**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interview for 1 of 3 residents (Resident #26) reviewed for dignity, the facility failed to make prompt efforts to resolve the resident's grievances of care provided. The findings include: Resident #26's diagnoses included anxiety, congestive heart failure and irritable bowel syndrome. The admission MDS dated [DATE] identified Resident #26 was cognitively intact, and dependent on staff for transfers, bed mobility and toileting. The care plan dated 2/22/25 identified Resident #26 was alert and oriented. Interventions included monitoring for changes in behavior, mood, appetite and sleep pattern with changes reported to the physician, providing adequate time and encouragement to voice feelings, emotions, concerns and psychiatry consultations as needed. In an interview with Resident #26 on 3/31/25 at 11:48 PM the resident identified there were employees on the evening shift that have a mean tone when interacting with the resident and do things on their own. Resident #26 indicated that although he/she reported this to the nurse, nothing has changed. Resident #26 did not want to identify the staff members. Review of the grievance log dated 1/1/25 - 4/7/25 failed to identify any care concerns or grievances documented for Resident #26. Review of nurses notes dated 3/21/25, 3/24/25, 3/25/25, 3/26/25, 3/28/25, 3/29/25, 3/30/25, 4/1/25, 4/2/25, 4/3/25 and 4/4/25 identified Resident #26 had accusatory statements about staff and care given. Review of the current care plan on 4/7/25 failed to reflect that Resident #26 had accusatory behaviors with interventions to address such. Interview with the DNS 4/7/25 at 11:55 AM identified Resident #26 has reported in the past, complaints of caregivers talking to her/him in a poor manner. However, when it was followed up on by the supervisors, Resident #26's story changed, so no formal investigation was started, and nothing was ever put in writing. Interview with LPN #10 on 4/7/25 at 2:52 PM identified Resident #26 makes accusatory statements toward staff on a regular basis, but they were not factual due to his/her advanced age. LPN #10 could not identify what the accusations were, stating Resident #26 makes statements that he/she cannot recall, so as a precaution he/she has 2 caregivers for care. Interview with SW #1 on 4/7/25 at 2:49 PM identified that he was the facility Greivance Officer and the facility policy on grievances was to investigate any allegations within 24 hours and put interventions in place. Interview with the DNS on 4/7/25 at 3:16 PM identified the facility policy on accusations made by residents was to start an investigation initiated by the supervisor, see if there is a conflict with the care giver and then she would get a briefing. The DNS identified she was not aware of any investigations for Resident #26, but per the nurses notes she should have been. Follow up interview and record review with the DNS on 4/8/25 at 12:52 PM identified she had an investigation in her mailbox that she had not seen. The investigation dated 4/4/25 identified Resident #26 made a care concern allegation against evening shift nurse aides on 4/4/25 for being rude and not answering his/her call light in a timely fashion. The supervisor initiated an investigation, and the intervention was 2 caregivers at all times, with education provided to staff on respect, dignity and communication to with the charge nurse and supervisor. No grievance was filed, and the grievance officer was not notified. The DNS stated that this was the only investigation for Resident #26 that she was aware of, and no investigations were initiated for the allegations on 3/21/25, 3/24/25, 3/25/25, 3/26/25, 3/28/25, 3/29/25, 3/30/25, 4/1/25, 4/2/25, or 4/3/25. Interview and record review with SW #1 on 4/8/25 at 12:59 PM identified the nurses notes dated 3/21/25, 3/24/25, 3/25/25, 3/26/25, 3/28/25, 3/29/25, 3/30/25, 4/1/25, 4/2/25, 4/3/25 and 4/4/25, identified Resident #26 was making accusatory statements about staff and the care given, however he was not aware of any of them and indicated if he had been he would have followed up with Resident #26 to obtain more information, such as details on the staff member and then initiated education, SW #1 could not follow up at the time as Resident #26 was out of the building. Review of Patients Complaints/Grievances policy dated 7/24/2014 directed if a grievance is received by staff in person, by telephone or in writing, a report shall be originated by the staff receiving the grievance and then forward to the grievance officer for investigation and resolution. Each issue defined as a grievance shall be followed up with a written notice and a decision from the officer with a resolution within 7 days. Additionally, the Grievance officer is responsible for ensuring that all individuals adhere to the requirements of this policy, and any noncompliance is reported to the Administrator. Review of the Resident Behaviors and Accusations policy directed that all resident concerns and accusations will be taken seriously and investigated thoroughly, reported immediately to the Administrator or DNS with an internal investigation completed within 24 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interviews for 1 residents (Resident #46) reviewed for bowel and bladder incontinence, the facility failed to develop a comprehensive care plan for a resident with incontinence and for 1 of 2 residents (Resident #418) reviewed for tube feeding, the facility failed to develop a comprehensive care plan that identified the resident was to receive nothing by mouth (NPO). The findings include: 1. Resident #46's diagnoses included Parkinson's disease, bipolar disorder, and major depressive disorder. The annual MDS dated [DATE] identified Resident #46 had intact cognition, required substantial/maximal assistance with bed mobility and transfers and was dependent with toileting. The MDS also indicated Resident #46 used a walker and wheelchair as mobility devices and was frequently incontinent of bladder and always continent of bowel. The MDS further indicated a toileting program trial had not been attempted with the resident since urinary incontinence was noted in this facility. The care plan dated 4/3/25 identified Resident #46 had limited physical mobility and decreased strength and endurance with impaired balance. Interventions included to anticipate and meet the residents needs and respond promptly to all requests for assistance with encouragement to fully participate with each interaction. The RCP failed to identify Resident #46's bladder and bowel incontinence. The NA flow sheet for Urinary Continence dated 3/9/25 to 4/6/25 identified Resident #46 had 12 recorded episodes of urinary continence and 98 recorded episodes of urinary incontinence (a 30 day look back). The NA flow sheet for Bowel Movements dated from 3/9/25 to 4/6/25 identified Resident #46 had 24 episodes of bowel continence and 6 episodes of bowel incontinence (a 30 day look back). Review of the written nurse aide assignment for Resident #46 indicated the resident was incontinent of bladder with mixed incontinence of bowel. Observation and interview with Resident #46 on 4/2/25 at 10:15 AM identified he/she was seated in the wheelchair and wearing an adult incontinence brief. Resident #46 indicated he/she experienced dribbling incontinence of urine overnight but otherwise was aware of when he/she had to urinate or move bowels. Resident #46 identified that due to his/her need for staff assistance in the bathroom to transfer to and from the toilet and because he/she had to wait for help from staff during the day, he/she had to wear an adult incontinence brief all the time. Resident #46 indicated if he/she was put on a toileting program, he/she may not need to wear an adult incontinence brief during the day, but the staff have not addressed his/her incontinence, and such a program had not been offered to her. Interview and review of the clinical record with the registered nurse supervisor (RN #3) on 4/7/25 at 12:35 PM identified an assessment for incontinence should have been completed for Resident #46 either on admission or with a change in his/her continence status. RN #3 indicated that based on the assessment a care plan should have been developed, and the resident should have been put on a toileting program. RN #3 identified the care plan nurse (RN #4) and charge nurse would have been responsible to develop and update the care plan for Resident #46 and she was unable to indicate why that was not done. Interview and review of the clinical record with the DNS on 4/8/25 at 11:50 AM identified she was unable to locate a completed bladder and bowel assessment for Resident #46 within the resident's entire medical record. The DNS indicated that she would have expected the assessment to be completed quarterly for a resident exhibiting a change in their continence, such as with Resident #46. The DNS further identified that had the assessment been completed for Resident #46, he/she would have had a toileting program customized for him/her and the care plan would have been developed to promote continence. The DNS indicated both measures could have helped the resident to maintain his/her continence, however, it was not done. The DNS further identified she would need to address the adding of incontinence to Resident #46's care plan with the care plan nurse (RN #4). Although attempted, an interview with the care plan nurse (RN #4) was not obtained. Review of the Continence Improvement Program policy, undated, directed the residents identified as participants in this program would have incontinence or a new onset of incontinence and a thorough assessment would be completed. The policy directed that once a determination was made as to the type of incontinence the resident exhibited a care plan and toileting program would be initiated. The policy further directed that ongoing reviews of the implemented program would be conducted when care planning was done, and it would be noted in the care planning summary. Review of the Care Plan policy, undated, directed a comprehensive care plan would be developed and updated as needed and would include assessments related to the resident's medical condition, functional abilities, and rehabilitation goals. The policy further directed regular assessments will be performed to monitor changes in the resident's condition and to adjust the care plan accordingly. 2. Resident #418's diagnoses included dysphagia (difficulty swallowing), gastrostomy status and pneumonitis due to inhalation of food and vomit. A physician's order dated 3/24/25 directed NPO (nothing by mouth), tube feeding for diet with NPO texture and NPO consistency. A nutrition evaluation dated 3/24/25 identified Resident #418's diet order was NPO with tube feeding of Jevity 1.2 at 70 ml per hour for 22 hours/day. The nutrition evaluation further indicated Resident #418's eating ability was NPO with a tube feeding for total nutrition related to a diagnosis of severe dysphagia. The admission MDS dated [DATE] identified Resident #418 was severely cognitively impaired and was dependent with bed mobility, toileting, and transfers. The MDS further indicated Resident #418 had difficulty with swallowing and a feeding tube. The care plan dated 4/2/25 identified Resident #418 had a swallowing problem and required a tube feeding related to a diagnosis of dysphagia. Interventions included that all staff would be informed of the resident's special dietary and safety needs, monitor the resident for difficulty swallowing (holding or pocketing food in mouth) and to provide a bland diet and sippy cup for liquids. The care plan indicated to follow physician's orders for current feeding. The care plan failed to identify Resident #418 was NPO. Review of the NA assignment sheet for Resident #418 on 4/3/25 failed to indicate the resident's NPO status. Interview, observation, and review of facility documents with LPN #3 on 4/3/25 at 12:50 PM identified Resident #418 was not listed as being NPO on the written NA assignment and that is what the NA's referred to for care specific information on residents. LPN #3 indicated that NPO should have been listed on the written NA assignment for Resident #418, otherwise the NA may not have known the resident was to have nothing by mouth. LPN #3 identified the admitting nurse should have told the unit clerk to put the NPO status on the written NA assignment since the NA's only use the computer for charting and not to reference care specific information. Interview with NA #3 on 4/3/25 at 4:15 PM identified she was unable to find in the computer that Resident #418 was NPO. NA #3 indicated that the written NA assignment should have had Resident #418's NPO status listed because the NA's refer to their written assignment for care specific information and only use the computer for charting purposes. Interview and review of facility documents with the DNS on 4/3/25 at 4:55 PM identified the NA would know Resident #418 was NPO because it would be written on the NA assignment. Review of the written NA assignment with the DNS failed to indicate Resident #418 was NPO. The DNS identified she would have expected the residents NPO status to be indicated on the assignment which should have been updated by the nursing staff, and written in by hand, if necessary, until the unit clerk was able to type it in. The DNS indicated the NAs still relied on paper because the facility was not fully computerized yet. Subsequent to surveyor inquiry, review of the written NA assignment sheet for Resident #418 on 4/7/25 indicated the resident's NPO status had been updated. An additional interview and review of the clinical record with the DNS on 4/8/25 at 11:50 AM identified NPO was not indicated on Resident #418's care plan. Although the DNS identified RN #4 created the original care plan for Resident #418, it would be the charge nurse's responsibility to further review, customize and tailor it to the resident's needs. The DNS indicated Resident #418's care plan should not have interventions listed for a bland diet or a sippy cup (since the resident was NPO) and that she would have the care plan corrected and updated. The DNS further identified that since both the care plan and the written NA assignment failed to indicate Resident #418 was NPO, the NA's may not have known because it would have been the responsibility of the nurse to verbally inform the NA's. Although attempted, an interview with the care plan registered nurse (RN #4) was not obtained. Review of the facility policy, NPO Status Policy, undated, directed the facility was committed to accurately communicating and documenting NPO status orders to all relevant staff and that NAs would be informed of the NPO status through their assignment sheets which would clearly indicate the resident's NPO status and any specific instructions. Review of the facility policy, Care Plan, undated, directed a comprehensive care plan would be developed and updated as needed and would include assessments related to the resident's medical condition, functional abilities, and nutritional needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 3 of 3 residents (Resident #74, 79 and 27), reviewed for Activities of Daily Living (ADL's), for Resident #74 and 79 the facility failed to maintain the residents' fingernails and for Resident #27, the facility failed to answer the residents calls for help in a timely manner after he/she had been incontinent. The findings include: 1. Resident #74's diagnoses included unspecified dementia-unspecified severity with agitation, chronic obstructive pulmonary disease, and metabolic encephalopathy. The monthly physician orders dated 1/29/25 directed skin and nail assessments weekly on shower days and document findings. The quarterly MDS dated [DATE] identified Resident #74 was moderately cognitively impaired and was fully dependent on staff for personal hygiene. The care plan dated 3/21/25 indicated Resident #74 had an ADL self-care deficit and limited physical mobility related to activity intolerance, metabolic encephalopathy and musculoskeletal impairment. Interventions included to monitor/document/report to MD any changes and reasons for self-care deficit. Review of the March 2025 TAR identified skin and nail assessment were administered weekly on shower days. Observations on 3/31/25 at 10:00 AM, 4/01/25 at 11:00 AM and 4/2/25 at 11:45 AM identified Resident #74's fingernails were very long with dark debris under the fingernails. Interview with Resident #74 on 3/31/25 at 10:00 AM indicated a family member will sometimes paint his/her fingernails because he/she does not wish to pay the salon for this service. The resident stated her/his preference is to keep the fingernails trimmed because sometimes food gets under the fingernails when they are longer. Interview with NA #8 on 4/3/25 at 9:15 AM indicated it is the nurse aides responsibility to cut and file resident's fingernails. Interview with LPN #5 on 4/3/25 at 9:15 AM indicated NA's do fingernail care on shower days or whenever necessary. Interview with the DNS on 4/7/25 at 12:20 PM identified it is the NA's responsibility to do fingernail care on shower days, at least once per week or in between. Interview with the DNS on 4/8/25 at 10:05 AM indicated she was not aware of any directive from the family that fingernail care would only be performed by family or that staff should not be doing nail care for Resident #74. Further, the DNS stated if nails are long and in need of attention, the expectation is that staff will perform nail care weekly on shower day. Subsequent interview with LPN #5 on 4/11/25 at 11:10 AM indicated she was not aware of any communication from Resident #74 or his/her family members that staff should not do fingernail care. Undated Bath-Shower and Bath-Bed policies indicated fingernails are to be cleansed and thoroughly dried and nail care to be performed if necessary. 2. Resident #79's diagnoses included Alzheimer's disease with early onset, essential hypertension and generalized anxiety disorder. The monthly physician order dated 1/10/25 directed skin and nail assessments weekly on shower days and document findings. The quarterly MDS dated [DATE] identified Resident #79 was moderately cognitively impaired and required partial/moderate assistance with showers, personal and toileting hygiene. The care plan dated 2/3/25 identified Resident #79 had an ADL self-care performance deficit and limited physical mobility related to activity intolerance, fatigue, impaired balance and limited mobility. Interventions included to monitor/document/report to MD changes or reasons for self-care deficit. A nurses note dated 3/25/25 at 1:16 PM identified Resident #79's skin was intact in relation to ordered skin and nail assessment on shower day. Observation on 3/31/25 at 10:30 AM identified Resident #79's nails were observed to be dirty and long. Resident #79 identified during that observation, he/she has asked the nurse aide to cut his/her nails, but no one has cut them. Observation on 4/3/25 at 10:47 AM identified Resident #79's fingernails were long and in need of trimming. Interview with LPN #5 on 4/3/25 at 9:15 AM indicated NA's do fingernail care on shower days or whenever necessary. Interview with NA #8 on 4/3/25 at 9:55 AM indicated it is NA's responsibility to trim and file resident's fingernails. NA #8 reported fingernails can be trimmed and filed at any time. NA #8 reported nurses are responsible for trimming fingernails for residents with diabetes. Interview with the DNS on 4/7/25 at 12:20 PM identified fingernail care is performed by the NA on shower days or any time. The DNS stated if a resident's nails are long and in need of attention, the expectation is the staff will perform nail care weekly on shower day. Review of the undated Bathing policy indicated fingernails are to be cleansed and thoroughly dried and nail care to be performed when necessary. 3. Resident #27's diagnosis included cerebellar ataxia, epilepsy, functional quadriplegia, and a feeding tube in place. The quarterly MDS dated [DATE] identified Resident #27 had no cognitive impairment, was dependent on staff for toileting, personal hygiene, bed mobility, and all transfers. The MDS identified that Resident #27 had impairment on both sides of the upper and lower extremities and was always incontinent of urine and frequently incontinent of bowel movements. The care plan dated 2/4/25 identified Resident #27 was incontinent of bladder. Interventions directed staff to change briefs at least every 2 - 3 hours and as needed. Constant observation on 4/2/25 at 11:21 AM - 12:21 PM identified the following. Resident #27 was in his/her room, in bed calling out for help. The door to the resident's room was closed and the call light above the door was illuminated. Upon entering the room, the resident stated he/she had a bowel movement and needed to be changed. The resident stated he/she had been calling for approximately 30 minutes. At 11:23 AM the resident pushed the call bell again and a staff member responded through the intercom and asked what the resident needed. The resident stated he/she had gone to the bathroom and needed to be changed. When the resident began to explain that he/she had been calling already for 30 minutes, the staff member hung up the intercom and an overhead page for assistance was heard. Between 11:23 AM and 12:21 PM while in the room, Resident #27 was observed to ring the call bell eight times. On three occasions, staff answered through the intercom but disconnected without speaking to Resident #27 or paging for assistance to the resident's room. Other times there was no answer. At 12:13 PM, staff told Resident #27 through the intercom he/she would need to wait because lunch trays were being passed out. At 12:21 PM, an hour later, NA #7 entered the room. The resident told NA #7 that he/she had been calling since 10:30 AM and NA #7 responded that they were busy and the facility was short-staffed. The resident again explained he/she had had a bowel movement and needed help, but NA #7 repeated that others needed help too and the resident would need to wait. NA #7 proceeded to provide incontinent care to the resident at that time who was observed to have a wet diaper. Interview with the Unit Secretary #7 on 4/2/25 at 12:31 PM identified that residents typically request assistance by using the call bell or approaching the front desk. Unit Secretary #7 identified that Resident #27 had requested help multiple times but Unit Secretary #7 did not take further action outside of overhead paging requesting assistance to the resident's room. Interview with LPN # 1 on 4/2/25 at 12:31 PM identified that typically if a resident needed bathroom assistance and the NA was too busy to help, another staff member would be expected to help. LPN #1 explained that the nurse aide indicated that she had already provided care for the resident, and she was not aware that no one entered the room to provide incontinent care. The LPN added that she would have expected someone to check on Resident #27, especially since there were several aides working that day. LPN #1stated, that should have never happened. Interview with NA #7 on 4/3/25 at 12:21 PM identified that she was in another resident's room and was unable to respond to the request for assistance. NA #7 stated that she did tell the nurse that she could not help, however, NA #7 could not identify who she told. LPN #15 indicated she had not been told NA #7 was unable to provide assistance to Resident #27. Review of the Incontinence/Perineal Policy that was in effect, directed incontinent care to be provided at least every 2 - 3 hours to keep Residents clean and dry.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #27) reviewed for dignity, the facility failed to provide activities of interest. The findings include: Resident #27's diagnosis included cerebellar ataxia, epilepsy, mild anxiety and depression. The quarterly MDS dated [DATE] identified Resident #27 had no cognitive impairment, was dependent on staff for toileting, hygiene, bed mobility, and all transfers, and required a wheelchair for ambulation. The care plan dated 2/4/25 identified Resident #27 was at risk for alterations in his/her psychosocial well-being. Resident #27 enjoyed bingo, reading, music, game shows, and pet therapy. Interventions instructed staff to offer Resident #27 activities such as reading materials, puzzles, cards, music, and ensure weekly transportation to a chosen activity. Additionally, Resident #27 was to be provided with an activity calendar and offered items from the activity cart three times per week. Nurse Aide Assignment Card dated 4/2/25 identified Resident #27 liked to attend bingo. Observation on 3/31/25 at 1:23 PM identified Resident #27 was lying in bed awake in a dark room. Observation on 4/1/25 at 11:45 AM identified Resident #27 lying in bed watching TV. Interview with Resident #27 on 4/2/25 at 11:27 AM identified that she liked to play bingo but had not attended in a long time. Interview with the Director of Recreation on 4/3/25 at 3:43 PM identified that Resident #27 used to attend bingo but had not been to the activity in a while because the resident was often not dressed and ready in time for bingo. Interview with Recreational Therapist #1 on 4/3/2025 at 3:46 PM identified she did not typically offer any activities to Resident #27 because the door was usually closed, and she did not want to disturb Resident #27. Recreation Therapist #1 was aware the resident enjoyed bingo but indicated he/she had not attended in some time. Recreational Therapist #1 had previously asked the nurse aides to get the resident out of bed and have him/her ready for bingo, but the resident continued to not be ready when the activity began. Recreational Therapist #1 identified he/she did not escalate the issue and could not recall the last time Resident #27 participated in bingo. Aside from a blessing visit on 3/13/25, Recreational Therapist #1 could not identify the last 1:1 interaction with the resident but mentioned she would occasionally stop into Resident #27's room to say hello and to see if he/she needed anything. Interview with LPN #5 on 4/8/25 at 10:55 AM identified that the Recreational Department generally notified nursing of scheduled events for the day, and nursing was responsible for ensuring the resident was out of bed and ready to attend. LPN #5 recalled that, in the past, Resident #27 sometimes refused to get up in time to be dressed and ready to attend bingo. Additionally, there were times the resident declined to attend the activity altogether. LPN #5 was unable to provide documentation in the clinical record indicating Resident #27 refused to get up for bingo. Interview with Director of Recreation on 4/8/25 at 11:27 AM identified that while it is acceptable for a resident to choose not to attend an activity, if a resident wished to attend but wasn't ready in time, the recreation therapist should have followed up with nursing. The Director of Recreation also emphasized that a 1:1 visit should involve engaging the resident in activities, such as reading or other interactive tasks, and the visit should be documented. Review of facility documentation dated 1/1/25 to 4/8/25 identified Resident #27 had not participated or refused to participate in bingo. Review of the Therapeutic Recreation Policy directed that Therapeutic Recreation offers meaningful activities that support each resident's social emotional and physical needs. The program aims to promote well-being, encourage socialization and help residents maintain or improve their abilities.

**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 5 residents (Resident #83) reviewed for pressure ulcers, the facility failed to correctly set and monitor an air mattress for a resident with a pressure ulcer. The findings include: Resident #83's diagnoses included a pressure ulcer to the left buttocks, Alzheimer's disease, and dementia. The admission MDS dated [DATE] identified that Resident #83 was severely cognitively impaired and required substantial/maximal assistance with bed mobility and was dependent with toileting and transfers. Additionally, the MDS identified Resident #83 required a pressure reducing device for his/her bed. The care plan dated 1/16/25 identified a potential for pressure ulcer development related to decreased mobility. Interventions included an air mattress with direction to check the air mattress every shift for proper functioning and inflation and to set the air mattress at 280. A physician's order dated 3/19/25 directed an air mattress on Resident #83's bed and to check for proper inflation and functioning every shift with the dial set at 280 every shift. A physician's order dated 3/28/25 directed to clean Resident #83's new stage 2 pressure ulcer on the left buttocks with normal saline followed by calcium alginate and zinc oxide daily for 7 days and then re-evaluate. Observation on 4/2/25 at 10:08 AM identified Resident #84 was in bed and on his/her back. The air mattress was operating, and the dial was set at 160. Observation, interview and review of the clinical record with LPN #8 on 4/2/25 at 11:50 AM identified Resident #84 was in bed on his/her back. The air mattress was operating, and the dial was set at 160. LPN #8 indicated that although she had signed the TAR that she had checked the air mattress, she did not know what the air mattress dial was ordered to be set at. LPN #8 proceeded to the nurse's station to check the physician's order and then returned to the resident's room and reset the air mattress dial from 160 to 280. LPN #8 identified that she had made a mistake and should have checked the air mattress setting and adjusted it to the correct setting before signing the TAR. LPN #8 further indicated she should have followed the physician's order and kept a better eye on the mattress setting. Interview with the IP nurse LPN #9 on 4/2/25 12:10 PM identified she had first observed Resident #83's pressure ulcer on 3/28/25 and initiated the treatment order. LPN #9 indicated Resident #83's air mattress should have been correctly set and monitored by the nurse every shift. Although LPN #9 was unable to indicate why the air mattress had been set at 160 for Resident #83, she indicated the nursing staff should have checked the mattress and kept it at the correct setting of 280 on all shifts. LPN #9 indicated that having the incorrect setting on Resident #83's air mattress could have affected the resident's wound development and healing and she would need to provide further education to the nursing staff. Interview and review of the clinical record with the DNS on 4/3/25 at 4:40 PM identified Resident #83's air mattress should have been correctly set and monitored by the nurse every shift. The DNS indicated the nurse had to sign off on the TAR and should have made sure the air mattress was kept at the correct setting of 280 on all shifts. The DNS identified she needed to reinforce with the nursing staff their responsibility to have Resident #83's air mattress at the correct setting because the incorrect setting on the air mattress could have affected the resident's wound development and healing. Review of the facility policy, Pressure Ulcer Prevention Protocol, undated, directed pressure relief mattresses were to be monitored for proper function every shift. Review of the facility policy, Proactive Protekt Aire Mattress Overlay Policy, undated, directed the device would be implemented for residents at risk for or currently experiencing pressure injuries and physician orders would be obtained prior to use. The policy further directed nursing staff would monitor placement and proper function of the device at least once per shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interviews for 1 resident (Resident #46 ) reviewed for bowel and bladder incontinence, the facility failed to provide appropriate treatment and services to restore bowel and bladder continence to the extend possible. The findings include: Resident #46's diagnoses included Parkinson's disease, bipolar disorder, and major depressive disorder. The annual MDS dated [DATE] identified Resident #46 had intact cognition, required substantial/maximal assistance with bed mobility and transfers and was dependent with toileting. The MDS also indicated Resident #46 used a walker and wheelchair as mobility devices and was frequently incontinent of bladder and always continent of bowel. The MDS further indicated a toileting program trial had not been attempted with the resident since urinary incontinence was noted in this facility. The care plan dated 4/3/25 identified Resident #46 had limited physical mobility and decreased strength and endurance with impaired balance. Interventions included to anticipate and meet the residents needs and respond promptly to all requests for assistance with encouragement to fully participate with each interaction. The RCP failed to identify Resident #46's bladder and bowel incontinence. The NA flow sheet for Urinary Continence dated 3/9/25 to 4/6/25 identified Resident #46 had 12 recorded episodes of urinary continence and 98 recorded episodes of urinary incontinence (a 30 day look back). The NA flow sheet for Bowel Movements dated from 3/9/25 to 4/6/25 identified Resident #46 had 24 episodes of bowel continence and 6 episodes of bowel incontinence (a 30 day look back). Review of the written nurse aide assignment for Resident #46 indicated the resident was incontinent of bladder with mixed incontinence of bowel. Observation and interview with Resident #46 on 4/2/25 at 10:15 AM identified he/she was seated in the wheelchair and wearing an adult incontinence brief. Resident #46 indicated he/she experienced dribbling incontinence of urine overnight but otherwise was aware of when he/she had to urinate or move bowels. Resident #46 identified that due to his/her need for staff assistance in the bathroom to transfer to and from the toilet and because he/she had to wait for help from staff during the day, he/she had to wear an adult incontinence brief all the time. Resident #46 indicated if he/she was put on a toileting program, he/she may not need to wear an adult incontinence brief during the day, but the staff have not addressed his/her incontinence, and such a program had not been offered to her. Interview and review of the clinical record with the registered nurse supervisor (RN #3) on 4/7/25 at 12:35 PM identified an assessment for incontinence should have been completed for Resident #46 either on admission or with a change in his/her continence status. RN #3 indicated that based on the assessment a care plan should have been developed, and the resident should have been put on a toileting program. RN #3 identified the care plan nurse (RN #4) and charge nurse would have been responsible to develop and update the care plan for Resident #46 and she was unable to indicate why that was not done. Interview and review of the clinical record with the DNS on 4/8/25 at 11:50 AM identified she was unable to locate a completed bladder and bowel assessment for Resident #46 within the resident's entire medical record. The DNS indicated that she would have expected the assessment to be completed quarterly for a resident exhibiting a change in their continence, such as with Resident #46. The DNS further identified that had the assessment been completed for Resident #46, he/she would have had a toileting program customized for him/her and the care plan would have been developed to promote continence. The DNS indicated both measures could have helped the resident to maintain his/her continence, however, it was not done. The DNS further identified she would need to address the adding of incontinence to Resident #46's care plan with the care plan nurse (RN #4). Although attempted, an interview with the care plan nurse (RN #4) was not obtained. Review of the Continence Improvement Program policy, undated, directed the residents identified as participants in this program would have incontinence or a new onset of incontinence and a thorough assessment would be completed. The policy directed that once a determination was made as to the type of incontinence the resident exhibited a care plan and toileting program would be initiated. The policy further directed that ongoing reviews of the implemented program would be conducted when care planning was done, and it would be noted in the care planning summary. Review of the Care Plan policy, undated, directed a comprehensive care plan would be developed and updated as needed and would include assessments related to the resident's medical condition, functional abilities, and rehabilitation goals. The policy further directed regular assessments will be performed to monitor changes in the resident's condition and to adjust the care plan accordingly.

**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 3 residents (Resident #27) reviewed for enteral nutrition and who received nutrition via gastrotomy tube (g tube), the facility failed to provide appropriate care to prevent complications. The findings include: Resident #27's diagnosis included cerebellar ataxia, COPD, severe malnutrition, and g tube placement. The quarterly MDS dated [DATE] identified Resident #27 had no cognitive impairment, was dependent on staff for toileting hygiene, transfers, and bed mobility and received nutrition through a feeding tube (g tube). The care plan dated 2/4/25 identified Resident #27 was totally dependent on tube feeding for all of nutritional needs. Interventions included to elevate the head of the bed 45 degrees during and for 30 minutes after tube feedings and to monitor for aspiration. A physician's order dated 3/4/25 directed to administer Jevity 1.5 tube feeding formula at 40cc/hour for 20 hours and to monitor for aspiration. The Nurse Aide Care Card dated 4/2/25 indicated Resident #27 was receiving tube feedings. Observation on 4/2/25 at 12:23 PM identified the resident lying on his/her back in bed and the tube feed was connected and infusing as ordered at 40cc/hour. NA #7 entered the room to provide incontinent care and began lowering the head of the bed to a flat position with the feeding infusing. This surveyor stopped NA #7. NA #7 indicated at that time, the head of the bed should not be lowered while the tube feed is running, my mistake. NA #7 raised the head of the bed back to a 45 degree angle and left the room to notify the nurse. NA #7 explained that she was from the agency and had not received a facility orientation, stating, you just come in blind. Interview with LPN #1 on 4/2/25 at 12:31 PM identified that the tube feed should have been paused or turned off prior to Resident #27 being placed in a flat position and she would have expected NA #7 to be aware of this and to pause the tube feed. LPN #1 explained that during orientation for agency staff, they are given a tour of the unit and informed about which residents are on tube feedings and the type of care each resident requires. LPN #1 acknowledged that she did not specifically instruct the NA #7 to pause the tube feedings and added, maybe I should have. Interview with DNS on 4/3/25 at 5:36 PM identified that basic nurse aide competencies are assumed for agency nurse's aides, as the agency is responsible for sending qualified and competent staff. The DNS explained that while agency staff were expected to follow the facility's policies and procedures, it was the agency's responsibility to conduct background checks and verify assessments and competencies. The facility did not provide formal training for agency staff; instead, nurses would have given a detailed report to each nurse aide, outlining resident-specific priorities and care needs. Review of the Aspiration Policy directed residents with tube feeding should have the head of bed up 30 - 45 degrees at all times. Subsequent to surveyor inquiry the Nurse Aide Assignment Card reflected staff to turn tube feeding off prior to laying Resident #27 flat.

Based on review facility documentation, facility policy and interviews and as part of the medication storage task the facility failed to have medications available to meet the needs of each resident. The findings include: A review of the facility Controlled Substance Disposition Records on 3/31/25 at 10:30 AM identified the following: a. Review of a Controlled Substance Disposition Record for Resident #218 identified on 3/25/25 at 7:30 PM (1) tablet of Lorazepam 0.5 mg was removed noting it was borrowed for Resident #69. b. Review of a Controlled Substance Disposition Record for Resident #468 identified on 3/22/25 at 4:30 PM (1) tablet Oxycodone 5mg 0.5 mg tab was removed noting it was borrowed for Resident #470. c. Review of a Controlled Substance Disposition Record for Resident #57 identified on 3/25/25 at 9:00 PM (2) Lorazepam 1 mg tablets were removed noting they was borrowed for (unidentifiable entry). d. Review of a Controlled Substance Disposition Record for Resident #29 identified on 11/26/24 at 11:30 AM (1) tablet of Tramadol 50 mg was removed noting it was borrowed for Resident #474. e. Review of a Controlled Substance Disposition Record for Resident #39 identified on 3/16/25 at 11:45 AM (1) tablet of Oxycodone 5mg was removed noting it was borrowed for (unidentifiable entry). An interview with LPN #2 on 3/31/25 at 12:24 PM identified if a medication was needed right away, the nursing supervisor has obtained the medication from another residents supply. An interview with RN #2 on 3/1/25 at 1:01PM identified there have been occasions in the past where the nursing supervisor had obtained pain medication from another residents supply for a resident reporting pain. An interview and facility documentation review with RN #3 on 4/1/25 at 10:40 AM identified she was the regularly assigned nursing supervisor for the 7:00 AM to 3:00 PM shift. RN #3 identified if a medication was needed and unavailable, the facility could access an after-hours (Pyxis) cart to obtain the medication, or the physician could be notified to request an alternative medication. RN #3 further identified on some occasions medications were borrowed from other resident's supply when unavailable. While RN #4 indicated physician's orders were obtained in those other instances, RN #4 was unable to provide documentation that physician's orders had been obtained for Resident #218, 468, 57, 2 and 39. An interview with the DNS on 4/02/25 at 1:00 PM identified that she was aware that on occasion, controlled medications were borrowed from other residents, recognizing this as poor practice. The DNS identified nursing staff were required to be preregistered to access the after-hours Pyxis system, which necessitated the presence of two nurses to remove controlled medication. However, not all shifts had nursing staff authorized to enter Pyxis system, thereby limiting access. The DNS identified limited access to the Pyxis system and late day admissions as root causes leading to the borrowing of medications from other residents. The DNS further identified this was mentioned by the pharmacy consultant as well. An interview with Person #8 on 4/3/25 at 2:04 PM identified she was the Pharmacy Consultant for the facility and routinely conducts medication storage room inspections. Person #8 identified she did note controlled medications were being borrowed and spoke to the DNS about this practice. Person #8 indicated that first doses should not be obtained for use from other residents. A review of the facility policy for Automated Medication Dispensing Systems directs only authorized nursing personnel approved by the DNS and with specialized training may have access to the Automated Medication Dispensing System.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interviews for 1 resident (Resident #420) reviewed for a significant medication error, the facility failed to ensure the correct dose of a controlled pain medication was administered per the physician's order. The findings include: Resident #420's diagnoses included displaced fracture of the left leg, spiral fracture of the left tibia and chronic pain. A physician's order dated 1/23/25 directed to administer Morphine Sulfate Oral Solution 10mg/5ml, give 2.5 ml by mouth every 4 hours as needed for moderate pain x 10 days. A pain evaluation and management record dated 1/23/25 identified Resident #418 had severe pain in his/her left leg and upper extremity and was being followed up by pain management. Review of the State of Connecticut Department of Public Health Reportable Events form dated 1/24/25 identified an unintentional overdose of Morphine Sulfate Oral Solution had occurred with Resident #418 at 10:00 AM. The form indicated that no adverse effects were noted, and the resident remained stable. A physician's order dated 1/24/25 at 12:30 PM directed to hold Morphine Sulfate Oral Solution 10mg/5ml by mouth until 6:00 PM this evening (1/24/25 at 6:00 PM) A nurse's note, written by the DNS dated 1/24/25 at 5:59 PM identified a medication error involving the administration of Morphine Sulfate Oral Solution had occurred at 10:14 AM. Resident #420 had been administered a 50mg dose of the medication instead of the 5mg dose that had been ordered (100mg/5ml solution was administered instead of the 10mg/5ml solution that was ordered). The resident, DNS, APRN and MD were all notified of the error, and the resident was ordered to be closely monitored with the Morphine Sulfate Oral Solution order put on hold for re-administration until 6:00 PM on 1/24/25. Resident #420 had exhibited no apparent adverse reactions at the time of the evaluation. A nurse's note dated 1/24/25 at 6:08 PM identified Resident #420 had been administered Morphine Sulfate Oral Solution 10mg/5ml, 2.5 ml by mouth as needed for moderate pain. The admission MDS dated [DATE] identified Resident #420 was cognitively intact and was dependent with bed mobility, toileting, and transfers. The MDS indicated Resident #420 frequently experienced pain and received scheduled and as needed pain medications. The care plan dated 2/3/25 identified an alteration in musculoskeletal status related to displaced spiral fracture of the shaft of the left tibia. Interventions included to administer analgesics as ordered by the physician and monitor and document for side effects and effectiveness. Interview and review of facility documents with the RN supervisor (RN #3) on 4/7/25 at 12:25 PM identified she did not have the Morphine Sulfate Oral Solution 100mg/5ml stored in the Omnicell because the bar code was not working, and she was unable to store the medication in the Omnicell. RN #3 identified the pharmacy, and the DNS were aware and while she awaited intervention by the pharmacy, she had the Morphine Sulfate stored in a locked cabinet in the nursing supervisor's office. RN #3 indicated on the morning of 1/24/25 she was contacted by LPN #8 who stated Resident #420's Morphine Sulfate Oral Solution had not yet arrived from the pharmacy and the resident was in a lot of pain. RN #3 identified that had the medication been in the Omnicell, that would have required two nurse witnesses, but since the medication was in the locked cabinet in the supervisor's office, she alone removed the Morphine Sulfate Oral Solution 100mg/5ml and brought it to LPN #8. RN #3 indicated that she should have compared Resident #420's physician's order to the medication before dispensing the Morphine Sulfate 100mg/5ml solution to LPN #8 but had made a mistake. RN #3 further identified that she was busy that day and when LPN #8 asked for the Morphine Sulfate Oral Solution she gave her what was in the locked cabinet and never checked the order in the computer. Interview with the DNS on 4/7/25 at 1:00 PM identified she was immediately notified of the medication error with the Morphine Sulfate Oral Solution on 1/24/25 and completed an assessment of Resident #420 after the incident. The DNS indicated that she was aware that the Morphine Sulfate Oral Solution 100mg/5ml was being kept in a locked cabinet in the supervisor's office and she identified she had emailed the pharmacy and informed them of the issue with the Omnicell/barcode. The DNS identified that if the Morphine Sulfate Oral Solution was secured in the Omnicell, it would have required 2 licensed nurses to remove the medication from the device. The DNS indicated that although RN #3 should have compared the Morphine Sulfate Oral Solution with Resident #420's physician's order before dispensing the medication to LPN #8, RN #3 did not, and LPN #8 assumed it was the correct medication and administered the incorrect dose to the resident. Per the DNS, when LPN #8 realized her medication administration error, she notified RN #3 and the DNS. The DNS identified that Resident #420 had no apparent ill effects after the medication error and both RN #3 and LPN #8 were disciplined and re-education was completed with the facility's licensed nursing staff after the incident. Although requested, the DNS was unable to provide her email to the pharmacy regarding the Omnicell/barcode issue. Interview with LPN #8 on 4/8/25 at 11:30 AM identified that although she read the medication order for Resident #420 from her computer when she called RN #3 to request the Morphine Sulfate Oral Solution on the morning of 1/24/25, she did not check the label on the Morphine Sulfate Oral Solution 100mg/5ml with the physician's order prior to administering the medication to Resident #420. LPN #8 identified after she administered the medication to Resident #420, she looked at the Morphine Sulfate oral solution box and realized she had made a mistake and administered the wrong concentration and dosage to the resident. LPN #8 indicated she immediately notified RN #3 and the DNS of her medication administration error and went and checked on Resident #420 and informed the resident about the error. LPN #8 further identified this was a serious error because she failed to complete the necessary checks before administering a controlled substance. Review of the facility policy, Medication Related Errors, dated 12/1/07, directed an example of an administration error would include when a facility administers to the resident a medication dose by the correct route but in a different dosage than was specified by the original order. Review of the facility policy, General Dose Preparation and Medication Administration, dated 12/1/07, directed the facility should take all measures required by facility policy and applicable law including using a 3 way check to compare the medication to the medication administration record (MAR) and to the prescription label. In addition, prior to administration of medication facility staff should verify each time a medication is administered that it is the correct medication, at the correct dose, and confirm that the MAR reflects the most recent medication order.

**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 6 resident shared bathrooms on 1 of 4 nursing units, the facility failed to ensure personal care items were stored in a manner to maintain a clean, comfortable, and homelike environment, and for 1 resident (Resident #89), the facility failed to maintain safe and comfortable water temperatures in the residents bathroom. The findings include: 1. Observation on 4/1/25 at 11:33 AM and observation and interview with NA #5 on 4/7/25 at 4:15 PM and LPN #13 on 4/7/25 at 4:22 PM identified the following. room [ROOM NUMBER]'s shared bathroom contained four bedpans, all unlabeled and uncovered and wedged inside a metal rack located on the door side wall. room [ROOM NUMBER]'s shared bathroom contained two bedpans and one toilet hat, all unlabeled and uncovered and wedged inside a metal rack located on the door side wall. The bedpan and toilet hat at the top of the metal rack also had a black clothing garment rolled up on top of them. room [ROOM NUMBER]'s shared bathroom contained 3 bedpans, all unlabeled and uncovered and wedged inside a metal rack located on the door side wall. room [ROOM NUMBER]'s shared bathroom contained three urinals and one toilet hat, all unlabeled and uncovered and sitting inside a metal railing along the door side wall. The open side of the toilet was touching the wall. room [ROOM NUMBER]'s shared bathroom contained three bedpans, two were labeled and all were uncovered and wedged inside a metal rack located on the door side wall. Interview with NA #5 on 4/7/25 at 4:15 PM identified it was the nurse aides responsibility to label, cover, and store the resident's personal care items. NA #6 failed to indicate why the policy was not followed and was uncertain as to why the bed pans were inappropriately stored. Interview with LPN #13 on 4/7/25 at 4:22 PM identified it was nurse aides responsibility to label, cover and store the resident's personal care items. LPN #13 failed to indicate why the policy was not followed and was uncertain as to why the bed pans were inappropriately stored. Interview with the IP Nurse (LPN #9) on 4/7/25 at 4:27 PM identified that resident's personal care items should be separated, labeled and covered per policy and that the nurse aide was responsible. LPN #9 was unable to indicate why the personal care items were inappropriately stored. Interview with the DNS on 4/8/25 at 10:12 AM identified all resident's personal care items should be labeled and covered with no duplicate items kept in the bathrooms. The DNS indicated the nursing staff was responsible to maintain items in that manner and that she would need to address it further with the staff on that unit. Subsequent to surveyor inquiry, an observation on 4/8/25 at 11:40 AM indicated the bathrooms of room [ROOM NUMBER], 5, 12, 16, 18 and 20 had all identified bedpans, urinals, and toilet hats bagged, labeled and appropriately stored in the bathrooms. Review of the facility policy, Disinfection of Bedpans and Urinals, undated, directed that each resident shall be assigned a bedpan or urinal for their exclusive use and the bedpan or urinal shall be labeled with the resident's name. 2. Resident #89's diagnosis included malignant neoplasm of the bladder and blindness. The quarterly MDS dated [DATE], identified Resident #89 had intact cognition, required partial to moderate assistance for eating, toileting hygiene, dressing, and was dependent on staff for all transfers. The care plan dated 1/23/25, identified Resident #89 had a self-care performance deficit related to limited physical mobility, and visual and hearing impairment. Interventions directed staff to anticipate the residents needs, assist with toileting, bed mobility and transferring. Observation on 3/31/25 at 11:26 AM identified the hot water temperature in Resident # 89's bathroom sink was 55°F. At 11:32 AM the hot water temp was 55°F. Interview with Maintenance Technician #5 stated he was not aware of the lack of hot water in Resident #89's room, but he would let the Maintenance Supervisor know. Observation on 4/1/2025 at 2:34 PM identified that the hot water temperature in Resident #89's bathroom sink was 56°F. Interview with Resident #89 on 4/3/3035 at 2:41 PM identified that he/she takes showers and at times receives a bed bath. Resident #89 stated that since the bathroom water was always cold, the staff have to bring in warm water from another room. Observation on 4/7/25 at 4:02 PM identified the hot water temperature in Resident #89's bathroom sink was 56°F. Interview with the Maintenance Supervisor #1 on 4/7/2025 at 4:02 PM identified there was a known problem with the hot water in Resident #89's bathroom but he indicated it had been fixed at some point last year. Maintenance Technician #6 entered the room, let the water run for 10 minutes and tested the hot water using his thermometer and determined it was 58°F. Maintentance Supervisor #1 stated he would look and see if he could repair the issue. At 4:29 PM Maintenance Supervisor #1 stated he had repaired the issue. The hot water temperature was retested and measured 119°F. The Maintenance Supervisor stated he had adjusted the mixing valve and reported there would not be an issue with the hot water moving forward. Observation and interview on 4/7/25 at 4:31 PM identified the hot water temperature in Resident #89's bathroom was 125.8°F, which exceeded acceptable guidelines. In a follow-up interview, Maintenance Supervisor #1 indicated that the issue had not actually been fixed and explained that the only way to get hot water in that room was by turning on the hot water at full strength in both the janitor's closet and the bathroom across the hall. The Maintenance Supervisor #1 identified he would call the plumber out that evening to properly address the problem. An interview with the Administrator on 4/8/2025 at 10:41 AM identified the Facility Administrator was aware of a historical problem with the hot water in Resident #89's room, noting that the water needed to run for approximately 15 minutes before becoming hot due to the room being serviced by a different line. The Administrator indicated he was not aware the water was running cold and identified this was a problem and stated once it was brought to his attention, he arranged for a plumber to come out to make the necessary repairs. Interview with the Administrator, Maintenance Supervisor #1, and Person #2 on 4/8/25 at 12:10 PM identified the hot water issue in Resident #89's room was caused by an improper connection made during the wing's renovation in 2008. Person #2 confirmed that the problem had existed since that time and stated it had not been fixed earlier because the facility never set up a time to repair it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interviews for 3 of 4 residents (Resident #45, 53 and 4) reviewed for abuse, the facility failed to report allegations of abuse to the Administrator, the State Agency and Police according to facility policy. The findings include: 1. Resident #45's diagnoses included cerebral palsy and adjustment disorder with anxiety. The quarterly MDS dated [DATE] identified Resident #45 had intact cognition, required the assistance of 2 via mechanical lift for transfers to the wheelchair, and was independent while in the wheelchair. a. Interview with Resident #45 on 3/31/25 at 11:50 AM identified that Resident #53 had grabbed Resident #45's neck and pushed the back of his/her wheelchair when exiting the dining room. Resident #45 stated that he/she in turn ran over Resident #53's feet three times with his/her wheelchair purposely. Resident #45 stated he/she sees Resident #53 in the hallway and Resident #53 is always looking in his/her (Resident #45's) room. The allegation of resident-to-resident abuse was reported by the surveyor to the DNS on 3/31/25 at 12:30 PM. The DNS indicated that she was not aware of any allegations of resident-to-resident abuse between Resident #45 and Resident #53. A review of Resident #45's care plan on 4/3/25 failed to reflect Resident #45's fear of Resident #53 or the alleged resident to resident allegation. b. Resident #53's diagnoses included Alzheimer's disease with agitation. The quarterly MDS dated [DATE] identified Resident #53 as being severely cognitively impaired and required a wheelchair for mobility. Physician's order for Resident #53 dated 3/5/25 directed to administer Trazadone (antidepressant) 50 mg every 6 hours as needed for anxiety. A review of Resident #53's nurse and social worker notes and care plan dated 2/1/25 through 4/3/25 failed to reflect the incident. Interview with Resident #53's representative on 4/1/25 indicated that he was not made aware that Resident #53 had grabbed Resident #45's neck and pushed the back of his/her wheelchair or that Resident #45 stated that he/she in turn ran over Resident #53's feet three times. Interview with LPN #6 on 4/2/25 at 10:50 AM, who was Resident #53's charge nurse during the 7:00 AM - 3:00 PM shift on 4/1/25 and 4/2/25 was unaware of any allegations made regarding Resident #45 and Resident #53. Interview with the DNS on 4/2/25 at 1:35 PM identified that the DNS reported the alleged allegation to the State Agency on 4/1/25 (a day after being notified) and had not reported the allegation to the police. The DNS indicated that the facility policy is to report alleged allegations to the State Agency immediately. The DNS indicated that she started the investigation first, which caused a delay in reporting and indicated that there was conflicting information regarding what occurred. The DNS also indicated that it is not normal practice to investigate first then report the allegation to the State Agency. The DNS indicated that the allegation happened a while ago, and SW #1 had addressed the issue. However, the first time the DNS was made aware of the alleged allegation was when it was reported to her by the surveyor on 3/31/25. The DNS identified the Social Worker had never made her aware of the incident. Interview with SW #1 on 4/3/25 at 10:22 AM identified that he was aware of the incident after it occurred as Resident #45 asked to speak to him. SW #1 indicated that Resident #45 never stated that Resident #53 grabbed his/her neck or that Resident #45 ran over Resident #53's feet. SW #1 stated that Resident #45 thinks that Resident #53 has pinpointed him/her but that Resident #53 has never been aggressive towards Resident #45 as far as he is aware. Resident #53 wheels independently by Resident #45's room frequently. Interview with PT #2 on 4/3/25 at 10:48 AM identified that Resident #45 had reported that he/she ran over Resident #53's feet purposely and that he/she is fearful of Resident #53. 2. Resident #4 diagnoses included dementia, depression and generalized anxiety disorder. Physician's order dated 3/3/25 directed to document behaviors once a shift and administer Citalopram 10 mg daily and Mirtazapine 30 mg daily for depression. The quarterly MDS dated [DATE] identified Resident #4 had severely impaired cognition and was independent with toileting, personal hygiene, and ambulation. Interview with Resident #4 on 3/31/25 at 11:30 AM identified that several weeks ago he/she believed that a nurse aide pushed him/her into the bathroom. Resident #4 was unable to identify the nurse aide by name but believed the nurse aide was white and worked during the day shift. Resident #4 stated that this nurse aide is around a lot and is mean and bossy. Resident #4 stated he/she does not want that nurse aide to care for him/her and that he/she had reported the incident to his/her resident representative when it occurred. The allegation was reported to the DNS on 3/31/25 at 12:30 PM by the surveyor. The DNS stated she was not aware of the allegation or concerns related to Resident #4 and it had not been reported. Interview with the Resident Representative on 4/2/25 at 10:25 AM identified that he/she was made aware of the allegation by Resident #4 but did not report the concern as he/she believed Resident #4 may have misinterpreted what occurred. Interview with LPN #6 on 4/2/25 at 10:50 AM identified she was Resident #4's charge nurse on the day shift on 4/1/25 and 4/2/25 and she is Resident #4's primary nurse every other week. LPN #6 indicated that Resident #4 frequently mentions that a nurse aide is mean but the resident is unable to identify the nurse aide. LPN #6 indicated that Resident #4 is consistent in saying the nurse aide is mean and bossy, however, Resident #4 has never indicated to her that she was pushed by the nurse aide. LPN #6 identified that Resident #4 is confused and cannot always express his/her concerns clearly. LPN #6 identified that she has never reported to the administration Resident #4's concerns regarding a nurse aide being mean and bossy. Interview with RN #6 on 4/4/25 at 10:30 AM identified she was made aware by Resident #4 that a nurse aide pushed the resident. RN #6 identified she investigated the situation when it was reported to her. RN #6 identified that a nurse aide had pushed Resident #4 in the wheelchair to obtain a weight and Resident #4 did not want to be weighed and was upset because he/she was being pushed in the wheelchair onto the scale. RN #6 indicated she does not think she reported the incident to the DNS at the time it occurred, she did not think she obtained any written statements from staff and was unsure if she documented the incident in the nursing notes. Interview with the DNS on 4/2/25 at 1:35 PM indicated that after the allegation was reported to her for the first time on 3/31/25 at 12:30 PM she started the investigation which caused a delay in reporting the incident to the State Agency. The DNS indicated that RN #6 had investigated the situation when it occurred, however, the DNS was not aware of the incident involving Resident #4 because RN #6 did not report it. Review of the nurses and social worker notes and the care plan dated 2/1/25 through 4/3/25 failed to reflect documentation of the allegation. Review of the Resident/Patient Abuse policy revised 2/8/23 identified that any alleged or witnessed incident of abuse is to be immediately reported to the nursing supervisor. This report shall be promptly reported to the appropriate department heads and the administrator. The DNS or designated representative shall promptly notify the Police, DPH, the attending physician, the medical director and Administrator within 2 hours of notification of abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interviews for 3 of 4 residents (Resident #45, 53 and 4) reviewed for abuse, the facility failed to immediately initiate a thorough investigation after allegations of abuse were either witnessed or reported, identify and remove the staff member involved, and report the results of the investigation to the administrator and to the State Agency within 5 working days of the incident. The findings include: 1. Resident #45's diagnoses included cerebral palsy and adjustment disorder with anxiety. The quarterly MDS dated [DATE] identified Resident #45 had intact cognition, required the assistance of 2 via mechanical lift for transfers to the wheelchair, and was independent while in the wheelchair. a. Interview with Resident #45 on 3/31/25 at 11:50 AM identified that Resident #53 had grabbed Resident #45's neck and pushed the back of his/her wheelchair when exiting the dining room. Resident #45 stated that he/she in turn ran over Resident #53's feet three times with his/her wheelchair purposely. Resident #45 stated he/she sees Resident #53 in the hallway and Resident #53 is always looking in his/her (Resident #45's) room. The allegation of resident-to-resident abuse was reported by the surveyor to the DNS on 3/31/25 at 12:30 PM. The DNS indicated that she was not aware of any allegations of resident-to-resident abuse between Resident #45 and Resident #53. A review of Resident #45's care plan on 4/3/25 failed to reflect Resident #45's fear of Resident #53 or the alleged resident to resident allegation. b. Resident #53's diagnoses included Alzheimer's disease with agitation. The quarterly MDS dated [DATE] identified Resident #53 as being severely cognitively impaired and required a wheelchair for mobility. Physician's order for Resident #53 dated 3/5/25 directed to administer Trazadone (antidepressant) 50 mg every 6 hours as needed for anxiety. A review of Resident #53's nurse and social worker notes and care plan dated 2/1/25 through 4/3/25 failed to reflect the incident. Interview with Resident #53's representative on 4/1/25 indicated that he was not made aware that Resident #53 had grabbed Resident #45's neck and pushed the back of his/her wheelchair or that Resident #45 stated that he/she in turn ran over Resident #53's feet three times. Interview with LPN #6 on 4/2/25 at 10:50 AM, who was Resident #53's charge nurse during the 7:00 AM - 3:00 PM shift on 4/1/25 and 4/2/25 was unaware of any allegations made regarding Resident #45 and Resident #53. Interview with the DNS on 4/2/25 at 1:35 PM identified that the DNS reported the alleged allegation to the State Agency on 4/1/25 (a day after being notified) and had not reported the allegation to the police. The DNS indicated that the facility policy is to report alleged allegations to the State Agency immediately. The DNS indicated that she started the investigation first, which caused a delay in reporting and indicated that there was conflicting information regarding what occurred. The DNS also indicated that it is not normal practice to investigate first then report the allegation to the State Agency. The DNS indicated that the allegation happened a while ago, and SW #1 had addressed the issue. However, the first time the DNS was made aware of the alleged allegation was when it was reported to her by the surveyor on 3/31/25. The DNS identified the Social Worker had never made her aware of the incident. Interview with SW #1 on 4/3/25 at 10:22 AM identified that he was aware of the incident after it occurred as Resident #45 asked to speak to him. SW #1 indicated that Resident #45 never stated that Resident #53 grabbed his/her neck or that Resident #45 ran over Resident #53's feet. SW #1 stated that Resident #45 thinks that Resident #53 has pinpointed him/her but that Resident #53 has never been aggressive towards Resident #45 as far as he is aware. Resident #53 wheels independently by Resident #45's room frequently. Interview with PT #2 on 4/3/25 at 10:48 AM identified that Resident #45 had reported that he/she ran over Resident #53's feet purposely and that he/she is fearful of Resident #53. Although PT #2 was aware of the incident, according to the DPH reportable events portal, the incident took place on 3/24/25, was not reported to DPH until 4/1/25, and the investigation summary was not submitted until 4/11/25. Review of the Resident/Patient Abuse policy revised 2/8/23, directed following the initial report of suspected or alleged abuse, the involved department supervisor(s)/department head(s) shall immediately initiate an investigation of the incident, this investigation shall include, but not limited to, interviewing of the resident and or family members and interviewing of all involved staff. 2. Resident #4 diagnoses included dementia, depression and generalized anxiety disorder. Physician's order dated 3/3/25 directed to document behaviors once a shift and administer Citalopram 10 mg daily and Mirtazapine 30 mg daily for depression. The quarterly MDS dated [DATE] identified Resident #4 had severely impaired cognition and was independent with toileting, personal hygiene, and ambulation. Interview with Resident #4 on 3/31/25 at 11:30 AM identified that several weeks ago he/she believed that a nurse aide pushed him/her into the bathroom. Resident #4 was unable to identify the nurse aide by name but believed the nurse aide was white and worked during the day shift. Resident #4 stated that this nurse aide is around a lot and is mean and bossy. Resident #4 stated he/she does not want that nurse aide to care for him/her and that he/she had reported the incident to his/her resident representative when it occurred. The allegation was reported to the DNS on 3/31/25 at 12:30 PM by the surveyor. The DNS stated she was not aware of the allegation or concerns related to Resident #4 and it had not been reported. Interview with the Resident Representative on 4/2/25 at 10:25 AM identified that he/she was made aware of the allegation by Resident #4 but did not report the concern as he/she believed Resident #4 may have misinterpreted what occurred. Interview with LPN #6 on 4/2/25 at 10:50 AM identified she was Resident #4's charge nurse on the day shift on 4/1/25 and 4/2/25 and she is Resident #4's primary nurse every other week. LPN #6 indicated that Resident #4 frequently mentions that a nurse aide is mean but the resident is unable to identify the nurse aide. LPN #6 indicated that Resident #4 is consistent in saying the nurse aide is mean and bossy, however, Resident #4 has never indicated to her that she was pushed by the nurse aide. LPN #6 identified that Resident #4 is confused and cannot always express his/her concerns clearly. LPN #6 identified that she has never reported to the administration Resident #4's concerns regarding a nurse aide being mean and bossy. Interview with RN #6 on 4/4/25 at 10:30 AM identified she was made aware by Resident #4 that a nurse aide pushed the resident. RN #6 identified she investigated the situation when it was reported to her. RN #6 identified that a nurse aide had pushed Resident #4 in the wheelchair to obtain a weight and Resident #4 did not want to be weighed and was upset because he/she was being pushed in the wheelchair onto the scale. RN #6 indicated she does not think she reported the incident to the DNS at the time it occurred, she did not think she obtained any written statements from staff and was unsure if she documented the incident in the nursing notes. Interview with the DNS on 4/2/25 at 1:35 PM indicated that after the allegation was reported to her for the first time on 3/31/25 at 12:30 PM she started the investigation which caused a delay in reporting the incident to the State Agency. The DNS indicated that RN #6 had investigated the situation when it occurred, however, the DNS was not aware of the incident involving Resident #4 because RN #6 did not report it. Review of the nurses and social worker notes and the care plan dated 2/1/25 through 4/3/25 failed to reflect documentation of the allegation. Although the resident reported the incident to RN #6 when it happened, RN #6 did not report the incident to the DNS or Administrator, the staff member was not identified or removed, and an investigation was not initiated. According to the DPH reportable events portal, the incident took place at the end of February 2025, was not reported to DPH until 4/1/25, and the investigation summary was not submitted until 4/11/25. Further, when requested, a statement obtained from RN #6, who was the supervisor on the day of the allegation, was undated and there was no statement from the alleged nurse aide involved. Review of the Resident/Patient Abuse policy revised 2/8/23 identified all incidents or events that constitute alleged, suspected or actual abuse will be thoroughly investigated, initially by the nursing supervisor to whom it was reported and a complete investigation by the department head. Following the initial report of alleged or suspected abuse, the involved department head shall immediately initiate an investigation of the incident that shall include, but not limited to interviewing of the resident and/or family, and interviewing all staff involved. As a first step, the employee shall be removed from the assignment and interviewed independently. The immediate and initial first response is suspension from duty pending final investigation outcome.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interviews for 3 of 5 residents (Resident #39, 42 and 49) reviewed as part of the medication storage task, the facility failed to ensure a licensed nurse documented the administration of controlled pain medications, including the level of pain and the effectiveness of the medication consistent with professional standards. As part of the medication storage task the facility failed to ensure controlled medications for pain and anxiety were available and were not borrowed from another resident's supply consistent with professional standards, and for 1 resident (Resident #25) the facility failed to ensure medications were administered according to accepted professional standards. The findings include: 1. Resident #39 had diagnoses that included unilateral hernia and wedge compression fracture of the vertebra. The admission MDS dated [DATE] identified Resident #39 was severely cognitively impaired required partial to moderate one person assist with bed mobility and transfers and was receiving medications to treat pain within the preceding 5 days and was not currently in pain. The care plan dated 1/6/25 identified Resident #39 was at risk for pain related to decreased mobility and chronic back pain. Interventions included the administration of pain medication as ordered, assess pain scale twice a shift and evaluating effectiveness of pain medications. Physician's order dated 3/18/25 directed to administer Oxycodone HCL 2.5 mg. Give 0.5 tablet, (narcotic/controlled drug) every 4 hours as needed for severe pain and conduct pain assessments twice a shift using a scale as follows. Zero indicating no pain, 1 - 3 indicating mild pain, 4 - 6 indicting moderate pain, and 7 - 10 indicting severe pain. a. Pain assessment dated [DATE] identified Resident #39 reported a pain level of zero at 1:00 PM. The controlled substance disposition record dated 3/18/25 identified LPN #16 administered Oxycodone 2.5mg to Resident #39 at 3:15 PM. The MAR dated 3/18/25 failed to reflect that LPN #16 administered Oxycodone 2.5 mg to Resident #39 at 3:15 PM, or its effectiveness. Review of the nurse's notes for 3/18/25 failed to reflect complaints of pain, the administration of Oxycodone 2.5 mg at 3:15 PM or its effectiveness. b. Pain assessment dated [DATE] identified Resident #39 reported a pain level of 6 at 11:00 PM. The controlled substance disposition record dated 3/18/25 identified LPN #16 administered Oxycodone 2.5mg to Resident #39 at 11:00 PM. The MAR dated 3/18/25 failed to reflect that LPN #16 administered Oxycodone 2.5 mg to Resident #39 at 11:00 PM, or its effectiveness. Review of the nurse's notes for 3/18/25 failed to reflect complaints of pain, the administration of Oxycodone 2.5 mg at 11:00 PM or its effectiveness. c. Pain assessment dated [DATE] identified Resident #39 reported a pain level of zero at 1:00 PM. The controlled substance disposition record dated 3/20/25 identified LPN #16 administered Oxycodone 2.5mg to Resident #39 at 4:00 PM. The MAR dated 3/20/25 failed to reflect that LPN #16 administered Oxycodone 2.5 mg to Resident #39 at 4:00 PM, or its effectiveness. Review of the nurse's notes for 3/20/25 failed to reflect complaints of pain, the administration of Oxycodone 2.5 mg at 4:00 PM or its effectiveness. d. Pain assessment dated [DATE] identified Resident #39 reported a pain level of zero at 9:00 PM. The controlled substance disposition record dated 3/20/25 identified LPN #16 administered Oxycodone 2.5mg to Resident #39 at 9:00 PM. The MAR dated 3/20/25 failed to reflect that LPN #16 administered Oxycodone 2.5 mg to Resident #39 at 9:00 PM, or its effectiveness. Review of the nurse's notes for 3/20/25 failed to reflect complaints of pain, the administration of Oxycodone 2.5 mg at 9:00 PM or its effectiveness. Interview and review of the clinical record with LPN #16 on 4/2/25 at 3:10 PM identified she was the assigned nurse responsible for medication administration during the 3:00 PM to 11:00 PM shift on 3/18/25 and 3/20/25. LPN #16 identified that when administering an as needed (PRN) medication, she would routinely sign out the medication on the MAR and a nurse's note would automatically generate in the progress note section of the electronic medical record (EMR) indicating the PRN medication was administered. The EMR system would later prompt to enter the resident's response/effectiveness of the medication following the administration. LPN #16 indicated that omitting the documentation of the administration of the Oxycodone 2.5mg on the MAR and its effectiveness was an oversight. LPN #16 further identified there were occasions during the shift where she recognized the need to complete documentation in the MAR, intended to do so, but unintentionally failed to do so. Interview with RN #7 on 4/2/25 at 3:41 PM identified she was a nursing supervisor who worked the 11:00 PM to 7:00 AM shift and conducted controlled drug audits twice monthly. RN #7 identified she did not routinely cross refence a signed out controlled drug with the MAR to identify discrepancies as part of her audits but would expect that any medication signed out by licensed staff from the controlled substance disposition record to also be documented as administered on the MAR. Interview and review of the clinical record with the DNS on 4/3/25 at 10:34 AM identified she would expect licensed staff to document on the MAR the administration of medications at when signing out the controlled substance disposition record. In doing so, the EMR system populates the administration of the medication in the nurse progress notes and later prompts documentation of the effectiveness. According to the American Nurses Association (2021) Nursing: Scope and Standards of Practice (4th edition) outlines professional standards emphasizes the importance of accurate and timely documentation of controlled medication as a core component of nursing practice. 2. Resident 42 had diagnoses that included intervertebral disc degeneration and osteoarthritis. The quarterly MDS dated [DATE] identified Resident #42 had intact cognition, was independent with bed mobility and transfers and mobilized independently with the wheelchair. The care plan dated 12/16/24 identified Resident #42 had osteoarthritis and chronic pain related to compression fractures of the sacrum. Interventions included administering pain medication according to physician's orders and assessing the effectiveness. Physician's order dated 12/19/24 directed to administer Tramadol 50mg (narcotic controlled drug/substance) every 6 hours as needed for moderate to severe pain, and conduct pain assessments twice a shift using a scale as follows. Zero indicating no pain, 1 - 3 indicating mild pain, 4 - 6 indicting moderate pain, and 7 - 10 indicting severe pain. a. A pain assessment dated [DATE] identified Resident #42 reported a pain level of zero at 9:00 PM. The controlled substance disposition record dated 12/27/24 identified LPN #16 administered Tramadol 50mg to Resident #42 at 9:45 PM. The MAR dated 12/27/24 failed to reflect that LPN #16 administered Tramadol 50mg to Resident #42 at 9:45 PM, or its effectiveness. Review of the nurse's notes for 12/27/24 failed to reflect complaints of pain, the administration of Tramadol 50mg at 9:45 PM or its effectiveness. b. A pain assessment dated [DATE] identified Resident #42 reported a pain level of zero at 9:00 PM. The controlled substance disposition record dated 12/30/24 identified LPN #16 administered Tramadol 50mg to Resident #42 at 10:00 PM. The MAR dated 12/30/24 failed to reflect that LPN #16 administered Tramadol 50mg to Resident #42 at 10:00 PM, or its effectiveness. Review of nurse's notes for 12/30/24 failed to reflect complaints of pain, the administration of Tramadol 50mg at 10:00 PM or its effectiveness. c. A pain assessment dated [DATE] identified Resident #42 reported a pain level of zero at 9:00 PM. The controlled substance disposition record dated 12/31/24 identified LPN #16 administered Tramadol 50mg to Resident #42 at 9:00 PM. The MAR dated 12/31/24 failed to reflect that LPN #16 administered Tramadol 50mg to Resident #42 at 9:00 PM, or its effectiveness. Review of nurse's note for 12/31/24 failed to reflect complaints of pain, the administration of Tramadol 50mg at 9:00 PM or its effectiveness. d. A pain assessment dated [DATE] identified Resident #42 reported a pain level of zero at 5:00 PM. The controlled substance disposition record dated 1/10/25 identified LPN #16 administered Tramadol 50mg to Resident #42 at 5:00 PM. The MAR dated 1/10/25 failed to reflect that LPN #16 administered Tramadol 50mg to Resident #42 at 5:00 PM or its effectiveness. Review of nurse's notes for 1/10/25 failed to reflect complaints of pain, the administration of Tramadol 50mg at 5:00 PM or its effectiveness. Interview and review of the clinical record with LPN #16 on 4/2/25 at 3:10 PM identified she was the assigned nurse responsible for medication administration during the 3:00 PM to 11:00 PM shift on 12/27/24, 12/30/24, 12/31/24 and 1/10/25. LPN #16 identified that when administering an as needed (PRN) medication, she would routinely sign out the medication on the MAR and a nurse's note would automatically generate in the progress note section of the electronic medical record (EMR) indicating the PRN medication was administered. The EMR system would later prompt to enter the resident's response/effectiveness of the medication following the administration. LPN #16 indicated that omitting the documentation of the administration of the Tramadol 50mg on the MAR and its effectiveness was an oversight. LPN #16 further identified there were occasions during the shift where she recognized the need to complete documentation in the MAR, intended to do so, but unintentionally failed to do so. Interview with RN #7 on 4/2/25 at 3:41 PM identified she was a nursing supervisor who worked the 11:00 PM to 7:00 AM shift and conducted controlled drug audits twice monthly. RN #7 identified she did not routinely cross refence a signed out controlled drug with the MAR to identify discrepancies as part of her audits but would expect that any medication signed out by licensed staff from the controlled substance disposition record to also be documented as administered on the MAR. Interview and review of the clinical record with the DNS on 4/3/25 at 10:34 AM identified she would expect licensed staff to document on the MAR the administration of medications at when signing out the controlled substance disposition record. In doing so, the EMR system populates the administration of the medication in the nurse progress notes and later prompts documentation of the effectiveness. According to the American Nurses Association (2021) Nursing: Scope and Standards of Practice (4th edition) outlines professional standards emphasizes the importance of accurate and timely documentation of controlled medication as a core component of nursing practice. 3. Resident #99 had diagnosis that included osteoarthritis of the right shoulder and intervertebral disc degeneration of the lumbar region. The annual MDS dated [DATE] identified Resident #99 had moderately impaired cognition, required one person assist with bed mobility, two person for transfers, had reported pain in the preceding five days and received opioid pain medication. The care plan dated 7/22/24 identified Resident #99 was at risk for pain related to osteoarthritis and chronic back pain. Interventions included assessing pain using pain scale, administer pain medications according to physician orders and evaluate effectiveness. Physician's order dated 8/11/24 directed to administer Tramadol 50mg (narcotic controlled drug/substance) every 6 hours as needed for moderate pain, and conduct pain assessments twice a shift using a scale as follows. Zero indicating no pain, 1 - 3 indicating mild pain, 4 - 6 indicting moderate pain, and 7 - 10 indicting severe pain. a. A pain assessment dated [DATE] identified Resident #99 reported a pain level of zero at 5:00 PM. The controlled substance disposition record dated 9/25/24 identified LPN #16 administered Tramadol 50mg to Resident #99 at 6:30 PM. The MAR dated 9/25/24 failed to reflect that LPN #16 administered Tramadol 50mg to Resident #99 at 6:30 PM, or its effectiveness. Review of the nurse's notes for 9/25/24 failed to reflect complaints of pain, the administration of Tramadol 50mg at 6:30 PM or its effectiveness. b. A pain assessment dated [DATE] identified Resident #99 reported a pain level of zero at 5:00 PM. The controlled substance disposition record dated 9/27/24 identified LPN #16 administered Tramadol 50mg to Resident #99 at 6:00 PM. The MAR dated 9/27/24 failed to reflect that LPN #16 administered Tramadol 50mg to Resident #99 at 6:00 PM, or its effectiveness. Review of the nurse's notes for 9/27/24 failed to reflect complaints of pain, the administration of Tramadol 50mg at 6:00 PM or its effectiveness. c. A pain assessment dated [DATE] identified Resident #99 reported a pain level of zero at 5:00 PM. The controlled substance disposition record dated 9/29/24 identified LPN #16 administered Tramadol 50mg to Resident #99 at 7:00 PM. The MAR dated 9/29/24 failed to reflect that LPN #16 administered Tramadol 50mg to Resident #99 at 7:00 PM, or its effectiveness. Review of the nurse's notes for 9/29/24 failed to reflect complaints of pain, the administration of Tramadol 50mg at 7:00 PM or its effectiveness. d. A pain assessment dated [DATE] identified Resident #99 reported a pain level of zero at 5:00 PM. The controlled substance disposition record dated 10/1/24 identified LPN #16 administered Tramadol 50mg to Resident #99 at 7:00 PM. The MAR dated 10/1/24 failed to reflect that LPN #16 administered Tramadol 50mg to Resident #99 at 7:00 PM, or its effectiveness. Review of the nurse's notes for 10/1/24 failed to reflect complaints of pain, the administration of Tramadol 50mg at 7:00 PM or its effectiveness. e. A pain assessment dated [DATE] identified Resident #99 reported a pain level of zero at 5:00 PM. The controlled substance disposition record dated 10/3/24 identified LPN #16 administered Tramadol 50mg to Resident #99 at 6:00 PM. The MAR dated 10/3/24 failed to reflect that LPN #16 administered Tramadol 50mg to Resident #99 at 6:00 PM, or its effectiveness. Review of the nurse's notes for 10/3/24 failed to reflect complaints of pain, the administration of Tramadol 50mg at 6:00 PM or its effectiveness. f. A pain assessment dated [DATE] identified Resident #99 reported a pain level of zero at 5:00 PM. The controlled substance disposition record dated 10/4/24 identified LPN #16 administered Tramadol 50mg to Resident #99 at 6:00 PM. The MAR dated 10/4/24 failed to reflect that LPN #16 administered Tramadol 50mg to Resident #99 at 6:00 PM, or its effectiveness. Review of the nurse's notes for 10/4/24 failed to reflect complaints of pain, the administration of Tramadol 50mg at 6:00 PM or its effectiveness. g. A pain assessment dated [DATE] identified Resident #99 reported a pain level of zero at 5:00 PM. The controlled substance disposition record dated 10/8/24 identified LPN #16 administered Tramadol 50mg to Resident #99 at 8:00 PM. The MAR dated 10/8/24 failed to reflect that LPN #16 administered Tramadol 50mg to Resident #99 at 8:00 PM, or its effectiveness. Review of the nurse's notes for 10/8/24 failed to reflect complaints of pain, the administration of Tramadol 50mg at 8:00 PM or its effectiveness. h. A pain assessment dated [DATE] identified Resident #99 reported a pain level of zero at 9:00 PM. The controlled substance disposition record dated 10/9/24 identified LPN #16 administered Tramadol 50mg to Resident #99 at 9:00 PM. The MAR dated 10/9/24 failed to reflect that LPN #16 administered Tramadol 50mg to Resident #99 at 9:00 PM, or its effectiveness. Review of the nurse's notes for 10/9/24 failed to reflect complaints of pain, the administration of Tramadol 50mg at 9:00 PM or its effectiveness. i. A pain assessment dated [DATE] identified Resident #99 reported a pain level of zero at 5:00 PM. The controlled substance disposition record dated 10/11/24 identified LPN #16 administered Tramadol 50mg to Resident #99 at 6:00 PM. The MAR dated 10/11/24 failed to reflect that LPN #16 administered Tramadol 50mg to Resident #99 at 6:00 PM, or its effectiveness. Review of the nurse's notes for 10/11/24 failed to reflect complaints of pain, the administration of Tramadol 50mg at 6:00 PM or its effectiveness. j. A pain assessment dated [DATE] identified Resident #99 reported a pain level of zero at 5:00 PM. The controlled substance disposition record dated 10/12/24 identified LPN #16 administered Tramadol 50mg to Resident #99 at 7:00 PM. The MAR dated 10/12/24 failed to reflect that LPN #16 administered Tramadol 50mg to Resident #99 at 7:00 PM, or its effectiveness. Review of the nurse's notes for 10/12/24 failed to reflect complaints of pain, the administration of Tramadol 50mg at 7:00 PM or its effectiveness. k. A pain assessment dated [DATE] identified Resident #99 reported a pain level of zero at 5:00 PM. The controlled substance disposition record dated 10/13/24 identified LPN #16 administered Tramadol 50mg to Resident #99 at 6:00 PM. The MAR dated 10/13/24 failed to reflect that LPN #16 administered Tramadol 50mg to Resident #99 at 6:00 PM, or its effectiveness. Review of the nurse's notes for 10/13/24 failed to reflect complaints of pain, the administration of Tramadol 50mg at 6:00 PM or its effectiveness. l. A pain assessment dated [DATE] identified Resident #99 reported a pain level of zero at 5:00 PM. The controlled substance disposition record dated 10/15/24 identified LPN #16 administered Tramadol 50mg to Resident #99 at 6:00 PM. The MAR dated 10/15/24 failed to reflect that LPN #16 administered Tramadol 50mg to Resident #99 at 6:00 PM, or its effectiveness. Review of the nurse's notes for 10/15/24 failed to reflect complaints of pain, the administration of Tramadol 50mg at 6:00 PM or its effectiveness. m. A pain assessment dated [DATE] identified Resident #99 reported a pain level of zero at 5:00 PM. The controlled substance disposition record dated 10/16/24 identified LPN #16 administered Tramadol 50mg to Resident #99 at 5:00 PM. The MAR dated 10/16/24 failed to reflect that LPN #16 administered Tramadol 50mg to Resident #99 at 5:00 PM, or its effectiveness. Review of the nurse's notes for 10/16/24 failed to reflect complaints of pain, the administration of Tramadol 50mg at 5:00 PM or its effectiveness. n. A pain assessment dated [DATE] identified Resident #99 reported a pain level of zero at 5:00 PM. The controlled substance disposition record dated 10/17/24 identified LPN #16 administered Tramadol 50mg to Resident #99 at 7:00 PM. The MAR dated 10/17/24 failed to reflect that LPN #16 administered Tramadol 50mg to Resident #99 at 7:00 PM, or its effectiveness. Review of the nurse's notes for 10/17/24 failed to reflect complaints of pain, the administration of Tramadol 50mg at 7:00 PM or its effectiveness. Interview and review of the clinical record with LPN #16 on 4/2/25 at 3:10 PM identified she was the assigned nurse responsible for medication administration during the 3:00 PM to 11:00 PM shift on 9/25/24, 9/27/24, 9/29/24, 10/1/24, 10/3/24, 104/24, 10/8/24, 10/9/24, 10/11/24, 10/12/24, 10/13/24, 10/15/24, 10/16/24 and 10/17/24. LPN #16 identified that when administering an as needed (PRN) medication, she would routinely sign out the medication on the MAR and a nurse's note would automatically generate in the progress note section of the electronic medical record (EMR) indicating the PRN medication was administered. The EMR system would later prompt to enter the resident's response/effectiveness of the medication following the administration. LPN #16 indicated that omitting the documentation of the administration of the Tramadol 50mg on the MAR and its effectiveness was an oversight. LPN #16 further identified there were occasions during the shift where she recognized the need to complete documentation in the MAR, intended to do so, but unintentionally failed to do so. Interview with RN #7 on 4/2/25 at 3:41 PM identified she was a nursing supervisor who worked the 11:00 PM to 7:00 AM shift and conducted controlled drug audits twice monthly. RN #7 identified she did not routinely cross refence a signed out controlled drug with the MAR to identify discrepancies as part of her audits but would expect that any medication signed out by licensed staff from the controlled substance disposition record to also be documented as administered on the MAR. Interview and review of the clinical record with the DNS on 4/3/25 at 10:34 AM identified she would expect licensed staff to document on the MAR the administration of medications at when signing out the controlled substance disposition record. In doing so, the EMR system populates the administration of the medication in the nurse progress notes and later prompts documentation of the effectiveness. According to the American Nurses Association (2021) Nursing: Scope and Standards of Practice (4th edition) outlines professional standards emphasizes the importance of accurate and timely documentation of controlled medication as a core component of nursing practice. 4. A review of the facility Controlled Substance Disposition Records on 3/31/25 at 10:30 AM identified the following: a. Review of a Controlled Substance Disposition Record for Resident #218 identified on 3/25/25 at 7:30 PM (1) tablet of Lorazepam 0.5 mg was removed noting it was borrowed for Resident #69. b. Review of a Controlled Substance Disposition Record for Resident #468 identified on 3/22/25 at 4:30 PM (1) tablet Oxycodone 5mg 0.5 mg tab was removed noting it was borrowed for Resident #470. c. Review of a Controlled Substance Disposition Record for Resident #57 identified on 3/25/25 at 9:00 PM (2) Lorazepam 1 mg tablets were removed noting they was borrowed for (unidentifiable entry). d. Review of a Controlled Substance Disposition Record for Resident #29 identified on 11/26/24 at 11:30 AM (1) tablet of Tramadol 50 mg was removed noting it was borrowed for Resident #474. e. Review of a Controlled Substance Disposition Record for Resident #39 identified on 3/16/25 at 11:45 AM (1) tablet of Oxycodone 5mg was removed noting it was borrowed for (unidentifiable entry). An interview with LPN #2 on 3/31/25 at 12:24 PM identified if a medication was needed right away, the nursing supervisor has obtained the medication from another residents supply. An interview with RN #2 on 3/1/25 at 1:01PM identified there have been occasions in the past where the nursing supervisor had obtained pain medication from another residents supply for a resident reporting pain. An interview and facility documentation review with RN #3 on 4/1/25 at 10:40 AM identified she was the regularly assigned nursing supervisor for the 7:00 AM to 3:00 PM shift. RN #3 identified if a medication was needed and unavailable, the facility could access an after-hours (Pyxis) cart to obtain the medication, or the physician could be notified to request an alternative medication. RN #3 further identified on some occasions medications were borrowed from other resident's supply when unavailable. While RN #4 indicated physician's orders were obtained in those other instances, RN #4 was unable to provide documentation that physician's orders had been obtained for Resident #218, 468, 57, 2 and 39. An interview with the DNS on 4/02/25 at 1:00 PM identified that she was aware that on occasion, controlled medications were borrowed from other residents, recognizing this as poor practice. The DNS identified nursing staff were required to be preregistered to access the after-hours Pyxis system, which necessitated the presence of two nurses to remove controlled medication. However, not all shifts had nursing staff authorized to enter Pyxis system, thereby limiting access. The DNS identified limited access to the Pyxis system and late day admissions as root causes leading to the borrowing of medications from other residents. The DNS further identified this was mentioned by the pharmacy consultant as well. An interview with Person #8 on 4/3/25 at 2:04 PM identified she was the Pharmacy Consultant for the facility and routinely conducts medication storage room inspections. Person #8 identified she did note controlled medications were being borrowed and spoke to the DNS about this practice. Person #8 indicated that first doses should not be obtained for use from other residents. A review of the facility policy for Automated Medication Dispensing Systems directs only authorized nursing personnel approved by the DNS and with specialized training may have access to the Automated Medication Dispensing System. 5. Resident #25's diagnoses include chronic kidney disease with hydronephrosis, neoplastic disease unspecified, and weakness/failure to thrive. Review of a self-administration of medication form dated 7/30/20 identified Resident #25 did not wish to self-administer medications. A quarterly MDS dated [DATE] identified Resident #25 had intact cognition and required set-up assistance for eating and oral hygiene. The care plan dated 3/18/25 identified Resident #25 had an activities of daily living (ADL) self-care deficit and limited mobility with interventions that included breaking down all tasks into sub-tasks for completion, provide rest periods as needed, and provide one-step directions, provide cueing as needed, monitor understanding and repeat as needed (prn). Observation on 4/1/25 at 10:30 AM and 4/3/25 at 9:30 AM identified Resident #25 was out of bed, seated in a recliner chair, with a small clear plastic medication cup on the tray table in front of the resident containing 4 pills. (Resident #25 identified the pills were a multivitamin with minerals, Lasix (a diuretic), Potassium, and Vitamin D). There were no licensed staff with Resident #25 or in the vicinity of Resident #25's room. Interview with Resident #25 at that time identified the pills were his/her morning medication that was left by the nurse (LPN #11) with instructions for the resident to take after he/she finished eating breakfast. Resident #25 further indicated nurses frequently leave medication for him/her to take without supervision. Interview with LPN #11 on 4/3/25 at 11:15 AM identified Resident #25 was alert/oriented and she had left Resident #25's medications in a cup with the resident and proceeded to administer another resident's medications in another room because the resident stated he/she was not ready to take the pills during breakfast. Additionally, LPN #11 stated she returned to Resident #25's room to ensure the resident had taken the pills. Additionally, LPN #11 stated she was aware she was not supposed to leave medication in front of the resident, but the resident requested her to leave the medication. Furthermore, LPN #11 stated a physician order can be obtained to leave medication with residents but could not confirm an order was present for medication to be left at the bedside. Interview with the DNS on 4/11/25 at 9:45 AM indicated that nurses may not leave medications unattended at the bedside for residents to self-administer as that is unacceptable practice. The General Dose Preparation and Medication Administration policy dated 12/1/2007 indicated facility staff should not leave medications or chemicals unattended, and staff must observe the resident's consumption of the medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 4 of 4 residents (Residents #110, 368, 25, 39) reviewed for respiratory care, the facility failed to determine the frequency with which oxygen and nebulizer tubing should be changed and implement such, and failed to administer oxygen according to the physician's order. The findings include: 1. Resident # 110's diagnoses included acute respiratory failure, hypoxia and centrilobular emphysema. The admission MDS dated [DATE] identified Resident #110 had intact cognition, required partial/moderate assistance from staff for transfers and changing position in bed and was on continuous oxygen therapy. The care plan dated 2/11/25 identified Resident #110 had emphysema, COPD, and interstitial lung disease. Interventions included providing oxygen, incentive spirometer, checking pulse oximetry as ordered and as needed. The physician's order dated 4/1/25 directed to administer oxygen at 2 to 3 liters per minute via nasal canula as needed to maintain a pulse oximetry greater than 92%, as needed every shift. Observation on 4/1/25 at 9:21 AM identified Resident #110 was in bed with oxygen at 1.5 liters per minute via nasal canula. Further, the oxygen tubing was without the benefit of a label/date as to when it was changed. Observation and interview with LPN # 7 on 4/1/25 at 10:27 AM identified that it is facility policy for the oxygen company to come out weekly and change oxygen tubing. Additionally, LPN #7 identified Resident #110 should be on 2 - 3 liters of oxygen per the physician's order, and she checks the pulse oximetry in the morning and at noon. Observation of the oxygen settings for Resident #110's concentrator with LPN #7 identified it was set to 1.5 liters (ball of the gauge was on 1.5. LPN #7 changed the gauge setting to 2.5 liters. Interview and order review with APRN #2 on 4/2/25 at 3:10 PM identified she would expect Resident #110 to be on 2 or 3 liters of oxygen as needed at all times, and to keep his/her pulse oximetry at 92% or above since he/she she had respiratory failure. APRN #2 identified a setting of 1.5 liters would not be appropriate since Resident #110 does not have a titration order. 2. Resident #368 diagnoses included acute respiratory failure with hypoxia, congestive heart failure (CHF) and pneumonia. The admission MDS dated [DATE] identified Resident #368 was cognitively intact and required partial/moderate assistance for transfers and toilet use. Additionally, it identified Resident #368 was on continuous oxygen therapy. The care plan dated 3/27/25 identified Resident #368 had an altered respiratory status and difficulty breathing. Interventions included providing oxygen, incentive spirometry, and checking pulse oximetry as ordered and as needed. The physician's order dated 3/19/25 directed to provide humidified oxygen at 2 liters per minute via nasal cannula continuously every shift, titrate to keep saturation above 92%. Observation on 3/31/25 at 11:20 AM identified Resident #368 was sitting in his/her recliner chair wearing oxygen at 1.5 liters via nasal canula. The oxygen tubing was without the benefit of a label/date as to when it was changed. Interview with LPN #4 on 4/1/25 at 10:06 AM identified the oxygen tubing should be labeled and dated by the oxygen company vendor weekly. Further, LPN #4 identified Resident #368 had an oxygen titration order, with a pulse oximetry of 96% on 1.5 liters of oxygen. Interview with the DNS on 4/2/25 at 10:02 AM identified the oxygen company vendor is responsible to change and label oxygen tubing weekly. Interview with the Oxygen Vendor on 4/7/25 at 11:05 AM identified the company is responsible for servicing the oxygen machines and comes out every 90 days or more frequently if there is an issue (which may include delivering oxygen tubing supplies). However, the facility is responsible for the changing and labeling of the tubing on a weekly basis. Follow up interview and oxygen vendor contract review with the DNS on 4/7/25 at 3:12 PM failed to identify that the oxygen vendor was responsible for changing or labeling the oxygen tubing in the facility. Review of the Oxygen policy dated 9/2023 directed in part its commitment to providing safe, and effective administration, monitoring and storage of oxygen therapy for residents in compliance with state and federal regulations. 3. Resident #25's diagnoses include chronic kidney disease, hydronephrosis and embolism. The monthly physician's orders dated 3/9/25 directed Resident #25 is to have oxygen at 2 liters per minute via nasal cannula for comfort as needed. The quarterly MDS dated [DATE] identified Resident #25 had no cognitive impairment, required set-up assistance for eating and oral hygiene and supervision/touching assistance for toileting hygiene and personal hygiene. The care plan dated 3/18/25 failed to reflect a focus or intervention relative to the administration and management of oxygen administered via nasal cannula. Observations on 3/31/25 at 10:05 AM and 4/01/25 at 9:50 AM identified Resident #25 was wearing a nasal cannula attached to the oxygen condenser; however, the oxygen tubing was not labeled with a date of the last change. Interview with the Oxygen Vendor on 4/7/25 at 11:05 AM identified the vendor swaps out the machines every 90 days, unless there is a problem identified, and they are called to come earlier to replace the equipment. Further, the Oxygen Vendor indicated the facility is specifically responsible for changing the oxygen supplies (nasal cannula, oxygen tubing and masks) and the vendor only maintains the machines to deliver respiratory care. Interview with the DNS on 4/7/25 at 3:12 PM identified he/she believed the oxygen vendor was responsible for changing the respiratory supplies weekly. However, in the DNS interview, the oxygen vendor contract was reviewed and tubing changing and labeling was not identified in the contract as provided by the oxygen vendor. The oxygen policy reviewed failed to reflect how often the oxygen tubing should be changed ad who was responsible for that task. 4. Resident #39's diagnoses include chronic obstructive pulmonary disease, centrilobular emphysema and ventricular fibrillation. The quarterly MDS dated [DATE] identified Resident #39 had severe cognitive impairment and was fully dependent on staff for all activities of daily living. The care plan dated 4/4/25 identified Resident #39 had congestive heart failure and interventions included administering oxygen as ordered by MD and check pulse oximetry as ordered and PRN. Physician's orders dated 3/25/25 directed to administer DuoNeb via nebulizer as scheduled and PRN. Physician's orders dated 4/2/25 directed oxygen to keep oxygen saturation above 92%. A nurses note dated 3/29/25 at 11:42 PM identified an oxygen saturation of 95% on 02 via nasal canula. A nurses note dated 4/3/25 at 3:23 PM identified an oxygen saturation of 94% on 02 at 2 liters, scheduled neb treatment. Observations on 3/31/25 at 10:10 AM and 4/1/25 at 9:55 AM identified the nebulizer and oxygen tubing were not labeled with a date of the last change. Interview with the DNS on 4/7/25 at 3:12 PM identified he/she believed the oxygen vendor was responsible for changing the respiratory supplies weekly. However, in the DNS interview, the oxygen vendor contract was reviewed and tubing changing and labeling was not identified in the contract as provided by the oxygen vendor. The oxygen policy reviewed failed to reflect how often the oxygen tubing should be changed ad who was responsible for that task.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility documentation, facility policy and interviews, the facility failed to ensure food was stored, prepared and served in safe, sanitary conditions in the main kitchen and one of the kitchenettes. The findings include:: During observations of meal service on 4/2/25 at 11:30 AM with the Director of Food Services, the following was identified: 1. a. Dietary aide #1 (DA) and DA #2 were working on the tray line plating condiments, fruit and beverages without the benefit of wearing beard restraints. Interview with the Director of Food Service at the time of observation identified beard restraints should be worn when plating food on trays and indicated that all staff are aware of the policy regarding beard restraints and that DA #1 and DA #2 forgot to put them on when they started to plate the trays with food items. After the surveyor inquiry, the Dietary Supervisor provided DA #1 and DA #2 beard restraints which were applied prior to resuming plating food. b. DA #3 was observed cooking 8 pieces of fish fillets on the stove grill directly next to an open, uncovered, full industrial size garbage can. After the surveyor inquiry, the Director of Food Services had DA #3 remove the fish from the grill and the garbage can was covered and removed from the area next to the stove. The Director of Food Services indicated that food should not be prepared next to an open garbage can and DA #3 must not have seen the full garbage can when she started preparing the fish. 2. a. Observations of dry storage area 4/2/25 at 12:30 PM identified the following items, opened and undated. There were 4 opened bags of [NAME] pasta undated and a large bag of rice. A large bag of twist pasta that was ½ full, a large bag of shell pasta that was ¾ full, a large bag of orzo pasta that was ½ full, a large bag of spaghetti that was ¼ full and a large bag of rice that was ½ full. The Director of Food Services indicated that these dry food items should have been labeled with the date opened by the dietary worker that opened the food items. The Director of Food Services directed a DA to discard the pastas and rice. b. Observations of the refrigerator and freezer storage areas on 4/2/25 at 1:00 PM identified a bag of 7 frozen breaded fish fillets opened with no date, a bag of fresh broccoli with a ¼ remaining in the bag opened with no date, and a quart of orange juice with ¼ used with no date. The Director of Food Services indicated that all the opened items should have been labelled with the date opened. All the unlabeled food items were discarded by the Director of Food Services. c. Observation of the 2 ice cream freezers identified no thermometers. A review of the temperature log for the ice cream freezers identified a temperature of 5 degrees documented for 4/2/25. An interview with the Director of Food Services at the time of observation indicated that he was not sure why there were no thermometers in place and that he was certain there were thermometers there previously. He indicated that he had documented the freezer temperatures for 4/2/25 but was unable to explain how he obtained the temperature readings without thermometers in place. A review of the Facial Hair Restraint policy dated 1/25/2018 directed, in part, facial hair more than two days growth and hanging must wear hair guard/beard restraint. A review of Labelling and Dating of Food Items policy directed, in part, open food items or prepared food items will be appropriately labeled displaying food items and name, date prepared/opened and discarded according to the expiration date on the original package or within 7 days for the standard disposal rule. A review of Temperatures on Refrigerator/Freezers policy directed, in part, all refrigerators/freezers will have a temperature log to check AM & PM temperatures, and all units will contain a thermostat for monitoring. 3. Observation on 3/31/25 at 10:00 AM, in the main dining room located on the west wing in the attached kitchenette identified the following. Inside the refrigerator/freezer combo unit was soiled with dried spilled liquids, crumbles of food products and was malodorous. The unit contained a thermometer placed in the door of both the refrigerator and freezer. A temperature log was not found and there was a bucket of carpet cleaner chemical on top of the unit. The refrigerator contained 5 single serving milk cartons in the door with expiration dates of 3/15/25, a quart of eggnog expired on 2/3/25, 2 half gallon serving pitchers without the benefit of a label or date and a Poland Springs 12 oz plastic bottle containing a dark liquid, 50% filled, unlabeled. In one of two drawers, a Styrofoam bowl with a clear plastic cover, not labeled or dated with extensive green material visible on the underside of the plastic cover. The second of two drawers contained a black plastic container with a clear plastic cover containing an unknown liquid, also not labeled with content or use by dates. Inside the refrigerator was a disposable plate with two cupcakes covered with plastic wrap and a resident name written in marker, without a date. The outside of the refrigerator and freezer was soiled around the handles and along the edge of the doors with brown matter. The front vent cover was off and to the side of the refrigerator on the floor. The microwave in the room was soiled on the inside with food debris on the sides and turntable and the outside was soiled with fingerprints, food debris, and dust buildup. There was a mixed salad on the opposite counter in a Styrofoam bowl covered in plastic wrap, not dated or labeled. To the right of the sink was a commercial coffee maker unplugged and with old coffee grounds spilled and other dried spillage and debris in and around the outside of the unit. The tile floor contained numerous stains and debris littered throughout. Interview with the DNS on 4/7/25 at 12:20 PM indicated the main dining room had been closed for a period of time due to an outbreak in the facility. The dates of the closure were from 12/3/2024 - 12/18/24. The DNS reported the dining room was not closed for any other time period and indicated the kitchen team was responsible for maintaining the kitchenette, including stocking the room, discarding expired items, cleaning the room and contents. Interview with the Dietary Services Director and Dietary Supervisor, together on 4/3/25 at 3:00 PM, indicated the dietary aides are responsible for maintaining the kitchenette in a clean and neat manner and checking and recording temperatures in accordance with professional standards of food safety and facility policy. The Dietary Services Director and Dietary Supervisor both indicated in the interview the temperature monitoring was stopped when the dining room was closed due to an outbreak and further indicated, it was just recently re-opened. Interview indicated the temperatures had been monitored up until the dining room was closed. However, when the logs were requested for viewing, both individuals stated they had not been monitoring temperatures for the refrigerator/freezer unit as previously indicated. The Dietary Services Director indicated resident food brought in from outside was not to be stored in this refrigerator and should be stored in the nourishment room. Further, the Dietary Supervisor reported that the kitchen does not stock this refrigerator, however, the items in the refrigerator were noted to have come from the kitchen. The Dietary Services Director indicated the coffee maker was not utilized and was broken and should be discarded. After surveyor interviews, the refrigerator was emptied and wiped down on the inside, however, some soiled areas in the doors and drawers remained. A sign was placed on the outside of the refrigerator/freezer indicating resident food was not to be stored in this unit. Further, a thermometer monitoring sheet was placed on the refrigerator door. The outside of the refrigerator/freezer, microwave and counters were not cleaned, and the coffee maker remained in place unplugged and soiled. Review of the undated Food and Nutrition Services Policy for Labelling and Dating of Food Items indicated all food items from an accredited vendor will be properly labeled and dated with an expiration date, including open items. Review of the undated Food/Nutrition Policy on Temperatures on Refrigerators/Freezers identified all refrigerators/freezers will have a temperature log to check AM & PM temperatures. All fridge temps must read between 32 - 40 degrees Fahrenheit and all freezer temps will read between -20-0 degrees Fahrenheit.

**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 3 of 10 residents (Resident #27, 83 and 93) reviewed for infection control and including transmission based precautions, the facility failed to ensure staff wore required PPE, failed to ensure staff performed hand hygiene with each glove change and prior to exiting the room, failed to ensure staff discard PPE prior to exiting the room, and failed to post the correct transmission based precaution signage outside the residents room. For 2 of 5 residents (Resident #63 and 83), reviewed for pressure ulcers, the facility failed to perform hand hygiene when required during a dressing change. Further, observation identified a staff member failed to handle soiled linen according to accepted infection control standards. The findings include: 1. Resident #27's diagnoses included cerebellar ataxia, epilepsy, failure to thrive with a Gastronomy-tube (g tube) in place. The quarterly MDS dated [DATE] identified Resident #27 had no cognitive impairment was dependent on staff for toileting, personal hygiene, bed mobility, and all transfers, had impairment on both sides of the upper and lower extremities, was always incontinent of urine and frequently incontinent of bowel. The care plan dated 2/4/25 identified Resident #27 was incontinent of bladder. Interventions included to change briefs every 2 - 3 hours and as needed. In addition, Enhanced Barrier Precautions (EBP) were required for Resident #27 because he/she had an indwelling medical device (g tube) in place. Observation on 3/31/25 at 1:23 PM identified an EBP sign was affixed to the door of Resident #27's room directing staff to wear gloves and a gown for high contact resident care including dressing, bathing, changing linen, device care and wound care. An isolation precaution cart stocked with gloves and gowns was provided outside of Resident #27's room. Observation on 4/2/25 at12:21 PM identified NA #7 entered Resident #27's and began to provide incontinent care to Resident #27 without the benefit of an isolation gown. Interview with NA #7 on 4/2/25 identified an EBP sign was posted on Resident #27's door and supplies were available just outside the resident's room. NA #7 said she should have a gown and gloves on and that she did not put on the appropriate PPE because she was just overwhelmed. Subsequently, NA #7 put on a gown and gloves. The Nurse Aide Assignment Card dated 4/2/25 identified Resident #27 was on Enhanced Barrier Precautions and required staff to wear a gown and gloves for high contact care. Review of the Enhanced Barrier Precautions policy directed, in part, that EBP are recommended for residents with indwelling medical devices or wounds who do not otherwise meet criteria for Contact Precautions, even though they do not have a history of having a multi-drug resistance colonization or infection. 2. Resident 63's diagnoses included dementia, osteoarthritis, and a history of venous thrombosis. The quarterly MDS dated [DATE] identified Resident #63 had both short and long-term memory loss and was severely impaired at making decisions. Resident #63 was dependent on staff for care for turning/repositioning, bed mobility, and toileting/tub transfers. The care plan dated 2/21/25 identified Resident #63 was at risk for the development of pressure ulcers related to decreased mobility. Interventions included providing treatment and medications as ordered, following policies and protocols for the prevention of skin breakdown, and repositioning the resident every 2 hours. A physician's order dated 4/2/25 directed staff to clean the left heel with normal saline and apply calcium alginate, followed by the application of an ABD pad (abdominal pad - a highly absorbent multi-layered medical dressing). Observation of wound care and interview with RN #1 on 4/7/25 at 10:56 AM, identified an Enhanced Barrier Precaution (EBP) sign affixed to the wall just outside of Resident #63's room. Prior to entering the room, RN #1 performed hand hygiene and donned an isolation gown. RN #1 opened all the necessary packaging on the tray table next to Resident #63. RN #1 then applied gloves without the benefit of hand hygiene and removed the old dressing. RN #1 performed the wound care treatment per the physician's order and then wrapped the wound with gauze. RN #1 removed her gloves, signed and dated the dressing, and then reapplied gloves without the benefit of hand hygiene. RN #1 gathered all the trash and changed the trash bag and changed gloves again without the benefit of hand hygiene and reapplied the resident's foot boot. RN #1 removed her PPE and performed hand hygiene. Interview with RN #1 identified hand hygiene should have been performed before and after each glove change. Interview with Infection Preventionist, LPN #9 on 4/7/25 12:10 PM, identified that hand hygiene would be expected before and after glove use. Review of the Standard Precaution Policy directed, in part, that staff were to wash their hands immediately after gloves were removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other patients or environments. 3. Resident #83's diagnoses included a pressure ulcer to the left buttocks, Alzheimer's disease, and dementia. The admission MDS dated [DATE] identified that Resident #83 was severely cognitively impaired and required substantial/maximal assistance with bed mobility and was dependent with toileting and transfers. Additionally, the MDS identified Resident #83 required a pressure reducing device for his/her bed. The care plan dated 1/16/25 identified a potential for pressure ulcer development related to decreased mobility. Interventions included to monitor and assess pressure ulcers for signs and symptoms of complications and provide dressing changes and treatments as ordered. A physician's order dated 3/28/25 directed to cleanse the new stage 2 pressure ulcer on the left buttocks with normal saline followed by calcium alginate and zinc oxide applied to the area once daily for 7 days and then re-evaluate. Observation of pressure ulcer treatment change by LPN #8 with the assistance of NA #6 on 4/2/25 at 11:50 AM identified Resident #83 was in bed in the supine position. After LPN #8 obtained dressing supplies from the treatment cart and entered the resident's room, she applied gloves without the benefit of hand hygiene. NA #6 rolled the resident onto his/her right side. LPN #8 prepared the dressing supplies on a clean field, then removed her gloves, and applied a new pair without the benefit of hand hygiene. LPN #8 opened Resident #83's brief, removed the dressing dated 4/1/25 and provided the resident with peri care. LPN #8 removed her gloves and applied a new pair without the benefit of hand hygiene. LPN #8 performed the treatment per the physician's order, removed her gloves, and left the room without the benefit of hand hygiene. NA #6 stayed with Resident #83 to assist with morning care. Interview with LPN #8 on 4/2/25 at 11:57 AM identified it was facility policy to perform hand hygiene before putting gloves on, when changing gloves and when removing gloves. LPN #8 indicated she was nervous and forgot to perform hand hygiene during Resident #83's dressing change and she proceeded back into the bathroom and washed her hands. Interview with IP nurse LPN #9 on 4/2/25 at 12:10PM identified she had first observed Resident #83's pressure ulcer on 3/28/25 and initiated the treatment order. LPN #9 indicated that during the wound treatment it would have been her expectation that the nurse would have completed hand hygiene prior to applying gloves, when gloves were removed and before leaving the resident's room. LPN #9 identified that although LPN #9 may have been nervous when completing the wound treatment, she should have still followed appropriate infection control practices. Interview with the DNS on 4/3/25 at 4:40 PM identified that while LPN #8 was conducting the wound treatment she should have performed hand hygiene upon entry into Resident #83's room, when her gloves were removed and before leaving the resident's room. The DNS indicated it was the policy of the facility that nursing staff complete appropriate hand hygiene and that LPN #8 must have forgotten. The DNS identified she would need to review appropriate infection control practices with LPN #8. Review of facility policy, Clean Dressing Procedure, dated 4/2011, directed to wash or sanitize hands when entering the resident's room, after removing/applying gloves and before exiting the resident's room. Review of facility policy, Standard Precautions, undated, directed to wash hands immediately after gloves are removed to avoid transfer of microorganisms to other patients or environments. 4. Resident #93's diagnoses included enterocolitis due to clostridium difficile (an infection of the colon), chronic kidney disease and pleural effusion. The quarterly MDS dated [DATE] identified Resident #93 was dependent on staff for toileting, transfers and dressing. Additionally, the MDS identified Resident #93 was always incontinent of bowel and bladder. The care plan dated 2/21/25 identified Resident #93 had clostridium difficile. Interventions included being placed in a private room and the need for contact isolation. The physician's order dated 3/14/25 directed contact precautions every shift. The Nursing Assistant care card identified Resident #93 was on contact precautions for clostridium difficile. The nurse's notes dated 3/14/25 to 4/7/25 intermittently identified Resident #93 was on contact precautions for clostridium difficile. Observation of Resident #93's room on 4/2/25 at 11:48 AM identified enhanced barrier precaution (EBP) signage posted. The sign directed that gloves and gown were applied for high contact activities such as dressing, bathing/showering, transferring, providing hygiene, changing linens, assisting with toileting, device care, and wound care. Additionally, a cart with personal protective equipment (PPE) consisting of gowns and gloves, as well as a trash bin were located outside the room. Interview and observation with the Infection Preventionist nurse (IP) on 4/3/25 at 11:53 AM identified Resident #93 was on contact precautions for clostridium difficile, she identified EBP signage was posted instead of contact precautions signage because the signs for contact and enhanced precautions don't really differ. Interview and observation with the IP on 4/3/25 at 11:54 AM identified LPN #1 exited Resident #93's room wearing an isolation gown and gloves, closed the door behind her, and removed the gown and gloves in the hallway, without the benefit of hand hygiene afterward. The IP nurse identified that removing PPE in the hallway was not acceptable and although the trash bins outside the room were instituted during a COVID outbreak, they should not be in the hallway, because removal of the PPE and hand hygiene should take place prior to exiting the room. Interview with LPN #1 on 4/2/25 at 11:55 AM identified she knew Resident #93 was positive for clostridium difficile in the stool per the physician's order for contact precautions but without access to the health record anyone entering Resident #93's room would not know he/she had an active infection because the EBP sign was the only sign posted. LPN #1 added that the nurse who receives the order is responsible for the sign placement, and the EBP sign was not appropriate, but precaution signs are not always available. Subsequent to surveyor inquiry the IP nurse obtained a contact precaution sign from the nurse's station cabinet and changed the signage to reflect active infection status. Interview and contact precaution sign review with LPN #1 on 4/02/25 at 12:43 PM identified the policy on PPE removal was to do so after contact with the resident, outside of the room, which was why the trash bin was located outside the room, stating she washed her hands when she got to the nurse's station. Review of the contact precaution signage posted directed that gown and gloves were discarded prior to exiting the room, and hand hygiene to be performed when leaving the room. Observation of Resident #93's room with LPN #1 on 4/2/25 at 12:45 PM identified NA #1 applying a clothing protector onto Resident #93 inside the room, without the benefit of wearing PPE or the benefit of hand hygiene when leaving the room per the contact precaution signage posted. Interview with NA #1 on 4/2/25 at 12:47 PM identified the facility policy is to wear a gown and gloves when in a contact precaution room, followed by hand hygiene prior to exiting the room, however she did not think to do so. Review of the Contact Precautions policy directed in part specified patients with known or suspected microorganisms that can be transmitted with direct, or indirect (touching of the environment) contact will be placed in a private room. Handwashing will be performed prior to entry and exit of the room, additionally gowns and gloves will be applied prior to room entry with removal prior to leaving the patient's environment. Review of the Enhanced Barrier Protection policy directed in part the use of gown and gloves for high-contact resident care activities is indicated when contact precautions do not otherwise apply, in residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for resident with MDRO infection or colonization. The Isolation Gown policy directed in part that precaution gowns limit the spread of infection, and to discard the gown in the trash container and wash hands prior to leaving the room. Review of the Placing a Resident on Precautions policy directed in part that residents with a known infection will be placed on precautions per Center for Disease Control (CDC) guidelines (the CDC recommends implementing contact precautions, including isolating patients with suspected or confirmed C. diff, using PPE like gowns and gloves, and thoroughly cleaning and disinfecting patient rooms). 5. An observation of NA #4 on 4/8/25 at 9:45 AM identified she was in the hall with visibly soiled linen in her right hand and visibly soiled brief in the left hand (both had visible brown staining and were wet). NA #4 lifted the soiled linen and garbage container using the back of each gloved hand and placed the soiled items in the containers. NA #4 was then observed to remove her gloves, discard them in the garbage container and then open the cover of the clean linen cart to obtain a clean linen and incontinent pad without first performing hand hygiene. The task was interrupted. An interview with NA #4 on 4/8/25 at 9:45 AM identified she should have performed hand hygiene before handling clean linen. An interview with the DNS on 4/8/25 at 3:11 PM identified NA #4 should have handled the soiled material with one gloved hand leaving a free ungloved hand to open and close doors and containers. Hand hygiene should have been performed following discarding soiled linen/garbage. A review of the facility policy for hand hygiene directed hand hygiene should be performed during times that include when handling used linen and potentially contaminated excretions, etc.

Based on review of facility documentation, facility policy and interviews, the facility failed to hire a qualified Infection Preventionist, that had specialized training in infection prevention and according to the facility policy. The findings include: Interview with the DNS on 4/2/25 at 10:50 AM identified she had an Infection Prevention certificate in (Healthcare Setting) and oversaw the Infection Prevention and Control Nurse (IP), who was an LPN and in the process of obtaining specialized IP training. Interview with the Infection Prevention Nurse (IP) on 4/2/25 at 10:52 AM identified she assumed the role of Infection Prevention and Control Nurse on 11/24/24, over 4 months ago, and started the Infection Control training in March of 2025. Follow up interview with the Infection Prevention Nurse on 4/8/25 at 11:52 AM identified she was aware of the mandatory infection prevention training but delayed getting the training because she was under the impression that she needed to attend the mandatory education in person. Additionally, she identified that due to the nature of the position things got busy, so she started the online training through Center for Medicare Services (CMS) and CDC Train. Review of the specialized training certificates on 4/8/25 at 11:55 AM identified online training through CMS COVID-19 Training for Nursing Home Management was completed on 3/26/25. Additionally, the infection control training modules offered through CDC Train Nursing Home Infection Preventionist Training identified 5 completed modules dated 3/27/25 and 3/28/25 (the training consisted of 23 modules and submodules). A review of the facility Infection Preventionist Nurse job description identified the individual was accountable for decreasing the incidence and transmission of infectious disease between patients, staff, visitors and the community. Through strategic planning, leadership, and consultation, lead a robust team in identification and implementation of infection prevention goals and objectives throughout the facility. Additionally, education, qualifications and credentials specified possessing a current CT license as an RN, 2 years of professional nursing experience in the long-term care setting was required and a minimum of 3 years in nursing administration, or a comparable management position with ICN training and APIC interaction.

Based on review of facility documentation and staff interview the facility failed to submit accurate PBJ staffing data on 2/26/24, 2/27/24, 2/28/24, and 2/29/24. The findings include: The PBJ 2nd quarter report for January 1, 2024, through March 31, 2024, triggered no licensed nurses 24 hours a day. Interview with the Administrator on 4/8/25 at 3:55 PM identified that he was not aware of what happened and why the report indicated a lack of nursing staff. The Administrator explained that the DNS usually takes care of the scheduling. Interview with DNS on 4/8/25 at 3:57 PM identified that while Person #3 was responsible for inputting PBJ data, she was not aware of why the report triggered no licensed staff 24 hours a day on 2/26/24, 2/27/24, 2/28/24, and 2/29/24. Subsequent to the interview, the DNS provided the schedules that confirmed licensed nursing staff were available on all shifts for the days in question. Attempt to interview Person #3 was unsuccessful. Review facility mandatory submission of staffing based on payroll data information directed, in part, the facility must submit complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #2), reviewed for medication administration, the facility failed to ensure the physician's order was transcribed correctly resulting in a medication error. The findings include: Resident #2 had diagnoses that included a non-displaced fracture of the left tibia. The nursing admission assessment dated [DATE] identified Resident #1 was alert, oriented, and able to make needs known, and required assistance with activities of daily living. Review of the W-10 (communication between the hospital and the receiving facility) dated 6/4/2024 directed to administer MS Contin ER (a narcotic pain medication) 60 milligrams (mg) extended release (ER) tablets every eight (8) hours around the clock with a maximum daily dose of 180 mg. A facility written physician's order dated 6/4/2024 at 4:10 P.M. directed to administer MS Contin ER 60 MG tablets, give 180 MG every eight (8) hours for pain. Review of the Medication Administration Record (MAR) identified on 6/5/24 at 6:00 A.M. LPN #2 administered Resident #2 MS Contin ER three (3) tablets of 60 MG for a total dose of 180 mg. Review of Pharmacist #1's consultant note dated 6/5/24 at 9:44 A.M. identified she completed Resident #2's medication regimen review and identified discrepancies with the current admission order that directs to administer MS Contin 60 MG, give 3 tablets for a total dose of 180 MG by mouth every 8 hours, however, Resident #2's discharge paperwork (W-10) identified the order directed to administer Resident #2 MS Contin 60 MG every 8 hours. Pharmacist #1 indicated she called the facility to discuss the discrepancy. A nurse's note dated 6/5/24 at 9:38 A.M. written by RN #2 identified she spoke with MD #1 regarding Resident #2 receiving the incorrect dose of MS Contin at 6:00 A.M. (180 mg versus the 60 mg dose) RN #2 identified Resident #2 stated h/she still had pain with a level of 7/10. RN #2 indicated MD #1 spoke with Resident #2 regarding pain medication regimen. Review of MD #1's progress note dated 6/5/24 at 11:30 A.M. he identified Resident #2 was accidentally given 180 mg of MS Contin at 6:00 A.M. versus MS Contin 60 mg. MD #1 identified Resident #2 presents as alert and oriented. A physician's order dated 6/5/24 at 11:39 A.M. directed to obtain Resident #2's vital signs and oxygen saturation levels every hour until 5:30 P.M., discontinue MS Contin ER 180 mg every eight hours and to administer MS Contin ER 30 mg at 2:00 P.M. today, and may resume MS Contin 60 mg by mouth at 10:00 P.M. today. Review of the facility's accident and incident report dated 6/5/24 identified at approximately 9:30 A.M. a medication error was identified, and Resident #2 was administered MS Contin 180 MG. The error occurred when the admission nurse, RN #1 was transcribing the original order from the hospital that read administer MS Contin 60 MG ER (Extended Release) take 1 tablet (60 MG total) by mouth every 8 hours around the clock maximum daily amount: 180 MG. RN #1 transcribed the order to read administer MS Contin oral extended release 60 MG (morphine sulfate) give 180 MG by mouth every 8 hours for pain. LPN #2 then administered the incorrect dosage due to the transcription error. The summary identified upon discovery of the error the following immediate actions were taken Resident #2 was promptly assessed by MD #1 and the nursing staff. Resident #2's vital signs and relevant clinical parameters were closely monitored. Resident #2 was thoroughly evaluated by MD #1 and determined that there were no dangerous outcomes or adverse effects because of the error. Resident #2 remained hemodynamically stable and exhibited no signs or symptoms of distress or opioid toxicity or harm. The corrective action plan to prevent reoccurrence immediate staff education regarding medication errors and transcription. An interview with LPN #1 on 6/14/24 at 10:35 A.M. identified on 6/5/24 during morning report they reviewed Resident #2's admission orders. LPN #1 identified she was a bit concerned that Resident #2 had an order for MS Contin with a dose of 180 MG every 8 hours. LPN #1 indicated she thought it was a high dose. LPN #1 identified shortly after morning report Pharmacist #1 called her about Resident #2's MS Contin order, she and Pharmacist #1 reviewed Resident #2's discharge orders from the hospital at which time it was identified Resident #2's MS Contin ER order was transcribed incorrectly by RN #1. LPN #1 identified the correct order for MS Contin ER directed to administer 60 MG every 8 hours not 180 MG every 8 hours. LPN #1 identified she notified RN #2 and MD #1 that Resident #2 received the wrong dose of MS Contin. LPN #1 indicated she went to evaluate Resident #2 and Resident #2 was alert, oriented with stable vital signs. Interview with RN #1 on 6/14/24 at 12:25 P.M. she identified on 6/4/24 she had transcribed Resident #2's admission orders on 6/4/24 that directed to administer MS Contin ER 60 MG (3 tablets) 180 MG every 8 hours. RN #1 identified when she read the order, she thought it read to administer MS Contin ER 180 MG every 8 hours. RN #1 indicated the next day the DNS made her aware she transcribed the order incorrectly which resulted in Resident #2's medication error. RN #1 indicated after a 2nd review of the orders she identified she in fact had misread the MS Contin ER order and the order should have been transcribed as MS Contin ER 60 MG every 8 hours maximum daily dose of 180 MG. Interview and clinical record review with DNS on 6/14/24 at 10:45 A.M. identified that on 6/5/24 between 5:30 - 6:00 A.M. a medication error occurred with Resident #2. The DNS identified Resident #2 was administered MS Contin 180 MG and should have been administered MS Contin ER 60 MG. The DNS identified review of Resident #2's hospital discharge orders directed to administer MS Contin ER 60 MG every 8 hours with a maximum daily dose of 180 MG. The DNS indicated her investigation identified the medication error happened because RN #1 transcribed the order incorrectly, the process for ensuring accuracy of transcribed orders was not followed, and the chart audit was not conducted. The DNS identified the process in place is that all physician's orders have 2 nurses confirm accuracy of all transcribed orders, additionally the nurse on the 11 P.M.- 7 A.M. shift is expected to conduct a chart audit to confirm accuracy of physician's orders written that day. The DNS identified the process for ensuring orders are accurately transcribed was not followed. Review of facility nursing staff education dated 6/7/2024 identified that the nursing staff were provided education on accurate medication order transcription with the following key highlights verification of orders, clarify ambiguities, check for completeness, double check for accuracy which includes peer review: it is the policy to have another nurse review the transcribed orders and sign off on it, and night shift chart audits are done to ensure completion and accuracy of transcribed doctor's orders. Review of the facility ensuring accuracy of orders policy dated as 2021 identified accurate transcription and verification of medical orders are crucial to providing safe and effective care all new orders will require the signature of a second nurse confirming accurate transcription in addition to the nightly 24-hour chart audits.

Based on a review of Resident Council Minutes, facility documentation review, facility policy review, and interviews, the facility failed ensure the Resident Council met on monthly and the facility failed to ensure staff responded to Resident Council concerns timely. The findings include: 1.A review of Resident Council Minutes dated January 2022 through December 2022 identified no council meetings took place January 2022, April 2022, May 2022, June 2022, September 2022, October 2022, and December 2022. Interview on 2/6/23 at 1:38 PM with the Director of Recreation identified the Resident Council meeting took place monthly and indicated the meetings did not take place consistently due to Covid 19 outbreaks. The Director of Recreation had only identified the prior week that she wanted to meet with residents individually when council meetings could not occur to provide an opportunity to express concerns. The Director of Recreation also was unable to provide documentation that monthly Resident Council meetings were held in any other format during the dates listed. The Director of Recreation indicated prior to January 2023, she did not have a process in place to meet with residents individually during Covid 19 outbreak to discuss any concerns. 2. A review of Resident Council Minutes dated January 2022 through December 2022 identified concerns related to resuming group dining activities, more time with meal trays and being rushed during mealtimes, request for a new computer on one unit that would allow access to email and internet and visiting hours. Review of the Resident Council Minutes January 2022 to December 2022 failed to identify a response to residents reported concerns. Interview on 2/6/23 at 1:38 PM with the Director of Recreation identified she was responsible for ensuring resident concerns were responded to by reaching out to the responsible department heads. The Director of Recreation was unable to provide documentation of staff response to resident concerns identified in Resident Council Minutes from January 2022 through December 2022. The Resident Council Policy directed in part, the residents in the facility have the right to participate in resident groups. Resident Council will provide residents the opportunity to discuss and offer suggestions affecting care, treatment, and quality of life, have input in planning and activities and shall be coordinated by the recreation department. The facility will listen to and consider the views and group recommendations and grievances and notes attempts will be made to accommodate the recommendations and the decisions will be discussed with the resident group.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, facility policy review and interviews for 1 of 4 residents (Resident #12) reviewed for abuse, the facility failed to protect the resident from further abuse by allowing the staff to work during the investigation. The findings include: Resident # 12's diagnoses included type 2 diabetes mellitus, Parkinson disease, depression, anxiety, osteoarthritis, and hypothyroid. The quarterly MDS assessment dated [DATE] identified Resident #12 with intact cognition and noted the resident required extensive assist of 1 to 2 person with transfer, toileting, hygiene, and non-ambulatory. The nurse's note dated 7/5/22 at 3:56 PM identified Social Worker (SW #1) received an e-mail from Person # 3 that there was a concern over the weekend Nursing Assistant (NA #2) 11:00 PM -7 :00 AM had allegedly told Resident #12 that she hates him/her, gave him/her a middle finger, and slapped his/her hand away. The Resident Care Plan (RCP) dated 7/6/22 identified Resident #12 had attempt to touch staff inappropriately. Intervention directed to discussed behavior with the resident and explained why the reason why the behavior was not acceptable, to encourage appropriate behavior and discourage inappropriate behavior, psychiatric consultation follow up as needed and to administered medication as ordered. Review of facility documentation working hour from 7/5/22 through 7/7/22 identified NA #2 worked on 7/5/22 and 7/7/22 while there was a pending allegation of abuse investigation. Interview with SW #1 on 2/6/23 at 9:55 AM identified all staffs had responsibility to report allegation of abuse to the nursing supervisor or Director of Nursing Services (DNS). He also identified the DNS would initiate the abuse investigation. SW #1 further indicated that the facility abuse policy was to ensure safety to the resident by removal of alleged staff, to start an investigation and to report to authority when needed. He indicated that he received an e-mail from Person # 3 of Resident #12 and reported the NA #2 of mistreating the resident. He further indicated that he made the DNS # 2 aware of Person # 3 alleged mistreatment but could not provide a reason why an investigation was not started. Interview with DNS on 2/6/23 at 11:30 AM identified the DNS would start the abuse investigation when there was an allegation of mistreatment. She also indicated the abuse investigation would start immediately. When the abuse allegation is involved a staff member, the staff member would immediately be removed from the care area until investigation was completed. The DNS could not provide a reason why the facility did not initiate an abuse investigation and why NA #2 continue to work while there was an allegation of mistreatment. She indicated DNS # 2 was charged when the allegation of mistreatment occurred. Although attempted, an interview with NA #2 was unsuccessful. The facility failed to protect Resident #12 from abuse by allowing NA #2 continue to worked in facility while there was a pending allegation of abuse. A review of facility policy Resident/Patient Abuse notes in part residents have the right to be free from abuse. Abuse is defined in part as physical abuse involved hitting, slapping, pinching and kicking and mental abuse involved to humiliation, harassment and threat of punishment. The policy notes for investigation the facility will involve the department supervisor or head to initiate an investigation of the incident. Additionally, notes for investigation any staff member suspected or alleged to have inflicted a resident abuse would be immediately suspended from duty.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, facility policy review and interviews for 1 of 4 residents (Resident #12) reviewed for abuse, the facility failed to protect the resident by allowing a staff member to work in the facility during the abuse investigation and removing the staff member within accordance to facility written policy.The findings include: Resident # 12's diagnoses included type 2 diabetes mellitus, Parkinson disease, depression, anxiety, osteoarthritis, and hypothyroid. The quarterly MDS assessment dated [DATE] identified Resident #12 with intact cognition and noted the resident required extensive assist of 1 to 2 person with transfer, toileting, hygiene, and non-ambulatory. The nurse's note dated 7/5/22 at 3:56 PM identified Social Worker (SW #1) received an e-mail from Person # 3 that there was a concern over the weekend Nursing Assistant (NA #2) 11:00 PM -7 :00 AM had allegedly told Resident #12 that she hates him/her, gave him/her a middle finger, and slapped his/her hand away. The Resident Care Plan (RCP) dated 7/6/22 identified Resident #12 had attempt to touch staff inappropriately. Intervention directed to discussed behavior with the resident and explained why the reason why the behavior was not acceptable, to encourage appropriate behavior and discourage inappropriate behavior, psychiatric consultation follow up as needed and to administered medication as ordered. Review of facility documentation working hour from 7/5/22 through 7/7/22 identified NA #2 worked on 7/5/22 and 7/7/22 while there was a pending allegation of abuse investigation. Interview with SW #1 on 2/6/23 at 9:55 AM identified all staffs had responsibility to report allegation of abuse to the nursing supervisor or Director of Nursing Services (DNS). He also identified the DNS would initiate the abuse investigation. SW #1 further indicated that the facility abuse policy was to ensure safety to the resident by removal of alleged staff, to start an investigation and to report to authority when needed. He indicated that he received an e-mail from Person # 3 of Resident #12 and reported the NA #2 of mistreating the resident. He further indicated that he made the DNS # 2 aware of Person # 3 alleged mistreatment but could not provide a reason why an investigation was not started. Interview with DNS on 2/6/23 at 11:30 AM identified the DNS would start the abuse investigation when there was an allegation of mistreatment. She also indicated the abuse investigation would start immediately. When the abuse allegation is involved a staff member, the staff member would immediately be removed from the care area until investigation was completed. The DNS could not provide a reason why the facility did not initiate an abuse investigation and why NA #2 continue to work while there was an allegation of mistreatment. She indicated DNS # 2 was charged when the allegation of mistreatment occurred. Although attempted, an interview with NA #2 was unsuccessful. The facility failed to protect Resident #12 from abuse by allowing NA #2 continue to worked in facility while there was a pending allegation of abuse. A review of facility policy Resident/Patient Abuse notes in part residents have the right to be free from abuse. Abuse is defined in part as physical abuse involved hitting, slapping, pinching and kicking and mental abuse involved to humiliation, harassment and threat of punishment. The policy notes for investigation the facility will involve the department supervisor or head to initiate an investigation of the incident. Additionally, notes for investigation any staff member suspected or alleged to have inflicted a resident abuse would be immediately suspended from duty.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interview for 1 of 2 residents (Resident # 74) reviewed for hospitalization, the facility failed to notify the state Ombudsperson following a hospital admission. The findings include: Resident #74 was admitted with diagnoses that included sepsis due to pseudomonas. admission MDS assessment dated [DATE] identified Resident #74 had severe cognitive impairment and required two persons assist with personal care. The care plan dated 8/22/22 identified Resident #74 had an indwelling Foley catheter related to obstructive uropathy and retention. Interventions included to monitor and record symptoms of urinary tract infection, keep bag below waist and monitor for discomfort. The nursing progress notes identified Resident # 74 was transferred to an acute care hospital and subsequently admitted on [DATE] through 10/18/22 and 11/1/22 through 12/14/22. An interview on 2/7/23 at 11:05AM with the facility President/Administrator identified there was no facility practice in place for notifying the state Ombudsperson of hospital transfers. The facility discharge policy did not include a directive to notify the state Ombudsperson of hospital transfers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, and interview of 1 of 5 residents reviewed for Preadmission Screening and Resident Review (PASSR) (Resident#22), the facility failed to follow through with PAASR 2 recommendations of psychotherapy and weekly individual counseling for a resident. The findings include: Resident # 22 's diagnoses included Major Depressive disorder, borderline personality disorder and adjustment disorder with anxiety and depressed mood. The quarterly MDS assessment dated [DATE] identified Resident # 22 had a mild cognitive impairment. The PASSR Level 2 dated 1/9/2023 recommendations include in part, weekly individual counseling, and individual psychotherapy. The Resident Care Plan (RCP) dated 2/2/2023 identified a positive PASSR level 2 due to mental illness. interventions including in part, individual psychotherapy with a trained psychotherapist and mental health counseling. Interview with the Social Worker on 2/7/2023 at 10:35 AM indicated he was responsible for reviewing the PASSR level two recommendations, talking with the resident regarding the recommendations and obtaining the services of the Licensed Clinical Social Worker (LCSW) by talking with the practitioner. The SW indicated he was also responsible for placing the recommendation for service in the psychiatric service referral book on the unit. The Social Worker was unable to find evidence of a discussion with Resident #22, psychotherapy or counseling notes and was unable to provide a reason for the delay (29 days after the PASSR date of 1/9/2023) in following through on the recommendation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy review and interviews for 1 of 4 residents (Resident #13) reviewed for fall, the facility failed to ensure a chair alarm was utilized in accordance to facility fall precaution policy. The findings include: Resident # 13's diagnoses included diabetes mellitus, osteoarthritis, overactive bladder, hypertension and hypothyroid. The Resident #13 risk for Accident/Injury assessment dated [DATE] identified he/she had a score of 8 indicative of high risk for fall with equivalent to strict fall precaution. The quarterly MDS assessment dated [DATE] identified Resident #13 with intact cognition and noted the resident required extensive assist of 1 to 2 persons with transfer, ambulation, toileting and hygiene. The Resident Care Plan (RCP) dated 12/15/22 identified Resident #13 at risk for fall related to impaired range of motion, balance and gait. Intervention included: to administered medication as ordered, ensure a non-skid sock pad on wheel chair at all time, chair alarm and to check to ensure device was in place and functioning every shift, to provide anti-tipper to the wheel chair and gripper pad to the wheel chair, re-educate and remind resident to call for assistance and when on toilet, please assess that he/she is sitting all the way back. The nurse's note dated 12/26/22 at 7:15 PM identified Resident #13 had a fall and was found sitting on floor in front of the toilet. Resident #13 stated to the nurse that s/he lost her/his balance and slipped to the floor. The fall was unwitnessed. The nurse's note dated 1/31/23 at 11:03 PM identified Resident #13 had a fall and was found lying in the bathroom on the floor at 10:00 AM with walker next to her/him. He/she stated to the nurse that s/he got up from the toilet without calling for assistance, lost her/his balance and twisted her/his right ankle. Physician directed to send the resident to an acute care hospital for an evaluation. Review of February 2023 physician's order failed to indicate the use of a chair alarm. Interview with Registered Nurse (RN #4) on 2/7/23 at 10:30AM identified any resident who had a care plan for a chair alarm would be identified in the physician's order and the staff would check the function every shift. Any resident who identified as a high risk for fall would not be left alone in the bathroom. Resident #13 was not using a chair alarm when he/she had a fall on 1/26/22 and 1/31/23. She further indicated she was not aware Resident #13 had a care plan for a chair alarm. She could not also explain why Resident #13 was not using a chair alarm when he/she had a care plan for a chair alarm. Subsequent to inquiry, a chair alarm was included in the physician's order for the resident. Interview with DNS on 2/7/23 at 11:00 AM identified a resident is assessed for risk of fall on admission and quarterly. She also identified that each resident fall would have a corresponding fall intervention to prevent the re-occurrence of a second fall. The DNS also indicated any resident who was identified a high for fall would be closely monitored and not be left alone in the bathroom. Resident # 13 who had a care plan for a chair alarm should have a chair alarm. She could not provide a reason why the alarm was not in place at time of the fall. She would expect the nursing staff to follow the resident care plan when a resident was care plan to use a chair alarm. The facility policy titled Fall Precaution notes when a resident is identified as a strict fall precaution a personal monitor will be utilized. Patient characteristic included: confusion, impulsive behavior, dementia with poor judgement, lack of safety awareness, unreliable or unpredictable behavior with intervention directed to use a personal monitor.

Based on review of facility staff training documentation and interviews, the facility failed to ensure that staff completed annual training and competencies related to providing Intravenous Therapy. The findings include: A review of the state agency documentation offsite review identified the facility has a licensed capacity of 229 and an IV therapy program. An interview with RN#2 on 2/2/23 at 11:30 AM indicated that she was not able to locate IV training and competencies for staff for January 2022 through December 15, 2022. Interview and review of the Intravenous therapy (IV) log for 2023 with RN #2 on 2/6/23 at 1:40 PM identified that IV therapy was provided during various timeframe in 2023; Resident #13: 1/22/23 to 1/30/23; Resident #50: 1/8/23 to 2/2/23, Resident #97 from 1/7/23 to 1/10/23. Interview with the DNS on 2/7/23 at 10:00 AM identified yearly competencies had not been completed due to DNS #2 who was also the staff development nurse who was not able to provide evidence of staff education due to competing priorities. The facility has recently contracted with a new pharmacy provider and has scheduled IV education and competencies to begin in March 2023. Additionally, the DNS added that they have a staff development position as a posted opening and are actively recruiting. The facility pharmacy policy, Qualifications for Nurse Providing Infusion Therapy dated August 2018 and reviewed on 11/16/22, in part, identified that documented annual infusion education is a required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility policy and interviews for one of five sampled residents (Resident # 46) reviewed for unnecessary meds, the facility failed to ensure that a psychotropic medication ordered on an as needed bases was limited to fourteen days and failed to provide a rationale for a sixty day order for the psychotropic medication. The findings include: Resident #46 was admitted to the facility on [DATE] with diagnoses that included depression, dementia without behavioral disturbance, and anxiety. The admission Resident Care Plan dated 9/21/2022 identified impaired cognitive function and impaired thought processes related to dementia with interventions that included: monitor/document/report to MD any changes in cognitive function, review medications and record possible causes of cognitive deficit, and approaches that maximize involvement in daily decision making. The admission MDS assessment dated [DATE] identified Resident #46 had severe cognitive impairment, required extensive assistance with all activities of daily living except for eating, the assessment noted the resident ate independently. Review of physician's orders identified the following: an order dated 9/22/2022 that directed to administer Trazadone (antidepressant) 50mg daily at bedtime. An order dated 9/23/2022 directed Trazadone 25mg to be administered twice daily on an as needed basis. A subsequent physician's order dated 10/28/22 directed Trazadone 25mg twice daily as needed for 14 days; a physician's order dated 11/12/2022 directed Trazadone 25mg twice daily as needed for 30 days; a physician's order dated 12/13/2022 directed Trazadone 25mg twice daily as needed for 60 days. Review of physician's orders and the medication administration record (MAR) from 9/23/22 through 2/3/2023 identified that the resident had the as needed order for Trazadone for a total of 134 days. The MAR identified that Resident #46 was administered the Trazadone on 5 occasions in September, four occasions in October, three occasions in November, none administered in December and administered once in January and none in February. Review of the physician's progress notes failed to identify a rationale for the use of the as needed Trazadone after the first fourteen days of use. Interview with APRN #1 on 2/7/2023 at 1:25 PM identified Resident #46 was experiencing increased episodes of anxiety. An initial order of Trazadone 25mg twice daily as needed was ordered on 9/23/2022. APRN #1 further indicated speaking with MD #2 regarding Resident #46's continued chest pain and was advised to continue Trazadone 25mg twice daily as needed for 14 days on 10/28/2022. Subsequently, APRN #1 continued Trazadone 25mg twice daily as needed on 11/12/2022 for 30 days and again on 12/13/2022 for 60 days. APRN #1 indicated she was not aware of the need to document a rationale for psychotropic medications ordered on an as needed basis used for more than fourteen days. Interview with the Medical Director on 2/7/2023 at 10:50 AM identified that he would not prescribe a standing order and an as needed order for a psychotropic medication simultaneously. He also indicated that he would not prescribe a psychotropic medication for more than thirty days.

Based on facility documentation review and interviews, the facility failed to ensure tracking of performance issues related to quality assurance were completed. The findings include: An interview on 2/07/23 at 1:07 PM to review QAPI with the Administrator and the DNS, both indicated they were new to their positions. Both indicated that they review resident concerns especially falls, they were unable to provide evidence of tracking of the performance issues that the facility is currently working at this time. The DNS indicated she has a form to use and planned to begin using the form but needed to address the facility staffing needs. The facility QAPI policy and procedure was reviewed and noted to meet criteria, but no copy was obtained.

Based on facility documentation review and interview, the facility failed to ensure that quarterly QAPI meetings were held prior to November 2022. The findings include: On 2/7/2023 at 1:07: PM an interview with the DNS and Administrator to review the QAPI program identified the DNS and the Administrator were unable to provide evidence of QAPI meeting and attendance lists prior to November 16, 2022. The Administrator indicated that he was new to the position and held the first QAPI meeting in November 2022 after he and the DNS started their new roles. The facility QAPI policy and procedure was reviewed and noted to meet criteria, but no copy was obtained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record, facility documentation, and interviews for 1 resident (Resident # 41) reviewed for respiratory care, the facility failed to ensure respiratory equipment was stored according to infection control standards and failed to observe appropriate infection control practices with the use of gloves when moving room to room and the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. The findings included: 1.Resdent #41 was admitted with diagnoses that included chronic obstructive pulmonary disease (COPD). Quarterly MDS assessment dated [DATE] identified Resident #41 had moderate cognitive impairment and required supervised assist with personal care. The care plan dated 11/22/22 identified Resident #44 had a cardio-pulmonary medical condition. Interventions included to administer medications as ordered and monitor for signs and symptoms of shortness of breath. The physician's orders dated 11/30/22 directed Budesonide Inhalation Suspension 0.25 MG/2 ML via Inhalation twice daily through 12/7/22. An observation on 2/01/23 10:45AM identified a nebulizer respiratory device uncovered and in the drawer of the bedside table. The tubing that attached to the machine was on the floor. An interview and observation on 2/01/23 at 12:31 PM with LPN #9 identified Resident #41 had not used the respiratory devise since 12/7/22 .LPN # 9 further indicated the tubing and devise should have been removed from Resident #41's room and discarded. An interview on 2/01/23 at 12:49 PM with the DNS identified the respiratory equipment should have been discarded when no longer in use. Although a facility policy was requested for the management of respiratory equipment once discontinued was requested, none was provided. 2. An observation on 2/03/23 at 6:05AM identified NA #1 exiting room [ROOM NUMBER] with a bag of soiled waste and enter into the dirty utility room pushing on the door and handle with the gloved hands. An interview with NA #1 identified it was a bad habit and that she should have removed the gloves prior to exiting the room. NA #1 indicated she did remove the gloves in this case because the dirty utility room was right next door. An interview on 2/03/23 at 7:45AM with the DNS identified staff should not be coming out of the room with soiled gloves and her expectation would be that staff remove gloves and perform hand hygiene. 3. A review of the facility infection control program identified the following: a. The facility lacked a measured trackable system for preventing, identifying, reporting, investigating, and controlling new and existing infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement before spread to other persons in the facility and procedures for reporting possible incidents of communicable disease or infections. b. The facility lacked tracking of multidrug resistant organisms (MDRO). A review of the Quarterly Nursing Department Quality Assurance Performance Standards (QAPI) Medical Staff Review dated 11/16/2022 noted Covid 19 updates, an overview of October 2022 infection percentages and although outlined the document lacked summaries of routine infection control monitoring and treatment. Interview with RN #2 on 2/2/2023 at 11:30 AM identified she was unable to locate a manual that was identified as an Infection Control Long Term Policy and Procedure secondary to being new to the position as of November 2022. She continued by verbalizing that although she had access to some of the documents and policies related to infection control, she had primarily been responsible for COVID- 19 process and procedures due to the facility's continued outbreak status since she took the position. RN #2 was attempting to address the other needed systems in place such as an IV log, an infection surveillance document that would provide updated information which included current and multi drug resistance infections outside of COVID-19 as well as interventions in regards to an MDRO program but the current COVID-19 outbreak was consuming her time. DNS # 2 had left suddenly mid November 2022 and left no documents for her. Interview with RN #2 on 2/6/23 at 12:30 PM identified she was previously a nursing supervisor at the facility and as part of that role, a 24 hour report was updated each shift by each supervisor which included the resident's infection status and antibiotic use. She collected the sheets daily and utilized the 24-hour report sheets to add to IV log and infection report at the end of the month but was not aware that she should be tracking MDROs, infections concurrently or complete information on IV therapy log. She also indicated she was unable to locate completed documents from the previous Infection Control Nurse who was also the DNS at the time and that when she took the job in November 2022 DNS # 2 did not provide her any education or resources in regard to certain elements of the Infection Control program. An interview on 2/7/22 at 9:24 AM with the DNS identified DNS # 2 left suddenly and did not readily share information and had been the Infection Control Nurse prior the RN #2 taking the position. She identified the facility had difficulties locating all the necessary documents due to the DNS # 2 sudden departure stating that the oversight of the Infection Control program and all the necessary documents to assure effective infection surveillance, tracking of MDROs were the responsibility of the Infection Control Nurse. An interview on 2/7/2023 at 10:35 AM with the Medical Director identified he believed the DNS #2 was previously overseeing the infection control program and that he visited the facility weekly where any concerns related to infection control were discussed. The Medical Director indicated he attended the November 2022 quarterly meeting but MDROs were not discussed or reviewed. He could not recall if infection control rates and incidents were discussed but was unaware there was no documentation included in the meeting minutes. The Medical Director also indicated he was not aware the facility did not have a tracking system in place for infection control monitoring and treatment, tracking of MDRO's. MD #1 indicated the tracking systems should have been in place. The Medical Director further indicated there had been a large changeover in staffing recently. He continued by stating that the November 2022 meeting was the first Medical staff/Quality Improvement meeting for the 2022 due to COVID. Although requested, the facility was unable to provide an Infection Control Long Term Policy and Procedure manual although a signed signature page dated 1/16/2022 as well as COVID-19 related policies and the Facility Pharmacy resource manual were provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review clinical record reviews, facility documentation, facility policy, and interviews for 4 residents (Resident #12, Resident #29, Resident #44 and Resident #94) reviewed for abuse, for (Resident #12, Resident #29 and Resident # 44), the facility failed to report an allegation of potential harm to an overseeing state agency and for ( Resident # 94), the facility failed to report the allegation of abuse and failed to report the alleged altercation between 2 residents to the state agency. The findings included: 1. Resident # 12's diagnoses included type 2 diabetes mellitus, Parkinson, depression, anxiety, osteoarthritis, and hypothyroid. The quarterly MDS assessment dated [DATE] identified Resident #12 with intact cognition and required extensive assist of 1 to 2 person with transfer, toileting, hygiene and non-ambulatory. The nurse's note dated 7/5/22 at 3:56 PM identified that Social Worker (SW #1) received an e-mail from responsible party that there was a concern over the weekend allegedly an assigned Nursing Assistant (NA #2) for 11-7 AM shift had told Resident #12 that she hates him/her, gave him/her a middle finger and slapped his/her hand away. The Resident Care Plan (RCP) dated 7/6/22 identified Resident #12 had attempt to touch staff inappropriately. Intervention directed to discussed behavior with the resident and explained why the reason on why the behavior was not acceptable, encourage appropriate behavior and discourage inappropriate behavior, psychiatrist consult follow up and as needed and administered medication as ordered. Review of facility documentation from 7/5/22 through 2/6/23 lacked evidence the facility initiate an investigation nor identified that there was an allegation of abuse. Interview with SW #1 on 2/6/23 at 9:55 AM identified that all staffs had responsibility to report allegation of abuse to the nursing supervisor or Director of Nursing Services (DNS). He also identified that the DNS would initiate the abuse investigation. He indicated that the facility abuse policy was to provide safety to the resident, removal of alleged staff and to start an investigation and report to authority when needed. He indicated that he received an e-mail from Person # 3 of Resident #12 and reported the NA #2 of mistreating the resident. He further indicated that he made DNS # 2 aware Person # 3 alleged mistreatment, but he could not provide a reason why an investigation was not started. Interview with DNS on 2/6/23 at 11:30 AM identified that the DNS would start the abuse investigation when there was an allegation of mistreatment. She also indicated that the abuse investigation would start immediately. When the abuse allegation involved a staff member, the staff member would immediately be removed from the care area until investigation was completed. She could not provide a reason why the facility did not initiate an abuse investigation and NA #2 continue to work while there was an allegation of mistreatment. She was not the DNS when the allegation of mistreatment occurred. She further indicated that she was not aware that any allegation of abuse or altercation between residents need to be reported to the state agency. The facility failed to report an allegation of abuse to the state agency timely. A review of facility policy title Resident/Patient Abuse - in part to reporting/response identified the administrator or the designated representative shall immediately inform the state agency and provide a subsequent report should be submitted to the state agency on the progress of an investigation. 2. Resident #29's diagnoses included a neuromuscular disease process, muscle weakness, slurred speech and osteoarthritis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 29 had no cognitive impairment and required extensive assistance of two persons for bed mobility, transfer, toileting, dependent of one person for eating and was dependent of two persons for bathing. The Resident Care Plan (RCP) dated 1/9/2023 indicated that Resident #29 has a deficit in self performance in activities of daily living (ADL) due to limited physical mobility. Interventions included in part to provide assistance with bathing and dressing and to encourage participation to the maximum ability. The care plan further indicated that Resident #29 had pain related to deconditioning. Interventions included in part, to position for comfort with physical support, to handle Resident #29 gently and to limit or remove causes of pain where possible. On 2/02/23 at 9:20 AM during an interview with Resident #29 indicated that a staff member handled him/her roughly recently. The resident further indicated having a history of a right shoulder dislocation years ago still provides discomfort presently when being turned and repositioned. On 2/02/2023 at 9:35 AM a discussion with the DNS occurred where she was made aware of Resident #29's allegation of being handled roughly. On 2/02/2023 at 2:40 PM the DNS indicated that the investigation was done and Resident #29 was sent to the hospital due to an unrelated medical concern. During an interview with the DNS on 2/3/2023 the DNS indicated re-education was completed staff regarding the resident's concern. 0n 2/06/23 at 9:45 AM an interview with the DNS was unable to provided evidence the allegation of abuse was reported to the state agency. The DNS indicated that she did not know she needed to report the incident to the state agency and within two hours of becoming aware of the allegation. The DNS was aware that an extended period of time had elapsed (5 days) since learning of the allegation. The DNS indicated that being new to the DNS position, she was unaware of the reporting guidelines and would now report the incident. On 02/06/23 1:21 PM the allegation was reported to the state agency on 2/6/2023 at 10:22:59. Review of the facility policy ( with no date) indicated in part the Administrator or his designated representative shall immediately inform the state agency of allegation of abuse and subsequent reports shall be submitted as often as necessary to inform about progress of an extended investigation. 3. Resident #44's diagnoses included respiratory syncytial virus pneumonia, mild cognitive impairment, and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #44 was without cognitive impairment and required two people assistance with bed mobility, transfers, and for personal hygiene one person assist. The care plan dated 7/25/22 identified Resident #44 had a diagnosis of depression. Interventions included: to arrange for psychiatric consultation as indicated, encourage expression of feelings and administer medications as ordered. The Complaint Report dated 8/23/22 completed by the Social Worker (SW #1) identified Resident #44 alleged being fearful on the unit and verbalized that a 3:00 PM-11:00 PM staff tried to harm him/her. Resident #44 was unable to provide a name, time and date of the incident. Resident #44 was offered a room change and given the alleged situation, agreed, and accepted. The Reportable Event dated 8/23/22 with no author signature noted patient (Resident #44) was now stating a splash of water from a hose was inserted in his/her nose. However, there was no documentation identified that the overseeing state agency was notified of the allegation of abuse. An interview on 2/07/23 at 8:55AM with the Director of Nursing Services ( DNS) identified she was not employed at the facility at the time of the incident and she was unaware of the alleged incident. The DNS was unable to provide documentation the allegation of abuse had been reported to the overseeing state agency. The DNS further indicated the allegation of abuse should have been reported to the state agency. The facility policy for Resident Abuse directs all allegations of abuse to be reported to the overseeing state agency immediately. 4. Resident # 94's diagnoses included type 2 diabetes mellitus, depression, anxiety, osteoarthritis, and insomnia. The annual MDS assessment dated [DATE] identified Resident #94 with mild cognitive impairment and required extensive assist of 1 person with transfer, toileting, hygiene and ambulation. The Resident Care Plan (RCP) dated 11/21/22 identified Resident #94 had medical diagnosis of depression and anxiety. Intervention directed to monitor and record risk for harming other, increased anger and agitation, encourage to express feeling, discussed with resident regarding any concern, fear or issue and pharmacy consultant review as needed. The nurse's note dated at 1/11/23 at 11:03 PM Resident #94 reported that the roommate hit him/her on the right arm. No injury was noted and denied any complain of pain. Review of facility documentation accident and incident report dated 1/11/23 identified Resident #94 indicated that h/she got out of bed to open the curtain so h/she could look out into the hallway when his/her roommate poke him/her on the right shoulder. Interview with SW #1 on 2/6/23 at 9:55 AM identified staff provided protection and safety to the resident and initiate an investigation when the altercation between two residents. He indicated that he was made aware of the altercation between the two residents. SW 31 further indicated the resident who had an issue would be offered to move or change the room; however, he could not provide a documentation whether a room change was offered to the resident. Interview with DNS on 2/6/23 at 11:30 AM identified she was aware of the two resident's altercation and Accident and Incident report was started. She indicated she did not report the altercation between two resident's because she was not aware that it needed to be reported to the state agency. The facility failed to report an altercation between two residents to the state agency timely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 3 resident of 4 residents (Resident #12 and Resident # 44) reviewed for abuse, the facility failed to investigate an allegation of potential harm for a staffed to resident allegation of mistreatment and for (Resident #94), the facility failed conduct a thorough investigation between two residents altercation. The findings included: 1. Resident # 12's diagnoses included type 2 diabetes mellitus, Parkinson disease, depression, anxiety, osteoarthritis, and hypothyroid. The quarterly MDS assessment dated [DATE] identified Resident #12 with intact cognition and required extensive assist of 1 to 2 person with transfer, toileting, hygiene and non-ambulatory. The nurse's note dated 7/5/22 at 3:56 PM identified Social Worker (SW #1) received an e-mail from Person # 3 that there was a concern over the weekend that allegedly an assigned Nursing Assistant (NA #2) for 11:00 PM-7:00 AM shift had told Resident #12 that she hates him/her, gave him/her a middle finger and slapped his/her hand away. The Resident Care Plan (RCP) dated 7/6/22 identified Resident #12 had attempt to touch staff inappropriately. Intervention directed to discussed behavior with the resident and explained why the reason on why the behavior was not acceptable, encourage appropriate behavior and discourage inappropriate behavior, psychiatrist consult follow up and as needed and administered medication as ordered. Review of facility documentation from 7/5/22 through 2/6/23 failed to indicate the facility initiate and conducted a thorough investigation for the allegation of abuse. Interview with SW #1 on 2/6/23 at 9:55 AM indicated that he made DNS # 2 aware of Person # 3 alleged mistreatment, but he could not provide a reason why an investigation was not started. Interview with DNS on 2/6/23 at 11:30 AM identified she could not provide any documentation that the allegation had been thoroughly investigated to identified if the allegation had been substantiated. The facility failed to initiate an investigation of an alleged violation of abuse and complete a thorough investigation of the abuse allegation. 2. Resident #44 was admitted with diagnoses that included respiratory syncytial virus pneumonia, mild cognitive impairment, and depression. The quarterly MDS assessment dated [DATE] identified Resident #44 was without cognitive impairment and required two people assist with bed mobility, transfers, one person assist with personal care. The care plan dated 7/25/22 identified Resident #44 had a diagnosis of depression with interventions that included arrange for psychiatric consultation as indicated, encourage expression of feelings and administer medications as ordered. The social worker progress note dated 8/23/22 at 3:45PM noted Resident #44 verbalized accusations towards a 3:00PM -11:00 PM NA. Resident #44 would have a room change the following day and support would be provided as needed. The Complaint Report dated 8/23/22 completed by the social worker (SW #1) identified Resident #44 alleged being fearful on the unit and that a 3:00 PM-11:00 PM staff had tried to harm him/her. Resident #44 was unable to provide a name, time and date of the incident. Resident #44 was offered a room change and given the alleged situation, agreed, and accepted. A Reportable Event dated 8/23/22 with no author signature noted patient (Resident #44 was now saying a splash of water from a hose was inserted in his/her nose. There was no documentation the overseeing state agency was notified. The psychiatric progress note dated 8/26/22 identified Resident #44 was accusatory to staff a few days prior. Resident #44 repeated a story of what happened a few days prior of his/her perceived concerns of a NA staff. Resident #44 was moved off the unit and stated s/he was fearful of 2 staff from the other unit but felt safe following the move. An interview on 2/06/23 at 2:18 PM with SW #1 identified Resident #44 the alleged incident but his/her story changed. SW # 1 discussed the incident with the DNS who was overseeing the investigation. SW #1 indicated he followed up with Resident #44 and s/he was also seen by psychiatry. An interview on 2/07/23 at 8:55AM with the DNS identified she was not employee at the facility at the time of the incident. The DNS was unable to provide documentation that the allegation had been thoroughly investigated to rule out abuse. The facility policy for Resident Abuse directs following a report of alleged abuse, the department head or designee initiate an investigation of the incident . The investigation shall include interviews of the resident and all involved staff. 3. Resident # 94's diagnoses included type 2 diabetes mellitus, depression, anxiety, osteoarthritis, and insomnia. The annual MDS assessment dated [DATE] identified Resident #94 with mild cognitive impairment and required extensive assist of 1 person with transfer, toileting, hygiene and ambulation. The Resident Care Plan (RCP) dated 11/21/22 identified Resident #94 had medical diagnosis of depression and anxiety. Intervention directed to monitor and record risk for harming other, increased anger and agitation, encourage to express feeling, discussed with resident regarding any concern, fear or issue and pharmacy consultant review as needed. The nurse's note dated at 1/11/23 at 11:03 PM identified Resident #94 reported his/her roommate hit him/her on the right arm. No injury was noted and denied any complain of pain. Review of facility documentation Accident and Incident report dated 1/11/23 identified Resident #94 indicated h/she got out of bed to open the curtain so h/she could look out into the hallway when his/her roommate poke him/her on the right shoulder. Interview with SW #1 on 2/6/23 at 9:55 AM identified staff provided protection and safety to the resident and initiate an investigation when the altercation between two residents occurred. He indicated he was made aware of the altercation between the two residents. SW 31 further indicated usually the resident who had an issue would be offered to move or change the room; however, he could not provide a documentation whether a room change was offered to the resident. Interview with DNS on 2/6/23 at 11:30 AM identified she was aware of the two residents' altercation and Accident and Incident report was started. She could not provide additional information regarding the investigation and altercation between the two residents. She could not provide information on what intervention was put in place after the allegation of altercation between two residents. Interview with Registered Nurse (RN #4) on 2/7/23 at 10:45 AM identified she received a report from the 11:00 AM-7:00 AM shift nurse Resident #94 alleged his/her roommate of hit him/her. She also identified she interviewed Resident #94 related to the hitting incident because the previous shift did not provide a detail information regarding the allegation of the hitting incident. RN # 4 could not recall what intervention was in place after the allegation of altercation between two residents. Although requested, a facility policy for resident altercation was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, and interviews for one of five sampled residents (Resident # 46) reviewed for unnecessary medications the facility failed to address the pharmacist's December 2022 recommendation for an AIMS test, orthostatic blood pressures and psychiatric evaluation. Resident #46 was admitted to the facility on [DATE] with diagnoses that included depression, dementia without behavioral disturbance, and anxiety. Physician's orders dated 9/21/2022 directed to administer Abilify (antipsychotic medication) 2mg daily and indicated an AIMS (abnormal involuntary movement scale) test upon admission and every six months thereafter. Review of the consultant pharmacist recommendation to MD dated 10/5/2022 identified that there was a recommendation for specific blood work. Review of the facility's record of pharmacy recommendations identified there were no irregularities noted with Resident #46's medication review. Review of the consultant pharmacist recommendation to MD dated 12/7/2022 identified a recommendation to obtain an AIMS assessment, obtain orthostatic blood pressures and a psychiatric evaluation due to the resident receiving an antipsychotic medication. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #46 was severely cognitively impaired and required extensive assistance with transferring, ambulating, and dressing. The Resident Care Plan dated 12/22/2022 identified impaired cognitive function/impaired thought processes with interventions that identified, monitor/document/report to MD any changes in cognitive function, review medications and record possible causes of cognitive deficit, and the need to minimize the potential for falls while providing diversion and distraction. Review of Resident #46's clinical record failed to identify that an AIMS assessment had been completed, orthostatic blood pressures were obtained and/or that a psychiatric evaluation had been ordered by the physician. Interview with the Director of Nurses (DNS) on 2/6/2023 at 1:57 PM identified that pharmacy recommendation reports are located in the paper chart and the pharmacy recommendation reports are mailed to the facility and then forwarded to the charge nurse on the unit and it is the charge nurses' responsibility to follow up on the pharmacy recommendation(s). The DNS further noted that the pharmacy recommendation dated 12/7/2022 for Resident #46 was left in her office accidentally and not forwarded to the unit until 2/4/2022. She further identified that pharmacy recommendations should be followed up on within the same month the pharmacy recommendation is made. A physician's order dated 2/4/2023 indicated an AIMS test every 6 months (February/August), orthostatic blood pressures each month, and a psychiatric consult per family's consent. Interview with LPN #11 on 2/7/2023 at 11:00 AM indicated the AIMS assessment should be completed upon admission and then every six months thereafter. LPN #11 indicated that the physician's order dated 9/21/2022 directed to perform the AIMS assessment upon admission and then every six months thereafter. LPN#11 indicated Resident #46 was admitted to the facility on [DATE] and was unable to provide the reason why the admission AIMS assessment was not completed. The facility's Antipsychotic Medication and AIMS testing policy indicated AIMS testing is required the following day after admission or the start of antipsychotic medication and then every six months.

Based on observation, review facility documentation, facility policy, and interviews, the facility failed to ensure the Treatment Cart with topical medication was maintained in a safe a secure manner and the facility failed to store emergency Intravenous (IV) solutions in the medication emergency box in a safe manner and failed to ensure that opened medications were labeled appropriately and failed to ensure that medication refrigerators were free of the staff's food The findings included: 1. An observation on 2/03/23 at 8:35AM identified the Treatment Cart was unattended in the middle of the hallway on a resident unit with one unopened package of xeroform on top of the treatment cart and keys left in the lock. No residents in the immediate area. An interview with LPN #2 identified she was assigned to complete treatments that day and should not have left a medication on top of the treatment cart and left the cart unsecured and unattended. An interview on 2/03/23 at 9:22 AM with the DNS identified keys to the treatment cart should be with the nurse at all times and topical medication should not be left on top on the cart and unattended . The facility policy for Safe Storage of supplies of medication and treatments directs medication supplied in carts (medication or treatment) should be stored securely and properly. The medication supply is to be accessible only to licensed personnel. 2. Observation with RN #2, the Infection Control Nurse, on 2/7/23 at 11:00AM of the facility emergency medication box identified eight (8) 1 liter Dextrose 5 percent in .45 percent Normal Saline (D51/2NS) with an expiration date of January 2023. Interview with RN #2 on 2/7/23 at 11:30AM identified the pharmacy is responsible for checking the automated dispensing emergency medication storage (ADS) to assure that the items stored are not expired. She also indicated the supervisors are responsible for checking for expiration dates when obtaining the medication or IV solution prior for use and that the facility is in the process of switching pharmacy companies. The facility policy, Automated Dispensing Systems for First Dose and Emergency Medications, identified in part the consultant pharmacy will provide routine inspections to evaluate condition and expiration dates of medications stored in the ADS. Subsequent to surveyor's observations, RN #2 disposed of the outdated IV solutions. 3. Observation of the Windsor wing medication cart on 2/06/23 at 2:00 PM indicated the following: Calcium 250mg + D3 was open and in use with no marked open date, in the top of the medication cart with an expiration date of 6/2022. An unmarked container with cut up apples was in the medication refrigerator. Hydrate lid and lash cleanser was in the medication cart and in use BID for the resident. There was no expiration date on the bottle and it was not dated with the date opened. Observations of the North Unit medication room on 02/07/23 at 9:00 AM with LPN #8, indicated the following: Acetic Acid was open and used. The expiration date was 9/25 however, there was no open date, resident name, or discard date. Hydrogen Peroxide 3%. Two bottles are open and used. There is no expiration date, nor an open date on the bottle. Review of the Medication preparation and general guidelines IIA8: Irrigation Solutions policy indicated that the irrigation solutions are labeled with the date and time immediately upon opening by the nurse opening the container. In addition, solutions without preservatives, in the original manufacturer's container (such as water, acetic acid and sodium chloride for irrigation), are disposed of within twenty-four (24) hours after opening. Observation of the East wing medication room on 02/07/23 at 9:25 AM and medication cart with LPN#9 identified the following: Hydrogen Peroxide 3%, two bottles were opened and used without open date. Interview with LPN #7 identified that they were used daily. Interview with the DNS on 02/06/23 identified that personal food should not be stored in the medication refrigerator. Review of the medication policy indicated that personal food items should not be in the medication refrigerator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, facility documentation, facility policy and interviews, the facility failed to discard expired food, failed to properly label prepared and opened food items and failed to follow proper masking and gloving protocols. The findings include: A. During the initial kitchen tour with the facility's dietitian on 2/1/2023 from 11:17 AM to 1:00 PM identified the following: The small dry storage room located in the kitchen contained an opened undated container of cinnamon spice and brown sugar. It also contained an opened undated box of graham crackers. The sandwich refrigerator contained opened and expired containers of sweet relish (12/13/2023), pitted green olives (3/31/2021), [NAME] Light Mayo (no opened date or expiration date), and maraschino cherries (11/6/2020). The dessert corner refrigerator contained an undated plate of cheese and crackers, individual servings of orange Jell-O, pasta salad, and individual servings of fruit cocktail. The cook's refrigerator contained opened and outdated Fleischmann's Yeast (1/16/2023), a jar of AH SO sauce (10/29/2022), apricot preserves (6/2/2020), and Admiration Dijon Mustard (1/28/2022). Walk in refrigerator #1 contained opened and undated prune juice, apple sauce, provolone cheese, and shredded cheese. It also contained an opened and expired container of cream cheese (1/26/2023). The produce refrigerator contained expired pastrami (11/28/2022), an opened container of fruit salad (1/10/2023), undated individual servings of cake, and four expired carving hams (7/19/2022). The walk-in freezer contained undated frozen cod filets. The main dry storage room contained a dented can of [NAME] Red Beets, an expired box of crackers (11/27/2022), an opened undated bag of mini marshmallows, an expired box of Ken's Blue Cheese Dressing (individual packets) (12/29/22), two bottles of expired Admiration Apple Cider Vinegar (1/9/2018 & 10/2019), an opened and undated container of croutons, a container of expired Balsamic Vinaigrette (8/2017), and an opened and undated container of panko breadcrumbs. Interview with the Dietician on 2/1/2023 at 1:00 PM identified that all opened containers of food should be labeled with an opened date and discarded by the expiration date listed on the container and all individual servings should be labeled with the preparation date, name of food item, and the use by date. She further identified that all prepared food items not used by the use by date should be discarded, and all expired food items were to be discarded by date listed on the container. She further noted that, they were in the process of reorganizing and re-educating the kitchen staff on proper food storage and preparation. The facility's Labelling and Dating of Food Items policy identified that opened food items or prepared food items will be appropriately labelled displaying the food item name, date prepared, date opened and discarded according to the expiration date on the original packaging or within the 7-day standard disposal rule. B. Observation of the tray line on 2/6/2023 at 11:20 AM identified Dietary Aide #2 touched his face with his right hand and failed to wash hands. Further observation noted that his face mask did not cover his nose. When it was brought to his attention, DA #2 pulled the face mask up to cover his nose but did not immediately leave the tray line to wash his hands until instructed to do so by the Dietician. Interview with the Dietician on 2/6/2023 at 11:25 AM indicated that proper mask use included covering both the mouth and nose. She indicated that handwashing, drying, and application of new gloves was required immediately following any hand contamination. The facility's Use of Facial Masks policy indicates all employees must wear a medical grade mask upon entering the building during their assigned shift and that medical grade masks need to be worn in accordance with infection control practices. The facility's Proper Use of Gloves policy indicates employees will properly wash their hands before putting on a new set of gloves and that glove changes need to be performed whenever the glove has been compromised.

Based on review of the clinical records, facility documentation, and interviews, the facility failed to ensure an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. The finding include: A review of the facility infection control program identified no current and complete tracking of antibiotic use or evidence of practice utilizing the principles of antibiotic stewardship that reduces the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use and implement a facility-wide system to monitor the use of antibiotics. A review of the Quarterly Nursing Department (QAPI) Medical Staff Review dated 11/16/2022 noted Covid 19 updates, an overview of October 2022 infection percentages and although outlined the facility lacked summaries of routine infection control monitoring and treatment and did not include any tracking of antibiotic and outcomes. Interview with RN #2 on 2/6/23 at 12:30 PM identified she was previously a nursing supervisor at the facility and as part of that role, a 24 hour report was updated each shift by each supervisor which included the resident's infection status and antibiotic use. She collected the sheets daily and utilized the 24-hour report sheets to add to IV log and infection report at the end of the month. She also indicated she was unable to locate completed documents from the previous Infection Control Nurse who was also the DNS at the time and that when she took the job in November 2022 DNS # 2 did not provide her any education or resources in regard to certain elements of the Infection Control program. An interview on 2/7/22 at 9:24 AM with the DNS identified DNS # 2 left suddenly and did not readily share information and had been the Infection Control Nurse prior the RN #2 taking the position. She identified the facility had difficulties locating all the necessary documents due to the DNS # 2 sudden departure stating that the oversight of the Infection Control program and all the necessary documents to assure effective infection surveillance, tracking of MDROs were the responsibility of the Infection Control Nurse. She continued by verbalizing she planned to implement protocols related to addressing recommended interventions to optimize use of antimicrobials and had prioritized Urinary tract Infections as the starting point. An interview on 2/7/22 at 9:24 AM with the DNS (interim) identified the last DNS left suddenly mid-November of 2022 and did not readily share information with other facility staff. The former DNS had been the Infection Control Nurse prior to RN #2 taking the position. She identified that the facility had difficulties locating all the necessary infection control documents due to the former DNS's sudden departure. An interview on 2/7/2023 at 10:35 AM with the Medical Director identified he believed the former DNS was previously overseeing the infection control program and that he visited the facility weekly where any concerns related to infection control were discussed. Efforts to contact DNS # 2 were unsuccessful. The facility policy Antibiotic Stewardship, dated last revised on 10/2017, identified that antimicrobial stewardship (AMS) is a systematic approach to optimizing use of antimicrobials (antibiotics) to reduce inappropriate us, improve resident outcomes and reduce adverse consequences of antimicrobials ( including antimicrobial resistance, secondary infections, toxicity and unnecessary costs). The policy in parts directs that tracking and reporting antibiotic use and outcomes and monitoring antibiotic prescribing and outcomes measures as components of the program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an observation, a review of the clinical record, staff interviews and a review of the facility policy for one sampled resident (Resident #59), the facility failed to develop a comprehensive care plan with interventions that were individualized. The findings include: Resident # 59 was admitted to the facility on [DATE] with diagnoses that included left breast cancer, diabetic, congestive heart disease, atrial fibrillation and hypertension. The Hospital Discharge summary dated [DATE] at 3:00 PM by MD #1 indicated Resident #59 was in hospital from [DATE]-[DATE] and had malignant neoplasm of breast and pneumonia. Additionally, an x-ray report dated 12/20/19 with a photo and description of the right chest wall port-a-cath with the tip projecting over the upper right atrium was identified. The admission Minimum Data Set (MDS) dated [DATE] identified moderate cognitive impairment, occasionally incontinent of bladder and required extensive assist of 1 for dressing, toileting, bed mobility, and transfers. Interview on 2/24/20 at 10:16 AM with RN #4 indicated Resident #59 did not have any access devices or a port-a-cath that she was aware of, because if Resident #59 had a port-a-cath nursing would follow MD orders for flushing it and RN #4 could flush it in the facility. Observation and interview on 2/24/20 at 11:45 AM with RN #4 identified Resident #59 had a port-a-cath when he/she pulled the residents shirt to the right side and observed the catheter. RN #4 indicated Resident #59 did have a right sided port-a-cath protruding from the right chest wall. Furthermore, RN #4 indicated she did not know how she missed it. Interview on 2/24/20 at 12:15 PM with RN #2 Infection Control Nurse identifed she was not aware Resident #59 had a port-a-cath. RN #2 indicated if Resident #59 had a port-a-cath there is a facility policy and protocol to follow. Resident #59 should have had orders from the physician to flush the port-a-cath every 28 days for routine maintenance and to maintain patency of the line. Interview on 2/24/20 at 12:30 PM with the DNS indicated she was not aware Resident #59 had a port-a-cath however, it was the responsibility of the RN on admission to review the paperwork from the hospital and to inform the physician that the resident had a port-a-cath. Interview on 2/24/20 at 1:35 PM with MD #1 indicated he was aware when Resident #59 was in the hospital that Resident #59 had a port-a-cath. MD #1 indicated Resident #59 refused to have it removed because he/she was afraid he/she may need surgery again. MD #1 indicated Resident #59's port-a-cath was present at admission to the facility and should be flushed at least monthly for patency to prevent it from getting a clot. MD #1 indicated the port could clot off and would lead to complications. MD #1 identified he thought the facility would have put policies in place to ensure it was flushed every month with heparin. MD #1 indicated he would make sure the orders were in place for flushing and monitoring of the site. A physician order dated 2/24/20 directed to access right chest port-a-cath tonight, verify blood return, flush per protocol. Additionally, directed to access right chest wall port-a-cath once every 28 days, verify blood return flush per protocol. Furthermore, to monitor right chest wall port-a-cath site for infection or migration once every shift. Central Vascular access Device Physician Order Sheet dated on 2/24/20 at 5:20 PM identified that Resident #59 had a Right chest wall port-a-cath directed to flush with 10 ml of normal saline, followed by 5 ml (10 units per ml) of heparin, once every 28 days to verify patency. The nurse's note dated 2/24/20 at 5:44 PM identified that Resident #42 spoke with MD #1 and received new orders to access right chest wall port-a-cath. The nurse's note dated 2/24/20 at 7:13 PM identified that Resident #42 had right chest wall port-a-cath accessed per protocol and had good blood return and was flushed. An interview with RN #3 MDS coordinator on 2/25/20 at 8:16 AM noted on the admission the admission/charge nurse can put in a care plan. The MDS coordinator creates the comprehensive care plan from all information that comes from the hospital discharge paperwork, the admission assessments done by the facility nurse's, and the physician's orders within a two of the admission. RN #3 indicated Resident #59 did not have a care plan from that identified he/she had a port-a-cath with interventions that were individualized and should have. A care plan created on 2/25/20 indicated Resident #59 had a right chest port-a-cath that is not in use. Interventions included the resident would need intravenous flushes per facility policy, monitor for signs and symptoms of infection to site. Assess for pain, swelling, redness, drainage, crepitus, and hematoma's. Update the physician with any changes. The facility policy entitled Implanted Venous Port Accessing directed in part that surgically implanted venous ports are implanted under the skin. The port was used for long term infusion therapy. The reserve may be stainless steel or titanium or plastic and a catheter which terminates in the superior vena cava. The nurse would be responsible and accountable for obtaining and maintaining competence with infusion therapy within his/her scope of practice. A physician or licensed independent practitioner must follow an order which includes flushing agents, strength, volume, and frequency. The implanted venous port would be accessed monthly for maintenance if not in use by flushing, using a non-coring safety needle that would be used and removed after the flush.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, a review of the clinical record, staff interviews and a review of the facility documentation, for one sampled resident (Resident #5) the facility failed to ensure placement of bed rail bumpers in accordance with the physician order and for one sampled resident (Resident #59), the facility failed to ensure a Register Nurse conducted an admission assessment and/or failed to ensure the admission assessment was comprehensive. The findings include: a. Resident #5's diagnoses included dementia, failure to thrive and a history of falls. The annual Minimum Data Set (MDS) assessment dated [DATE] identified severe cognitive impairment, did not exhibit behaviors and required extensive assistance with bed mobility, transfers and locomotion. The nurse's note dated 8/24/2019 at 9:44 AM identified Resident #5 was alert and confused, the resident was observed screaming and striking out, staff re-approached, bilateral upper arms observed to have intact purpura's and a new physician's order was put in place to apply bumpers to the side rails of the bed. The Resident Care Plan (RCP) dated 2/11/20 identified psychotropic medication administration and can be resistive during care and strike out at times. Interventions directed to re-approach if agitated, a behavior management program that included monitoring and documentation of behaviors. A physician's order dated 2/12/20 directed to provide bed bumpers to side rails while Resident #5 was in bed every shift. Observation on 2/23/20 at 7:55 AM identified Resident #5 in bed with a light blue side rail bumpers stored on the floor next to the bed. A second observation on 2/23/20 at 8:35 AM identified Resident #5 eating his/her breakfast in bed without the benefit of side rail bumpers which remained on the floor next to the bed. Observation of Resident #5 on 2/24/20 at 6:13 AM identified Resident #5 in bed asleep without the benefit of side rail bumpers. Observation on 2/25/20 at 6:15 AM identified Resident #5 in bed without the benefit of side rail bumpers. Observation of Resident #5 on 2/25/20 at 7:35 AM identified Resident #5 in bed, being repositioned by NA #3 and NA #4 without the benefit of side rail bumpers. Continued observation identified NA #3 and NA #4 left Resident #5's room without placing Resident #5's side rail bumpers. Interview and observation on 2/25/20 at 7:38 AM with RN #2 identified Resident #5 in bed without the benefit of side rail bumpers. RN #2 indicated the 11:00 PM to 7:00 AM shift staff had likely removed the bumpers, however the physician's order indicated the use of side rail bumpers at all times while Resident #5 was in bed. RN #2 found the side rail bumpers stored in Resident #5's closet. RN #2 failed to identify side rail bumpers were part of the care plan and failed to identify side rail bumpers were on the NA assignment. Interview with NA #4 on 02/25/20 at 7:45 AM failed to identify side rail bumpers were on her assignment but the charge nurse indicated side rail bumpers were to be used for Resident #5. NA #4 identified the 11:00 PM to 7:00 AM shift was responsible to ensure the side rail bumpers were in place. NA #4 identified that she was assigned to take care of Resident #5 on 2/24/20 and that she could not recall if Resident #5 had side rail pads on his/her bed on 2/24/20. Subsequent to surveyor inquiry, Resident #5 had his/her side rail bumpers placed by RN #2. b. Resident #59 was admitted to the facility on [DATE] with diagnoses that included acute chronic congestive heart failure, malignant neoplasm of breast, acute exacerbation of chronic obstructive pulmonary disease, diabetes and pneumonia. The hospital Discharge summary dated [DATE] at 3:00 PM by MD #1 indicated Resident #59 was in the hospital from [DATE] through 12/21/19 for acute on chronic diastolic congestive heart failure. The admission Minimum Data Set (MDS) dated [DATE] identified moderate cognitive impairment, occasionally incontinent of bladder and required extensive assistance of 1 for dressing, toileting, bed mobility, and transfers. Interview and review of the clinical record on 2/24/20 at 9:23 AM with RN #4 indicated an RN should complete the admission assessments when a resident was admitted into the facility. RN #4 reviewed the clinical record and indicated the admission assessment was completed by an LPN. Interview and review of the clinical record on 2/25/20 at 11:45 AM with the Director of Nursing (DNS) indicated the admission assessments and admission progress note were completed by LPN #4. The DNS indicated a RN has to conduct the admission assessments and if an LPN does any part of the admission related to the collection of data the RN has to co-sign the areas that were completed by the LPN and in this case the admission assessment was not co-signed or signed by the RN. Although attempted, an interview with LPN #4 was not obtained. Although a copy of the admission policy for nursing assessments was requested it was not provided. c. Interview on 2/24/20 at 12:30 PM with the Director of Nursing (DNS) indicated she was not aware Resident #59 had a port-a-cath when he/she was admitted to the facility however, review of the hospital discharge summary identified Resident #59 had a port-a-cath on admission to the facility. The DNS indicated it was the responsibility of the RN on admission to review the paperwork from the hospital and to inform the physician that the resident had a port-a-cath. Interview on 2/24/20 at 1:35 PM with MD #1 indicated he was aware when Resident #59 was in the hospital that Resident #59 had a port-a-cath. MD #1 indicated Resident #59 refused to have it removed because he/she was afraid he/she may need surgery again. MD #1 indicated Resident #59's port-a-cath was present at admission to the facility and should be flushed at least monthly for patency to prevent it from getting a clot. MD #1 indicated the port could clot off and would lead to complications. MD #1 indicated he thought the facility would have put the policies in place to flush it, because the facility had templates from the pharmacy to make sure it was flushed every month with heparin per the protocol. MD #1 indicated he would make sure the orders were in place. Subsequent to the surveyors inquiry a physician's order was obtained to flush the right chest med-port catheter with 10 milliliters (ml) of normal saline followed by 5 milliliters of Heparin (10 units/ml) once every twenty eight days to verify patency. Additionally the order directed to monitor the right chest wall site for infection or migration once every shift. The facility policy entitled Implanted Venous Port Accessing directed in part that surgically implanted venous ports are implanted under the skin. The port was used for long term infusion therapy. The reserve may be stainless steel or titanium or plastic and a catheter which terminates in the superior vena cava. The nurse would be responsible and accountable for obtaining and maintaining competence with infusion therapy within his/her scope of practice. A physician or licensed independent practitioner must follow an order which includes flushing agents, strength, volume, and frequency. The implanted venous port would be accessed monthly for maintenance if not in use by flushing, using a non-coring safety needle that would be used and removed after the flush.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a clinical record review, staff interviews, and a review of the facility documentation for one of three sampled residents reviewed for falls (Resident #237), the facility failed to ensure an alarm was utilized in accordance with the physician's order. The findings include: Resident #237 was admitted to the facility on [DATE] with diagnoses that included a recent femur fracture with a surgical procedure, dementia, hypertension, anemia, heart failure, chronic kidney disease and a hearing deficit. A physicians order dated 2/7/20 directed tabs alarm and to check placement and functioning every shift. The order further directed for the resident to be non-weight bearing to the right lower extremity. The resident's care plan dated 2/7/20 identified the resident was at risk for falls related to a history of falls, right femur fracture, impaired cognition and cardiac disease. Interventions included the use of safety monitor (tab alarm) and directed staff to ensure the device was in place and functioning. Review of the facility's Reportable Event Form dated 2/12/20 at 3:45 AM identified Resident #237 was found on his/her left side in the corner of his/her room facing the door. The Reportable Event Form further identified Resident #237 sustained a 2.1 centimeter (cm) skin tear to the left elbow and bruising with ecchymosis to left inner elbow. Review of facility investigation identified the resident did not have the monitor attached to him/her. The monitor was on the bedside table and not in use. The 5-day Minimum Data Set (MDS) dated [DATE] identified severe cognitive impairment, required a two person extensive physical assistance with bed mobility, transfers and ambulation in the room. Additionally, the MDS identified Resident #237 had falls in the last month prior to admission/entry or re-entry, and a fracture related to a fall in the 6 months prior to admission/entry or reentry. NA #2 received an employee notice of deficiency on 2/13/20 that identified deficient practice in safety habits and following instructions. The notice further identified Resident #237 fell and he/she had an order for a tab alarm. The tab alarm was found fully functioning on the resident's bedside table. NA #2 was in violation of following a physician order and the plan of care. NA #2 was not available for an interview. Interview with the Director of Nursing (DON) on 2/24/20 at 1:40 PM identified NA #2 should have applied the tab alarm as ordered. The DON indicated that although the alarms do not prevent falls, they alert the staff when the resident attempts to get up without assistance. Interview with RN #1 on 2/25/20 at 6:30 AM identified she/he responded to the resident calling out for help, Resident #237 was on the floor near the door and his/her tab alarm was disconnected on the bedside table. RN #1 further identified NA #2 that completed rounds and was responsible to make sure that the residents tab alarm was in place and was functioning after care was provided. RN #1 indicated NA #2 forgot to reapply the tabs alarm after she/he assisted the resident with care shortly before the fall. Interview with APRN #1 on 2/25/20 at 10:40 AM identified the facility staff should have followed the physician order to apply the tab alarm and to ensure placement and functioning every shift as the resident tried to get out of bed without asking for help. The facility policy entitled Accidents/Incidents identified strict fall precautions directed in part that personal monitors may be utilized. Patient characteristics included: confusion, impulsive behaviors or dementia with poor judgment, lack of safety awareness, unreliable or unpredictable behavior with interventions that directed the use of a personal monitor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, a review of the clinical record, staff interviews and a review of the facility policy, for two of three residents reviewed for respiratory care (Resident #23, and #117), the facility failed to implement infection control measures during care, handling, cleaning, and storage of respiratory equipment. The findings include: a. Resident #23 was admitted to the facility on [DATE] with diagnoses that included chronic heart failure, diabetes, and dementia. The quarterly Minimum Data Set (MDS) dated [DATE] identified severe cognitive impairment, incontinence of bowel and bladder, and required extensive assistance of two staff members for personal hygiene, incontinent care, dressing, bed mobility, and transfers. The care plan dated 12/10/19 identified pneumonia as a problem with interventions that directed oxygen therapy per physician orders and to check oxygen saturation levels via a pulse oximeter as ordered and as needed. A physician's order dated 2/14/20 directed pulse oximeter levels to be checked every shift and to administer oxygen at 3 liters via nasal cannula as needed to maintain pulse oximeter readings greater than 92%. The nurse's note dated 2/16/20 at 2:24 PM identified Resident #23 was agitated and non-compliant with oxygen therapy and kept taking the tubing off. Resident #23 was at nurses' station for close supervision. Interview on 2/23/20 at 08:01 AM with Person #1 identified Resident #23 had pneumonia twice in the last couple of months, and was non-compliant with oxygen therapy due to dementia. Observation on 2/23/20 at 8:05 AM identified Resident #23 was lying in bed in an upright position with the oxygen tubing off of his/her face. The tubing was in the resident's hand. The oxygen concentrator was on 3 liters via nasal cannula and a water bubbler, tubing, and storage bag that were not dated or labeled to identify when it was last changed. Person #1 reapplied the nasal cannula. Observation on 2/24/20 at 7:45 AM identified Resident #23 was lying in bed in a semi upright position with oxygen via nasal cannula on 3 liters with a water bubbler, tubing, and storage bag that was not dated or labeled. Observation on 2/24/20 at 10:42 AM identified Resident #23 was in a recreation program at the end of the hallway with a portable oxygen tank on 3 liters via nasal cannula. The nasal cannula tubing was not dated. Observations on 2/25/20 at 9:10 AM identified Resident #23 lying in bed with oxygen tubing that was wrapped around his/her ears and nasal prongs under his/her chin. Oxygen was running via concentrator at 3 liters the with a water bubbler, tubing, and storage bag were not dated or labeled. b. Resident #117 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure, chronic diastolic heart failure, chronic obstructive pulmonary disease, diabetes, and respiratory failure. A physician's order dated 1/26/20 directed to apply oxygen at 3 liters continuous every shift. A comprehensive MDS dated [DATE] identified moderate cognitive impairment, incontinence of bowel and bladder and required extensive assistance with personal hygiene, toileting, eating, dressing, bed mobility, and transfers and the administration of oxygen therapy. The care plan dated 2/7/20 identified Resident #117 had congested heart failure. Interventions directed to administer oxygen per physician order. Observation on 2/23/20 at 7:25 AM identified Resident #117 was lying in a semi upright position with oxygen via nasal cannula at 3 liters with the oxygen tubing and nasal cannula lying on the floor without a date on the nasal cannula tubing or a bag for storage with a date. Observation on 2/24/20 at 8:40 AM identified Resident #117 was sitting in a recliner chair with his/her oxygen cannula and tubing lying across his/her lap without a date on the nasal cannula tubing or a bag for storage with a date. Interview on 2/23/20 at 8:45 AM with RN #5 indicated Resident #117 does remove his/her oxygen when he/she does not want it. RN #5 identified the tubing was on the floor and would have to change it. RN #5 indicated the oxygen tubing should be dated and changed weekly. Interview on 2/24/20 at 8:46 AM with RN #4 indicated it was her responsibility to change the oxygen tubing weekly and the oxygen company does it sometimes. Additionally, RN #4 indicated the nebulizer masks and oxygen tubing are dated when it is changed, but she does not document when she changes them because she knows when she does it. RN #4 indicated she changes them when they look dirty and there is no specific day or shift they are scheduled to be changed. RN #4 indicated the oxygen company comes daily to fill the portable oxygen tanks and might change the tubing then if they think it needs it. Observation on 2/25/20 at 8:58 AM Resident #117 was lying in bed sleeping with oxygen concentrator running on 3 liters attached to nasal cannula that was lying on the floor. Observation on 2/25/20 at 9:15 AM Resident#117 was being fed breakfast by NA #6 without oxygen and the oxygen tubing was lying on the floor. Interview on 2/25/20 at 9:20 AM with NA #6 indicated she did not know if Resident #117 was supposed to be on oxygen. Observation on 2/25/20 at 9:57 AM identified LPN #3 took the oxygen tubing hanging over the concentrator not in a bag and disconnected it from the oxygen concentrator and re-applied the contaminated nasal cannula to the portable oxygen tank and placed it on the resident. Interview on 2/25/20 at 9:59 AM with LPN #3 after the surveyor him/her that the nasal cannula had been on the floor, LPN #3 indicated she was not informed by the nursing assistants that it was on the floor because if they told her she would not have put it on the resident. Additionally, LPN #3 indicated she would change the nasal cannula and tubing right away. Interview on 2/25/20 at 10:03 AM with NA #7 indicated she picked the nasal cannula tubing off the floor and hung it over the concentrator, because she did not want to trip and fall. NA #7 indicated she did not tell the nurse because she did not see it as a problem. Interview on 2/25/20 at 10:20 AM with LPN #3 indicated she was not sure who changed the oxygen supplies on a weekly basis, it might be the oxygen company but he/she was unsure. Interview on 2/24/20 at 8:46 AM with RN #4 indicated the oxygen company comes daily to fill the portable oxygen tanks. RN #4 identified it was her responsibility to change the oxygen tubing however the oxygen company occasionally completes this task. The nebulizer masks and oxygen tubing including the nasal cannula tubing's are dated when they are changed, but it was not documented in the clinical record. RN #4 indicated she remembers when to change the equipment and also changes them when they look dirty. Additionally, RN#4 indicated it was her responsibility to change the oxygen equipment however, there was no specific day, or shift scheduled as to when this task would be conducted. Interview on 2/25/20 at 11:15 AM with Infection Control RN #2 indicated the nurses were responsible to change the oxygen tubing, but when the oxygen company changes the nebulizer mask, or the nasal cannula tubing they place a white sticker on the tubing with the date they changed it. Further interview with Infection Control RN #2 indicated there was not a system to know when the tubing was changed on a weekly basis except for the date on the tubing. Interview on 2/25/20 at 11:50 AM with the Director of Nursing (DON) indicated the nursing staff were responsible to change the oxygen tubing's including the nasal cannula and the nebulizer masks. The DON indicated the tubing was to be changed weekly and as needed. The DON indicated the oxygen technician may change the equipment however, the nurses were responsible to make sure they are changed and dated even if the oxygen technician changes it. Review of facility policy for the administration of oxygen via cannula identified cannula's would be changed weekly. The facility failed to have a system in place for staff to monitor and document the weekly changing and storage of residents' oxygen equipment.

Based on an observation, a review of facility documentation, staff interviews and a review of the facility policy, the facility failed to maintain the kitchen in a clean and sanitary manner and failed to ensure staff utilized beard restraints when working in the kitchen. The findings include: During a tour of the kitchen on 2/23/20 at 7:00 AM with the AM Supervisor, observations identified the following issues: a. The kitchen floors and corners were noted with dirt debris and dry stains. b. The bottom of the 2 ovens were noted with accumulation of grease film, debris and spillage. c. The outside of the 2 oven doors were noted with moderate dry food splatter and spillage. d. The ice cream freezer was observed with (2) 16.9 ounce bottles of Honest Organic Blood Orange Mango flavored herbal tea and a plastic cup of ice wrapped in saran wrap frozen. e. The dessert prep area cabinet door was noted off the hinges and damaged. f. The dessert bowl stand was observed with dry stains and dry food debris with clean dessert bowls within it. g. The upper and lower compartments of the convection oven were noted with an accumulation of built-up grease film and food debris. h. The upper and lower outside doors of the convection oven were noted with moderate amount of dry stains and food debris. i. The soup kettle lid top was noted with a moderate amount of grease film and dry stains. j. The deep fryer was noted with used dark brown oil and floating food debris and particles. k. The upper and lower outside doors of the steamer compartments were noted with moderate amounts of dry stains. l. The sauce rack was noted with moderate amounts of dry stains and debris. m. The oil rack was noted with a moderate amount of oil spillage and debris. n. The fan in the kitchen was noted with an accumulation of dust and dust particles or dirt debris. o. One black cart was noted with a moderate amount of dry food stains and dry food debris. p. The bottom of the salad/sandwich shelf in the refrigerator was noted with a moderate amount of dry stains and food debris. q. The outside door of the salad/sandwich refrigerator was noted with dry stains. r. The dry food storage room underneath the cereal shelf was observed with cereal debris on the floor. s. The reach-in refrigerator bottom shelf was noted with dark brown stains. Observation on 2/23/20 at 7:03 AM identified Dietary Aide #1 who had facial hair was without the benefit of a beard restraint in the kitchen. Interview with Dietary Aide (DA) #1 on 2/23/20 at 7:03 AM indicated he/she was aware there was a beard restraint policy. DA #1 indicated he/she was going to put one on but did not. Interview with the AM Supervisor on 2/23/20 at 7:03 AM identified beard restraints should be worn in the kitchen during working hours. Interview with Dietary Aide (DA) #2 on 2/23/20 at 7:08 AM identified the 2 Honest Organic Blood Orange Mango flavored herbal tea bottles belonging to him/her. DA #2 indicated he/she placed the bottles in the ice cream freezer at 6:40 AM when he/she came in to work this morning. DA #2 indicated the ice cream freezer was for the facility food and he/she was not to place his/her personal food items in the freezer. Interview with AM Supervisor on 2/23/20 at 7:09 AM indicated the dietary aides are not to put their personal items in the freezer with the facility food items. Interview with AM Supervisor on 2/23/20 at 7:29 AM identified he/she was not aware of the issues identified during tour. The AM Supervisor indicated it was the responsibility of all cooks and dietary staff to make sure the kitchen was clean throughout the day. The AM Supervisor indicated the closing cook and dietary staff members were responsible for making sure the kitchen was clean at the end of the day. Interview with the Food Service Director (FSD) on 2/24/20 at 6:45 AM identified he/she was not aware of the issues identified. The FSD indicated it was the responsibility of all the cooks and dietary staff to make sure the kitchen was clean throughout the day. The closing cook and dietary staff members were responsible for making sure the kitchen was clean at the end of the day. The FSD indicated the dietary staff are not to put their personal items in the freezer with the facility food items. Furthermore the FSD indicated the dietary aides with facial hair were to wear hair restraints during working hours. Moreover, the FSD indicated an in-service would be given to all dietary staff regarding the cleanliness of the kitchen, hair/beard restraints and personal items. Review of the facility kitchen policy and operating procedure identified the cleanliness of any healthcare environment was important for infection prevention, infection control and patient well being. To minimize the risk of infection and maintain a clean environment, the staff was responsible for maintaining a clean environment. Clean was defined as removal or organic or in-organic materials from objects or surfaces. This would be completed daily. Review of the facility facial hair restraint policy identified the basics, good habits, importance in food safety, cleanliness, finger nails that were neat and trim, hair restraints and handwashing. Facial hair more than two days growth and hanging must wear hair guard/beard restraint.

Based on a review of the facility documentation, and staff interviews reviewed for the Infection Control Program, the facility failed to establish and implement a surveillance plan to identify, track and monitor infections. The findings include: Interview on 2/25/20 at 11:03 AM with RN #2 (Infection Control Nurse) indicated she has not maintained the daily or monthly line list of residents who potentially have infections or an actual infection that are on antibiotics. RN #2 identified she knew the facility should be using McGreers criteria for infections, but she did not evaluate if the residents infection met the McGreer's criteria or not. In addition RN #2 indicated she needs to educate the staff on the McGreers criteria, but has not done so to date. RN #2 identified she had not monitored the administration of antibiotics since she took the position in October of 2019. Interview on 2/25/20 at 11:36 AM with the Director of Nursing (DNS) indicated she was aware the Infection Control Nurse was not tracking infections using the McGreer's criteria to evaluate the residents in the facility since October of 2019, and that this task should have been conducted. The DNS indicated the last time infection tracking was conducted in the facility was in September of 2019 by the prior Infection Control Nurse. At that time monitoring included the infection type, if the infection was facility or community acquired, if it met McGreer's criteria, and the duration of antibiotics. Although requested, a facility policy for the monitoring and surveillance for residents with potential infections and antibiotic use was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, staff interviews and a review of the facility documentation, for 6 of 6 Residents (Resident #23, #42, #59, #62, #86, and #117) reviewed for Pneumococcal Immunizations, the facility failed to document, administer, and track Prevnar 13 vaccines. The findings include: a. Resident #23 was admitted to the facility on [DATE] with diagnoses that included chronic heart failure, diabetes, and dementia. Review of the clincial record identified Resident #23's date of birth was 1/12/19 and the consent form indicated he/she consented for Pneumococcal 23 vaccine on 1/12/16, however a consent form for Prevnar 13 was not obtained. Further review of the clinical record failed to identify that Resident #23 was administered Pneumococcal 23 or Prevnar 13. b. Resident # 42 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, depression, borderline personality disorder, and hypertension. Review of the clinical record identified Resident #42's date of birth was 12/31/39 and was administered Pneumococcal 23 on 4/2/09, however a consent was not obtained for Prevnar 13 and the immunization was not administered. c. Resident # 59 was admitted to the facility on [DATE] with diagnoses that included acute chronic congestive heart failure, malignant neoplasm of breast, acute exacerbation of chronic obstructive pulmonary disease, diabetes and pneumonia. Review of the clinical record identified Resident #59's date of birth was 11/20/29 and was administered Pneumococcal 23 vaccine in July of 2004, however a consent was not obtained for Prevnar 13 and the immunization was not administered. d. Resident # 62 was admitted to the facility on [DATE] with diagnoses that included diabetes, heart failure, and hypertension. Review of the clinical record identified Resident #62's date of birth was 1/18/27 and was administered Pneumococcal 23 on 5/9/12, however a consent was not obtained for Prevnar 13 and the immunization was not administered. e. Resident # 86 was admitted to the facility on [DATE] with diagnoses that included hypertension and pneumonia. Review of the clinical record identified Resident #86's date of birth was 6/3/31 and was administered the Pneumococcal 23 vaccine in January of 2015, however a consent was not obtained for Prevnar 13 and the immunization was not administered. f. Resident #117 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure, chronic diastolic heart failure, chronic obstructive pulmonary disease, diabetes, and respiratory failure. Review of the clinical record identified Resident #86's date of birth was 12/1/33 and was administered the Pneumococcal 23 vaccine on 5/6/11, however a consent was not obtained for Prevnar 13 and the immunization was not administered. Interview on 2/25/20 at 11:03 AM with RN #2 (Infection Control Nurse) indicated when a resident was admitted to the facility it was the responsibility of the charge nurse to ask the resident and/or family about their vaccine history. All resident vaccine records for Influenza, Pneumococcal 23, and Prevnar 13 were in the computer for every resident. RN #2 was responsible to review the charts and identify who had or had not received immunizations. RN #2 indicated she had not completed this task because she was very busy. RN #2 indicated she did not know when to give the Prevnar in relation to the pneumococcal vaccines. The CDC guideline for Pneumococcal 23 indicated the vaccine protects against 23 types of pneumococcal bacteria. PPSV 23 is recommended for all adults [AGE] years of age and older. The CDC guideline for Pneumococcal 13 indicated the vaccine protects against 13 types of pneumococcal bacteria including the types that cause meningitis and bacteremia.