**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure resident rights were promoted and dignity was maintained for one (#25) of two residents out of 46 sample residents. Specifically, the facility failed to ensure Resident #25 was provided with incontinence supplies. Findings include: I. Facility policy The Promoting/Maintaining Resident Dignity policy, revised 1/2023, was provided by the nursing home administrator (NHA) on 7/18/24 at 5:16 p.m. It documented in pertinent part, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances residents quality of life by recognizing each residents' individuality. II. Resident #25 A. Resident status Resident #25, age [AGE], was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included atrial fibrillation (abnormal heart rhythm), type two diabetes (high blood sugar) and muscle weakness. The 5/20/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required moderate assistance with transfers and could not ambulate. B. Resident interview Resident #25 was interviewed on 7/15/24 at 10:43 a.m. She said the facility got rid of the reusable incontinence pads a couple months ago. She said the staff put a folded bath blanket under her when she was lying in her bed. She said she sometimes had incontinent episodes and ended up saturated in urine because the bath mat did not absorb liquid. She said the bed would get completely covered in urine when she had a urinary incontinence episode. She said she felt frustrated by this and it upset her. C. Observations On 7/15/24 at 10:43 a.m. Resident #25's room was observed. There was a folded bath blanket over the fitted sheet in her bed. There was not an incontinence pad over the bath blanket. On 7/17/24 at 2:10 p.m. the [NAME] hall shower room. There were no reusable incontinence pads for residents on the linen cart. On 7/17/24 at 4:30 p.m. the central supply room was observed. There were no reusable or disposable incontinence pads in the room. III. Staff interviews The central supply director (CSD) was interviewed on 7/17/24 at 4:30 p.m. The CSD said the facility did not order the reusable incontinence pads anymore. She said the facility ordered the disposable pads only for residents with air mattresses or wounds. Certified nursing aide (CNA) #1 was interviewed on 7/17/24 at 2:10 p.m. CNA #1 said the facility stopped carrying the reusable incontinence pads a while ago. She said staff should check and change residents who were incontinent every two hours or as needed. She said the staff folded bath blankets and put them under some residents instead of the incontinence pads. CNA #1 said the facility had the disposable pads but they were only used for certain residents. CNA #1 said if a resident soiled their mattress she would change the sheets and wipe down the mattress with an incontinence wipe. She said she would only sanitize the mattress if the resident was out of the bed. The director of nursing (DON) was interviewed on 7/18/24 at 12:00 p.m. The DON said the facility had used reusable incontinence pads in the past, but no longer ordered the supply. She said the facility had stopped using them due to skin breakdown and infections. She said one resident had complained to her about no longer using the reusable incontinence pads and she educated the resident as to why the facility had gotten rid of them. She said she had not heard concerns regarding Resident #25. She said the facility used disposable pads only for residents with weeping wounds or air mattresses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure the self-administration of medication was clinically appropriate for one (#5) of one resident out of 46 sample residents. Specifically, the facility failed to ensure Resident #5 was assessed for safe self-administration of medications. Findings include: I. Facility policy and procedure The Resident Self-Administration of Medication policy and procedure, revised 2/2024, was provided by the nursing home administrator (NHA) on 7/18/24 at 5:16 p.m. It documented in pertinent part, A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered. Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the other resident's rooms. II. Resident #5 A. Resident status Resident #5, age [AGE], was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included muscle weakness, hypertension (high blood pressure) and a history of falling. The 6/10/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. She used a wheelchair and could ambulate around the facility with set-up assistance. B. Observations On 7/15/24 at 11:00 a.m. Resident #5 was in her room sleeping. There was a cup of medications on the bedside table with eight pills At 11:30 a.m. Resident #5 woke up and saw the cup of pills on her bedside table. She was observed self-administering the cup of pills. C. Record review According to the July 2024 CPO, Resident #5 was able to self-administer the following medications: Arformoterol nebulizer (inhaler) to be administered two times daily unsupervised self-administration, ordered on 5/1/23. Albuterol Sulfate (inhaler) to be administered every four hours as needed for shortness of breath or wheezing unsupervised self-administration, ordered 5/1/23. -The July 2024 CPO did not reveal a physician's order for the resident to self administer any of her other prescribed medications. The 6/27/23 self-administration assessment documented Resident #5 was able to self-administer Arformoterol nebulizer, Atrovent nebulizer and budesonide nebulizer. -There was no documented assessment for self-administration of any of her other prescribed medications. -Resident #5's comprehensive care plan did not include Resident #5's self-administration of medications. D. Staff interviews Registered nurse (RN) #2 was interviewed on 7/15/24 at 11:40 a.m. RN #2 said Resident #5 was sleeping when she attempted to administer her medications (on 7/15/24) so she left the medications at the resident's bedside. RN #1 was interviewed on 7/17/24 at 4:15 p.m. RN #1 said Resident #5 had a physician's order for the self-administration of an inhaler and nebulizer medication. He said if the resident was able to self-administer medications it should be included in her care plan. RN #1 said Resident #5's self-administration assessment did not include any pill medications and she needed a self-administration of medication assessment completed in order to self-administer pill medications. He said there were residents with dementia who were ambulatory on the unit with Resident #5, so it was a risk to leave a cup of pills at the resident's bedside. The director of nursing (DON) was interviewed on 7/18/24 at 12:00 p.m. The DON said in order for a resident to be able to self-administer medications, a self-administration assessment should be completed by the nurse, a physician's order obtained, education provided by the nurse to the resident and it should be included on the resident's comprehensive care plan. The DON said there were residents with dementia that wandered who lived on the same unit as Resident #5. The DON said Resident #5 had physician's orders and assessments to self-administer inhaler medications and nebulizers. She said Resident #5 did not have a physician's order or a self-administration assessment for any pill medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide reasonable accommodation necessary to accommodate mobility and accessibility in the resident's environment for one (#289) of one resident reviewed out of 46 sample residents. Specifically, the facility failed to ensure Resident #289's bathroom call light was consistently accessible to him. Findings include: I. Resident #289 status Resident #289, age [AGE], was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included cerebral infarction (stroke), chronic respiratory failure with hypoxia (low oxygen level) and chronic obstructive pulmonary disease (chronic lung disease that makes it hard to breathe and restricts air flow). According to the brief interview for mental status (BIMS) completed 7/11/24, the resident was cognitively intact with a score of 14 out of 15. He required substantial to maximum assistance of two staff members transferring from bed to chair, using the bathroom and turning in bed. According to the 7/13/24 functional assessment, Resident #289 required substantial to maximum assistance of two staff members transferring from bed to chair, using the bathroom and turning in bed. II. Resident interview and observations Resident #289 was interviewed on 7/16/24 at 11:15 a.m. Resident #289 said he had to yell, whistle or bang on the wall for help when he could not reach his call bell cord in the bathroom. He said last night (7/15/24) a staff person got upset with him for yelling, but he said he could not reach the call bell cord in the bathroom and he needed help. During the interview, Resident #289's call bell cord in the bathroom was observed to be wrapped around the grab bar on the right side of the toilet near the floor. Resident #289 said he could not reach his call bell when it was wrapped around the grab bar near the floor. He said his right arm was affected from his stroke and he did not have full range of motion. On 7/17/24 at 1:56 p.m. Resident #289's call bell cord in the bathroom was again observed to be wrapped around the grab bar on the right side of the toilet. The cord had fallen to the bottom of the grab bar. Resident #289 said it was difficult for him to reach his call bell cord with the limited range of motion in his right arm. On 7/18/24 at 10:30 a.m. Resident #289's call bell cord in the bathroom was observed tied to the top of the grab bar on the right side of the toilet. Resident #289 said he was better able to reach the call bell cord where it was placed on the top of the grab bar. III. Record review The baseline care plan, initiated 7/10/24, indicated Resident #289 was alert, oriented and able to follow instructions. The fall prevention intervention on the care plan indicated to keep the call light within reach at all times. The nurse practitioner visit note, dated 7/11/24, indicated the resident had a stroke with right hemiplegia (paralysis on one side of the body) and right upper extremity decreased range of motion. IV. Staff interview The director of nursing (DON) was interviewed on 7/18/24 at 2:54 p.m. The DON said call lights should be placed within the residents' reach. She said the certified nurse aides (CNA) should not leave residents in the bathroom, but instead, stand outside the bathroom door to give them privacy. She said the CNAs should always ensure the call light in the bathroom was within reach of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to take steps to prevent abuse for one (#23) of two residents reviewed for abuse out of 46 sample residents. Specifically, the facility failed to protect Resident #23 from sexual abuse by Resident #65. Findings include: I. Facility policy and procedure The Abuse, Neglect and Exploitation policy, revised October 2022, was provided by the nursing home administrator (NHA) on 7/15/24 at 10:00 a.m. It read in pertinent part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship. Assuring an assessment of the resources needed to provide care and services to all residents is included in the facility assessment. The identification, ongoing assessment, care planning of appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. II. Incident of sexual abuse between Resident #23 and Resident #65 on 5/24/24 The facility investigation was provided by the NHA on 7/17/24 at 12:00 p.m. The investigation included a written statement from the certified nurse aide (CNA) #5 who witnessed the incident. It documented on 5/24/24, while walking down the hall, Resident #65 was seen holding Resident #23's head with his left hand while rubbing her chest and stomach with his right hand. Licensed practical nurse (LPN) #3 was immediately notified. LPN #3 was able to get Resident #65 to stop and Resident #23 was taken back to her room. -The written statement was not dated. On 5/30/24 interviews were conducted with four staff members and four residents. None of the staff members or the residents had any concerns regarding abuse. The investigation failed to document if Resident #23 was assessed following the incident. -The investigation failed to document whether the facility substantiated or unsubstantiated the sexual abuse. III. Resident #65 (assailant) A. Resident status Resident #65, age greater than 65, was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included unspecified dementia and traumatic brain injury. The 6/26/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of seven out of 15. He required supervision or touching assistance with showering and bathing . He was independent with all other activities of daily living (ADL). According to the MDS assessment, Resident #65 had no physical behavioral symptoms directed towards others. B. Record review The affections care plan, initiated on 7/4/24 (over one month after the incident with Resident #23), documented Resident #65's affections could be distressing to others at times. Interventions included educating staff and family members regarding the normalcy of affectionate behaviors, discussing any plans to divert behaviors, discouraging or monitoring displays of affection, encouraging open discussion about affections with the resident's family and staff team to clarify preferences for how to handle the situations, offering activity props, directing the resident toward tasks and change seating to discourage behaviors. The personal space care plan, initiated on 5/24/24, documented Resident #65 tended to periodically invade the staff's personal space and could be verbally inappropriate with staff at times. Interventions included anticipating and meeting the resident's needs, providing the opportunity for positive interaction and attention, stopping and talking with the resident when passing by if reasonable, discussing the resident's behavior, explaining/reinforcing why behavior is inappropriate and/or unacceptable to the resident, intervening as necessary to protect the rights and safety of others, approaching and speaking in a calm manner, diverting the resident's attention, removing the resident from situation and taking to an alternate location as needed, offering reminders and cues as needed; redirecting the resident when needed, reminding the resident of healthy boundaries as needed and redirecting to another activity of choice. -Review of Resident #65's electronic medical record (EMR) revealed there were no progress notes related to the resident's sexual abuse incident with Resident #23 on 5/24/24. IV. Resident #23 (victim) A. Resident status Resident #23, age less than 65, was admitted on [DATE]. According to the July 2024 CPO, diagnoses included cerebral palsy and quadriplegia. The 5/13/24 MDS assessment revealed the resident had severe cognitive impairments and was not able to make decisions regarding daily life through staff assessment She was dependent on staff for all ADLs. B. Record review The impaired cognition care plan, initiated on 11/14/23, documented Resident #23 exhibited both short and long term deficits and had difficulty making herself understood and understanding others. Interventions included encouraging the use of one or two word responses and simple phrases, giving verbal cues and reminders when she could not remember, phrasing questions to yes or no responses, allowing ample time to respond using simple words and sentences, and validating thoughts and feelings when confused or anxious. The communication care plan, initiated on 12/6/23, documented Resident #23 had a communication problem related to neurological symptoms. Resident #23 was able to answer yes and no questions. Interventions included anticipating and meeting the resident's needs, communication, allowing adequate time to respond, repeating words as necessary, requesting clarification from the resident to ensure understanding, facing the resident when speaking, making eye contact, turning off the television/radio to reduce environmental noise, asking yes or no questions if appropriate, using simple, brief, consistent words/cues, using alternative communication tools as needed; and monitoring/documenting residents ability to express and comprehend language, memory, reasoning ability, problem solving ability and ability to attend. -Review of Resident #23's EMR revealed there were no progress note related to the incident with Resident #65 on 5/24/24. -Review of Resident #23's EMR did not document if Resident #23 was assessed following the incident. V. Staff interviews Registered nurse (RN) #3 was interviewed on 7/18/24 at 1:59 p.m. RN #3 said she had seen Resident #65 hovering over Resident #23 and getting too close prior to the 5/24/24 incident. She said Resident #23's representative told Resident #65 he was standing too close and to move away from Resident #23 on 5/23/24. She said she did not witness the incident where Resident #65 had touched Resident #23. RN #3 said she wrote a progress note about Resident #65 getting too close to Resident #23. She said that was the first time she had seen Resident #65 getting too close to another resident. She said when she witnessed any inappropriate behaviors she would write progress notes in the resident's EMR. RN #3 said she was not sure if Resident #65 was being monitored on one-to-one, or on safety fifteen-minute checks. She said both residents had always resided on separate hallways. She said Resident #65 walked all over the facility. She said she did not know if Resident #65 had any other sexually inappropriate behaviors towards others. CNA #5 was interviewed on 7/18/24 at 2:09 p.m. CNA #5 said she witnessed the inappropriate touching between Resident #65 towards Resident #23 on 5/24/24. She said the incident took place down the hallway where Resident #23 resided. She said Resident #65 had one hand over Resident #23's head and his other hand was rubbing Resident #23's chest. She said she told the nurse. She said the residents were separated. She said she took Resident #23 to her room and laid her down and the LPN asked Resident #65 to step away. She said Resident #65 argued with the LPN and said that Resident #23 had told him that she liked him. CNA #5 said Resident #65 was placed on a one-to-one caregiver for one to two weeks. She said she did not know if his care plan was updated. She said she was asked by the DON to write a statement on what she saw. CNA #5 said Resident #65 had a couple of occasions where he had gotten too close to Resident #23 before the inappropriate touching occurred. She said she had had to tell Resident #65 to walk away from Resident #23. -However, review of Resident #65's care plan did not indicate the resident had been placed on a one-to-one caregiver following the incident with Resident #23. CNA #5 said she had seen Resident #65 getting close to another female resident who also had cognitive issues. She said she had never seen Resident #65 touch anyone inappropriately. She said Resident #65 needed to be watched closely. The director of nursing (DON) was interviewed on 7/18/24 at 2:21 p.m. The DON said when she heard about the incident, an investigation was completed. She said she gathered witness statements from staff, residents and questionnaires with families. The DON said a progress note should have been documented in the EMR for both residents. She said the RN, or whomever the incident was reported to, should have written a progress note. The DON said the interdisciplinary treatment team (IDT) met the following business day after the incident (5/27/25). She said any time there was an investigation, the IDT met. She said a progress note should have been written to document the IDT met. She said she was responsible for putting in the IDT notes for risk management regarding skin and falls and for inappropriate behaviors. She said the inappropriate behavior between Resident #65 and Resident #23 was her first incident since she had started working at the facility. She said, moving forward, she would make sure that an IDT note was completed. The DON said staff received education about abuse and reporting following the incident. She said the staff were monitoring both residents to ensure they were not sitting close to each other during meal times in the dining room. She said when Resident #23 was up she was by the nurses' station so the staff could keep a close eye on her. She said Resident #65 was placed on-a-one to one caregiver after the incident on 5/24/24. She said Resident #65 was placed on a one-to-one until the investigation was concluded. She said the one-to-one was removed following the investigation because the residents who were interviewed during the investigation did not report feeling unsafe around Resident #65. The DON said she knew Resident #65 had made inappropriate statements to the receptionist but not towards female residents. She said she did not know if this was a one time incident. She said when she had a conversation with Resident #65 about the incident, he said he just wanted to talk to Resident #23. The DON said a care plan should have been implemented for Resident #65's inappropriate behaviors immediately after the incident. She said she needed to fix the process moving forward. LPN #3 was interviewed on 7/18/24 at 2:56 p.m. LPN #3 said she was working when the incident between Resident #65 and Resident #23 happened. She said when she was notified of what had happened, she alerted the charge nurse. She said the charge nurse had contacted the DON and the NHA. She said when the incident happened, she and CNA #5 separated the two residents. LPN #3 said she was informed that Resident #65 was not allowed down Resident #23's hallway after the 5/24/24 incident. She said she was told by the DON that they could not keep Resident #65 from walking down Resident #23's hallway because it was his right. She said Resident #65 walked down Resident #23's hallway several times a day and tried to peek into her bedroom. She said she checked in on Resident #23 all the time. LPN #3 said she was not aware if Resident #65 had been sexually inappropriate towards any other female residents. LPN #3 said she was given a directive from her charge nurse (RN #3) to hold off on writing a progress note in the EMR because they were waiting on CNA #5 to write her statement. She said she would have written a progress note but, because she was given a directive not to, she did not. CNA #6 was interviewed on 7/18/24 at 3:19 p.m. CNA #6 said Resident #65 was allowed to walk wherever he wanted to because it was his right. She said the DON and the NHA told her that it was a residents' right that he could walk anywhere. She said there should be more interventions put into place to keep Resident #65 from coming down Resident #23's hallway. CNA #6 said when Resident #23 was out of her room, she would sit in her wheelchair by the nurse's station. She said when Resident #23 was in her room she made sure that her door was closed so Resident #65 could not go in. She said when she saw Resident #65 coming down the hallway she would get up right away and would watch him to make sure he did not do anything inappropriate. She said sometimes he would stop at Resident #23's door, especially when no one was watching. The NHA was interviewed on 7/18/24 at 4:43 p.m. The NHA said he neither substantiated or unsubstantiated the abuse at the end of the investigation. The NHA said he did not know that Resident #65 had actually touched Resident #23 inappropriately. He said he had two to three days to follow up on the incident. He said he had not wanted to label Resident #65 as a sexual perpetrator. The NHA said he spoke to Resident #65 and he said he touched Resident #23 on the shoulder and held her head. The NHA said Resident #65 reported he was consoling Resident #23. The NHA said he did not stop that kind of touching. He said when talking to Resident #65, he said he would sit with Resident #23 and talk to her. He said Resident #65 said Resident #23 talked to him all the time. The NHA said Resident #65 said Resident #23 liked being consoled and spoken to. He said Resident #65 said he talked to Resident #23 about the weather. The NHA said he did not think that Resident #65 intended to touch Resident #23 inappropriately. He said he reported and investigated the sexual abuse. He said he only had one CNA who witnessed the inappropriate behaviors. He said Resident #65 had not had any other behaviors noted. The NHA said the only reason why he instructed the staff to keep the two residents separated was because Resident #23s representative had requested no contact between the two. He said Resident #65 had the right to walk down any hallway because it was his home too. He said if Resident #65 looked into Resident #23's room it was alright. He said he talked to staff all the time about making sure that care plans were updated and documentation was completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure one (#13) of one resident reviewed for assistance with activities of daily living (ADL) out of 46 sample residents received appropriate treatment and services to maintain or improve his or her abilities. Specifically, the facility failed to ensure Resident #13 received assistance with ADLs, in the areas of dressing, personal hygiene and eating, in accordance with her comprehensive care plan. Findings include: I. Facility policy and procedure The Activities of Daily Living (ADL) policy, revised 1/2023, was provided by the nursing home administrator (NHA) on 7/18/24 at 5:21 p.m. It revealed in pertinent part, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following ADLs: bathing, dressing, grooming and oral care, transfer and ambulation, toileting, eating, to include meals and snacks, and using speech, language or other functional communication systems. A resident who is unable to carry out ADLs will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. II. Resident #13 A. Resident status Resident #13, age [AGE], was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included lumbar spondylosis (abnormal wear on the cartilage and bones in the neck causing pain), chronic obstructive pulmonary disease (COPD) (damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe), hypertension, unspecified dementia without behavioral disturbance and muscle weakness. The 5/1/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of eight out of 15. She required partial to moderate assistance with dressing, minimal assistance with transferring and set up assistance for eating. The assessment revealed Resident #13 did not have any episodes of rejecting care. B. Resident observations and interviews On 7/15/24 at 10:47 a.m. Resident #13 was lying in bed wearing a hospital gown. Her breakfast was sitting on the overbed table in front of her, not eaten. The fitted sheet under her was off the bottom half of the bed with her legs directly on the mattress and uncovered. At 2:15 p.m. Resident #13 was lying in bed wearing a hospital gown. Her lunch was sitting on the overbed table in front of her, not eaten. The fitted sheet was still off the lower half of the bed with her legs directly on the mattress and uncovered. On 7/16/24 at 8:45 a.m. Resident #13 was lying in bed wearing a hospital gown. Her breakfast plate was on her overbed table in front of her. She was not eating. At 11:23 a.m. Resident #13 was lying in bed wearing a hospital gown. Her breakfast plate had been removed but there was a fork and breakfast food on the floor. At 12:43 p.m. Resident #13 was lying in bed wearing a hospital gown. Her lunch was on the overbed table in front of her with a small amount eaten. There was cake in a bowl by her lunch plate with plastic wrap still covering it. At 2:03 p.m. Resident #13 was lying in bed wearing a hospital gown. The cake was in front of her, with the plastic wrap removed, but none of it was eaten. She said she did not have a fork. There was not a fork observed on her table or on the floor. At 2:53 p.m. Resident #13 was lying in bed on her side facing the wall. She was wearing a hospital gown with her legs uncovered. On 7/17/24 at 9:19 a.m. Resident #13 was in bed wearing a hospital gown. Her breakfast was sitting on the overbed table in front of her. She was eating scrambled eggs with her fingers. There was a package of unopened plastic silverware on her overbed table. At 9:43 a.m. Resident #13 was in bed wearing a hospital gown. Her breakfast plate was on the floor and food was spilled. There was a bowl of dry cereal on the overbed table in front of her and she had no silverware. Her fingernails were observed to be long and had a dark substance under them. Her head was leaning off to the right side of the bed. At 12:56 p.m. an unidentified certified nurse aide (CNA) took lunch into Resident #13's room. The unidentified CNA moved the resident up in bed and raised the head of the bed, Resident #13 was wearing a hospital gown and was not covered with a sheet or blanket. The CNA gave the resident a hand wipe and asked her to clean her hands. The resident wiped her hands minimally and dropped the wipe into her lap. The CNA opened the plastic silverware packet and put the fork in her food. The CNA provided a flat sheet and covered the resident's legs. At 5:30 p.m. Resident #13 was lying flat in bed with beverages on the overbed table in front of her. She was attempting to drink one of the beverages while lying flat in her bed. She was wearing a hospital gown. The gown was rolled up to her chest, her stomach was exposed and her incontinence brief was open. She was not covered with a sheet or blanket. On 7/18/24 at 9:56 a.m. Resident #13 was up in the recliner in her room. She was wearing personal clothing and watching people walk by in the hallway. She said she was comfortable. At 12:34 p.m. Resident #13 was sitting in the recliner in her room. She had slid down to an almost flat position. She was holding her lunch plate in her lap and was eating with her fingers. A package of unopened plastic silverware was on her overbed table. There was a full piece of sausage on her plate that was not cut up for her. C. Record review The ADL care plan, initiated 2/1/24, documented Resident #13 had an ADL self-care performance deficit related to COPD, fracture of the sacrum, compression fractures, lumbar spondylosis and dementia. The resident required extensive assistance of staff for dressing and extensive to total assistance with personal hygiene. It indicated the resident was independent with eating after set up assistance. -However, observations during the survey revealed Resident #13 had difficulty with eating her food unassisted (see observations above). -The care plan did not indicate Resident #13 ate with her fingers, preferred to wear a hospital gown or preferred to stay in bed during the day and for meals. -The care plan did not indicate that the resident refused assistance with ADLs. -Record review did not reveal Resident #13 refused assistance with dressing or getting out of bed. III. Staff interviews CNA #4 was interviewed on 7/18/24 at 12:30 pm. CNA #4 said the goal was to get Resident #13 dressed and in her chair after breakfast if she agreed. CNA #4 said Resident #13 was able to communicate her preferences. She said Resident #13 usually preferred to wear a hospital gown. CNA #4 said the staff encouraged the resident to get dressed. CNA #4 said the resident was agreeable to getting dressed and out of bed today (7/18/24). -However, Resident #13's plan of care did not indicate that the resident preferred to stay in a hospital gown, rather than getting dressed and being provided personal hygiene assistance. It did not indicate that the resident had episodes of refusing care (see record review above). The director of nursing (DON) was interviewed on 7/18/24 at 2:54 p.m. The DON said morning care included getting the resident up out of bed, changing them or taking them to the bathroom, getting them dressed and assisting with personal hygiene. She said if a resident declined assistance with care in the morning, the CNAs should go back later in the day and offer again. The DON said the staff should encourage residents to get out of bed. The DON said Resident #13 did not always get out of bed. The DON said she had recently tried to assist the resident out of bed and she declined. The DON said the care plan for Resident #13 should reflect her preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to provide an ongoing program of activities for one (#62) of one resident reviewed for activity participation out of 46 sample residents. Specifically, the facility failed to regularly provide individualized, purposeful and therapeutic activities for Resident #62, who was a dependent resident. Findings include: I. Facility policy and procedure The Activities policy, revised October 2022, was provided by the nursing home administrator (NHA) on 7/18/24 at 4:30 p.m. It documented in pertinent part, It is the policy of the facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan and preferences. Group, individual and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental and psychosocial well-being. II. Resident #62 A. Resident status Resident #62, age [AGE], was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), pertinent diagnoses included non-Alzheimer's dementia (memory problems), Parkinson's disease (brain condition that causes uncontrollable movements and coordination problems) and muscle weakness. The 5/14/24 minimum data set (MDS) assessment documented the resident had severely impaired cognitive skills for daily decision making. A staff assessment for mental status revealed he had a memory problem. The MDS assessment documented Resident #62's preferred language was Spanish. He required maximal assistance for transfers and activities of daily living (ADL). The 11/12/23 annual MDS assessment revealed it was very important for the resident to listen to music he liked, be around pets, do his favorite activities, go outside when the weather was good and participate in religious services. A. Observations On 7/15/24 at 3:15 p.m. Resident #62 was sitting in his wheelchair in his room. He had his eyes open and there was no television or music playing. At 4:01 p.m. the resident was assisted to the hallway by an unidentified CNA. The CNA did not provide the resident with any meaningful activities. Resident #62 began sleeping in his wheelchair. On 7/16/24 during a continuous observation, beginning at 2:25 p.m. and ending at 4:38 p.m., the following was observed: At 2:25 p.m. Resident #62 was sitting in his wheelchair with his eyes open and his head facing the floor. He was positioned in the hallway by the dining room with no meaningful activities. Several staff members walked by him without acknowledging him. At 3:29 p.m. two unidentified certified nursing aides (CNA) assisted him into his room. The CNAs provided incontinence care and left him in the room when finished. His wheelchair was facing the window and there was no television or music playing. His head was facing down and his eyes were closed. -There was a British [NAME] puzzle group activity being offered at 2:30 p.m., however, the resident was not invited to attend. -There was an Emoji meaning group activity at 3:00 p.m., however, the resident was not invited to attend. At 4:10 p.m. an unidentified CNA assisted him into the dining room for dinner. On 7/17/24 during a continuous observation, beginning at 1:10 p.m. and ending at 3:19 p.m., the following was observed: At 1:10 p.m. Resident #62 was sitting in his wheelchair in his room with his eyes open. There was no music or television playing. At 2:02 p.m. two unidentified CNAs walked into the resident's room and provided incontinence care to the resident. They left him in the room once they were finished providing care and did not provide him with any meaningful activities. A housekeeper entered the resident's room to clean at 2:21 p.m. -No other staff members entered the room during the continuous observation. -There was a watercolor painting group activity at 2:00 p.m., however, the resident was not invited to attend. -There was a Discovering [NAME] dice game group activity offered at 3:00 p.m., however, the resident was not invited to attend. B. Record review The activities care plan, initiated 5/22/24, identified Resident #62 expressed individual activity interests including independent activities, such as people watching, propelling himself throughout the facility, chewing gum, snacking, dice games, listening to Spanish music, visiting with others (conversations in Spanish) and visiting with family. He liked pets, such as dogs, and would accept one on one visits. Interventions included inviting Resident #62 to group activities, encouraging family involvement, introducing him to residents with similar backgrounds and interests and assisting him to and from activities. Resident #62's one-on-one activity participation records revealed the following: In April 2024 (4/1/24 to 4/30/24) five informal one-on-one visits were documented. -The resident received activities during five out of a possible 30 days. In May 2024 (5/1/24 to 5/31/24) nine informal one-on-one visits were documented. -The resident received activities during nine out of a possible 31 days. In June 2024 (6/1/24 to 6/30/24) three informal one-on-one visits were documented. -The resident received activities during three out of a possible 30 days. In July 2024 (7/1/24 to 7/18/24) there were zero informal one-on-one visits documented. -The resident received activities during zero out of a possible 18 days. A review of the resident's electronic medical record (EMR) from 4/1/24 to 7/18/24 did not reveal any documentation related to the resident refusing to participate in individual or one-on-one activities. An activity assessment completed on 11/9/22 documented the resident enjoyed listening to music, being around animals, doing his favorite activities, going outside when the weather was good and participating in religious activities (Christian Spanish music). III. Staff interviews CNA #2 was interviewed on 7/18/24 at 1:00 p.m. CNA #2 said she never saw Resident #62 participate in activities. She said Resident #62 sat in his wheelchair most of the day in his room or the hallway. Registered nurse (RN) #1 was interviewed on 7/18/24 at 1:10 p.m. RN #1 said Resident #62 did not participate in many group activities. She said he liked to watch people as they walked by and propel himself around the hallways in his wheelchair. The activities director (AD) was interviewed on 7/17/24 at 3:22 p.m. The AD said Resident #62 enjoyed people watching, propelling himself around in his wheelchair, one-on-one discussions and listening to music. She said he was on their one-on-one program, which involved him participating in three one-on-one activities per week. She said the resident was not getting all the one-on-one visits due to a lack of activities staff. The AD said Resident #62 primarily spoke Spanish and the facility did not have a translator to be used in a conversation. She said the staff used pages with words in English and Spanish to communicate with the resident or relied on other staff members who spoke Spanish to translate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure one (#84) of three residents reviewed for pressure injuries out of 46 sample residents received care consistent with professional standards of practice to prevent pressure injuries. Specifically, the facility failed to implement timely interventions to prevent Resident #84 from developing a Stage 2 pressure injury to his coccyx. Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA (2019), retrieved from https://www.internationalguideline.com/guideline on 7/22/24, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures ( fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable. Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Facility policy The Pressure Injury Prevention policy, revised March 2024, was provided by the nursing home administrator (NHA) on 7/18/24 at 5:21 p.m. It read in pertinent part, To prevent formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present, Individualized interventions will address specific factors in the resident's risk assessment, skin assessment and any pressure injury assessment (for example, moisture management, impaired mobility, nutritional deficit, staging and wound characteristics), The goal and preferences of the resident and/or authorized representative will be included in the plan of care. Interventions will be implemented in accordance with physician orders, including the type of prevention devices to be used and, for tasks, the frequency for performing them. In the absence of prevention orders, the licensed nurse will utilize nursing judgment in accordance with pressure injury prevention guidelines to provide care, and will notify the physician to obtain orders. Interventions will be documented in the care plan and communicated to all relevant staff, Compliance with interventions will be documented in the medical record. III. Resident #84 A. Resident status Resident #84, age [AGE], was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included acute respiratory failure with hypoxia (low oxygen level), type 2 diabetes mellitus , Parkinson's disease with dyskinesia (uncontrolled involuntary muscle movements) and vascular disorder of the intestine (narrowing or blockage of the arteries that supply blood to the intestines). According to the 6/27/24 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15. The resident was dependent for all activities of daily living (ADL) including transfers and bed mobility and was always incontinent of bowel and bladder. The assessment revealed the resident was at risk for developing pressure ulcers but did not have a pressure ulcer at the time of his admission to the facility. He had a pressure reducing device for his chair and bed, was on a turning and repositioning program and received applications of ointments/medications other than to the feet. The assessment did not indicate the resident had any behaviors of rejecting care. B. Resident representative interview Resident #84's representative was interviewed on 7/15/24 at 4:15 p.m. The representative said the facility staff did not come in every two hours to provide incontinence care or reposition Resident #84. She said she sat with the resident every day. She said the facility staff would only enter the room when she pushed the call light. She said the facility had never provided Resident #84 with an air mattress (pressure redistribution mattress). C. Observations On 7/16/24 at 11:33 a.m. Resident #84 was lying in bed. -There was not an air mattress on the bed. On 7/17/24 1:47 p.m. Resident #84 was lying in bed and the resident representative was at the bedside. -There was not an air mattress on the bed. On 7/18/24 at 8:45 a.m. Resident #84 was observed lying in bed. Licensed practical nurse (LPN) #2 and registered nurse (RN) #3 were preparing to perform the resident's wound care. -There was not an air mattress on the bed. RN #3 turned the resident to one side while LPN #2 removed the bordered gauze covering the wound. LPN #2 cleansed the wound, exposing a pink wound bed with no slough (yellow/white material containing dead cells that accumulate over a wound bed). The wound size was approximately 2 centimeters (cm) wide by 2 cm long. D. Record review The baseline care plan, initiated 6/21/24, documented Resident #84 was incontinent of bowel and bladder and required total assistance from staff for repositioning in bed. -The care plan did not identify that the resident was at risk for developing pressure injuries or document any pressure wound preventative measures that were put in place. According to the admission assessment, completed 6/21/24, Resident #84 had multiple bruises and scabs to his arms and bruises on his abdomen. There was no pressure injury documented on the admission assessment. According to the Braden pressure ulcer risk assessment (a tool utilized to determine pressure ulcer risk), completed on 6/27/24, the resident was at risk for pressure injuries due to very limited mobility, being bedfast and the potential for friction and shear during repositioning. The skin assessment completed on 6/27/24 indicated the resident had no pressure injuries. The nursing progress note dated 7/4/24 documented Resident #84 had an open area to the coccyx with no drainage or redness noted to the area. A treatment order was obtained on 7/4/24 to cleanse the open area to the coccyx and cover with border gauze dressing every other day. The interdisciplinary team (IDT) progress note on 7/5/24 at 8:53 a.m., documented Resident #84 had a small wound on his coccyx. The recommendations included adding an alternating low loss air mattress and the wound care physician was to follow. -Review of Resident #84's electronic medical record (EMR) revealed a risk for pressure ulcer care plan was not initiated until 7/10/24 (20 days after the resident's admission to the facility and six days after the pressure ulcer was initially identified). The risk for pressure ulcer care plan indicated Resident #84 was at risk for pressure ulcers related to immobility, incontinence and cognitive deficits. Interventions included administering medications as ordered, monitoring/documenting for side effects and effectiveness, educating the resident, family, and caregivers as to causes of skin breakdown, including positioning requirements, good nutrition and frequent repositioning, encouraging the resident to turn side-to-side, monitoring nutritional status, monitoring and documenting changes in skin status and obtaining and monitoring laboratory/diagnostic work as ordered. -The care plan did not indicate the presence of an active pressure ulcer. It did not include interventions for wound care treatment, using a specialty mattress or frequent repositioning of the resident by staff. The nursing wound assessment dated [DATE] indicated the wound was identified on 7/6/24. Interventions included a pressure redistribution mattress, a wheelchair cushion, vitamin supplements and positioning devices. The assessment documented that the care plan was updated. -However, according to the nurse progress notes, the wound was initially identified on 7/4/24 (see progress notes above). -Additionally, the facility failed to ensure the care plan, which was not implemented until 7/10/24 (six days after the pressure injury was identified), was to include the pressure injury or interventions. -The facility failed to implement the air mattress which was a documented intervention on the wound assessment (see observations above). According to the wound physician's (WP) progress note dated 7/10/24, Resident #84 had an unstageable pressure injury to the coccyx, due to necrosis (death of tissue) with full thickness measuring 1.5 cm wide by 15 cm long by 0.2 cm deep. The physician's treatment order was changed on 7/10/24 to cleanse the area to the coccyx, apply Medi-honey to the wound bed and cover with bordered gauze dressing every day. The nursing wound observation note dated 7/10/24 revealed Resident #84's pressure wound on the coccyx measured 1.5 cm long by 1.5 cm in wide by 0.2 cm in deep and was unstageable. The note documented the care plan was reviewed, the physician was notified of changes, resident education was provided and the resident's representative was updated with changes. It noted that the wound was unresolved and was acquired after admission. -The measurements documented on the wound observation were significantly different from the WP progress note (see WP progress note above). IV. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 7/18/24 at 1:00 p.m. CNA #3 said when a resident was at risk for developing pressure ulcers, she repositioned the resident every two hours and applied barrier cream to their skin. CNA #3 said she was not aware that Resident #84 had a pressure ulcer. LPN #2 was interviewed on 7/18/24 at 1:04 p.m. LPN #2 said when a new pressure injury was identified, the director of nursing (DON) or the MDS assessment nurse should be notified. She said the DON and the MDS assessment nurse were responsible for initiating the care plan. LPN #2 said the care plan should include interventions, such as incontinence care and repositioning every two hours, or offloading the pressure injury site. LPN #2 said Resident #84 did not have a pressure ulcer when he was admitted to the facility. She said Resident #84 laid in bed most of the time and staff repositioned and provided incontinence care every two hours. She said the resident did not have an air mattress because his family requested the bolstered (with raised sides) mattress for fall prevention. -However, there was no documentation in the EMR indicating the resident's family was offered and declined the air mattress. The DON was interviewed on 7/18/24 at 2:54 p.m. The DON said upon a resident's admission to the facility, a Braden scale was completed to determine each resident's risk for developing pressure ulcers. She said if a resident was at risk, interventions, such as frequent repositioning, alternating air mattress, frequent incontinence care and dietitian involvement, were initiated. The DON said a care plan for Resident #84's risk of developing pressure injuries should have been developed upon his admission to the facility. She said the baseline care plan should have identified that the resident was at risk for pressure ulcers and preventative interventions should have been put into place. The DON said, initially, the resident's family did not allow him to get out of bed due to his pain. She said the staff had not done a good job of repositioning the resident until after he developed the pressure ulcer. The DON said the pressure ulcer was not identified on the resident's comprehensive care plan and it should have been. She said there were no interventions put into place until after Resident #84 developed the pressure injury to his coccyx. The DON said the family wanted a bolstered mattress because they were concerned about the resident falling out of bed and they declined the air mattress. She said the facility should have documented in the resident's EMR and comprehensive care plan that the resident's representative declined the air mattress. She said the facility might be able to get bolsters for an air mattress, however, she said they had not looked into it. The wound physician (WP) was interviewed on 7/18/24 at 4:30 p.m. The WP said he only assessed the wound once and it was covered with slough and was unstageable. He said the wound measured about 15 cm long by 1.5 cm wide by 0.2 cm deep. The WP said he understood from staff that the family had declined using the air mattress.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure one (#290) of nine residents out of 46 sample residents were free from significant medication errors. Specifically, the facility failed to ensure the insulin pen was primed prior to medication administration for Resident #290. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. Louis Missouri, pp. 606-607, retrieved on 7/22/24, Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment Professional standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: the right medication, the right dose, the right patient, the right route, the right time, the right documentation and the right indication. II. Manufacturer's guidelines According to the Humalog pen insulin lispro injection instructions, retrieved on 7/22/24 from https://www.accessdata.fda.gov/drugsatfda_docs/label/2004/20563slr046_humalog_lbl.pdf, The needle must be changed and the pen must be primed before each injection to make sure the pen is ready to dose. Performing these steps before each injection is important to confirm that insulin comes out when you push the injection button, and to remove air that may collect in the insulin cartridge during normal use. III. Resident #290 status Resident #290, age [AGE], was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus without complications, chronic kidney disease stage three and myocardial infarction (heart attack). According to the 5/29/24 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required partial to substantial assistance with transfers, dressing and bathing. IV. Observations On 7/16/24 at 3:25 p.m. licensed practical nurse (LPN) #1 was administering medication to Resident #290. The medication ordered was Insulin Lispro Subcutaneous (under the skin) Solution Pen-Injector 200 unit/milliliter, inject three units subcutaneously before meals for diabetes. Hold if blood glucose is lower than 150 milligrams/deciliter (mg/dl). After checking the resident's blood sugar, LPN #1 determined that three units of Insulin Lispro were required. LPN #1 drew up three units in the insulin pen and cleaned the resident's arm with an alcohol swab. Before she injected the insulin, LPN #1 was stopped from administering the insulin. -LPN #1 failed to prime the insulin pen per manufacturer's instructions. LPN #1 said she should have primed the insulin pen prior to drawing up the three units of insulin. LPN #1 proceeded to prime the pen and administer three units of insulin to Resident #290. V. Staff interviews LPN #1 was interviewed on 7/16/24 at 3:30 p.m. LPN #1 said she should have primed the insulin pen prior to drawing up the three units of insulin. LPN #1 said she had recently received training on priming insulin pens. The director of nursing (DON) was interviewed on 7/18/24 at 2:54 p.m. The DON said insulin pens should be primed prior to drawing up the dose of insulin to remove air that may have collected in the insulin cartridge and ensure the correct dose was given.

Based on observations and interviews, the facility failed to ensure medications and biologicals were properly stored and labeled in accordance with professional standards in one of four medication carts and one of two medication storage rooms. Specifically, the facility failed to: -Ensure a vial of Tubersol (used to test for tuberculosis) was discarded 30 days after it was opened; and, -Ensure expired medications were removed from the medication cart. Findings include: I. Professional reference The United States Food and Drug Administration (USFDA) (2/8/21) Don't Be Tempted to Use Expired Medicines, was retrieved on 7/23/24 from https://www.fda.gov/drugs/special-features/dont-be-tempted-use-expired-medicines. It read in pertinent part, Expired medical products can be less effective or risky due to a change in chemical composition or a decrease in strength. Certain expired medications are at risk of bacterial growth and sub-potent antibiotics can fail to treat infections, leading to more serious illnesses and antibiotic resistance. Once the expiration date has passed there is no guarantee that the medicine will be safe and effective. If your medicine has expired, do not use it. II. Manufacturer's guidelines According to the Tubersol package insert, retrieved on 7/23/24 from https://www.fda.gov/media/74866/download, A vial of tubersol which has been opened and in use for 30 days should be discarded. III. Observations On 7/17/24 at 5:14 p.m. the medication cart on the Diamond Way hall was observed with registered nurse (RN) #1. The following items were found: -A bottle of calcium 600 milligrams (mg) with vitamin D5 with an expiration date of June 2024; and, -A bottle of Fluticasone Propionate 50 micrograms (mcg) nasal spray with an expiration date of April 2024. On 7/17/24 at 5:33 p.m. the East medication storage room was observed with RN #3. The following item was found: -A vial of Tubersol solution with an opened date of 6/11/24. -According to the manufacturer's guidelines (see above), the Tubersol should have been discarded on 7/12/24. IV. Staff interviews RN #1 was interviewed on 7/17/24 at 5:14 p.m. RN #1 said the medications in the Diamond Way hall medication cart were expired and he would dispose of them. RN #3 was interviewed on 7/17/24 at 5:33 p.m. RN #3 said the Tubersol should have been discarded 30 days after it was opened. She said she would notify the director of nursing (DON). The DON was interviewed on 7/17/24 at 5:53 p.m. The DON said medications should be discarded when expired. She said the vial of Tubersol should have been discarded 30 days after it was opened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater. Specifically, the medication administration observation error rate was 9.68%, or three errors out of 31 opportunities for error. Finding include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. Louis Missouri, pp. 606-607, retrieved on [DATE], Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment Professional standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: the right medication, the right dose, the right patient, the right route, the right time, the right documentation and the right indication. II. Facility policy and procedure The Medication Administration policy, revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 5:21 p.m. The policy read in pertinent part, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice in a manner to prevent contamination or infection, keep medication cart clean, organized and stocked with adequate supplies, identify expiration date. If expired, notify the nurse manager, correct any discrepancies and report to the nurse manager. III. Manufacturer's Guidelines According to the manufacturer's guidelines for insulin lispro (Humalog), retrieved on [DATE] from https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/020563s172,205747s008lbl.pdf, Humalog is a rapid acting human insulin analog indicated to improve glycemic control in adults with diabetes mellitus. Administer Humalog by subcutaneous (under the skin) injection within 15 minutes before a meal or immediately after a meal. According to the Humalog pen insulin lispro injection instructions retrieved on [DATE] from https://www.accessdata.fda.gov/drugsatfda_docs/label/2004/20563slr046_humalog_lbl.pdf, The needle must be changed and the pen must be primed before each injection to make sure the pen is ready to dose. Performing these steps before each injection is important to confirm that insulin comes out when you push the injection button, and to remove air that may collect in the insulin cartridge during normal use. According to the manufacturer's guidelines for artificial tears (polyvinyl alcohol 1.4%), retrieved on [DATE] from https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=736f9577-d8ff-45c7-8205-dfdb7193492f, Artificial tears are for use in the eyes as a lubricant to prevent further irritation or to relieve dryness. To avoid contamination, do not touch the tip of the container to any surface. Replace cap after using. IV. Observations and interviews On [DATE] at 3:25 p.m. licensed practical nurse (LPN) #1 was administering medication to Resident #290. Resident #290 had a physician's order for insulin lispro subcutaneous solution pen-injector 200 unit/milliliter; inject three units subcutaneously before meals for diabetes. The insulin should not be given if blood glucose is lower than 150 milligrams/deciliter (mg/dl). After checking the resident's blood sugar, LPN #1 determined that three units of insulin lispro were required. LPN #1 drew up three units in the insulin pen and cleaned the resident's arm with an alcohol swab. -Before she injected the insulin, LPN #1 was stopped from administering the insulin. LPN #1 said she should have primed the insulin pen prior to drawing up the three units. Resident #290 had a physician's order for artificial tears ophthalmic solution 1 %, two drops in both eyes four times a day for dry eyes. LPN #1 took the eye drops from the medication cart and placed them in her pocket. She went to the resident's room, administered an oral medication and insulin. She then returned to her medication cart. Upon prompting, she said she forgot to administer the eye drops. She returned to the resident room and administered the eyedrops. On [DATE] at 9:27 a.m. registered nurse (RN) #1 was preparing medications for Resident #5. The resident had an order for calcium with vitamin D tablet 600-400 milligrams (mg)-unit. RN #1 said the facility did not have the prescribed dose in stock currently and he would have to contact the transportation coordinator (TC), who ordered the over the counter medications. He did not administer the calcium with vitamin D and made a progress note that it was unavailable. He contacted the TC but did not notify the physician. V. Additional staff interviews LPN #1 was interviewed on [DATE] at 3:30 p.m. She said insulin pens should be primed prior to administering the insulin. She said she did not prime the insulin pen prior to attempting to administer the insulin. LPN #1 said she forgot to administer eye drops to Resident #290. She said she would have noticed the eyedrops were in her pocket at some point in the day. The TC was interviewed on [DATE] at 10:39 a.m. She said she was responsible for tracking over the counter (OTC) medications. She said if a new OTC medication was ordered she would go to a local store and purchase it, then add it to her next supply order. The TC said she was not notified the facility was out of stock of the calcium with vitamin D 600-400 mg-unit until that day ([DATE]). She said the medication was on backorder and would not be available until [DATE]. The TC said she would pick the medication up at a local store today ([DATE]) to cover until the stock supply came in. The director of nursing (DON) was interviewed on [DATE] at 2:54 p.m. The DON said all medications should be administered according to the physician's orders. She said when an OTC medication was unavailable, the nurse should notify the TC immediately and the physician for clarification. She said it was easy to go to the local store to pick up an OTC medication. The DON said insulin pens should be primed before drawing up a dose of insulin. She said priming the insulin pen was important to ensure the resident received the correct dose of insulin. The DON said nurses should not put medications in their pocket due to infection control concerns.

Based on observations, record review and interviews, the facility failed to ensure residents consistently receive food prepared by methods that conserved nutritive value and were palatable in taste, texture and temperature. Specifically, the facility failed to ensure the resident's food was palatable in taste, texture and temperature. Findings include: I. Facility policy and procedure The Food Preparation Guidelines policy, revised 1/2023, was provided by the nursing home administrator (NHA) on 7/18/24 at 5:20 p.m. It read in pertinent part, It is the policy of this facility to prepare foods in a manner to preserve or enhance a resident's nutrition and hydration status. The cook, or designee, shall prepare menu items following the facility's written menus and standardized recipes. Food shall be prepared by methods that conserve nutritive value, flavor and appearance. Food and drinks shall be palatable, attractive, and at a safe and appetizing temperature. Strategies to ensure resident satisfaction include using spices or herbs to season food in accordance with recipes, serving hot foods/drinks hot and cold foods/drinks cold and addressing resident complaints about foods/drinks. II. Resident interviews Resident #41 was interviewed on 7/15/24 at 9:33 a.m. Resident #41 said the food was bad. She said the vegetables were mushy. She said she tried to eat a low carbohydrate diet but it was difficult with the facility menu. Resident #25 was interviewed on 7/15/24 at 10:26 a.m. Resident #25 said the food was cold. She said the facility served the same thing (burritos) every day. She said she had talked to the dietitian and it did not help. She said the alternative menu consisted of the same food and it did not change. Resident #64 was interviewed on 7/15/24 at 11:20 a.m. Resident #64 said the food tasted terrible. He said the food had no seasoning to it and was tough to chew. Resident #53 was interviewed on 7/15/24 at 11:33 a.m. Resident #53 said the food was bad. He said the food was always too spicy. He said the facility served a lot of potatoes. He said the sandwiches only had one slice of meat on them. Resident #51 was interviewed on 7/15/24 at 4:01 p.m. Resident #51 said sometimes the food was good and other times the food tasted bad. She said she ordered off the alternative menu all the time. She said the alternative menu could stand to be updated by adding new food items because she was tired of the options on the alternative menu. Resident #59 was interviewed on 7/15/24 at 4:27 p.m. Resident #59 said the food was terrible and was always cold. Resident #47 was interviewed on 7/15/24 at 4:53 p.m. Resident #47 said the food was undercooked. He said he had found hair in his food and the bread was moldy. III. Observations On 7/17/24 during a continuous observation of the dinner meal preparation and service in the main kitchen, beginning at 2:20 p.m. and ending at 5:52 p.m., the following was observed: At 3:52 p.m. the cook (CK) poured butter on the grill and began cooking the peppers on the stove to grill them. He said once the peppers were softened he would add the onions. At 3:58 p.m. the CK added the onions. He said he did not add any seasoning to the bell peppers and onions. At 5:52 p.m. the last tray was plated and placed in the insulated meal tray transport box. The insulated box was taken down the east hallway and the meals were served to the residents IV. Test tray On 7/17/24 at 6:06 p.m. a test tray was evaluated by four surveyors immediately after the last resident had been served their room tray for dinner. The regular diet test tray consisted of a sausage and veggie skillet, scalloped potatoes, garden salad with dressing, a roll and mandarin oranges. -The temperature of the ground sausage and peppers was 100.4 degrees Fahrenheit (F). The ground sausage and peppers felt lukewarm when consumed -The temperature of the scalloped potatoes was 119 degrees F. The scalloped potatoes were dry and hard as the potatoes were not cooked all the way through. The potatoes were bland. V. Record review The food committee meeting minute notes were received from the NHA on 7/17/24 at 12:35 p.m. The 2/9/24 food committee meeting minute notes documented one resident wanted less Spanish food and another resident requested more fruit. The residents were informed that due to the cold weather, fresh fruit was hard to get. The outcome documented the residents were overall satisfied with the dining experience. -The 2/9/24 food committee notes did not include how the facility was going to handle the suggestion of offering less Spanish food on the menu. V. Staff interviews The dietary manager (DM) was interviewed on 7/18/24 at 12:03 p.m. The DM said when he was informed that a resident had a concern or issue with the foods being served to them, he would talk to them and find out what they did not like. He said he would offer the resident something else to eat. He said the certified nurse aides (CNA) were responsible for taking the resident's meal orders. He said the CNAs asked the residents if they wanted what was being served on the ticket and, if not, then the CNAs would offer something from the alternative menu. The DM said the kitchen staff received the meal tickets two to three hours before meal service. He said all the residents should have an alternative menu in their room so it was readily available to them. The DM said he had received some food concerns regarding temperatures from the hallway trays. He said residents had complained about the food being delivered to their rooms cold as he only had insulated carts. He said some of the complaints were the residents did not like some of the foods being served. He said he had not heard of any complaints about the food being bland. He said he had a plan in place and was trying to get more residents to come and eat in the dining room. The DM said the food committee met once a month. He said the monthly meeting had been effective but he said he would like to get more residents to attend the meetings. He said he tried to promote the food committee to encourage more residents to attend. He said he was in charge of addressing the food concerns. He said as soon as he heard of a food complaint, he addressed them immediately. He said when he was told about a concern, he would ask the residents and the resident would tell him that everything was fine. He said he told the residents if they had a concern to let him know so he could fix the problem. He said if he did not know what the problem was he could not fix it. He said that he did not get many food concerns. The DM said he had not heard of any concerns about the food being over cooked, vegetables being mushy, food being greasy and the food tasting bad. He said he had temperature logs and he checked them daily to make sure they were correct. He said he checked the temperatures at the beginning of the meals, sometimes in the middle and checked trays randomly. He said he tasted all the food every day to make sure that it was not overcooked or undercooked. He said the food came down to preference and everyone had different preferences. He said he would keep an eye out on how the cooks were preparing the meals and talk to them and educate them. The DM said the trays being transported to the hallways were transported in an insulated box and were not hot boxes. He said he had two insulated boxes and they did not plug in to be kept heated. He said corporate management had bought the insulated boxes. He said he had mentioned getting hot boxes that plugged into the wall to the NHA. The NHA was interviewed on 7/18/24 at 12:42 p.m. The NHA said the room tray carts were not heating carts. He said the carts held the heat for approximately 45 minutes. He said he did not know that there were hot boxes that plugged into the wall to stay warm. He said he would talk to the DM and ask him if he wanted the plugged in hot boxes and he would buy it. He said the room trays should be served to the residents as soon as possible. He said he had a performance plan in place of not meeting food temperatures and making sure the concerns were being met. He said he had a plan to bring all the residents back to the dining room. He said he would love to see more residents eating in the dining room and not in their rooms The NHA said he looked at the grievance binder every day. He said he did not get a lot of food concerns and had not gotten any within the last month.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to establish a sanitary environment to help prevent the transmission of communicable diseases and infections on two of four hallways. Specifically, the facility failed to: -Ensure enhanced barrier precautions (EBP) were implemented and followed for residents with wounds and/or indwelling medical devices; -Ensure residents' laundry was appropriately covered during transportation; and, -Ensure housekeeping used the proper cleaning method to sanitize a residents' rooms. Finding include: I. Failure to implement and follow EBP for residents with wounds and/or indwelling medical devices A. Facility policy and procedure The Enhanced Barrier Precautions policy, revised 12/2022, was received by the nursing home administrator (NHA) on 7/18/24 at 5:16 p.m. It documented in pertinent part, It is the policy of this facility to implement enhanced barrier precautions (EBP) for the prevention of transmission of multidrug-resistant organisms. Prompt recognition of need: Clear signage will be posted on the door or wall outside of the residents' room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves. Initiation of EBP: an order for EBP will be obtained for residents with any wound and/or indwelling medical devices even if the resident is not known to be infected or colonized with a multi-drug resistant organism (MDRO). Implementation of EBP: make gowns and gloves available immediately outside of the resident's room. High contact resident care activities include: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care. B. Resident observations and interviews On 7/15/24 at 4:35 p.m. Resident #82 was observed in his room. He had a foley catheter drainage bag hanging on his bed. -There were no signs for EBP hanging outside the resident's room or on the door (see facility policy above). -There was no PPE located outside the resident's room (see facility policy above). Resident #82 was interviewed on 7/15/24 at 4:47 p.m. Resident #82 said staff helped him with many cares since he broke his shoulder and leg. He said they did bed baths, changed his briefs, emptied his foley catheter drainage bag, dressed him and got him up to the wheelchair. He said the staff wore gloves, but not gowns, when providing his care. He said he had had an indwelling catheter for a long time. On 7/18/24 at 8:45 a.m. Resident #84 was observed lying in bed. Licensed practical nurse (LPN) #2 and RN #3 were preparing to perform the resident's wound care. The door to the resident's room had signs indicating the resident was on EBP. -LPN #2 and RN #3 entered the resident's room without donning gowns. RN #3 turned Resident #84 to one side while LPN #2 removed the resident's old wound dressing. LPN #2 cleansed the wound and applied a new dressing to the wound. LPN #2 and RN #3 said they did not know why the resident was on EBP. C. Staff interviews The infection preventionist (IP) and director of nursing (DON) were interviewed on 7/18/24 at 10:00 a.m. The IP said any resident with open wounds or indwelling medical devices, such as a gastrostomy tube (feeding tube), intravenous device (IV), or catheters, would be placed on EBP. He said the residents should have a sign outside their door and a cart with PPE outside their room, which was how the facility chose to identify residents who were on EBP. Certified nurse aide (CNA) #2 was interviewed on 7/18/24 at 11:45 a.m. CNA #2 said residents on EBP were supposed to have a sign outside their door. She said the sign was how she knew that the resident was on EBP and she would put a gown and gloves on before providing resident care. She said if the resident did not have a sign outside their door, she would not put a gown and gloves on unless told otherwise CNA #2 said she had not been told Resident #82 was on EBP. Registered nurse (RN) #1 was interviewed on 7/18/24 at 11:50 a.m. RN #1 said residents were on EBP if they had a MDRO and if they had a wound or indwelling medical device, even if they did not have a MDRO. He said he put a gown and gloves on while providing care for residents on EBP II. Failure to use proper cleaning method when sanitizing residents' rooms A. Facility policy and procedure The 5-step Daily Patient Room Cleaning Guide, undated, was received from the housekeeping director (HSKD) on 7/17/24 at 4:45 p.m. It documented in pertinent part, The purpose is to show housekeeping employees the proper cleaning method to sanitize a patient's room or any area in a healthcare facility. Horizontal surfaces include disinfecting tabletops, headboards, window sills and chairs. Vertical surfaces are not wiped down daily but must be spot cleaned daily. Walls especially by trash cans, light switches and door handles will need special attention. B. Observations Housekeeper (HSK) #1 was observed on 7/16/24 at 12:19 p.m. HSK #1 was cleaning resident rooms on the [NAME] hallway. He cleaned the bedside table and television for bed A in room [ROOM NUMBER], switched out rags and cleaned the bedside table for bed B. He then cleaned the sink and paper towel dispenser. He cleaned the bathroom and swept the bedroom floor. After cleaning in room [ROOM NUMBER], HSK #1 then moved on to room [ROOM NUMBER]. He cleaned the bedside table for bed A. He said he was not going to clean the bedside table for bed B because that resident did not eat in the room much. He cleaned the sink and paper towel dispenser. He cleaned and mopped the bathroom. -HSK #1 swept and mopped the entire bedroom using the same dust mop and damp mop he had just used to sweep and mop the bathroom floor. -HSK #1 failed to clean the high-touch surfaces in the residents' rooms and mop the bedroom floor in room [ROOM NUMBER]. -HSK #1 failed to treat room [ROOM NUMBER] as separate areas when using the damp mop. -HSK #1 failed to clean bed B's bedside table in room [ROOM NUMBER]. HSK #2 was observed on 7/17/24 at 11:04 a.m. cleaning resident rooms on the East hallway. He cleaned the bedside table and television for bed A in room [ROOM NUMBER], switched out rags, and cleaned the bedside table for bed B. He then cleaned the sink and paper towel dispenser. He cleaned the bathroom and swept and mopped the bedroom floor. He then moved on to room [ROOM NUMBER]. He cleaned the bedside table for bed A, switched out rags, and cleaned the bedside table for bed B. He cleaned the sink and paper towel dispenser. He cleaned and mopped the bathroom. -HSK #2 swept and mopped the entire bedroom using the same dust mop and damp mop he had just used to sweep and mop the bathroom floor. -HSK #2 failed to clean the high-touch surfaces in the residents' rooms. -HSK #2 failed to treat rooms #33 and #31 as separate rooms when using the damp mop. C. Staff interview The housekeeping director was interviewed on 7/17/24 at 4:45 p.m. He said when cleaning a resident room with two sides, it should always be treated as two separate rooms. He said high touch surfaces should be cleaned daily. He said high touch surfaces included call lights, door handles, light switches, and phones. III. Failure to ensure residents' laundry was appropriately covered during transportation A. Facility policy and procedure The Infection Prevention and Control Program policy, revised 12/2022, was received by the NHA on 7/15/24 at 10:00 a.m. The policy documented in pertinent part, The facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Clean linen shall be delivered to the resident care units on covered linen carts with covers down. B. Observation An unidentified HSK was observed on 7/17/24 at 12:03 p.m. The HSK was dropping personal laundry off to residents' rooms. The laundry transport cart was overflowing with laundry and only the top part of the cart had a white sheet covering it. The bottom of the cart was enclosed with bars, but there were spaces between the bars with exposed laundry. The HSK took the sheet off the top of the laundry transport cart to expose the laundry, took out clothing, and walked into the resident's room to hang it up. She came out, moved the cart to the next room and took clothing out to give to the next resident. The HSK failed to replace the sheet over the remaining clean laundry as she continued delivering the laundry to residents' rooms. C. Staff interview The HSKD was interviewed on 7/17/24 at 4:45 p.m. He said clean linen and residents' laundry should always be covered during transportation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure resident rooms, bathrooms and hallways received necessary maintenance repairs. Findings include: I. Observations and resident interviews Observations throughout the survey were conducted on 7/15, 7/16, 7/17 and 7/18/24 and revealed the following: A. Individual resident rooms room [ROOM NUMBER] had a leaking toilet and the tile on the bathroom floor on the corner edge under the sink was coming off the floor. The bathroom smelled like urine and mildew. The towel rack in the bathroom was not labeled. The bathroom was shared with another resident. In room [ROOM NUMBER], the soap dispenser in the bathroom was broken and the resident had hand sanitizer to wash her hands. -The resident said she reported the broken soap dispenser to staff two weeks ago and was waiting for it to be fixed. The resident who resided in room [ROOM NUMBER] said every time it rained, water would come in from the bottom of the double doors in his room that led out to the courtyard. -There was no weatherstripping at the bottom of the doors to prevent water from coming in. room [ROOM NUMBER] was hot and there was no air conditioner in the room. The resident had a fan on but it was still hot. The resident said he was sweating and even with the fan he had on he said he was still hot. The heater vent in room [ROOM NUMBER] was coming off the wall by the window, the wall behind the head of the bed was patched and needed to be painted. One of the individual slats was broken and missing. The blinds in room [ROOM NUMBER] had one of the individual slats that was broken and missing. There was a broken tile as you entered the bathroom in room [ROOM NUMBER]. B. Hallways There was an outlet that was coming off the wall in the west hallway between room [ROOM NUMBER] and room [ROOM NUMBER]. The baseboard was coming off the wall in the east hallway between room [ROOM NUMBER] and room [ROOM NUMBER]. C. Shower rooms Observations of the four shower rooms were completed on 7/16/24. -The big shower room down the east hallway the paint was chipping as you entered the shower. The transition floor piece as you entered the bathroom from the hallway was missing and there was a gap. -The big shower room down the west hallway had three wet towels left on the floor of the shower. II. Facility environmental tour and staff interviews An environmental tour was conducted on 7/18/24 at 10:05 a.m. with the maintenance assistance (MA). Regarding all observations above, the MA said he was going around and fixing/repairing all the items that needed repaired or fixed while on survey. He said he walked the facility every day he was there to look for items that needed to be repaired. He said patching the walls and painting was an ongoing project. He said he saw the areas that needed to be repaired and was working on getting the repairs done. The MA said he was notified of work orders by a work maintenance program that staff had access to. He said the program sent him the work orders. He said he looked at the work orders everyday. He said the staff would also notify him in person on what needed fixing. He said he was working on getting all the repairs completed. He said he focused on one hallway at a time and, depending on how bad some rooms were, he would get to them first. The MA said the maintenance department was the only department who did walk-throughs of the building to determine what needed to be fixed. He said if he ran into any issues he would notify the administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure two (#47 and #70) of three sample residents received the highest practicable treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility failed to assess Resident #47 and Resident #70 after a change of condition. Findings include: I. Facility procedure The Change of Condition procedure, dated October 2022, provided by the nursing home administrator (NHA) on 2/15/23 at 12:14 p.m. included, A nursing assessment will assist the physician and the nursing staff to make good sound decisions. A situation, background, assessment and recommendation (SBAR) assessment will be completed on all residents with any of the above changes. Palliative/Hospice Care: Some residents have chosen to have end of life care or palliative care. The physician and/or hospice still need to know when a change in condition occurs so their needs and comfort can be addressed in a timely manner. II. Resident #47 A. Resident status Resident #47, age [AGE], was admitted on [DATE] and discharged [DATE]. According to the February 2023 computerized physicians orders (CPO), diagnoses included calorie malnutrition, neoplasm (cancer) of breast, and history of falling. The 1/24/23 minimum data set (MDS) assessment revealed the resident's cognitive status was moderately cognitively impaired with a brief interview for mental status (BIMS) score of nine out of 15. She had no identified behaviors or rejections of care during the assessment period. B. Record review The provider note, dated 12/23/22, included: Reason for appointment: Nursing request to evaluate right hand swelling. History of present illness: Patient seen per nursing request to evaluate right hand swelling .Suspect due to dependency. Encouraged patient to elevate the hand. -The facility did not have evidence of an assessment of the swelling of the right hand. C. Interviews Certified nurse aide (CNA) #1 was interviewed on 2/15/23 at 9:17 a.m. She said if she noticed anything different in the resident's appearance or cognition she would report the change to the nurse right away for the safety of the resident. Licensed practical nurse (LPN) #3 was interviewed on 2/15/23 at 9:17 a.m. She said if an aide reported a change in the resident she would let the nurse practitioner (NP) know. She said an assessment/progress note should be written in the resident's medical record to indicate the change in the resident. Registered nurse (RN) #1 was interviewed on 2/15/23 at 9:23 a.m. She said if she was notified of any change in a resident's status, she would complete an assessment of the identified area, complete a treatment if needed, and ask the resident about the identified area. She said she would complete an SBAR that included notification to the provider and the responsible party. The director of nursing (DON) was interviewed on 2/15/23 at 10:35 a.m. She said if the staff found a change in condition she would want a SBAR to be completed. She said she could not find an SBAR, a progress note, or any type of assessment beyond the NP progress note. She said it was important to assess immediately for the safety and well-being of the resident. III. Resident #70 A. Resident status Resident #70, age [AGE], was admitted on [DATE] and discharged [DATE]. According to the January 2023 CPO, diagnoses included chronic obstructive pulmonary disease (COPD), sleep apnea, hypertension, right sided heart failure, obstructive sleep apnea, and atrial fibrillation. The 1/10/23 minimum data set (MDS) assessment revealed the resident's cognitive status was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She had no identified behaviors or rejections of care during the assessment period. B. Record review The progress note, dated 1/11/23 at 7:44 a.m. documented, This a.m. (morning), resident summoned a nurse to the room. Resident with bruising to right rib area, related to post fall. There is a lump under the bruising, and the resident states that it's a rib. Call out to (provider)'s office. VM. (left a voice mail) -The facility did not have evidence of an assessment of the right rib area, or evidence of notifying the provider of a change in condition. C. Interview The DON was interviewed on 2/16/23 at 1:00 p.m. She said when she looked at the progress note, her expectation was for the staff to complete an SBAR, and notification to the provider. She said she could not locate any more information beyond the note. She said she was not in the facility at the time the progress note was written. She said going forward, she would work with the staff to include further education on documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** II. Resident #15 A. Resident status Resident #15, age of 72, was admitted on [DATE]. According to the February 2023 computerized physician orders (CPO) diagnoses included paranoia schizophrenia, major depressive disorder, and diabetes. The 11/10/22 minimum data set (MDS) assessment revealed the resident did not participate in the brief interview for mental status (BIMS), instead the staff completed the assessment. The resident was cognitively intact with independent decision making. The resident required one person assistance with transfers, dressing, walking, toilet use, bathing, and personal hygiene. The resident had unsteady balance but did not use any adaptive device (walker, cane) for ambulation. She was not on a toileting program, was frequently incontinent of urine and always incontinent of bowl. The MDS assessment marked that the resident had not had any falls since the last assessment on 8/19/22. B. Resident observations On 2/14/23 at 10:30 a.m., Resident #15 was observed coming out of her room and walking down the hallway. She was unsteady on her feet and teetered back and forth as she walked. She had only one non- skid sock on, the other foot was bare. A certified nursing assistant (CNA) walked past her twice without saying anything. A registered nurse (RN) walked past her, asked her to sit down so he could get her another sock and her walker. After the RN walked away, the resident kept walking towards the end of the hallway. She walked past the social services office and the business office on her way to the front lobby. There were staff in both offices with their doors open but no staff said anything to the resident. At 10:38 a.m., the resident entered the front lobby and sat in a chair next to the nursing home administrator's (NHA) office. The NHA's door was open. A CNA came with another sock for the resident, the RN never returned. At 10:47 a.m., a female staff member taking food orders finally came over to the resident and assisted her to walk to the dining room. On 2/14/23 at 1:34 p.m. the resident was observed in her room standing in front of her closet without her depends on. On the floor, her depends were soiled with an abundance of loose stool and there was a large pile of loose stool on the floor near her depends. The resident pulled the curtain in front of the feces but it was still visible from the hallway. She then walked over to her bed and sat down, pulling the curtain in front of her bed. There was a sound of urinating coming from the resident's bed and a pool of urine appeared on the floor. A bedside commode was observed next to the feces in the resident's room. Continuous observations from 1:34 p.m. to 2:20 p.m. showed staff members walked past her open door nine separate times taking other residents to the activity room which was directly next door. No staff noticed the mess on the resident's floor. At 2:08 p.m. the maintenance supervisor (MS) walked past her door, looked over, and kept walking without saying anything. At 2:15 p.m. a RN walked past the resident's room to go across the hall. He walked past her door twice and never looked over. C. Record review The comprehensive care plan fall focus initiated on 1/27/20 and revised 12/7/22, revealed the resident was a fall risk due to diabetes, incontinence, and use of psychotropic medications. Interventions revised on 7/15/22 were for staff to assess for spills/urine on the resident's floor, assist with changing socks frequently, encourage the resident to wear shoes and/or dry non-skid socks on both feet, and encourage her to sit if she appeared unsteady on her feet. The activities of daily living focus revised on 12/21/22 revealed the resident was independent with ambulation but the activities care plan revised on 2/13/23 revealed the resident required a walker to ambulate throughout the facility and needed assistance with ambulation. The resident also had poor vision and refused to wear glasses. Nursing fall assessment dated [DATE] revealed the resident was a low fall risk with 1-2 falls in the last three months. She was ambulatory without incontinence and her vision was adequate. She was identified as having balance problems and decreased muscular coordination. A nursing fall assessment for 12/21/22 was not located when the resident had fallen (see below). Nursing fall assessment dated [DATE] revealed the resident was a high fall risk. However, it documented she had not had a fall in three months, she was ambulatory without incontinence and her vision was adequate. She also was identified as having balance problems. Interdisciplinary (IDT) progress notes revealed, -On 8/10/22 the IDT reviewed fall from 8/3/22. The resident had an unwitnessed fall in her room. It was determined the cause of the fall was due to an incontinence episode on the floor in her room and she slipped in it. No injury. A bedside commode provided and the care plan was to be reviewed for person centered interventions. - On 12/21/22 the IDT reviewed fall from 12/20/22. The resident had an unwitnessed fall in the dining room. It was determined the cause of fall was due to the resident's poor balance and refusal to wear proper footwear. No injury. Physical therapy screened resident for services -On 2/1/23 the IDT reviewed fall from 2/1/23. The resident had an unwitnessed fall in her room. She was discovered yelling out for help on her floor. The resident was wearing her socks with a pile of papers around her. No injury. The cause of the fall was undermined. Physical therapy to screen the resident. -There were no progress notes located for the 2/14/23 incontinence episode. D. Staff interviews RN #2 was interviewed on 2/16/23 at 11:05 a.m. The RN stated she was aware of the resident's fall history. She said the resident's falls were due to improper footwear and slipping on her own incontinence. She was not aware of the IDT fall interventions and could not locate them in the resident's medical record. The RN said the resident was difficult to redirect but redirection was the most frequent intervention the staff used. The staff were to check on the resident in her room but there was no documentation of checks or room rounds. The housekeeping department was to park their cart outside of her door when they were cleaning that unit so they could make frequent checks as well. The resident had been screened by physical therapy but would refuse to participate when they would come to work with her. CNA #5 was interviewed on 2/16/23 at 11:15 a.m. The CNA stated the resident was very difficult to redirect. The resident had incontinence episodes all over the facility to include outside in the courtyard and in the dining room. She had fallen in her own incontinence in the dining room and in her own room before. The resident refused to wear shoes, liked to only wear one sock, and frequently walked without her walker. The fall interventions were frequent checks when the resident was in her room and to encourage her to wear socks when out of her room. The staff did not document the checks and the CNA could not say how frequent they were, just whenever the staff had an opportunity. The director of nursing (DON) was interviewed on 2/16/23 at 11:20 a.m. She said the resident had a history of recurring falls due to slipping on her own incontinence and refusing to wear proper footwear. The DON did not know how many falls she had in the last six months. The staff tried to do rounding every two hours to toilet her but she often refused. When the staff saw that she was not wearing proper footwear, they were to offer her clean socks. The staff were to do hourly rounding on the resident but there was no documentation of the rounding. The majority of the resident's falls were in her room with incontinence on the floor. She was unable to find the nursing fall assessment for the 12/20/22 fall. Based on observations, record review and interviews, the facility failed to ensure two (#68 and #15) out of 29 sample residents' environment remained free of accident hazards and the resident received adequate supervision to prevent accidents. Specifically, the facility failed to: -Ensure timely assessment for use of wander guard for Resident #68; -Ensure the wander guard (elopement device) was monitored appropriately for Resident #68; and, -Implement effective fall interventions for Resident #15. Findings include: I. Resident #68 A. Facility policy and procedure The Elopement & Wandering Residents policy, revised on 1/1/23, was provided by the nursing home administrator (NHA) on 2/16/23 at 10:17 a.m. It read in pertinent part, 'This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. B. Resident status Resident #68, age [AGE], was admitted on [DATE]. According to the February 2023 computerized physician orders (CPO), diagnoses included fracture of left femur (hip), psychotic disorder, hypertension, and heart disease. According to the 2/8/23 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. The resident had disorganized thinking. She required extensive assistance for bed mobility, transfers, grooming and toilet use. The resident had verbal and physical behaviors directed toward others. MDS revealed no use of wander guard. C. Resident observation On 2/13/23 at 2:35 p.m., the resident was observed sitting in her room in her wheelchair. On 2/14/23 at 9:58 a.m., the resident was sleeping in her wheelchair in the doorway of her room. -At 2:12 p.m., the resident was visiting with a friend in her room. On 2/15/23 at 2:30 p.m., Resident #68 was observed participating in activities in the dining room. -At 4:21 p.m., Resident #68 was lying in bed sleeping. During observations of Resident #68 (see above) she did not wander aimlessly about the facility or was observed exit seeking. D. Record review The care plan, initiated 12/28/22, identified the resident was an elopement risk/wanderer as she could be disoriented to place, has a history of attempts to leave the facility unattended, impaired safety awareness. Interventions include distracting residents from wandering by offering pleasant diversions such as singing, structured activities, food, conversation, television, book. Resident prefers: She likes funny movies, and likes to talk about dogs. Provide structured activities: toileting, offer to take for a walk inside and outside, reorientation strategies including signs, pictures and memory boxes, offer prayer. The wandering assessment dated [DATE] indicated that Resident #68 was a low risk for wandering. Nurse log note dated 1/18/23 at 10:13 a.m., documented in part: Resident #68's power of attorney gave permission to use the wander guard. The February 2023 CPO included residents who had a wander guard safety device. Please verify that device was intact. Start date 1/26/23. The January 2023 medication administration record (MAR) identified that the resident had a wander guard safety device. Please verify that device was intact every shift. Replace if not present every shift for elopement Y for yes if intact N not intact. Wander guard ordered on 1/26/23. The MAR documented the resident's wander guard was not monitored from 1/18/23 to 1/26/23. -Record review revealed no documentation of attempted elopements or wandering aimlessly in the facility. -Record review of nursing notes revealed no attempted elopements or wandering aimlessly in the facility. E. Staff interview Registered nurse (RN) #1 was interviewed on 2/15/23 at 8:57 a.m. She said the resident did have verbal and physical behaviors but she never had any wandering behaviors. She said she was not sure if the resident had a wander guard but she would check. -At 9:13 a.m. RN #1 stated Resident #68 did have a wander guard. Certified nurse aide (CNA) #2 was interviewed on 2/15/23 at 9:45 a.m. She said Resident #68 did not wander. She stated Resident #68 did not have a wander guard. CNA #4 was interviewed on 2/15/23 at 1:37 p.m. She said she was familiar with Residents #68. She said Resident #68 did not wander in the facility and she did not have a wander guard. Licensed practical nurse (LPN) #3 was interviewed on 2/16/23 at 9:39 a.m. She said she was familiar with Resident #68. She said Resident #68 did not have any wandering behaviors that she was aware of. She said when a resident attempted to elope or if they wandered she would document in a progress note or in the behavior tracking identifying the wandering behaviors. The director of nursing (DON) was interviewed on 2/16/23 10:43 a.m. The DON said if a resident was wandering or exit seeking staff would be documenting it in the behavior tracking or progress notes. She said the documentation should identify what the wandering was about and if the resident was exit seeking. She said the assessment should also identify the residents' risk of elopement to ensure the safety of the resident. The DON was told of the observations above and the score on the elopement assessment. She said she would have to search for the elopement assessment which identified Resident #68 was high risk. The social service director (SSD) was interviewed on 2/16/23 at 1:15 p.m. She said staff would communicate residents' wandering behaviors and an interdisciplinary team (IDT) would review them during IDT meetings and decide if wander guard placement was needed. She said an elopement assessment would be completed and it would show if the resident was a high or low risk for elopement. If the resident was high risk, the IDT would discuss placement of a wander guard. The SSD was told of observations above. She said the elopement assessment was a consideration and it did not cover all basis for wander guard placement. She said staff should have been documenting wandering behaviors to ensure the wander guard was needed. At time of exit on 2/16/23, no elopement assessment was provided that indicated the resident was at high risk as indicated by the DON interview.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop and implement policies and procedures related to pneumococcal immunizations for two (#10 and #69) of five residents reviewed for vaccinations out of 29 sample residents. Specifically, the facility failed to ensure Residents #10 and #69 were offered and/or received pneumococcal immunization. Findings include: I. Professional reference According to Center for Disease Control and Prevention, reviewed 11/21/22, retrieved on 2/14/23 from https://www.cdc.gov/flu/professionals/infectioncontrol/ltc-facility-guidance.htm. It read, in pertinent part, If possible, all residents should receive inactivated influenza vaccine (IIV) annually before influenza season. For persons aged 65 years (or older), the following quadrivalent influenza vaccines are recommended: high-dose IIV, adjuvanted IIV, or recombinant influenza vaccine. If not available, standard-dose IIV may be given. In the majority of seasons, influenza vaccines will become available to long-term care facilities beginning in September, and influenza vaccination should be offered by the end of October. Informed consent is required to implement a standing order for vaccination, but this does not necessarily mean a signed consent must be present. Although vaccination by the end of October is recommended, influenza vaccine administered in December or later, even if influenza activity has already begun, is likely to be beneficial in the majority of influenza seasons because the duration of the season is variable, and influenza activity might not occur in certain communities until February or March. According to the Centers for Disease Control and Prevention (CDC) Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2023, retrieved on 2/13/23 from https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf. It read, in pertinent part, The pneumococcal vaccine was to be administered to immunocompetent adults aged 65 years or older one dose of 13-valent pneumococcal conjugate vaccine (PCV13), if not previously administered, followed by one dose of 23-valent pneumococcal polysaccharide vaccine (PPSV23) at least one year after PCV13; if PPSV23 was previously administered but not PCV13, administer PCV13 at least one year after PPSV 23. For special situations (see-www.cdc.gov/mmwr/preview/mmwrhtml/mm6140a4. htm): individuals age [AGE]-64 years with chronic medical conditions (chronic heart excluding hypertension, lung, or liver disease, diabetes), alcoholism, or cigarette smoking: give 1 dose PPSV23. II. Facility policy The Pneumococcal Vaccine policy, revised January 2023, was provided by the nursing home administrator (NHA) on 2/16/23 at 10:28 a.m. the policy included, Policy: It is our policy to offer our residents, staff, and volunteer workers immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations. Policy Explanation and Compliance Guidelines: -Each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted. Any additional efforts to obtain information shall be documented, including efforts to determine date of immunization or type of vaccine received. -Each resident will be offered a pneumococcal immunization unless it is medically contraindicated or the resident has already been immunized. Following assessment for any medical contraindications, the immunization may be administered in accordance with physician-approved 'standing orders.' -Prior to offering the pneumococcal immunization, each resident or the resident's representative will receive education regarding the benefits and potential side effects of the immunization. a. The individual receiving the immunization, or the resident representative, will be provided with a copy of CDC's current vaccine information statement relative to that vaccine. b. If necessary, the vaccine information statement will be supplemented with visual presentations or oral explanations to assist vaccine recipients in understanding. -The resident/representative retains the right to refuse the immunization. A consent form shall be signed prior to the administration of the vaccine and filed in the individual's medical record. -The type of pneumococcal vaccine (PCV15, PCV20, or PPSV23/PPSV) offered will depend upon the recipient's age and susceptibility to pneumonia, in accordance with current CDC guidelines and recommendations. -Usually only one (1) pneumococcal polysaccharide vaccination (PPSV) is needed in a lifetime. However, based on an assessment and practitioner recommendation, additional vaccines may be provided. -A pneumococcal vaccination is recommended for all adults 65 years' and older and based on the following recommendations: a. For adults 65 years' or older who have not previously received any pneumococcal vaccine: Give 1 dose of PCV15 or PCV20. i. If PCV15 is used, this should be followed by a dose of PPSV23 at least one year later. The minimum interval is 8 weeks and can be considered in adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak ii. If PCV20 is used, a dose of PPSV23 in NOT indicated. b. For adults 65 years' or older who have only received a PPSV23: Give 1 dose PCV15 or PCV20. i. The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination. ii. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. c. For adults 65 years' or older who have only received PCV13: Give PPSV23 as previously recommended. -For adults 19 to 64 years' old who have only received PPSV23: Give 1 dose of PCV15 or PCV20. a. The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination. b. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. -For adults 19 to 64 years' old who have received PCV13 with or without PPSV23: Give PPSV23 as previously recommended. -The resident's medical record shall include documentation that indicates at a minimum, the following: a. The resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization. b. The resident received the pneumococcal immunization or did not receive due to medical contraindication or refusal. III. Resident #10 Resident #10, age [AGE], was admitted on [DATE]. The medical record revealed the resident received the influenza vaccination outside of the facility and his pneumococcal vaccination was not up-to-date. -The facility did not have evidence of an offer or refusal of the pneumococcal vaccine. IV. Resident #69 Resident #69, age [AGE], was admitted on [DATE] and readmitted [DATE]. The medical record revealed the resident received the influenza vaccination at the facility and her pneumococcal vaccination was not up-to-date. -The facility did not have evidence of an offer or refusal of the pneumococcal vaccine. V. Interview The director of nursing (DON) was interviewed on 2/16/23 at 12:40 p.m. She said she could not find any evidence of an offer or refusal of the pneumococcal vaccine for Resident #10 and #69. She said it was important to keep up to date on vaccines for the health of the residents. She said she would review all the residents to ensure other residents would be offered vaccines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment for residents in 18 of 61 resident rooms in four hallways. Specifically, the facility failed to ensure walls, baseboard coves, halls, floors, doors, and floor tiles were repaired, painted and properly maintained. Findings include: I. Initial observations Observations of the resident living environment conducted on 2/15/23 at 10:57 a.m. revealed: room [ROOM NUMBER]: The sink was clogged with dark rust water. The wall in front of the commode had damaged sheetrock from the wheelchair hitting it. The tile around the commode had water stains and the caulking was black. The residents head board was leaning against the wall at the foot of the bed. The transition strip from the entrance door to the hall was missing. room [ROOM NUMBER]: The bathroom door had a large hole approximately four in circumference. room [ROOM NUMBER]: The corner next to the restroom had chipped and peeling sheetrock approximately 10 inches high by three inches wide. The metal strip was exposed. room [ROOM NUMBER]: The heater vent was falling off of the heater unit. room [ROOM NUMBER]: The heater vent was lying on the floor. room [ROOM NUMBER]: The ventilation fan in the restroom was not functioning. The wall next to room [ROOM NUMBER] had four dime sized holes from where the hand sanitizer used to be. room [ROOM NUMBER]: The sink had black caulking and rust colored stains around the lip of the sink. The bathroom was missing the transition strip. room [ROOM NUMBER]: The floors were yellowish in color and sticky. room [ROOM NUMBER]: The restroom did not have a functioning ventilation fan in the restroom. room [ROOM NUMBER]: The floors were yellowish in color and sticky. room [ROOM NUMBER]: The heater vent was lying on the floor. room [ROOM NUMBER]: The tile next to the door was missing a section approximately six inches long by four inches. room [ROOM NUMBER]: The caulking around the commode had black and rust colored stains. The floors were yellowish and sticky. The electrical box outside of room [ROOM NUMBER] was damaged from the wheel chairs hitting it. room [ROOM NUMBER]: The toilet paper holder was missing and the floor were yellowish in color and sticky. room [ROOM NUMBER]: The caulking around the commode had black and rust colored stains. The floors were yellowish in color and sticky. room [ROOM NUMBER]: The door threshold was missing from the entrance door to the hall. room [ROOM NUMBER]: The toilet paper holder was missing. The tile around the commode had a large hole approximately nine inches long by seven inches wide. The caulking around the commode had black and rust colored stains. The metal door frame had water and rust stains approximately six inches high by three inches wide. The entrance door had a chip approximately seven inches long by six inches wide. The baseboard cove next to the west nursing station had damage approximately five feet long. II. Environmental tour and staff interview The environmental tour was conducted with the maintenance supervisor (MS) on 2/16/23 at 10:15 a.m. The above detailed observations were reviewed. The MS documented the environmental concerns. The MS said the facility utilized a computer system to identify environmental issues. He said staff had not been utilizing the facility system correctly and would educate staff again on how to fill out requisition requests for repairs in the facility. The MS said he did not have any repair requisition requests for the above-mentioned items. The MS said the above-mentioned damage should have been repaired and addressed in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards in one of four medication carts and one of two medication storage rooms. Specifically, the facility: -Failed to discard an expired vial of tuberculin; -Failed to date two vials of Levemir insulin when opened; -Failed to date a vial of glargine insulin (Lantus) when opened; -Failed to discard an expired vial of Humalog insulin; -Failed to date a vial of Novolog when opened; -Failed to date an Incruse and Trelegy inhaler when opened; -Failed to date an Advair inhaler when opened; and, -Failed to discard loose pills in the medication cart. Findings include: I. Professional references According to the Incruse Ellipta inhaler website, retrieved [DATE] from: https://gskpro.com/content/dam/global/hcpportal/en_US/Prescribing_Information/Incruse_Ellipta/pdf/INCRUSE-ELLIPTA-PI-PIL-IFU.PDF, Safely throw away INCRUSE ELLIPTA in the trash 6 weeks after you open the tray or when the counter reads '0' whichever comes first. Write the date you open the tray on the label on the inhaler According to the Tubersol package insert, retrieved [DATE] from: https://www.fda.gov/media/74866/download, A vial of TUBERSOL which has been entered and in use for 30 days should be discarded. Prescribing information for Advair diskus, retrieved [DATE] from https://gskpro.com/content/dam/global/hcpportal/en_US/Prescribing_Information/Advair_Diskus/pdf/ADVAIR-DISKUS-PI-PIL-IFU.PDF ADVAIR DISKUS should be stored inside the unopened moisture-protective foil pouch and only removed from the pouch immediately before initial use. Discard ADVAIR DISKUS 1 month after opening the foil pouch or when the counter reads '0'. According to the Levemir website, retrieved [DATE] from https://www.fda.gov/media/74866/download, Throw away all opened Levemir vials after 42 days, even if they still have insulin left in them. According to the Novolog website, retrieved [DATE] from https://www.novo-pi.com/novolog.pdf, Throw away all opened NovoLog vials after 28 days, even if they still have insulin left in them. According to the Lantus website, retrieved [DATE] from https://products.sanofi.us/Lantus/Lantus.pdf, Store in-use (opened) LANTUS vials in a refrigerator from 36°F to 46°F (2°C to 8°C) or at room temperature below 86°F (30°C) for up to 28 days. According to the Humalog website, retrieved [DATE] from https://uspl.lilly.com/humalog/humalog.html#pi, In-use HUMALOG vials, cartridges, and HUMALOG prefilled pens should be stored at room temperature, below 86°F (30°C) and must be used within 28 days or be discarded, even if they still contain HUMALOG. Protect from direct heat and light. According to the Trelegy Ellipta inhaler website, retrieved [DATE] from: https://gskpro.com/content/dam/global/hcpportal/en_US/Prescribing_Information/Trelegy_Ellipta/pdf/TRELEGY-ELLIPTA-PI-PIL-IFU.PDF, Discard TRELEGY ELLIPTA 6 weeks after opening the foil tray or when the counter reads '0' (after all blisters have been used), whichever comes first. The inhaler is not reusable. Do not attempt to take the inhaler apart. II. Observation and interview On [DATE] at 10:00 a.m. the medication cart for the west hall contained: -Two opened vials of Levemir insulin without an open date. -One open vial of Novolog insulin without an open date. -An open vial of Humalog insulin dated [DATE]. -An open vial of glargine insulin (Lantus) without an open date. -An open inhaler of Advair without an open date. -An open inhaler of Incruse without an open date. -An open inhaler of Trelegy without an open date. -Two plastic pouches, one with a handwritten note of Rosuvastatin (cholesterol medication), and one handwritten Sertraline (depression medication). The medication storage room refrigerator on the west hall had an open tuberculin vial dated [DATE]. Licensed practical nurse (LPN) #1 was interviewed on [DATE] at 10:00 a.m. She said she had returned to work after being gone and was not aware the identified medications were not dated or expired. She said it was important to make sure the residents received safe and current medications. She said she would discard the identified medications and make sure to date the replaced medications. III. Interviews The director of nursing (DON) was interviewed on [DATE] at 10:52 a.m. She said it was important to date medication when opened to ensure efficacy and safety of the medication. She said the nurse administering the medication should verify if the medications were safe to give. She said the expired vial of tuberculin should have been discarded 30 days after opening. She said nursing staff would be provided more education going forward.

Based on interviews and record review, the facility failed to conduct testing in a manner that is consistent with current standards of practice for conducting COVID-19 tests for five (#44, #12, #69, #20 and #22) of five residents reviewed out of 29 sample residents. Specifically, the facility failed to document in the resident records the results of COVID-19 tests for Residents #44, #12, #69, #20 and #22. Findings include: I. Record review Five residents (#44, #12, #69, #20 and #22) were reviewed for COVID-19 testing results for the previous six months. The medical record/chart did not have the testing results. The facility did not have COVID-19 test results in the medical record for any of the residents residing in the facility. II. Staff interview The nursing home administrator (NHA) was interviewed on 2/15/23 at 10:00 a.m. She said the facility kept track of the testing results, however, they did not have the results in the resident's charts. She said none of the testing results had been included in any resident's medical record/chart. She said going forward the facility would enter the results into the resident's chart to be in compliance.

Based on observations, record review and staff interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in one kitchen. Specifically, the facility failed to ensure: -Appropriate hand hygiene by food service staff; and, -Cutting boards were free from deep scratches and stains. Findings include: I. Improper hand hygiene A. Professional references According to the Colorado Retail Food Establishment Rules and Regulations (effective 1/1/19) pg.46-47, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service items and: -Before handling or putting on single use gloves for working with food, and between removing soiled gloves and putting on clean gloves. Food employees shall clean their hands and exposed portions of their arms including surrogate prosthetic devices for hands or arms with soap and water for at least 20 seconds and shall use the following cleaning procedure: 1. Vigorous friction on the surfaces of the lathered fingers, fingertips, areas between the fingers, hands and arms for at least 15 seconds, followed by; 2. Thorough rinsing under clean, running warm water; and 3. Immediately follow the cleaning procedure with thorough drying of cleaned hands and arms with disposable or single use towels or a mechanical hand-drying device. B. Observations On 2/14/23 at 8:41 a.m., an unknown certified nurse aide (CNA) was observed making coffee. She grabbed the coffee filter basket. She placed it in the trash can and proceeded to dump the old coffee ground in the trash can hitting the side of the trash can to remove the coffee filter and old coffee grounds. She then replaced the new filter and poured coffee into the filter basket and proceeded to brew a new pot of coffee. Observation of meal service was conducted on 2/15/23 at 10:30 a.m. Dietary aide (DA) #1 was observed scratching his head while rolling clean eating utensils in napkins. DA #1 was wearing a thin coat and would constantly lift his sleeves during this task. DA #1 would scratch his head and pick up service wear and roll them in to clean napkins. DA #1 finished wrapping all of the service wear and placed them onto the serving area. He took a dirty tray and other used utensils to the dishwasher and proceeded to rinse them and place them into the dishwasher. He removed the clean dishes and wiped his hands on the side of his pants. He then proceeded to plate the crumb cake into small dishes for the afternoon meal. During this process, DA #1 continued to scratch his head/face and lift his pants. He filled the tray with the deserts and moved them to the serving area. He retrieved another tray and proceeded to tray the remainder of the desserts. He had some crumbs from the desserts on the counter and proceeded to brush the crumbs into his hand and threw the crumbs into the trash touching the outside of the trash can. DA #1 did not perform hand hygiene during this process. The cook (CK) was preparing the special lunch meals. The CK grabbed several handfuls of frozen French fries and dropped them into the fryer with his bare hands. He wiped his hands on the side of his pants and dropped the French fries basket into the grease. He proceeded to grab approximately five breaded chicken and placed them into the deep fryer with his bare hand. He was preparing to make a chef salad. He walked over to the deep fryer and removed the breaded chicken. He dumped the chicken onto a brown board to let them cool down. After the chicken cooled down, he proceeded to grab them with his bare hand and cut the chicken into small pieces. He scooped them into his bare hand and proceeded to place them onto the plate of salad. He wiped his hands on the side of his pants/apron. He placed the salad on top of the counter to allow it to be served to a resident. The CK did not perform hand hygiene during this process. The CK then proceeded to prepare special orders. He reached into the bread bag and removed several slices of bread. He completed making the special meals on the stove top. The CK did not perform hand hygiene during this process. DA #2 was making the garlic bread in the toaster. DA #2 was observed grabbing the bread with his bare hand and placing the slices into the toaster. DA #2 would remove the toast with his bare hand and place it on the counter. He proceeded to hold the bread with his bare hand and used a large brush to put on the melted butter. He would then place the toast onto a tray. DA #2 was observed picking up his pants and proceeded back to toasting the bread. DA #2 completed the task and placed the bread on the serving line. DA #2 did not perform hand hygiene during this process. DA #2 proceeded to start serving the meals. DA #2 would review the meal tickets and place the order on the plate. He was observed to be constantly picking up his pants during the meal service. DA #2 did not perform hand hygiene during this process. C. Staff Interview The dietary manager (DM) was interviewed on 2/15/23 at 2:00 p.m. He said all kitchen staff needed to wash their hands when their hands become contaminated. He said all staff must wash their hands before handling or serving food. He said staff should never touch ready to eat foods with their bare hands. He said they should use serving tongs. Staff should also wash their hands when they leave the kitchen and dining area. The DM said all dietary staff should wash heir hands between tasks to avoid cross contamination. II. Cutting Boards A. Professional reference According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (updated 1/1/19), page 132, and Cutting surfaces that are scratched and scored must be resurfaced so as to be easily cleaned, or be discarded when these surfaces can no longer be effectively cleaned and sanitized. B. Observation The initial kitchen tour conducted on 2/13/23 at 8:49 a.m. revealed seven large cutting boards. There were brown, red, blue, yellow, green and two white cutting boards; all cutting boards were heavily scored and stained. On 2/14/23 at 8:54 a.m., DA #2 was cutting toast on the green cutting board. On 2/15/23 at 10:40 a.m. during kitchen observations the CK was observed cutting chicken on the brown cutting board. C. Staff Interview The DM was interviewed on 2/15/23 at 2:00 p.m. The DM was told of the observations of the cutting boards in the kitchen. He confirmed the cutting boards were visibly stained and showed wear. He said he had just recently replaced the cutting boards and could not understand why they were so discolored and scored. He said the deep scratches could be a potential for bacteria to grow.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** II. Resident #11 A. Resident status Resident #11, age [AGE], was admitted on [DATE]. According to the November 2021 computerized physician orders (CPO), diagnoses included paranoid schizophrenia, unsteadiness on feet, and cognitive communication deficit. The 8/7/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview of mental status score of 14 out of 15. It indicated the resident was independent with transfers, locomotion on the unit, and dressing. It was not indicated the amount of bathing support needed and the task was marked as activity itself did not occur. It revealed the resident indicated having the choice of a shower, tub bath, or bed bath was somewhat important. The MDS assessment indicated the resident did not demonstrate behaviors related to rejecting care. B. Record review The activities of daily living (ADL) care plan, updated 10/12/19, indicated the resident required assistance with ADLs and had a preference for showers on Sunday and Wednesday evenings. From 8/1/21 to 10/31/21 the bathing record revealed the resident had received three showers out of 20 opportunities. Three refusals were noted on the bathing record. C. Interviews Certified nurse aide (CNA) #4 was interviewed on 11/3/21 at 9:15 a.m. She said Resident #11 had not been refusing showers as often as she was previously. She said if Resident #11 requested a shower on a day that was not her set shower day; the staff would try to accommodate it. Licensed practical nurse (LPN) #1 was interviewed on 11/3/21 at 9:30 a.m. She said Resident #11 refused showers. She said she could not find the information in the resident ' s care plan on what to do should the resident refuse. The MDS coordinator was interviewed on 11/3/21 at 9:57 a.m. She said if a resident refused a shower or bath the facility protocol was to redirect, ask the resident again later, and try a different staff member. She said this was not in Resident #11 ' s care plan. The interim director of nursing (IDON) was interviewed on 11/3/21 at 1:25 p.m. She said residents should have information in the care plan regarding refusing care and how to handle refusals. She said bed baths should be offered. She said Resident #11 was more comfortable with specific nurses and CNAs. She said those specific nurses try to offer showers or baths when they were available. Based on record review and interviews, the facility failed to honor resident choices for two (#65 and #11) of three reviewed for self-determination, out of 35 sample residents. Specifically, the facility failed to ensure Resident #65 and Resident #11 received showers consistently according to her choice and frequency. Findings include: I. Facility policy and procedure The Bathing policy, implemented November 2020, was provided by the nursing home administrator (NHA) on 11/3/21 at 1:45 p.m. It revealed in pertinent part, It is the practice of this facility to assist residents with bathing to maintain proper hygiene and help prevent skin issues. The Activities of Daily Living policy, implemented November 2020, was provided by the NHA on 11/4/21 at 1:30 p.m. It revealed in pertinent part, The facility will ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. This includes the residents ability to bathe, dress, and groom. -The facility was unable to provide a policy for resident choices/preferences when requested. II. Resident #65 status Resident #65, age below 70, was admitted on [DATE]. According to the November 2021 computerized physician orders (CPO), the diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease (COPD), kidney transplant, adult failure to thrive, and type II diabetes. The 10/11/21 minimum data set (MDS) assessment revealed, the resident was cognitively intact with a brief mental status score (BIMS) of 15 out of 15. She required physical help with bathing. It was very important for her to choose her bathing schedule and type. A. Resident interview Resident #65 was interviewed on 11/1/21 at 10:12 a.m. She said she told staff that she would like her showers on Sunday, Tuesday, and Thursday. She said staff told her those days were not available and she could only receive two showers a week. She said she did not always get her two showers a week and prefered three. B. Record review The ADL care plan, initiated 10/7/21, documented the resident was at risk for declining ADL function related to chronic respiratory failure, COPD, asthma, arthritis and failure to thrive. The interventions included bathing/showering. The resident was able to shower herself, but may need assistance with hair, back, and lower extremities. The 10/31/21 nurse progress note revealed the resident requested her shower since it was Sunday. The staff explained to the resident that her showers would now be provided on different days. The resident became very agitated and began to demand her shower be done at that time. It documented she did not understand why she could not get her showers on the same days she had previously had. The staff attempted to explain that after she was moved to a different unit her date and time slot had been assigned to another resident. The 11/1/21 nurse progress note revealed the resident was offered a shower since it was now her scheduled shower day. The resident became very upset and stated she wanted her showers on Sunday, Tuesday, and Thursday. It was explained by multiple staff that her preferred days were not available and that her shower was today. The resident refused to sign the shower sheet that documented the resident refused her shower. III. Staff interviews Certified nurse aide (CNA) #2 was interviewed on 11/4/21 at 8:59 a.m. She said residents have a choice when they want their showers. She said they can pick their day and time of choice. She said all residents have a choice when they want to go to bed, wake up, and when to shower. She said she was on light duty and was not giving showers at that time so she was not aware of Resident #65's shower preferences. CNA #1 was interviewed on 11/4/21 at 10:08 a.m. She said Resident #65 initially had Sunday, Tuesday, and Thursday as her shower days. She said the resident was then moved to a different unit and her shower days were changed. She then returned to the original unit. CNA #1 said she was not sure why Resident #65 could not have the same showers days she previously had. Registered nurse (RN) #1 was interviewed on 11/4/21 at 10:20 a.m. She said when a resident was admitted , they were asked how frequently they would like to be showered and which day and time they would prefer. She said they normally gave two showers a week but if the resident wanted it three times a week they would get it three times a week. The regional clinical consultant (RCC) was interviewed on 11/4/21 at 12:15 p.m. She said the residents can make their own choices about wake up and bedtimes as well as shower days, frequency, and times. She said residents should be able to take a shower whenever they want one. She said she would educate staff on resident rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for one (#18) of three residents reviewed for oxygen therapy out of 35 sample residents. Specifically, the facility failed to ensure oxygen was administered according to physician orders for Resident #18. Findings include: I. Professional reference According to [NAME]/[NAME], Fundamentals of Nursing, ninth edition, Elsevier, Canada, 2017, p 900, Oxygen is a therapeutic gas and must be prescribed and adjusted only with a health care provider's order. II. Facility policy The Oxygen Administration policy, no revision date, provided by the nursing home administrator (NHA) on 11/2/21 at 2:08 p.m. included: Verify that there is a physician's order for this procedure. Review the physician's orders of facility protocol for oxygen administration. III. Resident status A. Resident #18 Resident #18, age [AGE], was admitted on [DATE]. According to the November 2021 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), mitral insufficiency, and anemia. The 8/23/21 minimum data set (MDS) assessment revealed the resident had no impairment with a brief interview for mental status (BIMS) score of 15 out of 15. She had no behaviors or rejections of care. She was identified as using oxygen. IV. Record review The care plan, initiated 6/8/21 and revised 8/23/21, identified the resident utilized oxygen therapy related to COPD and chronic respiratory therapy. Interventions included: -Administer medications as ordered by a medical doctor (MD). -Oxygen via nasal cannula (N/C) as ordered by MD. -The care plan did not identify the resident adjusted the concentrator on her own. The November 2021 CPO included: -Oxygen at 2 liters per minute (LPM) via nasal cannula (NC) night (NOC). Ordered on 8/22/2020. -The order did not clarify if the oxygen was to be on only at night or to measure her oxygen saturation levels at night. V. Observations and interviews Resident #18 was observed in her room on 11/1/21 at 10:56 a.m. Her concentrator was set at 3 liters per minute (LPM). Certified nurse aide (CNA) #3 checked the concentrator, said it was set at 3 LPM, and her order was for 3 LPM. Resident #18 was observed in her room on 11/2/21 at 1:50 p.m. Her concentrator was set at 5 LPM. Registered nurse (RN) #2 checked the concentrator and said the concentrator was set at 5 LPM. She said the resident's order was for 2 LPM. She adjusted the concentrator, Resident #18 said she had turned up the concentrator because she felt like she needed more oxygen. RN #2 provided her education. RN #2 said it was important to follow the physician's orders with oxygen. She said with Resident #18 having COPD it was important not to have too high a liter flow as to prevent the rebound effect with too much oxygen having the opposite effect of a lower dose and preventing her from exhaling carbon dioxide. She said she would contact the provider. VI. Administrative interview The interim director of nursing (IDON) and the regional clinical consultant (RCC) were interviewed on 11/2/21 at 3:00 p.m. The RCC said the care plan should reflect if the resident was adjusting the oxygen on her own. She said the provider would be notified and alerted that the resident was utilizing oxygen when she felt she needed it and would get an order to reflect that. She said staff would provide education to the resident on the dangers of too much oxygen. She said with oxygen being a medication, the orders should have been followed. The IDON said she did not know the resident was adjusting her own oxygen and would talk to the provider.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to provide psychosocial support for one (#11) of three out of 35 sample residents. Specifically, the facility failed to: -Address and train staff on behaviors; and, -Develop a behavior plan to reduce behaviors related to incontinence for Resident #11. Findings include: I. Facility policy The Behavior Management Plan policy, dated November 2021, was provided by the nursing home administrator (NHA) on 11/4/21. It read, in pertinent part, Residents who exhibit behavior concerns may require a behavior management plan to ensure they are receiving appropriate services and interventions to meet their needs. Behaviors should be documented clearly and concisely by facility staff. Documentation should include specific behaviors, observation of what may be triggering behaviors, what interventions were utilized, and the outcomes of the interventions. II. Resident #11 A. Resident status Resident #11, age [AGE], was admitted on [DATE]. According to the November 2021 computerized physician orders (CPO), diagnoses included paranoid schizophrenia, anxiety, depression, and cognitive communication deficit. The 8/7/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview of mental status score of 14 out of 15. It indicated the resident was independent with activities of daily living (ADL). It indicated the resident had indicators of psychosis including hallucinations and delusions. The MDS assessment indicated the resident did not demonstrate behaviors related to rejecting care. B. Record review The November 2021 CPO indicated behavior monitoring every four hours related to bowel and bladder was initiated on 8/26/21. According to the treatment administration record (TAR), from 8/26/21 to 10/31/21, Resident #11 had 32 incidents related to incontinence with bowel and/or bladder as identified in behavior tracking. A behavior note was completed on 8/21/21. It indicated the resident was seen urinating in front of other residents in the courtyard. The resident then stood in the urine and she walked into the facility. The writer indicated this behavior happens multiple times per day. A behavior note was completed on 8/27/21. It indicated the resident was incontent of bowel and bladder in the facility courtyard. The writer indicated the resident wears a brief but will take it off in order to have bladder or bowel movement when in common areas. It indicated positive reinforcement has been trialed but is not consistently effective. The note indicated the resident was under the care of a psychiatrist. A nursing note was completed on 9/20/21. It indicated Resident #11 removed her brief and urinated on the floor in the hallway leading to the courtyard. The writer reminded the resident this was not acceptable. A nursing note was completed on 10/20/21. It indicated Resident #11 had a bowel movement while seated in a chair in the courtyard. She then walked through it and tracked it in the hallway. The writer indicated to continue to encourage the resident to engage in safe and sanitary toileting habits. A behavior note was completed on 11/2/21. It indicated the resident was observed in her room with urine on the floor. The writer assisted in changing the resident's brief and the resident began to urinate again. The writer assisted in changing the resident's brief again and encouraged the resident to notify staff when she needs to urinate. The care plan did not address behaviors related to incontinence, how to address the behaviors in a person centered manner, or to find the etiology of the behaviors. C. Staff interviews Certified nurse aide (CNA) #5 was interviewed on 11/3/21 at 9:00 a.m. She said Resident #11 has urinated on the floor while she has worked. She said she is unsure whether this was a behavior or incontinence episode. CNA #4 was interviewed on 11/3/21 at 9:15 a.m. She said Resident #11 has urinated on the floor while she has worked. She said the staff try to stop by her room every 15-20 minutes to check to see if she needs anything or to assist with the bathroom. She said she was unsure whether this was a behavior or incontinence episode. Licensed practical nurse (LPN) #1 was interviewed on 11/3/21 at 9:20 a.m. She said she is aware of the behaviors Resident #11 has related to episodes of bladder or bowel incontinence in public spaces. She said the current protocol is to document episodes every four hours. She said she had provided education to the resident on proper toileting. She said she was unsure if any specific training had been provided to staff regarding Resident #11's behaviors. The social services director (SSD) was interviewed on 11/3/21 at 10:30 a.m. She said she was aware of Resident #11 having episodes of incontinence out of her room. She said the social services department has implemented interventions previously. She said staff has tried to use positive reinforcement such as earning a hamburger for desired behaviors though this reinforcement did not reduce the behaviors. She said the staff have also placed a bedside commode in the room to encourage proper toileting. She said the best intervention for the resident has been to build trust and have patience. SSD said currently the protocol has been to encourage frequent toileting and if an episode of incontinence has occurred, the CNAs are alerted. She said there has not been any formal training to the staff on this protocol other than verbal. The interim director of nursing (IDON) was interviewed on 11/3/21 at 1:25 p.m. She said she was aware of Resident #11's behaviors related to incontinence. She said staff have attempted to identify the behavior prior to it occurring as part of an intervention. She said the behavior is being monitored and tracked by nursing. She said the resident would benefit from a placement in a facility that specializes in psychological care. She said social services has been involved in seeking other placements. D. Facility follow-up No further documentation was provided by the facility to indicate staff were trained for Resident 11's behaviors to support a positive outcome and promote the highest practicable physical, mental and psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure one (#28) of five residents reviewed for unnecessary medications of 35 sample residents was free from unnecessary drugs. Specifically, the facility: -Failed to have an as needed (PRN) antipsychotic reviewed every 14 days for appropriateness of the medication by the physician or prescribing practitioner; and, -Failed to have an individualized person centered care plan addressing non-pharmacological interventions for the use of an antipsychotic PRN. Findings include: I. Facility policy and procedure The Use Of Psychotropic Drugs policy, implemented November 2020, provided by the nursing home administrator (NHA) on 11/4/21 at 1:30 p.m., included: A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include, but are not limited to the following categories: antipsychotics . As needed (PRN) orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. 14 days). II. Resident status Resident #28, age [AGE], was admitted on [DATE]. According to the November 2021 computerized physician orders (CPO), diagnoses included senile degeneration of the brain, cerebral infarction (stroke), cognitive communication deficit, anxiety, and disorders of the uterus. The 9/10/21 minimum data set (MDS) assessment revealed the resident had mild impairment with a brief interview for mental status (BIMS) score of 11 out of 15. She had no behaviors or rejections of care. III. Record review The care plan, initiated on 6/7/2020, identified the use of psychotropic medications related to behavior management caused by multiple strokes. The intervention listed stated to administer psychotropic medications as ordered by the physician. Monitor for side effects and effectiveness every (Q) shift. The care plan, initiated 10/1/2020, identified the resident used anti-anxiety medications related to agitation and terminal restlessness. Interventions included: -Administer anti-anxiety medications as ordered by a physician. Monitor for side effects and effectiveness Q (every) shift. -Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms. -Monitor Resident #28 for safety. The resident is taking anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia and increases risk of falls, broken hips and legs. -Monitor/record occurrence of for target behavior symptoms pacing, elopement attempts, wandering, and document per facility protocol. -Monitor/document/report PRN any adverse reactions to anti-anxiety therapy: Drowsiness, lack of energy, clumsiness, slow reflexes, Slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. unexpected side effects: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. -The care plans failed to identify resident specific individualized non-pharmacological intervention to attempt prior to the administration of the PRN Haldol (antipsychotic medication). The November 2021 CPO included: -Haldol: Give 0.5 milliliter orally every eight hours for Anxiety, Restlessness, Behaviors and give 0.5 milliliter orally every four hours as needed for Anxiety, Restlessness, Behaviors. Start date 9/3/21. The September 2021 medication administration record (MAR) documented Resident #28 received two doses of the PRN Haldol. The electronic medical record (EMR) did not identify non-pharmacological interventions prior to the administration of the medication. The October 2021 MAR documented seven PRN Haldol doses administered. The EMR did not identify non-pharmacological interventions prior to the administration of the medication. The November 2021 MAR did not identify the use of the PRN Haldol. -The EMR did not have ongoing timely (14 day) physician or prescribing practitioner review for the use of PRN Haldol. IV. Interviews Licensed practical nurse (LPN) #1 was interviewed on 11/4/21 at 9:30 a.m. She said she had been informed of the resident displaying agitation and anxiety. She said since she had been hired full time (two weeks ago) she had not seen any displayed behaviors of anxiety or agitation. She said Resident #28 was easily redirected. She said she had not administered PRN Haldol during her employment at the facility. She said she did not know how long a PRN antipsychotic medication order was valid for. LPN #2 was interviewed on 11/4/21 at 9:39 a.m. She said Resident #28 was easy to de-escalate. She said she had not administered the PRN Haldol. She said if Resident #28 displayed any behaviors, she would document the behaviors in the MAR and a progress note. She said she did not know how often an order needed to be reviewed for a PRN antipsychotic. The regional clinical consultant (RCC) was interviewed on 11/4/21 at 9:50 a.m. She said the director of nursing was responsible for reviewing the medication lists. She said Haldol was an antipsychotic. She said she was not aware Resident #28 had a PRN Haldol order. She said all PRN antipsychotics needed to be reviewed every 14 days to evaluate the ongoing need for the PRN. She said she would contact the provider for an evaluation to determine if the PRN Haldol was needed.

Based on observations, interviews and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards, in two of four medication carts and one of two medication storage rooms. Specifically, the facility: -Failed to date insulins when opened; -Failed to identify whom an open vial of insulin belonged to; -Failed to discard expired nitroglycerin sublingual tablets; -Failed to date tuberculin when opened; and, -Failed to date an inhaler when opened. Findings include: I. Professional references According to the Tubersol package insert, retrieved 11/8/21 from: https://www.fda.gov/media/74866/download, A vial of TUBERSOL which has been entered and in use for 30 days should be discarded. Prescribing information for Incruse (11/8/21), Discard Incruse Ellipta 6 weeks after opening the foil tray or when the counter reads 0 (after all blisters have been used), whichever comes first. https://gskpro.com/content/dam/global/hcpportal/en_US/Prescribing_Information/Incruse_Ellipta/pdf/INCRUSE-ELLIPTA-PI-PIL-IFU.PDF Prescribing information for Trelegy (11/8/21). The Discard date is 6 weeks from the date you open the tray. https://gskpro.com/content/dam/global/hcpportal/en_US/Prescribing_Information/Trelegy_Ellipta/pdf/TRELEGY-ELLIPTA-PI-PIL-IFU.PDF Prescribing information for Levemir FlexTouch and Levemir multi-dose vial, retrieved 11/8/21 from: https://www.novo-pi.com/levemir.pdf, A single patient use Levemir FlexTouch of 3 (milliliter) ml which has been opened and in use is good for 42 days. A single patient multi-dose vail of 10 ml which has been opened and in use is good for 42 days. Prescribing information for Lantus, retrieved 11/8/21 from: https://products.sanofi.us/Lantus/Lantus.html#section-15, Lantus available in a multidose 10 ml vial and a prefilled 3 ml pen, is viable for 28 days after opening. Prescribing information for Humalog lispro insulin, retrieved 11/8/21 from https://uspl.lilly.com/humalog/humalog.html#ug, After vials have been opened: Throw away all opened vials after 28 days of use, even if there is insulin in the vial. Prescribing information for Novolog insulin, retrieved 11/8/21 from https://www.novo-pi.com/novolog.pdf, After the vail has been opened, throw away after 28 days, even if they still have insulin left in them. II. Observations and interviews On 11/3/21 at 2:45 p.m. an opened undated vial of tuberculin was in the west hall medication storage room. Licensed practical nurse (LPN) #1 said the vial should be dated when opened and discarded 30 days after opening. She said she would discard the vial. On 11/4/21 at 8:04 a.m. in the first medication cart on the west hall was found: -A vial of Levemir with no open date; -Another vial of Levemir that did not identify who it belonged to; -A Trelegy inhaler with no open date; and, -An expired vial of sublingual nitroglycerin tablets (2/2020 expiration date). LPN #1 said the medications should have been dated when opened. She said she did not want to administer ineffective expired medications. She said she would discard the nitroglycerin tablets right away. On 11/4/21 at 8:15 a.m. in the second medication cart on the west hall was found: -An Incruse inhaler with no open date; -Two open Lantus vials with no open date; -An open vial of Humalog Lispro vial with no open date; -An open vial of Lantus with an open date of 9/8/21; -An open vial of Humalog with no open date; -An open vial of Novolog with no open date;and, -An open vial of Levemir with no open date. LPN #2 said all medications that have a limited viability should have an identified open date to ensure the efficacy of the medication. III. Interview On 11/4/21 at 9:50 a.m. the regional clinical consultant (RCC) was interviewed. She said medications with a limited shelf life should be dated when opened to ensure the efficacy of the medication. She said the identified medications would be discarded.