**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility documentation, review of facility policy and interviews for one of five sampled residents (Resident #3) unnecessary medications, the facility failed to ensure the care plan included interventions to address the possible side effects and the monitoring that should accompany the use of an anticoagulant and for one sampled resident (Resident #26) reviewed for skin condition, the facility failed to develop a comprehensive care plan to address the specific type of support surfaces device being utilized, how often the device should be worn, and the general care or monitoring of the device as it relates to the resident. The findings include: 1. Resident #3's diagnoses included pulmonary embolism (blood clot that prevents or stops blood flow to the lungs), hyperlipidemia, and dementia. The annual MDS assessment dated [DATE] identified Resident #3 had severe cognitive impairment, required total assistance with personal hygiene, transfers, toileting, was non-ambulatory, and utilized anticoagulant medication (blood thinner) that the assessment noted to be a high-risk medication. A physician's order dated 1/31/24 through 2/6/24 directed Lovenox/Enoxaparin Sodium injection (a blood thinner used to prevent blood clots) 80 milligrams (mg) to inject one syringe subcutaneously every 12 hours for bilateral pulmonary embolism (PE). A physician's order dated 2/6/24 through 6/18/24 directed Apixaban/Eliquis (a blood thinner used to prevent blood clots) 5 mg one tablet by mouth twice daily for bilateral pulmonary embolism (PE). Review of Resident #3's care plan dated 3/25/24 failed to identify a plan of care that included the use of anticoagulant medications with interventions that would had included administering the medication as ordered, monitor for: bleeding, unusual bruising, bloody or black tarry stools, bleeding precautions, and sudden change in mental status. According to Eliquis.com, the use of the medication poses a bleeding risk, in that it increases the risk of bleeding and can cause serious, potentially fatal bleeding. Interview and clinical record review with the ADNS, who is the MDS Coordinator on 6/17/24 at 1:43 PM identified Resident #3 care plan did not include a care plan that focused on anticoagulant therapy, but noted the resident should have had one. The ADNS added that she reviews the care plan when the MDS are due and should have identified at the time of the review that interventions addressing the side effects to monitor for a resident taking an anticoagulant medication could have been developed and implemented. The ADNS further identified that it was an oversight on her part as it was her responsibility as well as nursing to update and revise care plans as needed. Interview with the 7:00 to 3:00 PM Supervisor (RN #2) on 6/18/24 at 1:50 PM identified that a baseline care plan would be initiated when a resident was admitted or readmitted to the facility. RN # 2 added the admitting nursing supervisor would ensure care plans for pain, fall, skin conditions, elopement, and activities of daily living were initiated. RN #2 further added that a care plan should be initiated if the resident was currently taking an anticoagulant medication, and if the admitting nurse failed to add the care plan it is usually picked up by the MDS coordinator who reviews the final care plan. Subsequent to surveyor's inquiry a care plan for the use of anticoagulant dated 6/17/24 was developed and implemented with interventions that included administer anticoagulant as ordered, monitor for side effects and effectiveness, monitor for bleeding, and bleeding precautions. Review of the Baseline Care Plan policy identified that a baseline care plan should be developed within 48 hours of admission with the necessary information to properly care for the resident that includes but is not limited to falls, skin, psychotropic medication use, and anticoagulant use. Review of the Comprehensive Care Plan policy identified that the facility is to develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychological needs within 7 days after the completion of the comprehensive MDS assessment. Additionally, the policy identified that the care planning/interdisciplinary team is responsible for periodic review and updating of the care plans. 2. Resident #26's diagnoses included dementia, muscle weakness, and dysphagia. The significant change MDS assessment dated [DATE] identified Resident #26 had severe cognitive impairment, and was dependent on staff for personal hygiene, dressing, transfers, mobility, and was non-ambulatory. Observation on 6/12/24 at 12:29 PM identified Resident #26 seated in wheelchair around a table in the dining room wearing a blue colored boots (heel floating boots/bunny boots) to bilateral lower extremities. Observation with the Charge Nurse (LPN #2) on 6/13/24 at 12:15 PM identified Resident #26 seated in wheelchair around a table in the dining room wearing a blue colored boots known as heel floating boots/bunny boots to bilateral lower extremities. Interview and review of the clinical records with LPN #2 on 6/13/24 identified that Resident #26 had a wound to the right medial aspect of the foot inner aspect of the foot and wore the blue boots to bilateral feet. LPN #2 failed to identify a care plan or a physician's order directing the use of the light blue boots or any documentation on the nurse aides care card of Resident #26 for the use of the blue boots. LPN #2 added that an order or the care plan, and the nurse aide care card for Resident #26 should have been completed to indicate when the resident to wear the boots, to check skin integrity and when to remove for care. Interview with the Wound Nurse (RN #4) on 6/13/24 at 2:00 PM identified that Resident #26 wore the blue boots as a pressure relieving device due to a new wound identified on 6/1/24 on the right inner side of the foot. RN #4 further identified Resident #26 did not have a care plan nor an order but identified that the resident should have had one. RN #4 added that she recently took over the position as the wound nurse, and it was the responsibility of the charge nurse or the wound nurse to ensure that an order and a care plan was in place. Interview with the ADNS, who is the MDS coordinator, on 6/13/24 at 2:22 PM identified that the Resident #26 did not need a physician's order as the blue boots are being used preventable measure which was seen as a nursing measure. However, she added that the use of the blue boots should have had been documented in the resident's care plan and nurse aides care card of Resident #26 to indicate how often the boots to be worn, when to be removed, and the checking of the resident's skin integrity. In addition, the ADNS failed to identify a care plan that was developed and implemented regarding the use of the blue boots or the nurse aide care card for Resident #26 identifying the use of the blue boot. The ADNS added that it was both the responsibility of nursing and the MDS coordinator to review and update the resident's care plan, but it was the nurse's responsibility to update the nurse aide care cards. Interview with the Medical Record staff (Medical Record #1) on 6/17/24 at 10:00 AM identified that she would review the nurse aide binder with the resident's care card twice weekly for changes and retype the document. The Medical Record #1 identified that the blue boots were recently added to the nurse aide care card for Resident #26. Interview with the Physical Therapist (PT #1) on 6/17/24 at 10:05 AM identified that the blue boots or bunny boots are pressure redistribution devices which are utilized to prevent pressure injury, and to redistribute pressure by preventing the resident from being resting on a surface over a period. PT #1 identified that the blue boots can be worn at all times if the resident has a wound, however they should be removed for care, to check skin integrity, and to reposition the resident with knees supported to prevent improper body alignment. Interview with the former wound nurse (LPN #2) on 6/17/24 at 12:45 PM identified she had received the order from the wound physician for offloading heel per facility protocol, wherein the blue boots were applied, as she had documented in her notes dated 6/5/24. LPN #2 further identified that the blue boots were offloading. LPN #2 identified it was an oversight on her part and that the order and care plan should have had been updated. Review of the Comprehensive Care Plan policy identified that the facility is to develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet the resident's needs as identified in a comprehensive assessment with objectives that will be used to monitor the resident's progress, and alternative interventions will be documented as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility policy and interviews for for one of two sampled residents, (Resident #66) reviewed for accidents, the facility failed to ensure Resident #66 had a comprehensive care plan for wandering/elopement after found to be an elopement risk. The findings included: Resident #66 was admitted to the facility on [DATE] with diagnoses that included Heart Failure, AFIB, cognitive communication deficit and GERD. The admission MDS dated [DATE] identified the resident had intact cognition and had functional range of motion impairment on both upper extremities and no impairment of the lower extremities, but used a walker for ambulation. Review of the nursing progress notes dated 5/1/24 at 2:56 PM identified the resident was found getting off of the elevator on the first floor and told staff he/she was just looking around. Subsequent nursing notes dated 5/1/24 at 3:29 PM identified a wander guard was placed on the resident's left ankle. Review of the Elopement Risk assessment dated [DATE] identified the resident scored an 11 and was at risk of elopement and should have had interventions to minimize risk of elopement. Review of the Physician's Orders dated 5/3/2024 identified order to monitor wander guard every shift for elopement risk. Additionally, that order was discontinued and a new order to monitor the wander guard was placed 5/9/2024. The Comprehensive Care Plan dated 5/9/2024 failed to identify Resident #66 was an elopement risk or had a wander guard bracelet in place. Review of the Treatment Administration Record (TAR) for May 2024 identified a treatment to monitor for attempts to elope every shift for attempted elopement. The first recorded date for monitoring for elopement was charted on 5/3/24 on the night shift. The TAR identified the resident was being monitored from 5/3/24 through the dates of the survey 6/18/2024. Review of the TAR for June 2024 identified two additional treatments to check battery function on elopement bracelet every night shift, which is checked off from 6/5/24 through 6/17/24, and to check for wander guard placement (L ankle) before and after each LOA, which had not been checked off during the month of June. Review of the nurse progress notes dated 6/4/2024 at 11:46 PM identified the resident had been outside alone and was escorted back to the resident floor by a staff member. It was noted that the wander guard was not in place on the left ankle as it should have been. A new wander guard was placed on the left ankle at that time. Review of the Elopement Risk assessment dated [DATE] identified Resident #66 scored a 12. A score of 10 or higher is at risk and interventions to minimize risk of elopement should be implemented. Review of clinical chart nurse progress notes dated 6/7/2024 at 3:52 PM identified Resident #66 was not found on the unit, but outside with a friend. The nurses' note identified that both the resident and the friend were educated on the need to notify a staff member of where the resident goes for safety. The note identified the wander guard was in place on the resident's ankle but did not alarm when the resident left the unit. Observation of Resident #66 on 06/12/24 at 1:06 PM identified the resident did not have a wander guard in place. Resident #66 communicated feelings and identified preferences to daily care without issue and was able to identified the desire to return home. Interview with LPN #3 on 6/13/24 at 1:35 PM identified another staff member brought the resident up to the floor on 5/1/2024 after the resident was found on the 1st floor and that was when the wander guard was placed on the resident. LPN #3 identified the facility completed an elopement assessment and notified the supervisor of the change in score. LPN #3 identified that finding the resident on another floor would be considered elopement I don't fill out any paperwork. I just notify the supervisor. I did check the wander guard prior to her leaving, it was not there when she came back. Interview with the DNS on 6/13/24 at 2:19 PM identified if the resident was found off of the unit, that would be an attempt at elopement and an elopement assessment would be completed and, if appropriate, a wander guard bracelet would be placed. The elopement assessment scores, the cognitive assessment, and status of the resident, and the reason for leaving the unit are taken into account for placement of the bracelet. The orders for the wander guard to check the batteries on 11-7 for function and to check for placement every shift. The DNS identified this would be placed in the care plan. Review of the facility Elopement Policy identified Residents at risk for elopement, through risk score and/or behaviors, will have an Elopement Risk Care Plan implemented and have an elopement band placed on wrist. The policy identified the placement of the elopement bracelet will be monitored every shift and documented in the EMAR. Exit door and elevator monitors will be tested throughout the week by the maintenance department to ensure proper functioning. Review of the Baseline Care Plan Policy identified that in the event that the comprehensive assessment and comprehensive care plan identified a change in the resident's goals, or physical, mental, or psychosocial functioning not identified in the baseline care plan, those changes will be incorporated into the care plan within 48 hours of identification. Subsequent to surveyor inquiry, 6/13/2024, the elopement/wander guard was added to the resident care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, review of facility policy, review of facility documentation and interviews for one of two sampled residents (Resident #66) reviewed for accidents, the facility failed to provide adequate supervision to prevent an elopement. The findings include: Resident #66 was admitted to the facility on [DATE] with diagnoses that included heart failure, atrial fibrillation, and cognitive communication deficit. The admission Elopement Risk assessment dated [DATE] identified Resident #66 was not at risk for wandering. The admission MDS assessment dated [DATE] identified Resident #66 had intact cognition, no exhibited behaviors, range of motion impairments to both upper extremities and no impairment of the lower extremities and utilized a walker for ambulation. The nursing note dated 5/1/24 at 2:56 PM identified Resident #66 was found getting off of the elevator on the first floor and told staff he/she was just looking around. The Elopement Risk assessment dated [DATE] identified Resident #66 was at risk of elopement and should have interventions to minimize the risk of elopement. A nursing note dated 5/1/24 at 3:29 PM identified a wanderguard was placed on Resident #66's left ankle The physician's orders dated 5/3/2024 directed to monitor the wanderguard alarm every shift due to elopement risk. Review of the Treatment Administration Record (TAR) from May 3, 2024 through June 18, 2024 identified an intervention to monitor for attempts to elope every shift. Review of the TAR for June 2024 directed to check the battery function of the wanderguard bracelet every night shift. The TAR identified that it was checked off from 6/5/24 through 6/17/24. The TAR also noted to check for wanderguard placement (L ankle) before and after each LOA. The documentation did not reflect that the placement of the wanderguard had been checked. The nurse's note dated 6/4/2024 at 11:46 PM identified the resident had been outside alone and was escorted back to the unit by a staff member, and the wanderguard was not in place to the left ankle. A new wanderguard was placed on the left ankle at that time. The nurse's note dated 6/7/24 at 3:52 PM identified Resident #66 was found outside with a friend and noted that the resident and the friend were educated on the need to notify a staff member of where the resident goes for safety. Further, the note identified the wanderguard was in place but had not alarmed when the resident left the unit. Review of clinical chart nurse progress notes dated 6/7/2024 at 3:52 PM identified Resident #66 was not found on the unit, but outside with a friend. The nurses' note identified that both the resident and the friend were educated on the need to notify a staff member of where the resident goes for safety. The note identified the wanderguard was in place on the resident's ankle but did not alarm when the resident left the unit. Observation on 6/12/24 at 1:06 PM identified Resident #66 did not have a wanderguard in place. Interview with LPN #3 on 6/13/24 at 1:35 PM identified another staff member brought the resident up to the floor on 5/1/2024 after the resident was found on the 1st floor and that was when the wanderguard was placed on the resident. LPN #3 identified the facility completed an elopement assessment and notified the supervisor of the change in score. Interview with the DNS on 6/13/24 at 2:19 PM identified that when a resident is found off of the unit it is considered an elopement attempt and an elopement assessment is completed and if appropriate, a wanderguard bracelet is placed. The elopement assessment score, the cognitive assessment, status of the resident, and the reason for leaving the unit are taken into account for placement of the wanderguard. She further identified that orders to check the batteries for function and placement on the 11-7 shift would also be put in place. In addition, the DNS identified a resident found outside of the building is considered an elopement. Further interview with the DNS identified she was unaware of Resident #66's elopement attempts and noted that, there were no reportable event reports completed and investigations conducted to ascertain how the resident got out of the building on two occurrences. A tour of the building with the DNS on 6/18/24 at 10:30 AM identified alarm sensors located at the exit doors on the units, at exits to the building, and in the elevators, and in order to for the elevators to move when a wanderguard alarm is present, a code that has to be entered into the keypad located in the elevator. At the doors on the units and to exit, when the wanderguard system alarms and the door is pushed open, there is an audible alarm, and the door remains secured for 15 seconds and then will open due to fire safety measures. There is an alarm code that can be entered that will silence the alarm and allow the door to open. The DNS noted that most family members have the codes. Additionally, there is not a way to print a record of activations. The DNS further identified the system is checked weekly for function. Review of the facility Elopement Policy identified Residents at risk for elopement, through risk score and/or behaviors, will have an Elopement Risk Care Plan implemented and have an elopement band placed on wrist. The policy identified the placement of the elopement bracelet will be monitored every shift and documented in the EMAR. Exit door and elevator monitors will be tested throughout the week by the maintenance department to ensure proper functioning. The facility failed to ascertain how the resident eloped from the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record, review of facility policy and interviews for one sampled resident (Resident #369) reviewed for Respiratory Care, the facility failed to provide sanitary care of the nebulizer equipment related infection control. The findings include: Resident #369's diagnoses included chronic obstructive pulmonary disease, obstructive sleep apnea and anxiety. A transfer and discharge report dated 6/9/24 identified an order for Ipratropium-Albuterol inhalation solution 0.5-2.5 (3) milligram per milliliter; 3 milliliters-to be inhaled orally every 6 hours as needed for wheezing, dated 5/20/24. The admission nursing assessment dated [DATE] identified Resident #369 was alert and oriented, required a Continuous Positive Airway Pressure (CPAP) machine, had shortness of breath when lying flat and was an assist of 2 for bed mobility. The care plan dated 6/10/24 identified Resident #369 had limited physical mobility, confusion, and weakness. Interventions included Physical and Occupational therapy referrals. A physician's order dated 6/10/24 directed to administer DuoNeb (Ipratropium-Albuterol) solution 0.5-2.5 (3) milligrams per milliliter, 3 milliliters-to be inhaled orally every 6 hours as needed for wheezing. Observation on 6/12/24 at 11:09 AM in Resident #369's room, identified the nebulizer machine along with the equipment, including the mouthpiece and medicine cup lying on the windowsill without a covering and without a date. The mouthpiece and medicine cup were lying against the window screen. Interview on 6/12/24 at 11:10 AM with Resident #369 indicated she had not recently used the nebulizer machine and could not identify the last time it had been used. Interview on 6/12/24 at 11:22 AM RN #2, floor nurse, indicated the nebulizer equipment is normally dated and kept in a plastic bag, and not lying on the windowsill unbagged. The nurse then indicated she/he would change the equipment immediately, date it and place it in a bag per policy. Subsequent to surveyor inquiry, the nebulizer equipment was changed, dated, and placed in a plastic bag. Interview on 6/17/24 at 9:48 AM with the DNS identified the facility uses a company to help maintain the CPAP equipment, facility staff are required to maintain and provide the cleaning and storage of all respiratory equipment. nebulizer and oxygen equipment should be dated and stored in an oxygen bag in between uses. If a new resident came to the facility, the nebulizer or oxygen equipment is changed over to facility equipment and subsequently dated and bagged to maintain infection control. A Physician's order is then entered for monitoring and care of any oxygen, nebulizer, and CPAP equipment. The nebulizer sets/tubing are changed every Thursday by nursing on the 11-7 shift, dated and placed in an oxygen bag. The Medication Administration Record (MAR) dated 6/1/24-6/30/24 identified DuoNeb (Ipratropium-Albuterol) solution 0.5-2.5 (3) milligrams per milliliter, 3 milliliters-inhale orally every 6 hours as needed for wheezing, was administered on 6/12/24 at 2:42 PM. The Treatment Administration Record (TAR) dated 6/1/24-6/30/24 failed to identify the nebulizer treatment checks or care of nebulizer equipment. Review of the Nebulizer Procedure Policy directed, in part, to rinse tubing with water and let air dry after each use. Wrap tubing in a paper towel and place in a bag. Tubing should be dated and documented on the treatment sheet. Nursing will replace tubing, mask/mouthpiece every Thursday night shift and as needed. Review of the Care of Oxygen/Respiratory Equipment policy directed, in part, that small volume nebulizer's (SNV) and tubing are rinsed after each use and discarded weekly. New SNV's are dated and initialed when put into use. Documentation of any changes or checks are done on the resident's treatment [NAME].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, review of facility policy, review of facility documentation and interviews for one sampled resident (Resident #2) reviewed for hospice care, the facility failed to have complete hospice records that were readily available for review and for one of four sampled residents (Resident #55) reviewed for advanced directives, the facility failed to ensure that a signed copy of the advanced directives consent form was accessible in the resident's medical record. The findings include: 1. Resident #2's diagnoses included congestive heart failure, asthma, and difficulty swallowing. A physician's order dated [DATE] directed: evaluate Resident #2 for hospice services. The care plan dated [DATE] identified Resident #2 was receiving hospice services. Interventions included, provide care that maintained maximum comfort through the next review. The significant change Minimum Data Set assessment dated [DATE], identified Resident #2 was severely cognitively impaired, was dependent for transferring, toileting, bathing and was receiving hospice services. Review of Resident #2's clinical record on [DATE] at 2:30 PM identified the medical record failed to provide documented evidence of the following: Up to date every 2-week Interdisciplinary team notes, beginning after the resident was admitted to hospice, through [DATE], the Plan of Care and Certificate of Terminal Illness (CTI) dated [DATE]-[DATE] and the Medicare/Medicaid Hospice Benefit Election dated [DATE] and hospice medication list. Interview on [DATE] at 2:33 PM with LPN #1 and LPN #2 identified the only hospice documents in the resident's chart were the hospice agency's cover sheet and 4 hospice visit notes. No hospice admission note, admission consents/documents, Certificate of Terminal Illness (CTI), Interdisciplinary Team (IDT) notes, or plan of care were found in the resident's chart or uploaded to the Electronic Medical Record (EMR). No other binders or folders were kept or utilized for hospice documentation, according to LPN #1 and LPN #2. Interview on [DATE] at 9:58 AM with the DNS identified that Social Worker #1 helps with hospice admissions in the facility and the hospice paperwork. Interview on [DATE] at 10:04 AM with social worker (SW) #1, indicated after the physician's orders a hospice evaluation, the SW contacts the hospice agency selected by the resident or family. The hospice agency then updates the SW when an evaluation will occur and when the resident is admitted to a hospice level of care. The hospice agency is responsible for the paperwork. Subsequent to surveyor inquiry, the Hospice Benefit Election form and the facility Care Plan Conference sheet were provided to this Nurse Consultant. Interview on [DATE] at 11:48 AM with Hospice Manager RN #1 indicated, he/she would have to review the hospice admission process to ensure exactly which documents should have been included in the resident's medical record. He/she also indicated once a hospice referral is received from the facility, the hospice staff contacts the family. If the family or resident agreed to hospice services, then the hospice nurse would complete an evaluation and admit the resident to hospice care. The hospice Manager was not aware and was unable to explain why the hospice admission paperwork had not made it to Resident #2's chart. According to RN #1 hospice manager, there should have been a Hospice Medicare/Medicaid Benefit election form, a memo of understanding ([NAME]), between the hospice agency and facility, communication notes, and a cover sheet at least. The admitting hospice nurse brings a nursing home packet when admitting a resident. Which included all the hospice documents. All the hospice consent forms are configured electronically. RN #1 indicated a lack of awareness as to the requirement of the plan of care, Certificate of Terminal Illness (CTI) and the hospice Interdisciplinary (IDT) notes which should be part of the medical record. Subsequent to surveyor inquiry, RN #1 hospice manager, faxed over the Hospice Plan of Care dated [DATE]-[DATE]. RN #1 or the hospice medical record's personnel will fax over the hospice documents to the facility going forward, to ensure the resident's medical record is complete. Review of the Medical Records policy dated [DATE] directed, in part, that all active medical records are kept at the nurse's station, accessible only to authorized personnel. Although requested, a facility policy regarding Hospice documents was not provided. 2. Resident #55's diagnoses included dementia, type 2 diabetes mellitus, and anxiety disorders. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #55 cognition was severely impaired and required total assistance with personal hygiene, toileting, and was non-ambulatory. Review of the clinical record identified a physician's advance directive form consent dated [DATE] indicated Resident #55's code status of full interventions (full code), a full code means that if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive. This process can include chest compressions, intubation, and defibrillation and is referred to as CPR (cardiopulmonary resuscitation). The care plan dated [DATE] identified Resident #55 advanced directive of Do not Resuscitate (DNR) which means that a person has decided not to have CPR attempted on them if his/her heart or breathing stops and Do not Intubate (DNI), which means that a person has decided not to be connected to a ventilator if his/her lungs not working, with a goal to maintain resident wishes through the next review, with interventions that included to follow the facility advance directive protocol (to discuss with the resident or responsible party about advanced directives planning, obtain physician's order and place the order in the electronic medical record and copy in the chart). A physician's order dated [DATE] directed a do not resuscitate (DNR)/do not intubate (DNI)/ nurse may pronounce (NMP) code status for Resident #55. Interview and clinical record review with the Charge Nurse (LPN #2) on [DATE] at 12:30 PM identified in the advance directive tab of the paper chart a physician's advance directive form consent dated [DATE] that indicates full interventions and a black dot on the outside of the chart which indicated DNR. In addition, the electronic medical records indicated DNR/DNI/NMP. LPN #2 further identified that Resident #55 code status was changed on [DATE] to DNR/DNI/NMP. LPN #2 added that when a resident's code status is changed the new physician's advance directive form should be kept in the chart. Also, LPN #2 added that it was the responsibility of the staff who received the new order to ensure that the signed copy of the consent form is in the paper chart in the advance directive section. LPN #2 indicated that if the resident required life-saving measures, the physical chart at the nurse's station was one of the places she would look to confirm the resident's advanced directives as well as the physician's order. The nursing note dated [DATE] at 10:24 AM written by ADNS, who is also the MDS coordinator, identified that an interdisciplinary team meeting was held with the Resident #55's representative and family when they decided to changed Resident #55's code status to DNR/DNI/NMP. Interview with the ADNS on [DATE] at 2:09 PM identified that it was the practice of the facility to review resident's code status at care conference meeting when Resident #55's family made the change from full intervention to DNR/DNI/NMP. She identified that all the required steps were taken which included documentation, physician's order, and the consent form was in place in Resident #55's paper chart. The ADNS added that the overflow chart was checked, and she was unable to locate a copy of the physician advance directive form consent. She added that the Resident #55 was sent to the hospital in March of 2024 wherein the form might had been sent to the hospital in error as there were a signed transfer of Do Not Resuscitate order form that identified a DNR order was written for Resident #55 on [DATE]. The ADNS identified that moving forward the advance directive form consent would be scanned into the resident's electronic medical record. Interview with the Resident #55's representative (Person #2) on [DATE] at 11:00 AM identified that he/she had a discussion with the ADNS at a care conference meeting where the code status was change to DNR/DNI. Review of the Care Plan Conference sheet dated [DATE] at 10:00 AM identified that Resident #55's family was in attendance. The care plan conference sheet further identified that the Resident #55's code status was CPR and was reviewed and changed to DNR/DNI/NMP. Subsequent to surveyor inquiry, a physician's advance directive form consent dated [DATE] was completed with a consent obtained from the Resident #55's representative by two nurses, signed by provider, and placed into the paper chart in the advance directive section. Review of the Advanced Directives policy identified that copies of the advance directives should be placed in the resident's chart. The policy further identified that when changes are made to the advance directives it should be documented in the resident's medial record. Review of the Medial Records policy identified that all active medical records are kept at the nurse's station and accessible to only authorized staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of facility documentation, and interviews, the facility failed to implement Enhanced Barrier Precautions for residents who required enhanced barrier precautions and failed to include all residents that required tracking in their MDRO tracking and cohort accordingly. The findings include: 1. A tour of the facility on 6/13/24 at 9:24 AM identified that residents with a history of Multidrug Resistant Organisms (MDRO's), and residents with the presence of indwelling medical devices, the facility failed to place the residents on Enhanced Barrier Precautions (EBP). Review of the facility's MDRO log with the Infection Preventionist Nurse RN #4 on 6/13/24 at 12:49 PM identified 7 residents that she had identified as requiring EBP due to indwelling medical devices, or open wounds with infected organism. Interview with RN#4 on 6/13/24 at 2:35 PM identified that EBP was not implemented on the units currently, and the facility had just initiated the process. RN #4 identified that the facility was in the initial phase, which was formulating a policy, and identifying residents who would need EBP, however would need to start educating all staff, informing residents, families, and representatives. RN#4 identified that she knew this should have been implemented by 4/1/24 and has discussed this need with management however has received push back stating it would affect the dignity of the residents and the cost of the extra supplies were factors delaying the implementation. Interview with the Administrator on 6/13/24 at 2:50PM identified he was aware that the EBP process was in the works of being implemented however was unaware of it needing to be implemented by 4/1/24. The policy was in the works of being created however not currently implemented. The communication on implementation was never made clear to him of a date and felt as though the Infection Prevention Nurse RN#4 should have been responsible to know this information. On his behalf there was no pushback in the implementation as they are a non-profit organization and if they need funds to implement something they will find a way. Interview with the DON on 6/13/24 at 3:05 PM identified that they have started the process and are putting together education and the policy and starting to identify the resident affected and are really trying hard to protect the dignity of the residents and feels as though this is a huge dignity issue. She does not feel the need to have anyone on EBP but understands this is the new direction and did not understand there was a date this was to be implemented. The DON identified there was no pushback from department heads regarding this policy and there has been no discussion regarding financial constraints regarding implementation. The DON identified she is ultimately the person in charge of the Infection Preventionist and she should determine what information she would need and what would need to be implemented with what time frame. According to the Center for Clinical Standards and Quality Safety and Oversight Group (QSO) memo Ref: QSO-24-08-NH dated 3/20/24 identified that in 2019 the Centers for Disease Control and Prevention (CDC) introduced a new approach for the usage of personal protective equipment (PPE) called Enhanced Barrier Precautions which was updated in July 2022, and the Centers for Medicare and Medicaid (CMS) was updating its infection prevention and control guidance accordingly. The QSO-24-08-NH further identified that the effective date was April 1, 2024. Review of the facilities Enhanced Barrier policy received directed an order will be received for residents who do not have a chronic wound or indwelling medical devise and are infected or colonized with an MDRO that is not currently targeted by CDC but may ne considered epidemiogically important. An order for enhanced barrier precautions will be obtained for residents with any of the following, wounds, diabetic foot ulcers, unhealed surgical wounds, and chronic venous-stasis ulcer, and or indwelling medical devices, even if the resident is not known to be infected or colonized with a MDRO. 2. Review of the facility's MDRO list and with the Infection Preventionist Nurse (RN#4) on 6/18/24 at 10:26 AM failed to identify Resident #55 had a History of C-diff (clostridium difficile) on admission and was co-horted with an individual without a C-diff dx or history of. Resident #55 was admitted to the facility with enterocolitis due to clostridium difficile, gastro-esophageal reflux disease without esophagitis, irritable bowel syndrome with constipation. The care plan dated 10/21/22 did not identify Resident #55 had a history of C-diff. The admission MDS assessment dated [DATE] identified Resident #55 had moderately impaired cognition and required extensive assistance with toileting, hygiene, bathing, and dependent on personal hygiene, transfers. assistance with toileting hygiene, bathing and dependent on care personal hygiene, transfers, and non-ambulatory. A physicians order was not in effect for due to the fact the facility had not implemented EBP precautions. Interview with RN#4 on 6/18/24 at 10:30 AM identified that she was unaware of the history of C-diff on admission for Resident #55 admitted in October of 2022, however admission paperwork and current diagnoses included this diagnosis. RN#4 identified that she was responsible for identifying these diagnoses and reviews admission paperwork for each resident and took on this role in February of 2022 and it must have been an oversight. If she knew that Resident #55 had this diagnosis, she would have included it on her MDRO list and advocate for a single room for the resident or co-[NAME] with someone else with a history of C-diff. Interview with DON on 6/18/24 at 10:55 AM identified that someone with a history of C-diff should be reflected on the MDRO list. She would expect this to be reviewed by the infection control nurse upon admission. Typically, they would try to cohort with someone with the same diagnosis or give a single room to this person as they have a lot of single rooms. The policy titled Infection Control History Logs dated 8/2018 directed the infection control nurse to maintain a history log of residents who have been diagnosed with C-diff, MRSA, and VRE. The log is utilized when determining appropriate roommates and reviewing signs and symptoms of infections. When a new case of C-diff, MRSA, or VRE is diagnosed, the Infection Control Nurse enters the information in the appropriate history log. When the resident's infection has resolved and or colonized the information is documented in the log.

Based on observation, facility policy review, and interviews, the facility failed to ensure foods were dated and labeled appropriately, expired foods discarded and the cleanliness of the resident's nutritional refrigerator maintained. The findings include: Observation on 6/12/24 at 9:45 with [NAME] #1 identified the following in the walk-in freezer: * fajita meat in a large zip lock plastic container dated good through 3/22/24 * beef roast in a large zip lock plastic container dated good through 6/5/24 * ham and pork in a large zip lock plastic container dated good through 6/9/24 * ground ham in a large zip lock plastic container dated good through 5/17/24 * corned beef wrap with a saran wrap dated good through 5/17/24 * beef gravy in a large zip lock plastic container dated good through 6/5/24 * mac and cheese in a large zip lock plastic container dated good through 5/16/24 Interview with [NAME] # 1 on 6/12/24 at 10:00 AM identified that the Food Service Director (FSD) was responsible of ensuring there were no outdated food stored in the freezer. She identified that the good through date would be last day that the food item can be used and it should be thrown out after it expiration. She further identified that the expired food items should not be left in the freezer. Subsequent to surveyor inquiry, expired food items were thrown away. Observation on 6/12/24 at 10:05 AM with the Food Service Director (FSD) identified the following in the walk-in refrigerator: * macaroni pasta in a metal container cover with plastic with no label * open beef base in a manufacturer plastic container dated good through 6/11/24 Interview with FSD on 6/12/24 at 10:15 AM identified that all dietary staff should throw away expired food in the freezer and/or refrigerator. She typically checked the freezer and refrigerator for any outdated food items once a week and throw away any expired food. She also noted that any food stored in freezer and/or refrigerator should be appropriately label and no expired food should be kept in the walk-in freezer and/or refrigerator. Observation on 6/17/24 at 10:40 AM with LPN #1 identified the following in the resident's nutritional refrigerator: * 1 opened 46 ounces box thickened cranberry cocktail from concentrate without label * 1 opened 46 ounces box thickened orange juice from concentrate without label * 1 opened 32 ounces box 100% HC Plus orange juice without label * 1 opened 32 ounces box 100% HC Plus prune juice without label Observation on 6/17/24 at 10:50 AM with LPN #1 identified the following in the resident's nutritional freezer: * 2 pints of opened Talenti ice cream and covered with freezer burn * 1 pint of price chopper chocolate ice cream and covered with freezer burn * 6 cups of 120 ml ice cream and covered with freezer burn. Further observation of the resident's nutritional refrigerator/freezer identified multiple areas of sticky brown stain material inside the refrigerator and in the freezer. Interview with LPN #1 on 6/17/24 at 11:00 AM identified that housekeeping and/or dietary was responsible for cleaning the resident's nutritional refrigerator. She also identified the opened juice and ice cream were for the residents use. She further identified that juice should be label once it was opened, but she could not identified how long it was good for once it was opened. Interview with the FSD on 6/17/24 at 11:20 AM identified that the housekeeping and/or dietary staff was responsible of cleaning the resident nutritional refrigerator. She could not identified when was the last time the refrigerator was last clean. She further identified any un-label food items would be thrown away. Review of the Food and Storage Supply Policy directed that all food, non-food items and supplies used in food preparation shall be stored in a manner that would prevent contamination to maintain safety and safe for human consumption. Food past the use by date should be discarded and open packages would be cover, label and dated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, policy, and interviews for one of three sampled residents (Residents #1) who were reviewed for multiple falls, the facility failed to review and revise the plan of care to determine new interventions after Resident #1 sustained a fall to prevent further falls. The findings include: Resident #1's diagnoses included aphasia, anxiety, and history of falls. The Fall assessment dated [DATE] identified Resident #1 was a high risk for falls. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 required total assistance with getting in and out of the bed and chair, toilet use, personal hygiene, and extensive assistance with turning and repositioning while in bed, and had no falls since admission, entry or reentry or the prior assessment. The Facility Reported Incident form dated 7/24/23 at 12:05 PM identified Resident #1 was observed sitting on his/her buttock on the floor mat with their back resting against the bed and holding onto the side rail with his/her left hand, and no injuries were noted. The Resident Care Plan dated 7/26/23 identified Resident #1 was at risk for falls related to deconditioning, gait and balance problems, incontinence, and poor communication and comprehension. Interventions directed to be sure Resident #1's call light was within reach, Resident #1 needed prompt response to all requests for assistance, encourage Resident #1 to be in common areas for supervision, out of bed for all meals, every two (2) hour toileting while awake, every fifteen (15) minutes checks, and bed against the wall. The Facility Reported Incident form dated 7/30/23 at 6:45 PM identified Resident #1 was observed sitting on the floor mat at his/her bedside and no injuries were noted. The Facility Reported Incident form dated 8/3/23 at 1:30 AM identified it was noted on the video monitor that Resident #1 was restless, and although staff quickly responded Resident #1 was observed lying on the floor mat at the bedside when the nurse entered the room and the skin tear to the left upper extremity reopened. The Facility Reported Incident form dated 8/8/23 at 7:30 AM identified Resident #1 was lowered to the floor at 7:30 AM by a nurse aide and although there were no obvious injuries at the time, later in the evening Resident #1 developed bruising to the left great toe. Review of the clinical record failed to provide documentation Resident #1's care plan was reviewed and/or revised after each fall on 7/24, 7/30, 8/3 and 8/8/23 to determine new interventions. Interview and review of the clinical record with the Director of Nursing (DON) on 11/3/23 at 11:40 AM identified Resident #1's care plan was not reviewed and revised after the falls on 7/24, 7/30, 8/3 and 8/8/23. The DON indicated the Minimum Data Set Coordinator was responsible to review and/or revise Resident #1's care plan after each fall. Interview with Minimum Data Set Coordinator, Licensed Practical Nurse (LPN) #1, on 11/3/23 at 12:30 PM identified she was responsible to review and revise Resident #1's care plan, however it was not only her responsibility, but all nurses were responsible to review and revise a resident's care plan. The Comprehensive Care Plan policy directed the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly assessment. The comprehensive care plan will include measurable objectives and time frames to meet the resident's needs as identified in the residence comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative intervention will be documented as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, policy, and interviews for one of three sampled residents (Resident #1) who had potential for impairment to skin integrity, the facility failed to document that a complete assessment was conducted to identify the exact location and set a baseline when areas of discoloration were identified on admission and after Resident #1 sustained falls with injuries and failed to ensure a Registered Nurse assessment was conducted when abrasions were identified to right lower extremity. The finding include: Resident #1's diagnoses included aphasia, anxiety, and history of falls. A Fall assessment dated [DATE] identified Resident #1 was a high risk for falls. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 required total assistance with transfer, toilet use, personal hygiene, and extensive assistance with bed mobility, and had no falls since admission, entry or reentry or the prior assessment. The Resident Care Plan dated 7/26/23 identified Resident #1 had potential for impairment to skin integrity, was at risk for pressure sores due to decreased mobility, fragile skin, and incontinence. Interventions directed to keep skin clean and dry, use house lotion with personal care. a. The admission Nursing assessment dated [DATE] identified Resident #1 had an alteration in skin integrity. Resident #1 had scattered bruising on abdomen, bilateral arms. Review of the clinical record failed to reflect documentation that a complete assessment, i.e., size color and exact location, of the discolorations had been conducted when an area was first identified on 6/29/23 to establish a baseline description of the area for further evaluation to determine if there was an improvement or decline of the discolorations. b. The nurse's note dated 7/10/23 at 6:30PM identified a nurse was walking by Resident #1's room and saw Resident #1 lying on stomach in front of his/her recliner chair. A small bruise measuring 1.0 centimeter (cm) to the left wrist and a small bruise to lower lip were identified. No open areas or other new bruises were noted. Review of the clinical record failed to reflect documentation that a complete assessment, i.e., size color and description of the discolorations had been conducted when the areas were first identified on 7/10/23 to establish a baseline description of the area for further evaluation to determine if there was an improvement or decline of the discolorations and weekly thereafter. c. The nurse's note dated 8/3/23 at 2:58AM identified at 1:30AM noted on the video monitor Resident #1 was restless, and there was a pillow on the floor. The nurse quickly responded, upon entering the room Resident #1 was lying on the floor mat at bedside on his/her back, an old skin tear to left upper extremity was noted to be bleeding, the area was cleansed, and a border foam dressing was applied. Resident #1 stated no pain. Review of the clinical record failed to reflect documentation that a complete assessment, i.e., size color and description of the skin tear had been conducted when the area was first identified on 8/3/23 to establish a baseline description of the area for further evaluation to determine if there was an improvement or decline of the discolorations and weekly thereafter. d. Interview with Person #1 on 11/2/23 at 10:05 AM identified on 8/8/23 Person #1 noticed a series of five (5) puncture marks to Resident #1's right leg just above the ankle and no one was able to provide an answer as to how Resident #1 acquired these marks. Person #1 stated another series of the same marks appeared on Resident #1's leg again on 8/15/23 alongside the other puncture wounds. The weekly evaluation of alteration in skin integrity dated 8/9/23 identified a bruise to left great toe, small, scattered bruising to the bilateral lower and upper extremities. No other skin issues observed. Interview with the 7AM-3PM, nurse aide, Nurse Aide (NA) #1, on 11/3/23 at 9:30AM identified she did care for Resident #1 on 8/8/23 and she did not notice any puncture marks to Resident #1's right lower extremity. NA #1 stated she was Resident #1's regular nurse aide during the 7AM-3PM shift, and she did not notice any puncture marks to the right lower extremity while caring for Resident #1. Interview with the Director of Nursing (DON) on 11/3/23 at 10:50AM identified she was not aware of the puncture marks to Resident #1's right lower extremity. The DON indicated if a resident sustained an injury from a fall like a bruise, skin tear or any skin altercation, the Registered Nurse was responsible to complete skin assessment and the assessment was to include the location, size of the bruise, skin tear or any skin deformities and to obtain treatment when necessary. The DON stated the areas of skin altercations were to be assessed and documented weekly thereafter. The non-pressure skin condition policy directed the license nurse to document in nurses' notes description of non-pressure skin condition. The weekly skin evaluation policy directed the license nurse to complete the weekly skin evaluation. If a new area was discovered, the charge nurse was responsible to start appropriate documentation. The weekly skin evaluation of alterations in skin integrity instructions directed that this form should be completed on all bruises, skin tears, abrasions on a weekly basis until resolved. Be sure to document in the description what the altercation was- bruise or skin tear or abrasion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation and interviews for one of three sampled residents (Resident #1) who were reviewed for falls, the facility failed to consistently document Resident #1's location on the resident observation sheets while on every fifteen (15) minute monitoring. The findings include: Resident #1's diagnoses included aphasia, anxiety, and history of falls. A Fall assessment dated [DATE] identified Resident #1 was a high risk for falls. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 required total assistance with transfer, toilet use, personal hygiene, and extensive assistance with bed mobility, and had no falls since admission, entry or reentry or the prior assessment. The nurse's note dated 7/22/23 at 11:27 PM identified at 7:05 PM Resident #1 was noted sitting on floor mat with his/her back against the bed and the legs extended in front of him/her. Resident #1 was placed on every fifteen (15) minute monitoring. The Resident Care Plan dated 7/26/23 identified Resident #1 was at risk for falls related to deconditioning, gait/balance problems, incontinence, poor communication/comprehension. Interventions directed to be sure the call light was within reach, Resident #1 needed prompt responses to all requests for assistance, encourage Resident #1 to be in common areas for supervision, out of bed for all meals, every two (2) hours toileting while awake, every 15 minutes checks, bed against the wall. A review of nurse's note from 7/22/23 through 8/17/23 identified Resident #1 continued every fifteen (15) minute monitoring. Review of the resident observation sheet, every fifteen (15) minute monitoring form from 7/22/23 through 8/17/23 failed to provide documentation Resident #1 was consistently monitored on 8/15, 8/14, 8/10, 8/8, 8/5, 8/4, and 8/1/23 during the 7AM-3PM, 3-11PM and 11PM-7AM shifts while on every fifteen (15) minute monitoring. Interview with the Director of Nursing (DON) on 11/3/23 at 10:20 AM identified the nurse aides were responsible to monitor Resident #1 and document on every fifteen (15) minute monitoring form. The DON indicated she was unaware of every fifteen (15) minute monitoring form not being consistently documented. The DON identified there was no policy regarding every fifteen (15) minute monitoring.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical records reviews, facility's policy, and interviews for 3 of 3 residents (Residents # 5, #28, and #156) reviewed for Comprehensive Care Plan, the facility failed to establish a comprehensive person-centered care plan to address the resident's need. The findings included: 1.Resident #5 was admitted on [DATE] with diagnoses that included anxiety, dementia, and heart failure. The Minimum Data Set (MDS) assessment dated [DATE] directed Olanzapine (Anti-psychotic) 5 Milligrams (MG) 1 tablet by mouth at bedtime for dementia. The Omnicare Pharmacy Consultation Report dated 12/20/21 identified the resident received an antipsychotic and the recommendation was to include guidance for Olanzapine in the Interdisciplinary Care Plan. The quarterly MDS assessment dated [DATE] identified Resident #5 had modified independence for daily decision making and noted diagnoses of non-Alzheimer's dementia and anxiety. The quarterly MDS assessment further identified no potential indicators of psychoses and that the resident received 7 days of antipsychotics in that last 7 days. The care plan dated 1/26/22 failed to identify a care plan for psychotropic medication use. The physician's order dated 3/3/22 directed Depakote sprinkles 125 MG, 1 capsule by mouth once a day for behaviors and mood related to dementia with behavioral disturbance. A psychiatry visit dated 3/8/22 identified the medication Depakote 125 MG was therapeutic and the nursing staff agreed with recommendations. Interview and record review with the Director of Nursing Services (DNS) on 3/16/22 at 2:00 PM identified there was no care plan for Resident #5's psychotropic medication use. She further identified the MDS Coordinator is responsible for creating and updating care plans. Interview with Licensed Practical Nurse (LPN #2) MDS Coordinator, on 3/17/22 at 11:25 AM identified residents using psychotropic medications and/or antipsychotics should have their own psychotropic care plan addressing the medication use and behaviors. She further identified she did miss entering Resident #5 care plan for antipsychotics. The facility Comprehensive Care Plan Policy identified the comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. The policy further identified the comprehensive care plan will describe, at a minimum, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Although requested, a facility policy for psychotropic medication use was not provided. 2. Resident #28 was admitted on [DATE] with diagnoses that included right femur fracture with co-morbidity Type 2 Diabetes Mellitus, osteoarthritis, dysphagia, recurrent major depression, hypertension, Obstructive Sleep Apnea (OSA). The hospital Discharge summary dated [DATE] identified Resident #28 was attempting to transfer into his/her recliner when the resident dropped his/her crutch and fell, injuring his/her right leg. He/she experience immediate severe pain in the right thigh and knee. A Computed Tomography (CT) scan of the right femur without contrast showed comminuted fracture of the distal femoral and indicated the resident had an Open Reduction and Internal Fixation (ORIF) of right femur on 12/28/21. Resident #28 has been mobilizing primarily via wheelchair and crutches secondary to increasingly severe chronic right knee pain due to osteoarthritis. The hospital transfer medication record dated 1/11/22 identified that Resident #28 had a physician's order for Enoxaparin 40mg/0.4ml injection (anti-coagulant) subcutaneously (SQ) every 12 hours and noted non-weight bearing to the right lower extremity. A review of Medication Administration Record (MAR) dated 1/11/22 directed to administer Enoxaparin 40mg/0.4ml injection SQ every 12 hours at 9:00 AM and 9:00 PM. The Resident Care Plan (RCP) dated 1/12/22 reviewed on 3/16/22 failed to identify the use of an anticoagulant including measures to monitor the resident for adverse side effect. A review of facility policy for bleeding precaution notes in part all staff are aware of residents on anticoagulant therapy and are alert for any signs of abnormal, unusual bleeding. For procedure, the policy note's all residents on anticoagulant therapy have the therapy and observation for bleeding precautions identified on their care plan. Interview and review of the clinical record with the Director of Nursing Services (DNS) on 3/16/22 at 12:00 PM identified that the facility will monitor residents admitted with anti-coagulant for bleeding precaution. The DNS also indicated she would expect their MAR to show an alert to reflect residents who use anti-coagulant that are on bleeding precaution. Additionally, the DNS identified there should have been a care plan developed for the resident's use of an anticoagulant medication. On 3/17/22 at 11:00 AM, a follow-up interview with the DNS and License Practical Nurse (LPN #2) identified s/he is responsible for developing the resident comprehensive person-centered care plan. Interview and review of clinical record with LPN#1 on 3/16/22 at 1:30 PM identified she was aware Resident #28 was on anti-coagulant injection twice a day due to immobility. She also indicated she knew what to monitor such as: abnormal bruising, bleeding, black stool. LPN #1 stated the facility MAR will have an alert to show residents on bleeding precaution who utilized an anti-coagulant medication. Interview and review of clinical record with LPN#2 on 3/17/22 at 11:25AM identified all residents admitted with anti-coagulant medication will have a care plan to monitor for sign and symptoms of bleeding. LPN#2 stated the staff nurse is responsible for developing the resident's initial care plan; however, she further indicated she was responsible for reviewing the record and developing the comprehensive person-centered care plan. LPN#2 identified she failed to develop a care plan related to use of anti-coagulant in the clinical record. 3.Resident #156 was admitted with diagnoses that included heart failure, hypertension, and atrial fibrillation. A quarterly MDS assessment dated [DATE] identified that Resident #156 had intact cognition requiring extensive assistance of 2 for bed mobility, transfer, and personal hygiene. A physician's order dated 2/16/22 directed for Resident #156 to be seen and treated by hospice. A social service progress note dated 2/17/22 at 7:44 AM identified that Resident #156 requested hospice services and family agreed. On 3/17/22 at 11:00 AM during an interview with RN #1 identified Resident #156's clinical record lacked a hospice care plan and that Resident #156's facility comprehensive care plan also lacked an area to address Resident #156's change of condition to hospice. On 3/17/22 at 12:30 PM interview with the DNS identified that if a resident is on hospice, a care plan should be in place. For Resident #156, the DNS was unable to locate a hospice plan of care. She continued by stating that usually, hospice will place the care plan in the resident's medical record and facility staff will update the resident's comprehensive plan to identify that the resident is on hospice. Interview with LPN #2 (MDS Coordinator) identified that the resident's care plan would be updated to reflect the resident's change to hospice. LPN # 2 also indicated she would be notified by email from social services of the change. She continued by stating that she had started the significant change MDS assessment on 3/2/22 so she must have been made aware of Resident #156's change to hospice, but she could not recall an email. She further indicated that the Social Worker (SW) would place something in the resident's facility care plan and would check to see if a plan was in place. On 3/17/22 at 1:00 PM interview with the Social Worker identified that she would document a note when she received a fax from hospice indicating that the resident was accepted into the program. At that point she would send an email to the business office and would update the Interdisciplinary Team at morning report or by email. She would also update the resident's facility care plan. She also indicated she could not recall the specifics of why Resident # 156's care plan was not updated. Subsequent to the surveyor inquiry, the facility contacted hospice faxed Resident #156's hospice plan to the facility. The facility's policy: Comprehensive Care Plan in part directs that the facility develops and implement a comprehensive person-centered care plan for each resident, that meets a resident's medical, nursing, mental and psychological needs. The facility policy: Providing end of life care identified in part that Hospice care as a comprehensive set of services identified by an interdisciplinary group. The nursing facility hospice services agreement in part directs that in accordance with applicable federal and state, the facility shall coordinate with Hospice in developing a Plan of Care for each Hospice Patient.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility's policy, and interviews for 1 of 2 residents (Resident # 5) reviewed for dementia care, the facility failed to develop and implement plan of care to address the care and treatment for a resident with a diagnosis of dementia. The findings include: Resident #5 was admitted on [DATE] with diagnoses that included anxiety, dementia, and heart failure. The physician's order dated 12/16/21 directed Olanzapine 5 MG 1 tablet by mouth at bedtime for dementia. The Omnicare Pharmacy Consultation report dated 12/20/21 identified the resident receives an antipsychotic and the recommendation was to include guidance for Olanzapine in the interdisciplinary care plan. The quarterly MDS assessment dated [DATE] identified Resident #5 had modified independence for daily decision making. It further identified the resident had an active diagnosis of non-Alzheimer's dementia. The care plan dated 1/28/22 identified Resident #5 had a potential nutritional problem related to history of dementia. Interventions included to obtain and monitor laboratory work as ordered, reported results to Medical Doctor (MD), to provide diet as ordered and weight as ordered by physician. The care plan failed to address the care and treatment for Resident #5's dementia diagnosis. The social service note dated 2/16/2022 identified a decision was made for Resident #5 to remain at this facility rather than transfer to the Memory Care Unit. The physician's order dated 3/3/22 directed Depakote sprinkles 125 MG, 1 capsule by mouth once a day for behaviors and mood related to dementia with behavioral disturbance. On 3/16/22 at 2:00 PM interview with the DNS identified the MDS Coordinator is responsible for creating and updating care plans. On 3/17/22 at 11:25 AM Interview with LPN #2 (MDS Coordinator) identified residents with dementia usually have a dementia care plan or sometimes the dementia will be addressed with behavioral monitoring if they have behaviors. She further identified sometimes dementia will be vaguely put in with other care plan areas. The facility Comprehensive Care Plan Policy identified the comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. It further identified the comprehensive care plan will describe, at a minimum, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Although requested, a facility policy for dementia care was not provided.

Based on review of facility's documentation, review of facility's policy and interviews conducted regarding Covid 19 vaccination status staff, the facility failed to ensure documentation for a medical exemption was signed and dated by a physician and exemptions were securely maintained. The findings include: A review of facility's documentation of staff vaccinations on 3/15/22 identified that LPN #1 failed to have a medical exemption that explained the contraindication or clinical reasons for contraindication, statement by practitioner for exemption, which should include a signature, and dated by practitioner. On 3/15/22 at 1:00 PM interview with the DNS identified that the administrator was responsible for maintaining the documents for staff exemptions. She further identified LPN #1 and Nurse Aide (NA #1) medical exemptions were misplaced during renovations and the administrator was currently looking for the documents. Interview with the Administrator on 3/16/22 on 12:00 PM identified he did not have the required documentation that confirms recognized clinical contraindications to Covid 19 vaccines for a medical exemption for LPN #1. He identified he lost LPN #1 original medical exemption from her practitioner and her practitioner will not approve a new exemption for her. The administrator provided NA #1 religious exemption signed by the administrator on 9/7/21 and by NA #1 on 3/15/22. He further identified he lost NA #1 original religious exemption and created a new copy which is why there was a discrepancy in the signature dates. On 3/16/22 at 12:30 PM Interview with LPN #1 identified she did submit a physician note and physician signed medical exemption along with the facility's medical exemption form to the facility on 9/1/21. Review of timecard for LPN #1 identified she worked on 3/1/22 through 3/5/22 and 3/10/22 through 3/15/22. Covid 19 Mandatory Vaccination Policy identified the vaccination status of all employees shall be authenticated and documentation verifying such shall be maintained in a confidential manner. The following documentation will be maintained and shall be made available to the Department of Public Health at their request; fully vaccinated and the dates of vaccination, religious or medical exemption.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility policy and staff interview, for 1 resident (Resident #47) reviewed for privacy, the facility failed to maintain resident privacy while administering a medical treatment. The findings include: Resident #47 was admitted to the facility on [DATE] with diagnosis that included dementia, depression and anxiety. A physician's order dated 5/8/19 directed to apply Voltaren gel 1% (a medication used to treat joint pain caused by osteoarthritis) topically to bilateral knees every day and evening shift. The quarterly MDS dated [DATE] identified Resident #47 had severely impaired cognition, required extensive assistance of 1 person for bed mobility, transfers, dressing and toilet use, and walked with supervision. The care plan dated 8/22/19 identified Resident #47 had osteoporosis with an intervention to administer analgesics as needed for pain. Observation on 9/9/19 at 11:30 AM identified Resident #47 was seated in a wheelchair across from the nurse's station. LPN #1 was observed to pull up Resident #47's pant legs at the nurse's station, reach under the resident's clothing and apply gel to both of Resident #47's knees. Additionally, the application of the gel was in the presence of Resident #7 who was sitting beside Resident #47 in the hallway. Review of the September 2019 TAR identified, Voltaren gel 1% was administered on 9/9/19 during the day shift. Interview with LPN #1 on 9/9/19 at 11:35 AM identified she did not ask Resident #47 for permission to administer the Voltaren gel in the hallway. Interview with the DNS on 9/9/19 at 2:45 PM identified that LPN #1 should not administer a treatment in the hallway and/or in the presence of others. Review of the facility policy for medication administration identified to provide privacy when administering medications. Review of the residents bill of rights identified residents have the right to privacy in receiving personal and medical care and treatment.

**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 #50) the facility failed to ensure the resident's wheelchair was maintained in a safe, clean and/or homelike manner. The findings include: Resident #50 was admitted to the facility on [DATE] with diagnoses that included unspecified osteoarthritis and Parkinson's disease. Review of a 24 hour positioning plan dated 7/30/19 identified Resident #50 had a manual wheelchair, with instruction that nursing staff will notify maintenance if the wheelchair needed to be cleaned. Additionally, the positioning plan included a photograph of Resident #50 seated in the wheelchair which had sheepskin covered arm rests. The quarterly MDS dated [DATE] identified Resident #50 had severely impaired cognition, and required extensive assistance with bed mobility, transfers, locomotion, dressing, eating, toilet use and personal hygiene. The care plan dated 8/29/19 identified Resident #50 had a history of bruising and skin tears related to fragile skin. Interventions included the application of geri sleeves (sleeves to protect arms or legs) to the resident's arms for protection, physical therapy screening order to ensure that the wheelchair arms are at the proper height, and apply sheepskin to the right side of the wheelchair. Additionally, the care plan identified Resident #50 had a customized wheelchair and a 24 hour positioning plan was in place. A physician order dated 9/1/19 directed to apply lamb's wool to Resident #50's wheelchair arms. Observation on 9/9/19 at 10:48 AM and on 9/10/19 at 10:30 AM identified Resident #50 was seated in a customized wheelchair, dressed, with geri sleeves in place. Both arm rests of the wheelchair were covered with tan sheepskin that was matted down. Additionally, there were 2 quarter sized brown stains visible on the right armrest, and 3 pea sized brown stains visible on the left armrest. Interview with NA #2 on 9/11/19 at 11:06 AM identified Resident #50 uses a custom wheelchair and frequently has skin tears. NA #2 identified that nursing staff does not clean the resident's wheelchairs, and indicated that rehabilitation department maintained and cleaned the armrests with the sheepskin. NA #2 identified if she sees a wheelchair is dirty she would update the nurse. Interview and review of the clinical record with Director of Rehabilitation on 9/11/19 at 11:27 AM identified that housekeeping would be responsible for cleaning the sheepskin covered arm pads on the resident's wheelchairs. The Director of Rehabilitation identified that Resident #50's most recent custom wheelchair screen performed by the rehabilitation department was on 7/10/19. Although the screening documented the custom wheelchair was clean and that the fabric on the wheelchair was not sagging or torn, the Director of Rehabilitation could not identify if the rehabilitation staff assessed the affixed sheepskin on the wheelchair arms. The Director of Rehabilitation identified housekeeping is responsible to clean the sheepskin but indicated she was not certain how the sheepskin is cleaned. Although requested, the Director of Rehabilitation was unable to provide a policy for quarterly custom wheel chair screenings nor a policy related to rehabilitation's cleaning of resident wheelchairs. Interview and observation of Resident #50 with the infection control nurse, (RN #1) on 9/11/19 at 12:36 PM identified that nursing was responsible to notify housekeeping when the sheepskin on wheelchairs needs to be cleaned. Review of the housekeeping/maintenance communication book at that time failed to reflect nursing had requested Resident #50's sheepskin covered and affixed wheelchair arms be cleaned. Observation of Resident #50 with RN #1 identified the resident was seated in the custom wheelchair, the arm rests were covered with sheepskin which was matted down, and brown stains were visible on both arm rests. There was no additional sheepskin overlay identified on the wheelchair arm rests. RN #1 identified that the sheepskin on the arm rests was dirty and needed to be changed to ensure cleanliness and infection control. RN #1 indicated there was no process in place to ensure the sheepskin covered arm rests were cleaned. Interview with the Director of Housekeeping on 9/11/19 at 12:57 PM identified that she directed the housekeepers wipe down resident wheelchair frames with a germicide solution as part of their daily routine. The Director of Housekeeping noted that she was not aware that there were residents with sheepskin affixed to the wheelchair armrests and could not identify if or how the affixed sheepskin was cleaned and/or if the sheepskin should be cleaned with the germicide solution. The Director of Housekeeping identified that cleaning of the affixed sheepskin covered wheelchair armrests was overlooked. Interview with the Director of Rehabilitation on 9/12/19 at 9:34 AM identified that although custom gel filled sheepskin covered arm pads were delivered on 4/7/16, she was unable to locate the wheelchair manufacturer's guidelines on how the sheepskin was to be cleaned or maintained. Although requested, a policy for wheelchair assessment/cleaning was not provided. Review of the resident's rights identified that residents have the right to be in an environment that promotes maintenance or enhancement of quality of life, and in care for their personal needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility policy and staff interview for 1 of 3 residents (Resident #21) reviewed for accidents, the facility failed to provide adequate supervision to prevent a fall. The findings include: Resident #21 was admitted to the facility on [DATE] with diagnosis that included dementia, depression, macular degeneration, unsteadiness on feet, osteoarthritis of both knees, and repeated falls. Review of the clinical record identified Resident #21 had 8 falls between 3/19/19 - 5/17/19. Resident #21 fell on 3/19, 3/20, 4/5, 5/3, 5/8, 5/16, 5/23, and 5/27/19. The fall risk assessment dated [DATE] identified Resident #21 was at high risk for falls. The quarterly MDS dated [DATE] identified Resident #21 had severely impaired cognition, required extensive assistance of 1 person for bed mobility, transfers, walking in room, toileting, dressing and personal hygiene. Additionally, the MDS identified Resident #21 was occasionally incontinent of urine and was not steady and only able to stabilize with staff assistance to move on and off the toilet and had a history of falls. Review of the clinical record identified Resident #21 had 2 falls on 7/3 and 7/6/19. The care plan dated 7/11/19 identified Resident #21 was at risk for falls related to confusion and history of falls. Interventions included prompt responses to all requests for assistance, safe environment that is clutter free, adequate and glare free lighting, call light in reach, bed in low position, handrails on walls and personal items in reach. Review of the clinical record identified Resident #21 had 11 falls between 7/16/19 - 8/28/19, on 7/16, 7/17, 7/26, 7/27, 7/31, 8/5, 8/6, 8/7, 8/11, 8/15, and 8/26/19. The bedside [NAME] report, interventions undated, identified Resident #21 required assistance from staff for toileting. A fall scene investigation report dated 8/29/19 identified Resident #21 was found sitting on the bathroom floor in his/her room with a small skin tear noted to the left shin. A written statement by NA #1 identified she put Resident #21 on the toilet and told him/her to ring when ready. Additionally, NA #1 identified Resident #21 self-transferred. A call was placed to NA #1 on 9/11/19 at 11:45AM and was unable to reach. Interview with the DNS on 9/11/19 12:24 PM identified Resident #21 required assistance of 1 person for toileting and was at risk to fall. The DNS indicated she would have expected Resident #21 not be left alone in the bathroom. Review of the fall policy identified each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls. Although Resident #21 had severely impaired cognition, poor safety awareness, was at high risk to fall, and had 21 falls between 3/19/19 - 8/28/19, the facility provide adequate supervision to prevent the resident from repeated falls. Subsequently, on 8/29/19, Resident #21 was left in the bathroom without the benefit of supervision and had an unwitnessed fall.

**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 1 of 2 resident's, (Resident #36), reviewed for indwelling urinary catheter, the facility failed to ensure there was an indication for the continued use of the catheter. The findings include: Resident #36's diagnoses include dementia, ischemic heart disease and hemiplegia following intracranial hemorrhage. A significant change MDS dated [DATE] identified Resident #36 had moderately impaired cognition, required extensive assistance of with bed mobility and toilet use and was occasionally incontinent of urine. Review of the clinical record identified Resident #36 was hospitalized on [DATE] and was readmitted on [DATE] with an indwelling foley catheter. A physician's order dated 12/28/18 directed comfort measures only, do not hospitalize. A physician's order dated 1/28/19 directed may have hospice services. A significant change MDS dated [DATE] identified Resident #36 had short and long term memory problems, modified independence in cognitive skills, required extensive 2 person assistance with bed mobility, transfers, toilet use, had an indwelling catheter and received hospice services. A nurse's note dated 5/9/19 at 10:57 PM identified the resident had urinated onto the chuck pad despite the presence of an indwelling catheter. Additionally, the note identified the catheter was removed, and Resident #36 was placed on a voiding trial. A nurse's note dated 5/10/19 at identified Resident #36 was incontinent of a large amount of urine at 4:30 AM. A nurse's note dated 5/12/19 identified the physician was called because Resident #36 had not urinated in the past 8 hours. Resident #36 was straight catheterized for 200ml of cloudy amber urine. Subsequent to physician notification, new orders include to push fluids and re-insert the catheter if the resident does not urinate in 12 hours. At 7:30 PM, the indwelling catheter was re-inserted, urine output was 750ml golden at first, then thick brown with sediment. Review of the clinical record indicated Resident #36 was discharged from hospice services on 7/11/19. Review of the clinical record on 9/12/19, including nurse's notes, physician notes and physician orders dated 5/12/19 to present failed to reflect an indication and/or further plan for the continued use of the indwelling catheter. Review of Resident #36's diagnoses list on 9/12/19 identified a diagnosis of neuromuscular dysfunction of bladder was added to the diagnoses list on 9/10/19. Interview and review of the clinical record with RN #2 on 9/12/19 at 12:10 PM indicated there had been no diagnosis written by the physician for the continued use of the indwelling catheter. In addition, RN #2 indicated a diagnosis for the indwelling catheter was added to the diagnosis list after discussion with the clinical team on 9/10/19. Finally, RN #2 indicated there should have been re-evaluation for the use of the indwelling catheter after Resident #36 improved and was discharged from hospice services. Review of the facility policy for urinary catheters identified the licensed nurse is to ensure there is an appropriate diagnosis to support the use of indwelling catheters including neurogenic bladder, obstructive uropathy or terminal illness. The facility failed to complete timely ongoing and appropriate assessments, and the clinical record failed to reflect documentation by the attending physician of the valid clinical indication to support the ongoing use of the indwelling catheter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record and staff interviews, for 1 of 7 residents (Resident #42) reviewed for bedrails, the facility failed to conduct a bedrail assessment to identify entrapment risk, resident need and/or obtain informed consent for the use of a bed rail. The findings include: Resident #42 was admitted to the facility on [DATE] with diagnosis that included dementia, anxiety, depression, and psychotic disorder with delusions. Review of the resident council meeting minutes dated April 11, 2019 identified facility residents were informed that there are new regulatory standards regarding the use of bed rails. Additionally, the minutes identified side rails were considered a choking and fall hazard and the facility was in the process of removing side rails and those residents who need something to position themselves in bed will have a new bar installed. The significant change MDS dated [DATE] identified Resident #42 had severely impaired cognition, required extensive assistance of 2 persons for bed mobility, transfer, walking in room, dressing and personal hygiene. Additionally, the MDS identified Resident #42 did not use bed rails. Review of the care plan dated 8/14/19 failed to reflect the use of bedrails. Review of physician's orders for September 2019 failed to reflect bedrails. Review of the clinical record failed to reflect a bedrail assessment and/or informed consent for the use of bedrails had been completed/obtained. Observation of Resident #42 on 9/11/19 at 6:45 AM identified Resident #42 lying in bed, on an air mattress, in a non-power crank bed with the right side of bed against the wall. Additionally, a silver metal half bedrail was observed raised on the left side of the bed with 5 wide gaps. Interview and observation of Resident #42's bed rail with the DNS on 9/11/19 at 8:00 AM identified the bedrail was a half rail and was in a raised position with notable gaps. Additionally, the DNS indicated Resident #42 should not have a bedrail on the bed. Further, the DNS measured the gaps (gap #1 at the head of the bed measured 8 inches x 9 inches, gap 2 measured 16 inches x 4 inches, the middle gap measured 17 inches x 8 inches, gap 4 measured 16 inches x 4 inches and gap 5 near the middle of the bed measured 8.5 x 8 inches). The DNS identified that residents should have bedrails on their bed, unless they were positioning rails, and she indicated she did not know why the bedrail was being used for Resident #42. The DNS further identified the facility does not conduct any type of bedrail assessment to determine need, obtain informed consent and/or complete care plans for the use of bedrails. Subsequent, to surveyor inquiry the DNS indicated she would have the maintenance staff remove the bedrail from Resident #42's bed. Interview with the Director of Maintenance on 9/11/19 at 10:00 AM identified the maintenance department conducts bedrail assessments twice a year to check functionality, however an assessment for entrapment is not completed. Additionally, the Director of Maintenance indicated he removed the bedrail from Resident #42's bed this morning as requested by the DNS and identified the facility has removed a few bedrails as residents are discharged . Further, the Director of Maintenance identified all beds would be replaced with new electric beds without bedrails. Interview with the Administrator on 9/11/19 at 10:38 AM identified new beds without rails would be purchased, however the facility was currently trialing beds and there was no timeline or plan for replacement. Additionally, the Administrator identified she was not certain why the bedrails were still being used. Although a bedrail policy was requested a policy was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility policy and interview for 1 resident (Resident #55) reviewed for pain management, the facility failed to ensure narcotic medication was securely stored. The findings include: Resident #55 was admitted to the facility on [DATE] with diagnoses that included, abnormal posture and anxiety. Physician's order dated 5/6/19 directed to administer Oxycodone (schedule II narcotic pain medication) 10mg every 8 hours as needed (prn) for breakthrough pain. A self-administration of medication evaluation dated 8/7/19 identified Resident #55 requested to give self Oxycodone. This was discussed with the team and physician, and the resident was able to safely demonstrate abilities and will report upon taking and nurse will record and replace. The significant change MDS dated [DATE] identified Resident #55 had intact cognition. The August 2019 monthly physician's orders directed Oxycodone 10mg every 8 hours prn for breakthrough pain, Tramadol 50mg every 8 hours prn for pain, Trazodone 50mg, give 0.5 tablet every 6 hours prn for sleep and Zofran 4mg every 4 hours prn for nausea/vomiting. The care plan dated 8/9/19 identified Resident #55 may self-administer the following medications: Oxycodone, Tramadol, Trazadone and Zofran. Interventions included to provide a lock box if the resident keeps medications at bedside, and educate the resident to keep all medications secured. A physician's order dated 8/9/19 directed Resident #55 may self-administer prn Oxycodone and keep medication at bedside. Nurse will record dose as reported by resident. A physician's order dated 8/14/19 directed Resident #55 may self-administer prn Oxycodone, Ultram, Trazodone and Zofran and may keep at the bedside. Nurse will record dose as reported by resident. Observation and interview with Resident #55 on 9/9/19 at 11:33AM identified the resident had a private room and kept the door closed. There was a small silver box resting on the over bed table. Resident #55 indicated that the box was locked and contained medications he/she was able to take independently. The medications in the locked box were identified as Oxycodone, Tramadol, Trazodone and Zofran. Resident #55 indicated he/she had a key which was kept hidden and the nurse also had a key. Interview with LPN #2 on 9/10/19 at 1:20 PM identified that Resident #55 has had the medication lock box in his/her room for about a month. LPN #2 indicated there were 4 labeled envelopes in the lock box that contained 1 pill each of the 4 medications (Oxycodone 10mg, Tramadol 50mg, Trazodone 25mg and Zofran 4mg). LPN #2 identified that the resident informs the nurse after taking the medication, which is then documented in the electronic medical record (EMR) and the medication is replaced. LPN #2 could not explain why the lock box, that contained 2 narcotic medications, was not permanently affixed. Interview with the DNS on 9/10/19 at 2:00 PM identified that although she was aware that narcotic boxes stored in the medication room refrigerator needed to be permanently affixed, she had not thought about the need to do the same in the resident's room. The DNS identified that she would address the problem immediately. Review of the facility's self-administration of medication/resident lock boxes policy identified that a resident may self-administer their own medication after the facility's interdisciplinary team has determined medications may be administered safely. A lock box will be provided by the facility. Review of the facility's policy on controlled substances storage and accountability identified medications listed in schedules II, III, IV and V are stored under double lock in a locked cabinet or safe, or medication cart drawer designated for that purpose, separate from all other medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility policy and staff interviews for 1 resident (Resident #47) reviewed for infection control, the facility failed to perform hand hygiene (wash hands) after completing a treatment. Resident #47 was admitted to the facility on [DATE] with diagnosis that included dementia, depression and anxiety. The physician's order dated 5/8/19 directed to apply Voltaren gel 1% topically to both knees every day and evening shift. The care plan dated 8/22/19 identified Resident #47 had osteoporosis with interventions that included to administer analgesics as needed for pain. The quarterly MDS dated [DATE] identified Resident #47 had severely impaired cognition, required extensive assistance of 1 person for bed mobility, transfers, dressing and toilet use and walked with supervision. The September 2019 TAR identified Voltaren gel 1% was administered on 9/9/19 during the day shift. Observation on 9/9/19 at 11:30 AM identified Resident #47 was seated in a wheelchair across from the nurse's station. LPN #1, wearing a pair of gloves, pulled up Resident #47's pant legs and reached under the clothing to apply the cream to both knees. LPN #1 returned to the medication cart, removed her gloves, placed the gloves in the trash can on the medication cart, proceeded to the treatment cart down the hall and placed the cream back in the cart without the benefit of washing her hands. Additionally, LPN#1 returned to the medication cart, picked up a cup of medications, placed the medication in the pill crusher, crushed the medications and placed them in pudding without the benefit of washing her hands. Interview with LPN #1 on 9/9/19 at 11:35AM identified she did not wash her hands after she applied the cream to Resident #47's knees, and did not do so because she was nervous. Subsequent to surveyor inquiry, LPN #1 washed her hands. Interview with the DNS on 9/9/19 at 2:45 PM identified LPN #1 should have washed her hands after she removed her gloves. Review of the facility policy for hand hygiene identified hand hygiene shall be practiced after each resident contact even if gloves are worn. Additionally, the policy for glove use identified gloves do not replace hand hygiene.