**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review for 1 of 1 sampled residents (Resident #566) reviewed for an indwelling urinary catheter, the facility failed to provide a privacy covering on a urinary collection bag. The findings include: Resident #566's diagnoses include retention of urine, benign prostatic hyperplasia, and Parkinson's disease. The Resident Care Plan dated 7/31/24 identified Resident #566 utilized an indwelling foley catheter. Interventions included enhanced barrier precautions, foley to remain patent, to maintain the foley as ordered in the treatment administration record and to provide education on catheter use. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #566 was severely cognitively impaired, required substantial/moderate assistance for transfers and was dependent for toileting hygiene, bathing, and lower body dressing. Additionally, the MDS identified Resident #566 utilized an indwelling urinary catheter. Observations on 8/1/24 at 10:35 AM identified Resident #566 was in bed with an indwelling urinary catheter, the urinary collection bag was resting on the floor with urine visible in the collection bag, without the benefit of a privacy bag covering the collection bag. Observation on 8/5/24 at 6:26 AM identified Resident #566 was in bed with an indwelling urinary catheter (visible from the hallway), the urinary collection bag was resting on the floor with urine visible in the collection bag, without the benefit of a privacy bag covering the collection bag. Interview and observation with Registered Nurse (RN) #1 on 8/5/24 at 7:40 AM identified that per facility policy the drainage bag should be up off the floor and in a privacy bag. Subsequent to surveyor inquiry, Registered Nurse (RN) #1 placed a privacy covering on Resident #566's urinary collection bag and raised the collection bag off the floor. Interview with the Infection Control Nurse (LPN #5) on 8/7/24 at 10:16 AM identified collection bags should be stored on the bed rail or under wheelchair and in a privacy bag. Although requested, a facility policy for privacy coverings for urinary collection bags was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of the clinical record, and facility documentation for 1 of 5 sampled residents (Resident #47) reviewed for unnecessary medication, the facility failed to accurately transcribe an Advanced Practice Registered Nurse (APRN) medication order. The findings include: Resident #47 diagnosis included vascular dementia with behavioral disturbance, unspecified psychosis, and Alzheimer's disease. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #47 was severely cognitively impaired and required supervision with eating, partial assistance with oral hygiene, and was dependent with toileting, upper/lower body dressing, and personal hygiene. Additionally, the MDS identified Resident #47 received antidepressant medication. The Resident Care Plan dated 2/21/24 identified behavioral symptoms. Interventions included providing medications as ordered with physician discussion regarding dose revision and effect as needed. A Psychiatric progress note dated 4/17/24 written by APRN #1, identified that she was asked to evaluate Resident #47 for behavioral disturbances, restlessness, eating poorly, and trying to climb out of bed at night when his behaviors become acute. An order from APRN #1 dated 4/17/24 directed to discontinue Trazodone (a medication to treat depression) 50 milligrams (mg) at bedtime and start Trazodone 75 mg at bedtime. APRN #2 (medical APRN) entered an order in the electronic chart for Trazodone 25 mg at bedtime to start 4/17/24 (despite APRN #1 writing order for 75 mg). A nurse's note written by LPN #4 dated 4/17/24 at 8:48 PM identified an order written by APRN #1 that Trazodone was decreased to 25 mg at bedtime, despite APRN #1 writing an order for Trazodone for 75 mg (APRN #1's handwritten order was misinterpreted by LPN #4 to read 25 mg instead of 75 mg). Nursing notes dated 4/23/24 at 6:57 AM, identified extreme restlessness on the night shift; with Resident #47 removing his/her dry brief and soaker pad from the bed and urinating on the bed and clothes four times during the night. Additionally, the nursing notes identified Resident #47 had both legs over the side of the bed. Resident #47 wanted to check the roster, and staff unable to redirect the resident with offers of food or conversation, the resident did not sleep all shift. Nursing notes dated 4/24/24 at 7:17 AM, identified Resident #47 was restless all shift, again removing his/her brief and urinating on the linens on the floor three times during the night. Resident #47 had his/her legs over the positioning pillow and wanted to go to the theatre. Offers of food and fluids did not decrease restlessness. On 4/25/24 a progress note written by APRN #2 identified that Resident #47 had a recent reduction in two of his/her medications and that his/her restlessness had increased at night. APRN #2 recommendation at that time was to increase the Trazodone to 50 mg from 25 mg (despite the psychiatric APRN #1 originally writing order for Trazodone 75 mg on 4/17/24). Interview with LPN #5 on 8/6/24 at 2:00 PM identified that Psychiatric APRN #1 did not enter orders in the electronic chart but wrote her orders on paper. LPN #5 stated that LPN #4 (who no longer works at the facility) transcribed the orders incorrectly into the electronic chart. Interview with APRN #1 on 8/6/24 at 2:20 PM identified that she was unable to write orders in the electronic chart, but she communicated with nursing staff regarding the medication changes and the reason for the increase in dosage from 50 mg to 75 mg.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of the clinical record, and facility policy, for 1 of 2 residents (Resident #36) reviewed for pressure ulcers, the facility failed to ensure an alternating pressure mattress (APM) was set at the appropriate setting according to the physician's orders. The findings include: Resident #36's diagnoses included congestive heart failure, hypertension, unspecified protein calorie malnutrition and muscle weakness. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #36 was moderately cognitively impaired, and was dependent on staff with bed mobility, transfers, and ambulation. In addition, Resident #36 was frequently incontinent of urine and bowel and was at risk of developing pressure ulcers. Physician's order dated 7/24/24 directed an alternating pressure mattress (APM) with air loss at a weight setting of 165 pounds and to check placement and inflation each shift. The Resident Care Plan dated 8/1/24 identified Resident #36 was at risk for skin breakdown due to decreased mobility, and incontinence. Interventions included an alternating pressure air mattress, following skin care protocol using preventive measures when indicated, offloading heels while in bed, and providing treatments as ordered. A physician progress note dated 8/2/24 identified Resident #36 with a 1.5 centimeter (cm) by 1.0 cm dark purple area with a small superficial opening on the coccyx. The physician identified the area as a new deep tissue injury possibly developed when Resident #36's APM deflated accidentally as reported by the nursing staff. Observation on 8/6/24 at 10:00 AM and 8/7/24 at 9:00 AM identified that Resident #36's APM was set at 200 pounds. Review of Resident #36's clinical record identified that staff was signing off the APM setting of 165 pounds. Observation and interview with the Wound Advanced Practice Nurse (APRN #3) and wound Nurse (RN #3) on 8/7/24 at 9:10 AM identified that the APM was set at 200 pounds instead of 165 pounds (per the physician's order). The Wound APRN further stated that an APM setting of 200 pounds could negatively affect the healing of the wound for Resident #36. In addition, APRN #3 stated that the physician order should have been followed for a setting at 165 pounds. Subsequent to surveyor inquiry, the APM setting was adjusted by APRN #3 to reflect Resident #36's weight of 165 pounds. Interview with the RN #4 on 8/7/24 at 9:20 AM identified that the Charge Nurse on the unit was responsible for checking the placement and inflation of the APM each shift and as needed. RN #4 stated that she had not yet made her rounds for the day shift and could not explain the reason the APM was not set at the correct setting. Review of facilities Pressure Reducing Mattress policy identified, in part, that residents with an identified pressure area will be provided with an alternating pressure air mattress when appropriate and the APM will be checked for placement and inflation each shift and as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, review of the clinical record, and facility policy for 1 of 1 sampled resident (Resident #11) reviewed for range of motion (ROM), the facility failed ensure a device was applied for hand contractures. The findings include: Resident #11's diagnoses included Alzheimer's disease, poly osteoarthritis abnormal posture, and contractures of right/left hands. A Quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #11 had a short/long term memory problem and upper/lower extremity limited ROM/impaired on both sides. Additionally, the MDS identified Resident #11 required maximal assistance with eating and was dependent with oral hygiene, toilet use, shower/bathing and upper/lower body dressing. An Occupational Therapy (OT) evaluation and plan of treatment dated 1/17/24 indicated Resident #11 had impaired ROM to the right upper extremity (elbow, wrist, hand, thumb, index finger, middle finger, ring finger and little finger), additionally, impaired ROM to the left upper extremity (wrist, hand, thumb, index finger, middle finger, ring finger, and little finger). There was functional limitation present due to contracture and Resident #11's ability to express ideas, wants and ability to understand others was rarely or never understood. A physician's order dated 5/15/24 directed Resident #11 to have a [NAME] guard applied to the right hand daily for contracture management, remove for hand hygiene to be completed as needed every shift. Additionally, Resident #11 was to wear a rolled cloth to left hand daily, to remove for hand hygiene as needed every shift, ROM with morning and evening care every day and evening shift. The Resident Care Plan dated 7/10/24 identified functional deficits related to comorbidities and health conditions resulting in potential of low endurance and deconditioned state. Interventions included applying a rolled cloth to left hand as tolerated, transfer with assist of 2 with Hoyer lift and no ambulation at this time. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #11 was cognitively impaired with both short- and long-term memory problem, required total assistance with all activities of daily living (ADLS) and functional limitation in range of motion on both sides to both upper and lower extremities. An OT note dated 7/31/24 identified Resident #11 initially made facial expressions of pain when the therapist touched his/her right-hand and was initially guarded but tolerated ROM and minimal touching of his/her right hand, additionally he/she tolerated rolled up gauze in both hands. Nursing made aware. Observations on 8/1/24 at 10:33 AM, identified Resident #11 sleeping with hands in fists, without the benefit of cloth rolls in the hands. At 11:55 AM Resident #11 was up in the wheelchair sleeping with his/her neck leaning to right side and was moved into dining room by staff without the benefit of repositioning. Observations on 8/2/24 at 11:22 AM identified Resident #11 was up in the wheelchair without the benefit of a rolled cloth to the left hand. Interview with OT #1 identified that Resident #11 does not tolerate [NAME] guard in his/her right hand and should have a soft cloth hand rolls in his/her hands. An OT note date 8/2/24 identified Resident #11 gentle stretching to bilateral hands to decrease contractures to open hands for good hygiene care. Discussed with nursing that resident is unable to tolerate [NAME] guards and to continue to use soft cloth at this time. Observation on 8/5/24 at 10:33 AM identified Resident #11 sleeping with hands in fists without the benefits of cloth hand rolls. Observation on 8/6/24 at 11:55 AM identified Resident #11 was up in the wheelchair with his/her hands in a fist, without the benefits of cloth hand rolls or a palm guard. Observation on 8/6/24 at 12:16 PM identified Resident #11 in the dining room, handwashing was being provided for lunch, Resident #11 grimacing and crying out, pulling hand away. LPN #2 observed the resident's behavior, administered scheduled Tylenol and placed a call to APRN #4 for as needed medication for pain. Observation 8/6/24 at 1:50 PM identified Resident #11 in the room sleeping in a wheelchair without the benefit of a cloth hand roll in his/her hands, or palm guard. Observation on 8/7/24 at 9:27 AM identified Resident #11 lying in bed without the benefit of cloth handrolls in his/her hands. Observation on 8/7/24 at 10:01 AM with the DNS identified that cloth hand rolls were not in Resident #11's hands. In an interview, clinical record review and review of the Treatment Administration Record with the DNS on 8/7/24 at 10:01 AM failed to reflect documentation identifying resident refusals for the cloth hand rolls, except on 8/3/24. Subsequent to surveyor observations, a physician order was obtained to discontinue the palm guard on 8/6/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review for 1 of 3 residents (Resident #566) reviewed for infection control, the facility failed to ensure the urinary collection bag was maintained off the floor. Resident #566's diagnoses include retention of urine, benign prostatic hyperplasia, and Parkinson's disease. The Resident Care Plan dated 7/31/24 identified Resident #566 utilized an indwelling foley catheter. Interventions included enhanced barrier precautions, foley to remain patent, to maintain the foley as ordered in the treatment administration record and to provide education on catheter use. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #566 was severely cognitively impaired, required substantial/moderate assistance for transfers and was dependent for toileting hygiene, bathing, and lower body dressing. Additionally, the MDS identified Resident #566 utilized an indwelling urinary catheter. Observations on 8/1/24 at 10:35 AM and 8/5/24 at 6:26 AM identified Resident #566 was lying in bed with the urinary drainage collection bag resting on the floor with urine visible in the collection bag. Interview and observation of Resident #566 with Registered Nurse (RN) #1 on 8/5/24 at 7:40 AM identified that per facility policy the drainage bag should not be resting on the floor. Subsequent to surveyor inquiry, Registered Nurse (RN) #1 raised the collection bag so it was not resting on the floor. Observation of Resident #566 on 8/6/24 at 11:55 AM identified he/she was sitting in a wheelchair in the hallway with the urinary collection bag in a privacy bag located under the wheelchair and resting on the floor. Further observation at that time identified Nurse Aide (NA #1) pushing Resident #566 in the wheelchair in the hallway with the urinary drainage bag dragging on floor. Interview and observation with NA #2 in the presence of NA #1 on 8/6/24 at 11:55 AM identified that the drainage bag was dragging on the floor because there was no other place to secure the bag without it touching the floor. Subsequent to surveyor inquiry, NA #2 reported to the surveyor that the drainage bag was raised off the floor. Interview with the Infection Control Nurse (LPN #5) on 8/7/24 at 10:16 AM identified that collection bags should be kept off the floor, by being stored on the bed rail or under the wheelchair in a privacy bag. However, if the collection bag was in a privacy bag, then it was alright because the privacy bag acted as a barrier. Review of the Urinary Catheter Policy dated March 2024 directed to keep the collection bag below the level of the bladder and not place the urinary collection bag on the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of the clinical record, and facility policy for 1 of 4 residents (Resident #47) reviewed for nutrition, the facility failed to document the percentage of supplements consumed in regard to significant weight loss. The findings include: Resident #47's diagnoses included left sided hemiplegia and hemiparesis (muscle weakness) following a cerebral infarction, dysphagia, and dementia. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #47 was severely cognitively impaired and required supervision or touch assistance with eating, partial/moderate assistance with oral hygiene, and was dependent with personal hygiene. Additionally, Resident #47's MDS identified no significant weight loss at that time. The Resident Care Plan dated 12/8/23 identified a nutritional concern due to a cerebral vascular accident, hemiplegia and hemiparesis, dysphagia, and dementia. Interventions included to provide a one person assist with meals, give large portions, juice supplement as ordered, and to monitor appetite daily. A review of Resident #47's weights identified that Resident #47 weighed 129.3 pounds (lbs) on 1/1/24. A Dietitian's note dated 2/2/24 identified Resident #47 weighed 119 lbs (Resident #47 had a 10.3 lb/7.9% weight loss in one month) and that there was a significant decrease in weight. The Dietitian recommended that the house juice supplement be increased from twice daily to three times daily. A physician's order dated 2/2/24 directed to give a house juice supplement of 177 milliliters (ml) three times a day. Resident #47's weights were 121 lbs on 3/1/24, 115 lbs on 4/1/24, 114.2 lbs on 5/3/24, and 109 lb on 6/5/24 (a 12 lb/9.9% weight loss in 3 months). A Dietitian's note dated 6/19/24 identified Resident #47 was seen by the physician due to progressive weight loss. The Dietitian recommended that the house juice supplement be increased from three to four times daily. A physician's order dated 6/19/24 directed to give a house juice supplement four times a day. A review of Resident #47's weights identified that Resident #47 weighed 107 lbs. on 6/21/24 (which indicated a 22.3 lbs/17.2% weight loss in less than 6 months). Interview and clinical record review with the Dietitian on 8/6/24 at 12:12 PM identified that tracking consumption of the house supplement was not documented since the supplement was ordered on 2/2/24 and would be documented on the Electronic Medication Administration Record (EMAR). Additionally, the house supplement was not transcribed into the EMAR to include the ml amount consumed. Although the nurse aides document total daily fluid intake on the intake record, it does not delineate the amount of nutritional supplement consumed. Interview and clinical record review with LPN #1 on 8/6/24 at 1:42 PM identified that nurses provide residents nutritional supplements and document it was given on the EMAR. Additionally, LPN #1 identified that the consumption amount of the house supplement was not being documented on the EMAR for Resident #47. LPN #1 further indicated that Resident #47 would typically only drink about half or a quarter of the house supplement, and not drink the whole supplement at a time. Interview with the Dietitian on 8/6/24 at 1:46 PM identified that with tracking of the house supplement consumption, along with checking labs and completing closer weight monitoring, she would be able to further evaluate Resident #47's diet needs. Additionally, the Dietitian indicated that there was a high calorie gelatin that could be added to Resident #47's diet order. Subsequent to surveyor inquiry, the order for the house juice supplement was changed by the Dietitian on 8/6/24 to consume 90 ml four times a day and to document the ml actually consumed on the EMAR. Additionally, the Dietitian collaborated with the Advanced Practice Registered Nurse to have lab work ordered and recommended weight monitoring weekly for 6 weeks, then monthly. Review of the Use of Nutritional Supplements policy dated 4/23 directed, in part, that supplement orders are transcribed on the EMAR. The ml of the supplement consumed by the resident is charted on the EMAR. The Dietitian should complete periodic reassessments of the need for continuation of supplemental feeding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 Residents (Resident #26) reviewed for pressure wound, the facility failed to notify the responsible party in a timely manner. The findings include: Resident #26 was admitted to the facility with diagnoses that included rheumatoid arthritis and dementia. The care plan dated 3/10/22 identified a skin conditions and pressure ulcers. Interventions directed to derma septic to coccyx every shift and turn and reposition every 2 hours while in bed. Additionally, on 4/12/22 stage 2 pressure ulcer to left buttock. Intervention was to provide treatment as ordered. The quarterly MDS dated [DATE] identified Resident #26 had severely impaired cognition, was always incontinent of bowel and bladder and required extensive assistance with dressing and personal hygiene with assist of 2 and total care for toileting needed with assist of 2. Additionally, Resident #26 had no pressure areas. Day-Evening-Night Daily Report Sheet for Unit 1 dated 4/12/22 indicated on 11:00 PM - 7:00 AM (4/13/22) noted Resident #26 had left buttock 0.2 Centimeter (CM) x 0.2 CM superficial stage 2 open area noted. Physician was notified and staff was directed to apply triad cream to the area every 8 hours. Review of the Supervisor-to-Supervisor Daily Report Sheets dated 4/12/22 through 4/16/22 failed to indicated Resident #26 ' s Power of Attorney (POA)/family was notified of the new pressure wound. The Wound Report dated on 4/13/2022 at 3:04 AM indicated the wound type was dermatitis and the location was the left buttock that measured 0.2 CM x 0.2 CM. The nurse s note dated 4/13/2022 at 3:08 AM identified that Resident #26 was incontinent of a large amount bowel movement. Additionally, noted the resident had a superficial open area to left buttocks which measured 0.2 CM x 0.2 CM with no apparent discomfort to area. The physician was updated, and a new order was obtained to apply triad cream. A physician's order dated 4/13/22 directed to apply triad cream to open area left buttock every shift. The nurse's note dated 4/16/2022 at 1:14 PM identified that the POA was updated aware of superficial open area to left buttocks and treatment in place. Interview with MDS Coordinator RN #1 dated 4/25/22 at 9:21 AM indicated she added on 4/12/22 the resident had a stage 2 left buttock area on the care plan, because she had not seen area addressed on the 24-hour report. RN #1 review of the 24-hour report sheet dated 4/12/22 on 11-7 shift into the morning of 4/13/22 which indicated Resident #26 had a stage 2 to left buttock and the physician was notified and a new treatment order was put in place. RN #1 indicated the family was updated on 4/16/22. Observation and interview with the DNS on 4/25/22 at 10:20 AM during observation of the Resident #26's wound identified a stage 2 open area over the sacrum bony prominence on the left side. The DNS indicated her expectation would be the family would be notified immediately after a new wound was found or no later than the next shift. The DNS indicated after clinical record review she noted the wound was discovered on night shift therefore the the day nurse would be responsible for calling and updating the family. The day nurse would document the change in the progress note. The DNS indicated if the nurse was not able to reach the family, she would expect a progress note that the nurse attempted to call and left a message. The DNS indicated the RN that initially found the wound was responsible for notifying the physician, family, and the dietician. The DNS indicated Resident # 26's family was not notified until 4/16/22 three days later. Interview and clinical record review with the DNS on 4/25/22 at 1:05 PM indicated after clinical record review she would have expected the family to be notified on 4/13/22 and the family was not notified until 4/16/22 three days later. The DNS indicate she was not aware the responsible party had not been notified about the new pressure area until surveyor inquiry regarding the pressure area. Review of the Notification of Change of Condition Policy identified the facility will inform the resident's physician and responsible party when there was a significant change in residents physical, mental, or psychosocial status such as a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, review of facility documentation, review of facility policy, and interviews for one sampled resident (Resident #37) reviewed for supervision during dining, the facility failed to provide care and services in accordance with Speech Therapy (ST) recommendations. The findings included: Resident #37's diagnoses included chronic obstructive pulmonary disease, chronic kidney disease, dysphagia, osteoarthritis, status post COVID-19, dementia with behavioral disturbances, Alzheimer's disease, depression, psychosis and anxiety. The quarterly MDS assessment dated [DATE] identified Resident #37 with modified independence with cognitive skills for daily decision making, required extensive assist with bed mobility and supervision with eating. Further review identified no signs and/or symptoms of possible swallowing disorder. The care plan dated 1/6/22 identified problem with nutrition. Interventions directed to provide regular consistency diet and set up meal so the resident can eat independently in her/his room. Further review identified revised interventions dated 1/18/22 to provide mechanically altered consistency diet with thin liquids, to administer medication whole, no more than 2 to 3 pills at a time, to provide multiple sips of liquids via straw, check oral cavity before giving more. If difficulty, crush medications and put in puree. The Speech Therapist (ST) bedside dysphagia evaluation dated 1/18/22 identified Resident #37 presented with mild to moderate oral stage dysphagia with suspected mild pharyngeal stage dysphagia. The resident was at elevate risk for aspiration secondary to cognitive decline, reduced endurance, and need for increased assistance with intake. The ST note dated 2/8/22 identified that the resident was seen for dysphagia, oropharyngeal phase with recommendations to provide visual oversight in room to encourage compensatory strategies when staff assisted the resident with feeding, confirm swallow before continuing feeding and to provide alternate liquids with solids. The ST Discharge summary dated [DATE] identified the resident was able to tolerate mechanical altered, thin liquid diet. Staff was educated related compensatory strategies to utilize when feeding the resident including to alternate liquids with solids and to check if the resident swallowed before continuing feeding. A sign was also placed in the resident 's room for other staff who fed the resident to know the plan of care. The nurse's notes dated 3/27/22 identified the nurse attempted to administer 10:00 PM medication however Resident #37 was very sleepy. The resident was responsive to both verbal and tactile stimuli however wound not open eyes. Due to risk for choking medication was not given. The annual social service note dated 4/7/22 identified Resident #37 was alert and oriented with forgetfulness and confusion, at times declined assistance with activities of daily living. The note further identified the resident was independent with meal consumption and staff was available to assist as needed. Review of Resident Information Sheet dated 4/22/22 directed staff to encourage Resident #37 to eat in the dining room and to provide a mechanical altered diet. Further review failed to identified dysphagia precautions. Observation on 4/25/22 at 12:45 PM identified Resident #37 sitting in bed, in her/his room with the curtain partially pulled. The resident was eating her/his lunch unsupervised. Further observation identified a sign posted over the resident's bed directing staff When feeding: Alternate liquids with solids. Make sure she/he swallowed before feeding next bite. Interview with Licensed Practical Nurse (LPN #2) on 4/25/22 at 1:30 PM identified that Resident #37 did not required supervision during meals and was safe while eating alone in her/his room. LPN # 2 further identified that for the most part the resident eaten her/his meals independently and unsupervised in the room. Interview with Nurse Aide (NA #4) on 4/25/22 at 1:35 PM identified she delivered the resident's lunch tray and provided set-up assistance only. NA# 4 further identified that sometimes the resident required assistance with meals but when the resident was awake and alert, she/he was able to eat alone and did not required supervision during meals. Subsequent to inquiry the resident was evaluated by ST #1 on 4/25/22. Review of the Therapy to Nursing Communication sheet dated 4/25/22 identified recommendation for close supervision with assistance for feeding when needed. Patient to be verbally cued or assisted in alternating solids and liquids for food propulsion and residual clearance. Interview and review of Speech Therapy Evaluation dated 4/25/22 with ST #1 on 4/26/22 at 1:00 PM identified the resident 's overall status, behavior, alertness reportedly changes frequently during the day. The resident required close supervision during meals. Assistance with feeding should be provided when needed, depending on the resident's status. Safe feeding techniques should be followed: alternating solids with liquids, complete bolus clearance prior to presenting next bite. ST #1 further identified the resident should have been supervised during all meals since 1/18/22 evaluation. Interview with the Advanced Practice Registered Nurse (APRN #1) on 4/26/22 at 1:50 PM identified she was asked by nursing to evaluate the resident for worsening dysphagia and difficulty to swallow whole pills on 1/17/22 and at that time she requested a speech consult and discussed with pharmacy changing of medications to crushed. On 3/14/22 she evaluated the resident for dysphagia and frequent refusal of medications, the resident had no signs and symptoms of overt aspiration and the resident 's medications were changed. APRN #1 further identified she was not notified of the speech therapy recommendations, however expected to be notify or the facility should have called Medical Doctor (MD #2). Interview with MD #2 on 4/26/22 at 2:40 PM identified he would have expected to be notified of ST recommendations for Resident #37 to provide supervision and specific safety instructions during meals when discharged from ST on 2/10/22. MD #2 further identified if notified he would direct nursing staff to write an order to implement ST recommendations. Interview with Director of Nursing Services (DNS) on 4/26/22 at 2:45 PM identified that the facility was unable to locate the Therapy to Nursing Communication sheet when the resident was discharged from ST on 2/10/22 and possibly that was the reason why the recommendations were not implemented. The physician's order to provide supervision with meals, assist the resident if needed and to provide verbal cues for alternating fluids and solids when needed was obtained on 4/25/22. The nursing staff was educated and directed to provide supervision and safety to the resident during her/his meals and the residents care plan was updated on 4/25/22. Review of facility Policy and Procedure related to Dysphagia identified individuals with observed indicators of dysphagia (coughing, choking, delay swallow, pocketing of food, inability to manipulate food in the mouth, wet, gurgle voice, etc.) will be referred to the nursing to determine need for a speech evaluation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility policy and interviews for 1 of 2 residents (Resident #26) reviewed for pressure ulcer, the facility failed to have a complete and accurate initial and weekly assessment of the resident's pressure ulcer and failed to ensure the dietician had seen the resident with a new pressure area in a timely manner. The findings included: 1a. Resident #26 was admitted to the facility with diagnoses that included rheumatoid arthritis and dementia. The care plan dated 3/10/22 identified a skin conditions and pressure ulcers. Interventions directed to apply derma septic to coccyx every shift and to turn and reposition every 2 hours while in bed. Additionally, on 4/12/22 noted a stage 2 pressure ulcer to left buttock. Intervention was treatment as ordered. The quarterly MDS assessment dated [DATE] identified Resident #26 had severely impaired cognition, was always incontinent of bowel and bladder and required extensive assistance with dressing and personal hygiene with assist of 2. The assessment also noted the resident required total care for toileting needed with assist of 2 and no pressure areas. Day-Evening-Night Daily Report Sheet for Unit 1 dated 4/12/22 indicated on 11:00 PM - 7:00 AM (4/13/22) Resident #26 was noted with a left buttock 0.2 Centimeter (CM) x 0.2 CM superficial stage 2 open area. The physician was notified, and staff was directed to apply triad cream to the area every 8 hours. The Wound Report dated on 4/13/2022 at 3:04 AM indicated the wound type was dermatitis and the location was the left buttock that measured 0.2 CM x 0.2 CM. The nurse s note dated 4/13/2022 at 3:08 AM identified that Resident #26 was incontinent of a large bowel movement. Additionally, noted the resident had a superficial open area to left buttocks which measured 0.2 CM x 0.2 CM with no apparent discomfort to area. The physician was updated, and a new order was obtained to apply triad cream. A physician's order dated 4/13/22 directed to apply triad cream to open area left buttock every shift. The physician's progress note dated 4/22/22 indicated Resident #26 was on hospice care and had no new issues. MD #1 noted Resident #26 was able to eat 75% of meals. Vital signs were stable and to continue with hospice care. The physician's progress note identified no mention of a new pressure ulcer. The Resident # 26 Wound Report dated on 4/23/2022 at 3:04 PM indicated the left buttocks was length from head-to-toe direction 0.1CM and width from hip-to-hip direction 0.1 CM. Wound healing status. Interview with the DNS on 4/24/22 at 10:00 AM indicated there were no facility acquired pressure areas in the facility at this time. The DNS indicated she was responsible for the weekly wound measurements. Interview with MDS Coordinator RN #1 dated 4/25/22 at 9:21 AM indicated she added on 4/12/22 the resident had a stage 2 left buttock area on the care plan, because she had not seen the area addressed on the 24-hour report. RN #1 review of the 24-hour report sheet dated 4/12/22 on 11-7 shift into the morning of 4/13/22 indicated Resident #26 had a stage 2 to left buttock and the physician was notified. A new treatment order was put in place. RN #1 indicated the family was updated on 4/16/22. Observation and interview with the DNS on 4/25/22 at 10:20 AM during observation of Resident #26's wound identified a stage 2 open area over the sacrum bony prominence on the left side. The DNS indicated the open area was on an old scar area that reopened because the wound bed was red versus the old scar area that was larger and pink. The DNS indicated she was responsible for weekly wound measurement in the facility. The DNS indicated she was busy during the week and did not get to do Resident # 26's wound assessments and measurement until 4/23/22 (11 days later). Interview with MD #1 on 4/25/22 at 12:25 PM indicated he did not recall if any nurse informed him about the new pressure ulcer on the resident's coccyx. MD #1 indicated the day he saw Resident #26 he did not remember being told about a new pressure area on the coccyx when he had spoken with the nurse but did recall the nurse stating Resident #26 ate 75% MD #1 indicated Resident #26 was eating well and was on hospice so he would rely on hospice to guide him on the treatment. Interview and clinical record review with the DNS on 4/25/22 at 1:05 PM indicated the nurse's wound assessment dated [DATE] was entered into the system was noted as dermatitis therefore the assessment only asked for measurements. The DNS indicated the nurse failed to conduct a complete assessment of the wound because the assessment did not include the wound description, the peri wound description, and if there was any drainage or odor. The DNS further indicated since she coded it incorrectly, she would have expected a progress note including the descriptions listed and did not see any note completely describing the stage 2 pressure ulcer. The DNS indicated that the initial assessment on 4/13/22 and her assessment on 4/23/22 were incomplete and were not accurate. The DNS indicate she would change her documentation to reflect that Resident #26 had a pressure area to the coccyx not an area to the left buttock. The DNS indicated after looking at the area earlier she must have pulled the buttock skin too much causing her to misinterpret where the pressure area was located. Interview with the DNS on 4/26/22 at 11:00 AM indicated the facility does not have a wound doctor that comes to the facility but if a wound was bad enough, she would have the APRN follow the wound weekly with her. The DNS noted the APRN does not see all wounds in the facility. The DNS indicated the APRN did not see or was following Resident #26's pressure ulcer on the coccyx because it was not bad enough and was improving. Review of facility Pressure Ulcer Program Policy identified the following guidelines and interventions may be used on residents tin an effort to maintain and improve tissue tolerance to pressure. A resident who was dependent ono staff for repositioning should be repositioned at least every 2 hours per a turning schedule or more frequently depending upon the resident ' s condition and tolerance of the tissue load (pressure). b. Resident #26 was admitted to the facility with diagnoses that included rheumatoid arthritis and dementia. The care plan dated 3/10/22 identified a skin conditions and pressure ulcers. Interventions directed to apply derma septic to coccyx every shift and to turn and reposition every 2 hours while in bed. Additionally, on 4/12/22 noted a stage 2 pressure ulcer to left buttock. Intervention was treatment as ordered. The quarterly MDS assessment dated [DATE] identified Resident #26 had severely impaired cognition, was always incontinent of bowel and bladder and required extensive assistance with dressing and personal hygiene with assist of 2. The assessment also noted the resident required total care for toileting needed with assist of 2 and no pressure areas. Day-Evening-Night Daily Report Sheet for Unit 1 dated 4/12/22 indicated on 11:00 PM - 7:00 AM (4/13/22) Resident #26 was noted with a left buttock 0.2 Centimeter (CM) x 0.2 CM superficial stage 2 open area. The physician was notified, and staff was directed to apply triad cream to the area every 8 hours. The Nutrition Quarterly Assessment started on 4/13/22 and completed on 4/25/22 at 9:28 AM indicated Resident #26 had no open areas to his/her skin. Observation and interview with the DNS on 4/25/22 at 10:20 AM during observation of Resident #26's wound identified a stage 2 open area over the sacrum bony prominence on the left side. The DNS indicated the RN that initially found the wound was responsible for notifying the dietician. The DNS further indicated the nurse could leave a voice message for the dietitian at the time the wound was found and that she would expect the dietician to see the resident the same day or the next time the dietician was in the facility. The Wound Report dated 4/25/22 at 10:54 AM after surveyor inquiry noted the wound classification was a healing stage 2 wound to left sacrum with pinpoint open area with granulating tissue 0.1CM x 0.1 CM at bottom tip of old healed scar tissue. The Wound Report date 4/25/22 at 7:50 PM indicated the wound type was unspecified pressure ulcer measurement 0.1 CM x 0.1 CM with no depth and no tunneling. The surrounding tissue was pink, and the wound bed was granulation tissue. The wound was improving. The area to left sacrum was noted with a pinpoint open area with granulating tissue at bottom tip of old healed scar tissue from wound identified on 4/13/22. Interview and clinical record review with Registered Dietician (RD #1) dated 4/25/22 at 10:45 AM indicated she was at the facility daily during the week for a few hours a day. The dietician noted the quarterly assessment was started on 4/13/22 and was completed this morning on 4/25/22 at 9:28 AM. Review of her quarterly nutrition assessment RD #1 indicated that Resident #26 had intact skin. RD #1 noted she reviews the resident electronic medical record and the summary of all the nursing notes from the last quarter until today when she completed the assessment. RD #1 indicated she was rushing to complete Residents #26 's assessment. RD #1 noted sometimes nursing will call her to notify her of new skin issues. RD #1 indicated she was not aware that Resident #26 had a new wound on the coccyx or left buttock from 4/13/22. RD #1 indicated if she was notified on 4/13/22 she would have done a nutrition assessment and Resident #26 would have been placed on a supplement. She was aware the resident was a feed and does eat well better at breakfast and then the resident's consumption decrease. RD #1 noted the supplement 2 Cal does give some protein but would like to wait until she could evaluate if the treatment was effective and to identify the cause of the pressure area before adding anything in a week or 2. RD #1 indicated she would go and conduct an assessment today. The dietician progress note dated 4/25/22 at 12:56 PM indicated Resident #26 had impaired skin noted on 4/13/22 and on 4/18/22 noted as a healing stage 2 wound. Continue house supplement 3 times a day with good intake and physician order was updated to reflect 120 ml to be administered by nursing. Will consider addition of wound supplements in case of worsening of wound. Observation and interview with the DNS on 4/25/22 at 10:20 AM she indicated the RN that initially found the wound was responsible to notifying the dietician. The DNS indicated the nurse could have left a voice message for the dietitian at the time the wound was found. The DNS also indicated she would have expected the dietician to see the resident the same day or the next time the dietician was in the facility. Review of facility Pressure Ulcer Program Policy identified the following guidelines and interventions may be used on residents tin an effort to maintain and improve tissue tolerance to pressure. Under nutrition indicated consider providing additional calories to current diet, adding additional protein, and multivitamin or multivitamin with minerals. Additionally, identify if resident was at risk for hydration deficit or imbalance.

**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 #2) reviewed for Accidents, the facility failed to conduct a thorough investigation for an injury of unknow origin. The findings include: Resident #2 was admitted to the facility with diagnoses that included Parkinson's disease, dementia, cerebral infarct and vascular disease, and anxiety disorder. The quarterly MDS assessment dated [DATE] identified Resident # 2 had severely impaired cognition, was frequently incontinent of bowel and occasionally incontinent of bladder and required extensive assistance for dressing, toileting, personal hygiene, ambulating and required 2 people for transfers. The care plan dated 1/27/22 identified a risk for falls/safety. Interventions directed to apply a bed and chair alarm for safety, landing mats on each side of the bed on the floor for safety, gripper socks when in bed, and to keep pathways clear. Additionally, a revision of the care plan dated 2/13/22 directed to check staples to back of scalp. The care plan for at risk for fall updated on 2/14/22 directed a medication review, overbed table padded, physical therapy evaluation, to continue alarms and to provide supervision with all transfers and ambulation. The Accident and Incident report dated 2/12/22 at 10:40 PM identified that the nurse responded to sounding alarm and Resident #2 was standing near the bedside and the nurse redirected Resident #2 to go back to bed. The Nurse Aide (NA) went into the room to toilet Resident #2 and called the nurse into the resident's bathroom because the resident was noted bleeding from the back of the head. The APRN was notified, and an order was obtained to send Resident #2 to the emergency room for an evaluation. The risk analysis and investigation report for the 2/12/22 fall indicated Resident #2 was unable to explain how incident occurred. The nurse's note dated 2/12/2022 at 11:29 PM identified the charge nurse on the unit was notified that the resident was found with a laceration and bump to the back of the head. The nurse stated she responded to the alarm sounding and found the resident standing by her/his bed. The nurse's notes additionally noted that when the NA toileted the resident and observed the resident touching the back of her/his head the NA noted blood was on the resident's hand. Upon assessment the resident was noted with an actively bleeding laceration measuring 2.0 CM by 0.2 CM with a bump on the back of the head. Pressure was applied and the bleeding stopped after several minutes of applying pressure. Resident # 2 was unable to explain how she/he got the injury. The resident was assessed, and pupils were reactive to light and equal, the resident was unable to follow commands due to baseline mentation. Further neurological assessment identified vitals were conducted and noted the following: blood pressure 113/58, (Normal Range 120/80) heart rate 68, T 97.6, respirations 16, oxygen saturation on room air 98%. The physicians on call services notified the APRN who directed the resident the resident to be transferred to the emergency department for an evaluation. A message was left for the responsible party and the MD regarding resident's injury and transfer to hospital. Resident # 2 left the facility via ambulance at 11:15 PM. The discharge summary from the emergency department dated 2/13/22 indicated Resident #2 arrived on 2/12/22 after an unwitnessed fall. Resident #2 had dementia and got out of bed fell backwards hitting the back of the head against the end table sustaining a laceration. Resident #2 got out of bed with the alarm sounding and upon staff arrival to the room Resident # 2 was found on the floor. Resident #2 stated s/he hit his/her head. The resident was assessed and noted with a 2 CM laceration to occipital. Tetanus/Diphtheria/pertussis (Tdap) given intramuscularly. The nurses progress note dated 2/13/2022 at 8:58 AM noted day 1 status post unwitnessed fall, the resident sustained a 2 CM laceration to the posterior scalp. At 3:25 AM the facility received a phone call from emergency room informing this writer resident was returning to facility. The resident received staples to back of the head. A CAT scan to head was negative and no behavior issues, combativeness at hospital. At 3:40 AM the resident arrived awake, alert, verbally responsive confused, which is baseline. No behavior issues, or combativeness, cooperative, follows simple commands. neurological checks resumed. No changes in mental status. PERLA. Denied any pain. Does not appear to be in any discomfort. 4 staples to posterior scalp, dry intact, no bleeding noted. Resident made comfortable and positioned in bed. Bed alarm attached, bed in lowest position and locked, floor mat at bedside and call bell within reach. Safety precautions maintained. The APRN communication log directed a follow up. 6:30AM the resident was awake, alert, lying across the bed quietly. Resident#2 was repositioned in bed and with bed alarm attached. Safety precautions maintained. Additionally, noted the resident does not appear to be in any distress. The nurses progress note dated 2/13/2022 03:46 PM status post fall day 1, vital signs were stable, neurology assessment was at baseline, the resident denies pain or discomfort, no indication of pain. Care was provided during am, resident was combative and resistive, toileted with a lot of encouragement, resident attempted to place left leg over the sink while washing hands. redirected with a lot of difficulty. Laceration to back of had was cleansed, 5 staples noted in place, no drainage or redness was noted, the area was left open to air and no other obvious injuries were noted. Several attempts to self-transfer, alarm and landing mats in place, call light within reach. Visit with family in t room, family member aware on right back of head laceration and indiated the resident transfer to emergency room on 2/12/22. A physician's order dated 2/13/22 directed to monitor scalp laceration to back of head for signs and symptoms of infection, drainage, swelling, bleeding, and pain every shift. Additionally, leave open to air until resolved/healed for 4 staples present. The APRN progress note dated 2/15/22 at 3:57 PM indicated evaluated resident as follow up secondary to unwitnessed head injury that occurred on 2/12/22. The resident was found standing by bed with bleeding from posterior head and was sent to emergency room. Resident #2 returned 2/13/22 with head injury and sutures. Plan was to continue current medications and it was unclear if resident would benefit from physical therapy, poor rehabilitation potential. The nurses progress note dated 2/17/2022 4:55 PM noted staples recounted by this nurse today. Resident is noted to have 5 staples in the back of her head instead of 4 staples as previously noted. The Facility Rehabilitation Request Form with no dated from nursing indicated Resident #2 was a fall risk/ due to recent fall. The resident was referred to physical therapy for an evaluation. The Rehabilitation follow up dated 2/21/22 indicated PT #1 significant findings was an unwitnessed fall with head injury. Recommendations from Physical Therapy #1 was to continue with alarms and to provide supervision for transfers and ambulation. The APRN progress note dated 2/22/22 at 9:37 AM indicated she was asked to see Resident #2 to evaluate the resident for stable removal from the posterior head. Plan was to have staples removed by nursing. A physician's order dated 2/22/22 directed to remove 5 staples from back of head. The nurses progress note dated 2/22/2022 at 4:28 PM noted 5 staples were removed by 3-11 PM supervisor without any difficulty. Resident# 2 tolerated staple removal with no behaviors. Interview with Person #1 on 4/24/22 at 11:31 AM indicated the staff informed him/her that Resident #2 had fallen and sustained a laceration. The resident was transferred to the hospital on 2/15/22. interview with the DNS on 4/26/22 at 7:22 AM indicated for the Accident and Incident reports the DNS verbally conducted interviews with staff and document in the progress notes the outcome of the investigation. The care plan would be updated, and an event (Accident and Incident Form) completed by the DNS in the electronic medical record. The DNS indicated the staff did not write statements for investigations. Clinical record review with DNS identified there was no electronic Event for Resident #2 on or around the date of the incident 2/15/22. Interview with the DNS on 4/26/22 at 10:50 AM indicated at the time of the fall the nurse is responsible for interviewing staff, completing an Accident and Incident Form to identify contributing factors and writing a progress note with interventions to prevent the incident from re-occurring. The DNS further indicated she/he is responsible for reviewing the Event (Accident and Incident Form) and conducting a follow up. The DNS indicated based on the Accident and Incident Form she did not know who was on at the time of the fall, who was interviewed, when anyone was interviewed, and what each interviewed person had to say. Interview with RN#2 on 4/26/22 at 11:33 AM indicated she was the supervisor and was the charge nurse on the unit. RN #2 noted she could not recall what time exactly she answered the alarm sounding thought maybe 10 minutes prior to when the nursing assistant took Resident #2 to the bathroom. RN #2 indicated at the time she did not check Resident #2 's hair to see if there was blood. RN #2 indicated she could have had the laceration at that time, but she never thought to look, she just assisted the resident back onto the bed. RN #2 noted she never saw Resident #2 on the floor or partially on the floor. RN #2 noted the nurse aide called her into Resident #2's room while Resident#2 was sitting on the toilet with blood in his/her own hand. RN #2 indicated she then moved Resident #2's hair that was down to see where the blood had come from. RN #2 indicated there was a moderate amount of blood. RN #2 indicated she found the area and applied pressure to Resident #2's head and they assisted Resident #2 back to bed until EMS arrived. RN #2 indicated she did not know how Resident #2 got the laceration and Resident #2 could not explain what happened. RN #2 further indicated the nightstand was padded and she did not see any blood on the nightstand. RN #2 did not recall if Resident #2 had anything on his/her feet like slippers, grippy socks, or shoes while sitting on the toilet. RN #2 was unable to identify when Resident #2 was last seen or toileted prior to incident. RN #2 identified she/he did a complete assessment of Resident #2 then called the APRN and family. RN #2 indicated there were other incidents where the nurses have other nurses and nurse aides write statements of what had occurred on paper, but this practice was not done for this incident. RN #2 indicated because she had found the resident, she did not need the staff to write statements. RN #2 indicated she filled out the Accident and Incident form and left it on a clip board for the DNS who collect the reports. RN #2 indicated she did not see Resident #2 fall or assist him/her off the floor and did not see what caused the injury. Resident #2 was in a private room at the time. RN #2 indicated she did not know why she did not have the nurse aides write statements because she found the laceration on the resident therefor there was no need for statements. RN #2 indicated she did not recall who the nurse aide was that toileted Resident #2. Interview with the DNS on 4/26/22 at 1:30 PM indicated she felt the root cause for the laceration was Resident #2 had a lot of unsafe practices and believed the incident occurred from the Resident # 2 attempting to self toilet. The DNS was unable to state when Resident #2 was toileted prior to being toileted with a laceration on the head. The DNS was not able to indicate when Resident #2 was last seen prior to the laceration. The DNS noted Resident #2 was extremely unsteady and noted with balance problems. The DNS indicate that the resident keeps the over bed table near his/her bed with drinks on it and so Resident #2 may have hit her/his head on the bed table when s/he was trying to go to the bathroom. The DNS indicated the intervention was to pad the overbed table located on the door side of the bed where Resident #2 often attempted to self transfer to the bathroom. The DNS indicated Resident #2 was in a private room and was more impulsive and active at that time. Resident #2 was always getting up independently and staff would hear the alarms. Interview with PT #1 on 4/26/22 at 1:45 PM indicated if she receives a screen to do an evaluation from a fall or change of condition the resident would be seen in 24-48 hours. PT #1 indicated after reviewing the screening form she did not know when she received the screen from nursing, because it was not dated by nursing. PT#1 indicated Resident #2 was physically able to get him/herself up off the floor but cognitively did not think Resident #2 would know enough to get off the floor. PT #1 indicated the alarm would go off about 20 times an hour when Resident #2 would attempt to self ambulate. PT #1 indicate Resident #2 was an assist of 1 for ambulation at the time of the incident. Interview with NA #3 on 4/26/22 at 2:00 PM indicated she was on a different unit on 2/12/22 and was not aware of incident. Interview with NA#2 on 4/26/22 at 2:38 PM indicated Resident # 2 had fallen and landed on the floor. NA # 2 called the nurse and while she was waiting for the nurse, NA # 2 assisted the resident who got up and went to sit on the toilet. NA # 2 notified the nurse Resident # 2 was sitting on the floor and had blood on the right elbow. The resident was noted seated on floor between the bed and the closet. NA #2 was in the fall when NA #2 saw the resident fall backwards and was not able to grab her/him. NA #2 also indicated the resident did not hit her/his head. Interview with NA #8 on 4/26/22 at 3:08 PM indicated she was not the nurse aide that had the resident the evening of the incident but was on the nursing schedule as working. NA #8 called surveyor at 4:00 PM and indicated after reviewing payroll documents she was not working on 2/12/22. NA #8 indicated she has never been asked to write statements regarding falls, bruise, skin tears or any other accidents. Interview with NA#6 on 4/26/22 at 3:15 PM identified she was on the unit the day the incident occurred with Resident #2. NA #6 indicated she recalls a nurse aide coming to the nurse's station where she was sitting and indicated Resident #2 had blood on his/her hand. NA #6 did not recall who the nurse aide was or who the nurse was during that shift. NA #6 indicated the facility never had her write a statement related to Resident #2 or any other resident incident or fall. Review of facility Reportable Events Policy identified when an accident or incident occurs to a resident staff will inform the charge nurse immediately. In the event of an obvious injury the nurse will assess the party involved, render necessary first aid, observe until stable or transfer to emergency room. In all cases generate an Accident and Incident Form and give a description of the circumstances surrounding the event. Obtain descriptive statements from the resident, employees, and visitors. Although attempts were made to interview with RN #5 the attempts were unsuccessful Although attempts were made to interview NA #7 the attempts were unsuccessful. Although requested a facility policy for injuries of unknown origin it was not provided.

Based on, review of facility documentation, facility policy, and interviews the facility failed to implement appropriate plans of action to correct quality deficiencies once identified through Quality Assurance and Performance Improvement (QAPI). The findings include: A review of facility documentation identified 18 of 50 residents had electronic movement alarms. QAPI audit dated 10/18/21 noted 4 residents where the Position Change Alarms were removed. There was no documentation of measurable goals, step-by-step interventions to correct the problem and achieve established goals; and a description of how the QAA committee will monitor to ensure changes produce the expected results. An interview on 4/26/22 at 8:30AM with the Director of Clinical Operations identified an effort was made to address all residents who utilized alarms to see if there could be a reduction in their use back in 2019. The Director of Clinical Operations indicated she started in May 2021, and she identified a need to attempt to decrease the use of electronic movement alarms. However, the impact of the pandemic made it a challenge to follow through on those efforts. An interview on 4/26/22 at 2:30PM with the Corporate Administrator identified a staff nurse completed an alarm reduction project as part of an independent study back in 2019 but was unable to provide documentation of continued efforts to evaluate their use and plan for reduction for the residents who continued to utilize electronic movement alarms. The policy for QAPI Plan Policies and Procedures directs the facility will maintain a written QAPI plan that provides guidance for overall quality improvement. The QAPI plan involves all services, departments and employees and sets goals for performance and objectives and measured progress towards goals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, review of facility documentation, review of facility policy, and interviews, for 1 resident (Resident #7) reviewed for physical restraints the facility failed to ensure a device was not implemented after it was discontinued on the care plan. The findings include: Resident #7 was admitted on [DATE] with diagnoses that included fracture in unspecified part of the neck of the left femur and vascular dementia without behavioral disturbance. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #7 was severely cognitively impaired and required extensive one person assist with personal care. The fall risk assessment dated [DATE] noted a score of 19 indicating Resident #7 was at risk for falls. The care plan dated 1/17/19 identified Resident #7 was at risk for falls and/or injury related to a history of falls with interventions that included a wheelchair alarmed seatbelt- ensuring Resident #7 could unfasten his/herself to reposition every two hours and a clip alarm for the wheelchair. The care plan with a revision dated of 3/19/19 noted the clip alarm for the wheelchair had been discontinued. Physician's orders dated 8/13/19 though 9/23/19 did not included the use of a chair alarm. An observation on 9/23/19 at 11:36 AM identified Resident #7 to be seated in his/her wheelchair with an alarm device clipped on wheelchair. A subsequent observation, interview, and record review on 9/25/19 at 11:29 AM with Registered Nurse (RN) #1 identified Resident #7 continued to have the alarm device clipped to the back of the wheelchair in addition to the seatbelt alarm device located beneath the wheelchair. The alarm, according to RN #1 was discontinued on 3/19/19 and therefore should not have been clipped to the back of the wheelchair. RN #1 indicated the wheelchair alarm was not removed from the Nurse Aide (NA) care card. An interview on 9/25/19 at 1:09 PM with NA #1 identified he/she routinely cared for Resident # 7 and that the alarms were placed by 11-7 shift when Resident #7 got up in the morning and removed by the 3-11 staff at bedtime. NA #1 indicated and that both the wheelchair clip alarm and seatbelt alarm were required to be in place when Resident #7 was out of bed. Although a policy for the use of alarm devices was requested, RN #1 indicated there was no such policy. The facility failed to ensure the resident was free from an alarm device after it had been removed from the care plan.

Based on observation, review facility documentation, review of facility policy, and interview, the facility failed to ensure staff were practicing appropriate hand hygiene and/or glove use during food preparation and/or serving practices. The findings include: An observation on 9/25/19 at 7:35 AM identified Dietary Staff #1 assisting with meal tray preparation for the morning meal. Dietary Staff #1 stopped plating food, doffed his gloves and exited the kitchen pushing a meal cart without performing hand hygiene. An observation on 9/25/19 at 7:39 AM identified Dietary Staff #1 returning to the kitchen, don gloves, push the door opener to the microwave, open then close the microwave with the right hand, turn the knob on the on the stove using the right hand and pick up the handle of the pot on the stove with the left hand. Dietary Staff #1 was then observed to place a stack of bowls on the counter using both hands. Using a ladle, Dietary Staff #1 scooped a thick white substance into 4 food bowls, then reached inside a bag on the food prep area and retrieved lids with the right gloved hand and placed the lids onto the bowl containing the substance while touching the inside of the lid. An interview 9/25/19 at 7:39 AM with Dietary staff #1 identified that while he/she was aware to perform hand hygiene before putting on gloves and after removing, he/she had forgotten to do so on this occasion. The policy for Handwashing directed staff to wash hands as needed throughout the day including during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks and before donning gloves for working with food and or engaging in activities that contaminate the hands.