**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, facility policy review, and interviews for one of five residents (Resident #1) reviewed for quality of care, the facility failed to ensure that the medical provider was notified timely of the inability to provide ordered tube feeding on admission. The findings include: Resident #1 was admitted to the facility with diagnoses that included protein-calorie malnutrition and dysphagia. The nursing admission form dated 2/25/2025 at 7:38 PM identified Resident #1 was admitted via ambulance, was alert with some confusion, and had a gastrostomy tube (feeding tube). A nursing admission summary written by RN #1/nursing supervisor dated 2/25/2025 at 8:04 PM identified a J-tube (Jejunostomy tube inserted into the small intestine for feeding) present in the right upper (abdomen) quadrant. Per W10 (facility transfer document) admission orders J-tube was to be flushed every hour with 15 cubic centimeters (ccs) of water. Tube feed was to be at a rate of 55 milliliters (ml) per hour. Resident #1 was also on a regular diet with pureed consistency and thin liquids, and the on-call APRN was notified and verified orders. A physician order dated 2/25/2025 directed tube feed: Vital AF 1.2 (peptide-based therapeutic liquid nutrition), 55 ml per hour for 22 hours (daily for 22 hours) for J- tube feeding. A nursing Medication Administration Record (MAR) note written by RN #2 dated 2/26/2025 at 12:21 AM (approximately 4 hours after admission) identified Vital AF 1.2 at 55 ml per hour times 22 hours for J-tube was not available and waiting for the pharmacy to deliver supplies. A nursing MAR note written by RN #2 dated 2/26/2025 12:49 AM identified the change and date (J-tube) tubing set every night shift was not completed as supplies were not on hand. Interview and medical record review with RN #2 on 4/14/2025 at 10:47 AM identified she worked on 2/25/2025 during the 11 PM to 7 AM shift. RN #2 stated when her shift began she tried to initiate Resident #1's tube feeding as ordered, but she could not locate the tube feeding formula and the feeding tubing required for administration, as the items had not arrived from the pharmacy. RN #2 stated she had a large syringe used for feeding tubes in house, and was able to administer the medications and flush through the J-tube as ordered. RN #2 stated she did not notify the APRN/physician of the inability to provide the ordered feeding as she had come on shift at 11:00 PM and Resident #1 had arrived during the evening shift a few hours earlier, and indicated RN #1/evening shift supervisor, was aware the tube feeding had not started. Interview and review of the medical record with RN #1 on 4/14/2025 at 11:30 AM identified he recalled Resident #1 had arrived to the facility with two (2) or three (3) containers of the Vital AF 1.2 formula. RN #1 stated the formula was not the usual tube feed containers that can be spiked with tubing for administration. RN #1 stated he did recall the tube feeding was not started on arrival but could not recall why. RN #1 stated he did not recall contacting the APRN to notify that they did not start the ordered feeding. He stated if he had notified the APRN, he would have documented in Resident #1's medical record and stated if it's not documented, it's not done. RN #1 stated he should have notified the APRN to get an alternate plan for the feeding and could not recall why he did not. Interview with LPN #1 on 4/14/2024 at 11:07 AM identified she hung (started) Resident #1's ordered tube feed after report on 2/26/2025 at around 7:30 AM (approximately 11 and ½ hours after Resident #1 was admitted ). Review identified Resident #1 was without the ordered Vital AF 1.2 at 55 ml per hour times for J-tube from admission on [DATE] at 7:30 PM to 2/26/2025 at 7:30 AM, approximately 11 and ½ hours, or 660 ml of feeding. Interview with MD #1 on 4/14/2025 at 2:00 PM identified if Resident #1 could not receive an ordered tube feeding for 12 hours, the APRN or physician should have been contacted. An alternate plan would have been established to address the feeding that could have included an alternate available formula if needed. Interview with the DON on 4/15/2025 at 2:45 PM identified if a nurse cannot provide a Resident with an ordered tube feed, the APRN or physician needed to be notified, and she did not know why RN #1 and RN #2 did not notify the physician/APRN. The DON stated on 2/26/2025 when she came into work, she went to the unit and found the containers of Resident #1's tube feeding formula in the refrigerator on the unit. The DON stated the equipment/supplies needed to administer the feeding was located in the storage room on the unit. The DON stated she did not know why the nurses did not find the feeding formula and the supplies. The facility policy Notification of Changes dated 2/21/2023, directed in part, that the facility must immediately consult the resident's physician when a need to alter treatment significantly. The facility policy Enteral Feeding dated 12/3/2025 directed in part, that a resident who was fed via a gastrostomy tube received the appropriate treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, facility documentation, facility policies, and interviews with one of five residents (Resident #1) reviewed for quality of care, the facility failed to ensure a tube feeding was administered timely, in accordance with physician orders. The findings include: Resident #1 was admitted to the facility with diagnoses that included protein-calorie malnutrition and dysphagia. The nursing admission form dated 2/25/2025 at 7:38 PM identified Resident #1 was admitted via ambulance, was alert with some confusion, and had a gastrostomy tube (feeding tube). A nursing admission summary written by RN #1/nursing supervisor dated 2/25/2025 at 8:04 PM identified a J-tube (Jejunostomy tube inserted into the small intestine for feeding) present in the right upper (abdomen) quadrant. Per W10 (facility transfer document) admission orders J-tube was to be flushed every hour with 15 cubic centimeters (ccs) of water. Tube feed was to be at a rate of 55 milliliters (ml) per hour. Resident #1 was also on a regular diet with pureed consistency and thin liquids, and the on-call APRN was notified and verified orders. A physician order dated 2/25/2025 directed tube feed: Vital AF 1.2 (peptide-based therapeutic liquid nutrition), 55 ml per hour for 22 hours (daily for 22 hours) for J- tube feeding. A nursing Medication Administration Record (MAR) note written by RN #2 dated 2/26/2025 at 12:21 AM (approximately 4 hours after admission) identified Vital AF 1.2 at 55 ml per hour times 22 hours for J-tube was not available and waiting for the pharmacy to deliver supplies. A nursing MAR note written by RN #2 dated 2/26/2025 12:49 AM identified the change and date (J-tube) tubing set every night shift was not completed as supplies were not on hand. Interview and medical record review with RN #2 on 4/14/2025 at 10:47 AM identified she worked on 2/25/2025 during the 11 PM to 7 AM shift. RN #2 stated when her shift began she tried to initiate Resident #1's tube feeding as ordered, but she could not locate the tube feeding formula and the feeding tubing required for administration, as the items had not arrived from the pharmacy. RN #2 stated she had a large syringe used for feeding tubes in house, and was able to administer the medications and flush through the J-tube as ordered. Interview and review of the medical record with RN #1 on 4/14/2025 at 11:30 AM identified he recalled Resident #1 had arrived to the facility with two (2) or three (3) containers of the Vital AF 1.2 formula. RN #1 stated the formula was not the usual tube feed containers that can be spiked with tubing for administration. RN #1 stated he did recall the tube feeding was not started on arrival but could not recall why. Interview with LPN #1 on 4/14/2024 at 11:07 AM identified she hung (started) Resident #1's ordered tube feed after report on 2/26/2025 at around 7:30 AM (approximately 11 and ½ hours after Resident #1 was admitted ). Review identified Resident #1 was without the ordered Vital AF 1.2 at 55 ml per hour times for J-tube from admission on [DATE] at 7:30 PM to 2/26/2025 at 7:30 AM, approximately 11 and ½ hours, or 660 ml of feeding. Interview with MD #1 on 4/14/2025 at 2:00 PM identified if Resident #1 could not receive an ordered tube feeding for 12 hours, the APRN or physician should have been contacted. An alternate plan would have been established to address the feeding that could have included an alternate available formula if needed. Interview with MD #1 on 4/14/2025 at 2:00 PM identified if he was aware, he could have given orders for an alternate tube feeding. Interview with the DON on 4/15/2025 at 2:45 PM identified the tube feeding should have been provided as ordered. The DON stated on 2/26/2025 when she arrived at work, she looked on the unit for the tube feeding and located the formula in the unit refrigerator. Further, she located the required feeding supplies in the unit storage room. The DON stated she did not know why the nurses did not locate the formula and feeding supplies. The facility policy Enteral Feeding dated 12/3/2025 directed in part, that a resident who was fed via a gastrostomy tube received the appropriate treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #226) reviewed for rehabilitation, the facility failed to develop a baseline care plan for a newly admitted resident with multiple cardiac and respiratory issues who required a specialized device. The findings include: Review of hospital discharge documentation dated 12/31/24 identified Resident #226 was hospitalized from [DATE] - 12/31/24 for cardiac surgery that included coronary artery bypass surgery of 4 vessels and removal of an implanted pacemaker/defibrillator wires. The documentation further identified that during the hospitalization, Resident #226 had a spontaneous right sided pneumothorax (collapsed lung) that required chest tube placement and was removed prior discharge. The hospital documentation further identified that post operatively, Resident #226 required the use of a Lifevest device (a wearable defibrillator that continuously monitors the heart and delivers a controlled electrical shock if indicated). Resident #226 was admitted to the facility on [DATE] with diagnoses that included recent coronary artery bypass surgery, heart failure, chronic obstructive pulmonary disease, and atherosclerotic heart disease. The nursing admission assessment dated [DATE] identified Resident #226 was admitted following coronary artery bypass surgery with a right sided pneumothorax and had a Lifevest device in place. The baseline care plan dated 12/31/24 failed to identify documentation related to the resident's cardiac or respiratory diagnoses including his/her recent major cardiac surgery, spontaneous pneumothorax requiring a chest tube placement, or need for the Lifevest device. Interview with LPN #1 (MDS Coordinator) on 1/8/25 at 10:12 AM identified she was responsible for MDS assessments, reviewing and updating baseline and comprehensive care plans, and also had a dual role as a medical records clerk at the facility, and that due to her work load, she had fallen behind on ensuring the resident care plans were reviewed to ensure they were individualized to the resident's individual needs. LPN #1 identified that when a resident was admitted , the baseline care plan included, at a minimum, care plans to address pain, falls, skin, code status, and the admission diagnoses, and that after the comprehensive care plan was developed, the resident's specific needs should have been included. LPN #1 identified if a resident was admitted to the facility with a specialized device, or required additional interventions, such as post operative surgical site care, etc, these should be added to the baseline care plan and then would carry over to the comprehensive care plan. LPN #1 identified Resident #226 should have had a baseline plan that reflected the need for respiratory and cardiac monitoring and the use of the Lifevest device, as these were all identified on the hospital W-10 and should have been included in his/her care plan upon admission to the facility. The facility assessment provided to the survey team on 1/8/25 and dated 1/7/25, directed that the facility had the ability to provide person centered directed care and special care needs for all its residents. The assessment also directed that the facility had sufficient resources to provide staff education, competencies, and had policies and procedures for provisions of care for all facility residents. The facility policy on care plans directed at that the facility must develop a baseline care plan for each resident that would include the instructions needed to provide effective and person-centered care of the resident that met the professional standards of quality care. The policy further directed that the baseline care plan must be developed within 48 hours of admission and must include minimum healthcare information necessary to properly care for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 5 residents (Resident #9 and 224) reviewed for unnecessary medications, the facility failed to develop a comprehensive care plan with interventions to address fall risk, use of antidepressant, antianxiety, and anticoagulant medications and intravenous antibiotic medication via a specialized central line. The findings include: 1. Resident #9 was admitted to the facility on [DATE] with diagnoses that included depression, anxiety, and dissection of the thoracic aorta. The admission MDS dated [DATE] identified Resident #9 had moderately impaired cognition, had an active diagnosis of depression and anxiety disorder, was taking medications for antianxiety, antidepressant, and anticoagulant. Additionally, the MDS identified Resident #9 had a fall in the last month prior to admission and a fall in the last 2-6 months before admission. The MDS was completed on 12/30/24. A physician's order dated 12/26/24 directed to administer Lexapro (antidepressant medication) 20 mg daily, Alprazolam (antianxiety medication) 0.25mg one tablet every 12 hours as needed for anxiety, and Heparin solution (blood thinner) 5000 units inject subcutaneously 3 times a day. Review of the care plan on 1/6/25 failed to reflect interventions for the use of antidepressant, antianxiety, and anticoagulant medications or interventions to address the resident's risk of falls. Interview with LPN #1 (MDS coordinator) on 1/7/25 at 2:02 PM indicated she was responsible to do the comprehensive care plan within 21 days of admission. LPN #1 indicated that the comprehensive care plan was to include potential or actual problems that a resident has. LPN #1 indicated that a comprehensive care plan would include the resident's diagnosis and the medications taken. LPN #1 indicated that Resident #9's comprehensive care plan should include his/her fall risk, diagnosis of depression, anxiety and anticoagulant use. LPN #1 indicates that the care plan has a focus area for the problem or diagnosis, then the desired outcomes and the intervention or actions to be taken. LPN #1 indicated that the admission MDS (comprehensive assessment) should have been done by 12/24/24 but was not, and the comprehensive care plan ahould have to been done within the 7 days of the MDS but no later than 12/30/24. LPN #1 indicated that it was not done because she is behind and has no coverage when she is off. Interview and clinical record review with DNS on 1/7/25 at 2:10 PM indicated that the MDS coordinator LPN # 1 was responsible to do the comprehensive care plan. Review of the Care Plan Policy identified care plan is the plan of care that is developed by the interdisciplinary team, the resident and/or resident representative, and the attending physician. The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet the residents medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. A comprehensive care plan must be developed within 7 days after completion of the comprehensive assessment (MDS).2. Review of hospital documentation dated 12/18/24 identified Resident #224 weighed 195 lbs., was receiving Daptomycin (an intravenous antibiotic) daily for 6 weeks, and had a peripherally inserted central catheter (PICC) in place. The hospital documentation also identified to notify the physician for a weight gain of more than 4 lbs. in 2 days. Resident #224 was admitted to the facility on [DATE] with diagnoses that included MRSA bacteremia, chronic kidney disease, and insulin dependent diabetes. The physician's orders dated 12/18/24 directed to infuse 500 mg Daptomycin daily with an end date of 1/14/25: to flush the PICC line pre and post Daptomycin infusion, and to change the PICC dressing every 7 days. The admission MDS dated [DATE] identified Resident #224 had intact cognition, was always continent of bowel, required in indwelling catheter for bladder and was dependent on staff to assist with dressing, toileting, and transfers. The MDS also identified Resident #224 had a PICC line on admission to the facility. The corresponding care plan dated failed to identify interventions related to intravenous medications or the PICC line. Interview with LPN #1 (MDS Coordinator) on 1/8/25 at 10:12 AM identified that she was responsible for MDS assessments, reviewing and updating baseline and comprehensive care plans, and also had a dual role as a medical records clerk at the facility, and that due to her work load, she had fallen behind on ensuring the resident care plans were reviewed to ensure they were individualized to the resident's individual needs. LPN #1 identified that when a resident was admitted , the baseline care plan included, at a minimum, care plans to address pain, falls, skin, code status, and the admission diagnoses, and that after the comprehensive care plan was developed, the resident's specific needs should have been included. LPN #1 identified if a resident was admitted to the facility with a specialized device, or required additional interventions, such as post operative surgical site care, etc, these should be added to the baseline care plan and then would carry over to the comprehensive care plan as these would be identified on the hospital documentation and indicate the need for admission to the facility. LPN #1 identified Resident #224 should have had comprehensive care plan in place to address his/her need for prolonged antibiotic use through a PICC line, as this line was specialized due to the resident's need for long term antibiotic treatment. The facility policy on care plans directed the facility must develop a comprehensive person-centered care plan for each resident that must include measurable objectives and timetable table to meet the resident's needs. The policy further directed that the comprehensive care plan should include any specialized services, be completed within 7 days of the comprehensive assessment, and include desired outcomes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interview for 1 of 2 residents (Resident #224) reviewed for nutrition, the facility failed to ensure that weights were obtained per the physician's order for a newly admitted resident; and for 1 of 2 residents (Resident #226) reviewed for rehabilitation, the facility failed to ensure that a physician's order was obtained related to a specialized cardiac device to ensure function; and failed to ensure respiratory assessments were completed and documented per the physician's order; and for 1 resident (Resident #9) the facility failed to ensure a PPD (purified protein derivative is a skin test that determines if you have Tuberculosis) was completed on admission per the physician's order. The findings include: 1. Review of hospital documentation dated 12/18/24 identified Resident #224 had a weight of 195 lbs., (used to determine Daptomycin dosing) at 500 mg daily for 6 weeks, had a PICC line in place, and to notify the physician for a weight gain of more than 4 lbs. in 2 days. Resident #224 was admitted to the facility on [DATE] with diagnoses that included MRSA bacteremia, chronic kidney disease, and insulin dependent diabetes. A physician's order dated 12/18/24 directed to obtain Resident #224's weight on admission, daily for 3 days, weekly for 4 weeks, and then monthly. A nursing admission assessment, completed by RN #6 on 12/18/24 failed to identify documentation related to Resident #224's admission weight on that date. The care plan dated 12/20/24 directed that Resident #224 was at risk for malnutrition. Interventions directed to monitor closely for weight loss/gain. The nutrition admission assessment dated [DATE] by the Dietitian identified Resident #224 had a weight of 177.4 lbs., that Resident #224 reported a baseline weight of 182 - 183 lbs., and that Resident #224 had a history of recent weight loss but not significant. The admission MDS dated [DATE] identified Resident #224 had intact cognition, was always continent of bowel, required in indwelling catheter for bladder and was dependent on staff to assist with dressing, toileting, and transfers, and was independent with meals. The MDS also identified Resident #224 weighed 178 lbs. and had no recent history of weight gain or loss. Review of the clinical record identified an initial documented weight of 177.4 lbs. on 12/20/24, 2 days after admission to the facility, and a 17.6 lbs. or 9% loss from the last documented weight in the 12/18/24 hospital documentation. Review of the clinical record identified weights following the initial weight on 12/20/24 12/21/24 177.6 lbs. 12/30/24 180.0 lbs. 1/4/25 187.0 lbs. Further review of the clinical record identified Resident #224 had a weight of 189 lbs. documented on 1/6/25, a 12.6 lb or 6.54 % gain in 17 days. A physician's note dated 1/6/25 identified that Resident #224 was seen due to staff noting a weight gain of 10 lbs. since admission with an initial weight of 177 lbs. and now 189 lbs. The note identified Resident #224 was observed to have bilateral 3 + pitting edema to the lower extremities, dependent edema to the bilateral upper extremities and in the dependent part of the arms and lower skin folds. The assessment identified Resident #224 had fluid overload with increasing weight with a plan to start Lasix (a diuretic medication used to decrease fluid overload) 40 mg daily for 3 days and then 20 mg daily, and to obtain daily weights. Interview with the Dietitian on 1/8/25 at 9:20 AM identified that she completed an initial assessment on 12/20/24 and did not review the hospital documentation related to weights prior to the assessment. The Dietitian identified that she did not believe that the hospital weights were accurate, and did not review them as they often included weights from previous hospital admissions. The Dietitian identified that she was aware Resident #224 received daily Daptomycin therapy. The Dietitian was unable to identify why Resident #224's weight on the hospital documentation was not reviewed prior to her nutritional assessment, given the order for Daptomycin was new and would require a current weight to initiate this medication safely. Interview and record review with RN #6 on 1/8/25 at 9:30 AM identified he completed the admission assessment for Resident #224 on 12/18/24. RN #6's review of Resident #224's clinical record failed to identify an admission weight on that date. RN #6 identified he typically reviewed the hospital documentation, and the admission orders related to the residents' weights, and in this instance he was unsure what happened, but he was unable to locate an admission weight, or a reference to the hospital weight, but he should have ensured the admission weight was obtained. Interview with APRN #1 on 1/8/25 at 9:57 AM identified that he would expect facility nursing staff to obtain the resident's weight on admission per the facility policy, however this could be within 24 hours. APRN #1 identified that the nursing staff should at least review the hospital documentation related to weights, but that it would be hard to review all the hospital discharge paperwork related to weights. APRN #1 identified Resident #224 was currently gaining weight due to fluid retention, and while in the facility had gained weight. APRN #1 was unable to identify if Resident #224 had a true weight loss from the 195 lbs. per the hospital documentation. to 177.4 lbs. on 12/20/24 since the admission weight on 12/18/24 was not obtained. The facility policy on weights directed that residents would be weighed as directed by the physician and standards of care and would be documented in the clinical record. The policy further directed that if the resident had a weight loss or gain, a re-weigh should be obtained at the time of the weight change, and to notify the physician of a significant weight loss or weight gain. The policy further identified a significant weight loss/gain was 5% over one month; 7.5% over 3 months, or greater than 10 % over 6 months. 2. Review of hospital discharge documentation dated 12/31/24 identified that Resident #226 was hospitalized from [DATE] - 12/31/24 for cardiac surgery that included coronary artery bypass surgery of 4 vessels and removal of implanted pacemaker/defibrillator wires. The documentation further identified that during the hospitalization, Resident #226 had a spontaneous right sided pneumothorax (collapsed lung) that required chest tube placement for which was removed prior to discharge. The hospital documentation further identified that post operatively, Resident #226 required the use of a Lifevest device (a wearable defibrillator that continuously monitors the heart and delivers a controlled electrical shock if indicated). Resident #226 was admitted to the facility on [DATE] with diagnoses that included heart failure, chronic obstructive pulmonary disease, and atherosclerotic heart disease. The nursing admission assessment dated [DATE] identified Resident #226 had intact cognition and required the assist of one staff member with transfers and toileting. The admission assessment also identified Resident #226 was admitted following coronary artery bypass surgery of 4 vessels with a right sided pneumothorax and had a Lifevest device in place. The care plan dated 12/31/24 failed to identify interventions related to cardiac or respiratory issues or diagnoses for Resident #226, including need for the Lifevest device. A physician's order dated 12/31/24 directed to complete respiratory assessments daily for 7 days on the 11:00 PM - 7:00 AM shift. Review of the physician's orders failed to identify the Lifevest system, including monitoring checks for function and battery life, or orders related to battery changes. Review of the January 2025 TAR identified that respiratory assessments were signed off as completed daily from 1/1/25 - 1/6/25. Review of the clinical record identified nursing documentation related to respiratory assessment findings for 1/1/25 - 1/2/25. Further review of the clinical record failed to identify any additional documentation related to assessment findings for 1/3/25 - 1/6/24. Observation and interview with Resident #226 on 1/6/25 at 7:24 AM identified he/she had recent major heart surgery and had been admitted to the facility for post-surgery rehabilitation. Resident #226 identified he/she had only recently started rehab but had been having difficulty taking a deep breath at times, which he/she had reported to the clinical staff on 1/4/25, after he/she was provided a shower. During this interview, Resident #226 was observed wearing the Lifevest device. Interview with the DNS on 1/7/25 at 11:33 AM identified that the facility had not provided in service or training to facility staff related to the Lifevest device for Resident #226 prior to or after admission on [DATE]. The DNS also identified she did not have any documentation that the facility staff had ever been provided education on the Lifevest device. Interview with Resident #226 on 1/7/25 at 11:35 AM identified that he/she had all the education materials, including the manual for the device, in his/her room. Resident #226 identified that the device required a rechargeable battery for function and that he/she had been monitoring the battery life and changing the battery daily at 2:30 PM. Resident #226 identified he/she had a replacement battery on a charger located on his/her nightstand. Resident #226 identified he/she had some mild arthritis in his/her hands and this, along with overall weakness from his/her recent surgery, made it difficult at times to remove and replace the battery. Resident #226 identified that the facility nursing staff did not change the battery for the Lifevest device and only assisted with the battery changes at his/her request, when he/she had difficulty removing the old battery. Interview and clinical record review with LPN #2 on 1/7/25 at 12:20 PM identified that she was aware Resident #226 had a Lifevest device on, and that the nursing staff had been instructed that the battery for the device needed to be replaced daily at 2:30 PM by Resident #226. LPN #2 identified that she had not been educated on the device, and that she was aware of how the device worked based on training she received several years prior at another facility. LPN #2 identified upon review of the clinical record she was unable to locate any orders related to the Lifevest device. LPN #2 identified that the 2:30 PM daily battery change was based on Resident #226's preference as this was the time the battery changes occurred while Resident #226 was hospitalized . Interview with the DNS on 1/7/25 at 3:17 PM identified that Resident #226 had an order in place to complete daily respiratory assessments and these were done on the 11:00 PM - 7:00 AM shift. The DNS identified that the nursing staff were to sign off that the assessment had been completed daily on the TAR, and then the actual assessment findings were then documented under the Respiratory Screener observation area in the clinical record, which included detailed exam findings, and for the assessment to be considered completed, both the TAR sign off and the assessment would need to be documented. The DNS identified that the TAR sign off alone did not mean the assessment had been completed, since the assessment findings also needed to be documented. Interview with the DNS and Administrator on 1/8/25 at 1:45 PM identified that the facility staff should have been educated on use and care of the Lifevest device prior to Resident #226's admission to the facility and a physician's order should have been in place related to the battery changes. Review of the clinical record failed to identify instructions or manuals for Resident #226's Lifevest device. Although requested, the facility failed to provide any policies or procedures related to the Lifevest device. The facility policy on physician's orders directed that the DNS and/or medical records designee were responsible to ensure that the physician's orders were provided timely, confirmed with the resident's primary physician, and new admissions would have orders in place to provide care for the resident. The policy further directed that the written orders would include orders related to recommendations for admission to the facility and specialized rehabilitation treatments. The facility assessment provided to the survey team on 1/8/25 and dated 1/7/25, directed that the facility had the ability to provide person centered directed care and special care needs for all its residents. The assessment also directed that the facility had sufficient resources to provide staff education, competencies, and had policies and procedures for provisions of care for all facility residents. Review of the [NAME] Lifevest 4000 instruction manual materials, located in Resident #226's room, included a patient card which directed that the card [NAME] had a wearable defibrillator on due to high risk of sudden cardiac death, and the device was intended to automatically treat sudden cardiac death events that could occur without warning. The patient card also directed that device must be worn continuously and only be removed for a short shower. The instruction manual directed that if the patient needed to remove the garment for any reason, the battery pack should be removed prior to any removal of the Lifevest device and when reapplying the Lifevest, the electrodes and pads must be applied to bare skin to work accurately, and the battery pack should be reinserted as the last step, once the vest was fully applied. 3. Resident #9 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia and COPD. A physician's order dated 12/13/24 directed to administer PPD 2 step, 0.1ml on admission, if negative, repeat in 1 week. The December 2024 MAR identified Resident #9 had the step-1 PPD planted on 12/13/24 and a negative result was documented on 12/16/24. The MAR failed to identify that the step 2 PPD was repeated, per order. Interview and clinical record review with the Infection Preventionist (RN #1) and the DNS on 1/8/25 at 10:11 AM failed to identify that Resident #9 received the second PPD test. The DNS identified that the facility policy is to complete a 2-step Tuberculosis PPD test on new admissions to the facility. The day after admission the first PPD test is planted and read 48 - 72 hours after placement, and the second PPD test would be planted one week later and read 48 - 72 hours after placement. The DNS indicated that it is the responsibility of the floor nurse to plant and read the PPD, repeat the process one week later, and document all actions in the resident's MAR. The facility's TB Skin Testing for Residents policy directs all residents admitted will be screened for signs and symptoms of Tuberculosis and will complete TST (tuberculin skin test), or provide a statement from the physician stating that the resident is free from active pulmonary communicable TB. If the resident has not had a TST in the last year a 2-step TST will be required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #7) reviewed for nutrition, the facility failed to follow a physician's order for weight monitoring for a resident with severe protein-calorie malnutrition. The findings include: Resident #7 was admitted to the facility on [DATE] with diagnoses that included dysphagia, hyponatremia, Myelodysplastic Syndrome, and severe protein-calorie malnutrition. A physician's order dated 12/12/24 directed to weigh Resident #7 on admission, daily times 3 days, weekly times 4 weeks, and then monthly: every Monday on day shift. The APRN admission Note dated 12/13/24 at 8:00 AM identified Resident #7 had moderate protein-calorie malnutrition, likely related to cancer diagnosis. Monitor nutritional status and weight, consider nutritional supplements if needed. Current weight 110.5 lbs. The care plan dated 12/13/24 identified Resident #7 had a nutritional problem related to: severe malnutrition, weight loss, low BMI, increased nutrient needs, hyponatremia, and dysphagia. Interventions included monitoring, recording, and reporting to the physician signs and symptoms of malnutrition: emaciation, muscle wasting, and significant weight loss: 3 pounds in 1 week, greater than 5% in 1 month, greater than 7.5% in 3 months, and greater than 10% in 6 months. The care plan failed to identity a focus, desired outcomes, or interventions for refusals of care. The admission MDS dated [DATE] identified Resident #7 had intact cognition, required a setup or clean-up assist with eating, had a weight loss of 5% or more in the last month or a loss of 10% or more in the last 6 months, and was not on a physician-prescribed weight-loss regimen. Review of the Weights and Vital Summary and the December 2024 TAR failed to identify weekly weights were completed from 12/14/24 through 12/30/24 (a period of 16 days). The Weights and Vital Summary identified that on 12/12/24 Resident #7 weighed 112 pounds and on 12/31/24 Resident #7 weighed 98 pounds, which is a 12.5% loss. The nurse's notes dated 12/12/24 through 12/31/24 failed to identify that Resident #7 had refused his/her scheduled weights. Interview with Resident #7 on 1/6/25 at 7:34 AM identified that he/she was aware of the recent significant weight loss. Resident #7 identified his/her condition had been improving and he/she was planning on being discharged home at the end of the week. Resident #7 indicated that he/she was recently admitted to the hospital from another facility with sepsis and had already began losing weight prior to his/her admission to this facility. Resident #7 identified that the food at the facility was good, but he/she initially had a poor appetite, which had been improving, and that he/she was working in collaboration with the facility staff regarding his/her weight loss. Interview and clinical record review with the Dietitian on 1/7/25 at 8:33 AM identified that Resident #7 had begun losing weight prior to admission to this facility, had weighed 103 pounds during his/her hospital admission, and had an admission diagnosis of severe malnutrition. The Dietitian indicated that Resident #7 had refused a shower on 12/22/24 but was unable to identify documentation that Resident #7 had refused to be weighed. The Dietitian further indicated that upon the identification of Resident #7's weight loss, the provider was notified, and she met with Resident #7 to discuss his/her weight loss and subsequently exchanged the Magic Cup supplement for the Mighty Shake supplement, per the resident's preference. The Dietitian indicated that even if Resident #7 had weekly weights taken between 12/12/24 through 12/31/24, she believes the weight loss outcome would have still been the same, but she would have addressed the weight loss and modified the supplements sooner. Interview and clinical record review with LPN #5 on 1/08/25 at 8:44 AM identified that she had identified Resident #7's weight loss, on 12/31/24, and notified the Dietitian and the APRN. LPN #5 further identified that majority of the facility residents, except for a few residents, are weighed weekly, during the day shift on Mondays. LPN #5 indicated that all nursing staff are responsible for obtaining residents' weights, but typically the nurse aide would obtain all the assigned resident's weights and write the weight onto the weight sheet, and the assigned Charge Nurse would enter the resident's weight into the electronic health record. LPN #5 identified that she works full time, on the day shift but was off both Mondays that Resident #7's weights were not obtained. LPN #5 further identified that she was unaware if Resident #7 had refused to be weighed during the timeframe of 12/12/24 through 12/31/24, but that Resident #7 had never refused care/treatment while she had been assigned to him/her. Interview with LPN #2 on 1/08/25 at 9:06 AM identified that she had provided care for Resident #7 only a few times, and he/she had never refused care or weights for her. LPN #2 further identified that if a resident refuses a weight, she would ask him/her the reason for the refusal, then she would educate the resident on the importance of why the weight needs to be obtained and reapproach later, if appropriate. LPN #2 indicated that she would also notify the physician of a weight refusal and document in the clinical record. Interview and clinical record review with the DNS on 1/08/25 at 10:47 AM identified that weights are to be completed per the physician's orders. The DNS indicated that if Resident #7 had refused a weight, she would have expected the nurse to notify the provider and then reapproach on the next shift. The DNS identified that education will be provided to the nursing staff on the weight policy. Interview with APRN #1 on 1/08/25 at 9:44 AM identified that Resident #7's weight loss was anticipated due to his/her diagnoses of Myelodysplastic Syndrome, however he would have expected that Resident #7's weights were obtained per the physician's order because he/she was a brand new resident and identified as having malnutrition. APRN #1 indicated that the Dietitian had adjusted Resident #7's supplements, when the weight loss was identified and that he would not have made any other adjustments. The facility's Weights policy directs all resident maintain acceptable parameters of nutritional status, taking into account the resident's clinical condition. Resident will be weighed as directed by the physician, federal/state regulations, or standards of practice and weights will be documented in the electronic health record. If weight loss or weight gain has occurred, appropriate follow-up is initiated and proper documentation recorded on the resident's status and follow-up taken.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #174) reviewed for respiratory care, the facility failed to change the oxygen and nebulizer tubing weekly per physician order. The findings include: The hospital Discharge summary dated [DATE] identified Resident #174 was diagnosed on [DATE] with Covid-19 infection. Resident #174 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, chronic respiratory failure, Covid 19 and Dementia. A physician order dated 12/23/24 directed to maintain oxygen via nasal cannula at 2.5 liters may titrate to 2 liters if pulse ox level is greater than 90%. Additionally, administer Levalbuterol inhalation nebulizer solution 0.63 mg/3ml application inhale orally via nebulizer 4 times a day for congestion and/or shortness of breath and contact precautions isolation precautions every shift related to Covid-19. A physician's order dated 12/25/24 directed to change and date oxygen tubing set and nebulizer tubing every Wednesday night shift. The admission 5-day MDS dated [DATE] identified Resident #174 had severely impaired cognition and required total assistance with dressing, and transfers. Resident #174 was on oxygen on admission and while a resident at the facility. The care plan dated 12/27/24 did not reflect oxygen or nebulizer use. The physician order dated 12/28/24 at 11:59 PM directed to discontinue the contact isolation precautions for Covid-19. Observation on 1/6/25 at 8:00 AM identified Resident #174 was lying in bed wearing a nasal cannula connected to a concentrator set at 2.5 liters of oxygen. The nebulizer was on the nightstand at the bedside with mask inside the top drawer. The oxygen tubing and the nebulizer tubing had a piece of nursing tape attached to the tubing's dated 12/25/24 (12 days prior was last changed). Interview with LPN #2 on 1/6/25 at 9:07 AM indicated that Resident #174 was admitted with covid-19 and was receiving oxygen and nebulizer treatments. LPN #2 indicated that Resident #174's oxygen tubing and nebulizer tubing were to be changed every Wednesday by the charge nurse on the 11:00 PM to 7:00 AM shift. LPN #2 indicated that Resident #174's oxygen tubing he/she was wearing at the time and the nebulizer tubing were both dated 12/25/24. LPN #2 indicated that Resident #174 was receiving nebulizer treatments 4 times a day. LPN #2 indicated that both tubing's should have been changed on 1/1/25. Interview with the DNS on 1/6/25 at 9:13 AM identified that the oxygen tubing and nebulizer tubing had a piece of tape that was dated 12/25/24 and was scheduled to be changed every week on Wednesdays by the RN on the 11:00 PM to 7:00 AM shift. The DNS indicated that the nurse must date the tubing when it is changed and the nurse should not sign off that the tubing was changed it they did not change it. The DNS indicated that the oxygen tubing and nebulizer tubing were dated 12/25/24 and should have been changed last Wednesday (1/1/25) per the physician's order and the nurse should not have signed off that he did it when it was not done. Interview with RN #2 on 1/8/25 at 8:25 AM identified that oxygen and nebulizer tubing was to be changed once a week on Wednesdays by the 11:00 to 7: 00 nurse. RN #2 indicated that no one has shown him if there was a place to sign off that the tubing was changed. RN #2 indicated that each tubing when changed must be initial, dated and timed. Review of the facility Respiratory Equipment Changing identified all respiratory therapy equipment must be changed to prevent nosocomial infections. All equipment should be marked with a date that it was changed. All equipment should be changed on a weekly basis as well as needed if it becomes soiled or falls on the ground. This equipment includes nasal cannulas, nebulizer treatment equipment, corrugated tubing, simple masks, oxygen and suction tubing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record review, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #226) reviewed for rehabilitation, the facility failed to ensure nursing staff were provided training and education related to a specialized device for a newly admitted resident. The findings include: Review of hospital discharge documentation dated 12/31/24 identified that Resident #226 was hospitalized from [DATE] - 12/31/24 for cardiac surgery that included coronary artery bypass surgery of 4 vessels and removal of implanted pacemaker/defibrillator wires. The documentation further identified that during the hospitalization, Resident #226 had a spontaneous right sided pneumothorax (collapsed lung) that required chest tube placement for which was removed prior to discharge. The hospital documentation further identified that post operatively, Resident #226 required the use of a Lifevest device (a wearable defibrillator that continuously monitors the heart and delivers a controlled electrical shock if indicated). Resident #226 was admitted to the facility on [DATE] with diagnoses that included heart failure, chronic obstructive pulmonary disease, and atherosclerotic heart disease. The nursing admission assessment dated [DATE] identified Resident #226 had intact cognition and required the assist of one staff member with transfers and toileting. The admission assessment also identified Resident #226 was admitted following coronary artery bypass surgery of 4 vessels with a right sided pneumothorax and had a Lifevest device in place. The care plan dated 12/31/24 failed to identify interventions related to cardiac or respiratory issues or diagnoses for Resident #226, including need for the Lifevest device. Review of the physician's orders failed to identify the Lifevest system, including monitoring checks for function and battery life, or orders related to battery changes. Observation and interview with Resident #226 on 1/6/25 at 7:24 AM identified he/she had recent major heart surgery and had been admitted to the facility for post-surgery rehab. Resident #226 identified he/she had only recently started rehab but had been having difficulty taking a deep breath at times, which he/she had reported to the clinical staff on 1/4/25, after he/she was provided a shower. During this interview, Resident #226 was observed wearing the Lifevest device. Interview with the DNS on 1/7/25 at 11:33 AM identified that the facility had not provided any training to facility staff related to the Lifevest device for Resident #226 prior to or after admission on [DATE]. The DNS also identified she did not have any documentation that the facility staff had ever been provided education on the Lifevest device. Interview with Resident #226 on 1/7/25 at 11:35 AM identified that he/she had all the education materials, including the manual for the device, in his/her room. Resident #226 identified that the device required a rechargeable battery for function and that he/she had been monitoring the battery life and changing the battery daily at 2:30 PM. Resident #226 identified he/she had a replacement battery on a charger located on his/her nightstand. Resident #226 identified he/she had some mild arthritis in his/her hands and this, along with overall weakness from his/her recent surgery, made it difficult at times to remove and replace the battery. Resident #226 indicated he/she has difficulty removing and replacing the battery at times. Resident #226 identified that the facility nursing staff did not change the battery for the Lifevest device and only assisted with the battery changes at his/her request, when he/she had difficulty removing the old battery. Interview and clinical record review with LPN #2 on 1/7/25 at 12:20 PM identified that she was aware Resident #226 had a Lifevest device on, and that the nursing staff had been instructed that the battery for the device needed to be replaced daily at 2:30 PM by Resident #226. LPN #2 identified that she had not been educated on the device, and that she was aware of how the device worked based on training she received several years prior at another facility. LPN #2 upon review of the clinical record, was unable to locate any orders related to the Lifevest. LPN #2 identified that the 2:30 PM daily battery change was based on Resident #226's preference as this was the time the battery changes occurred while Resident #226 was hospitalized . Interview with NA #6 on 1/7/25 at 12:25 PM identified she was working with another nurse aide as she had only recently started employment at the facility but was assigned to Resident #226. NA #6 identified she was aware Resident #226 had a vest on but was not aware what the vest was for or why Resident #226 required it. NA #6 identified that she had only observed Resident #226 wearing the vest and she had not received any instructions, or training on the vest. Interview with PTA #1 (PT Director), PTA #2, OT #1, and OTA #1 on 1/7/25 at 12:30 PM identified they had each worked with Resident #226 providing PT and OT services daily since 1/1/25 and had not received any education or training from the facility related to the Lifevest device. OTA #1 identified she had never been trained or provided education on the device at any facility she had worked. OT #1 and PTA #2 identified they had both received training in the past on the device while working at another facility and were aware it was a cardiac monitor with a defibrillator. PTA# 1 identified she had received training on the device in the past while working at a different facility and was aware that Resident #226 must have the vest on at all times and that the Lifevest device had a response button that Resident #226 was required to push if the vest determined an irregular heart rhythm, and if he/she did not press the button, the vest would beep and administer a defibrillation shock to the resident. Interview with LPN #1 (MDS Coordinator) on 1/8/25 at 8 AM identified that she could not recall ever receiving education or training related to a Lifevest Device. Interview with the DNS and Administrator on 1/8/25 at 1:45 PM identified that the facility staff should have been educated on use and care of the Lifevest device prior to Resident #226's admission to the facility and a physician's order should have been in place related to the battery changes. Review of the clinical record failed to identify instructions or manuals for Resident #226's Lifevest device. Although requested, the facility failed to provide any policies or procedures related to the Lifevest device. The facility assessment provided to the survey team on 1/8/25 and dated 1/7/25, directed that the facility had the ability to provide person centered directed care and special care needs for all its residents. The assessment also directed that the facility had sufficient resources to provide staff education, competencies, and had policies and procedures for provisions of care for all facility residents. Review of the [NAME] Lifevest 4000 instruction manual materials, located in Resident #226's room, included a patient card which directed that the card [NAME] had a wearable defibrillator on due to high risk of sudden cardiac death, and the device was intended to automatically treat sudden cardiac death events that could occur without warning. The patient card also directed that device must be worn continuously and only be removed for a short shower. The instruction manual directed that if the patient needed to remove the garment for any reason, the battery pack should be removed prior to any removal of the Lifevest device and when reapplying the Lifevest, the electrodes and pads must be applied to bare skin to work accurately, and the battery pack should be reinserted as the last step, once the vest was fully applied.

Based on observation, review of facility documentation, facility policy, and interviews, the facility failed to ensure shift to shift controlled drugs count was consistently completed. The findings include: Observation on 1/8/25 at 12:00 PM of the medication carts with RN #1 identified the January 2025 change of shift inventory record for controlled drugs were missing nurse's signatures on multiple dates on the 7:00 AM - 3:00 PM shift, 3:00 PM - 11:00 PM shift, and 11:00 PM - 7:00 AM shift on the following units: The Short End unit was missing 3 signatures (between 1/1/25 - 1/8/25). Interview with LPN #2 on 1/8/25 at 12:20 PM identified it was the responsibility of each oncoming and off going nurse to sign the narcotic count sheet at the beginning of the shift and at the end of each shift at the time the controlled substance count is completed. Interview with RN #1 on 1/8/25 at 12:25 PM identified she was not aware of the missing narcotic count signatures until now during rounds with surveyor. RN #1 indicated the expectation is that the nurses will count the narcotics at change of shift and sign the narcotic count sheet after completing the count. Interview with the DNS on 1/8/25 at 12:30 PM identified she was not aware of the missing narcotic count signatures. The DNS indicated the expectation of the facility is that the oncoming and off going nurse count the controlled substances during each shift change and sign the narcotic count sheet after completing the count. Interview with the Administrator on 1/8/25 at 12:40 PM identified she was not aware of the missing narcotic count signatures. The Administrator indicated the expectation that the nurses will count the narcotics at change of shift and sign the narcotic count sheet after completing the count. Review of the facility-controlled substances count policy identified it is the policy of the facility and its affiliates to account for all Scheduled II - IV medications at the end of each shift and to promptly investigate discrepancies in controlled substances counts. At the end of each shift, the nurse/medication-distributing associate going off and the medication-distributing associate coming on the shift will count all controlled medications for their responsible area and document the count using the pharmacy's declining balance sheet. The medication-distributing associate leaving the shift shall count the medications on the declining balance sheet and the medication-distributing associate coming on the shift will count the actual medications in the container/card. The medication-distributing associate both oncoming and leaving are responsible for signing the controlled medication count/key sign out sheet after completion of the count and proper verification of accuracy has been completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documentation, facility policy, and interview, the facility failed to ensure that all licensed staff had valid, current CPR certification. The findings include: Review of CPR certification for licensed staff identified 2 RNs and 2 LPNs had valid CPR certification, and 13 LPNs had no CPR certification. Interview with the DNS on [DATE] at 11:00 AM indicated that the nurses are responsible to update their CPR cards when they are due and provide a copy to the DNS and HR. Interview with HR Person #1 on [DATE] at 11:10 AM indicted that the DNS was responsible to track that all licensed nurses had current CPR certification. Review of the nursing schedules dated [DATE] to [DATE] during 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM shifts identified licensed nurses without current valid CPR certification. Interview with the Administrator on [DATE] at 12:00 PM indicated that HR was responsible to track and make sure that all licensed nursing staff are CPR certified. Review of RN #2's personnel file on [DATE] at 12:15 PM identified RN #2 was hired on [DATE]. The file did not contain a valid current CPR certification. Interview with HR Person #1 on [DATE] at 2:10 PM indicated if she were aware that it was her responsibility to track and make sure that all licensed nursing staff were CPR certified, she would have made sure it was done, but it had previously been the responsibility of the DNS. HR Person #1 indicated that she called and received all the CPR cards for everyone except 2 nurses and indicated that the 2 nurses were supervisors. One was the full-time night shift RN who works by himself without any other nurse and the other was the full time 3:00 PM to 11:00 PM RN supervisor who works with one other nurse. Interview with the DNS and Administrator on [DATE] at 6:45 AM indicated that RN #2 does not have CPR certification. The DNS indicated that RN #2 is the only nurse and supervisor on the 11:00 PM to 7:00 AM shift. The Administrator indicated that the CPR card was to be in the employee file prior to hire but wasn't. The DNS indicated that HR Person #1 was responsible to check credentials Interview with the Administrator on [DATE] at 7:00 AM indicated that she was not aware that the CPR certifications were not being obtained at hire and were not being tracked after hire. Review of RN #2's punch detail from [DATE] to [DATE] identified he worked the 11:00 PM to 7:00 AM shift as the only nurse for 79 days out of 112 days. Interview with RN #2 on [DATE] at 8:25 AM indicated that he was the full-time night nurse at the facility on 11:00 PM to 7:00 AM shift and is the only nurse on duty. RN #2 indicated that he was CPR certified at the hospital in 2021, and it expired in 2023. RN #2 indicated that he had lost the expired CPR card from 2023. RN #2 indicated that when he was hired at this facility he recalls on the on boarding (electronic) paperwork which stated he needed to provide a CPR card, but he had lost his and could not provide it. RN #2 indicated that no one from the facility had asked him for his CPR card since he was hired. RN #2 indicated that since hire in [DATE] no residents have needed CPR during his shifts. Review of the Cardiopulmonary Resuscitation (CPR) Policy identified that CPR will be initiated according to the residents wishes and physicians order when there is an identified cardiac and/or pulmonary arrest event. CPR is to be performed only by a staff person that are certified to do so. All direct care giving staff, when required by state regulations, are required to obtain basic Adult CPR and Obstructive Airway certification and to be re-certified by state regulations. Certification is only obtained by attending a course offered through American Red Cross, and American Heart Association. The facility is to track the staff that are certified in CPR and Obstructed Airway Techniques.

Based on review of the clinical record, facility documentation, facility policies, and interviews, the facility failed to ensure all licensed nursing and supportive nursing personnel had the appropriate IV training/certification and competencies. The findings include: 1. Review of facility documentation identified that 7 out of 17 licensed nurses, including RN #2 and LPN #4, did not have an IV therapy certification on file. Review of facility documentation identified RN #2 cared for Resident #224 who had a peripherally inserted central catheter (PICC) line, including flushing the PICC line on 12/19/24, 12/20/24, 12/23/24, 12/24/24, 12/25/24, 12/26/24, 12/27/24, 12/31/24, 1/1/25, 1/252, and 1/3/25. Review of facility documentation identified on 1/6/25 LPN #4 administered IV Daptomycin via a PICC to Resident #224. Interview with RN #2 on 1/8/25 at 8:10 AM identified that he had provided care for residents receiving IV therapy, including flushing Resident #224's PICC line. RN #2 indicated that prior to working at this facility, he completed one day of IV training in the Emergency Department, worked in an acute care facility and took care of many IVs. RN #2 further indicated that he currently works only at this facility, and he did not have an IV certification for long-term care. RN #2 could not recall if he had ever completed any competencies or completed an IV skill demonstration while employed at this facility. Interview with the Human Resources Director on 1/8/25 at 7:15 AM indicated that she had been in this position for almost 2 years, and the prior DNS and Administrator had been responsible for obtaining IV certifications for the licensed nursing staff. The Human Resources Director further indicated that prior to this survey she was not aware that it was her responsibility to obtain the IV certifications, and the Administrator had informed her today, that moving forward, she would be responsible to obtain and track IV certifications, upon hire and thereafter. Although attempted an interview with LPN #4 was not obtained. Interview with the DNS on 1/8/25 at 10:11AM identified that she was not aware that 7 out of 17 licensed nurses did not have an IV therapy certification on file. The DNS indicated that Human Resources should be requesting IV certifications during the new employee on-boarding process. The DNS further indicated that she oversees staff development so ultimately the responsibility was hers for ensuring the IV therapy certifications were completed and the staff was competent in the skill sets necessary for IV therapy. The facility's Scope of Practice and Competency Assessment policy directs nurses administering infusion therapy and performing vascular access insertion and management must be qualified and competent based on their licensure and perform only duties within their scope of practice. Initial competency is assessed and documented before the skill is performed without supervision and ongoing competency assessment and documentation is determined by rules and regulations of the State Board of nursing or by facility policy. Documentation of completed continuing education and competency assessments should be available in facility or employee files. The Facility's Responsibilities policy directs that a facility instituting infusion therapy will specify educational requirements for nursing staff including initial training and ongoing competency evaluations and maintain records of personnel qualified by education and experience who may provide infusion therapy in the facility. 2. Review of facility documentation failed to identify that any of the facility's nurse aides had completed IV competency validation for Supportive Nursing Personnel in 2024. Interview and review of facility documentation with the DNS on 1/8/25 at 10:11 AM indicated that the facility had not had a lot of residents requiring IV therapy lately, and that it was her oversite that annual IV therapy education and competency evaluations were not completed for the nurse aides. The DNS further indicated that she was the one responsible for ensuring the annual education and competencies were completed. The facility's Guidelines for Infusion Education for Licensed Nursing Personnel and Supportive Nursing Personnel directs nurse aides caring for residents receiving IV therapy will be provided with IV education initially, yearly, and as needed based on an identified need and competency will be determined by the facility.

Based on review of facility documentation, facility policy, and interviews, the facility failed to complete 90-day performance evaluations, failed to complete annual performance evaluations for nurse aides for 2023 and 2024 and failed to provide the annual mandatory education for 2024. The findings include: Interview with the Director of HR on 1/7/25 at 12:15 PM indicated that performance evaluations were to be completed for new hires at 90 days and then annually, however, the facility had not been completing the 90-day evaluations because the department heads were busy. The Director of HR indicated she was responsible to track, and each month send a list of employees due for their annual evaluations to the department heads via email. The Director of HR indicated when the evaluation is completed it goes to the Executive Director for approval. The Director of HR indicated after that process is complete, she files the evaluations in the employee's file. The Director of HR indicated that when employees come to her and report that their performance evaluation were not done, she will notify the manager/department head. The Director of HR indicated if reported again she will notify the Executive Director. Interview with the DNS on 1/7/25 at 12:39 PM indicated that she was responsible to do the annual performance evaluations for the nursing department and was not sure if a new hire gets an evaluation before the annual. The DNS indicated that she receives a list for the nursing staff due that month for a performance evaluation. After review of the 5 nurse aides personnel files, the DNS identified that the 2023 and 2024 annual evaluations had not been done. The DNS indicated that she was aware that she was behind in doing the annual evaluations. Review of the personnel file of NA #1 identified the date of hire was 8/23/23, and there was not a 90-day or annual evaluation for 2024. Review of the personnel file of NA #2 identified the date of hire was 7/6/23 and there was not a 90-day evaluation or annual evaluation for 2024. Review of the personnel file of NA #3 identified the date of hire was 3/31/22 and there was not a 90-day evaluation or annual evaluation for 2023 and 2024. Review of the personnel file of NA #4 identified the date of hire was 2/28/18 and there was not an annual evaluation for 2023 and 2024. Review of the personnel file of NA #5 identified the date of hire was 4/13/22 and there was not a 90-day evaluation or annual evaluation for 2023 and 2024. Review of the Performance Evaluations Policy identified the facility would evaluate every staff person at the end of the introductory period and then annually. Each new staff person's immediate supervisor or designee shall prepare and provide the staff person with an evaluation using the appropriate evaluation form at the end of the 90-day introductory period and then on an annual basis. Evaluations should occur within one pay period of their anniversary date with any applicable increase to become effective the first full pay period following the anniversary date. Each employee will receive a copy of their evaluations, and the original shall be retained in the employee's personnel file. Interview and clinical record review with DNS on 1/8/25 at 12:15 PM was not able to provide the mandatory education for the nursing staff completed in 2024. Review of the personnel files for NA #1, NA #2, NA #3, NA #4 and NA #5 identified no mandatory education had been done for 2024. Form identified as Employee In-service Yearly listed the following topics for education: fire and disaster safety plan, Safety Chemical safety data sheets, accident prevention, body mechanics, resident rights and abuse, dementia training, infection control, blood borne pathogens, Hepatitis and Tuberculosis, standard infection control precautions, handwashing, understanding agitated behaviors, falls and falls management, emergency evacuation procedure, HIPPPA, incontinent care and skin prevention, pain management, customer service, IV line management, and Dialysis management. Although requested, a facility policy for nurses and nurse aide mandatory annual education, it was not provided.

Based on review of facility documentation, facility policy, and interviews the facility failed to ensure the Infection Preventionist completed specialized training in infection prevention and control. The findings include: The Infection Preventionist (RN #1) was hired on 10/23/24. During entrance conference on 1/6/25 at 8:15 AM the facility failed to provide documentation that RN #1 had completed specialized training in infection control including certification. Further, the DNS did not have a certification in infection control including certification. Interview with RN #1 on 1/7/25 at 10:10 AM identified that she had worked at the facility for approximately 90 days, over 40 hours per week, with majority of the hours dedicated to infection control responsibilities. RN #1 further identified that she had completed the Infection Preventionist certification course in 2019 but was unable to locate the certificate or documentation of modules completed in the CDC's online learning system, where she had completed the training. RN #1 indicated that paper documentation, including her Infection Preventionist certification, was in a binder 5 hours away. RN #1 identified that she had restarted the nursing home Infection Preventionist training modules and hoped to be completed with the learning activities and have her Infection Preventionist certification completed by 1/8/25. Interview with RN #1 and the DNS on 1/8/25 at 10:11 AM identified that RN #1 had completed all the training modules for the nursing home Infection Preventionist course, but she still had to sit for the exam to obtain the certification. RN #1 further identified that, upon hire, nobody had asked for her nursing home Infection Preventionist credentials. The DNS indicated that during the hiring process she did not ask RN #1 for documentation of her Infection Preventionist certification, as hat was the responsibility of the Human Resources department, and that she was unaware that RN #1 did not have documentation of her Infection Preventionist credentials until it was identified by the survey team on 1/6/25. Interview with the Human Resources Director on 1/8/25 at 11:31 AM failed to identify that she had requested or obtained RN #1's Nursing Home Infection Preventionist certification, prior to 10/23/24. The Human Resources Director indicated that she had worked at the facility for 2 years, and under prior leadership it had been the responsibility of the DNS or the Administrator to handle verification of specialized certifications, such as the Infection Preventionist, and she was not aware that obtaining specialized certifications had been her responsibility. Subsequent to surveyor inquiry, RN #1 provided a Nursing Home Infection Preventionist certification dated 1/9/25. The facility's Quality Assessment and Performance Improvement Infection Preventionist policy directs the Infection Preventionist will be qualified by education, training, experience, or certification.

**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 four (4) residents reviewed for wound care, (Resident #2), the facility failed to ensure wound care was performed and documented in accordance with facility policy. The findings include: Resident #2 was admitted to the facility with diagnoses that included orthopedic aftercare following fracture of femur and humerus, atrial fibrillation, and osteoporosis. The admission Minimum Data Set (MDS) dated [DATE] identified Resident #2 had intact cognition, was always incontinent of bowel and occasionally incontinent of bladder and required limited assistance with bed mobility and dressing and extensive assistance with personal hygiene. The Resident Care Plan (RCP) dated 12/31/21 identified a hip fracture and humerus fracture with interventions that included to anticipate and meet residents' needs, monitor, and document and report as needed signs and symptoms of complications. A physician's order dated 12/31/21 directed to cleanse staple line to right hip with normal saline, cover staples with Xeroform followed by a non-adherent dressing and cover with transparent dressing every 72 hours and as needed. Review of the Treatment Administration Record (TAR) dated 1/1/22 through 1/31/22 identified the wound care treatment scheduled for 1/6/22 had no electronic signature signifying it was performed. Interview with RN #2 ( who worked on 1/6/23) on 6/1/23 at 11:56 AM identified he/she did not recall if wound treatment was done and not documented on or was not done on 1/6/22. RN #2 further identified the normal procedure for wound treatment is to follow the physician orders and document the wound treatment done in the TAR. Interview and chart review with RN #1 (the nursing supervisor) on 6/1/23 at 1:03 PM identified facility policy is to document that wound treatment is done in the TAR. Additionally, RN #1 identified there was no documentation of wound treatment for Resident #2 on 1/6/22 in either the TAR or the nurses' notes in the electronic medical record (EMR). RN #1 further identified if wound care had been done on 1/6/22, it should have been documented in Resident #1's TAR or EMR. RN #1 identified the nurse who performed the wound treatment was responsible for documentation of the treatment. RN #1 was unable to identify why this wasn't done for Resident #2 on 1/6/22. Review of the facility policy title Nursing Notes dated 2/24/23 directed, in part, nursing notes shall include, either in narrative form or on specialized nursing forms, complete description of any skin breakdown, including measurements and the care given-preventative or curative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review and interviews for one of four residents (Resident #268) reviewed for choices, the facility failed to honor resident choice related to morning care. The findings include: Resident # 268's diagnoses included Rhabdomyolysis and diabetes mellitus. The admission MDS assessment dated [DATE] identified the resident was moderately cognitively impaired, had memory problems and indicated the resident required extensive assistance with ADL. The care card dated 11/7/22 identified the resident required the assistance of one staff member for bathing and dressing on the 7:00 AM - 3:00 PM shift, and failed to identify the resident's preference to be bathed, dressed and out of bed by 9:00 AM. Observation on 11/16/22 identified Resident 268 at 9:45 AM was observed in bed in her/his clothes. The resident was alert, and a family member was sitting in chair at bedside. Resident # 268 indicated s/he was not happy. Both the resident and the family member expressed concerns that Resident # 268 was still in bed and was not dressed. Resident # 268 indicated s/he usually has a private aide that comes from 9:00 AM - 12:00 PM but the private aide was not able to come today. Resident # 268 indicated s/he usually wake up at 6:00 AM and wanted to be out of bed and dressed soon after or at least definitely by 9:00 AM. Resident # 268 further indicated when s/he asked the staff about getting him/her dressed and out of bed they told her/him they having a rough morning. On 11/16/22 NA #1 entered the resident's room at 10:10 AM to provide morning care which included assisting her/him with dressing and getting out of bed and into the chair. Interview with Licensed Practical Nurse (LPN #1) at 2:30 PM on 11/16/22 identified s/he gave the resident his/her medications at 7:30 AM and Resident # 268 did not indicate to him/her that s/he wanted to get dressed and out of bed. LPN #1 further indicated staff have been made aware the resident sometimes liked to get out of bed before 8:00 AM but they could not always accommodate him/her due to staffing, and sometimes Physical Therapy (PT) wanted the resident to be in bed when they provided her/his therapy. On 11/17/22 at 9:50 AM Resident # 268 was observed dressed and sitting in chair in the room. S/he indicated s/he sometimes would have to wait until noon for staff to help her/him get dressed and out of the bed, although s/he had told a nurse (s/he was unsure of who s/he told) s/he wanted to get out of bed every morning by 9 :00AM. Interview with LPN #3 on 11/17/22 at 1:30 PM identified s/he was aware Resident # 268 wanted to get out of bed early and they tried to accommodate him/her as best they could. It depended on the NA assignments. Interview with Social Worker #1 on 11/17/22 at 10:35 AM identified s/he was unaware Resident #268 was not pleased with care. If s/he was made aware, the social worker department would have filed a grievance, review it with the DNS and nursing supervisor. Social Worker #1 further indicated s/he would resolve the issue as soon as possible by discussing it with nursing and try to accommodate the resident's wishes. S/he was going to write it up as a grievance today. On 11/21/22 at 10:30 AM Resident # 268 was observed dressed and in a wheelchair in the community area during recreation activity. Private NA from agency was sitting beside the resident. Resident# 268 indicated s/he had been receiving care by 8:00 AM each morning subsequent to inquiry by surveyor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation review, facility policy and interviews, for 1 of 5 residents, (Resident #3) reviewed for unnecessary medications, the facility failed to follow approved pharmacy recommendation from the physician regarding Vitamin D3 and accurately transcribe the physician's orders to meet professional standards of practice and prevent a medication error. The findings include: Resident #3's diagnoses included cerebral infarction, atrial fibrillation, chronic kidney disease, polyneuropathy, and spinal stenosis. The admission MDS assessment dated [DATE] identified Resident #3 had severe cognitive impairment and required extensive assistance of 2 person with transfer, dressing and toileting, hygiene, and non-ambulatory. The pharmacy recommendation dated 10/12/22 identified pharmacy recommendation to change Vitamin D 2000 International Unit (IU) by mouth once daily to Vitamin D3 50,000 IU by mouth once a month and indicated the physician approved the pharmacy recommendation. The physician's order dated 10/16/22 directed that Resident #3 receive vitamin D3 50,000 IU by mouth once a week instead of monthly. Resident #3 had received 5 doses instead of 2 doses. The Medication Administration Record (MAR) for the month of October and November 2022 identified Resident # 3 had received the Vitamin D3 50,000 IU on 10/16, 10/23, 10/30, 11/6 and 11/13/22. Interview and facility documentation review with RN # 1 (Assistant Director of Nursing Services) identified that she received the physician's order from the pharmacy recommendation. The pharmacy recommendation record was reviewed with RN #1, and she stated she would follow the approved recommendation from the pharmacy. Subsequent to inquiry, RN#1 corrected the vitamin D3 50,000 IU by mouth to be given once a month instead of weekly. She further indicated the error was an oversight and a mistake in transcribing the physician's order. The facility failed to follow the pharmacy recommendation approved the physician and transcribe accurately in the plan of care. A review of facility nursing policy title Physician's Orders identified in part it is the facility policy to obtain a current physician's order from the attending physician and the nurse that received the medication order would make an entry in the MAR for the specific resident so that the resident can receive the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation review, facility policy, and interviews, for 1 of 5 residents, (Resident #1) reviewed for unnecessary medications, the facility failed to follow physician's order to complete quarterly laboratory bloodwork. The findings include: Resident #1 was admitted to the facility with diagnoses that included hemiplegia and hemiparesis following a stroke, stage IV chronic kidney disease, diabetes mellitus and congestive heart failure. A quarterly MDS assessment dated [DATE] identified Resident #1 had moderate cognitive impairment and the resident required extensive assistance of 2 staff for transfers and extensive assist of staff for personal hygiene. The care plan revised on 3/22/22 for self-care deficit and needed assistance with ADL to include bed mobility with an assist of 2 staff and the Sara lift (sit to stand) lift, transfer assist of 2 and no ambulation. Additionally, the care plan identified that Resident #1 had a potential for fluid deficit due to use of a diuretic with an intervention to obtain and monitor laboratory bloodwork as ordered. A physician's order dated 5/30/22 directed for Resident #1 to have quarterly Laboratory bloodwork: Nephrology Laboratory - Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Lipids, Albumin, Pre-Albumin, Iron, Total Iron Binding Capacity (TIBC), Phosphorus, PTH, Ferritin, Vitamin D, HgbA1 one time a day every 4 month(s) starting on the 1st for 1 day(s) for quarterly laboratory test. The physician's order further identified the order was entered in to the electronic medical by LPN #2 on 5/30/22 at 10:54 PM with an order type of standard laboratory bloodwork order with a start date of 6/1/22. A laboratory report on 6/2/22, laboratory as ordered on 5/30/22 Nephrology laboratory- CBC, CMP, Lipids, Albumin, Pre-Albumin, Iron, TIBC, Phosphorus, PTH, Ferritin, Vitamin D, HgbA1 were drawn, and results were faxed to the provider on 6/3/22. The medical record lacked any evidence of an additional CMP, Lipids, Albumin, Pre-Albumin, Iron, TIBC, Phosphorus, PTH, Ferritin, Vitamin D, HgbA1 since the 6/2//22 laboratory bloodwork were drawn. Interview with Registered Nurse (RN #1) on 11/21/22 at 12:00 PM identified that any licensed staff member can enter a physician's order when it is received into the electronic medical record. She continued by stating that a laboratory order would be entered as an order type of other, then would be identified in the system as a laboratory order. If entered as order type other, the nurse would select laboratory which would initiate that order as a task on the Medication Administration Record (MAR)/ Treatment Administration Record (TAR) when due and initiate an auto-reminder for the staff 24 hours prior to the next scheduled laboratory blood draw to cue the nursing staff to make sure the laboratory test was scheduled. Additionally, the nurse entering the order would place a reminder in the unit calendar. RN #1 further identified the day supervisor would review all physician's orders for the past 24 hours to ensure the orders were entered correctly. She continued by stating the vendor for the electronic medical record had upgraded the system and the laboratory order should not have been entered as an order type of standard laboratory bloodwork. RN #1 further indicated s/he had emailed the vendor on 7/8/22 to inform them of the issue. RN #1 stated that is why the physician's order dated 5/30/22 directed for Resident #1 to have quarterly Laboratory: Nephrology Laboratory (CBC, CMP, Lipids, Albumin, Pre-Albumin, Iron, TIBC, Phosphorus, PTH, Ferritin, Vitamin D, HgbA1) one time a day every 4 month(s) starting on the 1st for 1 day(s) for quarterly laboratory was only completed once on 6/2/22. Review of the medical record and interview with RN #1 on 11/21/22 at 12:05 PM identified that the next ordered Nephrology laboratory blood draw should have been completed on October 1, 2022 and indicated this was not done as ordered. She also could not recall if the transcribing nurse had placed the order into the unit calendar or why the order must have been missed by the day supervisor on the next day review. Subsequent to inquiry, the Nephrology laboratory bloodwork were re-entered into the electronic medical record using the correct order type. The facility policy Skilled Nursing physician's order in part directs that the nurse will transcribe the physician's order into the resident's medical record.

Based on observation, facility policy review and interviews, the facility failed to ensure medications were stored in a secure manner and not left unattended on the medication cart. The findings include: Observation on 11/17/22 at 5:40 AM identified a medication cart in the hallway on the short unit left unattended with 3 loose medications placed on top of the cart in medication cups and the cart unlocked. There were no residents or nursing staff in in the immediate area. An interview on 11/17/22 at 5:40 AM with RN #1 (ADNS) identified medications should not be left unattended on top of the cart and the cart should be lock when unattended. An interview on 11/17/22 at 5:40 AM with RN #2 identified she was the assigned nurse for the unit. RN #2 indicated she left the cart briefly to obtain water and should not have left the medication cart unlocked and with medications on top. An interview on 11/22/22 at 8:29 AM with the Administrator identified it would be her expectation that all medications be stored in a safe and secure manner when the medication cart was left unattended. The facility policy for Medication Administration directs during administration of medications, the medication cart is to be kept closed and locked when out of sight of the medication nurse. No medications are to be kept on top of the cart. The cart must be clearly visible to the personnel administering medications when unlocked.

Based on observation, review of facility documentation, facility policy, and interviews, the facility failed to ensure waste was disposed of within accordance with infection control practices to prevent the spread of infection. The findings include: An observation on 11/17/22 at 5:45AM identified NA#2 exiting RM #11 with gloved hands, soiled incontinent material in a clear plastic bag carried in the right hand, a package of clean incontinent material carried in the left hand and a spray bottle also in the left hand. NA #2 then entered RM #10, close the door, then re-opened the door to exit the room with the same materials in the right and left gloved hand in less than 30 seconds. NA #2 placed the soiled waste on the floor with the right hand outside the door, closed the door using her right hand, pick up the soiled waste using the same right gloved hand. Placing both hands closer together with the same items in each hand, NA#2 then went across the hall to RM #3, pushed the door to the room with her left elbow, placed the clean and dirty items on the floor, entered the room, turned to pick up the items to bring into the room and then push the door in a slightly closed position. Surveyor entered the room just behind NA #2 and observed her raising the bed of the resident using the same left gloved hand. Task interrupted by surveyor and NA#2 asked to exit after lowering the bed for safety. An interview on 11/17/22 at 5:45AM with NA #2 identified she had no bins available to her to take room to room during rounds. NA #2 indicated that although she had worn the same gloves going from room to room carrying the soiled waste, she had donned a new pair of gloves before initially exiting RM #11 and felt she had not cross contaminated any surfaces. NA #2 indicated that although she used the same gloves to raise the resident bed in RM # 3, her intent was to perform hand hygiene and change gloves prior to initiating care. An interview and facility documentation review on 11/17/22 at 5:51AM with RN #1 identified she was responsible for providing education to the nurses regarding infection control practices. RN #1 indicated NA #2 should not have been brought the soiled waste from room to room with the same gloved hands. RN #2 further indicated she had previously provided NA #2 with education on the use of gloves and hand hygiene on 10/20/22 and would provide re-education. An interview on 11/22/22 at 9:37 AM with the Administrator identified her expectation would be that staff remove waste from the resident room and discard the waste in trash bins located in the dirty utility room and perform hand hygiene before entering another resident room. The facility policy Hand Hygiene directs to wear gloves to be worn when in contact with blood or potentially infectious material. Gloves to be removed after caring for a resident and do not wear the same pair of gloves to care for another resident. Standard precautions direct gloves to be changed and hand hygiene performed when moving from a contaminated to clean site during patient care and in between patient contact to avoid cross contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility policy review and interviews for two of five residents (Residents #270 and 271) reviewed for grievances, the facility failed to provide documented evidence that grievances were resolved to the satisfaction of the resident or his/her representative within accordance to facility policy. The findings included: A review of the facility grievance file dated 1/1/21 through 11/16/22 during the survey identified the following. 1. Resident #270 was admitted on [DATE] with a diagnosis include left hip joint replacement. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #270 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen, indicating intact cognition. The admission assessment also noted the resident required extensive assistance with transfers, limited assistance with activities of daily living (ADL), always continent of bowel and indicated Resident # 270 had an indwelling urinary catheter. Resident #270 filed a grievance on 9/20/22 which identified the resident rang his/her call bell at 2:00 AM on 9/20/22 and the call bell was not answered until 5:00 AM (a two-hour delayed response) The grievance form resolution on 9/21/22 identified the call bell was checked and was functioning and directed staff to round frequently on the resident. However, the facility failed to provide documented evidence that the resident was satisfied with the outcome of the resolution. 2. Resident #271 was admitted on [DATE] with diagnoses that included disruption of a surgical wound of his/her left foot, abnormal levels of serum enzymes, and metabolic encephalopathy. Resident #271's family member filed a grievance on 9/15/22 indicating the resident's bowel device had 'exploded' during the night and the 11:00 PM-7:00 AM nurse did not change it. According to the grievance report, the following 7:00 AM - 3:00 PM shift Nurse Aide (NA) observed that the bowel device was off. The facility resolution directed to check the resident's bowel device every two hours. However, the facility failed to provide documented evidence that the resident's family member was satisfied with the resolution. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #271 had a Brief Interview for Mental Status (BIMS) score of thirteen out of fifteen, indicating intact cognition. The resident required extensive assistance with activities of daily living (ADL), always incontinent of bladder, and noted the utilization of bowel elimination device. Interview with Social Worker #1 on 11/17/22 at 10:35 AM indicated s/he worked to resolve grievances as soon as possible. Social Worker #1 also indicated s/he tries to contact complainants to follow up regarding satisfaction with the resolutions to grievances but have not always been successful. Interview with the Administrator on 11/17/22 at 12:30 PM identified Social Worker #1 as the facility's Grievance Official. The Administrator indicated s/he was not able to provide documentation of Residents #270 and # 271 the resident and /or the representatives satisfaction with the resolutions to their grievances. The Administrator indicated the facility's grievance report did not provide a place on the form to document the grievance being resolved to the satisfaction of the complainant. The facility failed to follow their policy for following up with the person and or the representative to ensure satisfaction to grievance resolutions. Review of facility Concern/Grievance Policy directed in part, for the Grievance Official to inquire with the individual presenting the grievance to determine if resolution had been obtained to the persons satisfaction.

Based on observation, facility documentation, facility policy, and interviews the facility failed to ensure essential equipment was maintained in safe operable condition and failed to ensure daily temperature checks were recorded for essential equipment. The findings included. 1. Work Order history dated 5/17/21 through 5/22/22 noted the following: A Work Order dated 5/7/20 noted the hydrocollator in the Outpatient department was not working. A power cord was ordered. A Work Order dated 6/9/21 noted the hydrocollator was broken and could not be fixed. A Work Order dated 12/14/21 noted (2) Hydrocollators were delivered to the facility. A Work Order dated 12/16/22 noted a Hydrocollator was replaced in the Outpatient Therapy department. A Work Order dated 5/22/22 noted the hydrocollator was not heating further noting the issue was corrected. An observation and facility documentation review on 11/21/22 at 1:45PM identified the hydrocollator on the counter and powered on. 2. The temperature logs dated 6/2/22 through 11/16/22 noted daily temperature checks were not recorded from 6/23/22 through 10/12/22, from 10/15/22 through 1/16/22 with no recorded temperatures thereafter. The comments section noted an alternate (hydrocollator) was being used from another unit. An interview on 11/21/22 at 3:55PM and 11/22/22 11:49 AM with the Director of Rehabilitation identified the hydrocollator had not been in use since May 2022. A work order was generated through the front desk with a request to repair. The Rehabilitation Director indicated she was never made aware the hydrocollator had been fixed however, through intermittent temperature checks identified the temperature never came up. In the meantime, an alternate hydrocollator was being used when needed. An interview on 11/21/22 at 2:45PM and 11/21/22 at 3:05PM with the Physical Plant Director identified the hydrocollator was not working in May of 2021. The unit was replaced December 16, 2021. There were no reported issues until 5/22/22 when there was a report of no heat. The issue was corrected and there had been no reported issues since. The Physical Plant Director indicated a ticket system was in place to report concerns. If no ticket was generated, it would be difficult to know what the reported issues were. An interview on 11/22/22 at 8:29AM with Physical Plant Staff #1 identified he was the overseeing supervisor in the Director of Physical Plant's absence. Physical Plant Staff #1 indicated environmental rounds were to be completed monthly by physical plant staff to ensure essential equipment was functioning properly and that the outpatient department should have been included in those rounds. An interview on 11/22/22 at 8:29AM with Physical Plant Staff #2 identified there were issues with purchasing a replacement hydrocollator due to Covid. However, Physical Plant Staff #2 was unable to provide documentation detailing delays or efforts to purchase the hydrocollator from an alternate vendor. An interview on 11/22/22 at 8:29AM and 11/22/22 at 10:50AM with the Administrator identified she reviewed the environmental rounds noting that the outpatient department was not included. The Administrator indicated her expectation would be that any faulty essential equipment be identified and repaired. Going forward the outpatient department would be included on environmental grounds. The facility policy for Hydrocollator Maintenance directed water temperature be maintained at 160-165 degrees Fahrenheit (F). 2. Work Order dated 12/4/21 noted the freezer in the outpatient therapy department was not working. Comments indicated the freezer was checked and cleaned. Reading at 0 degrees F with frozen bottles inside. A Work Order dated 12/8/21 noted the freezer in the outpatient therapy department was still not working. Comments indicated the freezer was checked and tested at 0 degrees F with frozen water. A Work Order dated 5/26/22 noted the freezer in the outpatient room was broken. Comments indicated the issue was documented as done. An observation of the freezer identified the freezer at 10 degrees F. A frozen pack was the only item in the freezer. A review of the temperature log noted no recorded temperatures since 2/5/22. An interview on 11/21/22 at 3:55 PM and 11/22/22 11:49 AM with the Director of Rehabilitation identified the temperatures had not been recorded since February 2022 due to the freezer not working. The Director of Rehabilitation indicated she had not been notified the freezer had been fixed and had used an alternate freezer to store items. She had only incidentally learned the freezer was functioning the week prior. There was no staff on the weekend and the staff who worked the previous day should have recorded the freezer temperatures in the log. An interview on 11/21/22 at 2:45 PM and 11/21/22 at 3:05 PM with the Physical Plant Director identified a ticket system was in place to report faulty equipment. The last known reported problem was in December 2022 which was addressed. If no ticket was generated, it would be difficult to know what the reported issues were. An interview on 11/22/22 at 8:29AM with Physical Plant Staff #1 identified he was the overseeing supervisor in the Director of Physical Plant's absence. Physical Plant Staff #1 indicated environmental rounds were to be completed monthly by physical plant staff to ensure essential equipment was functioning properly and that the outpatient department should have been included in those rounds. An interview on 11/22/22 at 8:29AM with Physical Plant Staff #2 identified the last known issue related to the outpatient freezer not functioning properly was December 8, 2021. The issue was addressed then. Once completed the appropriate department was notified. An interview on 11/22/22 at 8:29 AM and 11/22/22 at 10:50 AM with the Administrator identified she reviewed the environmental rounds noting that the outpatient department was not included. The Administrator indicated her expectation would be that any faulty essential equipment be identified and repaired. Going forward the outpatient department would be included on environmental grounds. Although a policy recording freezer temperature was requested, none was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an observation, a review of the clinical record, staff interviews, and a review of the facility policy, for one of nine sampled residents reviewed for dignity (Resident #278) the facility failed to provide dining in a dignified manner. The findings include: Resident #278 was admitted to the facility on [DATE] with diagnoses that included dysphasia following a cerebral infarction, aphasia, and a Vitamin B and D deficiency. The care plan dated 1/17/20 identified Resident #278 was at risk for aspiration related to a stroke with dysphasia and confusion. Interventions directed to provide the ordered diet, assistance of 1 for setting up and feeding with a 2 handled cup, nectar thick liquids and the assistance of 1 during oral intake. The admission Minimum Data Set (MDS) dated [DATE] identified severe cognitive impairment, incontinence of bowel and bladder and required extensive assistance eating with a one person assist. Observation on 2/3/20 at 12:25 PM identified Resident #278 was sitting at a table with three residents with a family member sitting next to him/her. At 12:40 PM the two residents had their meal trays, were finished and starting on their desert. The third resident just received his/her soup. Resident #278 was sitting with nothing in front of her. At 12:45 PM Resident #278 received a plate of food. NA #2 came over and stood on the left side over Resident #278 and informed Resident #278 it was time to eat. NA #2 gave Resident #278 a bite and left to get a cloth protector, returned, and continued to stand while feeding the resident. NA #2 gave Resident #278 a few bites. One of the residents requested salt and pepper for his/her food, so NA #2 stopped feeding Resident #278 and went to find salt and pepper. Resident #278 was feeling around on the table and was not able to find his/her spoon or cup. NA #2 returned and began feeding Resident #278 a few more bites while standing over him/her. NA #2 then assisted another resident at the table to call his/her daughter on a cell phone. NA #2 went back to feed Resident #278 while standing. At 1:18 PM the Dietary Aide #1 brought blueberry pie and NA #2 stood over Resident #278 and fed him/her a few bites. During the entire meal there was an empty chair across the table and three empty chairs in the lounge area just outside of the dining room. Interview on 2/3/20 at 1:20 PM with NA #2 indicated she stood the entire time she fed Resident #278 because she didn't have a chair to sit on. Interview on 2/4/20 at 1:50 PM with LPN #2 (charge nurse), indicated the nursing assistants should sit at eye level while feeding a resident in the dining room and stay sitting until the nursing assistant finishes feeding the resident. LPN #2 indicated there were two other nursing assistants in the dining room for lunch that were assigned to assist the other residents. Interview with the Director of Nursing (DON) on 2/5/20 at 11:00 AM identified NA #2 should have been seated while feeding Resident #278. If chairs were not available in the dining room NA #2 should have taken a chair from outside of the dining room to assist with the feeding. The Facility Policy for Resident Rights directed in part that all staff members at all times, were responsible to enable personal dignity, well-being, and proper delivery of care. The facility must protect and promote the rights of the residents. The Facility Policy for Dining Services for eating directed in part that swallowing, and assistance with dining would be provided to ensure the safety and dignity of the residents. Affording dignity and safe swallowing are vital for residents in the dining process to stay healthy. Techniques for improving swallowing are to tell the resident who you are and what you are doing, when feeding , sit down on a chair in front of the resident, describe the menu, inform the resident when feeding utensils are near his/her mouth, and provide the resident with regular verbal cues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the clinical record, staff interviews, and a review of the facility documentation, for one sampled resident (Resident #2), the facility failed ensure a comprehensive assessment was conducted when there was a change in condition. The findings include: Resident #2 was admitted to the facility on [DATE] with diagnoses that included a recent open reduction internal fixation of the left femur, orthostatic hypotension, hypertension, anemia, and dementia. The care plan dated 1/14/20 identified an alteration in cardiovascular status due to orthostatic hypotension. Interventions directed to monitor vital signs as ordered and notify the physician of significant abnormalities. Additionally, Resident #2 was at risk for constipation due to side effects of medications and decreased mobility. Interventions included follow the facility bowel protocol for bowel management and monitor vital signs or symptoms of constipation by changes in mental status, new onset of confusion, decreased pulse, abdominal distention, and abdominal tenderness. Further, Resident #2 had anemia due to blood loss and interventions included to monitor, document, and report signs and symptoms of fatigue, syncope, dizziness, weakness, headache, palpitations, and changes of condition. The admission Minimum Data Set (MDS) dated [DATE] identified severe cognitive impairment, incontinence of urine and bowel, extensive assistance for bed mobility, dressing, toilet use, and personal hygiene. An Advanced Practice Registered Nurse (APRN) note dated 1/23/20 identified Resident #2 was seen due to complaints of back pain. Resident #2's lungs were clear and his/her abdomen was soft, non-tender and not distended. A Daily Medicare A Clinically Complex note dated 1/24/20 at 10:46 AM completed by LPN #2 indicated there had been a change of condition in the last 24 hours as Resident #2 had experienced pain. A Daily Medicare A Clinically Complex note dated 1/25/20 at 11:59 AM completed by LPN #2 indicated there had been a change of condition in the last 24 hours as the resident's appetite was poor. Resident #2 indicated I'm just not hungry and I feel nauseous vital signs were stable and the APRN was notified. An order for Zofran was obtained. The nurse's note dated 1/25/20 at 12:43 AM competed by RN #3 identified Resident #2 had a poor appetite with complaints of increased nausea. The APRN was updated and Zofran 4 milligrams (mg) was administered. A physician's order dated 1/25/20 directed to administer Zofran 4 mg every 6 hours as needed for nausea and/or vomiting. The nurse's note dated 1/25/20 at 4:12 PM by LPN #2 identified when Resident #2 was transferred out of bed to the wheel chair with Physical Therapy he/she experienced a syncopal episode. Resident #2 was unresponsive for approximately 15 seconds. The resident's skin was pale and diaphoretic with a blood pressure of 88/54 mmHG with normal oxygenation on room air. Resident #2 was put back to bed and fluids were encouraged. On 1/26/20 at 1:00 AM the electronic record indicated Resident #2 received a dose of Zofran. On 1/26/20 at 10:08 AM the electronic record indicated Resident #2 received a dose of Zofran. A Daily Medicare A Clinically Complex note dated 1/26/20 at 11:30 AM completed by LPN #2 indicated there has been a change of condition in the last 24 hours. Resident #2 verbalized pain, nausea and had loose stools, no emesis and continued with a poor appetite. Zofran was administered with some improvement. Resident #2 ate bites of oatmeal and a health shake for breakfast. On 1/26/20 at 12:52 AM the electronic record indicated that Resident #2 received a dose of Zofran at 10:08 AM that was ineffective. Resident #2 remained nauseous and refused lunch. The MDS Coordinator note dated 1/27/20 at 12:02 PM identified he/she received report from the RN that indicated Resident #2 was pale, slow to respond, skin tenting was noted, poor oral intake, lung sounds diminished on right side, and was seen by MD #10 with family members present. Orders directed stat blood work, a urinalysis, an influenza swab and intravenous fluids for 24 hours. The nurse's note dated 1/27/20 at 12:45 PM by the MDS Coordinator identified Resident #2 complained of indigestion and burning from the family member and indicated that Tums had worked in the past. Physician ' s orders directed Tums every 8 hours as needed. On 1/27/20 Resident #2 started vomiting and presented with another unresponsive episode. The physician was notified and the resident was transferred to the hospital. An interview and clinical record review on 2/4/20 at 1:50 PM with LPN #2 indicated on 1/25/20 Resident #2 complained of nausea and had pain in his/her back. LPN #2 indicated the resident would often complain of pain while sitting in the wheel chair and if put back to bed the pain would subside, so they laid him/her back down. LPN #2 indicated she called the APRN and orders for pain medication were changed to minimize the resident's nausea. LPN #2 indicated on 1/25/20 at 3:00 PM Resident #2 experienced a change in condition during therapy. LPN #2 identfied the resident had an unresponsive episode. LPN #2 obtained vital signs and the blood pressure was low. LPN #2 helped the resident into bed with the therapist. LPN #2 reported the information to RN #2 (nursing supervisor). An interview and clinical review on 2/4/20 at 3:15 PM with RN #2 indicated when she came in on 1/25/20 and received report she thought the incident for Resident #2 had passed and it was part of his/her history related to orthostatic hypotension and that was why she did not conduct an RN assessment. Interview and a clinical record review with MD #10 on 2/5/20 at 11:30 AM indicated he assessed Resident #2 on 1/27/20 and spoke to the family at that time. MD #10 ordered several tests and intravenous fluids. MD #10 indicated Resident #2's mental status was altered however his/her vital signs were stable. MD #10 identified he examined the resident's abdomen and was aware that the resident had a large bowel movement on 1/24/20, two large loose stools (diarrhea) on 1/26/20 and failed to have concerns with his abdominal examination. MD #10 identified Resident #2 had been vomiting with a poor oral intake and therefore was concerned about dehydration, anemia and a possible infection. An interview on 2/4/20 at 11:30 AM with the Director of Nursing (DNS) indicated if Resident #2 had a new onset of gastrointestinal symptoms, pain, unresponsive episodes, with nausea and/or vomiting, she would expect a registered nurse (RN) to conduct a comprehensive assessment. The RN would then document the assessment in the progress note and/or in the electronic record. The hospital emergency physician note dated 1/27/20 indicated Resident #2 was admitted for decreased oral intake and complaints of abdominal pain and nausea. An examination revealed moderate epigastric and left upper quadrant tenderness upon palpation without rebound guarding. The diagnosis included constipation and impacted stool in rectum. The facility failed ensure a comprehensive assessment was conducted by a Registered Nurse when there was a change in condition on 1/24/20 of pain, and on 1/25/20 with an unresponsive episode, nausea and a decrease in oral intake, and on 1/26/20 with continued complaints of nausea and a poor appetite.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an observation, a review of the clinical record, staff interviews, and a review of facility documentation, for one sampled resident reviewed for nutritional adequacy (Resident #278), the facility failed to ensure the resident's meal met her/his nutritional needs. The findings include: Resident #278 was admitted to the facility on [DATE] with diagnoses that included dysphasia following cerebral Vascular Accident (CVA), aphasia, and a Vitamin B and D deficiency. A physician's order dated 1/12/20 directed to administer Ergocalciferol 50,000 units once a month (as a dietary supplement for a Vitamin D deficiency), Cyanocobalamin 1000 micrograms per milliliter (ml) once a month (a dietary supplement for a Vitamin B deficiency), and Magnesium Oxide 400 milligrams two times a day for vitamin deficiencies. A physician's order dated 1/14/20 directed to administer liquid protein 30 ml daily. The care plan dated 1/14/20 identified a nutritional problem related to CVA, dysphasia, with interventions that included to provide and serve the diet as ordered. Monitor and record intake at every meal, dysphasia 3 nectar liquids and lactose restriction. The Dietary admission Data Collection dated on 1/14/20 at 12:47 PM indicated Resident #278 received a regular size portion and left 25% or more of his/her meals. Resident #278 had upper and lower dentures but they were not at the facility. Additionally, Resident #278 had a varied oral intake and was at risk for nutritional deficits due to varied intakes, dysphasia, and a recent CVA. The Dietary 48 hour Data Collection dated 1/14/20 at 2:17 PM indicated Resident #278 had a chewing and swallowing problem and was totally dependent for eating. The family indicated the resident preferred pasta, turkey, fish and sweets. The care plan dated 1/15/20 identified Resident #278 had a communication problem related to expressive aphasia, resident communicates with yes/no questions appropriately and uses a communication board. The care plan dated 1/17/20 identified Resident #278 was at risk for aspiration related to a CVA history with dysphasia and confusion. Interventions directed to provide the diet as ordered, assistance of one for setting up and feeding with a two handled cup, dysphagia two with nectar thick liquids and the assistance of one during oral intake. The admission Minimum Data Set (MDS) dated [DATE] identified severe cognitive impairment, incontinence of bowel and bladder, and required extensive assistance with eating with one person assistance with meals. A physician's order dated 1/25/20 directed the diet was a dysphagia the texture, nectar consistency, lactose restricted, two handled cup for liquids and an assistance of one for meals. Observation on 2/3/20 at 12:50 PM identified Resident #278 received a plate of food with a brown colored meat, chopped carrots, and chopped green beans. Additionally the resident received thickened liquids in a two handled cup that was delivered by Dietary Aide #1. NA #2 began feeding the resident. The surveyor questioned NA #2 regarding the lack of potatoes or a starch. NA #2 indicated she would ask dietary. NA #2 returned and offered sweet potatoes to Resident #278 and Resident #278 nodded his/her head indicating yes. Further observation at 1:00 PM identified the resident still had not received the sweet potatoe that was requested. After surveyor inquiry, NA #2 went to the kitchen area to retrieve the sweet potatoes. NA #2 fed Resident #278 ¼ of the sweet potatoes, with an intake of approximately 50-60% of the main meal originally provided. At 1:10 PM NA #2 asked Dietary Aide #1 for Resident #278's desert. Dietary Aide #1 indicated she had to go to the kitchen and get a piece of blueberry pie and clean the blender so she could blend it for Resident #278. At 1:18 PM the Dietary Aide #1 brought the blueberry pie and NA #2 fed the resident a few bites. Interview on 2/3/20 at 1:20 PM with NA #2 indicated Dietary Aide # 1 brought out the plate of food with the meat and two vegetables and she thought that was what the resident was supposed to get. After the surveyor inquiry, Dietary Assistant (DA) #1 informed NA #2 that Resident #278 was lactulose intolerant and couldn't have mashed potatoes because they were made with milk. NA#2 indicated DA #1 said she did have sweet potatoes if Resident #278 would like them. Interview on 2/3/20 at 1:30 PM with DA #1 indicated she brought the plate of food to Resident #278 with one serving of meat and 2 servings of vegetables because the resident was lactose intolerant and couldn't have the mashed potatoes. Dietary Aide #1 indicated whenever mashed potatoes were on the menu she would give Resident #278 two servings of vegetables instead of the potato, unless there was pasta on the menu and then she would blend it for the resident. The meal intake documentation on 2/3/20 by the NA#2 indicated Resident #278 ate between 76%-100% of meal and less than 500 cubic centimeters (cc) of liquid with the meal. The nurse's clinical complex note dated 2/3/20 at 4:01 PM identified Resident #278 was on a therapeutic diet and needed assistance and encouragement to eat. Resident #278 had crushed medications and thickened liquids. Resident #278 was alert with aphasia, confusion and self-propelled in wheel chair throughout unit. Resident #278 was cooperative with care and assist with meals and medications. Interview on 2/4/19 at 1:00 PM with Dietician #1 indicated residents should receive a protein, a starch and a vegetable for the meal unless the resident or family member requests something else and fills out the selective menu with an alternate food. Dietician #1 indicated Resident #278 was not capable of filling out the menu and does not have a family member that fills one out for her. Dietician #1 indicated the resident should have received the ground diet of turkey breast, carrots, sweet potato, and blueberry pie. Dietician #1 did not know why Dietary Aide #1 did not put a starch on his/her plate, or why the Dietary Aide took it upon herself to give 2 vegetables and absent a starch for a balanced meal. Dietician #1 indicated Resident #278 should have had a starch, resulting in a calorie deficit of 87 calories.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an observation, a review of the clinical record, a review of the facility documentation, staff interviews and a review of the facility policy, for one sampled resident (Resident # 25), reviewed for infection control, the facility failed to wear protective equipment and failed to perform hand hygiene when a resident was on contact precautions to prevent the transmission of an infection. The findings include: Resident #25 was admitted to the facility on [DATE] with diagnoses that included enterocolitis due to clostridium difficile (C-Diff), an ileus, and Alzheimer's disease. A physician's order dated 1/10/20 directed to administer Vancomycin 10 milliliters every 6 hours for c-diff until 1/12/20 then tapering doses until 2/21/20. A Physician's order dated 1/12/20 directed contact precautions for clostridium difficile (C-Diff). The care plan dated 1/12/20 identified C-Difficile as a problem related to recent antibiotic use with interventions that included contact isolation and a private room. The admission Minimum Data Set (MDS) dated [DATE] identified moderate cognitive impairment, occasionally incontinence of bowel and frequently incontinent of bladder, required extensive assistance of 2 staff members for transfers and toilet use and extensive assistance of 1 staff member for personal hygiene and dressing. The Medication Administration Record (MAR) dated January 2020 indicated isolation precautions for clostridium difficile (C-Diff) every shift commencing 1/12/20 through 1/31/20. The Medication Administration Record dated February 2020 indicated isolation precautions for clostridium difficile (C-Diff) every shift dated 2/1/20 through 2/4/20. Observations on 2/3/20 at 9:50 AM identified a multi-draw isolation cart in the hallway outside of Resident #25's room absent a visible sign on the isolation cart, the doorway, or the door that directed staff or visitors to see the nurse prior to entering the room, and failed to indicate the type of precaution. Inside the residents room was a double dirty hamper with both lids open with dirty white linen. The room was a double occupancy room. Observation and interview on 2/3/20 at 10:00 AM with LPN #1 indicated Resident #25 was on contact precautions for clostridium difficile (C-diff). Observation on 2/3/20 at 10:45 AM identified a visitor entered Resident #25's room and brought Resident #25 out of the room and down to end of hallway to sit and visit. The visitor entered the room without a gown or gloves and did not wash his/her hands when leaving the room and Resident #25 did not wash his/her hands prior to leaving the room. Observation on 2/3/20 at 11:15 AM identified a registered occupational therapist (OTR) in Resident #25's room sitting in the bedside chair between the bed and window with Resident #25 sitting in a wheel chair facing her. The OTR was touching the residents' hands and then the OTR took Resident #25's left arm and placed it against her body and began touching the Residents left posterior shoulder/back. The OTR was not wearing gloves or a gown. The OTR did not wash her hands or use hand sanitizer prior to leaving the Residents room. Interview on 2/3/20 at 11:25 AM with OTR #1 indicated she read Resident #25's chart before treating Resident #25 and she was aware Resident #25 was on contact precautions for clostridium difficile (C-diff). OTR #1 indicated she was educated that she only needed to wear a gown and gloves when she was providing care or toileting the resident with clostridium difficile. Observations on 2/3/20 at 12:00 PM identified LPN #1 had the medication cart in front of Resident #25's room in the hallway. Resident #25 was sitting in his/her wheel chair in between the two beds facing the commode with the call light on. LPN #1 poured liquid Vancomycin into a plastic medication cup. LPN #1 did not put on gloves or a gown prior to entering the room to administer the medication, as LPN #1 approached Resident#25 the resident attempted to stand up and the wheel chair began to move backwards. LPN #1 placed the medication and cup of water onto the over bed table and with her right hand grabbed the left arm rest of the wheel chair. She placed her left hand on the left shoulder of Resident #2 and asked him/her to sit down as she pushed the chair back and then administered the medication to the resident. At 12:05 PM NA #1 entered the room without a gown or gloves and asked Resident #25 what she/he needed then NA #1 proceeded to pull the privacy curtain between the 2 beds and transferred Resident #25 onto the commode in the center of the 2 beds. LPN #1 exited the room without washing hands. Interview on 2/3/20 at 12:10 PM with NA #1 indicated she was aware Resident #25 was on contact precautions for clostridium difficile (C-diff) in her stool. NA #1 indicated she knew she should have put on a gown and gloves but she was in a hurry as the resident needed to use the commode. A nurses note dated 2/3/20 at 3:55 PM indicated Resident #25 was always incontinent of bowel and bladder. Resident #25 was alert and forgetful/confused. Resident #25 continues on antibiotics for C-Diff and maintained on contact precautions. Interview on 2/4/20 at 11:45 AM with LPN #1 indicated she goes into Resident #25's room with a gown and gloves usually, but on 2/3/20 he/she was only giving her medications, but Resident #25 tried to stand up and she was afraid Resident #25 was going to fall, so she grabbed the chair and the resident to avoid a fall. Furthermore, LPN #1 indicated she did not wash her hands before leaving the room because she was in a hurry to get her medications passed. Interview on 2/4/20 at 2:50 PM with the Infection Control Nurse (ICN) indicated Resident #25 was currently on precautions for clostridium difficile (C-diff) in her stool. The INC identified all staff, therapists, and visitors entering Resident #25's room should put on gloves and a gown prior to entering the room. Additionally, the ICN indicated nurses should wear personal protective equipment (PPE) even when going into a room to administer medications. The ICN indicated if a resident was on isolation precautions isolation precautions would be maintained until the resident finishes the full course of antibiotic therapy and was without symptoms for 3 days after the antibiotic was completed. Interview with the Director of Nursing (DNS) on 2/5/20 at 11:10 AM indicated she would expect NA's, charge nurses, therapists and housekeeping to wear a disposable gown and gloves for resident with active c-diff when they are entering a room with contact precaution. The Certified Nursing Assistant care card indicated Resident #25 was on C-Diff precautions. Review of facility policy on Clostridium Difficile (C-Diff) identified in part to utilize contact precautions and wash hands frequently with soap and water since C-Diff is a spore forming bacteria. Alcohol based hand gels and lotions were not effective in reducing the spread of the organisms, and were not recommended. Gloves should be applied when entering the room and a gown if physical contact with the resident or the residents' environment was anticipated. Hand washing should be completed before leaving the resident room. The facility should have a system in place for alerting staff and visitors that a resident was on contact precautions, without compromising the residents' privacy. C-Diff is a spore forming bacillus that causes diarrhea and colitis in humans. Its spores can survive outside the human body for weeks to months on environmental surfaces and devices, including bedrails, commodes, thermometers, etc. C-diff spores are transferred to residents mainly via the hands of associates who have touched contaminated surfaces or items. Review of the facility policy entitled Infection Control Precautions directed that contact precautions would be utilized for direct skin to skin and physical transfer of microorganisms to a susceptible host form, an infected or colonized resident during care. The precautions would be utilized when there was a presence of organisms that require more stringent precautions. This would be used for MRSA and C-Diff. These residents would be cohorted or isolated dependent on the symptoms.

Based on an observation of the kitchen, staff interviews and a review of the facility policy and procedure, the facility failed to store food items in accordance with professional standards for food service safety. The findings include: Observation of the kitchen on 2/3/20 at 9:34 AM identified that food items were found undated and unlabeled in the refrigerator during tour and included fresh vegetable salads (8), slices of pie with whip cream (14), and oatmeal bar desserts (12). Interview with the Director of Dietary on 2/3/19 at 9:40 AM identified the undated and unlabeled fresh vegetable salads, slices of pie, and oatmeal bars were from 2/2/20 and should have been labeled. The Director of Dietary further identified the facility expectation/policy was posted on the refrigerator and the posting directed that all food items must be dated, and if not used, discarded after three days; directions for completing the label were also posted. The Director of Dietary indicated the facility expectation was to date when the item was opened or prepared and to place the expiration date on the label. Interview with [NAME] #1 on 2/3/20 at 10:00 AM identified all the vegetable salads, slices of pie, and oatmeal bars were discarded because they were not dated as directed by the facility policy. [NAME] #1 further identified the items should not have been placed in the refrigerator undated/unlabeled and indicated the reason this may have happened was because there was many new staff in the dietary department and the polices have not yet become routine for them. Further interview with [NAME] #1 indicated all dietary staff are informed of these expectations and policies related to labeling of food. Subsequent to surveyor inquiry education was provided to all dietary staff reiterating the procedure for labeling and dating foods. The facility policy relating to the labeling of foods directed in part that all food items would be labeled with both the date, when the food item was prepared, and the use-by date; all spaces on the label would be filled in.