**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, clinical record review, review of facility documentation, review of the facility policy and staff interviews for 1 of 3 residents reviewed for abuse (Resident #98), the facility failed to report an allegation of potential abuse to the state agency. The findings include: Resident #98 was admitted on [DATE] with diagnoses that included heart disease, respiratory failure, and diabetes mellitus. The admission MDS assessment dated [DATE] identified Resident #98 had moderate cognitive impairment and did not exhibit disorganized thinking, altered level of consciousness, or rejection of care. Additionally, Resident #98 required substantial assistance with toileting and personal hygiene. A care plan dated 5/3/2024 indicated Resident #98 did not have a history of dementia but had some short/long-term memory deficit. Interventions included encouraging the resident to participate in activities and providing cues and supervision. A care plan dated 6/28/2024 further indicated Resident #98 received palliative care. Interventions included offering the resident and family support. A review of the internal investigation dated 7/2/2024 identified Person #1 reported to social work that a nursing aide had slapped Resident #98. The internal investigation identified Resident #98 had indicated that s/he wanted to help the aide when getting cleaned up after a bowel movement, but the aide slapped her/his hand away. The internal investigation also indicated that when Resident #98 was asked for a return demonstration by the DNS, Resident #98 indicated NA #7 did not slap her/him hard and indicated NA #7 pushed his/her hand away. A review of the facility nursing schedule from 6/29/2024 through 7/9/2024 identified NA #7 was assigned to care for Resident #98 on Saturday, 7/6/2024. In an interview on 7/16/2024 at 12:12 PM, Resident #98 indicated that a few weeks ago in the evening, Nurse Aide (NA#7) had slapped his/her hand while providing care and indicated NA # 7 said s/he had her/his own way of doing things. Resident #98 indicated NA#7 was by her/himself when providing care. Resident #98 also indicated s/he had not told staff about the incident but told (Person #1) the next day. Person #1 was in the room during the surveyor's interview and further indicated the incident had occurred on the weekend after the July 4 the holiday (7/6 or 7/7/2024). Person #1 also indicated that s/he had spoken to the resident's day nurse the following day but were unsure what the date or the nurse's name was. Additionally, Person #1 indicated s/he had spoken to the Social Worker (SW) about 48 hours after Resident #98 had complained about the incident. Person #1 also indicated that s/he received a phone call from the Director of Nursing Services (DNS) regarding the incident. A review of the medical record, including nursing and social services progress notes from 6/26/2024 through 7/17/2024, did not identify any notes addressing the incident or any allegation of abuse. The facility was unable to provide an Accident/Incident report (A&I) addressing the incident or an allegation of abuse. Additionally, no report of the incident or allegation of abuse was noted in the state agency's online Reportable Event portal. On 7/18/2024 at 11:37 AM, an interview with the Director of Social Services (Social Worker #1) identified that Person #1 had informed her in the morning of 7/8/2024 or 7/9/2024 (Social Worker #1 could not recall the exact date) that a staff member had slapped Resident #98's hand over the weekend. Social Worker #1 further indicated that after being informed of the incident, she immediately notified the DNS. Social Worker #1 was unable to provide any documentation or evidence in the clinical record the date of the allegation of abuse to reported to her and was unable to explain why. On 7/18/2024 at 1:45 PM, an interview with the DNS identified on 7/2/2024, she was notified by Social Worker #1 that Person #1 had told her (Social Worker #1), Resident #98 had complained about being slapped Saturday night (6/29/2024). The DNS indicated s/he initiated an internal investigation and evaluated the resident's hands. After the internal investigation, the DNS determined that NA#7 had not slapped Resident #98. However, the DNS indicated s/he did not interview other staff members or potential witnesses since s/he was able to corroborate the incident with the interviews of NA# 7 and Resident #98. The DNS indicated that the incident was not recorded in the electronic medical record because there was no change to the plan of care. Additionally, The DNS indicated the incident was not reported to the state agency because the facility did not consider it an allegation of abuse. A review of the facilities Abuse Policy identified that the facility has trained employees to identify potential and actual occurrences of abuse. The policy also indicated the facility should investigate an allegation and report the allegation by following federal and state guidelines. Additionally, the facilities Abuse Observation and Recording Policy indicated that all allegations and/or reports of any type of abuse toward a resident would be thoroughly investigated, documented, and reported according to procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, review of facility policy and staff interviews and for 1 of 1 resident, (Resident #18), reviewed for nutrition, the facility failed to provide supervision with meals according to the plan of care and for 1 of 1 resident reviewed for pain (Resident # 24) the facility failed to ensure the resident's care plan included nonpharmaceutical interventions for pain relief and for 1 of 5 residents (Resident #70) reviewed for unnecessary medications, the facility failed to ensure a resident care plan addressed resident specific behaviors and interventions. The findings included. 1. Resident #18 had diagnoses included Alzheimer's disease, dysphagia (swallowing difficulties), and dyskinesia of esophagus (disorder of esophageal sphincters). On 4/22/24 The Advanced Practicing Registered Nurse (APRN) order directed a dysphagia advanced diet with thin liquids and no straws. An additional order on the same date and time directed aspiration precautions, 90 degrees with anything by mouth and to maintain 90 degrees for 30 minutes after eating, encourage small sips, small bites, slow pace, alternate liquids and solids. An APRN progress note on 5/3/24 at 9:09 A.M. identified a 10.1% weight loss in 6 months. A Speech Therapy Daily Treatment note dated 5/17/24 identified Resident #18's intake amounts increased by 25% - 50% with cueing. An APRN progress note on 5/20/24 at 9:41 A.M. identified Resident #18 required more cueing with meals The quarterly MDS assessment dated [DATE] identified Resident #18 as moderately impaired in cognitive function and requiring supervision or touching assistance with eating. On 7/16/24 at 9:25 A.M. and on 7/16/24 at 12:45 P.M., Resident #18 was observed in his her/room eating a meal independently with no staff present. Interview and clinical record review with LPN #4 on 7/16/24 at 12:52 P.M. identified Resident #18's level of assistance with meals was supervision and Resident #18 should not have been eating unsupervised. Interview and review of the electronic Nurse's Aide (NA) care card with NA #2 on 7/16/24 at 2:15 P.M. identified Resident #18 required supervision with meals. NA #2 stated s/he did not serve Resident #18 his/her meal trays and did not know who did. After surveyor inquiry on 7/16/24, the Speech Therapist (ST #1) reevaluated Resident # 18 for the need for assistance with meals, and the 7/17/24 Treatment Encounter note reflected a change from supervision to assistance as needed with meals. An interview with ST #1 on 7/19/24 at 11:35 AM indicated the meaning of supervision with meals as 100% supervision from the time the resident receives his/her meal tray until the meal tray is removed. ST #1 identified Resident #18 received supervision with meals to monitor and increase meal consumption by providing assistance and verbal cues. She/he further stated the level of assistance is no longer beneficial to Resident #18 or to the staff based on the documented resident meal consumption. ST #1 identified s/he does not have access to review flow sheets where level of assistance is documented but trusts interventions are followed once initiated. Review of the 7/1/24 through 7/22/24 NA flow sheets identified missing documentation for feeding assistance and amount consumed for 36 out of 64 meals. Of the documented meals, the NA's documented set up only assistance for 7 meals and no set up or physical help from staff for 1 meal. Remaining documented meals indicated one-person physical assist and no documentation indicated supervision. An interview with the DNS on 7/19/24 at 12:45 P.M. indicated the NA care card is an extension of the care plan and the instructions on the care card should be followed. The DNS further indicated a resident requiring supervision with meals should not be left unattended with a meal tray, The facility Feeding Policy states, in part, its purpose is to ensure that all residents receive appropriate and safe assistance with feeding promoting their nutritional well-being, dignity, and social engagement. The Feeding Policy further states provide appropriate assistance based on each residents feeding plan and record all assistance provided during mealtimes in the residents' medical record. 2. Resident #24's diagnosis include chronic pain. The physician's orders dated 4/19/2024 at 11:33 PM directed to provide Resident #24 Oxycontin 10 Milligrams (MG), crush resistant, extended-release tablet by mouth every 12 hours and to provide Oxycodone 5 MG tablet by mouth every 6 hours as needed for breakthrough pain. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #24 was cognitively intact, received scheduled and as needed (PRN) medication for pain and did not receive non medication interventions for pain. The care plan dated 6/13/2024 indicated in part Resident #24 had alteration in pain. Interventions included: to administer medications as ordered, complete a pain assessment every shift and to notify the provider if pain medication was ineffective. An Advanced Practice Registered Nurse (APRN) progress note dated 7/3/2024 indicated chronic pain and resident complaint of pain all over with opioid use and opioid constipation further indicating to continue the current medication regime and laxative. A follow up APRN progress note dated 7/5/2024 indicated Resident # 24 reported fair effect from current regimen and the PRN Oxycodone was utilized 1-2 x daily with good effect and prescriptions for refills for pain medications were provided. Interview and record review with the DNS on 7/22/2024 at 10:46 AM with the Administrator present indicated Resident #24 had been living at the facility for several years and prior to being admitted to the facility had been on opioid pain medications. The DNS further indicated that although s/he was unable to easy access the exact date, approximately 6 months ago upon return from the hospital Resident #24 returned on no opioid medications but was restarted on the medication several days after readmission due to pain. After surveyor inquiry, the DNS indicated 1:1 visit by recreational staff and diversional activities including watching television were nonpharmaceutical interventions provided to Resident #24. The DNS further indicated s/he was not aware if therapy had been consulted regarding alternative pain relief interventions other than opioid medications or if nursing had requested any other possible alternatives. The DNS further indicated the APRN follows Resident #24 closely for pain as the resident was subject to opioid constipation. During further review of the clinical record, the DNS was unable to locate any non-pharmaceutical interventions utilized in addition to the pain medication in Resident #24's care plan. The facility policy labeled pain management dated 6/2024 indicated in part the facility is committed to assist each resident to attain or maintain the resident's highest practicable mental and psychosocial well-being by assessing pain and using interventions to prevent pain from interfering with the quality of life. 3 Resident #70's diagnoses include traumatic cerebral hemorrhage and anxiety. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #70 was cognitively intact and received antianxiety and antidepressant medications and had no behavioral symptoms displayed during the 7-day lookback period. The physician's orders dated 6/13/2024 at 5:58PM directed to monitor and documents target behaviors every shift for use of Klonopin for antianxiety/restlessness and to document outcomes of interventions used for the behaviors and if worsened improved or unchanged every shift. The physician's order also directed to monitor for side effects related to the use of Klonopin every shift and to monitor for target behaviors every shift for use of Melatonin for insomnia/poor sleep. An interview and record review on 7/22/24 at 9:34 AM with MDS Nurse, RN #1 indicated Resident #70 had a diagnosis of anxiety and orders for behavioral monitoring. However, RN #1 was not able to find a care plan addressing the behaviors and interventions utilized to manage the behaviors and s/he further indicated there should be a care plan. An interview and record review with LPN #3 on 7/22/24 at 10:05 AM indicated s/he was speaking with RN #1 and identified the behavioral care plan must have been missed and should have been added to the care plan. After surveyor inquiry, a behavior care plan was added. LPN #3 further indicated without the behavioral care plan interventions used cannot be evaluated for effectiveness. The facility policy labeled Resident Care Plan indicated in part the goal is to achieve optimal physical, psychosocial, and functional status by initiating an interdisciplinary care plan on admission with reviews quarterly and as needed. The policy further indicated the care plan would be maintained in the medical record, updated as needed and reviewed quarterly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, observations, facility policy and interviews for 1 of 7 residents (Resident #69) reviewed during medication administration, the facility failed to ensure staff appropriately prepared Extended release/delayed release medications for administration to a resident. The findings include. Resident #69's diagnoses included essential hypertension, mood disorder and gastric esophageal reflux. A physician's order dated 3//19/2024 at 11:07 PM directed to provide Propranolol 120 MG, 24 hour extended-release capsule by mouth daily at 9:00 AM for hypertension. A physician's order dated 3//19/2024 at 11:07 AM directed to provide Duloxetine 60 MG capsule, delayed release by mouth daily at 9:00 AM for mood disorder. The care plan dated 4/1/2024 indicated Resident #69 had dysphagia with swallowing difficulty and interventions included in part to provide speech therapy as needed. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #69 as severely cognitively impaired. On 7/17/2024 at 8:42 AM observation and interview with LPN #6 during medication administration for Resident #69 identified Resident #69 requires medications to be crushed therefore s/he would be opening the capsules and crushing the other medications to put into applesauce. Further observation included LPN #7 preparing all medications as ordered for the time opening the capsule of Duloxetine Delayed Release and the capsule of Propranolol Extended-Release place in applesauce with the other medications mix and entered Resident #69's room again, LPN #1 scoop the medication onto spoon and start to administer to Resident #69. The surveyor intervened and asked LPN #7 to step out of the room with the surveyor for a moment. Once at the medication cart after surveyor inquiry, LPN#7 reviewed the medication orders and indicated the Propanol, and the Duloxetine capsules should not have opened, and s/he would need to repour the medications and provide whole in applesauce. On 7/17/24 at 9:07 AM LPN #7 repoured all medications crushed in applesauce with the Duloxetine and Propranolol capsules intake in the applesauce. Medications were administered via spoon of in applesauce to Resident #69 who at which time spit out the capsules but took all the other crushed medication. LPN #7 indicated s/he would call the supervisor to and provide an update and inform the APRN regarding refusal for further orders. After surveyor inquiry, a physician's order dated 7/17/2024 at 9:55 AM directed to provide Propranolol 60 mg tablet by mouth twice daily at 9:00 AM and 9:00 PM for hypertension. After surveyor inquiry, a physician's order dated 7/17/2024 at 10:42 AM directed to provide Duloxetine 60 mg delayed release capsule by mouth and not to open capsule. An interview and medication review for Resident #69 with Pharmacist #1 on 7/19/2024 at 11:26 AM indicated Propranolol 120 MG Extended release and the Duloxetine 60 mg delayed release should not be opened and the Propranolol information provided no option at all for opening the capsule. The facility policy labeled Medication Crushing Guidelines dated 6/2024, indicated in part time released capsules are designed to release medication over a sustained period usually 8-24 hours in which the contents are designed to dissolve at different times, utilized to reduce stomach irritation, in some cases and to achieve a prolonged medication action in other cases. Before opening a capsule to administer in food a reference or pharmacist should be consulted before administering in this manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policy and interviews for 2 of 3 sampled residents (Resident # 25 and # 42 ) reviewed for pressure ulcers, the facility failed to ensure a nutritional assessment was completed for a newly identified pressure injury and failed to reposition the resident according to the plan of care. The findings include: 1. Resident # 25's diagnosis include Multiple Sclerosis. The quarterly Minimum Data Set, (MDS) assessment dated [DATE] identified Resident #25 was moderately cognitively impaired, required extensive two person assist with bed mobility/transfers, was at risk for the development of pressure ulcers and had no unhealed pressure ulcers. The Resident care Plan (RCP) dated 2/12/24 identified Resident #25 was at risk for the development of pressure ulcers. Interventions directed to offload heels, check skin condition weekly and apply skin prep to heels twice daily. A Nutritional assessment dated [DATE] identified Resident #52's skin was intact with no pressure ulcers and that the current diet was meeting nutritional needs. An initial Pressure Ulcer assessment dated [DATE] identified a stage II pressure ulcer measuring 3 Centimeter ( CM), width: 2.5 CM, depth: 0 CM, with no exudate. A shallow, intact, red blister to left inner heel, surrounding area was blanchable, and noted to be non-tender with no drainage or odor. A review of the clinical record failed to identify a subsequent nutritional assessment or progress note detailing the newly identified pressure ulcer to determine what, if any nutritional modifications were warranted. An interview and clinical record review with the Dietitian on 7/18/24 at 9:38 AM identified she had been employed by the facility since 6/2024 and worked 20 hours weekly. The Dietitian identified she received a weekly wound report supplied by the wound nurse which was used to monitor the progress of any resident with wounds. For any newly identified wound, the Dietitian would complete a partial assessment including intake, weight and determine if any additional supplementation or protein would be required. The Dietitian identified the limited assessment would be documented in the clinical record. The Dietitian further identified that although she was not employed by the facility when the wound was first known, she was unable to say whether she was aware of Resident #25's pressure ulcer or explain why she had not assessed Resident #25's nutritional status at any time after the receipt of the pressure ulcer report identifying the wound. An interview with the Director of Nursing, DNS on 7/18/24 at 9:47 AM identified she would expect a dietary assessment be conducted for any resident with a newly identified pressure injury. A review of the facility policy for Medical Nutrition Therapy: Assessment and Care Planning identified the Registered Dietitian was responsible for a comprehensive assessment annually, on referral or as indicated by the clinical condition of the resident and that changes would be communicated to nursing staff. 2. Resident #42's diagnoses included diabetes mellitus, pain and Alzheimer's disease. The last nutritional assessment conducted, dated 5/8/24, noted skin is intact. There was no further nutritional assessment conducted with the development of 2 new pressure injuries to the left heel. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #42 as severely cognitively impaired, non-verbal, incontinent, at risk for developing pressure injuries and dependent for all aspects of care to include bed mobility, transfers, eating and hygiene. A progress note dated 5/24/24 identified discoloration to the left heel, an intact blister to the left heel, and supervisor notification. The facility Wound Pressure Ulcer Weekly Record assessment dated [DATE] identified a new facility acquired pressure injury with black eschar to the left heel, which was noted to be located over the site of a previously healed pressure injury. The assessment further noted an adjacent dark purple deep tissue injury. An APRN progress note dated 5/31/24 identified Resident #42 was at high risk for skin impairment due to immobility. The facility Braden Scale assessment dated [DATE] identified Resident #42 as a high risk for developing pressure injuries. The Resident Care Plan (RCP) and Nurse Aide (NA) care card dated 7/16/24 directed Resident #42 to be out of bed and in his/her custom wheelchair for lunch and dinner, not to exceed 2 hours in the wheelchair at a time. The RCP further directs Resident #42 to be transferred back to bed 1 hour after meals and to be turned and repositioned side to side every 2 hours. The RCP did not include interventions for pain or nutrition related to the 2 new pressure injuries. The RCP did not include diabetic foot monitoring and care. During an observation on 7/16/24 at 11:08 A.M., Resident #42 was sitting in his/her wheelchair, sleeping. During further observations at 11:35AM., 12:15 P.M., 12:40 P.M., 1:04 P.M., 1:30 P.M., 1:53 P.M., 2:10 P.M., and 2:30 P.M., Resident #42 was observed in his/her wheelchair in the same position. An interview and review of the NA care card with NA #3 on 7/16/24 at 2:25 PM indicated Resident #42 was out of bed and in his/her wheelchair for breakfast and remained in the wheelchair without any changes in position since transferred out of bed. When reviewing the NA care card, NA #3 indicated the turning and repositioning instructions were for when Resident #42 was in bed and that Resident #42 was not turned or repositioned while in the wheelchair. NA #4 stated we do not reposition him/her in the chair, only in bed. When reviewing the section of the NA care card that directed a 2-hour maximum time in the wheelchair, NA #3 indicated the instructions referred to lunch and dinner, and further indicated Resident #42 should be transferred back to bed after lunch and that she was late transferring him/her back to bed. Interview and review of the clinical record with LPN #4 on 7/16/24 at 2:30 P.M. identified Resident #42 had care planned instructions for a 2-hour maximum time in the wheelchair, had a pressure injury to the left heel and a history of a pressure injury to the coccyx area. LPN #4 indicated any resident who has an active pressure injury or history of a pressure injury should be repositioned every 2 hours. LPN #4 indicated Resident #4 is usually transferred out of bed for lunch and then is transferred back to bed after lunch. LPN #4 indicated after lunch would be by 2:00 P.M. When notified by the surveyor, that Resident #4 was still in his/her wheelchair, LPN #4 indicated he/she should be in bed. After surveyor inquiry of Resident #42's skin integrity identified the plan of care was not followed, LPN #4 performed a skin assessment. An interview with the Director of Nursing Services on 7/19/24 at 12:30 P.M. identified the expectation for repositioning a resident with a pressure injury or at risk of developing a pressure injury is every 2-3 hours unless there is an out of bed schedule. The facility Wound Management Program policy states, in part, in the prevention Protocol section, residents will be turned and repositioned every 2 hours as tolerated while in bed and every 60-90 minutes when in a wheelchair and to improve/maintain nutrition and hydration status as feasible, all residents will have a nutritional consult with condition change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, observations, facility policy and interviews for 1 of 7 residents (Resident #69) reviewed during medication administration, the facility failed to ensure staff appropriately prepared Extended release/delayed release medications for administration to a resident. The findings include. Resident #69's diagnoses included essential hypertension, mood disorder and gastric esophageal reflux. A physician's order dated 3//19/2024 at 11:07 PM directed to provide Propranolol 120 MG, 24 hour extended-release capsule by mouth daily at 9:00 AM for hypertension. A physician's order dated 3//19/2024 at 11:07 AM directed to provide Duloxetine 60 MG capsule, delayed release by mouth daily at 9:00 AM for mood disorder. The care plan dated 4/1/2024 indicated Resident #69 had dysphagia with swallowing difficulty and interventions included in part to provide speech therapy as needed. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #69 as severely cognitively impaired. On 7/17/2024 at 8:42 AM observation and interview with LPN #6 during medication administration for Resident #69 identified Resident #69 requires medications to be crushed therefore s/he would be opening the capsules and crushing the other medications to put into applesauce. Further observation included LPN #7 preparing all medications as ordered for the time opening the capsule of Duloxetine Delayed Release and the capsule of Propranolol Extended-Release place in applesauce with the other medications mix and entered Resident #69's room again, LPN #1 scoop the medication onto spoon and start to administer to Resident #69. The surveyor intervened and asked LPN #7 to step out of the room with the surveyor for a moment. Once at the medication cart after surveyor inquiry, LPN#7 reviewed the medication orders and indicated the Propanol, and the Duloxetine capsules should not have opened, and s/he would need to repour the medications and provide whole in applesauce. On 7/17/24 at 9:07 AM LPN #7 repoured all medications crushed in applesauce with the Duloxetine and Propranolol capsules intake in the applesauce. Medications were administered via spoon of in applesauce to Resident #69 who at which time spit out the capsules but took all the other crushed medication. LPN #7 indicated s/he would call the supervisor to and provide an update and inform the APRN regarding refusal for further orders. After surveyor inquiry, a physician's order dated 7/17/2024 at 9:55 AM directed to provide Propranolol 60 mg tablet by mouth twice daily at 9:00 AM and 9:00 PM for hypertension. After surveyor inquiry, a physician's order dated 7/17/2024 at 10:42 AM directed to provide Duloxetine 60 mg delayed release capsule by mouth and not to open capsule. An interview and medication review for Resident #69 with Pharmacist #1 on 7/19/2024 at 11:26 AM indicated Propranolol 120 MG Extended release and the Duloxetine 60 mg delayed release should not be opened and the Propranolol information provided no option at all for opening the capsule. The facility policy labeled Medication Crushing Guidelines dated 6/2024, indicated in part time released capsules are designed to release medication over a sustained period usually 8-24 hours in which the contents are designed to dissolve at different times, utilized to reduce stomach irritation, in some cases and to achieve a prolonged medication action in other cases. Before opening a capsule to administer in food a reference or pharmacist should be consulted before administering in this manner.

Based on observation, review of facilities policy and interview for 1 out of 2 medication rooms, the facility failed to label medications appropriately once opened. The finding include: Observation of the A/B Wing medication room on 7/19/24 at 10:53 AM identified Morphine Sulfate 100 MG every 4 hours as needed prescribed to Resident # 98; was opened, however, a date open sticker was not on the medication. Interview with LPN #2 on 7/19/24 at 10:53 AM identified the date was documented somewhere else. The Medication Book indicated the Morphine was opened 7/7/24. After inquiry, RN#2 prompted LPN #2 to place the open date on the container. The facility's Storage of Medications Policy notes when the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. The nurse shall place a date open/ sticker on the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the kitchen, facility policy, and interviews, the facility failed to ensure staff wore facial hair covering appropriately for 2 of 2 residents (Resident #19 and Resident #54) and the facility failed to perform hand hygiene and failed to handle and transport linens to prevent the spread of infection. The findings included: 1. On 7/17/2024 at 8:01 AM observation of the breakfast tray line in the kitchen noted while Dietary Aide #1 was plating food his/her facial hair covering was below the facial hair of the upper lip. After surveyor inquiry, the Dietary District Manager advised Dietary Aide #1 of the need to cover the upper lip facial hair and further indicated the covering must have slipped down. Dietary Aide #1 proceeded to adjust the facial hair net removed gloves and proceeded to apply a new pair of gloves without the benefit of conducting hand hygiene in between glove changes. The Dietary District Manager after surveyor inquiry indicated hands should be washed after removing old gloves and then proceed to reminded Dietary Aide #1 to wash his/her hands and apply new gloves The facility policy labeled Hand Hygiene dated 6/2024 indicated in part hand hygiene should be performed after gloves are removed and hands washed with soap and water after performing personal hygiene. 2.a. Resident #19's diagnoses included displaced fracture of 2nd cervical vertebrae, depression and hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #19 as cognitively intact, requiring partial/moderate assistance for toileting and set up/clean up assistance with personal care. During an observation on 7/16/24 at 11:10 A.M., Nurse Aid (NA) #4 was observed, exiting Resident #19's bathroom, with gloves on both hands and holding dirty linens in the right hand. NA #4 used the gloved left hand to open and close doors, and to access the dirty linen cart across the hall without the benefit of removing the dirty gloves. An interview with NA #4 on 7/16/24 at 11:10 A.M. indicated it was acceptable for her/him to walk into the hallway with two dirty gloves on because she did so quickly. S/he further stated she did not know the linen cart had been moved from right outside of the room to across the hall. NA #4 then stated she was going on break, removed the dirty gloves, placed them in the trash in the room, and walked down the hall without performing hand hygiene. Review of the facility's Hand Hygiene policy identifies, in part, hand hygiene should be performed immediately after gloves are removed, after handling soiled linens, and before and after assisting a resident with personal care. b. Resident #54's diagnoses included Alzheimer's disease, acute respiratory failure with hypoxia, and chronic obstructive pulmonary disease. The quarterly MDS assessment dated [DATE] identified Resident #54 as severely cognitively impaired, requiring set up or clean up assistance for eating and dependent for transfers, hygiene and dressing. During an observation on 7/16/24 at 12:45 P.M. NA #4 was observed standing at the end of the hallway eating a bag of chips and licking his/her soiled fingers. Resident #54 began to cough while eating lunch. NA #4 walked into Resident #54's room within full visual range of the surveyor, picked up a box of tissues from the dresser, pulled 1 tissue out and handed it to Resident #54 to cough in without the benefit of washing his/her hands before giving the tissue to the resident. NA #4 then exited the room and utilized the alcohol-based hand sanitizer on the outside of the room to perform hand hygiene. Review of the facility's Hand Hygiene policy identifies, in part, hands should be washed with soap, either plain or antimicrobial, and water, for at least 15 seconds when visibly soiled, before and after eating and handling food and before and after assisting a resident with toileting. An interview with the DNS on 7/19/24 at 12:30 P.M. identified NA #4 as an agency NA. Review of the Need-to-Know Information document, which is reviewed and signed by agency staff members who work in the facility, includes no food or drink on the wings but does not include any information related to infection control. An interview with the DNS on 7/19/24 at 12:30 P.M. indicated hand hygiene should be performed before and after providing resident care and before and after wearing gloves. She further identified the facility is within a COVID-19 outbreak, although there are no current cases, that started 6/6/24, s/he aims to close the outbreak if there are no new cases by 7/26/24. The DNS identified there was no additional staff education performed regarding infection control or hand washing during the most recent outbreak.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, observations, review of policy for 2 of 2 residents ( Resident # 32 and Resident # 52) reviewed for respiratory treatment, the facility failed to ensure the residents nebulizer tubing was changed and stored according to facility policy. The findings included: 1. Resident #32's diagnoses included centrilobular emphysema and presence of a cardiac pacemaker. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #32 was moderately cognitively intact and required one person assist with bed mobility, supervision with transfers, eating and toileting. The Resident Care Plan, (RCP) dated 6/7/24 identified Resident #32 experienced a decline in activities of daily living (ADL) related to dementia and oxygen due to shortness of breath related to emphysema. Interventions directed to provide two caregivers for ADL care and change tubing weekly. The physician's orders dated 6/27/24 directed DuoNeb (medication prescribed to open airways) 0.5mg-3 mg (2. 5mg base/3 ml solution for nebulization for one dose and every (6) hours for (5) days for wheezing. An observation on 7/16/24 at 10:15 AM with Licensed Practical Nurse, LPN #1 identified the tubing on nebulizing mask was dated 7/2/24. An interview with LPN #1 on 7/16/24 at 10:15 AM tubing for respiratory equipment should have been changed weekly while in use. An interview with the Director of Nursing Services, DNS on 7/16/24 at 2:38 PM identified she would expect respiratory equipment to be changed weekly according to policy. A review of the facility policy for Oxygen/ Respiratory Equipment Maintenance and Storage (no date) directed that nebulizer masks be changed weekly and as needed based on wear and tear and be stored in a clear bag when not in use. 2. Resident #51 had diagnoses that included congestive heart failure, (CHF) and a history of acute respiratory failure with hypoxia. The quarterly MDS assessment dated [DATE] identified Resident #51 was cognitively intact and required extensive two person assist with bed mobility, transfers and independent with eating. Physician orders dated 4/17/24 directed DuoNeb 0.5mg-3 mg (2. 5mg base/3 ml solution for nebulization every four hours as needed for shortness of breath. The RCP dated 4/25/24 identified Resident #51 had decreased cardiac output related to CHF. Interventions directed to observe for signs of respiratory distress, shortness of breath and administer medications as ordered. A review of the medication administration record, (MAR) for July 2024 identified Resident #51 last received DuoNeb on 7/10/24. An observation on 7/16/24 at 10:15 AM with LPN #1 identified Resident #51's nebulizer mask was observed directly on h/her bedside table without the benefit of a storage bag. An interview with LPN #1 on 7/16/24 at 10:15 AM identified the nebulizer mask should have been stored in a plastic bag after use. An interview with the Director of Nursing, DNS on 7/16/24 at 2:38 PM identified she would expect respiratory equipment to properly stored in a plastic bag when not in use according to policy. A review of the facility policy for Oxygen/ Respiratory Equipment Maintenance and Storage (no date) directed that nebulizer masks be changed weekly and as needed based on wear and tear and be stored in a clear bag when not in use. 3. Resident #52's diagnoses included chronic obstructive pulmonary disease, (COPD). The quarterly MDS assessment dated [DATE] identified Resident was moderately cognitively intact and required extensive two person assist with bed mobility, transfers, independent with eating. The RCP dated 2/1/24 identified Resident #52 diagnosis of COPD. Interventions directed to notify the physician of a change in condition, administer medications as ordered and monitor for therapeutic/side effects. The physician's orders dated 4/19/24 directed Duoneb 0.5mg-3 mg (2. 5mg base/3 ml solution for nebulization three times daily for (5) days. A review of the Medication Administration Record ( MAR) identified Resident #52 last received Duoneb was on 4/24/24 at 10:51 AM. An observation with LPN #1 on 7/16/24 at 10:55 AM identified the nebulizer mask observed directly on the bedside table without the benefit of bag with a date on tubing of 12/13/23. An interview with LPN #1 on 7/16/24 at 10:55 AM at 10:55 AM identified the nebulizer mask should have been changed weekly and placed in a bag after use. An interview with the Director of Nursing Services, DNS on 7/16/24 at 2:38 PM identified she would expect respiratory equipment to be changed weekly and placed in a bag after use according to policy. A review of the facility policy for Oxygen/ Respiratory Equipment Maintenance and Storage (no date) directed that nebulizer masks be changed weekly and as needed based on wear and tear and be stored in a clear bag when not in use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, facility policy, and interviews for 1 resident (Resident #88) reviewed for Urinary catheter, the facility failed to ensure the residents urinary catheter bags was covered with a privacy bag to maintain the resident's dignity. The findings include: Resident #88 was admitted to the facility with diagnoses that included cerebral infarct affecting the left side, polyneuropathy, dementia, and facility acquired stage 4 pressure ulcer of sacrum. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified the resident was severely cognitively impaired, required total dependence of two staff member for physical assistance with bed mobility, transfers, personal hygiene, noted one-person physical assistance with toileting and the utilization of an indwelling catheter. The care plan dated 4/7/22 identified at risk for coccyx pressure ulcer. Interventions directed indwelling catheter for wound management. The care plan dated 4/7/22 identified at risk for urinary tract infection with indwelling catheter. Interventions directed to ensure the drainage bag was secured in place. Additionally, the care plan at risk for compromised comfort and dignity. Intervention directed to promote and monitor the resident for comfort and dignity. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #88 had moderately impaired cognition, was always incontinent of bowel and had a catheter for bladder. The resident also required total assistance with dressing, personal hygiene and with managing the catheter and catheter bag. A physician's order dated 8/10/22 directed to empty Foley catheter output every shift and Foley catheter care by the nursing assistant every shift. Additionally, the physician's orders directed to secure indwelling catheter to upper thigh to prevent movement and to check securement and patency every shift. The nurse's note dated 8/23/22 at 10:05 PM identified Resident #88's Foley catheter was patent and draining slightly cloudy amber colored urine. The Nursing assistant Care Card for Resident #88 directed for Foley catheter care to empty the Foley bag every shift and to record the resident's output. Observation on 8/24/22 at 11:30 AM identified Resident #88 was lying in bed with his/her urinary catheter bag with urine noted on the bed frame and lying on the floor without the benefit of a privacy bag. Resident #88's urine was visible from the entrance doorway while standing in the hallway. Interview and observation with Licensed Practical Nurse (LPN #1) on 8/24/22 at 11:35 AM identified Resident #88's urinary catheter should not be on the floor and should have a privacy bag covering his/her urinary catheter bag and tubing. LPN #1 indicated the catheter bag with the privacy bag should be hanging from the bed frame. LPN #1 indicated it was the nursing assistant responsibility to notify the charge nurse if there was no privacy bag. LPN #1 noted if the catheter bag was observed by the charge nurse on the floor or without the privacy bag, the charge nurse is responsible for attaching the catheter bag to the frame and obtaining the privacy bag. LPN #1 removed the catheter bag off the floor and went to obtain a privacy bag. Interview with LPN #1 on 8/24/22 at 12:00 PM indicated she had spoken to the assigned nursing assistant for Resident # 88, and she was informed the nursing assistance did not provided care yet to Resident #88. The nursing assistant also indicated she was not aware the resident's catheter bag was on the floor and did not have a cover. An interview with the Director of Nursing Services (DNS) on 8/25/22 at 6:55 AM indicated her expectation was that Resident #88's urinary bag would not be on the floor but would be attached to the bed frame below the bladder. The DNS also noted the urinary bag should be covered in a privacy bag from no matter which side of the bed it was hanging. The DNS further indicated it was the charge nurse and the nursing assistant responsibility to make sure the privacy bag was on the resident. Review of facility Resident [NAME] of Rights identified the resident has the right to be treated with consideration, respect, and full recognition of their dignity and individuality. Although requested, a facility policy for placement of urinary catheters for infection control purposes and the use of a privacy bag was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review clinical record reviews, review of facility documentation, facility policy and interviews for 2 residents reviewed for abuse (Resident #4 and Resident #23), the facility failed to treat the residents with respect and dignity when providing care. The findings included: 1. Resident #4 was admitted to the facility with diagnoses that included diabetes mellitus with diabetic neuropathy, generalized muscle weakness, morbid obesity, anxiety, and adjustment disorder with depressed mood. A quarterly MDS assessment dated [DATE] identified Resident #4 had moderately impaired cognition, noted independence with set up help only for bed mobility, locomotion on unit (with wheelchair), extensive assistance with two staff for transfer and extensive assistance with 1 staff member for toileting. Additionally, noted the resident is continent of urine and occasionally incontinent of bowel. A care plan dated 8/22/22 identified activity of daily living deficit due to impaired mobility status post knee surgery with a potential for diminished sense of self-worth and dignity. Interventions included to assist with hygiene and toileting. Interview with Resident #4 on 8/25/22 at 12:00 PM identified on 8/22/22, a staff member came in with his/her dinner tray and s/he requested a bed pan. Resident #4 continued by stating that about an hour later Nurse Aide (NA#6) came in to pick up the dietary tray and s/he asked for the bedpan. NA #6 responded by stating she was in the middle of something therefore Resident # 4 would need to wait or should just poop in the bed. NA #6 further indicated she would come back and clean Resident # 4 up. Resident #4 stated that s/he reported the incident to Licensed Practical Nurse (LPN #2) and that LPN # 2 stated she would follow up with the NA #6. Interview with LPN #2 on 8/25/22 at 1:00 PM identified NA #6 reported on 8/22/22 that s/he went in with Resident #4's dinner tray. NA #6 stated that the Resident # 4 had already started moving his/her bowels so she told her/him to finish, and she would come back later to clean him/her up. NA #6 further indicated that after she finished cleaning up Resident #4, Resident #4 seemed upset with her but she was not sure why. LPN #2 continued by stating that she went into see Resident #4 who told LPN #2 that NA #6 refused to give her/him the bedpan. NA #6 had told /her him to just go in the bed and she would come back and clean her/him up later. LPN #2 could not recall the exact time she saw Resident #4 but stated Resident #4 was no longer soiled. LPN #2 continued by stating she asked NA #6 if Resident #4 had asked for the bedpan and NA #6 said yes and indicated she told Resident # 4 that since s/he had already started to move his/her bowels to just to finish and she would clean him/her up later. LPN #2 further indicated that NA#6 should have given the resident the bedpan when s/he asked and if Resident#4 was too soiled, she should have came and gotten her to clean the resident. LPN #2 stated that NA #6 failed to provide Resident # 4 with the bedpan upon request and did not notify her supervisor at the time of the incident . LPN # 2 further indicated she saw Resident #4 later in the evening interacting with NA #6 who appeared to be no longer upset. LPN #2 also indicated that after thinking about the incident later, she now realized that the incident was an allegation of mistreatment and that she should have told the supervisor about it and documented the event. Subsequent to inquiry, the DNS was informed of resident's allegation and the DNS immediately removed NA #6 off the unit and started an investigation. NA #6 was re-educated on 8/26/22 regarding the facility's Resident Rights Policy and Customer Service. Interview with Resident #4 on 8/31/22 at 9 :00AM identified Resident #4 felt that NA #6 was not respectful of his/her request for the bedpan on 8/22/22 and that it was an insult to her/his dignity. The facility policy, Resident's [NAME] of Rights directs in part the Residents have the right to be treated with consideration, respect and full recognition of their dignity and individuality. The facility failed to ensure that Resident # 4 was treated with dignity and respect. 2. Resident #23 was admitted to the facility with diagnoses that included mild cognitive impairment, depression, adjustment disorder with mixed anxiety, polyneuropathy, and muscle weakness. A quarterly MDS assessment dated [DATE] identified Resident #23 was cognitively intact requiring extensive assistance with 1 staff member for bed mobility, extensive assistance with 2 staff for transfers and toileting. Resident #23 had adequate hearing and was able to hear normal conversation and could be understood. A physician's order dated 2/25/22 at 1:06 PM for Resident # 23 directed weight bearing to left foot only for transfers. A care plan dated 3/16/22 identified Resident #23 had a potential for diminished self-worth and dignity due to activities of daily living decline. Interventions included: to assist as needed with toileting. The care plan continued by identifying that Resident #23 was a fall risk due to peripheral neuropathy with numbness of the legs from knees to feet with impaired balance and mobility. Interventions included the utilization of a Serita lift (stand lift) assist with 2 staff members for all transfers. A social services progress not dated 3/30/22 at 1:37 PM identified that she and Registered Nurse (RN #4) met with Resident #23 regarding an interaction with a nurse aide last evening where her/his roommate's family member reported an allegation of verbal abuse. Resident #23 identified that her/his interaction was not abusive, but the aide was frustrated by continued to state s/he has a positive relationship with the NA. An APRN note dated 3/30/22 at 2:56 PM identified Resident #23 did not express any concerns. A facility Accident and Incident Report dated 3/30/22 identified that an allegation of verbal abuse was reported involving Resident #23 that occurred on 3/29/22 at approximately 7:00 PM where the Person #1 reported that a NA was yelling at the Resident # 23. A facility statement dated 3/30/22 completed by Social Worker (SW #3) identified that Person #1 had reported that on the previous evening (3/29/22), Resident #23 needed to use the bathroom and was calling for help. NA #4 came into the room and initially joked with Resident #23 as she assisted Resident #23 onto the lift to take her/him to the bathroom. Person #1 heard NA #4 yelling for Resident #23 to not let go as NA #4 would lose her license. Resident #23 yelled back that NA #4 had to take her/him to the bathroom. Both Resident #23 and NA #4 continued to yell back and forth at each other noting that Resident #23 was upset and crying. The SW in her statement continued by stating that Resident #23 stated that NA #4 can yell at times and talks very loudly and that regarding last night, NA #4 was yelling and told her/him that she was on another assignment. The statement continued by indicating Resident #23 did not want to provide detailed information as s/he did not want to get NA #4 in trouble but did confirmed that NA #4 yelled at her/him. A facility statement dated 3/31/22 completed by NA #4 identified Resident #23 was in the hallway calling for assistance on 3/29/22 and that she was not the aide assigned but she brought Resident #23 into her/his room. NA #4 went to get the supplies including the lift to assist her. Resident #23 began to yell at her to hurry up. While in the lift, Resident #23 was unable to hold her/himself up and NA #4 told her/him that she needed to get help, she raised her voice so that Resident #23 could hear her over Resident #23's yelling. I told Resident #23 that I was not going to lose my license and then left to get another NA to help. A Psychiatric APRN consultation progress note dated 3/31/22 at 11:49 AM identified that she was asked to see the Resident #23 to follow up on the resident's mood and noted that Resident #23 is not anxious but can be slightly irritable. The psychiatric APRN recommended that staff approach Resident #23 gently as the resident needs to feel that s/he is understood or heard and to be clear about the task being done to meet her/his needs as this may help with Resident #23's frustrations. Interview with Person #1 on 8/31/22 at 8:30 AM identified she was visiting a family member, Resident #23's roommate on 3/29/22 when Resident #23 needed to use the bathroom. She went out into the hallway and finally saw a nurse aide in the break room having dinner at which time she let the nurse aide know that Resident #23 needed to go to the bathroom. Person #1 went back to Resident #23's room and saw Resident #23 had wheeled her/himself out into the hallway, yelling for assistance. NA #4 responded after getting Resident #23 into the room then leaving the room and returning with a lift. NA #4 began to assist Resident #23 by placing the lift straps on Resident #23. Resident #23 started to try to stand, and NA #4 told her/him to wait and sit down, Resident #23 started to yell that s/he needed to get to the bathroom and NA #4 started to yell back at her/him to sit back down. NA #4 started saying that she was not going to lose her license - sit down. Resident #23 kept yelling that s/he needed to go to the bathroom and NA #4 kept yelling back to sit down. Person #1 reported that they continued to yell back and forth, and it was so upsetting to Person #1, s/he had to leave the room. Person #1 continued by stating that Resident #23 appeared to be frustrated and began crying. Interview with LPN #4 identified that she did care for Resident #23 on the 3:00 - 11:00 PM shift on 3/29/22 and could not recall any reports that staff were yelling at the resident or that she witnessed anyone yelling. She routinely cares for Resident #23 and identified the resident has never identified that staff yelled at her/him. Interview with the DNS on 8/31/22 at 10:00 AM identified on 3/30/22 Person #1 had reported to the Social Worker that NA #4 had yelled at Resident #23 the previous evening (3/29/22). I did not take the report directly, but I did the investigation. My investigation identified that NA #4 responded when Resident #23 had called for help to go to the bathroom. NA #4 brought the lift into the room and Resident #23 started to get up. NA #4 told Resident #23 to wait as she needed to get another NA to help with the transfer. Resident #23 did not want to wait and started to get up. NA #4 repeated to the resident that she needed to get help and Resident #23 started to yell at her that s/he wanted to get up. NA #4 felt she needed to raise her voice as Resident #23 became very demanding to get up and was yelling at her. The DNS added that she believed that the NA bringing the lift into the room without being prepared to assist the resident immediately added to Resident # 23's frustration. The DNS's investigation identified that NA #4 was re-trained on Customer Service secondary to demonstrating poor customer service, exhibited poor attitude, failure to follow the Resident # 23's plan of care and behaving in an unprofessional manner. Additionally, the DNS identified NA # 4 received a written warning. Multiple attempts to contact NA # 4 were unsuccessful. An attempt to contact SW #3 was unsuccessful Multiple attempts to contact RN #4 (Evening RN supervisor) were unsuccessful. The Certified Nurse Assistant (NA)job description in part directs a NA must have patience, tact and be willing to handle residents based on whatever level of maturity the resident is currently functioning. The facility policy, Resident's [NAME] of Rights directs in part the residents have the right to be treated with consideration, respect and full recognition of their dignity and individuality. The facility failed to ensure that Resident # 23 was treated with dignity and respect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, review of facility policy and interviews for 2 residents (Resident #1 and #50) reviewed for Accommodations of Needs, the facility failed to ensure the residents call lights were within reach within accordance to facility practice. The findings included: 1. Resident #1 was admitted to the facility with diagnoses that included dementia, chronic pain, and polyosteoarthritis. The care plan dated 7/14/22 identified Resident #1 was at risk for falls. Interventions directed to keep call light in reach and do not leave alone in the bathroom. The quarterly MDS assessment dated [DATE] identified Resident # 1 had severely impaired cognition, was frequently incontinent of bowel and bladder and required extensive assistance with transfers, toileting, and the resident was totally dependent for dressing and personal hygiene. Observation on 8/24/22 at 11:45 AM noted Resident #1 lying in bed in an upright position with the overbed table in front of him/her with no items on it. Further observations identified across room in front of Resident #1-foot board a television stand with a dirty breakfast tray. Additionally, observations identified the resident's call bell was not in reach of Resident #1 secondary to being wrapped around the right upper side rail and the top where the button was behind the bed wedged between the side rail and the back of the bed. Interview with LPN #1 on 8/24/22 at 11:46 AM indicated all call lights must be in reach of the residents. Observation of Resident #1 by LPN #1 indicated Resident #1 would not be able to use the call light because the bell was between the upper side rail and the bed and the part to press was behind the bed. LPN #1 indicated Resident #1 would not be able to roll over and get the call light where it was located. LPN #1 untangled the call light cord and placed the call light button on top of Resident #1 within reach. LPN # 1 indicated it was the nursing assistant's responsibility to make sure call lights are always within reach of residents. LPN #1 indicated she would speak with the nursing assistant assigned to Resident #1. Observations on 8/29/22 at 8:45 AM identified Resident #1 was sitting upright in bed eating breakfast. The call light was wrapped around the top of the right upper side rail of the bed. Did not appear Resident #1 would be able to reach it. An interview with LPN #1 on 8/29/22 at 8:50 AM noted Resident #1 was not able to reach the call light because of where it was positioned. LPN #1 noted Resident #1 would not be able to roll over and reach the cord even to pull the call bell to him/herself. LPN #1 indicated NA #2 was responsible for making sure the call light was within reach of Resident #1. 2. Resident # 50 was admitted to the facility with diagnoses that included dementia and cerebral infarct. The quarterly MDS assessment dated [DATE] identified Resident #50 had severely impaired cognition, was frequently incontinent of bladder and occasionally bowel, and required extensive assistance with toileting, transfers, personal hygiene, and for dressing the resident required one-person physical assist. The care plan dated 7/14/22 identified was at risk for falls. Intervention directed to keep call light in reach. The social services note dated 7/14/22 at 10:37 AM identified Resident #50 presents as pleasantly confused. Observation on 8/24/22 at 11:20 AM Resident #50 was lying flat on his/her back in bed and the sensor pad call bell (the flat round call pad a resident can just hit or press to alarm) was on a pillow in a bedside chair out of reach. Observation and interview with LPN #1 on 8/24/22 at 11:45 AM indicated Resident #50's call bell should be in his/her reach and s/he did not know why the bell was placed on the pillow in the bedside chair out of Resident #50's reach. LPN #1 indicated Resident #50 would not be able to roll over and reach the sensor pad call bell if she needed assistance. LPN #1 moved the sensor pad call bell and placed it next to Resident #50 within reach. Interview with the DNS on 8/25/22 at 11:22 AM indicated call lights must be in reach of the residents and answered promptly. The DNS indicated the call light ensures the resident can be able to communicate when they have a need. The DNS indicated she was not aware Residents #1 and #50 did not have their call lights within reach and both residents should have their call lights in reach at all times. The DNS indicated RN #3 would be conducting education immediately with staff. Observation on 8/29/22 at 8:10 AM and 8:40 AM Resident #50 was awake with his/her eyes open sitting in the wheelchair on right side of bed eating his/her breakfast with a cup in his/her hand and no staff present at the time of the observation. The sensor pad call bell was on the opposite side of the bed on the bedside chair on a pillow. Observation and interview with LPN #1 on 8/29/22 at 8:51 AM indicated Resident #50 was not able to ambulate around the bed or reach the sensor pad call light. LPN #1 indicated NA #2 must had forgotten to give the sensor pad to Resident #50 after he had gotten Resident #50 washed and dressed and placed in the wheelchair. Interview with NA # 2 on 8/29/22 at 8:55 AM indicated he had washed and dressed Resident #50 and placed Resident #50 in the wheelchair. NA # 2 indicated Resident #50 could not reach the [NAME] pad call bell on the opposite side of the bed. NA #2 moved the sensor pad call bell onto the right side of the bed next to Resident #50. NA # 2 indicated the nursing assistant is responsible for making sure them resident's call bell is in reach at all times. NA #2 indicated he was in a hurry and had forgot to give Resident #50 the call light. Interview with the DNS and RN #3 on 8/29/22 at 1:00 PM indicated RN #3 had done education with the nursing staff on 8/25/22 and NA #2 was included in the education. The DNS indicated the nursing staff are aware that they are responsible for ensuring call bells are within reach. Interview with Staff Development RN #3 on 8/30/22 at 9:00 AM indicated upon hire at general orientation the newly hired staff are provided education regarding call bells. RN # 3 indicated it was everyone's responsibility to answer call bells. RN # 3 noted call bells should be within the residents reach at all times. RN #3 also indicated when a resident is in bed the call bell should be clip to the residents' linen. RN #3 also indicated before leaving the room that staff is responsible for ensuring that the call bell is within reach of the resident. Staff Education dated 8/25/22 identified the topic was call bells. Prior to leaving a residents' room, please make sure that the resident's call bell is within reach. When resident is in bed the call bells should be clip to the bedding. The call bell should be answered as soon as possible. Although requested, a facility policy for call lights the DNS indicated there was not a policy to provide.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, facility policy review and interviews for 1 resident (Resident #42) reviewed for edema, the facility failed to ensure that the dietician, physician, and responsible party were notified of the resident's weight loss. The findings include: Resident #42's diagnoses included dementia with behavioral disturbance, hypertension, hypothyroid, stage 3 chronic kidney disease, dysphagia, and anemia. The Resident Care Plan (RCP) dated 8/11/22 identified Resident #42 was at risk for weight loss related to dysphagia, poor food intake. Interventions included: to encourage resident in participation with food choices, to monitor food consumption, to monitor weight, to provide diet as ordered, provide supplement as ordered and to offer appropriate fluid and snack between meal per protocol. The quarterly MDS assessment dated [DATE] identified Resident #42 had severe impaired cognition and required extensive assistance of 1 person with transfer, dressing and toileting and ambulation. The physician's order dated 7/11/22 identified Resident #42 was on weekly weight monitoring. An additional physician's orders dated 8/4/22, 8/8/22, 8/11/22 and 8/25/22 requested a reweigh to be done by the nurse to confirm the resident's weight. A review of Resident #42's weight identified the following: on 6/21/22 was 166.9 pounds (lbs.), on 7/22/22 was 199 lbs. and on 8/8/22 was 198.7 lbs. which had a discrepancy of 32 lbs. in a month. Resident #42 's current weight was 152.2 lbs. taken on 8/26/22 which identified an 8.8 percent weight loss in 2 months. Interview with Licensed Practical Nurse (LPN #3) on 8/25/22 at 11:30 AM identified the nurse would review and evaluate the resident's weight. When a weight discrepancy was identified, the nurse would obtain a re-weight to confirm the weight. She also indicated that the reweight would be obtain the next day following the weight discrepancy. LPN # 3 further indicated when a resident is noted with a weight loss or gain, she would inform the dietician and physician. Subsequent to surveyor inquiry of Resident #42 weight discrepancy, LPN # 3 indicated she was aware of the resident's weight discrepancy and indicated Resident #42 had behaviors of refusing care. She also agrees that the weight discrepancy should have been resolve. Interview with Dietician on 8/29/22 at 10:30 PM identified the facility conducts weekly weight meetings which consists of the Director of Nursing Services (DNS), nursing supervisor and the wound nurse to discuss any resident with the weight issues. Subsequent to surveyor inquiry of Resident #42 weight discrepancy, the dietician indicated she was aware Resident # 42 had a weight discrepancy and she requested a reweight to get an accurate weight. Interview with RN #1 on 8/29/22 at 11:30AM identified the nurse would review and evaluate the resident weight. She also indicated that a weight discrepancy of 5 lbs. weight loss or gain required a reweigh to confirm the resident's weight. RN #1 further indicated she was aware of the resident's weight discrepancy. She also indicated that the nurse forgot to subtract the weight of the wheelchair. She was not aware of Resident #42 recent weight loss. She would notify the dietician, physician, and responsible party if she had been made aware of the weight loss. Interview with DNS on 8/29/22 at 12:00 PM identified the nursing staff would review and evaluate the resident weight timely. If determine there was a weight discrepancy, she expect that a reweight would be done immediately to confirm the resident's weight. She also identified that the facility conducts weekly meetings to discuss any weight issues. The DNS indicated she was aware Resident # 42's weight discrepancy. Subsequent to surveyor inquiry, Resident #42 's weight was obtained on 8/26/22 and identified it was 152.2 lbs. which noted an 8.8 percent weight loss in 2 months. The facility failed to notify the dietician, physician, and responsible party of the weight loss timely. A review of facility nursing policy title Weight Monitoring of Residents directed that weights would be obtain by the staff and overseen by licensed nursing staff as needed. If a resident's weight is 3 lbs. more or 3 lbs. less than the previous weight taken, the nursing assistant would reweigh the resident with another staff member and report the weight to the charge nurse. The charge nurse would also notify physician, responsible party if a resident weight were 5 percent loss in 30 days or 7.5 percent loss in 90 days or 10 percent loss in 180 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, facility policy, and interviews for 2 of 5 residents (Resident #78 and Resident #345) reviewed for dignity, the facility failed to ensure that the resident's confidential and personal care instructions was not posted for public view. The findings included: 1. Resident #78's diagnoses included cerebral infarction, hemiplegia affecting right dominant side, hyperlipidemia, hypertension, type 2 diabetes mellitus, dysphagia, osteoporosis, depression, and chronic pain. The Resident Care Plan (RCP) dated 6/2/22 identified Resident #78 had dysphagia (difficulty swallowing) related to cerebral infarction. Interventions included: to observed for and report any sign of symptoms of aspiration to the Medical Doctor (MD) and responsible party, to provide modified consistency of food as ordered, speech therapy as needed and aspiration precaution 90 degrees with all mouth intake and half-hour after small sips, small bites, alternate liquid, and solids. The quarterly MDS assessment dated [DATE] identified Resident #78 had intact cognition and required extensive assistance of 1 person with transfer, dressing and toileting and noted the resident was non-ambulatory. Observation on 8/24/22 at 10:30 AM identified Resident #78 in a semi-private room with instructions posted on the wall in the room directing staff to cut up my meat and put my dentures in my mouth for all meals that was visible to the public. A review of Resident #78 care card in the facility's computer system on 8/25/22 at 10:40 AM failed to identify that he/she needed to wear dentures for all meal and the staff needed to cut up the resident's meat in the plan of care. Interview with the DNS on 8/25/22 at 11:25 AM identified that the nursing assistant can view the resident care card in the computer system She also indicated that the nurse would update the resident's care card as needed. The DNS further indicated she was unaware Resident #78 resident care instructions was posted on the wall. The DNS also indicated she would expect the nurse to enter all pertinent resident plan of care in the computer system and no care related instructions should be posted on the wall. 2 Resident #345's diagnoses included non-traumatic intracerebral hemorrhage, hemiplegia affecting right dominant side, hypertension, dysphagia, cognitive communication deficit, seizures and acute respiratory with hypoxia. The admission MDS assessment dated [DATE] identified Resident #345 had severe impaired cognition and dependent with 2 people assist with transfer, dressing and toileting, eating and non-ambulatory. The Resident Care Plan (RCP) dated 8/17/22 identified Resident #345 had dysphagia (difficulty swallowing) related to non-traumatic intracerebral hemorrhage. Interventions included: to observed for and report any sign of symptoms of aspiration to MD and responsible party, honey thick fluid by teaspoon, puree consistency by teaspoon, total feed, tube feeding as ordered and aspiration precaution with single teaspoon size bites of texture/liquid, slow rate and allow for 2 swallow, to keep the resident fully upright during and at least 1 hour after intake and to take a break if coughing occurred. Observation on 8/24/22 at 10:45AM identified Resident #345 in a semi-private room with an instruction posted on the wall which directed staff to put the head of bed fully upright while eating or drinking and at least 1 hour after meals, all food or liquid by teaspoon, to allow for 2 swallows, take break if coughing occurred and to provide daily oral care. A review of Resident #345 care card in the facility's computer system on 8/25/22 at 10:45 AM failed to identify that his/her head of bed need to be fully upright during mealtime and to ensure the resident sit upright for 1 hour after each meal, to give all food or liquid by teaspoon, to allow for 2 swallows, to take break if coughing occur and to provide daily oral in the plan of care. Interviewed with Nursing Assistant (NA #1) on 8/25/22 at 10:20 AM identified that her assignment including the resident care card would be available to view in the computer system. She also indicated that the nurse or nursing supervisor would update the resident care card. She further indicated that the care instructions on the wall was use as a reminder for agency nursing assistant. She could not identify who put the resident care instructions on the wall. Interview with Licensed Practical Nurse (LPN #3) on 8/25/22 at 10:30 AM identified that Resident Care Card would be available in the computer system and the nurse would update the care card as needed. The LPN #3 could not identify who put the residents care instructions on the wall. The resident care card in the computer system should be updated to reflect the current resident plan of care. Interview with the DNS on 8/25/22 at 11:25 AM identified that the nursing assistant can view the resident care card in the computer system She also indicated that the nurse would update the resident's care card as needed. The DNS further indicated she was unaware that Resident #345 resident care instructions was posted on the wall. The DNS also indicated she would expect the nurse to enter all pertinent resident plan of care in the computer system and no care related instructions should be posted on the wall. The facility failed to ensure the resident personal and confidential plan of care instructions was not posted for public view. A review of facility nursing policy title Resident's [NAME] of Rights identified in part for personal and clinical record notes residents have the right to privacy and confidentiality regarding all records kept by the facility pertaining to resident care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy review and interviews for 1 of 2 residents (Resident #4) reviewed for abuse, the facility failed to the implement the facility's policies and procedure for reporting an allegation of mistreatment. The findings include: Resident #4 was admitted to the facility with diagnoses that included diabetes mellitus with diabetic neuropathy, generalized muscle weakness, morbid obesity, anxiety, and adjustment disorder with depressed mood. A quarterly MDS assessment dated [DATE] identified Resident #4 had moderately impaired cognition, noted independence with set up help only for bed mobility, locomotion on unit (with wheelchair), extensive assistance with two staff for transfer and extensive assistance with 1 staff member for toileting. Additionally, noted the resident is continent of urine and occasionally incontinent of bowel. A care plan dated 8/22/22 identified activity of daily living deficit due to impaired mobility status post knee surgery with a potential for diminished sense of self-worth and dignity. Interventions included to assist with hygiene and toileting. Interview with Resident #4 on 8/25/22 at 12:00 PM identified on 8/22/22, a staff member came in with his/her dinner tray and s/he requested a bed pan. Resident #4 continued by stating that about an hour later Nurse Aide (NA#6) came in to pick up the dietary tray and s/he asked for the bedpan. NA #6 responded by stating she was in the middle of something therefore Resident # 4 would need to wait or should just poop in the bed. NA #6 further indicated she would come back and clean Resident # 4 up. Resident #4 stated that s/he reported the incident to Licensed Practical Nurse (LPN #2) and that LPN # 2 stated she would follow up with the NA #6. Interview with LPN #2 on 8/25/22 at 1:00 PM identified NA #6 reported on 8/22/22 that s/he went in with Resident #4's dinner tray. NA #6 stated that the Resident # 4 had already started moving his/her bowels so she told her/him to finish, and she would come back later to clean him/her up. NA #6 further indicated that after she finished cleaning up Resident #4, Resident #4 seemed upset with her, but she was not sure why. LPN #2 continued by stating that she went into see Resident #4 who told LPN #2 that NA #6 refused to give her/him the bedpan. NA #6 had told /her him to just go in the bed and she would come back and clean her/him up later. LPN #2 could not recall the exact time she saw Resident #4 but stated Resident #4 was no longer soiled. LPN #2 continued by stating she asked NA #6 if Resident #4 had asked for the bedpan and NA #6 said yes and indicated she told Resident # 4 that since s/he had already started to move his/her bowels to just to finish and she would clean him/her up later. LPN #2 further indicated that NA#6 should have given the resident the bedpan when s/he asked and if Resident#4 was too soiled, she should have gotten her to clean the resident. LPN #2 stated that NA #6 failed to provide Resident # 4 with the bedpan upon request and did not notify her supervisor at the time of the incident. LPN # 2 further indicated she saw Resident #4 later in the evening interacting with NA #6 who was no longer upset. LPN #2 also indicated that after thinking about the incident later, she now realized that the incident was an allegation of mistreatment and that she should have told the supervisor about it and documented the event. Subsequent to inquiry, the DNS was informed of resident's allegation and the DNS immediately removed NA #6 off the unit and started an investigation. Interview with the DNS on 8/25/22 at 1:30 PM identified LPN #2 should have reported the incident to her supervisor on the evening of the 8/22/22. LPN #2 was re-educated on 8/26/22 that any allegation or conflict between a staff member and resident should be investigated and acted upon. She was also re-educated that any allegation of abuse should be immediately reported to the supervisor. The facility policy, Abuse- Observation and recording in part notes the facility goal is to ensure that residents are free from verbal, sexual, physical, mental abuse, exploitation mistreatment, neglect, involuntary seclusion, and misappropriation of funds by staff and visitors. The policy defines mistreatment as inappropriate treatment or exploitation and directs that any staff member who has knowledge of any abusive actions toward any resident is obligated to report the situation to the administrator or to their immediate supervisor so that the actions outlined in the procedure can be implemented. LPN #2 failed to report Resident #4's allegation of mistreatment to her supervisor on 8/22/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility policy and interviews for 1 resident (Resident # 73) reviewed for Care Conferences, the facility failed to ensure the resident was invited to quarterly and annual interdisciplinary meetings and for 1 resident (Resident #50) reviewed for specialized rehabilitation services, the facility failed to ensure physician orders for 1:1 feeding for a resident at risk of aspiration was revised on the plan of care. The findings included: 1. Resident #73 was admitted to the facility with diagnoses that included chronic respiratory failure with hypoxia, obstructive sleep Apnea, and chronic obstructive pulmonary disease. The quarterly MDS assessment dated [DATE] identified Resident #73 had intact cognition and required set up assistance for eating, dressing upper and lower body. The care plan dated 1/31/22 identified self-administer of medications. Interventions directed for Resident #73 to have a locked drawer and indicated the resident preferred to self-administer his/her medications. Resident #73 will be assessed for ability to self-administer medications safely quarterly and with a significant change in condition. The care also directed to monitor medications for compliance daily. A review of the Attendance Signature Sheet for Resident Care Conferences dated 1/31/22 identified a representative from Recreation, Social Worker, and MDS Coordinator (RN #2) had attended the meeting. The back side did of the sheet failed to identify if Resident #73 had been invited and attended or declined the meeting. The MDS Coordinator (RN #2) progress note dated 1/31/22 at 2:51 PM identified the resident care conference for quarterly review. Resident #73 had no falls and weight was stable. Resident #73 ambulates throughout the facility with a walker. Resident #73 was independent with activities of daily living. The interdisciplinary team agrees with plan of care. The social worker progress note dated 1/31/2022 at 4:28 PM indicated a quarterly review of Resident #73. Resident #73's moods have been stable and there are no new psychosocial issues. Attendance Signature Sheet for Resident Care Conferences dated 5/5/22 identified a representative from Recreation, Social Worker, and MDS Coordinator (RN #2) had attended the meeting. The back side was circled that the resident was invited and declined. There was no explanation why Resident #73 had declined or signature from Resident #73. The MDS Coordinator (RN #2) progress note dated 5/5/22 at 4:07 PM identified that the resident care conference for annual review. Resident #73 had one fall with minor injury this quarter. Resident #73 ambulates throughout the facility with a rollator. Resident #73 requires set up only for activities of daily living. The interdisciplinary team agrees with plan of care. The Social services note dated 5/6/22 at 4:02 PM a late entry for 5/5/22 at 5:31 PM noted annual review. Resident #73 meets his/her goal to engage in light conversation. Resident #73 was compliant with medications. Resident #73 had resided at facility for about a year and was doing well. This writer had spoken to the family member and asked the questions from the MDS. The family member had no interest in having Resident #73 reviewed for potential return to the community. The family member prefers to be asked this question only on annual reviews. Attendance Signature Sheet for Resident Care Conferences dated 8/4/22 identified a representative from Recreation, Social Worker, and MDS Coordinator (RN #2) had attended the meeting. The back side was circled that resident was invited and declined. There was no explanation why Resident #73 had declined or signature from Resident #73. The Social services note dated 8/4/22 at 3:48 PM identified resident care conference nursing had reported Resident #73 was ambulating with a rolling walker. Recreation indicated Resident #73 had attended some programs. Social worker will continue to provide support and no family members attended the meeting. The MDS (RN #2) progress note dated 8/4/22 at 4:32 PM identified that the resident care conference for quarterly review. Resident #73 had no falls and weight was stable. Resident #73 ambulates throughout the facility with a rollator. The interdisciplinary team agrees with plan of care. Interview with Resident #73 on 8/24/22 at 10:30 AM indicated s/he was not invited to attend or had attended the interdisciplinary quarterly meetings to discuss his/her plan of care. Resident #73 also indicated if s/he had been invited s/he would have attended the care conference meetings. Interview with SW #1 on 8/30/22 at 8:52 AM indicated Resident #73 should be invited to attend the quarterly and annual interdisciplinary meetings that were held in the social workers office. SW #1 indicated everyone who attends the meeting must sign including the resident. SW #1 indicated the MDS Coordinator (RN #2) was supposed to personally invite the residents and to see if the resident would be willing to attend. SW #1 also indicated if a resident refuses to attend the expectation was the MDS Coordinator (RN #2) would be responsible for writing a note and asking the resident why s/he did not want to attend. SW #1 noted MDS Coordinator (RN #2) was in charge of the sign in sheet. SW #1 noted the signatures on the top of the sheet noted who physically attended by providing a signature and at the bottom of the sheet was for someone who did not attend but provided information about Resident #73. Interview with MDS Coordinator (RN #2) on 8/30/22 at 9:07 AM indicated she was responsible for scheduling and overseeing the Resident Interdisciplinary Care Conferences every quarter for all long-term care residents. RN #2 indicates it was her writing on the 5/5/22 and the 8/4/22 noted that Resident #73 was invited but declined to attend. RN #2 indicated she was responsible to asking Resident #73 to attend and bringing the resident to the meeting. MDS Coordinator (RN#2) indicated she did not recall why Resident #73 had refused and did not document why. RN #2 indicated it would be her responsibility to write a progress note as to why Resident #73 had refused but in reviewing the documentation she did not. MDS Coordinator (RN #2) indicated the signature form dated 1/31/22 was blank as to whether Resident #73 or his/her family were invited and if either had refused to attend. RN #2 indicated I probably just missed it. RN #2 indicated the family was automatically invite and do not ask the resident if they want the family to attend. MDS Coordinator (RN #2) indicated she would write a progress note labeled IDT and, in the note, indicates who attended including the resident and the family member. RN #2 indicated if the family does not attend, she does not call them. Interview with the DNS on 8/30/22 at 9:21 AM indicated she would expect Resident #73 would be invited to his/her own interdisciplinary care conference. The DNS noted we always send letters to the responsible parties or family unless the resident tells us not to. The DNS indicated the social worker or nursing would invite and bring Resident #73 to the meetings. The DNS indicated if Resident #73 did not want to attend her expectation would be someone would write a progress note indicating why Resident #73 did not want to attend. The DNS indicated in review of the clinical record for the care conference dated 1/31/22 she did not see any documentation in the clinical record if Resident #73 was invited and had attended, the care conference dated 5/5/22 and 8/4/22 also did not indicate the resident was invited or refused and why. The DNS further indicated that her expectation was there would be a comprehensive note by MDS Coordinator (RN#2) to explain how they had encouraged Resident #73 to attend and why he/she did not attend. The DNS indicated Resident #73 should be invited and the information should be documented why the resident did not attend and that the MDS Coordinator would educate and encouraged Resident #73 to attend. The DNS indicated she did not see the documentation for the Interdisciplinary Care Meetings dated 1/31/22, 5/5/22, and 8/4/22 that Resident #73 was invited and by whom and that Resident #73 had refused and why. Review of facility Resident Care Conference Policy notes in part the MDS person or designee will be the chairperson for the resident care conference. This meeting will take place by day 21 after admission and quarterly thereafter. Discussion among the resident, family and interdisciplinary team is essential to establish holistic and personal care for each resident. Staff member within facility will invite the resident, family, Power of Attorney and interested party to attend. In the event such persons cannot attend, staff will contact them after the conference and inform them of the plan of care. In the case of competent or un-conserved resident, information is shared with other persons only with the resident's consent. Review of facility Resident's [NAME] of Rights identified the resident has the right to participate in planning their own care and treatment and to be fully informed in advance about changes in their care and treatment. 2. Resident #50 was admitted to the facility with diagnoses that included cerebral infarct, dementia, and dysphasia with oropharyngeal phase. A Speech Therapy Plan of Care evaluation dated 1/28/22 identified Resident #50 had functional deficits that were caused by dysphagia. Resident #50 was on precautions for aspiration precautions, risk of weight loss, malnutrition, dehydration, and reduced insight and safety. Resident #50 had delayed swallow initiation and a delay in throat clearing. Resident #50 was currently dependent on caregivers for assistance to ensure adequate intake and safe consumption of meals. Recommended 1:1 feed. Physician Orders in electronic medical record in place. A Speech Therapy Plan of Care evaluation dated 4/15/22 identified Resident #50 had functional deficits that were caused by dysphagia. Resident #50 was on precautions for aspiration precautions, was a 1:1 feed, and at risk of weight loss, malnutrition, dehydration, and reduced insight and safety. Resident #50 had delayed swallow trigger and decreased hyolaryngeal elevation per tactile palpation with both consistencies. Due to staff reporting coughing on nectar thick liquids on multiple occasions, severely impaired cognition, and history of dysphasia the resident will have a puree consistency diet with honey thick liquids as recommended at this time. Resident #50 was currently dependent on caregivers for assistance to ensure adequate intake and safe consumption of meals. Physician Orders in electronic medical record in place. The quarterly MDS assessment dated [DATE] identified Resident #50 had severely impaired cognition and required a mechanically altered diet and required extensive assistance of one with eating. The dietician note dated 6/30/22 at 12:24 PM noted Resident #50 was observed at breakfast today assisted with meal and eating well. The care plan dated 7/14/22 identified a decline in activity of daily living. Interventions directed to provide 1:1 feeding assistance. Additionally, directed to provide speech therapy screen and treat as ordered The APRN note dated 7/27/22 9:17 PM identified Resident #50 was on a modified puree diet with honey thick liquids due to dysphasia. Plan: continue with modified puree diet with honey thick liquids. Resident #50 was at high risk for aspiration. Maintain 90 degrees with all oral intake and 30 minutes after intake, small sips alternating with small bites, alternating liquids, and solids, monitor for pocketing of food, coughing with meals, weight loss, and reduced oral intake. A physician's order dated 8/25/22 directed 1:1 feed assistance: to monitor resident alertness level prior to meal offerings. Aspiration precautions: 90 degrees with all oral intake and 30 minutes after, small sips, small bites, alternate liquids, and solids. Dysphasia puree consistency diet with honey thick liquids. Observation on 8/25/22 at 9:00 AM identified Resident #50 was sitting in wheelchair at bedside on the right side of the bed with curtain partially pulled between Resident #50 and the exit door, so he/she was not visible from the hallway. Upon knocking and entering Resident #50's room he/she was holding a cup of milk colored liquid and the resident's meal tray was in front of him/her and the resident was noted eating breakfast. There was not a staff person in the room. Observation on 8/29/22 at 8:40 AM identified Resident #50 was sitting in wheelchair at bedside on the right side of the bed with curtain partially pulled between Resident #50 and the exit door, so he/she was not visible from the hallway. Upon knocking and entering Resident #50's room he/she was holding a cup of milk colored liquid in one hand and a spoon in the other. The meal tray was in front of him/her on the overbed table and he/she was eating breakfast. There was not a staff person in the room. Interview and observation of Resident #50 with NA # 2 on 8/29/22 at 8:55 AM indicated he had washed and dressed Resident #50 and placed her/him in the wheelchair. NA #2 indicated he sets up Resident #50 and Resident #50 will drink by him/herself and sometimes will feed him/herself. NA #2 indicated that this morning he set Resident #50 up with his/her tray and left him/her drinking the milk and continued passing trays and provided care in the bathroom to another resident at the end of the hallway on the left. NA #2 further indicated after he was done providing care morning care and dressing another resident, he was planning on going back to assist Resident #50 with the rest of his/her breakfast. NA #2 indicated he could leave Resident #50 alone with his/her meals and he/she will start to feed him/herself and drinks well independently. NA #2 indicated Resident # 50 just needs assistance at the end. NA #2 indicate he was not aware Resident #50 needed 1:1 for meals at all times because Resident #50 can feed him/herself sometimes. Interview with LPN #1 on 8/29/22 at 12:30 PM indicated Resident #50 was an assist with meals and the nursing assistants will set her/him up and then help or assist as needed. LPN #1 after review of physician's orders, indicated Resident #50 was a 1:1 feed and NA #2 should have stayed in the room and not have left Resident #50 unattended with the breakfast tray. LPN #1 noted NA #2 was supposed to stay in the room with Resident #50 during the breakfast meal but was told NA #2 was not in the room because he was caring for another resident at that time. Interview and clinical record review with ST #1 on 8/29/22 at 1:46 PM identified her expectation was Resident #50 was a 1:1 feed which means a nursing assistant need to be with Resident #50 throughout the whole meal including while providing liquids. ST #1 indicated if Resident #50 was left unattended he/she was at greater risk for aspiration because Resident #50 does not cognitively know how to carry out the strategies for small bites and alternating solids with liquids. Additionally, for Resident #50 who has impaired oral stimulation and impaired cognition need to have 1:1 assistance at all times so the resident doesn't pocket the food and uses the alternating technique so he/she washes down each small bite of food alternating then with a drink so the liquid will push the food into the stomach. ST #1 noted Resident #50 need to always have someone in the room assisting Resident #50. A review of Resident # 50's Nursing Assistant Card failed to reflect the physician's order to provide 1:1 feed assistance. Interview and clinical record review with DNS on 8/30/22 at 3:15 PM identified Resident #50 had a physician's order for a 1:1 feed. The DNS indicated her expectation was a nursing assistant or nurse must be in the room while Resident #50 has the dietary meal tray. The DNS indicated her expectation if Resident #50 was able to partially feed him/herself that the nursing staff would have updated her, and she would have put in another speech therapy screen for Resident #50. Although requested, a facility policy for 1:1 feed was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility documentation, facility policy review and interviews for 1 of 2 resident (Resident # 68) reviewed for Accidents, the facility failed to ensure a Registered Nurse (RN) assessment was completed for a discoloration noted on the resident. The findings include: Resident # 68 was admitted to the facility with diagnoses that included dementia, Alzheimer's disease with late onset, and diabetes mellitus. Additionally, Resident #68 does not have a diagnosis of purpura. The care plan dated 2/3/22 identified at risk for pressure ulcers. Interventions directed to conduct, and evaluation of the resident's skin conditions daily during care and to report any skin abnormalities to nurse. The quarterly MDS assessment dated [DATE] identified Resident # 68 had severely impaired cognition, was frequently incontinent of bowel and bladder and required extensive assistance for toileting and transfers with one-person physical assist. Additionally, the assessment noted no utilization of anticoagulants (blood thinner). An Accident and Incident report dated 6/18/22 at 3:30 PM by LPN #1 identified an unknown purpura on Resident #68's left hand near the thumb which measured 2.5 Centimeter (CM) x 2.0 CM. For action taken to monitor area. Resident #68 was assisting of 1 for transfers. Resident #68 did not have long nails, anxiety, behavioral problems that may have caused the resident to hit something. Resident #68 was not acting in a way that could suggest there could have been abuse. Resident #68 does not know what happened. The nurse's note dated 6/18/22 at 10:01 PM by LPN#1 identified that Resident #68's family member noticed a purpura on Resident #68's left hand. The area was noted with a 2.5 CM x 2.0 CM. Resident #68 does not know what happened. The supervisor notified. The Advanced Practice Registered Nurse (APRN) note dated 6/22/22 at 4:41 PM identified Resident #68 had 2 falls. Staff reported one fall where Resident #68 was picking a stuffed animal off floor while knelling and fell onto his/her knees. The other fall was unwitnessed. Resident #68 was awake, alert, confused and can follow some commands. Gait imbalance status post fall identified no apparent injuries from fall. A physician's order dated 6/23/22 directed to monitor left hand discoloration daily for 7 days. The social worker note dated 7/10/22 at 1:48 PM identified a family member stated when Resident # 68 go home he/she does well, and the resident is more talkative and enjoys being home. The Accident and Incident report dated 7/11/22 at 11:45 PM by LPN #1 noted Resident #68 had a discolored area on left elbow measuring 2.0 CM x 3.0 CM. The action taken was to apply skin repair cream to left elbow for 7 days. The nurses note date 7/11/22 at 12:53 PM by an LPN #1 noted discoloration to left elbow reported during shower and body audit. Measurement 3.0 CM x 2.0 CM will apply skin repair to area for 7 days and family updated. Additionally, noted the resident was found on floor in bedroom sitting on his/her buttocks. The nurses note dated 7/11/22 at 5:54 PM identified Resident #68 fell at 1:15 PM but does not recall why he/she fell. No visible injury noted. Continue 15-minute checks. The care plan at risk for falls dated 7/11/22 identified on 6/19/22 a witnessed fall to knees with no injuries. And 7/11/22 found on floor and had no injuries. A physician's order dated 7/11/22 directed to apply skin repair cream daily for 7 days to the left elbow for discoloration The APRN note dated 7/13/22 at 10:30 AM identified Resident had a fall. Resident #68 was unable to contribute to the interview. Resident #68 was sitting in chair crying. Resident #68 had gait imbalance status post fall with no apparent injuries from fall. An interview with DNS on 8/30/22 at 12:31 PM identified Resident #68 had Accident and Incident report dated 6/18/22 identified a purpura of unknown origin to left hand near thumb. The DNS during clinical record review noted Resident #68 did not have a diagnosis of purpura and the LPN#1 could not diagnosis the resident. The DNS indicated the LPN #1 could not document it was a purpura versus a bruise. The DNS identified there was no Registered Nurse assessment conducted for the new area with discoloration. The DNS indicated she believes no one would hurt Resident #68. Interview with the DNS on 08/29/22 at 12:33 PM identified in reviewing the Accident and Incident report dated 7/11/22 a nursing assistant noted a flat discoloration or a bruise in the shower. The DNS indicated the APRN was notified per the Accident and Incident report. After clinical record review the DNS noted there was no RN assessment and indicted an RN does not have do an assessment of the new discolored area. The DNS indicated an RN assessment was not necessary for a new skin tear or bruise, because the wound nurse will evaluate the area the next day. The DNS also noted there was no need for an RN assessment because Resident #68 could have bumped the area. Interview and clinical record review with DNS on 12:45 PM failed to provide documentation that an RN assessment was completed in a timely manner for the new discoloration area on 6/18/22 and 7/11/22. After clinical record review for Resident #68 the DNS indicated she did not see any RN assessment, wound nurse, or APRN note related to the discolored area on the left hand on 6/18/22 or left elbow on 7/11/22 for Resident # 68. Review of facility Documentation Guidelines for wounds identified measure and assess the wound. The charge nurse will notify the resident's physician (to obtain treatment orders), family member, and infection control nurse. Additional guidelines, document wound on 24-hour nursing report. Document in nursing notes and the miscellaneous wound/skin impairment form for skin tears, abrasions, lacerations. Although requested, a facility policy for RN Assessments was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documentation, review of facility policy and interviews for 1 of 2 residents, (Resident #24), reviewed for accidents, the facility failed to ensure adequate supervision to prevent an elopement. The findings included: Resident # 24 was admitted to the facility with diagnoses that included Dementia, Alzheimer's disease, and generalized muscle weakness. An APRN progress note dated 11/11/21 at 4:33 PM identified Resident #24 was admitted from an assistive living to the facility due to increased wandering and the need for 24/7 supervision. A care plan dated 11/12/21 identified Resident #24 had behavioral symptoms due to dementia and Alzheimer's disease-causing wandering behaviors with staff. Interventions included: to provide cueing and direction for appropriate behaviors. Additionally, the care plan noted Resident #24 unsafely wanders with direction to staff to provide supervision when resident is off the nursing unit. A care plan dated 11/15/22 identified Resident #24 was at risk for elopement with Wander guard on right ankle. A physician's order dated 11/15/21 at 4:57 PM directed to place an elopement bracelet to right ankle, check placement every shift. An admission MDS assessment dated [DATE] identified Resident # 24 was severely cognitively impaired and was independent for transfer, walk in room and locomotion on unit. Additionally Resident #24 was extensive assistance with 2 staff for personal hygiene and limited assistance with 1 staff for dressing. A psychiatric APRN note dated 11/19/21 identified Resident #24 per staff is frequently wandering the halls and entering other resident's room. The resident wandering was increasing in the afternoon and nighttime with no reports of aggressive behavior. A physician's order dated 12/2/21 at 1:28 PM directed staff to conduct every 15-minute checks times 5 days. A nursing progress note dated 12/2/21 at 12:53 PM identified Resident #24 was seen in the back parking lot this morning with her/his coat on. The resident was redirected to go back inside by facility staff without difficulty, the APRN and family were notified. An APRN progress note dated 12/2/21 at 4:21 PM identified Resident #24 was outside walking in the parking lot this morning, wearing a coat and was escorted back into the facility by staff. The progress notes further indicated the resident was assessed status post elopement and staff was directed to continue every 15-minute checks and wander guard. A care plan dated 12/2/21 identified Resident #24 had eloped from the building going downstairs unattended. Interventions on 12/2/21 included: every 15-minute checks and on 12/3/22 to remove Resident #24's coat from her/his closet and to provide sweaters. A psychiatric APRN progress note dated 12/3/21 at 9:37 AM identified that she was asked to evaluate Resident # 24 who wandered to back parking lot. Recommendations were made which included to continue current medications, to provide frequent redirection, and continue wander guard. Interview with LPN # 4 on 8/29/22 at 11:00 AM identified that she was caring for Resident #24 on the day shift on 12/2/21. She could not recall what time she had last seen Resident #24 prior to Resident #24 found outside in the back parking lot. LPN # 4 stated that it was early in her shift, after the breakfast trays but before lunch trays. She stated that she recalled that she was completing her am medication pass when Resident #24 returned to the unit. LPN # 4 recalled that Resident #24 had her/his coat on, shoes and dressed, stating that Resident #24 looked more like a visitor. LPN # 4 continued by stating that Resident #24 had not displayed exit seeking behaviors, stating Resident #24 never actively tried to enter code on the elevator vestibule entry door or seek to exit through any of the doors on the unit. LPN # 4 further indicated she did note that Resident #24 did wander on the unit, usually entering other residents 'rooms but could be easily re-directed. LPN #4 indicated that she believed Resident #24 had entered the elevator vestibule area through the secured door when the dietary staff was bringing trays up or taking them down to the kitchen (located on the first floor of the building while Resident #24 ' s unit is on the second floor. LPN # 4 continued by stating she regularly works with Resident #24 and stated that she was not aware of any other elopement attempts by Resident #24 since that time. Interview with the DNS on 8/29/22 at 12:00 PM identified that although Resident #24 was found outside in the facility ' s back employee parking lot, she did not consider it an elopement since the resident did not leave facility grounds and she did not complete an investigation or report it to the state department of public health. The DNS recalls that she was working on 12/2/21 and the front door wander guard alarm was not activated, stating that only the front vestibule door and the front entrance door are set up as part of the wander guard system. She stated that the only way Resident #24 could have left the building would have been through the back employee parking on the elevator past the secured door which is accessible only by a keypad code. She continued that Resident #24 was assessed as a high risk for elopement upon admission and had the wander guard in place since admission. Resident #24 was known to wander on the unit but never demonstrated any behaviors of seeking to exit the unit by any of the unit doors as well as the elevator vestibule door. Interview and review of NA #3 ' s with DNS on 8/30/22 at 1::00 PM identified that she now recalled Resident #24 had her/his coat on when she was found outside in the back parking lot on 12/2/21 and that Resident #24 with her/his coat on, more resembling a visitor than resident. The DNS could now recall that it was NA #3 who had found Resident #24 outside in the back parking lot and had escorted the resident back into the building. The DNS could not recall the specifics of her investigation but stated that based on review of the vendor/visitor and employee COVID 19 screening report, only the outside laboratory personal had entered the building during the timeframe prior to when NA #3 discovered Resident #24 in the back parking lot, and they had entered through the front door that is located on the second floor. The facility was experiencing a COVID - 19 outbreaks at the time and visitation as well as recreation activities had been placed on hold. She continued by stating that Resident #24 was placed on every 15-minute checks and the re-education was provided to all staff to be mindful of closing doors behind you especially on the stairwell and elevator vestibule door on 12/3/21. Interview with NA #8 on 8/30/22 on at 1:10 PM identified that although he could not recall the specific event with Resident #24, he stated he never heard the wander guard system activated by the resident while he was on shift. Interview with APRN # 1 on 8/30/22 at 4:21 PM identified that she recalled the elopement of Resident #24 on 12/2/21 and indicated she was in the facility at the time. She recalls assessing Resident #24 and the resident was identified at her/his baseline and agreed to continue every 15-minute checks. She also indicated Resident #24 has had no other episodes of elopement attempts since that time. Interview with NA #3 on 8/31/22 at 8:00 AM identified she was scheduled to take another resident on an appointment around 9:00 AM on 12/2/22 and observed Resident #24 outside in the back employee parking lot, dressed in coat and shoes on. NA # 3 further indicated she went up to Resident #24 who did not seem to be in any discomfort or distress and easily redirected her/him into the building and back onto to Resident #24 ' s unit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy review and interviews for one resident (Resident #42) reviewed for edema, the facility failed to ensure a timely reweight for a resident identified with a weight discrepancy. The findings include: Resident #42's diagnoses included dementia with behavioral disturbance, hypertension, hypothyroid, stage 3 chronic kidney disease, dysphagia, and anemia. The Resident Care Plan (RCP) dated 8/11/22 identified Resident # 42 was at risk for weight loss related to dysphagia, poor food intake. Interventions included: to encourage resident in participation with food choices, to monitor food consumption, to monitor weight, to provide diet as ordered, provide supplement as ordered and to offer appropriate fluid and snack between meal per protocol. The quarterly MDS assessment dated [DATE] identified Resident #42 had severe impaired cognition and required extensive assistance of 1 person with transfer, dressing and toileting and ambulation. The physician's order dated 7/11/22 identified Resident #42 was on weekly weight monitoring. An additional physician's orders dated 8/4/22, 8/8/22, 8/11/22 and 8/25/22 requested a reweigh by the nurse to confirm the resident's weight. A review of Resident #42's weight identified the following: on 6/21/22 was 166.9 pounds (lbs.), on 7/22/22 was 199 lbs. and on 8/8/22 was 198.7 lbs. which had a discrepancy of 32 lbs. in a month. Resident #42 's current weight was 152.2 lbs. taken on 8/26/22 which identified an 8.8 percent weight loss in 2 months. Interview with Licensed Practical Nurse (LPN #3) on 8/25/22 at 11:30 AM identified the nurse would review and evaluate the resident's weight. When a weight discrepancy is identified, the nurse would obtain a re-weight to confirm the weight. She also indicated that the reweight would be obtained the next day following the weight discrepancy. LPN # 3 further indicated when a resident is identified with a weight loss or gain, she would inform the dietician and physician. Subsequent to surveyor inquiry of Resident #42 weight discrepancy, LPN # 3 indicated she was aware of the resident's weight discrepancy and indicated Resident #42 had behaviors of refusing care. She also agrees that the weight discrepancy should had resolve. Interview with Dietician on 8/29/22 at 10:30 PM identified the facility conducts weekly weight meetings which consists of the Director of Nursing Services (DNS), nursing supervisor and the wound nurse to discuss any resident with the weight issues. Subsequent to surveyor inquiry of Resident #42 weight discrepancy, the dietician indicated she was aware Resident # 42 had a weight discrepancy and she requested a reweight to get an accurate weight. Interview with RN #1 on 8/29/22 at 11:30AM identified the nurse would review and evaluate the resident weight. She also indicated that a weight discrepancy of 5 lbs. weight loss or gain required a reweigh to confirm the resident's weight. RN #1 further indicated she was aware of the resident's weight discrepancy. She also indicated that the nurse forgot to subtract the weight of the wheelchair. She was not aware of Resident #42 recent weight loss. She would notify the dietician of the weight loss. Interview with DNS on 8/29/22 at 12:00 PM identified if determine there was a weight discrepancy, she expect that a reweight would be done immediately to confirm the resident's weight. Subsequent to surveyor inquiry, Resident #42 's weight was obtained on 8/26/22 and identified it was 152.2 lbs. which noted an 8.8 percent weight loss in 2 months. The facility failed to obtain an accurate weight timely. A review of facility nursing policy title Weight Monitoring of Residents directed that weights be obtained by the staff and overseen by licensed nursing staff as needed. If a resident's weight is 3 lbs. more or 3 lbs. less than the previous weight taken, the nursing assistant would reweigh the resident with another staff member and report the weight to the charge nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility policy and interviews for one resident (Resident # 73) reviewed for Respiratory Therapy, the facility failed to change the oxygen tubing on a weekly basis per physician order. The findings include: Resident #73 was admitted to the facility with diagnoses that included chronic respiratory failure with hypoxia, obstructive sleep apnea, and chronic obstructive pulmonary disease. The quarterly MDS assessment dated [DATE] identified Resident #73 had intact cognition and required set up assistance for eating, dressing upper and lower body. Additionally, the assessment noted the utilization of oxygen therapy. The care plan dated 8/4/22 identified as having chronic obstructive pulmonary disease. Interventions directed to provide oxygen therapy at 3 liters per minute via nasal canula and to provide oxygen per physician's order. A physician's order dated 8/25/22 directed to change oxygen tubing weekly every Tuesday at 11:00 PM -7:00 AM. Observation on 8/24/22 at 12:00 PM identified Resident #73 was sitting dressed in a bedside chair with oxygen on via a nasal cannula attached to a concentrator at 3 liters with a piece of white tape attached dated 8/11/22 and a portable oxygen tank sitting in the wheelchair next to Resident #73 with a piece of white tape dated 8/11/22. Interview with LPN #1 on 8/24/22 at 12:05 PM indicated the physician order was for the oxygen tubing to be change weekly by the 11:00 PM to 7:00 AM by charge nurse on Tuesdays or Wednesdays. The charge nurse will document the change in the electronic medical record. LPN #1 observation of Resident #73's oxygen tubing on the portable oxygen and the concentrator identified the tubing with a date of 8/11/22. She indicated the tubing should have been changed last week. LPN #1 further indicated she would change the tubing today. LPN #1 also indicated the nurse who changes the tubing is responsible for putting the date and initials. An interview with the DNS on 8/25/22 at 6:50 AM identified her expectation is that the oxygen tubing for the concentrator and the portable oxygen tank would be changed weekly based on the physician's order. The DNS further indicated the nurse should date the tubing's when he/she changes the tubing based on the physician's orders. DNS indicated her expectation would be that LPN # 1 changed the tubing's immediately on 8/24/22 after notified. Although requested, a facility policy for oxygen on 8/25/22 at 8:00 AM was not provided. The DNS identified this was not a policy and that oxygen tubing change is based on following the physician's order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policy review and interviews for 1 of 5 residents (Resident # 50) reviewed for unnecessary medications, the facility failed to respond to pharmacy recommendations in a timely manner. The findings include: Resident #50's diagnoses included Alzheimer's disease, hyperlipidemia, and anxiety. The physician's order dated 3/21/22 directed Atorvastatin (Anti-Cholesterol) 40 Milligram (MG) daily. Annual MDS assessment dated [DATE] identified Resident #50 had severe cognitive impairment and required assistance with personal care. The care plan dated 4/21/22 identified Resident #50 had a concern related to cardiovascular disease with hypertension and hyperlipidemia. Interventions included the administration of medications as ordered, to observe for side effects and to monitor laboratory work. The pharmacy consultation dated 4/22/22 noted a lipid panel from 4/22 laboratory work reflected low values with recommendations to decrease Atorvastatin to 20 MG once current 40 MG supply was depleted. A review of the Pharmacy Fill History dated 3/1/22 through 7/8/22 noted Atorvastatin 40mg (30) tabs were refilled on 4/11/22 which would have been deleted on 5/11/22. The physician's order dated 4/26/22 directed Atorvastatin 40 MG daily. Subsequent Pharmacy reviews dated 5/27/22 and 6/23/22 noted repeated recommendations to decrease Atorvastatin to 20 MG once current 40 MG supply was depleted. Physician's order dated 7/27/22 directed Atorvastatin 20mg daily. An interview on 8/30/22 at 12:16 PM with the DNS identified it was her responsibility to ensure pharmacy recommendations were reviewed and could not explain why this was not done. Subsequent to inquiry, the physician progress note dated 8/31/22 identified the dose reduction on 7/27/22 following a recommendation dated 4/22/22 was not clinically significant. Although a policy for responding to pharmacy recommendations was requested but was not provided.

Based on observations, review, facility policy review and interviews during review of medication storage and labeling, the facility failed to ensure that the medication refrigerators temperatures were checked and maintained daily, vaccines were safely stored within the appropriate temperature and checked twice a day, opened ophthalmic medication was dated once opened, over the counter medication was labeled with expiration date and that medication was securely stored. The findings included: 1. Observations on 8/29/22 at 10:28 AM of the A/B medication refrigerator that stored individual oral supplement drinks (that do not require refrigeration), revealed storage of 2 food items in addition to resident oral supplements. LPN #4 indicated that the food items were her lunch, and the food could be stored in that refrigerator but not the other refrigerator. LPN # 4 removed the food item from the refrigerator. A form noted on the left side of the refrigerator for In-Room refrigeration daily identified the refrigerator was last checked on 8/19/22 by staff. On 8/29/2022 at 11:50 AM an interview with the DNS indicated that she did not believe the facility had a policy for the medication refrigerators. The DNS also indicated staff lunches should not be stored in the medication room refrigerators. 2. Observations on 8/29/2022 at 10:28 AM noted the A/B unit, Refrigerator Temperature Log, was missing a temperature for 8/22/2022. The medication refrigerator temperature at the time of the observation was 42 degrees. Medication stored in this refrigerator were insulins, Ativan solution (double locked), and one resident specific Pneumovax, unopened. On 8/29/2022 at 11:20 AM observations of the short-term rehabilitation unit medication room identified one contained liquid oral supplements (that did not require refrigeration) with no refrigerator temperature list, and the other locked refrigerator contained insulin and a vial of tuberculin for Mantoux testing. The August refrigerator temperature log indicated temperature must be maintained between 35-45 degrees and if the temperature is not met per standard to adjust it immediately and notify maintenance. The July 2022 log was missing July 8,11,14, and 22 temperature checks. The August 2022 log temperature check list was missing August 8, 14, 15, 25, and 6th. The medication refrigerator temperature at the time of observation was 42 degrees. On 8/29/2022 at 11:50 AM although requested the DNS stated she did not believe that they had a policy for the medication refrigerators and vaccine storage therefore none was provided. 3. Observations on 8/29/2022 at 10:28 AM noted the A/B unit, Refrigerator Temperature Log, was missing a temperature for 8/22/2022. The medication refrigerator temperature at the time of the observation was 42 degrees. LPN # 1 also observed the 42 degrees temperature and one resident Pneumovax vaccine that was unopened stored in the refrigerator. 8/29/2022 11:20 AM an observation of the South Unit medication indicated the locked medication refrigerator contained insulin and a vial of Tuberculin for Mantoux testing. On 8/29/2022 at 11:50 AM DNS stated she did not believe that they had a policy for the medication refrigerators and vaccine storage but provided a policy for medication storage in the facility. The facility policy for medication storage in the facility directs that medications requiring refrigeration are stored in a refrigerator at temperatures 36 degrees to 46 degrees Fahrenheit, and the facility should maintain a temperature log in the storage area to record temperature at least once daily. The facility policy also indicated that the facility should check the refrigerator in which vaccines are stored at least two times daily. Per CDC guidelines. 4. Observation of the B wing medication cart on 8/29/22 at 10:28 AM identified an ophthalmic(eye)medication, Latanoprost, for Resident # 8 was not dated once opened which was verified by LPN # 4. The facility policy, Medication Storage in the Facility from 10/2015 indicated that when the original manufacturers seal is broken the container of vial will be dated. 5. Observations on 8/29/2022 at 10:28 AM a review of the over-the-counter medications in the A/B storage room and medication carts identified two open bottles (one in the storage shelf and one located on the B wing medication cart of a specific brand of Vitamin D3, 25 mcg capsules without an expiration date. LPN #4 indicated most residents receive the tablet form just a couple may receive the capsules. LPN# 4 and LPN# 1 and RN #1 were asked to locate the expiration date, a faint and non- legible and could not find any expiration date on either bottles of Vitamin D3 capsules. RN #1 rub the faint area and the area easily rub off. 8/29/2022 11:15 AM, RN#1 indicated that the bottle should have an expiration date and she would remove bottles out of circulation and will check the main storage for any other bottles of this brand. On 8/29/2022 at 11:25 AM an interview with the DNS indicated that over the counter medications should have an expiration date. The DNS ran a report of the residents in the building and the DNS further indicated that one resident, Resident #75, was the only resident that had an order for Vitamin D3 in the capsule form. The facility policy for storage of medication dated 10/1/2015, indicated that drugs dispensed in the manufacturer's original container must be labeled with the manufacturers expiration date. The policy further indicated that the nurse would check the expiration date of each medication before administering the medication, no expired medications will be administered to a resident and noted expired medication will be removed from the active supply. 6. 8/29/2022 11:20 AM an observation of the short-term rehabilitation unit medication room (South identified one medication cart South #1 First large drawer contained mostly resident medication cards, had 11 various pills scattered on the bottom of the drawer. LPN #5 was not sure who was responsible to clean the cart and could not identify the half and whole tablets of medication in the bottom of the medication cart drawer. The facility policy, Medication Storage in the Facility, dated 10/1/2015 indicated that all medications dispensed by the pharmacy are stored in the container with the pharmacy label. The policy directs that contaminated or deteriorated medications and those without secure closures are removed from inventory immediately. The A/B unit form titled, Refrigerator Temperature Log, was missing a temperature for 8/22/2022. Medication stored in this refrigerator were insulins, Ativan solution (double locked), and one vial of Pneumovax, unopened. Random review of over-the-counter medications in the A/B storage room, noted a specific brand of Vitamin D3 25 mcg capsules without an expiration date this bottle noted to be open. When inspecting medication cart B, the cart had one bottle of the specific brand of D3 25 mcg without an expiration date. LPN #4 indicated most residents receive the tablets just a couple may receive the capsules. LPN# 4 and LPN# 1 and RN #1 were asked to locate the expiration date, a fait area not legible was noted by all but they could not find any expiration date on either bottles of Vitamin D3. RN #1 indicated that she could rub the area and noted that what was left of what may have been an expiration date rubbed off. 8/29/2022 11:15 AM, RN#1 indicated that the bottle should have an expiration date and will take the bottles out of circulation and will check the main storage for any other bottles of this brand. 8/29/2022 11:20 AM an observation of the short-term rehab unit med room (South), observation of one medication cart South #1 First large drawer contained mostly resident medication cards, had 11 various pills scattered on the bottom of the drawer. LPN #5 was not sure who was responsible to clean the cart. Observation of the medication refrigerators showed one contained oral supplements with no refrigerator temp list, and the other locked refrigerator contained insulin and a vial of tuberculin for Mantoux testing. The Refrigerator temperature log indicated temperature must be maintained between 35-45 degrees and if the temperature is not met per standard to adjust it immediately and notify maintenance. The July log was missing was missing July 8,11,14, and 22 for temperature checks. August temperature check list was missing August 8, 14, 15, 25, and 6th. On 8/29/2022 at 11:25 AM an interview with the DNS indicated that over the counter medications should have an expiration date. The DNS ran a report of the residents in the building and the DNS further indicated that one resident, #75, was the only resident that had an order for Vitamin D3 in the capsule form. On 8/29/2022 at 11:50 AM DNS stated she did not believe that they had a policy for the medication refrigerators and vaccine storage but did indicate that staff lunches should not be stored in the medication room refrigerators. Review of facility policy dated 10/1/2015 titled, ID 1: Storage of Medications, indicated in part that the facility should maintain a temperature log in the storage area to record temperatures at least once daily. It also indicated that the facility should check the refrigerator or freezer in which vaccines are stored at least two times per day per CDC guidelines. The medication storage policy further indicated in part that certain medications such as ophthalmic require an expiration date shorter than the manufacturers expiration date to ensure medication purity and potency and when the manufacturer's seal is first broken upon opening, the nurse will label the date opened. The policy also indicated that medications dispensed in the manufacturer's original container will carry the manufacturer's original expiration date. Interview with the DNS on 8/29/2022 at 2:15PM Indicated that eye drops need to be labeled with the date they are opened and that refrigerators that contain vaccines should have temperatures checked twice daily. In conclusion, the facility failed to ensure that refrigerators in the medication rooms were maintained for resident use, refrigerator temperature monitoring and documentation were maintained for medication/vaccines stored, and proper labeling of ophthalmic and over the counter medication per current standards of practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility policy review and interviews for 1 resident (Resident #88) reviewed for Urinary catheter, the facility failed to ensure urinary catheter was not on floor to prevent the spread of infection. The findings include: Resident #88's diagnoses included cerebral infarct affecting the left side, polyneuropathy, dementia, and facility acquired stage 4 pressure ulcer of sacrum. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified the resident was severely cognitively impaired, required total dependence of two staff member for physical assistance with bed mobility, transfers, personal hygiene, noted one-person physical assistance with toileting and the utilization of an indwelling catheter. The care plan dated 4/7/22 identified at risk for urinary tract infection with indwelling catheter. Interventions directed to ensure the drainage bag was secure in place. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #88 had moderately impaired cognition, was always incontinent of bowel and had a catheter for bladder. The resident also required total assistance with dressing, personal hygiene and with managing the catheter and catheter bag. A physician's order dated 8/10/22 directed to empty Foley catheter output every shift and Foley catheter care by the nursing assistant every shift. Additionally, the physician's orders directed to secure indwelling catheter to upper thigh to prevent movement and to check securement and patency every shift. The nurse's note dated 8/23/22 at 10:05 PM identified Resident #88's urinary catheter was patent and draining slightly cloudy amber colored urine. The Nursing Assistant Care card for Resident #88 directed for urinary catheter care to empty urinary catheter bag every shift and record output. Observation on 8/24/22 at 11:30 AM identified Resident #88 lying in bed with his/her urinary catheter bag with urine hanging on the bed frame and lying on the floor. Interview and observation with LPN #1 on 8/24/22 at 11:35 AM identified Resident #88's urinary catheter should not be on the floor. LPN #1 indicated it is the responsibility of the nursing assistants to make sure the resident's urinary catheter bag was hanging from the bed frame not on the floor. LPN #1 removed the catheter bag off the floor. Interview with LPN #1 on 8/24/22 at 12:00 PM identified she spoke with the resident's assigned nursing assistant and was informed the nursing assistance had not provided care and the nursing assistants was unaware the urinary catheter bag was on the floor. An interview with DNS on 8/25/22 at 6:55 AM indicated her expectation is that Resident #88's urinary bag would not be on the floor but would instead be attached to the bed frame below the bladder. The DNS further indicated the charge nurse, and the nursing assistants are responsible for making sure residents' urinary bags are not on the floor. Although requested, a facility policy for placement of urinary catheters for infection control purposes was not provided.

Based on observations of the kitchen, facility policy and interviews, the facility failed to ensure foods were stored and prepared under sanitary conditions, hair net was covering hair, food temperature were taken before serving food, food was labeled and dated and the nourishment refrigerator was free from dirty, food in refrigerator and freezer were labeled or dated in a sanitary manner within professional standards. The findings included: Tour of the Kitchen with the Director of Dietary on 8/24/22 at 10:00 AM identified the following: 1 10:10 AM the cook was observed in front of the stove with a large tray in her hands. [NAME] #1 had her hair net on only covering the back half of her hair without the benefit of it covering the front half and her bangs. Interview with [NAME] #1 on 8/24/22 at 10:10 AM identified she could not explain why her hair net did not cover her entire hair. After inquiry, cook #1 readjusted the hair net to cover all her hair. Interview with the Director of Dietary on 8/24/22 at 10:11 AM indicated [NAME] #1 should always cover all her hair while in the kitchen and she had been educated on how to wear the hairnet correctly. 2. The Director of Dietary on 8/24/22 at 10:12 AM indicated [NAME] #1 had just used the red bucket to wipe down the cooking area surfaces. The Director of Dietary tested the red bucket that had Sanitizer Multi-Quat used for the cook's counter tops. The Director of Dietary indicated the testing strip after 10 seconds in the water tested well below the 150 PPM range and it should have tested between 200-400 PPM's to properly sanitize the surfaces in the kitchen. The Director of Dietary indicated the [NAME] #1 must have placed the sanitizer water in the bucket when she came in this morning at 5:30 AM and did not change it every 2 hours as directed. The Director of Dietary discarded the water from the red bucket and refilled bucket with sanitizer water and re-tested and noted 200 PPMs. Director of Dietary indicated the water had to be changed every 2 hours to be sanitary 3. Observation on 8/24/22 at 10:20 AM with Director of Dietary: Refrigerator #1 (air curtain refrigerator) had 2 cups of vanilla yogurt, 2 cups fresh fruit, 1 cup pre-poured honey thick milk, with disposable lids without the benefit of a label and date. The Director of Dietary indicated last evening staff pre-poured and prepared these items therefore they were responsible for labeling and dating the food items. Refrigerator #2 had one tray of 14 five-ounce cups of honey thick milk pre- poured, a second tray of 17 honey thick milk and 4 apple juice, and a third tray of 11 apple juice all with disposable lids without a label or date. Refrigerator #3 in front of the freezer had 9 slices of French toast in saran wrap, 3 pancakes and 1 slice French toast in a zip lock bag not labeled or dated. Additionally, there was partially used ham with saran wrap dated 8/14/22. The Director of Dietary indicated it was all dietary staff's responsibility to make sure all items were labeled and dated so food items could be discarded after 3 days. The Director of Dietary discarded all items. 4. Observation on 8/24/22 at 11:00 AM with the Director of Dietary in the A/B unit resident's nourishment room. a. a 12-cup glass coffee maker ¾ full of black coffee. The Director of Dietary indicated that was the staff's coffee maker and did not belong in the resident's nourishment room. b. There was a ½ chocolate sheet cake from stop and shop with the store sticker dated 8/20/22. The Director of Dietary indicate that was staffs and did not belong in this room. c. There was an ice scoop hanging off a screw next to the entrance door not in a container or bagged. The Director of Dietary indicated there was supposed to be a bin the ice scoop belongs in to keep it clean. The Director of Dietary indicate the entire bin was missing and must have been broken, but at the least the ice scoop should have been placed in a bag to protect it and be covered. The Director of Dietary noted he did not know how long the ice scoop bin had been missing or broken. e. The nourishment refrigerator had a sandwich, a large salad in a disposable container that was brown and soggy looking, and 3 small disposable cups with a brown liquid. The Director of Dietary discarded these items. 5. The refrigerator had splashed red liquid marks and other brown spots. The bottom draw had 4 health shakes and was all sticky and had a creamy brown liquid all over the bottom and sides of the drawer. The Director of Dietary indicated the nursing staff were responsible to wipe the refrigerator out daily for any spills and dietary was responsible on a weekly basis. 6. The freezer had partially eaten single serve Friendly's ice cream, and a ½ eaten chocolate bar without resident names or dates. The Director of Dietary indicated everything in the freezer should be labeled with the resident's name and the date it was put in the freezer. 7. The North Unit resident's nourishment room refrigerator had a sandwich, and 3 small disposable cups were not labeled or dated. The Director of Dietary discarded these items. Additionally, there was a staff 12-cup coffee maker full, and a staff member came in and got a cup of coffee in the presence of the surveyor in the nourishment room. Interview with the Director of Dietary indicated the resident's nourishment rooms were only to have items for the residents. The Director of Dietary indicated nursing staff is responsible for making sure when families bring items in for a resident that they place the residents name on each item and date the items so they can be discarded 3 days later. The Director of Dietary indicated staff should not have their items in the resident's nourishment room like the cake and the coffee. The Director of Dietary indicated the staff have their own area for food items. The Director of Dietary indicated all items must be labeled and dated. The Director of Dietary indicated the refrigerators should be kept clean and the ice scoop had to be kept covered when not in use. 8. Observation in the kitchen on 8/25/22 at 11:30 AM [NAME] #1 was serving food on the tray line. [NAME] #2 was calling out the meal ticket to [NAME] #1 and she was handing him the plate of food. There were 12 trays prepared and completed in the food truck. Interview with Director of Dietary on 8/25/22 at 11:30 AM indicated the cook should take the temperatures of all the food before starting to serve the food and document the temperatures at the time the temperatures were taken. The Director of Dietary indicated the food temperatures would be already documented in the temperature logbook. Review of the temperature logbook dated 8/25/22 for lunch was incomplete and blank. Interview with [NAME] #1 on 8/25/22 at 11:35 AM she would not answer if she had not taken the food temperatures prior to starting to serve the tray line. [NAME] #1 indicted she would take the temperatures now and document them. Interview with [NAME] #2 on 8/25/22 at 11:36 AM indicated the temperatures were not taken prior to starting the tray line to serve the resident meals. [NAME] #2 indicated they would stop the tray line and take the temperatures of all the food. [NAME] #2 indicated it was the cook's responsibility to make sure the temperatures were taken and documented prior to starting to serve on the food line, but there was usually only 1 cook and today they had 2 cooks. [NAME] #2 indicated there was more staff than usual and he thought [NAME] #1 was going to take the temperatures and she thought he would take the temperature and so no one took the temperatures. [NAME] #2 and the Director of Dietary at 11:40 AM took the food temperatures and documented. An interview with DNS on 8/29/22 at 10:40 AM indicated it was dietary's responsibility to wipe out and clean the nourishment refrigerators daily. The DNS also noted if the nursing staff spill something her expectation was, they would wipe it up right away. The DNS indicated all resident's food items must be labeled with the residents' name and dated. The DNS indicated the food items must be discarded after 3 days. The DNS indicated the nursing staff were not allowed to keep personal belongings in the resident's nourishment rooms. The Service Line Checklist for Monday 8/25/22 identified prior to service line the below must be verified with the initials of whomever completes the list. Staff were dressed appropriate attire with a clean uniform, hair restraints, and gloves. Food serving temperatures must be taken and recorded prior on the below log prior to meal service. Additionally, the items names and temperatures for all hot and cold foods should be taken prior to service and recorded in the boxes below. Temperatures: Hot foods greater than 135 degrees and cold foods less than 41 degrees. Review of facility Staff Attire identified all employees wear approved attire for the performance of their duties. All staff will have their hair off the shoulders, confined in a hair net or cap. Review of facility Food Preparation identified the temperature for time/temperature control for safety foods will be recorded at the time of service and monitored periodically during meal service periods. Review of facility Logging Food Temperatures identified food temperatures will be taken for each food item and in every consistence each meal. Temperatures will be recorded on the temperature monitoring log. Corrective measures should be taken if temperatures do not reach minimum safe temperature levels. Review of facility Foods from Visitors identified that all food for later consumption must be labeled with residents' name and with current date. The refrigerator and freezers were to be cleaned weekly. Review of the Ice Policy identified ice will be prepared and distributed in a safe and sanitary manner. Ice scoops will be cleaned and stored in a separate container that limits exposure to dust and moisture retention.