**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation(s), review of the clinical record, facility documentation, facility policy and interviews for the only sampled resident (Resident #286) reviewed for non-pressure skin conditions, the facility failed to obtain wound treatment orders upon admission for a resident with a surgical wound and a venous stasis ulcer. The findings include: Resident #286 was admitted to the facility in April 2025 with diagnoses that included chronic venous hypertension with inflammation, cellulitis of the lower limbs, and cutaneous abscess of left foot. Review of the hospital discharge records dated 4/26/25 identified Resident #286 had a left leg cellulitis and abscess with surgical debridement and a right lower extremity cellulitis and venous ulcer. The discharge records directed to continue daily dressing changes with Betadine and dry sterile dressing as well as Sodium Hypochlorite topical solution applied to foot ulcers daily with a dressing of gauze and gauze roll bandage twice daily. Although the discharge records further indicated see instructions with regards to treatments for the left and right lower extremity areas, they failed to identify wound treatment/dressing change orders and instructions for those areas. The admission nursing assessment dated [DATE] identified Resident #286 required assistance with transfers and activities of daily living. The admission skin assessment identified a right lower extremity venous ulcer and cellulitis on bilateral lower extremities with a surgical wound (abscess debridement) on the left foot. The admission physician's orders dated 4/26/25 directed Sodium Hypochlorite External Solution 0.125%, apply topically to foot ulcers daily every shift for wounds but failed to identify wound treatment/dressing change orders for Resident #286's bilateral lower extremities (venous ulcers/cellulits and surgical wound). The Resident Care Plan dated 4/28/25 identified cellulitis, a left foot abscess debridement, and chronic venous ulcers. Interventions included to provide treatments as ordered and provide wound care. An admission nursing note written by Registered Nurse (RN) #4 and dated 4/26/25 at 4:14 PM identified Resident #286's discharge medications and orders were reviewed to ensure a safe transition of care and hospital discharge orders were reviewed and updated as appropriate with the on-call provider. Observation on 4/28/25 at 11:10 AM identified Resident #286 was seated at the bedside in his/her wheelchair with his/her left lower extremity elevated and resting on the bed. Resident #286 had gauze dressings in place to his/her bilateral lower extremities and the dressing to the left lower extremity had red/brown colored drainage coming through the dressing and onto the bed sheet. Both lower extremity dressings were labeled and dated 4/28/25. An admission APRN note written by APRN #1 and dated 4/28/25 at 11:15 AM identified Resident #286 had chronic venous leg ulcers and an incision and drainage of a left foot abscess on 4/19/25. Although the progress note indicated to continue wound care with Sodium Hypochlorite 0.125% solution daily, the progress note failed to identify comprehensive wound treatment/dressing change orders for Resident #286's right lower extremity cellulitis and left foot surgical wound. The progress note further identified Resident #286 was to receive continued wound care and antibiotic therapy while at the facility with wound consult, treatment and assessment per protocol. The Treatment Administration Record (TAR) for April 2025 directed Sodium Hypochlorite External Solutions 0.125%, apply to foot ulcers daily topically every day shift for wounds. The TAR failed to identify wound treatment or dressing application directives for the resident's bilateral lower extremities. Interview and review of the clinical record with the Infection Preventionist (RN #3) on 5/1/25 at 2:45 PM identified Resident #286's wound treatment/dressing change orders were not obtained and incomplete to Resident #286's bilateral lower extremities since his/her admission on [DATE]. RN #3 indicated the hospital discharge orders were unclear and should have been clarified on admission by the nursing supervisor. RN #3 identified that since Resident #286's admission on [DATE], the nurses were putting dressings on Resident #286 without orders in place but she was unsure what was the dressing treatments consisted of. RN #3 indicated nursing should have clarified and obtained orders with the on-call provider on admission or subsequently with the APRN or Medical Director, and she was unsure why that was not done. RN #3 stated she had placed a call to Resident #286's podiatrist and infectious disease physician today and was awaiting a call back. Interview and review of the clinical record with the DNS on 5/1/25 at 3:12 PM indicated although, on admission, the nursing supervisor did assess and document Resident #286's wounds, she failed to clarify and obtain complete treatment/dressing orders. Review of the clinical record with the DNS identified that directives (site, frequency, dressing/gauze type) for how to dress the resident's wounds were not in place and nurses should not have been completing dressing changes on Resident #286 without wound treatment orders in place. The DNS indicated the nurses should have reached out and obtained the needed orders for Resident #286 and she was unsure why that was not done but would make sure it was addressed. Subsequent to surveyor inquiry, review of the physician's orders for 5/1/25 indicated new physician's orders for wound care were obtained for Resident #286 as follows: 1. Sodium Hypochlorite External Solution 0.125 % Apply to Right lateral calf topically every day shift for vascular, cleanse with Sodium Hypochlorite external solution 0.125% solution and pat dry. Apply Betadine moistened gauze and bordered foam daily and as needed (prn) AND apply to Right lateral calf topically as needed for vascular, cleanse with sodium Hypochlorite external solution 0.125% solution and pat dry. Apply Betadine moistened gauze and bordered foam prn if dressing missing, dislodged or soiled. 2. Sodium Hypochlorite External Solution 0.125 % Apply to Left medial foot surgical topically every day shift for wounds, cleanse with Sodium Hypochlorite 0.125 % and pat dry. Apply Betadine moistened gauze, ABD pad followed by gauze wrap daily and prn AND apply to Left medial foot topically as needed for surgical if dressing missing, dislodged or soiled. Interview with APRN #1 on 5/5/25 at 10:27 AM identified treatments and dressing changes should have been clear and updated and if wound care orders were vague or there was a discrepancy on the hospital discharge paperwork, the nursing staff should have called the hospital to clarify the orders. APRN #1 indicated the medical director was at the facility over the weekend when Resident #286 was admitted on [DATE], and it could have been addressed with him at that time as well. APRN #1 identified the nurses should not have been completing dressing changes on Resident #286 without comprehensive wound treatment orders in place and she was unsure why it was missed and was unaware of the issue when she saw the resident on 4/28/25. Attempts to contact RN #4 (the admitting RN Supervisor) were unsuccessful. Review of facility policy, Transcription of Orders, dated 01/2024, directed the facility was to establish guidelines for accepting and reviewing orders and orders were considered but not limited to medications, labs, diagnostics, or consultations. The policy further directed that orders are accepted by a registered nurse or a licensed practical nurse and can be obtained over the phone or from discharge and transfer paperwork from the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, clinical record review, and facility policy for one of three residents (Resident #22) reviewed for advanced directives, the facility failed to ensure the Resident Care Plan accurately reflected Resident #22's code status. The findings include: Resident #22 was admitted to the facility in April 2025 with diagnosis that included chronic obstructive pulmonary disease, diabetes, and falls. A Social Service initial assessment dated [DATE] identified that Resident #22 was a full code. There were no physician orders on admission directing Resident #22's code status. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #22 was moderately cognitively impaired, required set up assistance for eating, maximal assistance for toileting, showering, and dressing. Also identified was Resident #22 required moderate assistance with transfers. The Resident Care Plan (RCP) dated 4/15/25 identified that Resident #22's code status was cardiopulmonary resuscitation with interventions directed to review advanced directives with resident/responsible party on admission and at least quarterly, and honor advanced directives as directed by the resident/responsible party for guidance. Review of the signed advanced directive consent/acknowledgement release form dated 4/15/25 identified that Resident #22 wishes were to be a Do Not Resuscitate (DNR). An interview and review of the RCP on 4/28/25 at 2:22 PM with RN #1 identified that the RCP was incorrect, and that Resident #22 was a DNR, but the current care plan had Resident #22 identified as a full code. Further identifying that any nurse can update the care plan when the code status was changed, and it should have been updated to the correct code status. Review of the facility policy for Advanced Care Planning Code status identified that orders not to attempt cardiopulmonary resuscitation of a resident will be in writing, after consent has been obtained. This procedure will clarify the rights and obligations of residents, families, and other health care providers. Every resident admitted to the facility was presumed to consent to the administration of cardiopulmonary resuscitation in the event of cardiac/respiratory arrest unless there was a consent to a Do Not Resuscitate order. Further identified that upon admission the option of choosing to resuscitate or not to resuscitate will be offered and reviewed with the resident/family representative. A physician's order must be written accordingly. Also, identified documentation of the resident's choice to opt for resuscitation or not to resuscitate shall be maintained in the medical record. Subsequent to surveyor inquiry the physician orders were updated to reflect DNR on 4/29/25 and the RCP was updated on 4/30/25 to the correct code status of DNR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 4 residents (Resident #53) reviewed for accidents, the facility failed to ensure orthostatic blood pressures were monitored per the physician's order for a resident with postural hypotension and history of repeated falls. The findings include: Resident #53's diagnoses included unspecified dementia, orthostatic hypotension, and repeated falls. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #53 was cognitively intact and required setup or clean up assistance with transfers and toileting and was independent with bed mobility. The Resident Care Plan dated 4/1/25 identified recurrent falls, a fall with rupture of the globe of the right eye and orthostatic hypotension. Interventions included to monitor vital signs and monitor for signs and symptoms of orthostatic hypotension. A physician's order dated 4/5/25 identified Resident #53 had a history of postural hypotension and directed to take orthostatic blood pressures daily. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for April 2025 failed to indicate an order for daily orthostatic blood pressures had been transcribed and therefor orthostatic blood pressures were not taken. Interview and review of the clinical record with Licensed Practical Nurse (LPN #3) on 5/1/25 at 10:28 AM identified that although Resident #53 had a current order for daily orthostatic blood pressures, she was unable to locate in the clinical record where the orthostatic blood pressure results were documented. LPN #3 indicated it would be the nurse who would obtain the orthostatic blood pressures and document the results in the clinical record. After review of the MAR and the TAR for Resident #53, LPN #3 identified that the orthostatic blood pressure order was not there, and she did not know the reason. LPN #3 further indicated that she had not taken orthostatic blood pressures on Resident #53 before and would need to check with her nursing supervisor. Interview and review of the clinical record with the Nursing Supervisor (RN #1) on 5/1/25 at 12:25 PM identified that the nurse that transcribed the order for daily orthostatic blood pressures (when the order was originally placed on 9/20/24) did so incorrectly in the electronic health record (EHR) and the order was not shared onto the MAR or TAR. RN #1 indicated the error with the order should have been discovered by nursing when an audit was done, but it appeared that had also been missed. RN #1 identified the mistake was due to a transcription error and oversight by nursing and that the daily orthostatic blood pressures had never been completed on Resident #53. RN #1 indicated it would have been her expectation that the order was appropriately placed in the MAR and the daily orthostatic blood pressures would have been monitored per the physicians order. Interview and review of the clinical record with the DNS on 5/1/25 at 3:20 PM identified the order for Resident #53 to have daily orthostatic blood pressures was not transcribed correctly and if the nurse did not indicate an area to put the order in the electronic health record, then it would not automatically go onto the MAR or TAR. The DNS indicated that although Resident #53 had repeated falls prior to his/her admission to the facility, daily orthostatic blood pressures were not monitored for Resident #53 since the order was placed (on 9/20/24). The DNS identified that order audits done by the nurse on the 11:00 PM to 7:00 AM shift should have discovered the order and corrected the transcription error and she was unsure of the reason that did not occur. Subsequent to surveyor inquiry, on 5/1/25, the order for daily orthostatic blood pressures for Resident #53 was discontinued by APRN #1. Interview with APRN #1 on 5/5/25 at 10:19 AM identified the order for Resident #53 to have daily orthostatic blood pressures was initially placed upon admission and she was not aware that it was not correctly transcribed or completed since then. The APRN indicated she would expect the order would have been correctly transcribed, daily orthostatic blood pressures would have been monitored and the nurse would have been responsible. APRN #1 identified that although Resident #53 was admitted to the facility with repeated falls and postural hypotension, since the resident has not had any recent falls and has a steady gait, she discontinued the order for daily orthostatic blood pressures on 5/1/25, after it was brought to her attention. Review of facility policy, Transcription of Orders, dated 01/2024, directed the facility was to establish guidelines for accepting, transcribing, and reviewing orders. The policy directed that transcribing is the recording of orders by a registered nurse or a licensed practical nurse and accuracy of orders must be reviewed and verified. Additionally, the policy directed the EHR process for the transcription of orders was to be followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of clinical records, facility documentation, facility policy and interview for 2 of the 2 residents reviewed for infection control, the facility failed to ensure the peripheral lines had appropriate physician orders in place to rotate access site every 96 hours and as needed or the site was to be removed. 1. Resident #19's diagnosis included Covid 19, myocardial infarction, and hyponatremia. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #19 was cognitively intact, required maximal assistance for toileting, set up assistance for oral hygiene and eating. Also identified that Resident #19 was dependent on showering and transfers. Further identifying Resident #19 was not receiving intravenous therapy. A nursing note dated 4/16/25 at 11:42 AM written by Registered Nurse (RN) #1 identified a urine culture was obtained with sensitivities which the Advance Practice Registered Nurse (APRN) reviewed, and intravenous (IV) was to be started with a new order for IV Ceftriaxone. The Resident Care Plan (RCP) dated 4/16/25 identified IV medication of Ceftriaxone related to a urinary tract infection with intervention to rotate the peripheral site per protocol, observe/document/report as needed signs and symptoms of leaking at the IV site, and observe the IV dressing routinely for signs and symptoms of leakage/bleeding. Additionally, the RCP included to monitor site for placement, signs and symptoms of infection every shift and to change the dressing and site every 96 hours for peripheral lines. The Medication admission Record (MAR) dated 4/17/25 identified Ceftriaxone (an antibiotic) 2 grams daily, one time for a day for urinary tract infection for 5 days. Review of the physician orders and interview on 5/01/25 at 6:51 AM with the Director of Nursing services failed to identify a physician order that corresponded with the MAR dated 4/17/25 directing Ceftriaxone 2 grams daily. A nursing note dated 4/17/25 at 12:11 AM identified that Resident #19 was started on IV Ceftriaxone via left arm heplock due to a urinary tract infection. A nursing note dated 4/18/25 at 12:23 PM written by RN #1 identified the IV company was called to replace the peripheral IV and to continue with antibiotic treatment. A nursing note dated 4/18/25 at 9:39 PM identified Resident #19 peripheral IV was removed from his/her left arm and a new peripheral line was placed in his/her right hand, and the dressing was clean, dry, and intact. A nursing note dated 4/19/25 at 2:19 PM identified that Resident #19's IV to his/her right arm was flushed without difficulties, no infiltration noted, and no redness or swelling noted. The MAR dated 4/28/25 directed to flush the peripheral catheter with 10 cubic centimeters (cc) of Normal Saline every 8 hours while not in use (although there were no physician orders to correspond with the MAR instructions to flush the peripheral catheter). On 4/29/25 at 9:37 AM, interview with Resident #19 identified that he/she was receiving IV medications to his/her right arm. Observations at that time identified the dressing covering the IV insertion site was labeled 4/18/25 (11 days old). Interview on 4/29/25 at 9:50 AM with RN #1 identified that Resident # 19's peripheral line dressing should be changed one time a week and the last time it was changed was 4/18/25. Further, identifying the IV was last used on 4/22/25, had not been replaced/removed yet and the facility was waiting for lab results before removing it (the RCP interventions directed to change the IV site every 96 hours). RN #1 also identified a batch order set (a template type document that identifies routine IV orders for maintenance of the site) was to be put in place every time a resident was started on a peripheral IV which contained parameters to follow. Resident #19 did not have the batch order set in place when he/she was started on peripheral IVs and therefore the site wasn't rotated every 96 hours and the dressing not changed. RN #1 provided a copy of the batch order set which should have included the following: 1) Change IV tubing used for intermittent administration of fluids or medication every 24 hours for prophylaxis and as need prophylaxis. 2) Normal saline flush solution use 10 ml intravenously three times a day for infection. Flush before and after each medication administration, no flushing required with continuous infusions. 3) Monitor IV site for redness, swelling, drainage, any signs and symptoms of infection every shift for prophylaxis and as needed. 4) Rotate access site every 96 hours and as needed. Review of the nursing notes dated 4/29/25 at 11:47 AM identified the peripheral IV was discontinued. An interview on 5/1/25 at 6:51 AM with DNS identified that an IV peripheral line can stay in for 96 hours (Resident #19 was in place for 11 days), Resident #19 site should have been changed on 4/22/25 and IV parameters per the batch order set were not in place until 4/28/25. Also identifying that orders should have been put in place for each resident that was started on a peripheral IV and that she was responsible for this. Also identifying that it was an oversight. 2. Resident #236's diagnosis included sepsis, fracture of right femur, and chronic obstructive pulmonary disease. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #236 was moderately cognitively impaired, dependent on toileting and showering. and transfers. Also identified Resident #236 required moderate assist for eating, personal hygiene, and oral hygiene. Further identifying Resident #236 was receiving antibiotic therapy not through intravenous (IV) therapy. The nursing note dated 4/24/24 at 10:27 AM identified that Resident #236 was seen by the Advance Practice Registered Nurse (APRN) for right face cheek swelling, new orders in place for Prednisone 40 milligrams (mg) times 1, give now, then give 20 mg daily times 4 days, start a peripheral IV and give Ceftriaxone (an antibiotic) 1 gram x 5 days. The Resident Care Plan (RCP) dated 4/24/25 identified Resident #236 was on antibiotic therapy related to cellulitis to the right cheek with interventions to administer antibiotic medications as ordered by physician and monitor/document/report as needed adverse reactions to antibiotic therapy. The Medication Administration Record (MAR) dated 4/24/25 identified Ceftriaxone 1 gram IV every 24 hours for oral cellulitis for 5 days. A nursing note dated 4/29/25 at 1:22 PM identified Resident #236 was a day post IV of Ceftriaxone, no adverse reactions noted due to IV antibiotics. APRN notified, new orders given to discontinue the peripheral IV. An interview on 4/29/25 at 9:50 AM with RN #1 identified a batch order set was to be put in place every time a resident was started on a peripheral IV which contained perimeters to follow. Resident #19 and #236 did not have the batch order set in place when started on peripheral IV's. RN #1 provided a copy of the batch order set which included the following: 1) Change IV tubing used for intermittent administration of fluids or medication every 24 hours for prophylaxis and as need prophylaxis. 2)Normal saline flush solution use 10 ml intravenously three times a day for infection. Flush before and after each medication administration, no flushing required with continuous infusions. 3)Monitor IV site for redness, swelling, drainage, any signs and symptoms of infection every shift for prophylaxis and as needed. 4)Rotate access site every 96 hours and as needed. Subsequent to surveyor inquiry the MAR was updated on 4/29/25 to include parameters which directed to provide normal saline flush, use 10 milliliters intravenously one time a day for cellulitis, flush before and after each medication administration. Also, to monitor peripheral site for redness, swelling, drainage, any sign of infection every shift for prophylaxis. Review of the physician orders and interview on 5/1/25 at 6:51 AM with the DNS failed to identify a physician order was written that corresponded with the MAR directing Ceftriaxone 1 grams daily for 5 days. An interview on 5/1/25 at 6:51 AM with the DNS identified that an IV peripheral line can stay in for 96 hours and an order should have been put in place for each resident started on a peripheral IV. Also, identifying Resident #236 IV should have been pulled out on 4/28/25 not 4/29/25 and it was not pulled on time, it was an oversight. Further, identifying she was responsible over seeing this. Although requested, a written facility policy for maintaining a peripheral intravenous site was not provided, however the DNS identified that the facility uses the batch order set to direct the maintenance/treatment of a peripheral line.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and review of facility policy for two of three medication storage rooms, the facility failed to ensure expired medication was disposed of and supplies and medications were stored properly. The findings include: a. Interview and observation of the 4th floor medication room with Licensed Practical Nurse (LPN) #2 on [DATE] at 10:40 AM identified 20 hemoccult cards were observed that had an expiration date of 8/2023 and a bottle of hemoccult developer that expired in 8/2021 in the cabinet drawer. Further observation identified 6 full unopened tubes of Collagen Hydrogel (3 ounce each) with an expiration date of 3/31/ 25 and a 24-French 8.0 millimeter (mm) indwelling catheter with an expiration date of [DATE]. b. Interview and observation of the 3rd floor medication room with LPN #7 on [DATE] at 11:45 AM identified an unopened box of Lorazepam (a Schedule IV controlled medication) 30 milliliters (ml) oral concentrate on the bottom shelf in the medication refrigerator (not stored in a locked, affixed box) with other non-controlled medications stored with it (Insulins). The lock box that was present in the refrigerator was marked DO NOT USE. LPN #7 did not know the reason it was marked DO NOT USE and did not have a key to open it. The lock box was affixed to the inside of the refrigerator. Interview with the DNS on [DATE] at 2:15 PM identified she was not aware the lock box in the 3rd floor refrigerator was not being utilized for controlled medications such as the Lorazepam, or that it was marked DO NOT USE. A review of the maintenance log did not identify an entry regarding the 3rd floor lock box being broken in 2025. Interview with the DNS on [DATE] at 2:15 PM indicated that the Pharmacy representative did a monthly review of all the medication rooms and carts and a monthly summary report for each unit/floor was provided to the DNS. The date of the last pharmacy inspection was [DATE] for all three units but did not identify the failure of Lorazepam being in a locked box and affixed to the shelf. Additionally in the 3rd floor medication room, there was one box of COVID-19 tests in the overhead cabinet above the sink with an expiration date of [DATE], one pouch of COVID-19 rapid tests on the counter with an expiration date of [DATE] and a large cardboard box in a gray upright cabinet with 6 boxes of COVID-19 tests containing 4 tests each with an expiration date of [DATE]. Lastly, a two-thirds full gallon of distilled vinegar with a use by date written on it, [DATE] was identified to be in the medication room. Interview with the Regional Pharmacy Consultant on [DATE] at 2:00 PM identified the pharmacy consultant would not normally pick up on non-medication items. The Regional Consultant could not confirm the Lorazepam located in the 3rd floor medication room refrigerator was present at the time of the last pharmacy inspection on [DATE] as it was not identified on the summary report. Additionally, the Regional Consultant identified that Lorazepam locked in the medication refrigerator in the locked medication room would be sufficient. A review of the undated Medication Storage policy (PHNE132) identified Schedule II-V medications must be maintained in a separately locked, permanently affixed compartment or cabinet. The access system used to lock these medications cannot be the same access system used to lock other non-scheduled medications (i.e. two separate keys).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policy and interviews for 1 of 5 residents (Resident #33) reviewed for vaccinations, the facility failed to ensure the appropriate time was provided between COVID-19 vaccination administration. The findings include: Resident #33 had diagnoses that included weakness and partial paralysis affecting the left side following a stroke, dementia, and COVID-19. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #33 was cognitively intact, used a wheelchair, required setup or clean-up assistance with eating, partial/moderate assistance with bed mobility and was dependent for transfers. The Resident Care Plan (RCP) dated 8/6/24 identified Resident #33 was immunized against COVID-19, influenza, and pneumonia. Interventions included refer to the immunizations tab in Resident #33's chart for dates of vaccine administration. Review of the Immunization Report dated 4/30/25 identified Resident #33 received administration of the (Pfizer) COVID-19 2024-2025 on 10/9/24 in the left deltoid while in the facility and received administration of the (Pfizer) COVID-19 2024-2025 on 10/18/24 in the left deltoid (9 days after receiving a COVID-19 vaccine on 10/9/24) while in the facility. Interview with Registered Nurse (RN) #3 on 5/5/25 at 11:00 AM identified her process for administering vaccines was to obtain the consent signed by the resident/responsible party, provide the Vaccination Information Sheet (VIS), and after the vaccination was completed to enter the vaccine under the vaccination tab in the electronic medical record (EMR). RN #3 identified she administered most of the vaccinations, but sometimes she put an order in the EMR and scheduled the vaccine to be administered by the charge nurse. RN #3 identified per the Centers for Disease Control and Prevention (CDC) the COVID-19 vaccine for 2024 through 2025 was recommended to be given twice in the year, 6 months apart for residents who were immunocompromised. RN #3 identified in the EMR documentation of administration of a 2024 through 2025 COVID-19 vaccine given on 10/9/24. RN #3 identified she had documented administration of the 2024 through 2025 COVID-19 on 10/18/24. RN #3 identified that she was not aware a COVID-19 vaccine was administered on 10/9/24, and if she had seen the vaccine documentation, she would not have administered the 2024 through 2025 COVID-19 vaccine on 10/18/24 (9 days later). RN#3 was unable to identify the reason she had not seen the documentation for the 2024 through 2025 COVID-19 vaccination that was administered on 10/9/24 when she was administering the same 2024-2025 COVID-19 vaccination on 10/18/24. RN #3 identified vaccination administration was passed on in shift to shift report by the nurse who administered the vaccination. RN #3 identified she did not write progress notes after vaccine administration, and only documented the administration in the vaccination section of the EMR and that she did not think it was written policy to document vaccination administration in progress notes in the EMR. Review of the Infection Prevention and Control Program policy directed, in part, documentation for each resident who receives an immunization from facility staff would be in the resident's medical record and would include the date, site of administration, type of vaccine, dose, manufacturer, lot number, education provided, reactions if any, and the name of the person administering the vaccine.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility policy and interviews for 1 of 2 residents (Resident #33) reviewed for dental services, the facility failed to ensure timely dental services were provided related to non-restorable teeth. The findings include: Resident #33's diagnoses included weakness and partial paralysis affecting the left side following a stroke, dementia, and depression. The face sheet identified Resident #33's payor source was Medicaid. The Resident Care Plan (RCP) dated 2/14/23 and currently in effect identified Resident #33 had oral/dental health problems related to poor dentition. Interventions included monitor/document/report any signs and symptoms of oral/dental problems needing attention: pain (gums, toothache, palate), abscess, debris in mouth, teething missing/loose/broken/eroded/decayed and report pain, bleeding, broken teeth to the nurse. A quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #33 had intact cognition and required set up assistance with eating and oral hygiene. Additionally, the MDS identified Resident #33 required partial assistance with personal hygiene. A dental hygienist (RDH) note dated 11/2/23 at 4:18 PM and written by RDH #1 identified Resident #33 was seen for a comprehensive oral examination, routine oral cleaning, and fluoride treatment. The note identified Resident #33 expressed his/her concern again regarding the desire to have his/her teeth repaired. The nursing supervisor was informed of the dentist (DMD) #1's previous recommendation for Resident #33 to see a dentist in the community, and that a referral letter and x-rays were located in Resident #33's electronic medical record (EMR). A letter by DMD #1 and dated 1/31/24 identified Resident #33 was referred for dental services for evaluation and treatment regarding full mouth rehabilitation. The consult identified Resident #33 was asymptomatic at that time, however he/she had multiple non-restorable teeth with potential for developing acute episodes. The consult identified Resident #33 had expressed desire for dental implants. The consult further identified the facility staff would provide whatever additional medical information was required and dental radiographs would also be made available. A dental hygienist note written by RDH #1 and dated 2/2/24 at 5:04 PM as a late entry for 1/31/24 identified Resident #33's oral exam revealed poor oral hygiene and multiple teeth in various stages of failure. The note identified Resident #33 again asked about having implant retained dentures. The note identified Resident #33 was reminded that a referral to a dental provider in the community was indicated for this type of dental care. The note identified the nursing supervisor was informed of Resident #33's request and that a referral letter had been updated and made available in Resident #33's EMR. A dental hygienist note written by RDH #1 and dated 7/26/24 at 10:06 PM identified Registered Nurse (RN) #1 had been informed of the dental concerns regarding Resident #33. A dental hygienist note written by RDH #1 and dated 11/22/24 at 9:11 PM identified the nurse on duty notified RDH #1 that Resident #33 had requested to be seen by the dentist and that Resident #33 wanted to do something about his/her teeth and had changed his/her mind about implants. The note identified Resident #33 just wants to get the bad ones removed and partial dentures made. The note further identified Resident #33 would be seen by DMD #1 for further evaluation. A dental hygienist note written by RDH #1 and dated 12/6/24 at 9:57 PM identified Resident #33 was seen for exam and consultation regarding treatment options. The note identified Resident #33 was previously referred to a dental provider in the community for dental care as he/she had specifically asked for dental implants. The note identified the referral was not carried out and the reason was unknown. The note identified Resident #33's exam revealed complete fracture of almost all of his/her remaining teeth with only retained roots remaining. Additionally, RDH #1's note identified treatment options were discussed and Resident #33 indicated he/she was ready to have all remaining teeth removed and dentures fabricated. The note identified implants were discussed and if possible, Resident #33 wanted to have implants to assist in retaining the dentures. The note identified RN #1 was informed of Resident #33 wishes, and arrangements would be made for referral to an oral surgeon for full mouth tooth removal. The note further identified a dental referral letter would be made available in the EMR and once complete healing occurred, arrangements would be made for consultation and treatment regarding denture fabrication. A letter by DMD #1 dated 12/6/24 identified Resident #33 was referred for dental services for removal of all remaining teeth and alveoloplasty in preparation for fabrication of full dentures. The letter identified facility staff would provide whatever additional information was required. The letter further identified a request to forward a copy of the consultation to the fax number indicated on the letter. A dental hygienist note dated 3/14/25 at 9:57 PM identified Resident #33 was seen for an oral exam and Resident #33 inquired when his/her teeth would be removed so he/she could have dentures made. The note identified the social worker was consulted about DMD #1's referral to an oral surgeon for removal of all remaining teeth and recommendation of dentures and that Resident #33 had inquired about the treatment and wanted to proceed. The note identified the social worker requested nursing staff be informed. The note identified RN #3 was informed of the referral to an oral surgeon for removal of all remaining teeth and recommendation of dentures and that Resident #33 had inquired about the treatment and wanted to proceed. Observation on 4/28/25 at 1:25 PM identified Resident #33 was missing several teeth on both the top and bottom, and Resident #33 had visible tooth fragments along the top of the bottom gums and the gums were red. Interview with Resident #33 on 4/28/25 at 1:25 PM identified his/her teeth could be painful at times, and that his/her teeth were falling out. Resident #33 identified the meals provided look like they had been through a ricer because of the condition of his/her teeth, and that the meals were not very appealing because of that. Resident #33 identified that he/she was supposed to be getting his/her teeth fixed, but didn't know how or when that was going to happen. Interview with Registered Nurse (RN) #3 on 4/30/25 at 11:15 AM identified on 3/14/25 when she received a referral for Resident #33 to be seen by an oral surgeon for removal of teeth, she had given a slip to the receptionist who makes resident appointments. RN #3 identified she had notified RN #1 of the referral so that she could keep track of the appointment(s), and that she had not heard anything additional since that date of 3/14/25. Interview with Reception #1 on 4/30/25 at 11:20 AM identified she was responsible for making resident appointments and that Resident #33 was scheduled to go out to the dental health clinic for a consult with the oral surgeon 5/1/25 at 11:00 AM. Reception #1 identified Resident #33 had an appointment scheduled 4/11/25, but that transportation had not shown up, so the appointment needed to be rescheduled. Interview with Resident #33 on 5/5/25 at 9:15 AM identified he/she was seen by the dentist at the facility and was supposed to get dentures but he/she doesn't know when because first the rest of his/her teeth needed to be removed. Resident #33 identified that when he/she eats it is uncomfortable because the food rubs against some of the broken teeth, but that the discomfort is only momentary and goes away quickly so he/she doesn't ask for medication. Resident #33 identified that the facility had not helped to his/her satisfaction with getting an appointment in the community for dental services, that he/she does not know what the delay is with getting an appointment to get his/her remaining teeth pulled. Interview with RN #1 on 5/5/25 at 10:15 AM identified referrals from DMD #1 are uploaded into the EMR, then the referral was approved by the Medical Doctor/Advanced Practice Registered Nurse (MD/APRN) and then it goes to the front desk for the appointment to be made. RN #1 identified it was the responsibility of the charge nurse and/or the Supervisor to ensure recommendations from DMD #1 are followed up on and that appointments or follow-up visits are made. RN #1 identified that when an appointment needed to be rescheduled the receptionist would reschedule the appointment and then let the nurses know of the new appointment date. Interview with DMD #1 on 5/5/2025 at 10:49 AM identified Resident #33 had initially requested to get something permanent like implants to replace his/her missing and broken teeth which required a referral. DMD #1 identified she had written a letter and uploaded it into the EMR and then spoke with nursing to explain what Resident #33's wishes were. DMD #1 identified that she had written multiple referral letters for Resident #33. DMD #1 identified she and RDH #1 had followed up with the facility and followed through with reminding the nursing staff many times of the referral letter(s) in Resident #33's EMR. DMD #1 identified there was a delay in Resident #33 receiving outside services to facilitate his/her acquiring implants/dentures, and DMD #1 did not know the reason for the delay. DMD #1 identified communication from the facility wasn't ideal as nursing staff did not communicate changes or delays to DMD#1. Interview with Reception #1 on 5/5/25 at 11:50 AM identified she did not recall receiving a referral for Resident #33 for dental services from an outside resource until recently (this year). Reception #1 identified she did not retain the referral sheets/forms she received from the nursing staff for longer than 3 to 4 months after making an appointment. Reception #1 identified the excel spreadsheet she used on her computer for resident appointment scheduling went back to at least 2023 and identified she had searched through all resident appointments since January 2023 and she had located only 3 appointments for Resident #33 for dental services outside of the facility. All 3 appointments were with Resident #33's oral surgeon's office, and it was Resident #33's initial consultation with the oral surgeon which needed to be rescheduled 2 times. The original appointment was scheduled for 4/11/25 but the wheelchair transport did not arrive to pick Resident #33 up and the appointment was rescheduled for 5/1/25. On 4/30/25 Resident #33 was positive for COVID requiring the appointment on 5/1/25 to be rescheduled for 5/15/25 (but failed to identify dental services had been scheduled from her recommendations on 11/2/23, 2/2/24, and 12/6/24) when RDH #1 initially requested Resident #33 be seen by a dentist in the community related to a desire to have his/her teeth repaired. Interview with Director of Nursing Services (DNS) on 5/5/2025 at 12:05 PM identified she was unaware of referrals for dental services for Resident #33 prior to December 2024. After being informed the first referral letter from DMD #1 for Resident #33 was 2/16/23, the DNS was unable to identify reasons for the delay in Resident #33 receiving dental services from an outside resource. DNS further identified the nursing staff did not typically write notes in the EMR to document barriers or difficulties for the scheduling of appointments for residents. Review of the Dental Services policy directed, in part, the facility is responsible to provide an outside resource, routine, and emergency dental services to meet the needs of each resident, assistance for dental care upon the resident's request, and the facility will also assist with providing transportation as needed. The policy further directed in the event there is a delay in obtaining a dental appointment, the facility will document the reason for the delay.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, review of the clinical record and facility policy for 6 residents (Resident #4/Resident #36 (roommates), Resident #13/Resident #25 (roommates)and Resident #33/Resident #37 (roommates) on isolation precautions, the facility failed to ensure the nursing staff donned the appropriate Personal Protective Equipment (PPE) and for 1 of 6 sampled residents (Resident #36) reviewed for infection control documentation, the facility failed to ensure documentation was accurate and consistent regarding the type of precautions Resident #36 required. The findings include: 1a. Resident #4 was admitted in April 2021 with diagnoses that included Alzheimer's disease and dementia (was roommates with Resident #36). The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had a short/long term memory problem and had severely impaired cognitive skills for tasks of daily living. Additionally, the MDS identified Resident #4 required substantial/maximal assistance with upper body dressing and was totally dependent for lower body dressing and personal hygiene. Nursing notes dated 4/28/25 and 4/30/25 identified Resident #4 was tested for Covid-19 with negative results on both days. Observation during a tour of the facility on 4/29/25 at 9:50 AM, identified Licensed Practical Nurse (LPN ) #3 was preparing medications at the medication cart in the hall on the 3rd floor in front of Residents #4/Resident #36's room. The room had a sign posted on the door frame stating that room was on transmission-based precautions for droplets (related to Resident #4's roommate/Resident #36 testing positive for Covid-19) and required staff to don a gown, eye protection, an N95 face mask and gloves. Further observation identified LPN #3 entered the room to pass medications to Resident #4, wearing only a surgical mask (and failed to apply a gown, eye protection, an N95 mask or don gloves) . Interview with LPN #3 on 4/30/25 at 12:45 PM identified that she did not don a gown, gloves, eye protection or an N95 mask when going into Resident #4/Resident #36's room on 4/29/25 at 9:50 AM and she was only wearing a surgical mask because she was administering medications to Resident #4 who tested negative for Covid-19 on 4/28/25. Further interview with LPN #3 identified she should have donned a gown, eye protection, gloves and N95 face mask which were located outside of the room and she should don the proper PPE to go into any residents room that was labeled as droplet precautions regardless of the residents' roommates status of infection. b. Resident #36 was admitted to the facility in April 2024 (was roommates with Resident #4) with diagnoses that included Alzheimer's disease, malignant neoplasm of the breast, immunodeficiency due to drugs and tested positive for Covid-19 on 4/27/25. A physician's order dated 4/28/25 identified Resident #36 was put on contact and droplet precautions every shift for 10 days, ending on 5/8/25 due to Covid-19. The Quarterly Minimum Data Set (MDS) assessment dated [DATE], identified Resident #36 was severely cognitively impaired and required partial/moderate assistance with toilet hygiene and required supervision with upper/lower body dressing and personal hygiene. Nursing notes dated 4/28/25 through 5/2/25 identified Resident #36 was showing symptoms of dry cough, stuffy nasal passages, weakness and increased difficulty in walking on 4/27/25 then tested positive for Covid-19 on 4/28/25 at 6:48 AM. Further review identified implementation of precautions were documented; however, the type of precautions implemented were inconsistent and differed with each day/different shifts: on 4/28/25 at 6:48 AM the nurse documented transmission- based precautions (TBP) then on the same day 4/28/25 at 2:00 PM, a different nurse documented Resident #36 was on enhanced-barrier precautions (EBP). On 4/29/25 at 6:48 AM and 9:42 PM and 4/30/25 at 5:54 AM TBP was documented, but on 4/30/25 at 6:38 PM, EBP was documented. Further review of the nursing notes identified inconsistent documentation of the type of precautions documented for Resident #36 continued through 5/5/25. 2a. Resident #13 had diagnoses that included asthma, anxiety, and chronic peripheral venous insufficiency. (was roommate with Resident #25) The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #13 was moderately cognitively impaired, was up-to-date with COVID-19 vaccinations, was independent with eating and personal hygiene, and required setup or clean-up assistance with bed/chair transfers. The Resident Care Plan (RCP) dated 4/16/25 identified Resident #13 was at risk for complications of asthma related to seasonal allergies. Interventions included to assist Resident #13 in identifying asthma triggers and strategies for prevention, encourage prompt treatment of any respiratory infection, and give medications as ordered. b. Resident #25's diagnoses included being positive for Covid-19, pleural effusion, and dementia. (Resident #25's roommate was Resident #13). A physician's order dated 4/25/25 directed for isolation related to being positive for Covid-19, every shift for infection control measures for 10 days. The Resident Care Plan (RCP) dated 4/25/25 identified that Resident #25 was confirmed Covid-19 positive with interventions that included contact/droplets precautions, assist resident with the application of face mask as needed, and assist resident with hand hygiene as needed. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #25 was moderately cognitively impaired, required supervision for bed mobility, transfers, eating, and toilet use. Additionally, the MDS identified Resident #25 was up to date with Covid-19 vaccinations. i. Observation on 4/29/25 at 9:50 AM identified signage posted on the door frame of the room that indicated Resident #25 was on contact/droplet precautions and staff and/or visitors entering the room were required to don the following personal protective equipment (PPE) prior to entering the room: gown, N95 mask, eye protection/shield, and gloves. Observation at that time noted Licensed Practical Nurse (LPN) #1 in the room wearing a blue surgical mask (not an N95 mask), failed to don a gown, eye shield and gloves and standing in front of the bed conversing with Resident #25. Interview with LPN #1 on 4/29/25 at 9:53 AM identified Resident #25 was on contact/droplet transmission-based precautions, and the signage posted on the doorframe of Resident #25's room directed staff/visitors to don the PPE listed on the signage prior to entering the room. LPN #1 identified that while she was wearing a surgical mask, she should have been wearing an N95 mask, gown, eye shield and gloves. LPN #1 identified she had been in a rush and had not put on the required PPE before entering the room. Interview with the Infection Preventionist (RN #3) on 4/30/25 at 12:20 PM identified prior to entering a room with signage posted that indicated one or both the residents in that room were on contact/droplet precautions, all staff were required to don the appropriate PPE (gown, N95 mask, eye shield, and gloves) before entering the room. RN #3 identified that even if a staff member was entering the room to assist the resident who was not on contact/droplet precautions, the staff were still expected to don the required PPE prior to entering the room. RN #3 identified wearing the required PPE was part of infection prevention. ii. An observation made outside of Resident #25's room on 5/1/25 at 7:50 AM identified signage was posted outside the room, that the resident's were on enhanced barrier precautions (EBP) which directed that isolation droplet/contact precautions were in place and that staff must wear gloves, a gown, N95 mask and eye protection upon entering the room. A cart containing isolations gowns and other personal protective equipment (PPE) was observed outside of Resident #13's/Resident #25's room. Additionally, Nurse Aide (NA) #6 was observed to don gloves, a gown, an N95 mask but failed to don eye protection upon bringing a breakfast tray into the room. An interview on 5/1/25 at 7:59 AM with NA #6 once she exited Resident #25's room the cart outside the room did not contain any eye protection, that she needed to request more be brought up to the unit and NA #6 knew the policy for wearing eye protectors in a room with droplet/contact precautions but she went in the room anyway without wearing. An observation of the unit on 5/1/25 at 8:00 AM identified that other EBP carts were placed in the hallway with one cart containing 3 eye protectors not far from Resident #13's/Resident #25's room. An interview on 5/1/25 at 8:20 AM with the Director of Nursing (DNS) identified that full PPE was to be worn when entering Resident #25's room which included eye protectors. Also, identifying that was the policy and what the signage was outside the doorway of the room. 3a. Resident #33 had diagnoses that included COVID-19, dementia, and depression.(Resident #33 was roommates with Resident #37). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #33 was cognitively intact, was up-to-date with COVID-19 vaccinations, required setup or clean-up assistance with eating, partial/moderate assistance with bed mobility and was dependent for transfers. The Resident Care Plan (RCP) dated 1/30/25 identified Resident #33 was at risk for altered respiratory status/difficulty breathing. Interventions included administer medication as ordered, oxygen per medical doctor (MD) orders, and monitor for signs and symptoms of respiratory distress and report to MD as needed: increased respirations, decreased pulse oximetry, increased heart rate, restlessness, lethargy, and confusion. A physician order dated 4/25/25 directed isolation for positive COVID-19 every shift for 10 days. b. Resident #37 had diagnoses that included lymphedema, epilepsy, and stroke. (Resident #37 was roommates with Resident #33). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #37 was cognitively intact, was not up-to-date with COVID-19 vaccination, required setup or clean-up assistance with eating, partial/moderate assistance with bed mobility, and substantial/maximal assistance with transfers. The Resident Care Plan (RCP) dated 4/2/25 identified Resident #37 had a Multi-Drug Resistant Organism (MDRO) infection/colonization of a wound to the right leg. Interventions included enhanced barrier precautions: don gown and gloves when performing high contact care activities, and private room or cohort with appropriate roommate. Observation on 4/29/25 at 10:04 AM identified signage posted on the door frame of the room that indicated Resident #33 was on contact/droplet precautions and staff and/or visitors entering the room were required to don the following personal protective equipment (PPE) prior to entering the room: gown, N95 mask, eye protection/shield, and gloves. Nurse Aide (NA) #1 was observed in the room, walked away from the foot of Resident #33's bed and stopped at the disposal receptacles and removed her gown and gloves and placed the used gown in the laundry receptacle and the gloves in the trash can. The observation identified NA #1 was wearing a blue surgical mask (and not an N95 mask) that she did not take off prior to exiting the room and going into the hallway. Interview with NA #1 on 4/29/25 at 10:05 AM identified Resident #33 was on contact/droplet transmission-based precautions, and the signage posted on the doorframe of Resident #25's room directed staff/visitors to don the PPE listed on the signage prior to entering the room. NA #1 identified that although she was wearing a surgical mask, gown and gloves inside the room, she should have been wearing an N95 mask instead of the surgical mask and an eye shield also. NA #1 identified she had not donned all the required PPE because she had rushed into the room because she heard Resident #33's roommate (Resident #37) crying. Interview with the Infection Preventionist (RN #3) on 4/30/25 at 12:20 PM identified prior to entering a room with signage posted that indicated one or both the residents in that room were on contact/droplet precautions, all staff were required to don the appropriate PPE (gown, N95 mask, eye shield, and gloves) before entering the room. RN #3 identified that even if a staff member was entering the room to assist the resident who was not on contact/droplet precautions, the staff were still expected to don the required PPE prior to entering the room. RN #3 identified wearing the required PPE was part of infection prevention. Review of the COVID-19 policy directed, in part, under the section for PPE, upon entry to a COVID-19 positive resident room all healthcare workers are to wear an N95 mask, eye protection, gown and gloves which is to be removed prior to exiting the room. Review of the policy for Precautions to prevent infection identified that there are two tiers of precautions to prevent infectious agents, Standard Precautions and Transmission -Based Precautions. Transmission-Based Precautions are for patients who are known or suspected to be infected or colonized with infectious agents, including certain epidemiological important pathogens, which require additional control measures to effectively prevent transmission. Further, identified to make PPE, including gowns, and gloves available immediately outside the resident's room when on Transmission-Based precautions. Also, identified for Standard and Enhance Barrier Precautions PPE was always readily available to all staff. Gloves are in each resident room, gowns are available in/on linen carts, eye protection and face mask are available in the clean utility room.

Deficiency Text Not Available

Based on the tour of the Dietary Department and Nourishment Rooms, staff interviews, and review of facility policies, the facility failed to ensure opened items were labeled and dated when opened, food that was expired was discarded and the 3 of 3 nourishment refrigerator/freezer/ice makers were sanitary. The findings included: Tour of the Dietary Department on 4/28/25 at 10:40 AM during the initial walk through with the Dietary Director identified the following: a. 16 hot dog buns were in an opened package and not dated when opened b. 1 loaf of French bread, opened and not dated when opened c. 2 slices of French toast on a plate, covered with plastic wrap and located in the walk in refrigerator and not dated when opened d. 8 donuts in a box that was opened and not dated when opened e. 1 package (5 lb) egg noodles with an expiration date of 4/2023 f. 1 (48 ounces) plastic container of honey that was ¾ full, opened and not dated when opened g. 1 bag of peas located in the walk in refrigerator was opened and not dated, with a hole in the packaging h. 1 (5 pound) bag of egg noodles was opened and not dated when opened, located in the dry storage room i. 1 (5 pound) package of elbow macaroni that was ½ full, was opened and not dated when opened, located in the dry storage room j. 1 (25 pound) bag of rice that was ½ full and opened located in the dry storage room, was not dated when opened k. 4 (28 ounce) cans of pinto beans with an expiration date on 10/19/23 An observation made with the Dietary Director on 4/30/25 at 9:30 AM of the walk in refrigerator identified the following: a. 4 loaves of cooked meatloaf, on a tray uncovered and undated b. 1 loaf package of white American cheese that was ½ full, opened and not dated when opened c. tomato juice in a 1-gallon plastic container approximately ¾ full, opened and not dated when opened d. prepared soup in a plastic container that was approximately ½ full dated 4/23/25 (7 days old) e. sliced beef with prepared gravy in a metal container dated 4/23/25 (7 days old) f. a small chaffing metal container approximately ½ full of cooked egg noodles was dated 4/23/25 (7 days old) g. 1 package of Tortellini with an expiration date of 3/23/24 h. 1 plastic container of beef broth approximately 1/3 full, not labeled, and not dated On 4/30/25 at 10:35 AM a tour of the nourishment rooms with Dietary Director identified the following: 2nd floor nourishment room: a. The coffee maker was soiled with a heavy accumulation of coffee grounds on the machine and staining covering the machine. b. a single serving size box of cereal with an expiration of dated 4/7/25 was located on the counter c. 2 chocolate cookies on a plate, loose, and uncovered were located on the counter d. 2 slices of bread not dated on a plate, uncovered, not dated located on the counter e. the refrigerator was observed to have brownish drip marks on multiple shelves on the inside The 3rd floor nourishment room was identified with the following: a. The ice maker was observed with a brown substance in the ice scoop container located attached to the side of the ice maker b. The wall was coming away with noted debris behind the ice maker toward the floor c. 1 package (approximately 1 lb) of brown sugar was opened and not dated d. 1 foil wrapped item not dated (unable to determine what the item was without unwrapping) e. The nourishment room refrigerator was noted to be tacky to touch with brown substance located along the inside door, bottom of the refrigerator, plastic shelving 4th floor nourishment room: a. The ice maker was noted to have a heavy accumulation of a brown and white substance on front grate and along the side. The ice scoop container which also had a brown substance at the bottom of the holder b. 1 container (32 ounce) of mayo that was almost full, opened and not dated when opened c. 1 container (24 ounce) of salsa that was ¾ full, opened and not dated when opened Interview on 4/30/25 at 11:00 AM with the Dietary Director identified that he was unsure of the policy on items to be labeled with the date and going through inventory for expired food items. He also identified that the nourishment room refrigerator/freezer/ice makers needed to be cleaned on all 3 units, Further, identifying that the dietary department was responsible for maintaining the cleanliness of the nourishment rooms, and that he makes round to check on the cleanliness but apparently not often enough. Review of the facility policy for Storage of food and supplies food, non-food items, and supplies used in food preparation and service shall be stored in such manner as to maintain safety and sanitation of the food or supply for human consumption at outline in the federal drug administration food code, state regulation, and city/county health codes. Identified labeling and rotating food supply, food products that are opened and not completely used, transferred from its original container package to another storage container, or prepared at the facility and stored should be labeled as its contents and used by dates. Also identified was food removed from its original container must be labeled with the common name of the food. Further identifying that refrigerator time/temperature safety, ready-to-eat food that was opened but not completely used and was held for longer than 24 hours should be labeled with the common names and use by day, with day 1 counted as the day the item was opened. Rotate food product (dry, refrigerated, or frozen) to ensure the oldest inventory was used first. Discard food that exceeds their used by date or expiration date, was damaged, spoiled, has the time/temperature danger zone requirements, or was incorrectly stored such that it was unsafe, or its safety was uncertain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #3) reviewed for abuse, the facility failed to ensure a resident with known wandering behaviors was supervised to prevent an incident of sexual abuse. The findings include: Please cross reference F 657 1. Resident #2 diagnoses included Alzheimer's disease and generalized anxiety disorder. The quarterly MDS dated [DATE] identified Resident #2 had severely impaired cognition, and was independent with transfers and ambulation. The care plan dated [DATE] identified Resident #2 has the potential for negative behaviors related to coping with Alzheimer's with interventions that directed to approach and speak in calm manner, divert attention, remove from an overstimulating environment, and redirect to an alternate location as needed. Review of APRN #1's note dated [DATE] identified she was asked to see Resident #2 related to symptoms of restlessness and agitation. APRN #2 identified upon assessment Resident #2 is observed pacing, tearful, and fearful. APRN #2 identified Resident #2 required frequent redirection and reassurance. APRN #2 indicated the plan was to start Resident #2 on Remeron and Trazodone for anxiety and agitation. A physician's order dated [DATE] directed to administer mirtazapine (Remeron) 7.5 milligrams (MG) by mouth at bedtime and administer 25 MG of trazodone every 8 hours as needed for anxiety/agitation. A nurse's note dated [DATE] at 4:16 A.M. written by RN #1 (11 PM-7 AM supervisor) identified Resident #2 noted with agitation, anxiousness, and walking into other rooms. RN #1 identified Resident #2 was unable to be redirected. The nurse's note dated [DATE] at 4:42 A.M. written by RN #1 identified that Resident #2 is extremely anxious, entering other resident's rooms, and disrupting the floor. RN #1 indicated Resident #2 had an order in the past for Ativan as needed, but the order is expired. RN #1 identified she called the APRN #3 who was on-call, and a verbal order were obtained for Ativan as needed. A physician's order dated [DATE] directed to administer lorazepam (Ativan) 0.5 MG every 8 hours as needed for anxiety. The nurse's note dated [DATE] at 8:10 P.M. written by LPN #8 identified Resident #2 noted with agitation, anxiousness, and walking into other rooms. LPN #8 indicated attempts to redirect with PRNs with little effect. LPN #8 identified Resident #2 was given a shower and it had a calming effect. Review of APRN #1's note dated [DATE] identified collaboration with the nurse and DNS regarding Resident #2 requiring near constant redirection. APRN #1 identified Resident #2 seen today for follow up evaluation after starting mirtazapine for depression, anxiety, and insomnia. APRN #2 identified Resident #2 has continued anxiety, near constant pacing on the unit, and requires much staff redirection. APRN #2 indicated Resident #2 would benefit from an increase in mirtazapine to 15 mg at bedtime. A physician's order dated [DATE] directed to administer mirtazapine 15 mg at bedtime. The nurse's note dated [DATE] at 10:18 A.M. written by LPN #2 identified this morning Resident #2 had increased anxiety, pacing in the hallway and stopping to try an open the doors. LPN #2 identified Resident #2 was unable to be redirected or distracted. LPN #2 indicated after multiple attempts Resident #2 took h/her morning medications. Review of APRN #1's note dated [DATE] identified Resident #2 has ongoing behaviors related to dementia. APRN #1 identified Resident #2 was pacing the unit and attempting to elope. APRN #1 indicated Resident #2 becomes agitated at times, verbally aggressive, and attempts to throw objects at staff. APRN #1 identified upon her assessment Resident #2 is restless and voices frustration. APRN #1 identified given Resident #2's symptoms h/she would benefit from liquid Depakote for behavioral disturbances. A physician's order dated [DATE] directed to administer valproate sodium oral solution 250 MG/5 milliliters (ML) 2.5 ml's orally two times per day related to Alzheimer's disease. The nurse's note dated [DATE] at 1:41 P.M. written by LPN #2 identified Resident #2 had increased anxiety, pacing the floor, and wandering into other resident's rooms. LPN #2 identified Resident #2 was unable to be redirected. LPN #2 indicated multiple attempts were made to administer as needed Ativan and Resident #2 initially refused stating 'you're trying to poison me'. LPN #2 identified after multiple attempts Ativan was administered to Resident #2. 2. Resident #3's diagnoses included Alzheimer's disease and unspecified dementia. The quarterly MDS dated [DATE] identified Resident #3 had short- and long-term memory problem with severely impaired cognitive skills for daily decision making and was dependent with ADLs. The care plan dated [DATE] identified Resident #3 had a potential of psychosocial well-being problem related to incident with a female resident being sexually inappropriate with interventions that directed to monitor for any changes in psychosocial well-being, social work to follow up, and consult with psychiatric/psychological services. A nurse's note dated [DATE] at 10:05 P.M. written by RN #5 identified at 8:15 P.M. she was notified by LPN #1 that NA #2 observed Resident #2 in Resident #3's room and Resident #2 was groping Resident #3 who was in bed. RN #5 indicated the residents were immediately separated and Resident #2 was taken out of Resident #3's room. RN #5 identified Resident #2 was placed on 1:1 observation. RN #5 identified she notified the on-call MD, DON, the police were called, and the responsible parties. The nurse's note dated [DATE] at 10:09 P.M. written by LPN #1 identified Resident #2 was very aggressive this shift cursing, pacing up and down hallway, and pushing items on the floor. LPN #2 identified she was told by NA #2 that Resident #2 was seen touching Resident #3's private part in h/her room asking for sex. A review of the Facility's Reportable Event form dated [DATE] identified on [DATE] at 8:00 P.M. Resident #2 was observed groping Resident #3. The facility's investigation identified on [DATE] Resident #2 was last seen at 7:00 P.M. wandering in and out of rooms and was able to be redirected. On [DATE] at 8:00 P.M. NA #2 did not see Resident #2 walking in the hallway prompting her to look for Resident #2 and NA #2 found Resident #2 in Resident #3's room. NA #2 noted that Resident #3's first strap of the Velcro on h/her brief was undone and Resident #2's hand was under the brief. NA #2 removed Resident #2 from Resident #3's room, informed LPN #1 of the incident, and Resident #2 was placed on one-to-one observation. Interview with NA #2 on [DATE] at 10:00 A.M. identified on [DATE] she observed Resident #2 pacing the hallways per h/her usual behaviors. NA #2 identified at times Resident #2 wandered into other resident's rooms, however was always re-directable. NA #2 identified on [DATE] at approximately 7:00 P.M. she observed Resident #2 standing outside of Resident #3's room which is across the hall from Resident #2's room. NA #2 identified she re-directed Resident #2 who continued to pace the hallways and at approximately 7:30 P.M. NA #2 identified at approximately 8:00 P.M. she came out of another resident's room and did not see Resident #2 in h/her room nor pacing in the hallways. NA #2 identified she went to look for Resident #2 and found Resident #2 in Resident #3's room. NA #2 identified she observed Resident #2 standing at Resident #3's bedside with Resident #3 laying h/her bed and observed Resident #2's hand on Resident #2's private part with one side of Resident #2's brief undone. NA #2 indicated she immediately removed Resident #2 from Resident #3's room reported the incident to LPN #1. Interview with LPN #1 on [DATE] at 9:25 A.M. she identified that Resident #2 at times wanders into other resident's rooms, although easily redirected. LPN #1 identified on [DATE] she observed Resident #2 was walking the hallways and at approximately 7:00 P.M. she and NA #2 observed Resident #2 standing in the doorway of Resident #3's room. LPN #1 identified NA #2 went down the hallway and redirected Resident #2 away from Resident #3's doorway and Resident #2 went into h/her own room. LPN #1 identified NA #2 reported to her that she found Resident #3 in Resident #2's with h/her hand on Resident #3's private part. LPN #1 indicated the residents were immediately separated and Resident #2 was placed on one-to-one observation. Interview with LPN #2 on [DATE] at 10:35 A.M. she identified Resident #2 paces the hallways on the unit and wanders into other resident's rooms. LPN #2 indicated Resident #2 is able to be redirected when h/she wanders into other resident's rooms; however, requires frequent redirecting. Interview with NA #3 on [DATE] at 10:50 A.M. she identified Resident #2 paces the hallways and wanders throughout the unit. NA #3 identified Resident #2 does wander into other resident's rooms and requires frequent redirection. Interview with the DNS on [DATE] at 12:00 P.M. identified prior to the incident that happened on [DATE] between Resident #2 and Resident #3 she was unaware that Resident #2 was wandering into other resident's rooms, if she had been aware she would have ensured a care plan was in place to address the wandering behaviors. The DNS indicated Resident #2 had no previous history of resident to resident incidents nor any history of inappropriate sexual behaviors. The DNS identified following the incident on [DATE] Resident #2 was placed on one-to-one monitoring until h/she was cleared by psych on [DATE]. Interview with APRN #1 on [DATE] at 1:25 P.M. she identified prior to the incident on [DATE] Resident #2 had no inappropriate sexual behaviors nor any other resident to resident incidents. APRN #1 identified Resident #2 has end stage dementia which can provoke inappropriate sexual behaviors and APRN #1 has adjusted Resident #2's Depakote dose to aid in impulsive behaviors. Review of facility abuse resident to resident policy identified, in part, the policy is to prevent residents residing in the facility from inflicting harm (physical/mental) on other residents. To ensure that any incident of inappropriate resident to resident contact is thoroughly investigated and managed to prevent reoccurrence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #4) reviewed for pressure injury, the facility failed to develop a comprehensive care plan with interventions to prevent skin breakdown when the resident was identified at high risk for developing pressure injuries. The findings include: Resident #4 had diagnoses that included multiple sclerosis, Guillan-Barre syndrome, and generalized muscle weakness. The nursing admission assessment dated [DATE] identified Resident #4 was alert to person, place, and situation, continent of bowel and bladder, required the assistance of one with bed mobility, assistance of 2 to ambulate, and Resident #4's skin was intact. Review of the Resident #4's Braden Scale for predicting pressure sores dated 6/22/24 identified Resident #4 was at high risk. The admission MDS dated [DATE] identified Resident #4's skin was intact, a formal clinical assessment was conducted, and determined Resident #4 was at risk for developing pressure ulcers/injuries. The nurse's note dated 7/24/24 at 12:37 P.M. written by RN #4 identified during weekly skin check Resident #4 was noted to have an intact fluid blister to the back of h/her left heel. RN #4 indicated skin prep was applied and APRN #2 was notified. RN #4 indicated she provided education to Resident #4 on offloading pressure to heels, frequent repositioning, maintain adequate nutrition, and wear proper fitting shoes. RN #4 identified she updated Resident #4's wife on the new blister on Resident #4's left heel and Resident #4's wife will bring in a larger pair of sneakers. The care plan dated 7/24/24 identified Resident #4 had the potential for skin breakdown due to decreased mobility with interventions that directed weekly skin evaluations, skin checks with care and report any changes to nurse and provide a pressure redistribution mattress. A physician's order dated 7/24/24 directed to apply skin prep to the blister on left heel every day and evening shift. Review of Resident #4's care plan dated 7/24/24 identified Resident #4 has a blister to left heel with interventions that directed heel boots on except for transfers and ambulation, sneakers on only when ambulating, and off load heels with heels boots when in bed and/or at all times. Review of MD #3's (wound doctor) note dated 7/26/24 identified Resident #4 is being seen for an initial wound assessment. MD #3 identified Resident #4's left heel has a deep tissue injury with non-blanchable deep red, maroon, or purple discoloration. MD #3 directed to off load Resident #4's heels per facility protocol. Interview and clinical record review with DNS on 9/19/24 at 12:30 P.M. she was unable to provide documentation to reflect that Resident #4 had a comprehensive care plan developed and implemented on 6/22/24 when Resident #4 was identified at high risk for developing pressure injuries. The DNS identified her expectation is when any resident is identified at risk for skin breakdown a comprehensive care plan is implemented with appropriate interventions. The DNS indicated on 7/24/24 after Resident #4 developed a deep tissue injury to h/her left heel a comprehensive care plan was developed and interventions were implemented. The DNS identified that off loading heels and turning every two hours is standard of practice, and although not documented prior to 7/24/24, both were in place. Review of the facility Baseline/Comprehensive Person-Centered Care Plan policy; in part, identified the interdisciplinary team will utilize the Comprehensive Person-Centered Care Planning process to address residents' strengths, needs, and/or problems identified on the admission discharge summary, as well as other professional assessments. The interdisciplinary team will identify functional disabilities and high-risk factors requiring interventions for potential improvement or prevention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #2) reviewed for behaviors, the facility failed to review and revise a resident's care plan when the resident was identified as wandering in and out of other resident's rooms. The findings include: Resident #2 diagnoses included Alzheimer's disease and generalized anxiety disorder. A nurse's note dated 7/21/24 at 8:37 P.M. written by LPN #8 identified Resident #2 pacing the unit, visibly upset, entering other resident's rooms. The care plan dated 8/15/24 identified Resident #2 has the potential for negative behaviors related to coping with Alzheimer's with interventions that directed to approach and speak in calm manner, divert attention, remove from an overstimulating environment, and redirect to an alternate location as needed. The quarterly MDS dated [DATE] identified Resident #2 had severely impaired cognition, and was independent with transfers and ambulation. A nurse's note dated 8/21/24 at 4:16 A.M. written by RN #1 (11 PM-7 AM supervisor) identified Resident #2 noted with agitation, anxiousness, and walking into other rooms. A nurse's note dated 8/21/24 at 4:42 A.M. written by RN #1 identified that Resident #2 is extremely anxious, entering other resident's rooms. A nurse's note dated 8/21/24 at 8:10 P.M. written by LPN #8 identified Resident #2 noted with agitation, anxiousness, and walking into other rooms. LPN #8 indicated attempts to redirect with PRNs with little effect. LPN #8 identified Resident #2 was given a shower and it had a calming effect. A nurse's note dated 8/31/234 at 1:41 P.M. written by LPN #2 identified Resident #2 had increased anxiety, pacing the floor, and wandering into other resident's rooms. LPN #2 identified Resident #2 was unable to be redirected. LPN #2 indicated multiple attempts were made to administer as needed Ativan and Resident #2 initially refused stating 'you're trying to poison me'. LPN #2 identified after multiple attempts Ativan was administered to Resident #2. A nurse's note dated 8/31/24 at 10:05 P.M. written by RN #5 identified at 8:15 P.M. she was notified by LPN #1 that NA #2 observed Resident #2 in Resident #3's room and Resident #2 was groping Resident #3 who was in bed. RN #5 indicated the residents were immediately separated and Resident #2 was taken out of Resident #3's room. RN #5 identified Resident #2 was placed on 1:1 observation. Interview with LPN #1 on 9/18/24 at 9:25 A.M. she identified that Resident #2 is always pacing the hallways on the unit and at times Resident #2 wanders into other resident's rooms, and usually can be redirected out of other resident's rooms. Interview with NA #2 on 9/18/24 at 10:00 A.M. she identified Resident #2's baseline behaviors include pacing the hallways on the unit and wandering into other resident's rooms. Interview with LPN #2 on 9/18/24 at 10:35 A.M. she identified Resident #2 paces the hallways on the unit and wanders into other resident's rooms. LPN #2 indicated Resident #2 is able to be redirected when h/she wanders into other resident's rooms; however, requires frequent redirecting. Interview with NA #3 on 9/18/24 at 10:50 A.M. she identified Resident #2 paces the hallways and wanders throughout the unit. NA #3 identified Resident #2 does wander into other resident's rooms and requires frequent redirection. Interview and clinical record review with the DNS on 9/18/24 at 12:00 P.M. indicated prior to 8/31/24 she was unaware that Resident #2 had been wandering into other resident's room. The DNS identified she became aware of Resident #2's history of wandering while investigating the incident that happened on 8/31/24 when Resident #2 wandered into Resident #3's room and was observed inappropriately touching Resident #3. The DNS identified that she would expect to be notified when a resident is wandering into the other resident's rooms and the care plan should be reflective of the resident wandering into other resident's rooms. Subsequent to surveyor inquiry Resident #2's care plan was revised. Review of Resident #2's care plan dated 9/19/24 identified Resident #2 wanders on the unit and into other's rooms and demonstrated inappropriate sexual behavior toward a male resident with interventions directed to redirect, offer snacks/fluids, offer activity to patient when wandering into other's rooms. Review of the facility Baseline/Comprehensive Person-Centered Care Plan policy; directed in part, the interdisciplinary team will utilize the Comprehensive Person-Centered Care Planning process to address residents' strengths, needs, and/or problems identified on the admission discharge summary, as well as other professional assessments. The Comprehensive Person-Centered Care Plan will be periodically reviewed and revised by a team of qualified persons.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of maintenance logs, and staff interview for 1 of 8 rooms (room [ROOM NUMBER]) observed during tour, the facility failed to ensure the air conditioner grill was not exposed and was free from dust/debris/sediment. The findings include: On 7/10/23 at 1:15 PM, an observation of the air conditioner in room [ROOM NUMBER], conducted with the Director of Maintenance identified an air-conditioned unit located below the window, without a grill cover, exposing dust, debris, sediment, and the presence of a green, fuzzy-like substance the behind vent grill. An interview with the Director or Maintenance at that time identified the air conditioners were checked for functionality and filters changed quarterly, but vent cleaning was not part of the maintenance. Additionally, he identified the facility was in the process of replacing the air conditioner units, and this unit was due. Review of maintenance logs on 7/12/23 at 12:00 PM indicated the air conditioner in room [ROOM NUMBER] was last checked for functionality and had the filter cleaned on 6/10/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility policy and interviews for one sampled resident (Resident #68) who was at risk for falls, the facility failed to ensure the resident had adequate supervision during ambulation resulting in the resident sustaining a fall. The findings include: Resident #68's diagnoses included bradycardia, history of falls, muscle weakness, difficulty walking, Alzheimer's disease, and dizziness. A fall risk assessment dated [DATE] identified Resident #45 was at risk for falls and that safety devices should be in place as well as appropriate footwear. A physical therapy Discharge summary dated [DATE] identified Resident #68 required supervision for ambulation. A quarterly MDS assessment dated [DATE] identified Resident #68 had significant cognitive impairment, required supervision for transfers, bed mobility, ambulation, and eating, required limited assistance for toileting and hygiene. The assessment further noted that Resident #68 utilized a walker for mobility. The resident care plan (RCP) dated 1/28/23 identified Resident #68 had a history of falls, positional vertigo, and memory impairment with interventions that included: use of a rolling walker with staff supervision for ambulation up to 125 feet, supervision to move between surfaces when transferring. The nurse's note (SBAR) dated 4/8/23 at 3:17 PM identified Resident #68 was ambulating in the corridor with his/her walker and the activity person heard a thump. Resident #68 was found lying on the floor near the entrancce to the dining room. The fall was unwitnessed. Resident #68 complained of pain, and the resident's leg was noted to be externally rotated with poor range of motion. 911 was called, the family and the physician were notified. The nurse's note dated 4/8/23 at 5:56 PM identified Resident #68 had a fractured left hip. A Reportable Event Report dated 4/8/23 completed by RN #2 identified that the state survey agency was notified of the resident's fall and that an investigation into the fall was initiated. Review of the facility's investigation identified that written statements were obtained from all the staff on duty on the unit at the time the resident fell LPN #3 (charge nurse), NA #2 (assigned to the resident) and two other nurse aides. Review of the facility's investigation failed to identify why the resident's fall was unwitnessed by the unit staff and failed to identify a reason why the resident was ambulating independently without staff supervision. Interview with OT #1 on 7/13/23 at 11:30 AM identified she worked with Resident #68 in the past, and after reviewing the rehabilitation Discharge summary dated [DATE] identified Resident #68 required supervision for ambulation. She further identified that the resident did not require staff to have physical hands on him/her during ambulation but noted that the resident needed to be in visual site during ambulation. She further indicated that if staff did not witness Resident #68's fall, they were not following the plan of care. Interview with LPN #3 on 7/13/23 at 12:00 PM identified that her understanding of the level of care Resident #68 required was visual supervision. She noted that the resident was typically steady with the use of the walker and self-initiated ambulation. She further identified that she did not see Resident #68 fall and reported she was in another resident's room when she heard a noise and went to investigate and found the resident on the floor in the hall by the dining room. LPN #3 further identified that she had observed Resident #68 ambulating prior to entering a resident room in response to the call bell ringing. LPN #3 further identified that all staff were responsible for supervising the resident during ambulation. Interview with NA #2 on 7/13/23 at 2:15 PM identified Resident #68's family had been visiting and after the visit, the resident went back to his/her room and shortly after began walking up and down the hallway. NA #2 noted that she was in and out of resident rooms providing care. NA #2 further identified that she thought the resident required supervision when ambulating but was not sure if that meant visual supervision. Review of the facility's Fall Prevention program identified that the agency implements interventions that may include assistance with activities of daily living and referrals to PT/OT for an evaluation of gait, balance, use of assistance divices and transfer techniques.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and staff interviews for 1 of 3 sampled residents (Resident #61) reviewed for nutrition, the facility failed to provide large portions per Dietician recommendations. The findings include: Resident #61's diagnoses included anorexia, Type 2 diabetes and anxiety disorder. Quarterly Nutritional Assessment interventions dated 4/13/23 indicated Resident #61 should have received large protein portions with lunch and dinner. A Quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #61 had moderately impaired cognition, and required supervision with 1 for bed mobility, dressing and personal hygiene. The MDS further identified Resident #61 required supervision after set up with transfers and was independent with eating after being set up. Additionally, the MDS identified Resident #61's weight was 124 pounds (lbs) and did not have any significant weight loss. The Resident Care Plan dated 4/27/23 identified Resident #61 was at risk for malnutrition due to advanced age, dementia, a history of anorexia and Type 2 diabetes. Interventions included honoring food preferences as able, monitor/record/report to MD as needed for signs and symptoms of malnutrition (examples include emaciation, muscle wasting, significant weight loss being defined as 3 lb weight loss in one week, greater than 5% in 1 month, greater than 7.5% in 3 months, or greater than 10% in 6 months). Additional interventions included to provide and serve a diet as ordered, monitor intake and record every meal, Registered Dietician to evaluate and make diet change recommendations as needed and to weigh as ordered per policy or MD. The Quarterly Nutritional Assessment interventions from the Dietician and dated 7/6/23 indicated Resident #61 should have received large portions at all meals. Interview and observation of Resident #61's lunch tray with the Food Service Director on 7/12/23 at 1:15 PM indicated Resident #61 received approximately a 3 to 4 ounce portion of chicken, ½ cup of au gratin potatoes and ½ cup of string beans. The Food Service Director further identified the portion size on the tray was a regular sized portion and not a large lunch portion. The Food Service Director also indicated although Resident #61's meal ticket identified large portions in the lower section, he did not know the reason large portions were not provided. Interview with the Registered Dietician on 7/13/23 at 10:03 AM indicated that she increased Resident #61's portion sizes due to him/her being extremely active on the unit. The Dietician also identified that a large portion tray would include an additional scoop of the side for the meal and an additional piece of protein (chicken). Interview with the Food Service Director on 7/13/23 at 10:10 AM indicated he did not notice large portions listed on the tray card ticket. The Food Service Director also identified that the first Dietary Aide in the Dietary line would call the ticket orders out for the rest of the line but due to the small size of the font and the large portion identification being at the bottom of the ticket, it may have been the reason it was missed. Subsequent to surveyor interview, the Food Service Director increased the font size indicating large portions on the tray card ticket.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, review of facility documentation and interviews for one sampled resident (Resident #30) who had a gastrostomy tube in place and received enteral nutrition on a continuous basis, the facility failed ensure that the enteral nutrition was administered continuously as ordered resulting in the resident not receiving the enteral nutrition for more than three hours. The findings include: Resident #30's diagnoses included dysphagia (difficulty swallowing), cerebrovascular disease, severe protein calorie malnutrition, anemia, dementia, and candida stomatitis. The admission MDS assessment dated [DATE] identified Resident #30 had moderately impaired cognition, required extensive assistance for bed mobility, was totally dependent for eating, experienced weight loss in the past month. The assessment further identified that the resident weighed 122 lbs. and utilized a feeding tube. Resident #30's care plan dated 6/15/23 identified Resident #30 required tube feeding related to dysphagia with interventions that included: monitoring, documenting, and reporting as needed any signs and symptoms of aspiration, fever, tube dislodgement or shortness of breath. The care plan further identified Resident #30 had severe malnutrition related to swallowing difficulties and chronic illnesses. Interventions included providing enteral/tube feed nutrition formula as per physician order. A physician's order dated 7/3/23 directed Resident #30 should have a dysphagia Osmolite (high protein liquid nutrition) 1.5 liquid diet at 50 milliliters (ml) per hour continuously. Observation on 7/11/23 at 9:45 AM identified Resident #30 lying in bed with eyes closed. The Osmolite connected to the pump, but the pump was turned off and the resident was not receiving the Osmolite as ordered. Observation on 7/11/23 at 12:45 PM identified Resident #30's in the same position as the previous observation and the feeding tube remained disconnected. Interview with LPN #2 on 7/11/23 at 12:56 PM identified Resident #30 pulled out one of the attachments on the feeding tube and he was going to try to fix it but had not had the opportunity to address it. LPN #2 further identified that he had updated the APRN who was also waiting for him to fix the tube and if it was not repaired then Resident #30 would be sent out to hospital for a replacement tube. Interview with RN #4 (morning supervisor) on 7/11/2023 at 2:21 PM identified that LPN #2 provided update sometime between 8:00 AM and 9:00 AM that he was having issues with Resident #30's gastrostomy tube (G-tube). She further identified that she told LPN #2 to provide an update if the issue was not resolved. RN #4 further identified that when she did not hear back from LPN #2, she assumed the issue was resolved. Interview with APRN #1 on 7/11/23 at 1:16 PM identified LPN #2 had recently called to provide an update that Resident #30's nutrition via feeding tube had been withheld for at least three hours. She further identified that she would have preferred to be updated within a reasonable time frame to intervene appropriately. She identified that she was going to assess Resident #30. APRN #1's note dated 7/11/23 at 2:13 PM identified that she was notified at 1:00 PM that the Osmolite enteral (tube) feeding had been held for approximately 3 hours. The note further identified that nursing safely reconnected the tube feeding. APRN #1 noted that she completed an assessment of Resident #30, and no abnormal findings were noted. Additionally, the note identified that Resident #30 had repeated episodes of impulsivity/agitation which resulted in continuous pulling at medical equipment and the behavior was related to the resident's progressive dementia and history of cerebrovascular accident (CVA). RN #4's note dated 7/11/23 at 2:41 PM identified Resident #30 had been getting up and walking with the G-tube attached and this presented a safety issue. Resident #30 was redirected many times without effect. The note further identified that Resident #30 would often twist and pick at the G-tube. In addition, the not identified that RN #4 was notified by the charge nurse identified that the second port was broken, and that tube feeding was leaking out. Resident #30 was assessed and had good skin turgor, and mucous membranes were moist. Interview with the DNS on 7/11/23 at 2:58 PM identified that when the supervisor was updated about the issues with Resident #30's tube feeding, the supervisor should have performed an assessment and followed through to update the APRN or MD so that the appropriate intervention could be implemented. A review of the enteral nutrition (G-tube) policy dated 6/2023, identified that the licensed nurse will administer nutrition through a nasogastric, gastric, jejunostomy tube per physician's order. A review of the facility's Change of condition (COC) policy dated 4/2023 identified that the facility will inform the resident's healthcare provider when there is a change of condition. It further identified that the purpose is to ensure that the resident's COC is evaluated and documented properly to ensure the resident's COC was reported to the healthcare provider and family representative. The policy further noted that a COC included incidents involving the resident that may result in an injury or required medical treatment. The policy also noted that if there is a COC for a resident the licensed nurse per state regulations notifies the attending physician, if the physician does not return the call in a timely manner, the nurse manager/supervisor/designee will contact the medical director.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review facility documentation and staff interviews, the facility failed to ensure Registered Nurse (RN) #2 was working with a current nursing license. The findings include: Review of personnel files for RN #2 identified RN #2's State of Connecticut Registered Nurse (RN) License expired on [DATE] (134 days ago). The RN licensed copy in the personnel file identified RN #2's license was initially granted on [DATE]. Human Resources from the facility was not able to provide a copy of a current RN license for RN #2. Interview with the State Agency on [DATE] at 10:54 AM indicated that RN #2's license expired on [DATE]. In addition, RN #2 had a 90-day grace period to renew her license, did not renew her license, now needed to re-apply for a license, so she had been working without a valid nursing license since [DATE]. Review of RN #2's time card identified she worked at the facility on [DATE], [DATE], [DATE], [DATE] from 7:00 AM to 7:30 PM, and on [DATE] from 11:00 PM to 7:30 AM. Additionally, RN #2 worked on [DATE] from 7:00 AM to 11:30 PM. Interview with Director of Human Resources on [DATE] at 11:04 AM indicated that he validates all licenses upon hire but does not verify nursing licenses each year because nurses do not let their license expire. Interview with RN #2 on [DATE] at 11:45 AM identified that she did not have a valid RN license. Additionally, RN #2 indicated that she paid for the license renewal in [DATE] but did not follow up to ensure her license was renewed. Interview with RN #3 (Corporate Clinical Specialist) indicated that the facility does not have a policy regarding staff's responsibility in maintaining their license, but it is part of their job description to maintain their license in their discipline.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of clinical record, review of facility documentation, facility policy, and interviews for one sampled resident (Resident #20) who was administered insulin, the facility failed to ensure that the glucometer was cleaned in an appropriate manner to maintain acceptable infection prevention and transmission precautions and for one nurse's aide (NA #1) observed with long nails, the facility failed to ensure the nurses' aide's nails were of an appropriate length to prevent the potential transmission of infection. The findings include: 1. Based on observation, review of facility policy and staff interview, the facility failed to ensure NA #1's nails were of the appropriate length. The findings include: Resident #20 diagnoses included Type 2 diabetes mellitus with diabetic neuropathy, peripheral vascular disease, and generalized muscle weakness. Physician's orders dated 3/17/23 directed Humalog solution 100 unit per ml inject per the sliding scale and finger sticks to be administered before meals. Resident #20's quarterly MDS assessment dated [DATE] identified that the resident was severely cognitively impaired, required extensive assistance of two people for bed mobility, extensive assistance of one person for transfers, dressing, toileting, and hygiene. Observation of LPN #5 on 7/10/23 at 11:05 AM identified that she washed her hands, checked Resident #20's physician order, cleaned the glucometer using an alcohol wipe and proceeded to the resident's room. LPN #5 cleaned the resident's finger, checked the resident's blood sugar without the benefit of donning gloves, reported the blood glucose reading to the resident and told the resident she would return with insulin. Once at the cart, LPN #5 placed the glucometer on the cart and after administering insulin to Resident #20, LPN #5 returned to the medication room, disposed of the self-retracting needle, documented in the medication administration record, and then left the medication room and locked the medication room door. Interview with LPN#5 on 7/10/23 at 11:15 AM identified that the policy for the cleaning of the glucometer id to use and alcohol wipe or some form of antiseptic and leave it on the glucometer for five minutes before drying. LPN #5 further noted that there were other wipes to use but that she did not have them, but noted that when she needs supplies, she calls the supervisor. LPN #5 noted that she typically used alcohol to clean the glucometer and acknowledged that she is supposed to clean the glucometer after every finger stick. She further noted that she was nervous and forgot. In addition, LPN #5 identified that she never wears gloves when she is utilizing the glucometer for blood glucose monitoring. Interview with the infection control nurse (RN#1) and RN #5 on 7/12/23 at 12:30 PM identified that staff are trained on glucometer cleaning and acceptable cleaning solutions to use per the policy. They indicated that alcohol is not allowed to be used and indicated that LPN #5 has been trained on this policy and is aware of the process to ask for supplies if there is a need on the unit. RN#1 and RN#5 further indicated that per the infection control policy and fingerstick procedure guidance, it is not acceptable to perform finger sticks without wearing gloves. Review of the glucometer cleaning in-service sign in sheet noted LPN #5 signed it on 4/28/23 indicating that she received training. She also signed an in-service sight in sheet dated 1/13/22 indicating that she attended training on infection control. The facility policy on glucometer use and cleaning directs staff to clean and disinfect the meter prior to the first use on each shift and after each use on each patient. The policy further identified the three acceptable cleaning supplies that the agency provides to use (alcohol wipes are not included). Per the facility policy on blood glucose testing competency, staff are to apply clean gloves prior to obtaining blood from a fingerstick. Based on observation, review of clinical record, review of facility documentation, facility policy, and interviews for one of three sampled residents (Resident #20) who was administered insulin, the facility failed to ensure that the glucometer was cleaned in an appropriate manner to maintain acceptable infection prevention and transmission precautions. The findings include: Resident #20 diagnoses included Type 2 diabetes mellitus with diabetic neuropathy, peripheral vascular disease, and generalized muscle weakness. Physician's orders dated 3/17/23 directed Humalog solution 100 unit per ml inject per the sliding scale and finger sticks to be administered before meals. Resident #20's quarterly MDS assessment dated [DATE] identified that the resident was severely cognitively impaired, required extensive assistance of two people for bed mobility, extensive assistance of one person for transfers, dressing, toileting, and hygiene. Observation of LPN #5 on 7/10/23 at 11:05 AM identified that she washed her hands, checked Resident #20's physician order, cleaned the glucometer using an alcohol wipe and proceeded to the resident's room. LPN #5 cleaned the resident's finger, checked the resident's blood sugar without the benefit of donning gloves, reported the blood glucose reading to the resident and told the resident she would return with insulin. Once at the cart, LPN #5 placed the glucometer on the cart and after administering insulin to Resident #20, LPN #5 returned to the medication room, disposed of the self-retracting needle, documented in the medication administration record, and then left the medication room and locked the medication room door. Interview with LPN#5 on 7/10/23 at 11:15 AM identified that the policy for the cleaning of the glucometer id to use and alcohol wipe or some form of antiseptic and leave it on the glucometer for five minutes before drying. LPN #5 further noted that there were other wipes to use but that she did not have them, but noted that when she needs supplies, she calls the supervisor. LPN #5 noted that she typically used alcohol to clean the glucometer and acknowledged that she is supposed to clean the glucometer after every finger stick. She further noted that she was nervous and forgot. In addition, LPN #5 identified that she never wears gloves when she is utilizing the glucometer for blood glucose monitoring. Interview with the infection control nurse (RN#1) and RN #5 on 7/12/23 at 12:30 PM identified that staff are trained on glucometer cleaning and acceptable cleaning solutions to use per the policy. They indicated that alcohol is not allowed to be used and indicated that LPN #5 has been trained on this policy and is aware of the process to ask for supplies if there is a need on the unit. RN#1 and RN#5 further indicated that per the infection control policy and fingerstick procedure guidance, it is not acceptable to perform finger sticks without wearing gloves. Review of the glucometer cleaning in-service sign in sheet noted LPN #5 signed it on 4/28/23 indicating that she received training. She also signed an in-service sight in sheet dated 1/13/22 indicating that she attended training on infection control.The facility policy on glucometer use and cleaning directs staff to clean and disinfect the meter prior to the first use on each shift and after each use on each patient. The policy further identified the three acceptable cleaning supplies that the agency provides to use (alcohol wipes are not included). Per the facility policy on blood glucose testing competency, staff are to apply clean gloves prior to obtaining blood from a fingerstick. 2. Observation and interview with Nurse Aide (NA) #1 on 7/11/23 at 10:35 AM identified she was wearing fake fingernails, approximately 1 ½ inches in length. NA #1 indicated that she received fake nails for her birthday (7/6/23) but planned to remove them soon. NA #1 further was noted to be working on the unit and completing a resident assignment. Interview and review of the infection control program with RN #1 (Infection Control Nurse) on 7/11/23 at 10:40 AM indicated that staff are not allowed to wear fake nails, the facility was aware of the problem and working on it. A review of facility policy, Personal Appearance and Dress, identified that fingernails should not be more than quarter (1/4) inch long from the tip of the finger for employees involved in direct resident/patient care or where infection control may be an issue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview for 1 of 10 sampled residents (Resident #64) observed during the initial screening process, the facility failed to ensure Resident #64's call bell was within reach and accessible. The findings include: Resident #64's diagnoses included hemiplegia following a cerebral vascular accident, delusional disorder and anxiety. An Annual Minimum Data Set (MDS) dated [DATE] identified Resident #64 was moderately cognitively impaired and required extensive assistance of 1 for bed mobility, dressing, toilet use and personal hygiene. Additionally, the MDS identified Resident #64 required extensive assistance of 2 for transfers and required limited assistance of 1 for eating. A Resident Care Plan dated 7/7/23 identified a problem with having an activities of daily living self-care performance deficit. Interventions included to provide extensive assistance of 1 for showers, dressing, personal hygiene and toilet use. On 7/10/23 at 10:43 AM, observation of Resident #64 identified he/she was lying in bed with the head of the bed raised. Two quarter side rails were in the raised position and the call bell was observed to be coiled up on a nightstand, located behind the resident and out of reach. Upon surveyor inquiry to Resident #64 on how to summon assistance from staff, Resident #64 was observed to feel around the bed linen for the call bell (which was inaccessible). On 7/10/23 at 11:30 AM, observation of Resident #64 with RN #1 identified Resident #64 remained lying in bed with the head of the bed raised. Two quarter side rails were raised and the call bell was observed to be coiled up on a nightstand, located behind the resident and out of reach. RN #1 identified Resident #64 could utilize a call bell, the call bell was out of reach and noted it should be pinned/clipped to the sheet to be accessible to the resident. Subsequent to surveyor inquiry, RN #1 clipped the call bell to Resident #64's sheet near his/her right hand.

Based on observations, review of facility policy, and interviews, the facility failed to ensure that proper handwashing and glove use occurred during the handling of soiled and clean dishes to prevent cross contamination. The findings included: Observation during the kitchen tour on 6/16/21 at 10:42 AM with the Food Services Director (FSD) identified; Dietary Aid (DA) #1 in the dishwashing area with vinyl gloves on her hands. DA #1 was noted to load and then place two racks of soiled dishes through the dishwashing machine. Further observation identified that after the racks with cups and plates went through the dishwashing machine DA #1 pulled one rack loaded with the cleansed dishes from the dishwashing machine while wearing the same vinyl gloves. DA #1 was then observed to empty dirty plates and cups from a food cart and loaded a dishwashing rack with the soiled dishes while wearing the same vinyl gloves. Further observation identified DA #1 removed the vinyl gloves and without the benefit of handwashing or donning clean gloves, she proceeded to unload the clean dishes from the dishwashing rack. Interview with DA #1 on 6/16/21 at 10:55 AM identified that she was rushing and forgot to wash her hands. She further identified that she should be focused and remember to wash her hands after doffing gloves. DA #1 also identified that she was aware of the handwashing and glove use policy. Interview with FSD on 6/16/21 at 11:00 AM identified that staff should perform handwashing after removing used gloves and put on clean gloves to remove and empty racks with cleaned dishes. The FSD identified that staff would be in-serviced on the importance of proper handwashing and identified that the facility's dishwashing protocol included annual competencies completed by the dietary staff that directed staff to identify infection control practices that prevent cross contamination of clean and dirty dishes. The FSD further identified that employees are not to move from the loading area of the dishwashing machine to the receiving area of the dishwashing machine without removing gloves, apron, washing hands, and donning clean disposable gloves. Review of facility's Dining Services Handwashing policy identified dining services employees are to consistently wash their hands using techniques recommended by the Centers for Disease Control and Prevention when moving from one task to another after touching contaminated surfaces or handling raw food items.