**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for two (#2 and #1) of three residents reviewed for bathing out of three sample residents. Specifically, the facility failed to ensure Resident #2 and Resident #1, who were dependent on staff for bathing, received their scheduled showers. Findings include: I. Facility policy and procedure The Bathing/Shower policy, revised February 2018, was provided by the regional clinical resource (RCR) on 1/21/25 at 4:24 p.m. It read in pertinent part, The purpose of this procedure is to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. The documentation includes the date and time the shower/bath was performed, the name and title of the individual who assisted the resident with the shower, all the assessment data obtained during the shower, how the resident tolerated the shower, if the resident refused the shower, the reason why, the intervention taken and report the refusal to the supervisor. The Activity of Daily Living policy, revised March 2018, was provided by the RCR on 1/21/25 at 4:20 p.m. It read in pertinent part, Residents who are unable to carry out activities of daily living (ADL) independently will receive the services necessary to maintain good nutrition, grooming, personal hygiene and oral hygiene. Care and services will be provided for the following activities: -Bathing, dressing, grooming and oral care; -Transfer and ambulation; -Toileting; -Dining to include meals and snacks; and -Using speech, language or other functional communication systems. II. Resident #2 A. Resident status Resident #2, age greater than 65, was admitted on [DATE]. According to the January 2025 CPO, diagnoses included end stage renal failure, dependence on dialysis, cognitive communication deficit, limitations of activities due to disability, sacral pressure injury and depression. The 12/30/24 MDS assessment revealed she had modified independence with cognitive skills for daily decision making. She used a wheelchair and was dependent on staff for bathing. B. Resident interview and observation Resident #2 was interviewed on 1/21/25 at 3:32 p.m. She said she was not receiving two showers weekly as scheduled. She was lying in bed in a hospital gown with her hair disheveled. C. Record review The ADL care plan, revised on 10/12/23, revealed Resident #69 had an ADL self-care performance deficit related to impaired mobility and end stage renal disease. Interventions included providing two staff members with extensive assistance for transfers and ADL care. -Review of the comprehensive care plan did not reveal documentation indicating the resident's shower preferences. Review of the October 2024 through January 2025 shower logs revealed the following: The October 2024 (10/1/24 to 10/31/24) shower documentation revealed Resident #2 was provided bathing on two out of nine opportunities. The November 2024 (11/1/24 to 11/31/24) shower documentation revealed Resident #2 was provided bathing on two out of eight opportunities. The December 2024 (12/1/24 to 12/31/24) shower documentation revealed Resident #2 was provided bathing on seven out of nine opportunities. III. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE] and discharged on 12/16/24. According to the January 2025 computerized physician orders (CPO), diagnoses included complete rotator cuff tear of the right shoulder, dependence on a wheelchair, pressure ulcer to the right buttocks, pressure induced deep tissue damage of the left heel and acute respiratory failure. The 11/19/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. He had impairment to one side of his upper and lower extremities. He used a wheelchair and was dependent on staff for bathing. B. Record review The ADL care plan, revised 12/30/24, revealed Resident #1 had an ADL self-care performance deficit related to recent hospital stay for urinary tract infection and right shoulder pain which was found to be caused by complete tearing of three rotator cuff muscles. Interventions included providing two staff maximal assistance with bathing. -Review of the comprehensive care plan did not reveal documentation that indicated the resident's shower preferences. Review of the October 2024 through January 2025 shower logs revealed the following: The October 2024 (10/1/24 to 10/31/24) shower documentation revealed Resident #1 was provided bathing zero out of four opportunities. The November 2024 (11/1/24 to 11/30/24) shower documentation revealed Resident #1 was provided bathing on one out of nine opportunities. The December 2024 (12/1/24 to 12/31/24) shower documentation revealed Resident #1 was provided bathing on one out of five opportunities. III. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 1/21/25 at 3:38 p.m. CNA #1 said the shower aide was responsible for giving the residents their showers. CNA #2 was interviewed on 1/21/25 at 3:50 p.m. CNA #2 said she was the shower aide and was responsible for giving the residents their showers. She said all of the showers were documented on a shower sheet including bed baths and refusals. She said if the resident did not have a shower sheet completed, the shower was not given. She said when the floor staff was short staffed, she was pulled to work the floor and the showers did not get done. She said she was pulled to work the floors a lot of times. Licensed practical nurse (LPN) #1 was interviewed on 1/21/25 at 3:53 p.m. LPN #1 said the shower aide was responsible for completing the residents showers. She said all showers should be documented on a shower sheet indicating g if the shower was completed or refused. She said the CNA would turn in the shower sheet for the nurse to sign. The director of nursing (DON) was interviewed on 1/21/25 at 3:57 p.m. The DON said she had only been employed at the facility for two days. She said the facility had staffing challenges and the shower aide was often pulled to work the floor. She said the CNA assigned to the resident with a scheduled shower was responsible for giving the shower if the shower aide was unavailable. She said she was not aware how many shower aides were scheduled daily. She said she did not like using shower sheets because they could get lost. She said the showers should be documented in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide written notification of room changes and roommate changes for two (#72 and #14) of four residents reviewed for notifications out of 47 sample residents. Specifically, the facility failed to provide timely written and/or verbal notification of room and/or roommate changes to Resident #72 and Resident #14 and/or their representatives. Findings include: I. Facility policy and procedure The Room Change and Room Change Notices policy, dated 11/4/23, was provided by quality mentor (QM) #1 on 3/21/24 at approximately 2:00 p.m. The policy read in pertinent part To ensure that residents are afforded their right to prior notification of room or roommate changes and the right to appeal these changes. Residents will be notified in advance of room or roommate changes and of their right to appeal these changes. The SSD/RSD (social service director/ resident service director) or designee will meet with the resident to explain the purpose of the room/roommate change and to provide an opportunity for the resident to express any concerns and ask questions as a result of the change(s). The resident/legal representative will be asked to review and sign the five days notice of the room change, prior to the change occurring. The resident will be advised of the right to waive the notice and/or to appeal the change within those five days. II. Resident #72 A. Resident status Resident #72, age [AGE], was admitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included Parkinson's disease and hypertension. The 3/11/24 minimum data set (MDS) assessment showed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. The resident was dependent on staff for activities of daily living. B. Resident interview Resident #72 was interviewed on 3/21/24 at 10:50 p.m. Resident #72 said he received a new roommate a few weeks ago. He said he was not provided anything in writing or provided any verbal notice before he got his new roommate. C. Record review -Review of Residents #72's electronic medical record (EMR) revealed no documentation to indicate the resident was informed he would be getting a new roommate. III. Resident #14 Resident #14, age [AGE], was admitted on [DATE]. According to the March CPO, diagnoses included type II diabetes mellitus, chronic obstructive pulmonary disease and end stage kidney disease. The 2/20/24 minimum data set (MDS) assessment showed the resident had moderate cognitive impairment with a BIMS score of seven out of 1. The resident was dependent on staff for activities of daily living. B. Resident interview Resident #14 was interviewed on 3/19/23 at 3:39 p.m. Resident #14 said she did not like her roommate because she talked too much. She said she was not asked or told anything by the facility when the roommate moved in. She said she was at dialysis and when she returned to her room, the new roommate had moved in. Resident #14 was not informed and was not provided anything in writing regarding getting a new roommate. C. Record review -Review of Residents #14's EMR revealed no documentation to indicate the resident was informed she would be getting a new roommate. III. Interview The social services director (SSD) was interviewed on 3/21/24 at 12:25 p.m. The SSD said a room change authorization form should be filled out for each resident room change or when a resident got a new roommate. He said the form included a five day notice of the change. He said residents were informed verbally of any new roommate. He said the licensed nurses on the floor were responsible for completing room change forms when a new resident was admitted . The SSD said that there were no written room change or new roommate authorization forms completed for either Resident #72 or Resident #14. Registered nurse (RN) #8 was interviewed on 3/21/24 at 2:20 p.m. RN #8 said room change or room mate change forms were not her responsibility and she did not complete any forms. She said the social services department was responsible for completing the forms and informing residents of new roommates

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure one (#29) of two residents reviewed for abuse out of 47 sample residents was kept free from abuse. Specifically, the facility failed to ensure Resident #29 was kept free from physical abuse by Resident #27. Findings include: I. Facility policy and procedure The Abuse policy, revised 5/3/23, was provided by the nursing home administrator (NHA) on 3/17/24 at 5:13 p.m. It read in pertinent part: -Communities does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers, and staff of other agencies serving the resident, family members, legal guardians, resident representative, sponsors, friends, or any other individuals. -Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff of other agencies serving the residents, family members or legal guardians, friends, or other individuals. -Resident abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment of a resident resulting in physical harm or pain, mental anguish, deprivation of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being. Willful - means the individual must have acted deliberately, not that he/she must have intended to inflict injury or harm. -Each facility assesses each potential resident prior to admission. This assessment includes a behavior history. Persons with a significant history or high risk of violent behavior are carefully screened and assessed for appropriateness of admission. II. Incident of physical abuse by Resident #27 toward Resident #29 The investigation was provided by the quality mentor (QM) #1 on 3/19/24 at 12:10 p.m. The investigation, dated 3/14/24, documented Resident #29 reported Resident #27 struck her with a closed fist in the right shoulder/back of the head area after Bingo. Resident #29 reported Resident #27 was upset that other residents were winning at Bingo. The residents were separated and frequent checks were initiated. Assessments were performed with no evidence of injury per report. According to the abuse investigation report, current status of the victim: Resident #29 returned to baseline shortly after the incident. The resident was tearful in the dining room but did not wish to eat lunch elsewhere and stated she was okay if the alleged assailant was seen/came down to the dining room for lunch. The investigation revealed staff and resident witnesses who confirmed Resident #27 made contact and hit Resident #29. The investigation included an interview with Resident #27 who indicated she did not remember what happened. The facility substantiated the physical abuse. III. Resident #27 A. Resident status Resident #27, age under 65, was admitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included leukemia (cancer), diabetes, depression and cognitive communication deficit. The 2/22/24 minimum data set (MDS) assessment revealed the resident had a moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. She was independent with hygiene, dressing and transferring herself. Resident #27 exhibited behavioral symptoms not directed toward others one to three days in the past seven days (examples of physical symptoms such as hitting or scratching self, pacing, rummaging, verbal/vocal symptoms like screaming). B. Record review The delusions/paranoia behavior care plan, revised 3/5/24, documented Resident #27 had a history of confusion and agitation with aggressive behaviors. The interventions included medications per order and pain assessment every shift when agitated, ascertaining causes of symptoms, conducting interventions matching causes of symptoms including resident habits, preferences, current ability and notifying the physician of behaviors. On 3/15/24 at 7:53 a.m., provider documentation included the following progress note: Per staff report and documentation, the patient has been having increasing behaviors over the last several weeks, especially in the evenings, including verbal aggression toward staff and other residents, paranoid delusions with racial fixation and even struck another resident. IV. Resident #29 A. Resident status Resident #29, age [AGE], was admitted on [DATE]. According to the March 2024 CPO, diagnoses included diabetes, hemiplegia (paralysis on one side), respiratory failure and chronic kidney disease. The 1/26/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The MDS assessment revealed the resident had not exhibited any behavioral symptoms. B. Resident interview Resident #29 was interviewed on 3/18/24 at 3:00 p.m. Resident #29 said she was hit by Resident #27 four days earlier (3/14/24). She said Resident #27 hit her on the right side of her shoulder with her fist. She said it hurt when it happened but felt better after. Resident #29 said Resident #27 was mad that other residents won at Bingo. She said Resident #27 got mad at Resident #29 for saying it was a game. Resident #29 said there were witnesses to the incident. Resident #29 said the social service director (SSD) told her the police were going to come talk to her and they had not done so yet. She said she wanted to press charges. Resident #29 said the SSD said he would be back the next day to meet about what happened but he had not returned to see her. Resident #29 was interviewed again on 3/21/24 at 9:05 a.m. She said she had not had further issues with Resident #27. She said the facility had moved Resident #27 to a different table (apart from Resident #29) and staff supervision was provided. She said she felt safe and was not fearful. C. Record review Resident #29 had a behavioral care plan, revised 12/8/23, which addressed her potential to make false allegations and display misperception of reality. Interventions included anticipating needs, reassurance staff were there to assist, provide opportunity for positive interaction, stopping to talk with Resident #29 when walking by and monitoring behavior episodes to determine underlying cause. A nursing progress note on 3/13/24 at 11:00 a.m. documented in pertinent part: Resident (#29) reported to nurse that resident (#27) hit me in the right arm. Skin warm, dry and intact. Skin color within normal limits for the resident, denies pain/discomfort. Provider notified. A nursing skin assessment on 3/14/24 at 8:48 p.m. documented in pertinent part: Skin intact, no new skin conditions noted. Continuing on every 15 minute checks related to altercation with another resident. V. Staff interviews Registered nurse (RN) #5 was interviewed on 3/20/24 at 3:56 p.m. RN #5 said Resident #29 told her she was punched by another resident at Bingo a few days ago. She said Resident #29 did not indicate any further concerns. RN #4 was interviewed on 3/21/24 at 9:19 a.m. RN #4 said he was aware Resident #29 was hit by another resident. He said Resident #29 did not seem fearful and she had not indicated she was in pain. The SSD was interviewed on 3/21/24 at 10:23 a.m. The SSD said he was in the dining room when a nurse told him Resident #27 had hit Resident #29. He said the activities assistant separated the residents with assistance from the activity director. The SSD said he asked Resident #29 if she felt safe and she responded that she was okay. The SSD said he told Resident #29 the police might come to talk with her. The SSD said he contacted Resident #29's representative and provided the police case number. The SSD said the resident did not tell him she wanted to press charges against Resident #27. The SSD said he had not yet spoken with Resident #29 about the results of the investigation conducted by the facility. The NHA was interviewed on 3/21/24 at 1:55 p.m. The NHA said she was not aware Resident #29 wanted to press charges against Resident #27 until 3/21/24. The NHA said she spoke with the investigating officer who had spoken with Resident #29 on 3/21/24, during the survey. The NHA said according to witnesses, Resident #27 hit Resident #29 with a closed fist and the physical contact was substantiated. The NHA said Resident #29 had not indicated that she was fearful of Resident #27. The NHA said the facility had put interventions in place to prevent physical altercation from Resident #27 during Bingo. The NHA was interviewed again on 3/21/24 at 2:35 p.m. The NHA said the facility was going to utilize a sitter for Resident #27 until a plan was in place to prevent further abuse. Resident #23 was interviewed on 3/21/24 at 6:15 p.m. She said she was sitting next to Resident #29 when the incident occurred. She said the residents had just finished playing Bingo when Resident #27 became angry. Resident #23 said Resident #27 was sitting at a table behind Resident #29. She said Resident #27 turned toward Resident #29 and hit her. Resident #23 did not remember the location of impact or if Resident #27's fist was closed when she hit Resident #29. Resident #23 said she was not fearful of Resident #27.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide assistance with activities of daily living (ADL) for two (#17 and #19) of two residents reviewed for ADLs out of 47 sample residents. Specifically, the facility failed to ensure Resident #17 and #19 received showers as scheduled. Findings include: I. Facility policy and procedure The Bathing policy was provided by quality mentor (QM) #1 on 3/21/24 at 2:19 p.m. It read in pertinent part: The facility will try to bathe residents in their preferred way at their preferred times. II. Resident #17 A. Resident status Resident #17, age [AGE], was admitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included chronic kidney disease, hemiplegia (one sided paralysis), diabetes and neuromuscular dysfunction of the bladder. The 2/14/24 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. He was independent with eating and oral hygiene, dependent for toileting hygiene and required substantial assistance with dressing. The assessment documented tub and shower transfers were not attempted during the seven day MDS assessment look back period due to the resident's medical condition. The 11/14/23 MDS assessment revealed Resident #17 found it was very important to choose between tub bath, shower and bed bath. B. Resident interview and observation Resident #17 was interviewed on 3/18/24 at 11:45 a.m. Resident #17's hair appeared disheveled. Resident #17 said he had missed showers approximately once per week during the past month because the facility did not have someone available to assist him. He said he enjoyed his showers and feeling clean afterward. He said the staff did not notify him when they were unable to offer a shower on his scheduled shower dates. C. Record review Resident #17's care plan, revised 12/6/23, revealed his bathing preference was three times per week. He required extensive assistance of one staff member for transfer between surfaces for bathing. The facility Bath and Skin Report for 1/23/24 through 3/19/24 was provided by QM #1 on 3/20/24 at 5:00 p.m. It revealed the following shower documentation for Resident #17: During a four week period from 1/23/24 to 2/20/24, the resident received showers on 1/23/24, 1/28/24, 2/1/24, 2/6/24, 2/8/24, 2/11/24, 2/13/24, 2/15/24, 2/18/24 and 2/20/24. Resident #17 refused to shower on 2/4/24. -There were 12 scheduled opportunities for showers during this period and Resident #17 received 10 showers (and refused one shower). During a four week period from 2/21/24 to 3/19/24, the resident received showers on 2/22/24, 2/27/24, 2/29/24, 3/5/24, 3/7/24, 3/12/24, 3/17/24 and 3/19/24. Resident #17 refused to shower on 2/25/24. -There were 12 scheduled opportunities for showers during this period and Resident #17 received eight showers. A shower log note documented on 2/25/24 revealed Resident #17 refused his shower on 2/25/24 but requested the shower be given on 2/26/24. -There was no documentation that the resident received a shower on 2/26/24. D. Staff Interviews Licensed practical nurse (LPN) #5, who was the unit manager, was interviewed on 3/20/24 at 2:09 p.m. LPN #5 said she expected Resident #17 to receive at least 12 showers over four weeks based upon his preference of three showers per week. She said Resident #17 should have received three additional showers over the past four weeks. Registered nurse (RN) #5 was interviewed on 3/20/24 at 3:53 p.m. RN #5 said Resident #17 had not told her he was not showering enough, however, she said he told her when he received his showers because the resident said he liked his showers. RN #4 was interviewed on 3/21/24 at 9:15 a.m. RN #4 said Resident #17 told him one week ago he was not getting his showers as scheduled. III. Resident #19 A. Resident status Resident #19, age [AGE], was admitted on [DATE]. According to the March 2024 CPO,diagnoses included kidney disease, heart disease, diabetes and depression. The 1/2/24 MDS assessment revealed Resident #19 was cognitively intact with a BIMS score of 15 out of 15. Resident #19 was independent with eating, hygiene and transferring self from bed to wheelchair. The assessment revealed it was very important for Resident #19 to choose between tub bath, shower and bed bath. B. Resident interview Resident #19 was interviewed on 3/18/24 at 2:00 p.m. Resident #19 said the facility was understaffed and often reassigned the certified nurses aide (CNA) who was assigned to shower duty which caused residents to miss showers. Resident #19 said if a shower day was missed the residents often had to wait until the next scheduled shower day. She said there were at least two days per month she was not getting showers as planned. C. Record review Resident #19's care plan, revised 12/8/23, revealed her bathing preference was two times per week and she required set-up assistance with bathing. The facility Bath and Skin Report for the 1/23/24 through 3/19/24 was provided by QM #1 on 3/20/24 at 5:00 p.m. It revealed the following shower documentation for Resident #19: During a four week period from 1/23/24 to 2/20/24, the resident received at least two showers per week. During a four week period from 2/21/24 to 3/19/24, the resident received showers on 2/25/24, 2/28/24, 3/6/24, 3/13/24, 3/17/24 and 3/20/24. -There were eight scheduled opportunities for showers during this period and Resident #19 received six showers. There were no documented refusals during this period. D. Staff interviews CNA #1 was interviewed on 3/20/24 at 2:02 p.m. CNA #1 said the facility sometimes would pull the shower aide off bath duties to the floor due to staffing. CNA #1 said when the shower aide was pulled to the floor residents would not receive a shower on their scheduled day or the next day if she was not working. LPN #5 was interviewed on 3/20/24 at 2:09 p.m. LPN #5 said she expected Resident #19 to receive at least eight showers in four weeks based upon her preference of two showers per week. She said Resident #19 should have received two additional showers over the past four weeks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews the facility failed to ensure residents with limited range of motion (ROM) received the appropriate treatment and services to maintain or prevent a further decrease in their ROM for one (#36) of one resident reviewed for limited ROM out of 47 sample residents. Specifically, the facility failed to ensure Resident #36 was provided with restorative services to maintain or prevent worsening of her right hand contracture (a permanent tightening of the muscles, tendons, skin and nearby tissues that causes the joints to shorten and become very stiff). Findings include: I. Facility policy and procedures The Restorative Nursing Services policy, revised March 2018, was provided by quality mentor (QM) #1 on 3/21/24 at 2:19 p.m. It read in pertinent part, Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (physical, occupational or speech therapies). Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care. Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care. The resident or representative will be included in determining goals and the plan of care. Restorative goals may include, but are not limited to supporting and assisting the resident in: adjusting or adapting to changing abilities; developing, maintaining or strengthening his/her physiological and psychological resources; maintaining his/her dignity, independence and self-esteem; and participating in the development and implementation of his/her plan of care. II. Resident #36 A. Resident status Resident #36, age under 65, was admitted on [DATE] and readmitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included Cerebral palsy, limitation of activities due to disability, history of traumatic fracture and contracture. The 12/11/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. According to the assessment, the resident did not exhibit behaviors or refuse care. The resident was totally dependent on staff for toileting, dressing and bed mobility. She required maximum assistance for personal hygiene. She required supervision for oral hygiene and was independant with eating. The assessment documented the resident did not receive any therapy services during the seven-day review period. B. Resident interview and observations On 3/17/24 at 5:24 p.m. Resident #36 was seated at the dining room table and eating with her left hand. She had a right arm/wrist/hand contracture. -She did not have any splint in place on her right hand to help prevent her contracture from worsening. On 3/18/24 at 2:08 p.m., the resident was seated in a chair next to the nurses station. She had a right arm/wrist/hand contracture. -She did not have any splint in place on her right hand to help prevent her contracture from worsening. On 3/19/24 at 3:04 p.m., Resident #36 was seated in a chair next to the nurses station. She had a right arm/wrist/hand contracture. She was holding a coloring book with her left hand. -She did not have any splint in place on her right hand to help prevent her contracture from worsening. On 3/20/24 at 10:14 a.m., the resident was seated in a chair next to the nurses station. She had a right arm/wrist/hand contracture. -She did not have any splint in place on her right hand to help prevent her contracture from worsening C. Record review An activities of daily living (ADL) care plan, initiated 10/22/22 and revised 7/5/23, revealed Resident #36 had ADL deficits related to cerebral palsy, right ankle fracture and right arm contracture. Pertinent interventions included the resident required the use of a wheelchair for mobility, staff were to assist the resident with eating and the resident required extensive assistance by one staff member for bed mobility and transfers. -The care plan failed to have any interventions related Resident #36's right hand contracture. A limited physical mobility care plan, initiated 10/22/22 and revised 7/5/23, revealed Resident #36 had limited physical ability related to cerebral palsy, right ankle fracture and right arm contracture. Pertinent interventions included the resident required assistance by one staff to move between surfaces, staff were to provide supportive care and assistance with mobility as needed, physical therapy (PT) and occupational therapy (OT) referrals as needed, and restorative nursing staff was to provide an active range of motion program to include exercises of the resident's choice to the upper and lower extremities as tolerated. -On 3/20/24, during the survey, an additional intervention was added to Resident #36's limited mobility care plan. The new intervention documented restorative nursing would provide passive range of motion to the right upper extremity by providing the resident with gentle stretch extension to the right elbow/shoulder/wrist. The staff were to provide gentle extension as tolerated. The staff were to provide extension with gentle pressure for a 10 to 15 second count as tolerated, monitor facial grimace and provide three to five repetitions per joint as tolerated for contracture prevention. An alteration of musculoskeletal status care plan, initiated on 11/1/22, revealed Resident #36 had altered musculoskeletal status related to cerebral palsy, right ankle fracture and right arm contracture. The relevant interventions were for the staff to anticipate and meet needs and ensure the resident's call light was within reach and response was prompt for all calls for assistance. A therapy progress note, documented by physical therapy on 10/29/23 at 4:28 p.m., revealed the resident was screened for therapy services to address contracture management. The resident was not interested in contracture management focused therapy. Resident #36 had several comorbidities impacting the resident's ability to tolerate interventions. Nursing also reported no known changes in contracture status. No skilled therapy services to address contracture management were recommended. A restorative progress note written on 3/20/24 at 5:14 p.m., during the survey, documented the resident was to begin a restorative passive range of motion (PROM) program to the right upper extremity for contracture prevention. The goal was to increase/maintain ROM to assist the resident to maintain/increase her ADLs. III. Staff interviews Licenced practical nurse (LPN) #4, who was also in charge of the facility's restorative nursing program, was interviewed on 3/20/24 at 3:32 p.m. LPN #4 said Resident #36 was not currently on a restorative nursing ROM or splinting program. He said he trained a few certified nursing aides (CNA) to help perform passive range of motion for residents enrolled in the restorative program. He said only the CNAs trained by him were permitted to document PROM in residents' electronic medical records (EMR). Registered nurse (RN) #4 was interviewed on 3/21/24 at 1:24 p.m. RN #4 said any resident with a contracture was supposed to be managed by restorative nursing in addition to having evaluations with PT/OT if the resident was eligible for therapy services. He said splints were not used for every resident with contractures but it was a common practice to help prevent worsening contractures. RN #4 said Resident #36 did have a diagnosis of a contracture but was not enrolled in the restorative program for the contracture specifically, but because of her posture. He said he would have Resident #36 evaluated for her right hand contracture as soon as possible. V. Facility follow up On 3/25/24 at 12:56 p.m., after the survey exit, an occupational therapy evaluation, completed on 3/22/24 was provided by the NHA via email. The evaluation identified new goals for Resident #36 to include that the resident would increase active range of motion (AROM) in her right elbow/forearm extension in order to facilitate optimal pain-free performance during ADLs for short term and would participate in the right upper extremity PROM to decrease risk of further musculoskeletal deficits. -The occupational therapy evaluation was not completed until after the survey exit on 3/21/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one (#54) of one resident out of 47 sample residents. Specifically, the facility failed to ensure trauma assessments were conducted to determine the residents history of post-traumatic stress disorder (PTSD) and/or trauma, identify triggers and develop person centered interventions within the comprehensive care plan for Resident #54. Findings include: I. Facility policy The Trauma Informed Care policy and procedure, revised August 2022, was provided by quality mentor (QM) #1 on 3/21/24 at 2:19 p.m. It read in pertinent part, Resident Assessment: Assessment involves an in-depth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identification of triggers.Utilize licensed and trained clinicians who have been designated by the facility to conduct trauma assessments. Use assessment tools that are facility-approved and specific to the resident population. Resident Care Planning: Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate. Identify and decrease exposure to triggers that may re-traumatize the resident. Recognize the relationship between past trauma and current health concerns (e.g., substance abuse, eating disorders, anxiety and depression). Develop individualized care plans that incorporate language needs, culture, cultural preferences, norms and values. For example: food preparation and choices; clothing preferences such as covering hair or exposed skin; physical contact or provision of care by a person of the opposite sex; or cultural etiquette, such as avoiding eye contact or not raising the voice. II. Resident #54 A. Resident status Resident #54, age [AGE], was admitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included respiratory disease, limitations of activity due to disability, insomnia and PTSD. The 1/30/24 minimum data set (MDS) assessment revealed the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. He required extensive assistance of two staff members with transfers, dressing, toilet use and personal hygiene. He displayed no behavioral symptoms. B. Record review A Resident Trauma interview, dated 3/21/24 at 2:08 p.m. (during the survey) revealed Resident #54 had a history of PTSD due to exposure to active duty combat while serving in the Vietnam War. He experienced the following symptoms related to his trauma: nightmares, flashbacks, intrusive images, sleep disturbance and irritation. He was not using any methods to cope with his trauma but said he wouldn't mind talking to someone about his experiences because talking about it helps take the trauma away. The interview revealed the residents were a good fit for a trauma informed care plan. The interview determined the follow parameters for a care plan for resident #54. The trauma related care plan, initiated 3/21/24 (during the survey), revealed Resident #54 had a past history of trauma related to active duty combat in Vietnam. He had a history of trauma that resulted in difficulty connecting and trusting others. Behaviors the resident might exhibit included being resistive to care and poor interpersonal interactions. The resident would communicate needs and preferences to staff in order to help accept recommended care and would verbalize feelings and identify ways staff could support feelings of safety. Interventions recommended included involving family and other supports in resident care whenever possible to maintain/develop connections and personal interests as well as providing consistent care providers whenever possible. -The social services director (SSD) who completed the interview, did not select interventions related to limiting triggering stimulus, assessment for further therapeutic services/specialists and interventions directing staff to approach directly and speak to the resident in a calm manner. -Review of Resident #54's electronic medical record (EMR) did not reveal documentation to indicate the facility had conducted a screening assessment specific to trauma or initiated a care plan related to the resident's PTSD to include personalized triggers, person-centered individualized interventions or personalized signs and symptoms of retraumatization completed when the resident admitted to the facility on [DATE]. C. Staff interviews Registered nurse (RN) #4 was interviewed on 03/21/24 at 1:24 p.m. RN #4 said the facility did not do any training based on trauma informed care. He said the facility did not provide any training for residents with mental health diagnoses. He said being trained to better understand residents with PTSD, to include what things could trigger them, would greatly increase the quality of care he provided to the residents. The SSD was interviewed on 3/21/24 at 12:12 p.m. The SSD said the facility did not generate care plans for residents with a PTSD diagnosis. He said the facility was aware of common PTSD triggers to look out for to include loud noises and bright lights so there was no reason to know individual resident triggers. He said he was aware of Resident #54's PTSD diagnosis but did not know any history or triggers associated with the resident specifically because the facility had not completed any assessments or interviews to determine any individualized care the resident would need. The SSD said to accurately care for the residents that had PTSD diagnoses, the facility should have created care plans specific to each resident's trauma and triggers. He said not knowing a resident's triggers or being knowledgeable about every resident's individualized trauma and needs could put the resident or other residents and staff in danger. The SSD said without proper psychosocial care training the staff could misinterpret the residents' behaviors and responses to certain things and do more harm than good when caring for the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure residents received food prepared in a form designed to meet their needs for two (#15 and #39) of four residents reviewed for therapeutic diets out of 47 sample residents. Specifically, the facility failed to provide meals prepared according to the prescribed food orders for Resident #15 and Resident #39. Findings include: I. Facility policy and procedure The Menus and Nutrition Adequacy policy, revised January 2024, was received from quality mentor (QM) #1 on 3/21/24 at 2:19 p.m. It read in pertinent part: Menus must meet the nutritional needs of residents in accordance with established national guidelines, be prepared in advance be followed, reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups, be updated periodically and be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy II. Resident #15 A. Resident status Resident #15, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the March 2024 CPO, diagnoses included diabetes mellitus with diabetic neuropathy, anemia, stage 4 kidney disease, essential hypertension and chronic pain. The 2/22/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a BIMS score of 11 out of 15 with no behaviors. The resident required staff supervision for eating. The resident received six insulin injections during the seven-day review assessment. B. Resident interview and observations The resident was interviewed on 3/18/24 at 9:02 a.m. He said he wanted to be on a diabetic diet and he was not. He said he was served foods that were not on his prescribed diet. The resident was interviewed again on 3/20/24 at 3:00 p.m. He said he was served the main entree for each meal. He said each of the meals contained lots of carbohydrates and he always ate what they placed in front of him. He said he knew better than to eat the carbohydrates but he ate them anyway. He said staff had not talked with him regarding the foods that he should/should not eat and he felt someone should have discussed this with him. He said he had gained approximately 15 pounds and he did not want to gain weight. The resident's plate was observed on 3/20/24 at 5:40 p.m. and there were two slices of tomato on the plate. The resident said, because he was on a renal diet, he should not have been served the tomatoes. C. Record review A physician's order started on 2/16/24 at 6:25 p.m. revealed a controlled carbohydrate (CCHO) regular diet with a level 7 texture and a thin level 0 consistency. A care plan for diabetes mellitus was initiated on 2/16/24. The pertinent interventions were for a dietary consult for nutritional regimen and ongoing monitoring. Discuss with the resident his meal times, portion sizes, dietary restrictions, snacks that were allowed in his nutritional plan and his compliance with the nutritional regimen initiated on 3/10/24. A care plan for nutritional problems or potential nutritional problems related to diabetes, hypertension, depression, anemia, chronic kidney disease, depression and dementia, weakness, skin breakdown, and diet restrictions was initiated on 2/21/24. The pertinent interventions were to provide and serve the diet as ordered. Monitor the resident's meal intakes and record for each meal. The resident's meal card, dated 3/20/24, revealed a regular CCHO diet with thin liquids. III. Resident #39 A. Resident status Resident #39, age greater than 65, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included Alzheimer's disease and anxiety. The 1/23/24 MDS assessment showed the resident had severe cognitive impairments with a BIMS score of five out of 15. B. Record review The 1/27/24 CPO showed an order which read regular diet, level seven please cut up patient's food into bite size pieces. The nutrition care plan, revised 1/31/24 showed the resident was at risk for nutritional problems related to Alzheimer's disease. The pertinent intervention was to provide and serve diet as ordered. The resident's meal ticket read cut up food into bite size pieces. C. Observations On 3/19/24 at 12:15 p.m. the Resident #39 received a peanut butter and jelly sandwich for lunch. When the sandwich left the kitchen it was cut in half. When it was served the activity director (AD) served the meal to the resident. The sandwich was cut one more time into fourths. D. Interview The registered dietitian (RD) was interviewed on 3/20/24 at 5:07 p.m. The RD said the peanut butter and jelly sandwich for Resident #39 should have been cut into bite size pieces. She said cutting the sandwich into four pieces was not sufficient. IV. Additional interviews The dietary manager (DM) was interviewed on 3/21/24 at 11:16 a.m. The DM said the facility had been using the International Dysphagia Diet Standardization Initiative (IDDSI) program for therapeutic diets since February 2023. She said when the training was initiated, staff were trained about the new program. She said since the first training was completed the facility had not trained on the IDDSI, however, she said there had been a lot of staff turnover since then and not all staff was trained. She said she personally trained all the kitchen staff that prepared and cooked the food but had not trained any of the serving staff. The speech therapist (ST) was interviewed on 3/21/24 at 1:42 p.m. The ST said, although residents were on therapeutic diets, the facility could issue waivers to allow the residents to liberalize their own diets. She said residents who did not follow their IDDSI plan were at risk for choking or unplanned nutritional deficits due to increased difficulty to chew.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** V. Resident #16 A. Resident status Resident #16, age greater than 65, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included heart disease, chronic obstructive pulmonary (lung) disease, major depressive disorder and post traumatic stress disorder. The 1/26/24 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of two out of 15 with no behaviors. B. Record review A physician's order dated 7/8/23 at 8:00 p.m. revealed Mirtazapine 15 mg give one tablet at bedtime for depression and insomnia. A physician's order dated 7/12/23 at 5:00 p.m. revealed Venlafaxine 100 mg give 100 mg twice daily for depression. A care plan for the use of an antidepressant medication related to major depressive disorder and post traumatic stress disorder (PTSD) was initiated on 7/8/23. The interventions were for staff to educate the resident/family/caregivers about risks, benefits and the side effects or toxic symptoms of antidepressant for depression with insomnia. Staff were to monitor, document and report adverse reactions to antidepressant therapy, change in behavior, mood and cognition, hallucinations, delusions, social isolation, suicidal thoughts, withdrawal, decline in activities of daily living (ADLs), continence, no voiding, constipation, fecal impaction, diarrhea, gait changes, rigid muscles, balance problems, movement problems, tremors, muscle cramps, falls, dizziness, vertigo, fatigue, insomnia, appetite loss, weight loss, dry mouth and dry eyes. The March 2024 MAR revealed the resident was administered Mirtazapine 20 times and Venlafaxine 41 times. -Review of Resident #16's EMR failed to reveal a signed informed consent form for Mirtazapine or Venlafaxine. C. Staff interviews The pharmacist (PH) was interviewed on 3/20/24 at 1:00 p.m. The PH said the informed consents for psychotropic medications were to be completed by the nurses or the physician and signed by the resident/resident representative prior to the medication being administered. IV. Resident #33 A. Resident status Resident #33, age over 65, was admitted on [DATE] and readmitted on [DATE]. According to the March 2024 CPO, diagnoses included Alzheimer's disease, severe dementia with agitation and history of falls. The 1/12/24 MDS assessment revealed the resident's cognitive status was severely impaired with a BIMS score of three out of 15. The assessment did not identify the resident had any behaviors during the assessment period. The assessment did not identify the resident's functional abilities and goals at the time of the assessment. B. Record review A physician's order dated 2/20/24 at 3:05 p.m. revealed Zyprexa 10 mg, give 10mg by mouth in the afternoon for dementia with agitation. The antipsychotic medication use care plan, initiated on 8/1/23, revealed Resident #33 had symptoms and behaviors associated with the diagnosis of dementia Relevant interventions included staff to administer psychotropic medications as ordered by the physician and monitor for side effects and effectiveness,staff to perform behavior monitoring for anti-psychotic medication,staff considered medication reductions and or risk benefit assessments as indicated,staff to review medications with the interdisciplinary team (IDT) quarterly and as indicated and attempt gradual dose reduction when clinically indicated and staff were to utilize the following non pharmacological interventions: cold, range of motion, massage, relaxation and breathing techniques, imagery and distraction techniques, repositioning, aromatherapy and therapeutic touch and massage. A review of Resident #33's MAR from 3/1/24 - 3/21/24 revealed the resident received 21 doses of Zyprexa during the reviewed timeframe. -Review of Resident #33's electronic medical record (EMR) failed to reveal a signed informed consent form for Zyprexa. C. Staff interviews Registered nurse (RN) #4 was interviewed on 3/21/24 at 1:24 p.m. RN #4 said all psychotropic medications needed a consent signed by the resident or resident's representative before being administered any psychotropic medications. He said he was not sure who was responsible for obtaining the informed consents.Based on record review and interviews the facility failed to ensure residents were kept free from unnecessary medications for four (#15, #16, #33 and #76) of five residents reviewed for unnecessary medications out of 47 sample residents. Specifically, the facility failed to ensure informed consents were signed prior to the administration of psychotropic medications for Residents #15, #16, #33 and #76. Findings include: I. Facility policy and procedures The Psychopharmacological Policy, dated 3/10/23, was provided by quality mentor (QM) #1 on 3/20/24 at 12:42 pm. The policy revealed the community (facility) supported the appropriate use of psychopharmacological drugs that were therapeutic for residents suffering from mental illness. If a resident was admitted with orders for psychopharmacological drug use, the following would occur: a licensed nurse would review admission medication orders and ensure appropriate diagnosis for use of each medication from the primary care physician, the licensed nurse would complete the PCC Psychotropic Informed Consent with the resident or responsible party. This would be completed at admission and as needed. If the information was not obtained prior to admission, the licensed nurse and/or social service director (SSD) would make every effort to determine if there were any potential behavior symptoms that might require special monitoring and/or care planning. Possible sources of this information include, but were not limited to, physician, family, pre-admission screening & resident review program (PASRR), mental health clinician/developmentally disabled specialist (DDS), prior placement, or resident history. The licensed nurse or designee would document any known targeted behaviors and potential interventions on the [NAME] (nurse worksheet that included a summary of a resident's information, such as medications, clinical follow-ups and daily care schedules). This would help to assure certified nursing assistants received communication related to the initial plan of care as appropriate. The licensed nurse would complete a baseline Abnormal Involuntary Movement Scale (AIMS) on admission, quarterly and as needed if the resident had orders for antipsychotic medications and/or as ordered by the primary care physician or psychiatrist (if applicable). The admission record would be reviewed within 72-hours (weekdays) of a resident's admission by the interdisciplinary team (IDT) to assure admission orders, applicable policy and procedures had been initiated. This review would include the use of psychopharmacological drugs, appropriate diagnosis, behavioral symptom(s) and the initial plan of care. The interdisciplinary team (IDT) would proceed to care planning for the use of psychopharmacological drugs, and the care plan for psychopharmacological medications would be implemented. The care plan would include the resident's focus and target behaviors for the medication. Realistic and measurable goals would be utilized and approaches would include alternatives to psychopharmacological drug use. The plan of care must include behavior interventions and medication monitoring/dosage reduction if appropriate. Consideration should be given to potential underlying causes of the behavior symptoms to assure appropriate treatment. II. Resident #15 A. Resident status Resident #15, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included dementia, diabetes mellitus, chronic pain, dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. The 2/22/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15 with no behaviors. The resident had additional diagnoses of depression, renal insufficiency, and non-Alzheimer's dementia. During the seven-day assessment period the resident was administered antipsychotics, antidepressants, opioids, and hypoglycemic medications. B. Record review A physician's order dated 2/16/24 at 3:26 p.m. revealed Trazodone hydrochloride (HCL) 100 milligrams (mg) give one tablet by mouth at bedtime for insomnia. A physician's order dated 2/16/24 at 3:26 p.m. revealed Quetiapine Fumarate (Seroquel) 50 mg give one tablet by mouth once a day for insomnia. A physician's order dated 2/16/24 at 4:26 p.m. revealed Zyprexa 2.5 mg give one tablet by mouth for insomnia. A physician's order dated 2/16/24 at 3:26 p.m. revealed Sertraline HCL 25 mg give one tablet by mouth once a day for depression. A care plan for the use of an antidepressant medication related to depression and sleep was initiated on 2/16/24 and revised on 2/27/24. The interventions were for staff to monitor behaviors for the use of an antidepressant medication. Staff were to monitor/document/report, as needed any adverse reactions to antidepressant therapy. Staff were to observe for changes in behavior/mood/cognition, hallucinations/delusions, social isolation, suicidal thoughts, withdrawal, decline in activities of daily living, continence, lack of voiding, constipation, fecal impaction, diarrhea, gait changes, rigid muscles, balance problems, movement problems, tremors, muscle cramps, falls, dizziness/vertigo, fatigue, insomnia, appetite loss, weight loss, nausea/vomiting, dry mouth, and/or dry eyes. Staff were to complete the patient health questionnaire-9 (PHQ-9) assessment on admission, quarterly, annually, and with a change of condition. The resident's medications would be reviewed with the interdisciplinary team quarterly and as needed and attempt gradual dose reduction when clinically indicated. A care plan for the use of an anti-psychotic medication for insomnia was initiated on 3/9/24. The interventions were for staff to administer psychotropic medications as the physician ordered. Staff were to monitor for side effects and effectiveness of the medications. Staff were to complete the abnormal involuntary movement scale (AIMS) assessment quarterly or as needed. Staff were to consult with the pharmacy and a physician to consider a dose reduction, when clinically appropriate at least quarterly. Staff were to discuss with a physician, power of attorney (POA) or the family regarding the ongoing need for the use of the medication. Staff were to review the behaviors/interventions, alternate therapies attempted and their effectiveness according to the facility policy. Staff were to educate and inform the resident of the current medication regimen and change recommendations. Staff were to educate the resident, POA (power of attorney), family and caregivers about the risks, benefits and the side effects and/or toxic symptoms of the psychotropic medication drugs being given. Staff were to attempt medication reductions and/or risk benefit assessments as indicated. Staff were to monitor, document, report, as needed any adverse reactions of the use of psychotropic medications. Staff were to observe for unsteady gait, tardive dyskinesia, extrapyramidal side effects (RPS) such as shuffling gait rigid muscles or shaking. Staff were also to observe for frequent falls, refusal to eat, sedation, difficulty swallowing, dry mouth, depression, extrapyramidal reaction, weight gain, edema, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, constipation, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. Staff were to review the resident's medications with the interdisciplinary team quarterly and as indicated and attempt gradual dose reductions when clinically indicated. The medication administration record (MAR) for February 2024 revealed the resident was administered Quetiapine Fumarate 14 times, Sertraline HCL 13 times, Trazodone HCL 14 times and Zyprexa 13 times. The medication administration record (MAR) for March 2024 revealed the resident was administered Quetiapine Fumarate 13 times, Sertraline HCL 15 times, Trazodone HCL 13 times, and Zyprexa 11 times. -The resident signed the Informed Consent for Psychoactive Medications forms for the use of Sertraline, Trazodone, and Seroquel on 3/19/24 at 5:44 p.m., after the survey started. The Zyprexa was discontinued on 3/18/24. C. Staff interviews The director of nursing (DON), QM #1, QM #2 and the pharmacist (PH) were interviewed on 3/20/24 at 11:35 a.m. They agreed on the psychotropic medications the resident was administered. The PH said the resident's physician wanted the resident on multiple medications for his insomnia. The PH said the resident was admitted from the hospital with the same medications for a diagnosis of insomnia. The PH said there was some off-labeling (use of a medication that was not approved to treat a specific condition/diagnosis) of some of the medications for the resident's insomnia. The PH said the facility kept the same diagnosis for medications when the medications arrived and the facility would make changes as they could. The PH said the staff had not observed the resident being over sedated and the Zyprexa was discontinued on 3/18/24, after the survey started. The Quetiapine Fumarate was still at 50 mg with a diagnosis of dementia with behaviors. This diagnosis was changed on 3/18/24, after the survey started. The PH said the facility would continue to discontinue other medications. The facility had to wait at least a week for the Zyprexa to get out of his system. The DON, QM #1, QM #2 and the pharmacist (PH) were interviewed again on 3/20/24 at 11:48 a.m. They agreed the resident had been administered the above psychotropic medications. QM #2 said the consents for the use of psychotropic medications were not obtained prior to the administration of the medications. The consents were obtained on 3/19/24, after the survey started. III. Resident #76 A. Resident status Resident #76, age [AGE], was admitted on [DATE]. According to the March 2024 CPO, diagnoses included anxiety, essential hypertension, fluid overload, lumbar region spondylolisthesis diabetes mellitus and chronic kidney disease stage 5. The 3/20/24 minimum data set (MDS) assessment revealed the resident had intact cognitive ability with a BIMS score of 14 out of 15 with no behaviors. B. Record review A physician's order dated 3/14/24 at 4:20 p.m. revealed Sertraline HCL 100 mg give two tablets by mouth at bedtime for anxiety with depression. A care plan for the use of an antidepressant medication related to depression was initiated on 3/18/24. The interventions were for staff to monitor behaviors for the use of an antidepressant medication. Staff were to monitor/document/report, as needed any adverse reactions to antidepressant therapy. Staff were to observe for changes in behavior/mood/cognition, hallucinations/delusions, social isolation, suicidal thoughts, withdrawal, decline in activities of daily living ability, continence, lack of voiding, constipation, fecal impaction, diarrhea, gait changes, rigid muscles, balance problems, movement problems, tremors, muscle cramps, falls, dizziness/vertigo, fatigue, insomnia, appetite loss, weight loss, nausea/vomiting, dry mouth, and/or dry eyes. Staff were to complete the patient health questionnaire-9 (PHQ-9) assessment on admission, quarterly, annually, and with a change of condition. The resident's medications would be reviewed with the interdisciplinary team quarterly, as needed, and attempt gradual dose reduction when clinically indicated. A care plan for the use of an anti-anxiety medication related to an anxiety disorder was initiated on 3/18/24. The pertinent interventions were to administer the medication as physician ordered. Staff were to monitor for side effects and effectiveness. Staff were to monitor, document, report as needed any adverse reactions to the anti-anxiety therapy. The adverse reactions might include drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking/judgment, memory loss, forgetfulness, nausea, stomach upset, blurred and/or double vision. The staff were also to observe or unexpected side effects such as; mania, hostility, rage, aggressive or impulsive behavior, and/or hallucinations. The resident's medications would be reviewed with the interdisciplinary team quarterly, as needed, and attempt gradual dose reduction when clinically indicated. The MAR for March 2024 revealed the resident was administered Sertraline HCL 4 times. -The resident signed the Informed Consent for Psychoactive Medications form for the use of Sertraline on 3/20/24 at 10:56 a.m., after the survey started. C. Staff interviews The DON, QM #1, QM #2 and the pharmacist (PH) were interviewed on 3/20/24 at 11:48 a.m. They agreed the resident was administered the above psychotropic medication. The consent for the medication was obtained on 3/18/24, after the survey started. They agreed a consent should have been obtained before the medication was given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored in accordance with professional standards on two of four medication carts. Specifically, the facility failed to ensure: -Medications were labeled with the date opened; -Expired and discontinued medications were removed from the medication cart; and, -Labeled medications were legible. Findings include: I. Facility policy and procedure The Storage of Medications policy, revised [DATE], was provided by quality mentor (QM) #1 on [DATE] at 12:42 p.m. The policy read in pertinent part: The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. II. Professional references According to the manufacturer [NAME] Lilly and Company, Basaglar Insulin Glargine 100 units/milliliter (ml), (February 2024), retrieved on [DATE] from https://www.basaglar.com/how-to-use-basaglar, After insulin use, store your opened pen at room temperature and throw it away after 28 days. According to the manufacturer [NAME] Lilly and Company, Humalog Insulin Lispro U-100 Insulin (February 2024), retrieved on [DATE] from https://www.humalog.com/u100, Opened Humalog vials, prefilled pens, and cartridges must be thrown away 28 days after first use, even if they still contain insulin. According to the manufacturer Sanofi-Aventis US, Lantus Insulin Glargine Injection 100 units/ml- How to Use Your Lantus Solostar Pen, ([DATE]), retrieved on [DATE] from https://www.lantus.com/dam/jcr:817aed9c-a677-4cd6-a6b3-d93d8aba629a/lantus-solostar-pen-guide.pdf, Your opened Lantus Solostar pen - After 28 days, throw your Lantus pen away, even if it still has insulin in it. III. Observations and interviews On [DATE] at 2:51 p.m., the Alpine Back medication cart was observed with licensed practical nurse (LPN) #1. The following item was found: An opened Insulin Glargine (Basaglar) 100 units/ml (milliliter) pen was not labeled with the date it was opened. LPN #1 said he expected to see a date opened label so he would know when the insulin pen should be discarded. On [DATE] at 3:37 p.m., the Challenger Back medication cart was observed with registered nurse (RN) #1. The following items were found: An Insulin Lispro (Humalog) 100 units/ml pen was dated as opened on [DATE]. -The insulin pen should have been discarded on [DATE], 28 days after it was opened. An Insulin Glargine (Lantus) 100 units/ml pen was dated as opened on [DATE]. -The insulin pen should have been discarded on [DATE], 28 days after it was opened. An opened Insulin Glargine (Lantus) 100 units/ml pen had a label on it, however, the writing on the label was illegible and the date it was opened was unable to be determined. RN #1 said the insulin pens should be discarded 28 days after opening and she proceeded to remove them from the medication cart. She said the insulin pen with illegible writing should be discarded. IV. Staff interviews The director of nursing (DON) and quality mentor (QM) #2 were interviewed on [DATE] at 10:13 a.m. The DON said the undated opened insulin pen should have been labeled, and if it was not labeled, it needed to be discarded. The DON said the insulin pen with the illegible label should be discarded. He said the insulin pens opened on [DATE] and [DATE] should have been discarded 28 days after opening. The pharmacist (PH) was interviewed on [DATE] at 11:33 a.m. The PH said insulin pens needed to be dated upon opening. She said Lantus and Lispro insulins should be discarded 28 days after opening. She said staff should discard any pens with illegible labels.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection on two of three units. Specifically, the facility failed to: -Ensure housekeeping staff followed appropriate infection control practices; -Ensure high touch areas were cleaned; -Ensure staff followed proper hand hygiene practices; -Ensure hand hygiene was offered to residents prior to meals; and, -Ensure Foley catheter bags were hung in a sanitary manner. Findings include: I. Failure to ensure housekeeping staff were following the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touched areas A. Professional reference Assadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection, (2021) Jul;113:104-114, retrieved on 3/31/24 revealed in pertinent part: High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease) Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolong hospital stays, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. The CDC Environment Cleaning Procedures (5/4/23), retrieved on 3/31/24 from https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html#, read in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: -bedrails -IV (intravenous) poles -sink handles -bedside tables -counters -edges of privacy curtains -patient monitoring equipment (keyboards, control panels) -call bells -door knobs. B. Observations On 3/20/24 at 10:00 a.m., housekeeper (HSK) #1 cleaned room [ROOM NUMBER]. -HSK #1 failed to clean the door knobs to the resident room entrance, pull cords and light switches in the room. HSK #1 was observed to spray the door knobs of the bathroom with the disinfectant. -However, she then cleaned the toilet and with the same gloved hands she touched the door knobs of the bathroom as the door began to close. She did not go back and disinfect the door knob after the contamination. C. Interview The housekeeping supervisor (HSKS) was interviewed on 3/20/24 at approximately 4:00 p.m. The HSKS said that the high touch areas such as door knobs, call lights and light switches needed to be cleaned with a disinfectant as part of the room cleaning. He said that HSK #1 should have not touched the bathroom door knobs with contaminated gloves. The infection preventionist (IP) was interviewed on 3/21/24 at 9:38 a.m. The IP said she had not completed a start to finish observation of the housekeepers during cleaning of rooms. She said high touch areas (frequently touched surfaces) should be cleaned daily. The IP said the residents' call lights and door knobs should be cleaned daily. II. Failed to ensure staff performed hand hygiene A. Facility policy The Handwashing/Hand Hygiene policy, revised August 2019, was provided by the quality mentor (QM) #1 on 3/21/24 at 2:19 p.m. It read in pertinent part, All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Use an alcohol-based hand rub containing at least 60% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: Before and after coming on duty; Before and after direct contact with residents; Before preparing or handling medications; Before performing any non-surgical invasive procedures; Before and after handling an invasive device (e.g., urinary catheters, IV access sites); Before donning sterile gloves; Before handling clean or soiled dressings, gauze pads, etc.; Before moving from a contaminated body site to a clean body site during resident care; After contact with a resident's intact skin; After contact with blood or bodily fluids; After handling used dressings, contaminated equipment, etc.; After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; After removing gloves; Before and after entering isolation precaution settings; Before and after eating or handling food; Before and after assisting a resident with meals; and After personal use of the toilet or conducting your personal hygiene. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. The Infection Control and Surveillance policy, revised July 2023, was provided by the nursing home administrator (NHA) on 3/17/24 at 5:10 p.m. It read in pertinent part: Important facets of infection prevention include educating staff and ensuring that they adhere to proper techniques and procedures. B. Observations 3/17/24 -At 4:51 p.m., kitchen staff were delivering room trays to room [ROOM NUMBER], #22 and #23. The kitchen staff failed to perform hand hygiene after delivering the room trays. -At 4:54 p.m., oom trays were delivered to rooms # 4, #6, #7, #8, #11 and #16. The unidentified kitchen staff member failed to perform hand hygiene prior to entering or after exiting each room. -At 5:05 p.m., room trays were served to resident room # 27, #28, #31, 37, #39 and #45. The unidentified staff failed to perform hand hygiene after exiting and entering the next room. 3/19/24 -At 4:15 p.m., CNA #7 took the vitals of Resident #13. After CNA #7 finished taking the resident's vital signs, he failed to perform hand hygiene. -At 4:23 p.m., registered nurse (RN) #5 was observed during the medication pass. RN #5 used hand sanitizer on both hands while wearing cloth hand and wrist braces on both hands. RN #5 prepared the medications and applied gloves. She wore gloves in Resident #18's room, administered the medications to the resident and then used hand sanitizer. -At 4:37 p.m., CNA #7 entered room [ROOM NUMBER] and pushed a resident out of the room to the dining room. CNA #7 assisted the resident with oxygen. CNA #7 failed to perform hand hygiene after adjusting the resident's oxygen. CNA #7 went into another room to assist another resident without performing hand hygiene. -At 4:38 p.m., RN #5 continued to wear the cloth wrist braces. She prepared medications without gloves and administered the medications to Resident #32 without gloves. RN #5 rinsed her hands under water for five seconds in the resident's room. RN #5 did not sanitize with soap. After rinsing her hands with water, RN #5 used hand sanitizer with the wrist braces on. -At 4:43 p.m., CNA #7 assisted a resident to the dining room by pushing his wheelchair. CNA #7 left the resident in the dining room and went to help another resident with another task. CNA #7 failed to perform hand hygiene between residents and tasks. -At 4:50 p.m., RN #5 prepared and administered medications to Resident #17 while still wearing her wrist braces. She rinsed her hands under water in the resident's room for five seconds and did not perform appropriate hand hygiene by removing the braces or using soap or hand sanitizer. C. Resident and staff interviews CNA #6 was interviewed on 3/17/24 at 5:24 p.m. CNA #6 said he was trained to sanitize his hands and hand sanitizer should be used after caring for every resident to ensure germs would not spread. The infection preventionist (IP) was interviewed on 3/21/24 at 9:38 a.m. The IP said staff was required to do hand hygiene between delivery of each meal tray and after any contact with a resident. The IP said RN #5 should not wear the wrist braces during medication passes. She said she provided education to RN #5 on 3/20/24 (during the survey) and RN #5 agreed not to wear the braces during medication administrations. The IP said all staff should perform hand hygiene between residents. She said gloves should not replace hand hygiene. III. Failed to offer hand hygiene to residents prior to meals A. Professional reference The Centers for Disease Control and Prevention (CDC) Hand Hygiene in Healthcare Settings (1/30/2020), retrieved on 3/31/24 from https://www.cdc.gov/handhygiene/providers/guideline.html, included the following recommendations, in pertinent part for hand hygiene, Use an alcohol-based hand sanitizer immediately before touching a patient, before performing an aseptic task or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal. B. Observations The dinner meal was observed on 3/17/24 starting at 5:20 p.m. The observations were as follows: -At 5:28 p.m., Resident #2 was served dinner, however, the resident was not offered hand hygiene prior to meal delivery. -At 5:36 p.m., Resident #55 was served his meal from CNA #5, however, he was not offered hand hygiene prior to eating his meal. -At 5:39 p.m,. Resident #16 and #22 were served their meals in the dining room. They were not offered hand hygiene prior to meal delivery. -At 5:44 p.m., Resident #23, #29, #35, and #47 were served their meals in the dining room. They were not offered hand hygiene prior to meal delivery. The lunch meal was observed on 3/19/24 starting at 11:50 a.m. The observations were as follows: -At 12:00 p.m., the residents sitting at the restorative table did not get offered hand hygiene prior to their meal being served. The lunch meal was observed in the dining room on 3/20/24 starting at 11:54 p.m. The meal was fried chicken. The observations were as follows: -At 11:54 a.m., some of the tables had wrapped hand wipes. However, not every table had them. -Resident #123 received his meal, however, the resident was not offered hand hygiene prior to eating. -Resident #64 received his meal and was not offered hand hygiene prior to eating. -Resident #15 was not offered hand hygiene prior to eating. C. Resident and staff interviews Resident #66 was interviewed on 3/17/24 at 5:34 p.m. Resident #66 said hand hygiene was not offered or encouraged to residents. Resident #73 was interviewed on 3/17/24 at 5:36 p.m. Resident #73 said hand hygiene was not offered or encouraged to residents. Resident #51 was interviewed on 3/17/24 at 5:41 p.m. Resident #51 said hand hygiene was not offered or encouraged to residents. CNA #5 was interviewed on 3/17/24 at 5:48 p.m. CNA #5 said she did not offer hand sanitizer to residents prior to serving the residents' meals. Registered nurse (RN) #1 was interviewed on 3/17/24 at 5:50 p.m. RN #1 said she did not offer or see anyone offer hand sanitizer to residents in the dining room prior to serving the residents' meals. The infection preventionist (IP) was interviewed on 3/21/24 at 9:38 a.m. The IP said residents should be offered hand hygiene prior to their meal being served. The IP said residents should be offered a hand sanitizing wipe or bottled hand sanitizer. IV. Failed to ensure Foley catheter bag was hung in a sanitary manner A. Observation On 3/20/24 at 11:10 a.m., Resident #51's Foley catheter bag was observed hooked to a trash can with trash in it next to the resident's bed. The catheter was hanging down inside the trash can. B. Interview CNA #8 was interviewed on 3/20/24 at 11:15 a.m. CNA #8 said the catheter bag should not be hung in the trash can. She said it should be hung on the side of the bed. She said the night shift staff probably hung it in the trash can. She confirmed there was trash present in the trash can. The IP was interviewed on 3/21/24 at 9:38 a.m. The IP said Resident #51's Foley catheter should never be hung on or in the garbage can. The IP said the catheter should be hanging from the bedrail, lower than the level of Resident #51's bladder. V. Facility follow-up The IP provided documentation of staff in-service education completed on 3/21/24 (during the survey) which included the following: -Gloves must be changed between each task when cleaning resident rooms. -Hand hygiene must be performed prior to glove application. -Gloves do not replace hand hygiene. -The education failed to include education regarding offering residents hand hygiene prior to meals, how to hang Foley catheter bags or appropriate processes for cleaning resident rooms.

Based on observations and interviews, the facility failed to ensure facility menus met the needs of residents and were followed. Specifically, the facility failed to: -Ensure menu extensions were followed; and, -Ensure residents were provided with all menu options and substitutions were offered when appropriate. Findings include: I. Facility policy and procedure The Menus and Nutrition Adequacy policy and procedure, revised January 2024, was provided by quality mentor (QM) #1 on 3/21/24 at 2:19 p.m. It read in pertinent part: Menus must meet the nutritional needs of residents in accordance with established national guidelines, be prepared in advance, be followed, be updated periodically and be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy. The US Foods Detailed Menu Cycle Nutritional Analysis was provided by the facility on 3/21/24 at 9:03 a.m. It read in pertinent part: The facility offered a total of 2,000 Kcal (calorie) daily nutritional intake across all meals. Milk was to be offered at every meal, offering 118 Kcal per each meal, 354 Kcal per day and 2,478 Kcal per week. II. Lunch meal observation Certified nursing aide (CNA) #8 was observed on 3/20/24 at 11:30 a.m. passing drinks to residents in the main dining room. She was observed to walk up to the table and ask what the residents would like to drink. -CNA #8 did not offer residents milk or an alternative if the resident declined milk. CNA #8 informed residents their drink choices were lemonade, iced tea or water. III. Menu and extensions The menu extensions read in part: Lunch 3/19/24: Regular diet: three individual Cheese Manicotti, 0.5 cup of green beans, 0.5 cup of butterscotch pudding, one slice of garlic parmesan bread, 8 fluid ounces of milk, 8 fluid ounces of beverage of choice. -However, milk was not offered to the residents even though it was included as part of the menu (see observation above). Liberal renal diet: two ounce beef patty and 0.5 cup of noodles, 0.5 cup of green beans, cookie, one slice of garlic parmesan bread, 8 fluid ounces of fruit punch, 8 fluid ounces of beverage of choice. -The kitchen staff did not prepare the renal substitute of beef patty and noodles. IV. Staff interviews CNA #8 was interviewed on 3/20/24 at 11:48 a.m. CNA #8 said the residents could get anything they wanted to drink. She said there was no mandatory drink such as milk that the residents had to have. She said staff offered the residents any drinks they would like and the facility served what was requested. The dietary manager (DM) was interviewed on 3/21/24 at 11:16 a.m. The DM said the kitchen staff who cooked the meals were trained on the facility's different menus and diets but the servers were not trained. She said everything listed on the menu extensions was to be offered to every resident and included on meal trays. She said if any item was omitted it was the facility's responsibility to provide a substitute of comparable nutritional value. The DM said residents needed to receive all items on the menu to meet the 2000 calorie daily requirement. The registered dietician (RD) was interviewed on 3/20/24 at 5:07 p.m. The RD said all items on the menu extensions were to be offered and provided to all residents unless special dietary constraints were in place. She said the extensions provided a nutrition meal and daily meal totals were at 2000 calories per day. She said any menu item excluded from being served could cause residents to have a daily calorie deficit.

Based on observations, interviews and record review, the facility failed to store, prepare, distribute and serve food in a sanitary manner. Specifically, the facility failed to: -Ensure kitchen staff prepared and served food in a sanitary environment in the main kitchen; and, -Ensure the two facility ice machines were properly cleaned and sanitized according to the manufacturer's instructions. Findings include: I. Ensure kitchen staff prepared and served food in a sanitary environment in the main kitchen A. Facility policy and procedure The Cleaning and Disinfection of Environmental Surfaces policy, revised August 2019, was provided by quality mentor (QM) #1 on 3/20/24 at 5:43 p.m. It documented in pertinent part: Environmental surfaces will be disinfected (or cleaned) on a regular basis daily and when surfaces are visibly soiled. Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled. Horizontal surfaces will be wet dusted regularly using clean cloths moistened with an EPA-registered hospital disinfectant (or detergent). The disinfectant (or detergent) will be prepared as recommended by the manufacturer. B. Observations During a continuous observation of the kitchen on 3/18/24, beginning at 2:00 p.m. and ending at 2:15 p.m., the following was observed: Main Kitchen: -Unfinished drywall and chipped paint to the left of the big sinks; -Dust buildup on pipes and emergency lights above prep tables and food storage areas in the kitchen; -Chipped paint on the runners along the floor and chipped paint above the hand washing sink; and, -Dirt and grime was built up under the hand washing sink. Chemical storage area: -Air vent was hanging open and light covers were missing. Dish room: -Large rodent hole under the dishwashing machine leading to the outside of the building; -Chipped tiles and dark substance build up under the sink; and, -Broken fan in the dish room was hanging from the ceiling. Main Dining Room: -All three doors leading to the kitchen had chipped paint and a dark substance was built up around the bottoms of the door frames. C. Staff interviews The dietary manager (DM) was interviewed on 3/21/24 at 11:16 a.m. The DM said she was not sure how often the kitchen was supposed to be deep cleaned to include the walls, floors and ceilings but said it had been a while since it was deep cleaned. She said she had not reached out to maintenance for the repairs to the broken tiles and holes but would reach out as soon as she could. The DM said without a clean and sanitary kitchen environment, the facility was at risk for contamination of food and food preparation surfaces. II. Ensure ice machines were properly cleaned and sanitized according to manufacturer's instructions A. Facility policy and procedure The Manitowoc Ice Machine Technician's Handbook was provided by the nursing home administrator (NHA) on 3/18.24 at 4:40 p.m. It read in pertinent part, Cleaning/ Sanitizing Procedure: Ice machine cleaner is used to remove lime scale and mineral deposits. Ice machine sanitizer disinfects and removes algae and slime. Use 1/2 (half) of the sanitizer/water solution to sanitize all removed components. Use a spray bottle to liberally apply the solution to all surfaces of the removed parts or soak the removed parts in the sanitizer/water solution. Do not rinse parts after sanitizing. Use half of the sanitizer/water solution to sanitize all food zone surfaces of the ice machine and bin (or dispenser). Use a spray bottle to liberally apply the solution. When sanitizing, pay particular attention to the following areas: side walls, base (area above water trough), evaporator plastic parts - including top, bottom and sides and bin or dispenser. Do not rinse the sanitized areas. Replace all removed components. Wait 20 minutes. Reapply power to the ice machine and press the clean button. C. Observations During the initial kitchen tour on 03/17/24 at 1:19 p.m. it was observed that the facility had two ice machines, one on the first floor and one on second floor. No cleaning schedule logs were seen on or around the machine. The kitchen staff said maintenance was responsible for cleaning the ice machines. D. Record review The ice machine cleaning schedule was provided by NHA on 3/18/24 at 3:55 p.m. It read in pertinent part, The maintenance department is responsible for the cleaning and disinfecting of both facility ice machines. This will be done every 6 (six) months and documented as such. Procedure: All ice will be removed from the bin and thrown away, bleach will be sprayed on all areas inside the unit, all bleached areas will then be rinsed at least three times using hot water. Units are now ready to be turned back on, let both units make at least three dumps of ice cubes, throw all away and the fourth dump can then be used. -The facility provided records which indicated the ice machines had been cleaned, however, the chemical the facility used for the process did not contain a sanitizer (see record review and interview below). -The instructions on the cleaning schedule did not document the appropriate cleaning procedure per the manufacturer's instructions (see manufacturer's instructions above). The solution the facility used to clean the ice machines was identified as H.B. (Hydro-Balance) 30 Ice Machine Cleaner. -The product was identified as a commercial ice machine cleaner, however, the product did not include a sanitizing component. E. Staff interviews The maintenance assistant (MA) was interviewed on 3/21/24 at 10:19 a.m. The MA said he was responsible for cleaning the ice machines. The MA said he had been in the facility about a year. He said he had never cleaned ice machines before this position and said he had not been trained on how to clean the ice machines located in the facility. He said he learned how to clean the ice machines by watching a YouTube video. The MA said since he had been responsible for the ice machines he had not sanitized them due to lack of training and fear of using too much disinfectant. He said no one had trained him how to sanitize the ice machines and said the facility had not ever sanitized the ice machines to his knowledge. The MA said no specific parts of the ice machines should be removed to clean and sanitize the machines except for the ice tray. -However, the manufacturer's instructions documented that parts of the ice machine were to be removed during the cleaning and sanitizing process (see manufacturer's instructions above). F. Facility Follow-up The facility provided a receipt of service form on 3/20/24 at 8:45 a.m. It showed the facility hired a contract service to clean and sanitize the two facility ice machines on 3/19/24 at 8:45 a.m. The facility said they would continue to use the contract service provider every time the ice machines need to be cleaned and sanitized in the future.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure the residents' right to make choices about aspects of their lives in the facility that were significant to them for one (#32) of 17 residents reviewed for bathing preferences out of 22 sample residents. Specifically, the facility failed to provide consistent showers for Residents #32 according to their preferences and routine shower schedules. Findings include: I. Facility policy and procedures The Bathing policy, was developed on 11/25/15, was provided by the nursing home administrator (NHA) on 12/1/22 at 10:20 a.m. The policy revealed the facility would try to bathe residents in their preferred way and at their preferred times. For some residents, bathing could be a frightening and uncomfortable experience. This might be due to confusion, pride, pain or other reasons. Staff were to help minimize the discomfort by offering a choice. II. Resident #32 A. Resident status Resident #32, age [AGE], was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), diagnoses included chronic diastolic (congestive) heart failure, chronic respiratory failure, paroxysmal atrial fibrillation, muscle weakness, hemiplegia and hemiparesis (paralysis) following cerebral infarction(stroke) affecting the left non-dominant side. The 9/22/22 minimum data set (MDS) assessment revealed that the resident was cognitively intact with a brief interview for mental status (BIMS) of 15 out of 15 with no behaviors. The resident required extensive staff assistance for bed mobility, transfers, dressing, toileting, personal hygiene. The resident was totally dependent on staff for bathing with a one-person physical assistance. B. Resident interview The resident was interviewed on 11/28/22 at 12:54 p.m. The resident said sometimes she only received one shower a week because they skip over her. She said she wanted at least two showers each week. She said missing a shower made her feel dirty. C. Record review A care plan for individual preferences, revised on 9/15/21, revealed the resident chose to be highly involved in her daily care decisions regarding suggested or recommended interventions and had specific preferences related to bathing. Some of the interventions included that the resident requested to have a shower twice a week on Monday and Friday afternoon. The resident preferred assistance from a female staff member. The staff were to honor the resident's choices and preferences as able within the parameters of the facility and other resident's safety, choices and or preferences. A care plan for self-care deficit with bathing/hygiene due to hemiplegia was initiated on 12/15/21. The two interventions were to provide privacy during the bathing routine and the resident required partial/moderate assistance of one staff member for bathing. The resident's [NAME] (a system of communication and organization used to document a resident's care summaries) revealed the resident wanted a shower twice a week on Monday and Friday afternoon. The resident preferred assistance from a female staff member. The Bath and Skin Report 2022 revealed the resident received or refused four showers in September 2022, received six showers in October 2022 and received or refused six showers in November 2022. For each of the three months, the resident should have received or refused a minimum of eight showers each month, according to her preference. D. Staff interviews The NHA was interviewed on 11/30/22 at 3:29 p.m. She agreed with the above-mentioned resident's Bath and Skin reports. She said staff tried to accommodate as many showers as a resident preferred. She said the facility used bath aides and at times certified nurse aides (CNAs) to assist residents with showers. She said showers should be offered twice a week. She said it was the right of a resident to refuse a shower. The NHA said if a resident refused a shower, a CNA would inform a nurse that the resident refused. The nurse would go and talk with the resident regarding the refusal. She said a nurse manager would also go and talk with the resident about the refusal of a shower. She said a nurse would document the resident refused a shower in the resident's clinical record; point click care (PCC). The NHA said showers were provided to residents to improve their skin integrity, ensure their skin was not dirty, make the resident feel better and as an encouragement to get out of bed. CNA #2 was interviewed on 12/1/22 at 9:10 a.m. She said she did provide showers to residents. She said she would document that a shower had been given or refused on the Bath and Skin report. She said she would ask a resident several times if they wanted a shower and if they refused she would go inform a nurse. She said the nurse would go ask the resident if they wanted a shower. She said by the end of her shift, she would transcribe the information from the Bath and Skin report, into the resident's clinical record: point of care (POC). She said she was able to document that a resident had refused a shower in POC. She provided the facility resident bathing sheet and acknowledged that the resident preferred a shower on Monday and Friday between breakfast and lunch. CNA #3 was interviewed on 12/1/22 at 9:34 a.m. She said she did provide showers to residents. She said she documented a shower had been given or refused on the Bath and Skin report. She said she transcribed this information for the report into the resident's POC, at the time the shower was given or at least by the end of her shift. She said she could document refusals in POC. She said if a resident refused a shower, she would ask them two more times; for a total of three times. She said on the first refusal, she would tell a nurse of the refusal. She said the nurse would go and talk with the resident regarding the refusal of a shower. She said she knew of a resident's shower preference by reviewing their [NAME]. She said she also reviewed the facility bathing sheet to know a resident's preference for a shower. The NHA was interviewed on 12/1/22 at 10:28 a.m. She said a Quality Assurance & Performance Improvement (QAPI) action plan for showers was started in June 2022. The NHA provided the plan. The plan did not have a specific start date or ending goal date. The identified concern was that residents were not being showered according to their preferences. The facility documentation for showers was not accurate and staff were not documenting accurately nor per facility expectations. She said resident showers were discussed in the daily morning meetings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure two (#26 and #52) residents out of three who required respiratory care received the care consistent with professional standards of practice out of 22 sample residents. Specifically, the facility failed to : -Ensure physicians orders documented the appropriate care of a continuous positive airway pressure (CPAP) machine for Resident #26; -Follow manufacturer recommendations to maintain, clean, sanitize, and store Resident #26's CPAP; -Accurately complete section O in Resident #26's comprehensive minimum data set (MDS) assessment under respiratory treatments; -Ensure a care plan was in place to include settings, cleaning, disinfecting, and storage of Resident #26's CPAP; and, -Clean and store Resident #52's nebulizer appropriately. Findings include: I. Facility policies and procedures The CPAP/BiPAP (Continuous Positive Airway Pressure/Bilevel Positive Airway Pressure) Support, revised March 2015, was provided by the director of nursing (DON) on 11/30/2022 at 3:18 p.m. The policy revealed, in parts: Only a qualified and properly trained nurse or respiratory therapist should administer oxygen through a CPAP mask. Review the physician's order to determine the oxygen concentration, flow, and the peep pressure for the machine. Review and follow manufacturer's instructions for CPAP machine setup and oxygen delivery. Wipe machine with warm soapy water and rinse at least once a week and as needed. Clean humidifier weekly and air dry. To disinfect, place vinegar-water solution (1:3) in clean humidifier. Soak for 30 minutes and rinse thoroughly. Clean mask, nasal pillow and tubing daily by placing in warm, soapy water and soaking/agitating for five minutes. Mild dish detergent was recommended. Rinse with warm water and allow it to air dry between uses. Wash head gear with warm water and mild detergent as needed and allow to air dry. Document the following in the resident's medical record: time CPAP was started and duration of the therapy; mode and settings; oxygen concentration and flow; oxygen saturation during therapy, and notify the physician if the resident refuses the procedure. The Nebulizer policy, revised October 2010, was provided by the DON on 11/30/22 at 2:40 p.m. The policy revealed, in parts: Rinse and disinfect the nebulizer equipment according to facility policy, or: -Wash pieces with warm, soapy water; -Rinse with hot water; -Place all pieces in a bowl and cover with isopropyl (rubbing) alcohol. Soak for five minutes; -Rinse all pieces with sterile water (Not tap, bottled, or distilled); and -Allow to air dry on a paper towel. II. Manufacturer recommendations According to https://www.resmed.com/en-us/sleep-apnea/cpap-parts-support/cleaning-cpap-equipment/, retrieved on 12/5/22, in parts: Daily cleaning: in a sink or tub, clean your mask cushion and headgear to remove any oils. Gently rub with soap and warm, drinking-quality water. Avoid using stronger cleaning products, including dish detergents, as they may damage the mask or leave harmful residue. Rinse again thoroughly with warm, drinking-quality water. Place the cushion and frame on a flat surface, on top of a towel, to dry. Avoid placing them in direct sunlight. We strongly discourage using alcohol and bleach to clean CPAP equipment, as the residual vapors can be harmful if inhaled. III. Resident #26 A. Resident status Resident #26, age above 65, was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), the diagnoses included acute and chronic respiratory failure with hypoxia (low blood oxygen), pneumonia, chronic obstructive pulmonary disease (COPD), unspecified asthma, obstructive sleep apnea, and acute pulmonary edema. The 10/27/22 minimum data set (MDS) assessment revealed, the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) of one out of 15. She required oxygen therapy. -The use of BiPAP/CPAP was not triggered/coded in MDS section O. B. Observations The CPAP was observed on 11/28/22, 11/29/22, 11/30/22, and 12/1/22 on the shelf above the head of the bed. The CPAP mask and tubing was laying over the CPAP machine. C. Record review The November 2022 CPO documented: Oxygen at 4l/M (four liters per minute) via CPAP. A physician order was entered on 11/29/22, during the survey, which documented: Use CPAP wipes to clean all pieces of the CPAP unit. Use one clean wipe to wipe out the inside of the PAP mask, use a second clean CPAP cleaning wipe to wipe down the outer shell of the CPAP mask. Use a third clean CPAP wipe to wipe down outside of CPAP tubing as well as outside of the actual CPAP unit to keep dust free. Every day. A physician order was entered on 11/29/22, during the survey, which documented unplugging the CPAP unit from the electrical outlet. Disconnect the CPAP tubing from the CPAP unit as well as the mask. In a wash basin, fill with warm soapy water using antibacterial soap. Place mask, head gear, as well as tubing into the wash bin in a soapy mixture. Allow to soak for 5 minutes. Then agitate in this mixture for several minutes. Rinse all parts thoroughly under warm running water. Allow to dry on a clean towel on the counter top. Post air dry, reassemble and plug into out;let for use every day shift every friday. A physician order was entered on 11/29/22, during the survey, which documented RT (respiratory therapy) to evaluate and treat. RT to evaluate and CPAP check this week. -The November 2022 CPO did not include any orders related to CPAP settings. The oxygen therapy care plan, initiated 10/21/22 and revised on 10/22/22, documented the resident had oxygen therapy related to chronic respiratory failure. The interventions included four liters of oxygen continuous with CPAP at night. -The care plan did not include settings, cleaning, disinfection and storage of the CPAP machine, tubing and mask. D. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 11/30/22 at 3:28 p.m. She said Resident #26 used oxygen during the day and at night. She said the nurses were responsible for placing the CPAP on the resident and cleaning the equipment. Registered nurse (RN) #1 was interviewed on 12/1/22 at 9:48 a.m. She said the CPAP settings should be on the physician order and in the resident's medication administration record (MAR). She said she was not sure how often the CPAP should be cleaned, however the mask should be stored in a bag when not in use. Licensed practical nurse (LPN) #3 was interviewed on 12/1/22 at 9:51 a.m. He said the CPAP should be cleaned daily and stored in a bag when not in use. He said he was not sure what the CPAP should be cleaned with. LPN #1 was interviewed on 12/1/22 at 9:53 a.m. He said the RT was responsible for the CPAP settings. He said the CPAP mask should be cleaned daily with the purple wipes (Sani-wipes). He said when the CPAP was not in use, the mask and tubing should be stored in a plastic bag. He observed Resident #26's CPAP and acknowledged it was not stored properly. He said it was very concerning that it was not stored properly because of the residents respiratory history. He said he would immediately get a plastic bag to store it in. He also observed no date on the CPAP tubing and was not sure when it had last been replaced. He said he was not sure how often the tubing should be replaced. The DON was interviewed on 12/1/22 at 10:37 a.m. He said the CPAP should be cleaned daily with warm water, air dry, and stored in a plastic bag. He said CPAP physician orders should include the settings, frequency of cleaning, and storage. He said the CPAP care plan should include the settings, frequency of cleaning, and diagnoses. He said the MDS assessment should have been triggered for the CPAP use. He said when a resident was admitted , the RT would be notified and the resident should be immediately assessed. The infection preventionist (IP), was interviewed on 12/1/22 at 10:40 a.m. She said the CPAP mask and tubing should be stored at the bedside on a clean surface. She said the tubing and mask should be stored in a bag when not in use. She said the CPAP should be cleaned weekly and as needed. She said the facility should get the manufacturing recommendations for cleaning each resident's CPAP. She said the staff used Sani-wipes (which contain 55% isopropyl alcohol) to clean the CPAP mask and tubing. She said they did not have specific CPAP wipes. She said she was not aware of the manufacturer's recommendation to not use alcohol on the mask. She said she would immediately do an audit and notify the RT to train the staff on the proper cleaning and storage of CPAP machines. The MDS coordinator was interviewed on 12/1/22 at 12:08 p.m. She said she did not trigger the O section of the MDS because there was no physician order for the use of the CPAP. She said the physician order was just entered during the survey and she would add it to the MDS assessment. IV. Resident #52 A. Resident status Resident #52, age [AGE], was admitted on [DATE]. According to the November 2022 computerized physician orders, diagnoses included chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia (low blood oxygen) and obstructive sleep apnea. According to the 10/19/22 minimum data set (MDS), the resident was cognitively intact with a brief interview for a mental status score of 14 out of 15 with no behaviors. The resident required staff supervision for bed mobility, transfers, dressing, eating, toileting, and personal hygiene. B. Resident interview and observations Resident #52 was interviewed on 11/28/22 at 1:48 p.m. The resident said the nebulizer machine was provided by the facility and he used the machine for breathing treatments. The resident said he had not seen any staff clean the machine or the face mask. He said the mask looked dirty to him and was not clean. He said he had not seen any staff change the tubing on the machine. Resident #52 was interviewed again on 11/29/22 at 4:18 p.m. He again said the face mask was still dirty and he had not seen any staff clean the machine. He said he had not seen any staff change the tubing on the machine. C. Record review A physician's order dated 10/13/22 at 9:50 a.m., revealed to administer Ipratropium-Albuterol Solution 0.5-2.5 (3) milligrams/3militers (3ml). The resident was to inhale orally every four hours as needed for shortness of breath or wheezing utilizing a nebulizer and 3 ml inhaled orally twice a day for dyspnea (difficulty breathing). A care plan for the utilization of oxygen therapy related to chronic obstructive pulmonary disease was revised on 10/28/22. Some of the interventions were to administer medications as physician ordered and monitor/document side effects and effectiveness. Staff were to monitor the resident for signs/symptoms of respiratory distress and report to his physician as needed related to respirations, pulse oximetry, increased heart rate (tachycardia), restlessness, diaphoresis (excessive sweating), headaches, lethargy (lack of energy), confusion, atelectasis (collapse of lung), hemoptysis (spitting of blood derived from lungs), cough, pleuritic pain, accessory muscle use and skin color. -The care plan did not reveal how to clean the resident's nebulizer, face mask or when to change the tubing. D. Staff interviews The director of nursing (DON) was interviewed with the NHA on 11/30/22 at 4:44 p.m. The DON said the nebulizer was provided by hospice services on 10/13/22. The DON said the physician orders for cleaning, storage and changing of tubing were obtained on 11/30/22, after the survey started, and there were no previous orders. He said the orders should have been in place prior to the utilization of the nebulizer. The DON said the nebulizer machine, face mask and tubing needed to be cleaned/changed for infection control purposes. The DON said when an order was taken by a nurse, the nurse also had the responsibility to ensure orders were obtained for the cleaning, storage and changing of the tubing for the nebulizer machine. E. Facility follow-up (during the survey) The updated November 2022 computerized physician orders included: The CPO dated 11/30/22 at 8:59 a.m., revealed to change the oxygen and nebulizer tubing each week on Monday, during the day shift. The CPO dated 11/30/22 at 9:49 a.m., revealed to cleanse the nebulizer machine along with the mask every night shift and secure it in a bag.

Based on record review and interviews, the facility failed to ensure five out of five nursing staff members were able to demonstrate skills and techniques necessary to care for residents' needs. Specifically, the facility failed to conduct annual nursing competencies. I. Facility policy and procedure The Competency of Nursing Staff policy, revised May 2019, was provided by the infection preventionist (IP) on 12/1/22 at 3:11 p.m. It documented in pertinent part, All nursing staff must meet the specific competency requirements of their respective licensure and certification. In addition, nurse assistants will participate in a facility-specific competencies-based staff development and training program, and demonstrate specific competencies and skill sets deemed necessary to care for the needs of the residents as identified through resident assessments and described in the plans of care. The facility assessment included an evaluation of the staff competencies that were necessary to provide the level and types of care specific to the resident population. Facility and resident-specific competency evaluations would be conducted upon hire, annually and as deemed necessary based on the facility assessment. II. Record review The employee files for five CNAs (certified nurse aides), were reviewed on 12/1/22 at 12:27 p.m. and did not contain a skills competency checklist. CNA #8's last competency was completed on 8/27/19, CNA #9's last competency was completed on 4/28/2020, CNAs #5, #6, and #7 had no competencies on file. III. Staff interviews The director of nursing (DON) was interviewed on 12/1/22 at 1:50 p.m. He said the staff development coordinator (SDC) was hired in August 2022, but had been out related to health issues. He said at that time the two unit managers stepped in to help. He said the previous week he had asked human resources (HR) for a list of CNAs whose competencies were due. He said the five CNAs missing their competencies must not have been on the list. He said they had an annual skills fair and that was when the competencies were completed. He said the facility did not perform individualized training for the CNAs. He said moving forward he would work with HR to provide accurate lists of annual competencies needed. The nursing home administrator (NHA) was interviewed on 12/1/22 at 3:13 p.m. She said the facility had a turn over of SDCs and HR staff. She said the facility held an annual skills fair in April 2022 to make sure staff was getting their training. She said the training was not individualized but rather a mass training. She said the facility had a new SDC and would work with corporate on a tracking process for annual evaluations and competencies.

Based on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored and labeled in two of four medication carts and one of two storage rooms. Specifically the facility failed to: -Ensure loose medications in cart were properly disposed of; -Ensure temperature of refrigerators were kept within a safe range; and, -Ensure medications were labeled with open dates. Findings include: I. Manufacturer's recommendations According to the Tubersol package insert, retrieved 12/7/22 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. II. Facility policy and procedure The Storage of medications policy, undated, received from the infection preventionist (IP) on 12/1/22 at 12:45 p.m. revealed in pertinent part, The facility stores all drugs and biologics in a safe, secure and orderly manner. Drugs and biologics used in the facility are stored under proper temperatures. Medications requiring refrigeration are stored in a refrigerator located in the drug room at nurses station or other secured location. Medications are labeled accordingly. The nursing staff are responsible for maintaining medications storage, and preparation areas in clean, safe, and sanitary manner. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy. III. Observations and interviews On 12/1/22 at 11:25 a.m. Cart one on the Challenger hallway assigned to registered nurse (RN) #1. The cart contained 21 whole tablets and one half tablet loose in the cart. The nurse was unable to identify any of the loose medications. She did not know who was responsible for maintaining the cleanliness of the medication carts. She said medications needed to be disposed of immediately into a drug buster to prevent medications from harming a resident if they were able to get a hold of it. At 11:30 a.m. Cart two on Alpine hallway assigned to RN #2 revealed three whole tablets and one half tablet loose in the cart. The nurse was unable to identify medications. One Lantus insulin (medication for diabetes) pen was found to be open with no open date. She said the insulin pen should have been dated on opening to ensure staff know when it expires. She said she opened it with this morning dose. She then labeled the insulin pen with an open date of 12/1/22. She said she did not know by who or when the medication carts were cleaned. She disposed of loose pills into drug busters and said medications should be disposed of into drug busters to prevent residents getting wrong medication. The Alpine medication room was reviewed with the IP at 11:45 a.m. Upon opening the medication room a beeping noise was heard. The medication refrigerator was open, the temperature reading was 75 degrees fahrenheit, which was verified by IP. She was unable to determine how long the refrigerator was left open for. The refrigerator contained the following medications: a lock box with Ativan (anti-anxiety medication); emergency kit with Humalog, Humulin R and Lantus insulins (all used to treat diabetes); 30 acetaminophen 650 mg suppositories (fever and pain reducer); two Lantus insulin pens; one Humalog insulin pen; two vials of Humalog insulin; two vials of Turbersol (used to test for tuberculosis); and three bottles of Brimonidine tartrate (eye drops). The IP said all medications need to be evaluated to see if they could be used or if they need to be replaced. She said she would call the pharmacy and determine what needed to be done with variation in temperature. One vial of Tubersol was found opened and undated. The IP said it should have been dated with an open date to ensure it is not used past its expiration date. She said the TB medication needed to be destroyed as the staff are unable to determine when the vial was first accessed. The director of nursing (DON) was interviewed at 12:06 p.m. He said the nurses were responsible for maintaining the cleanliness of the medication carts. The duty of cleaning the cart was not assigned to any specific shift nor did he have any way of ensuring that the carts were maintained clean. He said loose medications in carts should be disposed of into the drug buster as soon as they were not used or found to prevent a resident from getting the wrong medication which could be harmful to their health. He said a vial/pen of insulin should be dated with the open date when first accessed, to ensure staff know when to use the medication by. Insulins should be discarded 28 days after the open date. Tubersol vials also need an open date applied when the initial access occurred to prevent the medication from being used past the expiration date. He said he did not know the expiration date of the Tubersol once opened. He said the unit nurse manager had the responsibility of removing expired medications from circulation on the carts and the medications rooms. The IP was interviewed a second time at 12:40 p.m. She said she called the pharmacy to discuss medications found in the open refrigerator. The pharmacist instructed her that the eye drops medications did not need to be stored in the refrigerator. The emergency kits containing insulin were safe for 24 hours at room temperature. All other insulin medications will be put into circulation today with an expiration date 28 days from 12/1/22. The Ativan was okay to be stored at room temperature for 60 days. The Tubersol would be discarded due to no date and temperature fluctuations.

Based on interviews and record review, the facility failed to ensure an effective quality assurance improvement program (QAPI) to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to resident rights, quality of care, pharmacy services, and infection control. The facility failed to identify quality deficiencies and develop effective action plans to ensure systemic and lasting change and improvements in these areas. Specifically, the QAPI committee failed to identify and address concerns related to resident rights, quality of care, pharmacy services and infection control. Findings include: I. Cross-referenced citations Cross-reference F561: the facility failed to ensure one resident received showers according to their preference. Cross-reference F695: the facility failed to ensure physician orders documented the appropriate care and settings of a continuous positive airway pressure (CPAP) machine; failed to follow manufacturer's recommendations for cleaning the CPAP machine; failed to store the CPAP machine properly; failed to identify the CPAP machine on the resident's minimum data set (MDS); and failed to develop a care plan for the use of a CPAP machine. The facility also failed to obtain physician orders for the use, cleaning and storage of a resident's nebulizer machine. Cross-reference F761: the facility failed to properly label and store medications in medication rooms and ensure medications were stored appropriately in medication carts. Cross reference F880: the facility failed to ensure proper hand hygiene occurred during peri care, clean supplies were not stored in the soiled utility room, air vents were cleaned in the laundry room, high touch areas were cleaned in a resident's room, and scissors were cleaned/sanitized prior to use in wound care. II. Facility policy and procedures The Quality Management Plan/Quality Assurance and Performance Improvement Plan policy, reviewed 11/19/18, was provided by the nursing home administration (NHA) on 11/28/22 at 4:07 p.m. The policy revealed this program was designed to objectively, systematically monitor and evaluate the residents' care and health care services. This comprehensive program was designed to provide care that was optimal within available resources and was consistent with achievable goals. Objectives: To ensure that monitoring quality of residents' care was performed systematically and continuously. To identify the organizational components responsible for Quality Management and QAPI Program functions and to delineate the components which included the line of authority, responsibility and accountability. To assure communication among all departments for the improvement of resident care and identifying problems through the use of on-going monitoring by focusing on identification, analysis, and resolution of problems. To evaluate the results of actions taken by each department and to maximize the use of resources available within the facility. The governing body was responsible for oversight and direction of the quality management program (QMP)/QAPI program. The governing body would be responsible for establishing and approving policies to sustain the facility's QMP/QAPI program and would set expectations around resident safety, rights, choice and respect. The Administrator, or designated chairperson, assumed the responsibility for the program and for assuring that the quality of residents' care was the highest possible by demonstrating performance consistent with established standards and enhancing standards through increasing knowledge, commitment, and improvement of care in a cost-effective manner. The QMP/QAPI committee may include but was not limited to medical director, nursing home administrator, director of nursing, department supervisors, pharmacy consultant, and charge nurses. The committee would meet at least quarterly. The department supervisors would report pertinent information for their departments based on data collected from the various systems and committee meetings. It was the goal of the facility to integrate QMP/QAPI into all care and service areas of the organization. The following will be key areas of focus of the facility: clinical care, quality of life, resident choices and care transitions. Effective performance improvement efforts would focus on the development, maintenance and periodic improvement of systems that influenced organizational outcomes. Systems would be designed and modified to achieve reliable, efficient outcomes. III. Repeat deficiencies F561 for resident self-determination During a recertification survey on 8/12/21, resident self-determination was cited at a E level. During the recertification survey on 12/1/22, resident self-determination was cited at an D level. F695 for resident respiratory/tracheostomy care and suctioning During a recertification survey on 8/12/21, resident respiratory/tracheostomy care and suctioning was cited at a E level. During the recertification survey on 12/1/22, resident respiratory/tracheostomy care and suctioning was cited at a D level. F761 for facility labeling and storage of drugs and biologicals During a recertification survey on 8/12/21, facility labeling and storage of drugs and biologicals was cited at a E level. During the recertification survey on 12/1/22, facility labeling and storage of drugs and biologicals was cited at a E level. F880 infection control During a recertification survey on 8/12/21, infection control was cited at a F level. During the recertification on 12/1/22, infection control was cited at an E level. III. Staff interviews The NHA and the director of nursing (DON) was interviewed on 12/1/22 at 4:00 p.m. The NHA said the QAPI committee met on a monthly basis, on the third Wednesday of the month. The NHA said the attendees to the meeting were the NHA, DON, medical director, pharmacist consultant, activity director, dietary manager, health information manager, staff development coordinator, registered dietitian, social services director, business office manager, director of rehabilitation, medical records staff and a restorative nurse. The NHA said the facility gathered information form grievance forms, committee weekly meetings, resident council meetings, huddles (interdisciplinary team meets with floor staff each morning), 24-hour reports, [NAME] reports (a report of clinical indicators), past hospitalizations, satisfaction survey with residents and families, a weekly clinical report that was sent to the corporate office, clinical quality improvement staff review ten random residents' clinical records each month, mock pre-surveys, and the review of past survey results. They conduct audits to find things that they are not doing well. Any staff member or resident can bring a concern to the QAPI committee. The NHA said the committee analyzed the root cause of the concern by using the 5 Whys ( problem solving methodology that explored the underlying cause and effect of a specified concern) approach. The committee then developed an action plan or a performance improvement plan (PIP) to address the concern. The committee developed specific goals for the PIP. The committee developed interventions to achieve the desired goals for the identified concern. The length of the PIP depended on the goals that were developed and how effective the interventions were working. The NHA said the interventions were effective by conducting a lot of audits and measuring the audits with the established goals. She said once the goals had been met, the audits were spaced further apart to make sure the goals continued to be sustained. The NHA said if the audits demonstrated the goals were not being met, the committee reviewed the action plan and determined new interventions to achieve the desired goals. She said the committee could meet as needed to make any necessary changes to the interventions. She said the PIP was a working document. The NHA said for F561 for resident self-determination for showers. On the last survey dated 8/12/21 the facility was missing the resident's shower preference on admission. She said at this time the facility had a good plan to capture the resident's shower preferences and at times they were not able to provide showers according to their preferences. She said currently some of the issues related to this concern were, at times the bath aides did not show up for work and the facility had to use floor certified nurse aides (CNAs) to provide showers. She said the facility also had shower documentation concerns in the resident's clinical record. She said the staff should document that a shower had been given or refused by the end of their shift. The NHA said for F695, the facility previously had missing physician orders and/or they were not following the physician orders that they received. She said upon admission the facility needed to audit all of the physician orders to ensure they were in place. The NHA said for F761 the facility did audits for a long time and felt that this deficiency was corrected. She said the facility needed to make regular audits to ensure this deficiency was still corrected. The NHA said for F880, the facility had completed audits on infection control. She said she did not remember any of the current concerns with infection control had been identified in the audits.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment in two of two units. Specifically the facility failed to: -Ensure proper hand hygiene during peri-care (providing care to private areas); -Ensure scissors were clean/sanitized before and and after wound care; -Ensure clean supplies were not stored in the soiled utility rooms; and, -Ensure high touch areas were cleaned in resident rooms. Findings include: I. Professional reference The disinfection of medical equipment, updated 5/24/19, retrieved on 12/8/22, from: https://www.cdc.gov/infectioncontrol/guidelines/disinfection/healthcare-equipment.html, documented in part. Equipment; scissors, hemostats, clamps, blood pressure cuffs, stethoscopes should be disinfected with an EPA(Environmental Protection Agency)-registered disinfectant unless the item is visibly contaminated with blood; in that case a tuberculocidal agent (or a disinfectant with specific label claims for HBV and HIV) or a 1:100 dilution of a hypochlorite solution (500-600 ppm free chlorine) should be used. This procedure accomplishes two goals: it removes soil on a regular basis and maintains an environment that is consistent with good patient care. The Hand Hygiene guidance, updated 1/30/2020, retrieved on 12/7/22, from: https://www.cdc.gov/handhygiene/providers/guideline.html, documented in part, Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Before moving from work on a soiled body site to a clean body site on the same patient. According to the environmental cleaning procedures, reviewed 4/21/2020, retrieved on 12/7/22 from: https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html, documented in part, At Least once daily or every 24 hours high touch surfaces are to be cleaned. II. Facility policy and procedures The Handwashing/Hand hygiene policy, undated, received from the infection preventionist (IP) on 12/1/22 at 3:11 p.m. revealed in pertinent part, The facility considers hand hygiene the primary means to prevent the spread of infection. The use of an alcohol-based hand rub or soap and water for hand hygiene after following situations; before moving from a contaminated body site to a clean body site during resident care; after removing gloves; and, after handling used dressings or contaminated equipment. The Standard Precaution policy, undated, received from the IP on 12/1/22 at 3:11 p.m. revealed in pertinent part, standard precautions presume that all body fluids, secretions, and excretions, non intact skin and mucous membranes may contain transmissible infectious agents. Resident care equipment, reusable equipment is not used for the care of more than one resident until it has been appropriately cleaned and reprocessed. The Cleaning and Disinfecting Residents' Rooms policy, undated, received from the IP on 12/2/22 at 11:08 a.m. revealed in pertinent part, clean horizontal surfaces (bedside tables, over bed tables, and chairs) daily with cloth moistened with disinfectant solution. III. Infection control failures On 11/29/22 at 1:05 p.m. the soiled utility rooms on the Alpine and Challenger hallways were storing clean supplies that included boxes of unopened gloves, lotion, denture tablets and peri care cleanser. This room also contained a hopper where soiled linens were cleansed prior to sending to laundry. On 11/30/22 at 9:30 a.m. the soiled utility rooms on both Alpine and Challenger halls had clean supplies stored in them like boxes of unopened gloves, lotion, denture cleansing tablets, and peri care cleansers. The soiled utility rooms contained a hopper. At 10:00 a.m. certified nurse aide (CNA) #4 provided peri care to a female resident. She failed to change gloves after touching and handling potentially contaminated surfaces and moving to handling clean surfaces. She used dirty gloves to put away clean cleansing wipes in the night stand and covered the resident with a blanket of her choice. She removed gloves and handed the resident a Pepsi, collected trash and applied sanitizer on exit of the room. At 10:00 a.m. wound care observation with licensed practical nurse (LPN) #2 was provided to Resident #22. The LPN brought in all the supplies for wound care. She placed a barrier pad on the bed, placed wound care supplies on it. She then pulled a pair of scissors from her pocket and placed them on the barrier pad. She provided wound care, using the scissors to cut a piece of alginate (specialized dressing for wounds) to be placed in the open wound. Upon completion of wound care, the scissors were cleaned with a sani-cloth (germicidal disposable wipe). LPN #2 was immediately interviewed after the observation said the scissors were her own scissors and she cleaned them with the sani-cloth after wound care to disinfect. She stated she used the scissors for multiple things throughout her shifts. LPN #4 was present during the wound care interview and she stated she was unaware of sani-cloth not disinfecting the scissors enough. CNA #4 was interviewed on 11/30/22 at 10:27 a.m. She said peri care was provided with a collection of supplies, washing of hands, applying gloves, providing care from front to back with a clean section of peri wipes used for each wipe, applying a new brief and removing gloves at end of care and then sanitizing hands. Changing of gloves in the middle of care only occurs if gloves appear to be soiled with a bowel movement. At 10:32 a.m. the housekeeper (HSK) was observed cleaning a resident room [ROOM NUMBER]. She failed to clean high touch areas like door handles, bedside tables, remotes and call lights. The HSK was interviewed immediately after the observation. She said housekeepers normally clean high touch surfaces daily but due to staffing she was the only one cleaning rooms that day and had to get through all the rooms. IV. Administrative interviews The IP was interviewed on 11/30/22 at 1:30 p.m. She said when performing peri care on the resident, the CNA should change their gloves and perform hand hygiene after cleaning the soiled surfaces and prior to applying clean items like a new brief or touching resident personal items. The IP said wound care supplies should be resident specific and kept in the treatment cart in a ziplock bag with the residents name on it. Items returned to the cart should be cleaned with sani-cloth if appropriate. She was not aware of scissors needing to be resident specific and how to properly clean scissors to prevent group A Streptococcus (a type of bacteria) if items are to be shared among residents. The IP observed the clean items being stored in the soiled utility room and she said they should have been stored in the clean utility room. When storing clean items in the soiled utility room they become contaminated especially with the use of the hopper in the room. The hopper could create a splash back and travel onto other items. The director of nursing (DON) was interviewed on 12/1/22 at 9:50 a.m. He said hand hygiene should be completed at the beginning and at the end of peri care being provided to a resident. CNAs were to change gloves only when visibly soiled. The CNA should wash hands prior to touching resident personal items, especially after peri care was provided. He said clean supplies should not be stored in the soiled utility rooms. They should be in the clean utility room or in central supply. He said high touch items like bedside tables and door handles should be cleaned daily. He said wound care items were stored in the treatment cart. Each resident was to have their own individual bag for supplies. Scissors should not be shared amongst residents or other tasks. They should be resident specific as well. Scissors should not be kept in nurses pockets. The housekeeping supervisor (HSKS) was interviewed on 12/1/22 at 10:45 a.m. He said high touch areas in resident rooms should be cleansed daily including bedside tables, remotes, and door knobs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to prevent misappropriation of property for two (#6 and #15) of 12 residents reviewed for missing property, out of 37 sample residents. Specifically, the facility failed to: -Ensure Resident #6's new lock box was secured after her previous lock box with money went missing; and, -Prevent an agency staff member from taking rings from Resident #15. Findings include: I. Facility policy and procedure The Abuse policy, last revised 10/28/2020, was provided by the nursing home administrator (NHA) via email on 8/8/21 at 3:04 p.m. It read in pertinent part, (The facility) does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers, and staff of other agencies serving the resident, family members, legal guardians, resident representative, sponsors, friends, or any other individuals. -Misappropriation of resident property is defined as the deliberate misplacement, exploitation or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. Misappropriation includes, but is not limited to theft, fraud, and financial exploitation. -The facility did not have a policy regarding resident property. II. Resident #6's missing lock box A. Resident status Resident #6, age [AGE], was admitted on [DATE]. According to the August 2021 computerized physician orders (CPO), diagnoses included Parkinson's disease, chronic obstructive pulmonary disease (COPD), and anxiety disorder. The 5/6/21 minimum data set (MDS) assessment revealed the resident had no cognitive impairments with a brief interview for mental status (BIMS) score of 14 out of 15. She required supervision and one person physical assistance for bed mobility, transfers, walking in her room, toileting, and personal hygiene. She required limited assistance with one person physical assistance for dressing. She was independent in locomotion on and off the unit. B. 2/7/21 Facility investigation The nursing home administrator (NHA) provided the facility's 2/7/21 misappropriation investigation regarding Resident #6 on 8/10/21 at 11:11 a.m. The investigation revealed Resident #6 reported her lock box, which contained $160.00, was missing on 2/7/21 and felt someone had taken it. The resident was interviewed by the previous NHA on 2/9/21 at 6:30 p.m. The resident was very upset that her lock box was missing. The resident said she thought she last saw the box on 2/7/21. The resident said she did not see anyone take the box. The previous NHA completed a room search with the resident's permission and checked the laundry room but was unable to locate the lock box. Eight other residents were interviewed about missing items and four staff members were interviewed. The eight residents had no concerns with missing items. Three of the four staff members were aware of Resident #6's lock box and one of the staff said she remembered seeing the resident's lock box on 2/5/21. The facility substantiated the allegation of misappropriation of property because the facility failed to secure the lock box, making it easier for the lock box to be taken or misplaced. The facility's follow-up was to have maintenance staff ensure all lock boxes were secured. The facility reimbursed the resident $160.00 and provided her with a new lock box. C. Resident observation On 8/11/21 at 10:30 a.m. the resident was in her room in her bed. The resident refused to be interviewed. The resident's grey metal lock box was sitting on top of a puzzle on her bedside table and it was not secured as indicated in the investigation (see above). D. Staff interviews The NHA and quality improvement specialist (QIS) were interviewed on 8/11/21 at 1:07 p.m. The QIS said Resident #6 was reimbursed for her missing money and the lock box and that maintenance staff were supposed to secure the lock box to furniture after the incident. The QIS said maintenance staff drilled the lock box into the resident's closet today and was not sure why it had not been completed in February (2021) after the initial incident. -The facility failed to provide the necessary follow-up to ensure the resident's new lock box was secured and could not go missing or be misappropriated. E. Facility follow-up On 8/12/21 at 9:49 a.m. the resident was in her room in bed. The resident showed the surveyor that her metal lock box had been bolted down inside of her closet. The resident showed the surveyor that she had the key to the lockbox on a lanyard around her neck. The resident said she was satisfied with the new placement of the lock box. III. Resident #15's missing rings A. Resident status Resident #15, age [AGE], was admitted on [DATE] with a readmission date of 2/17/21. According to the August 2021 computerized physician orders (CPO), diagnoses included dementia without behavioral disturbance, congestive heart failure, and post-traumatic stress disorder. The 5/20/21 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of zero out of 15. She required extensive assistance and two person physical assistance for bed mobility and transfers. She required extensive assistance and one person physical assistance with dressing, toileting, and personal hygiene. B. Family interview Resident #15's family member was interviewed over the phone on 8/9/21 at 9:51 a.m. The family member said an agency certified nurses aide (ACNA) stole some rings off the resident's finger in April 2021. He said the facility filed a report about the incident but he was never provided information to be able to pursue criminal charges. He said he had pictures on his phone of the resident wearing the rings and then around the Easter holiday he noticed they were gone. He said the resident told him a lady pulled on her fingers in the middle of the night and took her rings. He was very upset that the rings were gone as they held sentimental value and he could never replace them. C. Facility investigation The nursing home administrator (NHA) provided the facility's 4/23/21 misappropriation investigation regarding Resident #15 on 8/10/21 at 11:11 a.m. The investigation revealed Resident #15's rings were reported to be stolen by the resident's family member. Resident #15 was interviewed by the previous assistant director of nursing (ADON) on 4/27/21 at 2:20 p.m. Resident #15 reported that she woke up and someone was going through her dresser drawers. She went back to sleep, but then she woke up and someone was pulling on her fingers. She reported it was a little black lady. She said she was still wearing the rings when asked what happened to them (resident had severe cognitive impairments, as mentioned above). Four other residents and the resident's roommate were interviewed. None of the residents had any concerns about missing items. Two staff members were interviewed. Licensed practical nurse (LPN) #1 revealed in her interview that the resident's family member reported to her on 4/24/21 that the resident's two rings were missing. LPN #1 said the family member reported to her that the resident said a little Mexican girl was going through my drawers. LPN #1 reported the issue to the social services department. LPN #6 revealed in her interview that the resident's family member voiced concern that the resident said a Mexican girl came in and took my rings off while I was sleeping and went through my stuff. The family member also said he was not accusing anyone of anything but that the resident seemed to have a good memory of what happened. The facility substantiated the allegation of the missing rings. The investigation report revealed the facility was unable to determine who may have taken them, however, the report also revealed that the suspected agency staff was taken off the facility schedule and the facility notified the agency staff's employer of the incident. D. Staff interviews The NHA and quality improvement specialist (QIS) were interviewed on 8/11/21 at 1:07 p.m. The NHA said that based on the facility investigation and the resident's description, they believed ACNA #4 may have taken the rings. The NHA said they notified the staffing agency and the police of the allegation and ACNA #4 was suspended pending investigation. The NHA said the facility was unable to interview ACNA #4 because the agency conducted their own investigation. The NHA said she did not have information regarding the outcome of the agency's investigation but did learn that ACNA #4 was no longer employed with the agency. The QIS said ACNA #4 was also reported to the board of nursing. The NHA said the resident's family member did not want to be reimbursed for the missing rings, he just wanted to ensure that ACNA #4 would not be able to do the same thing to anyone else.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to provide care and services to prevent the development and worsening of pressure injuries for two (#15 and #54) of four residents reviewed out of 37 sample residents. Specifically, the facility failed to: -Notify the physician of a new toe wound, developed from a brace, to obtain treatment orders for Resident #54; and, -Prevent the development of a pressure wound to Residents #15's back when her air mattress deflated, and she was lying on her oxygen tubing. Findings include: I. Facility policy and procedure The Pressure Injury Prevention policy, revised 10/9/19, was received from the quality improvement specialist (QIS) on 8/12/21 at 10:40 a.m. The policy documented in pertinent part, a pressure injury is any lesion caused by unrelieved pressure that results in damage to underlying tissue(s). Although friction and shear are not primary causes of pressure injuries, friction and shear are important contributing factors to the development of pressure injuries.A pressure injury can occur wherever pressure has impaired circulation to the tissue. Critical steps in pressure injury prevention and healing include: identifying the individual resident at risk for developing pressure injuries, identifying and evaluating the risk factors and changes in the resident's medical condition, identifying and evaluating factors can be removed or modified,implementing individualized interventions to attempt to stabilize, reduce or remove underlying risk factors, monitoring the impact of interventions, and modifying the interventions as appropriate. It is important to recognize and evaluate each resident's risk factors and to identify and evaluate all areas at risk.When a pressure injury is identified the nurse will obtain a physician order and initiate a prescribed treatment. II. Resident #54 A. Resident status Resident #54, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the August 2021 computerized physician orders (CPO), diagnoses included, diabetes mellitus (DM), peripheral vascular disease, non-pressure chronic ulcer of other part of foot (ankle), fracture of the right lower leg, and stage three pressure ulcer of the right heel. The 7/24/21 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. Resident #54 required extensive one person assistance with bed mobility, dressing, toileting and personal hygiene. She required supervision with transfers and walking in the corridors. The MDS assessment documented she was not at risk of pressure ulcers, and had a history of diabetic foot ulcers. B. Observations and interviews On 8/11/21 at 3:00 p.m. licensed practical nurse (LPN) #4 was observed providing wound care to Resident #54. Resident #54 had a chronic wound to her right lower leg and her right middle foot. Additionally, a circular wound was observed to the top of her right second toe just above the second joint. The wound was red and moist, with macerated (white due to moisture) edges. There was moderate serosanguinous (blood and fluid) drainage. The resident stated the wound developed last week due to pressure and rubbing on her brace when she walked. LPN #4 said she had observed the wound last week but it was worse now. She said the wound was very wet now. It was drier last week. LPN #4 said she did not know what to put on the wound. She said she had not notified the resident's physician of the wound for treatment when she found the wound last week. She said the resident was seen by an outside wound care center every three weeks, rather than the wound care company that came to the facility. She then left the room to find the director of nursing (DON) to ask her what to put on the wound. In the bed with the resident were scissors and a roll of tape. On the bedside table, with the residents personal belongings, a drink, crumbs, and papers, were the wound dressings. There was no clean field set up under the supplies. Some of the dressing rested directly on the table (cross-reference F-880, infection control). LPN #4 returned to the room after a few minutes with the DON. She performed hand hygiene and put on gloves. She measured the wound, and said it was 0.9 cm x 1.5 cm. LPN #4 then took gauze, a spray wound cleanser, and cleaned all of the wounds. She did not perform hand hygiene or change gloves after cleaning the three wounds. She then picked up a dressing from the bedside table and placed it over the wound on the right lower leg (cross-reference F-880, infection control). She asked the DON if she should put the same dressing on the new wound on the toe. The resident then said to the DON, the wound was from rubbing on her brace. The DON agreed with the resident. The DON told LPN #4 to call the physician to see what treatment they wanted to order. The facility failed to notify the physician and obtain treatment orders for a new wound, which was now, according to LPN #4 and the resident was larger. The facility knew the resident was at risk of poor wound healing with her diagnosis of peripheral vascular disease, DM, history of stage three pressure ulcer to the right heel, and slow healing of a chronic wound to her right lower leg (see record review below). -However, they failed to take timely action when a new wound developed to her right toe from her brace. The DON was interviewed on 8/11/21 at 3:16 p.m. She said the facility did not have a wound care team. She said LPN #4 and herself did wound rounds with a wound care physician that came in weekly. She said neither she nor LPN #4 were wound certified and she could not stage the wound. She said it was from pressure. She said Resident #54 was seen by her own outside wound care physician every three weeks. The DON said when the nurse found the new wound last week she should have called the resident's wound care physician or primary physician for treatment. She said the nurse should assess and document a description of the wound including size, color, and darianage. She acknowledged LPN #4 said the wound was now larger and draining. She said when a nurse found a wound they should notify the DON, the provider for orders right away, and notify the residents representative if there was one. Additionally, she said the nurse should write it on the new 24 hour report the facility had started. The DON said the facility had many broken systems. She said LPN #4 failed to follow through, and there was a lack of communication. She said the facility had to get get back to basics and follow up. The DON said she believed the resident who said the wound was due to her brace. The DON was interviewed again on 8/11/21 at 5:05 p.m. She confirmed the area was due to pressure and the facility was aware of it from last week. She and LPN #4 provided documentation of the size of the wound from 8/4/21. She said the LPN did not notify her or the physician last week when the wound was found on 8/4/21. The DON said there were no orders for treatment, but she was waiting to hear from the physician for treatment orders tonight. The QIS was interviewed on 8/11/21 at 533 p.m. She said the facility would have the wound care company they have a contract with, look at the wound via telehealth that evening. -However, the resident was not followed by the facility contracted wound care company. She had her own wound care physician that she saw outside the facility. The QIS was interviewed again on 8/12/21 at 10:17 a.m. She said the physician who worked for the facility contracted wound care company and would like to discuss the wound. She said he had not seen the wound, but had an opinion on the wound. She said he believed the wound was vascular. However, the the resident, DON, and LPN #4 said it was due to the boot. Additionally, the facility did not follow up on the wound and notify the physician on 8/4/21, and the wound was worse. A voice message was left for the facility's contracted wound physician on 8/12/21 at 4:05 p.m. There was no return call. C. Record review LPN #4 provided a paper document titled Skin report, Non pressure Wounds. On 8/4/21, the form documented right second toe 0.8 x 0.6 cm scab. On 8/11/21, the form documented, right second toe, 0.9 x 1.5 cm. there was no further description. -The box on the form for pain yes or no was blank on both days. The box for the date acquired, treatment and type of wound was blank for both weeks. The nursing progress notes were reviewed. There was no documentation of a wound to the resident's second toe until 8/11/27 at 3:27 p.m. after the observation of wound care. The nurse note at that time documented, Call placed to wound clinic in regards to open area on right second toe. Order received to cleanse wound, apply betadine and cover with band-aid three times weekly. -There was no further description of the wound. The pressure ulcer skin assessment risk (Braden) dated 7/22/21 was reviewed. The form documented the resident was at risk for pressure ulcers due to limited mobility, friction and shearing. The skilled nursing skin assessment dated [DATE] at 2:31 p.m., documented the left foot was bandaged and the dressing was clean, dry and intact. -However, the previous wounds were on the right foot, and there was no further documentation of the existing or new wound. The skin integrity care plan dated 9/6/2020, documented in pertinent part, I have alterations in my skin integrity including diabetic ulcerations to my right ankle and foot and I'm at risk for pressure injuries with a history of a healed/resolved pressure injury to my heel. My strength: I am able to communicate my needs to staff. Administer treatments as ordered and monitor for effectiveness. Resident goes to wound clinic weekly.Assess/record/monitor wound healing weekly. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Avoid positioning the resident on right heel- wears custom orthotic. Educate the resident/family/caregivers as to causes of skin breakdown; including:transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Elevate right leg on pillows to level of comfort- encourage to keep at or above level of heart. If the resident refuses treatment, confer with the resident, IDT (interdisciplinary) and family to determine why and try alternative methods to gain compliance. Document alternative methods. Inform the resident/family/caregivers of any new area of skin breakdown.Monitor nutritional status. Serve diet as ordered, monitor intake and record. Monitor pain level prior to, and during, treatment and treat pain as per orders to ensure the resident's comfort as needed. Monitor/document/report PRN any changes in skin status. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow. -However, the resident was not going to the outpatient wound clinic weekly, she was going every three weeks, and the facility failed to report changes in the skin status as documented in the care plan. Additionally, the care plan documented the resident wore a custom orthotic. There was no documentation of the surgical walking boot she was wearing at all times. The physician's orders were reviewed on 8/11/21 at 12:15 p.m. There was a physician's order dated 6/3/21, Keep surgical boot in place at all times except for dressing changes. On 8/11/21 at 3:26 p.m. There was a new physician's order to Cleanse wound right 2nd toe, apply betadine and cover with band-aid. The wound notes from Resident #54s outpatient wound clinic were reviewed. A wound note dated 7/28/21, documented the resident had a wound to the right lower leg, right middle foot, and right back of foot. The resident was to wear a surgical boot while ambulating. -There were no notes regarding a wound to the right toes. D. Facility follow-up On 8/12/21 at 1:41p.m. After the survey, the facility submitted a physician's assistant (PA) note dated 8/12/21. The note documented in pertinent part, Seen and examined today for evaluation of open area right second dorsal toe. WBAT (weight bearing as tolerated) to RLE (right lower extremity). Ulceration of right second dorsal toe noted yesterday.On exam open area present to dorsal right 2nd toe 1x 0.8 x0.1 cm. Minimal drainage. No purulence or odor. No erythema or warmth of surrounding area. Etiology of wound is vascular in nature, and due to her chronic peripheral angiopathy. Potential complicating factor for wound healing is DM dx. Discussed with pt - Resident #54 feels ulceration looks much better today than it did yesterday. Discussed benefit of keeping area non-macerated - dress with calcium alginate cut to size of wound bed, and secure in place with foam dry dressing bandaid. Change MWF (Monday, Wednesday, and Friday) and as needed. Pt is scheduled to see wound care MD that she routinely follows with at (wound clinic) next Wednesday. -However, Resident #54, BIMS of 15, LPN #4 and the DON, said the boot was rubbing her toe and caused the wound. Additionally, the ulceration of the toe was not noted yesterday as documented in the PA note. The wound was observed and documented by the facility on 8/4/21. Nevertheless, the facility failed to treat timely a wound to Resident #54's right second toe. The resident was at known risk of skin breakdown. The facility wound physician was interviewed on 8/18/21 at 9:59 a.m. via telephone. He said he had not seen the resident's wound, but had reviewed the PA note from 8/12/21. He said he thought the wound might be vascular, but it could be pressure from the boot. He was not sure. He said he had recommended the facility get orders for vascular studies to rule out a vascular wound. III. Resident #15 A. Resident status Resident #15, age [AGE], was admitted on [DATE]. According to the August 2021 computerized physician orders (CPO), diagnoses included congestive heart failure, polyneuropathy, epilepsy and dementia. The 5/20/21 minimum data set (MDS) assessment revealed the resident was unable to complete a brief interview for mental status (BIMS). According to the physicians assistant (PA) note dated 7/29/21, she was confused with a BIMS of 11, and able to make her needs known. Resident #15 required extensive two person assistance with bed mobility and transfers. She required extensive one person assistance with dressing, toileting, and personal hygiene. She was at risk of pressure ulcers. B. Observations and interviews On 8/9/21 at 2:07 p.m., Resident #15 was observed with LPN #5. Resident #15 had an undated foam bandage on her left upper back, to the left of her spine. LPN #5 peeled up one side of the undated bandage. There was moderate serosangious drainage on the bangade. Resident #15 had an approximately 2.0 cm irregular shaped purple area with an approximately 0.5 cm open area in the center. LPN #5 replaced the same dressing. She said she did not know when the dressing had been placed on the wound as there was no date. She said the day nurse told her the dressing was covering a mole the resident had. The DON was interviewed on 8/10/21 at 2:14 p.m. She said she was notified of the wound to Resident #15 around 5:00 p.m. or 6:00 p.m. on 8/7/21. She said the night certified nurse aide (CNA) from 8/6/21 to the morning of 8/7/21 was interviewed. She said the CNA told her the mattress was inflated and fine at 4:00 a.m. She said at 7:00 a.m. or 7:30 a.m. (three to three and half hours later), the mattress was observed to be deflated and the nasal cannula was off the resident. She said the resident removed the oxygen sometimes. The DON said she thought maybe the bed became unplugged during care around 4:00 a.m., when the CNA saw her. The DON said she thought it might be a stage one pressure injury from laying on the wound. She then said the top layer of skin appeared to be gone and it had been bleeding, and therefore she thought it was maybe stage two. She said the wound physician would be in on 8/11/21, and would see the wound. On 8/11/21 at 5:04 p.m. , the DON was interviewed again with LPN #4. The DON said the wound care physician said he agreed it was a stage two pressure injury. He gave orders for Medihoney and dry dressing. LPN #4 said she thought it was no longer a deep tissue injury, the purple area had gone down, but the wound had opened. C. Record review The August 2021 physicians orders were reviewed. Resident #15 had the following orders: -Low air loss mattress, setting: alternating pressure, comfort level 4 every shift for skin breakdown, dated 8/10/21. -Monitor wound to mid back daily every day shift. Cleanse w/NS (normal saline) and apply bordered gauze daily in the afternoon, dated 8/10/21. The facility contracted wound physician notes were received from the DON on 8/11/21 at 5:11 p.m. The physician documented the upper back wound was a stage one to stage 2. The size was 1.7cm x 1x6 cm x0.1 cm. There was scant drainage and the periwound was bruised. He ordered a Medihoney treatment and dry dressing to be done every other day. On 8/7/21 at 6:37 p.m. The nurses noted documented in pertinent part, open area to her mid back with bruising surrounding it. The pt (patient) was noted to be laying on her oxygen nasal cannula with it on. The wound measured 2cm x 1cm and was cleaned with NS, patted dry, and covered with a foam border dressing. The pt was also noted to have a bruise measuring 1.7cm x 1.3cm to the inner left elbow. DON, family, and MD notified. This nurse passed along to CNAs and oncoming staff to verify placement of all nasal cannulas. The last skin risk assessment (Braden) dated 5/19/21, documented the resident was at risk for skin breakdown due to immobility, shearing and friction, inadequate nutrition and moisture. On 8/8/21 at 10:08 p.m. The nurses note documented a left arm bruise and open area to mid back. On 8/9/21 at 8:16 p.m., the risk management note documented, Bruise on left upper/inner arm and bruise with small skin tear to mid back. Root Cause: Resident laying on her nasal cannula and air mattress deflated. Treatment required: mid back skin tear cleansed with normal saline and applied bordered gauze.Interventions put into place: Nursing staff to frequently check resident has not pushed her nasal cannula off over her head to her back and that air mattress is plugged in. The bruise/skin risk injury care plan, dated 7/19/21 was reviewed. On 8/9/21 (during survey), the care plan was updated to include nursing staff including CNA's to check for risk for bruising, specifically that the nasal cannula is on properly and the resident has not pushed it back over her head, and the air mattress is inflated. D. Facility follow-up On 8/13/21 at 1:41p.m., again after the survey, and six days after the wound occurred, the facility submitted a nurse practitioner note dated 8/13/21 at 11:46 a.m. The note documented in pertinent part, The nursing staff asked if I could identify the patient's wound on her upper back. Per nursing staff patient was laying on a deflated mattress for a while and her oxygen tubing was underneath her. The nurse pulled the oxygen tubing which also opened up the wound. I looked at the opened wound. It appears to be a mole with irregular brown shape around the edge. There is no mark of oxygen tubing on her skin. Per my assessment the wound does not look like a pressure ulcer. Patient is followed up by a dermatologist. -However, the facility's wound physician documented on 8/11/21, it was a pressure ulcer.

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety. Specifically, the facility failed to: -Ensure the storage of food in the nourishment/snack freezers was not stored with ice packs for residents in three out of four freezers; and, -Ensure all food items are labeled with date opened and resident name if a resident specific food item, and discard any opened, unlabeled, undated food items. Findings include: I. Facility policy and procedure The Food Receiving and Storage policy and procedure, revised December 2008, was provided by the registered dietitian (RD) on 8/11/21 at 11:33 a.m. It read in pertinent part, Food items and snacks kept on the nursing units must be maintained as indicated below: -All food items to be kept below 40 degrees F must be placed in the refrigerator located at the nurses ' station and labeled with a ' use by ' date. -All foods belonging to residents must be labeled with the resident's name, the item and the 'use by' date. -Refrigerators must have working thermometers and be monitored for temperature according to state-specific guidelines. -Beverages must be dated when opened and discarded after twenty-four hours. -Other opened containers must be dated and sealed or covered during storage. -Partially eaten food may not be kept in the refrigerator. -Medications, blood or blood products may not be stored in the same refrigerator with food. II. Snack and nourishment freezers on the nurse units A. Observations and staff interviews On 8/11/21 at 10:41 a.m. the refrigerator in the activity office was observed. Ice packs for resident use were observed in the freezer next to resident food. Two gatorade drinks were found in the freezer, they were opened but not dated or labeled. One gatorade drink was found in the refrigerator, opened but not dated or labeled. The freezer was not clean with a green/blue colored syrup on the floor of the freezer. The AA #2 said the refrigerator/freezer in the activities office was used for residents' snacks and nourishment. The AA #2 said the gatorade drinks belonged to a staff member. The AA #2 said the staff have a cleaning schedule for once a week and it would be cleaned later that day. The RD joined the interview and said all food items, snacks, and drinks should be labeled and dated. The RD said the ice packs may not have been used on a resident but only for resident lunches. She said that some of the ice packs came with the chocolates for the activities department but acknowledged they were still stored with resident snacks in the freezer. The pickles, mayonnaise, ranch dressing, and chili paste were not labeled or dated. The RD acknowledged these items were not labeled or dated and discarded the items. She said many of the unlabeled items in the refrigerator/freezer were for personal staff use. The RD said she would do some staff education today and create signage. The Challenger Point nurse unit refrigerator was observed. Multiple ice cream cups in the freezer were stored alongside six ice packs. The RD said she thought the ice packs were for keeping food cold. Licensed practical nurse (LPN) #4, also the unit manager, said after viewing the ice packs, that they are used by the residents for pain. LPN #4 said the nursing staff disinfects them after use, and also uses the ice packs for lunches when a resident was going to dialysis. The Alpine Meadow nurse unit refrigerator was observed. Twelve ice cream cups used for residents were stored alongside three ice packs in the freezer. The RD acknowledged the improper storage of resident ice packs with food in the freezers. III. Facility follow-up On 8/11/21 at 1:01 p.m. the RD provided documentation of signage that will be placed on all refrigerators/freezers in the nurse units and activity department. It read in pertinent part, All opened food/beverages must be labeled with resident name, date, and food/beverage item name. All foods will be discarded after three days. Absolutely no employee food/beverage is allowed in the refrigerator. All items not properly labeled will be gone. The RD provided documentation of education for nursing, activities, and food and nutrition services department on the topic of food storage, including labeling with date and name, cleaning and type of cleaner, and that ice packs for resident use will be stored in a non-food refrigerator/freezer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review; the facility failed to honor resident choices for three (#9, #10, and #57) out of eight resident's reviewed for self-determination. Specifically, the facility failed to: -Ensure Residents #9, and #10 received showers according to their choice of frequency; -Ensure Resident #9 received a minimal standard of nail care according to the resident's choice; and -Honor Resident #57 choice to stay in bed. Findings include: I. Facility policy and procedure The policies and procedures for bathing and activities of daily living (ADLs) were requested on 8/11/21 at 12:35 p.m. However, the quality improvement specialist (QIS) said, The facility does not have those policies, we follow general standards of practice. II. Resident #9 A. Resident status Resident #9, age [AGE] , was admitted on [DATE]. According to the August 2021 computerized physician orders (CPO), the diagnoses included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke), and dementia with behavioral disturbances. The 5/13/21 minimum data set (MDS) assessment revealed the resident with severe cognitive impairment with a brief interview for mental status score of five out of 15. He required extensive assistance with one person physical assistance for bed mobility, transfers, wheelchair mobility, dressing, toilet use, and personal hygiene. Supervision of one person for eating. Total dependence with one person required for bathing. B. Resident interview and observations On 8/8/21 at 1:05 p.m. Resident #9's fingernails, on both hands, were untrimmed, jagged and not clean with yellow and brown stains. Resident #9 shook his head yes and said he would like them trimmed when asked. On 8/11/21 at 11:25 a.m. Resident #9 said yes he would like his nails trimmed. Observed very long jagged nails (approximately one inch) yellow, brown, and dirty on both hands. The resident had a shower yesterday and they were not trimmed at that time. On 8/11/21 at 4:00 p.m. RN #3 observed and acknowledged Resident #9 long, jagged, dirty fingernails and said yes definitely his nails should be trimmed. She said not trimming his nails could be harmful to himself, or others due to the sharpness. She said in addition it's more comfortable and hygienic for the resident to have them trimmed. RN #3 immediately went and got an emery board board and began filing. She then went and got multiple emery boards and said it was going to take awhile due to how long the nails were. As RN #3 worked on the nails, Resident #9 said it's feeling better. On 8/11/21 at 4:14 p.m. the DON observed and acknowledged the residents' long, jagged, dirty nails and said yes, of course those should have been trimmed. She said if they were not trimmed they risked injury to his skin or to others. She said infection control with hand and nail hygiene is very important. She said the nails should be kept clean and short. Resident #9 was interviewed on 8/12/21 at 8:46 a.m., he said his nails felt more comfortable since they were trimmed. He said he would like more showers, he suggested four per week by holding up four fingers, however he said two per week would be ok. He said he is not sure why he does not even have two showers per week. He shook his head no and said there is not enough staff to get the help he needs. (Cross-reference F725 failure to provide sufficient staffing). He was wearing a dirty shirt with food stains. He said he had finished eating breakfast and had fed himself. C. Record review The CPO revealed no orders for nail care or showers. The progress notes revealed no documentation of nail care, or showers. The care plan revealed no plan regarding nail care. The care plan revealed that the resident prefers his showers twice a week on Tuesday and Thursday in the morning. Date Initiated: 1/24/2019. The [NAME] (electronic medical record that gives a brief overview of a resident) dated as of 8/11/21, report reveals, ADL-Bathing twice a week as requested by resident on Wednesday and Sunday. The point click care (PCC) medical record task section revealed no nail care in the last 30 days. There was also no documentation of refusals. The PCC medical record task section revealed that Resident #9 received four showers in the last 30 days; 7/19; 7/28; 8/5; 8/10 (during survey). For an average of less than one shower per week. No resident refusals were documented. -In the past 90 day from 5/8/21 to 8/10/21, there were a total of 12 showers given; 5/14; 5/18; 5/21; 5/25; 5/28; 6/1; 6/11; 6/18; 7/19; 7/28; 8/5; and 8/10. Resident #9 preferred showers twice per week but only received 12 out of 28 opportunities.No resident refusals were documented. D. Staff interview The QIS was interviewed on 8/11/21 at 3:54 p.m. She said showers were recorded in multiple places. In a perfect world it would all be in point click care (PCC), however it's a hybrid system now. Some on paper. The staff scheduler (STS) said she now gets the paper sheet and she adds it to the PCC. Before that the papers went to the director of nursing (DON) office. The QIS said if a nurse needs information to ensure resident ADL care/showers they would need to look in multiple locations to gather information on their residents. -At 5:00 p.m. the QIS confirmed that she had provided all the documentation that they had regarding showers and ADL care. RN #4 was interviewed on 8/11/21 at 4:20 p.m. She said they occasionally do showers in the evening and sometimes there is an evening shower aide, but there was not one scheduled for that evening. Certified nurse aide (CNA #6) was interviewed on 8/11/21 at 4:30 p.m. she said she occasionally does showers in the evening if the day shift CNA let's her know they are needed. She said if a resident refuses a shower she let's the nurse know right away. She said if they do have a shower, she documents any skin issues on a slip of paper and gives it to the nurse, and then she documents the shower in the computer task section. IV. Resident #57 A. Facility reported incident on 7/7/21 The nursing home administrator (NHA) provided the facility investigation on 8/10/21 at 9:09 a.m. regarding an allegation of staff physical abuse made by Resident #57 on 7/7/21. The investigation included an interview with Resident #57, interviews with the two agency certified nurse's aides (ACNAs) mentioned in the allegation, and six other resident interviews. The resident alleged that two ACNAs helped her to the edge of her bed and were shaking her arms. The resident said she was not scared of them. The two ACNAs (#1 & #2) were interviewed by the NHA on 7/7/21. ACNA #1 said she and ACNA #2 assisted the resident to the edge of the bed to provide incontinence care and help transfer her into her chair. ACNA #1 said the resident did not want to get out of bed but she (ACNA #1) was told by the nurse that they had to get the resident up. ACNA #1 said she and ACNA #2 did not shake the resident's arms but did put their arms underneath the resident's arms in order to transfer her to the chair. ACNA #2 said Resident #57 ate breakfast in her room and mentioned that she wanted to get up to see her husband. ACNA #2 said she and ACNA #1 provided incontinence care and then transferred the resident into her wheelchair. -However, ACNA #2's interview contradicted ACNA #1's interview regarding whether the resident did or did not want to get out of bed at that time. The interviews with the five other residents and Resident #57's roommate revealed none of the other residents had concerns with ACNA #1 or #2 and the roommate did not see or hear anything out of the ordinary during the alleged abuse incident on 7/7/21. ACNA #1 and #2 were removed from the care of Resident #57 during the investigation and were educated about resident rights. The facility did not substantiate the allegation of abuse. B. Resident #57 status Resident #57, age [AGE], was admitted on [DATE]. According to the August 2021 computerized physician orders (CPOs), diagnoses included dementia without behavioral disturbance, chronic kidney disease, type 2 diabetes mellitus, and cerebrovascular disease (stroke). The 7/28/21 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 extensive assistance with one person physical assistance for bed mobility, locomotion on/off the unit, dressing, and personal hygiene. She required extensive assistance and two person physical assistance with transfers and toileting. C. Record review The resident's comprehensive care plan, last revised 8/3/21, revealed the resident chose to be highly involved in daily care decisions regarding suggested or recommended interventions and had specific preferences related to her care. The goal was to honor the resident's personal preferences, routines and habits within safe limitations of the facility. The intervention was to honor individual choices and preferences as possible within the parameters of the facility and other individual's safety and choices or preferences. D. Interviews Resident #57 was unable to be interviewed during the survey period due to a recent change in cognition. ACNA #2 was interviewed on 8/11/21 at 9:03 a.m. ACNA #2 said she recalled the incident on 7/7/21 with Resident #57. She said she and ACNA #1 transferred Resident #57 into her wheelchair around lunch time. She said they had to put their arms under the resident's arms in order to transfer her. She said the resident was agitated during the transfer on that day. She said that the nurse who was working that morning said the resident needed to get up for one meal a day. She said the resident usually had breakfast in bed so they generally got her out of bed for lunch. She said she thought the resident did not like getting up for meals and if the resident absolutely did not want to get up for a meal they would let her stay in bed. ACNA #1 was interviewed on 8/11/21 at 11:53 a.m. ACNA #1 said she recalled the incident on 7/7/21 with Resident #57. She said she and ACNA #2 helped transfer the resident from her bed to her wheelchair. She said the resident seemed a little agitated but the nurse requested they get her out of bed for lunch. She said the resident was huffing and puffing but did not say anything. She said the resident normally huffed and puffed when she got out of bed or was repositioned. She said the resident normally did not like to get out of bed but she needed to get out of bed so she would not have skin breakdown on her buttocks. She said if the resident said they did not want to get out of bed they would not force them to get out of bed. She said residents have the right to refuse and that if Resident #57 refused to get out of bed then they would give her five or ten minutes to calm down and then reapproach her. She said they did not reapproach Resident #57 on the date of the incident because the resident was not resisting getting out of bed. Licensed practical nurse (LPN) #1 was interviewed on 8/11/21 at 12:05 p.m. LPN #1 said she did not recall the specific incident on 7/7/21, but was familiar with Resident #57 and her routine. She said the staff tried to get every resident up for meals in the dining room to help with skin breakdown. She said Resident #57 would sometimes say no to getting up and would eat in her room. She said Resident #57 woke up around 10-10:30 a.m. and would have breakfast in bed and then would be transferred to her wheelchair or recliner. She said Resident #57 required extensive assistance from two staff members for transfers. She said Resident #57 was not combative or resistant to getting up and she had not heard of the resident reporting any issues during transfers. The NHA and quality improvement specialist (QIS) were interviewed together on 8/11/21 at 1:07 p.m. The NHA said the unit manager was present for part of the transfer of Resident #57 during the alleged incident on 7/7/21. The NHA said she recalled speaking with the unit manager that day because he was the one who reported the incident to the physician and resident's family member but she did not get a written interview with him. The NHA said Resident #57's granddaughter had been unhappy about the resident not getting up for meals which is why they were encouraging the resident to get out of bed for lunch on that day. The NHA said a resident did not have to get out of bed if they did not want to, which is why she provided resident rights education to the two ACNAs. III. Resident status Resident #10, age [AGE], was admitted [DATE] and readmitted [DATE]. According to the August 2021 CPO diagnoses included rheumatoid arthritis, abnormalities of gait and mobility, muscle weakness, and lack of coordination. The 8/2/21 minimum data set (MDS) assessment indicated Resident #10 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She did not have mood or behavior symptoms She was totally dependent on one staff member for bathing. A. Resident interview Resident #10 attended a resident council meeting on 8/10/21 at 3:00 p.m. When interviewed, she said she was not getting the required showers twice a week that she was supposed to get. She said showers were often not completed and that she was lucky to get a shower once a week. She said she had to ask her nurse to get her shower and even then it was not guaranteed to get done. Resident #10 was interviewed again on 8/12/21 at 8:25 a.m. She said for the last three or four months she had not been receiving showers as they were scheduled because they are short staffed. She said she was unable to shower herself and depended on them to help her and even though she did not do much, a shower made her feel better. She said if they were unable to complete her shower on a scheduled day they used to offer a different day or time but that does not happen any more. B. Record review According to the undated certified nurse aide (CNA) shower schedule sheet, provided by the QIS on 8/11/21 at 2:40 p.m., Resident #10 was to receive showers on Wednesdays and Saturdays. The CNA care [NAME] indicated Resident #10 required extensive assistance of one staff member with bathing and she was to receive showers twice a week as requested. The 8/3/21 care plan revealed Resident #10 had an ADL self-care performance deficit and limited physical mobility related to weakness and she required extensive assistance of one staff member with bathing/showering. On 8/12/21 at 11:36 a.m. the nursing home administrator (NHA) provided a copy of an action plan created on 7/28/21 indicating an identified concern that shower documentation was inaccurate and showers were not being provided per community expectations. It read: -Starting 7/29/21 the staffing coordinator was to take over receiving the paper shower forms to input into the computer. -On 8/9/21 the action plan was to be reviewed during quality assurance and performance improvement (QAPI) and the committee would make recommendations and changes as needed. -On 8/10/21 staff were to ensure residents identified as not having a shower were offered a shower in the past week/per resident preferences with refusals documented. -On 8/13/21 an audit was to be conducted of all residents in the community to ensure they were receiving showers per preferences. -Beginning 8/20/21 licensed nurses were to be educated on reviewing shower documentation daily to ensure showers were being completed per schedule. This was to be ongoing until all staff were trained. -Ongoing interventions included: CNAs will be re-educated on how to appropriately document showers. Nurses will check for completion and accuracy of shower documentation prior to the end of each shift. The assistant director of nursing/unit manager will pull the look-back report weekly to ensure showers are being documented appropriately. The director of nursing (DON) will review the look-back report monthly to ensure showers are occurring. No further documentation was provided related to the 8/10/21 staff assurance that residents who were identified as not receiving showers were offered a shower in the past week or any refusals were documented. Although the action plan identified on 7/28/21 that showers were not being completed, the CNA shower documentation for Resident #10 from 7/28/21 to 8/11/21 revealed she received a shower on 7/28/21 and did not receive another shower until 8/10/21. According to her shower schedule she should have received three showers in that time frame, on 7/31, 8/4, and 8/7/21. Review of nursing notes from 7/28-8/11/21 revealed no documentation the resident refused any showers. C. Resident and staff interviews On 8/10/21 at 3:00 p.m., during a resident council meeting, the following residents were interviewed: Resident #14 said he liked to have a shower twice per week but for the last few months he had only been getting one shower per week. Resident #54 said showers were often not completed due to low staffing. Resident #159 said she liked to have a shower twice per week but had only been getting one shower per week recently. The DON was interviewed on 8/12/21 at 8:25 a.m. She said, Showers are a resident right, we have a huge focus on getting back to basics right now, showers are missed, sometimes due to lack of coverage and staff who call in. We try to staff a shower aide to do all showers, but if we don't have enough CNAs then there is no shower aide and the CNA's have to do their own showers. CNA #1 was interviewed on 8/12/21 at 8:40 a.m. She said, the normal number of CNAs on Alpine Meadows would be three CNAs and a shower aide, but if we are short staffed they don't always have a shower aide and showers that are not done on those days, we try to do them the next day. Agency certified nurse aide (ACNA) #1 was interviewed on 8/12/21 at 8:43 a.m. She said, we are supposed to have two CNAs and a shower aide on the Challenger hall but at least weekly there is no shower aide and we are short. We have to do our own showers and work the floor. It is hard to get the showers and everything else done, and showers do get missed because there is too much to do. -At 10:42 a.m. the DON was again interviewed. She said the normal number of staff on Alpine Meadows would be two nurses, three CNAs, and a shower aide, if we had enough staff, but that did not always happen. She acknowledged showers were not being completed as scheduled and contributed the issue to lack of staffing. Cross-reference F725 for adequate staffing to meet the needs of residents to ensure showers were completed as scheduled

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to provide necessary respiratory care and services consistent with professional standards of practice and the comprehensive person-centered care plan for five (#27, #40, #41, #42, and #55) of six residents reviewed for respiratory care out of 37 total sample residents. Specifically, the facility failed to: -Ensure oxygen tubing was marked with the date the tubing was replaced for Resident #27 and #41; -Obtain physician orders for oxygen that includes liter flow, frequency, and route for Resident #40 and #42; -Ensure oxygen was included on the comprehensive care plan for Resident #40; and, -Ensure CPAP machine was cleaned for Resident #27 and #55. Findings include: I. Facility policy and procedures The Oxygen Administration policy and procedure, revised October 2010, was provided by the director of nursing (DON) on 8/10/21 at 1:51 p.m. It read in pertinent part, Verify that there is a physician's order for this procedure. Review the resident's care plan to assess any special needs of the resident. After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: date and time that the procedure was performed;the name and title of the individual who performed the procedure; the rate of oxygen flow, route, and rationale; the frequency and duration of the treatment; the reason for as needed (PRN) administration; all assessment data obtained before, during, and after the procedure. II. Resident #27 A. Resident status Resident #27, age [AGE], was originally admitted on [DATE], and readmitted [DATE]. According to the August 2021 computerized physician orders (CPO), the diagnoses included Alzheimer's disease, diabetes mellitus type two, and chronic respiratory failure with hypoxia. The 6/25/21 minimum data set (MDS) assessment revealed the resident with severe cognitive impairment with a brief interview for mental status score of zero out of 15. She required total dependence with two person physical assistance with bed mobility, transfers, bathing and personal hygiene. Total dependence with one person for wheelchair mobility, and dressing. Oxygen therapy respiratory treatment. B. Observation On 8/8/21 at 1:32 p.m. the oxygen concentrator was next to Resident #27's bed. Resident #27 was in bed, not wearing any oxygen. The oxygen tubing was not labeled or dated and was rolled up and stored on top of the concentrator unit. The continuous positive airway pressure (CPAP) machine was also without a label or date, and the machine, hose, and mask/nosepiece were not clean and yellow in color. On 8/9/21 at 9:41 a.m. Resident #27 was asleep seated in her wheelchair. She was wearing a nasal cannula connected to a portable oxygen tank. The oxygen tubing was not labeled or dated. The portable oxygen tank was set at three liters per minute (3LPM) but the tank was empty. After being notified, the licensed practical nurse (LPN #3) saw and acknowledged the empty oxygen tank and said that the resident was not getting the prescribed amount of oxygen. LPN #3 said, the tank should be full and that the resident needed continuous oxygen. C. Record review Review of the August 2021 CPO revealed orders for: - Oxygen at three liters per minute (LPM) via nasal cannula continuous every shift for respiratory failure with hypoxia. -CPAP to be applied at bedtime (HS) and removed in the morning. Settings: Pressure-14; 3 liters oxygen; be sure the machine is off when it is removed in the morning two times a day. -Change the nose portion of the CPAP mask every month, supplies kept in the cupboard above her closet in her room every day shift every 28 day (s). The treatment administration record (TAR) was initialed to indicate the last CPAP mask change was 7/21/21. -However the CPAP machine had no date or label. Review of the care plan revealed in pertinent part, The resident has oxygen therapy and CPAP related to chronic respiratory failure with hypoxia; frequently takes her nasal cannula off; CPAP to be applied at HS and removed in morning. Settings: Pressure- 14, three liters O2(oxygen); be sure the machine is off when it is removed in the morning; Oxygen settings: O2 via nasal cannula at three LPM as ordered. -No CPAP machine cleaning plan on the care plan or in CPO. -No CPO or care plan to ensure the oxygen tubing was marked with the date the tubing was replaced for Resident #27. III. Resident #41 A. Resident status Resident #41, age [AGE], was admitted on [DATE]. According to the August 2021 computerized physician orders (CPO), the diagnoses included Hypertensive chronic kidney disease, chronic obstructive pulmonary disease (COPD), dementia, and chronic respiratory failure with hypoxia. The 7/13/21 minimum data set (MDS) assessment revealed the resident with severe cognitive impairment with a brief interview for mental status score of zero out of 15. She required extensive assistance with one person physical assistance for bed mobility, transfers, dressing, and personal hygiene. Supervision with one person assistance for wheelchair mobility. Oxygen therapy respiratory treatment. B. Observation On 8/8/21 at 1:14 p.m. Resident #41 was sitting in her wheelchair, wearing a nasal cannula connected to a portable oxygen tank and was set to 2 LPM. -There was no label or date on the oxygen tubing going to the portable tank and no label or date on the oxygen tubing going to the concentrator. On 8/9/21 at 9:40 a.m. Resident #41 had a nasal cannula on that was connected to a portable oxygen tank. The oxygen tubing was not labeled or dated when it was last changed. C. Record review Review of the August 2021 CPO revealed Resident #41 had the following orders: -Oxygen (O2) at two LPM continuous via nasal cannula every shift for COPD. -New orders were added by nursing after the interview with DON and brought to the facility's attention. Order date 8/10/21, start date 8/16/21. Change oxygen tubing every Monday. Place a label on new tubing with date, time and initials every shift, every Monday for infection control. Review of care plan revealed in pertinent part, altered respiratory status related to COPD; The resident's risk for complications related to short of breath (SOB) will be minimized through the review date; The resident's risk for signs and symptoms (s/sx) of poor oxygen absorption will be minimized through the review date; Administer medications as ordered; Monitor for effectiveness and side effects; Monitor /document changes in orientation, increased restlessness, anxiety, and air hunger; Monitor for s/sx of respiratory distress and report to medical doctor (MD) as needed (PRN): Increased Respirations; Decreased pulse oximetry; Increased heart rate (Tachycardia);Restlessness; Diaphoresis; Headaches; Lethargy; Confusion; Hemoptysis; Cough; Pleuritic pain; Accessory muscle usage; Skin color changes to blue/grey; Oxygen settings: O2 via nasal cannula as ordered; Oxygen settings: O2 via nasal cannula at two LPM, may titrate as ordered. D. Follow-up After the facility staff had been informed, Resident #41 was observed on 8/9/21 at 3:03 p.m. seated in her wheelchair, receiving oxygen by a nasal cannula connected to a portable tank. A new label had been placed on the oxygen tubing dated 8/9/21. IV. Resident #40 A. Resident status Resident #40, age [AGE], was admitted on [DATE]. According to the August 2021 computerized physician orders (CPOs), diagnoses included anxiety disorder, chronic pain, congestive heart failure, and insomnia. The 7/8/21 minimum data set (MDS) assessment revealed the resident had no cognitive impairments with a brief interview for mental status (BIMS) score of 14 out of 15. She required limited assistance with one person physical assistance for bed mobility, transfers, and dressing. She required extensive assistance and one person physical assistance for toileting and personal hygiene. The resident received oxygen therapy. B. Record review The August 2021 CPOs revealed a physician order to titrate oxygen to 90% every shift (initiated 1/26/21). The order did not specify the underlying diagnosis, delivery method, frequency of use, or the liters per minute (LPM) for the oxygen flow. Review of Resident #40's comprehensive care plan revealed there was no care plan regarding oxygen use. Review of the resident's electronic medical record revealed her oxygen levels were above 90% every time it was checked (multiple times per day) for the last three months. C. Resident interview and observation Resident #40 was interviewed on 8/10/21 at 8:51 a.m. Resident #40 said the staff at the facility did not do anything with her oxygen and the only people who touched her oxygen concentrator and tubing were the people from the oxygen company. She said she had to remind facility staff to fill the humidifier attached to her oxygen concentrator. She said her oxygen was supposed to be on 3LPM and that her oxygen concentrator was kept turned on all the time. The oxygen concentrator was set at 2LPM during the interview. D. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 8/10/21 at 9:48 a.m. LPN #1 said she checked Resident #40's oxygen level every shift and that her oxygen concentrator was set to 2LPM. She said Resident #40 chose not to use her oxygen often, but she would administer oxygen to her whenever she wanted it. She said the resident's oxygen levels were usually above 90%. She said if the resident's oxygen levels were above 90% with room air, it was acceptable for the resident to not be using the oxygen concentrator, but if the resident wanted the oxygen staff would give it to her. E. Facility follow-up A new physician order was started on 8/10/21 for Resident #40's oxygen, which documented that the resident was to receive oxygen via nasal cannula at 2LPM. -However, the order still did not clarify the resident's underlying condition or the frequency of oxygen use. V. Failure to administer oxygen per order A. Policy and procedure The Oxygen policy, revised 10/2020, was received from the director of nursing (DON) on 8/10/21 at 1:51 p.m,. The policy documented in pertinent part, verify that there is a physician's order .review the residents care plan. B. Resident #42 status Resident #42, age [AGE], was admitted on [DATE], and readmitted on [DATE]. According to the August 2021 computerized physician orders (CPO), the diagnoses included atrial fibrillation, hemiparesis and hemiplegia due to non traumatic intracranial hemorrhage affecting the non dominant side. -The CPO did not list hypoxia as indicated on the care plan (see record review) The 7/14/21 minimum data set (MDS) assessment revealed the resident's cognitive status was not assessed and he was unable to complete a brief interview for mental status (BIMS). His cognition care plan, dated 1/11/21, documented he had moderate cognitive impairment. Resident #42 required extensive was totally dependent on two staff for transfers, personal hygiene, and dressing. Resident #42 was on oxygen therapy. C. Record review The August 2021 physician's orders were reviewed. Resident #42 had a physician's order, dated 7/9/21, for oxygen at three liters per minute via nasal cannula continuous every shift. The residents oxygen therapy care plan, dated 12/11/2020. The care plan documented in pertinent part, oxygen via nasal cannula at 3(three) liters per minute. The resident's [NAME] (resident information sheet) used by the certified nurse aides (CNA's ) was received from the DON on 8/10/21 at 1:33 p.m. The [NAME] did not list the resident's oxygen orders. D. Observations and interviews On 8/8/21 at 1:23 p.m., Resident #42 in his room and he was receiving two liters per minute by a nasal cannula that was connected to an oxygen concentrator. On 8/9/21 at 8:11 a.m., Resident #42 was in his wheelchair seated in the hallway outside of his room. He had a nasal cannula on, connected to a portable oxygen tank on the back of his wheelchair. The portable oxygen tank was set on zero liters per minute. CNA #5 walked by the resident at 8:13 a.m. She said she was the CNA for Resident #42. CNA #5 said the resident was supposed to be on two liters of oxygen per minute. She looked at the portable oxygen tank and said, I must have forgotten to turn it on. She turned the oxygen on to two liters. On 8/9/21 at 8:34 a.m., Resident #42 was back in his room. He was seated in his wheelchair, and was connected to the oxygen concentrator in his room. The oxygen concentrator was set at one and a half liters per minute. On 8/9/21 at 11:41 a.m., Resident #42 was in his wheelchair, at a table, in the dining room. He had oxygen on via nasal cannula, connected to a portable oxygen unit. The portable oxygen was set at two liters per minute. Restorative nurse aide (RNA) was present at the table with resident #42. He looked at the portable unit and said it was set on two liters per minute. The RNA said he thought the resident was supposed to be on three liters of oxygen per minute. The RNA turned the oxygen up to three liters per minute without checking with the nurse. On 8/10/21 at 8:35 a.m., Resident #42 was in his room. He was in his wheelchair, and had oxygen on via nasal cannula at two liters per minute. Licensed practical nurse (LPN) #2 entered the room. She said she did not know how much oxygen the resident was supposed to be on and she would check his orders. LPN #2 went to her medication cart and looked up his physician order on her computer. She said the order is for three liters per minute continuously. She went back to the room and turned his oxygen to three liters per minute. LPN #2 said the CNA's can put the oxygen on the resident but can not adjust the liter flow. She said she did not know how the CNA's knew how many liters the resident was to be on. VI. Failure to clean CPAP A. Facility policy and procedure The CPAP/BiPAP Support policy, dated 3/2015, was received from the DON on 8/10/21 at 1:51 p.m. The policy documented in pertinent part, wipe machine with warm soapy water at least once per week and as needed .Clean humidifier weekly and air dry. To disinfect, place vinegar-water solution in clean humidifier. Soak for 30 minutes and rinse thoroughly. Rinse filter under running water once per week .Masks and tubing, clean daily by placing in warm soapy water and soaking/agitating for five minutes. Rinse with warm water and allow to air dry. B. Resident #55 status Resident #55, age [AGE], was admitted on [DATE], and readmitted on [DATE]. According to the August 2021 computerized physician orders (CPO), the diagnoses included obstructive sleep apnea and diabetes mellitus. The 7/26/21 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. Resident #55 was independent with bed mobility, and required supervision with transfers, dressing and personal hygiene. She was independent with toileting. -The MDS indicated she was not on a CPAP (continuous positive airway pressure) machine, despite her diagnosis of chronic sleep apnea and order for a CPAP. C. Record review The August 2021 physician's orders were reviewed. Resident #55 had an order dated 5/18/2020 for CPAP nightly (pressure setting 5-20 cmH2o) as needed at night for sleep apnea. The resident's care plan was reviewed. There was no care plan related to sleep apnea or the use of a CPAP machine. The July and August 2021 treatment administration records (TARs) were reviewed. The TARs documented, CPAP nightly, (pressure settings 5-20 cmH20) as needed for OSA (obstructive sleep apnea). -The TARs were not inialted off by a nurse, on any of the night shifts either month to indicate the CPAP was used. The TAR did not indicate if the CPAP or equipment was ever cleaned or changed. The CNA [NAME] was reviewed. The [NAME] did not document the use of a CPAP machine. D. Observations and interviews Resident #55 was observed in her room on 8/9/21 at 1:33 p.m. She had a CPAP machine next to her bed. Resident #55 said she used the CPAP machine every night because she had sleep apnea. She said the nursing staff never cleaned the machine. She said she had to call them each night just to get them to fill the machine with water. There were no dates or labels on the machine or tubing. The DON was interviewed on 8/10/21. She said the CPAP machine should be cleaned weekly with vinegar and water. She said the tubing should be changed monthly and as needed. The DON said the CPC should be signed off the TAR by the nurse when the resident had used the machine. She said the cleaning of the machine should be documented on the TAR. She said we need to clean the machine and change the equipment to prevent infections. She said, Resident #55 should have had a care plan for the sleep apnea diagnosis, and use of CPAP machine. -However, the CPAP was not signed off the TAR, there were no instructions on the TAR for cleaning the machine or changing the equipment, it was not on the MDS assessment, and there was no care plan. The DON said the facility had failed to clean the CPAP. VII. Staff interview The director of nursing (DON) was interviewed on 8/10/21 at 10:17 a.m. She said there should be an order for all oxygen administration. She said the orders should include oxygen flow, route, frequency, duration, and rationale. The DON said facility staff does not titrate oxygen and should not be titrating a resident's oxygen levels. She said the nurses should set the oxygen liter flow rate, not the certified nurse aide (CNA's). She said the nurse should check and approve the settings. The DON said there should have been a care plan for any resident who used oxygen therapy. She said there should always be a label on the oxygen tubing for when last changed and that was important for infection prevention. She said they changed the oxygen tubing weekly. She said they were in the process of determining which day of the week to do that. The DON said there should be a dated label on the CPAP machine and that the CPAP machine should be cleaned weekly. She said the CPAP mask/tubing should be changed monthly. She said CPAP machine cleaning was essential for infection control and should be on the care plan for a vinegar and water soak and rinse. She said the portable oxygen tanks should be filled in the mornings and as needed. She said she recently told the CNA's to round every two hours to check the portable tanks.

Based on observations, interviews, and record review the facility failed to provide services by sufficient numbers of personnel on a 24 hour basis to provide nursing care to all residents in accordance with resident care plans on one of two halls reviewed for sufficient nursing staff. Specifically, the facility failed to provide sufficient certified nurse aide (CNA) staff to ensure Residents #10, #18, and #40, on Alpine Meadows, and Residents #14, #51, #54, #55 and #159 on Challenger Pointe had their call lights answered timely and showers were provided per resident preference and as scheduled for Residents #9, #10, #14, #54, and #159. Findings include: The facility assessment tool dated 6/2/21, provided by the nursing home administrator (NHA) on 8/8/21 at 3:11 p.m. indicated an average daily census of 50 residents. The staffing plan for certified nurse aides (CNAs) was four to nine daily (depending on census and acuity). I. Facility policy On 8/11/21 at 12:35 p.m. a policy was requested for staffing and the quality improvement specialist (QIS) said the facility did not have a specific policy for staffing. She said, we follow general standards of practice. II. Record review Review of the resident census and conditions, dated 8/9/21 revealed the following: Census 53; For bathing: 41 residents needed assistance of one to two staff members and 12 residents were dependent; For dressing: 30 residents needed assistance of one to two staff and six residents were dependent; For transfers: 29 residents needed assistance of one to two staff and five residents were dependent; For toilet use: 25 residents needed assistance of one to two staff and nine residents were dependent; For eating: 10 residents needed assistance of one to two staff and two residents were dependent. The current census on Challenger Pointe was 18 and on Alpine Meadows was 35. After the director of nursing confirmed the required number of CNAs for each shift to adequately care for the residents on Alpine Meadows hall, review of the CNA schedules, resident shower documentation, and review of call light wait times from 6/15/21-8/10/21 revealed the following: From June 16-30 the CNA schedule indicated there were two days out of 15 that a CNA was scheduled as a shower aide, and two to three CNAs scheduled routinely with 13 days of less than the required three CNAs and a shower aide. For the month of July 2021 there were 11 out of 31 days a CNA was scheduled to provide showers. There was one CNA routinely scheduled on the day shift from July 1-July 15 and no routine CNA scheduled July 16- July 31. There were 12 days of less that the required three CNAs. For the month of August 2021 there was no shower aide specifically scheduled on the master copy of the daily schedule and there were from two to five open shifts on a daily basis. -See STS interview below Review of the call light logs for Residents #10, #18, and #40, from 6/15/21-8/10/21, revealed the following: The call light logs for Resident #10 revealed 30 instances of the call lights not being answered for longer than 30 minutes and of those 30, six instances of greater than 45 minutes; 15 instances of greater than one hour, and of those 15, three were greater than an hour and a half. The call light logs for Resident #18 revealed wait times of greater than 30 minutes on 48 occasions, and of those 48, 15 were greater than 45 minutes; 19 instances of greater than an hour and seven of those 19 were greater than an hour and a half. Review of Resident #40s call light logs revealed 29 instances of greater than a 30 minute wait time, and of those 29, six were greater than 45 minutes; and there were four instances of a wait time greater than an hour. Cross-reference F550 for dignity related to long call light wait time for Resident #40. III. Resident interviews Resident #18 was interviewed on 8/8/21 at 1:21 p.m. He said he had waited up to an hour to have his call light answered and it did not happen on any particular shift. Resident #10 was interviewed on 8/8/21 at 3:59 p.m. She said she noticed during meal times that there were not enough staff to answer call lights. She said she had waited half an hour and longer for her call light to be answered. Resident #40 was interviewed on 8/9/21 at 12:57 p.m. She said some staff answer the call light right away, but it depends on the staff, some would take 45 minutes. She said it had happened in the mornings after ordering breakfast and it would get worse around meal times. Resident #55 was interviewed on 8/9/21 at 1:35 p.m. She said there was not enough staff and she would wait 15-45 minutes for her call light to be answered. She said the facility used a lot of agency staff who did not know the residents. It is very unsettling. She said during meals you could wait at least 30 minutes for the call light to be answered. She said showers get missed because of not enough staff. Residents #10, #14, #51, #54, and #159 attended a resident group interview on 8/10/21 from 3:00 p.m. to 3:40 p.m. The residents all agreed the facility did not have sufficient nursing staff to ensure all residents received the care and services they required. When interviewed the residents said: -Resident #10 said showers were often not completed and that she was lucky to get a shower once a week. She said she had to ask her nurse to get her shower and even then it was not guaranteed to get done. She said she had waited over 30 minutes for her call light to be answered before and sometimes CNAs did not not show up for their shifts and that was part of the reason it would take so long to get help. She said she sometimes had to wait longer during meal times to get help, but it depended what CNA was working that shift. -Resident #14 said he liked to have a shower twice per week but for the last few months he had only been getting one shower per week. -Resident #51 said she did not think there were enough staff in the building to take care of everyone ' s needs because you never knew how long it would take them to answer your call light and if you needed them in a hurry, you were out of luck. -Resident #54 said there used to be two CNAs for the front hall and the back hall and now there was just one. She said showers were often not completed due to low staffing. She said there had been a few days where she had to wait 45 minutes to over an hour for her call light to be answered. -Resident #159 said she liked to have a shower twice per week but had only been getting one shower per week recently. Resident #10 was again interviewed on 8/12/21 at 8:25 a.m. She said for the last three or four months she had not been getting showers as they were scheduled because they are short staffed. She said if they were unable to complete her shower on a scheduled day they used to offer a different day or time but that did not happen any more. Cross-reference F561 for not providing showers per resident preference. IV. Staff interviews CNAs #3 and #4 were interviewed on 8/8/21 at 12:30 p.m. CNA #3 said she had started her third week at the facility. She said at times it was difficult to get all her work done. She said she had 11 residents on this day. She said Alpine Meadows had three halls and there was supposed to be a CNA for each hall. She said the resident rooms did not have a light that illuminated at their door to let you know if they had pushed their call light. She said there was a screen mounted near the ceiling outside the nurses station that would light up with the room number if a resident used their call light. She said they had phones they were supposed to carry that would show the room numbers if the call light was initiated, but the phones did not buzz or make a noise to let them know a resident needed help. The CNAs would not know if a call light was on unless they constantly checked the phone or looked at the screen by the nurses station. They said there was only one screen for all three halls on Alpine Meadows and it could not be seen if you were on the back hall or on the far end of the front hall. They said most of the CNAs left the phones on the desk where the CNAs chart and then they would not get charged and could not be used. Licensed practical nurse (LPN) #1 was interviewed on 8/11/21 at 8:19 a.m. She said she normally passed medications to rooms 37-48 on the front hall of Alpine Meadows and she was supposed to carry one of the phones for the call light system but I don't have it. When I get done with my medication pass on this hall I am usually down near the screen that shows the room number when a resident pushes their call light, so I just check it every now and then. Registered nurse (RN) #2 was interviewed on 8/11/21 at 8:44 a.m. She said the nursing staff were to carry one of the phones for the call light system but the phone itself did not alert them, by vibrating or beeping, if a resident turned their call light on. She said staff had to frequently check the phone to see if any call lights were on and you could not see the screen by the nurses station back on this back hall. CNA #2 and the occupational therapy assistant (OTA) were interviewed on 8/11/21 at 3:45 p.m. They said they did not normally provide showers on the evening shift. They said the call light system had phones that the CNAs were to carry so they knew when a resident turned on their call light. The OTA said the phones had not been working lately. The staff scheduler (STS) was interviewed on 8/11/21 at 3:50 p.m. She said she took over scheduling the nursing staff in February 2021. On Alpine Meadows hall, she said in order to have sufficient staff she would schedule two nurses, three CNAs and a shower aide on the day shift, two nurses and three CNAs on the evening shift, and one nurse and two CNAs on the night shift. But if someone called off, they would scramble to try and cover the open shift but shifts sometimes did not get covered. She said the nursing staff worked eight hour shifts. She said if a nurse called off for their shift they had on-call nurses that would fill in if available, as well as the director of nursing (DON). She said if a CNA called off for their shift they were to let her know and she would call other staff to see if the spot could be filled but that was not always possible. She said they used a lot of set agency staff that they try to block and schedule certain days of the month for them to work. She said they try to use the same agency staff routinely. She said agency staff would sometimes call off their shift or not show up at all, then those spots were open. She said the day shift usually completed showers but if a resident requested a shower in the evening instead of the day they would try to accommodate that request if they had enough CNAs. She said as of July 29, 2021 she was responsible for documenting the information from the shower sheets the CNAs were to complete when they gave a shower. She said she did not always get the shower sheets. RN #4 was interviewed on 8/11/21 at 4:20 p.m. She said she did not keep track of, and had not noticed, if there were enough staff. She said they did showers in the evening occasionally. Sometimes there was an evening shower aide, but not one for this evening. CNA #6 was interviewed on 8/11/21 at 4:30 p.m. She said she felt there was enough staff and that she was able to get everything done. She said if someone called off work, she would just stay longer as needed. She said she occasionally did showers in the evening if the day shift CNA let her know that it was needed. She said if a resident refused a shower she would let the nurse know right away. If they did have a shower, she would document any skin issues on a slip of paper and give it to the nurse, and then she would document the shower in the computer task section. LPN #3 was interviewed on 8/12/21 at 8:35 a.m. She said on Alpine Meadows hall there were three CNAs and a shower aide today but that was not always the case. If they did not have enough CNAs then there was no one extra to give the showers. She said she was an agency nurse and had been working at the facility for six weeks but tomorrow would be her last day. She did not have one of the phones for the call light system. She said she forgot to get it when she came on duty. She said the phones did not vibrate or ring to indicate a call light had been turned on so she would leave it on top of the medication cart so she could see it light up, because if it was in my pocket I would not know if a resident needed help. CNA #1 was interviewed on 8/12/21 at 8:40 a.m. She said the normal number of CNAs on Alpine Meadows would be three CNAs and a shower aide,but if we are short staffed they don't always have a shower aide and if showers did not get done on those days, we would try to do them the next day but there was no guarantee they would be done. The DON was interviewed on 8/12/21 at 10:42 a.m. She said the normal number of staff on Alpine Meadows would be two nurses, three CNAs, and a shower aide if we have enough staff but that did not always happen. She acknowledged showers were not being completed as scheduled and contributed the issue to lack of staffing. She said we aren ' t even giving the residents their preferences. She acknowledged the excessive call light wait times were unacceptable and residents should not have to wait longer than 15-20 minutes for their call light to be answered. She acknowledged the call light system was not the best way to track call lights. She said the phones connected to the system did not work properly and said if the staff were not repeatedly checking the phone they would not know if a call light was on and there were only two screens in the facility that show the room number of a call light that has been turned on, so if you were on the back hall you could not see the screen. She said she was going to look into getting the pagers back that used to be used with the call light system because they would alert the staff if a resident initiated their call light. She said if a CNA called off for their shift, they were to do so at least two hours before their shift and let the STS or the DON know. The STS would attempt to replace that staff member for the shift but was not always successful. She said the facility has had to use agency staff for quite some time and they try to block shifts for six weeks at a time for them to try and provide consistency for the residents but the agency staff sometimes would not show up or call off their shift causing a shortage of CNAs. She said they did not have any on-call CNAs at this time that would be available to work in case there was a call-in.

Based on observations, record review, and interviews the facility failed to ensure all drugs and biologicals were properly labeled, dated, stored/removed in one of two medication storage rooms and two of four medication carts. Specifically, the facility failed to ensure expired vaccines were removed timely and beverages were not kept in the same refrigerator for one of two medication storage room refrigerators as well as ensuring expired ear drops, throat spray, loose tablets, suppositories, and injectable medications were labeled and stored properly in two of four medication carts. Findings include: I. Facility policy The Medication Administration policy, dated 9/30/13, revised 11/26/19, provided by the quality improvement specialist (QIS) on 8/11/21 at 12:08 p.m., read in pertinent part: -The nurse is responsible to read and follow precautionary or instructions on the prescription labels. -Report any discrepancies to the pharmacy. -Note the physical appearance and packaging of the medication. Never administer medications from an unmarked container. -Follow the medication/pharmacy guidelines for storage. -Medications are kept in a locked medication cart or a locked medication storage room. The QIS did not provide a separate medication storage policy that was requested. II. Manufacturer's instructions The Fluzone High Dose Quadrivalent and the Flucelvax influenza vaccine storage and handling instructions indicated the medications were Not to be used after the expiration date shown on the labels. The Tubersol Tuberculin Purified Protein Derivative storage instructions indicated, A vial of Tubersol which had been entered and in use for 30 days should be discarded. III. Observations and interviews On 8/11/21 at 10:15 a.m., review of the medication storage room on Alpine Meadows hall, with the director of nursing (DON) revealed the following expired and undated medications: -Seven prefilled syringes of Fluzone High Dose influenza vaccine that expired 6/30/21. -Nine unopened 5 milliliter (ml) multi-dose vials of Flucelvax influenza vaccine that expired 6/30/21. The DON said, The prior assistant director of nursing was supposed to have removed all the expired vaccines from the refrigerator before he left. -One opened, multi-dose vial of Tubersol (tuberculin serum), one third full, dated 7/2/21. -One opened, undated, multi-dose vial of Tubersol. -One opened, 32 ounce bottle of a sports drink in the door of the medication refrigerator. The DON removed the bottle that left a red ring underneath it and said, Well that shouldn ' t be in there. -At 10:45 a.m., review of the medication cart on the front hall of Alpine Meadows with the DON and licensed practical nurse (LPN) #1 revealed the following: -One bottle of ear wax removal drops that expired June 2020. -One open bottle, containing several Nitroglycerin (vasodilator) 0.4 milligram (mg) tablets that was unlabeled and not contained in its original packaging. -Two Bisacodyl (laxative)10mg suppositories lying loose in the top drawer not labeled or contained in their original box. -One open bottle of Systane eye lubricant drops that was unlabeled and not contained in its original box. LPN #1 said she was unaware medications had to be labeled correctly and stored in the original packaging from the pharmacy. -One bottle of Timolol (beta-blocker to decrease pressure in the eye) Ophthalmic 0.5% eye drops that was labeled with a resident's name but was contained in a box of a different eye drop that belonged to another resident. Both eye drops were still in use by each resident. -At 11:00 a.m., review of the medication cart on the back hall of Alpine Meadows with the DON and registered nurse (RN) #2 revealed the following: -One unlabeled bottle of Phenol (topical antiseptic) sore throat spray that was one third full and expired May 2021. -One blister pack of 12 Simethicone (gastrointestinal agent) 125 mg tablets that had two tablets missing, with a resident's name written on the foil was not contained in the original box. RN #2 said, I don't know why his name is on there, he doesn't have an order for that. -One open, undated, and unlabeled multi-dose vial of Lidocaine (local anesthetic) 2% that was three quarters full. The DON said, I have no idea why that would be in there. -Five Bisacodyl 10 mg suppositories laying loose in the top drawer, unlabeled, and not contained in their original box. IV. DON interview The DON was interviewed on 8/11/21 at 11:30 a.m. She said she had been at the facility for five weeks and the facility's assistant director of nursing/staff development coordinator quit recently without notice and that staff member was responsible for reviewing the medication rooms and the medication carts to remove any expired medications and ensure all medications were correctly packaged and labeled. She said when they hire new staff for those positions as well as a unit manager, they will be responsible for maintaining the medication storage rooms and the medication carts. She said the pharmacist did not inspect the storage rooms or the medication carts. She said the nurses administering medications should be aware of expirations dates and appropriate labeling of the medications they administer. She acknowledged all medications were to be labeled and remain in their original packaging and staff were not to store drinks in refrigerators that contained medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections in two of two units. Specifically, the facility failed to: -Ensure staff wore masks appropriately while in areas of the facility with potential residents; -Ensure residents were offered hand hygiene before meals; and, -Ensure wound care was provided in a sanitary manner for Resident #54. Findings include: I. Ensure staff wore masks appropriately while in the areas of the facility with potential residents A. Professional reference The Center for Disease Control (CDC), Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings, last updated 4/13/2020, retrieved 8/16/21 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#minimize, read in pertinent part, Healthcare Personnel as part of source control efforts, HCP should wear well-fitting source control at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers. According to the CDC guidance, Strategies for Optimizing the Supply of Face Masks, last revised, 3/17/2020, retrieved 8/16/21from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/face-masks.htm Healthcare personnel (HCP) must take care not to touch their facemask. It is unknown what the potential contribution of contact transmission is for SARS-CoV-2, care should be taken to ensure that HCP do not touch outer surfaces of the mask. If they touch or adjust their facemask they must immediately perform hand hygiene. B. Facility policy and procedure The facility policy on staff mask use and resident hand hygiene was requested from the director of nursing (DON) on 8/11/21 at 1:02 p.m., during an interview regarding infection control, and was not received by the end of the survey on 8/12/21. C. Observations On 8/8/21 at 11:45 a.m., dietary worker (DW) #1 was in the main dining room, serving multiple unmasked residents, with her mask below nose. She pulled the mask up over her nose five times by grabbing the front of the mask. She repeatedly touched her mask, menu cards, and an ink pen. She did not perform hand hygiene after adjusting her mask. On 8/8/21 at 12:21 p.m., the staff person sitting at the front desk was observed with their mask down below her nose. On 8/9/21 11:24 a.m., activity assistant (AA) #1 was observed talking to the staff member seated at the front desk. AA#1's mask was below her chin. She pulled the mask over her nose after the surveyor approached. At 11:26 a.m., AA #1 was observed again talking with the staff person at the front desk with her mask below her nose. On 8/9/21 at 12:11 p.m. AA #1 was again observed in the hall with her mask below her nose. On 8/9/21 at 12:18 p.m., a housekeeper was observed walking down the hall on the Alpine resident care unit, past resident rooms. Her mask was below her chin. She was drinking something and speaking with another housekeeper who walked with her. On 8/9/21 at 12:21 p.m., the beautician was in the beauty shop cutting a male resident's hair. Her mask was observed below her nose. The resident did not have a mask on. On 8/9/21 1:18 p.m., registered nurse (RN) #1 was observed walking down the front hall of the Challenger unit past resident rooms. Her mask was below her nose. At 1:46 p.m., she was sitting at the desk on the Challenger unit. Her mask was below her nose. Certified nurse aide (CNA) #7 was standing near the desk. Her mask was below her nose. On 8/10/21 at 3:47 p.m., a staff person was sitting behind the nurses station on the Alpine resident care unit. Her mask was below her chin. She touched her mouth, and then continued talking to another staff person at the desk with her mask below her chin. On 8/11/21 at 8:05 a.m., a dietary staff person delivered a tray to room [ROOM NUMBER] on the Alpine unit. The resident was behind the curtain in the room. The dietary staff person was behind the curation as well, talking to the resident. When the dietary staff person came out from around the curtain her mask was below her chin. On 8/11/21 at 10:57 a.m., a housekeeper entered room [ROOM NUMBER] on the Alpine unit. She had eye goggles on, and a mask below her nose. On 8/11/21 at 12:50 p.m., CNA #7 was again observed in the hallway on the Challenger unit with her mask below her nose. On 8/11/21 at 12:59 p.m., the social service assistant (SSA) was observed at the front desk. She did not have her mask on. It was in her hand. On 8/11/21 at 4:37 p.m., a staff person was at the time clock near the front of the building, her mask was below her nose, she clocked in, and walked down the hall toward the main dining room. The person at the front desk observed her, but did not say anything about her mask. On 8/12/21 at 8:45 a.m. The staff person sitting at the front desk had her mask below her nose. Resident #56 was sitting in the lobby area near the front desk. The staff person pulled her mask up over her nose when the surveyor approached. D. Interview The DON was interviewed on 8/11/21 at 1:02 p.m. She said she was currently the infection preventionist (IP). The DON said masks were required to enter the facility. She said the masks should be worn up over the nose while in the facility. If the mask needed to be adjusted, it should be adjusted by the ear loops, and not the front of the mask. II. Hand Hygiene A. Professional reference The Centers for Disease Control (CDC) Hand Hygiene updated 5/17/2020, retrieved on 8/16/21 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/hand-hygiene.html, revealed in part, Hand hygiene is an important part of the U.S. response to the international emergence of COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in healthcare settings. CDC recommendations reflect this important role. The exact contribution of hand hygiene to the reduction of direct and indirect spread of coronaviruses between people is currently unknown. However, hand washing mechanically removes pathogens, and laboratory data demonstrate that ABHR formulations in the range of alcohol concentrations recommended by CDC, inactivate SARS-CoV-2. ABHR effectively reduces the number of pathogens that may be present on the hands of healthcare providers after brief interactions with patients or the care environment. The CDC recommends using ABHR with greater than 60% ethanol or 70% isopropanol in healthcare settings. Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and are effective in the absence of a sink. B. Observations On 8/8/21 from 11:26 a.m. to 12:02 p.m., observation of the lunch meal in the main dining room, with 23 residents seated for the meal, revealed the following breaks in infection control: As the meals were served, no form of hand hygiene was offered to any of the residents. Many residents were seen eating baked chicken, chicken nuggets, buttered rolls, and grilled cheese sandwiches with their hands and then licking their fingers. An unknown housekeeping staff member was seen assisting in the dining room. Her mask would often fall below her nose and she would repeatedly touch the mask and her glasses then touch the menu cards and an ink pen. She did not perform hand hygiene and approached the serving window touching multiple surfaces near food being served. She exited the dining room without performing hand hygiene. On 8/9/21 11:30 a.m. during the lunch meal service in the main dining room with 24 residents seated for the meal, it was observed that no hand hygiene was offered to the residents prior to eating their meal or after they finished eating. The meal included breadsticks to be eaten with their fingers. Resident #18 was seen propelling himself in his wheelchair to the dining room and he was not offered hand hygiene after he parked himself at a table. On 8/10/21 from 11:31 a.m. to 12:10 p.m. observation of the lunch meal in the main dining room, with 19 residents seated for the meal, revealed no hand hygiene was offered to residents prior to or after the meal. The meal included hamburgers, chicken nuggets, dinner rolls, grilled cheese sandwiches, and french fries to be eaten with their fingers. Residents were observed to lick their fingers. C. Resident interviews All residents were identified by facility and assessment as interviewable. Resident #18 was interviewed on 8/8/21 at 1:23 p.m. He said he propels himself to and from the dining room for meals and the staff did not offer him a way to sanitize his hands prior to or after eating his meals. He said, it would be nice since my hands are touching the wheelchair's wheels. Resident #14 was interviewed on 8/10/21 at 8:39 a.m. He said staff did not offer hand hygiene before or after meals. On 8/10/21 at 3:00 p.m. during a resident council meeting, the following residents were interviewed: Resident #10 said staff used to offer hand hygiene but, now they're slacking. Resident #14 said they offered him hand hygiene today but, it doesn't happen every day. Resident #54 said staff were not offering hand hygiene before meals. Resident #159 said hand hygiene was not offered at every meal, definitely not on a regular basis. Resident #23 was interviewed on 8/11/21 at 9:00 a.m. She said when meals were delivered she was not offered a way to clean her hands prior to eating her meals. D. Staff interview The DON was interviewed on 8/11/21 at 1:02 p.m. She said hand hygiene was to be offered to residents before and after their meals, before and after using the restroom, and if hands were visibly soiled. The room trays were to have a wet nap wipe on the tray when it was delivered to the room and the residents who eat in the dining room were to be offered hand hygiene before their meal was placed on the table and after they finished their meal. She said there used to be hand sanitizer on the tables in the dining room but those were removed and staff should offer hand hygiene gel from their pocket sanitizer they carried in their pockets. III. Ensure wound care was provided in a sanitary manner for Resident #54 A. Facility policy and procedure The facility policy on wound care was requested from the director of nursing (DON) on 8/11/21 at 3:16 p.m., and was not received by the end of the survey on 8/12/21. B. Observation On 8/11/21 at 3:00 p.m. licensed practical nurse (LPN) #4 was observed providing wound care to Resident #54 (cross-reference F686 for pressure injury). Resident #54 had a chronic wound to her right lower leg and her right middle foot. On the bed, next to the resident's right leg, were scissors and a roll of tape. On the bedside table, with the residents personal belongings, a drink, crumbs, and papers, were the wound dressings. There was no clean field set up under the wound supplies on the table. Some of the dressing rested directly on the table. LPN #4 performed hand hygiene and put on gloves. She measured the wound. LPN #4 then took gauze, a spray wound cleanser from the bedside table, and sprayed and wiped the wounds with gauze. She did not perform hand hygiene or change gloves after cleaning the wounds. She then picked up a dressing from the bedside table and placed it over the wound on the right lower leg. C. Staff Interview The DON was interviewed on 8/11/21 at 3:16 p.m. She was present for part of the wound care. She said she observed the nurse had not set up a clean field for the wound care for Resident #54. She said LPN #4 should have set up a clean field for her supplies. She said she had observed the gauze roll sitting directly on the bedside table.The DON further said the nurse should have removed her gloves and completed hand hygiene after cleaning the wounds, and before touching and placing the new wound dressings. IV. Facility follow-up On 8/11/21 at 1:05 p.m. the nursing home administrator (NHA) provided a document titled Action Plan for F-880-Infection Control, dated 3/18/21 and 7/26/21. The action plan documented in pertinent part, Infection control has not been managed effectively in the past year as there were significant changes in the community. Audits to be completed, resident hand hygiene before meals, PPE (personal protective equipment donning and doffing. There was no documentation specific to staff wearing masks appropriately while in the facility. The audits had no dates, but documented ongoing. The person responsible was the IP/SDC, (infection preventionist/staff development coordinator). -However, the facility did not currently have an SDC, and the DON was acting as the IP. V. Facility COVID-19 status The DON reported on 8/8/21 at 11:06 a.m. The facility was currently reporting zero total residents positive for COVID-19, zero presumptive positive resident cases of COVID-19, and zero staff positive for COVID-19.