**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policy and interviews for two (2) of three (3) sampled residents (Residents #1and #2) who were incontinent of bowel and bladder and required staff assistance with personal hygiene, the facility failed to ensure the residents were provided with incontinent care as documented in the resident care plan. The findings include: 1. Resident #1's diagnoses included neuromuscular dysfunction of the bladder (loss of normal bladder control) and hemiplegia (weakness of left side extremities). The annual Minimum Data Set assessment dated [DATE] identified Resident #1 had a Basic Interview for Mental Status (BIMS) score of 12 out of 15 indicating some memory recall deficit and was dependent on staff for personal hygiene, had an indwelling catheter to drain the bladder of urine and was always incontinent of bowel. The Resident Care Plan revision dated 4/9/25 identified Resident #1 had actual skin breakdown to the coccyx. Interventions directed to provide incontinent care every two (2) hours and keep all areas of the skin clean and dry. Review of the nurse aide care flow sheets dated 4/9/25 through 4/15/25 identified Resident #1 as having been incontinent of bowels multiple times a day. On 4/14/25 the flow record identified documentation at 6:50 AM Resident #1 had a bowel movement on the 11PM-7AM shift and the flow record identified at 9:46 PM Resident #1 had a bowel movement. The flow record failed to reflect documentation for the 7AM-3PM shift. 2. Resident #2's diagnoses included benign prostatic hyperplasia (enlargement of the prostate gland). The quarterly Minimum Data Set, dated [DATE] identified a Basic Interview for Mental Status (BIMS) score of 12 out of 15 indicating some memory recall deficit, was dependent on staff for personal hygiene, and was always incontinent of the bladder and frequently incontinent of bowel. The Resident Care Plan dated 3/12/25 identified Resident #1 was always incontinent of urine and frequently incontinent of bowel. Interventions directed to provide incontinent care every two (2) hours and as needed, keep all areas of the skin clean and dry, and offer a bedpan every two (2) hours. Review of the nurse aide care flow sheets dated 4/9/25 through 4/15/25 identified Resident #2 was incontinent on each shift. On 4/14/25 the flow record identified documentation Resident #2 voided and had a bowel movement on the 11PM-7AM shift and the 3-11PM shift however the flow record failed to reflect documentation for the 7AM-3PM shift. The Violation of Work Standards Policy dated 4/15/25 identified the Director of Nursing (DON) initiated a written disciplinary action for a 7AM-3PM nurse aide, Nurse Aide (NA) #1, after Resident #1 was found soiled with feces and dirty linens and Resident #2 was found to have soaked pads and sheets with dried and wet urine on them, as well as a soaked brief with urine at the change of the 7AM-3PM to 3-11PM shifts on 4/14/25 Interview with the Director of Nursing (DON) on 6/6/25 at 10:50 AM identified on 4/14/25 a 3-11PM nurse aide, Nurse aide (NA) #2, had asked her to go to Resident #1 and Resident #2's rooms with her to assess how she found the residents who had been incontinent and were lying on soiled, both wet and dry, linens. The DON stated on 4/14/25 NA #1 was the assigned nurse aide for the 7AM-3PM shift, after her observations she had a conversation with NA #1, and a written disciplinary with education was issued regarding the importance of incontinent care. Interview with NA #1 on 6/6/25 at 11:35 AM identified that she checks the residents when she first arrives on shift, assists with breakfast, then begins to provide morning car, and begins the last rounds at 1:30 PM. Interview with NA #2 on 6/6/25 at 2:55 PM identified on 4/14/25 she reported to the DON that on first rounds she had found Residents #1 and #2 were lying on dried and wet soiled pads, sheets, and briefs. Review of the perineal care/incontinent care dated 4/7/25 policy directed all residents will receive incontinent care every two (2) hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, review of the clinical record, facility documentation, and facility policy for 1 of 3 residents (Resident #46) reviewed for urinary catheters, the facility failed to maintain dignity for a resident with a urinary catheter drainage bag. The findings include: Resident #46 was admitted to the facility in October of 2023 with diagnoses that included osteoarthritis of bilateral knees, neuromuscular dysfunction of bladder, generalized muscle weakness and cognitive communication deficit. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #46 had moderate cognitive impairment (Brief Interview for Mental Status (BIMS) score of 12), and was dependent on toileting hygiene, personal hygiene, bed mobility and transfers. The MDS identified that Resident #46 had an indwelling catheter, and was always incontinent of bowel. The Resident Care Plan dated 1/1/24 identified Resident #46 had an indwelling catheter due to obstructive uropathy (a urinary tract disorder that occurs when urine flow is obstructed either structurally or functionally) and neurogenic bladder (lack of bladder control due to medical issues). Interventions included enhanced barrier precautions, foley catheter care every shift, foley bag/leg bag to be changed weekly and foley to be changed monthly. Observations on 2/19/25 at 10:45 AM and on 2/20/25 at 9:30 AM and 11:04 AM identified Resident #46 lying in bed without the benefit of a privacy cover over the drainage bag. Urine was visible in the drainage bag from the hallway. A privacy cover was observed positioned above the drainage bag. Interview and observation with NA #8 on 2/20/25 at 11:55AM identified a privacy cover connected to a drainage bag but the privacy cover was positioned above the drainage bag and not covering the drainage bag. NA #8 identified that a privacy cover should cover the drainage bag and should not be positioned above the drainage bag. NA #8 could not explain why the privacy cover was positioned above the drainage bag. Subsequent to surveyor inquiry, Resident #46's privacy cover was pulled down to cover the drainage bag. Interview with the Unit Manager (LPN #6) on 2/20/25 at 12:10 PM, identified that privacy covers are used for dignity purposes and indicated that they should cover the drainage bag and should not be left pulled up or positioned above the drainage bag. LPN #6 was unable to explain why staff pulled the privacy cover above the drainage bag leaving urine visible from the hallway. Interview with the DNS on 2/20/25 at 1:55 PM identified that privacy covers should cover the drainage bag to conceal urine from public view. The DNS further identified that privacy covers provide dignity for residents with urinary catheters. Although requested, a policy for urinary catheter drainage bags or privacy covers was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #20) reviewed for abuse, the facility failed to keep Resident #20 free from physical restraint. The findings include: Resident #20 was admitted to the facility in June of 2022, with diagnoses that included Alzheimer ' s disease, dementia with other behavioral disturbance and anxiety disorder. The quarterly Minimum Data Set assessment dated [DATE], identified Resident #20 was cognitively impaired (Brief Interview for Mental Status (BIMS) score of 3), was dependent for bed mobility, transfer and toileting, was non-ambulatory, and was independent with eating. A Resident Care Plan dated 10/12/2024 (start date of 7/12/23) identified increased combative behaviors and anxiety with medications and an intervention to start Trazadone 30 minutes prior to morning and evening care twice daily. The Accident and Incident report dated 10/31/2024, identified NA #10 alleged that LPN #9 hit Resident #20. A statement dated 10/31/2024 by NA #10 indicated that when she walked into Resident #20 ' s room to deliver a meal tray, she overheard LPN #9 speaking to Resident #20 in an aggressive tone, while attempting to administer medications. The statement identified NA #10 then saw LPN #9 hit Resident #20 on the arm. The statement indicated NA #10 delivered and set up the meal tray and encouraged Resident #20 to take his/her medication, then left the room. The statement identified LPN #9 returned to her medication cart and LPN #9 told staff nearby that Resident #20 scratched her. A statement dated 10/31/2024 by LPN #9 identified she was administering medications in applesauce to Resident #20 with a spoon and Resident #20 accepted the first bite then resisted taking another bite. The statement indicated Resident #20 scratched LPN #9 ' s arm and held onto LPN #9 ' s arm tightly. The statement indicated LPN #9 placed her hands on top of Resident #20 ' s hands and held Resident #20 ' s hands against his/her stomach. The statement identified that at that time, NA #10 entered the room with the meal tray. The statement indicated LPN #9 attempted to administer the rest of the medication to Resident #20, but Resident #20 refused. The statement identified that NA #10 approached LPN #9 about the incident and that LPN #9 called the Assistant Director of Nursing Services (ADNS) and that the Director of Nursing Services (DNS) initiated an investigation. A Progress note by Physician ' s Assistant (PA) #1 dated 11/1/2024 at 9:22 AM identified she was requested to assess Resident #20 for agitation and combativeness. The note identified that Resident #20 was reported to have had an episode involving nursing and was increasingly noncompliant with taking medications and becoming more agitated when reapproached by nursing to administer medications. The note further identified that Resident #20 was calm at the time seen and given the frequency of refusals, would attempt switching to liquid medications and/or discontinuing non-essential medications. Interview on 2/20/2025 at 10:30 AM with the DNS identified the facility conducted an investigation for the 10/31/24 allegation of abuse and the outcome of the investigation was unsubstantiated because NA #10 gave conflicting statements. The DNS was unable to produce documentation of the conflicting statements. The DNS identified that during the investigation no other residents on the unit were interviewed. She identified that statements were obtained from the alleged abuser, the alleged witness, the nursing supervisor and one other NA but failed to obtain statements from the remaining 4 staff members who were working on the unit. Interview on 2/21/2025, at 4:18 PM with NA #10 identified that on 10/31/2024 at approximately 5:00 PM, she entered Resident #20 ' s room to deliver a meal tray and witnessed LPN #9 standing on the door side of Resident #20 ' s bed, facing Resident #20 while Resident #20 was lying in bed, and she observed LPN #9 holding Resident #20 ' s hands down and LPN #9 hit Resident #20 ' s arm. Interview on 2/25/2025 at 12:37 PM with LPN #9 identified that on 10/31/2024 at around 5:00 PM she was trying to administer medications to Resident #20 and that Resident #20 grabbed her (LPN #9 ' s) hand. LPN #9 indicated that she did not call for help when Resident #20 became agitated/combative and did not attempt to step away from Resident #20 when he/she became agitated/combative. LPN # 9 indicated that the incident happened fast and grabbing Resident #20 ' s hands was a reaction. LPN #9 indicated that, at times, it was difficult to administer medications to Resident #20 and Resident #20 needed to be reapproached but had not attempted reapproaching Resident #20 during this incident. LPN #9 identified that she had not received training to restrain residents. Review of the Abuse, Neglect Exploitation and Misappropriation of Residents Property policy directed, in part, to provide protection for the health, welfare and rights of each resident by implementing written policies and procedures that prohibit abuse, neglect, exploitation, and misappropriation of resident property. The facility has developed and implemented these written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property and establishes policies and procedures to investigate any such allegations and includes training for new and existing staff on activities that constitute abuse, neglect, exploitation and misappropriation of resident property, reporting procedures and dementia management and resident abuse prevention. Additionally, it establishes coordination with the facility QAPI program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record and facility policy for 1 of 3 residents (Resident #80) reviewed for elopement the facility failed to develop a comprehensive Resident Care Plan (RCP) for a resident at risk for elopement. The findings include: Resident #80 was admitted to the facility in May of 2024 and had diagnoses that included dementia, hypertension and depression. The Elopement Risk assessment dated [DATE] identified Resident #80 was at risk for elopement and precautions must be initiated. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #80 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 3), had fluctuating behaviors of inattention, fluctuating behaviors of disorganized thinking, was independent with eating, transfers and ambulating at least 150 feet without an assistive device. The RCP dated 9/18/2024 identified Resident #80 was alert and oriented to self with confusion and forgetfulness and walked around the unit. Interventions included to provide a daily routine that resembled Resident #80's prior lifestyle and provide a safe environment. The RCP identified Resident #80 was at risk for altered cognition related to dementia and would become confused as to where his/her room was, would enter other rooms and would lay down in empty beds thinking they were his/her bed. Interventions included to monitor cognitive changes and reorient as needed. The RCP failed to identify Resident #80 was at risk for elopement. A Provider progress note by PA #1 on 12/4/2024 at 1:15 PM identified Resident #80 was alert and disoriented, his/her mental status was at baseline, he/she ambulated around the unit, was generally quiet, enjoyed sitting at the nurses station and had poor safety awareness which was expected to progress. Review of the Elopements and Wandering Residents policy identified residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered care plan. The policy defines wandering as random or repetitive locomotion that may be goal-oriented or non-goal directed or aimless. The policy identified the facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Review of the Comprehensive Care Plans policy directed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs including all services identified in the resident's comprehensive assessment. The process will include an assessment of the resident's strengths and needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record, facility policy and interviews for 2 of 4 residents (Resident #21 and Resident #57) reviewed for oxygen therapy the facility failed to revise the Resident Care Plan (RCP) for residents on oxygen therapy per facility policy. The findings include: 1. Resident #21 was admitted to the facility in August of 2024 and had diagnoses that included Alzheimer's disease, chronic obstructive pulmonary disease (COPD), and diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #21 was severely cognitively impaired, required substantial/maximal assistance for eating and bed mobility, and dependent for transfers. The Resident Care Plan (RCP) dated 1/8/2025 identified Resident #21 was at risk for altered cardiopulmonary status. Interventions included assessing lung sounds per provider orders and consult with respiratory therapist as needed. The RCP failed to identify interventions for administration of continuous/intermittent oxygen with flow rate and type of oxygen delivery system, changing and labeling of the nasal cannula oxygen tubing, and monitoring for complications related to oxygen use. Review of the admission Nursing assessment dated [DATE] identified Resident #21 required oxygen at 2 liters per minute (LPM) via nasal cannula. The Medicare 5 day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #21 was severely cognitively impaired, received continuous oxygen therapy, and was dependent for oral hygiene, bed mobility, and transfers. A provider order dated 1/30/2025 directed to change oxygen tubing weekly on Sundays during the 11 PM to 7 AM shift and included instructions which directed to place tubing in a labeled bag and not leave tubing exposed. A provider order dated 2/18/2025 directed to administer oxygen at 2 LPM via nasal cannula as needed for comfort. Interview with Registered Nurse (RN) #5 on 2/19/2025 at 12:10 PM identified her (RN #5) and Licensed Practical Nurse (LPN) #4 updated the RCPs. RN #5 identified she completed RCPs for short term care residents and new admissions. RN #5 indicated she did not update RCPs for short term residents because they did not often remain in the facility for greater than a couple weeks. RN #5 identified she was not aware Resident #21 had an order for oxygen for comfort and that Resident #21 was transitioned to long term care. RN #5 further identified that LPN #4 completed the RCPs for long term care residents. Interview with LPN #4 on 2/19/2025 at 12:20 PM identified that she updated the RCPs for the long-term care residents. LPN #4 identified she added information to the focus section of the RCP as she received it, but the interventions were updated quarterly or if residents had a significant change. 2. Resident #57 was admitted to the facility in January of 2022 and had diagnoses that included pneumonia, dysphagia, and chronic kidney disease. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #57 was moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 12), required setup or clean-up assistance with eating, and was dependent for bed mobility and transfers. Observation on 2/11/2025 at 12:45 PM AM identified an unlabeled oxygen nasal cannula connected to a portable oxygen tank belonging to Resident #57. The Resident Care Plan (RCP) dated 2/17/2025 identified Resident #57 was at risk for altered cardiopulmonary status. Interventions included assessing lung sounds per provider orders and consult with respiratory therapist as needed. The RCP failed to identify interventions for administration of continuous/intermittent oxygen with flow rate and type of oxygen delivery system, changing and of the nasal cannula oxygen tubing, and monitoring for complications related to oxygen use. Observation on 2/19/2025 at 7:40 AM identified an unlabeled oxygen nasal cannula connected to an oxygen concentrator, set at 3 LPM, belonging to Resident #57. Interview with LPN #4 on 2/19/2025 at 12:20 PM identified that she updated the RCPs for the long-term care residents. LPN #4 identified she added information to the focus section of the RCP as she received it, but the interventions were updated quarterly or if residents had a significant change. Review of the Oxygen Administration Policy directed that the resident's care plan shall identify interventions for oxygen therapy based upon resident assessments and provider orders and include but not be limited to: the type of oxygen delivery system; when to administer oxygen (continuous or intermittent) and/or when to discontinue oxygen; equipment setting for the ordered flow rate (LPM); monitoring of oxygen saturation levels (blood oxygen level) or vitals signs per provider order; and monitoring for the complications associated with oxygen use (vertigo, nausea, convulsions, slowed respiratory rate, medical device related pressure injury). The policy further directed to change oxygen tubing weekly and as needed if soiled or contaminated. Review of the Comprehensive Care Plans policy identified the comprehensive care plan includes measurable objectives and timeframes to meet the resident's needs and alternative interventions are documented as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record, facility policy and interviews for 1 of 4 residents (Resident #62) reviewed for dining the facility failed to provide supervision for a resident who required supervised feeding. The findings include: Resident #62 was admitted to the facility in November of 2020 and had diagnoses that included dementia, respiratory failure with hypoxia, and dysphagia. A Physician ' s Order dated 7/25/2024 directed an assist of 2 staff members for activities of daily living and assist of 1 staff member for supervision for feeding. A Physician Order dated 12/12/2024 directed for a dysphagia evaluation with treatment 3 times a week for 4 weeks. The significant change in status Minimum Data Set (MDS) assessment dated [DATE] identified Resident #62 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 15), was on a mechanically altered diet, started speech therapy on 12/12/2024, required setup or clean-up assistance with eating, and was dependent for bed mobility and transfers. The MDS failed to accurately code Resident #62's eating functional ability per provider orders. A Physician Order dated 12/31/2024 directed to provide a carbohydrate controlled, no added salt, mildly thick diet which included instructions for a lidded sippy cup, extra sauce/gravy on the side, may have cheerios with thickened milk (let sit to get soft),thickened coffee and super oatmeal daily with breakfast. The Dysphagia Therapy note by Speech Therapist (ST) #1 dated 1/7/2025 at 2:46 PM identified Resident #62 was seen in the morning for dysphagia therapy, that nursing staff informed ST #1 that a chest X-RAY was performed for Resident #62 on 1/6/2025 which revealed aspiration pneumonia. ST #1 subsequently placed Resident #62 on aspiration precautions which included supervision with meals. The note further identified that nursing staff were informed of the new recommendations. A Physician's Order dated 1/7/2025 directed aspiration precautions: Supervision during meals, encourage Resident #62 to be out of bed for all meals, and if eating in bed, position Resident #62 upright with HOB at 90 degrees. The Resident Care Plan (RCP) dated 1/8/2025 identified Resident #62 was at risk for inadequate nutrition and required feeding assistance with meals but would refuse. Interventions included 1 to 1 feeding and that Resident #62 should be out of bed for all meals, but if in bed, the head of the bed (HOB) must be positioned at 90 degrees. The Resident Care Card (RCC) dated 1/15/2025 identified Resident #62 was on a limited concentrated sweets, no added salt, soft and bite sized diet, aspiration precautions, swallowing precautions, needed to sit upright with the HOB at 90 degrees during meals, and required 1 to 1 feeding assistance. A Dysphagia Therapy note by ST #2 dated 1/28/2025 at 5:51 PM identified Resident #62 was seen for dysphagia therapy and during the session Resident #62 verbalized that he/she had vomited earlier during the lunch meal because the meal was too dry and the food just wouldn't go down. The note further identified Resident #62 had emesis at the end of therapy treatment which was reported to the nurse. A Nutrition Assessment progress note by the Dietician dated 2/4/2025 at 10:58 AM identified Resident #62 had a history of dysphagia, was on a mechanically altered diet and was seen by ST #1. The note identified Resident #62 was observed at meals and ate well and identified a goal to have no symptoms of aspiration. Observation in the dining room on 2/11/2025 at 12:32 PM identified Resident #62 eating his/her meal without assistance or supervision from staff. No staff members were in the dining room while Resident #62 ate lunch. A Dysphagia Therapy note by ST #3 dated 2/20/2025 at 6:22 PM identified Resident #62 was seen for dysphagia therapy, and upon entry into the dining room, Resident #62 was observed red faced and coughing and reported, It just wouldn't go down for a second. The note further identified no additional swallowing difficulties observed with food and fluid intake during the therapy session and that safe swallowing strategies were reviewed with Resident #62. Observation on 2/25/2025 at 8:38 AM identified Resident #62 sitting upright (90 degrees) in bed, eating behind a privacy curtain, with no staff member in the room. Observation of the plate identified part of a muffin and some scrambled eggs were consumed. Resident #62 was observed drinking juice from a handled lidded sippy cup. Interview with RN #3 on 2/25/2025 at 8:40 AM identified there was a provider order for Resident #62 to have supervised feeding assistance, Resident #62 was not on the list of residents requiring feeding assistance, Resident #62 should have been on the list of residents requiring feeding assistance, and Resident #62 should not have been eating alone in his/her room without staff member supervision. Subsequent to surveyor inquiry, Resident #62 was added to the supervised feeding assistance list and RN #3 instructed a staff member to supervise Resident #62 with breakfast. Interview with NA #1 on 2/25/2025 at 9:05 AM identified she used the RCCs to determine the care residents needed. NA #1 identified that Resident #62 was not on the list of residents who required feeding assistance and she did not realize the RCC instructed to feed Resident #62 because she had not looked at it. Further identified by NA #1 was that if no one was in the dining room while Resident #62 was eating lunch, she would sit with Resident #62 until his/her meal was finished. Interview with ST #1 on 2/25/2025 at 11:08 AM identified Resident #62 was receiving speech therapy because he/she had a history of aspiration pneumonia and requested a diet upgrade to liberalize his/her diet. ST #1 identified Resident #62 had aspiration pneumonia again while on therapy services and he/she was subsequently placed on aspiration precautions. ST #1 indicated Resident #62 should have a staff member present while eating to help him/her during coughing episodes and to cue him/her to slow down and use proper swallowing techniques. ST #1 further identified it was beneficial for Resident #62 to have an extra set of eyes on him/her during meals to help prevent future episodes of aspiration. The Aspiration Precautions Protocol policy identified, in part, that for residents on aspiration precautions to follow these steps: encourage resident to maintain the HOB at 90 degrees if tolerated, offer small sips and bites at a feeding rate suitable for residents, and if a resident has trouble, notify the nurse immediately for: inability to chew food within diet consistency, increased coughing during feeding/after bites or sips, choking, and with pocketing of food (food getting trapped in cheek or mouth without swallowing).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, review of the clinical record, facility documentation, and facility policy for 1 of 3 residents (Resident #46) reviewed for pressure ulcers, the facility failed to follow the plan of care for a resident with a pressure ulcer. The findings include: Resident #46 was admitted to the facility in October of 2023 with diagnoses that included abnormal weight gain, osteoarthritis of bilateral knees, neuromuscular dysfunction of bladder, generalized muscle weakness and cognitive communication deficit. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #46 had moderate cognitive impairment (Brief Interview for Mental Status (BIMS) score of 12), and was dependent on toileting hygiene, personal hygiene, bed mobility and transfers. The MDS identified that Resident #46 had an indwelling catheter, was always incontinent of bowel, was at risk of developing pressure ulcers and had a pressure reducing device for bed. The Resident Care Plan (RCP) dated 12/18/24 identified Resident #46 was a potential for skin breakdown. Interventions included an air mattress to the bed and to turn and reposition every 2 hours. A Physician ' s order dated 1/1/25 directed an air mattress with instructions to check functioning every shift. Review of the Weekly Ulcer Skin Assessment Flow Sheet dated 1/8/25 by the Infection Preventionist Nurse (LPN #3) identified a new stage II facility acquired pressure ulcer to the left buttock measuring 1.5 centimeters (cm) by 1.1 cm by 0 cm and was described as having a wound bed containing 55% red granulation tissue, 37% yellow and 8% black (discolored) tissue, was tender to touch with scant serosanguinous drainage noted. The flow sheet identified topical treatment with Medi-honey followed by a piece of calcium alginate (absorptive topical treatment) and border gauze dressing. The Resident Care Card dated 2/1/25 failed to direct turning and repositioning every 2 hours. Although the RCC contained a section to check off turning and repositioning, this intervention was not selected. Review of Weekly Ulcer Skin Assessment Flow Sheet dated 2/10/25 by LPN #3 identified a stage II pressure ulcer to the right and left buttock with treatments in progress. The wound on the left buttock measured 1.7 cm by 1.5 cm by 0 cm and the wound on the right buttock measured 0.6 cm by 0.5 cm by 0 cm. 1. Observation and interview with Resident #46 on 2/11/25 at 1:07 PM identified he/she was lying in bed with the head of the bed elevated. Resident #46 indicated he/she did not have the ability to re-position him/herself in bed and relied on staff for bed to chair transfers. Resident #46 identified that she had sores in his/her buttocks with ongoing treatments. An air mattress was observed in place but appeared mildly deflated. The indicator light on the power switch did not display any light. Interview and observation with Resident #46 on 2/11/25 at 2:54 PM identified Resident #46 lying in bed with head of bed elevated. The air mattress was observed in place but still appeared mildly deflated and the indicator light on the power switch did not display any light. Resident #46 indicated that he/she could not feel the air mattress fluctuate as it always did, and the bed felt uncomfortable. Interview and observation with LPN #1 on 2/11/25 at 2:56 PM identified that she disconnected the air mattress plug from the wall outlet when she performed incontinent care for Resident #46 before lunch. LPN #1 indicated she forgot to plug the air mattress back in and did not check for functioning before leaving Resident #46's bedside. LPN #1 identified that she should have checked the air mattress for functioning before leaving Resident #46's bedside. LPN #1 further identified that Resident #46 had a stage II pressure ulcer to the bilateral buttocks and was receiving daily wound treatments. Subsequent to surveyor inquiry, the air mattress was plugged into the wall outlet and placement and functioning was confirmed by LPN #1 prior to leaving the bedside. Interview with the DNS on 2/25/25 at 1:58 PM, identified that LPN #1 should have checked air mattress function and placement after performing incontinence care. 2. Observation and interview with Resident #46 on 2/20/25 at 10:00 AM, identified that he/she was lying on his/her back with head of bed slightly elevated. Resident #46 identified that he/she had been incontient of stool for approximately 1 hour and was waiting for staff to assist him/her with incontinence care. Resident #46 identified that, at times, it takes up to 4 hours for staff to assist him/her with incontinence care and indicated that waiting for staff to assist with washing him/her up caused him/her distress. Resident #46 identified that he/she turned on the call bell to request help at 10:30 AM and 1 of the NA's went into his/her room, switched the call bell off and informed him/her that his/her assigned NA was with a different resident and would assist him/her when finished. Observation on 2/20/25 at 11:20 AM identified Resident #46 had still not received incontinence care and Resident #46 again turned on the call bell. LPN #1 responded at 11:25AM, switched off the call bell, and informed Resident #46 that his/her assigned NA would be available shortly to assist him/her with incontinence care. Observation on 2/20/25 at 11:55 AM identified NA #8 arrived at Resident #46's bedside to assist Resident #46 with incontinence care. Observation of Resident #46 ' s skin identified a Stage II pressure ulcer to the right buttock and a stage II pressure ulcer to the left buttock. Resident #46 was observed lying on his/her back before the incontinence care was provided and was returned to his/her back after the incontinence care. Interview with NA #8 on 2/20/25 at 12:05 PM identified that Resident # 46 was not repositioned in bed after the incontinence care because he/she is not bed bound. NA #8 identified that turning and repositioning only occurs for residents who are bed bound. NA #8 indicated that Resident #46 is sometimes transferred to a recliner at the bedside, therefore he/she is not considered bed bound. NA #8 further identified that the RCC did not direct Resident #46 to be turned and repositioned every 2 hours. Interview with LPN #1 on 2/20/25 at 12:08 PM identified that she was the nurse assigned to care for Resident #46 and that Resident #46 repositioned him/herself in bed. Interview and record review with the Unit Manager (LPN #6) on 2/20/25 at 12:10 PM identified an RCP intervention to turn and reposition Resident #46 every 2 hours effective 9/24/24. LPN #6 indicated that the intervention of turning and repositioning every 2 hours should have been added the RCC and a Physician's order for turning and repositioning should have been obtained. LPN #6 indicated that since the RCC was not updated and there was no Physicians order, staff had not been turning and repositioning Resident #46 in bed, but only transferred him/her out of bed to the recliner. LPN #6 identified that Resident #46 was dependent for turning and repositioning in bed and currently had a stage II pressure ulcer to the right buttock and to the left buttock and needed to be turned and repositioned every 2 hours while in bed. Interview with the Rehabilitation Director on 2/24/25 at 11:35 AM identified that Resident #46 was dependent on staff for bed mobility and transfers and did not have the ability to turn or reposition him/herself in bed. Interview with the DNS on 2/25/25 at 1:58 PM identified Resident #46 had mobility issues and needed staff assistance with bed mobility and transfers. The DNS indicated that the RCC should have included interventions to turn and reposition Resident #46 every 2 hours as a pressure ulcer prevention strategy. Interview with PA #1 on 2/25/25 at 2:30 PM identified that Resident #46 did not have the ability to turn or reposition him/herself in bed. PA #1 identified that there were no contraindications to turning or repositioning Resident #46 in bed. PA #1 further identified that NAs were responsible for turning and repositioning residents in bed and indicated that they should have been turning and repositioning Resident #46. PA #1 indicated that if a resident is left in the same position and not moved, they would develop pressure ulcers, wounds or breakdown in skin. Review of facility policy titled, Turning and Repositioning Policy, identified that all residents at risk or with existing pressure injuries, will be turned and repositioned unless it is contraindicated due to a medical condition. In this case small shifts in repositioning will be employed. Turning and repositioning is a primary responsibility of nursing assistants. However, all nursing staff are expected to assist with turning and repositioning. A routine turn schedule includes using both side-lying and back positions, alternating from the right, back, and left side. A resident's condition will warrant whether specialized turn schedule is warranted. The frequency of turning and repositioning will be documented in the resident's plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy, and interviews for 2 of 3 residents (Resident #14 and Resident #80) reviewed for elopement, the facility failed to provide adequate supervision to prevent elopement. The findings include: 1. Resident #14 was admitted to the facility in September of 2024 with diagnoses that included alcohol and opiate use disorder, cognitive impairment, major depressive disorder and diabetes. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #14 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 15), was independent with eating, required partial/moderate assistance with transfers and ambulated with a walker. An Elopement risk assessment performed on 11/4/24 identified Resident #14 as at risk for elopement. A Physician ' s order dated 12/23/25 by Physician Assistant (PA#1), directed to apply a wander guard (a wearable monitoring device to ensure resident safety and prevention of exiting the facility) to left ankle and check function and placement every shift. The Resident Care Plan (RCP) dated 12/24/24 Identified Resident #14 as at risk for elopement. Interventions included applying a wander guard for safety or 15 minutes checks for wander guard refusal, involving Resident #14 in recreation/diversional activities, maintaining safety and offering rest breaks, redirecting out of other residents rooms or staff areas, encouraging rest periods, providing emotional support, speaking in a calm and gentle tone and visitation by the social worker as needed. A Nursing progress note by RN #1 on 1/8/25 at 1:21 PM identified Resident #14 went to a medical appointment accompanied by NA #7. The note identified that upon return from the appointment with NA #7, Resident #14 refused to re-enter the facility. The note further identified that Resident #14 stepped out of the transport vehicle and began walking away from facility, refused redirection and was aggressive. Additionally, the note identified that NA #7 left Resident #14 unattended, outside on the sidewalk, and went inside the facility to request assistance. The note identified that the Director of Nursing (DNS), the Assistant Director of Nursing (ADNS) and NA #7 went outside to assist Resident #14 who was identified across the street at the stop sign of a 4-way intersection. The note further identified that Resident #14 continued walking to a liquor store despite being re-directed back to the facility and the DNS and ADNS remained with the Resident until he/she returned to the facility. A Nursing progress note by the ADNS on 1/9/25 at 12:31 PM, identified Resident #14 was accompanied by person #2 (a volunteer escort from an outside agency) to a medical appointment. Upon arrival back to the facility, Resident #14 was unresponsive in the transport van and subsequently transferred to the hospital. Physician's Evaluation/Conservatorship (PC-370) form dated 1/17/25 by MD #2 identified Resident #14 with alcohol dependance and associated cognitive impairments, major depression and multiple medical conditions. MD #2 further identified Resident #14 had poor insight and judgement, minimized risk and harm caused by his/her drinking, was vulnerable to abuse and became confused easily when ill. Interview with NA #7 on 2/19/25 at 2:22 PM identified that she escorted Resident #14 to a medical appointment on 1/8/25 in a medical transportation van. NA #7 indicated that Resident #14 was calm and cooperative throughout the trip but once they arrived back to the facility, Resident #14 told her he/she wanted to buy alcohol from a liquor store. NA #7 indicated that she tried to redirect Resident #14 but he/she became agitated and pushed her out his/her way. NA #7 identified that she ran back to the building and notified the DNS and the ADNS who responded to the incident and Resident #14 was located across the street at a stop sign of a 4-way intersection, approximately 150 feet from the facility's entrance. NA #7 indicated that they tried to redirect Resident #14, but he continued walking towards a liquor store. NA #7 identified that she was directed by the DNS to go back to the facility and notify the provider that Resident #14 eloped. NA #7 identified that she was not aware that Resident #14 was an elopement risk, and no education was provided to her prior to the appointment. She indicated that she worked on a different nursing unit and was pulled off her assignment to accompany Resident #14, who she had never previously cared for. She indicated she did not know how to respond to the incident and could not identify if she could have used her cell phone to alert the facility rather than leaving Resident #14 unattended outside the facility. Interview with the Unit Manager (LPN #6) on 2/19/25 at 3:56 PM identified that volunteer escorts do not receive resident healthcare information or education prior to escorting residents on medical appointments as that would be a Health Insurance Portability and Accountability Act (HIPAA) violation. LPN #6 further identified that Person #2 was not notified that Resident #14 was at risk of elopement. LPN #6 was unable to identify why NA #7 was not notified of Resident#14's elopement risk prior to the medical appointment on 1/8/25. Interview with the DNS on 2/20/25 at 2:00 PM identified that NA #7 accompanied Resident #14 to his/her medical appointment for safety due to his/her elopement risk. The DNS further identified that NA #7 should have been notified by the unit nurse that Resident #14 was an elopement risk and education should have been provided to NA #7 prior to accompanying Resident #14 to the medical appointment. Observation with the DNS on 2/20/25 at 2:15 PM, identified a one-way street in front of the facility's entrance, with cars parked on both sides of the street, causing low visibility, and a stop sign at a busy 4-way intersection, approximately 150 feet from the facility's entrance, on the opposite side of the street, was the location where Resident #14 was discovered during the elopement incident on 1/8/25. Interview with RN #1 on 2/20/25 at 3:36 PM identified that verbal education was provided to NA #7 after the elopement incident, but no education was provided to other facility staff. Interview with the DNS on 2/21/25 at 10:35 AM identified that the facility does not perform elopement drills for locating missing residents. Interview with Person #2 on 1/24/25 at 10:55 AM identified that no information, including Resident #14's elopement risk, was communicated to him by the facility, prior to accompanying Resident #14 to a medical appointment on 1/9/25. 2. Resident #80 was admitted to the facility in May of 2024 and had diagnoses that included dementia, hypertension and depression. The Elopement Risk assessment dated [DATE] identified Resident #80 was at risk for elopement and precautions must be initiated. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #80 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 3), had fluctuating behaviors of inattention, fluctuating behaviors of disorganized thinking, was independent with eating, transfers and ambulating at least 150 feet without an assistive device. The Resident Care Plan (RCP) dated 9/18/2024 identified Resident #80 was alert and oriented to self with confusion and forgetfulness and walked around the unit. Interventions included to provide a daily routine that resembled Resident #80's prior lifestyle and provide a safe environment. The RCP further identified Resident #80 was at risk for altered cognition related to dementia and would get confused as to where his/her room was and enter other rooms and lay down in empty beds thinking they were his/hers. Interventions included to monitor cognitive changes and reorient as needed. The RCP failed to identify Resident #80 as an elopement risk. The Resident Care Card (RCC) dated 9/27/24 identified Resident #80 was oriented to self, confused at times, forgetful, independent with transfers, and independent with ambulation. Further identified was an entry dated 10/6/2024 which directed staff to take Resident #80 to a common area when awake. The RCC failed to identify Resident #80 was an elopement risk. A Provider progress note by PA #1 on 12/4/2024 at 1:15 PM identified Resident #80 was alert and disoriented, his/her mental status was at baseline and Resident #80 ambulated around the unit, was generally quiet and enjoyed sitting at the nurses station. Further identified was Resident #80 had poor safety awareness which was expected to progress. A Nursing progress note by Registered Nurse (RN) #2 on 12/8/2024 at 9:20 PM identified Resident #80 had dinner at 5:00 PM, had snacks at 6:00 PM, and was escorted to the unit at 6:40 PM by Security Guard #1. The note identified that the front desk cameras were reviewed and identified Resident #80 had exited the facility from a stair well door and walked toward the front door and re-entered the facility by the front door. The progress note further identified Resident #80's possible exit was by a wet floor sign inside the door, and that the Director of Nursing Services (DNS) and Resident #80's family member were notified of the incident. The RCP dated 12/11/2024 identified Resident #80 was at risk for elopement related to Resident #80 walking off the unit through the stair well door that was propped open and went down the stairs and out the door and walked back in through the front door. Interventions included to complete an elopement assessment per policy and as needed, redirect Resident #80 as needed, and provide an escort for off unit activities. A Psychiatric progress note dated 12/31/2024 at 1:50 PM identified Resident #80 received services in the context of behavioral assessment and medication management related to dementia, and Resident #80 was almost always confused. Interview with RN #2 on 2/24/2025 at 11:00 AM identified she had been notified by Licensed Practical Nurse (LPN) #8 on 12/8/24, that Resident #80 was brought back to the unit by Security Guard #1 at 6:40 PM after Resident #80 walked in the front door of the facility. RN #2 indicated that no staff members were aware Resident #80 was missing prior to Security Guard #1 bringing Resident #80 back to the unit and she did not know the last time Resident #80 was seen after Resident #80 received a snack at 6:00 PM. RN #2 identified she filled out an Accident and Incident (A&I) report which included statements from herself and Security Guard #1 and that she notified the DNS and Resident #80's family member of the incident. She indicated she recently destroyed the copy of the A&I report she filled out because she thought it was no longer needed. RN #2 further identified Resident #80 walked around the unit alone and she did not know if Resident #80's picture was in the elopement book at the nurses station. Interview with LPN #8 on 2/24/2025 at 12:32 PM identified Security Guard #1 brought Resident #80 back to the unit after Resident #80 walked in the front door. LPN #8 identified that none of the staff on the unit knew how Resident #80 exited the unit and did not know how long Resident #80 was off the unit. LPN #8 identified she was not aware of the elopement book on the unit, that exit seeking was passed on in report, and she had not received in report that Resident #80 was exit seeking. LPN #8 further identified she did not complete an elopement assessment for Resident #80 after the elopement, and she did not recall receiving education on elopement except during orientation to the facility. Interview with the DNS on 2/24/2025 at 1:35 PM identified she had been notified by RN #2 that Resident #80 had gone outside through the stairwell door next to the Chapel, walked left out the door, and then walked to the front door and re-entered the facility where he/she was discovered by Security Guard #1 and brought back to the unit. The DNS identified she had not reported the 12/8/2024 incident of Resident #80 exiting the building unattended by staff because she was new to her position and did not know the criteria for defining an elopement. The DNS identified she did not perform further investigation of the incident beyond the investigation conducted by RN #2 on 12/8/2024. The DNS did not know how long Resident #80 was off the unit and had not reviewed the A&I report filled out by RN #2 after the incident. The DNS identified the criteria for a resident being entered into the elopement book was a resident having the ability to ambulate in addition to exit seeking behaviors. The DNS was unable to identify why Resident #80 was not in the elopement book. Interview with LPN #6 on 2/24/2025 at 3:00 PM identified the unit managers are responsible for updating the elopement books and was unable to identify why the elopement book had not been updated to include Resident #80's picture. Interview with Security Guard #1 on 2/25/2025 at 12:54 PM identified he was at his post at the front desk on the ground floor on 12/8/2025 when Resident #80 walked into the building through the front door wearing a long sleeved shirt and pants. Security Guard #1 identified he asked Resident #80 if he could help him/her but did not receive a response, and after asking multiple questions without a response, Resident #80 finally responded yes to living at the facility. Security Guard #1 identified he immediately brought Resident #80 to the first floor unit and indicated the staff were surprised to see Resident #80 with him. Security Guard #1 further identified he reviewed the camera at the front desk and saw Resident #80 exit the building through the stairwell door and turn left and walk straight to the front door and re-enter. Review of the Incidents and Accidents policy dated 12/23/2024 identified it is the policy to use the CT Accident and Injury form to report, investigate, and review accidents or incidents that occur, and elopement is listed in the policy as an incident requiring a report be written. Review of the Elopements and Wandering Residents policy identified residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered care plan addressing the unique factors contributing to wandering or elopement risk. The policy defined elopement as when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. The policy identified the facility is equipped with door locks and alarms to help avoid elopements, a photo of each resident deemed to be at risk for elopement will be placed at the front desk and each nurse's station, and adequate supervision would be provided to help prevent accidents or elopements.

Based on review of facility documentation, facility policy and interviews for 3 of 5 employee files, the facility failed to ensure that the required Communication training/in-service was completed. The findings include: 1. NA #1's date of hire was 12/11/24. Review of the facility documentation for NA #1 identified that she had worked in the facility between 1/28/25 and 2/13/25. Review of the employee file for NA #1 failed to identify that required Communication training/in-service had been provided and included in the files from the date of hire until present. Although requested, the facility could not provide documentation that the required Communication training had been completed for NA #1. 2. NA #2's date of hire was 12/23/24. Review of the facility documentation for NA #2 identified that she had worked in the facility between 1/28/25 and 2/13/25. Review of the employee file for NA #2 failed to identify that the required Communication training/in-service had been provided and included in the files from the date of hire until present. Although requested, the facility could not provide documentation that the required Communication training had been completed for NA #2. 3. NA #3's date of hire was 10/19/21. Review of the facility documentation for NA #3 identified that she had worked in the facility between 1/28/25 and 2/13/25. Review of the employee file for NA #3 failed to identify that the required Communication in-service training had been provided and included in the files from 2023 until present. Although requested, the facility could not provide documentation that a current required Communication training had been completed for NA #3. Interview and review of facility documentation with the Staff Development RN (RN #1) on 2/13/25 at 3:48 PM identified that she was unable to provide current documentation for the required Communication in-service training for NA #1, NA #2, and NA #3 because the prior staff development nurse did not keep good records. RN #1 indicated that it would have been the responsibility of the prior Staff Development nurse to ensure the required in-service training was completed, documented, and placed in the employee file. Although RN #1 provided in-service documents for NA #3 from 2023 she indicated that she could not locate the current required in-service documentation for NA #1, NA #2 or NA #3 for 2024 or 2025. RN #1 indicated that it is facility policy to have staff complete the required Communication in-service training upon hire and annually, but she had only worked at the facility since December of 2024. Interview and review of facility documentation with the Director of Nurses (DNS) on 2/13/25 at 3:52 PM identified that she was unable to locate the required Communication in-service training documentation for NA #1, NA #2 and NA #3 and that it would have been the responsibility of the prior Staff Development nurse to ensure the required in-service trainings were completed, documented, and placed in the employee file. The DNS identified it is facility policy that staff complete the required Communication in-service training upon hire and annually and that she and RN #1 would work on getting it completed. Review of the facility policy, Training, dated 2/2010, directed that the facility maintains an effective training program for all employees and the required annual in-service training of employees would be offered at the discretion of the Administrator and/or Department Head.

Based on review of facility documentation, facility policy and interviews for 3 of 3 nurse aides, the facility failed to provide required annual training. The findings include: 1. NA #1's date of hire was 12/11/24. Review of the facility documentation for NA #1 identified that she had worked in the facility between 1/28/25 and 2/13/25. Review of the employee file for NA #1 failed to identify that in-service training had been provided (Resident Rights, Dementia, Communication and Behavioral Health) and included in the files from the date of hire until present. Although requested, the facility could not provide documentation that the required trainings had been completed for NA #1. 2. NA #2's date of hire was 12/23/24. Review of the facility documentation for NA #2 identified that she had worked in the facility between 1/28/25 and 2/13/25. Review of the employee file for NA #2 failed to identify that in-service training had been provided (Resident Rights, Dementia, Communication and Behavioral Health) and included in the files from the date of hire until present. Although requested, the facility could not provide documentation that the required trainings had been completed for NA #2. 3. NA #3's date of hire was 10/19/21. Review of the facility documentation for NA #3 identified that she had worked in the facility between 1/28/25 and 2/13/25. Review of the employee file for NA #3 failed to identify that annual in-service training had been provided (Resident Rights, Dementia, Infection Control, Communication and Behavioral Health) and included in the files from 2023 until present. Although requested, the facility could not provide documentation that the required annual trainings had been completed for NA #3. Interview and review of facility documentation with the Staff Development Registered Nurse (RN #1) on 2/13/25 at 3:48 PM identified that she was unable to provide current documentation for the required in-service training for NA #1, NA #2 and NA #3 because the prior Staff Development nurse did not keep good records. RN #1 indicated that it would have been the responsibility of the prior Staff Development nurse to ensure the required in-service trainings were completed, documented, and placed in the employee file. Although RN #1 provided in-service documents for NA #3 from 2023 she indicated that she could not locate the current required in-service documentation for NA #1, NA #2 or NA #3 for 2024 or 2025. RN #1 indicated that it is facility policy to have staff complete the required in-service trainings upon hire and annually, but she had only worked at the facility since December of 2024. Interview and review of facility documentation with the Director of Nurses (DNS) on 2/13/25 at 3:52 PM identified that she was unable to locate the required in-service training documentation for NA #1, NA #2 and NA #3 and that it would have been the responsibility of the prior Staff Development nurse to ensure the required in-service trainings were completed, documented, and placed in the employee file. The DNS indicated that the facility did not have a staff person trained to conduct Dementia training and that the only staff person trained to conduct Dementia training worked in another building. The DNS identified it is facility policy that staff complete the required in-service trainings upon hire and annually and that she and RN #1 would start working on them. Review of the facility policy, Training, dated 2/2010, directed that the facility maintains an effective training program for all employees and the required annual in-service training of employees would be offered at the discretion of the Administrator and/or Department Head.

Based on facility documentation, facility policy and interviews for 4 of 6 employee files, the facility failed to ensure the required annual performance evaluations were completed. The findings include: 1. NA #3's date of hire was 10/19/21. No performance evaluation was identified in the employee's personnel file. Although requested, the facility could not provide annual evaluations for NA #3. 2. NA #4's date of hire was 6/6/18. No performance evaluation was identified in the employee's personnel file. Although requested, the facility could not provide annual evaluations for NA #4. 3. NA #5's date of hire was 10/20/21. No performance evaluation was identified in the employee's personnel file. Although requested, the facility could not provide annual evaluations for NA #5. 4. NA #6's date of hire was 3/1/95. No performance evaluation was identified in the employee's personnel file. Although requested, the facility could not provide annual evaluations for NA #6. Interview and review of facility documentation with the Director of Nurses (DNS) on 2/13/25 at 1:19 PM identified that performance evaluations would be in the employee's personnel file and that she was not aware that the evaluations had not been completed. The DNS indicated that the prior DNS would have been responsible for completing the performance evaluations and that she (the current DNS) had only been the DNS since December of 2024. The DNS identified that it is facility policy that performance evaluations be completed annually and that she would work on getting them completed. Review of the facility policy, Performance Evaluations, dated 7/2012, directed that employees will receive an evaluation after completing 90 days of consecutive service and then be placed on an annual schedule. The policy further directed that evaluations will be prepared by Supervisors, submitted to the Administrator for review and the evaluation would be maintained in the employee's personnel file.

Based on observations, interviews, and facility policy for 2 of 2 medication rooms reviewed for medication storage and lebeling, the facility failed to date 3 of 3 multi dose Tuberculin PPD vials upon opening. The findings included: During a review of the facility medication storage rooms on 2/13/25 at 10:17 AM, the following was identified: a. On the K1 unit a vial of Tuberculin PPD was stored in the refrigerator. The vial was noted to have been opened, was half full, without the benefit of being dated. b. On the K1 unit a vial of Tuberculin PPD was stored in the refrigerator. The vial was noted to have been opened, and was slightly more than half full, without the benefit of being dated. c. On the K2 unit a vial of Tuberculin PPD was stored in the refrigerator. The vial was noted to have been opened, was half full, without the benefit of being dated. Observation and interview of the K1 medication room with Registered Nurse (RN) #1 on 2/13/25 at 10:07 AM identified it is facility policy that the nurse who opens a multi-use vial dates it upon opening. Observation and interview of the K2 medication room with Licensed Practical Nurse (LPN) #1 on 2/13/25 at 10:51 AM identified it is facility policy for multi-use vials to be dated when opened. Interview with Pharmacist #1 on 2/13/25 at 2:15 PM identified multi use vials are good for 28-30 days, and should be dated upon opening. If a multi-use vial of tuberculin PPD is not dated, but used after 30 days of opening the efficacy of the medication and the accuracy of the Mantoux test (a diagnostic procedure that uses tuberculin PPD to detect latent tuberculosis infection) can be impacted. Review of the Multi-Dose Vials Policy dated 12/23/24 directed, in part, that multi-dose vials will be re-labeled with a beyond use date, 28 days after the vial is opened or punctured. The beyond use date rule will begin on the first day the multi-use vial is opened or punctured and the medication label will also include the initials of the nurse who opened the vial. The unit manager will perform random checks of opened multi dose vials for appropriate dating.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: Green, [NAME] Based on facility policy and interviews for 8 residents (Resident #7, Resident #13, Resident #24, Resident #39, Resident #62, Resident #72, Resident #73, and Resident #76) reviewed for Resident Council, the facility failed to provide a selective menu for residents to make selections for meals. 1. Interview with Resident #72 on 2/11/2025 at 11:25 AM identified he/she did not receive a selective menu and would like to be able to choose what he/she is served at mealtime. Resident #72 indicated food was often overcooked and meats tough. Interview with Resident #76 on 2/11/2025 at 2:00 PM identified Resident #76 did not know what he/she would be served at mealtimes until the tray arrived. Resident #76 indicated he/she was not provided a selective menu and indicated he/she would like a menu to choose from because he/she was served the same foods repeatedly. During the Resident Council meeting on 2/13/2025 at 1:30 PM Resident #7, Resident #13, Resident #24, Resident #39, Resident #62, and Resident #73 identified they did not fill out selective menus, staff did not review menus with them, and they did not know what they were being served until they received their meal. The residents identified that if they sent their meal back to the kitchen because they did not like what they were served, an alternative meal would take up to 30 minutes to be delivered. The residents further identified they wanted selective menus to make their own menu selections and identified that the same request had been made at previous Resident Council meetings. During the Resident Council meeting on 2/13/2025 at 1:30 PM Resident #13 identified he/she had not had a staff member review a menu with him/her in over 2 years. Interview with the Interim Dietary Manager on 2/25/2025 at 10:20 AM identified that there were not enough staff in the dietary department to help residents fill out selective menus. Review of the Selective Menus policy identified residents may be offered the option of selecting his/her menus. Selective menus are available to those residents who choose to make their own menu selections. The dietary staff will label menus with the resident's name, room number, and diet and deliver the menus to the residents, menus are returned to the dietary department once they are filled in.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record, facility policy and interviews for 4 of 4 residents (Resident #13, Resident #21, Resident #35, and Resident #57) reviewed for oxygen therapy, the facility failed to label, date and store oxygen tubing per facility policy. The findings include: 1. Resident #13 was admitted to the facility in July of 2022 and had diagnoses that included chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, and congestive heart failure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #13 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 15), received oxygen therapy, was independent with eating, and required partial/moderate assistance with bed mobility and transfers. The Resident Care Plan (RCP) dated 2/5/2025 identified Resident #13 was at risk for altered cardiopulmonary status. Interventions included changing oxygen tubing weekly and monitor oxygen concentrator every shift. Observation on 2/13/2025 at 9:17 AM identified an unlabeled oxygen nasal cannula connected to an oxygen concentrator belonging to Resident #13. Observation on 2/19/2025 at 7:59 AM identified an unlabeled oxygen nasal cannula connected to an oxygen concentrator belonging to Resident #13. Interview with Licensed Practical Nurse (LPN) #2 on 2/19/2025 at 12:25 PM identified it was the responsibility of the 11 PM to 7 AM shift nursing staff to label and date oxygen tubing weekly. Interview with Registered Nurse (RN) #4 on 2/19/2025 at 2:35 PM identified that she changed, labeled and dated all oxygen tubing on Sundays during the 11 PM to 7 AM shift. RN #4 further identified that if any resident's tubing was not labeled and dated she must have missed labeling that tubing. Review of the Physician Order Report dated 2/1/2025 through 2/20/2025 identified a provider order (order start date 2/19/2024) which directed to change oxygen tubing weekly on Sundays during the 11 PM to 7 AM shift. Review of the Treatment Administration History report for February of 2025 identified RN #4 documented the order for the oxygen tubing change as administered on 2/9/2025 and 2/16/2025. 2. Resident #21 was admitted to the facility in August of 2024 and had diagnoses that included Alzheimer's disease, chronic obstructive pulmonary disease (COPD), and diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #21 was severely cognitively impaired, required substantial/maximal assistance for eating and bed mobility, and dependent for transfers. The Resident Care Plan (RCP) dated 1/8/2025 identified Resident #21 was at risk for altered cardiopulmonary status. Interventions included assessing lung sounds per provider orders and consult with respiratory therapist as needed. The RCP failed to identify changing and labeling of the nasal cannula oxygen tubing per facility policy. A provider order dated 1/30/2025 directed to change oxygen tubing weekly on Sundays during the 11 PM to 7 AM shift and included instructions which directed to place the tubing in a labeled bag and to not leave the tubing exposed. A provider order dated 2/1/2025 directed to administer oxygen continuously at 2 LPM via nasal cannula. Observation on 2/11/2025 at 11:12 AM identified an unlabeled oxygen nasal cannula connected to an oxygen concentrator belonging to Resident #21. A provider order dated 2/18/2025 directed to administer oxygen at 2 LPM via nasal cannula as needed for comfort. Observation on 2/19/2025 at 7:32 AM identified Resident #21's oxygen concentrator was turned off with a labeled oxygen nasal cannula oxygen disconnected from the oxygen concentrator and lying uncovered on a chair on top of a blanket. Observation on 2/19/2025 at 12:25 PM identified Resident #21's oxygen concentrator was off with two separate labeled oxygen nasal cannulas laying on top of the oxygen concentrator with one hanging approximately 2 inches from the top of a trash can. Interview with Licensed Practical Nurse (LPN) #2 on 2/19/2025 at 12:25 PM identified it was the responsibility of the 11 PM to 7 AM shift to label and date oxygen tubing weekly. LPN #2 identified the two unbagged oxygen nasal cannulas on top of the oxygen concentrator should not have been exposed and she removed the tubes and discarded them. Interview with Registered Nurse (RN) #4 on 2/19/2025 at 2:35 PM identified that she changed, labeled and dated all oxygen tubing on Sundays during the 11 PM to 7 AM shift. RN #4 further identified that if any resident's tubing was not labeled and dated she must have missed labeling that tubing. Review of the Medication Administration Record for February of 2025 identified RN #4 documented the order for the oxygen tubing change as administered on 2/9/2025 and 2/16/2025. 3. Resident #35 was admitted to the facility in October of 2023 and had diagnoses that included congestive heart failure (CHF), chronic kidney disease, and obstructive sleep apnea. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #35 was moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 10), received oxygen therapy, and was independent with eating, bed mobility, and transfers. The Resident Care Plan (RCP) dated 2/13/2025 identified Resident #35 was at risk for altered cardiopulmonary status. Interventions included assessing lung sounds per provider orders and change oxygen tubing weekly as scheduled. Observation on 2/13/2025 at 9:21 AM identified an oxygen nasal cannula connected to an oxygen concentrator, belonging to Resident #21, labeled with a date of 2/3/2025. Observation on 2/20/2025 at 10:30 AM identified an oxygen nasal cannula connected to an oxygen concentrator, belonging to Resident #21, labeled with a date of 2/3/2025. Interview with Licensed Practical Nurses (LPN) #5 on 2/24/2025 at 12:55 PM identified she changed oxygen tubing on Sundays during the 11 PM to 7 AM shift and did not know why Resident #35 ' s oxygen tubing was not labeled and dated. Review of the Physician Order Report dated 2/1/2025 through 2/25/2025 identified a provider order (order start date 3/22/2024) which directed to administer oxygen continuously via nasal cannula at 2 liters per minute (LPM). Review of the Physician Order Report dated 2/1/2025 through 2/25/2025 identified a provider order (order start date 3/22/2024) which directed to change oxygen tubing every weekly on Sundays during the 11 PM to 7 AM shift. Review of the Treatment Administration History report for February of 2025 identified LPN #5 documented the order for the oxygen tubing change as administered on 2/2/2025 and 2/16/2025. 4. Resident #57 was admitted to the facility in January of 2022 and had diagnoses that included pneumonia, dysphagia, and chronic kidney disease. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #57 was moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 12), required setup or clean-up assistance with eating, and was dependent for bed mobility and transfers. Observation on 2/11/2025 at 12:45 PM AM identified an unlabeled oxygen nasal cannula connected to a portable oxygen tank belonging to Resident #57. Observation on 2/13/2025 at 10:41 AM identified an unlabeled oxygen nasal cannula connected to an oxygen concentrator belonging to Resident #57. The Resident Care Plan (RCP) dated 2/17/2025 identified Resident #57 was at risk for altered cardiopulmonary status. Interventions included assessing lung sounds per provider orders and consult with respiratory therapist as needed. The RCP failed to identify changing and labeling of the nasal cannula oxygen tubing per facility policy. Observation on 2/19/2025 at 7:40 AM identified an unlabeled oxygen nasal cannula connected to an oxygen concentrator belonging to Resident #57. Interview with Licensed Practical Nurse (LPN) #2 on 2/19/2025 at 12:25 PM identified it was the responsibility of the 11 PM to 7 AM shift to label and date oxygen tubing each week. Review of the Physician Order Report dated 2/1/2025 through 2/20/2025 identified a provider order (order start date 2/9/2025) which directed to change oxygen tubing weekly on Sundays during the 11 PM to 7 AM shift and included instructions which directed to place tubing in a labeled bag and not leave tubing exposed. Review of the Treatment Administration History report for February of 2025 identified RN #4 documented the order for the oxygen tubing change as administered on 2/9/2025 and 2/16/2025. Interview with Registered Nurse (RN) #4 on 2/19/2025 at 2:35 PM identified that she changed, labeled and dated all oxygen tubing on Sundays during the 11 PM to 7 AM shift. RN #4 further identified that if any resident's tubing was not labeled and dated she must have missed labeling that tubing. Review of the Oxygen Administration Policy directed that oxygen is administered under orders of the provider, the resident's care plan shall identify the interventions for oxygen therapy, to change oxygen tubing/nasal cannula weekly and as needed if soiled or contaminated, and keep oxygen delivery devices (tubing) in a plastic bag when not in use.

Based on observations, review of the clinical records, facility documentation, facility policy and interviews for 2 of 2 nursing units, the facility failed to ensure residents who did not meet clinical criteria to reside on a locked unit were provided with a method of opening doors independently. The findings include: Observations on 2/11/2025, 2/13/2025, 2/18/2025, 2/19/2025, 2/20/2025, 2/21/2025, 2/24/2025 and 2/25/2025 identified both nursing units: first floor (unit K1) and second floor (unit K2), had secured doors for entering and exiting the units to both stairwells and the elevator. A number code entered into a keypad was required to open the doors. Intermittent observation on all survey days identified only facility staff inputting the code for visitors and residents to enter and exit the units. Additionally, signage on the doors instructed to call a phone number if staff were not available to open the doors and to avoid knocking on the window/door to obtain staff members attention for opening the doors. Review of the Elopement Risk report dated 2/20/2025, for unit K1 identified 32 residents (Resident #12, Resident #15, Resident #17, Resident #21, Resident #24, Resident #26 , Resident #37, Resident #38, Resident #42, Resident #49, Resident #52, Resident #56, Resident #57, Resident #61, Resident #62, Resident #65, Resident #66, Resident # 67, Resident #73, Resident #81, Resident #84 , Resident #192 , Resident #193, Resident #194, Resident #195, Resident #196, Resident #197, Resident #198, Resident #199, Resident #200, Resident #201, and Resident #202) who were not at risk for elopement, Review of the Elopement Risk report dated 2/20/2025, for unit K2, which was equipped with a Wander Guard system (safety system that utilizes bracelets and door sensors to alert caregivers when a resident approaches the monitored area) identified 31 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #18, Resident #20, Resident #23, Resident #27, Resident #28, Resident #30, Resident #36, Resident #40, Resident #45, Resident #46, Resident #50, Resident #51, Resident #53, Resident #54, Resident #58, Resident #59, Resident #64, Resident #68, Resident #70, Resident #75, Resident #76, Resident #78, Resident #82, Resident #86, and Resident #203) who were not at risk for elopement. Although requested, the facility was unable to identify or provide a risk assessment for any residents residing on the secured/locked units or criteria for requiring a secured/locked unit. Interview on 2/19/2025 at 9:35 AM with LPN #1 identified that the unit doors were locked and residents needed to be accompanied by a staff member to different units or the lobby. LPN #1 indicated no residents were allowed off the unit without a staff member, independent/cognitively intact residents included. Interview with the Chief Operations Officer (COO) on 2/19/25 at 3:35 PM identified that both units were locked, unit K2 was equipped with a Wander Guard system and an Elopement Risk assessment was performed for all residents upon admission to the facility. Interview on 2/20/2025, at 3:35 PM with the Maintenance Director identified that the State Agency's Building Fire Safety Inspection on 2/6/2025 recommended the facility install delayed egress hardware because the existing keypad system prohibited anyone from leaving the units. Observation on 2/20/2025, at 3:55 PM, on the elevator from the first floor to the second floor, identified Resident #23 exited the elevator to the second floor and was unable to enter the unit because he/she did not have the code to the keypad. Resident #23 began to panic and stated to the surveyor let me in, please let me in. The surveyor entered the code and entered unit K2 with Resident #23. Observation of the unit identified that no staff were present near the door to the elevator and the closest staff identified were approximately 15 to 20 feet away, near the nurse's station, on the opposite side of the elevator. Interview on 2/20/2025, at 3:55 PM with NA #3 identified that Resident #23 was a resident on unit K2. NA #3 identified that a staff member should have accompanied Resident #23 from the first floor to the second floor and that Resident #23 should have knocked on the door to enter the unit if he/she was alone when he/she exited the elevator to obtain attention from a staff member to open the locked door. Interview on 2/25/25 at 9:41 AM with the DNS identified that independent residents residing on unit K1 were provided the keypad code to freely enter and exit the unit while independent residents residing on unit K2 (unit equipped with a Wander Guard system) were not provided with the keypad code. The DNS was unable to explain how the facility would ensure residents provided with the keypad code would know to secure the door behind them when entering or exiting the unit or how they would know what residents were not permitted to leave the units. The DNS further identified that the facility had no strategy to secure only the residents who were identified as elopement risks and identified all residents, whether or not an elopement risk, were scattered throughout both units indicating the need to secure both units in entirety. Although requested, a facility policy for secured/locked units was not provided. Although requested, a facility policy for assessment/criteria for placement on a secured/locked unit was not provided. A review of the Elopement and Wandering Resident policy identified, in part, that the facility ensures that residents that exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered care plan addressing the unique factors contributing to wandering or elopement risk. The policy further identified that the facility is equipped with door locks and alarms to help avoid elopement. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring effectiveness and modifying interventions when necessary.

Based on the tour of the Dietary Department, observations, staff interview, facility documentation and facility policy, the facility failed to ensure the Dietary Department served food at temperatures outside of the danger zone and failed to maintain dishwasher hot water temperatures at or above 160 degrees Fahrenheit. The findings included: 1. Observation of the tray line on 2/18/2025 at 12:49 PM identified a test tray was placed on the last meal delivery cart which was brought to the first floor. The meal delivery cart lacked doors and resembled a commercial sheet pan rack. The meal plates were covered with hard plastic covers and did not contain warming pellets. The test tray was the last tray served on the first floor. On 2/18/2025 at 1:00 PM the surveyor and [NAME] #1 obtained temperatures of the test tray food which identified the vegetable temperatures as follows: Surveyor temperature: 121.5 degrees Fahrenheit, [NAME] # 1 temperature:122.5 degrees Fahrenheit Interview on 2/18/2025 at 1:00 PM with [NAME] #1 identified that the meal delivery carts did not contain covers or doors and that a pellet system (heating system to keep plates warm to maintain food temperatures) was not used for food that is transported from the kitchen to resident rooms and dining rooms. Interview on 2/19/2025, at 9:47 AM with the Interim Dietary Director identified the meal delivery carts had always been uncovered and that a pellet system had never been used. Observation on 2/19/2025 at 12:21 PM identified a test tray was placed on the last meal delivery cart which was brought to the first floor. On 2/19/2025 at 12:25 PM the surveyor and [NAME] #1 obtained temperatures of the test tray food which identified the vegetable temperatures as follows: Surveyor temperature: 129.9 degrees Fahrenheit, [NAME] # 1 temperature:130.1 degrees Fahrenheit Interview on 2/19/2025 at 12:25 PM with [NAME] #1 identified that the food temperatures were low. Review of the policy Food Safety Handling identified danger zone food temperature are between 41 degrees Fahrenheit and 135 degrees Fahrenheit and allow for rapid growth of pathogenic microorganisms that can cause food borne illnesses. Holding hot food temperature to minimize the growth of microorganisms after food has been cooked to its proper temperature should be held at or above 135 degrees Fahrenheit until it is served. Appropriate food transport equipment is to be used to maintain safe temperatures for food while transporting the food in the facility to help minimize the risk of foodborne illness. 2. Observation on 2/24/2025 at 10:59 AM identified the dishwasher hot water temperatures were 149 to 150 degrees Fahrenheit and should have been 160 degrees Fahrenheit according to the label on the dishwasher temperature gauge. Interview on 2/24/2025 at 11:02 AM with the Dietary Manager identified that after several cycles of washing, the wash temperature did not rise above 150 degrees Fahrenheit which is below the standard of 160 degrees Fahrenheit. The Dietary Manager indicated he would notify the Maintenance Director and Ecolab (dishwasher servicer) of the low water temperatures. Subsequent to surveyor inquiry, the dishes were rewashed and sanitized in the 3 bay sink. Observation on 2/24/2025 at 1:20 PM identified that a Ecolab servicer was evaluating the dishwasher and identified a damaged terminal which he was replacing. The dishwasher temperatures were at 170 degrees Fahrenheit after the terminal was replaced. Review of food safety best practices from Ecolab identified, in part, a malfunctioning or improperly maintained machine that fails to clean tableware adequately can increase the risk of cross-contamination the next time it comes into contact with food or beverages. To help ensure that your machine functions as it should to effectively clean dishes and destroy harmful microorganisms, perform these steps: Inspect racks for damage and replace them when necessary. For conveyer-style machines: check the gauges and compare their readings with the minimum temperatures, chemical concentrations and pressure measurements listed on the data plate: High-temperature, or heat-sanitizing, machines will show a minimum rinse temperature of 180°F and minimum wash temperatures of 150°F, 155°F or 160°F, depending on machine type and make and model.

**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 had an open area and required daily wound treatments, the facility failed to ensure the physician's order was followed and wound care was conducted daily. The findings include: Resident #1's diagnoses included rhabdomyolysis, anxiety, depression, heart failure, and age-related cognitive deficit. A physician's order dated 3/1/24 directed to apply a dry, clean dressing to the left outer knee skin tear and monitor the left knee skin tear for signs and symptoms of infection daily on the evening shift. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 made reasonable and consistent decisions regarding tasks of daily life, required extensive assistance with turning and repositioning and had a skin tear with the application of a non-surgical dressing. The Resident Care Plan dated 2/29/24 identified a potential for skin breakdown. Interventions directed to perform all skin and wound treatments as ordered. The nurse's note dated 3/9/24 at 8:48 PM identified the skin tear dressing on Resident #1's left outer knee was dated 3/4/24 on the 3-11PM shift. The note identified the wound had a moderate amount of yellow, thick discharge, measured 3.3 centimeters (cm) by 4.0 cm and the treatment in place was performed. The Facility Reportable Incident form dated 3/9/24 identified Resident #1 had an order for a dry, clean dressing dated 3/1/24. The form indicated on 3/9/24, it was noted that the dressing was last changed on 3/4/24 on the evening shift. The report identified the dressing change was signed off by the 3-11PM charge nurse on March 6, 7, and 8, 2024 as being completed but it was discovered that the wound care had not been performed since 3/4/24. The March 2024 Medication Administration Record (MAR) identified the treatment for the dry, clean dressing was not signed off by any nurse on 3/5/24 and was signed off by as being completed on 3/6/24, 3/7/24, and 3/8/24. A physician's order dated 3/9/24 identified the skin tear treatment was changed to cleanse with Normal Saline or Wound cleanser, pat dry, apply Manuka [NAME] Honey, followed by a dry, clean dressing, change daily. An interview was conducted on 4/15/24 at 10:10 AM with the 3-11PM charge nurse, Licensed Practical Nurse (LPN) #4. LPN #4 stated she was assigned to Resident #1 on the dates of 3/6/24 through 3/8/24, she did not perform the wound care during those shifts and could not give a reason as to why she did not perform the wound care. Interview with the wound care nurse, LPN #6, on 4/15/24 at 1:48 PM identified Resident #1 was admitted with a skin tear to his/her left lower extremity and there was a treatment in place on admission. LPN #6 stated it was discovered that the wound care treatment was not performed on the dates of 3/6/24, 3/7/24 and 3/8/24 when the skin tear was assessed on 3/9/24 and the wound had some purulent drainage. LPN #6 identified Resident #1 was then placed on the list to be seen by the wound care physician. LPN #6 identified the facility policy directed to follow all physician orders for treatment to a wound. Interview with the Director of Nursing (DON) on 4/15/24 at 2:01 PM identified Resident #1's wound care had not been performed for the dates of 3/6/24, 3/7/24, and 3/8/24 even though LPN #4 had signed off in the MAR that the treatments were done. The DON identified the investigation concluded LPN #4 had not performed the wound care as ordered by the physician and the facility policy directs to always follow physician orders. Review of the facility policy titled Clean Dressing Change, undated, directed, in part, it is the policy of the facility to provide wound care in a manner to decreased potential for infection and/or cross contamination and physician's orders will specify the type of dressing and frequency of changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policy and interviews for one of four sampled residents (Resident #2) who were reviewed for medication administration, the facility failed to administer the correct intravenous solution as prescribed by the physician. The findings include: Resident #2's diagnoses included dementia, protein and calorie malnutrition and failure to thrive. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 made reasonable and consistent decisions regarding tasks of daily life and required set-up with meals. The Resident Care Plan dated 10/18/23 identified the need for adequate nutrition and hydration. Interventions directed to allow ample time to consume meals, consult registered dietitian (RD) as needed, diet as ordered: regular, thin liquids, encourage completion of meals and fluids on tray, offer fluids between meals, selective menu, update dietary preferences as needed and snacks and beverages as desired. A physician's order dated 12/1/23 directed to administer Dextrose 5% and 0.9% Sodium Chloride solution (a fluid and electrolyte replenishment and caloric supply) at 100 milliliters (ml) per hour, give three (3) liters intravenously (IV) for poor po intake and fluids. The nurse's note dated 12/3/23 at 2:36 AM identified at 11:55 PM on 12/2/23 Resident #2 complained of discomfort at the IV site in the right forearm and slight swelling and erythema were noted. The note identified the IV was shut off with approximately 200 ml left in the bag, the Advanced Practice Registered Nurse (APRN) was notified the IV line had infiltrated and the IV solution that was hanging at the time was a one (1) liter bag of Sodium Chloride 0.9% instead of the Dextrose 5% and 0.9% Sodium Chloride as prescribed by the physician and no new orders were given. An interview was conducted on 4/15/24 at 9:30 AM with the 7AM-3PM charge nurse, Licensed Practical Nurse (LPN) #2. LPN #2 identified she hung the IV solution right before she left the building, and she could not recall the circumstances regarding Resident #2 being given the wrong IV solution. Interview with the Director of Nursing (DON) on 4/15/24 at 2:01 PM identified LPN #2 had admitted to her that she hung the wrong IV solution on 12/2/23. The DON identified the facility policy directs to use the five (5) rights of medication administration prior to giving any medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policy and interviews for one of four sampled residents (Resident #12) who were reviewed for medication administration, the facility failed to ensure a medication to treat Resident #12's anxiety was not discontinued without a physician's order to prevent the omission of several doses. The findings include: Resident #12's diagnoses included Paranoid schizophrenia. The quarterly Minimum Data Set, dated [DATE] identified Resident #12 made reasonable and consistent decisions regarding tasks of daily life and received antipsychotic, antianxiety and antidepressant medications. The Resident Care Plan dated 1/1/24 identified a potential or alteration in mood as related to schizophrenia. Interventions directed to allow for expression of feelings as desired, medicate per the physician order, monitor safety, observe mood state, provide emotional support and reassurance, and update physician on onset of new symptoms. A physician's order dated 1/22/24 directed to administer a medication for anxiety Ativan 0.5 milligrams (mg) once a day in the morning and Ativan 0.5 mg give two (2) tablets (a total dose of one (1) mg) three (3) times a day at 1:00 PM, 5:00 PM, and 9:00 PM. The nurse's note dated 3/6/24 at 2:53 PM identified Resident #12 had increased anxiety, irrational thinking, and paranoid thoughts, the psych Advanced Practice Registered Nurse (APRN) was contacted, and an order was obtained to send Resident #12 to the Emergency Department (ED) for evaluation. The APRN note dated 3/6/24 at 3:11 PM identified the APRN was asked to see Resident #12 for increased anxiety and agitation and Resident #12 had stated he/she wanted to go back to the geri-psych unit at the hospital. The note identified the scheduled doses of Ativan were stopped one (1) week prior, Ativan 1 mg was administered immediately, the Ativan was resumed, and there was a concern Resident #12 was experiencing Ativan withdrawal and needed to be seen urgently in the hospital for possible psych admission for behavioral issues. The Facility Reported Incident form dated 3/6/24 at 9:00 AM identified Resident #12 missed several doses of Ativan due to a transcription error, the APRN was notified, Resident #12 was sent to the ED for evaluation and subsequently admitted to the hospital. Review of the February and March 2024 Medication Administration Records identified the last doses of Ativan were administered on 2/21/24, therefore Resident #12 missed receiving fourteen (14) doses of Ativan 0.5 milligrams (mg) once a day in the morning and forty-two (42) doses of Ativan 0.5 mg give two (2) tablets three (3) times a day at 1:00 PM, 5:00 PM, and 9:00 PM. An interview was conducted on 4/15/24 at 12:14 PM with the Nursing Supervisor, Registered Nurse (RN) #3. RN #3 stated she took the verbal order from the psychiatric physician for Resident #12's Ativan and put an end date on the order when she transcribed the order into the electronic medical system. RN #3 identified when Resident #12 returned from the physician's appointment, she called the office for clarification of the times of the doses on the order and was given a stop date as the physician had indicated he wanted to taper the dose, but she did not put the information in her nurse's note or in the transcription of the order. Interview with the Director of Nursing (DON) on 4/15/24 at 2:01 PM identified RN #3 transcribed the order for Resident #12's Ativan with a stop date. The DON stated scheduled psychotropic medications are not given a stop date so that they do not fall off the orders, and only as needed psychotropics require a stop date. The DON indicated there was no written note that identified there was a stop date given by the psychiatric physician for the medication. Review of the facility policy titled Medication Administration, undated, directed, in part, medications are administered by licensed nurses, or other staff who are legally authorized to do so in the state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Additionally, the policy directed, in part, ensure that the six rights of medication administration are followed: right resident, right drug, right dosage, right route, right time and right documentation; review the medication administration record (MAR) to identified medication to be administered, and compare medication source (bubble back, vial, etc.) with the MAR to verify resident name, medication name, form dose, route and time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy review and interviews for 1 of 3 residents (Resident #61) reviewed for Advanced Directives, the facility failed to obtain a physician's order reflecting a change from Do Not Resuscitate to the resident's choice of CPR. The findings include. Resident #61's diagnoses included Type 2 diabetes mellitus, hypertension, and anxiety. A physician's order dated [DATE] directed to Do Not Resuscitate for code status. The Resident Care Plan (RCP) with a start date of [DATE] for Advanced Directives had an intervention Do Not Resuscitate (DNR). The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 61 had a moderate cognitive impairment and the resident required extensive assistance with most Activities of Daily Living (ADL). Resident #61's Cardiopulmonary Resuscitation (CPR) form indicated the resident's desire for CPR to be initiated, signed by the resident on [DATE]. A quarterly MDS assessment dated [DATE] indicated no cognitive impairment and extensive assistance with most ADL. The Care Plan dated [DATE] for Advanced directives noted interventions in part, DNR. On [DATE] at 2:30 PM interview and clinical record review with Licensed Practical Nurse (LPN#4) indicated the electronic medical record chart screen identified Full Code Status upon review of a document dated [DATE] which indicated a request by the resident for Full code (CPR). Further clinical record review with LPN #4 identified current physician's orders directed Do Not Resuscitate. LPN #4 located a nurse's note dated [DATE] which indicated Resident #61 requested full code status and the paperwork was signed. However, the nurses noted [DATE] did not indicate that a physician's order was obtained for the Full Code. In the event of an emergency when a resident's code status needed to be determined, LPN #4 indicated she would look at the physician's orders to determine whether to provide or not provide CPR. LPN#4 indicated the Advanced Practice Registered Nurse (APRN) was in the building and she would have the APRN address this concern. LPN#4 indicated that she did not know why the code status was not changed on [DATE]. On [DATE] at 1:00 PM an interview with the Director of Nursing Service (DNS) indicated Advanced Directives are the nursing supervisor's responsibility on admission to complete and both the nursing supervisor and the nurse on duty on consult with each other. The DNS further indicated that advanced directives are reviewed periodically at the care plan meetings by the MDS nurse. Review of the facility policy labeled Advanced Directive Policy indicated in part, an Advanced Directive should be identified after admission to the facility, consent forms will be signed, and an order will be entered into the electronic order system.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policy, and interviews for 2 residents (Resident #9 and Resident #60) reviewed for nutrition, the facility failed to address a significant weight discrepancy according to policy by failing to notify the APRN and dietician of a significant weight discrepancy. The findings included: 1. Resident #9 was admitted with diagnoses that included schizophrenia, diabetes, and stomach reflex disease. Resident #9's monthly weight for November dated 11/11/22 at 11:00 AM was 177 pounds (lbs.). An annual Minimum data set (MDS) assessment dated [DATE] identified Resident #9 was severely cognitively impaired requiring extensive help of 1 staff member for personal hygiene and eating. The recorded weight for Resident #9 was 177 lbs. A care plan last reviewed on 12/14/22 identified Resident #9 had an identified need for adequate nutrition and hydration with a goal to maintain a stable weight. Interventions included for Resident # 9 to sit upright with head of bed at 90 degrees to prevent aspiration, to supervise all feedings and to offer substitutes for uneaten food at meals. Resident #9's weight on 12/16/22 at 7:06 AM was recorded as 153.4 lbs. A loss of 23.6 lbs. or 13.3 percent weight loss. A physician's order active for December 2022 directed that Resident #9 be given a regular, mildly thick, pureed diet and to assisted with meals with a 2 handled sippy cup, small bites, and pacing. Aspiration precautions and for the resident to be supervised for all meals. An APRN note dated 12/1/22 at 12:36 PM identified Resident #9 had dark vomitus over the weekend, no nausea or abdominal tenderness noted. A weight was not recorded. An annual nutritional assessment dated [DATE] at 8:04 PM identified Resident #9 was not on nutritional supplements and Resident #9's weight had been stable for the past 6 months. The nutritional goals were for the resident to have no significant weight changes and staff was directed to monitor. An APRN follow up note dated 12/21/22 at 12:11 PM identified Resident #9 weight was 153.6 lbs.; the note does not address the resident's weight loss of 12/16/22. A nursing progress note dated 12/25/22 at 10:42 PM identified Resident # 9 was holding/pocketing food. A nursing progress note dated 12/27/22 at 10:32 PM identified Resident #9 required a reweight in the morning. Resident # 9's weight on 12/28/22 at 1:24 PM was recorded as 155 lbs. (consistent with the 12/16/22 recorded weight of 153.6 that demonstrated a 13% weight loss for Resident #9). Interview and review of the medical record with the Dietician on 1/3/23 at 1:30 PM identified on 11/11/ 22 at 11:00 AM, Resident # 9's weight was documented as 177 lbs.; the next weight recorded on 12/16/22 at 7:06 AM was 153.4 lbs. The Dietician commented that would be a big drop for 1 month for Resident #9 and indicated she was not contacted regarding the 12/16/22 weight. She indicated that she would have first asked for a reweigh to verify the weight and if confirmed, she would have evaluated the resident. She further stated that she only works 24 hours on Monday, Tuesday, and Wednesday. The nursing staff could call her or tell her face to face when she is in the facility, but the facility process is for the nursing staff to email her for any nutrition concerns. She continued by stating that she would expect a reweigh automatically by the nursing staff if the weight is significantly different from the last weight and she did not know why one was not done on 12/16/22. She would expect an email notification regarding Resident #9's 12/16/22 weigh as it was roughly a 13% difference from Resident #9's last weight. An email is the standard method to contact her plus 12/16/22 was a Friday, and she would have not been on site at the facility on that day. She continued by stating she had become aware of the Resident #9's recorded weight from 12/16/22 during her end of the month reconciliation where she checks all resident's weights to be sure the weights were completed for the month. She is new to the facility, and this is a process she did prior to her employment at the facility. Upon completing the end of December 2022 reconciliation that she began on 12/27/22, she identified Resident #9's recorded 12/16/22 weight and requested a reweigh at that time. She identified that she had not had a discussion with the APRN regarding the Resident #9's weight change as she wanted to get a reweigh to confirm. During interview and review of Resident #9's medical record with Dietician on 1/3/23 at 1 :30 PM identified Resident #9s documented reweight on 12/28/22 at 1:24 PM was 155 lbs. She continued by stating she was not contacted with the 12/28/22 reweigh results and had just identified the results during this interview and review of the medical record Resident#9's weight was recorded as 155 lbs. consistent with the 12/16/22 documented weight of 153.4 lbs (13 % weight loss), Interview with Director of Nurses (DNS) 1/3/22 at 1:50 PM identified if staff weigh a resident and there's a significant change, she expects them to reweigh the resident within a few days. If the reweigh confirmed the original weight and the weight change was 5% loss or gain, they should contact the dietician and the APRN immediately or at least by the next day, The nursing staff should contact them directly by phone or face to face if either the APRN or dietician are on site but if not, they can email them. Interview and review of the medical record with the DNS on 1/3/22 at 2:00PM identified Resident #9 had a weight loss between her/his November 2022 weight and the 12/16/22 weight. She continued by identifying Resident #9 should have been reweighed to determine accuracy of the weight within a few days of the inconsistent weight. If the reweight was consistent, the nurse should have documented and contacted the dietician, family and APRN. The DNS further indicated with Resident #9's 12/16/22 weight, the supervisor should have been notified who would have directed the staff to reweigh the resident, she was unclear as to why the nurses did not document in the progress notes or notify anyone of Resident #9's 12/16/22 weight. She continued by identifying that a reweight was completed on 12/28/22 and it was consistent with the 12/16/22 documented weight. The DNS also indicated that the expectation is if the Dietician requests a reweigh, the dietician should be contacted with the results. For Resident #9, reviewing the recorded weights, the staff was expected to contact the Dietician and the APRN immediately after completing the 12/28/22 weight by email or at least by the next day. Resident #9's weight on 1/3/23 at 2:33 PM was recorded as 146.8 lbs. A loss of an additional 6.2 lbs. from the 12/16/22 recorded weight and a loss of 8.2 lbs. or 5% in 1 week (since the 12/28/22 recorded weight of 155 lbs.). A dietician note dated 1/3/23 at 3:43 PM subsequent to surveyor's observations identified Resident #9 has had 6% weight loss times 30 days and 21% weight loss times 180 days with recommendations to increase choice with meals, discontinuing controlled carbohydrate diet (CCHO) and to start a nutritional supplement 120 milliliters (mls.) 3 times a day (provides an extra 720 calories and 30 grams of protein) to better meet nutritional needs and address weight loss. Additionally start weekly weights times 4 weeks. The dietician identified that Resident #9 from July 2022 to September 2022 consumed 50- 100% of meals with an occasional 25% meal intake and from October 2022 to date, Resident #9 consumed 25% to 100% of meals. A psychiatric APRN note dated 1/3/23 at 6:54 PM identified staff reports that Resident #9 has a good appetite, and that weight is stable and unchanged and to continue gradual dose reduction of antipsychotic medications. Interview with LPN #8 on 1/4/23 at 9:00 AM identified when a resident is due to get her/his weight done, the assigned NA obtains the weight. The NA reports the weight to the nurse so it can be entered into the medical record. The nurse then compares the reported weight to any previous weights and if there was either a 5lb weight loss or gain, the supervisor is notified who would then notify the dietician and APRN by email. Interview with LPN #5 ( nursing supervisor) on 1/4/22 at 9:30 AM identified the NA gets the weight either by Hoyer, wheelchair or bed side scale- depending on the resident, reports /records the weight for the nurse, the nurse would look at previous weights and determine if there was a 5lb plus or loss, if there was they should notify the dietician and the APRN either by calling them directly If they are here, if not an email notification is sent, usually by the supervisor but nursing can send it too. She also indicated that she was not on when the 12/16/22 weight was completed and although she attempted to contact LPN #10, LPN #10 has been out sick. LPN #5 identified that she did not know why LPN #10 did not contact the dietician, but she would have expected LPN #10 to reweigh Resident #9 on 12/16/22. If the reweigh confirmed the weight, the Dietician and the APRN should have been contacted. She continued by indicating that she did the reweigh on 1/3/22 after the Dietician contacted her directly, she continued by stating that when the APRN rounds today she would let her know. Review of the medical record and interview with LPN #5 on 1//4/22 at 9:40 AM identified that she reconciles weights at the beginning of the month for the previous month and had not been notified of the 12/16/22 weight or the 12/28/22 weight. She continued by stating that she had noticed the 12/28/22 weight when she was starting her reconciliation and that the dietician contacted her the same day she saw it, on 1/3/22. She identified the APRN note dated 1/3/22 was documented by the Psychiatric APRN who had indicated Resident #9's weight was stable and that the Psychiatric APRN was primarily focused on Resident #9's gradual dose reduction of her/his psychiatric medications. She continued by stating that there is also an APRN communication book used primarily for the medical APRN. Interview and review of the APRN book with LPN #5 at the time of the interview identified the APRN book lacked any documentation of Resident #9's weights for 12/16/22 or 12/28/22. Interview and review of Resident #9's medical record with APRN #2 on 1/4/23 at 11:00 AM identified that although she documented in her not on 12/21/22 at 12:11 PM Resident #9 weight was 153.6 lbs., she had not been notified that this was a significant change for the resident. The note was a follow up note as Resident #9 had had some issues earlier in the month. If the staff had noted a significant change, they would email me or if not, urgent they could put it in the communication book on the unit. The facility utilizes an email communication is sent to the dietician and me. She continued by stating that she would have expected an email notification of the weight discrepancy on 12/16/22 once it was confirmed by reweigh, she thought a reweigh would have been completed within a few days of the first weight discrepancy as well as the reweigh on 12/28/22 since it confirmed the weight loss, Interview with LPN #7 on 1/4/22 at 11:30 AM identified that she had documented Resident #9's weight on 12/28/22 as the resident was to be reweighed, she continued by stating that she did not contact the dietician or the APRN as the weight was consistent with the previous documented weight for Resident #9. Interview with APRN #3, on call APRN on 1/4/22 at 12:00 PM identified she had been contacted numerous times on 12/28/22 but was never notified of Resident #28's documented weight or that Resident #28 has had a significant change in weight. The facility policy, Resident Heights/Weights identified the purpose of the policy was to provide a process to determine resident's ideal body weight, nutritional needs, current body weight and a prompt identification of the weigh change directing that any weight gain or loss of 5% or greater will be reweighed in 48 hours for accuracy and that any verified weight change of 5% or greater will be reported to the MD, the Registered Dietician and the family for intervention. 2. Resident #60 was admitted with diagnoses that included Type II diabetes, hypertension, and protein calorie malnutrition. Quarterly minimum data set (MDS) assessment dated [DATE] identified Resident #60 had severe cognitive impairment, required supervision with eating and extensive one person assist with personal care. Care plan dated 10/6/22 identified a need for adequate nutrition and hydration. Interventions included diet as ordered, provide Boost glucose control as ordered and obtain monthly weight. If there was a five-pound weight gain or lose, please reweigh the resident at that time. Nutritional quarterly note dated 10/2/22 noted Resident was continuing a carbohydrate-controlled diet with intakes improving over time 50-100%. Weight history noted recorded weights on 8/20/22 (127 lbs), 7/2022 (113 lbs.) and 6/2022 (107 lbs.) indicating and 18% gain in three months. BMI 22.6 which is within normal limits and a beneficial weight gain. Resident #60 noted to enjoy milk and drink throughout the day as well as continued weight monitoring. Weight record dated 9/1/22 through 11/15/22 noted no recorded weight for September 2022, 10/11/22 a recorded weight of 122.9 lbs. and on 11/15/22 a recorded weight of 135.9 lbs. reflecting a 10.8% weight increase in one month with no documented re-weight. Nutritional progress note dated 12/7/22 identified Resident #60 had a 27% weight gain in the past six months. 6/30/22 107 lbs, 11/15/22 135 lbs, 12/3/22 136 lbs. Resident #60 had been known to consume large amounts of milk daily and A1C (measurement of blood sugar over time) had also increased. Discussed plan of care with supervisor. Resident was to receive 8oz. Lactaid milk at all meals to improve blood glucose control and lower A1C. Start weekly weights and monitor. APRN progress note dated 12/8/22 identified Resident #60 had been experiencing weight gain related to increased calorie intake. New orders directed to discontinue Boost Glucerna twice daily, switch whole milk to Lactaid milk and limit milk intake per dietitian, and continue to monitor weight. An interview on 1/4/23 at 11:40 AM and 1/4/23 at 12:31 PM with APRN #2 identified she was made aware of the significant weight discrepancy on 12/8/22 and made changes to Resident #60's diet once notified. APRN #2 indicated she would expect to be notified the same day a verified weight discrepancy was identified. An interview on 1/04/23 at 1:03 PM with the DNS identified a weight discrepancy be documented and re-weight obtained as soon as possible that day when a weight discrepancy was identified by nursing. The dietitian and APRN was to be notified once a true weight discrepancy was verified within 24 hours to address the discrepancy. An interview on 1/04/23 at 1:14 PM with the facility Dietitian identified she had been working at the facility for five weeks. Although she was not present when the weight discrepancy was identified for Resident # 60, she would request a reweight for any significant weight discrepancy within 24 hours and follow a resident weekly and look at weights over time. The Dietitian indicated she would also ensure the APRN was notified. An interview on 1/04/23 at 1:33 PM with LPN #5 identified nursing staff was responsible for obtaining weights. If there was a weight discrepancy, a re-weight should be completed by nursing. An email notification would then be sent to the APRN and dietitian. LPN #4 indicated no weight was obtained for the month of September 2022 as requested by the dietitian and that she was unable verify that a re-weight was completed for the month of November regarding the significant weight discrepancy. The facility Weight policy directs weights to be obtained monthly unless clinically indicated. Re-weights were to be obtained using the same scale. If significant loss/gain, the IDT, Dietitian, physician and family were to be notified. 2. Resident #60 was admitted with diagnoses that included Type II diabetes mellitus, hypertension, and protein calorie malnutrition. The nutritional quarterly note dated 10/2/22 noted Resident was continuing a carbohydrate-controlled diet with intakes improving over time 50-100%. Weight history noted recorded weights on 8/20/22 (127 lbs), 7/2022 (113 lbs.) and 6/2022 (107 lbs.) indicating and 18% gain in three months. BMI 22.6 which is within normal limits and a beneficial weight gain. Resident #60 noted to enjoy milk and drink throughout the day as well as continued weight monitoring. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #60 had severe cognitive impairment, required supervision with eating and extensive one person assist with personal care. The care plan dated 10/6/22 identified a need for adequate nutrition and hydration. Interventions included: diet as ordered, provide Boost glucose control as ordered and to obtain monthly weight. If there was a five-pound weight gain or lose, please reweigh the resident at that time. The weight record dated 9/1/22 through 11/15/22 noted no recorded weight for September 2022, 10/11/22 a recorded weight of 122.9 lbs. and on 11/15/22 a recorded weight of 135.9 lbs. reflecting a 10.8% weight increase in one month with no documented re-weight. The nutritional quarterly note dated 10/2/22 noted Resident was continuing a carbohydrate-controlled diet with intakes improving over time 50-100%. Weight history noted recorded weights on 8/20/22 (127 lbs), 7/2022 (113 lbs.) and 6/2022 (107 lbs.) indicating and 18% gain in three months. BMI 22.6 which is within normal limits and a beneficial weight gain. Resident #60 noted to enjoy milk and drink throughout the day as well as continued weight monitoring. The nutritional progress note dated 12/7/22 identified Resident #60 had a 27% weight gain in the past six months. 6/30/22 107 lbs, 11/15/22 135 lbs, 12/3/22 136 lbs. Resident #60 had been known to consume large amounts of milk daily and A1C (measurement of blood sugar over time) had also increased. Discussed plan of care with supervisor. Resident was to receive 8oz. Lactaid milk at all meals to improve blood glucose control and lower A1C. Start weekly weights and monitor. An APRN progress note dated 12/8/22 identified Resident #60 had been experiencing weight gain related to increased calorie intake. New orders directed to discontinue Boost Glucerna twice daily, switch whole milk to Lactaid milk and limit milk intake per dietitian, and continue to monitor weight. An interview on 1/4/23 at 11:40 AM and 1/4/23 at 12:31 PM with APRN #2 identified she was made aware of the significant weight discrepancy on 12/8/22 and made changes to Resident #60's diet once notified. APRN #2 indicated she would expect to be notified the same day a verified weight discrepancy was identified. An interview on 1/04/23 at 1:03 PM with the DNS identified a weight discrepancy should be documented and re-weight obtained as soon as possible that day when a weight discrepancy was identified by nursing. The dietitian and APRN should be notified once a true weight discrepancy was verified within 24 hours to address the discrepancy. An interview on 1/04/23 at 1:14 PM with the facility Dietitian identified she had been working at the facility for five weeks. Although she was not present when the weight discrepancy was identified for Resident # 60, she would request a reweight for any significant weight discrepancy within 24 hours and follow a resident weekly and look at weights over time. The Dietitian indicated she would also ensure the APRN was notified. An interview on 1/04/23 at 1:33 PM with LPN #5 identified nursing staff was responsible for obtaining weights. If there was a weight discrepancy, a re-weight should be completed by nursing. An email notification would then be sent to the APRN and dietitian. LPN #4 indicated no weight was obtained for the month of September 2022 as requested by the dietitian and that she was unable verify that a re-weight was completed for the month of November 2022 regarding the significant weight discrepancy. The facility Weight policy directs weights to be obtained monthly unless clinically indicated. Re-weights are to be obtained using the same scale. If significant loss/gain, the IDT, Dietitian, physician, and family were to be notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, facility policy review and interviews for 1 of 2 residents (Resident #29) reviewed for privacy, the facility failed to provide privacy by not posting instructions for the resident's dental needs on the wall in a semi-private room and within public view. The findings include: Resident # 29's diagnoses included dementia, dysphagia, hypothyroid and hypertension. The physician's order dated 2/21/22 directed to collect the denture at bedtime and apply in the morning. The significant change in status MDS assessment dated [DATE] identified Resident #29 had severe cognition impairment and required extensive assistance of 1 person with transfer, dressing, toileting, and non-ambulatory. The Resident Care Plan (RCP) dated 10/25/22 identified Resident #29 had a partial bottom denture. Interventions included: to assist resident with applying and removing denture daily, assist with oral care and denture in for all meal. Observation on 12/28/22 at 9:50 AM identified Resident #29 in a semi-private room with an instruction posted on the wall directing staff to put denture in everyday per family request. Interview and observation with Licensed Practical Nurse (LPN #2) on 12/29/22 at 12:00 PM identified that the master copy of resident care card would be available at the nurse station and a carbon copy of resident care card would also be available at the back of the resident closet and the nurse would update the resident care card as needed. She also indicated no personal resident care should be posted on the wall. Observation with LPN #3 on 12/29/22 in Resident #29 room identified a sign of the resident's denture care posted on the wall. LPN #2 further indicated the sign should not be place on the wall and could not identify who place the resident care instructions on the wall. Interview with the DNS on 12/29/22 at 12:20 PM identified the process was the charge nurse would update the master copy of the resident care card at the nurse station and carbon copy of the resident care card would be place at the back of the resident closet. The DNS also indicated that no resident care sign should be posted on the wall. She further indicated that placement of denture was included in the physician order to alert nursing to remind the nurse aide to put the denture in the morning. The facility failed to provide Resident # 29 privacy by posting the resident plan of care on the wall. The facility failed to provide the resident privacy when the facility posted the resident's personal care instruction visible to the public. A review of facility nursing policy title Personal and Medical Records identified that the resident has a right to a secure and confidential medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, facility policy review and interviews for 1 resident (Resident # 61) reviewed for Abuse, the facility failed to ensure an allegation of abuse was reported to the state agency. The findings include: Resident #61's diagnoses included Type 2 diabetes mellitus, hypertension, and anxiety. The quarterly MDS assessment dated [DATE] identified Resident # 61 had no cognitive impairment and required extensive assistance of one person for bed mobility and transfer. A progress note dated 7/12/2022 at 8:44 AM indicated in part that at approximately 6:00 AM Resident #61 made a report to a nurse aide that during the night a strange, masked man had entered her/his room and touched her/his on the hip. The progress notes further indicated, in part, the staff on duty and the roommate of Resident #61 were interviewed without findings and the DNS and the Assistant Director of Nursing Services (ADNS) were notified. A facility statement written by Nurse Aide (NA#2) dated 7/12/2022 no time indicated, stated the writer reported to the supervisor that Resident #61 indicated being molested by a man during the middle of the night. An Interview on 1/4/2023 at 9:05 AM with NA #2 indicated the incident occurred between 6 :00 and 6:30 AM that morning and s/he was obtaining vital signs when Resident #61 shared her/his allegation with NA#2. NA#2 indicated that she immediately notified the supervisor Registered Nurse (RN#3) who then went to see Resident#61and NA#2 was present during the visit. On 1/4/2023 at 9:49 AM and several other times attempts were made to contact RN#3 via phone but the attempts were unsuccessful. On 1/4/2023 an interview and review of facility documentation regarding the 7/12/2022 Reportable Incident with the DNS, indicated that she would need to review her notes to be accurate regarding indicating the exact time RN#3 notified her of the incident as well as the reason for the delay in reporting the incident to the state agency. The DNS also indicated she is aware that the allegation needed to be reported within two hours. An interview on 1/4/2023 at 2:10 PM with the DNS indicated that the delay in reporting occurred because she was only told that a person had entered the resident's room and the word Molested was discovered when the DNS reviewed the statements which was done after attending a medical staff meeting the morning of 7/12/2022. The State Agency Reportable Event Report dated 7/12/2022 indicated 11:15 AM as the time the incident was reported to the State Agency (5.25 hours after the incident occurred and 3.50 hours after RN#3's 8:44 AM progress note indicating the DNS was notified). The facility policy for Abuse Prevention Policy, indicated that the state agency report must be entered on the state agency site within 2 hours.

Based on clinical record review, facility policy review and interview for 1 of 5 residents (Resident #38) reviewed for unnecessary medication, the facility failed to ensure that a significant change MDS assessment was completed within 14 days of the resident electing hospice services. The findings include: Resident #38's diagnoses included dysphagia, diabetes mellitus, and hospice terminal diagnosis of malnutrition. The quarterly Minimum Data Set (MDS) assessment dated 11/07 2022 identified Resident # 38 was able to make consist, reasonable decisions independently. The MDS assessment further indicated Resident #38 requires extensive assistance of 2 persons for bed mobility and transfer and supervision with assistance of one person for eating. The care plan in part, dated 11/9/2022 indicated a plan for Advanced Directive with approaches including Do Not Resuscitate, to check bracelet every shift and to provide education on end-of-life issues as indicated. The care plan further indicated a problem regarding cancer that required surgery and chemotherapy with a resulting history of a blood disorder. Interventions were to provide nutritional support, social service visits and treatment as directed by physician. A physician's order dated 12/15/22 directed for a hospice consult to be completed. The Hospice Visit note dated 12/17/2022 at 1:00 PM identified Resident #38 was admitted to hospice care due to terminal diagnosis of malnutrition. A progress note dated 12/17/2022 indicated that a hospice provider had consulted with the resident and family and Resident #38 was on hospice services. Interview, with LPN # 6, MDS Coordinator Nurse on 1/3/2022 at 10:55 AM identified there was a miscommunication regarding the date of hospice election. LPN #6 further indicated that although the MDS assessment should have been completed timely, (within 14 days of election) she has now scheduled a significant change MDS assessment for 1/6/2023 (20 days after Hospice election) and notified interdisciplinary team. The Facility significant change in condition policy notes nursing staff will notify the Resident Care Coordinator (MDS nurse) of changes in a resident's condition in order that a determination of significant change and need for full MDS assessment can be made timely. The policy further indicated the Resident Care Coordinator (MDS Nurse) is responsible for initiating a Significant change MDS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, facility policy review and interviews for 1 resident (Resident # 338) reviewed for Urinary Catheter, the facility failed to ensure a residents Foley catheter collection tubing and bag was noted off the floor within accordance to facility policy to reduce the potential for developing an infection and for 1 of 18 sampled residents (Resident #27) reviewed for participation in care planning, the facility failed to document in the medical record the resident's participation, refusal, or input into the care planning meeting process. The findings included: 1. Resident #338's diagnoses included Benign Prostatic Hyperplasia (BPH) with lower urinary tract symptoms, hematuria, and diabetes mellitus. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 338 had no cognitive impairment and required extensive assistance of one person for bed mobility, transfer, and toilet use. The Resident Care Plan (RCP) dated 12/01/2022 identified in part a decline in functional ability due to illness with the potential for improvement. Interventions included toilet transfer and toilet hygiene to maintain at current level or improve with assistance from therapy department. The NA Care Card dated 12/01/2022 indicated in part not to leave Resident #338 on the toilet and briefs were utilized. A physician's order dated 12/12/2022 directed in part the use of an indwelling Foley catheter to drain urine from the bladder, to provide catheter care and empty the drainage bag every shift. A physician progress note dated 12/12/2022 at 10:57 AM indicated that resident #338 had gone to the emergency room on [DATE] where a Foley catheter was placed due to urinary retention. Observations on 12/27/2022 at 11:20 AM identified Resident #338 lying in bed with eyes closed and Foley catheter tubing leading to the urine collection bag was lying on the floor under the resident's bed. Observation and interview on 12/27/2022 at 12:05 PM with LPN # 1 while exiting Resident #338's room during surveyor inquiry, LPN# 1 looked under the bed and confirmed the Foley catheter drainage bag was on the floor and after donning gloves, immediately moved the bag off the floor onto the bed frame and indicated the Foley bag should not have been on the floor and further indicated Resident #338 moves a lot and therefore the bag may have become unattached from the bed frame. Interview with the DNS on 1/3/2023 at 1:00 PM indicated she would have expected a Foley urine drainage bag to have been attached to the bed frame below the bladder of the resident and not on the floor. Review of the facility policy labeled Catheter, Indwelling, indicated the purpose of the policy was to minimize the incidence of catheter associated urinary tract infections through the establishment of an effective system for the care of all urinary catheters. The policy further indicated in part, that the tubing would be checked routinely to assure patency, and that no portion would touch the floor. 2. Resident #27's diagnoses included anxiety disorder and adjustment disorder. The annual Minimum Data Set assessment dated [DATE] identified Resident #27 was cognitively intact and had interest in being asked about his/her discharge preference at all assessments. The Resident Care Plan (RCP) dated 7/25/22 identified the need to encourage Resident #27 to attend activities and identified he/she was interested in attending activities. Interventions included for staff to approach Resident #27 and encourage his/her participation in upcoming activities. Additionally, the RCP addresses the adjustment to a long term stay in the facility. Approaches included involving Resident #27 in discharge planning, and encouraging Resident #27 to attend activities, included observing Resident #27's adjustment and wellbeing On 12/28/22 at 11:04 AM interview with Resident #27 identified he/she had not been invited to RCP meetings and had he/she been invited, would have attended. Interview with Social Worker (SW) #2 on 1/3/23 at 10:31 AM indicated she does not send a letter to Resident #27 concerning his/her care conference but does send one to the conservator. Additionally, SW #2 indicated she instead meets with Resident #27 prior to the RCP meeting to get his/her input, but Resident #27 typically refuses to attend the meeting. SW #2 indicated she did not document the meetings with Resident #27, including Resident #27 input, refusal to attend or measures used to encourage attendance. Review of Nursing, Social Service and the MDS Coordinator progress notes from 1/1/22 through 1/4/23 failed to identify documentation regarding Resident #27's invitation to RCP meetings and any documentation concerning his/her attendance at RCP meetings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and clinical record review for 1 of 3 sampled residents (Resident #36) reviewed for abuse, the facility failed to follow professional standards of care for documenting a provider assessment and notification to responsible party following an incident with another resident. The findings include: Resident #36's diagnoses included dementia with behavioral disturbance, major depressive disorder, psychotic disorder and idiopathic normal pressure hydrocephalus. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #36 was moderately cognitively impaired, required extensive assistance with one person for bed mobility, transfers, dressing, toilet use and personal hygiene. A Resident Care Plan dated 07/22/2022 identified that Resident #36 had a problem with psychosocial well-being with interventions that included to encourage participation in programs, provide emotional support and social work visits as needed. The facility Reportable Event (RE) form dated 09/06/2022 at 2:00 PM identified a female resident (Resident #63) kissed him/her on the cheek. Additionally, the RE identified both residents were immediately separated and were seen by psychiatry. a. Clinical record review identified no documentation of a psychiatric assessment from 09/06/2022 through 12/29/2022. Interview and record review with APRN #1 (Psychiatric APRN) on 12/29/2022 at 1:15 PM failed to identify a psychiatric assessment had been completed related to the 09/06/2022 RE. Additionally, APRN #1 identified she completed an assessment in her computer on 09/06/2022 but did not transfer the assessment to the facility's electronic record or printed a hard copy for the paper chart. Subsequent to surveyor inquiry on 12/29/2022, APRN #1 cut and pasted her 09/06/2022 assessment from her computer into the facility's electronic record. Interview with the DNS on 01/04/2023 at 1:26 PM identified that she would expect for the provider note to be documented after the assessment and placed in resident's clinical record. Additionally, the DNS identified that she was not aware APRN #1 did not document in Resident #36's chart after an assessment was completed. According to [NAME], Nursing 2022, The Peer-Reviewed Journal, a rule of documentation is to follow the nursing process completely. The nursing process requires assessment, diagnosis (nursing), planning, implementation and evaluation. This process must be reflected in the documentation of interactions with the patient during care. b. Review of the nurses notes, social services notes, and APRN progress notes dated 9/6/22 through 1/4/223 failed to identify the responsible person/conservator was notified regarding Resident #36 being kissed on the check by Resident #63. Interview and record review with LPN #8 on 1/4/23 at 1:00 PM indicated she recalled the incident regarding Resident #36 being kissed on the check by Resident #63 and that it was a quick peck. Additionally, LPN #8 indicated that she believed a nurses note was written in both residents clinical record regarding the incident and notification of the responsible person, but was unable to locate the documentation in Resident 36 ' s clinical record. Further record review with LPN #8 identified that a nurses note about the kissing incident was only documented in Resident #63 ' s clinical record, but for both residents and the documentation identified 2 power of attorneys (POA) were notified. LPN #8 identified that she only wrote one note in Resident #36's clinical record, but for both residents who were involved in the kissing incident. LPN #8 further identified that she probably should have written two separate notes in each of the resident ' s clinical record. Interview and record review with LPN Supervisor #5 on 1/4/23 at 1:05 PM further failed to identify a nurses note had been documented from 9/6/22 through 1/4/23 in Resident #36 ' s clinical record related to the kissing incident including family notification and indicated that there should be documentation in Resident #36 ' s clinical record. Interview with the DNS on 1/4/23 at 1:26 PM identified that the expectation was for nurses to document an incident in each resident ' s clinical record. According to the website www.nursingworld.org related to nursing documentation, the electronic health record provides an integrated real-time method of informing the healthcare team about patient status. Timely documentation of assessments, communication with and education of patient, family and designated support person ensures informed decisions and continuity of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, facility policy review and interviews for 1 of 2 residents (Resident #336) reviewed for edema, the facility failed to follow physician's instruction orders consistently to prevent medication errors. The findings include: Resident # 336's diagnoses included spinal stenosis, emphysema, atrial fibrillation, hypertension, and localized edema. The admission MDS assessment dated [DATE] identified Resident #336 had intact cognition and required extensive assistance of 1 person with transfer, dressing, toileting, and hygiene. The physician's order dated 12/19/22 directed to administered furosemide (anti-diuretic medication) 20 MG by mouth daily as needed if weight greater than 245 pounds. Observation on 12/27/22 at 9:50 AM identified Resident #336 sitting on the wheelchair with bilateral leg edema and a blue foam boot on the left foot. Review of the weight record from 12/20/22 through 12/29/22 identified Resident #336 weights were recorded greater than 245 pounds on 12/20, 12/23, 12/24, 12/25, 12/26, 12/27, 12/28 and 12/29/22. The Medication Administration Record (MAR) from 12/20/22 through 12/29/22 identified Resident #336 did not receive the furosemide 20 MG by mouth on 12/20, 12/23 and 12/27/22 indicating the resident missed 3 doses of furosemide 20 MG by mouth out of 8 doses. Interview and clinical record review with Licensed Practical Nurse (LPN #2) on 12/29/22 at 11:50 AM identified the charge nurse on the floor would follow the physician's instruction from the physician's order. Clinical record review of Resident #336 weight with LPN #2 identified Resident # 336 should have received the furosemide 20 MG by mouth on 12/20, 12/23 and 12/27/22. She further identified the 11-7 AM shift nurse was responsible for obtaining the weight and to administer the furosemide 20 MG by mouth daily when it met the criteria per physician's instruction. LPN# 2 further reviewed Resident #336 clinical record and indicated she could not explain why Resident #336 did not receive the furosemide 20 MG per physician's order. She further indicated would be considered a miss medication dosage. Interview and clinical record review with the DNS on 12/29/22 at 12:10 PM identified the charge nurse is expected to follow the direction in the physician's order. Clinical record review of Resident # 336 weight with DNS identified the charge nurse should have administered the furosemide 20 MG by mouth on 12/20, 12/23 and 12/27/22 when it met the criteria of the physician's instruction. She further indicated the licensed nurses are expected to follow the 5 medication rights: the right resident, drug, dose, time, and route to prevent medication error. The facility failed to follow the instruction in the physician order that resulted of 3 missed doses of furosemide. A review of facility nursing policy title Medication Errors identified to provide a process in which tracking the performance trend, training and educational need will result in a safe medication practice. Surveyor: Tan, [NAME]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policy, and interviews for 1 resident (Resident #9) reviewed for nutrition and 1 resident (Resident # 60) reviewed for edema, the facility failed to address a significant weight discrepancy according to policy by failing to have the dietician evaluate a significant weight discrepancy timely. The findings included: 1. Resident #9 was admitted with diagnoses that included schizophrenia, diabetes mellitus, and stomach reflex disease. Resident #9's monthly weight for November dated 11/11/22 at 11:00 AM was 177 pounds (lbs.). An annual MDS assessment dated [DATE] identified Resident #9 was severely cognitively impaired requiring extensive help of 1 staff member for personal hygiene and eating. The recorded weight for Resident #9 was 177 lbs. A care plan last reviewed on 12/14/22 identified Resident #9 had an identified need for adequate nutrition and hydration with a goal to maintain a stable weight. Interventions included to sit upright with head of bed at 90 degrees to prevent aspiration, to supervise all feedings and to offer substitutes for uneaten food at meals. Resident #9's weight on 12/16/22 at 7:06 AM was recorded as 153.4 lbs. A loss of 23.6 lbs. or 13.3 percent weight loss. A physician's order active for December 2022 directed Resident #9 receive a regular, mildly thick, pureed diet and to assisted with meals with a 2 handled sippy cup, small bites, and pacing. Aspiration precautions and to be supervised for all meals. An annual nutritional assessment dated [DATE] at 8:04 PM identified that Resident #9 was not on nutritional supplements and that Resident #9's weight had been stable for the past 6 months with goals to have no significant weight changes and to monitor. Resident #9's weight on 12/16/22 at 7:06 AM was recorded as 153.4 lbs. A loss of 23.6 lbs. or 13.3 percent weight loss. An APRN note dated 12/1/22 at 12:36 PM identified Resident #9 had dark vomitus over the weekend, no nausea or abdominal tenderness noted. A weight is not recorded. An APRN follow up note dated 12/21/22 at 12:11 PM identified Resident #9' s weight was 153.6 lbs. A nursing progress note dated 12/27/22 at 10:32 PM identified Resident #9 was to be reweigh in the morning. Resident # 9's weight on 12/28/22 at 1:24 PM was recorded as 155 lbs. (consistent with the 12/16/22 recorded weight of 153.6 that demonstrated a 13% weight loss for Resident #9). Interview and review of the medical record with the Dietician 1/3/23 at 1:30 PM identified on 11/11/ 22 at 11:00 AM, Resident # 9's weight was documented as 177 lbs.; the next weight recorded on 12/16/22 at 7:06 AM was 153.4 lbs. The Dietician commented that would be a big drop for 1 month for Resident #9 and continued to indicate she was not contacted regarding 12/16/22 weight. She indicated that she would have first asked for a reweigh to verify the weight and if confirmed, she would have evaluated the resident. She stated that she only works 24 hours on Monday, Tuesday, and Wednesday. The nursing staff could call her or tell her face to face when she is in the facility, but the facility process is for the nursing staff to email her for any nutrition concerns. She continued that she would expect a reweigh automatically by the nursing staff if the weight is significantly different from the last weight and she did not know why one was not done on 12/16/22. She would expect an email notification regarding Resident #9's 12/16/22 weigh as it was roughly a 13% difference from Resident #9's last weight. An email is the standard method to contact her plus 12/16/22 was a Friday, and she would have not been on site at the facility on that day. She continued by stating she had become aware of the Resident #9's recorded weight from 12/16/22 during her end of the month reconciliation where she checks all Resident's weights to be sure the weights were completed for the month. She is new to the facility, and this is a process she did prior to her employment at the facility. Upon completing the end of December reconciliation that she began on 12/27/22, she identified Resident #9's recorded 12/16/22 weight and requested a reweigh at that time. The interview and review of Resident #9's medical record with Dietician on 1/3/23 at 1 :30 PM c identified that Resident #9's documented reweigh on 12/28/22 at 1:24 PM was 155 lbs. She continued by saying she was not contacted with the 12/28/22 reweigh results and had just identified the weight change during this interview and review of the medical record that Resident#9's weight was recorded as 155 lbs. consistent with the 12/16/22 documented weight of 153.4 lbs. (13 % weight loss), Interview with Director of Nurses (DNS) 1/3/22 at 1:50 PM identified that if staff weigh a resident and there's a significant change, she expects staff to reweigh the resident within a few days. If the reweigh confirmed the original weight and the weight change was 5% loss or gain, staff should contact the dietician and the APRN immediately or at least by the next day. She would expect the Dietician to evaluate immediately or with the next few days after the weight change was identified. Interview and review of the medical record with the DNS on 1/3/22 at 2:00 PM identified Resident #9 had a weight loss between her/his November 2022 weight and the 12/16/22 weight. She continued by identifying that Resident #9 should have been reweighed to determine accuracy of the weight within a few days of the inconsistent weight. If the reweigh was consistent, the nurse should have documented and contacted the dietician, family and APRN. The DNS further indicated with Resident #9's 12/16/22 weight, the supervisor should have at least been notified who would have directed the staff to reweigh the resident, she was unclear as to why the nurses did not document in the progress notes or notify anyone of the Resident #9's 12/16/22 weight. She continued by identifying that a reweight was completed on 12/28/22 and it was consistent with the 12/16/22 documented weight. The DNS continued that it is the expectation that if the Dietician requests a reweigh, she should be contacted with the results. For Resident #9, reviewing the recorded weights, the staff was expected to contact the Dietician and the APRN immediately after completing the 12/28/22 weight by email or at least by the next day. Resident #9's weight on 1/3/23 at 2:33 PM was recorded as 146.8 lbs. A loss of an additional 6.2 lbs. from the 12/16/22 recorded weight and a loss of 8.2 lbs. or 5% in 1 week (since the 12/28/22 recorded weight of 155 lbs.). A dietician note dated 1/3/23 at 3:43 PM subsequent to the surveyor's observations identified Resident #9 has had 6% weight loss times 30 days and 21% weight loss times 180 days with recommendations to increase choice with meals, discontinuing controlled carbohydrate diet (CCHO) and to start a nutritional supplement 120 milliliters (mls.) 3 times a day (provides an extra 720 calories and 30 grams of protein) to better meet nutritional needs and arrest weight loss. Additionally start weekly weights times 4 weeks. The dietician identified Resident #9 from July 2022 to September 2022 consumed 50- 100% of meals with an occasional 25% meal intake and from October 2022 to date, Resident #9 consumed 25% to 100% of meals. Interview with LPN #8 on 1/4/23 at 9:00 AM identified that when a resident is due to get her/his weight done, the assigned NA obtains the weight. The NA reports the weight to the nurse so it can be entered into the medical record. The nurse then compares the reported weight to any previous weights and if there was either a 5 lb. weight loss or gain, the supervisor is notified who would then notify the dietician and APRN by email. Interview with LPN #5 ( nursing supervisor) on 1/4/22 at 9:30 AM identified the NA gets the weight either by Hoyer, w/c or bed side scale- depending on the resident, reports /records the weight for the nurse, the nurse would look at previous weights and determine if there was a 5 lb. plus or loss, if there was they should notify the dietician and the APRN either by calling them directly If they are here, if not present an email notification is sent, usually by the supervisor but nursing can send it too. She continued that she was not on when the 12/16/22 weight was completed and although she attempted to contact LPN #10, LPN #10 has been out sick. LPN #5 identified that she did not know why LPN #10 did not contact the dietician, but she would have expected LPN #10 to reweigh Resident #9 on 12/16/22. If the reweigh confirmed the weight, the Dietician and the APRN should have been contacted. She continued by indicating that she did the reweigh on 1/3/22 after the Dietician contacted her directly, she continued by stating that when the APRN rounds today she would let her know. Review of the medical record and interview with LPN #5 on 1//4/22 at 9:40 AM identified she reconciles weights at the beginning of the month for the previous month and she had not been notified of the 12/16/22 weight or the 12/28/22 weight. She continued by stating that she had noticed the 12/28/22 weight when she was starting her reconciliation and that the dietician contacted her the same day she saw it, on 1/3/22. LPN #5 identified the APRN note dated 1/3/22 was documented by the Psychiatric APRN who had indicated Resident #9's weight was stable and that the Psychiatric APRN was primarily focused on Resident #9's gradual dose reduction of her/his psychiatric medications. She continued by stating that there is also an APRN communication book used primality for the medical APRN. Interview and review of the APRN book with LPN #5 further identified the APRN book lacked any documentation of Resident #9's weights for 12/16/22 or 12/28/22. Interview with LPN #7 on 1/4/22 at 11:30 AM identified she had documented Resident #9's weight on 12/28/22 as the resident was to be reweighed, she continued by stating that she did not contact the dietician or the APRN as the weight was consistent with the previous documented weight for Resident #9 that was recorded on 12/16/22. The facility policy, Resident Heights/Weights identified the purpose of the policy was to provide a process to determine resident's ideal body weight, nutritional needs, current body weight and a prompt identification of the weigh change. The policy directs that any resident who experience a weight gain or loss of 5% or greater will be reweighed in 48 hours for accuracy and that any verified weight change of 5% or greater will be reported to the MD, the Registered Dietician, and the family for intervention. 2. Resident #60 was admitted with diagnoses that included Type II diabetes, hypertension, and protein calorie malnutrition. Quarterly minimum data set (MDS) assessment dated [DATE] identified Resident #60 had severe cognitive impairment, required supervision with eating and extensive one person assist with personal care. Care plan dated 10/6/22 identified a need for adequate nutrition and hydration. Interventions included diet as ordered, provide Boost glucose control as ordered and obtain monthly weight. If there was a five-pound weight gain or lose, please reweigh the resident at that time. Nutritional quarterly note dated 10/2/22 noted Resident was continuing a carbohydrate-controlled diet with intakes improving over time 50-100%. Weight history noted recorded weights on 8/20/22 (127 lbs), 7/2022 (113 lbs.) and 6/2022 (107 lbs.) indicating and 18% gain in three months. BMI 22.6 which is within normal limits and a beneficial weight gain. Resident #60 noted to enjoy milk and drink throughout the day as well as continued weight monitoring. Weight record dated 9/1/22 through 11/15/22 noted no recorded weight for September 2022, 10/11/22 a recorded weight of 122.9 lbs. and on 11/15/22 a recorded weight of 135.9 lbs. reflecting a 10.8% weight increase in one month with no documented re-weight. Nutritional progress note dated 12/7/22 identified Resident #60 had a 27% weight gain in the past six months. 6/30/22 107 lbs, 11/15/22 135 lbs, 12/3/22 136 lbs. Resident #60 had been known to consume large amounts of milk daily and AC (measurement of blood sugar over time) had also increased. Discussed plan of care with supervisor. Resident was to receive 8oz. Lactated milk at all meals to improve blood glucose control and lower A1C. Start weekly weights and monitor. An interview on 1/04/23 at 1:03 PM with the DNS identified a weight discrepancy be documented and re-weight obtained as soon as possible that day when a weight discrepancy was identified by nursing. The dietitian and APRN was to be notified once a true weight discrepancy was verified within 24 hours to address the discrepancy. The DNS also indicated weights were also discussed in morning meetings. However, the dietitian was not generally present for those discussions. An interview on 1/04/23 at 1:14 PM with the facility Dietitian identified she had been working at the facility for five weeks. Although she was not present when the weight discrepancy was identified for Resident # 60, she would request a reweight for any significant weight discrepancy within 24 hours and follow a resident weekly and look at weights over time. The Dietitian indicated she would also ensure the APRN was notified. An interview on 1/04/23 at 1:33 PM with LPN #5 identified nursing staff was responsible for obtaining weights. If there was a weight discrepancy, a re-weight should be completed by nursing. An email notification would then be sent to the APRN and dietitian. LPN #4 indicated no weight was obtained for the month of September 2022 as requested by the dietitian and that she was unable verify that a re-weight was completed for the month of November regarding the significant weight discrepancy. The facility Weight policy directs weights to be obtained monthly unless clinically indicated. Re-weights were to be obtained using the same scale. If significant loss/gain, the IDT, Dietitian, physician and family were to be notified. 2. Resident #60 was admitted with diagnoses that included Type II diabetes mellitus, hypertension, and protein calorie malnutrition. The quarterly MDS assessment dated [DATE] identified Resident #60 had severe cognitive impairment, required supervision with eating and extensive one person assist with personal care. The care plan dated 10/6/22 identified a need for adequate nutrition and hydration. Interventions included diet as ordered, provide Boost glucose control as ordered and obtain monthly weight. If there was a five-pound weight gain or lose, please reweigh the resident at that time. The nutritional quarterly note dated 10/2/22 noted Resident was continuing a carbohydrate-controlled diet with intakes improving over time 50-100%. Weight history noted recorded weights on 8/20/22 (127 lbs), 7/2022 (113 lbs.) and 6/2022 (107 lbs.) indicating and 18% gain in three months. BMI 22.6 which is within normal limits and a beneficial weight gain. Resident #60 noted to enjoy milk and drink throughout the day as well as continued weight monitoring. The weight record dated 9/1/22 through 11/15/22 noted no recorded weight for September 2022, 10/11/22 a recorded weight of 122.9 lbs. and on 11/15/22 a recorded weight of 135.9 lbs. reflecting a 10.8% weight increase in one month with no documented re-weight. The nutritional quarterly note dated 10/2/22 noted Resident was continuing a carbohydrate-controlled diet with intakes improving over time 50-100%. Weight history noted recorded weights on 8/20/22 (127 lbs), 7/2022 (113 lbs.) and 6/2022 (107 lbs.) indicating and 18% gain in three months. BMI 22.6 which is within normal limits and a beneficial weight gain. Resident #60 noted to enjoy milk and drink throughout the day as well as continued weight monitoring. The Nutritional progress note dated 12/7/22 identified Resident #60 had a 27% weight gain in the past six months. 6/30/22 107 lbs, 11/15/22 135 lbs, 12/3/22 136 lbs. Resident #60 had been known to consume large amounts of milk daily and A1C (measurement of blood sugar over time) had also increased. Discussed plan of care with supervisor. Resident was to receive 8oz. Lactaid milk at all meals to improve blood glucose control and lower A1C. Start weekly weights and monitor. An interview on 1/04/23 at 1:03 PM with the DNS identified a weight discrepancy should be documented and re-weight obtained as soon as possible that day when a weight discrepancy was identified by nursing. The dietitian and APRN should be notified once a true weight discrepancy was verified within 24 hours to address the discrepancy. The DNS also indicated weights were also discussed in morning meetings. However, the dietitian was not generally present for those discussions. An interview on 1/04/23 at 1:14 PM with the facility Dietitian identified she had been working at the facility for five weeks. Although she was not present when the weight discrepancy was identified for Resident # 60, she would request a reweight for any significant weight discrepancy within 24 hours and follow a resident weekly and look at weights over time. The Dietitian indicated she would also ensure the APRN was notified. An interview on 1/04/23 at 1:33 PM with LPN #5 identified nursing staff was responsible for obtaining weights. If there was a weight discrepancy, a re-weight should be completed by nursing. An email notification would then be sent to the APRN and dietitian. LPN #4 indicated no weight was obtained for the month of September 2022 as requested by the dietitian and that she was unable verify that a re-weight was completed for the month of November 2022 regarding the significant weight discrepancy. The facility Weight policy directs weights will be obtained monthly unless clinically indicated. Re-weights are to be obtained using the same scale. If significant loss/gain, the IDT, Dietitian, physician and family were to be notified. Surveyor: Vanbeverengola, Vict

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, review of facility policy and interview for 1 sampled resident, (Resident #387), reviewed for Intravenous (IV) Therapy, the facility failed to ensure scheduled dressing changes, monitoring and catheter measurements were completed per facility policy and consistent with professional standards of practice. The findings include: Resident #387 was admitted to the facility on [DATE]. Diagnoses included infection associated with internal left hip prosthesis, iron deficiency anemia and hyperlipidemia. A physician's order dated 12/16/22 directed Cefepime 2 grams (g) intravenous every 12 hours, 9:00AM, 9:00PM. An Infusion Order Medication Administration Record for December 2022, which was in a binder at the nurse's station, and used to document the PICC line dressing changes and external catheter measurements, indicated the dressing was to be changed weekly and as needed. Review of the flow sheet indicated the dressing was to be changed on the 7:00AM-3:00PM shift and the dates were blocked off every 7 days. The dates of 12/15/22 and 12/22/22 were checked off as completed, however were not initialed. The area designated to document the PICC Baseline Assessment for the external length of the catheter was blank. Further review identified there was no documentation indicating the shift required to complete the measurement and no blocked off dates indicating the date due. Review of the admission Nursing assessment dated [DATE] and all nurse's notes since admission, failed to show evidence that the dressing was changed, or external catheter measurements were obtained. Interview and review of the Infusion Order Medication Administration Record with RN#1, who was the Infection Preventionist (IP) on 12/28/22 at 12:20PM, identified the PICC line dressing changes and external catheter measurements were to be completed weekly on the same day. Upon review of the documentation, RN #1 identified the nurses should sign their initials when completing the dressing change, not place a check mark in the area. RN#1 also identified the external catheter measurement should have been completed by the nurse who admitted the resident on 12/15/22 and documented on the flow sheet. Additionally, the catheter measurement should have been completed 7 days later on 12/22/22, at the same time the dressing was changed. Interview with LPN#5, clinical nurse manager for the unit, on 12/28/22 at 12:25PM identified the nurse who starts/gives the first dose of the IV antibiotic was responsible for initiating the Infusion Order Medication Administration Record, which is the flow sheet designated to document the dressing changes and catheter measurements and should be done together every 7 days. LPN # 5 identified the nurse should indicate the shift responsible for the dressing change/measurement and block off the dates due so the nurses can easily see when they need to be done. Observation of Resident #387 on 12/28/22 at 12:30PM with RN#1, the IP nurse, identified resident had a PICC line located on the inner aspect of the right upper arm. The right side of the transparent PICC line dressing was noted to be loose and not adhered to the resident's arm. Further observation identified that the date written on the transparent dressing was 12/15/22, 13 days ago. RN #1 identified the dressing had not been changed since 12/15/22 and she would have the charge change the dressing and measure the external catheter length (which also had not been done since admission) immediately. RN#1 identified that the RN completing the admission assessment should have measured the external catheter, documented it on the flow sheet and then it should have been measured weekly, along with the weekly dressing change per the flow sheet and their facility policy. RN#1 further identified it was important to have an initial measurement on admission, so they have a baseline for which to compare subsequent weekly measurements. Interview with LPN#4, on 12/28/22 at 12:40PM, who was the charge nurse for resident today and administered the 9:00AM IV antibiotic, identified she had administered the scheduled IV antibiotic this morning but had not noted the date on the dressing or that the dressing was not adhered on one side. LPN # 4 identified she thought the date was 12/22/22, because looking at the flow sheet, it was checked off as changed last on 12/22/22. Although LPN#4 identified she was aware that PICC site dressings were to be changed weekly and as needed, she had not noticed the condition of the dressing earlier or the date on the dressing. LPN#4 further indicated i if she had, she would have changed it. Subsequent to inquiry, the IP nurse instructed LPN#4 to change the PICC dressing and obtain the external catheter measurement. Review of the facility's policy entitled Central Line Dressing Change (provided by Partners Pharmacy), identified the purpose is to reduce the risk of infections and minimize contamination of the catheter. The transparent (TSM) dressing will be used over the insertion site and will be changed every 7 days or immediately if the dressing is loose or soiled. During each dressing change and PRN, observe the site for signs and symptoms of complications. If PICC, measure the external length with each dressing change and PRN and to compare to previous measurement. Notify the physician for any changes and discuss clinical plan which may include chest x ray for tip re-confirmation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure medications were maintained in a secure location. The findings include. During an observation on 1/04/2023 at 9:00AM a medication cart was observed between rooms [ROOM NUMBERS] unattended, unlocked with 2 clear medication cups with what appeared to be applesauce with crushed medications and the other with a red-orange opaque substance and spoon in each. On 1/04/2022 at 9:02 AM further observations identified LPN #7 walked over to the medication cart and indicated she was called away to assist another resident for an emergency nosebleed and left the medications and the cart at its location in the hall while she went to see what the emergency with the resident was. LPN #7 further indicated that one medication cup contained applesauce and medications that were crushed and the other contained potassium that was thickened. On 1/4/2022 at 10:10 AM an interview with the DNS identified she would expect the medication cart to be locked and without medications on top without licensed staff attendance. Subsequent to inquiry the DNS indicated she would reeducation staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review and interviews for 1 resident (Resident #387) reviewed for choices, the facility failed to provide laboratory services as ordered by the physician. The findings include. Resident # 387's diagnoses included infection of a surgical site, iron deficiency anemia, hypertension, and hyperlipidemia. A physician's Discharge summary dated [DATE] indicated in part Resident #387 would require Intravenous antibiotic therapy every 12 hours for six weeks and would require weekly laboratory work. The Resident Care Plan (RCP) dated 12/16/2022 identified a plan to return to the community once resident completes the course of treatment as outlined in the plan of care. Interventions included in part to assess discharge potential, refer to a home health agency to provide education to the resident and family as needed and for the social worker to consult as needed. A physician's order dated 12/20/2022 directed to obtain laboratory blood work including a Complete Blood Count (CBC) with differential, a Comprehensive Metabolic Panel (CMP), Erythrocyte Sedimentation Rate (ESR) and C-reactive protein test (CRP) on Monday (12/26/2022). The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident # 387 was cognitively intact. An interview and facility document review on 12/28/2022 at 11:45 AM with LPN#5 indicated there was a laboratory slip still in the laboratory book for Resident #387 indicating completion date of 12/26/2022(2 days ago on Monday). LPN#5 further indicated she was unsure why the laboratory blood work had not been complete, but she usually looks back to the prior day in the laboratory book to check that the laboratory blood work had been completed. Subsequent to surveyor inquiry, LPN #5 further indicated that she called the laboratory, and they did not come out on Monday due to the holiday but would come out today as soon as possible to obtain the laboratory work ordered for Resident #387. Interview on 1/4/2022 at 10:10 AM with the DNS indicated the supervisor is responsible for checking the laboratory book daily ensure that all laboratory work had been completed and to follow up with the laboratory, APRN or physician as appropriate. Review of laboratory results dated [DATE] indicated the facility completed laboratory blood work due on 12/26/22 and the APRN was updated with no new orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, observations and review of the clinical record for 1 of 4 sampled residents (Resident #59) reviewed for dining, the facility failed to ensure the menu was followed and a nutritional supplement was provided according to the ticket menu. The findings include: Resident #59's diagnoses included schizophrenia, dysphagia, anxiety, prediabetes, and being underweight. The quarterly MDS assessment dated [DATE] identified Resident #59 was severely cognitively impaired, had progressed from eating with limited assist of one to extensive assistance of one. A Resident Care Plan dated 10/18/22 identified Resident #59 was at risk for getting adequate nutrition and hydration, decreased ability to perform activities of daily living (ADL's), and decreased level of consciousness. Interventions included to assist with meals, ensure resident was upright at 90 degrees, encourage completion of meals/fluids on tray, offer fluids between meals and provide supplements (Ensure plus & Magic cup daily). On 12/27/22 at 12:01 PM, observation of Resident #59 identified he/she was in bed with the head of the bed raised and being fed by NA #1. Review of the meal ticket on Resident #59's meal tray indicated Resident #59 was receiving a minced and moist diet. The diet ticket identified the items were minced and moist sweet & sour pork, minced and moist stir fried vegetables, cream of rice, pureed bread, margarine, cinnamon applesauce, whole milk, apple juice, coffee and Magic cup. Observation of the food being fed to Resident #59 by NA #1 identified the meat in color appeared like beef (not pork), mashed potatoes (not rice), mashed carrots (not mixed stir fried vegetables), regular formed slice of bread (not pureed as the meal ticket indicated) and Magic cup was not present on the tray. Additionally, NA #1 identified she has observed that frequently, the meal tickets do not match what resident's receive and that many time Magic cup was not provided. On 12/27/22 at 12:09 PM an interview and observation of Resident #59's food tray and meal ticket was made with the Director of Food Services. He indicated the Speech Language Therapist indicated the stir fried vegetables have peas that do not break up when mincing to conform with the international dysphagia diet. Additionally the Director of Food Service confirmed the meal ticket did not match the meal tray (as beef was served in place of pork, mashed potato in place of rice), Magic cup was omitted and that the facility does not provide pureed bread. On 12/29/22 at 12:00 PM, observation of the tray line identified Dietary Aides putting Magic cup on trays during the set up. On 1/3/23 at 10:25 AM interview with the Director of Food Services indicated Resident #59 was given a substitute of beef instead of pork because pork was not minced and the cook only minced beef, and cream of rice was substituted for mashed potatoes. Subsequent to surveyor inquiry on 1/3/23, the Director of Food Service indicated that the cook had been instructed not to substitute beef for pork and to follow the menu.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, facility policy review, and interviews for 1 residents (Resident # 338) reviewed for urinary catheter, the facility failed to ensure a residents Foley catheter collection tubing and bag was maintained in a sanitary manner to reduce the potential for developing an infection, failed to ensure that the guidelines for disinfecting the glucometer were followed and failed to store the bath basin and bed pan in a sanitary way and in accordance to the facility practice. The findings included: 1. Resident #338's diagnoses included Benign Prostatic Hyperplasia (BPH), with lower urinary tract symptoms, hematuria, and Diabetes. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 338 had no cognitive impairment and required extensive assistance of one person for bed mobility, transfer, and toilet use. The Resident Care Plan (RCP) dated 12/01/2022 identified in part a decline in functional ability due to illness with the potential for improvement. Interventions included toilet transfer and toilet hygiene to maintain at current level or improve with assistance from therapy department. The NA Care Card dated 12/01/2022 indicated in part noted not to leave Resident #338 on the toilet and that briefs were utilized. A physician's order dated 12/12/2022 directed in part the use of an indwelling Foley catheter to drain urine from the bladder, to provide catheter care and empty the drainage bag every shift. A physician progress note dated 12/12/2022 at 10:57 AM indicated Resident #338 had went to the emergency room on [DATE] where a Foley catheter was placed due to urinary retention. Observations on 12/27/2022 at 11:20 AM identified Resident #338 lying in bed with eyes closed and Foley catheter tubing leading to the urine collection bag was lying on the floor under the resident's bed. Observation and interview on 12/27/2022 at 12:05 PM identified LPN # 1 exiting Resident #338's room after attending to the resident. Upon surveyor inquiry, LPN# 1 looked under the bed and confirmed the Foley catheter drainage bag was on the floor and after donning gloves, immediately moved the bag off the floor onto the bed frame. LPN #1 further indicated the Foley bag should not have been on the floor and indicated that Resident #338 moves a lot which may have caused the bag to become unattached from the bed frame. Interview with the DNS on 1/3/2023 at 1:00 PM indicated that she would have expected a Foley urine drainage bag to have been attached to the bed frame below the bladder of the resident and not on the floor. Review of the facility policy for Catheter, indwelling notes in part the purpose of the policy was to minimize the incidence of catheter associated urinary tract infections through the establishment of an effective system for the care of all urinary catheters. The policy further indicated in part, that the tubing would be checked routinely to assure patency, and that no portion would touch the floor. 2. Observation and interview on 12/27/2022 at 11:45 AM with LPN # 1 identified she wipes down the glucometer before and after use with the Sanitizing Super Wipes and indicated that she had cleaned the meter earlier and proceeded to complete hand hygiene prior to gathering supplies. The test strip was placed into the glucometer at the medication cart then brought into the resident room along with an alcohol wipe, tissue, lancet and a pair of clean gloves. Once in the room, gloves were donned by LPN #1, permission obtained, and explanation of procedure given to the resident. The selected finger pad was wiped with the alcohol pad, let dry, then the lancet was used to prick the finger for the specimen. The blood drop was placed on the test strip in the meter and the results were read by LPN #1. While applying pressure to the finger pad with the tissue LPN#1 then removed the test strip from the meter and placed it in a small disposable container along with the lancet then brought to the medication cart sharps container for disposal. After placing the glucometer on the medication cart LPN#1 removed the gloves, completed hand hygiene unlocked the medication cart and removed the super Sanitizing Super Wipe container removed a wipe then proceed with wiping down the glucometer on all sides with the one wipe then placed the glucometer on the medication cart. LPN #1 indicated that she wipes the entire glucometer with the wipe for 5-10 seconds then it can be used again. On 12/27/2022 at 1:25 PM LPN #3(Infection Preventionist) indicated she would obtain the facility policy for glucometer cleaning and sanitizing as well as in-service training of staff including LPN#1. On 12/27/2022 at 2:25 PM interview with the Infection Preventionist, LPN #3 provided the facility policy for cleaning and disinfecting the glucometer and indicated that the dwell time is two minutes after the glucometer is cleaned. LPN #3 further indicated that is why each of the medication carts have two glucometers so while one is drying the other can be utilized. An interview on 12/27/2022 at 2:40 PM with LPN#1 indicated that she had been employed by the facility for 4 months and had yet to be in-serviced on how to clean and sanitize the glucometer. On 12/28/2022 at 10:00 AM LPN#3 provided in-service attendance sheets along with the information used for the training regarding use, cleaning, and quality checks. Although the attendance sheet included 16 licensed nurse's signatures LPN #3 indicated she was unable to find documentation that LPN#1 was in- serviced regarding glucometer use, cleaning, and quality checks. The facility blood glucose test procedure notes in part to clean and disinfect the glucometer per the policy. The policy, not dated but labeled Cleaning and Disinfecting the Glucometer, indicated that glucometer cleaning should take place prior to and immediately after use to prevent the spread of pathogens from blood or body fluids like hepatitis and Tuberculosis. The procedure further indicated if blood is visibly present on the glucometer, two wipes must be used, one to remove debris and the second wipe to disinfect. It further indicated the glucometer would then be placed on a non-porous surface to allow 2-4 minutes wet time. Review of the facility policy without a date labeled Glucose Monitoring Via Fingerstick indicated in part to see attached instructions for use of the blood glucose system. The attached instruction indicated in part that after wiping the entire surface of the meter 3 times horizontally and 3 times vertically to allow the meter to remain wet for the appropriate contact time for the disinfectant brand indicated (Super Sani-Cloth wipes, 2 minutes). 3. Observation on 12/27/22 at 10:30 AM in room [ROOM NUMBER]-D and room [ROOM NUMBER]-W's bathroom occupied by 2 residents. The bathroom contained one set of 2 unlabeled used bed pans on top of each other that were placed on top of the toilet, and another set of 2 unlabeled used bed pans were found on top of a set of 2 unlabeled used bath basins, which were all found on top of the wheelchair. Observation on 12/27/22 at 10:33 AM in room [ROOM NUMBER]-D and room [ROOM NUMBER]-W's bathroom occupied by 2 residents. The bathroom contained 1 unlabeled used toothbrush and tooth paste in a toothbrush basin place on top of the handrail and 1 unlabeled used bed pan was tuck into the handrail beside the toothbrush basin and another set of 2 unlabeled used bath basins were found on top of a set of 2 unlabeled used bed pans, which were all found on top of the toilet. Observation on 12/27/22 at 10:35 AM in room [ROOM NUMBER]-D and room [ROOM NUMBER]-W's bathroom occupied by 2 residents. The bathroom contained one set of 2 unlabeled bath basins that were place on top of 1 unlabeled used bed pan, which were all found on top of the wheelchair. Observation on 12/27/22 at 10:38 AM in room [ROOM NUMBER]-D and room [ROOM NUMBER]-W's bathroom occupied by 2 residents. The bathroom contained 1 unlabeled used bath basin was found on top of 1 unlabeled used bed pan, which were all found on top of the toilet. Observation on 12/27/22 at 10:40 AM in room [ROOM NUMBER]-D and 105-W's bathroom occupied by 2 residents. The bathroom contained 1 unlabeled used bath basin was found on top of the open commode and another 1 unlabeled used bed pan was tuck into the handrail. Interview and observation with Nursing Assistant (NA #2) 12/27/22 at 11:00AM identified the residents had been using the bath basin and bed pan. She indicated that the bed pan, and bath basin would be wash and kept in the resident side table. Although she knew that the bed pan and bath basin should be kept inside the side table, she sometimes forgets to keep the bed pan or bath basin in their proper storage. Interview and observation with License Practical Nurse (LPN #1) on 12/27/22 at 11:10 AM identified nursing assistant was using the bath basin and bed pan to care for the resident. She identified that the bath basin and bed pan would be clean and kept in the resident side table. She indicated she used bed pan and bath basin should be label with resident room number and kept inside the side table when surveyor showed her what was stored in the bathroom. Interview and observation with DNS on 12/27/22 at 11:30AM identified the nursing assistant would keep all clean bed pan and bath basin inside the side drawer. She also indicated that used bed pan and bath basin should not be kept in the bathroom when surveyor showed her what stored in the bathroom. Subsequent to surveyor inquiry, the bed pans, and bath basins were removed from the bathroom.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, facility policy review and interviews for 1 of 3 residents (Resident #29) reviewed for accident, the facility failed to implement/ revise the NA assignment card immediately to prevent future falls with injury. The findings include: Resident #29's diagnoses included dementia, atrial fibrillation, protein malnutrition, osteoporosis, and epilepsy. The Resident # 29 quarterly MDS assessment dated [DATE] identified Resident #29 had severe cognition impairment and required extensive assist with 2 people with transfer, bed mobility, toileting and hygiene and non-ambulatory. Resident #29 also required an extensive assist of 1 with eating. The Resident Care Plan (RCP) dated 7/7/22 identified Resident #29 at risk for fall related to history of fall. Intervention included: to re-assess the resident fall risk quarterly after each fall, medication review per policy, call bell in reach at all times, body pillow when in bed and dycem (anti-slip material) to the wheelchair. The fall risk assessment dated [DATE] identified Resident #29 had a score of 17 indicative of he/she was a high risk for fall. The nurse's note dated 8/4/22 at 2:43 PM identified Resident #29 had a fall from her/his wheelchair in the common area. Resident #29 fell on her/his head and hit his/her forehead on the floor. The physician directed to send Resident #29 to emergency room for an evaluation. Review of Accident and Incident report dated 8/4/22 identified Resident #29 had a fall from her/his wheelchair and hit her/his head and forehead. The intervention related to the fall on 8/4/22 was to place the resident back to bed after lunch by 1:30 PM. The RCP intervention dated 8/5/22 directed Resident #29 return to bed after lunch by 1:30 PM. Review of the Discharge summary dated [DATE] from the acute care hospital identified Resident #29 with diagnosis of right frontal scalp hematoma. The nurse's note dated 9/24/22 at 1:56 PM identified Resident #29 had a witness fall from the wheelchair and Resident #29 fell on her/his head and was noted with bleeding from the head. The physician directed to send Resident #29 to emergency room for an evaluation. The nurse's note dated 9/24/22 at 6:48 PM identified Resident #29 returned from the emergency room hospital with wound to the nose and forehead. Resident #29 had received 3 to 5 sutures to the forehead. The forehead wound measured 3 CM length x 2 CM x 0.1 CM depth and the nose abrasion measured 2 CM length x 0.3 CM width x 0.1 CM depth. Review of the Accident and Incident report dated 9/24/22 identified Resident #29 had a fall face down in the common area at 1:35PM. Review of the Nurse Aide (NA) assignment card identified the fall intervention of Resident #29 to place the resident back to bed after lunch by 1:30 PM was not implemented until 9/30/22 (58 days later). Interview with Nursing Assistant (NA #3) on 1/3/23 at 11:00 AM identified the NA assignment card was available in every resident closet. She also identified she checked the NA assignment card every day. NA # 3 further indicated Resident #29 was sitting in the common area in front of the table when Resident #29 sustained the fall on 9/24/22. She also indicated Resident #29 had finished eating his/her lunch. Although she checked the NA assignment card every day, she could not remember whether Resident #29 had return to bed after lunch when the fall occurred, but she did not put him/her back to bed after lunch. She also identified that she had been employed 10 days at the facility when the Resident #29 had the fall. Interview and facility documentation review with the DNS on 1/3/23 at 11:30 AM identified the charge nurse or the nursing supervisor was responsible for updating the NA assignment card after each resident fall. She also indicated that the fall intervention should be implemented immediately after a resident fall to prevent another fall. Review the Accident and Incident report dated 8/4/22 with DNS identified Resident #29 had a fall and the fall intervention was he/she would return to bed after lunch by 1:30PM, however, the intervention was not implemented/revised on the NA assignment card until 9/30/22. She could not identify why the fall intervention was not implemented immediately after the fall, but the facility policy was that a fall intervention will be implemented immediately to prevent another fall. The facility failed to implement the first fall intervention timely which resulted an additional fall causing the resident to sustain head laceration and sutures to close the forehead wound. A review of facility nursing policy title Fall Procedure notes in part every fall required an intervention and updating the NA assignment card with any new intervention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, review of facility documentation and facility policy for 1 of 1 sampled resident (Resident #27) reviewed for faulty medical equipment, the facility failed to ensure the medical equipment was in good repair and preventative maintenance was conducted per facility policy. The finding include: Resident #27 diagnosis included primary generalized arthritis, difficulty in walking, and generalized muscle weakness. The annual MDS assessment dated [DATE] identified Resident #27 had intact cognition and required limited assistance of 1 with bed mobility, transfers, and locomotion on/off the unit. The Resident Care Plan (RCP) dated 7/25/22 identified Resident #27 had a problem with alteration in mobility due to decreased mobility. Interventions included Resident #27 was independent for all transfers at wheelchair level, monitor gait, and physical therapy screen as ordered. Physician orders dated 8/25/22 directed a Dycem (a non-slip material pad) in the wheelchair at all times and check for placement every shift. Interview and observation with Resident #27 on 12/27/22 at 11:02 AM identified the manual hand brake on the right side of his/her wheelchair was missing causing the brake on that side to not function. Additionally, Resident #27 indicated it had been missing for a long time and although he/she identified reporting the missing brake to several staff members, could not recall their names. Additional interview on 12/29/22 at 11:00 AM with Resident #27 identified he/she had the hand brake in his/her storage drawer for a while and would subsequently give it to the nurse. Interview on 1/3/23 at 12:10 PM with Maintenance Associate (MA) #1 identified that no one completes preventative maintenance or checks on wheelchairs in the facility. In addition although a wheelchair maintenance log (provided by the facility) had his initials, he indicated he did not initial the log or do the checks and was not aware who put his initials on the form. Interview on 1/3/23 at 12:35 PM with MA #1 indicated that MA #2 did repair the wheelchair on 7/27/22 related to a loose screw on the right side brake. Additionally, he indicated not being aware of any issues with Resident #27's wheelchair since that date (7/27/22). He further indicated there was not a process in place for staff to log or record maintenance concerns on the nursing units for maintenance to review. The usual process for notification of repairs was for staff to verbally tell him when walking around the unit. Interview on 1/3/22 at 1:00 PM with the Director of Residential Care indicated the facility had a mock survey in July 2022 resulting in the recommendation the facility adopt a wheelchair preventative maintenance program. He further indicated the facility developed a policy that checks would be done weekly but they had not been done. Additionally, he indicated a monthly check was more realistic due to the number of wheelchairs in the facility but also identified the maintenance staff had not been completing the monthly checks either. Facility policy regarding Wheelchair Preventative Maintenance Program (developed after a mock survey in July 2022) indicated maintenance checks should be performed weekly or as indicated. The check would include, checking frames for damage or fracture; checking wheels; clean and lubricate bearing if needed; check axle hubs and lock washers; check seats; arm rests; cushions for tears or missing screws, and check brakes and brake extension in good repair and able to hold the chair immobile during transfers. The procedure also indicated if the wheelchair fails any of the elements of the preventative maintenance check, the wheelchair should be identified for repair and taken out of service until the repair is complete.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documentation, review of facility policy, and interviews, for one of three sampled residents (Resident #26) reviewed for Preadmission Screening and Resident Review (PASRR), the facility failed to provide an occupational therapy evaluation and failed to obtain previous psychiatric records per the PASRR recommendations. The findings include: Review of the PASRR Level II assessment for Resident #26 dated 8/26/19 identified recommendations for an occupational therapy evaluation and to obtain psychiatric records. Resident #26's was admitted on [DATE] with a diagnoses that included paranoid schizophrenia, anxiety, and Parkinson's disease. A physician's order dated 8/27/19 directed to administer Olanzapine 2.5 mg at bedtime. The admission Resident Care Plan (RCP) dated 8/28/19 identified schizophrenia. Interventions directed to medicate with Olanzapine and provide psychiatric consultation as needed. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #26 was without cognitive impairment and required limited assistance with bed mobility and transfers and supervision with eating. Interview and review of the clinical record with the Rehabilitation Director on 2/5/20 at 9:12 AM identified that the Nursing Department or the Social Service Department would have been responsible to ensure the Rehabilitation Department was notified of the need for an occupation therapy evaluation. Although the Physical Therapist had screened Resident #26, the Rehabilitation Director was unable to provide documentation that Resident #26 had been evaluated by an occupational therapist. Interview and review of the clinical record with the Director of Nurses (DNS) on 2/5/20 at 9:33 AM identified that although all residents are seen on admission per the facility policy by both the Physical Therapy and Occupational Therapy Departments, Resident #26 had not been evaluated. Additionally, the psychiatric records were never obtained but the facility was currently working to obtain the previous psychiatric records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility documentation, review of facility policy, and interviews, for 3 of 5 residents (Residents #20, # 21, and #86) reviewed for immunizations, the facility failed to ensure that pneumococcal vaccines were administered according to standards of practice and facility policy. The findings include: a. Resident #20 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus and chronic obstructive pulmonary disease. The Medication Administration Record dated 6/2/2017 identified that Resident #20 received the Prevnar 13 (PCV 13) but failed to provide evidence that Resident #20 was offered the Pneumovax 23 a year after being administered the PCV 13 or since residing in the facility. b. Resident #21 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease and dementia. The Medication Administration Record dated 3/20/18 identified that Resident #21 received the PCV 13 vaccine but failed to provide evidence that Resident #21 was offered the Pneumovax 23 a year after being administered the PCV 13 or since residing in the facility. c. Resident #86 was admitted to the facility on [DATE] with diagnoses that included type 2 Diabetes Mellitis, chronic kidney disease, and mood disorder. The Medication Administration Record dated 4/6/2016 identified that Resident #86 received the PCV 13 vaccine but failed to provide evidence that Resident #86 was offered the Pneumovax 23 a year after being administered the PCV 13 or since residing in the facility. Interview with RN #2 on 2/5/2020 at 10:30 AM identified that when he/she mailed out consent forms for PPSV23 in June 2019. He/She did not receive the consents back on several residents, the flu vaccination season had started and he/she was busy with those vaccinations. Interview with the Director of Nurses (DNS) on 2/6/2020 at 9:35 AM identified that it was his/her expectation that residents receive the pneumococcal vaccine within a year of receiving the PCV13 as long as they didn't refuse the vaccine. The Facility Pneumococcal vaccine policy identified that all residents would be offered and administered the PPSV23 and the PCV13 who were [AGE] years of age and older according to the CDC guidelines. Additionally, upon admission, each resident and/or their responsible party will be asked if the resident had received the PPSV23 vaccine or the PCV13 vaccine. If the Resident had received the PCV13 and had not received the PPSV23 and it had been at least one year since the administration of the PCV13 vaccine, the PPSV23 vaccine would be offered to the resident.