**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and policy review for 1 of 2 sampled residents (Resident #26) reviewed for dignity, the facility failed to return laundry in a timely manner to ensure Resident #26 had sufficient clothes and did not have to be dressed in a hospital gown. Resident #26's diagnoses included Type 2 Diabetes Mellitus, chronic venous hypertension with ulcer of bilateral lower extremity and cellulitis of right and left limbs. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #26 was cognitively intact, required partial to moderate assistance for transfers and upper body dressing and was dependent for lower body dressing and toileting. The Resident Care Plan dated 6/19/24 identified Resident #26 had an adjustment disorder. Interventions included encouragement to participate in activities of choice and providing the opportunity to communicate feelings regarding attending activities. Interview and observation of Resident #26 on 8/29/24 at 1:15 PM during the Resident Council meeting identified Resident #26 was wearing a hospital gown and stated it was because he/she had not received clothing back from laundry in 5 days. Interview with Resident #26 in his/her room on 8/30/24 at 11:20 AM identified he/she told everyone about the missing laundry and still not received it back. Interview with the Nurse Aide (NA) #7 on 8/30/24 at 11:20 AM identified and agreed that Resident #26 told everyone about the missing laundry items and she notified laundry on 8/27/24, adding there is a huge pile of clothing down there and I'm not looking through that. Interview and observation of Resident #26 on 8/30/24 at 11:42 AM identified he/she was seated in his/her wheelchair in a common hallway with the Physical Therapist, wearing a hospital gown with both lower extremities exposed and wrapped in ace bandages. Resident #26 identified it was 5 or 6 days that he/she had to wear a hospital gown, it bothered him/her not to have their own clothing, and that was the reason he/she was not doing therapy in the gym. Interview on 8/30/24 at 12:00 PM with the Director of Environmental Services identified the turnaround time for laundry was usually 2 to 3 days and today was the first time she heard of Resident #26 missing items. Additionally, the department was extremely short staffed, and the regular full-time employee whom it was most likely reported to worked her last day on 8/27/24. However, she was currently implementing easy to read labels and personalized bags to cut down on lost and missing resident clothing since that had been an issue. Interview with Social Worker #2 on 8/30/24 at 12:35 PM identified that she was not made aware of Resident #26's missing clothing until 8/30/24 (despite NA #7 being aware of Resident #26's missing clothing on 8/27/24). Interview with the Physical Therapist (PT) #1 on 8/30/24 at 12:40 PM identified that therapy was not done in the gym due to Resident #26 preference because it bothered him/her to be wearing a hospital gown when in the gym, but it did not impact the physical therapy progress. Observation of Resident #26 on 8/30/24 at 1:54 PM identified him/her wearing a hospital gown while sitting in the dining room waiting for lunch. Facility policy on Personal Items identified it was the responsibility of all staff members to report any missing items to the supervisor who will report it to the Social Worker and/administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of the clinical record, and facility policy for the only sampled resident (Resident #36) reviewed for non-pressure skin conditions, the facility failed to notify the responsible party of the development of an open area requiring a treatment and for 1 of 4 residents (Resident #69) reviewed for pressure ulcers, the facility failed to notify the physician per the physician's order for a greater than 3 pound (lbs) weight loss in one day for a resident with congestive heart failure (CHF) and for 1 of 1 residents (Resident #476) reviewed for a lumbar brace, the facility failed to notify the physician/APRN of Resident #476's refusals to wear the lumbar brace. The findings include: 1. Resident #36's diagnoses included stroke, right-side hemiplegia, osteoporosis. The Annual Minimum Data Set assessment dated [DATE] identified Resident #36 was severely cognitively impaired and dependent for toileting hygiene, for putting on and taking off footwear, and required partial/moderate assistance to roll to the left and right. The Resident Care Plan in effect from 8/1/24 to 8/30/24 identified Resident #36 was at risk for an alteration in skin integrity related to decreased mobility. Interventions included use of a bed cradle, offloading both heels while in the bed or chair, and reporting of any areas of concerns identified during performance of skin checks with care. A weekly skin assessment dated [DATE] at 8:51 AM identified Resident #36's right toes were pink with a rash. A non-pressure wound weekly tracking assessment dated [DATE] at 3:15 PM identified Resident #36 had a superficial open area to the right great toe with measurements of 0.4 centimeters (cm) by 0.3 cm by 0.0 cm. The wound bed had 76% to 100% granulation, with a scant amount of bloody drainage. It was further identified that the treatment was to cleanse the right great toe with wound cleanser, pat dry, then apply Xeroform (yellow petroleum gauze) to the open area, and cover with a non-adherent pad followed by gauze wrap every day and as needed. A physician's order dated 8/5/24 directed to cleanse the right great toe open area with wound cleanser, pat dry, then apply Xeroform to the open area, and cover with a non-adherent pad followed by gauze wrap every day and as needed. A non-pressure wound weekly tracking assessment dated [DATE] at 1:37 PM identified that the superficial open area to the right great toe was resolved with a scab noted. It was further identified that the previous treatment was discontinued, and a new treatment initiated for skin-prep (protective barrier) to the right great toe. A physician's order dated 8/6/24 directed to apply skin-prep to the scab to the right great toe every day on the day shift. Clinical record review on 8/28/24 at 12:49 PM identified that from 8/2/24 when the open area to the right great toe was identified to 8/6/24 when the open area to the right great toe was documented as resolved, there had been no documentation that the responsible party for Resident #36 had been notified of an open area to Resident #36's right great toe which required a treatment. Interview with the Wound Nurse, (RN #1) on 8/29/24 at 2:45 PM identified that the nursing staff updated RN #1 with new skin issues that were identified. RN #1 stated that it was the responsibility of the nurse or unit manager who identified the skin issue or open area to call the responsible party and update them on the new finding, unless the wound was substantial and required detailed explanation by RN #1. RN #1 was unable to identify the reason the responsible party had not been notified. Interview with Person #1 on 8/30/24 at 9:40 AM identified that there had been no notification from the facility about the open area to Resident #36's right great toe documented by RN #1 on 8/2/24. A facility policy for family notification of change/new orders/wounds was requested and the Change in Condition policy was provided. This policy was reviewed and directed, in part, that the responsible party must be notified of changes in status and this notification is documented in the nurses' notes. 2. Resident #69's diagnoses included chronic systolic chronic heart failure (CHF), acute kidney failure, and hypertension (high blood pressure). A physician's order dated 7/7/24 directed to weigh Resident #69 one time a day for CHF and notify the physician or Advanced Practice Registered Nurse (APRN) if the weight was greater than or less than 3 pounds (lbs) per day, or greater than or less than 5 lbs per week. The admission Minimum Data Set assessment dated [DATE] identified Resident #69 was moderately cognitively impaired, required partial/moderate assistance with personal hygiene, and was dependent with toileting hygiene and sit to lying position. The Resident Care Plan dated 7/25/24 identified a potential for impaired nutrition/hydration due to chronic kidney disease, use of a diuretic, and weight loss. Interventions included diet as ordered and weights as ordered/as needed. Review of Resident #69's weights identified that Resident 69's weight was 125.6 lbs on 7/21/24 and 120 lbs on 7/22/24 (a 5.6 lb weight loss/a greater than 3 lb weight loss in one day). Interview with LPN #7 on 8/29/24 at 11:07 AM identified the Nurse Aides (NA) were responsible for completing the weights on the residents, and that the nurses were responsible for documenting the resident's weight in the clinical record. Additionally, if there was a weight fluctuation of greater than or less than 3 lbs in one day, then it would be the responsibility of the nurse to notify the supervisor and APRN, and document it in a nursing note. Interview and clinical record review with APRN #1 on 8/20/24 at 9:43 AM identified that per the physician's order, she would have expected to have been notified when Resident #69 had lost more than 3 lbs in one day on 7/22/24. Additionally, APRN #1 identified that she would have assessed the change in weight further to determine the cause of the fluctuation and whether the resident needed to be evaluated. Review of the nurses' notes failed to identify that the physician or APRN was notified regarding the greater than 3 lb weight loss on 7/22/24. Review of the Weights/Re-weights Policy and Procedure updated 3/4/24 directed, in part, that for residents with CHF, the physician would be consulted for orders for daily weights and/or reporting parameters, or as ordered. 3. Resident #476's diagnosis included multiple vertebral compression fractures, pneumonia, and falls. Physician progress notes dated 8/13/24 directed Resident #476 to wear a thoracic lumbar sacral orthosis (TSLO) brace while out of bed. An Advance Practice Registered Nurse (APRN) progress note dated 8/14/24 identified that Resident #476 was to wear the TSLO back brace when he/she was out of bed. The admission Minimum Data Set assessment dated [DATE] identified Resident #476 was moderately cognitively impaired, required extensive assist of 1 for bed mobility, moderate assist for toileting, and personal hygiene, limited assist of 1 for transfers, and independent for eating. Observation on 8/26/24 at 1:50 PM noted Resident #476 coming out of the bathroom with the walker, sat him/her self in the wheelchair without the benefit of wearing the TSLO. Additionally, observation on 8/27/24 at 9:35 AM noted Resident #476 seated in the wheelchair without the benefit of wearing the TSLO. Further observation on 8/28/24 at 9:53 AM identified Resident #476 was seated in the wheelchair without the benefit of wearing the TSLO (the TSLO was observed to be on Resident #476's bed). On 8/28/24 at 12:12 PM, an interview with Nurse Aide (NA) #6 identified Resident #476 refused to wear the TSLO brace and she reported that to Licensed Practical Nurse (LPN) #1. On 8/28/24 at 12:15 PM an interview with LPN #1 identified that Resident #476 refused to wear the TSLO brace, and that she removed it all the time herself. LPN #1 also identified that she was unaware if the physician had been notified of the resident's refusal to wear the brace and if there was an order in place for refusals. Subsequent to surveyor inquiry, nursing notes dated 8/28/24 at 2:19 PM identified that LPN#1 had notified the APRN and spoke to the spine center that follows Resident #476 regarding the resident's refusal to wear the TSLO. On 8/30/24 at 9:42 AM, APRN #1 identified that she was unaware that Resident #476 was refusing to wear the TSLO brace and would expect to be notified of the resident's refusal to wear. Review of the facility policy for Refusal of Treatment was to determine the resident's cognitive capacity to decide refusal of treatment, if a resident continues to refuse, determine severity of the refusal, if the refusal will negatively affect the resident notify the Physician/ APRN of refusal if noted to be of significant importance. Subsequent to surveyor inquiry, the RCP was updated on 8/28/24 identifying Resident #476 may decline the use of the TSLO brace at times with interventions to encourage the resident to wear the TSLO brace, to reapproach as needed, and to document refusals. Furthermore, a follow-up appointment was made with the spine specialist.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #106) reviewed for abuse, the facility failed to ensure the resident was free from mistreatment. The findings include: Resident #106's diagnoses included osteoarthritis. The admission assessment dated [DATE] identified Resident #106 was alert and oriented and self-mobile in his/her wheelchair. The Resident Care Plan (RCP) dated 8/9/2024 Resident #106 exhibited accusatory behaviors at times and had the potential to be verbally aggressive due to ineffective copying skills. Intervientions directed to guide away from sources of distress, engage calmly in conversation, if response is aggressive to staff walk away calmly and approach later. Review of the facility Reportable Event Form dated 8/16/2024 at 6:25 PM identified a staff to resident abuse without injury, Resident #106 alleged that LPN #12 swore at him/her. Review of Facility Summary Report dated 8/19/2024 at 12:00 AM identified the allegation was substantiated; LPN #11 observed the incident and intervened, the RN supervisor was immediately notified and Resident #106 had called the police. The summary indicated LPN #12's employment was terminated. Review of LPN #12's statement dated 8/16/2024 identified that he was providing care for another resident, when he looked at the door and saw his medication cart was being pushed away. LPN #12 stepped around the corner, saw Resident #106 and asked Resident #106 to not touch or move the cart, if he/she wanted it moved LPN #12 would move it. LPN #12's statement further indicated he then got into a verbal exchange with Resident #106, and he called Resident #106 an idiot and swore at him/her (called him/her a ****** ****er). Resident #106 then wheeled toward LPN #12 and LPN #12 stated go ahead and hit me as LPN #11 stepped between LPN #12 and the resident. The statement then indicated LPN #12 walked away, as Resident #106 called the police and reported that he/she had been threatened. Review of LPN #11's statement dated 8/16/2024 identified that she was passing medications when she heard arguing and observed Resident #106 and LPN #12 yelling at each another. The statement indicated both Resident #106 and LPN #12 were using profanities, she stepped between both parties in an attempt to diffuse the situation and she notified the supervisor. Interview and facility documentation review with LPN #12 on 9/3/2024 at 11:49 AM identified Resident #106 was moving his medication cart and he asked Resident #106 not to touch the cart, to ask for it to be moved. LPN #12 further indicated that Resident #106 turned his/her wheelchair toward LPN #12 and they had a verbal exchange. LPN #12 stated to Resident #106 that he was not going to be the resident's ****** ****er and as LPN #11 stepped between them, the resident ran over LPN #11's foot. LPN #12 stated he walked away as more words were exchanged between him and the resident. LPN #12 stated that he did swear and he did call the resident a swear word. Interview and facility documentation review with LPN #11 on 9/3/2024 at 1:55 AM identified that Resident #106 and LPN #12 were yelling at each other and she heard a lot of cursing between them, and she stepped between them to stop the incident. Interview, clinical record review and facility documentation review with the DON and ADNS on 9/3/2024 at 1:15 PM DNS identified on 8/16/2024 at 6:30 PM, LPN #12 and Resident #106 got into a verbal exchange, and LPN #12 swore at Resident #106. The exchange was witnessed by LPN #11, and LPN #12 admitted he swore at Resident #106. LPN #12 indicated that he felt provoked by Resident #106 and the DNS stated staff should not swear at any resident; the verbal exchange should not have occurred. The DNS stated no matter what a resident says or does, staff cannot respond back. The abuse was substantiated and LPN #12's employement was terminated. Review of facility Abuse/Retaliation Prohibition Policy, directed in part to ensure each resident has the right to be free from abuse, mistreatment, neglect. Verbal abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents and to their families. Facility documentation review identified staff education was initiated on 8/16/2024 for all departments regarding abuse, resident rights, customer service, and retailation, and competency testing for staff was completed. Audits were initiated, to include staff-to-resident observations, on 8/16/2024, and a QAPI meeting and Resident Council meeting was held on 8/16/2024. Based on review of facility documentation, past non-compliance was identified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review for 1 of 2 residents (Resident #32) reviewed for Activities of Daily Living (ADLs), the facility failed to ensure a dependent resident was provided with necessary assistance to maintain good grooming. The findings include: Resident #32's diagnoses included unspecified macular degeneration, bilateral cataracts, cerebral infraction and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #32 was severely cognitively impaired, and needed substantial/maximal assistance for eating, toileting and transfers. The Resident Care Plan dated 8/28/24 identified Resident #32 had an ADL self-care performance deficit relating to confusion, Alzheimer's dementia and limited mobility. Interventions included assistance of one staff member for bathing/showering, dressing, personal hygiene, and oral care/grooming. Nursing notes dated 8/27/24 through 8/29/24 did not identify resident refusals of care. Observations of Resident #32 on 8/27/24 at 11:47 AM, 8/28/24 at 12:47 PM and 8/29/24 9:20 AM noted Resident 332 was unshaven with disheveled hair. Observation of Resident #32 on 8/28/24 at 12:46 PM identified Resident #32 was still unshaven with more facial hair since 8/27/24's observation. Interview with Nurse Aide (NA) #2 on 8/28/24 at 12:47 PM identified she did not shave Resident #32 because she had a hard time using the disposable razor since it did not catch all the hair, adding that facility policy was to shave Resident #32 on shower days (residents routinely receive weekly showers) and if unable to do so, report it to the nurse. Interview with NA #3 on 8/28/24 at 1:20 PM identified it was the facility policy to shave Resident #32 every day or every other day as needed and to let the nurse know if the resident refused. Interview with Licensed Practical Nurse (LPN) #4 on 8/28/24 at 1:23 PM identified it was facility policy that all shifts shave residents when needed, report any refusals to the nurse, who would reapproach then document the refusal, adding there's barely any refusals here 9/10 times the residents allow it. LPN #4 identified that no refusals were reported on Resident #32 that day. Review of the Grooming Policy directed that grooming is to be done to maintain a resident's dignity regarding hairstyle and facial hair, in addition if a resident is unable to express their personal preference socially acceptable and age-appropriate grooming should be provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy review, and interviews for one of three residents (Resident #375) reviewed for advanced directives, the facility failed to ensure advance directives were addressed timely after admission to the facility. The findings include: Resident #375 was admitted on [DATE] with diagnoses that included hypothyroidism and a fracture of the left femur. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #375 had moderately impaired cognition and required assist with ADLs. The Resident Care Plan (RCP) 2/21/2024 identified Resident #375 an alteration in skin integrity, femur fracture, and potential alteration in nutrition. Interventions directed to assist with ADLs. Record review identified Resident #375 had a Power of Attorney (POA) for health care decisions. The clinical record included a living will that directed life support systems the resident did not want which included artificial respiration, cardiopulmonary resuscitation and artificial means of providing nutrition and hydration. Record review identified Resident #375 was a full code. Interview and record review with the DON and ADON on 9/19/2024 at 1:15 PM identified advanced directives should be addressed upon a resident admission. Interview identified Resident #375's advance directives were not addressed during Resident #375's admission. The DON and ADON stated Resident #375's advanced directives should have been addressed, and they were unable to explain why it was not done. Review of facility Policy of Advanced Directives, dated 3/31/2023, directed in part to ensure a resident's choice regarding advanced directives will be honored in accordance with state law and facility policy. The care plan and face sheet will be updated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record and interviews for 1 of 5 sampled residents (Resident #61) reviewed for accidents, the facility failed to ensure a physician's order for ambulation was implemented according to the resident plan of care. The findings include: Resident #61's diagnoses included wedge compression fracture of fourth thoracic vertebra, osteoarthritis, history of breast cancer, thoracolumbar fusion of spine. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #61 was cognitively intact, independent with personal hygiene, toilet transfers, and that ambulation was not applicable. The Resident Care Plan dated 7/2/24 identified Resident #61 required assistance with activities of daily living (ADLs) and had decreased mobility related to chronic disease process. Interventions included Resident #61 was independent for squat pivot transfers, required one person assist for bathing and dressing, and required one person assist with ambulation for short distances using a rolling walker. A physician's order dated 8/8/24 directed to ambulate Resident #61 with two persons assist using the rolling walker. The Nurse Aide (NA) Resident Care Card (Individualized Resident Assignment) dated 8/8/24 identified Resident #61 required two persons assist with ambulation for short distances using a rolling walker. The NA Resident Care Card dated 8/28/24 identified Resident #61 required two person assist with toileting, transfers, and ambulation for short distances using a rolling walker. Interview with the Rehabilitation Director/Occupational Therapist (OT) #1 and Physical Therapist (PT) #2 on 8/29/24 at 12:15 PM identified that the facility policy was to enter their orders into the computer. This information was communicated to the Nursing Department and the nurse who entered the orders updates the Resident Care Card for the NA staff. OT #1 stated that orders were not written for a specific number of times a resident should ambulate, or where they should ambulate, and that ambulation was mostly initiated by the resident and completed to their tolerance. OT #1 indicated if there were orders in the computer for ambulation, the facility practice had been for nursing staff to ambulate Resident #61 to and from the bathroom, and in the hallway without the need to specifically direct that within the physician's order. Interview with NA #1 on 8/29/24 at 1:30 PM identified that she did not ambulate Resident #61 because PT does so. NA #1 indicated that if the Resident Care Card had directed her to ambulate the resident every day, she would have. NA #1 stated that she followed what is written on the Resident Care Card, but that the care card only indicated that Resident #61 requires two person assistance for ambulation and the instruction did not specify to ambulate Resident #61. NA #1 explained that this was why she had been documenting in the Point of Care electronic record that ambulation for Resident #61 was not applicable. NA #1 identified that the orders for ambulation were for PT, who was seeing the resident, not, her, and that only PT was responsible to ambulate Resident #61. NA #1 further indicated that she wheeled Resident #61 into the bathroom and would stand and pivot transfer the resident from the wheelchair to the toilet and back again.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of the clinical record, and facility policy for 1 of 2 residents (Resident #32) reviewed for positioning, the facility failed to follow physician's orders for proper positioning and documentation and for 1 of 4 residents (Resident #69) reviewed for pressure ulcers, the facility failed to follow a physician's order to obtain daily weights for a resident with Congestive Heart Failure (CHF). Additionally, for the only sampled resident (Resident #153) reviewed for anticoagulant therapy, the facility failed to address the continuation of an anticoagulant for a resident with a diagnosis of deep vein thrombosis (DVT) and for 1 of 3 residents (Resident #173) reviewed for closed records, the facility failed to perform blood glucose monitoring as directed by a provider and failed to initiate an intervention to prevent hypoglycemia for a resident experiencing hypoglycemic episodes. The findings include: 1. Resident #32's diagnoses included unspecified macular degeneration, bilateral cataracts, cerebral infraction and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #32 was severely cognitively impaired, and required substantial/maximal assistance for eating, toileting and transfers. The Resident Care Plan dated 8/28/24 identified Resident #32 had an Activities of Daily Living (ADL) self-care performance deficit relating to confusion, Alzheimer's dementia and limited mobility. Interventions included transfer with assistance of 2 staff members and out of bed to a customized wheelchair per a 24-hour positioning plan. A physician's order dated 10/13/22 and currently in effect, directed Resident #32 to be out of bed per 24-hour positioning plan. A physician's order dated 4/15/23 directed to document on Resident #32's custom wheelchair comfort, positioning and pain in the nurses progress notes every 15th of the month. The 24-Hour Positioning Plan directed Resident #32 to be out of bed after morning (AM) care, out of chair or back to bed as needed for peri-care on the 7:00 AM to 3:00 PM shift, and out of bed as tolerated on the 3:00 PM to 11:00 PM shift. Clinical record review of Nursing progress notes dated 3/1/24 through 8/29/24 failed to reflect monthly custom wheelchair documentation on Resident #32's comfort, positioning or pain. Observations on 8/26/24 at 12:41 PM, 8/27/24 at 11:47 AM and 8/29/24 at 11:05 AM identified Resident #32 in bed after AM care (and not out of bed per the 24 hour positioning plan). Interview with the Occupational Therapist (OT) #1 on 8/29/24 at 10:42 AM identified the 24-hour positioning plan was individualized for each resident, and nursing staff was responsible for ensuring it was followed, as well as reporting issues to therapy. Furthermore, monthly notes were written by the nursing department, and quarterly notes for customized wheelchairs were written by the therapy department. OT #1 identified effects of not following the positioning plan for Resident #32 included increased weakness, pneumonia and everything that goes along with not getting out of bed. Interview and record review with Nurse Aide (NA) #5 on 8/29/24 at 11:21 AM identified that Resident #32's care card (NA Resident Assignment) sheet directed for Resident #32 to be out of bed to a custom wheelchair with a 24-hour positioning plan, offer for back to bed after lunch/dinner and offer to be out of bed if awake on the 3:00 PM to 11:00 PM shift. NA #5 identified that she usually gets Resident #32 up and out of bed 2 times a week, and since Resident #32 was up and out of bed yesterday, she was going to keep him/her in bed today. When questioned if Resident #32 wanted to stay in bed, NA #5 confirmed no that was my preference, since he/she was up all day yesterday. Interview and clinical record review with Licensed Practical Nurse (LPN) #6 on 8/29/24 at 11:30 AM identified the NA was responsible for getting the residents up and out of bed, and Resident #32 should have been out of bed. The clinical record failed to reflect documentation on Resident #32's customized wheelchair positing per physician's order. Interview and clinical record review with OT #1 on 8/30/24 at 10:49 AM identified the therapy department wrote quarterly customized wheelchair notes, however notes could not be provided because Resident #32 was technically in an adaptive wheelchair, and the two terms adaptive and customized should not be used interchangeably. Review of the Occupational Therapy Encounter note dated 11/15/23 signed by OT #1 identified Resident #32 would benefit from skilled OT to maximize functional endurance for self-feed and out of bed activities in custom wheelchair. Review of the Customized Wheelchairs policy directed to identify resident who will benefit from improved wheelchair positioning, additionally upon delivery of custom wheelchair the following will be done: complete therapy evaluation, establish a 24 hour positioning plan, complete nursing documentation monthly in PCC (the electronic health record program) using the template, complete therapy documentation quarterly in the therapy department, and request any necessary modification based on clinical review or as identified during daily care. 2. Resident #69 was admitted to the facility on [DATE] with diagnoses that included chronic systolic CHF, acute kidney failure, and hypertension (high blood pressure). A physician's order dated 7/7/24 directed to weigh Resident #69 one time a day for CHF and notify the physician or Advanced Practice Registered Nurse (APRN) if the weight was greater than or less than 3 pounds (lbs) per day, or greater than or less than 5 lbs per week. The admission Minimum Data Set assessment dated [DATE] identified Resident #69 was moderately cognitively impaired, required partial/moderate assistance with personal hygiene, and was dependent with toileting hygiene and to the sit to lying position. The Resident Care Plan dated 7/25/24 identified a potential for impaired nutrition/hydration due to chronic kidney disease, use of a diuretic, and weight loss. Interventions included diet as ordered and weights as ordered/as needed. Review of the Electronic Medication Administration Record (EMAR) identified that daily weights were signed off as completed on 7/11/24, 7/13/24, 7/16/24, 7/18/24, 7/20/24, 7/25/24, 7/27/24, 7/29/24, 8/2/24, 8/3/24, 8/4/24, 8/5/24, 8/7/24, 8/8/24, 8/9/24, 8/10/24, 8/12/24, 8/14/24, 8/15/24, 8/16/24, 8/17/24, 8/18/24, 8/19/24, 8/21/24, 8/23/24, 8/25/24, 8/26/24, and 8/27/24, but the weight for each corresponding day was not documented in Resident #69's clinical record (despite being signed off as completed). Additionally, the clinical record failed to identify if Resident #69 refused to be weighed on any of these days. Interview with Nurse Aide (NA) #3 on 8/29/24 at 10:56 AM identified that the NAs were responsible for completing the weights on the residents. Additionally, the NAs would tell the nurse how much the resident weighed, and the nurse would document the weight in the resident's clinical record. The NAs would also advise the nurse if the resident refused to be weighed. NA #3 further indicated that she would know if a resident had to be weighed daily by referring to the NA care card. Interview with Licensed Practical Nurse (LPN) #7 on 8/29/24 at 11:07 AM identified that the NAs were responsible for completing the weights on the residents. The NAs would know if a resident had to be weighed daily by referring to their daily assignment sheet, the NA care card, and/or the nurse would verbally tell the NA. Additionally, the nurse was responsible for documenting the resident's weight in the clinical record as the NAs do not look at the EMAR. LPN #7 further indicated that it would be the responsibility of the nurse who transcribed the physician orders to also update the NA care card. Interview and clinical record review with Registered Nurse (RN) #1 on 8/29/24 at 12:05 PM identified that she had transcribed the physician order of daily weights into the EMAR. but identified that she did not add daily weights to the NA care card. RN #1 further indicated that the NAs would know if a resident had to be weighed daily by being told verbally by the nurse and/or by referring to their daily assignment sheet. Interview and clinical record review with LPN #6 on 8/29/24 at 12:15 PM identified that she had signed off on the EMAR that weights were completed for Resident #69 on 8/3/24, 8/4/24, 8/5/24, 8/9/24, 8/10/24, 8/12/24, 8/14/24, 8/15/24, 8/17/24, 8/19/24, 8/23/24, and 8/26/24 without documenting the weight. LPN #6 further indicated that the weights could either have not been completed or not documented on these days. Review of the NA care card (revised 7/8/24) failed to identify that Resident #69 had to be weighed daily. Review of the NA assignment sheet dated 8/29/24 failed to identify that Resident #69 had to be weighed daily. Additionally, a blank copy of the NA assignment sheet also failed to identify Resident #69 had to be weighed daily. Interview with the Assistant Director of Nursing Services (ADNS) on 8/30/24 at 8:42 AM identified that it was the responsibility of the charge nurse or supervisor to update the NA care card. Additionally, the ADNS identified that he would not add daily weights to the NA care card. The ADNS further indicated that the NAs would know if a resident had to be weighed daily by referring to their daily assignment sheet. Although requested, a facility policy for NA care cards was not provided. Review of the Weights/Re-weights Policy and Procedure updated 3/4/24 directed, in part, that for residents with CHF, the physician would be consulted for orders for daily weights and/or reporting parameters, or as ordered. Additionally, weights would be inputted into the medical record by the nurse. 3. Resident #153's diagnoses included acute embolism and thrombosis (blood clot) of the right femoral vein and bilateral lower extremities, surgical aftercare following surgery on the circulatory system (thrombectomy/blood clot removal) and presence of other vascular implants and grafts. An inter-agency patient referral form (W10) from Resident #153's initial admission to the facility on 6/27/24 indicated Lovenox (an anticoagulant medication) 100 milligrams/milliliter (mg/ml), inject 100 mg subcutaneously one time a day for status post deep vein thrombosis (blood clot in the legs, or DVT) with no end date. A physician's order dated 6/27/24 indicated anticoagulation medication, Enoxaprin Sodium injection Solution/Lovenox 100 mg/ml , inject 100 mg subcutaneously one time a day for status post DVT and directed to monitor for signs of bleeding, bruising, change in mental status or vital signs every shift. A physician's progress noted dated 6/28/24 at 4:15 PM identified Resident #153 was found to have an extensive clot burden in his/her bilateral lower extremities and was seen by hematology and neurology for anticoagulation recommendations. Additionally, the progress note indicated Resident #153 had been started on Lovenox for recurrent bilateral lower extremity DVT. Review of the W10 and hospital discharge summary from Resident #153's re-admission to the facility from the acute care hospital on 7/11/24 directed Lovenox 100 mg/ml, inject 100 mg subcutaneously one time a day for status post DVT and no stop date was indicated. Additionally, the hospital Discharge summary dated [DATE] identified that Resident #153 had presented from the skilled nursing facility (SNF) on 6/30/24 as a stroke alert for altered mental status (AMS), confusion and dysphagia (difficulty speaking) and that neurology suspected the symptoms were due to an amyloid spell (brief neurological episode). A physician's progress note dated 7/12/24 at 9:12 PM identified recurrent bilateral lower extremity DVT with thrombectomy (clot removal) and to continue Lovenox. A medication order from the Advanced Practice Registered Nurse (APRN #1) dated 7/12/24 indicated Enoxaparin Sodium (Lovenox) 100 mg/ml, inject 100 mg subcutaneously one time a day for history of DVT until 7/28/24. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #153 was moderately cognitively impaired and required substantial/maximal assistance of 2 persons for transfers, toileting and bed mobility. Additionally, the MDS identified Resident #153's diagnosis of DVT with indication for an anticoagulant. A progress note from APRN #2 on 7/16/24 at 1:34 PM identified Resident #153 was re-admitted to the facility following a hospitalization from 6/30/24-7/11/24 with recent bilateral lower extremity deep vein thrombosis (blood clot, or DVT) status post thrombectomy (clot removal) on 6/20/24 and a history of pulmonary embolism (blood clot in the lung, or PE) and inferior vena cava (IVC) filter. Additionally, the 7/16/24 progress note identified Resident #153 was on Lovenox with a prolonged hospitalization and to continue Lovenox. The Resident Care Plan dated 7/23/24 identified anticoagulation medications with interventions that included to administer relevant medications and monitor labs as directed. A progress note from APRN #2 on 7/29/24 at 1:32 PM identified recurrent bilateral lower extremity DVT, history of DVT and PE, status post IVC filter with recent bilateral lower extremity DVT and status post thrombectomy on 6/20/24. Additionally the progress note indicated that Lovenox was started with prolonged hospitalization and to continue Lovenox despite intermittent hematuria. Interview and record review with the Advanced Practice Registered Nurse (APRN) #1 on 8/28/24 at 1:51 PM identified that Resident #153 had not received Lovenox from 7/28/24 through 8/28/24 in error. The inter-agency patient referral form (W10) and discharge summary from 7/11/24 did not identify an end date for the Lovenox. APRN #1 indicated that for Resident #153's re-admission to the facility on 7/11/24, all medication orders should have been taken from the W10 and that the Lovenox order should not have been discontinued. APRN #1 was unable to identify the reason the 7/12/24 order for the Lovenox, with an end date of 7/28/24, was put into the electronic health record (EHR) under her name. APRN #1 further identified that with Resident #153's history of DVT and PE he/she should have been continued on an anticoagulant and that not being on an anticoagulant could cause non-dissolution of blood clots and a recurrence of a DVT or PE. Subsequent to surveyor inquiry on 8/28/24, APRN #1 entered a new order directing to administer Lovenox (Enoxaparin Sodium)100 mg/ml, inject 100 mg subcutaneously one time a day for history of DVT. Interview and record review with the ADNS on 8/29/24 at 9:30 AM indicated that for re-admissions to the facility it was the facility policy to follow the W10 for medication orders and that the discharge summary may be cross referenced. The medication orders are then verified with the MD or APRN. The ADNS identified that both the W10 and discharge summary from 7/11/24 for Resident #153 did not indicate an end date for the Lovenox. Interview with APRN #2 on 8/29/24 at 10:30 AM indicated that she was not aware that Resident #153 was no longer being administered Lovenox when she wrote her progress note on 7/29/24 noting Resident #153 continued on Lovenox. APRN #2 further identified that she did not recall an end date on the Lovenox order and that although her progress note from 7/29/24 was uploaded into the EHR, she was not sure if the nursing staff would have reviewed it, but that Resident #153 should have been continued on the Lovenox. Additionally APRN #2 indicated that, based on Resident #153's recent and recurrent history of DVT and PE, there was no reason for the Lovenox order to have an end date and that she had not discontinued it. Interview with LPN #10 on 8/29/24 at 11:32 AM indicated that she was familiar with Resident #153 but was unable to recall all of the medication orders or the reason the 7/12/24 Lovenox order was given an end date of 7/28/24. LPN #10 further identified that APRN #1 wrote the Lovenox order on 7/12/24 with the 7/28/24 end date. LPN #10 indicated that she confirmed and transcribed the Lovenox order, but did not initiate or change the Lovenox order on 7/12/24. Review of the facility Admissions Policy, undated, directed to review the W10 and hospital discharge summary and to transcribe all orders onto the physician's order sheet. Review of the facility policy, Verification of New admission Medication Orders, dated 9/2022, directed that medication orders were to be transcribed from the hospital W10/Discharge summary upon admission and put into the residents EHR. Review of the facility policy, Anticoagulation Therapy, undated, directed the purpose of anticoagulation therapy was to treat someone who has a blood clot, such as a clot in the veins of the leg (a deep vein thrombosis, or DVT) or the arteries of the lung (a pulmonary embolus, or PE), and to prevent a blood clot in someone who is at high risk of getting one. 4. Resident #173 diagnoses included type II diabetes mellitus (DM), chronic kidney disease, and congestive heart failure. An admission physician order dated 6/5/24 directed blood glucose monitoring four times a day (before meals and at hours of sleep) with sliding scale Insulin coverage. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #173 had intact cognition and required extensive assistance for bed mobility and transfers. An Advanced Practice Registered Nurse (APRN) progress note dated 6/17/24 at 1:19 PM identified Resident #173 was seen for DM after experiencing hypoglycemia (low blood sugar), at times, in the morning. The Assessment and Plan section of the APRN progress note identified Humalog Insulin would be discontinued and directed to monitor blood sugars (Resident #173 was also to continue Glipizide 5 mg every day). An APRN progress note dated 6/20/24 at 1:22 PM identified Resident #173 was seen for DM after continued hypoglycemia in the morning/fasting blood sugar in the morning was 60-80 at times. The Assessment and Plan section of the APRN progress note directed to monitor blood sugars, decrease Glipizide to 2.5 mg by mouth every day and provide a nighttime snack as needed. Review of the June 2024 Order Summary Report identified Resident #173's Humalog Insulin was discontinued on 6/17/24 by APRN #2, attached to the Humalog Insulin order, in the electronic medical record (EMR), was the blood glucose monitoring action. The Humalog Insulin and the blood glucose monitoring were discontinued simultaneously. Additionally, there was no order in June of 2024 for providing a nighttime snack. Review of the Weights and Vitals Summary identified blood glucose monitoring 4 times per day from admission through 6/16/24 was completed. The last blood glucose documented was on 6/17/24 at 7:26 AM with no further blood glucose monitoring completed until a transfer to the hospital was initiated on 6/29/24, and a blood glucose level of 49 was identified. Review of the clinical record identified Resident #173 experienced a change in condition on 6/29/24. The facility document titled SBAR Communication Form and Progress Note dated 6/29/24 at 4:59 PM identified Resident #173 complained of chest pain, was diaphoretic, had an elevated blood pressure (170/80) and a blood glucose level of 49 requiring the administration of Glucagon (an emergency injection used to treat severely low blood sugar in people with DM). Resident #173 was transferred to the hospital. Review of the hospital Discharge summary dated [DATE] at 3:59 PM identified Resident #173 was hypothermic upon arrival to the hospital and the hypothermia was felt to be related to the hypoglycemia. Interview and review of the clinical record with the ADNS on 8/28/24 at 2:48 PM identified there was no provider order to provide a nighttime snack as needed. The ADNS further identified there should have been an order if the APRN directed the intervention. The ADNS was unable to provide any form of documentation that Resident #173 received nighttime snacks. Interview with APRN #2 on 8/29/24 at 10:36 AM indicated blood glucose monitoring should be performed for a resident experiencing hypoglycemic episodes as well as for a resident requiring changes to medications used to treat DM. APRN #2 identified she was aware the blood glucose monitoring action, in the EMR, was at times attached to insulin orders and indicated it was not her intention to discontinue the blood glucose monitoring. APRN #2 further identified if she did not add an order for a nighttime snack but directed to provide a nighttime snack in her Assessment and Plan, she would have given a verbal order, to a nurse, who should have added the order in the EMR and did not know where she obtained the information that Resident #173 had hypoglycemia in the morning from her 6/20/24 progress note since there was no blood glucose monitoring results available. Interview with the Director of Nursing (DNS) on 8/29/24 at 11:34 AM indicated orders entered by a provider were presumed to be correct by the nursing staff. The DNS stated there was an order verification process but could not describe the process and further indicated nursing would not question the accuracy of a provider entered order. The inadvertently discontinued blood glucose monitoring omitted 50 instances of blood glucose monitoring over 13 days. Although requested, the facility was unable to provide a policy on order verification.

Based on interviews and a sample taste tray, the facility failed to ensure food was palatable. The findings include: Interview with Resident #45 on 8/26/24 at 11:30 AM identified he/she didn't like the taste of the food, and the food was of poor quality. Additionally, the cold food was not cold and there was not enough fresh fruit/vegetables provided. On 8/28/24 at 12:00 PM, a taste tray was conducted which consisted of cooked broccoli stems (no florets) and 2 manicotti (substituted for stuffed shells which were on the menu). Both items (broccoli stems and manicotti) were overcooked/mushy and extremely bland. Interview with the Food Service Director (FSD) at that time identified he was aware the broccoli was overcooked, and although there was a recipe to follow, the chef cooked the broccoli too long. He further identified although he doesn't conduct audits on the food quality, he does demonstrations with the cooks, but did not have any documentation to reflect what type of demonstrations he conducted. On 8/29/24 at 1:11 PM, during the Resident Council meeting Resident #53 indicated the food was of poor quality, the rice was uncooked, the fish was not edible, the minestrone soup was just pasta and peas, the burger bun top was tasty but the bottom was stale, there was a lack of fresh vegetables/fruit, and the food was salty. Additionally, Resident #106 indicated the macaroni and cheese was like a block and the ice cream was served melted and not frozen. Also, during the Resident Council meeting on 8/29/24 at 1:11 PM, Resident #29 indicated the salad was wilted, mushy and slushy. Facility policy for meat and vegetable cookery identified food items shall be prepared to conserve maximum nutritive value, to develop and enhance flavor and appearance.

Based on the tour of the Dietary Department, observations, interviews, facility policy, and facility documentation, the facility failed to ensure open food items were dated, failed to ensure the ice scoop and ice scoop tray for the ice machine and the ice machine were kept in a clean and sanitary condition, failed to maintain clean vents in the dish room and failed to cover a garbage can on the clean side of the dish room. The findings include: Tour of the Dietary Department on 8/26/24 at 11:18 AM with the Dietary Manager identified the following: a. The walk in freezer #1 contained an open package with 7 chicken patties, no open date or expiration date was identified, and the chicken patties contained freezer burn. b. The walk in refrigerator #2 was observed with an opened package of 1/4 pound (lb) American cheese, a 1 lb open package of ham, 2 lb open package of ham and a 1 lb open package of roast beef, loosely wrapped with plastic wrap, without the benefit of an opened date and expiration dates. c. The ice machine scoop was stored in a visibly soiled holder which was adhered to the side of the ice machine. The vents on outside of the machine had soiled removable filters and the exterior vents were covered in a thick layer of dust. Review of the Monthly Ice Machine cleaning log identified the ice machine was last cleaned 7/11/24. d. 2 dish room ceiling vents were found to contain a thick layer of dust. e. An observation on 8/27/24 at 9:14 AM identified an uncovered garbage can approximately 1/4 full with garbage was located on the clean side of the dish area of the dish room and not being utilized for food prep. f. An observation on 8/28/24 at 12:07 PM identified the storage of a staff members beverages in the kitchen juice refrigerator near the food service tray line. The contents of the staff members beverages included: 1/2 full 16 oz. plastic water bottle, 3/4 full plastic Coca-Cola bottle, and a teal colored reusable stainless steal water container. Additionally contained in the juice refrigerator were resident foods to include: 2 chef salads and 4 fruit plates. The chef salads were the lunch meal alternate. An interview with the Dietary Manager at the time of the tour identified whoever opened food items was responsible for covering and labeling food with an open date and that the food would be considered expired 3 days after opening. The Dietary Manager further indicated the facility would not know the expiration date of the opened food if not labeled with an open date. An interview with Dietary Aide (DA) #1 on 8/26/24 at 11:47 AM identified he did not notice that the ice machine was soiled, as it was last cleaned on 7/11/24 and was not yet cleaned for the month of August . An interview with the Dietary Manager on 8/27/24 at 9:14 AM identified the facility maintenance department was responsible for cleaning the ceiling vents and it would be the Dietary Manager's responsibility to identify the vents were dirty and notify maintenance. The interview further identified the trash on the clean side of the dish room should have been covered. An interview with DA #1 on 8/28/24 at 12:07 PM identified staff beverages should not be stored in facility kitchen refrigerators and could not indicate the reason he stored his beverage in there, despite knowing he should not. An interview with the Dietary Manager on 8/28/24 at 12:07 PM identified staff beverages were not to be stored in facility kitchen refrigerators and could not confirm the beverages were clean. Review of the facility policy titled Date Marking states, in part, Foods will be date marked with the name of the product, the date of the production or opening. Review of the facility policy titled Cleaning Ice Machine, Scoop and Tray states, in part, the ice machine and equipment (scoop and tray) will be cleaned on a regular basis to maintain a clean, sanitary condition and the ice scoop and tray will be washed and sanitized at least weekly in the dishwasher and allowed to air dry.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, reviews of the clinical record, facility documentation, facility policy, and interviews for 3 of 7 residents (Resident #32, Resident #36, Resident #74) reviewed for Enhanced Barrier Precautions (EBP) the facility failed to ensure appropriate personal protective equipment (PPE) was donned (placed on) prior to personal care, for the only sampled resident (Resident #76) reviewed for Transmission Based Precautions (TBP), the facility failed to ensure the required signage had been placed to alert all persons of the need for PPE, and during a tour of the laundry room, the facility failed to ensure fans with debris were not blowing on clean laundry. The findings include: 1. Resident #32's diagnoses included unspecified macular degeneration, bilateral cataracts, cerebral infraction and artificial opening of the urinary tract. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #32 was severely cognitively impaired, and required substantial/maximal assistance for eating, toileting and transfers. The Resident Care Plan dated 8/28/24 identified Resident #32 was on Enhanced Barrier Precautions relating to an illeal conduit (a surgical procedure that creates a new tube for urine to drain). Interventions included donning of a gown and gloves while bathing, showering, providing hygiene, dressing, transferring, and incontinent care (changing brief, assisting with toileting, changing linens, colostomy care, wound treatment, central line, urinary catheter, feeding tube). A physician's order dated 4/10/24 and currently in effect directed that every shift follow Enhanced Barrier Precautions for Clostridium Difficile (C-Diff), Methicillin Resistant Staphylococcus (MRSA) and an illeal conduit. The care card (NA Resident Assignment) identified Enhanced Barrier Precaution were in place. Observation on 8/28/24 at 9:23 AM identified Enhanced Barrier Precaution signage on Resident #32's room door directing to wear gloves and a gown for high contact resident care (dressing, bathing, changing linen, device care and wound care) and a precaution cart stocked with gloves and gowns. Observation on 8/28/24 at 9:24 AM identified Nurse Aide (NA) #2 in Resident #32's room emptying the illeal conduit urinary bag wearing gloves, without the benefit of a gown. Interview with NA #2 on 8/28/24 at 9:26 AM identified she received education on Enhanced Barrier Precautions, and signage posted on the door meant the resident had a bag or wound, and she should wear gloves and a gown when emptying the bag to protect all residents, however she forgot to put the gown on. Interview with Licensed Practical Nurse (LPN) #4 on 8/28/24 at 9:30 AM identified Enhanced Barrier Precautions signage on the door meant staff should wear personal protective equipment (gowns and gloves) with high contact activities such as providing personal care and transfers. The facility Enhanced Barrier Precautions policy dated 4/19/24 identified the required use of a gown and gloves for select residents during specific high-contact resident care activities in which there is an increased risk of transmission of multi drug resistant organisms. 2. Resident #36's diagnoses included dysphagia with a feeding tube, right-side hemiplegia, and a history of extended spectrum beta lactamase (ESBL) resistance infection. The annual Minimum Data Set assessment dated [DATE] identified that Resident #36 was severely cognitively impaired and dependent for toileting hygiene, upper body dressing, and received nutrition through a feeding tube. The Resident Care Plan dated 6/4/24 identified Resident #36 was on EBP related to the presence of a feeding tube. Interventions included donning of gown and gloves when providing hygiene, dressing, providing incontinent care, and assisting with the feeding tube. Review of the Resident Care Card (Individualized Resident Assignment) for Resident #36 included the need for Enhanced Barrier precautions due to presence of a feeding tube. A physician's order dated 8/14/24 directed to use EBP every shift due to Resident #36's feeding tube and history of ESBL infection. Observation of Resident #36's doorway indicated a sign to utilize PPE for EBP. Observation and interview with NA #4 on 8/28/24 at 2:50 PM identified that she was standing at Resident #36's bedside adjusting the blanket wearing gloves but no gown. NA #4 carried a bag that contained a dirty brief and paper towel, but no gown (PPE). NA #4 indicated that she had just completed incontinent care for Resident #36. Although NA #4 indicated that she was aware Resident #36 was on EBP and was aware of the sign outside the resident's door, Resident #36 didn't have anything. Additionally, NA #4 stated she was aware that she needed PPE (gown and gloves) when providing hands on care but didn't realize that hands on care included incontinent care. Interview with the Infection Preventionist, Registered Nurse (RN) #3, on 8/28/24 at 3:06 PM identified that per the EBP policy PPE (gown and gloves) needed to be worn when providing care to a resident requiring contact who was on EBP per the facility policy. RN #3 indicated that NA #4 should have worn the appropriate PPE when she provided care to Resident #36. RN #3 indicated that the staff have been educated that for residents on EBP, PPE is used to protect the residents from the staff. 3. Resident #74's diagnoses included type 2 diabetes mellitus, anemia, and hyponatremia. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #74 was cognitively intact and required extensive assistance of two persons for transfers, toileting and bed mobility. Additionally, the MDS identified Resident #74 had an unhealed pressure ulcer. The Resident Care Plan dated 8/14/24 identified EBP related to wounds with interventions that included donning of gown and gloves when providing wound treatment. A physician's order dated 8/14/24 directed EBP to be maintained every shift for wound. A physician's order dated 8/21/24 directed Santyl External Ointment be applied to left buttock pressure area twice daily, cleanse the pressure area with wound cleanser, and pat dry with skin prep. Additionally, the physician order directed to apply Santyl Collagenase to the per-wound area followed by Calcium Alginate which was to be covered with a foam dressing. Observation of Resident #74's room on 8/28/24 at 1:10 PM identified EBP signage was posted on the door frame which directed staff must wear gloves and a gown for wound care. A cart containing disposable isolation gowns and other personal protective equipment (PPE) was located outside of Resident #74's room. Observation of Resident #74's left buttock wound care with the wound doctor (MD #1) and the wound nurse (RN #1) on 8/28/24 at 1:11 PM identified RN #1 was observed to enter Resident #74's room and completed wound care to the left buttock pressure area without the benefit of donning a gown throughout the treatment. Interview with Registered Nurse (RN) #1 on 8/29/24 at 2:38 PM identified residents on EBP, staff should wear gloves and a gown when care and treatments are provided for a resident with a wound. RN #1 indicated that she could not recall the reason she did not don a gown when she provided wound care for Resident #74 and that she must have thought she had donned a gown before she had started the wound care and then forgot. Review of facility education on EBP directed, in part, that a gown and gloves must be worn during high contact care activities, that these residents are not on isolation, but are being protected from any organisms staff may have on their clothes and hands, and to wear the gown and gloves when providing hygiene/incontinent care/changing briefs. It was further identified that NA #4 had received this education. Review of the facility EBP policy directed that use of gloves and a gown was required for certain residents during specific high-contact resident care activities in which there was an increased risk for transmission of multidrug-resistant organisms. High-contact resident care activities included bathing/showering, providing hygiene, dressing, transferring, linen changes, toileting, device care and wound care and that all staff will receive training on EBP upon hire and annually 4. Resident #76's diagnoses included Covid-19 infection, diabetes, hypertension, and muscle weakness. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #76 was severely cognitively impaired, required moderate assistance with bed mobility and transfers, and was dependent on staff for personal hygiene and toileting. The Resident Care Plan dated 8/20/24 identified Resident #76 with a Covid-19 diagnosis. Interventions included placing Resident #76 on droplet precautions, obtaining labs as ordered, encouraging fluids, and performing respiratory monitoring and assessments per the physician's order. Review of the clinical record identified Resident #76 had tested positive for a Covid-19 infection on 8/20/24 and was noted to be on the facility TBP list. Physician's orders dated 8/26/24 directed facility staff to place Resident #76 on isolation precautions and to provide meals, activities, rehab and care in his/her room from 8/20/24 until 8/31/24. Observations on 8/26/24 at 12:30 PM and 1:50 PM, failed to identify that the required signage used to alert staff and visitors of the need for additional instruction, prior to entering the room, was not posted. Observation and interview with Licensed Practical Nurse (LPN) #3 on 8/26/24 at 1:54 PM, identified Resident #76 had been recently diagnosed with a Covid-19 infection and was still being isolated. LPN #3 indicated that although there was no current signage on Resident #76's door, the sign had been taken down by the Infection Prevention Nurse (RN #3) that morning. LPN #3 indicated that RN #3 had stated that she would replace the sign. Interview with RN #3 on 8/28/24 at 10:00 AM, identified that the Infection Control Nurse (herself) and RN supervisors were responsible for posting signage in appropriate locations for residents on TBP. RN #3 stated that Resident #76 tested positive for a Covid-19 infection on 8/20/24 and isolation would continue for 10 days per the facility policy. RN #3 indicated signage was required to be posted outside Resident #76's door and should have been there according to the facility policy. Further RN #3 denied removing the required signage from Resident #76's door. Review of the Covid 19 Facility Assessment policy directed, in part that signage on the use of specific PPE (for staff) will be posted in appropriate locations in the facility (e.g., outside of a resident's room, wing, or facility -wide). 5. On 8/28/24 at 10:50 AM, tour of the laundry room identified a fan with a heavy accumulation of dust, was blowing on clean laundry that had been placed in front of the fan. On 8/28/27 at 11:00 AM an interview with the Director of Housekeeping identified that the fan was dirty, was unsure of when it was last cleaned and did not report the dirty fan to Maintenance. On 8/28/24 at 11:18 AM an interview with the Director of Maintenance identified that maintenance was responsible for cleaning the facility fan in the laundry room, that it was cleaned once a month and that maybe it should be cleaned twice a month to ensure cleanliness. Also, the Maintenance Director identified that he was not notified that the fan needed to be cleaned. Furthermore, the Director of Maintenance provided a log for the cleaning of the laundry room fan which was last done on 7/11/24. Review of the facility policy for Monthly cleaning for laundry room fan identified that the fan was to be cleaned by Maintenance Department on a regular basis to maintain a clean, and a sanitary condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #1) reviewed for diabetes management, the facility failed to ensure a hemoglobin A1c was obtained in accordance with physician's orders and for for one (1) of two (2) residents, (Resident #1), reviewed for prevention of pressure ulcers, the facility failed to ensure skin assessments were conducted and documented weekly per facility policy. The findings include: a. Resident #1 was admitted to the facility with diagnoses that included type II diabetes, dementia and peripheral vascular disease. The quarterly MDS dated [DATE] identified Resident #1 had severely impaired cognition, a diagnosis of type II diabetes, did not receive insulin in the past seven days, required extensive assistance of two staff for bed mobility, was always incontinent of bowel and bladder. The care plan dated 12/13/22 identified Resident #1 had diabetes mellitus with interventions that included diabetic foot checks every night shift, diabetic snacks every night shift, monitor/document/report as needed for signs and symptoms of hypoglycemia and hyperglycemia. Review of the lab results report dated 12/21/22 at 2:03 PM identified Resident #1's A1c was 5.3 (normal reference range 4.8 - 5.6) An APRN progress note dated 1/26/23 identified Resident #1's hemoglobin A1c (blood test that shows what that average blood sugar level was over the past three months) was stable at 5.3%. The note further directed the plan for controlled type II diabetes was that Resident #1 was not on medication therapy and to monitor Resident #1's A1c every six months. Review of Resident #1's progress notes dated June - July 2023 failed to identify measurement of Resident #1's A1c was discussed with Resident #1's conservator and if Resident #1's conservator had refused to measure Resident #1's A1c. Review of the lab results report dated 7/12/23 at 6:51 AM identified Resident #1 had a complete blood count with differential and Thyroid Stimulating Hormones labs drawn. The report failed to identify an A1c was drawn. Review of the lab results report dated 11/23/23 at 1:57 AM identified Resident #1's glucose was over 800 (normal fasting reference range 70 - 120), the results were repeated and the facility was called at 1:57 PM. Resident #1's A1c was 12.1. A RN progress note dated 11/23/23 at 2:35 PM identified she received a call from the lab because the lab results drawn at 1:00 AM were not available on the computer yet. The lab verbally reported that Resident #1's glucose at 1:00 AM was greater than 800 (repeated two times), the APRN was updated with a new order of lispro insulin 10 units and was given. An APRN ordered Resident #1 to be transferred to the emergency department to rule out Diabetic Ketoacidosis (when the body does not have enough insulin to lower blood sugar levels) and Resident #1's conservator agreed. Situation Background Assessment Request (SBAR) form dated 11/23/23 at 2:20 PM identified Resident #1 had elevated blood sugar greater than 800 from the lab drawn on 11/23/23 at 1:00 AM and Resident #1 was not on any diabetic medication. It identified per the APRN to transfer Resident #1 to the hospital for evaluation to rule out DKA. Review of the hospital summary dated 11/23/23 - 1/4/24 identified Resident #1 had hyperglycemia that suggested DKA with an unclear trigger. It identified Resident #1 was initiated on an insulin drip with improvement in blood glucose. Interview with APRN #1 on 4/9/24 at 12:30 PM identified for diabetic residents, their A1c is checked every six months and Resident #1 should have had an A1c drawn six months from her last A1c (12/21/22). She identified Resident #1's conservator only wanted yearly labs, however Resident #1 had lab work preformed July 2023 and could not identify why Resident #1's A1c was not drawn in July 2023. She identified she did not know why Resident #1's glucose increased which is why she had sent her to the emergency department for an evaluation. Review of the clinical management of diabetes policy directed that glucose monitoring is completed per physician's orders. b. The quarterly MDS dated [DATE] identified Resident #1 had severely impaired cognition, required extensive assistance of one staff for bed mobility, was always incontinent of bowel and bladder, did not have any pressure ulcers and was at risk of developing pressure ulcers/injuries. The care plan dated 3/10/23 identified Resident #1 had a potential for alteration in skin integrity with interventions that included pressure reducing mattress to bed, pressure reducing cushion to chair, off load heels, encourage and assist with toileting every two hours and as needed. Review of Resident #1's skin assessments identified on 5/19/23 Resident #1 had Moisture Associated Dermatitis (MASD) to the left gluteal fold. It identified to cleanse left gluteal fold with normal saline, pat dry, apply bacitracin ointment mix with vitamin A&D and leave open to air every shift. The Braden scale dated 5/19/23 identified Resident #1 was at risk for pressure sores. Non-pressure weekly tracking form dated 5/22/23 identified the left gluteal fold was resolved. A nursing note dated 5/26/23 identified Resident #1's left gluteal fold was still closed, and there were no open areas. Non-pressure weekly tracking form dated 6/6/23 identified there was old pink scarring to the coccyx/sacrum that was not open. Review of Resident #1's medical record failed to identify weekly skin assessment were documented in the nursing progress notes and/or weekly skin assessment were completed between 6/6/23 - 6/20/23 (two weeks). Wound nurse progress note dated 6/20/23 at 12:46 PM identified Resident #1's skin was checked with no open areas or redness. Review of the medical record failed to identify a weekly skin assessment was documented in the nursing progress notes and/or a weekly skin assessment was completed between 6/20/23 - 7/6/23 (one week). Interview with the DNS on 4/9/24 at 11:40 AM identified there were no weekly skin assessments between 6/6/23 - 7/6/23. She identified she would like the skin assessments to be completed weekly. She further identified she encourages staff to complete weekly skin assessments even when the resident is being seen by the wound nurse to ensure there isn't a skin concern elsewhere on the body. Interview with the Wound RN on 4/9/24 at 12:20 PM identified Resident #1 had a left gluteal fold that resolved on 5/22/23. She identified she continued to check on the area on 5/26/23 and 6/6/23 to ensure the area remained closed. She further identified it is the responsibility of the charge nurse on the floor to complete the weekly skin assessments. Review of the skin assessment policy directed that resident will have a skin assessment performed weekly. It identified the skin assessment should be documented in point click care (electronic medical record).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation and interviews for one sampled resident (Resident #1) who had wandered off the facility property unattended, the facility failed to thoroughly investigate the incident to determine how the resident was able to leave without staffs' awareness and failed report to the incident to the state agency at the time the incident occurred. The findings include: Resident #1's diagnoses included Alzheimer's disease and adjustment disorder with mixed anxiety and depressed mood. The Wandering Risk Evaluation dated 5/9/23 identified Resident #1 was a low risk for wandering. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 made poor decisions regarding tasks of daily life and was independent with walking in the room, corridor and locomotion on the unit. The nurse's note dated 8/5/23 at 2:28 PM, written by the Nursing Supervisor, identified Resident #1 attempted to go home without notifying staff, spoke with Resident #1 and he/she verbalized he/she wanted to go home, stating I'm [AGE] years old and I do not belong here. Resident #1 was re-educated for safety purposes Resident #1 was not allowed to go out without his/her family or a staff member with him/her and will follow up with social worker about it on Monday and Resident #1 understood he/she will wait until then. The note indicated Resident #1 refused to have a wander guard despite several attempts, Resident #1 stated I'm responsible for myself and I'm not going to use that, I will wait until Monday. One to one (1:1) monitoring was initiated, Resident #1was added to the wanderer/elopement list, and the staff, receptionist, and social worker were notified. Upon further review, the clinical record failed to reflect documentation that a Facility Reported Incident form and an investigation were initiated until 11/3/23. The Facility Reported Incident form dated 11/3/23 at 12:30 PM identified information was received today that Resident #1 had eloped from the facility property on 8/5/23 and was brought back to the facility by a family member. The report indicated Resident #1 was returned to the facility on 8/5/23 by Person #1 and the Director of Nursing (DON) was not aware that on 8/5/23 Resident #1 had left the facility property. The report identified the information given to the DON on 8/5/23 was Resident #1 was walking on the sidewalk near the driveway still on the property. The report indicated Resident #1 was currently safe in the facility and has been since 8/5/23. On 8/5/23 upon returning to nursing unit a wander guard was attempted to be placed on Resident #1, Resident #1 refused, one to one (1:1) supervision was immediately initiated and Resident #1 has been on 1:1 supervision since 8/5/23. Interview with Person #1 on 11/22/23 at 9:50 AM identified he/she received a phone call from a family member that Resident #1 was walking home. Person #1 indicated he/she called Resident #1 and Resident #1 stated I'm walking home and told Person #1 where he/she was. Person #1 identified he/she got in his/her car and drove directly to where Resident #1 was. Person #1 identified he/she could not find Resident #1, so Person #1 called Resident #1 again and then ended up finding Resident #1 on main road. Person #1 indicated he/she brought Resident #1 back to the facility, went in and stated to the receptionist he/she just found Resident #1 about three (3) miles from this location. Person #1 identified the facility staff did not even know that Resident #1 had left the facility. Interview with the 7AM-3PM nurse aide, Nurse Aide (NA) #1, on 11/22/23 at 11:39 AM identified Resident #1 was independent with walking and walked around the building. NA #1 indicated she did not know what happened on 8/5/23 and she did not know Resident #1 had left the facility premises. Interview with the 7AM-3PM charge nurse, Licensed Practical Nurse (LPN) #1, on 11/22/23 at 12:35 PM identified she did not know what happened on 8/5/23 and the Nursing Supervisor was dealing with that. LPN #1 indicated Resident #1 ambulated independently on the unit and would converse with staff or certain residents. LPN #1 identified all the doors had a code on Resident #1's unit and she had seen Resident #1 push the code in to the elevator to go downstairs to the first floor where the main entrance was located. LPN #1 indicated Resident #1 had been putting the code in and on 8/5/23 it was not Resident #1's first time, Resident #1 went downstairs a couple of times a week. Interview with Receptionist #1 on 11/22/23 at 1:14 PM identified the only thing she remembered was Person #1 coming into the facility telling her Resident #1 was walking down a main road and Person #1 wanting to speak with the Nursing Supervisor. Receptionist #1 indicated she did not see Resident #1 exit the facility or in the lobby on 8/5/23, however there were other ways to exit the facility. Interview with the 7AM-3PM Nursing Supervisor, Registered Nurse (RN) #1, on 11/22/23 at 1:40 PM identified on 8/5/23 she received a phone call from the receptionist that Resident #1 went outside the building and Person #1 brought Resident #1 in. RN #1 indicated she was busy, and she did not go to Resident #1's room right away. RN #1 identified once she went to Resident #1's room Person #1 was no longer there. RN #1 indicated she interviewed Resident #1 and Resident #1 stated he/she wanted to go home, and he/she did not belong here at the facility. RN #1 identified she did not ask Resident #1 where he/she went. RN #1 indicated she updated the DON, left a message for Resident #1's emergency contact person and spoke with Person #1 on 8/5/23, and Person #1 stated Resident #1's emergency contact person was aware of what had happened. RN #1 identified later that evening she received a phone call from Resident #1's emergency contact person, and he/she stated he/she was trying to call Resident #1 and Resident #1 was not answering the room phone, so Resident #1's emergency contact person called Resident #1's cell phone and Resident #1 told Resident #1's emergency contact person where he/she was. RN #1 indicated Resident #1's emergency contact person called Person #1 to pick Resident #1 up. RN #1 identified Resident #1's emergency contact person mentioned the street name, however she did not remember, but it was outside the facility premises. RN #1 indicated when she received the information that Resident #1 was off the facility premises, she did not call and update the DON because it was late at night and there was a plan in place for Resident #1, Resident #1 was on one-to-one supervision, the receptionist and staff were updated, and Resident #1 was added to the elopement/wandering list. Interview and review of the exit doors with Maintenance Assistant #1 on 11/22/23 at 2:00 PM identified there were seven (7) exit doors on the first floor leading to the outside that required a code to open them except the main entrance where there was always a receptionist until 8:00 PM, then the main entrance door was locked. Maintenance Assistant #1 indicated the code to all the exit doors were the same code as was the code to the elevator. Maintenance Assistant #1 identified he did not remember the last time the code was changed. Interview with the Director of Nursing (DON) on 11/22/23 at 2:20 PM identified on 8/5/23 she received a phone call from RN #1 who stated she had heard Person #1 brought Resident #1 into the facility and she was asking RN #1 questions so she could picture as to where Resident #1 was. The DON identified she asked RN #1 if Resident #1 was on the sidewalk right up front and RN #1 replied I think so, but I do not know. The DON indicated she asked RN #1 if Person #1 visited Resident #1 as she was trying to picture how Person #1 ended up with Resident #1, however RN #1 did not have an answer for her. The DON identified she stated if Resident #1 was going outside then RN #1 needed to place a wander guard on Resident #1 and that was how they ended the conversation. The DON indicated she did not have the information as to how Resident #1 exited the facility and where Resident #1 was found. A subsequent interview with the DON on 11/22/23 at 3:07 PM identified the facility was not a locked unit, residents can go floor to floor and alert, oriented residents knew the code to the elevator, however she did not know how many residents knew the code. The DON indicated until today she did not know Resident #1 knew the code to the elevator. Interview with the Administrator on 11/22/23 at 3:10 PM identified there was no schedule to change the code. The Administrator indicated he could not recall the last time the code was changed and he had been at the facility for a little over a year. The Elopement Assessment policy and procedure directed if resident was noted to have eloped from facility property or safe area, supervisor was to be notified immediately. The supervisor then notifies the Administrator and DON or designee immediately. Investigation will be initiated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policy and interviews for one of three sampled residents (Resident #1) who was reviewed for care and services, the facility failed to develop a comprehensive care plan to include the care and management of resident with a colostomy. The findings include: Resident #1's diagnoses included advanced urethral cancer with ureterectomy (cancer and removal of the tube that leads from the bladder to the outside of the body that empties urine) and rectovaginal fistula (abnormal connection between the rectum and vagina) with a colostomy (opening created from the large intestine to the outside of the body). The Hospital Discharge summary dated [DATE] identified Resident #1 was readmitted from 6/23/23 to 7/3/23 for diagnosis and treatment of vaginal bleeding and concern for worsening osteomyelitis. Upon discharge from the hospital Resident #1 was tolerating a regular diet and the ostomy was functioning well and the discharge recommendations included to continue antibiotic therapy and an ostomy check follow up on 7/13/23 with no additional recommendations for the care of the colostomy. A physician's order dated 7/3/23 directed to change the colostomy and urostomy bags every three (3) days and as needed for maintenance. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 made reasonable and consistent decisions regarding tasks of daily life, required one (1) person assist with toileting and had an ostomy that included an urostomy (an opening form the kidneys to the outside of the body) and a colostomy. The Resident Care Plan dated 7/13/23 identified Resident #1 had an alteration in skin integrity with the potential for further alteration related to decreased mobility and incontinence coming from the vagina. Interventions directed to complete skin checks and report any concerns, complete treatments as ordered and use protective lotions or barriers to the skin. Upon further review, the resident care plan did not include the care and management of a colostomy with measurable goals and interventions. An interview with the Director of Nursing on 8/21/23 at 3:30 PM identified a comprehensive care plan should have been developed for the management of Resident #1's colostomy. A review of the facility policy for Care Planning directed the care plan be developed by the interdisciplinary team, resident and family and must include problems, goals and interventions triggered from the Minimum Data Set and any other pertinent issue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policy and interviews for one sampled resident (Resident #1) who was reviewed for care and services, the facility failed to implement recommendations from a specialty provider for a resident with a colostomy. The findings include: Resident #1's diagnoses included advanced urethral cancer with ureterectomy (cancer and removal of the tube that leads from the bladder to the outside of the body that empties urine) and rectovaginal fistula (abnormal connection between the rectum and vagina) with a colostomy (opening created from the large intestine to the outside of the body). The Hospital Discharge summary dated [DATE] identified Resident #1 was readmitted from 6/23/23 to 7/3/23 for diagnosis and treatment of vaginal bleeding and concern for worsening osteomyelitis. Upon discharge from the hospital Resident #1 was tolerating a regular diet and the ostomy was functioning well and the discharge recommendations included to continue antibiotic therapy and an ostomy check follow up on 7/13/23 with no additional recommendations for the care of the colostomy. A physician's order dated 7/3/23 directed to change the colostomy and urostomy bags every three (3) days and as needed for maintenance. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 made reasonable and consistent decisions regarding tasks of daily life, required one (1) person assist with toileting and had an ostomy that included an urostomy (an opening form the kidneys to the outside of the body) and a colostomy. The Resident Care Plan dated 7/13/23 identified Resident #1 had an alteration in skin integrity with the potential for further alteration related to decreased mobility and incontinence coming from the vagina. Interventions directed to complete skin checks and report any concerns, complete treatments as ordered and use protective lotions or barriers to the skin. A physician's progress note dated 7/4/23 identified Resident #1's skin was benign for abnormalities at the peri-colostomy site and the colostomy was functioning well with a plan to monitor output. The nurse's notes dated 7/3/23 through 7/13/23 identified the colostomy was functioning, intact and Resident #1 had no complaints. The nurse's note dated 7/14/23 at 4:12 PM identified the colostomy bag was changed due to leakage. The nurse's note dated 7/15/23 at 10:34 PM identified Person #1 had concerns with the ostomy leakage, redness was noted around the colostomy site, the Advanced Practice Registered Nurse (APRN) was notified, and a new order was prescribed for Coloplast (a barrier cream) to the reddened area every shift. The Advanced Practice Registered Nurse (APRN) note dated 7/23/23 identified Resident #1 was experiencing dermatitis to the lateral (outer) side of the colostomy due to leakage of feces with a plan to continue to apply barrier spray to the skin prior to placing a new colostomy bag and apply Nystatin powder to the surrounding skin around the ostomy. Review of the nurse's notes dated 8/4/23 through 8/7/23 identified Resident #1's colostomy began to experience some leakage that required an appliance change. Review of the Medication Administration Record dated 7/3/23 through 8/7/23 identified Resident #1's colostomy was changed every three (3) days as ordered and on four (4) occasions. The gastroenterology surgical consult dated 8/8/23 identified Resident #1 was seen for a follow up post colostomy placement where significant peristomal irritation and superficial ulceration were noted toward the flank (backside). Recommendations included supplies: [NAME] Soft Convex 1-piece 85711, Barrier sheet #32105, Paste #12050, Belt #7299, Ostomy powder, 3M Cavilon spray, and Strips #120700, change the colostomy bag every two (2) days, remove with adhesive releaser to minimize pain/trauma, cleanse site with warm water, Domeboro soaks for ten (10) to fifteen (15) minutes to dry weeping skin, utilize ostomy and antifungal powder (Nystatin) to area around ostomy, secured with barrier spray, place protective sheet toward flank, apply paste to posterior to pouch opening, utilized [NAME] pouch #85711, barrier strips and belt and once the skin was healed, the schedule could change to every three (3) to five (5) days depending on the health of the skin. Upon further review, although the recommendations were noted as having been reviewed on 8/9/23 by APRN #1 the clinical record failed to reflect corresponding physician's orders of the surgeon's recommendations. An interview with the emergency contact for Resident #1, Person #1, on 8/21/23 at 9:20 AM identified there were ongoing issues with maintaining the integrity of Resident #1's colostomy bag, questioning if supplies were appropriate and long wait times for colostomy bag changes. Person #1 indicated Resident #1 made an appointment to an ostomy clinic after feeling as though his/her colostomy was not being properly managed and a nurse, Registered Nurse, RN #1, went with Resident #1 on 8/8/23. An interview with Resident #1 on 8/21/23 at 11:30 AM identified he/she was having some issues with the colostomy appliance leaking. Resident #1 indicated RN #1 attended an outside appointment on 8/8/23 at a clinic that specialized in colostomy care. In an interview with RN #1 on 8/21/23 at 1:21 PM and 8/21/23 3:39 PM identified she was primarily responsible for infection control. RN #1 indicated she attended the specialty ostomy clinic with Resident #1 to see if anything different could be learned regarding colostomy care as Resident #1 was experiencing some leakage at the colostomy site. RN #1 indicated she placed the specialty clinic's recommendations on the APRN clip board for review upon return to the facility. Interview with the Director of Nursing (DON) on 8/21/23 at 3:30 PM identified she would expect the APRN to add the orders into the clinical record once the recommendations were reviewed. An interview with APRN #1 on 8/21/23 at 3:49 PM identified although she could not recall reviewing Resident #1's recommendations, it was her understanding once reviewed, the unit manager would transcribe the physician's order. Interview with the Medical Director on 8/21/23 at 4:20 PM identified although Resident #1's skin irritation improved and did not experience harm in this instance, he would expect the facility to follow the recommendations of specialty services. Although a policy for reviewing specialty recommendations and responding was requested, none was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 1 sampled residents (Resident #101 and Resident #129) reviewed for edema, the facility failed to ensure Resident #101 was provided a compression glove and failed for ensure TED stocking were applied to Resident #129 per physician's order, and for 1 of 1 sampled residents (Resident #95) reviewed for a urinary catheter, the facility failed to ensure Resident #95 attended a Urology appointment that was scheduled per the hospital and then directed by the APRN. The findings included: The findings include: 1. Resident # 101's diagnoses included edema, chronic pain, depression and adjustment disorder. An Interdisciplinary Referral and Rehab Screen form (not dated) completed by nursing staff, indicated Resident #101 had a change in upper extremity range of motion with complaints of left-hand pain. Occupational Therapist (OT) evaluated and recommended therapy on 12/9/20. The OT evaluation and plan of treatment dated 12/9/20 identified that Resident #101 presented with slight non-pitting edema of the left hand most prevalent at the Metacarpophalangeal (MCP) joints with impaired fine motor coordination noted and Resident #101 would benefit from a trial of a compression glove and other pain management strategies. An OT treatment note dated 12/17/20 indicated Resident #101 tolerated 4 hours of glove wearing with complaints of discomfort as the glove seam caused an indentation, nursing was informed to watch, and caregiver education was initiated regarding trial of glove. Physician's orders from 12/29/20 through 4/19/22 directed to apply a left hand edema glove with AM care and to remove with PM Care. The OT Discharge summary dated [DATE] indicated on 1/5/21 education was provided to staff regarding carryover of proper schedule of edema glove and proper application. Further discharge recommendations include that edema glove to follow wearing schedule (on with AM, off with PM). An annual Minimum Data Set (MDS) assessment dated [DATE], identified Resident #101 was cognitively intact and required extensive assistance of one person for bed mobility. The MDS further identified Resident #101 required total assistance of 2 persons for transfers, toileting and bathing and was independent with set up for eating. Observation of Resident #101 on 4/18/22 at 11:00 AM and 4/19/22 at 2:30 PM failed to identify Resident #101 was wearing a left hand edema glove (despite physician's order in place from 12/29/20 through 4/19/22). \ On 4/21/22 at 9:40 AM interview and review of the Resident Care Plan, Nurse Aide (NA) care card and Treatment Administration Record (TAR) with RN #2 failed to reflect the physician's order from 12/29/20 through 4/19/22 was implemented regarding the application of a left hand edema glove. RN #2 stated the physician's order directing the use of an edema glove was not included in the TAR because OT was responsible for electronically inputting a schedule in the computer which gets carried over to the TAR. On 4/21/2022 at 11:45 AM interview and record review with OT #1 indicated that the discharge plan for glove use for Resident #101 was to use the glove per the schedule on 1/11/21 (apply in AM and remove in PM) at the time of OT discharge on [DATE]. OT #1 identified nursing would be aware to apply the glove because a physician's order would be put in the computer by the therapist. An electronic physician's order dated 12/29/20 was identified to be put in the computer by OT. OT #1 additionally stated after an order was written, nursing needs to confirm the order and both therapy and nursing were responsible to be sure the schedule was correct. OT #1 further indicated at the time of the initial physician order, there was a different therapy company in place so he was unable to check with the original therapist that wrote the order. On 4/21/22 at 12:45 PM although a written policy for Transcription of Physician Orders was requested, the DNS identified she was unable to locate a written policy but did identify nursing and therapy need to work together to put a schedule in place. The facility did not follow the physician's order from 12/29/20 through 4/19/22 regarding the application of an edema glove for Resident #101 who was experiencing discomfort and edema in the left hand. 2. Resident #129 was admitted to the facility with diagnoses that included failure to thrive, polyneuropathy, and ataxia. An admission MDS assessment dated [DATE] identified Resident #129 had intact cognition, was frequently incontinent of bowel and bladder and required extensive assistance of one person for bed mobility and transfers. The MDS further identified Resident #129 required extensive assistance of two persons for toileting. The Resident Care Plan dated 3/17/22 identified Resident #129 had the potential for altered cardiovascular status related to cardiomyopathy and hyperlipidemia. Interventions included to administer cardiovascular related medications as ordered, diet as ordered/diet consult as needed (prn), monitor/document/report prn any signs/symptoms of coronary artery disease, chest pain or pressure, heartburn, nausea and vomiting, shortness of breath, excessive sweating, and dependent A physician's order dated 4/5/22 directed to apply TED stockings (anti-embolism stockings) on in the morning and off at hours of sleep (hs). Nurse's notes dated 4/3/22 at 3:21 PM identified Resident #129 was observed with bilateral lower extremity (BLE) edema from the mid calf to the feet, 3+ edema, shiny skin, Resident #129 currently on Lasix (a diuretic medication) 20 mg by mouth daily. The nurse's notes further identify Resident #129 denied any pain, was observed sitting with his/her legs down, elevated legs but after few minutes Resident #129 removed the leg rest. Resident #129 was reeducated, updated the on call APRN and ordered to obtain blood work a Comprehensive Metabolic Panel (CMP) in the morning and request the in house APRN assess Resident #129 in the morning. The APRN progress note dated 4/5/22 at 11:50 AM identified nursing reported increased lower extremity edema. Resident #129 with legs in a dependent position throughout the day. He/she does not have a history of heart failure, positive for leg swelling, assessment BLE edema and pedal, legs in dependent position, positive pedal pulses, warm, no erythema. The APRN progress note further identified the edema was likely dependent, start TED stockings and elevate legs while out of bed. Nurse's notes dated 4/5/22 at 2:57 PM identified Emergency Contact #1 was updated regarding BLE edema, Resident #129 was seen by the in house APRN and ordered TED stocking. Interview with Resident #129 on 4/18/22 at 11:19 AM identified that he/she was supposed to have compressions stockings on both legs to be applied in the morning and taken off at night, but that he/she had not had them for almost 3 weeks. Resident #129 was observed wearing regular socks during interview. Interview with LPN #1 on 4/20/21 at 8:25 AM identified that the 11:00 PM to 7:00 AM shift was responsible for applying TED stockings to Resident #129 and they are taken off in the evening by the 3:00 PM to 11:00 PM shift when Resident #129 goes to bed. LPN #1 also identified that the nurse who puts them on the resident signs it off in the Treatment Administration Record (TAR). LPN #1 indicated the TAR directed TED stockings were to be applied at 6:00 AM. Additionally, LPN #1 stated that she does not check that TED stockings are applied to Resident #129 because it does not show in the TAR for her shift. LPN #1 further identified that the use of TED stocking should also be on the Nurse Aide care card. Review of the NA care card regarding Resident #129's failed to identify Resident #129 utilized TED stockings. Surveyor observation on 4/20/22 at 8:45 AM of Resident #129 identified Resident #129 wearing regular socks and not TED stockings as physician ordered. Resident #129's bilateral legs were noted with edema. Interview with the ADNS on 4/20/22 at 10:00 AM identified that if the resident has a physician's order for TED stockings, the Resident Care Plan and NA care card should be updated, and also in the TAR for the nurses to sign off. Additionally, the ADNS stated that the nurses should include it when doing shift to shift reports and the NA's should also be made aware of the order. The ADNS further identified that TED stocking should be applied by the nurse so that the legs can also be assessed at the same time. Interview with LPN #2 on 4/20/22 at 1:04 PM identified that he worked on the 11:00 PM to 7:00 AM shift on 4/19/22 and was aware that Resident #129 had an order for TED stockings but did not put them on Resident #129's legs because he was told that the NAs put them on the residents. The TAR identified that LPN #2 signed off that TED stockings were on Resident #129. Subsequent to surveyor inquiry, Resident #129 was observed on 4/20/22 at 1:00 PM with TED stockings on his/her bilateral lower extremities. 3. Resident #95 was admitted to the facility on [DATE] with diagnoses that included retention of urine, dementia, anxiety, depression and the presence of a urinary catheter. The Interagency referral (W-10) from the hospital dated 11/2/21 identified Resident #95 had urinary retention with benign prostatic hypertrophy (BPH) and failed several trials for discontinuing catheter. The W-10 further indicated continuation of the medication regimen of Flomax (a medication to treat urinary retention) and Finasteride (a medication to treat BPH) and required a follow-up with Urology with an appointment for 11/5/21 at 9:30 AM. A physician's order dated 11/2/21 directed Resident #95's Foley catheter bag to be changed weekly on Sunday on the 11:00 PM to 7:00 AM shift, Foley catheter care every shift and as needed, and to irrigate the Foley catheter with 30 ml's of sterile water as needed. The Resident Care Plan (RCP) dated 11/2/21 identified Resident #95 required assistance with activities of daily living and had decreased mobility due to recent hospitalization and weakness. Interventions included to provide assistance of one for personal hygiene, bathing, and dressing. The RCP further indicated Resident #95 required assistance of one person for Foley catheter management, that the Foley bag could be placed in a basin on the floor beside the bed, if not hooked to the bed, and the bed to be in the low position. An APRN progress note dated 11/19/21 indicated to monitor the Foley catheter, continue with Tamsulosin (Flomax) and Proscar (Finasteride) and follow up with Urology (Resident #95 had an appointment previously scheduled by the hospital for 11/5/21 at 9:30 AM). An APRN progress note dated 12/6/21 indicated Resident #95 pulled out his/her Foley catheter with the bulb intact while walking to the bathroom. The APRN note further indicated that although there was some initial bleeding, the Foley catheter was replaced and that the Foley was in place for failed voiding trials in the hospital. The APRN note further indicated that a voiding trial was going to be started but needed to be deferred due to the recent trauma. Physician order on 1/22/22 directed to change Resident #95's Foley catheter monthly on the 23rd of each month during the day shift. An APRN note dated 1/31/22 indicated Resident #95 had a diagnosis of acute cystitis. The admission MDS assessment dated [DATE] indicated that Resident #95 was cognitively intact and independent with bed mobility. The MDS further indicated Resident #95 required supervision with transfers, was independent with set up for eating, extensive assistance of one for toileting and limited assistance of one for bathing. An APRN note dated 2/8/22 indicated Resident #95 had a urinary tract infection associated with the indwelling urethral catheter. A physician note dated 2/22/22 indicated Resident #95 recently started an antibiotic for a urinary tract infection associated with the indwelling urethral catheter. Observation on 4/18/22 at 12:00 PM noted Resident #95 sleeping in bed with a Foley catheter bag visible. Interview and clinical record review with RN #2 on 4/21/22 at 10:30 AM failed to reflect Resident #95 attended the Urology appointment that the hospital scheduled for 11/5/21 at 9:30 AM and failed to reflect a Urology appointment was scheduled as directed by the APRN progress notes on 11/19/21. RN #2 further indicated that the nurse on duty at the time of admission would transfer the orders from the W-10 to the electronic orders and would call the scheduler to make her aware of the appointment and transportation needed. RN #2 indicated there was a different scheduler when Resident #95 was admitted . Subsequent to surveyor inquiry, RN #2 indicated she would ask the current scheduler to call the Urology office to ask for a copy of the appointment results. RN #2 at 2:30 PM indicated that the Urology office had no record of Resident #95 coming in for his/her appointment and a new appointment was scheduled for June 5th 2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, clinical record review, review of facility documentation, and review of facility policy for 3 of 5 residents reviewed for vaccinations, (Resident #63, Resident #68, and Resident #201) the facility failed to administer vaccinations following consent to receive the vaccinations and according to CDC guidelines. The findings included: 1. Resident #63 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, atrial fibrillation, and dementia. Resident #63's date of birth was 12/30/36. The immunization record identified that one dose of Pneumococcal Conjugate PCV-13 was administered to Resident #63 on 6/7/18. Resident #63's responsible party signed a consent form on 6/1/18 requesting a second dose of pneumococcal vaccination (Pneumovax-23 was due). 2. Resident #68 was admitted to the facility on [DATE] with diagnoses that included Diabetes Mellitus Type 2, major depressive disorder, and schizophrenia. Resident #68's date of birth was 1/19/23. The immunization record identified that one dose of Pneumococcal Conjugate PCV-13 was administered to Resident #68 on 6/8/18. Resident #68's responsible party signed a consent form on 5/31/18 requesting Resident #68 receive a second dose of pneumococcal vaccination (Pneumovax-23 was due). 3. Resident #201 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, hydronephrosis and coronary artery disease. Resident #201's date of birth was 10/12/38. The immunization record identified that one dose of Pneumococcal Conjugate PCV 13 was given on 9/7/18. Resident #201's responsible party signed a consent form on 9/7/19 requesting Resident #201 receive a second dose of pneumococcal vaccination (Pneumovax-23 was due). Interview with the Infection Preventionist, RN #1, on 4/20/22 at 1:20 PM identified that Resident #63, Resident #68, and Resident #201 had not received the recommended vaccinations according to CDC recommendations. A review of the Pneumococcal Conjugate Vaccine - Prevnar 13 Policy identified, in part, that in order to protect older adults from pneumococcal disease, the CDC recommends that residents would be evaluated by their physician for the vaccine and given per CDC guidelines. CDC guidelines dated 2014 and currently in effect indicate all adults aged 65 years or older should continue to receive 1 dose of PPSV23 (Pneumovax-23). If the decision is made to administer PCV13, it should be given at least 1 year before PPSV23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, facility documentation and interviews for 1 of 1 sampled resident (Resident #95) reviewed for a urinary catheter, the facility failed to ensure Resident #95 attended a Urology appointment that was scheduled per the hospital and then directed by the APRN. The findings included: Resident #95 was admitted to the facility on [DATE] with diagnoses that included retention of urine, dementia, anxiety, depression and the presence of a urinary catheter. The Interagency referral (W-10) from the hospital dated 11/2/21 identified Resident #95 had urinary retention with benign prostatic hypertrophy (BPH) and failed several trials for discontinuing catheter. The W-10 further indicated continuation of the medication regimen of Flomax (a medication to treat urinary retention) and Finasteride (a medication to treat BPH) and required a follow-up with Urology with an appointment for 11/5/21 at 9:30 AM. A physician's order dated 11/2/21 directed Resident #95's Foley catheter bag to be changed weekly on Sunday on the 11:00 PM to 7:00 AM shift, Foley catheter care every shift and as needed, and to irrigate the Foley catheter with 30 ml's of sterile water as needed. The Resident Care Plan (RCP) dated 11/2/21 identified Resident #95 required assistance with activities of daily living and had decreased mobility due to recent hospitalization and weakness. Interventions included to provide assistance of one for personal hygiene, bathing, and dressing. The RCP further indicated Resident #95 required assistance of one person for Foley catheter management, that the Foley bag could be placed in a basin on the floor beside the bed, if not hooked to the bed, and the bed to be in the low position. An APRN progress note dated 11/19/21 indicated to monitor the Foley catheter, continue with Tamsulosin (Flomax) and Proscar (Finasteride) and follow up with Urology (Resident #95 had an appointment previously scheduled by the hospital for 11/5/21 at 9:30 AM). An APRN progress note dated 12/6/21 indicated Resident #95 pulled out his/her Foley catheter with the bulb intact while walking to the bathroom. The APRN note further indicated that although there was some initial bleeding, the Foley catheter was replaced and that the Foley was in place for failed voiding trials in the hospital. The APRN note further indicated that a voiding trial was going to be started but needed to be deferred due to the recent trauma. Physician order on 1/22/22 directed to change Resident #95's Foley catheter monthly on the 23rd of each month during the day shift. An APRN note dated 1/31/22 indicated Resident #95 had a diagnosis of acute cystitis. The admission MDS assessment dated [DATE] indicated that Resident #95 was cognitively intact and independent with bed mobility. The MDS further indicated Resident #95 required supervision with transfers, was independent with set up for eating, extensive assistance of one for toileting and limited assistance of one for bathing. An APRN note dated 2/8/22 indicated Resident #95 had a urinary tract infection associated with the indwelling urethral catheter. A physician note dated 2/22/22 indicated Resident #95 recently started an antibiotic for a urinary tract infection associated with the indwelling urethral catheter. Observation on 4/18/22 at 12:00 PM noted Resident #95 sleeping in bed with a Foley catheter bag visible. Interview and clinical record review with RN #2 on 4/21/22 at 10:30 AM failed to reflect Resident #95 attended the Urology appointment that the hospital scheduled for 11/5/21 at 9:30 AM and failed to reflect a Urology appointment was scheduled as directed by the APRN progress notes on 11/19/21. RN #2 further indicated that the nurse on duty at the time of admission would transfer the orders from the W-10 to the electronic orders and would call the scheduler to make her aware of the appointment and transportation needed. RN #2 indicated there was a different scheduler when Resident #95 was admitted . Subsequent to surveyor inquiry, RN #2 indicated she would ask the current scheduler to call the Urology office to ask for a copy of the appointment results. RN #2 at 2:30 PM indicated that the Urology office had no record of Resident #95 coming in for his/her appointment and a new appointment was scheduled for June 5th 2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the clinical record, a review of the facility documentation, staff interviews and a review of the facility policy for one of two residents reviewed for nutrition (Resident#70), the facility failed to conduct a comprehensive assessment of the resident's food preferences. The findings included: A review of the clinical record identified Resident #70 was admitted to the facility on [DATE] with diagnoses that included terminal lung disease, anxiety disorder, and muscle weakness. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified intact cognition, independent with ambulation, transfers, eating, personal hygiene, no known weight loss, and/or no known weight gain of 5% or more within the last 6 months. A review of Resident #70's food preference form dated 8/5/19 completed by RD#1 identified 12 columns of food groups for the resident to choose from that included: meat/substitutes that offered 22 choices, vegetables- 24 choices, fruits-16 choices, starches-12 choices, breads-11 choices, soups-6 choices, cereal-3 choices, egg-4 choices, miscellaneous foods offered-11 choices, desserts offered- 9 choices, and juices offered-5 choices. The form identified out of a combined total of 123 food/fluid items listed, only six items identified the resident's food preferences. The resident care plan dated 8/12/19 identified an alteration in nutrition related to lung disease with goals that included an intake of greater than 75% of meals and snacks, and to maintain a weight greater than 96 pounds (lbs.) Interventions included a dietary consult for evaluation and recommendations, fortified foods with meals, monitor weight, and administer supplements as ordered. Review of Resident #70's weight from April 2019 to September of 2019 identified the residents weight was between 97 and 99 pounds, with a most recent weight of 98 lbs. on 9/1/19. On 9/10/19 at 10:00 AM during the resident council meeting Resident #70 identified he/she did not like the food that was served and although the facility offered Resident #70 alternative food choices the resident indicated it wasn't what he/she really wanted. On 9/11/19 at 10:33 AM an interview with the RD #1 indicated the food service director and registered dietician were responsible for reviewing and revising the residents meal preferences. Meal preferences were identified at the time of admission and when an initial evaluation was conducted with the registered dietician. Updates were completed with the dietician at quarterly visits, also with the food service director, and nursing staff. On 9/11/19 at 10:44 AM an interview and review of Resident #70's food preference form with RD #1 indicated he/she had updated the form on 8/5/19 however the list failed to thoroughly identify the resident's food preferences and should have. RD #1 indicated he/she would meet with the resident to update the resident's food preference list. Subsequent to the surveyors inquiry on 9/11/19 at 11:04 AM Resident #70's food preference form was update by RD #1 with Resident #70's input. RD #1 indicated that out of 123 items and/or food choices offered, Resident #70 selected 54 food items as his/her preferences and/or likes. Seven food items were xxxx out noting the resident dislikes. Additional information included Resident #70's preference for turkey, ham sandwiches, vanilla ice cream, broccoli rabe, and omelettes. RD#1 further indicated the updated information for R#70's food preferences would be communicated to the food service director and dietary staff. According to the facility's policy for food preferences as noted in the Standard of Practice for Individualized Honoring Choices identified in part, residents had the right to make an informed choice regarding their diet.