview and record review on 4/10/2025 at 2:47 p.m. with LVN 1, reviewed Resident 86's MAR. LVN 1 stated there was a physician's order to flush Resident 86's g-tube with 30 ml of water before and after medication administration which she did. LVN 1 stated she did not give water flush in between medications because there was no order to flush in between medications. During a concurrent interview and record review on 4/10/2025 at 2:55 p.m. with LVN 1, reviewed the facility's P&P titled, Tube Feeding Maintenance and Medication Administration, last reviewed 12/5/2024. LVN 1 stated she did not follow their P&P to flush in between medications and did not check Resident 86's g-tube placement and patency at every scheduled medication administration. LVN 1 stated the EHM provided the instructions that there is no need to check for g-tube placement and patency at every scheduled medication administration, and that checking for g-tube placement and patency once at the beginning of the shift or the first scheduled medication during her shift was good. During an interview on 4/11/2025 at 11:26 a.m. with the EHM, the EHM stated the standard of practice for g-tube administration is to check for placement, patency, residual, flush with water before medication administration, in between medications, and after medication administration. The EHM stated she did not provide instruction to LVN 1 to only checking placement and patency at the beginning of the shift during the first scheduled medication. The EHM stated their policy is to check for placement, patency, and residual done before administering every scheduled medication to be administered. The EHM stated flushing in between medications is done as to not mix the medications. The EHM stated when flushing in between medications is not done, then it is the same as mixing the medications in the same cup. The EHM stated LVN 1 should have followed their policy when LVN 1 administered medications to Resident 86. During an interview on 4/11/2025 at 1:18 p.m. with the DP, the DP stated their (facility) MARs have a built-in one hour before and one hour after time frames to record medication administration. The DP stated if the medication nurse was unable to sign Resident 19's MAR, they (licensed nurses) would need to check with the provider (resident's physician) if it is okay to give outside the scheduled time. The DP stated the MAR has specified window of when medications can be given because they do not want to give medications too early or too late. The DP stated she expects the medication nurse (licensed nurse) to notify the provider directly or to let the pharmacy know so they (licensed nurses) can place the order. The DP stated the medication nurse should not give the medication outside of the prescribed time because it is deviating from the current order. The DP stated all medications administered should be documented on the MAR and reflect the actual time it was given. During an interview on 4/11/2025 at 1:25 p.m. with the DP, the DP stated medications given through the g-tube should not be mixed and should be flushed in between medications to maintain g-tube patency and to ensure Resident 86 received the whole dose. The DP stated there is a potential for medication interactions and clogging of the g-tube. During an interview on 4/11/2025 at 5:17 p.m. with the DLTC, the DLTC stated it is important for the medication nurse to flush in between medications because they would not know what the drug interaction for Resident 86 and this is to ensure the patency of the g-tube and that the resident receives the medications as ordered. The DLTC stated the purpose of checking for patency and placement is to ensure the g-tube is in the right place. The DLTC stated when this is not done the resident could potentially not receive the medications or the medication could go to a different area of the body and would not be properly absorbed. During a review of the facility's P&P titled, Tube Feeding Maintenance and Medication Administration, last reviewed 12/5/2024, the P&P indicated the purpose of the policy is to provide medication administration when unable to take orally and to monitor for signs and symptoms of infection, irritation at the stoma (a surgically created opening on the abdomen) site. The P&P indicated procedure for medication administration: 1. Check doctor's order. 2. Wash hands and prepare equipment. 3. Identify patient and explain procedure. 4. Position patient; semi-Fowler's position. 5. [NAME] (put on) gloves and check feeding tube for placement, patency, and residual. 6. For GT/JT placement check: air auscultation (a method used to listen to the sounds of the body by using a stethoscope [medical device), stomach secretions, aspiration . 7. Check gastric residual before giving medication (unless otherwise ordered). 8. If residual is greater than 100 ml, hold medication for one hour and repeat check . 9. Flush tube with 30 ml of water prior to administering medication unless physician orders different amount for flush. 10. Administer prepared medication separately (Do not mix medication) and flush with 15 ml to 30 ml (unless otherwise ordered) of water between each med (Prevent air from entering the tube and follow feeding procedure). 11. After medication is administered, instill 30 mls of water to clear the tube or as GNP/ General Nurse Practitioner (GNP)/Physician order indicates. During a review of the facility's P&P titled, General Administrative, last reviewed 3/2024, the P&P indicated the purpose its policy to provide a safe and efficient medication distribution system which shall include the evaluation, selection, purchase, storage, control, dispensing and administration of all drugs, chemicals and pharmaceuticals used throughout the Motion Picture and Television Fund Hospital (MPTF) organization. During a review of the facility's P&P titled, Medication Administration, last reviewed 12/5/2024, the P&P indicated Medication shall be accurately and safely administered to MPTF patients slash resident, by authorized personnel. The P&P indicated the six (6) Rights of Safe Medication Administration are Right Medication, Right Dose, Right Patient/Resident, Right Route, Right Time, and Right Documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from significant medications errors for one (1) of 1 sampled resident (Resident 10) reviewed for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) use and for three of five sampled residents (Resident 66, 19, and 86) reviewed under Medication Administration facility task, by: 1. Failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites for Resident 10. This deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). 2. Failing to ensure Residents 66 and 19's scheduled medications were administered as ordered at the scheduled time. 3. Failing to flush water in between medications for Resident 86 when Licensed Vocational Nurse (LVN) 1 administered the resident's gastrostomy tube (g-tube- a surgical opening fitted with a device to allow feedings to be administered directly to the stomach for people with swallowing problems). These deficient practices had the potential to result in Resident 86 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and the potential to result in Residents 66 and 19's health and well-being to be negatively impacted. Cross reference: F658, F755, F759) Findings: 1. During a review of Resident 66's Face Sheet (FS- front page of the chart that contains a summary of basic information about the resident), the FS indicated the facility admitted the resident on 8/18/2023. During a review of Resident 66's Clinical Record Abstract (CRA), the CRA indicated Resident 66 had diagnoses including dementia (a progressive state of decline in mental abilities), paraplegia (loss of movement and/or sensation, to some degree, of the legs), and seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of Resident 66's Minimum Data Set (MDS-a resident assessment tool), dated 3/21/2025, the MDS indicated Resident 66 had adequate hearing, clear speech, had the ability to make self understood, and usually understand others. The MDS indicated Resident 66 required substantial assistance with eating and was dependent on staff on functional abilities in mobility. During a review of Resident 66's Orders (physician's orders), the Orders indicated: - carboxymethylcellulose sodium (Refresh Tears-eye drops) 0.5 percent (%-a unit of measurement), take two drops twice a day, indication for irritation or dry eye, dated 9/29/2023. - cetirizine hydrochloride (HCL) (Zyrtec-antihistamine helps relieve allergies), give 10 milligrams (mg-a unit of measurement), give 10 mg (1 tablet) by mouth daily, indication for pruritus (itching), dated 4/9/2024. - Eyelid cleanser (Ocusoft lid scrub), instill one pad into both eyes, twice a day, indication for blepharitis (inflammation of the eyelid), dated 12/6/2024. - lacosamide (Vimpat-antiseizure medication) give 150 mg, one tablet by mouth, twice a day, indication for seizure disorder, dated 8/31/2023. - levetiracetam (Keppra- antiseizure) 500 mg, give 750 mg (1.5 tablets) by mouth, twice a day, indication for seizure disorder, dated 2/8/2024. During a review of Resident 66's Medication Administration Record (MAR-a record of medications administered to residents), for April 2025, the MAR indicated the scheduled time for Resident 66's medications to be given at 9 a.m. included carboxymethylcellulose sodium, cetirizine hydrochloride, eyelid cleanser, lacosamide, and levetiracetam. During a concurrent observation and interview on 4/10/2025 at 7:27 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 prepared the following medications for Resident 66: lacosamide, one tablet (tab); levetiracetam 500 mg, 1.5 tabs; cetirizine 10 mg, one tab; carboxymethylcellulose eye drops; and eyelid cleanser. LVN 1 stated she has a total of 3.5 tablets and one eye drops to give. During an observation and interview on 4/10/2025 at 7:31 a.m. with LVN 1, at Resident 66's bedside, LVN 1 administered 3.5 tablets, and one eye drop medications to Resident 66. LVN 1 stated she completed medication administration for Resident 66. During a concurrent interview and record review on 4/10/2025 at 7:34 a.m. with LVN 1, reviewed Resident 66's MAR for 4/10/2025. LVN 1 stated she cannot sign Resident 66's MAR with the actual time she gave the medications because the system will not allow her until 8 a.m. LVN 1 stated the medications she gave were scheduled at 9 a.m. LVN 1 stated she will continue to pass (administer) medications. During an interview on 4/10/2025 at 7:45 a.m. with LVN 1, LVN 1 stated she has notified Residents 66's nurse practitioner weeks before (does not recall exact date) with regard to the resident's preference to administer the medications earlier than the scheduled time. LVN 1 stated they (licensed nurses) have one hour before and one after from the scheduled time to give the medications. LVN 1 stated she was informed by the nurse practitioner and/or physician (does not recall exactly who) that if the resident continues to request to receive the medications earlier than the scheduled time then the timing will be changed. LVN 1 stated she gave the medications earlier because when Resident 66 was up in the chair, it was difficult to administer the eye drops compared to when the resident is was still on bed. LVN 1 stated she also asked Resident 66 if he would like to receive his medications before the scheduled time and Resident 66 stated he would like to take his medications if they were ready. LVN 1 stated she gives the medications to Resident 66 outside the scheduled time about three times a week but not all the time. During an interview on 4/11/2025 at 11:26 a.m. with the Employee Health Manager (EHM), the EHM stated medications should be administered at the scheduled time and can be administered one hour before or one hour after the scheduled time. The EHM stated LVN 1 should have documented the reason for giving medication early for Resident 66. During an interview on 4/11/2025 at 1:18 p.m. with the Director of Pharmacy (DP), the DP stated their MARs have a built-in one hour before and one hour after (time frames to record medication administration). The DP stated if the medication nurse was unable to sign the MAR of Resident 66, they (licensed nurses) would need to check with the provider (resident's physician) if it is okay to give outside the scheduled time. The DP stated the MAR has specified window of when medications can be given because they do not want to give medications too early or too late. The DP stated she expects the medication nurse (licensed nurse) to notify the provider directly or to let the pharmacy know so they (licensed nurses) can place the order. The DP stated the medication nurse should not give the medication outside of the prescribed time because it is deviating from the current order. The DP stated all medications administered should be documented on the MAR and reflect the actual time it was given. During an interview on 4/11/2025 at 5:17 p.m. with the Director of Long-Term Care (DLTC), the DLTC stated medications should be given at the scheduled time. The DLTC stated when medications are not given at the scheduled time, Resident 66 may not get the full effect and may have potential drug interactions. The DLTC stated the medication nurse is expected to clarify with the provider regarding the timing of the medication of Resident 66 and document the communication with the provider. During a review of the facility's P&P titled, General Administrative, last reviewed 3/2024, the P&P indicated the purpose its policy to provide a safe and efficient medication distribution system which shall include the evaluation, selection, purchase, storage, control, dispensing and administration of all drugs, chemicals and pharmaceuticals used throughout the Motion Picture and Television Fund Hospital (MPTF) organization. The P&P indicated that All medications administered to patients must be first ordered by a physician on the MPTF medical staff or an individual who has been granted clinical privileges. Each dose of medication shall be accurately recorded in the patient's medical record. During a review of the facility's P&P titled, Medication Administration, last reviewed 12/5/2024, the P&P indicated Medication shall be accurately and safely administered to MPTF patients/resident by authorized personnel. The procedure P&P indicated the licensed nurses to Sign the eMAR after administration or non-administration of all medications. The P&P indicated the six (6) Rights of Safe Medication Administration are Right Medication, Right Dose, Right Patient/Resident, Right Route, Right Time, and Right Documentation. The P&P indicated the physician's order must include the date and time of the order, name of medication, dose, frequency, route, indication, duration, if appliable, and diagnosis. 2. During a review of Resident 19's FS, the FS indicated the facility admitted the resident on 8/7/2024. During a review of Resident 19's CRA, the CRA indicated Resident 19 had diagnoses including dementia, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and constipation (a problem with passing stool). During a review of Resident 19's MDS, dated [DATE], the MDS indicated Resident 19 had minimal difficulty hearing, clear speech, had the ability to make self understood and understand others. The MDS indicated Resident 19 required staff assistance with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) and mobility. During a review of Resident 19's Orders, the Orders indicated the following: - donepezil HCL (Aricept-used to treat dementia), give 5 mg, one tablet by mouth daily, indication for dementia, dated 8/7/2024. - gabapentin (Neurontin- nerve pain medication), give 100 mg, one capsule by mouth, twice a day, indication for depression m/b refusing and resistance to care, dated 12/24/2024. - metformin extended release (Glucophage Extended Release- medication that helps lower high blood sugar) 500 mg, give 1000 mg (two tablets) by mouth, twice a day, indication for diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), dated 8/7/2024. - pantoprazole (Protonix- decreases amount of acid produced in the stomach) 40 mg, give 40 mg, one tablet by mouth, daily, indication for gastroesophageal reflux disease (GERD- a condition in which the stomach contents move up into the esophagus), dated 8/7/2024. - polyethylene glycol 3350 (Miralax- used to treat constipation) 15 grams (g-a unit of measurement)/dose, give 17 g (one powder) by mouth daily, mix with eight (8) ounces (oz- a unit of measurement) of liquid or juice, indication for constipation, dated 8/7/2024. - solifenacin succinate (Vesicare- used to treat overactive bladder [OAB- a problem with bladder (organ that stores urine before leaving the body) function that causes the sudden need to urinate]) 5 mg, give 5 mg (one tablet) by mouth, daily, indication for OAB, dated 2/21/2025. During a review of Resident 19's MAR, for April 2025, the MAR indicated the scheduled time for Resident 19's medications to be given at 9 a.m. on 4/10/2025 included donepezil HCL, gabapentin, metformin extended release, pantoprazole, polyethylene glycol 3350, and solifenacin. During a concurrent observation and interview on 4/10/2025 at 7:37 a.m. with LVN 1, LVN 1 prepared Resident 19's including medications: pantoprazole 40 mg, one tab; metformin 500 mg, two tabs; gabapentin 100 mg, one capsule; solifenacin 5 mg, one tab; donepezil 5 mg, one tab; polyethylene glycol 17 g. LVN 1 stated she will administer a total of eight medications with seven tablets and one powder. LVN 1 stated she will separate buspirone and gabapentin into a separate medication cup because Resident 19 usually does not want to take all the medications. During a concurrent observation and interview on 4/10/2025 at 7:43 a.m. with LVN 1, at Resident 19's bedside, LVN 1 stated Resident 19 does not want to take all the medications. LVN 1 offered buspirone and gabapentin to Resident 19 which the resident took. LVN 1 offered the rest of the medications but Resident 19 refused. During a concurrent interview and record review on 4/10/2025 at 7:44 a.m. with LVN 1, reviewed Resident 19's MAR for 4/10/2025. LVN 1 stated she cannot sign at 7:44 a.m. the medications administered because the electronic MAR will not save the date and time she gave the medications. LVN 1 stated she will have to wait until 8 a.m. to sign Resident 19's medications. During an interview on 4/10/2025 at 7:45 a.m. with LVN 1, LVN 1 stated she has notified Resident 19's nurse practitioner weeks before (does not recall exact date) with regard to the resident's preference to administer the medications earlier than the scheduled time. LVN 1 stated they (licensed nurse) have one hour before and one after from the scheduled time to give the medications. LVN 1 stated she was informed by the nurse practitioner and/or physician (does not recall exactly who) that if the resident continues to request to receive the medications earlier than the scheduled time then the timing will be changed. During an interview on 4/11/2025 at 11:26 a.m. with the EHM, the EHM stated Resident 19's medications should be administered at the scheduled time and can be administered one hour before or one hour after the scheduled time. The EHM stated LVN 1 should have documented the reason for giving medication early. During an interview on 4/11/2025 at 1:18 p.m. with the DP, the DP stated their (facility) MARs have a built-in one hour before and one hour after time frames to record medication administration. The DP stated if the medication nurse was unable to sign Resident 19's MAR, they (licensed nurses) would need to check with the provider (resident's physician) if it is okay to give outside the scheduled time. The DP stated the MAR has specified window of when medications can be given because they do not want to give medications too early or too late. The DP stated she expects the medication nurse (licensed nurse) to notify the provider directly or to let the pharmacy know so they (licensed nurses) can place the order. The DP stated the medication nurse should not give the medication outside of the prescribed time because it is deviating from the current order. The DP stated all medications administered should be documented on the MAR and reflect the actual time it was given. During an interview on 4/11/2025 at 5:17 p.m. with the DLTC, the DLTC stated Resident 19's medications should have been given at the scheduled time. The DLTC stated when medications are not given at the scheduled time the resident may not get the full effect and may have potential drug interactions.The DLTC stated the medication nurse is expected to clarify with the provider regarding the timing of the medication and document the communication with the provider. During a review of the facility's P&P titled, General Administrative, last reviewed 3/2024, the P&P indicated the purpose its policy to provide a safe and efficient medication distribution system which shall include the evaluation, selection, purchase, storage, control, dispensing and administration of all drugs, chemicals and pharmaceuticals used throughout the Motion Picture and Television Fund Hospital (MPTF) organization. The P&P indicated that All medications administered to patients must be first ordered by a physician on the MPTF medical staff or an individual who has been granted clinical privileges. Each dose of medication shall be accurately recorded in the patient's medical record. During a review of the facility's P&P titled, Medication Administration, last reviewed 12/5/2024, the P&P indicated Medication shall be accurately and safely administered to MPTF patients/resident by authorized personnel. The procedure P&P indicated the licensed nurses to Sign the eMAR after administration or non-administration of all medications. The P&P indicated the six (6) Rights of Safe Medication Administration are Right Medication, Right Dose, Right Patient/Resident, Right Route, Right Time, and Right Documentation. The P&P indicated the physician's order must include the date and time of the order, name of medication, dose, frequency, route, indication, duration, if appliable, and diagnosis. 3. During a review of Resident 86's FS, the FS indicated the facility admitted Resident 86 on 3/5/2025. During a review of Resident 86's CRA, the CRA indicated Resident 86 had diagnoses including epilepsy (a condition that affects the brain and causes frequent seizures, muscle spasm (a sudden, involuntary movement in one or more muscles), neuralgia (a sharp, shocking pain that follows the path of a nerve and is due to irritation or damage to the nerve), and neuritis (inflammation of a nerve). During a review of Resident 86's MDS, dated [DATE], the MDS indicated Resident 86 had unclear speech, adequate hearing, rarely/never made self understood, and rarely/never understands others. The MDS indicated Resident 86 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 86 required assistance from staff with ADLs and mobility. The MDS indicated the resident had a feeding tube (a flexible tube inserted into the stomach or intestines to deliver liquid nutrition) while a resident of the facility. During a review of Resident 86's Orders, the Orders indicated: - gabapentin 300 mg, give 300 mg (one tablet) via g-tube three times a day, administer through the percutaneous endoscopic gastrostomy (PEG- a procedure for placing a feeding tube directly into the stomach through the abdominal wall, bypassing the mouth and esophagus) tube, indication for neuralgia and neuritis, dated 3/5/2025. - quetiapine fumarate (Seroquel- drug used to manage abnormal condition of the mind described as involved a loss of contact with reality) 100 mg, give 100 mg (one tablet) via g-tube three times a day via PEG tube, indications for encephalopathy (a disease that affects the function or structure of the brain) secondary to hypoxic brain injury (low levels of oxygen in the brain causing irreversible damage) m/b agitation, dated 3/6/2025. - baclofen 10 mg, give 15 mg (1.5 tablets) via g-tube, three times a day, indication for muscle spasticity of cerebral (brain) origin, dated 4/6/2025. During a review of Resident 86's MAR, for April 2025, the MAR indicated the scheduled time for Resident 86's medications to be given at 2 p.m. included gabapentin, quetiapine, and baclofen. During a concurrent observation and interview on 4/10/2025 at 1 p.m. with LVN 1, LVN 1 prepared Resident 86's medications: quetiapine 100 mg, one tab; gabapentin 300 mg, one capsule; baclofen 10 mg, 1.5 tablets. LVN 1 stated she will administer three medications, total 3.5 tablets to give. LVN 1 crushed each tablets separately in a plastic pouch and poured separately into each medication cup. Observed LVN 1 poured five to 10 ml of water into each medication cup and stirred the medications. During an observation on 4/10/2025 at 1:10 p.m. with LVN 1, at Resident 86's bedside, LVN 1 informed Resident 86 that she (LVN 1) prepared the resident's medications to administer. LVN 1 located Resident 86's g-tube and checked g-tube residual (the amount aspirated from the stomach following administration of enteral feed) which was zero (0) ml. LVN 1 flushed Resident 86's g-tube with 30 ml of water by gravity. LVN 1 administered all three medications with no flushing of water in between medications then flushed with 30 ml of water afterwards. LVN 1 stated she had completed medication pass for Resident 86. During an interview on 4/10/2025 at 1:24 p.m. with LVN 1, LVN 1 stated she prepared Resident 86's medications then she went inside Resident 86's room. LVN 1 stated she checked Resident 86's g-tube residual and there was none. LVN 1 stated she flushed the g-tube with 30 ml and gave the medications then flushed the g-tube another 30 ml afterwards. LVN 1 stated she did not flush the g-tube in between medications because she follows the physician's order which was to flush the g-tube before and after medication administration. LVN 1 stated there was no order to flush the g-tube in between medications. During a concurrent interview and record review on 4/10/2025 at 2:15 p.m. with the DLTC, reviewed the facility's policy and procedure (P&P) titled, Tube Feeding Maintenance and Medication Administration, last reviewed 12/5/2024. The DLTC stated the P&P for g-tube medication administration is to check placement, patency, and residual before every scheduled medication administration time. The DLTC stated the P&P indicated #10 administer prepared medication separately (Do not mix medication) and flush with 15 ml to 30 ml (unless otherwise ordered) of water between each med (prevent air from entering the tube and follow feeding procedure). The DLTC stated medication nurses are expected to flush 15 to 30 ml between every medication unless there is an order to administer specific amount of water to flush. The DLTC stated if there is no physician's order; the standard of practice applicable to residents including Resident 86 is to flush 15 ml to 30 ml of water between medications. During a concurrent interview and record review on 4/10/2025 at 2:47 p.m. with LVN 1, reviewed Resident 86's MAR. LVN 1 stated there was a physician's order to flush Resident 86's g-tube with 30 ml of water before and after medication administration which she did. LVN 1 stated she did not give water flush in between medications because there was no order to flush in between medications. During a concurrent interview and record review on 4/10/2025 at 2:55 p.m. with LVN 1, reviewed the facility's P&P titled, Tube Feeding Maintenance and Medication Administration, last reviewed 12/5/2024. LVN 1 stated she did not follow their P&P to flush in between medications and did not check Resident 86's g-tube placement and patency at every scheduled medication administration. During an interview on 4/11/2025 at 11:26 a.m. with the EHM, the EHM stated the standard of practice for g-tube administration is to check for placement, patency, residual, flush with water before medication administration, in between medications, and after medication administration. The EHM stated flushing in between medications is done as to not mix the medications. The EHM stated when flushing in between medications is not done, then it is the same as mixing the medications in the same cup. The EHM stated LVN 1 should have followed their policy when LVN 1 administered medications to Resident 86. During an interview on 4/11/2025 at 1:25 p.m. with the DP, the DP stated medications given through the g-tube should not be mixed and should be flushed in between medications to maintain g-tube patency and to ensure Resident 86 received the whole dose. The DP stated there is a potential for medication interactions and clogging of the g-tube. During an interview on 4/11/2025 at 5:17 p.m. with the DLTC, the DLTC stated it is important for the medication nurse to flush in between medications because they would not know what the drug interaction for Resident 86 and this is to ensure the patency of the g-tube and that the resident receives the medications as ordered. The DLTC stated the purpose of checking for patency and placement is to ensure the g-tube is in the right place. The DLTC stated when this is not done the resident could potentially not receive the medications or the medication could go to a different area of the body and would not be properly absorbed. During a review of the facility's P&P titled, Tube Feeding Maintenance and Medication Administration, last reviewed 12/5/2024, the P&P indicated the purpose of the policy is to provide medication administration when unable to take orally and to monitor for signs and symptoms of infection, irritation at the stoma (a surgically created opening on the abdomen) site. The P&P indicated procedure for medication administration: 1. Check doctor's order. 2. Wash hands and prepare equipment. 3. Identify patient and explain procedure. 4. Position patient; semi-Fowler's position. 5. [NAME] (put on) gloves and check feeding tube for placement, patency, and residual. 6. For GT/JT placement check: air auscultation (a method used to listen to the sounds of the body by using a stethoscope [medical device), stomach secretions, aspiration . 7. Check gastric residual before giving medication (unless otherwise ordered). 8. If residual is greater than 100 ml, hold medication for one hour and repeat check . 9. Flush tube with 30 ml of water prior to administering medication unless physician orders different amount for flush. 10. Administer prepared medication separately (Do not mix medication) and flush with 15 ml to 30 ml (unless otherwise ordered) of water between each med (Prevent air from entering the tube and follow feeding procedure). 11. After medication is administered, instill 30 mls of water to clear the tube or as GNP/ General Nurse Practitioner (GNP)/Physician order indicates. During a review of the facility's P&P titled, General Administrative, last reviewed 3/2024, the P&P indicated the purpose its policy to provide a safe and efficient medication distribution system which shall include the evaluation, selection, purchase, storage, control, dispensing and administration of all drugs, chemicals and pharmaceuticals used throughout the Motion Picture and Television Fund Hospital (MPTF) organization. During a review of the facility's P&P titled, Medication Administration, last reviewed 12/5/2024, the P&P indicated Medication shall be accurately and safely administered to MPTF patients/resident by authorized personnel. 4. During a review of Resident 10's Face Sheet, the Face Sheet indicated the facility admitted the resident on 6/30/2021. During a review of Resident 10's Clinical Record Abstract printed on 4/11/2025, the Clinical Record Abstract indicated Resident 10's diagnoses including type 2 diabetes mellitus (DM 2-a disorder characterized by difficulty in blood sugar control and poor wound healing), anxiety disorder (mental health condition characterized by excessive and persistent worry, fear, and unease that can interfere with daily life), and chronic pain syndrome. During a review of Resident 10's History and Physical (H&P) dated 9/27/2024, the H&P indicated Resident 10 was alert and oriented to full name, exact date, and location. During a review of Resident 10's Minimum Data Set (MDS, a resident assessment tool), dated 3/4/2025, the indicated Resident 10 had an intact cognition (mental action or process of acquiring knowledge and understanding) and required substantial/maximal assistance to total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS further indicated Resident 10 received insulin. During a review of Resident 10's physician's order, the physician's order dated 10/2/2024 liraglutide (Victoza - a long-acting insulin) 0.6 milligrams (mg - a unit of measurement) per 0.1 milliliter (ml - a unit of measurement), inject 1.8 mg (0.3 ml) subcutaneously daily at eight (8) a.m. for DM 2. During a review of Resident 10's care plan (CP) titled Medical Condition: related to DM2, initiated on 6/30/2021, the CP indicated to administer liraglutide (Victoza) as one of the interventions to prevent complications or problems with medical conditions. During a concurrent interview and record review, on 4/11/2025 at 8:57 am., reviewed Resident 10's physician's order, subcutaneous administration sites for Victoza from 1/8/2025 to 4/11/2025, and the MDS with Registered Nurse (RN) 1. RN 1 stated Resident 10 received insulin, had a physician's order for Victoza, and were administered as follows: - 3/19/2025 9:26 a.m. left middle mid-thigh - 3/20/2025 9:10 a.m. left middle mid-thigh - 1/27/2025 9:21 a.m. right lower back of arm - 1/28/2025 8:43 a.m. right lower back of arm - 1/5/2025 8:59 a.m. right lower quadrant - 1/6/2025 8:22 a.m. right lower quadrant RN 2 stated administration sites for insulin should be rotated per standards of practice and manufacturer's guideline to prevent hardening or lumps in the skin. RN 2 stated the location of administration sites for Resident 10's insulin was not rotated. RN 2 stated Resident 10's administration sites should have been rotated to prevent pain, redness, irritation, and lumps on the resident's skin which can affect the absorption of the insulin. RN 2 stated not rotating the insulin administration sites can be considered a medication due to no following the standards of practice and manufacturer's guideline. During an interview on 4/11/2025 a 4 p.m., with the Director of Long-Term Care (DLTC), the DLTC stated the nurses are supposed to rotate insulin administration sites according to standards of practice, and as indicated in the manufacturer's guideline. The DLTC stated the location of administration sites for Resident 10's insulin was not rotated. The DLTC stated Resident 10's administration sites for the Victoza should have been rotated to prevent adverse effects such as bruising, skin irritation, skin pits, lipodystrophy and amyloidosis which can affect absorption of the insulin. The DLTC stated not rotating the insulin administration sites can be considered a medication due to no following the standards of practice and manufacturer's guideline. During a review of the facility-provided manufacturer's guideline for Victoza liraglutide injection1.2 mg/1.8 mg dated 11/2024, the manufacturer's guideline indicated: - Inject Victoza SQ in the abdomen, thigh, or upper arm. - Rotate injection sites within the same region in order to reduce the risk of cutaneous amyloidosis. - Adverse reaction includes injection site reactions such as injection site rash and erythema (redness of the skin).

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. One disposable cup of coffee belonging to a kitchen staff was placed on top of a metal cart outside the dry food storage area. 2. One and a half boxes of open box of dried noodles and not labeled with an open date was stored in the dry storage area 3. One open bottle of instant coffee and not labeled with an open date was stored in the dry storage area. 4. One open box of wonton chips inside an unsealed plastic bag as not labeled with an open date. 5. One container had a label peas, black eyed dried but observed brown colored short grain inside the container. 6. Observed red potatoes inside a bin that was wet. These deficient practices had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (transfer of bacteria from one object to another) in 88 of 89 residents who receive food from the kitchen. Findings: During a concurrent observation during initial kitchen tour and interview on 4/7/2025 at 8:05 a.m. with the Director of Hospitality Services (DHS), observed the following: 1. One cup of disposable cup of coffee belonging to a kitchen staff was placed on top of a metal cart outside the dry food storage area. The DHS stated there should be no personal or staff food items in the kitchen area to prevent cross contamination. 2. One and a half boxes of open box of dried noodles and not labeled with an open date in the dry storage area. The DHS stated the facility has a labeling machine that dispenses the exact date and time and that all opened items should have a label with an open date. The DHS stated both boxes of the noodles should have been labeled with an open date so the staff would know when the item or product was opened. 3. One open bottle of instant coffee and not labeled with an open date in the dry storage area. The DHS stated all opened items should have a label with an open date. The DHS stated the bottle of instant coffee should have been labeled with an open date so the staff would know when the item or product was opened. 4. One open box of wonton chips inside an unsealed plastic bag and was not labeled with an open date. The DHS stated all opened items should be labeled with an open date and sealed inside the plastic bag. The DHS stated the plastic bag containing the wonton chips should have been sealed when opened and labeled with an open date to prevent contamination of the food item inside the box. 5. One container had a label peas, black eyed dried but observed brown colored short grain inside the container. The DHS stated the brown colored short grain inside the container did not look like dried black-eyed peas. The DHS stated the brown colored short grain in the container looks like brown rice. The DHS food items should be labeled correctly to prevent confusion. The DHS stated the container should have been labeled properly to prevent confusion with the staff. 6. Observed red potatoes inside a bin that was wet. The DHS stated produce items should be stored in a dry container. The DHS stated the red potatoes should have been stored in a dry container as it had the potential to develop mildew and cause contamination of the food item in the container. During an interview on 4/11/2025 at 3:30 p.m. with the Director of Long-Term Care (DLTC), the DLTC stated there should be no personal food items by the kitchen staff in the kitchen food preparation area as it had the potential for cross contamination in the kitchen. The DLTC stated all opened items should be labeled with an open date so the staff would know when to discard the items. The DLTC stated all produce should be stored in a dry container as it had the potential to develop mold. The DLTC stated the containers should be labeled properly to prevent confusion with the staff during food preparation. The DLTC all these failures placed the residents at risk for food borne illnesses. During a review of the facility's policy and procedure (P&P) titled, Food and Supply Storage, last reviewed on 1/2025, the P&P indicated all food and non-food items and supplies used in food preparation shall be stored in a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. The P&P further indicated: - Cover, label, and date unused portions and open packages. - Store potatoes in a dry, dark area. - Store foods in their original packages. Foods that must be opened must be stores in NSF approved containers that have tight fitting lids. Label both the bin and the lid. During a review of Food Code 2022, the Food Code 2022 indicated, 3-501.17 Commercially processed food, open and hold cold, (B) except specified in (E) - (G) of this section, refrigerated, ready-to-eat time/temperature control for food safety food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacture's use-by- date if the manufacturer determined the use-by date based on food safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain timely and accurate resident medical records for two of 21 sampled residents (Residents 4 and 86) when: a. For Resident 4, the Physical Therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) Discharge Summary (DC) and Occupational Therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Discharge Summary was not completed after PT treatment and OT treatments were completed in 1/2025. b. For Resident 86, the PT Discharge Summary was not completed after PT treatment was completed on 3/26/2025. These deficient practices had the potential for inaccurate medical documentation and cause a delay in provision of appropriate interventions for Residents 4 and 86. Findings: a. During a review of Resident 4's Face Sheet (FS), the FS indicated Resident 4 admitted to the facility on [DATE] with diagnoses including, but not limited to congestive heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and polyarthritis (swelling and tenderness of multiple joints causing pain and stiffness). During a review of Resident 4's Minimum Data Set (MDS, resident assessment tool) dated 2/21/2025, the MDS indicated Resident 4 had moderate cognitive impairment (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving). The MDS indicated Resident 4 had no functional limitations in range of motion (ROM, full movement potential of a joint) in both upper extremities (UE, shoulder, elbow, wrist/hand) and had impairments in ROM on both sides of the lower extremities (LE, hip, knee, ankle/foot). The MDS indicated Resident 4 required supervision for eating, substantial assistance with toileting, bathing, sit to stand, and bed to chair transfers. During a review of Resident 4's Physical Therapy Evaluation dated 8/29/2024, the PT evaluation indicated a recommendation for PT treatment two times a week for four weeks and recommended Resident 4 for ROM and strengthening at discharge. During a review of Resident 4's PT medical records, the PT medical records indicated the last PT treatment note was completed on 1/3/2025. There was no PT DC noted in the resident's medical record. During a review of Resident 4's OT Evaluation dated 8/29/2024, the OT Evaluation indicated a recommendation for OT treatment two times a week for four weeks. During a review of Resident 4's OT medical records, the OT medical records indicated the last OT treatment note was completed on 1/4/2025. There was no OT DC noted in the resident's medical record. During an interview on 4/9/2025 at 2:51 p.m., the Registered Nurse Supervisor (RN 1) stated once a resident was discharged from PT and OT services, the therapists would write a discharge summary and recommendation and inform the nursing staff so that nursing could input the recommendations. During an interview and record review on 4/10/2025 at 11:04 a.m., the Therapy Manager/Occupational Therapist (TM/OT) reviewed Resident 4's therapy medical records and stated the last OT treatment was completed on 1/4/2025 and Resident 4 was discharged from OT on 1/7/2025. TM/OT stated the OT DC should have been completed on 1/7/2025 and it was not completed. The TM/OT stated the last PT treatment was on 1/3/2025 and Resident 4 was discharged from PT on 1/7/2025. TM/OT stated the PT DC should have been completed on 1/7/2025 and it was not completed. TM/OT stated all residents that have been discharged from therapy services should have a completed DC summary. TM/OT stated the DC summary shows the resident's progress, current level of function, and recommendations at DC such as an RNA program. TM/OT stated Resident 4's RNA recommendation at therapy DC should have been for ROM and transfers and Resident 4's RNA orders should have been updated. During a review of the facility's policies and procedures (P&P) proved 6/13/2024, titled, Inter-disciplinary Resident/Patient Assessment and Reassessment, the P&P indicated all documentation must be completed within 48 hours of service provided or service attempted. b. During a review of Resident 86's Face Sheet (FS), the FS indicated Resident 86 admitted to the facility on [DATE] with diagnoses including but not limited to anoxic brain damage (damage to brain due to lack of oxygen supply to the brain), hemiplegia (weakness to one side of the body) affecting right dominant side, monoplegia (paralysis of one side of the body) of upper limb affecting left nondominant side, and aphagia (a disorder that makes it difficult to speak). During a review of Resident 86's MDS dated [DATE], the MDS indicated was severely impaired in cognitive skills for daily decision making. The MDS indicated Resident 86 had functional limitation impairments in ROM on both sides of the upper extremities and on one side of the lower extremities. The MDS indicated Resident 86 was dependent on staff for oral hygiene, toileting, bathing, dressing, and bed to chair transfers. During a review of Resident 86's PT Evaluation dated 3/6/2025, the PT Evaluation indicated a recommendation for PT treatment three times a week for four weeks. During a review of Resident 86's PT medical records, the PT medical records indicated the last PT treatment note was completed on 3/26/2025. There was no PT DC noted in the resident's medical record. During an interview and record review on 4/9/2025 at 3:43 p.m., the Physical Therapist (PT 1) stated Resident 86's last PT treatment was completed on 3/26/2025 and was discharged from PT on 4/1/2025. PT 1 stated the PT DC was not completed. PT 1 stated it was important for therapy staff to complete DC summaries for all residents, because it informed everyone that Resident 86 was no longer on PT services. PT 1 stated it provided a summary of how the resident performed during PT, and provided recommendations after discharge for the resident. During a review of the facility's policies and procedures (P&P) proved 6/13/2024, titled, Inter-disciplinary Resident/Patient Assessment and Reassessment, the P&P indicated all documentation must be completed within 48 hours of service provided or service attempted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 86's Face Sheet (FS), the FS indicated Resident 86 admitted to the facility on [DATE] with diagnoses including but not limited to anoxic brain damage (damage to brain due to lack of oxygen supply to the brain), hemiplegia (weakness to one side of the body) affecting right dominant side, monoplegia (paralysis of one side of the body) of upper limb affecting left nondominant side, and aphagia (a disorder that makes it difficult to speak). During a review of Resident 86's Minimum Data Set (MDS, a resident assessment tool) dated 3/11/2025, the MDS indicated was severely impaired in cognitive skills for daily decision making. The MDS indicated Resident 86 was dependent on staff for oral hygiene, toileting, bathing, dressing, and bed to chair transfers. During a review of Resident 86's Care Plan (CP) dated 3/5/2025, the CP indicated Resident 86 was on EBP related to gastronomy tube (g-tube, a tube placed directly into the stomach for long-term feeding), wear appropriate PPE during activities of daily living, cleaning and disinfecting the environment, mobility assistance and preparing to leave the room, and transferring. During an observation and interview on 4/8/2025 at 9:33 a.m., there was a sign outside Resident 86's room indicating EBP for Resident 86 and an isolation cart with gowns and gloves. Resident 86 was laying on the bed dressed and had a hoyer lift (a mechanical lift that allows a person to be transferred from one surface to another) sling underneath Resident 86. CNA 1 stated she was going to get assistance from another staff to transfer Resident 86 to the geriatric chair (a large, padded chair designed to help persons with limited mobility). CNA 1 exited the room and CNA 1 re-entered the room and put on gloves. Staff 1 put on gloves and entered Resident 86's room. CNA 1 and Staff 1 proceeded to transfer Resident 86 from the bed to the geriatric chair with a hoyer lift. While Resident 86 was in the geriatric chair, CNA 1 assisted Resident 86 with oral hygiene using swabs. CNA 1 and Staff 1 were not observed wearing isolation gowns while providing care inside Resident 86's room. During an interview on 4/8/2025 at 9:46 a.m., Licensed Vocational Nurse (LVN 1) stated Resident 86 was on EBP, because Resident 86 had a g-tube. LVN 1 stated staff providing care such as transferring and hygiene for Resident 86 would need to wear an isolation gown and gloves. During an interview on 4/8/2025 at 9:51 a.m., CNA 1 stated Resident 86 had a g-tube so staff needed to wear isolation gown and gloves when working with Resident 86. CNA 1 stated she did not wear an isolation gown when she assisted Resident 86 with transfers and when providing oral hygiene. CNA 1 stated staff should wear PPE when there was possible contact with bodily fluids because it protected staff and the residents they worked with. CNA 1 read the EBP sign outside Resident 86's door and stated the sign indicated to wear gown and gloves during activities such as transferring and hygiene. During an interview on 4/9/2025 at 11:03 a.m., the Infection Preventionist (IP) stated for any resident with wounds or devices like a g-tube, staff need to follow EBP when performing close contact activities with residents. IP stated staff needed to wear isolation gowns and gloves with resident-care activities such as dressing, toileting, transferring, and oral care,. During a review of the facility's policy and procedures (P&P) revised 3/1/2025, titled, Enhanced Barrier Precautions, the P&P indicated the need for EBP by healthcare providers while caring for residents at high-risk for MDRO transmission, presence of indwelling devices: feeding tube, wounds covered by a dressing. High-contact resident care activities for which EBP would apply: dressing, transferring, changing linens, changing briefs or assisting with toileting. Procedure: perform hand hygiene, don PPE gown, gloves upon entry and before beginning activity. Remove and discard PPE and perform hand hygiene in the room when activity is complete. 3. During a review of Resident 39's Face Sheet, the Face Sheet indicated the facility admitted the resident on 4/18/2018. During a review of Resident 39's Clinical Record Abstract, the Clinical Record Abstract indicated Resident 39's diagnoses including neurocognitive (a decline in thinking, reasoning, and memory abilities due to a medical condition, injury, or illness affecting the brain) disorder with Lewy bodies dementia (a type of progressive dementia [a progressive state of decline in mental abilities] that leads to a decline in thinking, reasoning and independent function due to protein deposits in the brain), stage 2 pressure ulcer (partial-thickness loss of skin, presenting as a shallow open sore or wound) sacral region (a bone located at the bottom of the spine), and retention of urine. During a review of Resident 39's History and Physical (H&P) dated 2/17/2025, the H&P indicated the resident was non-verbal but occasionally makes eye contact and able to track voices. During a review of Resident 39's Minimum Data Set (MDS - a resident assessment tool) dated 3/14/2025, the MDS indicated Resident 39 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 39's care plan (CP) on stage 2 pressure injury on sacrum initiated on 11/25/2024, the CP indicated the resident is on EBP related to wound, wear appropriate PPE during ADL as one of the interventions to assist heal the wound without complications. During an observation on 4/7/2025 at 10:18 a.m., inside Resident 39's room, observed Certified Nursing Assistant (CNA) 5 providing care to the resident and not wearing a gown. Observed a sign outside the door for an EBP which indicated everyone must clean their hands before entering and when leaving the room, and providers and staff must wear gloves and a gown during high-contact resident care activities such as dressing, bathing, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device, and wound care. During an interview on 4/7/2025 at 10:24 a.m. with CNA 5 outside Resident 39's room, CNA 5 stated he did not clean his hands prior to putting on gloves and did not put on a gown while providing care to Resident 39. CNA 5 stated he forgot that the resident was on EBP. CNA 5 stated the staff are supposed to clean their hands using the hand sanitizer and put on gloves and gown prior to providing care to residents on EBP. CNA 5 stated he should have cleaned his hands with the hand sanitizer prior to putting on gloves and wear a gown while providing care to Resident 39 to protect the spread of infection between residents. During an interview on 4/7/2025 at 10:30 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 39 was on EBP due to presence of wound on the sacral region and the staff should wear a gown while providing care to the resident and during wound care. LVN 1 stated CNA 5 should have put on a gown while providing care to Resident 39 to prevent the spread of infection between residents. During an interview on 4/11/2025 at 3:43 p.m. with the Director of Long-Term Care (DLTC), the DLTC stated the staff are supposed to wear a gown during high contact activities such as dressing, bathing, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device, and wound care as indicated in the signage outside the doors. The DLTC stated CNA 5 should have performed hand hygiene prior to putting on gloves and then put on a gown while providing care to Resident 30 to protect the staff as well as spread of infection to other residents who are vulnerable. During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, last reviewed on 3/1/2025, the P&P indicated a purpose to implement EBP as a resident-centered approach and activity approach for preventing Multidrug Resistant Organisms (MDRO - a germ, usually bacteria, that has become resistant to many different antibiotics) transmission in a healthcare setting. The P&P further indicated: - The use of PPE by healthcare personnel during specific care activities is based on periodic assessments of a resident's risk for MDRO colonization and transmitting MDROs. - To assess characteristics of residents at high risk for MDRO colonization and transmission: Wounds covered by a dressing, especially chronic wounds. - High-contact resident care activities for which EBP would apply: Dressing Bathing/Showering Transferring Changing linens Changing briefs or assisting with toileting Device care or use Wound care; any skin opening requiring a dressing - Perform hand hygiene. - If needed, based on the procedure about to be performed to a resident, don (put on) PPE such as gown and gloves upon entry and before beginning activity. Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections for three of 21 sampled residents (Residents 47, 86, 39) investigated during the Infection Control task by failing to ensure: 1) Activities Assistant (AA) 1 donned (put on) Personal Protective Equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) upon entering Resident 47's room who was on droplet precautions (measure aimed to prevent the spread of diseases transmitted through respiratory droplets). 2) Certified Nursing Assistant (CNA 1) and Staff 1 donned an isolation gown when performing high contact activities with Resident 86 who was on Enhanced Barrier Precautions (EBP, infection control practice to reduce transmission of infectious organisms). 3) Certified Nursing Assistant (CNA 5) donned proper PPE prior to performing activities of daily living (ADL - basic tasks that must be accomplished every day for an individual to thrive) care to Resident 39 who was on EBP. 4) Linen Carts A, B, C were not covered with a loosely woven/permeable (having pores or openings that permit liquids or gases to pass through) material to protect the clean linens inside the cart. These deficient practices had the potential to spread infections and illnesses to residents, visitors, and staff. Findings: 1. During a review of Resident 47's Face Sheet, the Face Sheet indicated the facility admitted the resident on 9/8/2021. During a review of Resident 47's Patient Diagnosis Information, the Patient Diagnosis Information indicated the resident had diagnoses including bilateral (both, left and right) osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of knees and hypertensive heart disease with heart failure (refers to heart problems that occur because of high blood pressure that is present over a long time, and results in heart failure in which the heart does not pump blood to the body effectively). During a review of Resident 47's Minimum Data Set (MDS - resident assessment tool), dated 2/7/2025, the MDS indicated the facility most recently admitted the resident on 4/25/2022. The MDS indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated the resident required substantial/maximal assistance from staff for upper body dressing and was dependent on staff for toileting, bathing, lower body dressing, and chair to chair/bed transfers. During a review of Resident 47's Care Plan (CP) titled, Alteration in Respiratory Function as evidenced by low grade fever, cough, nasal congestion, watery eyes, initiated 4/8/2025, the CP indicated interventions including the infection control nurse was notified, to test the resident for viruses, and to place the resident on droplet precautions for respiratory symptoms. During a review of Resident 47's physician orders, dated 4/9/2025, the physician orders indicated an order for droplet precautions until 4/14/2025. During a concurrent observation and interview, on 4/9/2025, at 9 a.m., with AA 1, outside of Resident 47's room, Resident 47 had a droplet precaution sign posted at the room entrance. Resident 47's room entrance had a closed door. AA 1 opened Resident 47's door from inside the room. AA 1 spoke with Resident 47 without a mask and exited the room. AA 1 stated he was discussing activities with Resident 47 and did not need to wear a mask or any PPE because he was not providing care to Resident 47. AA 1 looked at the droplet precaution sign and stated the sign was a different color than it was yesterday. AA 1 stated he did not read the sign prior to entering Resident 47's room. AA 1 reviewed the droplet precaution sign and stated the sign indicated droplet precautions, stop and see the nurse before entering the room, and wear a disposable surgical-grade mask when entering the resident room. AA 1 stated he was not sure why there was a droplet precaution sign on Resident 47's door but would ask the assigned nurse. During a concurrent observation and interview, on 4/9/2025, at 9:05 a.m., with Licensed Vocational Nurse (LVN) 3 and AA 1, AA 1 spoke with LVN 3 and stated he did not wear any PPE while speaking to Resident 47 at the bedside. LVN 3 stated the droplet precaution sign was placed on the resident's door because the resident is symptomatic of a respiratory virus. LVN 3 stated AA 1 should pay attention and read the sign prior to entering the resident's room to ensure AA 1 donned a mask. AA 1 stated he did not see the sign. LVN 3 stated the importance of wearing a mask in the resident's room is to prevent the spread of contagious illnesses like the flu (a highly contagious respiratory illness, which spreads easily through the air or when people touch contaminated surfaces) or COVID-19 (a highly contagious viral infection that can trigger respiratory tract infection) to other staff, visitors, or residents. During an interview, on 4/11/2025, at 11:15 a.m., with the Director of Long-Term Care (DLTC), the DLTC stated droplet precautions are used to prevent the transmission of infections by coughing. The DLTC stated isolation signs are posted at the entrance to a resident's room as the main method of communication with staff and visitors regarding any precautions. The DLTC stated she was made aware that AA 1 entered Resident 47's room without a mask. The DLTC stated AA 1 did not check the droplet precaution sign prior to entering Resident 47's room, but AA 1 should have. The DLTC stated the facility policy and procedure (P&P) was not followed by AA 1 and there is the potential that AA 1 may spread infections from Resident 47 to other staff and residents resulting in resident illness. During a review of the facility P&P titled, Listing of Category - Specific Isolation Precaution Techniques, last reviewed 10/2024, the P&P indicated there are two (2) levels of isolation precautions. The first, and most important, level are those precautions designed for the care of all residents, regardless of their diagnosis or presumed infection status. These are called Standard Precautions. The second level are precautions designed only for the care of specified residents. These additional Transmission-Based Precautions are for residents known or suspected to be infected by significant pathogens spread by airborne or droplet transmission or by contact with dry skin or contaminated surfaces. In addition to Standard Precautions, use Droplet Precautions, or the equivalent, for a patient known or suspected to be infected with microorganisms transmitted by droplets (large-particle droplets that can be generated by the patient during coughing or sneezing). In addition to standard precautions, wear a mask when working within six feet (a unit of measure) of the patient/resident. 4. During a concurrent observation and interview on 4/11/2025, at 10:21 a.m., with Certified Nursing Assistant (CNA) 3, on the unit hallway, observed Linen Carts A and B covered with loosely woven/permeable cover to protect the clean linens inside the cart. CNA 3 stated the cover had tiny holes that bacteria and viruses could go through, and liquid can permeate the cover and will not totally protect the linens from environmental contaminants. During a concurrent observation and interview on 4/11/2025, at 10:24 a.m., with CNA 4, on the unit hallway, observed linen Linen Cart C covered with loosely woven/permeable cover to protect the clean linens inside the cart. CNA 4 stated the cover had tiny holes that bacteria and viruses could go through, and liquid can permeate the cover and will not totally protect the linens from environmental contaminants. During a concurrent observation an interview on 4/11/2025, at 10:27 a.m., with Licensed Vocational Nurse (LVN) 3, on the unit hallway, observed Linen Carts A and B covered with loosely woven/permeable cover to protect the clean linens inside the cart. LVN 3 stated the cover was not totally protecting the linens inside the carts as air and water can penetrate the cover. LVN 3 stated viruses and bacteria were minute and can penetrate the cover and settle on the linen causing infection to residents. During an interview on 4/11/2025, at 10:51 a.m., with the Director of Environmental Services (DEVS), the DEVS stated the covers for the linens were not totally protecting them (linens) from environmental contaminants because air and water can seep through the covers. During an interview on 4/11/2025, at 3:23 p.m., with the Director of Long-Term Care (DLTC), the DLTC stated they should use non-permeable cover to protect the clean linens in the facility to prevent the spread of infection among residents. During a review of the facility's recent policy and procedure (P&P) titled Linen, last reviewed on 10/2024, the P&P indicated to ensure that neither dirty laundry does not serve as a means of transmission for infection or colonization. To prevent contamination of clean linen. Clean linen should be transported in covered carts/containers.

Based on observation, interview and record review, the facility failed to provide care in a manner that maintained or enhance a resident's dignity and respect in full recognition of their individuality during one (Resident 11) of one random observation by failing to ensure the resident's urinary catheter drainage bag (a bag designed to urine drained from the bladder via a catheter) was covered with a privacy bag. This deficient practice had the potential to affect the residents' sense of self-worth and self-esteem. Findings: A review of Resident 11's Face Sheet indicated the facility admitted the resident on 2/14/2024 with diagnoses including neuromuscular dysfunction of bladder (refers to a number of urinary conditions in people who lack bladder control due to a brain, spinal cord or nerve problem), spinal stenosis (narrowing of the spinal column that causes pressure on the spinal cord, and benign prostatic hyperplasia (BPH - a condition in which the prostate gland becomes very enlarged and may cause problems associated with urination). A review of Resident 11's History and Physical (H&P) dated 3/27/2024, indicated the resident was able to make his needs known but did not indicate the capacity to make decisions. A review of Resident 11's Minimum Data Set (MDS - an assessment and care screening tool) dated 10/5/2023, indicated the resident had severely impaired cognition ((mental action or process of acquiring knowledge and understanding) and required supervision or touching assistance with eating; partial or moderate assistance with oral hygiene and roll left and right; substantial or maximal assistance with upper body dressing, personal hygiene sit to lying and lying to sitting o side of bed; dependent with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 11's Physician's Orders indicated the following orders on 12/18/2023. - Foley catheter daily as needed. Indwelling foley catheter 18FR- 10 ml to gravity drainage. May replace as needed plugged or bypassing. - Foley catheter every eight hours. Foley catheter care every shift. No intake and output monitoring needed. During a concurrent observation and interview on 4/1/2024 at 11:30 a.m. in Resident 11's room with Licensed Vocational Nurse 2, (LVN 2) verified the resident's urinary catheter drainage bag was visible from the doorway and did not have a privacy cover. LVN 2 stated the drainage bag should have a privacy cover per facility policy to preserve the resident's dignity and self-worth. During an interview on 4/4/2024 at 1:10 p.m., with the Director of Nursing (DON), the DON stated urinary catheter drainage bags should have privacy covers especially when facing the door to preserve the resident's dignity and self-worth. A review of the facility's policy and procedure titled, Catheter Care, last reviewed 2/3023, indicated all foley catheter drainage bags smut have a dignity bag to ensure privacy for the patient.

Based on interview and record review, the facility failed to provide the resident and the resident's representative information regarding formulating an advance directive for one of one sampled resident investigated during review of advance directive care area (Resident 38). This deficient practice had the potential for Resident 83 and their responsible person to not be informed of their right to formulate an advance directive and not honor the resident's wishes regarding end-of-life care. Findings: A review of Resident 83's Face Sheet (admission Record) indicated the facility admitted Resident 83 on 6/28/2023. A review of Resident 83's Patient Diagnosis Information, dated 6/28/2023, indicated Resident 83's diagnoses included, but were not limited to, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). A review of Resident 83's History and Physical (H&P), dated 6/29/2023, indicated Resident 83 was awake, alert, and unable to engage in conversation. A review of Resident 83's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/2/2024, indicated Resident 83 had severe cognitive impairment (when a person has problems remembering things and solving problems) and required maximal assistance or was dependent on staff for activities of daily living, such as eating, hygiene, and surface to surface transfers. During a concurrent interview and record review with the Director of Social Services (DSS), on 4/4/2024, at 8:35 a.m., Resident 83's medical record was reviewed and the DSS confirmed that Resident 83's medical record did not contain documentation on whether Resident 83 or Resident 83's representative were asked if the resident had an advance directive or if they were provided information regarding the creation of an advance directive. The DSS stated Resident 83 was non-verbal, not able to make her own decisions, and the responsible person was her husband. The DSS stated upon admission, residents are asked if they have an advance healthcare directive, and a copy is requested if the resident has one. The DSS stated residents and their responsible persons are educated on what an advance healthcare directive is and how to create an advance directive if the resident does not have an advance directive. The DSS stated it is important to provide residents and their responsible persons information regarding advance directives and determine if a resident has an advance directive so that the resident's wishes are carried out. The DSS further stated if residents or their representatives are not provided with information regarding the creation of an advance directive, the facility would not know how to treat residents during end-of-life care. A review of the facility's policy and procedure (P&P) titled, Advance Directives, last reviewed 10/18/2023, indicated upon admission to the facility, the admitting registrar shall give each adult patient or appropriate responsible party a copy of the Department of Health Services pamphlet: Your Right to Make Decisions about Medical Treatment and will inquire of each adult patient or responsible party regarding the existence of previously executed advance directives and/or the desire to execute a new advance directive. The P&P further indicated the existence, amendment, or revocation of an advance directive (oral or written) is documented in the resident's medical record and social services shall be responsible for documenting on long term care residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2 .a. A review of Resident 77's Face Sheet indicated the facility admitted the resident on 12/14/2023, with diagnoses including dementia, nontraumatic (not caused by trauma) subdural hemorrhage (a collection of blood between the covering of the brain and the surface of the brain), and seizures (a sudden, uncontrolled burst of electrical activity in the brain). A review of Resident 77's History and Physical (H&P), dated 12/14/2023, indicated the resident was alert and oriented to person and place, with major neurocognitive disorder (decreased mental function due to a medical disease other than psychiatric illness) with functional dependency and need for protective environment. A review of Resident 77's MDS, dated [DATE], indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident was dependent on sitting on side of the bed to lying flat on the bed, move from lying on the back to sitting on the side of the bed, come to a standing position from sitting in a chair, wheelchair, or on the side of the bed, transfer to and from a bed to a chair, and to get in and out of a tub/shower. The MDS also indicated the resident had a bed alarm (warns caregivers when patients leave or attempt to leave their beds). A review of Resident 77's care plans did not indicate any plan of care on the safe use of restraints. During an observation and interview on 4/2/2024, at 11:25 a.m., with Certified Nursing Assistant/Restorative Nursing Aide 1 (CNA/RNA 1), in Resident 77's room, observed the resident's bed pushed against the wall, with both upper side rails up, and a chair alarm (warn caregivers, and in some cases patients themselves, when a patient leaves or attempts to leave the chair) in place on the resident's chair. CNA/RNA 1 stated the bed was pushed against the wall to give space for a transfer aid equipment (a non-powered device that ensures residents can be positioned from sit-to-stand transfers safely, quickly and with ease). CNA/RNA 1 stated the upper side rails of the resident were up and the resident had a chair alarm because the resident was at risk for fall. safe Patient Handling Equipment 1 (SPH 1, is a non-powered device that ensures residents can be positioned from sit-to-stand transfers safely, quickly and with ease). 2.b.A review of Resident 56's Face Sheet indicated the facility admitted the resident on 12/6/2023, with diagnoses including Alzheimer's, dementia, and glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of the eye). A review of Resident 56's H&P, dated 12/6/2023, indicated the resident was alert and oriented to self, unaware of his situation, with severe word finding difficulties. A review of Resident 56's MDS, dated [DATE], indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident required substantial to maximal assistance to roll from lying on back to left and right side, and return to lying on back on the bed, to a standing position from sitting in a chair, wheelchair, or on the side of the bed, transfer to and from a bed to a chair, and to get on and off a toilet or commode. The MDS also indicated the resident had bed and chair alarm (warns caregivers when patients leave or attempt to leave their chair). A review of Resident 56's Care Plans did not indicate any plan of care on the safe use of restraints. During an observation and interview on 4/2/2024, at 11:49 a.m., with Nursing Supervisor 1 (NS 1), in Resident 56's room, observed Resident 56's bed pushed against the wall and the resident's chair with an alarm in place. NS 1 stated the bed was pushed against the wall and the resident's chair has an alarm because the resident was high risk for falls. NS 1 stated there was no care plan on the use of restraints because they consider pushing the resident's bed against the wall and using side rails and chair alarms as nursing interventions. 2.c.A review of Resident 70's Face Sheet indicated the facility admitted the resident on 12/30/2022, with diagnoses including Alzheimer's disease, dementia, and abnormalities of gait (a manner of walking or moving on foot) and mobility. A review of Resident 70's H&P, dated 12/27/2023, indicated the resident was awake and alert, speech was mostly coherent, but non-fluent at times. A review of Resident 70's MDS, dated [DATE], indicated the resident sometimes had the ability to make self-understood and understand others. The resident had moderately impaired vision. The MDS indicated the resident required supervision or touching assistance to roll from lying on back to left and right side, and return to lying back on the bed, move from sitting on side of bed to lying flat on the bed, move from lying on back to sitting on the side of the bed, come to a standing position from sitting in a chair, wheelchair, or on the side of the bed, transfer to and from a bed to a chair, get on and off a toilet or commode, and get in and out of tub/shower. The MDS indicated the resident had a bed alarm. A review of Resident 70's Care Plans did not indicate any plan of care on the safe use of restraints. During an observation and interview on 4/2/2024, at 9:33 a.m., with Certified Nursing Assistant 3 (CNA 3), in Resident 70's room, observed Resident 70's left side of the bed pushed against the wall, with both upper side rails up, and an overbed table placed on the right lower side of the bed. CNA 3 stated the resident's bed was pushed against the wall and the side rails were up so the resident can only get out on one side of the bed, preventing a fall. During an interview on 4/4/2024, at 10:08 a.m., with the Nurse Informaticist (NI), the NI stated there were no care plans on restraint use for Residents 77, 56, and 70, because they do not consider using side rails and chair alarms and pushing the bed against a wall as restraints. During an interview on 4/4/2024, at 1:04 p.m., with the Director of Nursing (DON), the DON stated there should be a care plan on the use of bilateral side rails and chair alarms and placement of beds against a wall. The DON stated it is important to have an individualized care plan in order to be aware of the resident's problems. The DON stated the care plan should indicate interventions to be implemented to accomplish the goal. The DON further stated failure to develop and implement a care plan can lead to resident injury. A review of the facility's recent policy and procedure titled, Care Plan- Resident, last revised on 1/10/2023, to assure a coordinated and comprehensive written plan is developed based on the resident assessment and the individual needs and preferences of the resident. The comprehensive care plan may include problems that are ongoing. Based on observation, interview and record review, the facility failed to develop a comprehensive person-centered care plan (CP, a written course of action that helps a patient achieve outcomes that improve their quality of life) reflective of resident preferences and consistent with the resident rights to meet a resident's medical, nursing, mental, and psychosocial needs for four of four sampled residents (Residents 8, 77, 56, and 70) reviewed during investigation of restraint (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) use by failing to: 1. Develop and implement a CP for side rail (SR, adjustable rigid plastic bars attached to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) and placement of bed against a built-in dresser wall cabinet for Resident 8. 2. Develop and implement CPs for use of restraints for Residents 8, 77, 56, and 70. This deficient practice had the potential for residents to not receive the proper and necessary care regarding SRs and restraints with the potential to result in injury of the resident by failing to provide ongoing assessment, monitoring, and re-evaluation of SRs and restraints. Findings: a. A review of Resident 8's Face Sheet (admission Record) indicated the facility admitted the resident on 6/11/2020 with diagnoses that included Alzheimer's disease (a type of dementia [a general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life]) with late onset, anxiety disorder (a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear), and abnormalities of gait and mobility. A review of Resident 8's History and Physical (H&P), dated 5/26/2023, indicated the resident had dementia with behavioral disturbances and was unable to follow commands. The H&P indicated the resident had a history of falls resulting in a fractured hip. A review of Resident 8's Minimum Data Set (MDS - an assessment and care screening tool) dated 2/6/2024, indicated the facility most recently readmitted the resident on 5/19/2021 and the resident sometimes was able to understand others and sometimes was able to make herself understood. The MDS further indicated the resident was dependent on staff for eating, toileting, bathing, dressing, personal hygiene, and mobility. The MDS indicated the resident did not use SRs as a physical restraint. During an observation on 4/2/2024 at 11:05 a.m., observed Resident 8 in bed with eyes closed and did not verbally respond to the surveyor. Observed the resident's bed with bilateral SRs in raised position and the left side of the bed was placed against a built-in dresser wall cabinet with no access for bed exit on the left side. During an observation and interview on 4/2/2024 at 11:18 a.m. with Certified Nursing Assistant 6 (CNA 6), observed Resident 8 in bed. CNA 6 stated the resident had fallen in the past and can move. CNA 6 stated the bed against the dresser and raised upper side rails were used for fall prevention and the resident was safer with the bed against the dresser. During an interview and record review on 4/3/2024 at 8 a.m. with the Director of Nursing (DON), the DON stated the definition of a restraint is anything that restricts resident movement. The DON stated placing the bed against the wall with SRs raised restricts the resident from exiting the bed on the left side and the resident cannot remove the restrictions themself. During a follow up interview on 4/4/2024 at 8:15 a.m. with the DON, the DON stated placing the resident bed against the wall was a restraint. During an interview and record review on 4/4/2024 at 11:12 a.m. with the Minimum Data Set Coordinator (MDSC), reviewed Resident 8's care plans. The MDSC stated there were no CPs for the use of SRs or placing the bed against the dresser. The MDSC stated there were no CPs for restraints. During an interview and record review on 4/4/2024 at 1:03 p.m. with the Director of Nursing (DON), reviewed the facility policy regarding CPs. The DON stated the comprehensive CP is an individualized plan of care based on a specific resident that identifies resident problems, goals, and interventions. The DON stated without a CP they are not able to meet the needs of the resident because problems are not identified with interventions in place to solve them. The DON stated there were no CPs for SRs, the bed against the dresser, or restraint usage. The DON stated without the CPs it could potentially lead to the resident not being assessed or monitored for the effectiveness of the SRs and bed against the dresser resulting in accidents and injury to the resident. The DON stated the facility policy was not followed because Resident 8 did not have the CPs. During a review of the facility policy and procedure titled, Care Plan- Resident, last reviewed 3/6/2020, indicated the purpose of the policy was to assure a coordinated and comprehensive written plan is developed based on the resident assessment and the individual needs and preferences of the resident. The CP will be person centered and reflect the preferences and needs of the resident. The CP will include the start date, goals, interventions, and target date for the next review. The comprehensive CP may include problems that are ongoing. A multi-disciplinary care plan meeting will update goals quarterly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice by failing to follow the physician's order to apply thromboembolic deterrent (TED hose- stockings that help prevent blood clots and swelling in the legs) in two of twenty-two random observations (Residents 77 and 56) during the initial screening. The deficient practice had the potential for residents to have poor circulation to the extremities that could lead to thrombosis (the formation of a blood clot within blood vessels). Findings: 1. A review of Resident 77's Face Sheet indicated the facility admitted the resident on 12/14/2023, with diagnoses including acute embolism (when a clump of material, most often a blood clot, get stuck in an artery in the lungs, blocking the flow of blood) and thrombosis, and nontraumatic (not caused by, or not causing, trauma) subdural hemorrhage (a type of bleeding near your brain). A review of Resident 77's History and Physical (H&P), dated 12/14/2023, indicated the resident was alert and oriented to person and place. A review of Resident 77's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/15/2024, indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was dependent on sitting on side of the bed and to lying flat on the bed, to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed, and transfer to and from bed to a chair. A review of Resident 77's Physician's Order, dated 3/11/2024, indicated an order for: - TED hose every twelve hours. Request type: Routine. Comments: Apply TED hose (as much as the resident is tolerating it. Indication: both lower (b/l) extremities (ext) deep vein thrombosis (DVT, a medical condition that occurs when a blood clot forms in a deep vein). A review of Resident 77's Care Plan titled, Cognitive/Communication/Falls/activities of daily living (ADL's)/Incontinence (inability to control the flow of urine from the bladder)/Skin integrity as evidenced by forgetfulness, confusion ., initiated on 12/14/2023, indicated an intervention to apply [NAME] hose every twelve hours. Request type: Routine. Comments: Apply TED hose as much as the resident is tolerating it. Indication: bilateral extremities DVT. During an observation and interview on 4/2/2024, at 11:25 a.m., with Certified Nursing Assistant/Restorative Nursing Aide 1 (CNA/RNA 1), in Resident 77's room, observed the resident not wearing TED hose. CNA/RNA 1 stated he is not aware if the resident had an order for TED hose. CNA/RNA 1 stated he cannot find the [NAME] Hose in the resident's room; and stated it is probably in the laundry. During an interview and record review on 4/2/2024, at 12 p.m., with Nursing Supervisor 1 (NS 1), reviewed Resident 77's Physician's Order. NS 1 stated there is an order to apply TED hose on resident as tolerated. NS 1 stated she does not know why the resident was not wearing the TED Hose. NS 1 stated it is important for the resident to wear TED hose to prevent edema (swelling caused by too much fluid trapped in the body's tissues) and DVT. 2. A review of Resident 56's Face Sheet indicated the facility admitted the resident on 12/6/2023, with diagnoses including history of venous thrombosis (when the blood clot blocks a vein) and embolism, and atrial fibrillation (an irregular and often very rapid heart rhythm). A review of Resident 56's H&P, dated 12/6/2023, indicated the resident was alert and oriented to self, unaware of the situation, and had severe word finding difficulties. A review of Resident 56's MDS, dated [DATE], indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident required substantial to maximal assistance to roll from lying back to left and right side, come to a standing position from sitting in a chair, wheelchair, or on the side of the bed, transfer to and from bed to a chair, and get on and off a toilet or commode. A review of Resident 56's Physician's Order, dated 4/1/2024, indicated an order of TED hose twice a day. Request type: Routine. Comments: Apply [NAME] hose. Indication: both lower extremities (BLE) edema. A review of Resident 56's Care Plan titled, Alteration in Perfusion (the flow of fluid or blood to cells and tissues) related to possible DVT as evidenced by left lower edema, initiated on 3/17/2024, indicated an intervention for [NAME] hose twice a day. Request type: Routine. Comments: Apply TED hose. Indication: BLE edema. During a concurrent observation and interview on 4/2/2024, at 8:55 a.m., with Certified Nursing Assistant 2 (CNA 2), in Resident 56's room, observed Resident 56 not wearing the TED hose. CNA 2 stated the resident was wearing regular socks. CNA 2 also stated she does not know if the resident ever wore a TED hose. During an interview on 4/4/2024, at 2:10 p.m. with the Director of Nursing (DON), the DON stated staff should apply the TED hose as ordered by the physician. The DON stated the purpose of the TED hose is to promote circulation to the lower extremities to prevent thrombosis and DVT. The DON stated they do not have a policy for use of TED hoses. A review of the facility's recent policy and procedure titled, Processing and Noting of Provider orders, last reviewed on 1/10/2023, indicated to process and note provider orders. The health unit secretary may process ancillary and treatment orders into the electronic medical record (EMR). The licensed nurse must note all provider orders.

2. A review of Resident 24's Face Sheet indicated the facility admitted the resident on 9/6/2023 with diagnoses that included Parkinson's disease (a progressive disorder that affects the nervous system that causes unintended or uncontrollable movements), osteoarthritis (a disease of the joints [area where two bones make contact] that causes pain), insomnia (difficulty sleeping), and chronic pain. A review of Resident 24's History and Physical (H&P), dated 9/12/2023, indicated the resident had a history of progressive functional decline complicated by cognitive decline and was dependent on staff for activities of daily living but was generally able to feed himself. A review of Resident 24's Minimum Data Set (MDS - an assessment and screening too) dated 3/15/2024, indicated the resident was able to understand others and make himself understood. The MDS further indicated the resident was dependent on staff for eating, toileting, bathing, dressing, personal hygiene, and transferring between the bed to chair. A review Resident 24's Care Plan (CP) titled, Cognitive / vision / falls / activities of daily living (ADLs) / ., dated 9/6/2023, indicated the resident was alert with some forgetfulness. A review of Resident 24's physician orders indicated an order for lidocaine 4% pain relief roll-on: apply to affected areas, indication: pain, order dated 1/23/2024. During a concurrent observation and interview, on 4/2/2024 at 9:25 a.m., with Resident 24 and Assistant Activities Coordinator 1 (AAC 1), observed AAC 1 sitting at bedside and assisting Resident 24 with feeding. Observed a bottle of lidocaine 4% roll-on sitting on the bedside table next to the resident's meal tray. AAC 1 stated the lidocaine bottle was labeled with the resident's name and she did not know why the bottle was on the table. Resident 24 stated it was his medication and the staff applied it on his foot last night. During a concurrent interview and record review on 4/2/2024 at 10 a.m., with Licensed Vocational Nurse 2 (LVN 2), reviewed Resident 24's Medication Administration Record (MAR- a record of all medications taken by a resident on a day-to-day basis). LVN 2 stated she was the medication nurse for Resident 24 and she did not leave the lidocaine bottle in the resident's room. LVN 2 stated the MAR indicated the lidocaine was last documented as administered on 3/3/2024. LVN 2 stated she did not know how long the lidocaine bottle was in Resident 24's room or when it was last administered. LVN 2 stated medications should not be left in a resident's room for safety issues. LVN 2 stated the resident, or another resident, could have used the medication when it was left in the room. During a concurrent interview and record review, on 4/4/2024 at 8:15 a.m., with the Director of Nursing (DON), reviewed the facility policy and procedure regarding medication administration. The DON stated Resident 24 was forgetful, confused, and not safe for medication self-administration. The DON stated medication should not be left at Resident 24's bedside. The DON stated she spoke with staff and does not know when the lidocaine was left in the resident's room or if it was administered. The DON stated the facility policy indicates to not leave medications at bedside because it could potentially cause harm if the medication is not appropriately used. The DON stated there was also potential harm to other residents if they took and used the medication when it was not indicated. The DON stated there was an additional risk for medication to go missing and not be available for the next time it was needed for administration. A review of the facility policy and procedure titled, Medication Administration, last reviewed 6/2023, indicated medications shall be accurately and safely administered to facility residents by authorized personnel. Do not leave medications unattended with the resident. Based on observation, interview, and record review, the facility failed to provide an environment free from accidents and hazards by: 1. Failing to ensure Certified Nursing Assistant 5 (CNA 5) did not transfer one out of one sampled resident (Resident 82) from bed to wheelchair while using a Hoyer lift (a patient lift used by caregivers to safely transfer patients) without another staff assistance investigated during a random observation. This deficient practice placed Resident 82 at risk for falls and serious injuries that include possible fractures and bleeding. 2. Failing to ensure residents did not have lidocaine (a topical [placed on the skin] medication used to treat pain) 4 percent (%, concentration of medication in a solution) roll-on bottle at bedside for one of one sampled resident (Resident 24) investigated under the care area Pain Management. This deficient practice had the potential to result in residents self-administering medications without staff knowledge resulting in overdose, loss of resident medication, or a delay in care and services. Findings: 1. A review of Resident 82's Face Sheet indicated the facility admitted the resident on 4/27/2023 with diagnoses including polyosteoarthritis (a joint condition that involves four or more joints characterized by joint stiffness and pain), abnormalities of gait and mobility, and presence of right artificial knee joint. A review of Resident 82's History and Physical dated 5/2/2023, indicated the resident was pleasant and cooperative but unable to provide meaningful history. A review of Resident 82's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 1/19/2024 indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision or touching assistance with eating; partial/moderate assistance with oral hygiene, and upper body dressing; dependent with toileting hygiene, and putting on/taking off footwear; substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 82's care plan on cognitive/falls/ADLs/incontinence/skin integrity related to forgetfulness and confusion, high risk for fall initiated on 4/27/2023 with target date of 4/27/2023, indicated a goal that resident will be safe and have no falls or injury and will remain safe within the facility. The interventions included: - Resident 82 uses wheelchair for locomotion. - Resident 82 is up on wheelchair daily, needs extensive assistance for transfers A review of Resident 82's CNA Shift Note, dated 4/1/2024 to 4/4/2024, indicated Resident 82 was dependent with the ability to transfer to and from a bed to chair or wheelchair and required the assistance of two or more helpers for the resident to complete the activity. A review of Medical Equipment 1 (ME 1) user manual, undated, indicated the company recommends 2 assistants for all lifting preparation, transferring from and transferring to procedures, the equipment permits proper operation by 1 assistant based on the evaluation of the healthcare professional. During an observation on 4/2/2024 at 10:32 a.m., observed CNA 5 transferring Resident 82 from bed to a wheelchair using a Hoyer lift without another staff member present in the room. Observed Licensed Vocational Nurse 4 (LVN 4) enter the room at 10:35 a.m. and assisted CNA 5 by holding the wheelchair when Resident 82's transfer was almost completed. During an interview on 4/2/2024 at 2:46 p.m., CNA 5 verified that she transferred Resident 82 from bed to wheelchair using the Hoyer lift by herself during most of the task. CNA 5 stated LVN 4 entered the room to assist when Resident 82's transfer was almost completed. CNA 5 stated transfers with Hoyer lift were supposed to be with two (2) staff members. CNA 5 stated other staff were busy with their own tasks and were unable to assist her. CNA 5 stated she should have waited for LVN 4 to come prior to completing the transfer from bed to wheelchair while using the Hoyer lift as it placed the resident at risk to fall. During an interview on 4/4/2024 at 10:10 a.m., the Minimum Data Set Coordinator (MDSC) stated mechanical lift or Hoyer lift transfers of residents from bed to wheelchair or wheelchair to bed requires 2-person assist. The MDSC stated CNA 5 should have transferred Resident 82 with another staff member for resident safety to prevent falls and/or injury. During an interview on 4/4/2024 at 2 p.m. the Director of Nursing (DON) stated mechanical lift transfers require 2-person assist at all times. The DON stated CNA 5 should have transferred Resident 82 from bed to wheelchair with another CNA or licensed nurse for resident safety as it placed the resident at risk for accidents, falls, and/or injury. A review of the facility's policy and procedure titled, Mechanical Lift - Use of for Patients/Residents, last reviewed 1/10/2023 indicated a purpose to provide safe transfers for residents/patients. The policy indicated to use 2-person assist when using mechanical lift for transfer - one person to operate lift and one person to guide patient/resident in sling. A review of the facility's policy and procedure titled, Accident Prevention, last reviewed and revised 3/2024, indicated a statement to ensure the environment is free form accident hazards as is possible and identify residents who require supervision and/or assistive devices to prevent accidents. The policy indicated to identify types of accident hazards including transferring assistance/safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to label the valproic acid (used to treat seizure disorders [a sudden, uncontrolled burst of electrical activity in the brain], mental/mood conditions) 250 milligrams (mg, a unit of mass or weight) / 5 milliliter (ml, a unit of volume) 125 mg (2.5 ml) solution bottle with an expiration date, affecting Resident 70 in one out of three inspected medication carts (Med Cart A). The deficient practice of failing to label the medication with the expiration date increased the risk that Resident 70 could have received medication that had become ineffective or toxic and could result in health complications. Findings: A review of Resident 70's Face Sheet indicated the facility admitted the resident on 12/30/2024, with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and eventually, the ability to carry out the simplest tasks), and major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once [NAME] joy). A review of Resident 70's History and Physical (H&P), dated 12/27/2023, indicated the resident was awake and alert, speech was mostly coherent, but non-fluent at times. A review of Resident 70's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/22/2024, indicated the resident sometimes had the ability to make self-understood and understand others. A review of Resident 70's Physician's Order indicated an order for: -10/29/2023 Valproic acid (As Sodium Salt) (Depakene oral solution) 250 mg/5 ml. Give 125 mg (2.5 ml) by mouth daily. Indication: Dementia related behavior monitor for behavior (m/b) physical aggression. -10/28/2023 Valproic acid (As Sodium Salt) (Depakene oral solution) 250 mg/5 ml. Give 250 mg (5 ml) by mouth at bedtime. Indication: Dementia related behavior m/b physical aggression. During a concurrent observation and interview on 4/4/2024, at 12:35 p.m., with Licensed Vocational Nurse 1 (LVN 1), observed in Med Cart A Resident 70's valproic acid 250 mg/5 ml, 125 mg (2.5 ml) solution bottle without an expiration date. LVN 1 stated it is important to label the medication with an expiration date, so the nursing staff know when to discard the medication. During an interview on 4/4/2024, at 2:06 p.m., with the Director of Nursing (DON), the DON stated the valproic acid solution bottle should be labeled with an expiration date, so the nursing staff know when to use the medication by. A review of the facility's policy and procedure titled, General Administrative, last reviewed on 3/2024, indicated all drugs are labeled in accordance with state and federal requirements. Containers with worn illegible or missing labels are returned from the nursing units to the pharmacy for proper disposition.

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly by not covering the garbage container next to the hand washing station in the kitchen during the initial tour of the kitchen conducted on 4/2/2024 between 7:54 a.m. to 9:00 a.m. This deficient practice had the potential for the spread of bacteria and cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) after hand washing. Findings: During a concurrent observation and interview with the Director of Hospitality (DH), on 4/2/2024, at 7:54 a.m., inside the kitchen, the garbage container next to the sink did not have a lid and contained crumpled white paper towels. The DH stated the observed sink was used in the kitchen as the hand washing station. The DH confirmed the garbage container next to the hand washing station did not have a lid. The DH further stated he was unsure if the garbage container next to the hand washing station should be lidded. During an interview with the Registered Dietitian (RD), on 4/2/2024, at 8:34 a.m., the RD stated there should be a lid on the garbage container next to the hand washing station to prevent the possible spread of bacteria after hand washing. During an interview with the RD, on 4/4/2024, at 11:00 a.m., the RD stated the garbage container next to the hand washing station is not in constant use and should be covered. During an interview with the Director of Nursing (DON), on 4/4/2024, at 1:36 p.m., the DON stated the garbage container next to the hand washing in the kitchen should have a lid to contain the dirty contents from coming out of the garbage. The DON further stated without a lid on the garbage container, cross-contamination can possibly occur, and the residents can possibly get sick if cross-contamination occurs. A review of the facility's policy and procedure (P&P) titled, Solid Waste Disposal, last reviewed 10/18/2024, indicated garbage containers are clean, lined, and covered at all times. The P&P further indicated during periods of constant use in food production, food services and dish room areas, garbage cans may remain uncovered if local jurisdiction allows this practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain timely resident medical records for one of four (Resident 38) when Resident 38's Physical Therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function)) Initial Evaluation dated 11/8/2023 was not documented until 4/4/2024. This deficient practice had the potential for inaccurate medical documentation and cause a delay in provision of appropriate interventions for Resident 38. Findings: A review of Resident 38's Face Sheet indicated the facility admitted Resident 38 admitted on [DATE]. A review of Resident 38's Patient Diagnosis Information indicated Resident 38 had diagnoses including, but not limited to polyosteoarthritis (swelling and tenderness of a joint causing pain and stiffness), morbid (severe) obesity due to excess calories (disorder involving excessive body fat that increased risk for health problems), abnormalities of gait (walking) and mobility. A review of Resident 38's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 2/27/2024 indicated Resident 38 was cognitively intact (sufficient judgement, planning, organization to manage average demands in one's environment), had no impairment in functional limitation in range of motion (ROM, full movement potential of a joint) in both sides of the upper extremity (UE, shoulder, elbow, wrist, hand) and had impairments on both sides of the lower extremity (LE, hip, knee, ankle, foot). The MDS indicated Resident 38 required set up assistance with eating, partial assistance (helper does less than half the effort) oral hygiene, substantial assistance (helper does more than half the effort) with upper body dressing, personal hygiene, and dependent assistance (helper does all of the effort) for lower body dressing, shower, toileting hygiene, chair/bed to chair transfer. A review of Resident 38's PT Initial Evaluation dated 11/8/2023 indicated the PT Initial Evaluation was signed on 4/4/2024 (about five months later). During a phone interview on 4/4/2024 at 11:16 a.m., with Physical Therapist (PT 1), PT 1 confirmed he did not complete and sign the PT Initial Evaluation for Resident 38 until today (4/4/2024) even though the resident was seen on 11/8/2023. PT 1 stated the documentation was completed late and should have been completed on 11/8/2023. PT 1 stated that all documentation should be completed timely. During an interview on 4/4/2024 at 12:36 p.m., with the Director of Nursing (DON), the DON stated all documentation should be completed within the day or as soon as it happened. The DON stated documentation should be completed timely to make sure that the documentation was accurate because if staff waited too long, the information could be inaccurate, and staff could forget something to document. A review of the facility's policies and procedures dated 9/7/2018, titled, Inter-disciplinary Long Term care Resident Assessment and Reassessment, indicated under Physical Therapy, that documentation must be completed within 24 hours of service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach of the resident for four out of five sampled residents (Residents 77, 56, 70 and 13) investigated during review of environment facility task. These deficient practices had the potential for delaying care and services requested by the residents and placing the residents at risk for falls and injuries. Findings: 1. A review of Resident 77's Face Sheet indicated the facility admitted the resident on 12/14/2023, with diagnoses of nontraumatic (not caused by trauma) subdural hemorrhage (a type of bleeding near your brain), seizures (a sudden, uncontrolled burst of electrical activity in the brain), and dementia (the loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 77's History and Physical (H&P), dated 12/14/2023, indicated the resident was alert and oriented to person and place. The H&P indicated the resident had major neurocognitive disorder (decreased mental function due to a medical disease other than a psychiatric illness) with functional dependency and need for protective environment. A review of Resident 77's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/15/2024, indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident was dependent on oral hygiene, toileting, showering/bathing self, lower body dressing, putting on/taking off footwear, and personal hygiene. A review of Resident 77's Fall Risk Evaluation, dated 3/15/2024, indicated the resident was high risk for falls. A review of Resident 77's Care Plan titled, Alteration in safety/safety awareness related to dementia as evidenced by low energy, requiring max assist with ambulation and meals, initiated on 2/27/2024, indicated an intervention to explain and reinforce safety measures (i.e., call light within reach, bed in low position, patient items within reach, skid proof footwear, etc. Responsible discipline: Nurse. During a concurrent observation and interview on 4/2/2024, at 11:25 a.m., with Certified Nursing Assistant/Restorative Nursing Aide 1 (CNA/RNA 1), in Resident 77's room, observed Resident 77's call light on top of the bed, while the resident was sitting on a chair away from the bed. CNA/RNA 1 stated the call light was not within the reach of the resident. CNA/RNA 1 stated the call light should be within reach of the resident so the resident can call for help and to prevent falls. 2. A review of Resident 56's Face Sheet indicated the facility admitted the resident on 12/6/2023, with diagnoses including Alzheimer's disease (a brain disorder that slowly destroys memory and thinking and, eventually, the ability to carry out the simplest task), dementia, and glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of the eye called the optic nerve). A review of Resident 56's H&P, dated 12/6/2023, indicated the resident was alert and oriented to self, unaware of his situation, and has severe word finding difficulties. A review of Resident 56's MDS, dated [DATE], indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident required substantial to maximal assistance on toileting hygiene, showering/bathing self, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. A review of Resident 56's Fall Risk Evaluation, dated 3/8/2024, indicated the resident was high risk for falls. A review of Resident 56's Care Plan titled, Cognitive/Communication/Vision/Falls/ activities of daily living (ADL's)/Incontinence (inability to control the flow of urine from the bladder)/Skin Integrity as evidenced by hard of hearing ., initiated on 12/6/2023, indicated an intervention of high fall risk: call light in reach, red identification arm band/tag, remote monitoring devices on bed and chair, non-skid socks/shoes, maintain bed at appropriate height, and keep personal items within reach. During a concurrent observation and interview on 4/2/2024, at 9:50 a.m., with Certified Nursing Assistant 2 (CNA 2), in Resident 56's room, observed Resident 56's call light on top of the bed, while the resident was sitting on a chair away from the bed. CNA 2 stated the call light was not within the reach of the resident. CNA 2 stated the call light should be within reach of the resident so the resident can call for help and to prevent falls. 3. A review of Resident 70's Face Sheet indicated the facility admitted the resident on 12/30/2022, with diagnoses including Alzheimer's disease, abnormalities of gait (a manner of walking or moving on foot) and mobility, and dementia. A review of Resident 70's H&P, dated 12/27/2023, indicated the resident was awake and alert, speech was mostly coherent, but non-fluent at times. A review of Resident 70's MDS, dated [DATE], indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident had moderately impaired vision. The MDS also indicated the resident required partial to moderate assistance on oral hygiene, toileting, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. A review of Resident 70's Fall Risk Evaluation, dated 3/22/2024, indicated the resident was high risk for falls. A review of Resident 70' Care Plan titled, Cognitive/Falls/ADL/Incontinence/ skin integrity related to resident forgetfulness, confusion ., with a target date of 6/30/2024, indicated an intervention of high fall risk: call light in reach, red identification arm band/tag, remote monitoring devices on bed and chair, non-skid socks/shoes, maintain bed at appropriate height, and keep personal items within reach. During a concurrent observation and interview on 4/2/2024, at 9:33 a.m., with Certified Nursing Assistant 3 (CNA 3), inside Resident 70's bed, observed Resident 70's call light clipped on a folded blanket at the foot of the bed away from the resident. CNA 3 stated the resident will not be able to reach the call light because it was not within the resident's reach. CNA 3 stated not having the call light within reach could result in the resident not being able to call for help and placed the resident at risk for falling while reaching for the call light. During an interview on 4/4/2024, at 1:30 p.m., with the Director of Nursing (DON), the DON stated it was important to keep the call light within reach to enable the resident to call for help when needed. The DON stated the resident could fall while reaching for the call light. A review of the facility's recent policy and procedure titled, Call light, last reviewed on 4/2023, indicated the purpose of the call light was to alert nursing staff that patient has a request or need. To ensure patient access to call light at all times. Ensure call light is within reach of patient. If patient is ambulatory or mobile in a wheelchair; ensure that there is easy access to the call light. A review of the facility's recent policy and procedure titled, Falls, last reviewed on 3/2023, indicated under general safety interventions to place call light and frequently needed objects within reach. A review of the facility's recent policy and procedure titled, LTC Standard of Care Nursing Protocol, last reviewed on 2/2023, indicated initiate safety measures as indicated: 4. Call bell within reach. 4. A review of Resident 12's Face Sheet (admission Record) indicated the facility admitted the resident on 6/30/2021 with diagnoses that included hemiplegia (total or partial paralysis [unable to make voluntary muscle movements] of one side of the body and hemiparesis (one-sided muscle weakness following cerebral infarction (stroke, when blood flow to the brain is blocked or there is sudden bleeding in the brain), and morbid obesity (body weight that is higher than what is considered healthy for a given height). A review of Resident 12's History and Physical, dated 1/22/2024, indicated the resident's speech was coherent and fluent and the resident was alert and oriented. A review of Resident 12's Minimum Data Set (MDS - an assessment and care screening tool) dated 3/19/2024, indicated the resident's most recent admission was on 3/3/2023 and had the ability to understand others and make herself understood. The MDS further indicated the resident had impairment of one upper extremity and both lower extremities that interfered with daily functions or placed the resident at risk of injury. The MDS indicated the resident was dependent on staff for toileting, bathing, dressing, rolling left and right, and transferring from the bed to chair. A review Resident 12s's Care Plan (CP) titled, Medical Conditions: related to Chronic stoke with Left side hemiplegia; vascular dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life caused by brain damage from impaired blood flow to the brain); .functional dependence, dated 6/30/2021, indicated the resident wanted to be free from complications or problems with medical conditions daily. A review Resident 12s's Care CP titled, Falls/Activities of Daily Living (ADLs)/Incontinence .: related to needs assistance with ADLs .needs assistance with toileting .at risk for fall due to impaired balance and mobility, dated 6/30/2021, indicated an intervention to keep the call light within easy reach of the resident at all times. During a concurrent observation and interview on 4/2/2024 at 10:28 a.m., observed Resident 12 in bed. Observed the call light cord extending from the wall to the left side rail of the bed. The call light was tied to the left upper side rail and dangling on the outside of the bed toward the floor. Resident 12 stated she couldn't use her left arm and she couldn't reach the call light. Resident 12 stated she could use the cell phone to call staff. During an observation and interview on 4/2/2024 at 10:35 a.m. with Certified Nursing Assistant 7 (CNA 7), CNA 7 stood outside Resident 12's room and stated the resident could not move her left arm and everything should be placed on the Resident's right side. CNA 7 stated Resident 12 had a cell phone, but the call light should still be placed on the resident's right side in case the cell phone fell, or the resident was not able to use it. CNA 7 entered Resident 12's room and stated the call light was on the left side rail and out of reach of the resident. CNA 7 stated the call light should have been placed on the other side of the resident. Observed CNA 7 remove the call light from the left side rail and placed on the right side of the bed. During an interview and record review on 4/3/2024 at 3:44 p.m. with the Director of Nursing (DON), reviewed the facility policy and procedure regarding call lights. The DON stated the call should be accessible. The DON stated the call light placed on Resident 12's left side would be hard to reach, and the right side would be better. The DON stated the call light should have been placed on Resident 12's right side and within reach of the resident. The DON stated it was important to have the call light available in case the resident's cell phone did not work. The DON stated the policy was not followed because Resident 12's call light was not within reach. A review of the facility policy and procedure titled, Call Light, last reviewed 4/2023, indicated the purpose of the policy was to alert nursing that patient has a request or need and to ensure patient access to the call light at all times. The procedure indicated ensure the call light was within reach of the patient.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. a. A review of Resident 77 ' s Face Sheet indicated the facility admitted the resident on 12/14/2023, with diagnoses including dementia, nontraumatic (not caused by trauma) subdural hemorrhage (a collection of blood between the covering of the brain and the surface of the brain), and seizures (a sudden, uncontrolled burst of electrical activity in the brain). A review of Resident 77 ' s History and Physical (H&P), dated 12/14/2023, indicated the resident was alert and oriented to person and place, with major neurocognitive disorder (decreased mental function due to a medical disease other than psychiatric illness) with functional dependency and need for protective environment. A review of Resident 77 ' s MDS, dated [DATE], indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident was dependent on sitting on side of the bed to lying flat on the bed, move from lying on the back to sitting on the side of the bed, come to a standing position from sitting in a chair, wheelchair, or on the side of the bed, transfer to and from a bed to a chair, and to get in and out of a tub/shower. The MDS also indicated the resident had a bed alarm (warns caregivers when patients leave or attempt to leave their beds). A review of Resident 77 ' s Fall Risk Evaluation, dated 3/15/2024, indicated the resident was high risk for falls. A review of Resident 77 ' s Physician ' s Order did not indicate any order for restraint usage. A review of Resident 77 ' s Care Plans did not indicate any plan of care on the safe use of restraint. During an observation and interview on 4/2/2024, at 11:25 a.m., with Certified Nursing Assistant/Restorative Nursing Aide 1 (CNA/RNA 1), in Resident 77 ' s room, observed the resident ' s bed pushed against the wall, with both upper side rails up, and a chair alarm (warn caregivers, and in some cases patients themselves, when a patient leaves or attempts to leave the chair) in place on the resident ' s chair. CNA/RNA 1 stated the bed was pushed against the wall to give space for a transfer aid equipment (a non-powered device that ensures residents can be positioned from sit-to-stand transfers safely, quickly and with ease). CNA/RNA 1 stated the upper side rails of the resident were up and the resident had a chair alarm because the resident was at risk for fall. During an interview and record review on 4/2/2024, at 12 p.m., with Nursing Supervisor 1 (NS 1), reviewed Resident 77 ' s Physician ' s Order and care plans. NS 1 stated the resident does not have orders for restraints. NS 1 stated the bed was pushed against the wall with both upper side rails up and the resident ' s chair has an alarm to prevent falls. NS 1 stated placing the bed against the wall and using side rails and chair alarms are considered nursing interventions and do not require a physician ' s order. 3.b.A review of Resident 56 ' s Face Sheet indicated the facility admitted the resident on 12/6/2023, with diagnoses including Alzheimer ' s disease, dementia, and glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of the eye). A review of Resident 56 ' s H&P, dated 12/6/2023, indicated the resident was alert and oriented to self, unaware of his situation, with severe word finding difficulties. A review of Resident 56 ' s MDS, dated [DATE], indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident required substantial to maximal assistance to roll from lying on back to left and right side, and return to lying on back on the bed, to a standing position from sitting in a chair, wheelchair, or on the side of the bed, transfer to and from a bed to a chair, and to get on and off a toilet or commode. The MDS also indicated the resident had bed and chair alarm (warns caregivers when patients leave or attempt to leave their chairs). A review of Resident 56 ' s Fall Risk Evaluation, dated 3/8/2024, indicated the resident was high risk for falls. A review of Resident 56 ' s Physician ' s Order did not indicate orders for use of restraints. A review of Resident 56 ' s Care Plans did not indicate a care plan for use of restraints was developed. During an observation and interview on 4/2/2024, at 11:49 a.m., with Nursing Supervisor 1 (NS 1), in Resident 56 ' s room, observed Resident 56 ' s bed pushed against the wall and the resident ' s chair with an alarm in place. NS 1 stated the bed was pushed against the wall and the resident ' s chair has an alarm because the resident was high risk for falls. NS 1 stated placing the bed against the wall and using a chair alarm are considered nursing interventions and do not require a physician ' s order. 3.c. A review of Resident 70 ' s Face Sheet indicated the facility admitted the resident on 12/30/2022, with diagnoses including Alzheimer ' s disease, dementia, and abnormalities of gait (a manner of walking or moving on foot) and mobility. A review of Resident 70 ' s H&P, dated 12/27/2023, indicated the resident was awake and alert, speech was mostly coherent, but non-fluent at times. A review of Resident 70 ' s MDS, dated [DATE], indicated the resident sometimes had the ability to make self-understood and understand others. The resident had moderately impaired vision. The MDS indicated the resident required supervision or touching assistance to roll from lying on back to left and right side, and return to lying back on the bed, move from sitting on side of bed to lying flat on the bed, move from lying on back to sitting on the side of the bed, come to a standing position from sitting in a chair, wheelchair, or on the side of the bed, transfer to and from a bed to a chair, get on and off a toilet or commode, and get in and out of tub/shower. The MDS indicated the resident had a bed alarm. A review of Resident 70 ' s Fall Risk Evaluation, dated 3/22/2024, indicated the resident was high risk for falls. A review of Resident 70 ' s Physician ' s Order did not indicate orders for use of restraints. A review of Resident 70 ' s Care Plans did not indicate a care plan for use of restraints was developed. During an observation and interview on 4/2/2024, at 9:33 a.m., with Certified Nursing Assistant 3 (CNA 3), in Resident 70 ' s room, observed Resident 70 ' s left side of the bed pushed against the wall, with both upper side rails up, and an overbed table placed on the right lower side of the bed. CNA 3 stated the resident ' s bed was pushed against the wall and the side rails were up so the resident can only get out on one side of the bed, preventing a fall. During an interview on 4/3/2024, at 7:54 a.m., with the DON, the DON stated she was not aware that side rails can used as restraints. The DON stated the resident should be assessed on the safe use of bed rails because of entrapment risk. The DON stated they pushed the resident ' s bed against the wall for fall prevention. The DON stated by pushing the bed against the wall, the resident will only be getting on one side of the bed and lessen the chances of a fall. The DON stated they used the chair alarm on residents to alert staff if the resident was moving or trying to get out of the bed to prevent falls. The DON stated there was no informed consent obtained from the resident or the resident representative prior to placing the bed against the wall and prior to use of side rails and chair alarm. The DON stated they do not have a policy for restraints because the facility is a restraint free facility. The DON further stated placing the bed against the wall and using side rails and chair alarms are considered nursing interventions and do not require a physician ' s order. During an interview on 4/4/2024 at 8:10 a.m. with the Administrator (ADM), the ADM stated they were now aware of the regulations regarding SR use in the facility. The ADM stated they now have clarity on the regulation and there should be a specific policy for restraints, and they do not have one. The ADM stated it was her responsibility to ensure policies were in place and the SR policy should include an assessment for SR usage and informed consent for any SRs used in the facility. The ADM Stated they will be developing a policy based on the standards of practice. During a follow up interview on 4/4/2024 at 8:15 a.m. with the DON, the DON stated now she was aware that all siderail use should be assessed for risk of injury from entrapment and consent should be obtained from the resident or resident representative. The DON stated without assessments and consents the resident is at risk for injury due to entrapment. The DON stated when the bed was placed against the dresser there was a risk for restriction in mobility and there was a risk for entrapment by the side rail and being squeezed against the wall. The DON stated when residents become entrapped it could possibly lead to fractures, wounds, and skin tears. The DON stated it was important to ensure resident safety, ensure the family is aware, and to respect the resident ' s rights as well. The DON also stated chair alarms was considered a restraint as it restricts resident ' s mobility and should not be used for staff convenience. The DON stated the use of chair alarms requires a physician order, assessment of appropriate use, and a consent from the resident/resident representative. A review of the facility's recent policy and procedure titled, Patients/Residents Rights and Responsibilities, last reviewed on 1/10/2023, indicated you and/or surrogate decision maker have the right to: 14. Be free from restraints and seclusion of any form used as a means of coercion, discipline, convenience, or retaliation by staff. A review of the facility provided Hospital Bed 1 (HB 1) Instructions for Use Service Manual, dated 2011, indicated to avoid personal injury read all sections pertaining to the bed model before use. Rails are not meant for patients considered as high risk for entrapment (i.e., patients with pre-existing conditions such as confusion, restlessness, lack of muscle control, altered mental status). Additional safety measures should be considered for such high-risk patients. Based on observation, interview, and record review the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the patient ' s body that he or she cannot easily remove that restricts freedom of movement or normal access to one ' s body) for four of four sampled residents (Residents 8, 77, 56, and 70) investigated during review of use of restraints by failing to: 1. Ensure side rails (SR, adjustable rigid plastic bars attached to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) were not used without assessing for the need, assessing for risk for entrapment (occurs when a resident is caught between the mattress and bed rail or within the bed rail itself), obtaining informed consent (process in which residents or resident representatives are given important information, including possible risks and benefits, about a procedure or treatment) prior to use, and obtaining an order from the physician for Residents 8, 77, and 70. 2. Ensure the bed was not pushed up against the walls without assessing the need for use, assessing for risk for entrapment prior to use, obtaining informed consent prior to use, and obtaining an order from the physician for Residents 8, 77, 56, and 70. 3. Ensure chair alarms (alerts care givers when a resident leaves their chair or wheelchair) were not used without assessing the need for, obtaining an order from the physician, and obtaining informed consent for Residents 77 and 56. These deficient practices had the potential to result in the restriction of residents ' freedom of movement, a decline in physical functioning, psychosocial harm, physical harm from entrapment, and death of residents. Cross reference to F656 and F700. Findings: 1. A review of Resident 8 ' s Face Sheet (admission Record) indicated the facility admitted the resident on 6/11/2020 with diagnoses that included Alzheimer ' s disease (a type of dementia [a general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life]) with late onset, anxiety disorder (a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear), and abnormalities of gait and mobility. A review of Resident 8 ' s History and Physical (H&P), dated 5/26/2023, indicated the resident had dementia with behavioral disturbances and was unable to follow commands. The H&P indicated the resident had a history of falls resulting in a fractured hip. A review of Resident 8 ' s Minimum Data Set (MDS - an assessment and care screening tool) dated 2/6/2024, indicated the facility most recently readmitted the resident on 5/19/2021 and the resident sometimes was able to understand others and sometimes was able to make herself understood. The MDS further indicated the resident was dependent on staff for eating, toileting, bathing, dressing, personal hygiene, and mobility. The MDS indicated the resident did not use SRs as a physical restraint. A review Resident 8 ' s Care Plan (CP) titled, Cognitive / Communication / vision / Falls . related to (Resident 8) has forgetfulness, confusion related to Alzheimer dementia, hard of hearing, impaired vision ., dated 6/11/2020, indicated the resident wanted to be safe, reduce risk for falls and injury and to remain safely in the facility. The CP further indicated an intervention that if the resident was noted as restless and trying to get out of bed, to assist her to the wheelchair and sit her across from the nursing station. During an observation on 4/2/2024 at 11:05 a.m., observed Resident 8 in bed with eyes closed and did not verbally respond to the surveyor. Observed the resident ' s bed with bilateral SRs in raised position and the left side of the bed was placed against a built-in dresser wall cabinet with no access for bed exit on the left side. During a concurrent observation and interview on 4/2/2024 at 11:18 a.m. with Certified Nursing Assistant 6 (CNA 6), observed Resident 8 in bed. CNA 6 stated the Resident had fallen in the past and can move. CNA 6 stated the bed against the dresser and raised upper side rails were used for fall prevention and the resident was safer with the bed against the dresser. During an interview on 4/2/2024 at 11:27 a.m. with Licensed Vocation Nurse 5 (LVN 5), LVN 5 stated the facility does not require a physician ' s order for the use of SRs and Resident 8 did not have an order for SRs. During an interview with Family Member 1 (FM 1) on 4/2/2024 at 2:10 p.m., FM 1 stated Resident 8 has advanced dementia and bruises easily. FM 1 stated Resident 8 is not mobile, but she can slip out of the bed and the facility has found her on the floor. FM 1 stated she was aware that SRs and bed positioning were used to keep Resident 8 in the bed and off the floor, but she does not remember anyone ever discussing the risks of using them. During an interview and record review on 4/3/2024 at 8 a.m. with the Director of Nursing (DON), reviewed the policy and procedure regarding resident rights. The DON stated the facility uses bilateral upper SRs that are connected to the bed. The DON stated the process for using SRs is the Interdisciplinary Team (IDT) decides to use two SRs if the resident is assessed and able to use them and that the SRs do not restrict movement. The DON stated if the resident was not assessed then the SRs should not be up. The DON stated the possible adverse effects of using SRs was restriction of movement and entrapment. The DON stated there was no documentation indicating there was an assessment of Resident 8 for use of SRs. The DON stated there was no documentation indicating an assessment for risk of entrapment for Resident 8 prior to using SRs. The DON stated informed consent is usually obtained by the physician from the resident or resident representative when consent is needed for a treatment. The DON stated there was no documentation indicating informed consent was received prior to using the SRs. The DON stated Resident 8 was a high risk for fall and the bed was against the dresser for fall prevention. The DON stated there was no documentation indicating an assessment was done prior to moving the bed against the dresser. The DON stated there was no documentation indicating informed consent was obtained prior to moving Resident 8 ' s bed against the dresser. The DON stated the policy indicated residents had a right to be free from restraints. The DON stated the definition of a restraint is anything that restricts resident movement. The DON stated placing the bed against the wall with SRs raised restricts the resident from exiting the bed on the left side and the resident cannot remove the restrictions themselves. The DON stated the risk of placing the bed against the dresser was it restricted removement and could possibly cause a decline in resident ' s movement abilities. The DON stated she could not think of any other possible risk of placing the bed against the wall. The DON stated the facility did not have a policy regarding the use of SRs or restraints because they are a restraint free facility. The DON stated the importance of policies was that they guide the facility to do what is supposed to be done based on the standard of care. During an interview on 4/4/2024 at 8:10 a.m. with the Administrator (ADM), the ADM stated they were now aware of the regulations regarding SRs used in the facility. The ADM stated they now have clarity on the regulation and there should be a specific policy for restraints, and they do not have one. The ADM stated it was her responsibility to ensure policies were in place and the SR policy should include an assessment for SR usage and informed consent for any SRs used in the facility. The ADM Stated they will be developing a policy based on the standards of practice. During a follow up interview on 4/4/2024 at 8:15 a.m. with the DON, the DON stated her previous understanding was that SRs were only considered a restraint when four side rails were up. The DON stated now she was aware that all siderail use should be assessed for risk of injury such as entrapment and consent should be obtained from the resident or resident representative. The DON stated without assessments and consents the resident is also at risk for injury due to entrapment. The DON stated it was important to ensure resident safety, ensure the family is aware, and to respect the resident ' s rights as well. The DON stated Resident 8 ' s family was not informed of the risks of placing the bed against the dresser. The DON stated when the bed was placed against the dresser there was a risk for restriction in mobility and there was a risk for entrapment by the side rail and being squeezed against the wall. The DON stated when residents become entrapped it could possibly lead to fractures, wounds, and skin tears. The DON stated residents have a right to be free from restraints and the bed against the wall was a restraint. The DON stated restraints can only be used if less restrictive methods are attempted, there is an assessment for risk of entrapment, and the risks and benefits are discussed with informed consent obtained. The DON stated Resident 8 did not have any of those completed prior to placing the bed against the wall with the SRs up. A review of the facility provided HB 1 Instructions for Use Service [NAME], dated 2011, indicated to avoid personal injury read all sections pertaining to the bed model before use. Rails are not meant for patients considered as high risk for entrapment (i.e., patients with pre-existing conditions such as confusion, restlessness, lack of muscle control, altered mental status). Additional safety measures should be considered for such high-risk patients. A review of the facility provided policy and procedure titled, Patient Rights and Responsibilities, last reviewed 3/2023, indicated the patient has the right to be free from restraints and seclusion of any form used as a means of convenience.

Based on observation, interview, and record review the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcer/pressure injury (ulcers that happen on areas of the skin that are under pressure from lying in bed, sitting in a wheelchair, or wearing a cast for a long period) to two out of three sampled residents (Resident 58 and 45) being investigated under pressure ulcers by failing to: 1. Set Resident 58's low air loss mattress (LALM, designed to distribute the resident's weight over a broad surface area and help prevent skin breakdown) according to resident's weight and apply Heel Protectors 1 (HP 1, have a cushioned bottom that floats the heel off the surface of the mattress, helping to reduce pressure) on both lower extremities of the resident. 2. Set Resident 45's alternating pressure mattress (APP, a mattress used to prevent or treat pressure ulcers/injuries) according to the user manual. The deficient practices had the potential for development and worsening of pressure ulcers/injuries to the residents. Findings: 1. A review of Resident 58's Face Sheet indicated the facility admitted the resident on 9/28/2022, with diagnoses including long term use of anticoagulants (a substance that hinders the clotting of the blood), edema (swelling caused by too much fluid trapped in the body's tissues), and abnormalities of gait (a manner of walking or moving on foot) and mobility. A review of Resident 58's History and Physical (H&P), dated 10/3/2023, indicated the resident was alert and oriented (knows who they are and where they are, but not what time it is or what is happening to them), and the speech was clear. A review of Resident 58's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/19/2024, indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident required substantial to maximal assistance on showering/bathing self, lower body dressing, putting on/taking off footwear, and partial to moderate assistance on toileting hygiene, upper body dressing, and personal hygiene. The MDS also indicated the resident required partial to moderate assistance to move from lying on back to sitting on the side of the bed, come to a standing position from sitting in a chair, wheelchair, or on the side of the bed, to transfer to and from bed to a chair, to get on and off a toilet or commode, and to get in and out of a tub/shower. The MDS further indicated the resident was at risk for developing pressure ulcers/injuries. A review of Resident 58's Pressure Injury Risk Assessment, dated 3/19/2024, indicated the resident was moderate risk for pressure injury. A review of Resident 58's Physician's Order, indicated the following orders: -3/29/2024 HP 1 every shift (qshift). Request type: Routine. Comments: To be worn at all times, may take off during care. Indication: Prophylaxis (attempt to prevent disease). -4/1/2024 Alternating Pressure Mattress LTC (known as air-flow mattresses, alternating pressure mattresses relieve and redistribute pressure through a dynamic lying surface) qshift. Request type: Routine. Indication: Prophylaxis. A review of Resident 58's Care Plan titled Risk for Alteration in Skin Integrity related to (r/t) dry, fragile skin, poor mobility, anticoagulant ., with a target date of 6/30/2024, indicated an intervention to apply alternating positive pressure (APP) mattress, assist resident to reposition, off load pressure areas frequently as indicated. Alternating Pressure Mattress- prophylaxis. Responsible discipline: Nurse, Certified Nursing Assistant. HP 1 qshift. Request type: Routine. Comments: To be worn at all times, may take off during care. Indication: Prophylaxis. During an observation, interview, and record review on 4/2/2024, at 11:12 a.m., with Nursing Supervisor 1 (NS 1), inside Resident 58's room, observed with NS 1, the HP 1 boots was only applied on the right lower extremity of the resident. NS 1 stated the should be on both lower extremities of the resident. NS 1 stated the HP 1 was used to protect the heels of the resident from skin breakdown. Reviewed the order for HP 1 with NS 1, NS 1 stated there was an order to apply HP 1 on both lower extremities to be worn at all times, may take off during care for prophylaxis. NS 1 stated she will order another HP 1 for the left lower extremity of the resident. NS 1 stated the failure to apply the HP 1 on the left extremity of the resident can lead to skin breakdown on the left heel. Observed with the NS 1 the low air loss mattress of the resident was set at 4. NS stated they set the LALM according to resident comfort. NS stated it was Central Supply Staff (CSS) who oversaw the LALM, and the CSS was the one setting the bed for the facility, and nobody touches the setting but him. During an interview and record review on 4/4/2024, at 9:23 a.m., CSS stated they set the LALM according to resident's comfort. CSS stated he just showed the staff on how to use the bed. CSS stated he watched the in-service video online and usually calls the manufacturer company's representative for questions. CSS stated that he was aware that they were not following the manufacturer's guideline to set the bed according to patient height and weight. CSS stated he was trying to clarify with the company on how to set the machine according to patient's height and weight per manufacturer's guideline, but he was not successful because they did not return his calls. CSS stated he did not inform the Administrator (ADM) regarding his issues with the company's responsiveness. CSS stated the failure to follow the manufacturer's guideline could result to ineffective use of the bed in preventing skin breakdown. During an interview on 4/4/2024, at 1:55 p.m., with the Director of Nursing (DON), the DON stated they do not have a policy on the use of the low air loss mattress. The DON also stated they need to get an order for the LALM. The DON stated CSS sets the bed up for the facility and checks them, and she was not sure on how often he checks the settings of the LALM. The DON stated that it was important to follow the manufacturer's guideline since they do not have a policy on the use of the LALM to make sure it was effective in preventing pressure injuries. The DON stated the HP 1 should be applied to the resident as ordered by the physician to offload the heels to prevent skin breakdown or pressure injuries. A review of the facility's recent policy and procedure titled, Pressure Injury Monitoring Guidelines, last reviewed on 5/2023, indicated to provide a comprehensive evaluation/treatment for patient/resident with pressure injuries. Assess if pressure alleviating devices would assist and report to medical provider. Devices require a medical provider order. A review of the facility's recent policy and procedure titled, LTC Standard of Care Nursing Protocol, last reviewed on 3/2023, indicated implementation of specialty beds as ordered. All regular beds are weight redistributing dense foam mattresses. A review of the facility provided Manufacturer's User Manual for LALM 1, Alternating Pressure Low Air Loss Mattress System, undated, indicated when the mattress is fully inflated, set the dial in accordance with the patient's size and weight. -Run the system check. -The system is ready for use. -Now the patient can be transferred onto the mattress. 2. A review of Resident 45's Face Sheet indicated the facility originally admitted the resident on 2/21/2024 with diagnoses including hemiplegia and hemiparesis (weakness and complete loss of strength of one side of the body) following cerebral infarction (stroke - a condition that occurs as a result of disrupted blood flow to the brain), age-related osteoporosis (a condition in which there is a decrease in the amount and thickness of bone tissue causing the bones to become weak and break more easily), and right kidney cancer. A review of resident 45's History and Physical dated 2/21/2024, indicated the resident was able to make her needs known but did not indicate the capacity to make decisions. A review of Resident 45's Minimum Data Set (MDS-a standardized assessment and screening tool) dated 3/14/2024, indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required partial/moderate assistance with eating, oral hygiene, and roll left and right; dependent with tub/shower transfer; substantial/maximal assistance with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 45's Pressure Injury Risk Assessment tool dated 2/21/2024, indicated the resident was a high risk for development of pressure injury. A review of Resident 45's physician's order dated 3/8/2024, indicated an order for alternating pressure (APP) mattress for prophylaxis. A review of Resident 45's care plan on skin integrity at risk for skin breakdown initiated on 2/21/2024 with target date 5/30/2024, indicated APP mattress, assist resident to reposition, offload pressure areas frequently as indicated. During a concurrent observation and interview on 4/2/2024 at 10:41 a.m. inside Resident 45's room, observed resident lying in an APP mattress with the setting at level 5. Resident 45 stated the mattress was a little bit hard and she had mild low back pain. Certified Nursing Assistant 4 (CNA 4) verified the APP mattress setting at level 5 and was at the firmest setting. CNA 4 stated the mattress were set up according to resident's comfort level. During an interview on 4/2/2024 at 11:20 a.m., Licensed Vocational Nurse 2 (LVN 2) APP mattress were set up according to resident comfort level by Central Supply Supervisor (CSS). LVN 4 stated if the mattress was not on the correct setting, it was not doing it's purpose to prevent skin breakdown. During an interview on 4/4/2024 at 1:59 p.m., the Director of Nursing (DON) stated APP mattresses were used if residents were at risk for or has skin breakdown after obtaining an order from the physician and were set up according to resident comfort level. The DON stated that it was important to follow the manufacturer's guideline since the facility did not have a policy on the use of the specialty mattresses to ensure it was effective in preventing pressure injuries. A review of the facility's recent policy and procedure titled, Pressure Injury Monitoring Guidelines, last reviewed on 5/2023, indicated to provide a comprehensive evaluation/treatment for patient/resident with pressure injuries. Assess if pressure alleviating devices would assist and report to medical provider. Devices require a medical provider order. A review of Low Air Loss Mattress 2 (LALM 2) owner's manual, undated, indicated the following: - LALM 2 models are powered, flotation therapy mattresses providing a pressure management surface for the prevention and treatment of pressure ulcers. - Comfort level selection allows selection of air cylinder firmness within a relatively small range. - Press softer or firmer button to achieve desired setting. - Begin in softest setting, then adjust for comfort as desired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide services and treatments to monitor and maintain joint range of motion (ROM, full movement potential of a joint) for four of five sampled residents by failing to: 1. Provide Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatments as ordered for two of five sampled residents (Residents 2 and 12) and 2. Provide a baseline upper extremity (UE, shoulder, elbow, wrist, hand) range of motion assessment for two of five sampled residents (Residents 45 and 63) upon admission to monitor ROM decline. These deficient practices had the potential to cause decline in ROM, mobility, and overall quality of life for Resident 2, 12, 45, and 63. Cross reference to F725 and F825 Findings: 1a. A review of Resident 2's Face Sheet indicated the facility admitted Resident 2 to the facility on 9/17/2020. A review of Resident 2's Patient Diagnosis Information indicated Resident 2 had diagnoses including, but not limited to Alzheimer's disease (a type of disease that affects memory, thinking, and behavior) and abnormalities of gait (walking) and mobility. A review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 1/9/2024 indicated Resident 2 had moderate cognitive impairment (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving) and had the ability to express ideas and wants. The MDS also indicated Resident 2 had no impairment in functional limitation in ROM on both of the upper extremity (BUE) and had impairments on one side of the lower extremity (LE, hip, knee, ankle, foot). The MDS indicated Resident 2 required supervision assistance with eating and oral hygiene, substantial assistance (helper does more than half the effort) with lower body dressing, toileting hygiene, chair transfer, sit to stand, and walking 50 feet with two turns. The MDS indicated Resident 2 required partial assistance (helper does less than half the effort) with walking 10 feet. The MDS indicated Resident 2 received one (1) day of Restorative Nursing Program (RNP) for active range of motion (AROM, movement at a given joint when the person moves voluntarily) and zero (0) days of RNP for walking. A review of Resident 2's physician's orders indicated an order dated 12/3/2023 for RNA for ambulation with two-wheeled walker (2WW, type of mobility aid with wide base of support and 2 wheels in the front) three (3) to five (5) days a week as tolerated. A review of Resident 2's care plan dated 9/12/2020 with target date of 4/30/2024, indicated Resident 2 had problems of cognitive/falls/ activities of daily living (ADL, basic activities such as eating, dressing, toileting)/incontinence (inability to control bowel or bladder)/skin integrity: related to Resident 2 has forgetfulness, still able to direct her daily care schedule, needs partial/maximum assistance with ADL's, incontinent of bladder and at risk for skin breakdown. The interventions for the care plan indicated RNA for ambulation with 2WW 3 to 5 days a week as tolerated, indication was maintenance. During a concurrent observation and interview on 4/2/2024 at 9:32 a.m., Resident 2 was sitting up in a wheelchair in an area near the nursing station. Resident 2 stated she wished she could do more exercises and walking. Resident 2 stated she walked when staff had time to walk with her which was not every day. Resident 2 was able to lift both knees up and down, and able to lift both arms up but not past shoulder level. Resident 2 required the use of the left hand to hold the right wrist to help move the right arm higher up. During a concurrent interview and record review on 4/3/2024 at 3:12 p.m., with Nursing Supervisor 1 (NS 1), reviewed Resident 2's physician's orders and RNA documentation. NS 1 stated Resident 2 had orders for RNA for ambulation 3 to 5 times a week as tolerated. NS 1 stated the RNA orders have a range of days to allow for staff to see the residents for three times a week in case the RNA staff could not see the residents for five times a week. After review of Resident 2's RNA documentation during January 2024, February 2024, and March 2024, NS 1 stated Resident 2 missed the following RNA treatments: -3 RNA treatments week of 1/1/2024 -1 RNA treatment week of 1/8/2024 -2 RNA treatments week of 1/15/2024 -1 RNA treatment week of 1/22/2024 -1 RNA treatment week of 2/5/2024 -1 RNA treatment week of 2/19/2024 -1 RNA treatment week of 3/4/2024 1b. During a record review of Resident 12's Face Sheet indicated the facility admitted Resident 12 to the facility on 6/30/2021. A review of Resident 12's Patient Diagnosis Information indicated Resident 12 had diagnoses including, but not limited to hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following cerebral infarction (blockage of the flow of blood brain, causing or resulting in brain tissue death) and osteoarthritis (swelling and tenderness of a joint causing pain and stiffness). A review of Resident 12's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 3/19/2024 indicated Resident 12 was cognitively intact (sufficient judgement, planning, organization to manage average demands in one's environment), had impairment in functional limitation in ROM on one side of the upper extremity and had impairments on both side of the lower extremity. The MDS indicated Resident 2 required set up assistance with eating, supervision assistance with oral hygiene, dependent assistance (helper does all the of the effort) with toileting hygiene, bathing, dressing, rolling left to right, and chair transfers. The MDS indicated the activities of walking 10 feet and sit to stand was not attempted. A review of Resident 12's physician's orders indicated an order dated 11/29/2023 for RNA to provide passive range of motion (PROM, movement at a given joint with full assistance from another person) to left UE (LUE) and left LE (LLE) as tolerated 3 to 5 days a week, active versus passive ROM to right LE (RLE) as tolerated 3 to 5 days a week, 2 pound weights on RUE exercises 3 to 5 days a week as tolerated, and right knee splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) on for six (6) to seven (7) hours as tolerated 3 to 5 days a week. A review of Resident 12's care plan dated 6/30/2021 with target date of 6/30/2024 indicated Resident 12 had problems of falls/ADL/incontinence/skin integrity: related to Resident 12 is alert and oriented to self, time, situation, needs assistance with ADL's, incontinent of bladder and at risk for skin breakdown, braces and impaired ambulation, at risk for fall due to impaired balance and mobility. The interventions for the care plan indicated RNA to provide passive range of motion to LUE and LLE extremities as tolerated 3 to 5 days a week, active versus passive ROM to RLE as tolerated 3 to 5 days a week, 2 pound weights on RUE exercises 3 to 5 days a week as tolerated, and right knee splint on for 6 to 7 hours as tolerated 3 to 5 days a week. During a concurrent observation and interview on 4/2/2024 at 9:01 a.m., Resident 12 was lying on her back in bed. Resident 12 stated she needed more RNA. Resident 12 stated in the last two weeks, she received RNA about once a week. Resident 12 stated that her RNA sometimes was switched to a Certified Nursing Assistant (CNA) so she did not get any RNA exercises on those days. Resident 12 stated she could not move her left arm or leg and needed RNA to help her move her arm and leg. Resident 12 stated she also need a splint for the left hand. Resident 12 was able to bring the right arm up past shoulder level and bend the right elbow, wrist, and fingers. Resident 12 was able to move the right leg up and down. Resident 12 stated the facility needed more RNA staff and said there was only about one or two RNA staff. No splints were observed on Resident 12's left hand. During a concurrent interview and record review on 4/3/2024 at 3:20 p.m., with NS 1, reviewed Resident 12's physician's orders and RNA documentation. NS 1 stated Resident 12 had orders for RNA for 3 to 5 times a week for PROM to LUE and LLE, AROM versus PROM RLE, 2 pound weight exercises to RUE, put on right knee splint, and left resting hand splint. After review of Resident 12's RNA documentation during January 2024, February 2024, and March 2024, NS 2 stated Resident 12 missed the following RNA treatments: -3 RNA treatments week of 1/1/2024 -1 RNA treatment week of 1/8/2024 -2 RNA treatments week of 1/22/2024 -2 RNA treatments week of 1/29/2024 -2 RNA treatments week of 2/5/2024 -1 RNA treatment week of 2/19/2024 -2 RNA treatments week of 2/26/2024 -2 RNA treatments week of 3/4/2024 -1 RNA treatment week of 3/18/2024 -2 RNA treatments week of 3/25/2024 During an interview on 4/3/2024 at 8:45 a.m., with Restorative Nursing Aide (RNA 2), RNA 2 stated there were 2 RNAs working today. RNA 2 stated RNA duties include doing RNA treatments such as ROM, ambulation, transferring, put on splints, helping with feeding residents, passing out meal trays, putting in weights in the system, and anything else that was needed including attending appointments with residents. RNA 2 stated RNAs worked Mondays to Fridays only and there were no RNAs on the weekend. RNA 2 stated they try to put on the splints in the morning and sometimes there was not enough time. During an interview on 4/3/2024 at 1:55 p.m., with NS 1, NS 1 stated the purpose of RNA was to maintain the resident's mobility, improve ambulation and ROM. NS 1 stated it is important for residents to receive their RNA treatments to maintain their overall well-being and quality of life and that residents should receive their RNA treatments as ordered. NS 1 stated that if the residents did not receive their RNA orders as ordered, then the residents were at risk for deconditioning, getting weaker, and their ROM and contractures (loss of motion of a joint) could get worse. During an interview on 4/3/2024 at 2:37 p.m., with the Director of Nursing (DON), the DON stated that RNAs were short-staffed. DON stated the facility was aware that residents with RNA orders were not receiving RNA treatments at least 3 to 5 times a week as ordered. DON also stated that sometimes RNAs were pulled to be CNAs if the CNAs did not have enough staff and then RNA treatments would not be done that day. DON stated RNA treatments were important to help prevent contractures and to help residents have full mobility. DON stated the current RNA staff was not enough to meet the needs of residents who required RNA treatments and services. During an interview on 4/4/2024 at 8:30 a.m. with Nursing Supervisor 2 (NS 2), NS 2 stated she was the RNA supervisor, and her role was to oversee the RNA care provided to the residents. NS 2 stated they were trying to ensure that the residents received RNA 3 to 5 times a week, but it was challenging to make that happen. NS 2 stated the residents were not getting enough RNA, missing treatments, and that the facility needed more RNA staff. During an interview on 4/4/2024 at 10:28 a.m., with Restorative Nursing Aide (CNA/RNA 1), CNA/RNA 1 sated she saw residents in multiple nursing stations at the facility because they needed to help cover other areas for RNA treatments. CNA/RNA 1 stated CNA/RNA 1 tried to see as many residents as they could, but there were residents that were not seen because there were too many residents, and they did not have enough time to see all the residents. During a review of the facility's policies and procedures dated 6/2023, titled Restorative Nursing Program, indicated the Restorative Nursing Program is designed to promote/improve/maintain strength, endurance, balance and mobility .responsibilities of the RNA include: administer restorative activities specific to resident needs and order of the physical therapist. The goal of these activities is performed 3 - 5 times a week as ordered. The Performance Improvement Plan indicated a Registered Nurse will review the Range of Motion exercises with the RNAs at least every month to ensure that orders are appropriate and are being provided to the residents. 2a. A review of Resident 45's Face Sheet indicated Resident 45 was admitted to the facility on [DATE]. A review of Resident 45's Patient Diagnosis Information indicated Resident 45 had diagnoses including, but not limited to hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following cerebral infarction (blockage of the flow of blood brain, causing or resulting in brain tissue death). A review of Resident 45's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 3/1/2024 indicated Resident 45 was cognitively intact (sufficient judgement, planning, organization to manage average demands in one's environment) and had no functional limitations in ROM in both upper and lower extremities lower extremity (LE, hip, knee, ankle, foot). The MDS also indicated Resident 45 required partial assistance (helper does less than half the effort) for eating, oral hygiene and substantial assistance (helper does more than half the effort) with dressing, toileting, chair transfers, and did not walk. A review of Resident 45's medical records indicated there was no Occupational Therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Initial Evaluation completed. A review of Resident 45's Physical Therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) Initial Evaluation dated 2/21/2024 indicated the ROM assessment was completed for the hip, knee, and ankle and did not include ROM assessment of the upper extremities. During a concurrent observation and interview on 4/3/2024 at 1:18 p.m., Resident 45 was sitting up in a wheelchair in the resident's room. Resident 45 was able to move the right arm up and down, and the right leg up and down. Resident 45 stated the left side was the problem side and was able to move the left arm and leg up and down a little. Resident 45 stated she never received any OT services and did not know that OT was offered here. During an interview on 4/4/2024 at 8:30 a.m., with Nursing Supervisor (NS 2), NS 2 stated all residents received an OT and PT evaluation upon admission in order to complete a range of motion assessment for both upper and lower extremities. NS 2 stated the facility had not been writing OT evaluation orders recently because there had not been an OT available to evaluate and see residents. NS 2 reviewed Resident 45's medical records and confirmed there was no OT evaluation completed. NS 2 reviewed a PT evaluation and confirmed that the PT evaluation did not include a range of motion assessment for the upper extremities. NS 2 confirmed Resident 45 did not receive a baseline ROM assessment upon admission. NS 2 stated it was important to establish a baseline for the resident's ROM in order to see where our residents were at so we know how to care for them and how to monitor them, so we could know if the residents declined in their ROM. NS 2 stated the facility would not know if the residents declined in their ROM or got better because the facility did not complete an assessment upon admission to know what the ROM was when the residents were admitted . NS 2 stated it was important to continue to monitor the resident's ROM and mobility to ensure that the residents were maintaining their quality of life and that their body was at their optimal functioning. 2b. A review of Resident 63's Face Sheet indicated Resident 63 was admitted to the facility on [DATE]. A review of Resident 63's Patient Diagnosis Information indicated Resident 45 had diagnoses including, but not limited to morbid (severe) obesity (disorder involving excessive body fat that increased risk for health problems) and chronic obstructive pulmonary disease (lung disease that causes obstruction of airflow and can limit normal breathing). A review of Resident 63's Minimum Data Set, dated [DATE] indicated Resident 63 was cognitively intact and had no functional limitations in range of motion in both upper and lower extremities. The MDS also indicated Resident 63 required supervision assistance for eating, oral hygiene and substantial assistance (helper does more than half the effort) with lower body dressing, toileting, chair transfers, and to walk 10 feet. A review of Resident 63's medical records indicated there was no Occupational Therapy Initial Evaluation completed. A review of Resident 63's Physical Therapy Initial Evaluation dated 3/6/2024 indicated the ROM assessment was completed for the hip, knee, and ankle and did not include ROM assessment of the upper extremities. During a concurrent observation and interview on 4/2/2024 at 3:00p.m., Resident 63 was sitting up in a wheelchair wearing a dress and Resident 63's spouse present in the resident's room. Resident 63 required extra time to verbalize needs. Resident 63 was able to move both arms and legs a little. During an interview on 4/4/2024 at 8:30 a.m., with NS 2, NS 2 stated all residents received an OT and PT evaluation upon admission in order to complete a range of motion assessment for both upper and lower extremities. NS 2 stated the facility had not been writing OT evaluation orders recently because there had not been an OT available to evaluate and see residents. NS 2 reviewed Resident 63's medical records and confirmed there was no OT evaluation completed. NS 2 reviewed a PT evaluation and confirmed that the PT evaluation did not include a range of motion assessment for the upper extremities. NS 2 confirmed Resident 63 did not receive a baseline ROM assessment upon admission. NS 2 stated it was important to establish a baseline for the resident's ROM in order to see where our residents were at so we know how to care for them and how to monitor them, so we could know if the residents declined in their ROM. NS 2 stated the facility would not know if the residents declined in their ROM or got better because the facility did not complete an assessment upon admission to know what the ROM was when the residents were admitted . NS 2 stated it was important to continue to monitor the resident's ROM and mobility to ensure that the residents were maintaining their quality of life and that their body was at their optimal functioning. During an interview on 4/3/2024 at 1:55 p.m., with NS 1, NS 1 stated for new admissions there was usually an order for OT and PT evaluation, but right now there was no OT to provide OT services. NS 1 stated the baseline ROM assessments were completed by PT and OT upon admission to the facility. NS 1 stated she was not aware of who was completing the UE ROM assessments for new admissions since there was no OT at this time. NS 1 stated it was important for the facility to monitor the residents' ROM and mobility to make sure any changes were reported to the physician to see if there were any interventions the residents may need. NS 1 stated declines in ROM and mobility could impact the residents such as their walking could get worse, and residents could develop contractures. During an interview on 4/3/2024 at 2:23 p.m., with NS 1, NS 1 confirmed the residents were only receiving PT evaluation for baseline ROM and there was no staff completing the baseline assessment for BUE ROM, because there was no OT right now. During a phone interview on 4/4/2024 at 11:16 a.m., with Physical Therapist (PT 1), PT 1 stated the PT evaluation documentation only included the lower extremities and the PT did not complete a baseline evaluation of range of motion assessment for the upper extremities. During an interview on 4/4/2024 at 11:30 a.m., with Nurse Practitioner (NP 1), NP 1 stated it is the facility's protocol and standard to order OT and PT evaluations for all residents upon admission to establish a baseline for the resident's function, ADLs, mobility, and to see if there were any opportunities for skilled therapy such as positioning, splinting needs, and if a RNA program was appropriate. NP 1 stated Resident 45 was not ordered OT evaluation because there was no OT available at the facility. NP 1 stated at minimum, an OT evaluation should have been completed to establish a baseline. During an interview on 4/4/2024 at 12:36 p.m., with the DON, the DON stated the facility had no system to formally monitor ROM and mobility for residents and depend on RNA, CNA, or LVN reporting any changes in ROM to staff. The DON stated at the minimum there should be a baseline assessment of ROM completed by PT and OT for all extremities in order for the facility to use the baseline ROM assessment to monitor and compare if the residents declined or got better. DON stated the newer residents that were admitted when the OT was not available did not receive baseline ROM assessments for the UE. The DON stated these residents were at risk for decline in the UE abilities and the facility would not be aware if the resident declined, because there would not be an assessment to compare it to. A review of the facility's policy and procedure dated 3/2023, titled, Long Term Care Standard of Care Nursing Protocol, indicated, provide measures to increase mobility per medical provider order: 1. ROM exercises, 3. Physical therapy consult as ordered. 4. Occupational therapy consults as ordered. During an interview on 4/4/2024 at 3:06 p.m., DON reviewed the Long Term Care Standard of Care Nursing Protocol policy and stated there were no other facility policies to provide rehabilitative therapy services to residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 77's Face Sheet indicated the facility admitted the resident on 12/14/2023, with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), nontraumatic (not caused by trauma) subdural hemorrhage (a collection of blood between the covering of the brain and the surface of the brain), and seizures (a sudden, uncontrolled burst of electrical activity in the brain). A review of Resident 77's History and Physical (H&P), dated 12/14/2023, indicated the resident was alert and oriented to person and place, with major neurocognitive disorder (decreased mental function due to a medical disease other than psychiatric illness) with functional dependency and need for protective environment. A review of Resident 77's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/15/2024, indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident was dependent on sitting on side of the bed to lying flat on the bed, move from lying on the back to sitting on the side of the bed, come to a standing position from sitting in a chair, wheelchair, or on the side of the bed, transfer to and from a bed to a chair, and to get in and out of a tub/shower. A review of Resident 77's Fall Risk Evaluation, dated 3/15/2024, indicated the resident was high risk for falls. A review of Resident 77's Physician's Order did not indicate orders for use of side rails. During an observation and interview on 4/2/2024, at 11:25 a.m., with Certified Nursing Assistant/Restorative Nursing Aide 1 (CNA/RNA 1), in Resident 77's room, observed the resident's bed pushed against the wall, with both upper side rails up. CNA/RNA 1 stated the bed was pushed against the wall to give space for a transfer aid equipment (a non-powered device that ensures residents can be positioned from sit-to-stand transfers safely, quickly and with ease). CNA/RNA 1 stated the upper side rails of the resident were up because the resident was at risk for fall. During an interview and record review on 4/2/2024, at 12 p.m., with Nursing Supervisor 1 (NS 1), reviewed the Physician's Order and Care Plans of the resident with NS 1. NS 1 stated the resident does not have any orders for side rails. NS 1 stated the bed was pushed against the wall with both upper side rails up to prevent falls. During an interview on 4/4/2024, at 8:15 a.m., with the DON, the DON stated all side rail use should be assessed for risk of injury from entrapment and consent should be obtained from the resident or the resident representative. The DON stated a physician's order is needed for use of side rails. 3. A review of Resident 70's Face Sheet indicated the facility admitted the resident on 12/30/2022, with diagnoses including Alzheimer's disease, dementia, and abnormalities of gait (a manner of walking or moving on foot) and mobility. A review of Resident 70's H&P, dated 12/27/2023, indicated the resident was awake and alert, speech was mostly coherent, but non-fluent at times. A review of Resident 70's MDS, dated [DATE], indicated the resident sometimes had the ability to make self-understood and understand others. The resident had moderately impaired vision. The MDS indicated the resident required supervision or touching assistance to roll from lying on back to left and right side, and return to lying back on the bed, move from sitting on side of bed to lying flat on the bed, move from lying on back to sitting on the side of the bed, come to a standing position from sitting in a chair, wheelchair, or on the side of the bed, transfer to and from a bed to a chair, get on and off a toilet or commode, and get in and out of tub/shower. A review of Resident 70's Fall Risk Evaluation, dated 3/22/2024, indicated the resident was high risk for falls. A review of Resident 70's Physician's Order did not indicate orders for use of side rails. During an observation and interview on 4/2/2024, at 9:33 a.m., with Certified Nursing Assistant 3 (CNA 3), in Resident 70's room, observed Resident 70's left side of the bed pushed against the wall, with both upper side rails up, and an overbed table placed on the right lower side of the bed. CNA 3 stated the resident's bed was pushed against the wall and the side rails were up so the resident can only get out on one side of the bed, preventing a fall. During an interview on 4/4/2024, at 8:15 a.m., with the DON, the DON stated all side rail use should be assessed for risk of injury from entrapment and consent should be obtained from the resident or the resident representative. The DON stated a physician's order is needed for use of side rails. A review of the facility provided Hospital Bed 1 (HB 1) for Use Service Manual, dated 2011, indicated to avoid personal injury read all sections pertaining to the bed model before use. Rails are not meant for patients considered as high risk for entrapment (i.e., patients with pre-existing conditions such as confusion, restlessness, lack of muscle control, altered mental status). Additional safety measures should be considered for such high-risk patients. Based on observation, interview, and record review the facility failed to ensure the safe and appropriate use of side rails (SR, adjustable rigid plastic bars attached to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) for three of four sampled residents (Resident 8, 77 and 70) investigated during review of restraints by failing to: 1. Conduct an assessment including the risk for entrapment (occurs when a resident is caught between the mattress and bed rail or within the bed rail itself) from side rails. 2. Review the risk and benefits of side rails with the resident or resident representative and obtain informed consent (process in which residents or resident representatives are given important information, including possible risks and benefits, about a procedure or treatment). These deficient practices had the potential to result in psychosocial harm and physical harm from entrapment and death of residents. Cross refernec to F604 and F656. Findings: 1. A review of Resident 8's Face Sheet (admission Record) indicated the facility admitted the resident on 6/11/2020 with diagnoses that included Alzheimer's disease (a type of dementia [a general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life]) with late onset, anxiety disorder (a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear), and abnormalities of gait (the pattern or style of movement involved in walking) and mobility. A review of Resident 8's History and Physical (H&P), dated 5/26/2023, indicated the resident had dementia with behavioral disturbances and was unable to follow commands. The H&P indicated the resident had a history of falls resulting in a fractured hip. A review of Resident 8's Minimum Data Set (MDS - an assessment and care screening tool) dated 2/6/2024, indicated the facility most recently readmitted the resident on 5/19/2021 and the resident sometimes was able to understand others and sometimes was able to make herself understood. The MDS further indicated the resident was dependent on staff for eating, toileting, bathing, dressing, personal hygiene, and mobility. The MDS indicated the resident did not use SRs as a physical restraint. A review Resident 8's Care Plan (CP) titled, Cognitive / Communication / vision / Falls . related to (Resident 8) has forgetfulness, confusion related to Alzheimer dementia, hard of hearing, impaired vision ., dated 6/11/2020, indicated the resident wanted to be safe, reduce risk for falls and injury and to remain safely in the facility. The CP further indicated an intervention that if the resident was noted as restless and trying to get out of bed, to assist her to the wheelchair and sit her across from the nursing station. During an observation on 4/2/2024 at 11:05 a.m., observed Resident 8 in Hospital Bed 1 (HB 1) with eyes closed and did not verbally respond to the surveyor. Observed the bed with bilateral SRs in raised position and the left side of the bed was placed against a built-in wall dresser cabinet with no access for bed exit on the left side. During an observation and interview on 4/2/2024 at 11:18 a.m. with Certified Nursing Assistant 6 (CNA 6), observed Resident 8 in bed. CNA 6 stated the Resident had fallen in the past and can move. CNA 6 stated the bed against the dresser and raised upper side rails were used for fall prevention. During an interview on 4/2/2024 at 11:27 a.m. with Licensed Vocation Nurse 5 (LVN 5), LVN 5 stated the facility does not require a physician's order for the use of SRs and Resident 8 did not have an order for SRs. During an interview with Family Member 1 (FM 1) on 4/2/2024 at 2:10 p.m., FM 1 stated Resident 8 has advanced dementia and bruises easily. FM 1 stated Resident 8 is not mobile, but she can slip out of the bed and the facility has found her on the floor. FM 1 stated she was aware that SRs and bed positioning were used to keep Resident 8 in the bed and off the floor, but she does not remember anyone ever discussing the risks of using them. During an interview and record review on 4/3/2024 at 8 a.m. with the Director of Nursing (DON), reviewed Resident 8's clinical record. The DON stated the facility uses bilateral upper SRs that are connected to the bed. The DON stated the process for using SRs is the Interdisciplinary Team (IDT) decides to use two SRs if the resident is assessed and able to use them and that the SRs do not restrict movement. The DON stated if the resident is not assessed then the SRs should not be up. The DON stated the possible adverse effects of using SRs was restriction of movement and entrapment. The DON stated there was no documentation indicating there was an assessment of Resident 8 for use of SRs. The DON stated there was no documentation indicating an assessment for risk of entrapment for Resident 8 prior to using SRs. The DON stated informed consent is usually obtained by the physician from the resident or resident representative when consent is needed. The DON stated there was no documentation indicating informed consent was received prior to using the SRs. The DON stated the facility did not have a policy regarding the use of SRs. The DON stated the importance of policies was that they guide the facility to do what is supposed to be done based on standards of care. During an interview on 4/4/2024 at 8:10 a.m. with the Administrator (ADM), the ADM stated they were now aware of the regulations regarding SR use in the facility. The ADM stated they now have clarity on the regulation and there should be a specific policy for restraints, and they do not have one. The ADM stated it was her responsibility to ensure policies were in place and the SR policy should include an assessment for SR usage and informed consent for any SRs used in the facility. The ADM Stated they will be developing a policy based on the standards of practice. During a follow up interview on 4/4/2024 at 8:15 a.m. with the DON, the DON stated now she was aware that all siderail use should be assessed for risk of injury from entrapment and consent should be obtained from the resident or resident representative. The DON stated without assessments and consents the resident is at risk for injury due to entrapment. The DON stated when the bed was placed against the dresser there was a risk for restriction in mobility and there was a risk for entrapment by the side rail and being squeezed against the wall. The DON stated when residents become entrapped it could possibly lead to fractures, wounds, and skin tears. The DON stated it was important to ensure resident safety, ensure the family is aware, and to respect the resident's rights as well. A review of the facility provided HB 1 Instructions for Use Service [NAME], dated 2011, indicated to avoid personal injury read all sections pertaining to the bed model before use. Rails are not meant for patients considered as high risk for entrapment (i.e., patients with pre-existing conditions such as confusion, restlessness, lack of muscle control, altered mental status). Additional safety measures should be considered for such high-risk patients. A review of the facility provided policy and procedure titled, Policy Review and Approval, last reviewed on 4/2023, indicated the policy was to maintain a standardized process for the development, review, revise, approval, implementation and maintenance of the facility policies and related standards, procedures, plans, and guidelines. The responsible person drafts policy consistent with the facility standards of policy design. The draft policy is submitted to [NAME] President, Legal Affairs, ADM, or designee who reviews the policy and ensure distribution to appropriate parties for review and comment. The routing for approval of policies is the Policy and Forms Committee, Medical Executive Committee, and Governing Body. [NAME] President, Legal Affairs, ADM or designee coordinates preparation of final draft policy for approval by the Chief Executive Officer and Governing Body. The approved policy is posted on the facility intranet.

Based on interview and record review, the facility failed to provide adequate and sufficient nursing staff to provide care for residents requiring Restorative Nursing Aide (RNA, nursing aide program that helps residents to maintain their function and joint mobility) services. This deficient practice had the potential for 70 residents with physician's orders for RNA to experience a decline in range of motion (ROM, full movement potential of a joint), mobility, and activities of daily living (ADL, basic activities such as eating, dressing, toileting) function. Cross Reference to F688 and F825 Findings: A review of the physician's orders for residents on RNA services dated 4/3/2024 indicated 70 residents had physician's orders for RNA to provide treatments and services including but not limited to, ROM exercises to upper extremities (UE, shoulder, elbow, wrist, hand) and lower extremities (LE, hip, knee, ankle, foot), application of splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) or braces (an external device to support, align, or correct a movable part of the body), ambulation (walking), strengthening exercises with weights, and transfers (moving from one surface to another). A review of the facility's Posting of Long Term Care (LTC/Skilled Nursing Facility[SNF]) Hours (nurse staffing hours worked for each day) for January 2024 indicated the following RNA staff assignments for the 7 a.m. to 3 p.m. shift from Monday to Friday: -Monday, 1/1/2024: zero (0) RNA -Tuesday, 1/2/2024: one (1) RNA -Wednesday, 1/3/2024: 0 RNA -Thursday, 1/4/2024: two (2) RNAs -Friday, 1/5/2024: 0 RNA -Monday, 1/8/2024: 2 RNAs -Tuesday, 1/9/2024: 2 RNAs -Wednesday, 1/10/2024: 1 RNA -Thursday, 1/11/2024: 2 RNAs -Friday, 1/12/2024: 2 RNAs -Monday, 1/15/2024: 1 RNA -Tuesday, 1/16/2024: 1 RNA -Wednesday, 1/17/2024: three (3) RNAs -Thursday, 1/18/2024: 1 RNA -Friday, 1/19/2024: 3 RNAs -Monday, 1/22/2024: 3 RNAs -Tuesday, 1/23/2024: 1 RNA -Wednesday, 1/24/2024: 1 RNA -Thursday, 1/25/2024: 2 RNAs -Friday, 1/26/2024: 2 RNAs -Monday, 1/29/2024: 2 RNAs -Tuesday, 1/30/2024: 2 RNAs -Wednesday, 1/31/2024: 2 RNAs A review of the facility's Posting of LTC Hours for February 2024 indicated the following RNA assignments for the 7 a.m. to 3 p.m. shift from Monday to Friday: -Thursday, 2/1/2024: 2 RNAs -Friday, 2/2/2024: 1 RNA -Monday, 2/5/2024: 2 RNAs -Tuesday, 2/6/2024: 1 RNA -Wednesday, 2/7/2024: 1 RNA -Thursday, 2/8/2024: 2 RNAs -Friday, 2/9/2024: 2 RNAs -Monday, 2/12/2024: 1 RNA -Tuesday, 2/13/2024: 2 RNAs -Wednesday, 2/14/2024: 2 RNAs -Thursday, 2/15/2024: 3 RNAs -Friday, 2/16/2024: 2 RNAs -Monday, 2/19/2024: 2 RNAs -Tuesday, 2/20/2024: 2 RNAs -Wednesday, 2/21/2024: 1 RNA -Thursday, 2/22/2024: 1 RNA -Friday, 2/23/2024: 2 RNAs -Monday, 2/26/2024: 1 RNAs -Tuesday, 2/27/2024: 1 RNA -Wednesday, 2/28/2024: 3 RNAs -Thursday, 2/29/2024: 2 RNAs A review of the facility's Posting of LTC Hours for March 2024 indicated the following RNA assignments for the 7 a.m. to 3 p.m. shift from Monday to Friday: -Friday, 3/1/2024: 1 RNA -Monday, 3/4/2024: 3 RNAs -Tuesday, 3/5/2024: 3 RNAs -Wednesday, 3/6/2024: 2 RNAs -Thursday, 3/7/2024: 2 RNAs -Friday, 3/8/2024: 2 RNAs -Monday, 3/11/2024: 3 RNAs -Tuesday, 3/12/2024: 3 RNAs -Wednesday, 3/13/2024: 3 RNAs -Thursday, 3/14/2024: 3 RNAs -Friday, 3/15/2024: 3 RNAs -Monday, 3/18/2024: 2 RNAs -Tuesday, 3/19/2024: 3 RNAs -Wednesday, 3/20/2024: 3 RNAs -Thursday, 3/21/2024: 3 RNAs -Friday, 3/22/2024: 3 RNAs -Monday, 3/25/2024: 1 RNA -Tuesday, 3/26/2024: 2 RNAs -Wednesday, 3/27/2024: 3 RNAs -Thursday, 3/28/2024: 2 RNAs -Friday, 3/29/2024: 0 RNA A review of the facility's Posting of LTC Hours for April 2024 indicated the following RNA assignments for the 7 a.m. to 3 p.m. shift from Monday to Friday: -Monday, 4/1/2024: 1 RNA -Tuesday, 4/2/2024: 2 RNAs -Wednesday, 4/3/2024: 2 RNAs During an interview, on 4/3/2024 at 8:45 a.m., Restorative Nursing Aide (RNA 2) stated there were 2 RNAs including RNA 2 working that day. RNA 2 stated RNA duties including doing RNA treatments such as ROM, ambulation, transferring, put on splints, helping with feeding residents, passing out meal trays, putting in weights in the system, and anything else that was needed including attending appointments with residents. RNA 2 stated RNAs worked Mondays to Fridays only and there were no RNAs on the weekend. RNA 2 stated they try to put on the splints in the morning and sometimes there was not enough time. During an interview, on 4/3/2024 at 1:55 p.m., Nursing Supervisor (NS 1) stated the purpose of RNA was to maintain the resident's mobility, improve ambulation and ROM. NS 1 stated it was important for residents to receive their RNA treatments to maintain their overall well-being and quality of life and that residents should receive their RNA treatments as ordered. NS 1 stated that if the residents did not receive their RNA orders as ordered, then the residents were at risk for deconditioning, getting weaker, and their ROM and contractures could get worse. During an interview, on 4/3/2024 at 2:37 p.m., the Director of Nursing (DON) stated there should be five RNAs staffed Monday to Friday, one for each nursing station. The DON stated that RNAs were short-staffed and that the facility was aware that the posting of LTC hours of nurse staffing indicated there were 0 to 3 RNAs staffed each day from January 2024 to present. The DON stated the facility was aware that residents with RNA orders were not receiving RNA treatments at least 3 to 5 times a week as ordered. DON also stated that sometimes RNAs were pulled to be CNAs if the CNAs did not have enough staff and then RNA treatments would not be done that day. The DON stated RNA treatments were important to help prevent contractures and to help residents have full mobility. The DON stated the current RNA staff was not enough to meet the needs of residents who required RNA treatments and services. During an interview, on 4/4/2024 at 8:30 a.m., Registered Nursing Supervisor (NS 2) stated that she was the RNA supervisor and oversaw the RNA services provided to the residents with RNA orders. NS 2 stated the facility was trying to ensure that residents received RNA treatments 3 to 5 times a week and that it was challenging to make that happen. NS 2 stated residents were not getting enough RNA treatments and that the facility needed more RNA staff. During an interview, on 4/4/2024 at 10:28 a.m., Restorative Nursing Aide (CNA/RNA 1) stated CNA/RNA 1 saw residents multiple areas at nursing stations at the facility because they needed to help cover other areas for RNA treatments. CNA/RNA 1 stated CNA/RNA 1 tried to see as many residents as they could, but there were residents that were not seen because there were too many residents and they did not have enough time to see all the residents. During a review of the facility's policies and procedures dated 6/2023, titled Restorative Nursing Program, indicated the Restorative Nursing Program is designed to promote/improve/maintain strength, endurance, balance and mobility .responsibilities of the RNA include: administer restorative activities specific to resident needs and order of the physical therapist. The goal of these activities is to performed 3 - 5 times a week as ordered. The Performance Improvement Plan indicated a Registered Nurse will review the Range of Motion exercises with the RNAs at least every month to ensure that orders are appropriate and are being provided to the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. a. A review of Resident 38's Face Sheet indicated the facility admitted the resident on 5/31/2023 with diagnoses that included diastolic heart failure (a condition in which the heart cannot pump enough blood to meet the body's needs), morbid (severe) obesity (body weight that is higher than what is considered healthy for a given height), chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of Resident 38's H&P, dated 6/1/2023, indicated the resident was alert and oriented to name, time, and place. A review of Resident 38's MDS, dated [DATE], indicated the resident was able to understand others and make himself understood. The MDS further indicated the resident was dependent on staff for toileting, bathing, lower body dressing, and chair / bed transfers. A review Resident 38's CP titled, Nutrition and Hydration as evidenced by several chronic medical conditions that have potential to affect (Resident 38) nutrition and hydration dated 5/31/2023, indicated the resident was to be comfortable with the foods / fluids provided. During an observation and interview, on 4/2/2024, at 11:43 a.m. with Resident 38, observed the resident sitting up in bed. Resident 38 stated the facility food was not that great and it was rarely delivered warm. 2.b. A review of Resident 4's Face Sheet indicated the facility admitted the resident on 12/8/2022 with diagnosis that included heart failure (a condition in which the heart cannot pump enough blood to meet the body's needs), anemia (low levels of healthy red blood cells), and type two diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]). A review of Resident 4's MDS, dated [DATE], indicated the resident's Brief Interview for Mental Status (a brief cognitive screening measure that focuses on orientation and short-term word recall) screening indicated the resident had intact cognition. A review of the Resident Council Minutes, dated 1/31/2024, indicated the meeting was canceled but resident comments were noted to include one of eight residents indicated the food is always cold. A review of the Resident Council Minutes, dated 2/28/2024, indicated 2 of nine residents indicated the food still comes cold. A review of the Resident Council Minutes, dated 3/27/2024, indicated two of ten residents stated food still comes cold. The minutes indicated to please remind residents that they can ask for food to be reheated. During a Resident Council interview, on 4/3/2024, at 9:56 a.m., Resident 4 stated the facility food was still delivered cold, no residents disagreed. During a concurrent observation and interview, on 4/3/2024, at 11:24 a.m., inside the kitchen, with the Trayline Manager (TM), a food warmer (kitchen device that maintains food temperatures above safe temperatures) indicated a temperature of 165 degrees Fahrenheit. The TM measured the temperature of a bowl of cream-colored soup inside the food warmer and the thermometer indicated a temperature of 128 degrees Fahrenheit. The TM stated residents would not like the soup if it is not served hot and if soup is served to residents at a low temperature, the residents can possibly get an upset stomach. During an interview, on 4/3/2024, at 12:30 p.m. with the Registered Dietician (RD), the RD stated he was aware there were two residents in the Resident Council who had concerns about the food not being warm. The RD stated those residents have their trays kept at the top of the metal delivery cart. During an interview, on 4/4/2024, at 8:15 a.m. with the Director of Nursing (DON), the DON stated she had heard there were complaints about the temperature of food. The DON stated the meal cart is delivered to the units and the trays should remain in the cart with the doors closed. The DON stated residents are just like everyone else and they want their food to be warm because it tastes better. The DON stated serving food warm is for resident satisfaction and when residents are not satisfied that can lead to depression. A review of the facility P&P titled, Food Handling Guidelines, last revised 1/2023 indicated foods should be held hot for service at a temperature of 135 degrees or higher. 3. During a concurrent observation and interview, on 4/2/2024, at 8:01 a.m., inside the kitchen's walk-in refrigerator, with the Director of Hospitality (DOH), a shelf held a box of lemons on the bottom shelf. The box of lemons contained multiple lemons with white and gray patches. The DOH stated there is some mold on some of the lemons. The DOH stated the lemons were delivered to the facility on 3/29/2024 and were supposed to be returned on 3/31/2024. The DOH stated the box of lemons should have been placed in the returns section of the kitchen. The DOH stated moldy foods should not be stored in the refrigerator because there is a possibility that the mold can spread inside the refrigerator. During an interview with the RD, on 4/2/2024, at 8:43 a.m., the RD stated moldy foods need to be thrown away and the area should be sanitized to make sure the mold does not spread to other areas in the fridge. The RD further stated moldy food items should not be served to residents since it can possibly cause food poisoning, which could potentially lead to death. During an interview with the DON, on 4/4/2024, at 1:36 p.m., the DON stated moldy lemons should be thrown away so that residents do not consume them and do not get sick from consuming the lemons. A review of the facility's P&P titled, Food Handling Guidelines, last reviewed 10/18/2023, indicated to inspect the produce and discard any spoiled, bruised, or damaged produce. The P&P further indicated if a contaminant is found in food, do not serve the food and remove all affected food from service, place is a covered container and label DO NOT SERVE. 4. During a concurrent observation and interview, on 4/3/2024, at 11:24 a.m., inside the kitchen, with the TM, a food warmer indicated a temperature of 165 degrees Fahrenheit. The TM measured the temperature of a bowl of cream-colored soup inside the food warmer and the thermometer indicated a temperature of 128 degrees Fahrenheit. The TM stated residents would not like the soup if it is not served hot and if soup is served to residents at a low temperature, the residents can possibly get an upset stomach. During an interview with the RD, on 4/3/2024, at 11:38 a.m., the RD stated the temperature on hot foods should be at least 140 degrees. The RD stated foods served below that temperature have a higher risk for bacterial growth and if served to residents, can possibly cause foodborne illness in residents. The RD further stated if foods are not served at appropriate temperatures, residents might not eat the food and can possibly cause malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat). During an interview with the DON, on 4/4/2024, at 1:36 p.m., the DON stated that food delivered to residents should stay warm to satisfy the needs of the residents. A review of the facility's P&P titled, Food Handling Guidelines, last reviewed 10/18/2023, indicated foods should be held hot for service at a temperature of 135 degrees or higher. 5. During a concurrent observation and interview, on 4/2/2024, at 8:21 a.m., inside the kitchen, with the DH, the drainpipe connected to the kitchen ice machine touched the drainage grate on the floor. The DH confirmed the drainpipe was touching the drain grate on the floor and stated the drainpipe should not be touching the drain grate. The DH stated the drainpipe should be elevated above the drain to prevent the possibility of flow reversal and cause cross-contamination between water in the drain and the ice machine. During an interview with the RD, on 4/4/2024, at 10:05 a.m., the RD stated there should be at least a one-inch gap between the ice machine drainpipe and the drain to prevent backflow. The RD further stated if there is backflow, the water from the drain would contaminate the ice and can possibly cause foodborne illness. During an interview with the DON, on 4/4/2024, at 1:36 p.m., the DON stated there should be a gap between the ice machine drainpipe and the drain to prevent backflow. The DON further stated if there is backflow, the ice can get contaminated and possibly cause illness to residents. A review of the U.S. Food and Drug Administration Food Code 2022, dated 1/18/2023, provided by the facility, indicated under backflow prevention methods, an air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch. Based on observation, interview, and record review, the facility staff failed to ensure proper storage, preparation, and distribution of food in accordance with professional standards for food service safety by failing to: 1. Ensure a sandwich labeled with a use by date (the date a food item should be discarded) of 3/31/2024 was not readily available for consumption in the resident's room for one of two sampled residents (Resident 24) investigated under the food care area. This deficient practice had the potential to place residents at increased risk of experiencing foodborne illness (an illness that comes from eating contaminated food or drinks). 2. Ensure food was served at a warm temperature for one of two sampled residents (Resident 38) investigated under the food care area and for one of nine residents (Resident 4) present during the Resident Council task. This deficient practice had the potential to affect residents' palatability leading to weight loss or malnutrition. 3. Dispose of a box of lemons containing mold in the walk-in refrigerator. This deficient practice had the potential for residents to be served contaminated food and potentially cause food poisoning. 4. Ensure soup kept in the kitchen food warmer maintained a temperature of 135 degrees Fahrenheit (a unit of measure for temperature) or higher. This deficient practice had the potential for bacterial growth and decrease the palatability of the food served to the residents. 5. Maintain an air gap between the kitchen ice machine drainpipe and the drain. This deficient practice had the potential for backflow in the ice machine and cause cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). Findings: 1. A review of Resident 24's Face Sheet (admission Record) indicated the facility admitted the resident on 9/6/2023 with diagnoses that included Parkinson's disease (a progressive disorder that affects the nervous system) with dyskinesia (uncontrollable and involuntary movements), osteoarthritis (a disease of the joints [area where two bones make contact] that causes pain), and insomnia (difficulty sleeping). A review of Resident 24's History and Physical (H&P) dated 9/12/2023 indicated the resident had a history of progressive functional decline complicated by cognitive (relating to or involving the processes of thinking and reasoning) decline and was dependent on staff for activities of daily living but was generally able to feed himself. A review of Resident 24's Minimum Data Set (MDS - an assessment and care screening tool), dated 3/15/2024, indicated the resident was originally admitted to the facility on [DATE] and was able to understand others and make himself understood. The MDS further indicated the resident was dependent on staff for eating, toileting, bathing, dressing, personal hygiene, and transferring between the bed to chair. A review Resident 24's Care Plan (CP) titled, Nutrition and hydration: chronic medical conditions that have the potential to affect nutrition and hydration, dated 9/6/2023, indicated the resident would receive assistance with foods / fluids. The CP further indicated an intervention for staff to assist at mealtime and between meals with food and fluids as needed. During an observation, on 4/2/2024, at 9:25 a.m., Assistant Activities Coordinator 1 (AAC 1) assisted Resident 24 with breakfast in the resident's room. Observed a sandwich in a plastic bag on Resident 24's nightstand labeled with a use by date of 3/31/2024, 8:14 a.m. During a concurrent observation and interview, on 4/2/2024, at 9:37 a.m., with AAC 1, observed AAC 1 exit Resident 24's room with a sandwich. AAC 1 stated she removed the peanut butter and jelly sandwich from Resident 24's nightstand and it was labeled with a use by date of 3/31/2024, 8:14 a.m. AAC 1 stated it was two days past the date the sandwich should have been used by. AAC 1 stated she did not know why the sandwich was still in Resident 24's room. During an interview, on 4/2/2024, at 10 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated sometimes Resident 24 eats at night and an expired sandwich was possibly delivered from the kitchen or the sandwich was left in the resident's room. LVN 2 stated the sandwich should not have been in the resident's room because it was expired and could have become hard. LVN 2 stated the sandwich could have also poisoned the resident leading to diarrhea. During a concurrent interview and record review, on 4/4/2024, at 8:15 a.m., with the Director of Nursing (DON), reviewed the facility policy and procedure (P&P) regarding food storage. The DON stated she was made aware Resident 24 had a sandwich with a use by date of 3/31/2024 in his room. The DON stated she did not think the kitchen would deliver expired food, and the staff assigned to the resident should have checked the date and removed the expired food. The DON stated the facility policy indicated to follow the use by date and the policy was not followed. The DON stated there was a potential for harm to the resident if he ate an expired sandwich resulting in stomach issues and food poisoning. A review of the facility P&P titled, Food Handling Guidelines, last revised 1/2023, indicated food is handled using a Hazard Analysis Critical Control Point (HACCP, a management system in which food safety is addressed) process in accordance with regulatory guidelines. All foods must be identified with the Company's label. A review of the facility P&P titled, Food and Supply Storage, last revised 1/2023, indicated all food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Most, but not all, products contain an expiration date. The words sell-by, best-by, enjoy-by or use-by should precede the date. Foods past the use by date should be discarded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide rehabilitative therapy services, including occupational therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) and physical therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) services to two of five sampled residents by failing to: 1. Provide OT services to any residents from 10/7/2023 to present, 2. Provide Residents 45 and 63 with an OT evaluation upon admission per the facility's stated standard of care for all admissions, 3. Provide adequate physical therapy treatments and services to meet Resident 45 and Resident 63's PT care plans and goals. These failures prevented residents from receiving OT evaluation and services to address residents' ROM (ROM, full movement potential of a joint), performance in activities of daily living (ADL, basic activities such as eating, dressing, toileting), and create a baseline of ROM for upper extremities (UE, shoulder, elbow, wrist, hand) upon admission. These failures also had the potential to delay progress in restoring Resident 45 and 63's ability to walk, transfer, and overall strength and mobility. Cross Reference to F688 and F725 Findings: 1. During an interview, on 4/2/2024 at 2:08 p.m., Physical Therapist 1 (PT 1) stated he was the only PT for the long-term care (LTC, skilled nursing facility [SNF]) part of the facility's campus. PT 1 stated he also saw patients in the outpatient part of the campus as well as the behavioral therapy part of the campus. PT 1 stated he was at the SNF part of the campus from 1:00 p.m. to 3:00 p.m. only and there was no director of rehabilitation for rehabilitation services here. PT 1 stated there was no OT at this time, because the previous OT left on leave and did not return to work. PT 1 stated he had no idea what would happen if a resident in the SNF needed OT services because there was no OT available. PT 1 stated he did not remember exactly when the OT left on leave, but it may have been about four months ago. During an interview, on 4/4/2024 at 9:27 a.m., the Administrator (ADM) stated the facility was aware that there had been no OT available for residents since October 2023 when the OT was out on leave. The ADM stated the facility had a contract with a company to provide PT and OT services to the residents in the facility and stated the company still had not provided an OT. During an interview, on 4/4/2024 at 11:30 a.m., the Nurse Practitioner (NP 1) stated she was the NP for residents who were under Medical Doctor's (MD 1) care. NP 1 stated she did not write any orders for OT services, because NP 1 knew there was no OT available to see the residents at this time. NP 1 stated that OTs helped to establish a baseline for all residents for their function, ADLs, and mobility and help to address issues like positioning and splinting (assessing need for splints [rigid material or apparatus used to support and immobilize a broken bone or impaired joint]). During an interview, on 4/4/24 at 2:23 p.m., the ADM stated the last date an OT was available to SNF residents was on 10/6/2023. ADM confirmed there had been no OT available since 10/7/2023 to present. A review of the facility's policy and procedure dated 3/2023, titled, Long Term Care Standard of Care Nursing Protocol, indicated, provide measures to increase mobility per medical provider order: 1. ROM exercises, 4. Occupational therapy consults as ordered. During an interview, on 4/4/2024 at 3:06 p.m., the DON reviewed the Long Term Care Standard of Care Nursing Protocol policy and stated there were no other facility policies to provide rehabilitative therapy services to residents. 2a. A review of Resident 45's Face Sheet indicated the resident was admitted to the facility on [DATE]. A review of Resident 45's Patient Diagnosis Information indicated Resident 45 had diagnoses including, but not limited to hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following cerebral infarction (blockage of the flow of blood brain, causing or resulting in brain tissue death). A review of Resident 45's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 3/1/2024 indicated Resident 45 was cognitively intact (sufficient judgement, planning, organization to manage average demands in one's environment) and had no functional limitations in ROM in both upper and lower extremities lower extremity (LE, hip, knee, ankle, foot). The MDS also indicated Resident 45 required partial assistance (helper does less than half the effort) for eating, oral hygiene and substantial assistance (helper does more than half the effort) with dressing, toileting, chair transfers, and did not walk. A review of Resident 45's medical records indicated there was no Occupational Therapy Initial Evaluation completed. During an observation and interview, on 4/3/2024 at 1:18 p.m., Resident 45 was sitting up in a wheelchair in the resident's room with eyes closed. Resident 45 stated she was sleepy. Resident 45 was able to move the right arm up and down, and the right leg up and down. Resident 45 stated the left side was the problem side and was able to move the left arm and leg up and down a little. Resident 45 stated she never received any OT services and did not know that OT was offered here. During an interview, on 4/3/2024 at 1:55 p.m., Nurse Supervisor (NS 1) stated for new admissions there was usually an order for OT and PT evaluation, but right now there was no OT to provide OT services. NS 1 stated the baseline ROM assessments were completed by PT and OT. NS 1 stated she was not aware of who was completing the UE ROM assessments for new admission since there was no OT at this time. During an interview, on 4/4/2024 at 8:30 a.m., Nurse Supervisor (NS 2) stated all residents received an OT and PT evaluation upon admission in order to complete a range of motion assessment for both upper and lower extremities. NS 2 stated the facility had not been writing OT evaluation orders recently because there had not been an OT available to evaluate and see residents. NS 2 reviewed Resident 45's medical records and confirmed there was no OT evaluation completed. During an interview, on 4/4/2024 at 11:30 a.m., Nurse Practitioner (NP 1) stated it was the facility's protocol and standard to order OT and PT evaluations for all residents upon admission to establish a baseline for the resident's function, ADLs, mobility, and to see if there were any opportunities for skilled therapy such as positioning, splinting needs, and if a RNA program was appropriate. NP 1 stated Resident 45 was not ordered OT evaluation because there was no OT available at the facility. NP 1 stated at minimum, an OT evaluation should have been completed. 2b. A review of Resident 63's Face Sheet indicated Resident 63 was admitted to the facility on [DATE]. A review of Resident 63's Patient Diagnosis Information indicated Resident 45 had diagnoses including, but not limited to morbid (severe) obesity (disorder involving excessive body fat that increased risk for health problems) and chronic obstructive pulmonary disease (lung disease that causes obstruction of airflow and can limit normal breathing). A review of Resident 63's Minimum Data Set, dated [DATE] indicated Resident 63 was cognitively intact and had no functional limitations in range of motion in both upper and lower extremities. The MDS also indicated Resident 63 required supervision assistance for eating, oral hygiene and substantial assistance (helper does more than half the effort) with lower body dressing, toileting, chair transfers, and to walk 10 feet. A review of Resident 63's medical records indicated there was no Occupational Therapy Initial Evaluation completed. During an observation and interview, on 4/2/2024 at 3:00p.m., Resident 63 was sitting up in a wheelchair. Resident 63 required extra time to verbalize needs. Resident 63 was able to move both arms and legs a little. During an interview, on 4/3/2024 at 1:55 p.m., NS 1 stated for new admissions there was usually an order for OT and PT evaluation, but right now there was no OT to provide OT services. NS 1 stated the baseline ROM assessments were completed by PT and OT. NS 1 stated she was not aware of who was completing the UE ROM assessments for new admission since there was no OT at this time. During an interview, on 4/4/2024 at 8:30 a.m., NS 2 stated all residents received an OT and PT evaluation upon admission to complete a range of motion assessment for both upper and lower extremities. NS 2 stated the facility had not been writing OT evaluation orders recently because there had not been an OT available to evaluate and see residents. NS 2 reviewed Resident 63's medical records and confirmed there was no OT evaluation completed. During an interview, on 4/4/2024 at 11:30 a.m., NP 1 stated it was the facility's protocol and standard to order OT and PT evaluations for all residents upon admission to establish a baseline for the resident's function, ADLs, mobility, and to see if there were any opportunities for skilled therapy such as positioning, splinting needs, and if a RNA program was appropriate. NP 1 stated Resident 63 was not ordered OT evaluation because there was no OT available at the facility. NP 1 stated at minimum, an OT evaluation should have been completed. A review of the facility's policy and procedure dated 3/2023, titled, Long Term Care Standard of Care Nursing Protocol, indicated, provide measures to increase mobility per medical provider order: 1. ROM exercises, 4. Occupational therapy consults as ordered. During an interview, on 4/4/2024 at 3:06 p.m., the DON reviewed the Long Term Care Standard of Care Nursing Protocol policy and stated there were no other facility policies to provide rehabilitative therapy services to residents. 3a. A review of Resident 45's Face Sheet indicated Resident 45 was admitted to the facility on [DATE]. A review of Resident 45's Patient Diagnosis Information indicated Resident 45 had diagnoses including, but not limited to hemiplegia and hemiparesis following cerebral infarction. A review of Resident 45's MDS dated [DATE] indicated Resident 45 was cognitively intact and had no functional limitations in range of motion in both upper and lower extremities. The MDS also indicated Resident 45 required partial assistance (helper does less than half the effort) for eating, oral hygiene and substantial assistance (helper does more than half the effort) with dressing, toileting, chair transfers, and did not walk. A review of Resident 45's Physical Therapy Initial Evaluation, dated 2/21/2024, indicated Resident 45 required moderate assistance (resident requires assistance with about 50 percent of task) with bed mobility, sit to stand, chair/bed to wheelchair transfer, and to walk 10 feet. The PT Initial Evaluation indicated the functional mobility discharge goals were to be independent (no assistance from another person necessary) in bed mobility, sit to stand, chair/bed to wheelchair transfer, and supervision assist to walk 10 feet, walk 50 feet with two turns, and to walk 150 feet. The PT Initial eval indicated resident was able to walk 20 feet with four-wheeled walker (4WW, type of mobility aid with wide base of support and 4 wheels) with moderate assistance of one person on level surface. The PT Initial Evaluation indicated a treatment plan of care for gait (walking) training, therapeutic activities, neuromuscular re-education (rehabilitation techniques to restore muscle function and movement), functional skills (transfers/bed mobility), and resident/family education/training. The PT Initial Evaluation indicated a frequency of treatment for one (1) to two (2) times a week for four (4) weeks. The PT Initial Evaluation indicated the resident's/family's goal for rehabilitation was to be independent with gait with 4WW and indicated recommendations was PT 1 to 2 times a week for 4 weeks for bed mobility, transfers, gait training with 4WW and LE strengthening. A review of the PT Daily Note, dated 2/26/2024, indicated Resident 45 had leg weakness and difficulty getting up from sitting and required moderate assistance for sit to stand. The PT Daily Note indicated resident performed sit to stand five times and was unable to ambulate. The PT Daily Note indicated Therapy Time spent with resident was a total of 15 minutes. A review of the PT Daily Note, dated 3/5/2024, indicated Resident 45 had leg weakness and difficulty getting up from sitting and required moderate assistance for sit to stand. The PT Daily Note indicated Resident 45 was unable to ambulate, and presented with impaired bed mobility, transfers, and gait with 4WW. The PT Daily Note indicated plan for pre-gait training with 4WW. PT Daily Note did not indicate Therapy Time spent with resident. A review of the PT Daily Note, dated 3/14/2024, indicated Resident 45 had leg weakness and difficulty getting up from sitting and required moderate assistance for sit to stand. The PT Daily Note indicated Resident 45 was unable to ambulate, and presented with impaired bed mobility, transfers, and gait with 4WW. The PT Daily Note did not indicate Therapy Time spent with resident. A review of the PT Daily Note, dated 3/20/2024, indicated Resident 45 had leg weakness and difficulty getting up from sitting and required moderate assistance for sit to stand. The PT Daily Note indicated Resident 45 was unable to ambulate, and presented with impaired bed mobility, transfers, and gait with 4WW. The PT Daily Note did not indicate Therapy Time spent with resident. A review of the PT Daily Note dated 3/25/2024 indicated Resident 45 had leg weakness and difficulty getting up from sitting and required moderate assistance for sit to stand. The PT Daily Note indicated Resident 45 was unable to ambulate, and presented with impaired bed mobility, transfers, and gait with 4WW. The PT Daily Note indicated Therapy Time spent with resident was a total of 15 minutes. A review of the PT Daily Note dated 4/1/2024 indicated Resident 45 had leg weakness and difficulty getting up from sitting and required moderate assistance for sit to stand. The PT Daily Note indicated Resident 45 was unable to ambulate, and presented with impaired bed mobility, transfers, and gait with 4WW. The PT Daily Note indicated Therapy Time spent with resident was a total of 15 minutes. During an interview on 4/2/2024 at 11:25 a.m., the ADM stated the rehabilitation therapy was provided through an outside contracted therapy company and PT 1 came to the SNF area of the campus every day from 1:00 p.m. to 3:00 p.m. During an observation and interview, on 4/3/2024 at 1:18 p.m., Resident 45 was sitting up in a wheelchair in the resident's room. Resident 45 was able to move the right arm up and down, and the right leg up and down. Resident 45 stated the left side was the problem side and was able to move left arm and leg up and down a little. Resident 45 stated she only received PT about once a week and for about 10 minutes. Resident 45 stated she wanted to walk again but the PT session was the same every time and they just moved the arms and legs up and down and did not do any walking. Resident 45 stated she did not feel like she was making any progress with her goals, because she was not getting enough therapy. Resident 45 stated she used to get a lot of therapy at another place, but she had not received a lot of therapy since she came here to the facility. During an interview on 4/4/2024 at 8:55 a.m., NS 2 stated PT was an issue at the facility. NS 2 stated the PT was only at the SNF from 1:00 p.m. to 3:00 p.m. and stated that the residents needed more PT. NS 2 stated she was not sure why the PT was not available for more hours for the SNF residents. NS 2 stated that PT 1 indicated the 2 hours of PT also included time for documentation, so PT 1 sees the SNF residents only 1 to 2 times a week and for a very short amount of time. NS 2 stated that residents had expressed concerns regarding their time spent with PT. During an interview, on 4/4/2024 at 9:27 a.m., the ADM stated the facility was aware of some performance issues with the PT provided through the contract rehabilitation company. During a phone interview, on 4/4/2024 at 11:17 a.m., PT 1 stated he was seeing Resident 45 for PT and the goals were to maintain Resident 45's ROM and transfers and not for walking. PT 1 stated he wrote a PT frequency for treatment for one to two times a week because that was all the time he had to complete the PT sessions. PT 1 stated he was only available to complete PT services at the SNF for 2 hours a day (between 1:00 p.m. and 3:00 p.m.) four days a week. PT 1 stated he had to complete evaluations, see RNA residents, document, and did not have time to see residents for more than 1 to 2 times a week. PT 1 stated he also only spent 15 minutes during PT treatments, because that was all the time PT 1 had time for. PT 1 stated all the residents on PT services, including Resident 45, needed more PT, but PT 1 stated he could not provide more. PT 1 stated he was not sure why he was the only PT scheduled to work at the campus, but he had to see patients in the outpatient part, SNF, and behavioral health units. 3b. A review of Resident 63's Face Sheet indicated Resident 63 was admitted to the facility on [DATE]. During a review of Resident 63's Patient Diagnosis Information indicated the resident had diagnoses including, but not limited to morbid (severe) obesity and chronic obstructive pulmonary disease. A review of Resident 63's MDS dated [DATE] indicated Resident 63 was cognitively intact and had no functional limitations in range of motion in both upper and lower extremities. The MDS also indicated Resident 63 required supervision assistance for eating, oral hygiene and substantial assistance (helper does more than half the effort) with lower body dressing, toileting, chair transfers, and to walk 10 feet. A review of Resident 63's PT Initial Evaluation, dated 3/6/2024, indicated Resident 63 required moderate assist with bed mobility, supervision assist for sit to stand, chair/bed to wheelchair transfer, and to walk 10 feet. The PT Initial Evaluation indicated the functional mobility discharge goals were to be independent in bed mobility, sit to stand, chair/bed to wheelchair transfer, and supervision assist to walk 10 feet, walk 50 feet with two turns, and to walk 150 feet. The PT Initial Evaluation indicated Resident 63 was able to walk 10 feet with front-wheeled walker (FWW, type of mobility aid with wide base of support and two wheels in the front) with contact guard assistance (CGA, physical steadying assistance) on a level surface. The PT Initial Evaluation indicated a treatment plan of care for gait training, therapeutic activities, functional skills (transfers/bed mobility), resident/family education/training, and assess equipment needs. The PT Initial Evaluation indicated a frequency of treatment for 1 to 2 times a week for 4 weeks. The PT Initial Evaluation indicated the resident's/family's goal for rehabilitation was to be independent with gait with FWW for 150 feet on a level surface. The PT Initial Evaluation indicated recommendations was PT 1 to 2 times a week for 4 weeks for functional mobility training with FWW. A review of Resident 63's PT Daily Note dated 3/7/2024 indicated Resident 63 required minimal assist for sit to stand, completed sit to stand 5 times. The PT Daily Noted indicated Resident 63 completed transfers with minimal assistance (resident requires less than 25% of assistance to perform the task) from wheelchair, performed walking for 15 feet with FWW with CGA, and transferred to the commode (portable toilet) in the room. The PT Daily Note did not indicate Therapy Time spent with resident. A review of Resident 63's PT Daily Note dated 3/11/2024 indicated Resident 63 required minimal assist for sit to stand, completed sit to stand 5 times. The PT Daily Noted indicated Resident 63 completed transfers with minimal assistance from wheelchair, performed walking for 20 feet with FWW with CGA, and transferred to the commode in the room. The PT Daily Note did not indicate Therapy Time spent with resident. A review of Resident 63's PT Daily Note dated 3/19/2024 indicated Resident 63 required minimal assist for sit to stand, completed sit to stand 5 times. The PT Daily Noted indicated Resident 63 completed transfers with minimal assistance from wheelchair, performed walking for 30 feet with FWW with CGA, and transferred to the commode in the room. The PT Daily Note did not indicate Therapy Time spent with resident. During a review of Resident 63's PT Daily Note dated 3/21/2024 indicated Resident 63 required minimal assist for sit to stand. The PT Daily Noted indicated Resident 63 completed transfers with minimal assistance from wheelchair and bed, performed walking for 20 feet with FWW with CGA, and transferred to the commode in the room. The PT Daily Note did not indicate Therapy Time spent with resident. A review of Resident 63's LTC note, dated 4/2/202m4 indicated Resident 63 refused PT that day stating she had a prior activity to attend at this time. During an interview, on 4/2/2024 at 11:25 a.m., the ADM stated the rehabilitation therapy was provided through an outside contracted therapy company and PT 1 came to the SNF area of the campus every day from 1 p.m. to 3 p.m. During an observation and interview, on 4/2/2024 at 3 p.m., Resident 63 was sitting up in a wheelchair in the resident's room. Resident 63 required extra time to verbalize complaints. Resident 63 was able to move both arms and legs a little. Resident 63 stated she was not getting enough PT and stated she was getting less than 30 minutes each time. Resident 63 stated she needed more PT and was not walking or doing much of anything during the therapy sessions. Resident 63 stated she felt like she was not getting what she needed in therapy to get better. During an interview, on 4/4/2024 at 8:55 a.m., NS 2 stated PT was also an issue at the facility. NS 2 stated the PT was only at the SNF from 1:00 p.m. to 3:00 p.m. and stated that the residents needed more PT. NS 2 stated she was not sure why the PT was not available for more hours for the SNF residents. NS 2 stated that PT 1 indicated the 2 hours of PT also included time for documentation, so PT 1 sees the SNF residents only 1 to 2 times a week and for a very short amount of time. NS 2 stated that residents had expressed concerns regarding their time spent with PT 1. During an interview, on 4/4/2024 at 9:27 a.m., ADM stated the facility was aware of some performance issues with the PT provided through the contract rehabilitation company. During a phone interview, on 4/4/2024 at 11:17 a.m., PT 1 stated he was seeing Resident 63 for PT. PT 1 stated he wrote a PT frequency for treatment for one to two times a week because that was all the time he had to complete the PT sessions. PT 1 stated he was only available to complete PT services at the SNF for 2 hours a day (between 1:00 p.m. and 3:00 p.m.) four days a week. PT 1 stated he had to complete evaluations, see RNA residents, document, and did not have time to see residents for more than 1 to 2 times a week. PT 1 stated he also only spent 15 minutes during PT treatments, because that was all the time PT 1 had time for. PT 1 stated all the residents on PT services, including Resident 63, needed more PT, but PT 1 stated he could not provide more. PT 1 stated he was not sure why he was the only PT scheduled to work at the campus, but he had to see patients in the outpatient part, SNF, and behavioral health units. A review of the facility's policy and procedure dated 3/2023, titled, Long Term Care Standard of Care Nursing Protocol, indicated, provide measures to increase mobility per medical provider order: 1. ROM exercises .3. Physical therapy consult as ordered. During an interview on 4/4/2024 at 3:06 p.m., the DON reviewed the Long Term Care Standard of Care Nursing Protocol policy and stated there were no other facility policies to provide rehabilitative therapy services to residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of Resident 38's Face Sheet indicated the facility admitted the resident on 5/31/2023 with diagnoses that included diastolic heart failure (a condition in which the heart cannot pump enough blood to meet the body's needs), morbid (severe) obesity (body weight that is higher than what is considered healthy for a given height), chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of Resident 38's H&P, dated 6/1/2023, indicated the resident was alert and oriented to name, time, and place. A review of Resident 38's MDS, dated [DATE], indicated the resident was able to understand others and make himself understood. The MDS further indicated the resident was dependent on staff for toileting, bathing, lower body dressing, and chair / bed transfers. A review of Resident 38's physician orders indicated the following orders: - Albuterol sulfate (a medication to open the air passages in the lungs) 2.5 mg / 3 milliliters (mL, a unit of measurement), inhale (breath in) 2.5 mg by mouth every four hours as needed via mask (a device of soft plastic designed to fit over the mouth that delivers medication for inhalation via a long hollow tube) for shortness of breath / wheezing, dated 10/24/2023. - Oxygen two liters (liters per minute [LPM], a unit of measurement) per NC as needed if saturation (amount of oxygen in the blood) is below 92 percent (%, a unit of measurement) for hypoxemia (low level of oxygen in the blood), dated 11/1/2023. - Oxygen two LPM per NC at bedtime for hypoxemia, dated 12/7/2023. A review of Resident 38's Care Plan (CP) titled, Medical Condition: related to . morbid obesity, .COPD with hypoxemia, .CHF, dated 5/31/2023, indicated (Resident 38) wants to be free of respiratory distress / discomfort / shortness of breath. The CP indicated an intervention to administer oxygen as ordered, to administer nebulizer (a device used for the inhalation of medication treatments) as ordered, and to observe for sign and symptoms of respiratory distress and notify the physician as indicated. During a concurrent observation and interview on 4/2/2024 at 11:50 a.m. with Resident 38, observed the resident lying in bed wearing a NC with the oxygen rate set to 2 LPM. Observed the NC with no labeled date. Resident 38 stated they do not label the oxygen tubing and they do not change it as often as he would like. Resident 38 stated he would like the tubing changed weekly, but they change the tubing about every three weeks, and the tubing gets hard. During a concurrent observation and interview on 4/2/2024 at 12:04 p.m. with Certified Nursing Assistant 4 (CNA 4), observed Resident 38's NC. CNA 4 stated Resident 38's oxygen tubing gets changed when he needs it. CNA 4 stated Resident 38's oxygen tubing was not labeled with the date. During a concurrent observation and interview on 4/2/2024 at 12:29 p.m. with Licensed Vocational Nurse 2 (LVN 2), observed Resident 38's NC and a bag labeled (Resident 38) .Albuterol .Date Issued 3/25/2024 hanging on the wall. LVN 2 stated Resident 38's NC was not labeled, and the bag contained an additional unlabeled mask with oxygen tubing. LVN 2 stated the bag was last changed 3/25/2024, but it should have been changed on 3/31/2024. LVN 2 stated the oxygen tubing should be changed every Sunday night by the licensed nurse, but the date on the bag indicated it was not changed. LVN 2 stated all oxygen tubing should be changed weekly because it gets dirty and can obstruct oxygen flow. LVN 2 stated there was also a concern for bacterial growth in the tubing that could go to the resident's lungs resulting in pneumonia (infection in the lungs). During a concurrent interview and record review on 4/4/2024 at 8:15 a.m. with the DON, reviewed the facility policy and procedure regarding oxygen. The DON stated every Sunday night oxygen tubing is changed by the licensed nurse. The DON stated the bag the oxygen tubing is placed in is labeled with the date, but staff does not label the oxygen tubing. The DON stated if the oxygen tubing itself was not labeled there was the potential that it would not be changed weekly. The DON stated the facility policy was not followed because the oxygen tubing was not changed weekly or labeled with the date. The DON stated not changing the tubing weekly could potentially result in respiratory infection because bacteria can grow in the tubing. A review of the facility P&P titled, Oxygen Therapy, last reviewed 1/2023, indicated to safely administer oxygen via mask or nasal cannula to treat and prevent the symptoms of hypoxia. Oxygen tubing is dated and replaced weekly. A review of the facility P&P titled, Infection Control Program, last reviewed 10/2023 indicated infections occur in skilled nursing facilities because residents who are vulnerable to infections are gathered in close quarters, frequent contacts are made between people, and pathogenic (harmful) microorganisms are present. Infection control is everyone's responsibility. Each employee is responsible for infection control. The overall goals of the facility Infection Control Program are to limit unprotected exposures to pathogens, limit the transmission of infections associated with procedures, and limit the transmission of infections associated with the use of medical equipment, devices, and supplies. Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections for two of four sampled residents observed during medication administration (Resident 2 and 87) and one of two residents investigated for respiratory care (Resident 38) when: 1. Licensed Vocational Nurse 3 (LVN 3) failed to perform hand hygiene prior to preparing Resident 2's medications. 2. LVN 4 failed to perform hand hygiene prior to donning (to put on) gloves and administering eye drops to 3. The facility failed to ensure nasal cannulas (NC, flexible plastic tubing with prongs fitted to the nose that is used to deliver supplemental oxygen or increased airflow to a resident in need of respiratory health) was labeled and dated within the last seven days. These deficient practices had the potential for residents to experience cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) during medication administration and had the potential to cause contamination of the oxygen tubing by infectious microorganisms leading to respiratory distress. Findings: 1. A review of Resident 2's Face Sheet (admission Record) indicated the facility admitted Resident 2 on 9/12/2020. A review of Resident 2's Patient Diagnosis Information, dated 4/4/2024, indicated Resident 2's diagnoses included, but were not limited to, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), acute atopic conjunctivitis (allergic condition of the eyelids and front surface of the eyes), allergic rhinitis (also known as seasonal allergies, an allergic reaction that causes sneezing, congestion, itchy nose and watery eyes), chronic atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), chronic congestive heart failure (CHF - condition in which the heart doesn't pump blood as well as it should), chronic obstructive pulmonary disease (COPD - A group of lung diseases that block airflow and make it difficult to breathe), and type 2 diabetes mellitus (long-term condition in which the body has trouble controlling blood sugar and using it for energy). A review of Resident 2's History and Physical (H&P), dated 10/20/2023, indicated Resident 2 was alert and oriented. A review of Resident 2 Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/9/2024, indicated Resident 2 had moderate cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions), required supervision with eating, oral hygiene, rolling left and right, required moderate assistance with upper body dressing, sit to lying, and walking 10 feet, required maximal assistance with toileting hygiene, lower body dressing, personal hygiene, sit to stand, chair or bed-to-chair transfer, toilet transfer, tub or shower transfers, and walking 50 feet with two turns, and was dependent on staff for putting on or taking off footwear. A review of Resident 2's Physician Orders indicated Resident 2 was ordered the following: - On 10/29/2023, metformin (medication used to treat diabetes mellitus type two) extended release (ER) 500 milligrams (mg - a unit of measure for mass) give 500 mg one tablet by mouth daily for type two diabetes mellitus. - On 11/22/2023, furosemide (medication used to treat CHF) 40 mg, give 40 mg one tablet by mouth daily for CHF. - On 2/1/2024, dabigatran etexilate mesylate (medication used to thin the blood for residents with atrial fibrillation) 75 mg, give one capsule by mouth every twelve hours, do not open capsule for atrial fibrillation. - On 2/1/2024, fluticasone propion/salmeterol (medication used to control and prevent symptoms caused by COPD) 100-50 micrograms (mcg - a unit of measure for mass), inhale one blister with inhalation device twice a day, rinse mouth with water after use for COPD. - On 2/1/2024, magnesium oxide (a type of mineral supplement) 400 mg, give 400 mg, one tablet by mouth twice a day for hypomagnesemia (low levels of magnesium in the blood). - On 2/1/2024, lactobacillus rhamnosus Gg (a type of bacteria that is naturally found in the gut and used to digestive symptoms) 15 billion cells, give 15 billion cells, give one capsule by mouth twice a day for Clostridioides difficile (a germ that can cause diarrhea and inflammation of the colon) prophylaxis (action taken to prevent disease, especially by specified means or against a specified disease). - On 2/1/2024, potassium chloride (a type of electrolyte that helps with nerve function, muscle movement, and heartbeat regulation) 20 milliequivalent (meq - a unit of measure), give 20 meq, one tablet, by mouth twice a day, do not crush, may mix with slurry with water, for hypokalemia (blood level that is below normal in potassium). - On 2/1/2024, guaifenesin (medication used to this mucus to make it easier to clear from the head, throat, and lungs) 600 mg, give 600 mg, one tablet by mouth twice a day, do not crush, for COPD. - On 2/18/2024, gabapentin (medication used to treat nerve pain) 300 mg, give 300 mg, one capsule, by mouth twice a day for neuropathic (relating to the nerves) pain. - On 2/19/2024, Ketotifen fumarate (medication used to prevent and treat itching of the eyes caused by allergies) 0.025 percent (%), instill one drop into both eyes twice a day for allergic conjunctivitis (eye inflammation caused by allergies). During a concurrent observation and interview, with LVN 3, on 4/3/2024, at 8:55 a.m., at the nursing station close to Resident 2's room, LVN 3 stated she was going to give Resident 2 her medications. LVN 3 moved the medication cart in front of Resident 2's room. LVN 3 placed the following medications into separate small clear cups: - Metformin 500 mg one tablet - Guaifenesin ER 600 mg one tablet - Magnesium oxide 400 mg one tablet - Lactobacillus rhamnosus one capsule - Furosemide 40 mg one tablet - Dabigatran etexilate mesylate 75 mg one tablet - Potassium chloride 20 meq one tablet - Gabapentin 300 mg one tablet LVN 3 opened the medication cart and took out the following medications and placed them onto a tray: - Fluticasone propion/salmeterol 100-50 mcg one inhalation. - Ketotifen fumarate 0.025% one drop on both eyes, Observed LVN 3 did not perform hand hygiene after moving the medication cart from the nursing station to the front of Resident 2's room. LVN 3 did not perform hand hygiene prior to preparing Resident 2's medications. LVN 3 administered the prepared medications to Resident 2. During an interview with LVN 3, on 4/3/2024, at 9:15 a.m., LVN 3 stated she did not perform hand hygiene prior to preparing Resident 2's medication outside the resident's room. LVN 3 stated she should have performed hand hygiene prior to preparing Resident 2's medications to prevent cross-contamination. LVN 3 further stated if cross-contamination occurs, there is a possibility that the residents could get sick from exposure to possibly infected surfaces. 2. A review of Resident 87's Face Sheet indicated the facility admitted Resident 87 on 1/18/2024. A review of Resident 87's Patient Diagnosis Information, dated 4/4/2024, indicated Resident 87's diagnoses included, but were not limited to, Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors, slow movement, stiffness, and loss of balance), mild intermittent asthma (condition in which a person's airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe), and cataracts (clouding of the normally clear lens of the eye that can result in blurry vision). A review of Resident 87's H&P, dated 1/19/2024, indicated Resident 87 was alert and oriented to himself. A review of Resident 87's MDS, dated [DATE], indicated Resident 87 had severe cognitive impairment, required setup assistance with rolling left and right, and required supervision or moderate assistance with activities of daily living, including eating, hygiene, and surface to surface transfers. A review of Resident 87's Physician Orders indicated Resident 87 was ordered the following: - On 1/18/2024, amantadine hydrochloride (a medication used to treat Parkinson's disease and its symptoms) 100 mg, give 100 mg, one tablet by mouth, twice a day for Parkinson's disease. - On 3/6/2024, budesonide (medication used to treat asthma) 90 mcg, inhale 90 mcg, one puff, inhalation twice a day for mild intermittent asthma. - On 3/9/2024, bromfenac sodium (medication used to treat eye swelling, redness, and pain after cataract surgery) 0.07%, instill one drop in the right eye, daily, after surgery, for post op (being in the period following surgery) cataract. - On 4/2/2024, ropinirole hydrochloride (medication used to treat Parkinson's disease) four mg, give four mg, one tablet by mouth, daily, do not crush, for Parkinson's disease. During a concurrent observation and interview, with LVN 4, in the nursing station close to Resident 87's room, LVN 4 stated he will be giving Resident 87 his medications. LVN 4 placed the following medications in a small cup: - Amantadine 100 mg one capsule. - Ropinirole four mg one capsule. LVN 4 removed the following meds from the medication cart and placed them on top of the medication cart: - Budesonide 90 mcg inhaler. - Bromfenac sodium 0.07% eye drops. Observed LVN 4 did not perform hand hygiene prior to preparing Resident 87's medication. LVN 4 entered Resident 87's room and administered the capsules and inhaler to Resident 87. LVN 4 donned gloves without performing hand hygiene prior to donning. LVN 4 asked Resident 87 if the resident had tissue paper for the resident's eye drops in the room and Resident 87 informed LVN 4 he did not. LVN 4 walked out of the Resident 87's room, while wearing gloves, entered a room around the nursing station, came out of the room with a box of tissues, entered Resident 87's room, and gave the box of tissues to Resident 87. LVN 4 did not doff (to take off) the gloves prior to leaving Resident 87's room to get the tissue box. LVN 4 administered eye drops to Resident 87's right eye and gave Resident 87 tissues to dab at the resident's eye. During an interview with LVN 4, on 4/3/2024, at 9:39 a.m., LVN 4 stated he did not perform hand hygiene prior to donning gloves and administering Resident 87's eye drops. LVN 4 stated hand hygiene is performed prior to donning gloves for infection control. LVN 4 stated there is a possibility of cross-contamination between surfaces if hand hygiene is not performed. LVN 4 further stated if cross-contamination occurs, bacteria can possibly be introduced to the resident during medication administration. During an interview with the Director of Nursing (DON), on 4/4/2024, at 1:36 p.m., the DON stated hand hygiene should be performed before preparing medications, before giving medications to residents, before donning gloves, and after glove use to prevent infection and cross-contamination. The DON further stated if cross-contamination occurs, residents might get sick. A review of the facility's policy and procedure (P&P) titled, Hand Hygiene, last reviewed 10/18/2023, indicated all healthcare staff should comply with hand hygiene practices as defined in this policy. The P&P further indicated if hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in the following clinical situations: - Before having direct contact with patients. - After contact with the resident's intact skin. - After contact with potentially infective material such as bodily fluids, excretions, mucous membranes, non-intact skin, and wound dressings if hands are not visibly soiled. - After contact with inanimate objects (including medical equipment) in the immediate vicinity of the resident. - Before putting on gloves and after removing gloves.

Based on interview, and record review the facility failed to establish and implement policies and procedures regarding the use of side rails (SR, adjustable rigid plastic bars attached to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) and physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body). This deficient practice had the potential to result in psychosocial harm, decline in physical functioning, physical harm from entrapment (occurs when a resident is caught between the mattress and SR or wall, or within the SR itself), and death of residents affecting 87 of 87 residents residing in the facility. Cross refernce to F604 and 700. Findings: During an interview and record review on 4/3/2024 at 8:00 a.m., with the Director of Nursing (DON), the DON stated the facility did not have a policy regarding the use of SRs or restraints because they are a restraint free facility. The DON stated the importance of policies was that the policies guide the facility to do what is supposed to be done based on the standard of care. During an interview on 4/4/2024 at 8:10 a.m. with the Administrator (ADM), the ADM stated they were now aware of the regulations regarding SRs used in the facility. The ADM stated they now have clarity on the regulation and there should be a specific policy for restraints, and they do not have one. The ADM stated it was her responsibility to ensure policies were in place and the SR policy should include an assessment for SR usage and informed consent for any SRs used in the facility. The ADM Stated they will be developing a policy based on the standards of practice. A review of the facility provided policy and procedure titled, Policy Review and Approval, last reviewed 4/2023, indicated the policy was to maintain a standardized process for the development, review, revise, approval, implementation and maintenance of the facility policies and related standards, procedures, plans, and guidelines. The responsible person drafts policy consistent with the facility standards of policy design. The draft policy is submitted to [NAME] President, Legal Affairs, ADM, or designee who reviews the policy and ensure distribution to appropriate parties for review and comment. The routing for approval of policies is the Policy and Forms Committee, Medical Executive Committee, and Governing Body. [NAME] President, Legal Affairs, ADM or designee coordinates preparation of final draft policy for approval by the Chief Executive Officer and Governing Body. The approved policy is posted on the facility intranet.

Based on interview and record review, the facility failed to follow the admissions policy by requiring one of eight sampled residents (Resident 1) to submit an application for admission packet as a pre-admission condition. This deficient practice has the potential to make all potential residents become automatically ineligible for, Medicare or Medicaid benefits and may also give the facility the ability to dictate how residents or potential residents distribute their assets. Findings: A review of the facility's admission policy titled admission Process. Policy number: 100. last revised 11/18. states that on the day of admission, admitting representative will print computer generated forms and provide newly admitting patient/resident with an admission Packet . A review of the facility's Application for admission (updated 6/17/2019) packet, requires residents to agree to not give away my real and personal properties and monies that I may hold an interest in or have in my possession and I am stating I have not transferred any of my assets for less than full market value within a two year period preceding the date of this application. A review of the facility's Application for admission (updated 6/17/2019) packet, also requires residents to Further, if accepted, I will personally preserve my assets and shall use said assets to pay for my care while I am a patient in the . facility. A review of the 22 CCR regs. Tit. 22, § 72516 (c) Standard admission Agreement., states, No resident or his or her legal representative shall be required to sign any other document at the time of, or as a condition of, admission to the licensee's facility, or as a condition of continued stay in the facility. During an interview and concurrent record review, on 7/27/2023 at 11:23 a.m., with Director of Risk and Regulatory (DRR), Manager of Admitting and Business Office (MABO), LTC Coordinator (LTCC) and Director of Social Services (DSS), DSS stated that all potential residents, as part of the facility admission process, must fill out and submit the facility's Application for admission (updated 6/17/2019) packet in addition to demographic information. DSS1 added the application packet is securely kept in files at the facility pending bed availability while potential residents are added to a waitlist. A review of a letter from the facility's [NAME] President of Legal Affairs (VPLA) dated 8/9/2023, VPLA's letter confirmed that the facility's Application for admission (updated 6/17/2019) packet, is filled out in advance by prospective residents as part of the facility's waitlist process. During an interview and concurrent record review, on 7/27/2023 at 11:23 a.m., with Director of Risk and Regulatory (DRR), Manager of Admitting and Business Office (MABO), LTC Coordinator (LTCC) and Director of Social Services (DSS), DSS stated that, upon receipt of the completed facility's Application for admission (updated 6/17/2019) packet, a social worker will contact the potential resident to discuss their financial status, if payment for services at the facility will be via private pay or medi-cal. DSS also added that facility staff will call potential residents to check if there have been changes to their financial and/or medical status when a bed becomes available for admission. During a Microsoft Teams telephone interview and concurrent record review, on 7/28/2023 at 11:39 a.m., with DRR, LTCC and DSS, LTCC stated the facility's Application for admission (updated 6/17/2019) packet, is used by the facility staff to verify if a potential resident will qualify for Medi-Cal based on their guidelines or not. If not, potential residents are then advised about being billed for services.

Based on observation, interview, and record review the facility failed to ensure the Transportation Coordinator (TC) sat at eye level to the resident while assisting the resident with feeding for one of two sampled residents (Resident 24). This deficient practice had the potential to affect the resident's sense of self-worth and self-esteem. Findings: A review of Resident 24's Face sheet indicated the facility admitted the resident on 2/5/2021 and readmitted the resident on 11/1/2021 with diagnoses including Alzheimer's diseases (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 24's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/10/2023 indicated Resident 24 can usually make self-understood and sometimes understands other. The MDS indicated Resident 24 was totally dependent on bed mobility, transferring, dressing, eating, and toilet use. A review of Resident 24's order dated 8/11/2022 indicated mechanical soft diet. A review of Resident 24's care plan, revised on 2/17/2021, indicated a care plan for cognitive communication, falls, vision, activity of daily living (ADL), incontinence, visual, skin integrity, has history of forgetfulness confusion due to Alzheimer and dementia. The intervention included Resident 24 needing total assistance with eating. During a concurrent observation and interview on 4/11/2023 at 8:47 a.m., observed Resident 24 sitting up in bed with the bedside table in front of her with breakfast tray. Observed TC standing over Resident 24 while assisting with her meal. The TC stated she should have moved the bed up and sat at eye level with resident to provide the resident dignity and to make sure the resident has swallowed the food before taking another bite because there is a risk for the resident choking. The TC also stated standing over the resident while they are eating can make them feel like they are being looked down on. During an interview on 4/13/2023 at 2:18 p.m., the Director of Long-Term Care (DLTC) stated staff should be assisting residents with meals at eye level. The DLTC stated there is a potential for the resident to choke when they are not assisted with meals at eye level because the staff assisting may not see how much food the resident is getting and swallowing. The DLTC also stated it provides the resident dignity when staff sit with them at eye level during meals. A review of the facility's policies and procedures, titled, Patient/Resident Privacy and Dignity, last revised on 3/3/2023 indicated facility will contribute to each patient's/resident's positive self-image through the provision and promotion of privacy and ensuring dignity.

Based on observation, interview, and record review, the facility failed to ensure the call light was within reach of the resident for one of two sampled residents (Resident 11). This deficient practice had the potential to result in residents not being able to ask health care workers for assistance and increase the resident's risk for injury due to fall. Findings: A review of Resident 11's Face sheet indicated the facility admitted the resident on 6/11/2020 with diagnoses including Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy). A review of Resident 11's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/24/2023 indicated Resident 11 can usually make self-understood and can usually understand others. The MDS indicated Resident 24 was totally dependent on bed mobility, transferring, dressing, and toilet use. A review of Resident 11's care plan, revised on 6/24/2020, indicated a care plan for cognitive communication, falls, vision, activity of daily living (ADL), incontinence, visual, skin integrity, has history of forgetfulness confusion due to dementia. The interventions included Resident 11 is a high fall risk, call light in reach, red badge/armband; remote monitoring devices on bed and chair, non-skid socks/shoes, maintain bed at appropriate height for her, keep personal items within reach. During a concurrent observation and interview on 4/10/2023 at 10:50 a.m. observed Resident 11 lying in bed with call light on floor out of Resident 11's reach. The Unit Secretary (US) stated the call light was not within Resident 11's reach and the resident would not be able to get help if she needed it. During an interview on 4/10/2023 at 10:55 a.m., with Certified Nursing Assistant 4 (CNA 4), CNA 4 stated Resident 11 did not have the call light within reach and would not be able to call for help. During an interview on 4/13/2023 at 2:22 p.m. with the Director of Long-Term Care (DLTC), the DLTC stated all residents should be given a call light so they can ask for assistance and staff would be able to attend to the resident's needs. A review of the facility's policies and procedures, titled Call Light, last revised on 3/3/2023 indicated ensure call light is within reach of patient.

Based on observation, interview, and record review, the facility failed to promote the resident rights to examine the results of the most recent survey (a survey to determine compliance with state and federal regulations) of the facility by failing to: 1. Post the most recent survey results in a place that are prominent and accessible (a place where individuals wishing to examine survey results do not have to ask to see them) to residents and the public. 2. Ensure the residents know where to find the results of the most recent survey for eight out of eight (Residents 25, 65, 36, 44, 55, 35, 6, and 41). These deficient practices had the potential to impede the resident rights and negatively affect residents' psychosocial wellbeing. Findings: During the Resident Council meeting on 4/11/2023 at 10:40 a.m., Residents 25, 65, 36, 44, 55, 35, 6, and 41 were asked, Without having to ask, are the results of the State inspection available to read? Eight out of eight residents stated they do not know where to find the results of the most recent survey. During a concurrent observation and interview on 4/11/2023 at 1:30 p.m. with Receptionist 1 1 (RECP 1) at the lobby, the survey binder from the previous survey was not visible. Asked the Receptionist 1(RECP 1) if he knew where the survey binder is located. RECP 1 stated he does not knowand will call someone to come look for it. During a concurrent interview and record review on 4/11/2023 at 2:20 p.m. with the ADM, the ADM handed over the survey binder to surveyor and stated the binder was in the lobby, but it was covered by the podium. Review of the previous survey results dated 11/15/2019 were available inside the binder. During a concurrent observation and interview on 4/12/2023 at 1:20 p.m. with the Director of Long-Term Care (DLTC), the DLTC stated in the conference room. Asked DON where the survey binder is located inside the facility. stated there is a survey binder on each unit and there is also supposed to be one in the lobby. Asked DON if she can show the surveyor where the survey binder is located. The DON indicated the location of the binder was next to the podium and proceeded to place the binder in a clear acrylic holder. The DON stated they will make sure survey binder will visible from now on to the residents.

Based on interview and record review, the facility failed to offer the resident or resident representative assistance with formulating an Advance Directive (AD - a legal document telling the doctor one's wishes about their healthcare in the event they cannot make the decision for themselves) upon admission for one (Resident 37) of two sampled residents investigated under the care area Advance Directives. This deficient practice violated the resident and/or their representatives the right to be fully informed of the option to formulate an AD and had the potential to cause conflict due to lack of communication regarding residents' wishes about their medical treatment. Findings: A review of Resident 37's Face Sheet, the facility admitted the resident on 6/15/2017 with diagnoses including cerebellar stroke syndrome (a condition that happens when blood supply to the cerebellum [part of the brain that helps with body movement, eye movement, and balance] is stopped), aphasia (a disorder that affects your ability to speak, read, write and listen) following cerebral infraction [a stroke that occurs in areas of the brain that control speech and language], hemiplegia (complete paralysis on one side of the body that can affect the arms, legs, and facial muscles) affecting left nondominant side. A review of Resident 37's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 1/10/2023, indicated the resident had severely impaired cognition ((mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicate limitation in ROM on one side of the upper and lower extremities. A review of Resident 37's Physician Orders dated 6/15/2017 indicated an order of code status (the type of emergent treatment a person would or would not receive if their - heart or breathing were to stop): do not resuscitate/do not intubate (DNR/DNI - no chest compressions, cardiac drugs, or placement of a breathing tube will be performed/chest compressions and cardiac drugs may be used, but no breathing tube will be placed) see physician's order for life sustaining order (POLST - a form consists of a set of medical orders that applies to a limited population of patients and addresses a limited number of critical medical decisions) dated 5/30/2017. A review of Resident 37's POLST indicated DNR/DNI was signed by the resident's spouse and the physician on of 2/1/2022. The POLST did not indicate if there was an AD on file. During a concurrent interview and record review on 4/12/2023 at 10:39 a.m., the electronic and physical health record were reviewed with the Medical Social Worker (MSW). The MSW stated the facility offers assistance to residents or their representatives in formulating an AD if interested. The MSW was unable to provide documented evidence that the resident and/or their representative was provided with information on how to formulate an AD. The MSW stated that it was important to offer information about AD to the resident and/or their representative to ensure that the resident has assigned someone to make the decisions for them (resident) in accordance with the resident's wishes when they are no longer able to. During a review of the facility's policy and procedure titled, Advance Directives, last reviewed on 3/3/2023 indicated that AD communicates resident health preferences should they become unable to make decisions for themselves. The policy indicated social workers provide assistance to long term care residents regarding AD. The policy indicated social services offers assistance if no AD is in place upon admission, annually and if needed and documented in the medical record.

Based on interview and record review, the facility failed to ensure licensed nurses provide care in accordance with professional standards by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin (a hormone that lowers the level of sugar in the blood) injection sites for one out of six sampled residents (Resident 39). This deficient practice had the potential to cause unnecessary tissue trauma and hardening of the area where frequent subcutaneous administration occurred that could lead to impaired absorption (a condition in which the body takes in another substance) of insulin. Findings: A review of Resident 39's Face Sheet indicated the facility admitted the resident on 11/4/2020 and readmitted the resident on 1/19/2023, with diagnoses including, type 2 diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar, is too high), hypoglycemia (low blood sugar), and encephalopathy (any disease of the brain that alters brain function or structure). A review of Resident 39's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/27/2023, indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was on insulin injection. A review of Resident 39's Physician Orders, dated 1/19/2023, indicated an order for: -Humalog 100 unit per milliliters (unit/ml, a standardized way to quantify the effect of a medication) vial, inject 4 units subcutaneously twice a day with lunch dinner hold for blood sugar below 150 (for diabetes type 2) -Lantus 100 unit/ml vial inject 15 units subcutaneously daily at 4: 30 p.m. hold if blood sugar below 160 (for diabetes type 2). A review of Resident 39's Care Plan, last revised on 1/19/2023, indicated a care plan for hypoglycemia, hyperglycemia (high blood sugar), and long-term use of insulin indicated a goal of the resident will be free of complications or problems with medical conditions. A review of Resident 39's eMAR (Electronic Medication Administration Record) on 1/1/2023-4/14/2023 indicated: -Humalog 100 unit/ml vial, inject 4 units subcutaneously twice a day with lunch dinner hold for blood sugar below 150 (for diabetes type 2) 1/4/2023 at 11:30 a.m. Right Lower Quadrant (RLQ) 1/4/2023 at 4:30 p.m. RLQ 1/20/2023 at 4:30 p.m. Right Deltoid (RDelt) 1/21/2023 at 11:30 a.m. RDelt 1/21/2023 at 4:30 p.m. Left Deltoid (LDelt) 1/22/2023 at 11:30 a.m. LDelt 1/7/2023 at 4:30 p.m. RLQ 1/8/2023 at 4:30 p.m. RLQ 1/28/2023 at 11:30 a.m. Left Lower Quadrant (LLQ) 1/28/2023 at 4:30 p.m. LLQ 2/5/2023 at 11:30 a.m. Right Upper Quadrant (RUQ) 2/6/2023 at 4:30 p.m. RUQ 3/7/2023 at 11:30 a.m. RLQ 3/7/2023 at 4:30 p.m. RLQ 3/8/2023 at 11:30 a.m. RLQ 3/9/2023 at 11:30 a.m. RLQ 3/10/2023 at 11:30 a.m. RLQ 3/13/2023 at 11:30 a.m. RLQ 3/13/2023 at 4:30 p.m. RLQ 3/16/2023 at 4:30 p.m. RUQ 3/17/2023 at 11:30 a.m. RUQ 3/25/2023 at 11:30 p.m. LLQ 3/25/2023 at 4:30 p.m. LLQ 3/27/2023 at 11:30 a.m. RLQ 3/27/2023 at 4:30 p.m. RLQ 3/30/2023 at 11:30 a.m. RUQ 3/31/2023 at 11:30 a.m. RUQ 4/2/2023 at 11:30 a.m. LUQ 4/2/2023 at 4:30 p.m. LUQ 4/7/2023 at 4:30 p.m. RUQ 4/8/2023 at 11:30 a.m. RUQ -Lantus 100 unit/ml vial inject 15 units subcutaneously daily at 4: 30 p.m. hold if blood sugar below 160 (for diabetes 2). 2/10/2023 at 4:30 p.m. Right Lower Quadrant (RLQ) 2/11/2023 at 11:30 p.m. RLQ 3/25/2023 at 4:30 p.m. RLQ 3/26/2023 at 4:30 p.m. RLQ 4/1/2023 at 4:30 p.m. RLQ 4/2/2023 at 4:30 p.m. RLQ 4/8/2023 at 4:30 p.m. LLQ 4/9/2023 at 4:30 p.m. LLQ 4/11/2023 at 4:30 p.m. RUQ 4/12/2023 at 4:30 p.m. RUQ During a concurrent interview and record review on 4/13/2023, at 8:09 a.m., reviewed eMAR with Licensed Vocational Nurse 1 (LVN 1). LVN 1 stated there were multiple incidence that the insulin administration sites were not rotated. LVN 1 stated the sites of administration should be rotated to prevent bruising and other complications. During an interview on 4/13/2023, at 2:05 p.m., the Director of Long-Term Care (DLTC) stated the site of administration should be rotated to prevent possible swelling and redness. The DLTC also added the deficient practice can result to potential infection at the injection site. A review of the facility's recent policy and procedure titled Medication Administration, last reviewed 3/3/2023, indicated when administering insulin, rotate injection sites. A review of the manufacturer's guideline on the use of Lantus (insulin glargine injection) for subcutaneous injection, with initial U.S. approval: 2000, indicated rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. A review of the manufacturer's guideline on the use of Humalog (insulin lispro injection), for subcutaneous or intravenous use with initial U.S. approval: 1996, indicated change (rotate) your injection sites within the area you choose with each dose to reduce your risk of getting lipodystrophy (pits in skin or thickened skin) and localized cutaneous amyloidosis (skin with lumps) at the injection sites.

Based on observation, interview, and record review the facility failed to ensure resident safety for one (Resident 41) out of two sampled residents investigated under the Accidents care area by failing to: 1. Implement its policy and procedure to provide supervision and smoking apron to the resident while smoking in the patio during scheduled smoking times. 2. Conduct a smoking risk assessment to determine if the resident required supervision during scheduled smoking times. These deficient practices placed Resident 41 at risk for smoking-related injuries Findings: A review of Resident 41's Face Sheet indicated the facility admitted the resident on 10/22/2020 with diagnoses including human immunodeficiency virus (HIV - a condition that weakens a person's immune system by destroying important cells that fight disease and infection), ataxia (lack of muscle coordination that may affect a person's speech, eye movements, and ability to swallow, walk, and pick up objects), spinal stenosis lumbar region (a condition that happens when the space inside the backbone is too small that may lead to walk, pain or numbness on the legs, and bowel and bladder difficulty). A review of Resident 41's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 1/27/2023, indicated the resident had moderately impaired cognition ((mental action or process of acquiring knowledge and understanding) and required supervision with eating and locomotion in the unit, extensive assistance from staff with bed mobility, personal hygiene, and dressing, and totally dependent to staff with other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 41's Physician Orders dated 1/13/2022 indicated resident may smoke on designated areas, assist with lighter use, supervise as needed, and resident to use protective apron while smoking. A review of Resident 41's care plan on smoking initiated on 1/13/2022, indicated the resident did not require supervision, will notify nurses when going out for a smoke, and provide the resident with an apron while smoking. A review of Resident 41's electronic health record (HER) and physical medical record indicated there was no documented evidence that a smoking risk assessment was done when the physician ordered to allow the resident to smoke. During an interview on 4/11/2023 at 11:48 a.m., Registered Nurse 1 (RN 1) stated she was not sure if there was a smoking risk assessment done on Resident 41. During a concurrent observation and interview on 4/11/2023 at 3:00 p.m., observed Resident 41 on his motorized wheelchair smoking in the water patio area by the hospital main entrance without any staff supervision and a protective apron. Resident 41 stated the nurse was aware he was going out to smoke and was not provided an apron. Resident 41 stated he is aware that he must be accompanied by staff and wear the apron while smoking for his safety. During a follow up interview on 4/12/2023 at 9:11 a.m., RN 1 stated that there was no smoking risk assessment done on Resident 41. as confirmed by the Director of Long-Term Care (DLTC). During an interview on 4/12/2023 at 2:48 p.m., Licensed Vocational Nurse 2 (LVN 2) stated Resident 41 should have been supervised by staff and provided a protective apron while smoking for his safety. and usually asks one of the social workers or activity staff to accompany him. LVN 2 stated Resident 41's cigarette, lighter, and apron were locked at the nurse's station. LVN 2 stated that she was not working on 4/11/2023 and in her opinion, the resident should have been accompanied by staff and should be wearing a protective apron for his safety. During a concurrent interview and record review on 4/13/2023 at 9:04 a.m., Resident 41's assessments, smoking care plan, and care conference meetings in the EHR were reviewed with the Medical Social Worker (MSW). The MSW stated that Resident 41 usually asks her to accompany him outside to smoke. The MSW stated that according to the resident's care plan, Resident 41 did not require supervision when smoking and but should have been provided with an apron. The MSW was unable to find documented evidence that an assessment was done when the physician allowed the resident to smoke. The MSW stated it is important to conduct a smoking risk assessment to determine if Resident 41 is able to smoke safely without supervision. During an interview on 4/13/2023 at 10:04 a.m., the DLTC stated that the facility does not do a smoking risk assessment. The DLTC stated that during the pre-admission care plan meeting with the resident and/or representative the facility will just initiate a care plan and obtain an order from the physician allowing a resident to smoke without supervision. The DLTC stated there was no documented evidence that a smoking risk assessment was done for Resident 41. The DLTC stated that the physician's order indicated to assist resident with lighter use, supervise as needed, and use of protective apron while smoking. The DLTC stated conducting a smoking risk assessment for Resident 41 ensures the safety of the resident. The DLTC stated Resident 41 should have been wearing the protective apron while smoking because it placed the resident at risk for accidents and injuries such as burns. A review of the facility's policy and procedure titled, Smoking, last reviewed on 3/3/2023 indicated smoking is permitted in designated areas and residents will be transported to these areas and observed by nursing staff according to a physician's orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to discard expired needles and syringes (small hollow tube used for injecting or withdrawing liquids) stored in the medication storage room. The deficient practice had the potential for nursing staff using needles and syringes on residents that may no longer be sterile. Findings: During an observation and interview on [DATE], at 9:06 a.m., with the Director of Pharmacy (DP), observed an expired, unopened 24 gauge needles with expiration date of 11/2020 and 20 milliliter (ml, a unit of volume) syringes with expiration date of 11/2017, in a bin in the medication storage room. The DP stated she will dispose of the expired supplies to prevent accidental usage that may cause infection. During an interview on [DATE], at 2:07 p.m., with the Director of Long-Term Care (DLTC), the DLTC stated the expired supplies should not be used because it can cause infection. A review of the facility's policy and procedure titled Shelf Life of Sterile Supplies, last reviewed on [DATE], indicated the purpose of the facility policy was to establish the period of time or circumstances when sterile items stocked on shelves, cabinets or in drawers are to be considered sterile and safe for use on a sterile procedure. Sterility is considered event related. Items packaged by the manufacturer are considered sterile as indicated, with the expiration date established by the manufacturer. NOTE: If there is no expiration date, the package is sterile indefinitely as long as the integrity is maintained in accordance with the event related sterility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide Restorative Nursing Assistance (RNA, a program designed to ensure each resident maintains their physical and functional abilities) services as ordered by the physician to four of thirteen sampled residents (Residents 2 and 43, 29, and 37). This deficient practice had the potential to result in a decline in mobility and range of motion (the extent or limit to which part of the body can be moved around a joint or a fixed point) for residents. Findings: a. A review of Resident 2's Face Sheet indicated the facility admitted the resident on 1/23/2020 and readmitted the resident on 9/12/2020, with diagnoses including, abnormalities of gait (a manner of walking or moving on foot) and mobility, polyosteoarthritis (a joint disease that involves at least five joints), and venous insufficiency (a condition in which the veins have problems sending blood from the legs back to the heart). A review of Resident 2's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/27/2023, indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident required extensive assistance on bed mobility, transfer, locomotion on and off unit, dressing, toilet use, and personal hygiene. The MDS also indicated the resident was using a walker (a light portable framework used for support and assistance in walking by a person with a gait impairment) and a wheelchair. A review of Resident 2's Physician Orders, dated 6/17/2021, indicated an order for Restorative Nurse Assistant (RNA) to ambulate resident with two-wheel-walker (2WW, a walking aid with two front wheels and no rear wheels) as tolerated with distance (per Physical Therapist [PT]) 5 days per week. A review of Resident 2's Care Plan, initiated on 6/17/2021, indicated a care plan for cognitive/falls/activities of daily living (ADL) and incontinence. The care plan indicated RNA to ambulate resident with 2WW as tolerated with distance (per PT) 5 days/week. A review of Resident 2's RNA Daily Notes for 1/1/2023 thru 4/10/2023 indicated there were no RNA notes on the following dates: 1/2/2023, 1/5/2023, 1/6/2023, 1/9/2023, 1/12/2023, 1/13/2023, 2/1/2023, 2/2/2023, 2/8/2023, 2/9/2023, 2/10/2023, 2/13/2023, 2/15/2023, 2/16/2023, 2/17/2023, 2/22/2023, 2/27/2023, 3/3/2023, 3/6/2023 to 3/10/2023, 3/13/2023 to 3/17/2023, 3/20/2023 to 3/24/2023, 3/27/2023 to 3/31/2023, 4/3/2023 to 4/7/2023, 4/10/2023, and 4/11/2023. During an interview on 4/11/2023 at 2:22 p.m., Restorative Nursing Assistant 1 (RNA 1) stated that her job title is RN, however, if they are short staffed, they have her work as a Certified Nursing Assistant (CNA). RNA 1 stated that on the days that she was working as a CNA, she was not able to provide therapy to the residents. During an interview on 4/12/2023, at 9:24 a.m., Restorative Nursing Assistant 2 (RNA 2) stated that there were two RNAs out on medical leave. During a concurrent interview and record review on 4/12/2023, at 11:59 a.m., reviewed RNA daily notes with Registered Nurse 1 (RN 1). RN 1 stated there were a lot of missing RNA therapy notes. RN 1 stated the failure to provide RNA therapy as ordered can result in resident losing or declining in function. RN 1 stated that in nursing if it was not documented, it was not done. b. A review of Resident 43's Face Sheet indicated the facility admitted the resident on 9/23/2021 and the readmitted the resident on 9/19/2022, with diagnoses including myasthenia gravis (a rare long-term condition that causes muscle weakness), osteoporosis (a condition in which there is a decrease in the amount and thickness of bone tissue), and polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body). A review of Resident 43's MDS, dated [DATE], indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident requires extensive assistance on bed mobility and transfer. The MDS further indicated the resident required total dependence on ambulating in the unit, toilet use, and personal hygiene. The MDS added that the resident was using a wheelchair. A review of Resident 43's Physician Orders, dated 1/20/2023, indicated an order of RNA for range of motion (ROM, the extent or limit to which a part of the body can be moved around a joint or a fixed point) of upper and lower extremities passive versus active/assisted exercises 5 days per week as tolerated. A review of Resident 43's Care Plan, initiated on 1/20/2023, indicated a care plan for cognitive/falls/ADL and incontinence. The care plan indicated RNA for ROM of upper and lower extremities passive vs active/assisted exercises 5 days per week as tolerated. A review of Resident 43's RNA Daily Notes for 1/1/2023-4/10/2023 indicated there were no RNA therapy notes on the following dates: 1/2/2023, 1/5/2023, 1/6/2023, 1/9/2023, 1/12/2023, 1/13/2023, 2/1/2023, 2/2/2023, 2/8/2023, 2/9/2023, 2/10/2023, 2/13/2023, 2/15/2023, 2/16/2023, 2/17/2023, 2/27/2023, 3/3/2023, 4/3/2023, 4/4/2023, 4/5/2023, 4/6/2023, 4/7/2023, 4/10/2023, and 4/11/2023. During a concurrent interview and record review on 4/12/2023, at 11:59 a.m., reviewed RNA daily notes with RN 1. RN 1 stated there were a lot of missing RNA therapy notes. RN 1 stated the failure to provide RNA therapy as ordered can result in resident losing or declining in function. RN 1 stated that in nursing if it was not documented, it was not done. During an interview on 4/13/2023, at 2:08 p.m., the Director of Long-Term Care (DLTC) stated they have RNAs from M-F 7:30 -3pm. The DLTC stated they were not able to provide RNA therapy on some days because some of the RNAs are out on medical leave. The DLTC stated not providing RNA therapy can potentially cause residents to develop more contractures. A review of the facility's recent policy and procedure titled LTC Standards of Care Nursing Protocol, last revised on 2/2023, indicated document that activities are performed as ordered. Perform/assist with range of motion exercises as ordered. Provide measures to increase mobility per medical provider order: (1) ROM exercises, ambulation, transfers. Overhead frames/trapeze. Physical therapy consults as ordered. Occupational therapy results as ordered. If resident refuses, document and inform medical provider. d. A review of Resident 37's Face Sheet, indicated the facility admitted the resident on 6/15/2017 with diagnoses including cerebellar stroke syndrome (a condition that happens when blood supply to the cerebellum [part of the brain that helps with body movement, eye movement, and balance] is stopped), aphasia (a disorder that affects your ability to speak, read, write and listen) following cerebral infraction [a stroke that occurs in areas of the brain that control speech and language], hemiplegia (complete paralysis on one side of the body that can affect the arms, legs, and facial muscles) affecting left nondominant side. A review of Resident 37's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 1/10/2023, indicated the resident had severely impaired cognition ((mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicate limitation in ROM on one side of the upper and lower extremities. A review of Resident 37's Physician Orders indicated the following orders: 1. RNA to continue for passive range of motion (PROM - a type of ROM in which a part of the body can move when someone or something is creating the movement) to all extremities as tolerated five days per week (5 days/week) 10/10/2019. 2. RNA to continue placing bilateral elbow extension splints, right hand carrot, and left-hand palm protector in order to prevent worsening contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues causing the joints to shorten and become very stiff) for five times per week (5x/week) for six to eight hours as tolerated. A review of Resident 37's daily RNA Progress Notes from 2/1/2023 to 4/11/2023 indicated there were no RNA therapy notes for PROM to all extremities and bilateral elbow extension splints, right hand carrot, and left-hand palm protector on the following dates: missing documentation on the following days: 1. 2/8/2023 2. 2/13/2023 3. 2/14/2023 4. 2/24/2023 5. 3/7/2023 6. 3/9/2023 7. 3/24/2023 8. 4/5/2023 9. 4/6/2023 10. 4/7/2023 11. 4/10/2023 12. 4/11/2023 A review of Resident 37's care plan indicated care plans for the following: 1. Medical Condition: History of cerebrovascular accident (CVA - also known as stroke, an interruption in the flow of blood to cells in the brain), hemiplegia and hemiparesis (weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) affecting left nondominant side initiated on 6/26/2017 with a target date of 6/20/2023 indicated RNA to continue for PROM to all extremities as tolerated 5x/week and RNA to continue placing bilateral elbow extension splints, right hand carrot and left hand palm to prevent worsening contractures for 5x/week for 6-8 hours or as tolerated. 2. ADL/Self-care: Resident had a stroke which left her unable to move her left side and has contractures on the left upper extremity (LUE) initiated on 6/23/2017 with a target date of 6/30/2023 indicated RNA to continue for PROM to all extremities as tolerated 5x/week and RNA to continue placing bilateral elbow extension splints, right hand carrot and left-hand palm to prevent worsening contractures for 5x/week for 6-8 hours or as tolerated. During observations on 4/10/2023 at 10:04 a.m. and 4/11/2023 at 11:24 a.m., observed Resident 37's LUE with contracture. During an interview on 4/11/2023 at 2:15 p.m., Certified Nursing Assistant 2 (CNA 2) confirmed that Resident 37 did not have her splints on 4/10/2023 and 4/11/2023 as the unit did not have an RNA scheduled. CNA 2 stated the splints should have been applied on the resident because the resident's contractures could potentially worsen. During a concurrent observation and interview on 4/12/2023 at 9:17 a.m., observed Resident 37 with the right carrot shaped cushion on the right hand, bilateral elbow splints and left-hand palm protector. Restorative Nursing Assistant 1 (RNA 1) stated that she was off on 4/10/2023 and 4/11/2023. RNA 1 stated RNA services are provided to resident 5 times a week on Mondays thru Fridays. RNA 1 stated all RNA services provided to residents are documented under the RNA Progress Notes daily and if it was not documented, then it was not done. RNA 1 stated that it is important to apply the splints to Resident 37 as ordered by the physician to prevent worsening of contractures. During a concurrent interview and record review on 4/12/2023 at 11:59 a.m., the daily RNA Progress Notes for Resident 37 were reviewed with Registered Nurse 1 (RN 1). RN 1 was unable to provide documented evidence that RNA services were provided to the resident on 2/8/2023, 2/13/2023, 2/14/2023, 2/24/2023, 3/7/2023, 3/9/2023, 3/24/2023, 4/5/2023, 4/6/2023, 4/7/2023, 4/10/2023, 4/11/2023 for Resident 37. RN 1 stated if it was not documented then it was not done. RN 1 stated the RNA services should have been provided as ordered by the physician to prevent worsening of contractures. During a concurrent interview and record revied on 4/13/2023 at 2:08 p.m., the daily RNA Progress Notes for Resident 37 were reviewed with the Director of Long-Term Care (DLTC). The DLTC verified that the RNA services were provided to the resident on 2/8/2023, 2/13/2023, 2/14/2023, 2/24/2023, 3/7/2023, 3/9/2023, 3/24/2023, 4/5/2023, 4/6/2023, 4/7/2023, 4/10/2023, 4/11/2023 for Resident 37. The DLTC stated that the facility had staffing issues and had the RNAs work as CNAs to provide direct patient care to meet the resident ADL needs. The DLTC stated that the RNA services should have been provided to Resident 37 as ordered by the physician because the resident could potentially develop more contractures. A review of the facility's policy ad procedure titled, LTC Standard of Care Nursing Protocol, last reviewed and approved on 3/3/2023 indicated the following: 1. Document that activities are performed as ordered such as performing/assisting with ROM exercises as ordered. 2. Provide measures to increase mobility per medical provider order such as ROM exercises, ambulation, and transfers. c. A review of Resident 29's face sheet indicated the facility admitted the resident on 4/8/2021 with diagnoses including multiple sclerosis (MS-a potentially disabling disease of the brain and spinal cord (central nervous system), major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), and neuromuscular dysfunction of bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems). A review of Resident 29's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/13/2023 indicated Resident 29 understood others and was understood by others. The MDS indicated Resident 29 required total assistance with bed mobility, transferring, and dressing, eating and toilet use. A review of Resident 29's Physician Orders dated 7/19/2022 indicated Restorative Nursing Assistant (RNA- work with individuals who need physical therapy or other restorative treatment) to provide passive range of motion exercises to all extremities including hands, wrist, and fingers daily 5 days a week. A review of facility document titled RNA Daily Notes for Resident 29 indicated: -Week of 3/17/2023-3/2023 was seen on 3/17/2023, 3/21/2023, 3/22/2023 total of 3 out of 5 ordered visits - Week of 3/3/2023-3/9/2023 was seen on 3/6/2023, 3/7/2023, 3/8/2023, 3/9/2023 4 out of 5 ordered visits -Week of 2/27/2023-3/2/2023 was seen on 2/28/2023, 3/1/2023, 3/2/2023 3 out of 5 ordered visits -Week of 2/20/2023-2/26/2023 was seen on 2/20/2023, 2/21/2023. 2/22/2023 3 out of 5 ordered visits -Week of 2/6/2023-2/1/20232 was seen on 2/6/2023, 2/7/2023, 2/8/2023, 3 out of 5 -Week of 1/23/2023-1/29/2023 was seen on 1/23/2023, 1/24/2023, 1/25/2023, 1/27/2023, 4 out of 5 ordered visits -Week of 1/9-1/15 was seen on 1/9, 1/10, 1/12, 1/13 4 out of 5 ordered visits -Week of 1/2-1/8 was seen on 1/4, and 1/6 2 out of 5 ordered visits During an interview on 4/10/2023 at 10:11 a.m. with Resident 29 stated that he has MS and his hands have become constricted and has not been getting any therapy for it. During an interview on 4/11/2023 at 2:22 p.m. with Restorative Nursing Assistant (RNA 1) stated she provides therapy to the residents on the RNA program based on the orders and schedule indicated in the RNA book. RNA 1 stated that when therapy is provided to the resident, the RNAs will make a note on the resident's chart, and if there is no note than the therapy was not done. RNA1 stated that the facility is short staffed sometimes and the RNAs are instructed to work as Certified Nursing Assistants (CNAs). RNA 1 stated that on the days that she was working as a CNA, she was not able to provide therapy to the residents. RNA1 stated the resident can possibly have a decline in range of motion (ROM) and ambulation if the facility does not have the staff to provide RNA therapy. During a follow-up interview on 4/11/2023 at 2:36 p.m. with Resident 29, the resident stated RNA1 came in and offered therapy but stated he refused because he was too tired. Resident 29 stated that staff did use to come in and ask if they could do therapy with him but today was the first time it was offered in a month. During an interview on 4/13/2023 at 2:10 p.m. with the Director of Long-Term Care (DLTC), the DLTC stated the RNAs are scheduled Monday through Friday from 7:30-3p.m. The DLTC stated that during the pandemic had staffing issues had to pull RNAs out of RNA work to do CNA work to meet resident care needs and some RNAs are currently on medical leave. The DLTC stated RNA therapy must offered to resident and documented when it is done. The DLTC stated not providing RNA therapy as ordered can potentially cause residents to develop more contractures. A review of the facility's policies and procedures titled, LTC Standard of Care Nursing Protocol, last revised on 2/2023 indicated provide measures to increase mobility per medical provider order: -ROM exercise, ambulation, transfers. -Overhead frames/trapeze -Physical therapy consults as ordered. -Occupational therapy consults as ordered. -If a resident refuses, document and inform medical provider.

Based on observation, interview, and record review, the facility failed to store food in a sanitary manner by failing to ensure food items were not expired. These deficient practices had the potential to result in foodborne illnesses (also called food poisoning, illness caused by eating contaminated food) for residents living in the facility. Findings: During a concurrent initial kitchen tour observation and interview on 4/10/2023 at 8:38 a.m. with the Director Hospitality (DH) and the Facility Chef (FC), observed the following: 1. A package of strawberries with grayish white fluff. 2. Two (2) cases of graham cracker crumb a total of four (4) bags that had an expiration date of November 28, 2022. 3. Frozen food with use by of 3/23/2023 stored in the freezer. 4. Prepared food with use by date of 3/11/2023 stored in the freezer. The DH and the FC verbally acknowledged the items were expired and stated it should have been discarded. The DH stated expired items have the potential to cause residents to get sick when ingested. During an interview on 4/11/2023 at 12:53 p.m. with the Dietary Supervisor (DS), the DS stated expired food should be thrown away; produce strawberries that were visibly moldy can spread mold and contaminate other food items. The DS stated contaminated food poses a risk for major respiratory issues and stomach issues for residents when ingested. A review of the facility's policy and procedures titled, Food and Supply Storage, last revised on 1/2023 indicated all food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Policy further indicated the word sell by date is the last date that food can be sold or consumed; do not sell products in retail areas or place on patient tray/resident plates past the date on the product, foods past the use by, sell by, best-by, or enjoy by date should be discarded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of Resident 75's Face Sheet indicated the facility admitted the resident on 11/1/2022, with diagnoses including Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and type 2 diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar, is too high). A review of Resident 75's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/10/2023, indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident had impaired vision and had severe cognitive impairment. The MDS further indicated the resident needed supervision in eating. A review of Resident 75' Care Plan, initiated on 3/22/2023, indicated a care plan for nutrition and hydration, with an intervention for staff to assist at mealtime and between meals with food and fluids as needed. During a concurrent observation and interview on 4/11/2023, at 12 p.m., observed Certified Nursing Assistant 1 (CNA 1) served lunch tray to Resident 75 without asking the resident to perform hand hygiene with either alcohol-based hand rub (ABHR, an alcohol-containing preparation [liquid, gel, or foam] designed for application to the hands to inactivate microorganisms and/or temporarily suppress their growth) or antiseptic (a chemical used for preventing infection) wipes prior to serving the lunch tray. CNA 1 stated that she should have offered an alcohol-based hand rub or antiseptic wipes to the resident prior to serving the food and letting the resident eat because she does not know whether the resident had just gone to the bathroom or touched dirty surfaces in the facility that could cause infection to the resident. During an interview on 4/13/2023, at 2:10 p.m., with the Director of Long-Term Care (DLTC), the DLTC stated the staff should have offered the ABHR/antiseptic wipes before letting the residents eat due to potential for infection that can cause food borne illnesses. During an interview on 4/13/2023, at 3:10 p.m., with the Infection Control Coordinator (ICC), the ICC stated the staff should have offered the hand sanitizer or wipes to the resident before serving the lunch tray to prevent food borne infection. Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program by: 1. Failing to ensure Food Service Worker (FSW 1) and FSW 2 washed their hands before donning and after removal of gloves 2. Failing to ensure the Transportation Coordinator (TC) observe hand hygiene and change gloves between residents during meal tray pass. 3. Failing to ensure CNA 1 provide hand hygiene to one out of six sampled residents (Resident 75) prior to meals. These deficient practices had the potential to result in contamination of residents' food through cross contamination (bacteria or other microorganisms are unintentionally transferred from one substance or object to another with harmful effect). Findings: 1.a. During an observation of the tray line service on 4/10/2023 at 11:17 a.m. observed Food Service Worker (FSW 1) wearing gloves while serving the trays. FSW 1 was observed removing gloves and applying new gloves, without washing his hands. observation of hand hygiene; washing hands and or using antibacterial hand rub (ABHR) in between glove change. During an interview on 4/10/2023 at 11:58 a.m. with FSW 1, FSW stated he should have washed his hands in between glove changes for infection control. During an interview on 4/10/2023 at 12:19 p.m. with the Dietary Supervisor, the (DS) stated staff should be washing hands in between glove changes because of a risk of spreading infection. During an interview on 4/13/2023 at 11:16 a.m. with the Infection Control Coordinator (ICC), the ICC stated kitchen staff should be washing their hands in between glove changes to prevent cross contamination. During an interview on 4/13/2023 at 2:33 p.m. with the Director of Long-Term Care (DLTC), the DLTC stated kitchen staff should be removing gloves before leaving the kitchen and wash their hands before and after glove changes. The DLTC also stated when staff are passing out trays, they do not need to be wearing gloves but if do, they need to change gloves and observe hand hygiene after exiting the resident room. The DLTC stated hand hygiene and changing gloves should be observed in order to prevent cross contamination. A review of the facilities policy and procedures titled Infection Control Manual, last reviewed on 3/3/2023 indicated gloves must be changed between task and procedures on the same patient/resident, and after contact with contaminated material. The policy further indicated gloves must be removed promptly after use and hand hygiene completed before touching ono-contaminated surfaces/items and before contact with another patient/resident. 1.b During an observation of the tray line service on 4/10/2023 at 12:15 p.m. observed Food Service Worker (FSW 2) wearing gloves. FSW 2 observed leaving tray line wearing gloves and exited kitchen, FSW 2 reentered kitchen shortly wearing gloves and went back on tray line. FSW 2 was not observed removing gloves and washing his hands before and after removal of gloves. During an interview on 4/10/2023 at 11:48 a.m. with FSW 2 stated he did not remove gloves when he left the kitchen, nor did he change them when he reentered the kitchen. FSW 2 stated he should have taken off his gloves before exiting the kitchen and washed his hands. FSW 2 also stated he should have washed his before applying new gloves and before returning to the tray line. FSW 2 stated not changing gloves and washing his hands is an infection control issue. During an interview on 4/10/2023 at 12:19 p.m. with the Dietary Supervisor (DS) stated the kitchen staff should have removed his gloves and washed hands before exiting the kitchen because of the risk for cross contamination. During an interview on 4/13/2023 at 11:16 a.m. with the Infection Control Coordinator (ICC), the ICC stated kitchen staff should be removing gloves when leaving the kitchen and washing hands in between glove changes to prevent food borne illness in the facility. During an interview on 4/13/2023 at 2:33 p.m. with the Director of Long-Term Care (DLTC), the DLTC stated kitchen staff should be removing gloves before leaving the kitchen and wash their hands before and after glove changes. The DLTC also stated when staff are passing out trays, they do not need to be wearing gloves but if do, they need to change gloves and observe hand hygiene after exiting the resident room. The DLTC stated hand hygiene and changing gloves should be observed in order to prevent cross contamination. A review of the facilities policy and procedures titled Infection Control Manual, last reviewed on 3/3/2023 indicated gloves must be changed between task and procedures on the same patient/resident, and after contact with contaminated material. The policy further indicated gloves must be removed promptly after use and hand hygiene completed before touching ono-contaminated surfaces/items and before contact with another patient/resident. 2. During a dining observation on 4/11/2023 at 8:30 a.m. observed Transportation Coordinator (TC) wearing gloves while passing out breakfast trays. TC was observed wearing gloves while removing tray from meal cart and taking it to room [ROOM NUMBER]. TC was observed wearing gloves coming out of room [ROOM NUMBER], went back into the meal cart, removed another tray and entered room [ROOM NUMBER]. TC was not observed removing gloves and washing hands between residents while passing out food trays. During an interview on 4/11/2023 at 8:47 a.m. with the TC, the TC stated she did not change gloves between residents during tray pass. The TC stated she should have changed gloves between each resident and performed hand hygiene because of the risk for infection During an interview on 4/13/2023 at 11:16 a.m. with the Infection Control Coordinator (ICC), the ICC stated during food tray pass, staff should be changing gloves and washing hands between each resident because of the risk for cross contamination. During an interview on 4/13/2023 at 2:33 p.m. with the Director of Long-Term Care (DLTC), the DLTC stated kitchen staff should be removing gloves before leaving the kitchen and wash their hands before and after glove changes. The DLTC also stated when staff are passing out trays, they do not need to be wearing gloves but if do, they need to change gloves and observe hand hygiene after exiting the resident room. The DLTC stated hand hygiene and changing gloves should be observed in order to prevent cross contamination. A review of the facilities policy and procedures titled Infection Control Manual, last reviewed on 3/3/2023 indicated gloves must be changed between task and procedures on the same patient/resident, and after contact with contaminated material. The policy further indicated gloves must be removed promptly after use and hand hygiene completed before touching ono-contaminated surfaces/items and before contact with another patient/resident.