**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documentation, facility policy, and interviews, the facility failed to ensure resident council funds, that were raised during fund raising events, had complete and accurate record keeping, and were in an interest-bearing account. The findings include: Review of the resident council meeting minutes identified the following. Minutes dated 9/11/23 identified starting 9/18/23 to 9/27/23 there would be a [NAME] to raise money for resident council. Minutes dated 11/13/23 identified the craft fair on 11/10/23 and 11/11/23 raised $1200. Minutes dated 2/5/24 identified someone donated an Afghan to be raffled off for Mother's Day. Minutes dated 3/11/24 identified residents had a tag sale on 4/26/24 and 4/27/24. The Director of Recreation informed the residents she would be using the proceeds from the raffles and tag sale to purchase cloths for the prom and other recreation items needed for the residents. Minutes dated 4/1/24 identified Director of Recreation informed residents the Easter [NAME] raised $250 and all proceeds from the raffles and tag sale would be used to purchase clothing for the prom in May. Minutes dated 9/10/24 identified there would be a craft show on 11/15/24 and 11/16/24 and the residents were making different crafts to sell. The Director of Recreation informed residents that recreation has money and asked for suggestions on how to use the money. The Recreation Assistant suggested an Elvis impersonator, pizza party, more entertainers, and more animal visits. Minutes dated 10/7/24 identified the Director of Recreation asked how residents wanted to spend money from the resident council fund but did not identify how much money was in the fund. The Director of Recreation suggested a game table and everyone liked the idea. The Director of Recreation indicated that the resident council funds would be used for a pizza party this month. The Director of Recreation asked residents about a visit from the Elvis impersonator and only a few residents showed interest. Minutes dated 11/11/24 identified a ping pong and air hockey table was purchased. Minutes dated 12/2/24 identified 2 residents were selling [NAME] tickets for a gift basket and there will be a sign-up sheet for residents to sell tickets. Review of the monthly recreation calendars dated 1/1/24 to 3/31/25 failed to reflect the fund-raising events. A resident council meeting held on 3/24/25 at 1:00 PM with Resident #22, 53, 60, 77, and 114 indicated they do fund raising for the resident council monthly. Residents #60 and 77 indicated they have repeatedly asked about having a treasurer for the raised funds and they were informed by the Director of Recreation they don't need a treasurer because they don't have an account, and she holds onto the money. Residents #60 and 77 indicated they had repeatedly asked the Director of Recreation after fundraisers each month how much profit they had made, and they are informed she does not know and was not able to tell them. Resident #60 and 77 indicated that they have asked how much money the resident council account has in its account and the Director of Recreation informs them she puts the resident council money with the recreation department money and does not know who has how much. Resident #22, 53, 60, 77, and 114 indicated they want to know how much money they have raised after every fund-raising event and how much the facility money is vs their money that the Director of Recreation has told them she doesn't know. Resident #22, 53, 60, 77, and 114 indicated they want their own bank account for resident council money and want to appoint a treasurer to keep track of it, so the resident council in their monthly meetings can state how much was made after sale events and how much is in the account, and they can decide how to spend the money and vote on it. The interview with Director of Recreation on 3/24/25 at 2:19 PM indicated the resident council sells tickets for 8 - 9 [NAME] baskets a year, has a tag sale every year in April, a craft and bake sale in November, and this summer will start selling candy bars. The Director of Recreation indicated that the residents from resident council have asked repeatedly how much money was raised after fund raising events and she informs them I don't know. The Director of Recreation indicated that she has not figured out how much was spent on fundraising events and how much the profit was made at each event for the last 3 years. The Director of Recreation identified she has money in her locked desk drawer that is resident council money. Director of Recreation indicated that the resident council wanted a pizza party approximately 3 times in the past 2 years, so she added the pizza as part of a recreation program and added it on her recreation calendar. The Director of Recreation indicated that she does not recall if it was voted on by the resident council for approval. The Director of Recreation indicates that she had used the resident council funds to buy an air hockey table for the recreation room and a white board used for playing word games during recreation activities. The Director of Recreation indicated that the residents had not voted on using their funds to purchase these items for the recreation room. The Director of Recreation indicated that she does not have any records of the resident council funds for the last 3 years and she does not report monthly or quarterly to the resident council how much money they have. The Director of Recreation indicated that she does not know how to set up a resident council fund bank account and how to bring a resident to the bank. The Director of Recreation indicated that she had not spoken with the Administrator about how to set up a council fund at a bank and that she was not able to inform/resident council each month what they had for funds in their account, or how much money they were making on the fundraising events. Interview with the Administrator on 3/24/25 at 2:41 PM indicated that the Director of Recreation was responsible for the resident council funds and notifying the residents in resident council what was made after each event. The Administrator indicated that the Director of Recreation had informed him what she had used the resident council funds for but was not aware that the resident council had not voted on it. The Administrator indicated that the Director of Recreation just informs him that she is using the resident council money to buy the monthly birthday cake (on the recreation calendars) for the residents, pizza, or Chinese food for the resident's, but he does not know who receives the food. The Administrator indicated that he was not aware that the residents were not being informed of how much they were making after sale/[NAME] events. The Administrator indicated that he was not informed that the residents had asked the Director of Recreation for an accounting for the resident council funds and that she had informed them that they did not need a treasurer when they wanted to appoint someone. The Administrator indicated that he thought the Director of Recreation was keeping track of the resident council funds separate from the recreation funds. The Administrator indicated that the resident council funds are for what the resident council wants to purchase or donate, not anything that recreation should be purchasing such as food or a white board that are for recreation activities and on the monthly recreation calendar. The Administrator indicated that the resident council funds should not be in a drawer and should be in an interest-bearing account and there should be a ledger of what money goes in and goes out. The Administrator indicated that he would open a separate account for the resident council funds. The interview with the Director of Recreation on 3/25/25 at 10:00 AM identified she was not able to give an accounting of how much residents had made monthly during the fundraising events or spent during 2023 and 2024. Review of the Resident Trust Fund identified the facility must maintain a separate and accurate accounting record of the resident trust fund. The fund cannot be comingled with any other account. Resident funds are managed and maintained in accordance with Federal and State Laws. The resident trust account must be reconciled monthly following the reconciliation of the bank statement. Quarterly a statement must be generated and sent to each resident and/or a responsible party. The statement is comprised of the individual resident account balance, deposits, and disbursements for the quarter and monthly interest allocations. Although requested, a facility policy for resident council funds was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #344) reviewed for dignity, the facility failed to ensure that the resident's medical information and care needs remained private. The findings include: Resident #344 was admitted to the facility on [DATE] with diagnoses that included sepsis, muscle weakness, and legal blindness. The care plan dated 3/21/25 identified Resident #344 had impaired visual function. Interventions included to tell the resident where items were being placed and to provide total feed assist with all meals. Observation on 3/23/25 at 11:00 AM identified a sign located on the exterior room door of Resident #344 and Resident #345 with the following: Resident is Legally Blind. Total Feed with meals. Keep items within reach. The sign also identified Resident #344's bed number. The 5 day MDS dated [DATE] identified Resident # 44 had intact cognition, was frequently incontinent of bowel and bladder and was dependent on staff to assist with dressing, showers, and required supervision with meals. Observation on 3/24/25 at 6:58 AM identified that the sign previously observed on Resident #344's exterior door was removed. Further observation identified that an identical sign was located taped to Resident #344's wall, directly above the resident's bed. Review of the clinical record identified Resident #344 was transferred to the hospital on 3/24/25 at 6:36 PM for evaluation of abdominal pain and rectal bleeding. Observation and interview with the ADNS on 3/25/25 at 7:02 AM identified that she was not aware that there was a sign placed above the resident's bed identifying the resident's medical or care needs, and it would be investigated. The ADNS also identified that it would not be appropriate to place any kind of sign on an exterior door of a resident's room related to diagnoses or care needs. Interview with the ADNS on 3/25/25 at 1:52 PM identified she had a discussion with LPN #3 via phone and identified the sign was placed at Person #1's request. The ADNS also identified that LPN #3, Person #1 and Resident #344 was present for the discussion. Subsequent to surveyor inquiry, review of the clinical record identified a late entry note dated 3/20/25 at 2:31 PM, documented on 3/25/25 at 2:35 PM, by LPN #3 identified Person #1, Resident #344's resident representative, requested a sign be placed over Resident #344's bed stating that Resident #344 was blind and needed assistance with meals. Review of the facility nurse staffing schedules identified LPN #3 did not work on 3/20/25 or 3/25/25. Interview with Person #1 on 3/26/25 at 8:50 AM identified he/she was the emergency contact for Resident #344, but that Resident #344 was responsible for him/herself. Person #1 identified that he/she had spoken with a female staff member at the facility on 3/19/25 following Resident #344's admission to the facility to make sure that the nurse and other facility staff were aware that Resident #344 was blind and needed assistance. Person #1 identified he/she did not remember the nurse's name, but identified after speaking to staff member, the staff member identified she would place a sign above Resident #344's bed. Person #1 identified he/she did not discuss the sign with Resident #344 and was unaware if Resident #344 knew the sign was in place as Resident #344 was not present during the discussion. Person #1 also identified that he/she was unaware if the female staff member, or if any facility staff, notified or discussed the sign with Resident #344. Person #1 also identified he/she had not seen a sign on Resident #344's exterior door related to Resident #344's blindness or care needs, and that it would not be appropriate for a sign to be on the exterior door as Resident #344 had a roommate as well as other visitors walking through the halls. Although attempted, an interview with Resident #344 was not obtained. Although attempted, an interview with LPN #3 was not obtained. The facility policy on resident rights directed that all residents had the right to have privacy and confidentiality regarding all personal and health information kept by the facility pertaining to the resident. The facility notice of privacy practices directed that the facility's responsibilities to the resident included understanding that information about the resident and resident's health was private and personal, and by law the facility was required to maintain the privacy of the resident's protected health care information. The policy further directed that protected health care information included the resident's past, present or future physical or mental health or condition, the provision of health care provided to the resident, and date that could actually or reasonably identify the resident. The policy also directed that the resident had a right to know if the facility used or disclosed the resident's health information in a manner that was not legally permitted and compromised the resident's security or privacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, and interviews for 1 of 3 residents (Resident #59) reviewed for pre-admission screening and resident review (PASARR), the facility failed to refer the resident, who had a new mental health diagnosis, to the State-designated authority. The findings include: Resident #59 was admitted to the facility in July 2022 with diagnoses that included anxiety disorder and osteoporosis with a pathological fracture. Notice of PASARR Level 1 Screen outcome dated 7/13/22 identified Resident #59 had no mental health diagnosis known or suspected and no diagnosis of dementia. No Level 2 is required because no serious behavioral health conditions or intellectual/developmental disabilities exist. If changes occur or new information refutes these findings, a new screen must be submitted. The quarterly MDS dated [DATE] identified Resident #59 had severely impaired cognition and had an active diagnosis of anxiety, depression, and dementia. The psychiatric APRN note dated 1/25/23 identified Resident #59 was receiving Aricept for dementia, Zoloft for depression, Seroquel for anxiety and agitation, and Xanax for anxiety. Resident #59 presents with paranoid delusions. Diagnosis of dementia with psychotic disturbances and psychotic disorder with delusions. The quarterly MDS dated [DATE] identified Resident #59 had severely impaired cognition and had an active diagnosis of anxiety, depression, dementia, and psychotic disorder. The care plan dated 9/25/23 identified Resident #59 was receiving psychotropic medication Seroquel. Intervention was to administer psychotropic medications as ordered by the physician. Interview with the Administrator on 3/25/25 at 10:45 AM indicated that the social workers were responsible for reviewing and updating the State-designated authority for PASARR's as needed based on the resident. Interview with SW #1 on 3/25/25 at 1:03 PM indicated she is responsible to do a new level of care screen if a resident receives a new psychiatric diagnosis while at the facility. SW #1 identified when a resident comes in and the psychiatric APRN or physician gives the resident a new diagnosis they do not tell her, so she is not aware. SW #1 indicated that when Resident #59 received the diagnosis of psychotic disorder with delusions, a new level 1 should have been submitted. After surveyor inquiry, SW #1 on 3/26/25 at 1:00 PM identified that she had updated the State-designated authority with a new PASARR screening for a level of care change for Resident #59. Although requested, a facility policy for PASARR Level 1 and Level 2 was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility policy, and interviews for 1 of 8 residents (Resident #112) reviewed for accidents, the facility failed to administer medications according to professional standards. The findings include: Resident #112 was admitted to the facility in October 2024 with diagnoses that included paroxysmal atrial fibrillation, dysphagia, and hypertension. The care plan dated 3/13/25 identified Resident #112 had a deficit in self-care function: activity intolerance. Interventions included set up/clean up assistance for eating/feeding and personal hygiene/oral care. The quarterly MDS dated [DATE] identified Resident #112 had intact cognition, required set-up or cleaning assistance with eating, had complaints of difficulty or pain with swallowing, and was on a mechanically altered diet while a resident. A physician's order dated 3/21/25 directed to administer the following medications. Apixaban 2.5mg, 1 tablet by mouth, twice daily for blood thinner related to paroxysmal atrial fibrillation. Ferrous sulfate 325mg (65 Fe), 1 tablet by mouth, twice daily for anemia. Miralax oral packet 17 gm by mouth, once daily for constipation, mix with 8 oz of water. Acetaminophen 325mg, 2 tablets by mouth, every 6 hours as needed for generalized discomfort. Multivitamin, 1 tablet by mouth, once daily for a supplement. Ascorbic acid 500mg, 1 tablet by mouth, once daily for wound healing. Metoprolol Tartrate 25mg, 1 tablet by mouth every 12 hours for hypertension. Enulose solution 10gm/15ml, give 30 ml by mouth, once daily for constipation. Observation and interview with Resident #112 on 3/23/25 at 8:00 AM identified a medication cup with 7 pills, a medication cup with a pale colored fluid, and a cup of a clear fluid on the resident's bedside table. Resident #112 indicated that he/she planned to take the medications once breakfast was served. Observation with LPN #5 on 3/23/25 at 8:03 AM identified that the medications left at Resident #112's bedside were not from her medication pass, as she had worked the night shift, but she would remove the medication from the bedside table and locate the day shift nurse. Interview with LPN #4 on 3/23/25 at 8:06 AM identified Resident #112 refused to take his/her medications this morning and wanted to wait until he/she had eaten breakfast. LPN #4 indicated that Resident #112 does not have an order to self-administer medications, and that she should have remained at the residents bedside until he/she took all of the medications or removed the medications and returned when the resident was ready to take the mediations. LPN #4 further indicated that the medications left at the bedside were from the morning medication pass: apixaban, iron (ferrous sulfate), miralax, Tylenol (acetaminophen), multivitamin, vitamin C (ascorbic acid), metoprolol, and lactulose (enulose). LPN #4 identified that she had just been in Resident #112's room to administer the medications, and they hadn't been left for more than a few minutes. LPN #4 further identified that the medications had been removed from the table, and she would administer the medications once breakfast had been served. Interview with the DNS on 3/25/25 at 2:24 PM identified that the expectation is that the nurse remains at the bedside with the resident until all of the medications are taken. The DNS indicated that Resident #112 likes to take his/her morning medications with breakfast and that his/her morning medication administration time has been adjusted to accommodate that request. The DNS further indicated that LPN #4 had been reeducated on not leaving medications at a resident's bedside. The facility's Medication Pass policy directs that residents are always observed until they have swallowed all medications that have been administered. Do not leave medications in the medication cup at the bedside or on the table.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 7 residents (Resident #59) reviewed for accidents, the facility failed to ensure every 15 minute checks were completed after an unwitnessed fall, per physician's order and per facility policy. The findings include: Resident #59 was admitted to the facility in July 2022 with diagnoses that included dementia, high blood pressure, history of falls, and heart failure. The quarterly MDS dated [DATE] identified Resident #59 had severely impaired cognition and required maximum assistance with dressing, toileting, and personal hygiene. The care plan dated 10/7/24 identified Resident #59 was at risk for falls Interventions included to remind Resident #59 to call for assistance, neurological checks and fall assessments per facility protocol. A reportable event form dated 11/15/24 at 7:30 AM identified Resident #59 reported falling in the dining room causing a bruise and abrasion to the left flank area. Interventions included to complete every 15-minute checks for 3 days and pad the wheelchair arm rest. The care plan and nurse's aide care card dated 11/15/24 identified Resident #59 was on every 15-minute checks and pad wheelchair armrest. A physician's order dated 2/18/25 at 7:00 AM directed for every 15-minute checks every shift indefinitely. Review of the every 15-minute checks daily forms dated 2/16/25 to 3/23/25 identified the following forms were missing: 2/16, 2/17, 2/18, 2/23, and 3/9/25. The following every 15-minute checks daily forms had days that were incomplete or had a line through the shift; 2/20, 2/21, 2/22, 2/27, 2/28, 3/1, 3/2, 3/3, 3/4, 3/5, 3/6, 3/7, 3/8, 3/10, 3/11, 3/12, 3/15, 3/16, 3/17, 3/18, 3/19, 3/21, 3/22, 3/23, and 3/25/25. An interview with the DNS on 3/26/25 at 7:15 AM indicated if Resident #59 fell on [DATE], he/she would not have been able to get him/herself up off the floor without staff assistance. The DNS indicated that she concluded there was no fall, but the abrasion and bruise was from the arm rest of the wheelchair. The DNS indicated that for this incident the intervention was every 15-minute checks for 3 days and pad the wheelchair arm rest. The DNS indicated that the nurse aides were responsible to document every 15-minutes checks with their initials on the form in the space provided. After clinical record review, the DNS indicated the nurse implemented every 15-minute checks daily starting on 11/15/24 for 3 days but she was not able to locate the every 15-minute daily forms from 11/15/24 to 11/18/24. The interview with Medical Records Person #1 on 3/26/25 at 8:00 AM indicated that when she receives or collects every 15-minute forms completed or when not complete she gives them to the ADNS. Medical Records Person #1 indicated that the ADNS completes the forms and gives them back to her to scan into the residents EMR. After clinical record review, Medical Records Person #1 indicated that she had not seen the every 15-minute daily forms for 11/15/24 to 11/18/24. Interview with the DNS on 3/26/25 at 7:20 AM indicated that the expectation for completing the every 15 minute check form included to complete each box indicating the check had been done at that time. The DNS indicated staff should not draw a line straight down the form for the entire shift. The DNS indicated that she was aware that nurse aides were doing that and education had been provided in the past. The DNS indicated that she printed all every minute check forms from the EMR. The DNS indicated the resident fell on 2/16/24, however, the nurse started the every 15-minute checks intervention on 2/18/25. The DNS indicated that she would continue to look for the missing dates. Interview with Medical Records Person #1 on 3/26/25 at 8:00 AM indicated that when she receives every 15-minute check daily forms and they are not completed she gives them to the ADNS. Medical Records Person #1 indicated that the ADNS completes the forms and gives them back to her to scan into the residents EMR. Interview with ADNS on 3/26/25 at 10:00 AM indicated that every 15-minute check was implemented for the fall on 2/16/25 for Resident #59. The ADNS indicated the nurse's aide assigned to the resident were responsible to see the resident every 15 minutes for safety and sign the form and if the aide is on break the nurse or another nurse's aide can sign for that 15-minute time slot. The ADNS indicated that the unit secretary or Medical Records Person #1 collects the daily forms from the units and places them in her mailbox to audit. The ADNS indicates that if a form was not completed, she will call the nurse's aide assigned to the resident and ask them if they had done every 15-minute checks on the resident and then have them sign the form the next time they come into the facility. The ADNS indicated there was not a policy for the every 15-minute checks form. Interview with Medical Records Person #1 on 3/26/25 at 11:25 AM indicated that the ADNS had found every 15-minute daily checks in her office for 3/22/25 but it was not complete. Requested the additionally missing dates 2/16, 2/17, 2/18, 2/21, 2/23, 3/7/25. Interview with Medical Records Person #1 on 3/26/25 at 2:00 PM indicated she was not able to find every 15-minute check daily forms for 2/16, 2/17, 2/18, 2/23, and 3/9/25. Although requested, a facility policy for every 15-minute checks form was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility assessment, and interviews, the facility failed to ensure a licensed nurse had the competencies and education to administer IV therapy. The findings include: Resident #390 was admitted to the facility on [DATE] with diagnosis that included sepsis, bacteremia, and acute and subacute endocarditis. The admission nurse's note dated 3/22/25 at 5:51 PM identified that Resident #390 was admitted from an acute care facility with a diagnosis of sepsis and acute renal failure. Blood culture showed Group B (beta) strep (Streptococcus) bacteremia and probable endocarditis. A PICC (peripherally inserted central catheter) was placed, and IV (intravenous) antibiotics were ordered for 6 weeks. Physician's orders dated 3/22/25 directed to administer Ceftriaxone Sodium Solution Reconstituted (IV antibiotic) 1gram, use 2 grams intravenously, once daily for sepsis until 4/29/25, before breakfast, and to monitor IV PICC site for redness, swelling, drainage, and any signs of infection, every shift for prophylaxis. The care plan dated 3/22/25 identified Resident #390 was receiving intravenous therapy via a PICC line. Interventions included flushing the line before and after antibiotic administration and to monitor the site for placement and for signs and symptoms of infection, every shift. The care plan further identified the Resident #390 was on antibiotic therapy related to sepsis. Interventions included administering the antibiotic medications as ordered. The March 2025 MAR identified that on 3/22/25 during the 11:00 PM - 7:00 AM shift, LPN #9 monitored Resident #390's IV site for redness, swelling, drainage or signs of infection, and on 3/23/25 at 6:32 AM, LPN #9 administered Ceftriaxone Sodium Solution Reconstituted 1 GM, intravenously. Interview and review of facility documentation with the Regional Director of Clinical Operations and the Infection Preventionist (RN#4) on 3/24/25 at 9:33 AM failed to identify that LPN #9, hired on 1/8/22, had a certificate of completion for infusion therapy or competencies related IV therapy on file. RN #4 indicated that LPN #9 worked per diem and typically did not provide care to residents with IV lines. Review of the clinical record identified LPN #9 had signed off Resident #390's IV antibiotics as administered, on 3/23/25. The Regional Director of Clinical Operations indicated that she would look for LPN #9's certificate of completion for infusion therapy and competencies related to IV therapy. Subsequent to surveyor inquiry LPN #9's Infusion Services Certificate of Completion dated 1/24/22 was provided. The Regional Director of Clinical Operations indicated that LPN #9 provided the facility with her certificate that was obtained at another facility. Interview and clinical record review with the Staff Development Nurse (RN #1) on 3/26/25 at 7:18 AM identified that according to facility documentation, LPN #9 was not identified as IV certified, therefore she was not on RN #1's list of annual competency for IVs. RN #1 indicated that if LPN #9 had obtained her IV therapy certification and competency at a different facility, she would have also expected her to complete the annual 2023 and 2024 on-line education and IV competencies at this facility. RN #1 indicated that when LPN #9 saw that Resident #390 had an IV medication scheduled to be given during her shift, she notified the 11:00 PM - 7:00 AM RN Supervisor (RN #6) for assistance, because she had not worked with an IV during her time at this facility. RN #1 indicated that RN #6 assisted LPN #9 with administering Resident #390's IV antibiotics. Interview with the DNS on 3/26/25 at 9:13 AM identified that she would expect a nurse administering an IV medication to have an IV therapy certification on file and the required annual education and competencies completed, however she was told that RN #6 had assisted LPN #9 with setting up the medication and hung Resident #390's IV antibiotic because LPN #9 did not have an IV certification. Interview with RN #6 on 3/26/25 at 9:37 AM identified that she had assisted LPN #9 with setting up the IV pump and priming the tubing because LPN #9 told her that she had been working outside of this facility and needed a reminder. RN #6 indicated that she was not aware that LPN #9 had not been up to date with her IV competencies and that she did not have an IV certification on file. RN #6 further indicated that she verbally went through the motions of flushing the PICC line and connecting the IV tubing to the IV port, but she was not present at the bedside when LPN #9 flushed Resident #390's PICC or connected him/her to the IV antibiotics. Interview with LPN #9 on 3/26/25 at 1:49 PM identified that she was employed as a per diem nurse and worked at this facility once in a while. LPN #9 further identified that she had completed the IV therapy certification program while employed at a different facility and had sent this facility her IV therapy certification, earlier this week. LPN #9 indicated that she had not completed the annual IV education or competencies at this facility, and that she does not provide IV therapy at her other job, only at this facility. LPN #9 further indicated that she had called the RN Supervisor (RN #6) for assistance with setting up Resident #390's IV antibiotics. LPN #9 identified that hung Resident #390's IV medications, but she could not recall if RN #6 was with her at the bedside. The Facility Assessment directs that services are based on evaluation of the residents' needs and the following reflects the resources needed to provide care related to medications: awareness of any limitations of administering medications, administration of medications that residents need by route of oral, nasal, buccal, sublingual, topical, subcutaneous, intravenous (peripheral of central lines), intramuscular, inhaled, etc. Assessment and management of polypharmacy. Training/education and competencies after hire occur throughout the year on topics related to patient care and services. All employees must have certain competencies related to topics discussed on orientation. These would include areas such as infection control, disaster procedures, resident rights, grievance procedures, HIPPA, OSHA standards, abuse etc. Although many of these topics are customized to the employee's job/function. All staff have certain competencies that are required in order to perform their jobs in an acceptable manner to support our resident population as outlined in the assessment. The competencies are demonstrated on hire and are checked annually to ensure continued competency. The following are competencies that are demonstrated by staff as appropriate: medication administration including injectable, oral, subcutaneous, topical, anal, and buccal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #4) reviewed for a specialized treatment, the facility failed to ensure that staff consistently monitored and recorded fluid intake and output for a resident on fluid restriction. The findings included: Resident #4 was admitted to the facility in September 2024, with diagnoses that included chronic kidney disease stage 3, and diabetes. The December 2024 physician's order directed a 1500 ml fluid restrictions per day (breakfast 420 ml, lunch 240 ml, dinner 240 ml, nursing 480 ml between days and evenings, and 120 ml on nights). Review of the fluid intake monitoring record dated December 2024 identified staff failed to document the resident's intake 17 out of 93 occasions. Review of the fluid intake monitoring record dated January 2025 identified staff failed to document the resident's intake 34 out of 93 occasions. The care plan dated 2/12/25 identified the resident requires hemodialysis related to renal failure. Interventions included a 1500 ml fluid restrictions per day (breakfast 420 ml, lunch 240 ml, dinner 240 ml, nursing 480 ml between days and evenings, and 120 ml on nights). The quarterly MDS dated [DATE] identified Resident #4 had intact cognition and required setup or clean-up assistance with eating. Review of the fluid intake monitoring record dated February 2025 identified staff failed to document the resident's intake 63 out of 84 occasions. A nutritional evaluation dated 3/25/25 identified Resident #4 required a fluid restriction of 1500 ml. Review of the fluid intake monitoring record dated March 2025 identified staff failed to document the resident's intake 51 out of 78 occasions. Interview with the DNS on 3/26/25 at 6:33 AM identified she was not aware that staff were not following the physician's order for the fluid restriction or recording Resident #4's intake and output forms consistently and there were missing shifts and days of documentation. Interview with LPN #6 on 3/26/25 at 7:20 AM identified she was not aware that intake and output forms were not being consistently completed. LPN #6 indicated that the nursing staff fills out the intake monitoring on the fluid restriction record each shift, and then the form goes down to the ADNS. LPN #6 indicated prior to Sunday 3/23/25 the nursing staff were not able to document the resident intake and output into the computer. LPN #6 indicated on Sunday 3/23/25 at 4:50 PM the nursing staff received a text message from the DNS indicating staff could go into the computer under a certain task and enter the amount of fluid the resident consumed. Interview with NA #7 on 3/26/25 at 8:50 AM identified she records Resident #4's fluid intakes on the intake and output form when she is working. Interview with the Registered Nurse at the specialized treatment center on 3/26/25 at 8:55 AM identified the specialized treatment center was not informed by the facility that staff were not consistently monitoring to ensure the residents fluid restriction. Interview with the Dietitian at the specialized treatment center on 3/26/25 at 11:26 AM identified the facility had not informed her that staff were not monitoring the fluid restriction. The Dietitian indicated the nursing staff should be following the physician's order for 1500 ml fluid restriction in 24 hours. Interview with MD #2 on 3/28/25 at 10:20 AM identified he was not aware staff were not consistently monitoring and recording the resident's fluid intake. MD #2 indicated the nursing staff should be following the physician's order for 1500 ml fluid restriction a day. Although attempted, an interview with the facility Dietitian was not obtained. Review of the facility hemodialysis policy identified a resident who is admitted to the facility requiring hemodialysis, with their consent, will have their dialysis needs met. The Licensed Nurse will obtain the healthcare provider orders for hemodialysis which should include possible fluid restriction. Review of the facility intake and output policy identified the facility is to maintain accurate fluid intake and/or output monitoring. Nursing personnel are responsible for documenting fluid intake and/or output totals in the plan of care. The nurse aides are responsible for documenting the total amounts of fluids taken with meals and those fluids taken in between meals that have been provided by the nurse aides.

Based on observation, review of facility documentation, facility policy, and interviews, the facility failed to ensure that nurse aides had annual performance evaluations completed for 2024, The findings include: During a review of performance evaluations for facility nursing staff on 3/25/25, facility documentation failed to identify a 2024 performance evaluation completed for NA #6. A request was made on 3/25/25 at 10:00 AM to the HR Director to provide the 2024 performance evaluation for NA #6. Review of the provided performance evaluation for NA #6 on 3/25/25 at 10:52 AM identified NA #6 had not signed the evaluation, and the signature from the DNS on the evaluation was dated 10/30/25, 7 months in the future. Interview with the HR Director on 3/25/25 at 10:52 AM identified she observed the DNS sign the evaluation today, just prior to the DNS handing the evaluation to the HR Director. Interview with the DNS on 3/25/25 at 11:00 AM identified she was aware that there were facility nursing staff who did not have annual evaluations completed for 2024, but this was due to the staff working per diem or being out on leave, and she would attempt to complete the evaluations when the staff were in the building. The DNS also identified that while she did have NA #6's performance evaluation in her office, she had just forgotten to give the evaluation to the HR Director to place in NA #6's personnel file. The DNS identified that she also could not remember if she did the evaluation with NA #6 in person or over the phone. When asked, the DNS reiterated she signed the evaluation on 10/30/24 and not when the HR director asked for it prior to surveyor review. Interview with the Human Resources (HR) Director on 3/25/25 at 4 PM identified that performance evaluations for facility staff were to be done initially 90 days after hire, and then annually per the facility policy. The HR Director identified she would prepare the evaluations that were due for nursing staff, placed them into a folder labeled by year (i.e. 2024, 2025) and would then give the folder to the DNS to keep in her office. The HR director identified while she assisted the DNS by filling out the preliminary information on the evaluation including the staff member name, job title, hire date, and type of evaluation (initial or annual), it was the responsibility of the DNS to then complete the evaluation, review and sign with the staff member, and return the completed and signed evaluation to the HR Director to be placed in the staff member's personnel file. A request was then made to the HR Director to provide the 2024 evaluation folder for review. Further review of the 2024 performance evaluation folder for nursing staff identified a total of 6 additional nurse aides that did not have a performance evaluation completed for 2024. The facility employee handbook directed it was the policy of the facility to review the performance of each staff member at the end of the first 3 months of employment and every year thereafter, that the purpose of performance reviews was to assure the facility that the employee was properly placed in his/her current position. The handbook also directed that attendance, attitude, and job performance were among the most important factors considered in the performance evaluation. The handbook further directed it was the policy of the facility to review the performance of each staff member at the end of the first 3 months of employment and every year thereafter, the purpose of performance reviews was to assure the facility that the employee was properly placed in his/her current position. The handbook also directed that attendance, attitude, and job performance were among the most important factors considered in the performance evaluation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #340) reviewed for transmission-based precautions, the facility failed to ensure nursing staff adhered to appropriate infection control techniques for a resident on contact precautions. The findings include: Resident #340 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, history of falling, and dysphagia. The admission MDS dated [DATE] identified Resident #340 had moderately impaired cognition, was always continent of bowel, occasionally incontinent of bladder and required partial assistance from facility staff with dressing, bathing, and toileting. The care plan dated 3/22/25 identified Resident #340 had gastroenteritis. Interventions included standard plus enteric contact precautions. A physician's order dated 3/22/25 directed to collect stool sample for Clostridium Difficile (C. Diff) one time for diarrhea. Observation on 3/23/25 at 11:43 AM identified a sign located outside of Resident #340's room along with a PPE cart labeled Contact Enteric Precautions. Visitors cleanse hands with sanitizer upon entering room and wash with soap and water upon leaving room. Doctors and staff must gown and glove at the door. LPN #3 was observed to enter Resident #340's room without the use of hand sanitizer, gowning, or gloving to provide assistance as Resident #340 appeared unsteady on his/her feet. NA #4 was observed standing outside of the room, directly facing the resident's doorway, the precautions sign, and PPE cart, observing Resident #340 and LPN #3. At 11:45 AM, LPN #3 asked NA #4 to provide assistance to Resident #340. LPN #3 then exited Resident #340's room and used a wall mounted hand sanitizer for hand hygiene. NA #4 entered Resident #340's room without use of hand sanitizer, gowning or gloving, and provided Resident #340 assistance to bed and then exited the room at 11:47 AM. Interview with LPN #3 and NA #4 immediately following the observation identified that LPN #3 was aware that Resident #340 was on precautions due to GI symptoms but was unsure if the resident had been diagnosed with any specific organism. LPN #3 identified that she did not don PPE due to Resident #340's need for immediate assistance but she should have washed her hands prior to exiting the room. NA #4 identified that she did not she need PPE since LPN #3 did not put on PPE. NA #4 identified she was unsure if she should have washed her hands or used hand sanitizer on entering or exiting. A C-Diff toxin PCR lab report dated 3/23/25 at 3:59 PM identified Resident #340 was negative. Interview with RN #1 (Staff Development Nurse) and RN #5 (Infection Prevention Nurse #2) on 3/25/25 at 1:04 PM identified that the facility was in a current GI outbreak and that any resident with diarrhea and GI symptoms was placed on contact enteric precautions while determining the cause. RN #1 identified that the precautions included ensuring gloves and gowns were used when a resident with symptoms had a bowel movement and that all staff should perform hand hygiene after doffing gloves. RN #1 identified that education regarding outbreak control, along with hand hygiene and PPE audits had been ongoing since 12/2024, and all staff received infection prevention, hand hygiene and PPE donning and doffing education upon hire and annually. RN #1 and RN #5 identified that the level of PPE needed depended on the level of care a resident may require but that with bowel movements staff should always don gloves. Review of education documentation for LPN #3 dated 7/31/24 identified competencies were noted as passed and performed correctly related to hand hygiene and all skills met related to PPE donning and doffing. Review of education documentation for NA #4 dated 9/26/24 identified competencies were noted as passed and performed correctly related to hand hygiene and all skills met related to PPE donning and doffing. The facility policy on precautions to prevent Infection directed that contact precautions were to be implemented for any resident with the presence of acute diarrhea or C-diff infection and PPE should be used with any room entry. The policy further directed that PPE should include gloves and gown (don before room entry, doff before room exit) and entrance to the room should be restricted to medically necessary care. The policy directed for use of alcohol based hand sanitizers except with C-Diff. Review of the hand hygiene competency education form directed all staff to remember to always use soap and water for patients with C. Diff or Norovirus.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 5 residents (Resident #59, 63, 72, 121, and 346), reviewed as part of the sufficient competent nurse staffing review, the facility failed to ensure that the physician and resident representatives were immediately notified when medication omissions/errors were identified. The findings include: 1. Resident #59 was admitted to the facility in September 2023 with diagnoses that included psychiatric disorder with delusions, dementia, and chronic obstructive pulmonary disease The care plan dated 8/23/24 identified Resident #59 required psychotropic medications. Interventions included to administer medications as ordered. The quarterly MDS dated [DATE] identified Resident #59 had severely impaired cognition, was frequently incontinent of bowel and bladder and required substantial assistance with dressing, bathing and toileting. Review of the September 2024 MAR identified on 9/22/24, LPN #3 signed off morning medications as administered as follows: 9:00 AM Prednisone tablet 10 mg daily (for wheezing). Gemtesa tablet 75 mg (for incontinence). Cholecalciferol tablet 1000 units (for osteoporosis). 9:30 AM Aspirin 81 mg by mouth (for prophylaxis). Bupropion extended release tablet 150 mg by mouth (for dementia and mood disturbance). Cardizem CD extended release tablet 120 mg (for hypertension). Cyanocobalamin tablet 1000 mg (b 12 supplement). Donepezil tablet 10 mg (for dementia). Gemtesa tablet 75 mg (for incontinence). Hydrochlorothiazide tablet 12.5 mg (for hypertension). Sertraline tablet 50 mg (for depression). Trilegy Ellipta 200-62.5-25 MCG inhaler one puff (for COPD). Budesonide 0.5 mg/2 ml inhalation one puff (for COPD). Gabapentin capsule 300 mg (for polyneuropathy). Preservision AREDs vitamin 1 tablet (for macular degeneration). Refresh Tears solution two drops to each eye (for dry eye). Reglan tablet 5 mg (for slow colonic transition). A nurse's note dated 9/23/24 at 1:40 AM by RN #6 identified that Resident #59 missed doses of all morning medications and an APRN was notified. Further review of the clinical record failed to identify any other documentation related to the missed doses of all morning medications. The clinical record failed to reflect documentation related to an assessment of Resident #59 after the missed doses of all morning medications. 2. Resident #63 was admitted to the facility in January 2020 with diagnoses that included Alzheimer's dementia, dysphagia and hypertension. The quarterly MDS dated [DATE] identified Resident #63 had severely impaired cognition, was always incontinent of bowel and bladder and was dependent on staff assistance with dressing, bathing and toileting. The care plan dated 8/22/24 identified Resident #63 had altered cardiovascular status due to hypertension. Interventions included to administer cardiac medications as ordered. Review of the September 2024 MAR identified on 9/22/24, LPN #3 signed off morning medications as administered as follows: 9:30 AM Amlodipine tablet 5 mg (for hypertension). Soothe XP artificial tears one drop in both eyes (for dry eyes). A nurse's note dated 9/23/24 at 1:44 AM by RN #6 identified that Resident #63 missed a 9:30 AM dose of amlodipine and an APRN was notified. Further review of the clinical record failed to identify any other documentation related to the missed dose of Amlodipine. The clinical record failed to reflect documentation related to an assessment of Resident #63 after the missed dose of Amlodipine. 3. Resident #72 was admitted to the facility in September 2021 with diagnoses that included Alzheimer's dementia, delusional disorder and adult failure to thrive. The annual MDS dated [DATE] identified Resident #72 had intact cognition, was always continent of bowel, occasionally incontinent of bladder, required supervision with bathing, and was independent with toileting and dressing. The care plan dated 9/9/24 identified Resident #72 had impaired cognitive function due to dementia. Interventions included to administer medications as ordered. Review of the September 2024 MAR identified on 9/22/24, LPN #3 signed off morning medications as administered as follows: 9:00 AM Ascorbic Acid tablet 500 mg (Vitamin C supplement). Polyethylene Glycol powder 17 GMS daily (for constipation). Cyclosporin emulsion 0.5% one drop to each eye (for inflammation). A nurse's note dated 9/23/24 at 1:42 AM by RN #6 identified that Resident #72 missed a 9:00 AM dose of Vitamin C and an APRN was notified. Further review of the clinical record failed to identify any other documentation related to the missed dose of Vitamin C. 4. Resident #121 was admitted to the facility on [DATE] with diagnoses that included pneumothorax, dementia, and hypertension. The admission MDS dated [DATE] identified Resident #121 had moderately impaired cognition, was occasionally incontinent of bowel and bladder and required partial staff assistance with dressing, bathing and toileting. The care plan dated 7/12/24 identified Resident #121 had a potential of untoward effects due to anticoagulant therapy. Interventions included to administer medications as ordered. Review of the September 2024 MAR identified on 9/22/24, LPN #3 signed off morning medications as administered as follows: 9:00 AM Cozaar 25 mg tablet (for hypertension). Lidocaine 4% patch apply to lower back topically (for pain). Loratadine tablet 10 mg by mouth (for allergy symptoms). Metoprolol 24 hour extended release tablet 25 mg (for beta blocker). Sertraline tablet 50 mg half tablet (for anxiety). Vitamin D 5000 unit tablet (for supplement). Eliquis 2.5 mg tablet (for anticoagulation). Memantine tablet 5 mg (for psychotropic). 9:30 AM Preservision AREDs vitamin 1 tablet (for supplementation). 12:00 PM Tylenol table 650 mg (for pain). A nurse's note dated 9/23/24 at 1:44 AM by RN #6 identified that Resident #121 missed 9:00 AM doses of Eliquis, Loratadine, Losartan, Memantine, Metoprolol, Vitamin D and a 12:00 PM dose of Tylenol, and an APRN was notified. Further review of the clinical record failed to identify any other documentation related to the missed doses of the morning medications. The clinical record failed to reflect documentation related to an assessment of Resident #121 after the missed doses of morning medications. 5. Resident #346 was admitted to the facility in November 2018 with diagnoses that included Alzheimer's dementia, heart failure and hypertension. The quarterly MDS dated [DATE] identified Resident #346 had severely impaired cognition, was occasionally incontinent of bowel, always incontinent of bladder, required substantial assistance with toileting and was dependent on staff to assist with dressing and bathing. The care plan dated 9/19/24 identified Resident #346 had impaired cognitive function due to dementia. Interventions included to administer medications as ordered. Review of the September 2024 MAR identified on 9/22/24, LPN #3 signed off morning medications as administered as follows: 9:00 AM Lorazepam oral concentrate 2 mg/ml - 1 ml by mouth (for anxiety and restlessness). Refresh tears one drop in each eye (for dry eye). 1:00 PM Lorazepam oral concentrate 2 mg/ml - 1 ml by mouth (for anxiety and restlessness). A nurse's note dated 9/23/24 at 1:14 AM by RN #6 identified that Resident #346 missed a 9:00 AM dose of Lexapro on 9/22/24 and an APRN was notified. Review of the clinical record failed to identify an order for Lexapro for Resident #346. During a review of performance evaluations for facility nursing staff on 3/25/25, a review of LPN #3's personnel file identified multiple documents related additional training, verbal and written counseling, and disciplinary actions related to medication administration errors involving multiple residents in the facility. A review of the file identified (on the job training) dated 9/22/24 identified LPN #3 to her failure to administer morning medications to 5 residents. The training provided included that all medications must be administered for each medication pass and if a resident was unable to get their medication for any reason, then a supervisor must be notified. Review the documentation failed to identify the names of the 5 residents involved, any investigations regarding the incident, or the outcome of the investigation. Interview with the DNS on 3/25/25 at 3:00 PM identified that she did not investigate the medication errors for the 5 residents identified in LPN #3's personnel file documentation. The DNS identified that the facility used a prepackaged packet system that contained all the medications due on a specific time/date for each resident of the facility. The DNS identified that on 9/22/24 when RN #6 came on duty for the 7:00 PM - 7:00 AM shift, she discovered prepackaged morning medications for 5 residents that had been assigned to LPN #3 during the 7:00 AM - 3:00 PM shift were in the medication cart. The DNS identified that RN #6 notified her of what occurred, and she spoke with LPN #3 the following day on 9/23/24. The DNS identified that LPN #3 reported to her that for those 5 residents, LPN #3 identified to her that she opted to use individual blister packets of each medication that were due to administer morning medications for just those 5 residents. The DNS identified this as a sufficient explanation but was unable to identify why LPN #3 would have dispensed the medications for just those 5 residents from individual blister packets, when each resident had individual fully prepacked medications for each administration time. The DNS also identified that she did not look any further into any additional medications that were not prepackaged for the impacted residents, as LPN #3 signed off the medications on the MAR. Interview with the DNS on 3/25/25 at 4:30 PM identified that, following a request to provide documentation of the 5 residents affected by the errors, the DNS identified Resident #59, Resident #63, Resident #72, Resident #121, and Resident #346 as the residents impacted. Interview with RN #6 on 3/26/25 at 9:37 AM identified she was the RN supervisor on the 7:00 PM - 7: AM shift on 9/22/24 and during the shift, LPN #10 notified her that 5 of her residents' prepackaged morning medications were in the medication cart. RN #6 identified that she instructed LPN #10 to place a note for each resident in the APRN notification book related to the errors, and then RN #6 then went through the packages and made notes in each resident's chart. RN #6 identified that LPN #3 had worked a double shift (7:00 AM - 11:00 PM) on 9/22/24, and that once the errors were discovered, she completed the on the job training form and completed education and counseling with LPN #3 prior to her shift ending. RN #6 identified that LPN #3 was unable to identify why the residents' morning medication packets were in the cart, and did not provide any explanation to her related to use of blister packets instead of the pharmacy prepackaged medications. RN #6 identified that she only reviewed the medication packets and did not look any further into the errors. RN #6 identified that LPN #10 was assigned to the 5 residents at the time the errors were discovered, and she was unsure if LPN #10 completed any assessments on the residents. Although attempted, an interview with LPN #3, LPN #10 and MD #1 (Medical Director) were not obtained. The facility policy on accidents and incidents directed that occurrences would be investigated in a timely manner and preventative measures would be initiated and the Risk Management system (RMS) event would be used to document incidents including those involving medication errors. The policy further directed that staff would notify the nursing supervisor when an incident occurred, the licensed nurse or nursing supervisor would complete and document an evaluation of the resident's condition, including but not limited to vital signs, neurological status, and evaluation of pain. The policy also directed that the healthcare provider would be notified with a date and time of notification in the RMS and nurse's notes with any new orders or recommendations made by the provider. If the healthcare provider could not be reached in a timely manner, the Medical Director should be called. The policy also directed that the resident representative should be notified by the licensed nurse or designee in the RMS and nurse's notes, including any failed attempts. The facility policy on change of condition directed that the facility must inform the resident, consult with the resident's healthcare provider and notify the resident's legal representative or family member when an incident involving the resident may result in injury or require medical treatment, a significant change in the resident's physical, mental, or psychological status; or a need to alter treatment significantly. The policy further directed that the licensed nurse would conduct a complete physical/mental evaluation and document the findings in the medical record, including the resident's reaction to symptoms (i.e pain, anxiety, etc). The policy also directed the licensed nurse should notify the resident, attending physician, and family and/or resident representative of the change of condition, and that repeated attempts would be made until successful and would be documented. The facility policy on medication pass directed that the physician should be notified immediately for any high risk medications for change of condition not given including but not limited to cardiac medications, anticoagulants, and psychotropics.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 7 residents (Resident #59, 63, 68, 72, 85, 121 and 346), the facility failed to provide care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. For 1 of 2 residents (Resident #59) reviewed for edema, the facility failed to follow the physician's order for compression stockings. For 2 of 2 residents (Resident #68 and 85) reviewed for edema, the facility failed to ensure the staff monitored the intake and output for a resident on a fluid restriction. For 5 residents (Residents #59, 63, 72, 121 and 346) the facility failed to ensure medications were administered per the physician's orders, and failed to ensure that following an identified medication administration error, a change of condition nursing assessment was completed. The findings include. 1. Resident #59 was admitted to the facility in July 2022 with diagnoses that included dementia, high blood pressure, and heart failure. The quarterly MDS dated [DATE] identified Resident #59 had moderately impaired cognition and required limited assistance for dressing and transfers with one staff member. The care plan dated 2/14/25 identified Resident #59 had altered cardiovascular status. Interventions included keeping legs elevated times 2 hours and notifying the physician of any change in condition. A physician's order dated 3/22/25 at 12:10 PM directed to apply compression socks in the morning and remove at bedtime. Observation on 3/23/25 at 10:40 AM identified Resident #59 was sitting dressed in his/her wheelchair wearing regular socks and slippers without the benefit of the compression socks. Observation on 3/24/25 at 11:00 AM identified Resident #59 was dressed and sitting in the wheelchair with regular socks on and slippers without the benefit of the compression socks. Observation on 3/25/25 at 11:30 AM identified Resident #59 was dressed and sitting in the wheelchair with regular socks on and slippers without the benefit of the compression socks. Observation on 3/25/25 at 2:40 PM identified Resident #59 was in the recreation room for bingo sitting in the wheelchair with regular socks on and slippers without the benefit of the compression socks. Interview with LPN #7 on 3/25/25 at 2:56 PM indicated that the nurses are responsible to put the compression socks on residents in the morning with morning care before a resident gets out of bed and the nurse must sign off on the TAR that the compression socks have been applied. LPN #7 indicated that she did not put the compression socks on Resident #59 this morning because she did not see an order for the compression socks. After clinical record review, LPN #7 indicated that although there is an order for compression socks, the compression socks are not listed on the TAR so LPN #7 indicated she was not aware. LPN #7 indicated that when transcribing the order from the physician, LPN #8 should have made sure it was added to the TAR and included specific times to apply and remove. Interview with APRN #1 on 3/25/25 at 3:10 PM identified Resident #59 had dependent edema in bilateral lower extremities and had poor circulation from sitting in a wheelchair. APRN #1 indicated that she had put the order for the compression socks in the EMR and the charge nurse is responsible to transcribe the order. APRN #1 indicated the nurses are responsible to follow the order and apply the compression socks every morning before the resident gets out of bed and if the resident had refused, the refusal should be documented, and she would have been notified. Interview with the DNS on 3/25/25 at 3:15 PM indicated the order for Resident #59 was for the white compression socks that are house stock and if not available the nurse can notify the pharmacy to send them. The DNS indicated APRN #1 had put in the order for the compression socks but did not trigger the order to display on the TAR to have the nurse sign off as applying the compression socks in the morning and the evening nurse to remove them. The DNS indicated that when LPN #8 confirmed the order he was responsible to check the order to make sure it was correct before signing off as transcribing/confirming the order. The DNS indicated that she would correct the order and make sure Resident #59 has a new pair of compression socks for tomorrow morning. Although requested, a facility policy for compression socks was not provided. 2. Resident #68 was admitted to the facility on [DATE] with diagnoses that included chronic heart failure (CHF) and cognitive communication deficit. A physician's order dated 3/3/25 directed to administer Torsemide (diuretic) 80 mg daily, and Cardizem LA extended release 120 mg daily. Additionally, maintain a fluid restriction of 1500 ml daily (breakfast 420cc, lunch240cc, 240ml dinner and evening, and 120 ml on nights) and daily weights for CHF. The care plan dated 3/13/25 identified Resident #68 has a 1500 ml per day fluid restriction. Interventions included giving 420 ml with breakfast, 240 ml with lunch, and 240 ml with dinner and nursing to give 480 ml. Resident #68 was non-compliant with fluid restrictions and diet. The quarterly MDS dated [DATE] identified Resident #68 had moderately impaired cognition, was always incontinent of bowel and bladder and required set up and clean up for eating, dressing and personal hygiene. Additionally, Resident #68 received diuretic medications. The nurse's aide care card failed to reflect the ordered fluid restriction. Review of the daily intake and output forms dated 3/19/25 to 3/22/25 identified 4 out of 4 days were not completed every shift and 24-hour totals were not calculated. Observation on 3/23/25 at 10:30 AM identified the resident was sitting in a recliner chair next to the bed with a large, insulated cup with a lid and straw drinking from it. Resident #68 indicated that the staff had filled it for him/her. Resident #68 indicated at that time that he/she was on a fluid restriction but does not know why and knows he/she does not follow it and drinks a lot more than he/she should. Interview with the DNS on 3/23/25 at 1:50 PM identified that Resident #68 was on a 1500 ml per day fluid restriction for CHF per physician's order. The DNS indicated that the charge nurse was responsible to ask the nurse's aide each shift what Resident #68' fluid intake was and document the total on the form. The DNS indicated that the intake and output is documented on paper, that are then scanned into the medical record and that staff do not document intake and output in the electronic medical record directly, only on paper. The DNS indicated that the 3:00 PM to 11:00 PM nurse was responsible to add the 24-hour total and if Resident #68 had gone over the restriction he/she is responsible for noting that in the APRN book. The DNS indicated that the charge nurse does not document notification to the APRN in the clinical record and only documents it in the APRN communication book on the unit if Resident #68 goes over the fluid restriction. After review of the clinical record, the DNS identified that the intake and output was not completed from 3/19/25 to 3/22/25. The DNS indicated that Resident #68 has a care plan for non-compliance with the fluid restriction and that the resident drinks more than he/she should. The DNS was not able to identify if Resident #68 was over or under the fluid restriction for the 4 days because the information was not completed. After surveyor inquiry, a physician order dated 3/24/25 at 8:16 AM transcribed by the ADNS directed the nurse to document Resident #68's fluid intake at end of each shift due to the fluid restriction. Interview with the Dietitian on 3/25/25 at 8:37 indicated that Resident #68 was on a 1500 ml per day fluid restriction for heart failure and edema. The Dietitian indicated that Resident #68 was not always compliant with the fluid restrictions and nursing was responsible to monitor the intake and output. The Dietitian indicated that it was important to monitor his/her fluid restriction because of the CHF and he/she could go into fluid overload if the fluid restriction is not followed. 3. Resident #85 was admitted to the facility in March 2024 with diagnoses that included chronic kidney disease, dysphasia, and hypertension. The quarterly MDS dated [DATE] identified Resident #85 had moderately impaired cognition, was occasionally incontinent of bladder and required maximum assistance for toileting, dressing, and personal hygiene. The care plan dated 12/26/24 identified Resident #85 had fluid overload or potential for fluid volume overload due to Chronic Kidney Disease (CKD) and hypertension. Interventions included setting the resident up for meals, and monitoring and document intake and output as per facility policy. Additionally, Resident #85 is on a 1500 ml per day fluid restriction 420 ml for breakfast, 240 ml for lunch, 240 ml for dinner, and 480 ml for nursing between dinner and evening and 120 ml during the night. Additionally, ensure all meals and fluid intake occur under staff supervision. A physician's order dated 2/14/25 directed a fluid restriction of 1500 ml per day with 420 ml for breakfast, 240 ml for lunch, 240 ml for dinner and 480 ml nursing between dinner and evening, and 120 ml for nights related to chronic kidney disease stage 3. Interview with the DNS on 3/23/25 at 2:00 PM identified that Resident #85 was on a 1500 ml per day fluid restriction for chronic kidney disease per the physician's order. The DNS indicated that the charge nurse was responsible for asking the nurse aides each shift what the resident's intake was and document the total on the form. The DNS indicated that the intake and output is documented on paper and then scanned into the medical record. The DNS indicated that they do not document the intake and output in the electronic medical, only on paper. The DNS indicated that the 3:00 PM to 11:00 PM nurse was responsible for adding the 24-hour total and if Resident #68 had gone over to write it in the APRN book for the APRN next visit. The DNS indicated that the charge nurse does not document the APRN notification in the clinical record and only documents it in the APRN communication book on the unit. Review of the clinical record identified that the intake and output was not completed from 3/19/25 to 3/22/25. The DNS was not able to identify if Resident #85 was over or under his/her fluid restriction for the last 4 days. After surveyor inquiry, a physician's order dated 3/24/25 at 8:19 AM created and transcribed by the ADNS directed the nurse to document Resident #85's fluid intake at end of each shift. The interview with Dietitian on 3/25/25 at 8:41 AM indicated Resident #85 was on a 1500 ml per day fluid restriction for chronic kidney disease. The Dietitian indicated that nursing was responsible to monitor and document the intake and output and notify her if Resident #85 was going over the fluid restriction. Review of the daily intake and output forms dated 3/19 to 3/22/25 identified 4 out of 4 days were not completed every shift and there were no 24-hour totals. Review of the Intake and Output Policy, revised in 3/2023, identified to accurately monitor, evaluate, and manage adequate hydration levels of those residents requiring fluid intake and output monitoring nursing personnel are responsible for documenting fluid intake and output totals in the EMR. The nurse's aide is responsible for documenting the total amounts of fluid taken with meals and those fluids taken between meals that have been provided by the nurse's aide. The nurse is responsible for documenting fluids given to the residents including tube feeding, IV, supplements, those given with medication pass, etc. the EMR will calculate the total fluid intake and output daily. This can be reviewed daily by accessing the look back report for each resident. The Licensed nurse will assess the total intake and output report requiring fluid intake monitoring to determine if the resident is meeting their hydration goals. Notify the healthcare provider of all fluid averages that fall below established fluid goals after 3 consecutive days. 4. Resident #59 was admitted to the facility in September 2023 with diagnoses that included psychiatric disorder with delusions, dementia, and chronic obstructive pulmonary disease The care plan dated 8/23/24 identified Resident #59 required psychotropic medications. Interventions included to administer medications as ordered. The quarterly MDS dated [DATE] identified Resident #59 had severely impaired cognition, was frequently incontinent of bowel and bladder and required substantial assistance with dressing, bathing and toileting. Review of the September 2024 MAR identified on 9/22/24, LPN #3 signed off morning medications as administered as follows: 9:00 AM Prednisone tablet 10 mg daily (for wheezing). Gemtesa tablet 75 mg (for incontinence). Cholecalciferol tablet 1000 units (for osteoporosis). 9:30 AM Aspirin 81 mg by mouth (for prophylaxis). Bupropion extended release tablet 150 mg by mouth (for dementia and mood disturbance). Cardizem CD extended release tablet 120 mg (for hypertension). Cyanocobalamin tablet 1000 mg (b 12 supplement). Donepezil tablet 10 mg (for dementia). Gemtesa tablet 75 mg (for incontinence). Hydrochlorothiazide tablet 12.5 mg (for hypertension). Sertraline tablet 50 mg (for depression). Trilegy Ellipta 200-62.5-25 MCG inhaler one puff (for COPD). Budesonide 0.5 mg/2 ml inhalation one puff (for COPD). Gabapentin capsule 300 mg (for polyneuropathy). Preservision AREDs vitamin 1 tablet (for macular degeneration). Refresh Tears solution two drops to each eye (for dry eye). Reglan tablet 5 mg (for slow colonic transition). A nurse's note dated 9/23/24 at 1:40 AM by RN #6 identified that Resident #59 missed doses of all morning medications and an APRN was notified. Further review of the clinical record failed to identify any other documentation related to the missed doses of all morning medications. The clinical record failed to reflect documentation related to an assessment of Resident #59 after the missed doses of all morning medications. 5. Resident #63 was admitted to the facility in January 2020 with diagnoses that included Alzheimer's dementia, dysphagia and hypertension. The quarterly MDS dated [DATE] identified Resident #63 had severely impaired cognition, was always incontinent of bowel and bladder and was dependent on staff assistance with dressing, bathing and toileting. The care plan dated 8/22/24 identified Resident #63 had altered cardiovascular status due to hypertension. Interventions included to administer cardiac medications as ordered. Review of the September 2024 MAR identified on 9/22/24, LPN #3 signed off morning medications as administered as follows: 9:30 AM Amlodipine tablet 5 mg (for hypertension). Soothe XP artificial tears one drop in both eyes (for dry eyes). A nurse's note dated 9/23/24 at 1:44 AM by RN #6 identified that Resident #63 missed a 9:30 AM dose of amlodipine and an APRN was notified. Further review of the clinical record failed to identify any other documentation related to the missed dose of Amlodipine. The clinical record failed to reflect documentation related to an assessment of Resident #63 after the missed dose of Amlodipine. 6. Resident #72 was admitted to the facility in September 2021 with diagnoses that included Alzheimer's dementia, delusional disorder and adult failure to thrive. The annual MDS dated [DATE] identified Resident #72 had intact cognition, was always continent of bowel, occasionally incontinent of bladder, required supervision with bathing, and was independent with toileting and dressing. The care plan dated 9/9/24 identified Resident #72 had impaired cognitive function due to dementia. Interventions included to administer medications as ordered. Review of the September 2024 MAR identified on 9/22/24, LPN #3 signed off morning medications as administered as follows: 9:00 AM Ascorbic Acid tablet 500 mg (Vitamin C supplement). Polyethylene Glycol powder 17 GMS daily (for constipation). Cyclosporin emulsion 0.5% one drop to each eye (for inflammation). A nurse's note dated 9/23/24 at 1:42 AM by RN #6 identified that Resident #72 missed a 9:00 AM dose of Vitamin C and an APRN was notified. Further review of the clinical record failed to identify any other documentation related to the missed dose of Vitamin C. 7. Resident #121 was admitted to the facility on [DATE] with diagnoses that included pneumothorax, dementia, and hypertension. The admission MDS dated [DATE] identified Resident #121 had moderately impaired cognition, was occasionally incontinent of bowel and bladder and required partial staff assistance with dressing, bathing and toileting. The care plan dated 7/12/24 identified Resident #121 had a potential of untoward effects due to anticoagulant therapy. Interventions included to administer medications as ordered. Review of the September 2024 MAR identified on 9/22/24, LPN #3 signed off morning medications as administered as follows: 9:00 AM Cozaar 25 mg tablet (for hypertension). Lidocaine 4% patch apply to lower back topically (for pain). Loratadine tablet 10 mg by mouth (for allergy symptoms). Metoprolol 24 hour extended release tablet 25 mg (for beta blocker). Sertraline tablet 50 mg half tablet (for anxiety). Vitamin D 5000 unit tablet (for supplement). Eliquis 2.5 mg tablet (for anticoagulation). Memantine tablet 5 mg (for psychotropic). 9:30 AM Preservision AREDs vitamin 1 tablet (for supplementation). 12:00 PM Tylenol table 650 mg (for pain). A nurse's note dated 9/23/24 at 1:44 AM by RN #6 identified that Resident #121 missed 9:00 AM doses of Eliquis, Loratadine, Losartan, Memantine, Metoprolol, Vitamin D and a 12:00 PM dose of Tylenol, and an APRN was notified. Further review of the clinical record failed to identify any other documentation related to the missed doses of the morning medications. The clinical record failed to reflect documentation related to an assessment of Resident #121 after the missed doses of morning medications. 8. Resident #346 was admitted to the facility in November 2018 with diagnoses that included Alzheimer's dementia, heart failure and hypertension. The quarterly MDS dated [DATE] identified Resident #346 had severely impaired cognition, was occasionally incontinent of bowel, always incontinent of bladder, required substantial assistance with toileting and was dependent on staff to assist with dressing and bathing. The care plan dated 9/19/24 identified Resident #346 had impaired cognitive function due to dementia. Interventions included to administer medications as ordered. Review of the September 2024 MAR identified on 9/22/24, LPN #3 signed off morning medications as administered as follows: 9:00 AM Lorazepam oral concentrate 2 mg/ml - 1 ml by mouth (for anxiety and restlessness). Refresh tears one drop in each eye (for dry eye). 1:00 PM Lorazepam oral concentrate 2 mg/ml - 1 ml by mouth (for anxiety and restlessness). A nurse's note dated 9/23/24 at 1:14 AM by RN #6 identified that Resident #346 missed a 9:00 AM dose of Lexapro on 9/22/24 and an APRN was notified. Review of the clinical record failed to identify an order for Lexapro for Resident #346. During a review of performance evaluations for facility nursing staff on 3/25/25, a review of LPN #3's personnel file identified multiple documents related additional training, verbal and written counseling, and disciplinary actions related to medication administration errors involving multiple residents in the facility. A review of the file identified (on the job training) dated 9/22/24 identified LPN #3 to her failure to administer morning medications to 5 residents. The training provided included that all medications must be administered for each medication pass and if a resident was unable to get their medication for any reason, then a supervisor must be notified. Review the documentation failed to identify the names of the 5 residents involved, any investigations regarding the incident, or the outcome of the investigation. Interview with the DNS on 3/25/25 at 3:00 PM identified that she did not investigate the medication errors for the 5 residents identified in LPN #3's personnel file documentation. The DNS identified that the facility used a prepackaged packet system that contained all the medications due on a specific time/date for each resident of the facility. The DNS identified that on 9/22/24 when RN #6 came on duty for the 7:00 PM - 7:00 AM shift, she discovered prepackaged morning medications for 5 residents that had been assigned to LPN #3 during the 7:00 AM - 3:00 PM shift were in the medication cart. The DNS identified that RN #6 notified her of what occurred, and she spoke with LPN #3 the following day on 9/23/24. The DNS identified that LPN #3 reported to her that for those 5 residents, LPN #3 identified to her that she opted to use individual blister packets of each medication that were due to administer morning medications for just those 5 residents. The DNS identified this as a sufficient explanation but was unable to identify why LPN #3 would have dispensed the medications for just those 5 residents from individual blister packets, when each resident had individual fully prepacked medications for each administration time. The DNS also identified that she did not look any further into any additional medications that were not prepackaged for the impacted residents, as LPN #3 signed off the medications on the MAR. Interview with the DNS on 3/25/25 at 4:30 PM identified that, following a request to provide documentation of the 5 residents affected by the errors, the DNS identified Resident #59, Resident #63, Resident #72, Resident #121, and Resident #346 as the residents impacted. Interview with RN #6 on 3/26/25 at 9:37 AM identified she was the RN supervisor on the 7:00 PM - 7: AM shift on 9/22/24 and during the shift, LPN #10 notified her that 5 of her residents' prepackaged morning medications were in the medication cart. RN #6 identified that she instructed LPN #10 to place a note for each resident in the APRN notification book related to the errors, and then RN #6 then went through the packages and made notes in each resident's chart. RN #6 identified that LPN #3 had worked a double shift (7:00 AM - 11:00 PM) on 9/22/24, and that once the errors were discovered, she completed the on the job training form and completed education and counseling with LPN #3 prior to her shift ending. RN #6 identified that LPN #3 was unable to identify why the residents' morning medication packets were in the cart, and did not provide any explanation to her related to use of blister packets instead of the pharmacy prepackaged medications. RN #6 identified that she only reviewed the medication packets and did not look any further into the errors. RN #6 identified that LPN #10 was assigned to the 5 residents at the time the errors were discovered, and she was unsure if LPN #10 completed any assessments on the residents. Although attempted, an interview with LPN #3, LPN #10 and MD #1 (Medical Director) were not obtained. The facility policy on accidents and incidents directed that occurrences would be investigated in a timely manner and preventative measures would be initiated and the Risk Management system (RMS) event would be used to document incidents including those involving medication errors. The policy further directed that staff would notify the nursing supervisor when an incident occurred, the licensed nurse or nursing supervisor would complete and document an evaluation of the resident's condition, including but not limited to vital signs, neurological status, and evaluation of pain. The policy also directed that the healthcare provider would be notified with a date and time of notification in the RMS and nurse's notes with any new orders or recommendations made by the provider. If the healthcare provider could not be reached in a timely manner, the Medical Director should be called. The policy also directed that the resident representative should be notified by the licensed nurse or designee in the RMS and nurse's notes, including any failed attempts. The facility policy on change of condition directed that the facility must inform the resident, consult with the resident's healthcare provider and notify the resident's legal representative or family member when an incident involving the resident may result in injury or require medical treatment, a significant change in the resident's physical, mental, or psychological status; or a need to alter treatment significantly. The policy further directed that the licensed nurse would conduct a complete physical/mental evaluation and document the findings in the medical record, including the resident's reaction to symptoms (i.e pain, anxiety, etc). The policy also directed the licensed nurse should notify the resident, attending physician, and family and/or resident representative of the change of condition, and that repeated attempts would be made until successful and would be documented. The facility policy on medication pass directed that the physician should be notified immediately for any high risk medications for change of condition not given including but not limited to cardiac medications, anticoagulants, and psychotropics.

Based on observation, review of the clinical record review, facility documentation, facility policy, and interviews, the facility failed to ensure all facility nursing staff were educated on the identifying mechanism for enhanced barrier precautions (EBP). The findings include: Observations on 3/23/25 at 11:37 AM of the 1st floor Passport unit identified multiple bright pink circular stickers placed on several exterior name plates for residents on the unit. No other information identifying what the pink stickers were for was observed. Interview with LPN #3 on 3/23/25 at 11:50 AM identified she was unsure what the pink circular stickers were for and identified that she thought they had been placed by the Infection Control Nurse, and had something to do with infections, but did not know anything else about the stickers. Interview with NA #4 on 3/23/25 at 11:51 AM identified she had seen the pink circular stickers on multiple resident entryways but had no idea what the stickers meant. Interview with NA #5 on 3/25/25 at 10:30 AM identified that the pink circular stickers were placed to identify if a resident needed to don PPE with wound care. NA #5 further identified that the stickers were also used for residents with colostomies. Interview with RN #1 (Staff Development Nurse) and RN #5 (Infection Prevention Nurse #2) on 3/25/25 at 1:04 PM identified that the pink circular stickers were implemented in March 2024 to identify residents who met the criteria for enhanced barrier precautions (EBP). RN #1 identified that the facility had multiple in-service education sessions for facility staff working in the facility at the time the sticker system was implemented, and that in addition, all newly hired staff were provided education on the sticker system as part of the new hire process. A review of facility in-service documentation related to the EBP sticker identification system identified education began on 3/27/24 and ended 4/7/24. Review of the in-service sign in logs failed to identify any documentation that LPN #3, NA #4, or NA # 5 were provided in-service education for the EBP sticker system. Further review of the in-service education sign in logs identified that 3 of 17 RNs, 9 of 27 LPNs, and 20 of 72 nurse aides in the facility had documented education on the EBP sticker system, including what EBP was, how the sticker system worked, and how EBP was implemented for an affected resident. A follow up interview with RN #1 on 3/25/25 at 4:25 PM identified that subsequent to surveyor inquiry she had begun auditing staff on the sticker system and had discovered that many staff were not aware of what the pink circular stickers were for, and advised she was now working on an education plan to reeducate the staff on the stickers, what enhanced barrier precautions were for, and how to implement them. The facility policy on enhanced barrier precautions (EBP) directed that residents would be on EBP to reduce the transmission of novel and MDROs when contact precautions did not apply when performing high risk resident care activities. The policy further identified that EBP was indicated for resident with pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, venous statis ulcers, central lines including hemodialysis catheters, urinary catheters, urinary catheters, feeding tubes, and tracheostomies. The policy also directed that high-risk care activities included dressing, bathing, showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use of a device, or wound care. The policy also identified that residents of the facility on EBP would have special precaution notes in their care profile and would be identified by a bright pink colored dot next to their name outside of their room door.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one resident of two residents (Resident #1) reviewed for pressure wounds, the facility failed to ensure care was provide timely. The findings include: Record review identified Person #1 was Resident #1's emergency contact. Resident #1 was admitted with diagnoses that included status post stroke with decreased movement on the right side. A nursing admission evaluation dated 9/26/2024 identified Resident #1 was alert and oriented, was a very high risk for pressure ulcer development and had blanchable redness on the sacrum, coccyx and groin area, and was dependent for transfers and did not walk. Physician note dated 9/26/2024 identified Resident #1 was aphasic (difficulty speaking) and followed commands. The Resident Care Plan dated (RCP) dated 9/27/2024 identified Resident #1 was dependent for toileting, ADLs, and had a potential for skin breakdown. Interventions directed to turn and reposition every two (2) to three (3) as tolerated by the resident and skin checks with care. Record review identified Resident #1 received incontinent care at 10:09 AM on 10/1/2024. A nursing note dated 10/1/2024 at 1:30 PM identified Resident #1 was out to a medical appointment accompanied by a family member. A nursing note dated 10/1/2024 at 5:00 PM identified Resident #1 had returned from a medical appointment. A facility grievance form dated 10/1/2024 at 8:54 PM identified Person #1 complained that incontinent care was not provided in a timely manner. Resident #1 was out for an appointment and care was provided after supper. The form stated Resident #1 had developed a red bottom. Interview with NA #1 and review of her written statement on 10/22/2024 at 11:50 AM identified she worked 3 to 11 PM on 10/1/2024 and she was assigned to care for Resident #1. Resident #1 had returned from a medical appointment and was in his/her wheelchair when she fed Resident #1 around 5:30 PM. NA #1 stated she did not check Resident #1 for incontinence prior to feeding him/her and stated Resident #1 did not express any concerns when she fed him/her. NA #1 stated after feeding Resident #1, she left him/her in the wheelchair and proceeded to provide care for other residents on her assignment. NA #1 stated she did not return to check on Resident #1 until she entered Resident #1's room about 8 PM to provide care. NA #1 stated she had not provided any care for Resident #1 prior to 8 PM, and Person #1 voiced concerns about the resident's care and Person #1 left the room to speak with the RN #2/supervisor. NA #1 stated she should have check Resident #1 for incontinence when Resident #1 returned from the appointment, when she fed him/her, or at least every two (2) hours, and stated she did not provide the care because she was very busy that evening. Interview with RN #1 identified that he was the charge nurse on 10/1/2024 during the 3 to 11 PM shift. RN #1 stated about 7:30 PM, Person #1 expressed that Resident #1 was being ignored and requested care for Resident #1. RN #1 then directed NA #1 to provide care. Further RN #1 stated he assessed Resident #1's skin on 10/2/2024 and identified a moisture associated skin damage (MASD) area on the sacrum and coccyx area. Interview with RN #2, nursing supervisor, identified on 10/1/2024 about 8 or 8:30 PM, Person #1 came stated Resident #1 needed care and had been ignored since returning from an appointment earlier in the shift. RN #2 stated she went to Resident #1's room, observed NA #1 in the room and Resident #1 was in his/her wheelchair, dressed, appeared messy, leaning to the right with no visible soiling or wetness. She assisted NA #1 transfer Resident #1, provide incontinent care, noted Resident #1 was incontinence of a large bowel movement, and his/her clothing was not wet. RN #2 noted that his/her sacrum was reddened with intact skin, and she assisted NA #1 to shower Resident #1. RN #2 stated NA #1 should have checked Resident #1 for incontinence care upon return to the facility and then every two (2) to three (3) and she initiated the grievance in response to Person #1's concern. Interview with the DON on 10/22/2024 at 1:30 PM identified that she expected NA #1 to check Resident #1 for incontinence for when he/she returned from the appointment at 4:00 PM and then every two (2) to three (3) hours throughout the shift. The DON stated she did not know why NA #1 did not provide the care. Subsequent to the incident, the DON stated a physician order was entered for Resident #1 to provide every 2-hour incontinent care. Facility documentation review identified staff education and audits were initiated on 10/7/2024. Education included providing incontinent care timely, and prior to leaving and upon return from appointments. A QAPI meeting was held on 10/10/2024. Based on review of facility documentation, past non-compliance was identified as of 10/10/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 3 of 6 residents (Resident #48, 52 and 89) reviewed for dining, the facility failed to provide a dignified dining experience. The findings include: 1. Resident #48's diagnosis included Alzheimer's disease, dysphagia and feeding difficulties. A Resident Care Plan dated 1/6/23 identified Resident #48 was at risk for an activities of daily living (ADL) self-care deficit secondary to dementia and decreased mobility. Interventions included to provide assistance of one for completion of meals with verbal cues and Resident #48 was non-ambulatory. The Quarterly Minimum Data Sheet (MDS) assessment dated [DATE] identified Resident #48 was severely cognitively impaired and required extensive assistance with two staff for bed mobility, transfers and toilet use. The MDS further identified Resident #48 required extensive assistance with two staff for dressing, personal hygiene and required limited assistance of one person assistance for eating. Observation of dining (breakfast) in the fourth floor Dining Room on 1/30/23 at 8:57 AM identified Resident #48 was seated at the same table as Resident #29. Resident #29 was noted to have a meal tray in front of him/her and was being fed by a Nurse Aide (NA) and there was no meal tray present for Resident #48. Resident #48 was provided a meal tray at 9:08 AM (11 minutes after Resident #29 was observed being fed), the meal tray was set up by NA #5 and NA #5 began feeding Resident #48. 2. Resident #52's diagnosis included cerebral infarction, hemiplegia and dementia. The Quarterly Minimum Data Sheet (MDS) assessment dated [DATE] identified Resident #52 was severely cognitively impaired and required extensive assistance of one with dressing and personal hygiene. The MDS further identified Resident #52 required assistance with one for bed mobility, transfers and toilet use. MDS additionally identified Resident #52 was independent with eating after being set up. A Resident Care Plan dated 12/8/22 identified Resident #52 was at risk for impaired cognitive function related to dementia. Interventions included to encourage making choices/decisions regarding activities of daily living (ADL), instruct one task, idea, question or command at a time and to cue, reorient as needed. Observation of dining (breakfast) in the fourth floor Dining Room on 1/30/23 at 9:02 AM identified Resident #52 was sitting at the same table as Resident #26. NA #2 was observed to provide Resident #26 a meal tray at 9:02 AM. Resident #52 was not provided a meal tray and was observed reaching for food from Resident #26's meal tray at 9:06 AM. Although Resident #52 continued reaching for Resident #26's food NA #2 continued to passing breakfast trays to other residents in the Dining Room. Additionally Resident #52 was observed to take and eat a piece of french toast from Resident #26's tray. Resident #52 was re-directed by NA #2, provided coffee, but not provided a meal tray until 9:10 AM (8 minutes after Resident #26 received his/her breakfast meal). Interview with NA #2 on 2/2/23 at 9:34 AM identified that she was trained and aware that residents at the same table should be served at the same time but didn't serve them at the same time because the other NA was in the hall passing trays and that the other NAs in the Dining Room were new. Interview with the DNS on 2/1/23 at 1:00 PM identified although there was not a written facility policy on dining, residents at the same table should be served at the same time. 3. Resident #89 was admitted to the facility with diagnoses that included chronic obstructive pulmonary disease, oropharyngeal phase dysphasia, dysphasia oral phase, and gastro-esophageal reflux disease. The quarterly MDS dated [DATE] identified Resident #89 had intact cognition, was occasionally incontinent of bowel and bladder and required extensive assistance with transfers, dressing, toilet use and personal hygiene. Additionally, Resident #89 was on a mechanically altered diet and was a set up for meals. The care plan dated 12/8/22 identified the resident was incontinent at times. Interventions included to ensure the resident has an unobstructed path to the bathroom. Observations on 1/30/23 at 12:34 PM identified NA #8 brought in Resident #89's meal tray and placed it on the overbed table. Resident #89 was sitting up in at 45-degree angle in bed with a urinal on the left side rail at the same height as the meal tray. The meal tray was positioned backwards with the desert and coffee nearest the resident and the main meal and silverware furthest from the resident. NA #8 did not offer to open any items on the tray, did not move or empty the urinal, did not reposition Resident #89 and did not raise the head of the bed. Interview with the ADNS on 1/30/23 at 12:40 PM indicated because Resident #89's care plan indicated to maintain aspiration precaution, the resident should not be at a 45-degree angle and should be at a 90-degree angle for meals. The ADNS noted the meal tray was backwards and noted she would turn it around facing the resident. The ADNS noted the nurse aide did not set up the meal tray for the resident. Subsequent to surveyor inquiry, the ADNS called for a nurse aide to reposition and boost the resident up in the bed and elevated the head of the bed to a 90-degree angle. The ADNS replaced the overbed table with the meal tray and continued to offer to set the meal tray up. The ADNS indicated Resident #89's urinal had urine in it and needed to be emptied and rinsed out. The ADNS before leaving the room emptied the urinal and rinsed it out. Review of the Residents' [NAME] of Rights identified that residents have the right to be treated with consideration, respect, and full recognition of your dignity and individuality. Additionally, have the right to receive quality care and services. Although requested, a facility policy for use of urinals was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #97) reviewed for resident rights, the facility failed to ensure the resident and/or resident's representative were invited to participate in the interdisciplinary care plan meetings. The findings include: Resident #89 was admitted to the facility on [DATE] with diagnoses that included diabetes, diabetic neuropathy, and heart failure. The comprehensive care plan record of team meetings indicated that meetings were held on 12/14/21, 5/17/22 (5 months later), 9/15/22 (4 months later), and 1/26/23 (4 months later). Resident #97 nor the resident representative signed the forms as having attended the meetings. The quarterly MDS dated [DATE] identified Resident #97 had moderately impaired cognition and required extensive assistance for bed mobility, dressing, toileting, and personal hygiene. The care plan dated 1/26/23 identified the resident was independent for meeting emotional, intellectual, physical, and social needs. Interventions included to provide assistance and escort the resident to activities. The social worker progress note for the resident care conference dated 1/26/23 identified that Resident #97 was stable for the last quarter and was alert and aware with some forgetfulness. An interview with Resident #97 on 1/30/23 at 10:10 AM indicated he/she was admitted to the facility about 2 years ago and had not been invited to or attended any interdisciplinary care plan meetings to discuss his/her plan of care. Resident #97 indicated he/she was never invited to attend any care planning meetings and if his/her spouse was aware would have attended. Resident #97 indicated if he was invited, he/she would have gotten out of bed to attend. Resident #97 indicated no one had offered to do the meeting in his/her room because he/she would prefer to do that if it was possible. Resident #97 indicated he/she depends on the staff to get him/her out of bed. Resident #97 indicated he/she would get out of bed to go to the meeting and his/her spouse would attend because he/she visits frequently. An interview with SW #2 on 2/1/23 at 12:41 PM noted the resident care conferences were required to be held every 90 day and additionally if a family asks for an interim meeting for the long-term residents. SW #2 indicated the MDS coordinator, LPN #5, was responsible to schedule the care conferences with the dates and times for all the care conferences. SW #2 indicated although it has not been assigned or established, she felt it was the MDS coordinator who was responsible to invite the resident and bring the resident to the meetings. SW #2 indicated she did not know how the resident is invited. SW #2 indicated Resident #97 has good days and some days are clearer than others, and Resident #97 definitely should attend the conferences if he/she wants to and will get out of bed. SW #2 indicated Resident #97 had a conference on 12/14/21 and the next resident care conference was 5 months later on 5/10/22, then the next one was 4 months later on 9/15/22, and the last one was 4 months later on 1/26/23. SW #2 indicated she just goes by the schedule given to her by the MDS Coordinator and she does not track the schedule to make sure the meetings were held every 3 months. SW #1 indicated she does not go to the resident's room the day of the meetings to invite the residents because she thought LPN #5 was responsible to do that. An interview with MDS coordinator LPN #5 on 2/1/23 at 1:05 PM indicated she was responsible to schedule the resident care conferences on a quarterly basis. LPN #5 noted she creates the schedule and gives it to the evening receptionist to mail out the letter to the families notifying them of the meetings. LPN #5 indicated the receptionist was responsible to mail the letters/invites to the person listed as the emergency person, responsible party#1, or the person listed as Resident care person. LPN #5 indicated she makes the calendar the month before. LPN #5 noted she did not know if the receptionist sends the letter to the resident representatives or to Resident #97. LPN #5 indicated it was not assigned to anyone to notify the residents of the care conference and she did not know who was responsible on the day of the care conference to invite the resident. LPN #5 indicated if she sees the resident in the hallway then she will ask the resident to attend. LPN #5 indicated Resident #97 does not get out of bed and his/her spouse was disabled so he/she was unable to attend. LPN #5 indicated Resident #97 can hold a good conversation and he/she can make his/her needs known. LPN #5 indicated Resident #97 should be invited to attend the interdisciplinary care conferences and would be able to participate. Review of the resident care conference sign in form for Resident #97, LPN #5 noted on the form there was a spot that indicated resident/designee was invited to the meeting but could not indicate if it was the resident or the designee that was invited because neither was circled on the form. LPN #5 indicated no one had instructed for her to circle who was invited, and she did not know for Resident #97 who was invited. LPN #5 indicated she did not know why the resident care conferences and the MDS were not done quarterly, every 3 months. LPN #5 indicated staff meet in the dining area and not in the resident's room. LPN #5 indicated Resident #97 had never requested to have the meeting in his/her room. LPN #5 does not recall if she has offered to do the care conference in the room. LPN #5 indicated SW #2 has a lot more communication with the residents than she does. LPN #5 indicated SW #2 does follow up with him as far as she was aware. An interview with Director of MDS, RN #5, on 2/1/23 at 1:24 PM indicated the resident care conferences are to be held every quarter, every 90 days. RN #5 indicated based on the documentation Resident #97 had an interdisciplinary care conference meetings every 4-5 months not every 90 days as required. RN #5 indicated Resident #97 should have been invited to the meeting at the time of the meeting and he/she could have attended. RN #5 indicated the scare conference can be held in the resident's room if the resident does not want to get out of bed but wants to participate. RN #5 indicated the resident or representative if had attended would sign in on the form. RN #5 indicated if the resident had refused to attend the expectation was it would be documented. Review of the clinical record failed to reflect Resident #97 had refused to attend. RN #5 indicated the social worker was responsible to ask the resident if they want to attend on the day and at the time of the meeting. Review of Resident [NAME] of Rights identified the resident had the right to participate in planning their own care and treatment, to identify individuals to be included in the care planning process, to be fully informed of the care to be provided and the caregivers who will be providing the care. Although requested a policy for resident interdisciplinary care meetings was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #89) reviewed for positioning, the facility failed to ensure the resident was positioned for meals to meet the resident's needs. The findings include: Resident #89 was admitted to the facility with diagnoses that included chronic obstructive pulmonary disease, oropharyngeal phase dysphasia, dysphasia oral phase, and gastro-esophageal reflux disease. A speech therapy evaluation and treatment plan dated 8/20/20 identified Resident #89 initially had a mild delay in mastication was slow but functional and occasionally a delay throat clearing. Resident #89 was educated to use compulsory strategies of safe swallowing with small bites, slow rate, alternating solids with liquids. Discharge recommendations included Resident #89 was to use and follow strategies and maneuvers during oral intake with general swallowing techniques and precautions upright position during meals and upright posture for 30 minutes after meals. Resident #89 requires occasional supervision. The quarterly MDS dated [DATE] identified Resident #89 had intact cognition and was on a mechanically altered diet with required set up for meals. The care plan dated 12/8/22 identified a diagnosis of dysphasia. Interventions directed to maintain aspiration precautions keeping head of bed elevated at 90-degree angle. Observe for signs and symptoms of aspiration. Additionally, provide a mechanically soft high moisture diet with set up assistance by 1 staff. The APRN progress note dated 1/18/23 identified Resident #89 had oropharyngeal phase dysphagia. Interventions included to continue current level 3 mechanically altered diet with thin liquids. Monitor for difficulty swallowing and coughing during meals. Speech therapy consult as needed. Additionally, Resident #89 had diagnosis of gastro-esophageal reflux disease. Encourage out of bed to chair for meals and avoid lying down in bed for 30 minutes after meals. Observation on 1/30/23 at 9:31 AM identified Resident #89 was lying flat in bed with the bedside table parallel to bed. The breakfast tray was on the overbed table over the left upper bed rail at the head of bed and Resident #89 was had to reach to get the French toast off the tray. Resident #89 was lying flat while chewing the French toast. Resident #89 had a coffee cup with a lid and a straw sticking out of it in his/her left hand while lying flat and a banana in-between his/her leg. Observations on 1/30/23 at 12:34 PM identified NA #8 brought in Resident #89's meal tray and placed it on the overbed table. Resident #89 was sitting up in a 45-degree angle (semi upright) in bed with a urinal on the left side rail at the same height as the meal tray. The meal tray was backwards with the desert and coffee near the resident and the meal plate and silverware were the furthest away. NA #8 did not offer to open any items on the meal tray and did not empty the urinal. NA #8 did not reposition Resident #89 and did not raise the head of the bed. Interview with the ADNS on 1/30/23 at 12:40 PM indicated Resident #89 should not be at a 45 degree angle, and should be at a 90 degree angle for meals because Resident #89 was on aspiration precautions. The ADNS indicated the meal tray was backwards and that the meal had not been set up for the resident. The ADNS called for a nurse aide to reposition and boost the resident up in the bed and elevated the head of the bed to a 90-degree angle. The ADNS replaced the overbed table with the meal tray and continued to offer to set the meal tray up. Interview with Speech Language Pathologist #1 on 2/2/23 at 9:30 AM indicated Resident #89 had a diagnosis of oral pharyngeal dysphasia. ST #1 indicated the oral was a problem with chewing, mastication, and bolus formation. ST #1 noted the pharyngeal means a problem with the pharyngeal swallow from the oral cavity and throat portion, and has to do with coughing response while swallowing that could be a weakness. ST #1 indicated she had treated Resident #89 on admission and indicated the resident should be sitting upright when eating, the standard of 90 degrees, and stay upright for 30 minutes after eating especially since Resident #89 had a diagnosis of GERD. ST #1indicated some strategies for the resident included to have the resident sitting upright taking small size bites go slow do not talk while chewing with occasional supervision means 2 - 3 visual checks while eating by staff. ST #1 indicated Resident #89 was at greater risk for aspirating when lying down and was at greater risk if laying down any degree other than a 90-degree angle so as the degree goes down from 90 it puts him/her at greater risk for aspiration. Review of Dysphagia Management Policy directed to identify the signs and symptoms of swallowing difficulty and dysphasia and request rehabilitation services to perform dysphasia screen. Signs and symptoms of dysphasia include but are not limited to coughing, wet, garbled voice or gaging during and/or after eating or drinking, history of choking on food or liquids, prolonged feeding time, spitting out food, thrusting tongue, prolonged swallowing, collection of food in the mouth, regurgitation of food through the nose or mouth, excessive secretions while eating, and increased congestion during and after meals. Contact a physician for a speech consult. Develop and interdisciplinary, patient centered care plan for dysphasia management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy and interview for 2 of 3 residents (Resident #41 and 82) reviewed for falls, the facility failed to provide the necessary supervision and assistive devices to prevent accidents. The findings include: 1. Resident #41 was admitted to the facility on [DATE] with diagnoses that included heart failure, lymphedema and chronic ischemic heart disease. A Fall Evaluation dated 1/13/23 identified Resident #41 had a history of falls in the last month prior to admission and was at risk for falls. The care plan dated 1/14/23 identified the resident had a self-care performance deficit. Interventions included to provide assistance of 1 with transfers and toileting with use of rolling walker. Further, the resident was at risk for falls related to bilateral lower extremity edema and generalized weakness. Interventions included to ensure appropriate footwear (non-skid socks, non-slip soles on shoes/sneakers) when ambulating or mobilizing in wheelchair. Physician's orders dated 1/16/23 directed to transfer the resident with a rolling walker and assistance of 1, and to ambulate greater than 50 feet with rolling walker and assistance of 1 twice daily. The admission MDS dated [DATE] identified Resident #41 had intact cognition and required extensive 1 person assistance with transfers and ambulation, used a walker for mobility and received anticoagulant medication daily. A reportable event form dated 1/24/23 identified at 9:25AM, while transferring with a student nurse, Resident #41 lost his/her balance, fell, and hit his/her head on the dresser. Resident #41 sustained a laceration to the back of head and a skin tear to the left wrist. The resident was assessed by an APRN and RN with new orders to send to the emergency department (ED) for evaluation. Pressure was applied to the head, and left wrist was cleansed and dressed. Resident #41 returned from the hospital with 5 staples to the back of head and orders to remove the staples in 7 days. The report identified the resident's care plan was updated to reflect education and competencies with student nurses and the student instructor was to monitor all transfers with students. Additionally, the care plan was updated to include monitoring resident for pain and monitoring back of head for signs and symptoms of infection. The [NAME] Report (resident care card) as of 1/24/23 identified resident required assistance of 1 with rolling walker for transfers and ambulation. Interview with LPN #3 (unit manager) on 1/31/23 at 2:00 PM identified that the nurse aides were aware of the expectation to always use their gait belts when assisting with resident transfers and ambulation. Additionally, LPN #3 identified nurse aides wear their gait belts around their waists, so they are always easily accessible. Interview with RN #3, Nurse Instructor, on 2/1/23 at 12:20 PM identified that this was Student Nurse #1's third day in the facility. RN #3 identified although Student Nurse #1 was signed off on all her skills including resident transfers and ambulation, she likes the senior student, who was Student Nurse #2 that day (1/24/23), to accompany and assist newer students when they are transferring or ambulating residents as an extra safety measure. RN #3 identified she had been standing at the doorway of Resident #41's room and witnessed Student Nurse #1 assisting the resident who was ambulating with a rolling walker. RN #3 (nurse instructor) identified while the resident was ambulating with a walker and turning to his/her right, it appeared the resident bumped the walker on the closet and somehow lost his/her balance and fell backwards and to the left, hitting his/her head on the closet or heater. RN #3 identified Student Nurse #1 knew she was supposed to have and use her gait belt whenever she was with a resident. Additionally, because there was such little space where the student was walking with the resident, Student Nurse #1 should have first moved the resident while still in wheelchair, over to the area in between the beds, where there was much more space, and then assisted the resident up for ambulation, utilizing the gait belt as well. RN #3 identified had the student done this first, there would have been sufficient space to accommodate both students and the resident. RN #3 identified had the student used a gait belt she may not have been able to prevent the fall but may have been able to break the fall and lessen the potential for injury. Additionally, RN #3 indicated had the students moved the resident while still sitting in the wheelchair, it would have allowed more space for all of them, and the fall most likely would have been prevented. Interview with the DNS on 2/1/23 at 12:45PM identified the facility's nurse aides have always been instructed and are expected to use a gait belt when assisting with resident transfers and ambulation and the students who come into the facility, should be using them as well for fall prevention. Subsequent to this incident, the DNS identified they initiated a QAPI to ensure nursing students who come into the facility have evidence of skills they have been educated on and completed competencies for, and also for instructors to monitor all resident transfers by students. Attempts to contact Student Nurse #2 (senior student) were unsuccessful. Review of the facility's Transfer Technique policy identified the purpose is to ensure that all resident transfers are completed in a safe and efficient manner for both the resident and the person and/or persons performing the transfer. Procedure includes prior to transferring the resident, the staff member will check the transfer status on the [NAME]/assignment to determine the proper transfer technique for the resident. Additionally, to prepare for transfer by ensuring there is enough space to transfer the resident in a safe manner. Although requested, a gait belt policy was not provided. 2. Resident #82 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, hearing loss, abnormalities of gait and mobility, and vertigo. The Fall Evaluation form dated 10/1/22 indicated Resident #82 was a high fall risk, and Resident #82 had fallen at least 1 - 2 times in the last 6 months. Resident #82 has problems with loss of balance while standing and balance problems when walking. Resident #82 had prior falls on 9/6/22 and 10/1/22 with intervention to ensure appropriate footwear of non-skid socks, or non-slip soles on shoes or sneakers when ambulating. The care plan dated 10/18/22 identified the resident was at risk for falls related to dementia, limited mobility, incontinence, vertigo, and psychotropic medication use. Interventions included to have appropriate footwear such as nonskid socks, non-slip soles on shoes or sneakers when ambulating. The quarterly MDS dated [DATE] identified Resident #82 had severely impaired cognition, was occasionally incontinent of bowel and bladder and required extensive assistance with 1 person with dressing, bed mobility, transfers, toileting, and personal hygiene. The APRN progress note dated 12/23/22 at 11:17 AM indicated Resident #82 was suspected to have Covid-19 and was walking less lately and can get to bathroom or wheelchair with help. A reportable event form dated 1/23/23 at 1:00 PM identified the resident was observed in prone position (face down) next to his/her bed with a laceration to the right eyebrow. The nurse's note dated 1/23/23 at 1:25 PM identified that at 12:50 PM the resident was noted by APRN laying on floor face down in his/her room. This writer was called to assess, upon entrance EMT's were with resident. Resident #82 had a 5.0 cm laceration to right eyebrow with moderate amount of bleeding. Resident #82 was transferred to stretcher moaning and crying. Resident #82 at time of fall was noted to have gripper socks on, but upside down so gripper portion was on top of the foot, not the bottom. Resident #82 was noted to be incontinent of stool at time of fall. The care plan was updated on 1/23/23 to check for proper placement and size of gripper socks and orthostatic blood pressures daily times 3 days. The hospital Discharge summary dated [DATE] at 5:51 PM indicated Resident #82 had a right nondisplaced orbital fracture with recommendations to follow up with ophthalmology. Additionally, Dermabond and steri-strips were applied to the laceration on the right forehead. Resident #82 required Haldol 5 mg IM and Ativan 1 mg IV while in emergency room. The nurse's note dated 1/23/23 at 10:41 PM indicated Resident #82 had returned from the hospital at 8:45 PM with a right orbital fracture and a urinary tract infection. The nurses note dated 1/24/23 at 2:27 PM noted Resident #82 had a laceration to right eyebrow with surrounding bruising measuring 4.5 cm x 6.0 cm around the periorbital held together with Dermabond and 5 steri-strips. Laceration to right temple 3.5 cm with sutures in place. Observations on 1/30/23 at 10:30 AM identified Resident #82 was dressed sitting in a bedside chair with light blue gripper socks on with gripper on the top and bottom of slipper. Resident #82 had a laceration to the right lateral forehead with dried dark blood noted and the right eye had a faded yellow pale green color around the right eye. Observation on 1/31/23 at 10:00 AM Resident #82 was ambulating independently in his/her room by the dresser dressed in aqua blue gripper socks with gripper on the sole of the foot not on top. Observation on 2/1/23 at 11:00 AM Resident #82 noted to be wearing the aqua colored gripper socks dressed sitting in the bedside chair. Observation on 2/2/23 at 10:30 AM Resident #82 was sitting in bedside chair dressed wearing socks and sneakers. Interview with the Director of Dietary on 1/30/23 at 2:30 PM indicated she was the first to find Resident #82 on the floor. The Director of Dietary indicated she was on the elevator and could see feet with green gripper socks on facing the floor not pointing towards the celling (not on the bottom of the feet). Director of Dietary indicated she got off the elevator and went to residents room and saw resident lying face down on the floor with blood around his/her head. The Director of Dietary indicated she called for help and two nursing assistants came to the room, but there was no nurse on the unit. The Director of Dietary indicated when the nursing assistants came, she went to the desk to call the supervisor. Interview NA #6 on 2/1/23 at 10:24 AM indicated there are different sizes of gripper socks and she can use any color as a standard gripper sock for any resident except for the dark blue that was extra wide extra-large which was only for residents with a lot of edema. NA #6 indicated at the time Resident #82 fell, she was in the dining room. NA #6 indicated she heard the Director of Dietary call for help that someone was on the floor, so she went to the room. NA #6 noted she stayed with the resident until the charge nurse and the APRN came off the elevator to assess the resident. Interview with NA #7 on 2/1/23 at 10:41 AM indicated she had Resident #82 the morning of the fall and was assigned to the resident full time. NA #7 indicated everyday usually Resident #82 was washed and dressed around breakfast time. NA #7 indicated Resident #82 was totally dependent on staff to wash, dress, toilet, provide incontinent care, and personal hygiene. NA #7 indicated Resident #82 could not put his/her socks or shoes on by him/herself. NA #7 indicated just before lunch she attempted to get Resident #82 out of bed and dressed but Resident #82 indicated he/she was tired. NA #7 noted Resident #82 was upside down in the bed with his/her head at the foot of the bed. NA #7 indicated at the time of the fall Resident #82 was dressed in a johnny, a brief that was wet and had stool, and aqua gripper socks which only had one gripper surface side. NA #7 indicated she could not recall if the gripper side was on the bottom or top of resident's feet. NA #7 indicated that was how she knew the resident did not roll off the bed because she was in the opposite direction when found on the floor. Interview with the DNS on 2/01/23 at 2:48 PM indicated Resident #82 could have rolled out of bed or had a syncope episode. The DNS indicated the ADNS had put in the intervention to check for proper placement of the gripper socks and size of the gripper socks every shift. The DNS noted Resident #82 already had the intervention to wear gripper socks prior to the fall but the problem was the gripper part of the sock was on the top of the resident's feet and there was no gripper material on the bottom of the feet. The DNS indicated Resident #82 was independent with ambulation and if fatigued required assist of 1. The DNS indicated she did not know if it was the day, night or the evening nursing assistant prior to the fall had put the gripper socks on Resident #82. The DNS indicated the resident was assist of 1 for all actives of daily living for getting dressed. The DNS indicated the gripper socks were to be with the gripper side down on the bottom of the resident feet to prevent falls. Review of Fall Prevention Program Policy identified the purpose was to reduce the incidence of falls for residents identified at high risk. Residents at high risk for falls will have interventions initiated to prevent falls. Develop interventions and incorporate them into the resident's care plan. Interventions may include assist and provide staff supervision with activities of daily living, assess for appropriate footwear, and follow up as necessary, and toileting program. Include fall prevention measures on the nursing assistant care [NAME] and assignment. Prevention of reoccurrence evaluate interventions and develop further interventions as necessary. Review of facility Accident and Incident Policy and Procedures Policy identified it is the staff responsibility to report incidents and accidents that occur at the facility. Occurrences are investigated in a timely manner and preventative measures initiated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of the clinical record review and facility policy for 1 of 1 sampled residents (Resident #2) reviewed for receiving a hemolytic treatment, the facility failed to monitor intake totals for a resident who was exceeding a physician ordered fluid restriction. Resident #2's diagnoses included end stage renal disease, heart failure, diabetes and Alzheimer's disease. Physician orders dated 9/1/22 (through 2/2/23) directed a fluid restriction of 800 milliliters (ml) per day and hemodialysis 3 times per week at a dialysis center. The Quarterly Minimum Data Sheet (MDS) assessment dated [DATE] identified Resident #2 was severely cognitively impaired and required one person assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. The MDS further identified Resident #2 was independent with eating after being set up and received dialysis. A Resident Care Plan dated 12/15/22 identified Resident #2 was at risk for a nutritional problem secondary to end stage renal disease, dementia, malnutrition, and hemodialysis. Interventions included to monitor intake and record every meal, Dietitian to evaluate and make diet change recommendations as needed, weekly weights and post dialysis weights. Intake and Output Report documentation identified in November 2022, Resident #2 exceeded the 800 ml fluid restriction 12 of 30 days, (for 12 days, total intake ranged from 920 ml to 1200 ml in a 24 hour period), in December 2022, Resident #2 exceeded the fluid restriction 9 of 31 days, (for 9 days, total intake ranged from 920 ml to 1320 ml in a 24 hour period). Additionally, in January 2023, Resident #2 exceeded the 800 ml fluid restriction 5 of 31 days (for 5 days, total intake ranged from 960 ml to 1320 ml in a 24 hour period). Communication log between the facility and the dialysis center dated 1/25/23 indicated Resident #2 had a weight gain between treatments over 4 times in the past month and to please evaluate fluid intake. On 2/1/23 at 10:03 AM interview with LPN #1 identified that the Nurse Aides record fluid intake but was unable to identify where the intake was documented. On 2/1/23 at 1:20 PM interview with the ADNS identified a system glitch and that the fluids consumed at meals was not accurate. Additionally, she indicated that it was unclear who was monitoring 24 hour intake totals and identified the facility doesn't follow a strict intake monitoring policy. She indicated residents are evaluated/assessed for edema, lung sounds and weight changes if they consistently exceed the fluid restriction, however the facility does not have a written policy for exceeding fluid intake. On 2/2/23 at 9:25 AM interview with the Dietitian identified that she was not aware that Resident #2 was exceeding his/her fluid intake restriction on several occasions. Additionally, she indicated she would begin to monitor fluid intake in the future. Facility policy on Intake and Output dated 9/28/22 identified the software documentation system calculates the total fluid intake and output daily and can be reviewed daily by assessing the look back report for each resident. Additionally, the policy indicated that the unit manager/supervisor will monitor fluid intake and/or output and report any concerns at morning meeting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident # 89) reviewed for dental services, the facility failed to ensure an oral surgeon referral was arranged in a timely manner. The findings include: Resident #89 was admitted to the facility with diagnoses that included oropharyngeal phase dysphasia, dysphasia oral phase, and gastro-esophageal reflux disease. A Dentist progress note dated 10/17/21 at 7:09 PM identified x-rays were taken and identified Resident #89 was missing the following teeth #1, 4, 5, 7, 9, 10, 13, 14, 16, 19, 22, and 29 - 32. Additionally, coronal portions of teeth #3, 6, 8, 18, 20, 21, 26, and #28. Extensive decay on tooth #24. Removal is recommended. Referral to an oral surgeon may be necessary depending on which teeth become active. The quarterly MDS dated [DATE] identified Resident #89 had intact cognition, was on a mechanically altered diet and was a set up for meals. The Dental Consultation Request Form, in the facility dental communication book identified on 1/31/22 ( a year ago) a nurse placed Resident #89 on the dental list to be seen for evaluation for the rest of his/her teeth to be pulled out. A dental hygienist progress note dated 2/7/22 at 3:58 PM identified resident was seen at the request of nursing for evaluation to have the rest of resident's teeth removed. The resident reported that he/she wanted all his/her teeth pulled out because the sharp ones bother his/her lower lip. The resident pointed to remaining root tips #6 and #8 and noted those are the worst. Exam identified multiple fractured teeth and root tips present. Exam shows area on lower lip was slightly red at #26 and #27 and resident reported that was where it gets sore. A dental hygienist progress note dated 3/18/22 at 2:52 PM identified the resident's oral hygiene was poor with generalized heavy plaque deposits present. The resident reports that he/she wants all teeth taken out. Dentist was notified of today's findings. A dental note dated 4/29/22 identified Resident #89 needed a referral at his/her request for removal of all remaining teeth with an oral surgeon. Should resident decide to have dentures fabricated in the future please prep alveolar ridges for denture insertion. The care plan dated 12/8/22 identified a Resident #89 had a nutritional problem with broken and missing teeth. Interventions included to provide a mechanically soft high moisture diet with set up assistance by 1 staff. Interview with Resident #89 on 1/30/23 at 9:31 AM indicated he/she was missing his/her front teeth on top and has broken and missing front teeth on the bottom. Resident #89 indicated he/she bites the inside his/her mouth, tongue, and lip while eating and it hurts when this occurs. Resident #89 indicated he/she had informed SW #2 about 3 weeks ago that he/she wanted to see a dentist to remove all his/her teeth. Additionally, Resident #89 indicated he had told the nurses but could not recall who. Observation of Resident #89's mouth on 1/30/23 at 9:45 AM noted many missing and broken teeth. Interview with SW #2 on 1/30/23 at 1:03 PM indicated Resident #89 had not informed her that he/she wanted to see a dentist to have all teeth removed for dentures. SW #2 indicated if she was aware she would have informed nursing and made sure resident was added to the dental list. Interview with the ADNS on 1/30/23 at 1:15 PM indicated she was not aware that Resident #89 wanted to see the dentist to have all his/her teeth removed. Interview with the ADNS on 1/30/23 at 2:00 PM indicated nursing was aware Resident #89 wanted all his/her teeth removed and had last been seen by the hygienist on 12/19/22 and now has an oral surgeon appointment on 2/14/23 at 1:45 PM. The social worker note dated 1/30/23 at 4:24 PM noted Resident #89 had indicated he had requested to see a dentist in order to remove his/her remaining teeth that are causing some concern. SW #2 spoke with the ADNS who reported an appointment was made and wheel chair transportation was arranged. SW #2 educated resident to eat and drink with head of bed elevated to help prevent aspiration. An interview with NA #7 on 2/01/23 at 8:50 AM indicated Resident #89 a while ago had complained he/she wanted his/her teeth removed. NA #7 noted resident had seen the dentist, but she did not know if anything was done. NA #7 indicated it happened a while ago but could not indicated if it was weeks, months, or a year ago. An interview with Medical Records Person #1 on 2/01/23 at 9:08 AM indicated she does all the calling/scheduling for consents for dental. Medical Records Person #1 indicated she receives a phone call from the nurses if a resident needs to be added to the dental list and she has the dental consult book in her office. Medical Records Person #1 indicated when the dentist comes in, she looks at the list of who needs to be seen. Medical Records Person #1 indicated the dentist and hygienist's document directly into the resident's electronical medical record. Medical Records Person #1 indicated no one follows up to review the dentist or hygienist notes, she depends on them to verbally tell her if someone needs a referral or follow up appointment. Medical Records Person #1 indicated the dentist sometimes will go to the unit and tell the nurse. Interview with DMD #2 on 2/01/23 at 11:02 AM indicated Resident #89 was referred, including a letter dated 4/29/22 to an oral surgeon. DMD #2 indicated Hygienist #1 had notified Medical Records Person #1 and SW #2 the same day that there was a referral made for an oral surgeon and that the letter was with the dental x-rays under the miscellaneous folder in the electronic medical record. DMD #2 indicated her expectation was the arrangements would have been made within a week or 2 but the appointment may not have been for 6 to 8 weeks. DMD #2 indicated her expectation was the facility would have reach out to her and notify her if the facility was not able to make an appointment. DMD #2 indicated if the facility had a problem scheduling an appointment, she would have made some phone calls to get it done. DMD #2 indicated she was not notified that the Resident #89 never had the appointment made with the oral surgeon since 4/29/22. Interview with Hygienist #1 on 2/01/23 at 11:05 AM indicated on 4/29/22 when DMD #2 had written the referral for the oral surgeon, she remembered having a verbal conversation with Medical Records Person #1 and SW #2 the same day, and the x-rays were in the electronic medical record. Hygienist #1 indicated the floor nurses are aware of who they see but they do not provide a list of who was seen to anyone. Interview with Medical Records Person #1 on 2/1/23 at 11:31 AM she was not aware of the referral to the oral surgeon until after surveyor inquiry and identified if she was aware of a referral, she could get it booked the same day. Interview with SW #2 on 2/01/23 at 12:39 PM indicated that she recalls something regarding Resident #89's teeth but does not recall anyone coming to her to inform her regarding a referral for an oral surgeon. SW #2 indicated Resident #89 was is in discomfort and she was frustrated with the lack of communication. An interview with the DNS on 2/1/23 at 2:57 PM indicated sometimes the nurse would schedule the appointment or ask/notify Medical Records Person #1. The DNS indicated once Medical Records Person #1 was aware the appointment would be scheduled within a couple of days including the transportation. The DNS indicated the dentist does progress notes and for that day there was not a progress note, however, the dentist scanned in the referral letter. Interview and clinical record review with the DNS on 2/1/23 at 3:00 PM identified that there was a dental referral for an oral surgeon made on 4/29/22 and the appointment was not made until 1/30/23. Review of Dental Services Policy identified the facility is responsible to provide assistance for dental care upon resident's/resident's representative's request. The facility will also assist with providing transportation as needed. In the event there is a delay in obtaining a dental appointment, the facility will document the reason for the delay and what measures were in place to ensure that the resident was capable of eating and drinking adequately.

Based on observation of the Dietary Department and staff interview, the facility failed to ensure a trash receptacle was covered and not in the proximity of clean utensils. On 1/31/23 at 11:55 AM, during a walk-through inspection of the Dietary Department with the Food Service Director (FSD) identified a large gray plastic trash receptacle was observed being stored and partially exposed from under the clean side of a 3 bay sink counter. The trash receptacle had a liner, was uncovered, and approximately 2/3 full of garbage. Above the trash receptacle were several clean serving utensils drying on the 3 bay sink counter. Interview at that time with the FSD indicated the utensils on the counter were clean and identified the trash container should have been covered and in its proper location which was on the soiled side of the 3 bay sink (not on the clean side of the sink). Additionally, she identified it was the responsibility of all kitchen staff to maintain sanitary conditions and that the Dietary Aides were primarily responsible to clean the kitchen equipment. Additionally, the FSD indicated she did not know who moved the trash receptacle to the clean side of the sink. Subsequent to surveyor inquiry the trash can was covered and moved at the time of the inspection to the soiled side of the 3 bay sink. She also identified she would remind staff concerning sanitary conditions and the proper location and covering of the trash container.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and observation for 1 of 1 sampled resident (Resident #221) reviewed for environment, the facility failed to ensure Resident #221's call light was within reach. The findings include: Resident #221 was admitted to the facility 2/20/20 with diagnoses that included end stage renal disease, glaucoma, and gait abnormality. An admission Nursing assessment dated [DATE] identified Resident #221 was alert, oriented to person, place, time and situation. The Nursing Assessment further identified Resident #221 was verbally appropriate and had impaired ability to see in adequate light. A Resident Care Plan dated 2/20/20 identified an activities of daily living deficit with interventions that included to provide limited assistance for bathing, bed mobility, dressing, personal hygiene, and to utilize 2 1/4 side rails up for assistance and bed mobility. On 2/25/20 at 10:12 AM, a resident interview was attempted, but Resident #221 verbalized several times (in a very soft spoken voice) wanting to be put back to bed. Resident #221's call light was across the room on the bed and out of Resident's #221's reach. There was no portable bell in place. Resident #221's room was out of sight from the hallway, and was in a low traffic area. Surveyor notified staff who then assisted Resident #221 back to bed. Interview with LPN #2 on 2/25/20 identified she could not ascertain the staff member responsible for not placing the call light within reach because many staff members provided care. Resident #221 had been in the chair since breakfast, was toileted by the Nurse Aide, received rehabilitation therapy in the room, and medication was provided. Additionally, the LPN #2 identified the call light could not reach the resident from the proximity of Resident #221's chair. Facility policy regarding Nurse Aide Standard of Care identified to place the call light within reach when the resident is in the room and answer promptly as part of the routine care provided by NA's. Subsequent to surveyor inquiry, LPN #2 provided Resident #221 with a hand held portable metal bell.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #49) reviewed for dining, the facility failed to ensure timely assistance with the meal. The findings include: Resident #49 was admitted to the facility on [DATE] with diagnosis that included dementia, dysphagia, mood disorder and anxiety. Physician's order dated 10/11/19 (and currently in effect) identified aspiration precautions and supervision with all meals, small bites/sips, and remain upright to 90 degrees 30 minutes post meal. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #49 was moderately cognitively impaired, required extensive assistance of one for bed mobility, dressing, toilet use, and personal hygiene. Additionally, the MDS identified Resident #49 required limited assistance of one for eating, was receiving a mechanically altered diet, and had not had any significant weight loss. The Resident Care Plan dated 1/1/20 identified Resident #49 had an activities of daily living self-care deficit and required a Ground Level 2 textured diet, nectar thick consistency, and was on aspiration precautions requiring supervision with all meals. Interventions included to provide small bites /sips, remain upright to 90 degree angle with by mouth intake 30 min post intake, and monitor verbal cues from resident regarding no talking while eating. A Dietician note dated 2/10/20 identified Resident #49 lost 3 pounds, 3% over one month, lost 16 pounds, 13% over 180 days, and had a meal intake of 25% to 100%. Super cereal, house supplement of 120 ml was provided four times a day, and Remeron (an appetite stimulant) was started on 2/5/20. The quarterly MDS dated [DATE] identified Resident #49 had a severely impaired cognition, required assistance of one for eating, was receiving a mechanically altered diet, and had a 5% or more weight loss. Physicians order dated 2/14/20 identified ground diet for dysphagia Level 2, nectar consistency, extra moisture diet. The Nurse Aide (NA) care card for Resident #49 identified he/she should be supervised with all meals, offered small bites/sips, and remain upright for 30 minutes post meal. Constant observation of Resident #49 on 2/24/20 from 12:29 PM to 1:05 PM identified Resident #49 was in bed with the hot food lunch tray, left uncovered on his/her over bed table at waist level, within Resident #49's reach, with no staff providing supervision. Observation on 2/24/20 at 1:05 PM identified NA #1 entered Resident #49's room and stood at her bedside. NA #1 then proceeded to try and feed resident from the lunch tray and was able to feed small bites to the resident. NA #1 then removed Resident #49's food tray and left the room. Interview with NA #1 on 2/24/20 at 1:10 PM identified that she had arrived at the facility at 11:15 AM and was a per diem NA. NA #1 stated that she typically gets her assignment when she arrives on the unit, but the aides were very busy, and she did not look up the needs of her residents on the computer screen prior to assisting in the dining room. NA #1 identified that when she arrived to Resident #49's room, she was not aware Resident #49 was on aspiration precautions and that her food had been uncovered and within reach of the resident. Interview with NA #2 on 2/24/20 at 1:35 PM identified that all NA's were caring for Resident #49 because the NA assigned to Resident #49 had gone home sick. NA #2 stated that she had brought in Resident #49 food tray and began to feed her, but Resident #49 was not wanting to eat, so NA #2 left the room (with the meal tray in front of Resident #49's reach) and began to feed another resident. NA #2 further identified that she had thought someone would go into Resident #49's room soon after, but was not aware the food was left within reach and uncovered for over a half an hour. Interview with the DNS on 2/26/20 at 8:30 AM identified that she was aware of the events on 2/24/20 for Resident #49 and had begun in-servicing staff on appropriate dining experiences and proper infection control procedures. Resident #49 was left in bed, unattended, with his/her meal tray within reach until meal assistance was provided approximately 25 minutes later.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #49) reviewed for dining, the facility failed to ensure adequate supervision was provided during a meal for a resident with dysphagia. The findings include: Resident #49 was admitted to the facility on [DATE] with diagnosis that included dementia, dysphagia, mood disorder and anxiety. Physician's order dated 10/11/19 (and currently in effect) identified aspiration precautions and supervision with all meals, small bites/sips, and to remain upright to 90 degrees 30 minutes post meal. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #49 was moderately cognitively impaired, required extensive assistance of one for bed mobility, dressing, toilet use, and personal hygiene. Additionally, the MDS identified Resident #49 required limited assistance of one for eating, was receiving a mechanically altered diet, and had not had any significant weight loss. The Resident Care Plan dated 1/1/20 identified Resident #49 had an activities of daily living self-care deficit and required a Ground Level 2 textured diet, nectar thick consistency and was on aspiration precautions requiring supervision with all meals. Interventions included to provide small bites /sips, remain upright to 90 degree angle with by mouth intake 30 min post intake, and monitor verbal cues from resident regarding no talking while eating. A Dietician note dated 2/10/20 identified Resident #49 lost 3 pounds, 3% over one month, lost 16 pounds, 13% over 180 days, and had a meal intake of 25% to 100%. Super cereal, house supplement of 120 ml was provided four times a day, and Remeron (an appetite stimulant) was started on 2/5/20. The quarterly MDS dated [DATE] identified Resident #49 had a severely impaired cognition, required assistance of one for eating, was receiving a mechanically altered diet, and had a 5% or more weight loss. Physician's order dated 2/14/20 identified ground diet for dysphagia Level 2, nectar consistency, extra moisture diet. The NA care card for Resident #49 identified he/she should be supervised with all meals, offered small bites/sips, and remain upright for 30 minutes post meal. Constant observation of Resident #49 on 2/24/20 from 12:29 PM to 1:05 PM identified Resident #49 was in bed with the hot food lunch tray, left uncovered on his/her over bed table at waist level, within Resident #49's reach, with no staff providing supervision. Observation on 2/24/20 at 1:05 PM identified NA #1 entered Resident #49's room and stood at her bedside. NA #1 then proceeded to try and feed resident from the lunch tray and was able to feed small bites to the resident. NA #1 then removed Resident #49's food tray and left the room. Interview with NA #1 on 2/24/20 at 1:10 PM identified that she had arrived at the facility at 11:15 AM and was a per diem NA. NA #1 stated that she typically gets her assignment when she arrives on the unit, but the aides were very busy, and she did not look up the needs of her residents on the computer screen prior to assisting in the dining room. NA #1 identified that when she arrived to Resident #49's room, she was not aware Resident #49 was on aspiration precautions and that her food had been uncovered and within reach of the resident. Interview with NA #2 on 2/24/20 at 1:35 PM identified that all NA's were caring for Resident #49 because the NA assigned to Resident #49 had gone home sick. NA #2 stated that she had brought in Resident #49 food tray and began to feed her, but Resident #49 was not wanting to eat, so NA #2 left the room (with the meal tray in front of Resident #49's reach) and began to feed another resident. NA #2 further identified that she had thought someone would go into Resident #49's room soon after, but was not aware the food was left within reach and uncovered for over a half an hour. Interview with the DNS on 2/26/20 at 8:30 AM identified that she was aware of the events on 2/24/20 for Resident #49 and had begun in-servicing staff on appropriate dining experiences and proper infection control procedures. Facility aspiration policy identified that resident should be supervised while eating, fed in the most upright position and should not be fed in bed/eat in bed unless supervised Resident #49 was an aspiration risk, was left in bed, unattended, with his/her meal tray within reach until meal assistance was provided approximately 25 minutes later.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy and staff interview for 4 of 5 sampled residents (Resident #51, Resident #52, Resident #74 and Resident #80) reviewed for immunizations, the facility failed to ensure accurate immunization tracking and offer the appropriate pneumonia vaccines as appropriate. The findings include: On 2/27/20 at 10:11 AM, interview and review of pneumococcal immunizations with the Infection Control Nurse (ICN) identified the following: a. Resident #51 was admitted to the facility on [DATE]. On 2/25/20, a review of the electronic immunization status identified Resident #51 received a Pneumococcal 23 (PPSV23) on 6/19/19. On 2/27/20, documentation of Resident #51 receiving the PPSV 23 had been changed to Resident #51 receiving the Prevnar 13 on 6/19/19 (and not the PPSV 23). Interview with the ICN at that time identified that subsequent to surveyor inquiry regarding the Infection Control Program and prior to surveyor reviewing immunizations with the ICN, the facility identified that the incorrect Pneumococcal vaccine was documented in the electronic record and had been incorrect since 6/19/19. b. Resident #52 was admitted to the facility on [DATE]. The electronic immunization record identified Resident #52 received a Pneumococcal 23 vaccine on 11/11/14. Interview with the ICN at that time failed to identify Resident #52 was offered a Prevnar 13 vaccine since residing at the facility. Additionally, the ICN identified that consent for a Prevnar 13 vaccine was obtained on 2/26/20 when an audit was completed to prepare for the Infection Control survey review. c. Resident #74 was admitted to the facility on [DATE]. The electronic immunization record identified Resident #74 received Prevnar 13 on 11/1/12. Resident #74 was eligible to receive Pneumococcal 23 six to twelve months later, but the ICN identified Resident #74 was not offered the Pneumococcal 23. d. Resident #80 was admitted to the facility on [DATE]. On 2/25/20, a review of the electronic immunization status failed to identify any Pneumococcal vaccination dates. On 2/27/20, an electronic entry identified Resident #80 received a Pneumococcal 23 on 9/15/06 and Prevnar 13 on 4/29/15. The ICN identified that a call was placed to Resident #80's community physician on 2/27/20 to obtain dates of Pneumococcal vaccination. Interview with the ICN on 2/27/20 at 10:30 AM identified that she has been in the role of ICN since October 2019 and was unaware that she was to review Pneumococcal status for residents, and is subsequently in the process of auditing resident's immunization status. Facility policy for Pneumococcal Vaccination identified that all residents admitted will be evaluated to determine if they have received Pneumococcal vaccination upon admission. The facility will offer residents on admission the Pneumococcal vaccine upon resident/responsible party consent. The PCV13 vaccine and the PPSV23 will be offered per the Center for Disease Control and Prevention guidelines.